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Discharge summary
|
report
|
Admission Date: [**2169-9-4**] Discharge Date: [**2169-9-16**]
Date of Birth: [**2151-1-16**] Sex: F
Service: NEUROLOGY
Allergies:
Peanut / Soy
Attending:[**First Name3 (LF) 2090**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
LP on admission and again [**9-5**]
History of Present Illness:
Ms. [**Known lastname 91283**] is a 18 year-old healthy woman who presented to the
ED this morning for evaluation of headache. She was well until
a few days ago, when she began having intermittent sharp
abdominal pains, associated with poor appetite, nausea, and
vomiting. No change in bowel movements, no blood in stool.
Also noted a new rash on her forehead a few days ago. This
morning she noted severe global headache [**8-28**] - never had this
type of headache before. +nausea, neck stiffness, and
photophobia; no numbness, tingling, or focal weakness. She is a
freshman at Pine Manor College and lives in the dorm; she says
that many of her classmates have been ill with the "flu"
recently.
.
In ED, initial vitals 100.3 100 142/90 18 100% RA. Lumbar
puncture performed: CSF with 465 WBC in Tube 1, 1250 WBC in Tube
4. Received 2L NS, ketorolac 30 mg iv, vancomycin 1g iv,
ceftriaxone total 2g iv, Percocet, and Zofran. CSF gram stain
was negative.
.
At the time of examination, she has no headache, but does have
neck stiffness, as well as R shoulder pain which began after
lumbar puncture.
.
Review of Systems: as per HPI
(+) Back pain
(-) Denies chills, night sweats, recent weight loss or gain.
Denies visual changes, rhinorrhea, sore throat or dysphagia.
Denies chest pain, palpitations, orthopnea, dyspnea on exertion.
Denies shortness of breath, cough or wheezes. Denies diarrhea,
constipation, BRBPR, melena. No dysuria, urinary frequency.
Denies arthralgias or myalgias. No increasing lower extremity
swelling. No numbness/tingling or muscle weakness in
extremities. No feelings of depression or anxiety. All other
review of systems negative.
Past Medical History:
Urinary tract infection, treated prior to admission
Social History:
Originally from [**Hospital1 189**]. Now a freshman at Pine Manor College in
[**Location (un) 55**]. Studying communications. Lives in [**Location **]. No
tobacco or illicit drugs. Occasional wine. Sexually active.
Family History:
Father with diabetes mellitus. Mother died in [**2169-6-19**] of an
"infection."
Physical Exam:
ADMISSION MEDICINE PHYSICAL EXAM:
Vitals 100.0 100 145/81 20 100% RA
Gen - lying comfortably in bed, no distress, pleasant
HEENT - pupils equal, EOMI, no oral lesions
Neck - no lymphadenopathy
Pulm - CTAB, good air movement
CV - RRR, soft systolic ejection murmur
Abd - +BS, soft, nontender, nondistended
Ext - warm, no edema
Skin - multiple tiny flesh-colored, round, elevated lesions on
forehead
Neuro - alert, conversant, interactive, CN 2-12 intact, normal
sensation to light touch, 5/5 strength bilateral UEs and LEs,
normal finger-nose-finger, +nuchal rigidity, negative Kernig's
sign, negative Brudzinski's sign
ADMISSION NEUROLOGY PHYSICAL EXAM:
Vitals Tmax 101, tcurrent 100, bp 145/81, HR 100, RR 20, 100% on
RA.
General: Awake, cooperative, rigoring
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions in
oropharynx
Neck: Supple, +Nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: tachycardic
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: diffuse maculopapular rash along forehead
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name DOW backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**1-19**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 4 5- 4 4 5 4+
R 5 5 5 5 5 5 5 4 5- 4 4 5 4+
-Sensory: Sensory level to pinprick T10 on the right and T12 on
the left
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 2 3 0 0
R 3 2 3 0 0
Plantar response was flexor bilaterally.
-Coordination: No dysmetria on FNF .
-Gait: Unable to support her weight on attempting to stand
decreased rectal tone. NIF -38 / VC 1.2L
Discharge Neurologic Physical Exam
- Mental Status: Alert, oriented x 3. Attentive. Language is
fluent. Speech was not dysarthric.
- Cranial Nerves: All intact.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No tremor, no asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**]
L 5 5 5 5 5 5 5 2 4+ 4- 2 4+ 3
R 5 5 5 5 5 5 5 2 5 4+ 4 5 4+
-Sensory: Sensory level to temp at T4 on the right and T8 on the
left. Proprioception decreased bilaterally.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat
L 2 2 2+ 2+
R 2 2 2+ 2+
Toes upgoing bilaterally, left more briskly. Clonus at ankles
([**1-20**] brisk)
-Coordination: No dysmetria on FNF.
Pertinent Results:
ADMISSION LABS:
[**2169-9-4**] 01:50PM URINE UCG-NEG
[**2169-9-4**] 12:20PM CEREBROSPINAL FLUID (CSF) PROTEIN-116*
GLUCOSE-49
[**2169-9-4**] 12:20PM CEREBROSPINAL FLUID (CSF) WBC-1250 RBC-100*
[**2169-9-4**] 12:20PM CEREBROSPINAL FLUID (CSF) WBC-465 RBC-285*
POLYS-90 LYMPHS-3 MONOS-0 MACROPHAG-7
[**2169-9-4**] 10:25AM LACTATE-2.4*
[**2169-9-4**] 10:15AM GLUCOSE-75 UREA N-8 CREAT-1.0 SODIUM-137
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2169-9-4**] 10:15AM ALT(SGPT)-12 AST(SGOT)-28 ALK PHOS-60 TOT
BILI-0.5
[**2169-9-4**] 10:15AM LIPASE-32
[**2169-9-4**] 09:25AM WBC-6.9 RBC-5.06 HGB-12.0 HCT-38.7 MCV-76*
MCH-23.7* MCHC-31.0 RDW-13.0 PLT COUNT-293
[**2169-9-4**] 09:25AM NEUTS-83.6* LYMPHS-12.3* MONOS-3.3 EOS-0.6
BASOS-0.3
DISCHARGE LABS:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2169-9-11**] 05:18 8.0 4.32 10.1* 33.1* 77* 23.3* 30.4* 14.0
203
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps
Metas
[**2169-9-9**] 05:20 86.8* 7.6* 5.0 0.3 0.4
Chemistry Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2169-9-12**] 05:55 132 16 0.6 136 3.5 103 28 9
CMV (-), EBV (-), HSV (-), Schtosoma (-), mycoplasma IgG (+),
IgM (-), Varicella (-), HIV (-), HTLV (-), Bartonella (-), RPR
(-)
Ro and La (-)
NMO/AQP4-IgG [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 9374**] to >160
Pending viral studies:
[**State 4565**], Arboro, EEE, [**Location (un) **], Entero
IMAGING:
MR SPINE [**2169-9-4**]: IMPRESSION:
1. Edema, possible mild contrast enhancement, and expansion of
the spinal
cord from C5 through T11. Diagnostic considerations include
either transverse myelitis, likely infectious given the lumbar
puncture findings, or venous edema/ischemia secondary to
meningitis.
2. Distended urinary bladder, congruent with the stated history
of urinary
retention.
MRI HEAD [**2169-9-5**]: IMPRESSION:
1. No evidence of acute infarct, intracranial hemorrhage, or
space-occupying lesion.
2. Subtle FLAIR hyperintense signal along the right frontal and
parietal
sulci (series 4, image 16), with mild post contrast enhancement
along the
sulci in these regions.
3. Hyperintense signal noted on T2-weighted images in the
visualized part of the cervical spinal cord extending to
cervicomedullary junction which has increased since the prior
study and is suggestive of extension of either transverse
myelitis or venous ischemia/edema secondary to meningitis.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 91283**] is an 18 yo RH woman with no significant PMHx who
presented with presumed baterial menigitis, but then developed
sudden onset of leg weakness that progressed to plegia and RUE
weakness. She had an MRI of her spine that was suspicious for a
very large inflammatory process (lesion from C5-T7) and
ultimately tested positive for NMO/AQP4-IgG (>160). Clinically,
her weakness has improvied on steroids and IVIG.
ICU and Hospital Course by System:
# NEURO: CSF cell count (WBCs of 1250) and neutrophil
predominance were throught to be consistent with bacterial
meningitis. Elevated CSF protein and low glucose (though not
extremely low) was felt initially to also fit this, and she was
admitted to the medicine service. However, she had no
peripheral leukocytosis, and did not appear toxic. Other than
nuchal rigidity, her neuro exam was initially normal. However,
once she developed leg weakness, it became clear that this was
more likely a viral or inflammatory/autoimmune process and not
bacterial meningitis. Her sx rapidly progressed until she was
unable to walk, and she was admitted to the neuro ICU. She was
continued on broad spectrum antibiotics until [**9-8**] when her
acyclovir and vancomycin were stopped because her gram stain was
negative and both her HSV and VZV PCR came back negative. She
was continued on ceftriazone per ID recs as well as levofloxacin
for possible mycoplasma coverage. She was started on IV
methylprednisolone with plan for prolonged high dose IV taper
followed by PO prednisone taper. She was also started on a 5 day
course of IVIG, finishing on [**9-9**].
The patient was transferred to the floor from the ICU and
continued to improve. Her strength in her UE returned to [**Location 213**]
and gradually has improved in her LE. She worked with PT/OT on a
daily basis with good results. Please see discharge physical
exam for details.
# ID: Patient had many CSF studies sent. The results showed
were all negative (including viral and bacterial cultures listed
in pertinent results. Some viral studies are still pending,
however these are thought to be much less likely (EEE, [**Location (un) 67061**],
etc.) She was also given 3 doses of praziquantal on [**9-8**] for a
suspicion of schistosomiasis causing her myelitis. These tests
later returned negative. On transfer to the floor she was
continued on CTX for nearly a 10 day course and levofloxacin
until mycoplasma studies returned with negative IgM and positive
IgM. Our ID team confirmed that IgM should remain elevated if
her illness was due to this.
While on the floor the patient gradually developped a sore
throat that was considered to be due to candidiasis. She was
started on Nystatin swish and swallow for at least a 7 day
course.
# PULM: initially patient had worsening NIF's and vital
capacities, but once started on steroids and IVIG these improved
and she was able to be sent out of the ICU once stable. On the
floor the patient had some subjective feeling of fullness in her
throat and trouble breathing that was attributed to her [**Female First Name (un) **]
pharyngitis. Her O2 saturation never fell below the high 90s.
# CV: The patient had 2-3 episodes of syncope during her
hospitalization. These were thought to be vasovagal and perhaps
exacerbated by autonmic dysfunction with thoracic cord
involvement. An EKG was obtained which showed a prolonged QTc
interval (> 500 ms) and cardiology was consulted. There was no
evidence of arrythmia and cardiology agreed that her syncope was
vasovagal and for now QTc prolonging medications should be
avoided. Cardiology would suggest a few more days of monitoring
with EKG at rehab to confirm that QT shortens with
discontinuation of QT prolonging meds.
# CODE: Full
# Discharge Plan:
-- Please continue PO prednisone taper with 60 mg [**Hospital1 **] for 3
days, followed by 80 mg daily for 3 days, followed by 60 mg
daily for 3 days, followed by 30 mg daily for 5 days.
-- Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **], the patient's primary neurologist may want
to extend this taper. Please be in touch with her
([**University/College 91284**] or [**Telephone/Fax (1) 5434**]) with any questions or
concerns.
-- Please encourage the patient to schedule a follow-up
appoitment with Dr. [**Last Name (STitle) **] soon after discharge from [**Hospital1 **].
-- Continue Nystatin swish and swallow for 7-10 days or until
symptoms are resolved.
-- Please obtain an EKG every 1-2 weeks and more frequently if
the patient is placed on any medications that prolong the QTc
interval.
-- She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] of Cardiology. She should
follow-up with him following discharge from rehab.
Medications on Admission:
Multivitamin
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED) for 3 weeks: While on high dose
steroids. .
6. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. prednisone 20 mg Tablet Sig: Three (3) Tablet PO twice a day
for 5 days: Taper: 60 mg [**Hospital1 **] for 5 days, 60 mg daily for 5 days,
30 mg daily for 5 days. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary diagnosis: Transverse Myelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Neuro Exam: Lower extremity weakness left worse than right, hip
flexors and tibialis anterior worse than other muscles.
Discharge Instructions:
Ms. [**Known lastname 91283**], You were admitted to the hospital with meningitis
and paralysis of your legs. You have been given a diagnosis of
neuromyelitis optica (NMO). This is an autoimmune process in
which antibodies from your immune system attack the coating of
your nerves. To treat this you were given medications that
supress your immune system (steroids and IVIG). The function of
your nerves are now slowly coming back as evidenced by the
improving strength in your legs.
You will be transferred to [**Hospital3 **] on an oral course of
steroids. You will follow up with Dr. [**Last Name (STitle) **].
Ms. [**Known lastname 91283**], You were admitted to the hospital with meningitis
and paralysis of your legs. You have been given a diagnosis of
neuromyelitis optica (NMO). This is an autoimmune process in
which antibodies from your immune system attack the coating of
your nerves. To treat this you were given medications that
supress your immune system (steroids and IVIG). The function of
your nerves are now slowly coming back as evidenced by the
improving strength in your legs.
You will be transferred to [**Hospital3 **] on an oral course of
steroids. You will follow up with Dr. [**Last Name (STitle) **].
Followup Instructions:
For rehab:
-- Please continue PO prednisone taper with 60 mg [**Hospital1 **] for 3
days, followed by 80 mg daily for 3 days, followed by 60 mg
daily for 3 days, followed by 30 mg daily for 5 days.
-- Dr. [**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **], the patient's primary neurologist may want
to extend this taper. Please be in touch with her
([**University/College 91284**] or [**Telephone/Fax (1) 5434**]) with any questions or
concerns.
-- Please encourage the patient to schedule a follow-up
appoitment with Dr. [**Last Name (STitle) **] soon after discharge from [**Hospital1 **].
-- Continue Nystatin swish and swallow for 7-10 days or until
symptoms are resolved.
-- Please obtain an EKG every 1-2 weeks and more frequently if
the patient is placed on any medications that prolong the QTc
interval.
-- She was seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 696**] of Cardiology. She should
follow-up as needed.
For the patient:
Following discharge from rehab you will be followed with Dr.
[**First Name8 (NamePattern2) 730**] [**Last Name (NamePattern1) **]. Please call her office to schedule a follow-up
appointment in the next 2-4 weeks ([**Telephone/Fax (1) 5434**]).
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]
|
[
"426.82",
"322.0",
"736.79",
"341.0",
"530.19",
"112.0",
"780.2",
"788.20",
"344.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"99.14"
] |
icd9pcs
|
[
[
[]
]
] |
14452, 14522
|
8587, 9056
|
282, 319
|
14605, 14605
|
6108, 6108
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|
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|
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9084, 12374
|
4144, 5325
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3108, 3536
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1479, 2019
|
234, 244
|
347, 1459
|
5437, 6089
|
6125, 6869
|
14562, 14584
|
14620, 14836
|
12390, 13381
|
2041, 2094
|
2110, 2332
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,739
| 151,972
|
13815
|
Discharge summary
|
report
|
Admission Date: [**2109-4-29**] Discharge Date: [**2109-5-4**]
Date of Birth: [**2042-5-21**] Sex: F
Service: NEUROSURGERY
Allergies:
pollen
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
seizure and right sided weakness
Major Surgical or Invasive Procedure:
Left frontal Craniotomy with resection of meningioma
History of Present Illness:
This is a 66 year old woman who had developed right lower and
then right upper extremity weakness over the past few years. She
had a spine work up with imaging of her cervical and lumbar
spine. conservative treatment was recommended. She had episodes
of contractions of the right lower extremity, which were lasting
for 10-15 minutes. In [**Month (only) 956**] of this year, she had what seemed
to be a right-sided seizure and since then, she was placed on
appropriate seizure medications and she had no symptoms from
that. MRI, EEG, and EMG were performed. The EEG showed some
slowness. The MRI revealed a left parietal brain tumor.
Past Medical History:
HTN, s/p appy, s/p hemorrhoidectomy, seizures, DDD
Social History:
She had smoked in past, occasionall uses alcohol, works as
flight attendant
Family History:
NC
Physical Exam:
Pre-op: Neuro: no CN deficit, IP on the right is 5- with
quadriceps and
hamstring 5- Plantar flexion is [**3-19**]. [**Last Name (un) 938**] is [**4-18**]. Deltoids to the
right and biceps are full, whereas triceps and wrist extension
is
4+/5. Finger intrinsics are very weak at 3/5. She has no left
sided deficit.
At Discharge: She is awake and alert, Or x 3.conversant with 2
word phrases, dysphasic. RUE: deltoid 3 R grip 4 R IP [**2-16**] She
has no strength in her right foot. Left sided strength is full.
Her wound is clean and dry. Her PE varies greatly due to issues
with execution due to damage to her pre-motor area.
Pertinent Results:
Brain MRI [**2109-4-29**]:
1. Redemonstration of a large lobulated enhancing extra-axial
mass lesion
measuring 4.4 cm with moderate surrounding vasogenic edema and
mass effect on the left lateral ventricle and the left side of
the corpus callosum for
surgical planning. The lesion is in close proximity to the
superior sagittal sinus and the adjacent venous tributaries.
Please see additional details on prior complete MR study done on
[**2109-4-8**].
2. A smaller enhancing focus along the lateral aspect of the
left frontal
lobe (series 2, image 65) measuring approximately 5 mm, may
represent an
additional small dural-based mass lesion such as meningioma.
This is
unchanged compared to the prior study of [**2109-4-8**].
CT head [**2109-4-29**]:
Expected post-surgical changes s/p left extraaxial mass
resection, including a small amount of hemorrhage in the
surgical bed.
MRI brain [**2109-4-30**]:
Status post recent left frontal/parietal craniotomy for
resection
of left parasagittal probable presumed meningioma with expected
postoperative changes. There is no definite residual tumor. Mild
thickening and enhancement of the falx adjacent to the tumor may
be post-operative though a continued followup would be helpful
to more definitively exclude a small amount of residual tumor.
CXR [**2109-5-1**]
Interval increase in overall cardiac silhouette is noted,
currently mild
cardiomegaly. Mediastinum is unremarkable. Lungs are essentially
clear
except for right basal opacity, laterally which might represent
atelectasis or infectious process. Note is made that there are
multiple external devices overlying the chest that preclude
precise evaluation and subtle lesions may be overlooked
CT head [**5-2**]
1. Post-operative changes with small residual pneumocephalus and
apparent
organizing hematoma in the left frontovertex surgical bed.
2. No hemorrhage elsewhere and no specific evidence of acute
vascular
territorial infarction
Brief Hospital Course:
The patient was admitted to the hospital for an elective
resection of Left frontal meningioma. Her surgery was
complicated by bleeding from the saggital sinus and she required
transfusion of 4 units intraop and 2 units post-op for this.
She remained hemodynamically stable and was recovered in the
ICU. Her post operative Hct was 34. She had significant post-op
weakness on the right side and was on Decadron 4mg Q6hr for 48
hrs for cerebral edema. Her exam improved. Transfer orders for
SDU were written on [**4-30**]. She was out of bed with PT. SQH was
started. On [**4-30**], she was noticed to have hypertension to 180s
and diminished speech with aggitation. PO ativan was given and
episode improved. Transfer orders were cancelled and patient
went for MRI. On [**5-1**], patient experienced another episode of
aggitation and diminished speech with hypertension. PO ativan
was given once again and episode resolved. Neurology was
consulted to evaluate for seizures. They recommend to continue
Keppra and place her on seziure prophylaxis. Given her
leukocytosis 14.2, they recommended infection work-up. But
given that she was afebrile, currently post op, and on
dexamethasone, we deferred further w/u unless she was febrile.
MRI read showed gross total resection of tumor with residual
hyperdensity within the falx. A repeat head CT was ordered for
increase RLE weakness on examination which demonstrated post
operative changes with mild edema but no evidence of infarct or
new hemorrhages. Overnight, she was complicated by labile HTN
and required intermittent doses of labetolol On [**5-2**], clonidine
was started and she was transitioned to prn lopressor. Her
foley was removed in routine fashion without incident and her IV
was heplocked.
On [**5-2**], she was transferred to floor in stable conditon. She
continued to show improvement in her RUE motor strength as well
as her RLE proximal muscles. She continued to have a baseline
Right foot drop. She remained on dexamethasone 4mg Q6h for an
additional 2 days. She had mild dysphasia and this slowly
continued to progress. She tolerated advances in her diet. She
had episodes on anxiety accompanied by transient difficulty with
movement of her RUE. This improved with prn ativan and
monitoring. She was evaluatd by pt/ot and speech and they
recommended acute rehab.
She is afebrile, VSS. She is tolerating a good oral diet and
pain is well controlled. She is set for d/c to rehab in stable
condition and will f/u accordingly.
Her PE varies greatly due to issues with execution due to damage
to her pre-motor area.
Medications on Admission:
atenolol 100mg qd, fish oil, keppra 1000 [**Hospital1 **], ativan 0.5mg prn,
MVI, valsartan 160/25 qd
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
5. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. atenolol 50 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day): Hold for SBP less than 100, HR less than 60
.
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. insulin regular human 100 unit/mL Solution Sig: Two (2) units
Injection ASDIR (AS DIRECTED): see sliding scale.
10. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
11. clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch
Weekly Transdermal QTHUR (every Thursday).
12. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for SBP less than 100
.
13. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 days: d/c night of [**5-5**].
14. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 3 days: Start: [**2109-5-6**]
.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left parietal Meningioma
cerebral edema
Seizure Disorder
Dysphasia
Hypertension
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:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You should remain on Keppra for anti-seizure medicine, take it
as prescribed.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????You may hae your staples removed at rehab on [**5-6**]. Please call
([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain
??????You will not need an MRI of the brain with/ or without
gadolinium contrast.
You will need to follow up in the Brain [**Hospital 341**] clinic, [**Hospital Ward Name 5074**] [**Location (un) **] on [**5-6**] at 10am. Please call [**Telephone/Fax (1) 1844**] if
you have any questions.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2109-5-4**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
|
[
[
[]
]
] |
7936, 8006
|
3841, 6439
|
303, 358
|
8129, 8129
|
1872, 3818
|
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|
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386, 1022
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,338
| 130,878
|
53867
|
Discharge summary
|
report
|
Admission Date: [**2152-3-17**] Discharge Date: [**2152-3-21**]
Date of Birth: [**2071-8-23**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 2080**]
Chief Complaint:
ERCP for suspected cholangitis
Major Surgical or Invasive Procedure:
[**2152-3-18**] - Endoscopic retrograde cholangiopancreatography
History of Present Illness:
The patient is an 80 yo m w hx of HTN, HLD, BPH, 3 weeks of
malaise and RUQ pain, fevers, chills, nightweats. He went to see
his PCP [**Last Name (NamePattern4) **] [**2152-3-17**] and was found to have elevated WBC and LFTs
then sent to ED at [**Hospital1 **]. RUQ US was unremarkable. At the OSH
ED, his labs were significant for WBC 34, 22% bands, creat 3
(baseline 1.5), elevated LFTs, received flagyl, zosyn, 2 L NS.
.
In the ED, initial VS were: 98.8 70 107/74 16 98% RA. He had a
WBC of 24, a Tbili of 8.9, a Cr 2.9 and an INR of 1.7. He was
given another 2L of NS. He was noted to have SBP's in the 90's
and there was concern for sepsis therefore a ICU was requested.
In the ICU, his exam was notable for jaundiced male, RUQ
tenderness to minimal palpation with min guarding, no rebound.
no hypotention in MICU.
He underwent RUQ which showed sludge. He was continued on zosyn
for suspected cholangitis. He also received an additional 1 L NS
and morphine.
.
stoic, oriented. no complaints currently.
.
In MICU, continued zosyn for ? cholangitis, getting morphine, 1
L NS.
Past Medical History:
Past Medical History (per MICU [**Location (un) **] admit note):
Hypertension
Hyperlipidemia
Gout
BPH
GERD
Low Testosterone/Low Growth Hormone
Glaucoma
Social History:
- Tobacco: 1 pack per day but states that he does not inhale
- Alcohol: denies
- Illicits: denies
Family History:
He notes that his sister died at the age of 43 from esophageal
cancer.
Physical Exam:
ADMISSION EXAM:
.
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
.
Pertinent Results:
ADMISSION LABS:
.
[**2152-3-17**] 09:34PM BLOOD WBC-24.0* RBC-3.42* Hgb-11.6* Hct-36.4*
MCV-106* MCH-33.8* MCHC-31.8 RDW-14.6 Plt Ct-180
[**2152-3-17**] 09:34PM BLOOD Neuts-97.4* Lymphs-1.4* Monos-0.9*
Eos-0.1 Baso-0.2
[**2152-3-17**] 09:34PM BLOOD PT-17.6* PTT-29.6 INR(PT)-1.7*
[**2152-3-17**] 09:34PM BLOOD Glucose-105* UreaN-55* Creat-2.9* Na-136
K-5.3* Cl-109* HCO3-16* AnGap-16
[**2152-3-17**] 09:34PM BLOOD ALT-143* AST-74* AlkPhos-356*
TotBili-8.9*
[**2152-3-18**] 05:28AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.5*
[**2152-3-17**] 09:42PM BLOOD Lactate-1.8
.
DSICHARGE LABS:
.
MICROBIOLOGIC DATA:
[**2152-3-17**] Blood cultures (x 2) - pending
[**2152-3-18**] MRSA screen - pending
.
IMAGING STUDIES:
.
[**2152-3-18**] ERCP - Cannulation of the biliary duct was successful
and deep with a sphincterotome using a free-hand technique.
Contrast medium was injected resulting in opacification. Biliary
Tree: A moderate diffuse dilation was seen at the biliary tree
with the CBD measuring 10 mm.
Three stones ranging in size from 6 mm to 10 mm that were
causing partial obstruction were seen at the lower third of the
common bile duct and middle third of the common bile duct. Full
cholangiogram was not obtained given cholangitis. Procedures: A
5cm by 10FR Double pig-tail biliary stent was placed
successfully using a Oasis system stent introducer kit.
Impression: Stones in the common bile duct causing obstruction.
Diffuse biliary dilation was noted. A biliary stent was placed.
Blood cx NGTD
Brief Hospital Course:
IMPRESSIONS: 80M with a history of CAD, HTN, HLD who presented
to his PCP's office with 5-weeks of feeling unwell and RUQ
abdominal pain noted to have a leukocytosis and hypotension
concerning for sepsis.
.
# Transaminitis - He is noted to have an elevated ALT, T-bili
and Alk Phos which is consistent with a cholestatic picture,
however, he may have a component of hepatocellular injury. Based
on history and leukocytosis there was concern for cholangitis.
RUQ U/S showed sludge in the gallbladder but no cholecystitis or
CBD dilation. Zosyn IV was started for probable cholangitis.
ERCP was performed on [**2152-3-18**] and no sphincterotomy was
performed given his coagulopathy but sphincterotome was placed
through the ampulla. He was dosed Morphine for pain control. ACS
surgery was following the patient given the need for possible
future cholecystectomy. Following ERCP, the patient will
continue antibiotics and need repeat ERCP in 3-weeks.
- Repeat ERCP in 3 weeks at [**Hospital1 18**]
- Complete 10 day course Augmentin (OSH cultures negative)
- Surgery follow up following ERCP to schedule cholecystectomy
.
# Hypotension - He notably had an elevated WBC and abnormal LFTs
which was concerning for cholangitis. With hypotension, he
appeared septic. He was given a dose of Zosyn and Flagyl at the
OSH. He was also given a total of 4L of NS prior to arriving to
the MICU. We continued Zosyn IV given his cholangitis concerns
and his pressures improved with fluid resuscitation. He was
ultimately transitioned to Augmentin to complete a course.
.
# Acute Renal Failure - On review of his VA records his
creatinine was 1.5 in [**2150-11-2**]. Based on his presentation, we
suspected a prerenal etiology. Urine lytes were obtained and his
creatinine trended. His creatinine improved with hydration. His
Cr was 1.8 on discharge. His home medications were resumed.
.
# Coagulopathy - He was noted to have an INR of 1.7 on transfer.
There is no previous INR's on review of his records. The
differential for him includes nutritional deficit vs. synthetic
dysfunction. He was noted to have an albumin of 3.4. He was
given vitamin K to help correct his defficiency
.
# Hypertension - He is hypertensive at baseline; however, with
possible sepsis his anti-hypertensive medications were held.
They were restarted on discharge.
.
# Gout - Appears to be well controlled on his current regimen.
We continued Allopurinol 300 mg PO daily.
.
# BPH - Patient noted that he has been having significant
symptoms from his BPH. Unclear what his regimen, however, noted
to be on tamsulosin which was held given hypotension concerns.
Medications on Admission:
Omeprazole 40mg Daily
Imodium 2mg QID
Allopurinol 300mg daily
Aspirin 325mg daily
Clobetasol 0.05% Cream [**Hospital1 **]
Glucosamine 1000mg daily
Hyzaar 50mg/12.5mg daily
Multivitiamin 1 tab daily
Somatropin 0.2mg Poweder
Zymar 0.3% Ophthalmic Solution
AndroGel Pump
Ketoraloac Tromethamine 0.5% Ophthalmic Solution
Saw [**Location (un) **] 160mg capsules [**Hospital1 **]
Tamsulosin 0.8mg qHS
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: Two (2)
Capsule, Ext Release 24 hr PO HS (at bedtime).
4. Hyzaar 50-12.5 mg Tablet Sig: One (1) Tablet PO once a day.
5. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
6. somatropin 0.2 mg/0.25 mL Syringe Sig: One (1) injection
Subcutaneous every other day.
7. clobetasol 0.05 % Cream Sig: One (1) application Topical
twice a day.
8. ketorolac 0.5 % Drops Sig: One (1) drop Ophthalmic once a
day.
9. Saw [**Location (un) **]
resume home dose
10. Outpatient Lab Work
Chem 7, BUN, creatinine, AST, ALT, T. bili, Alk Phos.
- next PCP follow up
11. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
12. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
Disp:*5 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Choledocholithiasis
Obstructive jaundice
Acute renal failure
Chronic kidney disease III
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were intially admitted to an outside hospital for malaise,
an elevated WBC and RUQ pain. You came to [**Hospital1 18**] for an ERCP for
which gallstones were found in your biliary duct, and a stent
was placed. You were also found to have kidney failure. You
improved with IV fluids.
You will need to have a repeat ERCP for stone removal.
Following that, you should see a surgeon to consider gallbladder
removal. Please resume your home medications. You will be
given an antibiotic to complete a full course
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] M.
Location: FAMILY MEDICAL ASSOCIATES
Address: [**Street Address(2) 84438**], [**Location (un) **],[**Numeric Identifier 84439**]
Phone: [**Telephone/Fax (1) 13553**]
Appointment: MONDAY [**3-27**] at 2:45PM
Department: ENDO SUITES
When: THURSDAY [**2152-4-13**] at 10:30 AM
Department: DIGESTIVE DISEASE CENTER
When: THURSDAY [**2152-4-13**] at 10:30 AM
With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Please call our surgery dept for a follow up appointment in
[**Month (only) 547**]
Description:
General Surgery
Appointment Scheduling
[**Hospital1 18**] Phone:
([**Telephone/Fax (1) 30009**]
|
[
"600.00",
"785.52",
"305.1",
"403.10",
"038.9",
"576.1",
"585.3",
"403.90",
"584.9",
"574.51",
"274.9",
"272.4",
"286.9",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8124, 8130
|
3961, 6587
|
337, 403
|
8279, 8279
|
2440, 2440
|
8972, 9895
|
1819, 1891
|
7033, 8101
|
8151, 8258
|
6613, 7010
|
8430, 8949
|
1906, 2421
|
266, 299
|
431, 1512
|
2456, 3126
|
8294, 8406
|
1534, 1687
|
1703, 1803
|
3143, 3938
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,191
| 161,285
|
36012
|
Discharge summary
|
report
|
Admission Date: [**2193-12-12**] Discharge Date: [**2193-12-18**]
Date of Birth: [**2155-8-31**] Sex: F
Service: MEDICINE
Allergies:
Prednisone
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Hypoxia, fever
Major Surgical or Invasive Procedure:
PICC placement
IVC filter placement (note: 2 filters placed due to duplicated
IVC)
History of Present Illness:
This a 38 year old female with recent intracranial bleed,
trach/peg who is transfered from Caritas for managment of PNA.
The patient was recently discharged from [**Hospital1 18**] on [**2193-12-10**] after
a large right intracranial bleeding. During that hospital
course, the patient had been intubated and was unable to wean of
the ventilator; received a trach/PEG and was discharged to rehab
at [**Hospital3 7665**]. She had been placed on dilantin for seizure
prophylaxis.
.
At rehab, she developed a fever and hypxoxia was O2sat 70's. She
was transfered to an OSH and found to have a PNA and UTI. She
was given Ceftriaxone and Azithromycin. Per family request, the
patient was transfered to [**Hospital1 18**].
.
In the ED, the patient arrived on a trach mask, was found to be
febrile, tachypnic and hypoxic with SaO2 88% on trach mask. She
was placed on BiPAP to improve oxygenation. CXR showed a RLL
PNA. The patient was given Vancomycin in addition to the
Ceftriaxone and Azithromycin at OSH. An attempt was made to wean
back to trach mask, but an ABG showed hypoxia with ph
7.49/44/44. She was placed back on BiPAP and had Sat's 100% on
60% Fi02 PEEP 10 PS 5. Vital signs were: temp Hr 115, BP 120/75
RR 20, 100% on 60% Fi02.
Past Medical History:
Migraine
hypertension
dental abcesses
uterine CA with Hysterectomy
Social History:
No tobacco EtOh or drugs per husband.
Family History:
Non-contributory.
Physical Exam:
VS Tm99.8 Tc98.4 134/80 p92 R22 96% 10L TC
GEN: Obese female, appears comfortable, no acute distress.
HEENT: Trach collar in place
RESP: CTA B. Fair AE.
CV: RRR. No mrg.
Abd: +BS. Soft, nt/nd. PEG in place.
EXT: No Cee. Bilateral groin access sites for IVC filter
placement CDI, no hematomas, eccymosis, or thrills.
Neuro: L hemiparesis. L plantar upgoing.
Psych: flat affect.
Access: PICC - Placed 1/5/009
Pertinent Results:
IMAGING:
[**2192-12-11**] Admission CXR:
Single AP chest radiograph compared to [**2193-12-9**], show
persistent low lung volumes with new consolidation in the right
mid lung. There is no
pleural effusion or pneumothorax. The cardiomediastinal contour
is stable. A tracheostomy is present. The distal end of the
right PICC line is coiled and terminates at the confluence of
the brachiocephalic vein.
.
LE Doppler study:
IMPRESSION: Limited exam. Acute-appearing deep vein thrombosis
extending
from the proximal left superficial vein to the popliteal vein.
.
IVC filter placement:
Preliminary Report !! PFI !!
PFI: IVC venogram demonstrated duplicated IVC, and one G2 IVC
filter was
placed at the right side infrarenally and one OptEase filter was
placed at the left side infrarenally.
Admission:
[**2193-12-12**] 01:42AM BLOOD WBC-14.4*# RBC-3.90* Hgb-11.7* Hct-32.9*
MCV-84 MCH-29.9 MCHC-35.4* RDW-14.2 Plt Ct-265
[**2193-12-12**] 01:42AM BLOOD Neuts-84.4* Lymphs-11.2* Monos-4.0
Eos-0.2 Baso-0.2
.
Discharge Labs:
[**2193-12-18**] 04:23AM BLOOD WBC-6.5 RBC-3.42* Hgb-9.9* Hct-28.9*
MCV-85 MCH-29.1 MCHC-34.4 RDW-14.3 Plt Ct-294
[**2193-12-18**] 04:23AM BLOOD PT-13.6* PTT-22.6 INR(PT)-1.2*
[**2193-12-17**] 06:06AM BLOOD Glucose-134* UreaN-10 Creat-0.3* Na-142
K-3.5 Cl-101 HCO3-36* AnGap-9
[**2193-12-16**] 05:02AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9
[**2193-12-14**] 04:30AM BLOOD Phenyto-15.3
[**2193-12-15**] 06:07AM BLOOD Phenyto-11.3
[**2193-12-16**] 05:02AM BLOOD Phenyto-9.6*
.
MICRO:
Sputum -
ACINETOBACTER BAUMANNII COMPLEX
| STAPH AUREUS COAG +
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- <=0.25 S
GENTAMICIN------------ =>16 R <=0.5 S
IMIPENEM-------------- 4 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- <=0.25 S
PENICILLIN G---------- 0.25 R
TOBRAMYCIN------------ 2 S
TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S
.
.
Legionella Urinary Antigen (Final [**2193-12-12**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
[**2193-12-12**] Blood culture x 2 - negative
[**2193-12-12**] Urine culture - negative
[**2193-12-13**] blood culture - results pending
Brief Hospital Course:
38 year old female with recent admission for spontaneous
intracrainial bleed with residual L hemiparesis, trachestomy and
PEG tube who presented from rehab 2 days after discharge from
BIMC with hypoxia and fever. Found to have right middle lobe
infiltrate. Was treated for hospital aquired PNA with vanocmycin
and zosyn, initially and then narrowed to Bactrim. ID consulted
[**12-16**] with resulting change to IV Unasyn x 14 days.
.
# Hypoxia: Likely secondary to right middle lobe PNA seen on
admission chest x-ray.
- hypoxia improved with antibiotics
.
# Pneumonia: On admission, fevers, leukocytosis and right middle
lobe infiltrate consisent with PNA. Patient given Ceftriaxone
and Azithromycin at OSH; however, the patient was recently
hospitalized, then at rehab and has a trach, putting her at risk
for HAP, MSRA and Pseudomonas so she was treated with vancomycin
and zosyn. Urine leigonella was negative. Sputum later showed
Acinetobacter and MSSA, therefore ID was consulted. Bactrim was
subsequently d/c'd and patient was started on Unasyn x 2 weeks
(day 1 = [**2193-12-17**]).
.
# Intracranial hemorrhage: Patient sustained a spontaneous
sub-arachnoid hemorrhage and was admitted here for treatment and
discharged on [**2193-12-10**] to rehab. Daily dilantin levels were
checked.
- Currently subtherapeutic; likely partially due to PEG route,
need larger doses.
- goal level 15-30. Increased dilantin from 300 mg TID to 400 mg
PGT TID on [**2193-12-16**].
- Please follow dilantin levels and titrate doses accordingly.
.
# LE swelling. Patient was also noted to have LLE swelling, and
had a LENI which showed an acute DVT. She was started on heparin
gtt with bridge to coumadin, however with further discussion
with patient's Neurosurgeon (Dr. [**First Name (STitle) **], decision was made to
d/c anticoagulation and have a temporary IVC filter placed due
to the risks associated with anticoagulation in the setting of
recent ICH. A temporary IVC filter was placed on [**2193-12-17**].
Please follow patient's DVT's and have her IVC filters removed
when no longer clinically indicated.
.
# Constipation. She was markedly constipated, and received
manual disimpaction and an aggressive bowel regimen with relief
of her symptoms.
- continue bowel regimen
.
# FEN: Continued tube feeds via PEG. Patient is able to eat as
per S+S recs, however she still is not taking sufficient oral
nutrition/hydration. Wean tube feeds as po nutrition improves.
# Access: PICC line.
# Code: Full CODE
# Communication [**Name (NI) **] [**Name (NI) 47331**] (husband) [**Telephone/Fax (1) 81743**]
# Dispo: to [**Hospital **] rehab today
Medications on Admission:
Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol [**Hospital **]: [**12-13**]
Puffs Inhalation Q4H (every 4 hours) as needed for wheeze.
Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: One (1) ml
Injection TID (3 times a day).
Famotidine 20 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Ten (10) ml PO BID
Senna 8.6 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO BID
Metoprolol Tartrate 25 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID
Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Dilantin 100 mg Capsule [**Month/Day (2) **]: Three Capsule PO
three times a day. (but discharged on four tablets TID)
Oxycodone-Acetaminophen 5-325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Day (2) **]: One (1) neb Inhalation every six (6) hours as
needed for SOB.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) MG
PO BID (2 times a day).
4. Citalopram 20 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
7. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Phenytoin 125 mg/5 mL Suspension [**Last Name (STitle) **]: Four Hundred (400) MG
PO TID (3 times a day).
9. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Thirty (30) ML PO TID (3
times a day) as needed for constipation.
11. Mirtazapine 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
12. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
13. 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.
14. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
15. Ampicillin-Sulbactam 3 g IV Q4H Duration: 14 Days
16. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: Five (5) MG PO Q6H (every
6 hours) as needed for pain.
17. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Six [**Age over 90 1230**]y
(650) MG PO Q6H (every 6 hours) as needed for pain and fever.
18. Insulin Regular Human 100 unit/mL Solution [**Age over 90 **]: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
# Pneumonia, Acinetobacter baumannii, Right middle lobe
# Chronic respiratory failure; has trach
# Recent Intracranial hemorrhage
# Acute DVT; Left lower extremity
# Constipation; fecal impaction
# Depression
Discharge Condition:
Stable.
Discharge Instructions:
Continue antibiotics as prescribed for 2 week course.
Followup Instructions:
Ongoing IV Unasyn x 14 days (day 1= [**2193-12-17**]).
Patient needs to follow up with [**Hospital **] clinic.
Patient needs to follow up with her dentist for possible dental
abscess. Had Panorex on [**12-9**] from previous hospitalization;
report pending.
Please follow patient's lower extremity DVT, and have her IVC
filters removed when no longer clinically indicated.
|
[
"V44.0",
"V10.42",
"997.31",
"799.02",
"560.39",
"518.84",
"482.41",
"346.90",
"401.9",
"V88.01",
"041.85",
"453.41",
"311",
"V58.61",
"564.09",
"438.20",
"599.0",
"V44.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.7",
"96.6",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
10405, 10452
|
4692, 7325
|
288, 373
|
10705, 10715
|
2269, 3271
|
10817, 11192
|
1801, 1820
|
8261, 10382
|
10473, 10684
|
7351, 8238
|
10739, 10794
|
3288, 4669
|
1835, 2250
|
234, 250
|
401, 1638
|
1660, 1729
|
1745, 1785
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
746
| 117,382
|
50415
|
Discharge summary
|
report
|
Admission Date: [**2159-11-26**] Discharge Date: [**2159-12-5**]
Date of Birth: [**2085-6-2**] Sex: M
Service: NEUROLOGY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 5868**]
Chief Complaint:
Acute Stroke, s/p IV t-PA
Major Surgical or Invasive Procedure:
IV TPA
History of Present Illness:
74 year old man with hx of CAD (s/p MI, s/p CABG), HTN, Right
carotid stenosis (s/p carotid stent [**10-5**]), and arthritis who
presented to the ED on [**11-25**] complaining of left sided weakness.
A code stroke was called and the stroke
fellow assessed the patient immediately (Please see Dr.[**Name (NI) 105059**]
note [**11-25**] for details of initial assessment). He was initially
found to have an NIHSS of 9. CT/CTA was done and was negative
for early signs of infarction, but did show a paucity of vessels
in the right MCA territory. IV tPA was administered by Dr.
[**Last Name (STitle) **] at 8:53am.
I arrived at 9:00AM and obtained the following history. Pt was
feeling well when he went to bed last night, [**11-24**]. He awoke in
his USOH on the morning of admission at 5am, watched the news,
then started to read a book. At that time, he was able to use
both hands to hold the book and had no difficulty turning the
pages. Around 6-6:30am, he got out of bed to go to the
bathroom. His left leg "gave out" and he slid to the floor. He
thought that there might be something wrong with his heart so he
reached for his nitroglycerine tablets. He noticed that he was
unable to grip the bottle with his left hand. He crawled back
into bed and called EMS. He was brought to the ED where he
arrived shortly after 8AM. He was noted to have a left visual
field cut, dysarthria, left sided inattention, left facial
droop, left hemiplegia (arm>leg) and left hemisensory deficit.
He was given IV-tPA. NIHSS=8 (see exam below).
He denies fever/chills, CP, SOB, palpitations, nausea/vomiting,
or dysuria. He denies having similar symptoms in the past.
Past Medical History:
1. CAD- s/p MI and CABG [**63**] yrs ago with subsequent coronary
stenting
2. COPD
3. HTN
4. High cholesterol
5. PVD-s/p right leg stenting
6. Osteoarthritis
Social History:
Divorced, lives alone. Used to work appraising properties for
the government. 60 pk yr smoking hx, quit 2 yrs ago. Drinks
once per week. No drugs.
Family History:
Brother - stroke
[**Name2 (NI) 6419**] parents had heart disease in their 60s.
Physical Exam:
T-96.6 BP-155/103 HR-72 RR-20 O2Sat-100
Gen: Lying in bed, NAD
HEENT: NC/AT, facial rubor, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, no carotid bruits
CV: RRR, Nl S1 and S2, [**2-4**] HSM
Lung: Decreased breath sounds throughout
aBd: +BS soft, nontender
ext: no edema
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. He is attentive,
says [**Doctor Last Name 1841**] backwards. Speech is fluent with normal comprehension
and repetition; naming intact. Moderate dysarthria. [**Location (un) **]
intact. Registers [**2-1**], recalls [**2-1**] in 5 minutes. No right left
confusion. He has left sided inattention, but does look at
examiner on the left.
Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. No visual field cut, +extinction to visual DSS
III, IV, VI: Right gaze preference, but extraocular movements
full bilaterally, no nystagmus.
V: Sensation decreased to LT and pin on left V1-V3
VII: Left lower facial palsy, also some weakness of orbicularis
occuli on the left-though forehead moves symmetrically.
VIII: Hearing intact to finger rub bilaterally
IX, X: Palate elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid normal bilaterally.
XII: Tongue midline (when facial droop corrected), movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
Left drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 4+
L 5- 5 5 3 2 1 2 5- 5 5 5 5 5 4+
Sensation: Intact to light touch, pinprick on right, decreased
by (?50%) on left. Vibration and proprioception diminished to
shin/ankle bilaterally. Decreased proprioception in left
fingers (intact on right). +agraphesthesia on left. +
extinction to DSS on left.
Reflexes:
+2 and symmetric throughout.
Toes upgoing bilaterally
Coordination: finger-nose-finger normal on left-ataxia in
proportion to weakness on left, heel to shin normal, Unable to
do RAMs on left.
Gait/Romberg: Unable to assess
Pertinent Results:
7.1>37.8<197 73N 17L 5E
Na 143 K 4.0 Cl 106 CO2 25 BUN 20 Cr 1.1 Glu 112
Ca 9.4 Mg 1.7 Ph 3.6
Lip 43
PT 12.8 PTT 23.3 INR 1.1
A1C 5.2
Chol 155 TG 110 HDL 69 LDL 64
U/A neg
Head CT [**11-25**] - Abrupt cut-off of the anterior division of the
right middle cerebral artery (M3), consistent with acute
occlusive thrombus or embolus. No intracranial hemorrhage or
mass effect.
Head CT [**11-26**] and [**12-3**] - Stable head CT with evidence of evolving
right middle cerebral artery territory infarct, without definite
hemorrhage.
MRI head [**11-25**] - Large area of restricted diffusion in the right
middle cerebral artery territory in the right frontal and
temporal lobes, consistent with acute infarct. MR [**First Name (Titles) 4058**] [**Last Name (Titles) 4579**]s significantly decreased flow in the right mid
cerebral artery branches
Transthoracic Echocardiogram [**11-26**] - Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%).
Carotid ultrasound [**11-28**] - Minimal plaque on the right with a
less than 40% carotid stenosis. On the left, there is moderate
plaque with a 40-59% stenosis.
Neck MRA [**11-27**] - Patent right internal carotid artery stent but
with apparent slow flow. Signal irregularity and apparent
diminutive flow through the stent could be secondary to magnetic
susceptibility from the stent, intimal hyperplasia, or a small
amount of thrombus.
Preliminarily transesophageal echocardiogram: simple atheroma
in descending aorta
Brief Hospital Course:
74 year old man with hx of CAD, HTN, high cholesterol, smoking,
s/p recent right carotid stent, and family hx of stroke who
presents with acute onset of left sided weakness. He is s/p IV
tPA 2.5hrs after symptom onset. Initial exam notable for left
sided inattention, dysarthria, left facial, left sided weakness
(primarily in arm with cortical hand), left sided sensory
deficit to all modalities, left sided cortical sensory loss.
Deficits localize to the right fronto-parietal region. He was
admitted to the neuro ICU after receiving tPA; MRI/A showed M2
or M3 occlusion, no recannulization.
Neuro - Stroke was most likely related to embolism from stent
thrombus. Serial head CTs stable, but more dense weakness
beginning on HD#2. Pt was continued on aspirin and plavix for
stent. Patient was started on low dose coumadin 2.5 mg a day
with no load given that he is already on two antiplatelets. The
target is for low INR around 2. Plan for Coumadin for 3 months,
re-image stent, if patent, discontinue Coumadin. Exam remains
most notable for dysarthria, L hemiplegia and L extinction to
double simultaneous stimulation.
CV - Ruled out for MI upon admission. Blood pressure was
initially allowed to autoregulate. HTN now controlled on
Metoprolol. No events on telemetry. TEE performed on [**12-5**] prelim
read: simple atheroma in descending aorta, moderately thick
aortic valve, no ASD or PFO (final report pending). Should
follow up with his outpatient Cardiologist, Dr. [**Last Name (STitle) 2912**],
[**Telephone/Fax (1) 25832**] after discharge from rehab. Should continue Plavix
for at least 6 months after stent placement; duration of therapy
to be guided directly by Pt's cardiologist.
FEN/GI - Pt failed initial swallow evaluations, requiring tube
feeds through [**12-3**]. Cleared by video swallow evaluation for soft
solids and thin liquids on [**12-4**].
Heme - Should start Coumadin 2.5mg QHS on [**12-5**], goal INR ~2 (low
therapeutic goal as Pt will also be on Aspirin and Plavix and
would be at high risk for bleeding with higher INR). Check INR
twice weekly.
ID - Being treated with Nitrofurantoin for UTI, course to be
complete on [**12-7**].
Tox - For significant alcohol history, Pt was started on
Thiamine, Folate.
Discharged to rehab on [**2159-12-5**] in stable condition.
Medications on Admission:
Plavix
ASA 325
Lipitor
NTG
Fluticasone
Atneolol
Lisinopril
Folate
Elavil
Pletal
Folate
Temazepam
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Right MCA stroke
Discharge Condition:
Stable
Discharge Instructions:
Please do not load with coumadin, just start coumadin gently and
allow inr to trend slowing to goal INR of 2.
Seek medical attention for worsened weakness, numbness,
difficulty speaking, sudden change in vision/hearing, severe
headache, seizure, or for other concerns.
Take all medications (including new ones) as prescribed.
Followup Instructions:
1. If you do not receive a call from Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] office
(Neurology) in [**12-3**] weeks, please call her office at [**Telephone/Fax (1) 105060**]
for an appointment
2. Follow up with your primary care physician after discharge
from rehab.
|
[
"401.9",
"412",
"493.20",
"V45.81",
"443.9",
"599.0",
"424.0",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8717, 8802
|
6260, 8569
|
298, 306
|
8863, 8872
|
4652, 6237
|
9248, 9548
|
2370, 2450
|
8823, 8842
|
8595, 8694
|
8896, 9225
|
2465, 2755
|
232, 260
|
334, 2003
|
3241, 4633
|
2794, 3225
|
2779, 2779
|
2025, 2185
|
2201, 2354
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,459
| 188,039
|
7460+55840
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-9-23**] Discharge Date: [**2192-9-26**]
Date of Birth: [**2117-5-10**] Sex: F
Service: ACOVE
CHIEF COMPLAINT: Transferred from [**Hospital 1474**] Hospital with acute
onset right upper quadrant pain.
HISTORY OF PRESENT ILLNESS: The patient is a 75-year-old female
with a history of gallstone pancreatitis, coronary artery
disease, peripheral vascular disease status post subclavian
stent, who presented with a one-day history of acute onset right
upper quadrant and epigastric pain.
She also complained of nausea and dry heaves. She also
complained of fever and positive rigors. She denied shortness of
breath, chest pain, constipation, diarrhea, bright red blood per
rectum, melena, and dysuria.
The patient initially presented to the [**Hospital1 1474**] Emergency
Department. Her laboratory data at [**Hospital 1474**] Hospital revealed
increased LFTs, increased amylase and lipase, and increased white
blood cell count of 16,000. In addition, her temperature at
[**Hospital 21145**] Hospital was 101.2??????. She was given Tequin 400 mg IV,
Flagyl 500 mg IV, and Lasix 40 mg IV, Morphine Sulfate 2 mg IV,
and Tylenol 650 p.r. Blood cultures were drawn. She was then
transferred here at [**Hospital6 256**] for an
ERCP.
In the [**Hospital3 **] Emergency Department, her blood pressure was
noted to be 86/78, and she was given 2 L of fluid, and blood
pressure subsequently increased to 140/55. Her temperature at
the [**Hospital3 **] Emergency Room was 101.9??????, pulse 79, and she had
an oxygen saturation of 99% on room air. She complained of pain
and was given 2 mg Morphine Sulfate times two.
PAST MEDICAL HISTORY: 1. Gallstone pancreatitis in [**2191-6-15**].
2. Hypertension. 3. Hypercholesterolemia. 4. Coronary artery
disease status post non-Q-wave myocardial infarction in [**2188**] and
[**2190**]. 5. Status post right knee surgery. 6. Status post
appendectomy. 7. Status post bilateral subclavian stenoses,
status post left subclavian stent. 8. Ejection fraction of
60-70% in [**2191-6-15**]. 9. Status post cataract surgery.
ALLERGIES: CODEINE CAUSES GI UPSET. AMOXICILLIN.
MEDICATIONS ON ADMISSION: Aspirin, Lipitor 10 mg p.o. q.d.,
Mavik 4 mg p.o. q.d., Atenolol 75 mg p.o. b.i.d., Isosorbide
30 mg p.o. q.d., Lasix 40 mg p.o. q.d., Ambien.
SOCIAL HISTORY: She lives with son and daughter. She denied
ethanol. She denied tobacco use. The patient has a remote
history of tobacco use.
PHYSICAL EXAMINATION: Vital signs: Temperature 101.9??????,
pulse 79, blood pressure 145/53, respirations 20, oxygen
saturation 99% on room air. General: There was an older
female, obese, who was in no apparent distress. HEENT: NG
tube was in place. Oropharynx pink. Dry mucous membranes.
Oropharynx dry. Cardiovascular: Regular, rate and rhythm.
There was a 2/6 systolic ejection murmur at the left upper
sternal border. Lungs: Bilaterally clear to auscultation.
No wheezing. No rhonchi. Good inspiratory effort. Abdomen:
Obese, soft, nondistended. Hypoactive bowel sounds.
Positive moderate tenderness in the right upper quadrant. No
rebound. No guarding. Extremities: Warm. No edema.
LABORATORY DATA: At the outside hospital sodium was 137,
potassium 4.3, chloride 97, bicarb 25, BUN 23, creatinine
1.3, glucose 222, calcium 9.7; white count 16.1, hematocrit
38.3, platelet count 254; PT 13, PTT 22, INR 1.1; total
protein 7.3, albumin 4.6, ALT 350, AST 340, alkaline
phosphatase 247, total bilirubin 2.8, delta bilirubin 1.4,
amylase 132, lipase 829; CK 84, MB 1.7, troponin less than
0.3; urinalysis 30 mg protein, positive bilirubin, few
bacteria.
RADIOLOGY: Chest x-ray at [**Hospital 1474**] Hospital was negative by
report. KUB at [**Hospital 1474**] Hospital was negative by report.
Electrocardiogram was normal sinus rhythm at 82, [**Street Address(2) 4793**]
depressions in I, II, AVL, V4-6, pseudonormalization of
T-waves in I, II, AVL, V2-6. This electrocardiogram was
compared to [**2191-7-16**].
Ultrasound at [**Hospital6 256**] showed
positive gallstones, no ductal dilatation, pancreas not
visualized.
ASSESSMENT: This was a 75-year-old female with a history of
gallstone pancreatitis, history of coronary artery disease status
post non-Q-wave myocardial infarction, history of peripheral
vascular disease, who presented with right upper quadrant pain.
Based on clinical exam, laboratory data, and radiologic findings,
with her right upper quadrant tenderness, increased LFTs,
increased amylase and lipase, and elevated white blood cell
count, with fevers and with chills, her presentation was
consistent with cholangitis and pancreatitis secondary to
gallstones.
HOSPITAL COURSE: 1. Gastrointestinal/cholangeitis and
pancreatitis presumed secondary to gallstones: The patient was
made NPO, and broad-spectrum antibiotics were started for
coverage. Antibiotics were Levaquin and Flagyl IV. The patient
had an ERCP done which showed, 1) pus discharge from the major
papilla, 2) biliary dilatation, 3) cystic duct did not fill with
contrast, 4) amorphous material seen in the bile duct consistent
with sludge, 5) no filling defects to suggest stone present in
the bile duct, 6) successful sphincterotomy, and 7) successful
sludge extraction.
The Gastrointestinal recommendations were that the patient be
kept NPO, and broad-spectrum antibiotic coverage with Vancomycin,
Levofloxacin, and Flagyl. In addition, because the cystic duct
was unable to fill with contrast, there was concern over the fact
that a stone may be located in the cystic duct. General Surgery
consult was placed for evaluation for cholecystectomy.
General Surgery evaluated the patient and felt that with numerous
gallstones, with right upper quadrant and epigastric pain, fever,
increased bilirubin/LFTs, that she had gallstone pancreatitis,
cholangitis, and occluded cystic duct. The Surgery Team was
concerned about elevated troponin of 10.1. Surgery was very
hesitant to operate on this patient. They felt that she was
not an operative candidate in this setting and recommended
insertion of cholecystostomy tube.
Interventional Radiology/General Radiology was then consulted
for percutaneous drainage with a cholecystostomy tube. The
patient was transferred to the SICU to have the percutaneous
drains placed in that setting. The patient was then transferred
to the SICU, and a percutaneous cystostomy tube was placed
without event. The patient was then transferred back to the
floor the following day.
Regarding the patient's bile fluid, the bile fluid culture grew
out enterococcus which is resistant to Vancomycin, penicillin,
Levofloxacin, and Ampicillin. Regarding the patient's laboratory
data, after the percutaneous drainage, the patient's liver
enzymes, as well as pancreatic enzymes had been trending
downward, and on the day of discharge, the ALT is 103, AST
23, alkaline phosphatase 222, amylase 13, total bilirubin
1.1, and lipase 23.
Regarding the length of duration of the patient's biliary drain,
General Surgery recommended that the percutaneous drain stay in
place until cholecystectomy is performed. Because there was a
likelihood that the cystic duct is occluded with a stone, if the
drain is pulled prematurely, then there would be increased
pressure within the gallbladder, and the same situation/scenario
would occur again. Thus, it was decided that the percutaneous
drains will remain in place until a cholecystectomy is performed,
which will be planned for approximately six months in the
future.
General Surgery typically does not operate on patients who have
had any type of coronary/cardiac event until six months post
event. Given the patient's elevated troponin of 10.1, they will
plan for cholecystectomy in approximately six months; however,
prior to operation, the patient does need full cardiac work-up
including a stress MIBI to identify any reversible wall motion
defects and possible coronary catheterization after the stress
MIBI to potentially stent/repair any culprit lesions. This plan
has been discussed with the patient, as well as with the
patient's primary care physician, [**Name10 (NameIs) 1023**] are both amenable to the
outpatient work-up.
The outpatient scheduling and work-up will be deferred to the
primary care physician and patient which will need to be done in
the next couple of months. Given that the patient has just had a
gastrointestinal infection and troponin leak, it is not the
appropriate time for her to proceed with cardiac work-up; thus,
this will be carried out as an outpatient.
2. Infectious disease: On the day of admission, the patient
was started on Levaquin, Flagyl, and Vancomycin. Subsequent
bile cultures have grown out Vancomycin resistant enterococcus.
At the time of discharge, her blood cultures are still pending. A
sputum culture was contaminated. Urine culture showed no growth.
An addendum will be made to the Infectious Disease section
regarding duration and antibiotic types, given that the patient
now has Vancomycin resistant enterococcus.
3. Cardiovascular: The patient has a history of coronary
artery disease status post non-Q-wave myocardial infarction
in [**2188**] and [**2190**], bilateral subclavian stenosis, status post
left subclavian stent, ejection fraction of 65-70%. The
patient was continued on medications of Captopril 12.5 mg
p.o. t.i.d., Metoprolol 25 mg p.o. t.i.d.
Cardiology consult was deferred. Due to the patient's troponin
leak and negative MB fraction and negative MB index, in the
setting of gallstone pancreatitis, there will be no cardiac
intervention at this time, given the [**Hospital 228**] medical stability
with no electrocardiogram changes and no chest pain. The patient
will need to pursue an outpatient cardiac work-up prior to
cholecystectomy. This has been outlined previously and includes
a stress test to identify any reversible defects, as well as
possible cardiac catheterization to stent/fix any culprit
lesions. This outpatient work-up can take place anytime within
the next six months but must be done prior to cholecystectomy.
4. Endocrine: The patient has no known history of diabetes
mellitus. The patient appeared to have stress hyperglycemia
in the SICU. She was placed on fingersticks q.i.d. and covered
with regular Insulin sliding scale. After the patient was
transferred back to the floor, the patient had no more elevated
blood glucose (all blood glucoses were less than 180 before and
after meals). Fingersticks q.i.d., as well as regular Insulin
sliding scale was discontinued.
5. Prophylaxis: The patient was given Protonix 40 mg p.o.
q.d. and Heparin 5000 U subcue q.12 hours for prophylaxis.
6. FEN: The patient was given maintenance fluids, and after
her percutaneous drainage, she was made NPO for one day. The
following day she tolerated a clear liquid diet well. The
patient was advanced to full liquids and then to full solids
without event. At the time of discharge, the patient had
tolerated a full solid diet with no nausea, no vomiting, and
no gastric pain. The patient's bowels were moving. The patient
had no urinary difficulty.
7. Access: The patient was noted to have very poor peripheral
access. She is not a candidate for internal jugular or
subclavian central lines given the patient's bilateral subclavian
stenoses. The patient therefore had a PICC placed on the left
side. This PICC line will be used for continuation of her
antibiotics.
8. Physical therapy: The patient is to have Physical
Therapy evaluation and clearance prior to her discharge.
CONDITION ON DISCHARGE: Good.
DISPOSITION: Discharge to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Cholangeitis.
2. Gallstone pancreatitis.
3. Cardiac ischemia, but no myocardial infarction.
4. Hypertension.
5. Hypercholesterolemia.
6. Coronary artery disease.
7. Bilateral subclavian stenoses.
8. Status post right knee surgery.
9. Status post appendectomy.
10. Ejection fraction of 60-70% in [**2191-6-15**].
11. Status post cataract surgery.
DISCHARGE MEDICATIONS: Morphine Sulfate 2-4 mg IV/subcue q.4
hours p.r.n., Heparin 5000 U subcue q.12 hours, this is while
the patient is not ambulatory, once the patient is
ambulating, this can be discontinued, Captopril 12.5 mg p.o.
t.i.d., Metoprolol 25 mg p.o. t.i.d., Guaifenesin [**3-23**] ml
p.o. q.6 hours p.r.n. for cough, Pantoprazole 40 mg p.o.
q.d., Aspirin enteric coated 325 mg p.o. q.d., Promethazine
25 mg IV q.6 hours p.r.n. nausea, Levofloxacin 250 mg IV q.24
hours x 14 days, Vancomycin 1 g IV q.24 hours x 14 days,
Atorvastatin 10 mg p.o. q.d., Tylenol 325-650 mg p.o. q.4-6
hours p.r.n., Lasix 40 mg p.o. q.d. which is her home dose.
FOLLOW-UP: The patient is to follow-up with her primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27331**]. The patient and Dr. [**Last Name (STitle) 27331**] have
been notified of the [**Hospital 228**] hospital course, as well as
the patient's discharge with [**Hospital 3058**] rehabilitation, as
well as the patient's need for cardiac work-up prior to
cholecystectomy.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Doctor Last Name 27332**]
MEDQUIST36
D: [**2192-9-26**] 11:53
T: [**2192-9-26**] 11:55
JOB#: [**Job Number 27333**]
Name: [**Known lastname 4727**], [**Known firstname 647**] Unit No: [**Numeric Identifier 4728**]
Admission Date: [**2192-9-23**] Discharge Date: [**2192-9-27**]
Date of Birth: [**2117-5-10**] Sex: F
Service: Medicine
Physical therapy evaluation reveals:
1. Decreased endurance.
2. Decreased strength in the right lower extremity
3. Decreased mobility
4. Knowledge deficit
Physical therapy clinical impression/prognosis: This is a 75
year old morbidly obese female, status post endoscopic retrograde
cholangiopancreatography plus prolonged hospital stay presents to
physical therapy with the above deficits. Recommend discharge to
rehabilitation, as the patient has good rehabilitation potential.
Discharge medication addendum: Regarding antibiotics the
1. Levofloxacin 500 mg p.o. q.d. times two weeks
2. Linezolid 600 mg p.o. q. 12 hours times two weeks
These are the only antibiotics the patient is to be discharged
on. The Linezolid is for Vancomycin-resistant Enterococcus.
[**Name6 (MD) 1034**] [**Name8 (MD) 1035**], M.D. [**MD Number(1) 1036**]
Dictated By:[**Last Name (NamePattern4) 4729**]
MEDQUIST36
D: [**2192-9-27**] 08:02
T: [**2192-9-27**] 08:11
JOB#: [**Job Number 4730**]
|
[
"574.20",
"576.1",
"428.0",
"577.0",
"411.89",
"401.9",
"412",
"414.01",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.01",
"51.88",
"51.85",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
12077, 14617
|
11694, 12053
|
2196, 2340
|
4721, 11488
|
11507, 11597
|
2510, 4703
|
155, 246
|
275, 1660
|
1683, 2169
|
2357, 2487
|
11622, 11673
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,137
| 189,885
|
30233
|
Discharge summary
|
report
|
Admission Date: [**2104-7-29**] Discharge Date: [**2104-8-12**]
Date of Birth: [**2039-3-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Scheduled ablation of liver mass.
Major Surgical or Invasive Procedure:
Radiofrequency ablation of liver mass
Endoscopy
Paracenteses
History of Present Illness:
65 yo M with EtOH cirrhosis complicated by portal hypertension
with esophageal varices and liver mass concerning for HCC
admitted for scheduled ablation of liver mass. The patient is
known to have an enlarging liver mass and rising AFP concerning
for HCC. He was admitted for ablation of the mass in order to
allow continued listing for transplant.
.
On [**2104-7-31**], pt underwent liver biopsy followed by RFA of one
large liver lesion. Procedure was discontinued when patient
started oozing and subsequent scan showed multiple liver
lesions. A postprocedure CT scan and ultrasound were performed
that showed no acute bleeding. A repeat stat HCT was 26. Patient
remained hemodynamically stable throughout procedure. A
paracentesis was also performed and 4L of bloody ascitic fluid
was removed.
.
On the day after the procedure, pt was noted to be hypoxic,
confused, and with abdominal pain, nausea, and vomiting. He was
found to be hypoxic 92% on 2L, and somewhat lethargic. ABG was
performed 7.51/33/67 on 2L nc. Diagnostic paracentesis was
performed which was neg for sbp (wbc 145). Cxr was significant
for L pleural effusion which is new since [**Month (only) **]. He was strated
on vancomycin and zosyn, and he was transferred to the MICU for
closer monitoring, and due to concern for hemobilia as a
complication of the RFA.
.
In the MICU, patient had EGD showing duodenitis thought to be
contributing to his bleeding. He remained HD stable. He received
2U PRBC's with a Hct increase from 23 to 26. His peritoneal
fluid grew GNR.
Past Medical History:
EtOH cirrhosis, diagnosed 06/[**2103**]. Prior complications of
ascites, malnutrition (now on tubefeeds), portal hypertension
with grade 2 esophageal varices and HCC.
Anemia
EtOH abuse, abstinent since [**2103-8-11**]
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs.
Family History:
Non contributory
Physical Exam:
PE: 98.8 Tm 100.1 70-90 90-110/30-70 18 96% on 2L [**0-0-**]
Gen: NAD. Comfortable in bed. A&Ox1-2.
HEENT: Icteric sclera.
CV: RRR. Systolic murmur R upper sternal border.
Pulm: Decreased breath sound [**3-15**] of the way up on the left and
crackles [**2-13**] of the way up on the right.
Abd: Soft, nontender, moderately distended. Ascites.
Ext: Trace edema.
Neuro: Asterixis
Pertinent Results:
below. AFP 32.8 ([**2104-5-18**]) -> 48.4 ([**2104-7-17**]).
.
[**Month/Day/Year 4338**] ([**2104-7-17**]): 1. Within the inferior aspect of segment V, a
mildly T2 hyperintense lesion that demonstrates early arterial
enhancement and washout is present and measures 4.3 x 3.8 cm.
This is increased in size from the prior examination and is
concerning for HCC. 2. Two additional hepatic lesions measuring
up to 1.4 cm in segment V and superior aspect of segment VIII
are noted and unchanged from the prior examination. 3. Ascites
and pleural effusion.
.
Endoscopy ([**2104-7-31**]):
Two cords of grade 1 esophageal varices with no stigmata of
bleeding.
Portal Hypertensive Gastropathy
Severe duodenitis with stigmata of bleeding.
Bilious fluid in stomach and duodenum.
Otherwise normal EGD to second part of the duodenum
.
135 104 15 / 123 AGap=12
-------------
3.6 23 1.2 \
ALT: 38 AP: 177 Tbili: 9.0
AST: 50
AFP: 45.6
96
9.0 \ 9.2 / 486
-----
27.2
PT: 22.5 PTT: 69.4 INR: 2.2
Fibrinogen: 93
.
Brief Hospital Course:
65 yo M with EtOH cirrhosis complicated by portal hypertension
with esophageal varices and HCC admitted for scheduled ablation
of liver mass, c/b duodenitis and rectal varices causing GI
bleeding, nausea, abdominal pain, fevers and hypoxia,
encephalopathy, SBP now improving with resolving peritonitis.
Patient was transferred to the MICU on [**6-4**] for BRBPR where
he received 2u FFP and 2u blood with stabilization, no evidence
of recurrent bleed and no intervention performed. On [**8-12**] he
underwent interventional thoracentesis (diagnostic and
therapeutic) for left-sided pleural effusion and was discharged
home. The patient's MELD score was 32 on discharge.
.
HOSPITAL COURSE BY PROBLEM:
.
#. SBP. peritonitis [**3-14**] Klebsiella pneumoniae (pan-sensitive).
ABx changed from Zosyn to Ciprofloxacin [**8-2**], and was discharged
on PO cipro for total 2-week course. Repeat paracentesis [**8-4**]
showed effective Abx treatment with decreased polys and negative
gramstain and culture. Patient was afebrile on discharge.
.
#. Duodenitis and rectal varices with GI bleeding. Patient with
large melenotic stool [**8-2**] and continuous BRBPR. Endoscopy
showed duodenitis (H. pylori negative) and grade I varices and
patient was placed on high-dose IV PPI,. Bleed was also
considered to be [**3-14**] trauma from RFA procedure. The patient's
bleeding persisted, however, and he was transferred to the MICU
where he receive 2u FFP and 2u RBCs and stablized without
further interventions. The bleeding was attributed to large
rectal varices. Transplant surgery confirmed that they would
not proceed with repair, e.g. banding. On [**8-8**] the patient
returned to the floor and serial Hct were stable with no
recurrent GI bleeds. The patient was hemodynamically stable on
discharge and will continue with PO PPI and Nadolol 20mg daily.
.
# Diarrhea: No infectious causes were found to explain the
patient's persistent diarrhea which may be attributed to tube
feeds, as patient demonstrated improvement while off feeds
during the day. As infection was ruled out, patient received
immodium PRN and lactulose was held during the hospitalization.
.
# Nutrition: TF were cycled overnight but patient did not
tolerate feeds at a rate of greater than 20cc/h [**3-14**] diarrhea.
His PO intake was greatly improved on discharge, though calorie
count remained low. His goal nighttime TF are 50-100cc/h of
home TF regimen and he will follow with outpt nutrition.
.
# Pleural effusion and hypoxia: Likley [**3-14**] ESLD, though must
rule out malignancy. Patient s/p thoracentesis by
interventional pulmonology and removal of 1.7L serosanguinous
fluid, no complications. The fluid was negative for infection,
cytology pending. He received 1unit FFP prior to procedure and
will f/u with interventional radiology as outpt. Patient's O2
saturation was improved on d/c and he required no home oxygen
therapy.
.
#. Liver mass. Path consistent with HCC. S/p radiofrequency
ablation complicated by arterial bleed requiring FFP,
post-procedure and transfusion fevers and desaturation, stable
on discharge.
.
#. EtOH cirrhosis. Complications of ascites, SBP, encephalopathy
and GI bleed. Patient underwent therapeutic and diagnostic
paracentesis as above. Patient's MELD score was 32 on discharge
and he was stable, awaiting transplant. He was discharged on
lasix and Nadolol and will restart lactulose and rifaximin when
more stable. Patient will f/u with Dr. [**Last Name (STitle) 497**] as outpatient.
.
#. Essential thrombocytosis: Patient with uncharacteristically
elevated platelets. JAK2 mutation work-up sent, patient will
f/u with Dr. [**Last Name (STitle) 497**].
.
#. Access. Patient received a PICC during hospitalization for
improved IV access. It was removed on the day of discharge.
.
#. Dispo: Patient discharged w/ home nursing services.
Medications on Admission:
Clotrimazole 10mg 5 times daily
Furosemide 40mg Daily
Rifaximin 200mg Three times daily
Nadolol 10mg Daily
Omeprazole 20mg Daily
Discharge Medications:
1. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane
5X/D (5 times a day).
2. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
3. Nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
5. Ciprofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a
week.
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Lactulose 10 g/15 mL Solution Sig: Three Hundred (300) ML PO
Q12H (every 12 hours) as needed: Titrate to 2-3BMs/day.
Disp:*qs ML(s)* Refills:*2*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day for 1 months.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**2-12**] Tablet,
Rapid Dissolves PO q6h PRN as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
11. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Primary diagnosis:
End-stage liver disease
Spontaneous Bacterial Peritonitis
Lower gastrointestinal Bleed
Duodenitis
Liver mass status-post radiofrequency ablation
Secondary diagnosis:
Essential thromcytosis
Pleural effusion
Discharge Condition:
Fair
Discharge Instructions:
You came in for ablation of a liver mass. Your hospital course
was complicated by anemia from a gastrointestinal bleed. You
were treated in the ICU and received blood products. Your
anemia stabilized. You improved and it was safe for you to be
discharged to home. Please note, you will be taking a new
medication, ciprofloxacin 750mg weekly, for peritonitis
prophylaxis.
Please continue your tube feeds as previously instructed. We
would like you to continue with a goal of 100cc/h as tolerated,
but a minimum of 50cc/h over 12 hours at night. You may take
some antidiarrheal medication if your diarrhea becomes severe.
Regardless, we would like you to have at least [**3-15**] BMs per day.
Please continue your medications as instructed and please keep
all medical appointments. If you develop any concerning
symptoms, please proceed to the emergency room or call your
primary care physician.
Followup Instructions:
- f/u Liver clinic with Dr. [**Last Name (STitle) 497**]: Thursday [**8-14**] at 10:10am
- Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2104-9-22**] 10:00
- f/u interventional pulmonology: [**8-21**] 2:00pm Deaconness
Building ([**Hospital Ward Name 121**] entrance) [**Location (un) **] rm 207, [**Hospital Ward Name **]
|
[
"572.3",
"V49.83",
"998.11",
"537.89",
"238.71",
"787.91",
"E878.8",
"535.61",
"456.21",
"511.9",
"799.02",
"789.5",
"571.2",
"455.2",
"572.2",
"567.23",
"155.0",
"041.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11",
"54.91",
"45.13",
"96.6",
"34.91",
"38.93",
"50.24"
] |
icd9pcs
|
[
[
[]
]
] |
9237, 9298
|
3944, 4617
|
347, 409
|
9567, 9574
|
2907, 3921
|
10526, 10891
|
2475, 2493
|
7979, 9214
|
9319, 9319
|
7825, 7956
|
9598, 10503
|
2508, 2888
|
274, 309
|
4645, 7799
|
437, 1976
|
9504, 9546
|
9338, 9483
|
1998, 2218
|
2234, 2459
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,148
| 118,689
|
1931
|
Discharge summary
|
report
|
Admission Date: [**2132-1-8**] Discharge Date: [**2132-1-22**]
Date of Birth: [**2060-7-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Biventricular pacemaker with ICD
History of Present Illness:
71M with dilated CMY, EF20% (hospitalized in [**2127**] for CHF
thought to be due to medication noncompliance), no significant
CAD on cath in [**2123**], CKD (baseline Cr 1.8), HTN, gout, who has
had a chronic cough since [**2131-7-11**] that was treated with
increased Lasix and PPI. As per OMR notes, his cough abated with
the PPI and his Lasix dose was decreased to 80 [**Hospital1 **]. As per
patient's wife, he's had a chronic progressive cough since
[**Month (only) 216**], associated with PND and orthopnea, and yesterday had
increased SOB and DOE, palpitation and chills. She reports that
he hasn't been having CP, abdominal pain, or fevers. She also
denies him reporting hematochezia or melena. In Dr.[**Name (NI) 10697**]
clinic note yesterday, the patient had apparently been taking
Lisinopril, which was supposed to be stopped on account of renal
failure, and there is a question as to whether he was taking his
carvedilol.
.
She does report that last week he had some right hand swelling
that was thought to be due to gout.
.
In the ED he was intubated for SOB, SBP to 70 mmHg, and
bradycardia to 17bpm (as per cardiology note) responsive to
atropine. He was started on Norepinephrine and Dopamine for
cardiogenic shock, and given Levofloxacin for concern for
pneumonia related sepsis.
.
He also had a potassium of 7.6 for which he received calcium,
insulin, bicarbonate. Repeat K pending. BNP [**Numeric Identifier 10698**]. Uric Acid 14.
.
He had a CXR that showed no overt failure and correct placement
of a RIJ central line. He also had a noncontrast Chest CT that
was negative for aneursym or focal consolidation.
.
On review of symptoms, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, syncope or presyncope
Past Medical History:
1. dilated cardiomyopathy: LVEF 23% ([**12/2123**])
2. Hypertension
3. chronic renal failure (baseline Cr 1.7)
.
Cardiac Risk Factors: -Diabetes, -Dyslipidemia, +Hypertension
Social History:
Lives at home with his wife. Denies tobacco use, IVDU. Drinks
3 drinks/week.
Family History:
Brother with MI at age 75.
Physical Exam:
VS: T 97, BP 118/73, HR 88, 02 95%
VENT SETTINGS: AC 550x16 FiO250% PEEP5
.
Gen: WDWN middle aged intubated and sedated, family at bedside
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple without obvious JVD
CV: PMI located in 5th intercostal space, slightly lateral from
midclavicular line, [**2-14**] holosystolic murmur at apex. RR, normal
S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis.
Assisted respirations 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: Femoral 2+ without bruit; 2+ DP, 2+ PT
[**Name (NI) 2325**]: Femoral 2+ without bruit; 2+ DP, 2+ PT
MEDICAL DECISION MAKING
.
Pertinent Results:
[**2132-1-7**] 03:24PM BLOOD WBC-6.4 RBC-4.76 Hgb-12.1* Hct-40.1
MCV-84 MCH-25.4*# MCHC-30.2* RDW-16.2* Plt Ct-557*#
[**2132-1-7**] 03:24PM BLOOD Plt Ct-557*#
[**2132-1-7**] 03:24PM BLOOD UreaN-65* Creat-2.6* Na-136 K-5.9* Cl-99
HCO3-22 AnGap-21*
[**2132-1-7**] 03:24PM BLOOD UricAcd-14.1*
[**2132-1-8**] 03:40AM BLOOD Calcium-8.5 Phos-6.1*# Mg-2.5
[**2132-1-8**] 06:25AM BLOOD Type-ART Rates-16/ Tidal V-550 PEEP-5
FiO2-100 pO2-488* pCO2-39 pH-7.28* calTCO2-19* Base XS--7
AADO2-199 REQ O2-41 -ASSIST/CON Intubat-INTUBATED
.
.
TTE ([**2132-1-8**]) - The left atrium is markedly dilated. The right
atrium is moderately dilated. Left ventricular wall thicknesses
are normal. The left ventricular cavity is severely dilated.
There is severe global left ventricular hypokinesis (LVEF =
15-20%). No masses or thrombi are seen in the left ventricle.
Right ventricular chamber size and free wall motion are normal.
The right ventricular cavity is mildly dilated with moderate
global free wall hypokinesis. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened and do not fully
coapt. A slightly-eccentric, posteriorly directed jet of severe
(4+) mitral regurgitation is seen. Quantitative evaluation of
mitral regurgitation demonstrates an effective regurgitant area
of 0.4 cm2 and a regurgitant volume of 47 ml/beat. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Severely dilated left ventricle with severe global
systolic dysfunction. Severe secondary mitral regurgitation.
Mild aortic regurgitation. Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2131-9-18**],
the findings are similar (severity of MR may have beenslightly
underestimated).
.
CT-Torso ([**2132-1-8**]) - IMPRESSION:
1. Non-contrast view of the aorta is unremarkable. No evidence
of
mediastinal or retroperitoneal hematoma.
2. Marked cardiomegaly.
3. Nasogastric tube in high position with tip above the
gastroesophageal
junction and advancement suggested.
4. Simple cholelithiasis.
5. Left inguinal hernia contains small bowel without evidence
of
incarceration or obstruction.
6. Hepatic and renal cysts as well as hypodensities too small
to
characterize.
7. Intramuscular lipoma of the gluteus musculature on the left.
.
TTE ([**2132-1-18**]) - The left atrium is markedly dilated. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity is
severely dilated. There is severe global left ventricular
hypokinesis (LVEF = 20 %). There is no ventricular septal
defect. The right ventricular cavity is dilated with depressed
free wall contractility. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Severe (4+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. Moderate [2+] tricuspid regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2132-1-8**], the findings are similar.
.
.
Brief Hospital Course:
71M with dilated cardiomyopathy with SOB admitted with
cardiogenic shock and intubated for respiratory distress, s/p
BIV-ICD placement
.
# Decompensated Systolic Heart failure: Initially, patient was
admitted in decompensated failure with severe pulmonary edema.
Patient required supportive therapy with milrinone and agressive
diuresis. Patient was weaned off ventilator and with ongoing
diuresis, able to maintain adequate oxygen saturation with
supplemental oxygen. Milrinone was also weaned off and patient
was able to tolerate re-initiation of cardiac medications.
Because of significant MR/TR and known dismotility, patient
underwent [**Hospital1 **]-ventricular ICD placement which he tolerated very
well. Patient will continue to follow in device clinic and with
Dr [**First Name (STitle) 437**], his primary cardiologist.
Please see medications section for details of discharge regimen.
.
# CAD/Ischemia: No known coronary artery disease. Patient
however was kept on aspirin on which he will be discharged.
Patient has not been on a statin and this was not started as
inpatient. Would strongly consider starting one as outpatient
.
# Bradycardia: Patient had episodic bradycardia with symptoms.
This was felt to be secondary to increased vagal tone and
resolved spontaneously. Patient also has pacemaker which is
protective of further events.
.
# Valvular Disease: Patient with known severe mitral
regurgitation. Systolic blood pressure was agressively treated
in order to maximize forward flow. Please see medication section
for details.
.
# Dyspnea: Improved, patient at baseline at time of discharge
.
# Acute on Chronic Renal Failure: Likely secondary to medication
error (patient continued taking lisinopril after this was
discontinued by PCP) and decreased forward flow from worsening
failure. This resolved however and creatinine returned to
baseline at time of discharge, suggesting this was mostly due to
renal hypoperfusion from worsening failure.
.
# Gout: Patient developed acute gout flare while hospitalized,
likely secondary to agressive diuresis. Patient was started on
renally dosed colchicine, with good symptom control. Defer
further treatment to PCP.
.
# FEN: Patient tolerated a cardiac diet.
.
# Code: Patient remained FULL CODE during this admission.
.
# Communication: with patient and wife
.
.
Medications on Admission:
Carvedilol 25 [**Hospital1 **]
ASA 325
Furosemide 80 [**Hospital1 **]
Omeprazole 40 qd
Cyclobenzaprine 10 daily
Colchicine 0.6 [**Hospital1 **]
Lisinopril 5 daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
2. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
[**Hospital1 **]:*30 Capsule(s)* Refills:*2*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
4. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
5. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
[**Hospital1 **]:*120 Tablet(s)* Refills:*2*
6. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Take until you are told to stop this medicine by a
doctor.
[**Last Name (Titles) **]:*30 Tablet(s)* Refills:*2*
7. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
[**Last Name (Titles) **]:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
[**Last Name (Titles) **]:*60 Tablet(s)* Refills:*2*
9. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO once a
day as needed.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
Congestive heart failure-- systolic, acute on chronic
Mitral valve regurgitation
.
Secondary Diagnoses:
Gout
Hypertension
.
Discharge Condition:
Stable-- blood pressure stable; breathing comfortably on room
air; feeling significantly less short of breath than on
admission.
Discharge Instructions:
You were admitted to the hospital because of shortness of breath
caused by fluid on your lungs from a weak heart.
.
You should weigh yourself at home everyday and record your
measurements in a book that you take to your doctors
[**Name5 (PTitle) 4314**]. You should call the office if you gain more than
3 pounds.
.
Several changes were made to your medications. You should only
take the medicines at the dosages listed in this packet. A
nurse will be visiting you at home to help you set up your
medicines.
.
You will also be getting physical therapy as an outpatient to
help you regain strength.
.
Followup Instructions:
You have the following [**Name5 (PTitle) 4314**]:
.
(1) DEVICE CLINIC to check your pacemaker.
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2132-1-24**] 9:00 am
.
(2) Primary care follow-up appointment
With [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-1-29**] 2:30
pm
You are also scheduled to have a CT Scan done of your chest on
the same date, [**2132-1-29**], at 10:15 AM. (Phone: [**Telephone/Fax (1) 327**])
.
(3) Rheumatology follow-up appointment for your gout
Dr. [**Last Name (STitle) 10699**], Department of Rheumatology, [**Hospital Unit Name **], [**Location (un) 1951**], [**Hospital Ward Name 517**], Phone: ([**Telephone/Fax (1) 1668**] Date/Time [**2132-2-6**]
09:00 am
.
(4) Please call Dr.[**Name (NI) 3536**] office at [**Telephone/Fax (1) 3512**] to make an
appointment to see him in the next 1 - 2 weeks.
.
|
[
"486",
"785.51",
"425.4",
"414.01",
"404.91",
"424.0",
"V15.81",
"518.81",
"274.0",
"426.3",
"428.0",
"790.6",
"518.0",
"428.23",
"280.9",
"427.1",
"584.5",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"00.51",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10869, 10926
|
7167, 9497
|
342, 376
|
11113, 11244
|
3755, 7144
|
11895, 12804
|
2804, 2832
|
9710, 10846
|
10947, 11049
|
9523, 9687
|
11268, 11872
|
2847, 3736
|
11070, 11092
|
283, 304
|
404, 2492
|
2514, 2691
|
2707, 2788
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,712
| 174,114
|
35360
|
Discharge summary
|
report
|
Admission Date: [**2173-5-1**] Discharge Date: [**2173-5-5**]
Date of Birth: [**2141-1-3**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 70850**]
Chief Complaint:
Labor
Reason for [**Hospital Unit Name 153**] transfer: Hypotension
Major Surgical or Invasive Procedure:
vaginal delivery
History of Present Illness:
32 y/o F with hx of tetralogy of fallot, surgically repaired at
age 3, admitted to L&D at 39w3d days in labor. On arrival to L&D
she denied any cardiac symptoms. She had a cards consult which
determined she was safe to push, has a normal EF.
Past Medical History:
1. Tetralogy of Fallot, s/p repair at age 3 at [**Location (un) 80622**] hospital, [**Country 14635**]. Per records had a VSD closed with a
dacron patch, excision of hypertrophied muscles in the crista
supraventricularis and opening of a hypoplastic pulmonary
annulus. Subsequent echo studies have shown (by report) mild PS
and mild to mod PR with mild RV dilation. Followed by Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Hospital **] [**Hospital3 **]'s adult congenital heart
disease clinic.
2. 1 episode of VT at age 14 s/p exercise
OBHx: G1P0
MedHx:
- Tetrology of Fallot s/p repair at age 3 as above
SurgHx: cardiac surgery, as above
Social History:
Denies tobacco, EtOH or illicit substances. Prior to pregnancy
pt went to yoga several times a week as well as used the
elliptical trainer ~2x/wk.
Family History:
MGM w/ an "enlarged heart". Otherwise non-contributory for SCD,
arrhythmia or CAD.
Physical Exam:
On arrival to L&D:
Vitals - T:97.3 BP:106/76 HR:82 RR:16
CV: 2/6 SEM at LSB
Gen: NAD, mildly uncomfortable with ctx
Abd: soft, gravid, no TTP, EFW 8# by [**Last Name (un) 23291**]
SVE: deferred, [**4-/2153**]/BBOW in triage
FHT: 120/mod var/+accels/no decels --> category I
Toco: q 5-6 min
Exam on arrival to [**Hospital Unit Name 153**]:
Vitals: T:96.3 BP:108/71 P:91 R:20 O2:98% room air
General: Alert, pleasant, oriented, no acute distress but mildly
anxious
HEENT: Sclera anicteric, MM dry, OP clear, no tonsillary
hyperemia or exudate
Neck: supple, no appreciable JVD or LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1 + S2. Pronounced holosystolic murmur most
prominent at left USB. No rubs or gallops
Abdomen: Soft, insensate to pressure while anesthetized. Bowel
sounds present. No organomegaly or pulsatile masses.
Ext: warm, well perfused, 2+ pulses, no cyanosis or edema. Cap
refill not assessed given fingernail paint
Neuro: AAOx3. Speech fluent, thought process clear. Moving upper
extremities freely. Can move lower extremities though relatively
weak in setting of epidural analgesia.
Pertinent Results:
[**Hospital Unit Name 153**] admission labs:
[**2173-5-1**] 02:26AM BLOOD WBC-9.5 RBC-4.28 Hgb-13.3 Hct-39.9 MCV-93
MCH-31.1 MCHC-33.3 RDW-12.9 Plt Ct-228
[**2173-5-1**] 10:29PM BLOOD WBC-25.7*# RBC-3.37* Hgb-10.6* Hct-31.0*
MCV-92 MCH-31.3 MCHC-34.0 RDW-12.9 Plt Ct-194
[**2173-5-1**] 10:29PM BLOOD Neuts-93.9* Lymphs-3.7* Monos-2.2 Eos-0.1
Baso-0
[**2173-5-1**] 10:29PM BLOOD PT-12.7 PTT-30.6 INR(PT)-1.1
[**2173-5-3**] 04:14AM BLOOD Fibrino-718*
[**2173-5-1**] 10:29PM BLOOD Glucose-87 UreaN-11 Creat-0.7 Na-135
K-4.0 Cl-104 HCO3-20* AnGap-15
[**2173-5-1**] 10:29PM BLOOD Calcium-8.2* Phos-4.0 Mg-1.8
Cardiac enzymes:
[**2173-5-1**] 10:29PM BLOOD CK(CPK)-374*
[**2173-5-1**] 10:29PM BLOOD CK-MB-16* MB Indx-4.3 cTropnT-0.09*
[**2173-5-2**] 05:02AM BLOOD CK(CPK)-285*
[**2173-5-2**] 05:02AM BLOOD CK-MB-11* MB Indx-3.9 cTropnT-0.02*
[**2173-5-2**] 12:13PM BLOOD CK(CPK)-287*
[**2173-5-2**] 12:13PM BLOOD CK-MB-9 cTropnT-0.02*
Urine:
[**2173-5-1**] 01:19AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.008
[**2173-5-1**] 01:19AM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
MICRO:
[**5-2**] BCx: pending
[**5-2**] UCx: negative
[**5-3**] BCx: pending
STUDIES:
[**5-1**] CXR: Heart is mildly enlarged. Mediastinum within normal
limits. Lungs are clear. Multiple leads project over the chest.
IMPRESSION: Probably no active disease in the chest.
[**5-4**]: TTE: The left atrium is normal in size. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is 0-5 mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 60%). There is a small paramembranous ventricular septal
defect. The right ventricular free wall is hypertrophied. The
right ventricular cavity is dilated with borderline normal free
wall function. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Ms [**Known lastname **] was admitted to L&D in active labor. She had a
spontaneous vaginal delivery. Her labor was uncomplicated. her
delivery was complicated by 2nd degree laceration and uterine
atony. She received 100 mcg cytotec PR, 0.2 mg methergine IM,
and 40 units of pitocin IV. The total estimated blood loss was
500cc. The uterotonics controlled the vaginal bleeding but
shortly after delivery the patient experienced palpiations. She
became hypotensive with nadir BP of 57/33. She received a total
of 1000 mcg of phenylephrine over the following several hours,
divided into several 100 and 200 mcg boluses. Her BP
subsequently stabilized with systolic readings in the 100-110s.
Her symptoms resolved. She was admitted to the [**Hospital Unit Name 153**] postpartum
for continued monitoring.
.
# Hypotension: Likely [**1-5**] hypovolemia, given blood loss during
delivery and conservative IV fluid resuscitation in setting of
known structural cardiac abnormalities. Cardiology was consulted
and felt that the patient could tolerate IV fluids, to which her
blood pressure responded well. She did not require phenylephrine
after arriving in [**Hospital Unit Name 153**]. No evidence of volume overload on CXR,
and no peripheral signs of right heart failure. No signs of
SIRS/sepsis, as patient is afebrile, with normal WBC this
morning. Cardiogenic etiology also thought possible, given
elevated cardiac enzymes, but less likely. She had a TTE to
evaluate for new wall motion abnormalities which showed only
stable mild pulmonary artery systolic hypertension (see attached
report). The on-call physician at the patient's cardiology
practice ([**Location (un) 86**] Adult Congenital Heart Disease clinic) was
contact[**Name (NI) **] and made aware of the events. The patient was
hemodynamically stable upon transfer to the postpartum floor. On
the postpartum floor her vitals remained normal and she denied
symtoms of palpitations/chest pain.
.
# Palpitations/chest pain/Tetralogy of Fallot: ECG abnormal in
setting of repaired tetralogy but generally unchanged from
prior, but had no ischemic changes. Cardiac enzyme elevation
(troponins peaked at 0.09) was likely [**1-5**] demand ischemia in
setting of hypotension, tachycardia, vasopressors. Tachycardia
likely [**1-5**] hypovolemia as above, +/- anxiety. Subjective
palpitations and tachycardia both improving with IV fluids and
reassurance.
.
# Vaginal bleed s/p spontaneous vaginal delivery: patient had
moderate lochia postpartum and her fundus remained firm. Her
hematocrit decreased from 39.9 on admission to 22.6 postpartum.
She received two units of packed RBCs and her Hct improved to
27.3, with follow-up Hct stable at 27.0.
Medications on Admission:
Medications (home):
PNV
Metamucil
.
Medications (on transfer):
oxytocin
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for Pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
2. breast pump Sig: [**12-5**] three times a day:
Pt s/p ICU admission, low milk supply.
Disp:*1 * Refills:*0*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every [**3-9**]
hours for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p fullterm vaginal delivery
postpartum hemorrhage
anemia
hypotension
s/p Tetralogy of Fallot repair
Discharge Condition:
good
Discharge Instructions:
follow printed instructions
Followup Instructions:
6 wks
within 2 wks with cardiologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Completed by:[**2173-5-10**]
|
[
"V27.0",
"648.92",
"V15.1",
"648.52",
"300.00",
"664.11",
"648.22",
"285.1",
"790.5",
"458.8",
"276.51",
"666.12",
"785.1",
"785.0",
"648.42",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"75.69",
"73.6"
] |
icd9pcs
|
[
[
[]
]
] |
8238, 8244
|
5015, 7713
|
394, 413
|
8390, 8397
|
2800, 2829
|
8473, 8607
|
1561, 1645
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7835, 8215
|
8265, 8369
|
7739, 7812
|
8421, 8450
|
1660, 2781
|
3422, 4992
|
287, 356
|
441, 684
|
2845, 3405
|
706, 1381
|
1397, 1545
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,406
| 189,325
|
48102
|
Discharge summary
|
report
|
Admission Date: [**2110-5-21**] Discharge Date: [**2110-5-26**]
Date of Birth: [**2057-12-27**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / Ace Inhibitors
Attending:[**First Name3 (LF) 1190**]
Chief Complaint:
dyspnea, hyponatremia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 52 year old woman with history of asthma/COPD, HTN,
CHF, mental retardation, among other medical problems who
presents with complaints of cough, shortness of breath, and
wheezing. The patient was seen on the day prior to admission by
her PCP and was apparently feeling well at that time. This
morning, she was noted by staff at her group home to be more
sleepy than usual. When they tried to get her up, she was
"shaky and disoriented." The patient complained at that time of
cough productive of small amounts of green sputum, as well as
shortness of breath. She usually is resistant to going to the
hospital, but today when asked if she felt she should come in
she replied "yes." The patient was seen in the clinic and per
report she had O2 sat 80% on RA, 88% on 2.5L nc.
.
In addition, labs drawn by her PCP yesterday revealed [**Name Initial (PRE) **] Na of
121. The patient has had a history of hyponatremia in the past.
This has been felt to be due to SIADH and successfully treated
with fluid restriction. Repeat Na on admission today was 116.
Of note, HCTZ was a recently added medication.
.
In the ED, the patient was given albuterol and atrovent nebs,
methylprednisolone 125mg, and azithromycin 250mg. (She also
received hydration with normal saline.) She felt much improved
after receiving these medications and currently feels
comfortable. She continues to complain of cough. She denies
CP, SOB, abdominal pain (although she did have an "upset
stomach" last night after eating eggs), fever/chills,
nausea/vomiting, urinary symptoms.
Past Medical History:
- COPD/Asthma on home O2 (2.5L/min)
- Restrictive lung disease
- HTN
- CHF (diastolic, EF 55% in [**2109-2-2**])
- Moderate mental retardation
- CKD, baseline Cr 1.8
- DM2
- h/o hyponatremia
- Chronic LE edema
- Dementia
- IgA nephropathy
- hearing loss
- tobacco use
- chronic constipation
- hyperlipidemia
Social History:
Lives in a group home. Smokes 1 ppd. No etoh.
Family History:
nc
Physical Exam:
Temp 98.8
BP 152/70
Pulse 59
Resp 16
O2 sat 95% on 2.5L nc
Gen - Alert, no acute distress at rest. NC O2 in place.
Speaking in full sentences. Not using accessory muscles.
HEENT - NCAT, anicteric sclera, PERRL, extraocular motions
intact, anicteric, mucous membranes moist, OP clear.
Neck - Supple, no lymphadenopathy, no JVD.
Chest - Few wheezes and diffuse rhonchi throughout bilaterally.
CV - Distant heart sounds. RRR, normal S1/S2, no murmurs, rubs,
or gallops.
Abd - Normoactive BS, soft, distended, nontender. No fluid wave
or shifting dullness. No masses or organomegaly.
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses
bilaterally. Dry skin and excorations bilaterally.
Neuro - Alert and oriented x 3, cranial nerves [**3-16**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact.
Pertinent Results:
[**2110-5-21**] 05:50PM BLOOD WBC-7.9 RBC-3.96* Hgb-12.4 Hct-35.3*
MCV-89 MCH-31.4 MCHC-35.2*# RDW-16.7* Plt Ct-301#
[**2110-5-22**] 04:50AM BLOOD WBC-9.5 RBC-3.84* Hgb-11.9* Hct-34.4*
MCV-89 MCH-30.9 MCHC-34.6 RDW-16.6* Plt Ct-347
[**2110-5-23**] 04:55AM BLOOD WBC-8.0 RBC-3.71* Hgb-11.4* Hct-34.4*
MCV-93 MCH-30.8 MCHC-33.2 RDW-16.6* Plt Ct-318
[**2110-5-24**] 08:05AM BLOOD WBC-7.9 RBC-3.89* Hgb-12.1 Hct-35.4*
MCV-91 MCH-31.1 MCHC-34.2 RDW-16.4* Plt Ct-349
[**2110-5-25**] 07:10AM BLOOD WBC-11.3* RBC-3.86* Hgb-12.2 Hct-35.6*
MCV-92 MCH-31.5 MCHC-34.1 RDW-16.5* Plt Ct-312
[**2110-5-26**] 05:31AM BLOOD WBC-10.8 RBC-3.83* Hgb-11.9* Hct-35.3*
MCV-92 MCH-31.0 MCHC-33.6 RDW-16.4* Plt Ct-324
[**2110-5-26**] 05:31AM BLOOD PT-12.5 PTT-23.2 INR(PT)-1.1
[**2110-5-26**] 05:31AM BLOOD Glucose-115* UreaN-75* Creat-2.6* Na-130*
K-4.4 Cl-87* HCO3-33* AnGap-14
[**2110-5-25**] 08:43PM BLOOD Glucose-258* UreaN-74* Creat-2.5* Na-127*
K-5.0 Cl-85* HCO3-33* AnGap-14
[**2110-5-25**] 07:10AM BLOOD Glucose-155* UreaN-71* Creat-2.5* Na-125*
K-4.2 Cl-83* HCO3-32 AnGap-14
[**2110-5-24**] 08:05AM BLOOD Glucose-182* UreaN-70* Creat-2.3* Na-126*
K-4.6 Cl-82* HCO3-32 AnGap-17
[**2110-5-23**] 03:35PM BLOOD Na-121*
[**2110-5-23**] 04:55AM BLOOD Glucose-83 UreaN-64* Creat-2.5* Na-123*
K-4.1 Cl-81* HCO3-31 AnGap-15
[**2110-5-22**] 04:06PM BLOOD Na-121*
[**2110-5-22**] 04:50AM BLOOD Glucose-119* UreaN-61* Creat-2.3* Na-120*
K-4.1 Cl-77* HCO3-30 AnGap-17
[**2110-5-21**] 05:50PM BLOOD Glucose-61* UreaN-59* Creat-2.2* Na-116*
K-3.8 Cl-78* HCO3-29 AnGap-13
[**2110-5-26**] 05:31AM BLOOD Calcium-8.5 Phos-5.4* Mg-2.2
[**2110-5-22**] 04:50AM BLOOD TSH-0.76
[**2110-5-24**] 12:58PM BLOOD Type-ART pO2-84* pCO2-85* pH-7.28*
calHCO3-42* Base XS-9
[**2110-5-25**] 11:53AM BLOOD Type-ART pO2-65* pCO2-82* pH-7.26*
calHCO3-39* Base XS-6
[**2110-5-25**] 03:57PM BLOOD Type-ART pO2-57* pCO2-60* pH-7.32*
calHCO3-32* Base XS-2
[**2110-5-26**] 07:28AM BLOOD Type-ART pO2-92 pCO2-81* pH-7.25*
calHCO3-37* Base XS-5 Intubat-NOT INTUBA
[**2110-5-26**] 07:28AM BLOOD Lactate-0.7
[**2110-5-21**] CXR: Cardiomegaly persists, some perihilar prominence
is seen consistent with some degree of failure. No infiltrates
are seen. There has been no significant change since the prior
chest x-ray of [**4-11**].
IMPRESSION: Persistent failure.
[**2110-5-24**] CXR: Portable erect AP radiograph of the chest is
reviewed, and compared with previous study of [**2110-5-21**].
There is continued mild congestive heart failure with
cardiomegaly. There is increasing opacity in the left lower
lobe, which raises the possibility of superimposed pneumonia. No
pneumothorax is seen.
IMPRESSION:
1. Continued mild congestive heart failure with cardiomegaly.
2. Probable left lower lobe pneumonia.
[**2110-5-25**] CXR:
AP CHEST RADIOGRAPH.
Again seen is cardiomegaly, unchanged from prior study.
Mediastinal contour appears unchanged. There is prominence of
the right hilum, consistent with enlarged pulmonary artery and
lymphadenopathy seen on [**2109-2-5**] chest CT. Again seen is
mild increase in interstitial opacities consistent with mild
CHF. No focal consolidations are seen in the increased opacity
at the left lower lobe is likely secondary to patient's
rotation.
IMPRESSION: No significant change from prior study with mild
CHF. Prominent right hilum consistent with enlarged pulmonary
artery and lymphadenopathy seen on previous CT.
Brief Hospital Course:
1. Resp distress: Pt's resp distress felt to be multifactorial
due to COPD exacerbation, pneumonia, and possibly component of
CHF. She was transferred to the MICU w/concern for need of
bipap given ongoing hypercarbia. However, she did well and did
not require emergent bipap. She likely has a component of
obstructive sleep apnea, and would benefit from bipap at night.
While in the MICU she was tried on bipap at 10/5 and did well,
so if she has more problems with OSA, would recommend this
regimen at night. She was continued on albuterol, atrovent, and
flovent. She also was kept on solumedrol for a presumed COPD
exacerbation and given levofloxacin for a LLL pna. She was
discharged on a prednisone taper, and her outpatient dose of
lasix 80 mg po bid.
2. Hyponatremia: This was felt to be due to polydypsia as well
as hydrochlorothiazide usage. It resolved with fluid
restriction of 1500 cc/day, and holding hctz.
3. Cardiovascular: She was felt to be volume overloaded, and
was diuresed. She was continued on toprol, procardia, and
valsartan.
4. Type II DM: She was kept on an insulin sliding scale, and her
glyburide was initially held while NPO. She was then started on
low dose of lantus. Her glyburide was continued to be held
because her creatinine was elevated from baseline (2.6 here,
baseline 1.8). She should be continued on lantus and a regular
insulin sliding scale on d/c, and when her renal function
improves, her glyburide can be restarted.
5. CKD: Felt secondary to IgA nephropathy, baseline per notes
between 1.8 and 2.4. Renal followed her while in-house and felt
that her hyponatremia was from polydypsia and HCTZ (see above).
She will f/u with Dr. [**Last Name (STitle) 1860**] as an outpatient.
6. Depression: She was continued on doxepin, remeron, and
tegretol.
Medications on Admission:
-Lasix 80mg [**Hospital1 **]
-toprol xl 200mg qday
-ASA 325mg qday
-glyburide 5mg qday
-MVI with iron
-Nifedipine SR 120mg qday
-prilosec OTC 20mg daily
-metamucil [**Hospital1 **]
-miralax qday
-milk of magnesia prn tid
-Acarbose 50mg tid w/ meals
-coalce 100mg tid
-singulair 10mg qday
-tegretol 800mg [**Hospital1 **]
-diovan 160mg qday
-doxepin 150mg qhs
-lipitor 20mg qday
-remeron 15mg qhs
-advair 250/50 [**Hospital1 **]
-combivent qid
-duoneb qid
-HCTZ 25mg 3 times a week (added recently)
-Lac-hydrin cream to skin [**Hospital1 **]
-premarin vaginal cream
-diabetic robitussin prn
-saline nasal spray
-tylenol prn
Discharge Medications:
1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Acarbose 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Carbamazepine 200 mg Tablet Sig: Four (4) Tablet PO BID (2
times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
8. Doxepin 25 mg Capsule Sig: Six (6) Capsule PO HS (at
bedtime).
9. Psyllium Packet Sig: One (1) Packet PO BID (2 times a
day).
10. Polyethylene Glycol 3350 17 g (100%) Packet Sig: One (1)
Packet PO daily ().
11. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical
ASDIR (AS DIRECTED) as needed for [**Hospital1 **] to skin.
12. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
13. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
14. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO daily ().
16. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal
QID (4 times a day) as needed.
18. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for fever, pain.
20. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
21. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
22. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
23. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulized
treatment Inhalation Q2H (every 2 hours) as needed for shortness
of breath or wheezing.
24. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
25. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulized
treatment Inhalation Q6H (every 6 hours).
26. Toprol XL 200 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
27. Lantus 100 unit/mL Solution Sig: Four (4) units Subcutaneous
at bedtime.
28. Humalog 100 unit/mL Solution Sig: One (1) unit Subcutaneous
QACHS: GIVE PER SLIDING SCALE (attached).
29. bipap
pt may need bipap 10/5. Please give this to her at night as
tolerated.
30. Prednisone 10 mg Tablets, Dose Pack Sig: Six (6) Tablets,
Dose Pack PO once a day for 7 days: Take 60 mg QD x1 day, then
40 mg daily x 2d, then 20 mg daily x 2 days, then 10 mg daily x
2 days, then off.
31. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary:
Hyponatremia
COPD
Congestive heart failure
Mental retardation
Chronic kidney disease
type II diabetes mellitus
Discharge Condition:
good
Discharge Instructions:
Please continue all medications as prescribed. If you develop
fever >101.3, shortness of breath, wheezing, or any other
concerning symptom, please contact Dr. [**Last Name (STitle) **] and/or return to
the emergency department
Followup Instructions:
Please plan to follow-up with Dr. [**Last Name (STitle) **] within the next two
weeks. You can call [**Telephone/Fax (1) 608**] to schedule an appointment.
You have an appointment with your kidney doctor: Provider:
[**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D. Date/Time:[**2110-6-27**] 2:00
|
[
"783.5",
"486",
"428.0",
"401.9",
"493.22",
"585.9",
"250.00",
"311",
"318.0",
"583.9",
"327.23",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12029, 12102
|
6617, 8427
|
308, 314
|
12266, 12273
|
3196, 6594
|
12549, 12898
|
2321, 2325
|
9101, 12006
|
12123, 12245
|
8453, 9078
|
12297, 12526
|
2340, 3177
|
247, 270
|
342, 1909
|
1931, 2241
|
2257, 2305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,682
| 114,351
|
30511
|
Discharge summary
|
report
|
Admission Date: [**2178-1-20**] Discharge Date: [**2178-2-3**]
Date of Birth: [**2122-3-21**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
Transfer from OSH with hypercarbic respiratory failure and acute
transaminitis
Major Surgical or Invasive Procedure:
intubated [**1-20**] and extubated [**1-25**]
History of Present Illness:
This is a 55 year old woman with a history of depression, hip
replacement, EtOH abuse, who presented to an OSH ED with CP,
SOB, and nausea. Patient is currently intubated and sedated, so
history is obtained form OSH records and her children. Per
patient's son and daughter, she was not feeling well for the
last several days. She had complained of dizziness,
lightheadedness, and nausea. She also may have fainted and had a
fall 2 days prior to admission. For the last day, she has had
shortness of breath and chest heaviness. The family do not
believe that she had fevers, chills, or cough. They are not
certain of any other symptoms. She went to an OSH ED because of
the SOB and chest heaviness.
.
On arrival at the OSH ED, HR was 82, BP 130/80. O2 sat was noted
to be 81% on 4L nc and she was placed on NRB. SL NTG was given
due to pt c/o chest heaviness. A dose of lovenox was also given.
The patient's son called in to say that the patient had been
taking multiple meds for hip and back pain, including darvocet,
percocet, and vicodin, as well as ativan and EtOH. For this
reason, narcan was given. It does not appear that there was any
improvement in her respiratory status. Flumazenil was also
given, with no improvement. ABG was done: 7.094/90.9/73. The
patient was intubated (etomidate and succinylcholine given). NGT
was inserted. Ativan was given for agitation with no effect,
versed was given with better effect. Propofol was then started.
Repeat ABG was 7.41/35/171 on vent settings AC at 550x18, PEEP
5, FiO2 100%. Mucomyst 14g was given via NGT. She was noted to
have about 350cc blood from NGT, then later vomited bloody brown
material around NGT. 2U FFP were started as the patient was
ready to be transferred. Protonix 80mg IV and a dose of Zosyn
were also given (for T 101). By report, blood cultures were
drawn.
.
The patient was then transferred to [**Hospital1 18**] for ICU level care.
Past Medical History:
HTN
s/p hip replacement in [**8-13**]
chronic back pain
depression
EtOH abuse
Social History:
Lives with youngest daughter, currently in a hotel while
apartment is being renovated. Not working, on disability. Quit
smoking 7yrs ago. Smoked 1/2ppd for 7 yrs. Drinks 1 pint of
vodka. No IVDU.
Family History:
Father had MI and peripheral nueropathy
Physical Exam:
VS: 99.5, 57, 174/72, 19, 100% (on AC Vt 550, RR 18, PEEP 5,
FiO2 100%)
Gen: intubated and sedated
HEENT: ETT in place
Neck: unable to assess JVP
Lungs: coarse breath sounds b/l
Heart: bradycardic, regular, no m/r/g
Abd: hypoactive BS, soft, obese, NT/ND
Extrem: warm, dry, no edema
Pertinent Results:
[**2178-1-20**] 01:30AM BLOOD WBC-9.0 RBC-3.38* Hgb-11.4* Hct-32.4*
MCV-96 MCH-33.8* MCHC-35.3* RDW-16.1* Plt Ct-97*
[**2178-1-26**] 03:57AM BLOOD WBC-6.2 RBC-2.95* Hgb-9.8* Hct-28.4*
MCV-96 MCH-33.1* MCHC-34.5 RDW-14.8 Plt Ct-113*
[**2178-1-20**] 01:30AM BLOOD PT-17.4* PTT-32.8 INR(PT)-1.6*
[**2178-1-26**] 03:57AM BLOOD Glucose-73 UreaN-39* Creat-5.8*# Na-142
K-3.7 Cl-99 HCO3-21*
[**2178-1-20**] 01:30AM BLOOD Glucose-122* UreaN-25* Creat-1.4* Na-140
K-3.2* Cl-101 HCO3-24 AnGap-18
[**2178-1-26**] 03:57AM BLOOD ALT-415* AST-47* LD(LDH)-308*
AlkPhos-132* Amylase-316* TotBili-1.6*
[**2178-1-20**] 01:30AM BLOOD ALT-5935* AST-[**Numeric Identifier 27680**]* LD(LDH)-[**Numeric Identifier 2494**]*
CK(CPK)-213* AlkPhos-80 Amylase-215* TotBili-1.0
[**2178-1-26**] 03:57AM BLOOD Lipase-484*
[**2178-1-21**] 04:08PM BLOOD Lipase-671*
[**2178-1-20**] 01:30AM BLOOD Lipase-192*
[**2178-1-20**] 01:30AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-4144*
[**2178-1-26**] 03:57AM BLOOD Albumin-3.0* Calcium-9.4 Phos-9.1*#
Mg-2.6
[**2178-1-20**] 04:08PM BLOOD Hapto-68
[**2178-1-20**] 01:30AM BLOOD calTIBC-338 Ferritn-GREATER TH TRF-260
[**2178-1-23**] 12:18PM BLOOD Acetone-NEGATIVE
[**2178-1-20**] 01:30AM BLOOD TSH-0.99
[**2178-1-20**] 01:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE IgM HAV-NEGATIVE
[**2178-1-23**] 04:42PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2178-1-20**] 01:30AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2178-1-20**] 01:30AM BLOOD HCV Ab-NEGATIVE
[**2178-1-20**] 03:46AM BLOOD Type-ART Temp-37.5 Rates-18/ Tidal V-550
PEEP-5 FiO2-100 pO2-456* pCO2-31* pH-7.54* calTCO2-27 Base XS-5
AADO2-251 REQ O2-48 -ASSIST/CON Intubat-INTUBATED
[**2178-1-25**] 10:55AM BLOOD Type-ART Temp-37.2 pO2-125* pCO2-47*
pH-7.34* calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2178-1-20**] 03:46AM BLOOD Lactate-2.0
[**2178-1-21**] 12:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.013
[**2178-1-21**] 12:50PM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-TR Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2178-1-21**] 12:50PM URINE RBC-[**5-17**]* WBC-[**2-9**] Bacteri-FEW Yeast-FEW
Epi-0-2
[**2178-1-21**] 12:50PM URINE Hours-RANDOM Creat-42 Na-53
[**2178-1-21**] 12:50PM URINE Osmolal-315
[**2178-1-20**] 05:58AM URINE bnzodzp-POS barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
.
Bcx [**1-20**]: no growth
Ucx [**1-20**]: no growth
.
[**2178-1-24**] 3:44 pm SPUTUM
GRAM STAIN (Final [**2178-1-24**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Preliminary):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup will be performed appropriate to the isolates
recovered from
this site.
MODERATE GROWTH OROPHARYNGEAL FLORA.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
STAPH AUREUS COAG +. HEAVY GROWTH.
.
Head CT [**1-20**]: Normal head CT
.
Abd u/s [**1-20**]:IMPRESSION:
1. No biliary ductal dilatation or focal liver mass.
2. Normal liver Doppler.
.
CXR [**1-20**]:
Heart size is top normal. Pulmonary mediastinal vasculature is
distended. Ascending thoracic aorta may be significantly
enlarged. Nasogastric tube ends in the stomach. ET tube in
standard placement. No pneumothorax or pleural effusion. No
evidence of pneumonia.
.
Renal ultrasound [**1-21**]:
No obstructing stones or hydronephrosis.
Brief Hospital Course:
This is a 55 year old woman with a history of depression, EtOH
abuse, back pain, s/p hip replacement, HTN, who presents with
hypercarbic respiratory failure and acute transaminitis.
.
# Respiratory failure: Initially hypercarbic respiratory failure
and had significant AG metabolic acidosis which resolved with
HD. Etiology of resp failure likely [**1-9**] to medications.
?hypoventilation vs dead-space. CNS process ruled out with
normal head CT. CXR not impressive for pna or chf. Blood and
urine cultures negative. Serum tox repeat negative X2, urine
positive for benzos and opiates-likely from ativan and darvon.
Echo [**2178-1-20**]: Preserved regional/global biventricular systolic
function. Moderate tricuspid regurgitation. Mild aortic
regurgitation. Mild mitral regurgitation. BNP elevated at
4,000, however CXR not impressive for volume overload, although
heart size appears enlarged. Extubation on [**1-25**], now doing well
with no O2 requirments, no chest pain, and no SOB. At time of
discharge, patient's respiratory status resolved to her baseline
prior to admission without symptoms of dyspnea and without O2
requirement.
.
# Acute hepatitis/liver failure: Transaminases initially rose to
ALT 6,000s and AST 16,000s. Likely due to toxicity from darvon.
Received Nac 14g at OSH and continued her until [**2178-1-23**]. On
admission, received activated charcoal and banana bag. Synthetic
function preserved (INR peaked at 1.6 and improved to 1.1,
albumin 3.9). Hepatitis panel negative. Abdominal U/S
w/dopplers unremarkable. Hemolysis labs negative. Liver
function improved to normal LFTs by time of discharge.
.
# Acid/base: Had significant AG metabolic acidosis (33)which
improved with HD. Likely [**1-9**] to her renal failure and cell death
from liver failure or toxin. Renal U/S neg. Has now had HD X 5
(as of [**2178-1-30**]). U/A on [**1-21**] had 30 protein and 15 ketones. On
discharge her AG metabolic acidosis had resolved.
.
# ARF: Cr 1.4 on admission, baseline unknown. Peaked at 7.9
during hospital course. Renally dosed meds and nephrotoxins were
avoided. Renal U/S negative for hydronephrosis. Renal failure
was thought most likely secondary to ATN. Hemodialysis was
initiated while inpatient with first session on [**2178-2-4**] and will
follow up with HD as outpatient as well. She has been
instructed on renal diet and will adhere to this as an
outpatient.
.
# GI bleed: Noted to have bloody NGT drainage and bloody brown
emesis at OSH. Not clear if guaiac was checked from NGT. There
was no further evidence of bleeding during her hospital stay.
She remained guaiac negative from below.
.
# Anemia: Baseline hematocrit during this hospitalization has
been in the low 30s. In OSH was 42 and had UGIB as above at OSH.
Retic count 2.8. Iron studies revealed iron 43, TIBC 306,
Ferritin 305. Ferrous sulfate was initiated at 325 mg PO TID for
iron deficiency anemia. She had drop in hct to 27s, with repeat
checks stable and without a source of bleeding including GI.
She will need hct monitoring as an outpatient to ensure
stability.
.
# Sinus bradycardia: Was found to be bradycardic upon transfer,
but BP stable. Pt is on BB at home, but based on pill count did
not appear to have overdosed. Head CT negative for intracranial
process. TTE unremarkable. Her beta blocker was held during her
stay and its reinitiation should be reevaluated in follow up.
.
# Peripheral neuropathy: She now has increased sensation in feet
although it remains difficult to walk. Normally takes darvon
for pain. She was started on neurontin 100 [**Hospital1 **] which can be
titrated up as appropriate in outpatient setting.
.
# EtOH use/abuse: Per patient's children, has at least [**1-10**]
drinks per day. Did not show signs of withdrawal during her
hospital stay. Given her acute hepatitis, she was instructed to
avoid EtOH. She will likely need social work and or substance
abuse counseling as outpatient as well.
.
# Pancreatitis: Amylase/lipase elevated on admission and had
normalized by time of discharge.
.
# Hypertension: Her beta blocker was held due to bradycardia as
above, and [**Last Name (un) **] was held in the setting of renal failure. She was
started on amlodipine for HTN which she tolerated well, on which
she will be discharged.
.
# Depression: Her home meds of wellbutrin and effexor were held
given her renal and hepatic failure. If continued improvement,
PCP may opt to reinitiate as an outpatient. Even with their
discontinuation, her mood has remained stable here.
Medications on Admission:
lasix 40mg Qd
toprol 50mg QD
wellbutrin 100mg Qd
effexor 37.5g TID
darvon 65mg TID
Diovan
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
For High Blood Pressure.
Disp:*60 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*0*
4. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed: for constipation.
Disp:*30 Suppository(s)* Refills:*0*
7. Neomycin-Polymyxin-HC 3.5-10,000-1 mg-unit/mL-% Drops,
Suspension Sig: Five (5) Drop Otic TID (3 times a day) for 8
days.
Disp:*QS ML* Refills:*0*
8. Outpatient Lab Work
Please check hematocrit at next hemodialysis session on Thursday
[**2178-2-4**]. Please phone result to patient's primary care doctor,
DR. [**Last Name (STitle) 72460**] [**Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 72461**]
Discharge Disposition:
Home With Service
Facility:
VNA of the [**Location (un) 1121**]
Discharge Diagnosis:
Primary
Hypercarbic respiratory failure
Hepatitis
Acute renal failure
.
Secondary
Hypertension
Peripheral Neuropathy
Chronic back pain
Depression
EtOH abuse
Discharge Condition:
Stable with no oxygen requirements, recovered liver function,
and on hemodialysis for renal failure.
Discharge Instructions:
You were admitted to the hospital for respiratory and liver
failure with subsequent renal failure. Please return to the
emergency room or call your doctor if you experience any of the
following symptoms: fever > 101.5, intractable nausea/vomiting,
dizziness or light-headedness, diarrhea, bleeding, rashes,
swelling, increasing redness/pain at your dialysis catheter
site, or any other concerning symptoms.
.
Please take all medications as prescribed. You should avoid all
alcholic beverages and avoid tylenol currently as your liver is
recovering from significant damage.
.
Please also adhere to the renal diet as outlined during your
hospital stay.
.
Please follow up as scheduled for hemodialysis on Thursday
[**2178-02-04**], where you will be followed by a nephrologist
.
Please follow-up with hepatology Dr. [**Last Name (STitle) 10924**] [**Name (STitle) **] [**Location (un) **] at 8:30 am on [**2-19**].
.
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 72462**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], Post
Office Square, [**Location (un) 16848**], Phone: ([**Telephone/Fax (1) 72463**] on Monday, [**2-7**] at 10:45am.
Followup Instructions:
Please follow up as scheduled for hemodialysis on Thursday
[**2178-02-04**], where you will be followed by a nephrologist
.
Please follow-up with the Liver clinic, Dr. [**Last Name (STitle) 10924**] [**Name (STitle) **]
[**Location (un) **] at 8:30 am on [**2-19**].
.
Please call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 72462**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], Post Office Square,
[**Location (un) 16848**], Phone: ([**Telephone/Fax (1) 72463**] on Monday, [**2-7**] at
10:45am.
|
[
"276.0",
"311",
"518.4",
"401.9",
"571.1",
"518.81",
"724.5",
"276.2",
"356.9",
"570",
"578.9",
"305.01",
"577.0",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.95",
"96.72",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12542, 12608
|
6665, 11190
|
392, 440
|
12809, 12912
|
3072, 5769
|
14154, 14694
|
2713, 2754
|
11334, 12519
|
12629, 12788
|
11216, 11311
|
12936, 14131
|
2769, 3053
|
5810, 6642
|
274, 354
|
468, 2379
|
2402, 2482
|
2498, 2697
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,689
| 197,331
|
28347
|
Discharge summary
|
report
|
Admission Date: [**2172-11-13**] Discharge Date: [**2172-11-30**]
Date of Birth: [**2092-11-24**] Sex: F
Service: SURGERY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Pancreatic Pseudocyst
Abdominal Pain
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 79 year old female who presented to [**Hospital3 **] Hospital
12 days ago with N/V, diarrhea, epigastric pain. She reported
intermittent fevers. She has had no prior episodes. Her doctor
diagnosed her with necrotizing pancreatitis secondary to
gallstones and performed a percutaneous and aspiration of
possible pancreatic abcess/pseudocyst. Her hospital course was
also significant for a PICC line infection, VRE UTI, and
baseline MS confusion.
Past Medical History:
Hypertension
Hypercholesterolemia
Depression
Anxiety
Social History:
Lives with Husband
Physical Exam:
VS: 97.9, 75, 130/84, 18, 96% 2L
Gen: A+O x 1, NAD
CV: RRR
Chest: Coarse BS
Abd: soft, obese, ND, midline epigastric drain
GU: + Foley
Ext: Trace pedal edema
Pertinent Results:
RADIOLOGY Final Report
CHEST (PA & LAT) [**2172-11-13**] 7:01 PM
Reason: eval for infiltrate
[**Hospital 93**] MEDICAL CONDITION:
79F pancreatic abscess
INDICATION: 79-year-old female with pancreatic abscess.
Evaluate.
IMPRESSION: Bilateral pleural effusions, left greater than
right, with left lower lobe collapse and consolidation.
Cardiology Report ECG Study Date of [**2172-11-13**] 10:21:42 PM
Sinus rhythm. Baseline artifact. Probably normal ECG. No
previous tracing
available for comparison.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
80 174 90 [**Telephone/Fax (2) 68812**] -6 21
RADIOLOGY Final Report
CT ABD W&W/O C [**2172-11-14**] 7:54 PM
Reason: PO + IV contrast please. Eval. pancreatic pseudocyst,
[**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
79F with gallstone pancreatitis complicated by infected
pancreatic pseudocyst, now with increased [**Last Name (un) 103**]. pain and nausea.
IMPRESSION:
1. Multiloculated fluid collection in lesser sac representing a
pseudocyst from head and neck of pancreas, with a pigtail drain
in it. Vascular structures appear patent. No bowel pathology is
seen.
2. Diverticulosis without diverticulitis, though evaluation of
the pelvic structures is limited by beam-hardening artifact.
3. Bilateral pleural effusions and bibasilar atelectasis.
Superimposed consolidation (aspiration vs pneumonia) should also
be considered given the presence of air bronchograms.
5. Nasogastric tube is coiled within a hiatal hernia.
The study and the report were reviewed by the staff radiologist.
RADIOLOGY Preliminary Report
CHEST (PORTABLE AP) [**2172-11-14**] 10:23 AM
Reason: Eval. for cardiopulm. changes.
[**Hospital 93**] MEDICAL CONDITION:
79 year old woman with acute SOB, diaphoresis, nausea
REASON FOR THIS EXAMINATION:
Eval. for cardiopulm. changes.
HISTORY: Shortness of breath.
Single portable radiograph of the chest again demonstrates a
left-sided pleural effusion, unchanged from [**2172-11-13**]. Small
right-sided pleural effusion persists as well. The aorta is
calcified and tortuous. Cardiomediastinal contours are
unchanged. No consolidation is evident. No pneumothorax.
Cardiology Report ECHO Study Date of [**2172-11-17**]
INTERPRETATION:
Conclusions:
The left atrium is normal in size. There is mild symmetric left
ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional
left ventricular wall motion is normal. 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 estimated pulmonary artery systolic pressure is
normal. There is
a trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild
aortic regurgitation.
[**2172-11-15**] 10:40 am FLUID,OTHER PANCREAS DRAIN.
GRAM STAIN (Final [**2172-11-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
CT PELVIS W/CONTRAST [**2172-11-23**] 12:58 PM
[**Hospital 93**] MEDICAL CONDITION:
79F with gallstone pancreatitis complicated by infected
pancreatic pseudocyst.
COMPARISON: [**2172-11-14**].
CT ABDOMEN WITHOUT AND WITH IV CONTRAST: The small right pleural
effusion has decreased in size. There is near resolution of the
left pleural effusion. The liver is stable. Small stones are
again noted in the gallbladder. The gallbladder is somewhat
distended, but unchanged in appearance. The spleen, adrenal
glands, kidneys, stomach and bowel loops are unchanged in
appearance. The pancreas is stable in appearance with
multiloculated collections extending anteriorly and posteriorly
from the pancreas. The drainage catheter is stable. No new
collections are identified. A large hiatal hernia is again
observed. There is no free air. No mesenteric or retroperitoneal
lymphadenopathy is identified.
CT PELVIS: Air is noted in the distended bladder. The patient is
status post recent Foley catheter removal. Extensive colonic
diverticulosis is observed without evidence of diverticulitis.
There is no free fluid and no pelvic or inguinal
lymphadenopathy. Bilateral fat-containing inguinal hernias are
again identified.
BONE WINDOWS: There are no suspicious lytic or sclerotic osseous
lesions. Left hip prosthesis is again observed.
IMPRESSION: Stable appearance of the pancreas with a
multiloculated pseudocyst and pigtail drainage catheter. No new
collections identified.
Brief Hospital Course:
She was admitted on [**2172-11-13**] from [**Hospital3 **] Hospital. She was
continued on Vanco and Imipenum.
.
ID: At [**Hospital **] Hospital she had a PICC line infection (Staph) and was
being treated with Vancomycin. The Imipenem was for the
pseudocyst (Coag Neg Staph). She was afebrile here and her
Imipenem was stopped. The Vancomycin will continue until her
follow-up appointment. She will need a repeat CT prior to that
appointment.
Resp: Upon admission she had an episode of diaphoresis and
dyspnea. She was admitted to the SICU. A CXR on [**11-13**] showed L>R
pleural effusion with LLL collapse/consolidation. She received
O2, nebs, Lasix with some relief. An EKG was done and enzymes
cycled which were negative.
.
Cardiology consult: Cardiac enzymes x 2 were negative. She was
also hypertensive and treated with Lopressor, Enalapril,
Nitropaste, and Hydralazine and Lasix. She was then transitioned
to PO meds and her BP was better controlled. An ECHO was done
and showed an EF>55%.
.
Abd: Her abdomen remained soft, nondistended and nontender. She
had a pigtail drain in place and it was draining small amounts.
A CT on [**2172-11-23**] revealed stable appearance of the pancreas with
a multiloculated pseudocyst and pigtail drainage catheter. No
new collections identified. The drain was subsequently D/C'd.
.
Neuro: Baseline confusion. Seems to wax and wane during the day.
She cleared during her admission and was at her baseline.
FEN: She was started on TPN. On [**11-17**] she passed speech and
swallow and ordered for a regular diet. Still, she was not
taking much PO. Calorie counts were ordered and revealed kcal of
556, 485 and 616. Repeat calorie counts revealed approximately
800 kcals/day. Her TPN was discontinued and a PO diet was
encouraged.
PT/OT: She was consulted by PT and OT and both recommended
Rehab.
Medications on Admission:
tricor, lipitor, nystatin, cipro, zofran, ASA, plavix, percs,
acidophilus
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
4. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
6. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed.
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
11. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q24H (every 24 hours).
12. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns
Intravenous Q 12H (Every 12 Hours).
13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
Liberty Commons Nursing & Rehab Center - [**Location (un) 4979**]
Discharge Diagnosis:
Pancreatic Abcess
Discharge Condition:
Fair
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
medications as ordered.
Continue to walk several times per day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment. You will need a CT prior to
your appointment.
Completed by:[**2172-11-30**]
|
[
"272.0",
"577.0",
"996.62",
"428.0",
"402.91",
"300.4",
"790.7",
"577.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
9054, 9146
|
5823, 7665
|
325, 332
|
9208, 9215
|
1124, 1222
|
9550, 9756
|
7790, 9031
|
4397, 5800
|
9167, 9187
|
7692, 7767
|
9239, 9527
|
943, 1102
|
240, 287
|
2933, 4160
|
360, 816
|
4287, 4360
|
838, 892
|
908, 928
|
4195, 4251
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,642
| 176,880
|
46857+58956
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-11-1**] Discharge Date: [**2197-11-8**]
Date of Birth: [**2121-4-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
witnessed aspiration
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a 76 year-old female with a history of diabetes,
hyperlipidemia, breast cancer and alzheimers who present with
dyspnea.
.
Of note, history obtained from ED signout and from interview
with covering nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] [**Hospital1 1501**].
.
Patient was at her baseline state of health until she had an
aspiration event at lunchtime on the day of admission. After
that event she was noted to have dropping BP, increasing pulse,
decreasing O2 sat with coughing up of secretions. Suction was
attempted and she was seen by staff physician who started her on
a course of levaquin. She was kept NPO in the evening but
continued to have worsening vitals with O2 desaturations to the
50-60s on 4L. Labs at [**Hospital1 1501**] showed WBC of 9.4. EMS was called at
that point for transport to [**Hospital1 18**] ED.
.
In the ED, vitals were T 98.8 BP 138/77 P 109 R 30s O2. HR
improved to the 70's after 1L of NS. Sats were consistantly 100%
on NRB. Respiratory rates was initially 37, decreased to 22 over
the course of the ED stay. FS was 261. Exam in ED notable for
ronchi and tachypnea. Foley was placed. She was given Vancymycin
1000mg IV and flagyl 500mg IV and admitted to the [**Hospital Unit Name 153**] due to
high oxygen demand. Of note, pt has a guardian who has stated
that pt is DNR/DNI (Documentation in chart), but wants pt to
recieve antibiotic therapy as needed.
.
From report, at baseline pt requires assistance with ADLs and
IADLs. She is alert but confused at baseline. She is non-mobile
at baseline.
Past Medical History:
Breast CA
DM
High cholesterol
Alzheimer's
Espohageal strictures
Social History:
Denies, EtOH, tobacco, drugs
Family History:
N/C
Pertinent Results:
[**2197-11-1**] 08:00PM BLOOD WBC-10.7# RBC-4.07* Hgb-13.4 Hct-40.7
MCV-100* MCH-32.9* MCHC-32.9 RDW-13.2 Plt Ct-281
[**2197-11-4**] 06:30AM BLOOD WBC-9.1 RBC-3.87* Hgb-12.4 Hct-37.5
MCV-97 MCH-32.0 MCHC-33.0 RDW-12.5 Plt Ct-221
[**2197-11-1**] 08:00PM BLOOD PT-12.3 PTT-22.7 INR(PT)-1.1
[**2197-11-1**] 07:50PM BLOOD Glucose-245* UreaN-17 Creat-1.0 Na-143
K-4.4 Cl-104 HCO3-24 AnGap-19
[**2197-11-4**] 06:30AM BLOOD Glucose-123* UreaN-9 Creat-0.8 Na-137
K-3.8 Cl-101 HCO3-24 AnGap-16
[**2197-11-2**] 04:45AM BLOOD ALT-6 AST-17 LD(LDH)-196 AlkPhos-76
TotBili-0.3
[**2197-11-3**] 05:30AM BLOOD Calcium-8.6 Phos-2.4* Mg-2.0
AP CHEST: Cardiac enlargement with left ventricular
configuration is redemonstrated. Pulmonary vascularity is
unremarkable and there is no evidence of overt edema or focal
consolidation. There is elevation the left hemidiaphragm with
streaky retrocardiac opacity which likely represents
atelectasis. No pneumothorax or large effusion.
IMPRESSION: No definite pneumonic consolidation or overt edema.
Brief Hospital Course:
1. dyspnea/aspiration pneumonitis -- Initially admitted to the
MICU with hypoxia, dyspnea and hypotension. Empiric
levofloxacin and flagyl were started. She improved rapidly, and
was on room air after transfer to the hospital medicine service.
She underwent swallow evaluation which showed difficulty with
solids, but ability to swallow pureed foods and thin liquids
without overt evidence of aspiration. On the medical [**Hospital1 **], she
continued to spike fevers, so antibiotics were adjusted for
broader empiric coverage with Vancomycin and Zosyn. After
discussion with her primary doctor (Dr. [**Last Name (STitle) 5351**], decision was
made to put her back on levofloxacin and flagyl to avoid having
to place a PICC or MID line if possible. She will be followed
at the [**Hospital3 537**] by Dr. [**Last Name (STitle) 5351**] who I discussed this with.
She has stated that if she feels the need to broaden her
antibiotic coverage again she will do so at the [**Hospital3 537**].
2. Alzheimer's dementia -- Her home medications including
namenda and donepizil were continued.
3. Somnolence - attributed to fever. Olanzapine titrated down
to 2.5 hs only. Valproate level checked - normal. CO2 checked
on blood gas - normal.
Medications on Admission:
Depakote sprinkles 500mg [**Hospital1 **]~
colace 100mg [**Hospital1 **]~
Namenda 10mg [**Hospital1 **]~
protonix 40 [**Hospital1 **]~
Zyprexa 5mg [**Hospital1 **]~
Acetominophen 1000mg q6h (standing)~
Aricept 10mg qhs ~
Levaquin 500 po qday x7 days (started today)~
Acidophillus po tid x7 days~
Senna [**Hospital1 **] prn~
Mylanta q6h prn~
Trazadone 50mg po q6h prn for agitation (Based on discussion
with [**Hospital1 1501**] nurse, not on transfer summary)
Robitussin 50mg q4h prn for cough
Discharge Medications:
1. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO BID (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
8. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 days.
10. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 4 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
aspiration pneumonitis
Discharge Condition:
stable, on room air
Discharge Instructions:
Take all medications as prescribed
Followup Instructions:
With Dr. [**Last Name (STitle) 5351**] at [**Hospital3 537**] (arranged).
Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 15929**]
Admission Date: [**2197-11-1**] Discharge Date: [**2197-11-8**]
Date of Birth: [**2121-4-1**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1408**]
Addendum:
Just before transfer, pt. noted to have axillary temp of 100.7,
so called PCP and informed her that I was going to put pt. back
on broad spectrum abx. (vancomycin and zosyn) and keep her in
the hospital for now.
A PICC line was placed in the right arm, and this inadvertently
went up into the neck (IJ). This was thus pulled back to a
Mid-line position.
She was discharged to the [**Hospital3 474**] with a planned further
seven days of vancomycin and zosyn after discussion with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], who will follow her there.
Discharge Medications:
1. Divalproex 125 mg Capsule, Sprinkle Sig: Four (4) Capsule,
Sprinkle PO BID (2 times a day).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Memantine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
6. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed.
8. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous
every twelve (12) hours for 7 days.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
Sig: 4.5 grams Intravenous Q8H (every 8 hours) for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 474**]- [**Location (un) 164**]
Discharge Diagnosis:
Aspiration pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed
Return to the [**Hospital1 8**] Emergency Department for:
Shorness of breath
Fevers
Followup Instructions:
With Dr. [**Last Name (STitle) **] at [**Hospital3 474**] (arranged).
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1410**] MD [**MD Number(2) 1411**]
Completed by:[**2197-11-8**]
|
[
"331.0",
"998.2",
"507.0",
"285.9",
"272.4",
"E878.8",
"294.10",
"V10.3",
"530.3",
"250.00",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8106, 8177
|
3180, 4424
|
335, 341
|
8242, 8251
|
2133, 3157
|
8420, 8649
|
2109, 2114
|
7146, 8083
|
8198, 8221
|
4450, 4946
|
8275, 8397
|
275, 297
|
369, 1959
|
1981, 2046
|
2062, 2093
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,945
| 181,352
|
41451
|
Discharge summary
|
report
|
Admission Date: [**2168-4-19**] Discharge Date: [**2168-4-25**]
Date of Birth: [**2104-9-18**] Sex: M
Service: SURGERY
Allergies:
Dilaudid / contrast
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p MVC, multiple traumatic injuries
Major Surgical or Invasive Procedure:
[**2168-4-20**] - ACDF C2/3
History of Present Illness:
Mr. [**Known lastname 6955**] is a 63 year old man who was involved in an MVC in
which he was t-boned by another driver going ~30-40mph. He was
initially taken to [**Hospital3 **] Hospital where he was stabilized and
imaging revealed that he had a R posterior acetabular blowout fx
and a L C2 pillar fx. He was transferred to our institution
because of a question of involvement of the vertebral artery.
Past Medical History:
PMH: CAD s/p MI w/ stenting x4, diabetes type II,
hyperlipidemia, HTN, ?musculoskeletal disorder, L4-S1
backpain/?nerve damage, C2-C7 spinal stenosis s/p
laminectomy/fusion
Social History:
SocHx: works in materials maintenance at [**Hospital3 **] Hospital, no
tobacco/EtOH/illegal drugs
Family History:
non-contributory
Physical Exam:
ADMISSION:
Afebrile, VSS
A&O x 3, NAD
BUE skin clean and intact, no tenderness to palpation, no pain
with passive ROM
Arms and forearm compartments soft
Axillary, Radial, Median, Ulnar SILT
EPL FPL EI ED FDP FDI B T Delts intact bilaterally
2+ radial pulses
RLE shortened and externally rotated, laceration over knee with
eccymosis
R knee TTP and pain with passive ROM, stable to valgus/varus
stress, negative anterior/posterior drawer
Thighs and leg compartments soft
LLE skin clean and intact, no TTP, no pain with passive ROM
Saphenous, Sural, Deep peroneal, Superficial peroneal, Tibial
SILT
RLE: [**5-10**] GC TA
LLE: [**6-9**] [**Last Name (un) 938**] FHL GC TA Q H IP
2+ PT and DP pulses
Pertinent Results:
LABS:
IMAGING:
CXR [**2168-4-19**]
FINDINGS: Portions of the chest and pelvis are obscured by the
underlying
trauma backboard.
Lung volumes are markedly diminished. Evidence of cervical
fusion hardware is noted at the superior edge of the radiograph
incompletely evaluated. The superior mediastinum is wide but
well defined. The cardiac silhouette is within normal limits for
size. The costophrenic angles are difficult to
assess due to overlying structures. No large effusion or
pneumothorax is
noted on the supine radiograph. The patient has undergone prior
median
sternotomy and CABG. No displaced fractures are evident.
The iliac crests have been excluded from view. The right greater
trochanter has been excluded from view as well. There is a
displaced bony fragment corresponding to the posterior right
acetabular wall. There is at least subluxation of the right
femoral head as well. Small bony fragments project also
inferiorly in the joint space. However, the iliopectineal and
ilioischial lines are intact. The sacrum likewise demonstrates
no fracture. There is baseline bony deformity of both femoral
heads due to significant underlying degenerative disease. The
proximal left femur is grossly unremarkable.
IMPRESSION: Wide mediastinum with well-defined margins. If there
is concern for mediastinal vascular injury, cross-sectional
imaging is advised. There is at least the posterior wall of the
right acetabulum fracture with likely subluxation to possible
dislocation of the right femoral head. Judet views or
cross-sectional imaging advised.
Brief Hospital Course:
He was seen and evaluated by the Acute Care Surgery team in the
ED. Orthopedics was consulted for the acetabular fracture and
was able to reduce his dislocated hip and placed traction pins
while the patient was in the ED. Orthopedic Spine was also
consulted for the C2 pillar fracture. He was transferred to the
Trauma ICU once stabilized in the ED.
His hospital course is as follows by systems:
NEURO: There was concern for vertebral artery injury based on
preliminary imaging. Because of allergies to contrast and
gadolinium he was unable to undergo a CTA, instead a
non-contrast MRI/MRA of the neck was obtained which showed no
acute vertebral artery injuries or dissection. He was taken to
the OR with Orthopedic Spine the following day for ACDF of
C2/C3. Post-op, he was left in a hard collar which should stay
in place for 8-12 weeks per the spine team. He is awake, alert
and oriented x3 and moving all 4 extremities. He will follow up
in 2 weeks with Orthopedic Spine surgery.
CV: He was restarted on his home antihypertensive and cardiac
medications on admission. He remained hemodynamically stable.
PULM: He was left intubated postop from his ACDF due to the
anesthesia team's concerns for laryngeal nerve damage and edema
given the extensive instrumentation of his cervical spine. He
was eventually weaned from the ventilator and successfully
extubated. He is currently on room air with O2 saturations 98%.
FEN/GI: He was made NPO and maintained on IV fluids when he was
first admitted. He was restarted on his diabetic diet and is
tolerating this.
GU: A Foley catheter was placed to monitor the patient's urine
output; this has since been discontinued and he is voiding on
his own.
HEME: His Hct on admission was 39.5; at time of discharge his
Hct is 25.7 which is up from a Hct of 21 postoperatively. He was
transfused with 1 unit packed red cells.
ENDO: His oral hyperglycemic medications were initially held
while he was NPO. His finger stick blood glucose levels were
checked routinely and he was covered with a regular insulin
sliding scale. His oral agents were eventually restarted.
ID: No active issues.
MUSCULOSKELETAL: He underwent ORIF acetabular fracture,
transverse posterior wall without any complications on [**2168-4-21**].
Postoperatively he is to remain touch down weight bearing. He
will follow up in [**Hospital 1957**] clinic in 2 weeks time. He is receiving
Heparin SQ and compression boots for DVT prophylaxis.
Dispo: He was seen and evaluated by Physical and Occupational
therapy and is being recommended for rehab after his acute
hospital stay.
Medications on Admission:
Glyburide 0.657mg QD, simcastatin 90mg Qhs, Isosorbide 60mL
daily, Isodorbide 30mg Qhs, Atenolol 25mg daily, ASA 325,
demerol 50mg prn, alium 5mg prn anxiety, zetia 10mg daily,
citalopram 60mg daily
Discharge Medications:
1. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO QAM (once a day
(in the morning)).
2. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO HS (at bedtime).
3. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. glyburide 1.25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. insulin regular human 100 unit/mL Solution Sig: One (1) Dose
Injection every six (6) hours as needed for per sliding scale:
see attached.
10. morphine 15 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
11. morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for breakthrough pain.
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
13. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ML
Injection TID (3 times a day).
15. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
16. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
s/p Motor vehicle crash
Forehead laceration
Left C2 pillar fracture
Right posterior acetabular blowout fracture
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital following an auto crash where
you sustained fractures of your cervical spine and your right
leg. Both injuries required operations to repair. You will be
required to wear a hard cervical collar for at least the next 2
months. It is being recommended that you NOT put full weight on
your right leg.
Followup Instructions:
Follow up in 2 weeks with Orthopedics, call [**Telephone/Fax (1) 1228**] for an
appointment.
Follow up in 2 weeks with Dr. [**Last Name (STitle) 363**], Ortho Spine, call
[**Telephone/Fax (1) 3573**] for an appointment.
Completed by:[**2168-5-18**]
|
[
"345.90",
"V45.81",
"412",
"806.04",
"873.42",
"250.00",
"285.1",
"401.9",
"293.0",
"E812.0",
"V45.4",
"850.11",
"873.0",
"808.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"80.51",
"03.53",
"79.39",
"08.81",
"81.02",
"79.09",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
7801, 7928
|
3444, 6040
|
315, 344
|
8108, 8108
|
1857, 3421
|
8647, 8899
|
1107, 1125
|
6290, 7778
|
7949, 8087
|
6066, 6267
|
8290, 8624
|
1140, 1838
|
239, 277
|
372, 778
|
8123, 8266
|
800, 975
|
991, 1091
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,897
| 149,090
|
6201
|
Discharge summary
|
report
|
Admission Date: [**2131-1-19**] Discharge Date: [**2131-1-23**]
Date of Birth: [**2076-8-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Demerol
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
increasing angina and SOB
Major Surgical or Invasive Procedure:
[**2131-1-19**] s/p Redo sternotomy, Aortic Valve Replacement (21mm [**First Name8 (NamePattern2) **]
[**Male First Name (un) 923**] mechanical Valve)
History of Present Illness:
54 yo male with CAD, s/p cabg x1 in [**2119**]. He has since had
multiple stents placed in [**2126**] and [**2129**]. Presents now with
increasing angina and SOB. Admitted [**1-1**]- [**1-3**] for cardiac cath
which revealed LAD 30% in-stent restenosis, 80% CX stent
restenosis amd an occluded RCA. LIMA was patent to LAD and
collaterals. Critical AS present with [**Location (un) 109**] 0.9 cm2. Referred for
reoperation.
Past Medical History:
1) CAD **intractable angina**
- s/p CABG in [**2119**] (LIMA to LAD with post op chronic stable
angina resistant to PTCA and other therapies - currently
controlled with fenatnyl patch and ativan)
-[**2-/2124**] cath: 3VD, no intervention.
-[**2127-5-21**] cath: LMCA bifurcation dz. Patent LIMA-LAD, successful
bifurcation stenting of distal LMCA. EF 50%.
-[**2127-5-26**] cath: Patent LM bifurcation stents. LIMA not injected.
-[**2128-5-21**] cath: Patent LIMA-LAD. Severely elevated LVEDP.
-[**2129-4-26**] cath: severe native 3VD, 50-60% narrowing
within his LMCA to LCX stent, a patent LIMA-LAD graft, mild AS
w/ a valve area of 1.7 cm2, with moderate diastolic dysfunction
-NO intervention performed.
-[**2130-7-28**]: in-stent restenosis of kissing stents in left main
into LAD/LCx s/p PCI of LM/LCx
-[**2131-1-2**]: Restenosis of proximal left circumflex stent.
1a) chronic, severe angina responsive to NTG
1b) TTE [**5-21**]: EF 50-55%, mildly dilated LV, 1+AR/TR
1c) vascular endothelial growth factor treatment in [**2121**]
2) hypertension
3) dyslipidemia
4) History of defibrillation [**2121**]
5) nephrolithiasis years ago
6) status post laparoscopic cholecystectomy in [**2129**]
Social History:
Quit tobacco in [**2119**] (25 pack-year history), no EtOH, never
IVDA. The patient is married, with 1 child.
Family History:
Brother died of MI at age 51.
Father died of MI at age 72
Physical Exam:
5'[**33**]" 88.5 KG
HR 51 RR 18 RIGHT 96/43 LEFT 107/47
skin/HEENT unremarkable
neck supple with full ROM, no bruits / ? murmur transmitted
bilat.
CTAB
RRR 3/6 SEM
soft, NT, ND, + BS
warm, well-perfused, no edema or varicosities
neuro grossly intact
2+ bil. fem/DP/PT/radials
Pertinent Results:
[**2131-1-23**] 03:35AM BLOOD WBC-6.6 RBC-3.61* Hgb-11.0* Hct-31.5*
MCV-88 MCH-30.5 MCHC-34.8 RDW-14.6 Plt Ct-118*
[**2131-1-23**] 03:35AM BLOOD PT-25.9* PTT-33.4 INR(PT)-2.6*
[**2131-1-23**] 03:35AM BLOOD Plt Ct-118*
[**2131-1-23**] 10:50AM BLOOD K-4.2
[**2131-1-23**] 03:35AM BLOOD Glucose-109* UreaN-26* Creat-0.9 Na-139
K-3.1* Cl-103 HCO3-26 AnGap-13
Cardiology Report ECHO Study Date of [**2131-1-19**]
PATIENT/TEST INFORMATION:
Indication: Abnormal ECG. Aortic valve disease. Chest pain.
Coronary artery disease. H/O cardiac surgery. Hypertension.
Shortness of breath.
Status: Inpatient
Date/Time: [**2131-1-19**] at 09:36
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW2-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *4.9 cm (nl <= 4.0 cm)
Right Atrium - Four Chamber Length: *5.9 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.6 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 40% to 45% (nl >=55%)
Aorta - Valve Level: 2.5 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.0 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *3.6 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 49 mm Hg
Aortic Valve - Mean Gradient: 29 mm Hg
Aortic Valve - Valve Area: *0.9 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
in the body of
the LA. No spontaneous echo contrast or thrombus in the body of
the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA.
Depressed LAA emptying velocity (<0.2m/s)
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. No
spontaneous echo
contrast in the body of the RA. A catheter or pacing wire is
seen in the RA
and extending into the RV. No ASD by 2D or color Doppler.
Prominent Eustachian
valve (normal variant).
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D
images. Mild symmetric LVH with normal cavity size. Moderate
symmetric LVH.
Normal LV cavity size. Mildly depressed LVEF. Transmitral
Doppler and TVI c/w
Grade II (moderate) LV diastolic dysfunction. No resting LVOT
gradient.
LV WALL MOTION: Regional LV wall motion abnormalities include:
basal anterior
- hypo; mid anterior - hypo; basal anteroseptal - hypo; mid
anteroseptal -
hypo; basal inferoseptal - hypo; mid inferoseptal - hypo; basal
inferior -
hypo; mid inferior - hypo; basal inferolateral - hypo; mid
inferolateral -
hypo; basal anterolateral - hypo; mid anterolateral - hypo;
anterior apex -
hypo; septal apex - hypo; inferior apex - hypo; lateral apex -
hypo; apex -
hypo;
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
Normal RV wall
thickness. Mildly dilated RV cavity. Normal RV systolic
function. Prominent
moderator band/trabeculations are noted in the RV apex.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in aortic
root. Normal ascending aorta diameter. Simple atheroma in
ascending aorta.
Normal aortic arch diameter. Simple atheroma in aortic arch.
Focal
calcifications in aortic arch. Normal descending aorta diameter.
Simple
atheroma in descending aorta.
AORTIC VALVE: Bicuspid aortic valve. Moderately thickened aortic
valve
leaflets. No masses or vegetations on aortic valve. Moderate AS
(AoVA
0.8-1.19cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate
mitral annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Borderline
PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with
physiologic 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 received antibiotic prophylaxis. The
TEE probe was
passed with assistance from the anesthesioology staff using a
laryngoscope.
The patient was under general anesthesia throughout the
procedure.
Conclusions:
PRE-CPB: 1. The left atrium is mildly dilated. No spontaneous
echo contrast is
seen in the body of the left atrium. No spontaneous echo
contrast or thrombus
is seen in the body of the left atrium or left atrial appendage.
The left
atrial appendage emptying velocity is depressed (<0.2m/s). No
spontaneous echo
contrast is seen in the body of the right atrium. No atrial
septal defect is
seen by 2D or color Doppler.
2. There is mild symmetric left ventricular hypertrophy with
normal cavity
size. There is moderate symmetric left ventricular hypertrophy.
The left
ventricular cavity size is normal. Overall left ventricular
systolic function
is mildly depressed. Transmitral Doppler and tissue velocity
imaging are
consistent with Grade II (moderate) LV diastolic dysfunction.
3. Right ventricular chamber size and free wall motion are
normal. The right
ventricular cavity is mildly dilated. Right ventricular systolic
function is
normal.
4. There are simple atheroma in the aortic root. There are
simple atheroma in
the ascending aorta. There are simple atheroma in the aortic
arch. There are
focal calcifications in the aortic arch. There are simple
atheroma in the
descending thoracic aorta.
5. The aortic valve is a functional bicuspid valve, with fusion
between the
LCC and the RCC. The aortic valve leaflets are moderately
thickened. No masses
or vegetations are seen on the aortic valve. There is moderate
aortic valve
stenosis (area 0.8-1.19cm2) Mild (1+) aortic regurgitation is
seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
7. There is borderline pulmonary artery systolic hypertension.
POST-CPB: Pt is on epinephrine infusion. There is a well-seated
mechanical
valve in the aortic position, no paravalvular leak. Normal
appearing washing
jets of AI. LV function is globally hypokinetic, improved with
the addition of
milrinone. LVEF now 40%. Normal RV systolic function. Trace MR
as described.
The aortic contour is normal post-decannulation.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2131-1-19**] 13:04.
[**Location (un) **] PHYSICIAN:
([**Numeric Identifier 24179**])
Brief Hospital Course:
Admitted [**1-19**] and underwent redo sternotomy / AVR with Dr.
[**Last Name (STitle) **].
Transferred to the CSRU in stable condition on epinephrine,
milrinone, neosynephrine and propofol drips. Left PTX noted on
postop CXR and chest tube placed. Bronchoscopy also done for RUL
collapse/ secretions. Transfused for postop bleeding. Platelet
count decreased to 79K, and HIT panel sent, heparin held.
Extubated on POD #1.Coumadin started for mechanical valve, and
transferred to the floor to begin increasing his activity level
on POD #2.Chest tubes and pacing wires removed without incident.
He made good progress and was cleared for discharge to home with
services on POD #4. Discharge INR 2.6. Target INR 2.5 - 3.0.
Medications on Admission:
diltiazem 60 mg QID
atenolol 50 mg QAM, 25 mg QPM
atorvastatin 80 mg daily
lisinopril 10 mg daily
plavix 75 mg daily
ASA 325 mg daily
ativan
fentanyl patch 150 mcg/ hs
celexa 45 mg daily
isosorbide 120 mg daily
lasix 20 mg daily
Discharge Medications:
1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day for 2
days: please take 4mg [**1-23**] and [**1-24**] - have inr checked [**1-25**] with
results to Dr [**Last Name (STitle) 410**] Fax #[**Telephone/Fax (1) 14511**] goal INR 2.5-3.0
.
Disp:*60 Tablet(s)* Refills:*0*
2. Outpatient [**Name (NI) **] Work
PT/INR as needed for coumadin dosing first draw [**1-25**] with results
to Dr [**Last Name (STitle) 410**] Fax #[**Telephone/Fax (1) 14511**] goal INR 2.5-3.0
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*0*
12. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day): please take twice daily for 1 week then decrease to once
daily for 1 week .
Disp:*21 Tablet(s)* Refills:*0*
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO twice a day for 14 days:
please take 20meq twice a day for 7 days and then decrease to
20meq once daily for 7 days .
Disp:*42 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Bicuspid Aortic Valve s/p redo sternotomy AVR
Aortic Stenosis
Coronary artery disease with stents [**2126**]/ [**2129**]
Hypertension
Dyslipidemia
Anxiety
Discharge Condition:
Good
Discharge Instructions:
[**Month (only) 116**] shower, no baths or swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns
Followup Instructions:
Dr [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment
Dr [**Last Name (STitle) 410**] in 1 week ([**Telephone/Fax (1) 3393**]) please call for appointment
Dr [**Last Name (STitle) **] in [**1-20**] weeks ([**Telephone/Fax (1) 10085**]) please call for
appointment
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3633**])
PT/INR as needed for coumadin dosing first draw [**1-25**] with results
to Dr [**Last Name (STitle) 410**] Fax #[**Telephone/Fax (1) 14511**] goal INR 2.5-3.0
Completed by:[**2131-2-9**]
|
[
"401.9",
"486",
"998.11",
"512.1",
"V45.81",
"424.1",
"411.1",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.22",
"39.61",
"33.24",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
12153, 12236
|
9032, 9752
|
299, 452
|
12435, 12442
|
2655, 3067
|
12907, 13514
|
2276, 2335
|
10032, 12130
|
12257, 12414
|
9778, 10009
|
12466, 12884
|
3093, 8936
|
2350, 2636
|
234, 261
|
480, 904
|
8971, 9009
|
926, 2131
|
2147, 2260
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,193
| 166,939
|
51505
|
Discharge summary
|
report
|
Admission Date: [**2161-4-9**] Discharge Date: [**2161-4-13**]
Date of Birth: [**2080-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Spironolactone / Radioactive Diagnostics, General Classif
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Recurrent angina
Major Surgical or Invasive Procedure:
Third time redo coronary artery bypass
grafting x2 with a free right internal mammary artery from
the diagonal graft vein [**Doctor Last Name **] to the left anterior descending
coronary artery. Reverse cephalic vein from the aorta to the
first diagonal coronary artery.
History of Present Illness:
The patient is an 80-year-old gentleman who 24
years ago underwent coronary artery bypass grafting. Twelve
years ago he underwent redo coronary artery bypass grafting
which was quite extensive. Upon entering the chest, the
patent mammary artery to diagonal was transected. At that
time, he had a Y vein graft to the diagonal and left anterior
descending coronary artery as well as a vein graft to the
posterior descending coronary artery. The patient did well
for many years but has recurrent angina. The patient has also
had multiple stenting of both his native circulation and vein
grafts and most recently had an intervention to the Y vein
graft which was not successful. The patient had recurrent
angina and was therefore referred for third time redo bypass
surgery.
Past Medical History:
allergies: Spironolactone; Radioactive Diagnostics, General
Classif
Coronary artery disease, including
Prior inferior myocardial infarction
s/p CABG [**2137**] and [**2149**]
s/p multiple percutaneous coronary interventions
Hypertension.
Hyperlipidemia.
Diabetes mellitus with
Peripheral neuropathy.
Retinopathy.
Mild chronic renal insufficiency.
Severe left ventricular diastolic heart failure
Possible right posterior thorax radiation burn.
Benign prostatic hypertrophy.
Social History:
Married, retired owner of a furniture store.
Family History:
Mother had heart disease with a mild MI in her 60's.
Physical Exam:
Physical examination in my office revealed a blood pressure of
130/70 with a pulse of 70 and regular and respirations of 18.
In
general, he was very pleasant elderly male in no acute distress,
somewhat obese and mildly short of breath. His skin was notable
to have a radiation burn on his back as well as multiple well
healed incisions. His oropharynx was benign. He was
edentulous,
but with full dentures. His neck was supple with full range of
motion. There was no JVD. His lungs were mostly clear to
auscultation bilaterally. His heart had a regular rate and
rhythm, normal S1 and S2, and a soft systolic ejection murmur
was
best heard over the aortic region. His abdomen was obese,
somewhat firm, but nontender with normoactive bowel sounds. His
extremities were warm with 1 to 2+ edema bilaterally. He did
have venostasis and rubor changes noted bilaterally. In
evaluating his greater saphenous vein, he had multiple incisions
on his leg. The only remaining greater saphenous vein segments
did appear to be at his ankles. Neurologically, he was alert
and
oriented x3. His cranial nerves II through XII were grossly
intact. He moved all extremities with full range of motion and
had 5/5 strength. His femoral pulses were absent as well as his
dorsalis pedis and posterior tibialis bilaterally. His radial
pulses were 2+. His carotid pulses were 1+ bilaterally and it
did appear that he did have a soft bruit.
Pertinent Results:
[**2161-4-9**] 03:13PM BLOOD WBC-13.4*# RBC-2.47*# Hgb-7.5*#
Hct-23.0*# MCV-93 MCH-30.5 MCHC-32.8 RDW-14.8 Plt Ct-136*
[**2161-4-10**] 02:45AM BLOOD WBC-15.0* RBC-3.64* Hgb-10.8* Hct-32.8*
MCV-90 MCH-29.7 MCHC-33.0 RDW-15.7* Plt Ct-193
[**2161-4-10**] 10:47AM BLOOD Hct-24.9*
[**2161-4-10**] 10:02PM BLOOD Hgb-9.9* Hct-30.7*
[**2161-4-12**] 10:17PM BLOOD Hct-22.8*
[**2161-4-13**] 02:08PM BLOOD Hct-32.7*
[**2161-4-12**] 09:06PM BLOOD PT-39.7* PTT-56.6* INR(PT)-4.3*
[**2161-4-13**] 02:11AM BLOOD PT-22.0* PTT-38.8* INR(PT)-2.1*
[**2161-4-11**] 11:23PM BLOOD Glucose-162* UreaN-43* Creat-2.7* Na-139
K-5.8* Cl-105 HCO3-20* AnGap-20
[**2161-4-11**] 11:23PM BLOOD Glucose-162* UreaN-43* Creat-2.7* Na-139
K-5.8* Cl-105 HCO3-20* AnGap-20
[**2161-4-11**] 11:23PM BLOOD ALT-989* AST-1561* TotBili-1.7*
[**2161-4-12**] 09:06PM BLOOD ALT-4093* AST-[**Numeric Identifier 77210**]* LD(LDH)-[**Numeric Identifier **]*
AlkPhos-84 Amylase-185* TotBili-2.9*
[**2161-4-11**] 09:11AM BLOOD Type-ART pO2-80* pCO2-54* pH-7.29*
calTCO2-27 Base XS--1
[**2161-4-12**] 03:55AM BLOOD Type-ART Temp-36 pO2-106* pCO2-40
pH-7.28* calTCO2-20* Base XS--7 Intubat-INTUBATED
[**2161-4-12**] 07:27PM BLOOD Type-ART pO2-84* pCO2-32* pH-7.30*
calTCO2-16* Base XS--9
[**2161-4-13**] 06:18PM BLOOD Type-ART pO2-64* pCO2-39 pH-7.26*
calTCO2-18* Base XS--8
[**2161-4-12**] 01:47AM BLOOD Lactate-7.1* K-5.0
[**2161-4-12**] 09:33AM BLOOD Glucose-132* Lactate-11.9* Na-135 K-4.9
Cl-97* calHCO3-21
[**2161-4-12**] 11:42PM BLOOD Glucose-349* Lactate-17.4*
[**2161-4-13**] 06:18PM BLOOD Glucose-134* Lactate-23.4* K-3.8
Brief Hospital Course:
Mr. [**Known lastname 106785**] was brought to the operating room on [**4-9**]. He was
transfused 1 unit of PRBC postoperatively. He was extubated
Friday POD#1 and maintained on 6L face tent. He was transfused
two more units of PRBC for a hct in the low 20s which rose
appropriately to 30. He had CI between [**2-22**] and blood pressure
was maintained on low dose epinephrine. Overnight on Friday he
developed a lactic acidosis to 10 which resolved by morning with
weaning of the epinephrine. POD #2 he again required pressors
for hypotension. Gradually he developed respiratory distress
and was intubated later in the evening. He also stopped making
urine and his creatinine rose to 3.2. His lactic acidosis
returned and his lactate was 10 by Sunday morning. He was also
requiring 3 pressors. Because of intestinal ischemia concern he
was brought to the operating room for an exploratory laparotomy
which was negative. An intra-operative echo showed poor right
ventricular function. He was subsequently brought to the cath
lab to rule out an occluded right bypass graft. All coronaries
were normal but again right ventricular function was poor. He
continued doing poorly Sunday. Oxygenation was maintained with
a high peep. Adequate preload was ensured with colloid
transfusions. CVVH was initiated and acidosis controlled with
bicarb dialysate. Cardiac index gradually diminished to below
2. Bladder pressures rose to mid 30s and his abdomen was
opened. This did not significantly affect hemodynamics. Lactate
rose to 20 by Monday morning. His chest was opened but also
resulted in no improvement. Patient expired later that morning.
Medications on Admission:
Aspirin
325 mg Tablet
One (1) Tablet by mouth DAILY (Daily).
Clopidogrel
75 mg Tablet
One (1) Tablet by mouth DAILY (Daily).
Felodipine
2.5 mg Tablet Sustained Release 24 hr
One (1) Tablet Sustained Release 24 hr by mouth DAILY (Daily).
Move to Active
Furosemide
40 mg Tablet
One (1) Tablet by mouth DAILY (Daily). Furosemide [Lasix]
First: [**2161-3-26**]
Latest: [**2161-3-26**]
Losartan
50 mg Tablet
One (1) Tablet by mouth twice a day. Losartan [Cozaar]
First: [**2160-8-18**]
Latest: [**2160-8-18**]
Nitroglycerin
0.6 mg/hr Patch 24 hr
One (1) Patch 24 hr Transdermal every twenty-four(24) hours.
Nitroglycerin [Nitro-Dur]
First: [**2160-8-18**]
Latest: [**2160-8-18**]
Propranolol
10 mg Tablet
Two (2) Tablet by mouth three times a day.
Simvastatin
40 mg Tablet
Two (2) Tablet by mouth DAILY (Daily).
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Death from right ventricular failure
Discharge Condition:
deceased
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2161-4-15**]
|
[
"570",
"729.73",
"518.81",
"428.0",
"413.9",
"403.90",
"585.9",
"285.21",
"250.00",
"423.3",
"272.0",
"428.30",
"600.00",
"286.9",
"276.2",
"584.5",
"457.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.59",
"38.95",
"54.11",
"88.72",
"34.03",
"39.63",
"88.43",
"39.95",
"54.12",
"36.11",
"96.04",
"89.64",
"38.91",
"37.22",
"31.42",
"99.05",
"39.61",
"99.07",
"36.15",
"96.71",
"88.56",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7677, 7686
|
5122, 6781
|
339, 612
|
7766, 7776
|
3520, 5099
|
7829, 7864
|
1999, 2053
|
7648, 7654
|
7707, 7745
|
6807, 7625
|
7800, 7806
|
2068, 3501
|
283, 301
|
640, 1412
|
1434, 1920
|
1936, 1983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,849
| 139,256
|
46679
|
Discharge summary
|
report
|
Admission Date: [**2130-6-9**] Discharge Date: [**2130-6-14**]
Date of Birth: [**2093-4-6**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Tegretol / Droperidol / Haldol / Reglan
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 37 F w/ PMH of chronic pancreatitis who presents with
what feels to her like another episode of the same. Two-weeks
ago, she finished a course of TPN and had transitioned to taking
orals. She did well for a week in which she did not need any
pain medicine. Then, on Tuesday (3-days ago), she began to feel
nauseated, vomit and have increasing abdominal pain. Last threw
up yesterday. Last urinated early this morning. Her abd pain is
sharp and shoots to the back. + chills but no fevers (she says
she is always cold). Last was hospitalized in [**Month (only) 956**].
.
ROS:
(+) HA over the past couple of days; + diarrhea this am.
(-) Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
.
On arrival to the floor, vitals 96.8, 80/50, 69, 16, 96% on RA.
Came up to 90s systolic with NS boluses (2L) but came back to
the 80s systolic. It appears that her BP always runs in 80s/90s
systolic range but she described feeling "clammy" "tingly" and
lightheaded with this pressure. Given blood pressure and
patient's symptoms, decision made to transfer to MICU. Received
2 L LR boluses by the time she reached MICU. Mildly hypoxic on
presentation to MICU.
Past Medical History:
1) chronic pancreatitis - unclear how chronic this is. She was
diagnosed at age 18 years (attributed to Sulfa or Tegretol), but
has been admitted several times since then with flares, etiology
is unclear
- [**6-/2123**] [**Name2 (NI) 60478**]: Mild dilation of distal CBD (8 mm) without other
evidence of biliary ductal dilatation or intraluminal calculus.
Possible atypical anatomy of pancreatic duct, with ducts
extending to both minor and major papillae. No dilation of
pancreatic duct. No signal abnormality within or around the
pancreas to suggest pancreatitis.
2) Peptic ulcer disease
3) Chronic abdominal pain: prior work-up in [**2123**] negative except
for elevated lipase, possibly related to chronic pancreatitis.
Negative abdominal CT scan, negative abdominal MRI, negative
flexible sigmoidoscopy, negative SBFT, negative X-lap, [**Doctor First Name **] (-),
RF (-), urine porphyria (-), HIV (-)
4) h/o endometritis
5) s/p cholecystectomy and appendectomy in [**2121**]
6) PTSD/anxiety/depression: psychiatrist Dr. [**Last Name (STitle) **]
Social History:
Lives with her Mother and son. Smokes 1 ppd and has smoked since
age 15 (at times up to 2-3 packs per day). Denies aclohol or
other drug use
Family History:
no pancreas issues; paternal uncle diagnosed with colon Ca in
60s, paternal aunt with [**Name (NI) 3685**] in 40's, cousin with ? lymphoma;
PGM and PGF died of cancer of unknown causes
Physical Exam:
VS - 96.6, 79-94, 90-94/56-66, 15-22, 97-98% 4L NC
HEENT - dry MM, + skin tenting over forehead, OP dry
LUNGS - CTA
HEART - RRR, S1, S2, no rmg
ABD - rigid, non distended, tender over epigastrium, RLQ, BS
minimal
EXT - atrophic muscles, no edema, warm
NEURO - A*O*3
Pertinent Results:
CT ABDOMEN WITH CONTRAST: No focal hepatic mass or intrahepatic
biliary duct dilatation is evident. The pancreas appears within
normal limits for size and is without calcifications on this
single-phase examination; while attenuation is homogeneous,
evaluation for pancreatic necrosis is limited. No peripancreatic
fluid collection is identified. The adrenal glands and spleen
appear unremarkable. The splenic vein appears patent.
Cholecystectomy has been performed. Note is made of bilateral
atelectasis and small pleural effusions.
CT PELVIS WITH CONTRAST: A Foley catheter and intraluminal air
resides within the distended bladder. No enlarged lymph nodes
are identified. A moderate amount of free fluid is within the
pelvis. Visualized bowel loops appear unremarkable.
Brief Hospital Course:
1) Pancreatitis/Abdominal pain: Pt was initially taken to the
MICU out of concern for hypotension, and she responded to fluid
bolues. After stabilization of blood pressure, she was called
out to floor. She continued to have abdominal pain, CT was
negative for abscess, pseudocyst, or stranding around pancreas.
She was started on diluadid PCA which controlled her pain, and
was then transitioned to oral pain meds. She was able to sit up
in a chair and advanced diet without nausea or worsening of
abdominal pain. She was followed by gastroenterology team
throughout her course. On discharge, she had tolerated full
diet. She was discharged with oxycodone SR until her f/u with
PCP.
.
2) PNA: Patient was noted on CXR to have RLL infiltrate, cough,
and very low grade fever. She was started on levaquin with plans
for 7 day course.
.
3) FEN: Nutrition was consulted for poor PO intake. TPN was
deferred as it was felt that patient should continue to try to
use her GI tract as much as possible. Patient was given
information to follow-up with nutritionist as an outpatient, and
she will continue to use Boost supplements.
.
4) Hx of UE DVT: patient continued lovenox injections and will
have 4 more days after discharge until she completes her
predesignated course.
Medications on Admission:
Ativan 1 mg qid (was taking until Tuesday)
Celexa 40 mg po qam
Creon 20 2 caps po before meals and 1 cap po before snacks
Lovenox 40 mg sc bid (for a DVT in R arm)
Oxycodone 10 mg [**Hospital1 **]
Risperidal 2 mg po qhs
Seroquel 25 mg po qhs
Trazodone 25 mg po qhs
Discharge Medications:
1. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
[**Hospital1 **] (2 times a day): You will have completed your course of this
medicine on [**2130-6-18**].
Disp:*8 syringe* Refills:*0*
2. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q 8H (Every 8
Hours). Tablet(s)
3. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
5. Risperidone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Risperidone 2 mg Tablet Sig: One (1) Tablet PO Q AM ().
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Levofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q24H
(every 24 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
9. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO twice a day for 14 days.
Disp:*14 Tablet Sustained Release 12 hr(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
Centrus Home Care
Discharge Diagnosis:
Primary:
pancreatitis
poor nutrition
left upper extremity deep vein thrombosis
Secondary:
peptic ulcer disease
PTSD
depression
Discharge Condition:
stable, pain improved, tolerating food well
Discharge Instructions:
You have pancreatitis, low blood pressure, and poor food intake,
which is now resolved. You also may have a mild pneumonia for
which you will need antibiotics.
.
Please call your primary doctor if you have any worsening pain,
fever, chills, nausea vomiting, inability to eat,
lightheadedness, or any other concerning symptoms.
.
Please take all medications as prescribed.
1) We have started you on 7 days of an antibiotic called
Levaquin.
2) We have given you a prescrition for pain medications which
should be adequate for until you go to your primary MD's office.
3) You only need to inject the Lovenox for 4 more days and then
you will have completed your recommended course
.
Please attend all follow-up appointments.
Followup Instructions:
Please attend your appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2130-7-5**] 9:40AM. Your primary care
physician's office will be in charge of your pain medications.
.
Please call [**Telephone/Fax (1) 99088**] to make an appointment to meet a
nutritionist to help with your weight loss and diet.
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,598
| 100,319
|
49219
|
Discharge summary
|
report
|
Admission Date: [**2187-8-12**] Discharge Date: [**2187-8-29**]
Date of Birth: [**2116-11-8**] Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
hemoptysis
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
70 yo M with CAD, s/p CABG x2, atrial fibrillation (on coumadin
at presentation) presented to an OSH (> 2 weeks ago) with 3 days
of fever, hemoptysis, cough, chills, and dyspnea. CT revealed
diffuse airspace disease, predominant in the R and lower lobes.
His initial labs were WBC 6.6, HCT 38, Plt 199, Cr 0.6, TBili
2.7, DBili 0.7, AST 19, ALT 33. He was then treated empirically
for CAP with ceftriaxone/azithromycin but had continuing
hemoptysis, dyspnea, and developed [**First Name3 (LF) 5283**] abdominal pain. Patient
was noted to have dropping HCT despite transfusion and worsening
respiratory distress. He was then transferred to the ICU,
intubated and given with additional pRBC and FFP. His TBili
increased to 4.3 with a Direct Bili of 1.8 and ALT increased to
32 and AST to 63. Patient had a [**First Name3 (LF) 5283**] ultrasound and CT that were
remarkable only for layering gallbladder sludge vs. small
stones. GI consult suggested [**Doctor Last Name 9376**] disease. He was then
transferred to [**Hospital1 18**] MICU.
At the time of admission to the MICU ([**2187-8-12**]): Tmax= 102, Hct
25, INR 1.3, TBili 4.5, AST of 58, LDH 366, Lipase 92, Alb 3.0,
Na 130. Flexible bronchoscopy was performed and demonstrated
frank blood in all airways without any endobronchial lesions.
Due to his multilobe involvement and diffuse bleeding and high
temperature of 102 he was then placed on triple Abx for presumed
necrotizing pneumonia: Vancomycin, Azithromycin, and ZOSYN. He
was intubated for about 1 week because of hypoxemia and ARDS.
Because of the bleeding both coumadin (which he normally takes
for his A-fib) and aspirin were held. During [**8-12**] and [**8-13**], he
was given a total of 6 u pRBC, which raised the HCT to 33 (an
inappropriate increase suggesting possible hemolysis). Patient
was found to be p-ANCA +. This then suggested either microscopic
polyangiitis (MPA) or Churg-[**Doctor Last Name 3532**] syndrome. The findings that
make Churg-[**Doctor Last Name 3532**] less likely are the absence of asthma and no
eosinophilia. Consistent with MPA are the findings of hemoptysis
and hematuria (with wich the patient presented). Even though the
p-ANCA is nearly 70% specific for MPA, a biopsy could be used
for a more definite diagnosis (specifically necrotizing
inflammation of arterioles, capillaries, and venules w/o
granulomas or eosin). Accordingly, Rheumatology was consulted
and suggested likely MPA, with the rec of starting high dose IV
steroids and Bactrim for PCP [**Name Initial (PRE) 1102**]. Patient's pulmonary
function improved and he was successfully extubated on [**8-20**].
However, his elevated TBili kept increasing, following a bimodal
pattern:
([**8-14**]): TBili 16
([**8-18**]): TBili 7.2
([**8-22**]): TBili 23
([**8-25**]): TBili 10
with a IndirectBilli in the range of [**1-23**]. Concurrently his LFT's
started increasing considerably:
([**8-19**]): ALT 60, AST 69, LDH 657, AlkPhos 93
([**8-22**]): ALT 168, AST 147, LDH 1103, AlkPhos 164
([**8-25**]): ALT 267, AST 100, LDH 608, AlkPhos 160, Amylase 123.
Due to increasing LFTs Hepatology was consulted, and suggested
that the pattern of lab abnormalities combined with the
patient's clinical picture point to a drug reaction. Based on
lab/imaging studies there is no evidence for viral or alcoholic
hepatitis and history and imaging are not consistent with NASH.
Although many medications can cause cholestatic jaundice, they
suspect a reaction to Zosyn. Expected to resolve with stopping
the offending [**Doctor Last Name 360**] however MRCP performed on [**8-24**] showed no
evidence of intrahepatic biliary disease. A [**8-13**] [**Name (NI) 5283**] sono showed
gallbladder sludge and [**Doctor Last Name 5691**], no biliary ductal dilatation and
trace perihepatic free fluid. Furthermore, the increased LDH and
TBilli, as well as low haptoglobin (<20) was suggestive of a
delayed hemolytic anemia in the setting of multiple blood
transfusion. After examining the transfused blood it was
determined that 5 u pRBCs that were transfused were JK positive
and the patients blood was JK antibody positive, suggestive of a
transfusion reaction that would increase the IndirectBilli.
Concomitantly, the presumed liver toxicity induced by zosyn and
resulting intrahepatic cholestatis could potentially explain the
increase in DirectBilli.
On the morning of [**8-22**] the patient had a tonic-clonic seizure.
While on the bed pan talking to the nurse, he suddenly gave out
a yelp, his body became tense, head and eye movement turned to
the right, followed by jerking of his right arm for about 1
minute. The nurse administered 2mg Ativan IV and there was a
gradual resolution of movement, followed by about 15 min of
confusion. There was no apparent bowel incontinence or tongue
biting. The patient doesn't remember the seizure and returned to
his basline mental status (AOx3). Neurology was then consulted,
differential included new stroke due to vasculitis vs.
cardioembolic (off coumadin) Another possiblity was
re-expression of a prior stroke due to toxic metabolic
infectious abnormalities. The seizure unlikely to be related to
the hyperbilirubinemia. An head MRI was done on [**8-22**] showing no
acute infarcts, minimal amount of chronic microangiopathic
changes, and a normal MRA of the head.
Past Medical History:
Hyperlipidemia
Hypertension
Coronary Artery Bypass Grafting [**2163**]
Multiple percutaneous coronary interventions
Sleep apnea
Restless leg syndrome
Past bilateral hernia repairs
Right knee arthritis
Social History:
Widowed, has 3 sons. lives with 2 sons in [**Name (NI) 1268**], retired
but works at golf course during spring/summer season, rare ETOH.
Used to work as an electrical engineer.
Family History:
Father 1st MI age 51, died of an MI at age 62.
Physical Exam:
VS- Tc 96.8, Tm 98.9, HR 79 , BP 103-140/65-89, 13, 98% RA
HEENT- icteric sclerae, MMM, OP clear, no skin tenting noted
LUNGS- CTA
HEART- irregular irregular. + gallop; unclear if S3 or S4. +
systolic murmur somewhat difficult to appreciate in setting of
irregular rhythm.
ABDOM- soft, ND, NT, BS+, liver nl span by percussion. No
stigmata of chronic liver disease
EXTRE- wwp, no edema
NEURO- A*O*3
Pertinent Results:
[**2187-8-12**] 03:13PM PT-14.7* PTT-34.2 INR(PT)-1.3*
[**2187-8-12**] 03:13PM PLT COUNT-173#
[**2187-8-12**] 03:13PM WBC-9.7 RBC-2.74* HGB-8.3* HCT-24.9* MCV-91
MCH-30.3 MCHC-33.3 RDW-14.8
[**2187-8-12**] 03:13PM NEUTS-89.1* LYMPHS-7.4* MONOS-2.9 EOS-0.4
BASOS-0.2
[**2187-8-12**] 03:13PM [**Doctor First Name **]-POSITIVE TITER-1:40 [**Last Name (un) **]
[**2187-8-12**] 03:13PM ANCA-POSITIVE
[**2187-8-12**] 03:13PM ALBUMIN-3.0* CALCIUM-8.3* PHOSPHATE-2.2*
MAGNESIUM-2.1
[**2187-8-12**] 03:13PM LIPASE-92* GGT-43
[**2187-8-12**] 03:13PM ALT(SGPT)-32 AST(SGOT)-58* LD(LDH)-366* ALK
PHOS-82 AMYLASE-65 TOT BILI-4.5*
[**2187-8-12**] 03:13PM estGFR-Using this
[**2187-8-12**] 03:13PM GLUCOSE-115* UREA N-21* CREAT-0.6 SODIUM-130*
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-32 ANION GAP-7*
[**2187-8-12**] 03:14PM OTHER BODY FLUID WBC-0 RBC-0 POLYS-77*
LYMPHS-8* MONOS-15*
[**2187-8-12**] 03:50PM freeCa-1.08*
[**2187-8-12**] 03:50PM LACTATE-1.9
[**2187-8-12**] 03:50PM TYPE-[**Last Name (un) **] PH-7.35
[**2187-8-12**] 05:13PM URINE MUCOUS-FEW
[**2187-8-12**] 05:13PM URINE RBC-54* WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
[**2187-8-12**] 05:13PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-12* PH-6.5
LEUK-TR
[**2187-8-12**] 05:13PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2187-8-12**] 05:13PM URINE HOURS-RANDOM CREAT-120 SODIUM-LESS THAN
[**2187-8-12**] 05:40PM TYPE-ART TEMP-37.3 O2-100 PO2-245* PCO2-42
PH-7.49* TOTAL CO2-33* BASE XS-8 AADO2-444 REQ O2-74 -ASSIST/CON
INTUBATED-INTUBATED
[**2187-8-12**] 09:21PM HCT-25.5*
[**2187-8-22**] 03:42AM BLOOD ALT-168* AST-147* LD(LDH)-1103*
AlkPhos-164* TotBili-22.7* DirBili-18.9* IndBili-3.8
[**2187-8-29**] 05:20AM BLOOD ALT-218* AST-68* AlkPhos-134*
TotBili-6.4*
[**2187-8-29**] 05:20AM BLOOD WBC-12.7* RBC-3.64* Hgb-10.9* Hct-35.0*
MCV-96 MCH-30.0 MCHC-31.1 RDW-17.5* Plt Ct-280
[**2187-8-29**] 05:20AM BLOOD PT-12.6 PTT-25.7 INR(PT)-1.1
[**2187-8-29**] 05:20AM BLOOD Glucose-129* UreaN-22* Creat-0.6 Na-133
K-4.6 Cl-98 HCO3-29 AnGap-11
[**2187-8-29**] 05:20AM BLOOD ALT-218* AST-68* AlkPhos-134*
TotBili-6.4*
[**2187-8-29**] 05:20AM BLOOD Calcium-9.1 Phos-2.6* Mg-2.3
[**2187-8-12**] 03:13PM BLOOD ANCA-POSITIVE
[**2187-8-12**] 03:13PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **]
[**2187-8-21**] 11:41AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HAV-NEGATIVE
[**2187-8-23**] 04:13AM BLOOD ALPHA-1-ANTITRYPSIN-Test
[**2187-8-12**] BAL: negative for malignant cells. Blood, pulmonary
macrophages - some hemosiderin-laden, and rare bronchial
epithelial cells.
[**2187-8-12**] CXR: Extensive right lung alveolar consolidation and
rounded parenchymal opacities in left lung. Although
nonspecific, the findings might represent extensive right lung
hemorrhage due to vasculitis given history of hemoptysis.
Differential diagnosis includes multifocal pneumonia and
multiple pulmonary infarcts in the left lung with asymmetric
pulmonary edema on the right. A more chronic entity such as
bronchoalveolar cell carcinoma is also possible.
[**2187-8-13**] Abdominal US: No focal or textural hepatic abnormality.
Unremarkable Doppler interrogation of the liver. A small amount
of free fluid as described. Cholelithiasis with equivocal mild
gallbladder wall thickening, though clinical correlation is
recommended. Left pleural effusion partially imaged.
[**2187-8-15**] CXR: Endotracheal tube tip terminates about 8 cm above
the carina. A nasogastric tube continues to coil in the stomach
with distal tip directed cephalad, directed toward the GE
junction. Diffuse air space opacities throughout the right lung
and involving the left mid and lower lung appear slightly worse
compared to the previous study, but may be accentuated by lower
lung volumes.
[**2187-8-18**] CXR: Lines and tubes unchanged. No significant change
in bilateral airspace disease.
[**2187-8-21**] CXR: In comparison with the study of [**8-20**], there is
little change in the diffuse opacification involving most of the
right lung. Areas of increased opacification are again seen at
the left base. The endotracheal and nasogastric tubes have been
removed. The right subclavian catheter persists with its tip in
the mid superior vena cava at the level of the carina.
[**2187-8-22**] ECHO: The left and right atria are moderately dilated.
No left atrial mass/thrombus seen (best excluded by
transesophageal echocardiography). The estimated right atrial
pressure is 11-15mmHg. The right ventricular cavity is mildly
dilated. Free wall motion is good. The ascending aorta is mildly
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. An eccentric, inferolaterally
directed jet of mild to moderate ([**11-21**]+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
[**2187-8-22**] MR head w/ and w/o contrast: No acute infarcts. Minimal
amount of chronic microangiopathic changes. Normal MRA of the
head.
[**2187-8-23**] CXR: Partial additional improvement in right lung
consolidation.
[**2187-8-24**] MRCP: Biliary sludge and stones without biliary
dilatation or evidence of cholecystitis. No
choledocholithiasis. Known adrenal calcifications, and basilar
pulmonary atelectasis/effusion, and scattered pulmonary
opacities.
Brief Hospital Course:
# Hemoptysis/Vasculitis: Patient presents to an Outside Hospital
with hemoptysis, described as several teaspoons of dark red
blood mixed with sputum, cough, shortness of breath, chills and
a fever of Tmax=102 for the 3 days prior to admission. There, a
CT scan was performed revealing diffuse alveolar disease, mainly
in the Right Middle and Right Lower Lobes. He was then started
on Ceftriaxone and Azithromycin. Warfarin was stopped because of
persistent hemoptysis.
Over the next two days his Hematocrit dropped from 38 to 29 and
he was transfused 1 unit of Packed Red Blood Cells.
On [**8-12**] due to his worsening hemoptysis and shortness of
breath, as well as a further decrease in the Hematocrit to 27 ,
he was transferred to the ICU at the Outside Hospital. There he
was given more blood, vitamin K, vancomycin and 2 units of Fresh
Frozen Plasma.
He was then intubated and transferred to the [**Hospital3 **] MICU.
Due to his multilobe involvement and diffuse bleeding and fever
he was then placed on triple Abx for presumed necrotizing
pneumonia: Vancomycin, Azithromycin, and ZOSYN (Piperacillin and
Tazobactam). During the first 48hrs in the [**Hospital3 **] MICU he
was given 6 units pRBCs and his HCT increased to 33.
Labs sent out: P-ANCA positive with MPO positivity, [**Doctor First Name **] positive
(1:40, diffuse))
Rheumatology: High dose IV steroids and Bactrim (Trimethoprim/
Sulfamethoxazole) for PCP [**Name Initial (PRE) 1102**].
Patient's pulmonary function improved and was successfully
extubated on [**8-20**] with no further episodes of hemoptysis.
Based on the presentation it was believed to be a kidney-sparing
microscopic polyangiitis and a treatment of steroids was
continued. Rheumatology and Pulmonary felt there was no need for
a lung biopsy at this time. If patient fails steroids would
consider cytoxan vs. cellcept vs. methotrexate.
.
# Hyperbilirubinemia/LFTs: During his stay at the MICU the
patient's LFTs increased drastically:
([**8-12**]): ALT 32, AST 58, LDH 366, AlkPhos 82, Tbili
4.5
([**8-19**]): ALT 60, AST 69, LDH 657, AlkPhos 93 , Tbili
8.5
([**8-22**]): ALT 168, AST 147, LDH 1103, AlkPhos 164, Tbili 18.9
([**8-25**]): ALT 267, AST 100, LDH 608, AlkPhos 160, Tbili 10.7
(IndirectBili: 3-5 range)
MRCP performed on [**8-24**] showed no evidence of intrahepatic
biliary disease.
[**Name (NI) 5283**] sono showed gallbladder sludge and [**Doctor Last Name 5691**], no biliary ductal
dilatation.
Hepatology was consulted and suggested Zosyn induced
hepatotoxicity and Zosyn was stopped followed by gradual
decrease of the Tbili. Hepatology also considering liver biopsy
as outpatient.
After examining the transfused blood it was determined that 5 u
pRBCs that were transfused were JK positive and the patient's
blood was JK antibody positive, suggesting a possible delayed
transfusion reaction that could have contributed to the
hyperbilirubinemia.
.
# Seizure: In the MICU on the morning of [**8-22**] the patient had a
tonic-clonic seizure. While on the bed pan talking to the nurse,
he suddenly gave out a yelp, his body became tense, head and eye
movement turned to the right, followed by jerking of his right
arm for about 1 minute. The nurse administered 2mg Ativan IV and
there was a gradual resolution of movement, followed by about 15
min of confusion. There was no apparent bowel incontinence or
tongue biting. The patient doesn't remember the seizure and
returned to his basline mental status (AOx3). He was then
started on Keppra. Imaging studies of the head (MR & CT)
suggested no evidence of acute infarcts and no intracranial
hemorrhage. CT of the head: No evidence of intracranial
hemorrhage. During his stay patient has had no other seizure
events and was sent home with Keppra.
.
# CAD: Several days prior to discharge patient reported chest
pain consistent with stable agina, acute pain overnight/morning,
with an unchanged EKG. He was placed on telemetry and pauses
>2sec between beats occured multiple times over 24hrs. The
metoprolol was decreased to 12.5mg [**Hospital1 **] (which is his home dose).
MI was ruled out with negative cardiac enzymes. ASA, beta
blocker were continued. Patient had no further episodes.
.
# Afib: The metoprolol dose was decreased to 12.5mg [**Hospital1 **] due to
presence of pauses (>2sec) between beats. Due to his vasculitis
the coumadin was stopped.
.
Medications on Admission:
Protonix 40 mg daily
Metoprolol 12.5 mg [**Hospital1 **]
Isosorbide mononitrate 60 mg [**Hospital1 **]
Simvastatin 80 mg daily
Zolpidem (Ambien) 5 mg qhs
Warfarin 2-4mg as directed
Lorazepam 1 mg tid
Aspirin 81 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
Disp:*60 Capsule(s)* Refills:*2*
2. Outpatient Lab Work
Please draw LFTs, INR, Tbili, Indirect bili, albumin, alk.
phos., and CBC on [**2187-9-4**].
.
Please fax results:
Dr. [**Last Name (STitle) 4469**], fax: [**Telephone/Fax (1) 23978**]
Dr. [**First Name (STitle) **], fax: [**Telephone/Fax (1) 44524**]
Dr. [**Last Name (STitle) **], fax: [**Telephone/Fax (1) 9730**]
Dr. [**First Name (STitle) **], fax: [**Telephone/Fax (1) 33403**]
Dr. [**Last Name (STitle) **], fax: [**Telephone/Fax (1) 4400**]
Dr. [**Last Name (STitle) **], fax: [**Telephone/Fax (1) 3341**]
3. Folic Acid 1 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Calcium Citrate 950 mg Tablet Sig: One (1) Tablet PO q12hr ()
for 4 months.
Disp:*62 Tablet(s)* Refills:*4*
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO Q12HR ().
Disp:*120 Tablet(s)* Refills:*2*
9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for restless leg syndrome.
10. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*1*
11. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO qAM.
Disp:*90 Tablet(s)* Refills:*2*
12. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety.
13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual q 5min x 3 as needed for chest pain: take
one under the tongue every five minutes until the pain subsides
for a maximum of three nitroglycerin pills. If chest pain not
resolved by then, please go to ED.
Disp:*20 Tablet, Sublingual(s)* Refills:*0*
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Primary:
p-ANCA vasculitis
.
Secondary:
1. Coronary artery disease: s/p CABG in [**2175**] (SVG to PDA, OM-1
and jump graft to D1 and distal LAD), ostial stent placed [**2176**],
LAD stent in [**2180**]. [**2180**] cath demonstrated occlusion of SVG-OM
and SVG-PDA. He had re-do CABG with LIMA-LAD, SVG-OM, SVG-PDA.
Last cath [**2184**] revealed proximal LAD occlusion after first
septal and filled with LIMA. LCx proximally occluded and filled
from graft. SVG-PDA patent, SVG-OM (86) occluded but new SVG-OM1
patent. SVG-D1-LAD from 86 CABG occluded but LIMA-LAD patent.
--Last Echo: [**2-22**]: mod [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], RA dilated, LVSF 45%, RV
wall hypokinesis.
2. Atrial fibrillation/Atrial flutter: developed
post-operatively from 2nd CABG--s/p ablation for Aflutter, but
now with chronic atrial fibrillation.
3. Hyperlipidemia
4. Hypertension
5. Sleep apnea
6. Restless leg syndrome
7. Past bilateral hernia repairs
8. Right knee arthritis
9. Gastroesophageal reflux disease
Discharge Condition:
Good
Discharge Instructions:
You were seen at [**Hospital1 18**] for pulmonary hemorrhage. You
subsequently needed to be transferred to intensive care with
intubation. You recovered in the MICU and were transferred to
the general medicine [**Hospital1 **] where you continued to be stable. You
were diagnosed with vasculitis and started on prednisone. You
should continue on prednisone as below until you are seen by
rheumatology and they advise you on medication regimen.
.
You have follow up as below. You should also have your labs
drawn on Tuesday, [**9-4**], for which you have been provided with a
prescription.
.
The following medications have been changed from you home
regimen:
- Prednisone 60mg every morning.
- You were started on Keppra, 1000mg twice daily for your
seizure. You should continue taking this for about a month.
- You were started on sulfamethoxazole/trimethoprim SS one tab
daily to guard against bacterial infections while you are on an
immunosuppressant (prednisone).
- You were started on calcium and vitamin D
- You were given an albuterol inhaler for any shortness of
breath
- You were started on folic acid 5mg daily.
- Your Imdur was stopped
- Your simvastatin was stopped
- Your ambien was stopped
- your coumadin was stopped - rheumatology and pulmonology along
with your primary care physician will follow up on when to
restart this.
- your aspirin dose was increased to 325mg/day - at some point,
the liver specialists may want to hold this for 5 days for a
liver biopsy.
.
You should return to the ED or call your primary care provider
if you experience coughing or vomiting blood, blood in your
urine, chest pain, abdominal pain, fever greater than 101.4
degrees F, or any other symptoms that concern you.
Followup Instructions:
Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-8-30**] 8:00
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2187-9-5**] 4:20pm
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] Phone:[**Telephone/Fax (1) 4475**] [**2187-9-6**] at 11:30am
.
Provider: [**Name10 (NameIs) 454**],THREE [**Name10 (NameIs) 454**] Date/Time:[**2187-9-7**] 8:00
.
Provider: [**Name10 (NameIs) 703**] WEST INTERVENTIONAL/PROSTATE US RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2187-9-7**] 9:30
.
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Rheumatology Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2187-9-11**] 8:30
.
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], pulmonology. Phone:[**Telephone/Fax (1) 612**].
[**2187-9-18**] at 8:00am, please be there at 7:30 for pulmonary
function tests.
.
Test for consideration post-discharge: Hepatitis C Virus RNA by
PCR, Qualitative
.
Also, Dr.[**Name (NI) 19783**] office will contact you about a liver
appointment in one month. Phone: [**Telephone/Fax (1) 2422**]
.
Dr.[**Name (NI) 10444**] office will contact you about a neurology
appointment with Dr. [**First Name (STitle) **] in one month. You currently have an
appointment on [**2187-11-8**] at 4pm, but they will set you up with an
earlier one. Phone: [**Telephone/Fax (1) 541**]
.
Please call if you need to change any appointment times or if
you have any questions.
Completed by:[**2187-9-25**]
|
[
"276.3",
"427.31",
"780.39",
"V45.81",
"786.3",
"518.81",
"530.81",
"414.00",
"447.6",
"486",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
19015, 19066
|
12081, 16476
|
276, 289
|
20133, 20140
|
6547, 12058
|
21910, 23596
|
6064, 6112
|
16754, 18992
|
19087, 20112
|
16502, 16731
|
20164, 21887
|
6127, 6528
|
226, 238
|
317, 5630
|
5652, 5854
|
5870, 6048
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,323
| 150,513
|
3507+55477
|
Discharge summary
|
report+addendum
|
Admission Date: [**2160-12-2**] Discharge Date: [**2160-12-8**]
Date of Birth: [**2091-2-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Angiotensin Recp Antg&Calcium Chanl Blkr
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
[**2160-12-4**] Coronary artery bypass grafting x4 with the left
internal mammary artery to left anterior descending artery and
reverse saphenous vein graft to the right coronary artery and
the obtuse marginal artery.
History of Present Illness:
This 69 year old female has a history
CAD, HTN, mod. MR, and asthma. On [**11-30**] while walking she had
reflux symptoms and stopped 4 times while walking around block.
These waxwd/waned over evenign and she went to ED. Enzymes neg.
She presented to [**Hospital6 1109**] [**2160-12-1**] and was
started
on a Heparin drip. She underwent cardiac cath [**12-2**] which
revealed 3 vessel CAD.
Past Medical History:
GERD, Vasovagal after cath->CPR 17 yrs ago while having PCI
Social History:
Race:cauc
Last Dental Exam:2months
Lives with:husband
Occupation:clerical worker until 3yrs ago.
Tobacco:neg
ETOH:social
Family History:
father died of MI age 47, 3 sisters s/p CABG
Physical Exam:
Pulse: 78 Resp:14 O2 sat:
B/P Right:138/80 Left: 140/80
Height:59" Weight:61kg
General:WDWN, NAD
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur n
Abdomen: Soft [] non-distended [] non-tender [] bowel sounds +
[]
Extremities: Warm [], well-perfused [] Edema Varicosities: None
x[]
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left: 2
DP Right: 2 Left: 2
PT [**Name (NI) 167**]: 2 Left: 2
Radial Right: 2 Left: 2
Carotid Bruit Right: n Left: n
Pertinent Results:
Admission:
[**2160-12-2**] 09:10PM PT-12.6 PTT-21.2* INR(PT)-1.1
[**2160-12-2**] 09:10PM PLT COUNT-219
[**2160-12-2**] 09:10PM WBC-8.6 RBC-4.20 HGB-13.3 HCT-37.1 MCV-88
MCH-31.8# MCHC-36.0* RDW-13.4
[**2160-12-2**] 09:10PM %HbA1c-5.5 eAG-111
[**2160-12-2**] 09:10PM ALBUMIN-4.1 CALCIUM-9.1
[**2160-12-2**] 09:10PM LIPASE-32
[**2160-12-2**] 09:10PM ALT(SGPT)-28 AST(SGOT)-31 LD(LDH)-180 ALK
PHOS-70 AMYLASE-57 TOT BILI-0.3
[**2160-12-2**] 09:10PM GLUCOSE-103* UREA N-16 CREAT-0.7 SODIUM-142
POTASSIUM-3.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
Discharge:
[**2160-12-8**] 06:45AM BLOOD WBC-9.0 Hgb-11.6* Hct-34.4* Plt Ct-212#
[**2160-12-8**] 06:45AM BLOOD Plt Ct-212#
[**2160-12-8**] 06:45AM BLOOD UreaN-15 Creat-0.5 Na-141 K-4.0 Cl-104
[**2160-12-8**] 06:45AM BLOOD TotBili-0.6
[**2160-12-8**] 06:45AM BLOOD Mg-2.5
Radiology Report CHEST (PA & LAT) Study Date of [**2160-12-8**] 1:06 PM
[**Hospital 93**] MEDICAL CONDITION: 69 year old woman with s/p cabg
Final Report
Patient is status post CABG with sternal wires and surgical
clips
again seen. Small bilateral pleural effusions with associated
compressive
atelectasis are unchanged. Right internal jugular central venous
catheter has been removed. There is no pneumothorax. Mild
cardiomegaly is unchanged.
IMPRESSION: Unchanged small bilateral pleural effusions with
associated
atelectasis.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.9 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 3.9 cm
Left Ventricle - Fractional Shortening: *0.19 >= 0.29
Left Ventricle - [**Hospital1 16118**] Fraction: 40% to 45% >= 55%
Left Ventricle - Stroke Volume: 56 ml/beat
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.0 cm <= 3.0 cm
Aorta - Ascending: 3.0 cm <= 3.4 cm
Aorta - Arch: 2.3 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.0 cm <= 2.5 cm
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 1.8 cm
Mitral Valve - MVA (P [**2-2**] T): 4.2 cm2
Mitral Valve - E Wave: 0.6 m/sec
Mitral Valve - A Wave: 0.7 m/sec
Mitral Valve - E/A ratio: 0.86
Findings
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA. Good (>20 cm/s) LAA [**Month/Day (2) **] velocity.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Moderately depressed LVEF.
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. Simple
atheroma in aortic arch. Normal descending aorta diameter.
Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. No AS. No AR.
MITRAL VALVE: No MVP. No MS. Mild to moderate ([**2-2**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. The patient appears to be in sinus rhythm.
patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre CPB:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 40-45 %), with
a basal inferoseptal aneurysm.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
There are three aortic valve leaflets. There is no aortic valve
stenosis. No aortic regurgitation is seen. There are focal
calcifications seen at the sinotubular junction near the right
coronary sinus. There is no mitral valve prolapse. Mild to
moderate ([**2-2**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results.
Post CPB:
The patient is being AV paced on a phenylephrine infusion.
There is mild MR.
[**First Name (Titles) **] [**Last Name (Titles) **] fraction is improved at 45-50%.
The visible contours of the thoracic aorta are intact.
Brief Hospital Course:
Ms [**Known lastname 16119**] was transfered from [**Hospital6 3872**] after
a cardiac catheterization revealed 3 vessel disease. After the
usual pre-operative cardiac surgery workup incluing echo and
carotid ul;trasound the patient was brought to the operating
room on [**12-4**]. PLease see the operative report for details, in
summary she had: Coronary artery bypass grafting x4 with the
left internal mammary artery to left anterior descending artery
and reverse saphenous vein graft to the right coronary artery
and the obtuse marginal artery. Her bypass time was 74 minutes
with a crossclamp of 62 minutes. She tolerated the operation
well and post-operatively was transferred from the operating
room to the cardiac surgery ICU in stable condition. In the
immediate post-op period she remained hemodynamically stable,
woke neurologically intact, was weaned from the ventilator and
extubated. On POD1 she continued to be hemodynamically stable
and was transferred from the ICU to the cardiac surgery stepdown
floor. All tubes, lines and drains were removed per cardiac
surgery protocol. The remainder of her hospital course was
uneventful. Once on the floor she worked with physical therapy
and the nursing staff to advance her activity level and recover
from her surgery. She made steady progress and on POD4 she was
discharged home with visiting nurses. She is to follow up with
Dr [**Last Name (STitle) **] in 3 weeks
Medications on Admission:
amlodipine 10mg daily
ASA 81 mg daily
Zantac 150mg [**Hospital1 **]
Atenolol 75mg [**Hospital1 **]
Imdur 60mg daily
HCTZ 25mg daily
Simvastatin 40mg daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
7. valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. 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:*0*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for
10 days: Should resume HCTZ when lasix complete please check
with office prior to changing .
Disp:*10 Tablet(s)* Refills:*0*
10. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
11. potassium chloride 10 mEq Capsule, Sustained Release Sig:
One (1) Capsule, Sustained Release PO once a day for 5 days.
Disp:*5 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p CABG x3
Hypertension
Gastric esophageal reflux disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema trace bilateral
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **] for Dr [**Last Name (STitle) **] at [**Hospital1 **] heart center on
Thrusday [**1-1**] at 9:00am [**Telephone/Fax (1) 6256**].
Cardiologist: Dr [**Last Name (STitle) 6254**] on [**1-16**] at 11:40am [**Telephone/Fax (1) 6256**]
Please call to schedule appointments with your
Primary Care Dr [**Last Name (STitle) **] in [**5-5**] weeks [**Telephone/Fax (1) 7328**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2160-12-9**] Name: [**Known lastname 2532**],[**Known firstname **] P Unit No: [**Numeric Identifier 2533**]
Admission Date: [**2160-12-2**] Discharge Date: [**2160-12-8**]
Date of Birth: [**2091-2-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors / Angiotensin Recp Antg&Calcium Chanl Blkr
Attending:[**First Name3 (LF) 135**]
Addendum:
Follow up is with Dr [**Last Name (STitle) **] in 3 weeks-not Dr [**Last Name (STitle) **]
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**]
Completed by:[**2160-12-9**]
|
[
"414.2",
"424.0",
"733.00",
"493.90",
"458.29",
"413.9",
"530.81",
"V45.82",
"414.01",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
12460, 12665
|
6852, 8280
|
336, 557
|
10149, 10379
|
1912, 2816
|
11303, 12437
|
1217, 1264
|
8486, 9950
|
2853, 5522
|
10043, 10128
|
8306, 8463
|
10403, 11280
|
5561, 6600
|
1279, 1893
|
285, 298
|
585, 978
|
1000, 1062
|
1078, 1201
|
6610, 6829
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,115
| 137,568
|
21964
|
Discharge summary
|
report
|
Admission Date: [**2169-9-6**] Discharge Date: [**2169-9-11**]
Date of Birth: [**2094-7-13**] Sex: M
Service: MEDICINE
Allergies:
Amiodarone
Attending:[**Last Name (un) 11974**]
Chief Complaint:
ICD firing three times
Major Surgical or Invasive Procedure:
VT Ablation
History of Present Illness:
Mr. [**Known lastname 57523**] is a 75 year old male with past medical history of
type2 DM, atrial fibrillation s/p AVN ablation and several AADs,
CAD complicated by systolic heart failure with LVEF of 25%,
ventricular tachycardia s/p ICD placement and VT ablation in
[**2164**] complicated by right iliac artery disection requiring
emergent angiography and stenting.
He woke up this morning with ICD shock. He does not report chest
pain, shortness of breath, palpatations or syncope prior to the
episode. He went to his PCP today where [**Name9 (PRE) 1543**] interrogation
was thought to be inappropriate. He was instructed to go home
and come to the ED if he has ICD shock. He did have ICD shock x
2 this evening without any associated symptoms. He called EMS
and was brought to [**Hospital3 **]. Labs at OSH were notable for
normal electrolytes, creatinine at baseline of 1.56, BNP of 193,
nomral CBC and troponin of 0.068. He was transferred to [**Hospital1 18**]
for further management.
In the ED, initial vitals were: 98.2 70 141/91 18 100% 2LNC. EP
was consulted who recommended increasing metoprolol to 100 mg
[**Hospital1 **], trending troponin and admission to [**Hospital1 **] after interrogation
revealed his ICD shocks were appropriate for 330 ms cycle length
ventricular tachycardia.
Past Medical History:
AAA - 4 cm per recent ultrasound
Peripheral Vascular Disease s/p iliac disection and stenting
[**2165-4-25**]
Prostate Cancer
Coronary Artery Disease s/p angioplasty
s/p pacemaker placement
GERD
Hyperlipidemia
Hypertension
Sciatica
Hyperthyroidism
Atrial Fibrillation
Type II diabetes
Stage III Chronic Kidney Disease
Social History:
Patient quit smoking in [**2158**]. He has a 10 pack year smoking
history. He occassionally has alcohol. He never uses other
drugs. He was never married. He is a priest and lives in a
monastary.
Family History:
His father did of a heart attack at age 46, his sister at age
59.
Physical Exam:
Admission Physical Exam:
VS: 98.0 134/80 88 18 98%RA
Gen: Elderly male, pale, lying in bed in no acute distress.
Oriented x 3, mood and affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 7 cm, left sided carotid bruit
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
AICD site intact, well healed incision.
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: No c/c/e. Bilateral femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Physical Exam:
VS: t = 97.9, bp = 99/58 - 111/56, hr = 81, rr = 18, O2 sat =
99% on RA
General: Older Caucasian male, no acute distress, sitting up
easily this morning.
HEENT: Normocephalic, atraumatic. MMM. OP clear.
Neck: Supple. Nondistended JVD.
Heart: Regular rate, S1 and S2. No audible mumurs, rubs, or
gallops. AICD site intact with well healed incision.
Lungs: No increased WOB or accessory muscle use. Lungs clear
bilaterally to wheezes, rhonchi, rhales.
Abd: NABS, soft, nondistended. Nontender to palpation.
Ext: Warm to perfusion, no edema. Distal pulses diminished but
intact.
Pertinent Results:
Admission Labs:
[**2169-9-6**] 08:57PM BLOOD WBC-9.5 RBC-3.76*# Hgb-12.7*# Hct-36.6*#
MCV-97 MCH-33.8* MCHC-34.7 RDW-14.2 Plt Ct-222
[**2169-9-6**] 08:57PM BLOOD Neuts-77.1* Lymphs-14.6* Monos-5.7
Eos-1.7 Baso-0.8
[**2169-9-6**] 08:57PM BLOOD PT-32.3* PTT-41.8* INR(PT)-3.1*
[**2169-9-6**] 08:57PM BLOOD Glucose-118* UreaN-30* Creat-1.7* Na-140
K-4.0 Cl-102 HCO3-26 AnGap-16
[**2169-9-6**] 08:57PM BLOOD cTropnT-0.03*
[**2169-9-7**] 03:21AM BLOOD CK-MB-3 cTropnT-0.03*
[**2169-9-7**] 12:27PM BLOOD CK-MB-3 cTropnT-0.02*
[**2169-9-7**] 03:21AM BLOOD Calcium-8.6 Phos-3.4 Mg-2.3
[**2169-9-6**] 08:57PM BLOOD TSH-7.1*
[**2169-9-7**] 12:27PM BLOOD T4-7.9
[**2169-9-6**] 08:57PM BLOOD Digoxin-0.8*
Discharge Labs:
[**2169-9-11**] 06:33AM BLOOD WBC-8.4 RBC-3.58* Hgb-11.7* Hct-35.3*
MCV-98 MCH-32.6* MCHC-33.2 RDW-14.2 Plt Ct-211
[**2169-9-11**] 06:33AM BLOOD Plt Ct-211
[**2169-9-11**] 06:33AM BLOOD Glucose-117* UreaN-34* Creat-1.8* Na-136
K-4.2 Cl-101 HCO3-26 AnGap-13
[**2169-9-11**] 06:33AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.2
Imaging
EKG ([**2169-9-7**]):
A-V sequential pacing with a very short A-V interval.
Ventricular paced
complex is of the appropriate left axis deviation, but with a
right
bundle-branch block pattern in the precordial leads consistent
with
biventricular pacing. Compared to the previous tracing of the
same date the overall rate has increased with uniform atrial
pacing rather than intermittent atrial sensing. Morphology of
the ventricular paced beats is unchanged.
CXR ([**2169-9-7**]):
FINDINGS: As compared to the previous radiograph there is no
relevant change. No pulmonary edema. No pneumonia. Borderline
size of the cardiac silhouette. Moderate tortuosity of the
thoracic aorta. Pacemaker in left pectoral position. No
pneumothorax.
Brief Hospital Course:
75 yo M with history of ischemic cardiomyopathy, recurrent
Vtach, atrial fibrillation, and PVD who p/w recurrent VT. He had
an unsuccessful VT ablation, and was started on quinidine and
mexilitine, w/ suppression of VT, prior to discharge.
# Vtach: The patient has a h/o Vtach and is s/p 2 ablations and
ICD placement previously. He presented with recurrent Vtach from
a scar focus with ICD firing and ATP pacing successful in
terminating VT. The patient was taken to the EP lab and
underwent ablation. In the PACU, he had an episode of Vtach,
either from irritation of the myocardium from the procedure
versus failed ablation. The patient was given lidocaine bolous
and started on lidocaine drip in the PACU. He was then sent to
the CCU for monitoring. He was started on mexilitine and recived
2 doses before the lidocaine gtt was stopped. He was monitored
on telemetry without event. The mexilitine was stopped the day
after the procedure. He returned to the floor, and had two
additional episodes of VT the following day. He was started on
quinidine and mexilitine prior to discharge. At the time of
discharge, he had been VT free for over 24 hours.
# PVD: The patient has PVD and has a R iliac artery stent from
previous admission. During the cath, a long sheath was used that
traversed the stent. This occluded the stent and caused
transient leg ischemia. Once the sheath was pulled, LE perfusion
returned. Pulses were monitored and at time of discharge were at
his normal baseline.
# A fib: Coumadin was continued for goal INR [**1-6**]. Home
metoprolol and digoxin were continued. Because of interaction
with quinidine, coumadin was restarted post-EP procedure at a
lower dose, and he will need an INR check 2-3 days
post-discharge.
# CAD: Continued statin, plavix, aspirin, lisinopril, and
metoprolol.
# Chronic Systolic CHF: Continue lisinopril, metoprolol, lasix.
Patient received 80mg IV lasix x 1 on arrival to CCU because
appeared volume overloaded. He responded well and was euvolemic
the next day.
# DM2: The patient's home insulin regimen was continued and he
was additionally covered with ISS.
# BPH: Continue flomax
Transitional Issues:
- Follow up on hospital thyroid studies - TSH elevated, but T4
normal suggesting subclinical hypothyroidism
- Follow up INR check 2-3 days post-discharge
- Follow up with EP scheduled for Friday.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Aspirin 81 mg PO DAILY Start: In am
2. Clopidogrel 75 mg PO DAILY Start: In am
3. Metoprolol Tartrate 100 mg PO BID
Hold for SBP < 95 or HR < 65
4. Furosemide 80 mg PO DAILY Start: In am
Hold for SBP < 100
5. Lisinopril 10 mg PO DAILY Start: In am
Hold for SBP < 95
6. Digoxin 0.125 mg PO 4X/WEEK (MO,WE,FR,SA) Start: In am
7. Ranitidine 150 mg PO BID
8. Tamsulosin 0.4 mg PO HS
9. Atorvastatin 80 mg PO DAILY Start: In am
10. 70/30 22 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Warfarin 2 mg PO DAILY16
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 80 mg PO DAILY
Hold for SBP < 100
5. 70/30 22 Units Breakfast
NPH 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. Ranitidine 150 mg PO BID
7. Tamsulosin 0.4 mg PO HS
8. Outpatient Lab Work
Please get INR checked on Tuesday, [**9-12**] and Friday [**9-15**]
9. quiniDINE Gluconate E.R. 324 mg PO Q12H
RX *quinidine gluconate 324 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*2
10. Digoxin 0.0625 mg PO 4X/WEEK (MO,WE,FR,SA)
RX *digoxin 125 mcg 0.5 (One half) tablet(s) by mouth 4x/week
Disp #*10 Tablet Refills:*0
11. Lisinopril 10 mg PO DAILY
Hold for SBP < 95
12. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
13. Mexiletine 150 mg PO Q12H
RX *mexiletine 150 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
Community VNA, [**Location (un) 8545**]
Discharge Diagnosis:
Ventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 57523**],
It was a pleasure taking care of you at [**Hospital1 827**]. You came in after your ICD went off several
times for a heart arrhythmia called ventricular tachycardia.
While in the hospital, you received a VT ablation procedure. You
were also started on 2 anti-arrhythmic medications. Please
continue to take these medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 2946**] A
Location: [**Hospital **] MEDICAL ASSOCIATES
Address: [**Street Address(2) 57526**], [**Location (un) **],[**Numeric Identifier 14085**]
Phone: [**Telephone/Fax (1) 40106**]
*Please call your primary care provider to book [**Name Initial (PRE) **] follow up
appointment for your hospitalization. You need to be seen within
1 week of discharge.
We are working on a follow up appointment for your
hospitalization with Dr. [**Last Name (STitle) **] [**Name (STitle) **]. It is recommended you be
seen within 2 weeks of discharge. The office will contact you at
home with an appointment. If you have not heard within 2
business days please call the office [**Telephone/Fax (1) 62**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
|
[
"V17.41",
"440.20",
"V45.82",
"V53.39",
"427.31",
"403.90",
"428.0",
"250.00",
"428.23",
"530.81",
"272.4",
"412",
"414.8",
"585.3",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.34",
"37.26",
"37.27"
] |
icd9pcs
|
[
[
[]
]
] |
9557, 9627
|
5541, 7683
|
292, 306
|
9695, 9695
|
3744, 3744
|
10324, 11159
|
2211, 2279
|
8595, 9534
|
9648, 9674
|
7927, 8572
|
9846, 10301
|
4454, 5518
|
2319, 3122
|
7704, 7901
|
230, 254
|
334, 1635
|
3760, 4438
|
9710, 9822
|
1657, 1977
|
1993, 2195
|
3147, 3725
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,581
| 122,726
|
1757
|
Discharge summary
|
report
|
Admission Date: [**2127-8-18**] Discharge Date: [**2127-8-23**]
Date of Birth: [**2048-11-29**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Streptomycin / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Left hip pain after fall
Major Surgical or Invasive Procedure:
Open reduction and internal fixation of left periprosthetic
femur fracture
History of Present Illness:
78F, Russian speaking only with h/o CAD s/p CABG, HTN, DM2, CVA,
presented on [**8-18**] after a fall at her N where she attempted to
get out of bed, reached for her wheelchair and fell onto her L
side. Of note pt was hospitalized [**4-15**] for a Left hip
hemiarthroscopy c/w hypotension and hypoxia requiring MICU
transfer. In ED she was found to have L femur fracture. Due to
her complicated PMH she was admitted to the medicine service and
underwent ORIF of left femur on afternoon of transfer to MICU.
Past Medical History:
* CAD s/p CABG X 2
* hypertension
* type 2 DM
* atrial fibrillation on coumadin (goal INR 3-3.5 per recent d/c
summary)
* h/o stroke ([**2125**], [**2127**])
* h/o bioprosthetic MVR
* s/p pacemaker
* h/o LBBB
* h/o L retinal detachment, vitreous hemorrhage
* CRI
* CHF - per NH records, occasionally uses 2L NC at night for
dyspnea
* Anemia
* h/o UTIs
* Vascular dementia
Social History:
Nonsmoker. No alcohol. Recently living at Tower [**Doctor Last Name **] Rehab
follow her stroke in [**Month (only) 404**]. Daughter lives in [**State 4565**].
Family History:
noncontributory
Physical Exam:
Vital Signs: Temp 97.8 RR 16 SpO2 98% RA, HR 84 BP 98/60
.
General NAD, A&Ox3
HEENT: PEERLA, normal eye movements, left eye covered after
surgery.
Neck: Supple, no JVD, no bruits, thyroid normal size
Heart: RRR, no m/r/g
Lungs: CTAB
Abdomen: non-tender, non-distended, normal bowel sounds, no
bruits.
Extremities: wound in left side clean, covered. Patient cannot
move L leg. Right leg with full range of motion.
.
Pertinent Results:
[**2127-8-18**] 09:00PM WBC-11.5* RBC-4.66# HGB-12.8# HCT-37.1#
MCV-80* MCH-27.5 MCHC-34.6 RDW-16.3*
[**2127-8-18**] 09:00PM NEUTS-85.2* LYMPHS-10.2* MONOS-4.1 EOS-0.4
BASOS-0.1
[**2127-8-18**] 09:00PM PT-15.3* PTT-25.3 INR(PT)-1.4*
[**2127-8-18**] 09:00PM PLT COUNT-188
[**2127-8-18**] 09:00PM DIGOXIN-0.2*
[**2127-8-18**] 09:00PM CALCIUM-9.1 PHOSPHATE-3.2 MAGNESIUM-1.8
[**2127-8-18**] 09:00PM GLUCOSE-135* UREA N-30* CREAT-1.4* SODIUM-141
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16
Hip X-rays (before surgery):
There is a fracture through the proximal shaft of the left
femur. This
fracture is through an area which is traversed by the stem of
the femoral head
prosthesis. The left hip joint appears intact. There are minor
OA changes
present at the right hip joint. The bones are osteopenic
CXR: Increased opacity in the RUL compared to prior films.
Echo:
The left atrium is moderately dilated. There is asymmetric
septal hypertrophy with small cavity and very good systolic
function, but distal septal hypokinesis (LVEF = >55 %). No
resting LVOT gradient is identified. There is a mobile
echodensity in the left ventricular cavity c/w free papillary
muscle. The right ventricular cavity is mildly dilated The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. A
well-seated bioprosthetic mitral valve prosthesis is present,
but with mildly thickened leaflets and mildly increased
gradient. Moderate (2+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2127-1-25**], the
distal septal hypokinesis appears to be new. The other findings
are similar (the severity of mitral regurgitaiton was
underestimated on the prior study).
If clinically indicated, a TEE would be better able to clarify
the mitral valve morphology and severity of mitral
regurgitation.
Brief Hospital Course:
Ms. [**Known lastname 9950**] was tarnsfered from rehab after a fall. In the ED
she arrived with left leg shorter on physical exam and in pain.
Her vital signs were VS 96.0 96/50 71 18 94% RA. Her hematocit
was 32.3, WBC 11.5, INR of 1.4 and creatinine 1.1. An X-ray of
the hip was taken and a fracture of the proximal shaft of the
femur was diagnosed. Orthopedics were consulted and she went to
the OR, where she had an open reduction and internal fixation
with an approximate blood loss of 1.4 L. In the OR she received
~1.5 L of fluid and 500 of 5% albumin and 2 pack RBCs. Patient
was transfered to the medical floor after surgery. Her vital
signs after the OR were 100.5 110/D 77 18 98% 3L with an HCT of
34.1. Three hours later her hematocrit dropped to 31.1 and
patient became hypotensive with an SBP in the 70s. She
triggered, received 2 L of NS and was transfered to the ICU. She
received multiple IV fluid boluses, 3 U of RBCs and orthopedics
re-evaluated her. Ortho did not recommend going back to surgery.
Patient had blood cultures taken (no growth), urine analysis
that showed signs of UTI, she had a urine culture that grew E
coli resistant to ciprofloxacin; an CXR with RUL consolidation
that has been stable from the past. Patient was prophylactically
started on ciprofloxacin for a UTI on [**8-20**] and was changed to
nitrofurantoin when the sensitivities came back on [**8-22**].
Patient will need a 10 day course for compliacted UTI Patient
did not required pressor. Patient was monitored for 24 hours
with serial hematocrits and was stable. Patient's SBP was in the
90s and she was asymptomatic, then she was transfered to the
medicine floor.
In the medicine floor hematocrits were checked every 8 hours and
was stable between 34-36; pt's SBP was 90-110 mmHg. Foley and
central line (right IJ) were removed on [**8-22**] without
complications. Patient had pain in the surgical site only on
movement, but it was controlled with oxycodone. Physical therapy
worked with her and she recommended further therapy in
rehabilitation.
Patient was explained all the events with the help of a russian
interpreter and was discharged back to the rehab where she was
before.
Medications on Admission:
Vitamin D 1000 units daily
Calcium carbonate 650 mg [**Hospital1 **]
Docusate 100 mg daily
Milk of magnesia 30 cc daily prn
amiodaron 200 mg daily
Miralax prn
Senna qhs
Simvastatin 40 mg daily
Coumadin - no dose provided, held for past 10 days
Mirtazapine 15 mg qhs
Iron 325 mg daily
Lasix 40 mg daily
SL NTG prn
Hydrocortisone 1% cream [**Hospital1 **]
Miconazole 2% powder [**Hospital1 **]
Tylenol 650 mg q4h prn
Discharge Medications:
1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
3. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day.
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: 30 mL PO three
times a day as needed for constipation.
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
6. Miralax 100 % Powder Sig: One (1) PO three times a day as
needed for constipation.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual four times a day as needed for chest pain.
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*3*
14. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day) as needed.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
16. Scopolamine HBr 0.25 % Drops Sig: One (1) Drop Ophthalmic
[**Hospital1 **] (2 times a day).
Disp:*1 unit* Refills:*2*
17. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic QID (4 times a day).
Disp:*1 unit* Refills:*2*
18. Bacitracin-Polymyxin B 500-10,000 unit/g Ointment Sig: One
(1) Appl Ophthalmic [**Hospital1 **] (2 times a day).
Disp:*1 Unit* Refills:*2*
19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
21. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 9 days.
Disp:*18 Capsule(s)* Refills:*0*
22. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO four
times a day as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary diagnosis
Left hip fracture
.
Secondary diagnosis
* CAD s/p CABG X 2
* hypertension
* type 2 DM
* atrial fibrillation on coumadin (goal INR 3-3.5 per recent d/c
summary)
* h/o stroke ([**2125**], [**2127**])
* CKD
* CHF
* Anemia
* Vascular dementia
Discharge Condition:
Stable, breathing comfortable on room air, pain controlled.
Discharge Instructions:
You were seen in the ER of the [**Hospital1 18**] with a left hip fracture.
You had surgery on [**2127-8-19**]. After the surgery your blood
level was low and you required to be transfered to the ICU where
they monitored your blood level closely. You needed some blood
transfusions during the first day in the ICU. The following day
your blood level was stable and you were more awake; you were
transfered to the general medicine floor.
.
In the medicine floor we kept watching your blood level and was
stable; we controlled your pain as well. We had physical therapy
work with you and evaluate you. A urine analysis was positive
for infection, so you were started on antibiotics for that,
which we need to continue for a total of 10 days.
.
You now are transfered to the rehab where you were before. You
are going to need physical therapy and pain control. Please
follow the appointment with your orthopedic doctors as [**Name5 (PTitle) 9953**]
below.
.
Followup Instructions:
You will need to followup with nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9954**] in the orthopedics clinic ([**Hospital Ward Name 23**] 2 [**Telephone/Fax (1) 1228**]) on
Thursday [**9-4**] at 9am.
.
Please followup with your eye doctor Dr. [**Last Name (STitle) 9955**] at [**Hospital 100**]
Rehab the week of [**2127-8-25**].
.
Please followup with Dr. [**Last Name (STitle) **] in one month.
|
[
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"996.44",
"428.0",
"285.1",
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"437.0",
"V58.61",
"E884.4",
"290.40",
"428.30",
"414.00",
"V12.54",
"250.00",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"79.35",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8905, 8970
|
4166, 6351
|
336, 413
|
9272, 9334
|
2006, 4143
|
10337, 10799
|
1539, 1556
|
6816, 8882
|
8991, 9251
|
6377, 6793
|
9358, 10314
|
1571, 1987
|
272, 298
|
441, 950
|
972, 1346
|
1362, 1523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,769
| 120,240
|
52656+59448
|
Discharge summary
|
report+addendum
|
Admission Date: [**2133-3-27**] Discharge Date: [**2133-3-31**]
Date of Birth: [**2051-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 81 [**Hospital 108663**] nursing home resident, who presented to [**Hospital1 **]
[**Location (un) **] with fevers to 105.2. He was in his usual state of
health as of last night, improving from recent hospitalizations
for bowel obstrution/mesenteric ishemia, with discussions of
leaving rehab for home. He developed acute onset of fever to 105
and rigors at 2am. Was transferred to [**Hospital1 **] [**Location (un) 620**]. Was given
ceftriaxone and vancomycin at their ED and transferred to [**Hospital1 18**]
In the ED initial vitals were 97.0 BP 108/55 HR 106 96% on 3L.
SBP dropped to 70s when sitting up. 20g PIV placed. CXR
revealed a LLL infiltrate. He was given 1L NS and flagyl.
.
Upon arrival to the MICU, pt is somnalent but arousable.
Afebrile and normotensive.
Past Medical History:
ESRD on dialysis MWF
DM
CAD s/p CABG
Dementia - multi infarct with significant sundowning
CVA
Bladder cancer [**2128**]
Melanoma (superficial)
PVD s/p SMA stent 4 weeks ago
C dif in [**1-14**]
Social History:
Currently at [**Hospital1 1501**]. Previously lived with wife in [**Name (NI) 620**] 40 pack
year smoking history, quit 25 years ago. no alcohol.
Family History:
brother died in 70's with DM, unknown history of CAD, no DM
Physical Exam:
Vitals: T: 96.9 BP:112/50 P:89 R:12 SaO2:100% on 4L
General: Somnolent, NAD.
HEENT: NC/AT, Pupils pinpoint, no scleral icterus noted, MMdry,
no lesions noted in OP
Neck: supple, no JVD or carotid bruits appreciated
Pulmonary: Inspiratory crackes at left base
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No edema
Skin: no rashes or lesions noted. Sacral decub. large R heel
ulcer
Neurologic: somnolent. moves all extremities.
Pertinent Results:
[**2133-3-27**] 06:15AM WBC-21.8*# RBC-3.44* HGB-9.4* HCT-29.8*
MCV-87 MCH-27.3 MCHC-31.4 RDW-18.2*
[**2133-3-27**] 06:15AM GLUCOSE-116* UREA N-38* CREAT-4.5* SODIUM-141
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-18* ANION GAP-17
[**2133-3-27**] 06:15AM CALCIUM-7.4* PHOSPHATE-2.2*# MAGNESIUM-1.0*
[**2133-3-27**] 06:26AM LACTATE-1.5
Brief Hospital Course:
# Pneumonia. The patient was switched to levofloxacin for
community acquired PNA on arrival to the MICU. DFA was negative
for influenza. He was initially mildly hypotensive; he
responded well to IVF bolus. The patient remained afebrile and
did not have an oxygen requirement; he was called out to the
floor on [**3-28**]. On the floor, he remained afebrile and his
leukocytosis resolved. His blood pressure remained stable.
.
# Hypertension - The patient's blood pressure medications were
held in the ICU given his transient hypotension; his metoprolol
was restarted on transfer to the floor on [**3-28**].
.
# Renal failure- The patient was followed by renal for his ESRD.
He showed no signs of renal disease and was dialyzed as needed,
most recently [**3-30**]. His phosphate binders were held as per
renal. He will resume a M/W/F dialysis schedule on discharge.
His electrolytes will be followed by renal after discharge, and
his renagel will be restarted PRN.
.
# Skin breakdown - The patient has decubitus ulcers over his R
heel and coccyx. Wound care was cxonsulted and meticulous skin
care was performed.
.
# Dementia- The patient was continued on seroquel, namenda, and
aricept.
.
#DM: The patient was covered with SSI; his sugars remained in
good control.
.
The patient is DNR/DNI confirmed by his HCP.
Medications on Admission:
Proscar 5 mg po qd
Seroquel 150 mg po qd
Toprol xl 50 mg po QAM sat sun, tues, thurs and 37.5 QHS daily
Reglan 10 mg po tid
MTV
Renagel 1600 mg tid with meals
ASA 81 mg po qd
loratidine 10 mg po qd
Folate
Aricept 10 mg po qd
namenda 5 mg po qd
Discharge Medications:
1. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO at bedtime.
2. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO qSunday, Tuesday, Thursday,
Saturday: Give on non-dialysis days. .
3. Quetiapine 50 mg Tablet Sig: Three (3) Tablet PO QD ().
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
6. Memantine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 9 days.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
10. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day.
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
13. Loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
14. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day
as needed.
15. Wound Care
Foam cleanser to perianal tissue, B/L groin, medial thighs and
scrotum. Pat dry.
Apply Antifungal ointment over affected tissue TID.
16. Wound Care
Commercial wound cleanser or normal saline to irrigate/cleanse
all open wounds.
Pat the tissue dry with dry gauze.
Right heel: Apply moisture barrier ointment to the periwound
tissue with each drg change.
Apply a thin layer of DuoDerm Gel (wound gel) the open ulcer to
soften necrotic tissue and provide for moist wound healing,
Cover with dry gauze, ABD, Kerlix wrap
Change dressing daily.
17. Lower Extremity Ulcers
Please use Multipodis Splints B/L LE's
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Hemodynamically stable, satting well on room air, afebrile.
Discharge Instructions:
During this admission you were treated for Pneumonia. We have
started an antibiotic (Levofloxacin). It is important to take
the full course of this medication.
.
Please seek immediate medical care if you develop fevers,
chills, worsening cough, shortness of breath or any other
concerning symptoms.
Followup Instructions:
Follow up with your primary care doctor within 1 week of leaving
rehab. Call [**Last Name (LF) **],[**First Name3 (LF) 198**] P. [**Telephone/Fax (1) 19980**] for an appointment.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Name: [**Known lastname 2534**],[**Known firstname **] D Unit No: [**Numeric Identifier 17784**]
Admission Date: [**2133-3-27**] Discharge Date: [**2133-3-31**]
Date of Birth: [**2051-4-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 758**]
Addendum:
#Hematuria: The patient was noted to have hematuria on [**3-28**].
This was likely due to traumatic foley placement in a patient
known to have BPH; however, the patient has a history of bladder
cancer, followed by Dr [**Last Name (STitle) **]. He will follow up with Dr [**Last Name (STitle) **]
as an outpatient after leaving rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6418**] Healthcare - [**Location (un) 407**]
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**] MD, [**MD Number(3) 765**]
Completed by:[**2133-3-31**]
|
[
"250.00",
"443.9",
"995.91",
"486",
"599.7",
"585.6",
"294.8",
"038.9",
"707.07",
"458.9",
"V45.81",
"V45.1",
"414.00",
"V10.51",
"707.05",
"403.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7526, 7766
|
2529, 3855
|
333, 340
|
6056, 6118
|
2168, 2506
|
6467, 7503
|
1557, 1618
|
4150, 5895
|
6023, 6035
|
3881, 4127
|
6142, 6444
|
1633, 2149
|
275, 295
|
368, 1160
|
1182, 1377
|
1393, 1541
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,348
| 178,083
|
40359
|
Discharge summary
|
report
|
Admission Date: [**2102-10-27**] Discharge Date: [**2102-10-31**]
Date of Birth: [**2053-8-29**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Left main coronary artery disease
Major Surgical or Invasive Procedure:
emergency coronary artery bypass grafts
xLIMA-LAD,SVG-OM1-OM2-PDA) [**2102-10-27**]
History of Present Illness:
Progressive chest pain over three weeks requiring frequent nitro
spray. A stress test was positive and the day of transfer
catheterization revealed subtotal left main and an occluded
right coronary artery. He was pain free and on no
anticoagulants nor Nitroglycerin.
Past Medical History:
? COPD
ETOH abuse
paroxysmal atrial fibrillation s/p CV x3 ( refused coumadin in
past)
hypertension
dyslipidemia
tobacco abuse
remote mycardial infarction
Social History:
smokes 2ppd
10 beers /day
works as driver
Family History:
Mother CABG in her 40s
younger Sister s/p CABG
Physical Exam:
admission:
Pulse:60 Resp: O2 sat:12 100% RA
B/P Right:146/70 Left:
Height:5'8" Weight: 65kg
General: AAo x 3in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [], well-perfused [] Edema Varicosities: None
[x]
Neuro: Grossly intact
Pulses:
Femoral Right:2+ Left:2+
DP Right:2+ Left:2+
PT [**Name (NI) 167**]:2+ Left:2+
Radial Right:2+ Left:2+
Carotid Bruit Right:none Left:+
Pertinent Results:
[**2102-10-27**] 06:49PM BLOOD WBC-8.3 RBC-4.28* Hgb-14.0 Hct-40.9
MCV-96 MCH-32.6* MCHC-34.1 RDW-13.0 Plt Ct-209
[**2102-10-27**] 06:49PM BLOOD Glucose-83 UreaN-8 Creat-0.8 Na-135
K-6.3* Cl-102 HCO3-26 AnGap-13
[**2102-10-27**] 06:49PM BLOOD ALT-17 AST-42* LD(LDH)-647* AlkPhos-40
TotBili-0.6
Prebypass:
Left ventricular wall thicknesses and cavity size are normal.
Aside from the inferior wall which is akinetic, regional wall
motion is normal. Overall left ventricular systolic function is
mildly depressed (LVEF= 40%). Right ventricular chamber size and
free wall motion are normal. There are simple atheroma in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
Due to the emergent nature of surgery and fluctuating
hemodynamics interatrial septum was not examined for defects by
2D or color flow.
Postbypass:
The patient is on infusions of phenylephrine and is not paced.
Normal Right ventricular systolic function. LVEF 40%. No
valvular issues. Intact thoracic aorta.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2102-10-27**] 23:53
Brief Hospital Course:
Following admission, he was started on a Heparin infusion. He
was taken to the Operating Room that night, where quadruple
grafts were performed. He weaned from bypass on Neo Synephrine,
weaned and was extubated the following morning.
The pressor was weaned off and he remained stable. He was
diuresed gently and his digoxin and sotalol were resumed.
Physical Therapy was consulted and he transferred to the floor
on POD #2. Continued to make good progress and was cleared for
discharge to home with VNA on POD #4. All f/u appts were
advised.
Medications on Admission:
Lisinopril 10mg daily
Sotalol 120mg [**Hospital1 **]
Digoxin 0.125mg daily
ASA 325mg daily
Klonipin 1mg QID
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. 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*
5. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*1*
6. 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*
7. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
paramentor VNA and Community Care
Discharge Diagnosis:
left main coronary artery disease s/p cabg
myocardial infarction (several years ago)
? COPD
ETOH abuse
paroxysmal atrial fibrillation s/p CV x3 ( refused coumadin in
past)
hypertension
dyslipidemia
tobacco abuse
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema -trace
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Surgeon:Dr. [**Last Name (STitle) **] (for Dr. [**First Name (STitle) **] at [**Hospital1 **] on Thursday
[**11-23**] @ 9:15 AM
Cardiologist:Dr. [**Last Name (STitle) 8051**] ([**Telephone/Fax (1) 8058**]) on [**11-30**] @ 10:30 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**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2102-10-31**]
|
[
"305.1",
"401.9",
"305.01",
"V45.82",
"413.9",
"427.31",
"496",
"412",
"272.4",
"440.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4853, 4917
|
3162, 3708
|
356, 442
|
5173, 5401
|
1712, 3139
|
6241, 6810
|
993, 1041
|
3866, 4830
|
4938, 5152
|
3734, 3843
|
5425, 6218
|
1056, 1693
|
283, 318
|
470, 740
|
762, 918
|
934, 977
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,977
| 165,239
|
29997
|
Discharge summary
|
report
|
Admission Date: [**2106-3-26**] Discharge Date: [**2106-4-1**]
Date of Birth: [**2026-9-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2880**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Temporary Pacer Placement
History of Present Illness:
79 y/o male with h/o CAD, HTN, Dyslipidemia, Dementia presented
to OSH with dizziness, was found to be in complete heart block
and was then transferred to [**Hospital1 18**] for pacemaker placement.
Patient developed dizziness around 5 days back. He was
asymptomatic at rest but would get dizzy when he would start to
walk. He always uses a walker to ambulate. The episodes of
dizziness were not associated with any chest pain, SOB,
palpitations, sweating or syncope. He does not report any
previous episodes of syncope or LOC. He reports feeling fatigued
for the past few days with decreased food intake. He has had
multiple falls in the last 2 years and also had been
occassionally dizzy although they were not correlated. He was
taken to [**Hospital3 68789**] today where he was noted to be
bradycardic in a ventricular escape rhythm.
Past Medical History:
Hyperlipidema
HTN
AAA (one repaired)
Femoral aneurysm
Intestinal obstruction
Gout
Dementia (vascular vs Alzheimers)
Social History:
smoked pipe almost 40 yrs back, occassional alcohol
Family History:
no h/o premature CAD or SCD
Physical Exam:
VS: 99.1, 120/67, 79, 24, 96%/L
Gen: pleasant, AOx3
HEENT: PERLA, EOMI, no elevated JVD, RIJ catheter present
Heart: S1/S2, 1/6 systolic murmur at apex
Lungs: CTAB
Abd: soft/NT/ND, no hepatosplenomegaly
Ext: no pedal edema
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:
[**2106-3-26**] 06:52PM BLOOD WBC-8.4 RBC-4.22* Hgb-12.1* Hct-36.0*
MCV-85 MCH-28.8 MCHC-33.7 RDW-16.1* Plt Ct-228
[**2106-3-26**] 06:52PM BLOOD Neuts-85.2* Lymphs-11.8* Monos-2.8
Eos-0.1 Baso-0
[**2106-3-26**] 06:52PM BLOOD PT-13.4* PTT-27.0 INR(PT)-1.2*
[**2106-3-26**] 06:52PM BLOOD Glucose-127* UreaN-41* Creat-1.3* Na-139
K-6.0* Cl-103 HCO3-20* AnGap-22*
[**2106-3-26**] 06:52PM BLOOD Calcium-10.3* Phos-5.0* Mg-2.3
[**2106-3-27**] 06:09AM BLOOD calTIBC-221* Ferritn-439* TRF-170*
.
[**3-27**] CXR
There is again a right IJ pacemaker wire with the tip overlying
the right ventricle. No evidence of pneumothorax. The cardiac
silhouette is within normal limits. The aorta is calcified and
slightly tortuous. The lungs are clear. Pulmonary vasculature is
within normal limits.
IMPRESSION: Essentially stable appearance post-pacemaker wire
placement. No pneumothorax
.
EKG from OSH: bradycardia @ 27, third degree block, AV
disassociation, RBBB
HCT 34.9
Creatinine 1.6 (GFR 45)
TSH 2.99 (N
Brief Hospital Course:
79 y/o male with h/o CAD, Dyslipidemia, Dementia presented with
dizziness, found to have CHB, now with temp pace wire.
.
# Complete heart block. This was likely degenerative in the
setting of known baseline RBBB with possible left posterior
fascicular block. A temporary pacing wire was placed on
admission. The patient was scheduled for permanent pacemaker
placement on Monday [**2106-3-29**]. The patient was given Cefazolin 1gm
q8h for prophylaxis and Vancomycin was on-call to the EP
laboratory. In EP lab, he had a permanent pacemaker placed
without incident. PA and Lat CXR was reviewed by EP. He was
discharged with plan to follow-up in [**Hospital1 **] device clinic and given
a course of Keflex for prophylaxis.
.
# Coronary artery disease: Questionable history of CAD based on
OSH transfer records. Per the patient or his wife, there was no
history of MI or anginal symptoms. The patient was continued on
aspirin, ACE-inhibitor, and statin. The patient's beta-blocker
was held in the setting of CHB.
.
# AAA: Pt had hx of repaired AAA (done at [**Hospital1 2025**]) and followed by
MD [**First Name (Titles) **] [**Last Name (Titles) 2025**]. He is due for repeat CT in [**2106-6-4**]. Last CT in [**6-9**]
and showed 5 cm, per family non-surgical. This was noted on
lateral CXR at [**Hospital1 18**]. Given hemodynamic stability, it was
decided that he will follow-up as planned at [**Hospital1 2025**] at outpatient.
.
# Pump: Ejection fraction unknown. The patient was euvolemic
during admission.
.
# Hypertension: The patient was continued on his ACE-inhibitor.
Beta-blockers were held as above.
.
# Hyperlipidema: The patient was continued on Zocor.
.
# Anemia: The patient's baseline hematocrit from OSH records was
35-36. The patient's hematocrit dropped to 31 during admission
but was subsequently stable. Further work-up and management
deferred.
.
# Renal: The patient's creatinine was 1.6 at the OSH. The
patient's creatinine improved to 0.8 during admission for GFR
99.
.
# Gout: The patient was continued on allopurinol.
.
# Depression: The patient was continued on sertraline.
.
# Dementia: The patient's razadyne and memantine were held for
CHB, but can be restarted once permanent pacemaker placed.
.
# FEN: cardiac/heart healthy
.
# Code: Full
Medications on Admission:
Metoprolol 12.5 [**Hospital1 **]
ASA 81 mg
MVI
Allopurinol 300 mg QD
Razadyne (Galantamine Hydrobromide) 12 mg [**Hospital1 **]
Sertraline 100 mg [**Hospital1 **]
Memantine 10 mg QD
Lisinopril 5 mg QD
Calcium 600mg QD
Simvastatin 80 mg QD
Fosamax weekly
Discharge Medications:
1. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Memantine 5 mg Tablet Sig: Two (2) Tablet PO daily ().
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Galantamine 4 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
7. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
8. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO every eight (8)
hours for 2 days.
Disp:*6 Capsule(s)* Refills:*0*
10. Fosamax
Please resume your home dose.
11. Vitamin
Please resume your home multivitamin.
12. Calcium 600 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 21892**] Healthcare Nursing
Discharge Diagnosis:
Primary:
1. Complete heart block
.
Secondary:
1. Hyperlipidema
2. HTN
3. AAA (one repaired)
4. Femoral aneurysm
5. Intestinal obstruction
6. Gout
7. Dementia (vascular vs Alzheimers)
Discharge Condition:
Stable. Tolerating PO. Afebrile. Paced.
Discharge Instructions:
You were admitted to the hospital for symptomatic bradycardia or
slow heart rate due to a condition called complete heart block.
You required permanent pacemaker placement. You should return to
the ED or call your doctor if you experience any of the
following symptoms: fever > 101.4, chest pain or discomfort,
dizziness or lightheadedness, palpitations, fainting or any
other concerning symptoms.
.
Please take all medications as prescribed.
.
Please follow up with all appointments as instructed.
Followup Instructions:
Please attend your appointment in the cardiac device clinic to
check your pacemaker. Your appointment is in the DEVICE CLINIC
Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2106-4-7**] 11:30AM
.
.
Please call your primary care physician after you are discharged
form rehab to make an appointment for follow-up.
.
Please follow-up with your doctor regarding your aortic
aneurysm. You are due for a repeat CT scan in [**Month (only) **] of this year.
[**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**]
|
[
"441.4",
"403.90",
"414.01",
"442.89",
"274.9",
"285.21",
"294.8",
"585.9",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.83",
"37.78",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
6306, 6372
|
2878, 5150
|
324, 352
|
6599, 6641
|
1862, 2855
|
7188, 7771
|
1447, 1477
|
5455, 6283
|
6393, 6578
|
5176, 5432
|
6665, 7165
|
1492, 1843
|
275, 286
|
380, 1221
|
1243, 1361
|
1377, 1431
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,439
| 185,797
|
42342
|
Discharge summary
|
report
|
Admission Date: [**2174-8-15**] Discharge Date: [**2174-8-27**]
Date of Birth: [**2091-7-18**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Aortic valve replacement (19mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Porcine), Coronary artery
bypass grafting times three
History of Present Illness:
Ms. [**Known lastname 12409**] is a 82 year old female with known aortic stenosis.
After she underwent a cardiac catheterization at [**Hospital 3278**] Medical
Center on [**8-8**] which showed multi-vessel coronary artery
disease, she was deemed not to be a good
surgical candidate due to heavily calcified aorta. Therefore,
she was discharged home with medical management. Shortly after
being home she developed worsening shortness of breath and was
admitted to [**Hospital3 **] on [**8-14**]. She was referred from
there to the [**Hospital1 18**] cardiac surgery service for consideration of
an aortic valve replacement and coronary artery bypass grafting.
Past Medical History:
Congestive heart failure related to severe aortic stenosis,
hypertension, hyperlipidemia, reflux, transitory ischemic
attacks, osteoarthritis, carotid stenosis, hyperlipidemia,
hammer toes right foot, callus right foot, right hip replacement
times two, left hip replacement, right knee replacement,
hysterectomy, appendectomy, tonsillectomy and adenoidectomy
Social History:
Ms. [**Known lastname 12409**] lives independently at home in [**Hospital1 2436**] after
husband died in [**11-30**].
She denies a smoking history and any alcohol or illicit drug
use.
Family History:
non-contributory
Physical Exam:
Pulse:74 Resp: 14 O2 sat: 100 on 3l
B/P Right: 158/75 Left:151/65
Height:5ft Weight:114lbs
Five Meter Walk Test #1_______ #2 _________ #3_________
General:
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [] Full ROM [] stiff neck
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade _4/6_____
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] none_____
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:+1 Left:+1
DP Right: +1 Left:+1
PT [**Name (NI) 167**]: +1 Left:+1
Radial Right: +2 Left:+2
Carotid Bruit Right: positive Left:Positive
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91722**] (Complete)
Done [**2174-8-22**] at 1:10:41 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **] R.
[**Hospital1 18**], Division of Cardiothorac
[**Hospital Unit Name 4081**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2091-7-18**]
Age (years): 83 F Hgt (in): 60
BP (mm Hg): 180/90 Wgt (lb): 114
HR (bpm): 73 BSA (m2): 1.47 m2
Indication: Aortic valve replacement, CABG
ICD-9 Codes: 424.1, 424.0, 424.2
Test Information
Date/Time: [**2174-8-22**] at 13:10 Interpret MD: [**Name6 (MD) 3892**] [**Name8 (MD) 3893**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3893**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2011AW1-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *6.0 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *5.9 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *55 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 39 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast
or thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
Left-to-right shunt across the interatrial septum at rest.
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and
regional/global systolic function (LVEF>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Normal ascending aorta diameter.
Simple atheroma in ascending aorta. Focal calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch. Focal calcifications in aortic arch. Normal
descending aorta diameter. Complex (>4mm) atheroma in the
descending thoracic aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). Trace AR.
MITRAL VALVE: Moderately thickened mitral valve leaflets. No
MVP. Moderate mitral annular calcification. Moderate thickening
of mitral valve chordae. Moderate to severe (3+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient. See Conclusions for post-bypass data
Conclusions
PRE-BYPASS:
The left atrium is markedly dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. A patent foramen ovale is present. A left-to-right
shunt across the interatrial septum is seen at rest.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the ascending aorta. There are
simple atheroma in the aortic arch. There are focal
calcifications in the aortic arch. There are complex (>4mm)
atheroma in the descending thoracic aorta.
The aortic valve leaflets are severely thickened/deformed. There
is critical aortic valve stenosis (valve area <0.8cm2). Trace
aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. There is moderate thickening of the
mitral valve chordae. Moderate to severe (3+) mitral
regurgitation is seen.
There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results before
surgical incision..
POST-BYPASS:
Normal RV systolic function.
LVEF 55%.
Stable prosthesis in the native aortic position, no perivalvular
leaks and a mean gradient of 15 mm of Hg across the aortic
valve.
Moderate MR. [**First Name (Titles) **] [**Last Name (Titles) **].
Intact thoracic aorta
Brief Hospital Course:
Ms. [**Known lastname 12409**] was admitted on [**2174-8-15**] for a pre-operative work-up.
She was diuresed with lasix. She was newly diagnosed as
diabetic and given diabetic teaching. She was cleared for
surgery by the dentistry service. She was treated for a urinary
tract infection with ciprofloxacin. On [**2174-8-22**] she underwent an
aortic valve replacement (19mm St. [**Male First Name (un) 923**] porcine), coronary
artery bypass grafting times three (left internal mammary to
left anterior descending, saphenous vein graft to diagonal and
obtuse marginal), performed by Dr. [**Last Name (STitle) **]. Please see the
operative note for details. She tolerated the procedure well
and was transferred in critical but stable condition to the
intensive care unit. By the following day she was extubated and
weaned from pressors. She required atrial pacing for blood
pressure support initially, but this therapy was weaned by
post-operative three, at which time she was hemodynamically
stable with a sinus rhythm in the 70s. She experienced delirium
which cleared over the ensueing days. She is anxious at baseline
and tends to become tacypneic when she is anxious but responds
well to reassurance. She was transferred to the surgical step
down floor. She was started back on statin therapy, [**Last Name (un) **],
betablocker and gently diuresed back to her pre-operative
weight. She was evaluated by physical therpay for strength and
conditioning and rehab was recommended upon discharge. On POD# 5
she was discharged to [**Hospital 66217**] Rehab in [**Hospital1 2436**]. All follow
up appointments were advised.
Medications on Admission:
Asa 81mg daily, atenolol 50mg daily, lipitor 40mg daily, vitamin
c 1000mg daily, vit b 12 1000mcq daily, zetia 10mg daily, iron
325mg daily, diovan 320mg po daily, prilosec 20mg daily,
lisinopril 5mg daily new
Discharge Medications:
1. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
2. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day): DVT prophylaxis.
3. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. cholecalciferol (vitamin D3) 1,000 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
7. cyanocobalamin (vitamin B-12) 500 mcg Tablet [**Last Name (STitle) **]: Two (2)
Tablet PO DAILY (Daily).
8. ezetimibe 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
9. atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
10. magnesium hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
11. bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. metoprolol tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO
three times a day.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for dypnea.
14. Diovan 160 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day: HOME
dose 320mg-please titrate as tolerated.
15. potassium chloride 10 mEq Tablet Extended Release [**Last Name (STitle) **]: Four
(4) Tablet Extended Release PO Q12H (every 12 hours) for 2
weeks: while on lasix.
16. Lasix 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day for 2
weeks: d/c when edema resloves and at pre-op weigth of 50kg.
Discharge Disposition:
Extended Care
Facility:
Aberjona Nursing Center - [**Hospital1 2436**]
Discharge Diagnosis:
aortic stenosis
Congestive heart failure related to severe AI, hypertensive,
hyperlipidemia, GERD, TIA, osteoarthritis, carotid stenosis,
hyperlipidemia, hammer toes right foot, callus right foot, ?TIA,
RHR x2, LHR, RKR, hysterectomy,appendectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage.
Edema 1+ edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2174-9-28**] 1:15in the
[**Hospital **] Medical office building [**Last Name (NamePattern1) **]. [**Location (un) 86**] [**Hospital Unit Name **]
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **],DHIREN K. [**Telephone/Fax (1) 59986**] in [**2-22**] weeks
Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 2 weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2174-8-27**]
|
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63,999
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43104
|
Discharge summary
|
report
|
Admission Date: [**2163-9-7**] Discharge Date: [**2163-9-9**]
Date of Birth: [**2081-2-24**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Clindamycin /
Nsaids / Benicar / Trazodone / Hydrochlorothiazide / Ace
Inhibitors
Attending:[**First Name3 (LF) 6701**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy
Colonoscopy
History of Present Illness:
82 year old female breast cancer grade 1, ER/PR +, HER2/new
negative invasive carcinoma s/p excision on Arimidex, history of
UGIB [**12-29**] angiodysplasia, history of sigmoid adenoma presented
with worsening fatigue, dyspnea, and pallor x 1 week. She went
to see her doctor today because of her symptoms. However, had +
guaiac positive brown stool in the clinic. Therefore was sent
to the ED.
.
Her symptoms have been on-going x 1 week. She reports having
had some periumbilical pain, nausea, but no vomiting. She says
that her stool color has not really changed but she takes iron
pill daily. She denies seeing bright red blood in her stool or
urine. Denies any hemoptysis or hematemesis. She says that she
has not felt like this before.
.
Of note her EGD back in [**2160**] had non-bleeding angioectasias. In
her [**2157**] colonoscopy, she had adenoma with high-grade dysplasia.
She has been on omeprazole and sulcrafate.
.
In the ED, initial vitals T98.7, P60, BP138/59, RR18, O2Sat 100%
RA. Her Hct was 20 down from mid-30-40s last year. Per report
she was not orthostatic. She was noted to have guaiac + brown
stool. NG lavage was negative for blood. No fever/CP/abd
pain/vomiting/hematuria/hematuria. She has 2 18 g IV and 2
units of pRBC in the ED. She was also started on pantoprazole.
Her transfer vitals were HR 56, RR 18, O2Sat 100% on RA, BP
113/64 (SBP 110-130s)
.
On the floor, denies any discomfort other DOE and feeling
fatigued over the last week. No pain currently.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies vomiting, diarrhea,
constipation, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
.
Past Medical History:
- HTN
- breast cancer, grade 1, ER/PR +, HER2/new negative invasive
carcinoma s/p excision on Arimidex
- lumbar radiculopathy
- angiodysplasia of the stomach and duodenum
- history of shoulder pain
- atrophic vaginitis
- insomnia
- degenerative joint disease, osteoarthritis
- cataract
Social History:
- Grew up in Mission [**Doctor Last Name **], lives at home with sister
- Widowed
- has good social support from her family
- Tobacco: quit in the [**2131**]
- Alcohol: none
Family History:
- mother with parkinson's, DM, ? CAD
- father died at 90
Physical Exam:
Physical Exam on Arrival to MICU
Vitals: T: 97, BP: 132/92, P:61 R:19 O2:96% RA
General: Alert, oriented, no acute distress
HEENT: pale sclera, mucous membrane slightly dry, OP clear,
tongue also appears pale throughout
Neck: supple, JVP not elevated
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley present
Ext: cool, 2+ pulses, no clubbing, cyanosis or edema. left leg
slightly more swollen than the right, but patient resports this
has been chronic for years. No pain or palpable cord in the
popliteal fossa.
.
On discharge home:
Vitals: 94.4 156/80 66 16 94% RA
GEN:: Alert, oriented, very pale, no acute distress
HEENT: pale conjuctiva, MMM, OP clear, tongue also appears pale
throughout
NECK: supple, JVP not elevated
LUNGS: very mild crackles at both bases, does not resolve after
coughing, lungs otherwise clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: cool, 2+ pulses, no clubbing, cyanosis. No edema.
DERM: very pale skin, loss of erythema in palmar creases
NEURO: AOx3, moving all extremities, grossly nonfocal
Pertinent Results:
ADMISSION LABS:
[**2163-9-7**] 10:45AM BLOOD WBC-3.4* RBC-2.67*# Hgb-5.3*# Hct-20.4*#
MCV-76*# MCH-19.8*# MCHC-26.0*# RDW-18.6* Plt Ct-109*
[**2163-9-7**] 10:45AM BLOOD Neuts-57 Bands-3 Lymphs-32 Monos-6 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2163-9-7**] 10:45AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-2+ Polychr-1+ Target-OCCASIONAL
Schisto-OCCASIONAL Tear Dr[**Last Name (STitle) 833**]
[**2163-9-7**] 10:45AM BLOOD PT-13.5* PTT-24.2 INR(PT)-1.2*
[**2163-9-7**] 10:45AM BLOOD Glucose-94 UreaN-16 Creat-0.9 Na-141
K-4.6 Cl-107 HCO3-25 AnGap-14
[**2163-9-7**] 05:28PM BLOOD Calcium-8.4 Phos-3.4 Mg-2.0 Iron-PND
[**2163-9-7**] 10:45AM BLOOD cTropnT-<0.01
[**2163-9-7**] 10:52AM BLOOD Glucose-98 Lactate-1.0 K-4.1
[**2163-9-7**] 10:52AM BLOOD Hgb-5.8* calcHCT-17
[**2163-9-7**] 05:28PM BLOOD WBC-4.0 RBC-3.31* Hgb-7.8*# Hct-25.9*#
MCV-78* MCH-23.5*# MCHC-30.1*# RDW-18.4* Plt Ct-90*
[**2163-9-7**] 03:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
[**2163-9-7**] 03:19PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.007
.
DISCHARGE LABS:
[**2163-9-9**] 06:20AM BLOOD WBC-5.4 RBC-3.92* Hgb-9.5* Hct-32.0*
MCV-82 MCH-24.3* MCHC-29.8* RDW-18.4* Plt Ct-80*
[**2163-9-9**] 06:20AM BLOOD Glucose-87 UreaN-10 Creat-0.8 Na-142
K-4.0 Cl-110* HCO3-25 AnGap-11
[**2163-9-9**] 06:20AM BLOOD Calcium-8.7 Phos-2.9 Mg-1.9
.
MICROBIOLOGY:
Urine culture: no growth
MRSA screen: no MRSA isolated
.
OTHER STUDIES:
EKG:
Sinus rhythm. Prolonged P-R interval. Compared to the previous
tracing
of [**2161-6-20**] there is no change.
.
PORTABLE CXR:
There is new mild-to-moderate pulmonary edema. Moderate
cardiomegaly is
stable. If any, there is a small left pleural effusion. There is
no evident
pneumothorax.
.
ABDOMINAL ULTRASOUND:
CONCLUSION: Essentially normal abdominal ultrasound status post
cholecystectomy. No hepatic or splenic abnormalities.
Small bilateral effusions noted incidentally.
.
EGD:
Findings:
Esophagus:
Other Food particles in the esophagus.
Stomach:
Mucosa: Localized friability, erythema and petechiae of the
mucosa with contact bleeding were noted in the antrum. These
findings are compatible with GAVE. Argon-Plasma Coagulation was
applied successfully.
Impression: Food particles in the esophagus.
Friability, erythema and petechiae in the antrum compatible with
GAVE (thermal therapy)
Otherwise normal EGD to third part of the duodenum
Recommendations: Follow-up with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2987**] or Dr
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in 4 weeks for repeat EGD with APC.PCP f/u of hct.
Additional notes: The patient's home medication list is appended
to this report. The attending was present for the entire
procedure. FINAL DIAGNOSES are listed in the impression section
above. Estimated blood loss = zero. No specimens were taken for
pathology
.
COLONOSCOPY:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. The
efficiency of a colonoscopy in detecting lesions was discussed
with the patient and it was pointed out that a small percentage
of polyps and other lesions can be missed with the test. A
physical exam was performed. The patient was administered
moderate sedation. Supplemental oxygen was used. The patient was
placed in the left lateral decubitus position.The digital exam
was abnormal. Hemorhoids. The colonoscope was introduced through
the rectum and advanced under direct visualization until the
cecum was reached. Careful visualization of the colon was
performed as the colonoscope was withdrawn. The procedure was
somewhat difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Recommendations: Follow-up with Dr [**Last Name (STitle) 2987**] or Dr [**Last Name (STitle) 497**] to discuss
interval of colonscopy follow up.
Additional notes: The procedure was performed by the fellow and
the attending. The attending was present for the entire
procedure. Degree of difficulty 3 (5 most difficult) FINAL
DIAGNOSES are listed in the impression section above. Estimated
blood loss = zero. No specimens were taken for pathology
Brief Hospital Course:
82F with history of breast cancer on Arimidex, history of
angiodysplasia and upper GI bleed, history of high grade
dysplasia of the colonic polyp presents with dyspnea on
exertion, guiaic positive brown stool, and Hct drop from last
year.
.
ACTIVE ISSUES:
# Anemia, microcytic: The patient had no recent Hct in the [**Hospital1 **]
system but last year Hct was in the mid-30 to low 40s. She was
on no new therapy for breast cancer. Her blood smear showed
various morphologies. Per patient she was on iron supplement
but the daily amount was unclear. Chronic slow GI bleed was
considered, with recent more acute bleed likely given the
abdominal discomfort last week despite being on omeprazole and
sulcrafate. Nasogastric lavage without frank blood and guaiac
stool without melena are reassuring for the speed of the bleed.
She was initially given 2 units of pRBC for Hct 20.4 with
improvement to 25. She was placed on pantoprazole gtt and
continued home sulcrafate. She received IVF for maintenance.
GI performed EGD and colonoscopy which found antral friability,
petechiae, and erythema, consistent with GAVE, treated with
thermal therapy. She was given 2 more units of pRBCs and her Hct
was 32 on the day of discharge. Pancytopenia was noted and her
PCP may want to consider Heme consult for further work-up.
.
# Thrombocytopenia and mild leukopenia: Thrombocytopenia could
be secondary to consumption in the setting of GI bleed, but
platelets have been persistently low throughout the years based
on OMR record. Leukopenia is relatively new based on our
system; however, it is unclear if she could also have this in
her outpatient PCP's office. If so, she would have all 3 cell
lines down, concerning for bone marrow production problem. [**Name (NI) 6**]
abdominal ultrasound showed no portal congestion or splenomegaly
so sequestration is unlikely. Her PCP may want to consider Heme
consult for further workup.
.
# Insomnia: chronic; her home Ambien was held while in the MICU.
Her PCP may want to consider discontinuing Ambien given risk of
fall.
.
# History of breast cancer: she was continued on her home
Arimidex.
.
# Chronic pain/neuropathy: She was continued on gabapentin;
pharmacy advised decreasing her home gabapentin dose based on
renal function to 300 mg [**Hospital1 **], but she was sent home on her home
dose so her PCP may want to consider adjusting this.
.
TRANSITION OF CARE:
Pending results to follow up: none
Follow up appointments:
Name: [**Last Name (LF) **], [**First Name3 (LF) 1409**] PA
Specialty: INTERNAL MEDICINE
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: FRIDAY [**9-16**] AT 11:30AM
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2163-10-12**] at 10:00 AM
With: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: WEDNESDAY [**2163-10-12**] at 10:00 AM
.
CODE STATUS: DNR, okay to intubate, confirmed with the patient
.
CONTACT INFORMATION:
Name of health care proxy: [**Name (NI) **] [**Known lastname 69306**]
Relationship: Son
Phone number: [**Telephone/Fax (1) 92942**]
Proxy form in chart: No
Comments: [**Telephone/Fax (1) 92943**] cell
Medications on Admission:
per OMR and [**Hospital1 778**] note
- Arimidex 1mg daily
- gabapentin 300 mg, 2 cap qHS, 1 cap qAM
- omeprazole 40 mg [**Hospital1 **]
- sucralfate 1 gram [**Hospital1 **]
- zopidem 10 mg qHS
- calcium carbonate-vitamin D3. 500mg-200 units. 2 tabs daily
- iron tab daily
- MVI 2 centrium silver daily
- sodium chloride 1 gram [**Hospital1 **]
- Estring 2 mg ring q3 months
- lidodern 5% patch daily
Discharge Medications:
1. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
2. sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
4. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release
Sig: One (1) Capsule, Extended Release PO DAILY (Daily).
5. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
8. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
9. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM.
10. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO at
bedtime.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
- gastrointestinal bleed
.
Secondary diagnoses:
- hypertension
- breast cancer, grade 1, ER/PR +, HER2/new negative invasive
carcinoma s/p excision on Arimidex
- lumbar radiculopathy
- angiodysplasia of the stomach and duodenum
- atrophic vaginitis
- insomnia
- degenerative joint disease, osteoarthritis, R shoulder surgery
x3
- cataract
- basal cell carcinoma on back, s/p excision
- open cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 69306**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for further evaluation and
treatment of anemia (low blood level). Your blood levels were
quite low when you were admitted and your stool had hidden blood
in it as well, so you were initially given a transfusion of 2
units of blood to increase your levels. You also had a
colonoscopy and an upper endoscopy done. The upper endoscopy
showed a very fragile stomach lining which was bleeding very
slowly; heat treatment was used to cauterize the vessels to stop
the bleeding. After the procedures, you were given another blood
transfusion to increase your blood levels further since your
fragile stomach lining may start slowly bleeding again. Your
blood levels are nearly normal now, and you are being discharged
home. Because there is a chance that your stomach lining may
start slowly bleeding again, it is very important that you
follow up by keeping the appointments listed below.
.
No changes were made to your medications during your
hospitalization.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name3 (LF) 1409**] PA
Specialty: INTERNAL MEDICINE
Location: [**Hospital6 5242**] CENTER
Address: [**Location (un) 5243**], [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 798**]
Appointment: FRIDAY [**9-16**] AT 11:30AM
Department: DIGESTIVE DISEASE CENTER
When: WEDNESDAY [**2163-10-12**] at 10:00 AM
With: [**First Name8 (NamePattern2) 2671**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST Best Parking: Main Garage
Department: ENDO SUITES
When: WEDNESDAY [**2163-10-12**] at 10:00 AM
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6708**]
Completed by:[**3-6**]
|
[
"V10.83",
"338.29",
"401.9",
"790.01",
"V15.82",
"455.6",
"724.4",
"537.83",
"366.9",
"627.3",
"780.52",
"284.19",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
13595, 13601
|
8740, 8981
|
397, 421
|
14071, 14071
|
4378, 4378
|
15318, 16237
|
2897, 2956
|
12718, 13572
|
13622, 13622
|
12292, 12695
|
14222, 15295
|
5518, 8717
|
2971, 4359
|
13689, 14050
|
11178, 11183
|
1975, 2378
|
349, 359
|
8996, 11167
|
11207, 12266
|
449, 1956
|
4394, 5502
|
13641, 13668
|
14086, 14198
|
2400, 2688
|
2704, 2881
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,908
| 168,755
|
33308
|
Discharge summary
|
report
|
Admission Date: [**2122-3-24**] Discharge Date: [**2122-4-1**]
Date of Birth: [**2069-1-20**] Sex: M
Service: SURGERY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP
Placement of open cholecystostomy tube.
Placement of left femoral arterial line.
Placement of left femoral central venous line.
History of Present Illness:
53M transferred from OSH with RUQ pain, question of cholangitis,
for ERCP. Pt c/p RUQ pain for three weeks, [**4-25**], sharp,
worsening with po intake, w/o radiation. Pain at first
intermittent but starting [**2122-3-22**] became constant. No vomiting,
no diarrhea, no fevers.
.
At the OSH, a RUQ ultrasound showed multiple gallstones with
normal CBD diameter (4mm). LFTs and bili elevated and pt had
leukocytosis. Pt underwent MRCP at OSH - per verbal report to
Dr [**Last Name (STitle) 70485**] at [**Hospital1 18**] it showed "possible cholecystitis", started on
Zosyn.
ROS: No chest pain, palp. No dysuria, urgency. No weakness,
dizziness. ROS otherwise neg except as per HPI and resident
note.
Past Medical History:
CAD s/p CABG [**7-22**]
GERD
Social History:
Lives with wife. H/o tobacco x30 years, quit around time of MI
in [**7-22**]. Minimal EtOH, no IVDU.
Family History:
Mother had [**Name (NI) **] removed in last 1-2 years.
Physical Exam:
{on presentation)
VS: 98 110/82 101 16 96% RA
Gen: NAD
HEENT: PERRL, EOMI, OP clear, MM dry
CV: tachy, regular, nl S1/S2, no murmurs
Pulm: cta b/l
Abd: soft, ttp in RUQ and epigastrium, distended, quiet bowel
sounds but present, no rebound
Ext: no [**Location (un) **], good distal pulses
Pertinent Results:
[**2122-3-25**] 04:22AM BLOOD WBC-20.8* RBC-5.10 Hgb-16.1 Hct-46.3
MCV-91 MCH-31.5 MCHC-34.8 RDW-13.7 Plt Ct-221
[**2122-3-25**] 04:22AM BLOOD ALT-271* AST-144* LD(LDH)-259*
AlkPhos-282* Amylase-29 TotBili-8.3*
.
MRCP (OSH per report): possible cholecystitis
US: GB thickening, CB stones
.
[**2122-3-27**] 06:25AM BLOOD WBC-9.3 RBC-3.75* Hgb-11.8* Hct-35.0*
MCV-93 MCH-31.4 MCHC-33.7 RDW-13.8 Plt Ct-251
[**2122-3-27**] 06:25AM BLOOD Glucose-97 UreaN-17 Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-25 AnGap-15
[**2122-3-27**] 06:25AM BLOOD ALT-96* AST-35 AlkPhos-173* TotBili-1.9*
[**2122-3-26**] 01:08PM BLOOD CK-MB-4 cTropnT-<0.01
.
ECHO:
Conclusions
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. 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 Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). There is no ventricular septal defect. 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 structurally normal. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
.
ERCP [**2122-3-25**]
A 5 cm by 10 F Cotton [**Doctor Last Name **] biliary stent was placed
successfully.
Impression: 1.Normal major papilla
2. Cannulation of the biliary duct was performed with a
sphincterotome using a free-hand technique.
3. Normal biliary tree
4. Given the recent use of Plavix it was decided to place a
biliary stent, a 5 cm by 10 F Cotton [**Doctor Last Name **] biliary stent was
placed successfully.
Recommendations: NPO overnight , then advance diet as tolerated
in AM.
Remain on antibiotics for total of 7 days
Follow-up with Dr. [**Last Name (STitle) 1968**]
Consider cholecystectomy
Repeat ERCP in 2 months for stent removal.
.
PORTABLE ABDOMEN [**2122-3-30**] 8:44 AM
FINDINGS: There has been no interval change in multiple
distended small bowel loops. No supine evidence of free
intraperitoneal air is identified. The colon is nondistended.
The biliary stent is in place. Drainage tube is identified in
the pelvis.
IMPRESSION: No interval change in multiple distended small bowel
loops and nondistended colonic loops.
.
[**2122-3-30**] 08:15AM BLOOD WBC-7.1 RBC-4.37* Hgb-12.9* Hct-39.7*
MCV-91 MCH-29.5 MCHC-32.5 RDW-13.7 Plt Ct-441*
[**2122-3-30**] 08:15AM BLOOD Glucose-119* UreaN-12 Creat-0.7 Na-140
K-3.8 Cl-104 HCO3-24 AnGap-16
[**2122-3-29**] 06:10AM BLOOD ALT-80* AST-56* AlkPhos-184* Amylase-42
TotBili-0.9
[**2122-3-29**] 06:10AM BLOOD Lipase-29
[**2122-3-26**] 01:08PM BLOOD CK-MB-4 cTropnT-<0.01
[**2122-3-30**] 08:15AM BLOOD Calcium-8.4 Phos-2.2* Mg-2.0
Brief Hospital Course:
This is a 53 yo M transferred from OSH with cholangitis. At the
OSH, a RUQ ultrasound showed multiple gallstones with normal CBD
diameter (4mm). Pt underwent MRCP, the results were not
available.
.
He was started on Zosyn at OSH. He was transferred to [**Hospital1 18**] and
admitted on [**2122-3-24**]. He underwent ERCP on [**2122-3-25**] and had biliary
stent placement w/o sphincterotomy. A filling defect was seen in
his distal bile duct. ERCP showed no stones and a normal biliary
tree.
.
The Surgery service was consulted and he was referred for a lap
chole. In the pre-op area his HR was noted to be 120, BP 107/69.
Following induction of general anesthesia he dropped his SBP to
60. He required Neo just after intubation. Lap chole was not
attempted secondary to him being unstable. Phenylephrine was
started. He had a left femoral art line and CVL placed in the OR
after multiple attempts at other sites. Of note his O2sat was
maintained and his EtCO2 was normal throughout. He had an open
Cholecystostomy tube placed. He was transferred to the [**Hospital Unit Name 153**]
intubated and sedated.
.
The next day he was transferred to the [**Hospital Ward Name 517**]. His
hospital stay was prolonged due to abdominal distention with
tympany requiring him to be NPO for several days. His diet was
slowly advanced over the course of his stay on [**Hospital Ward Name 121**] following
return of normal bowel fuction. Following RBF he had several
loose stools, and in light of his previous C. diff infection he
was ruled out for a new infection x 3. The drain remained in
place during his stay and had scant output. He continued on
Zosyn due to the sepsis. Cultures obtained of his bile revealed
no PMNs and no bacteria. He was discharged on Cipro/Flagyl PO
for treatment of his cholangitis.
.
At the time of discharge, Mr. [**Known lastname 10083**] was afebrile, tolerating a
regular diet, with his usual bowel function, ambulating without
assistance, and with excellent pain control with PO pain
medication.
.
2)Transaminitis: Likely due to obstruction. Monitor, check
albumin, INR, bili.
3)CAD: CABG in [**2119**]. Stable, continue plavix, beta blocker,
aspirin.
4)Benign HTN: Stable, continue [**Last Name (un) **], on avapro at home.
5)Hyperlipidemia: Stable, continue zetia, zocor.
.
He will need a repeat ERCP in 2 months for stent removal. Given
the recent use of Plavix, stent placed in the setting of
suspected cholangitis.
Medications on Admission:
plavix
zetia
avapro
toprol
ranitidine
simvastatin
asa
zosyn
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*60 tablets* Refills:*2*
2. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
6. Ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**] - [**Location (un) 14663**]
Discharge Diagnosis:
Cholangitis and cholecystitis
Hypotension
Discharge Condition:
Stable, to home with services
Discharge Instructions:
You were admitted with Cholangitis and had an Open
Cholecystostomy Tube placed.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**9-30**] lbs) for 6 weeks.
* Monitor your incision for signs of infection
* You may shower and wash. No tub baths or swimming. Keep your
incision clean and dry.
* Continue with drain care.
.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] in 2 weeks. Please call her
office at ([**Telephone/Fax (1) 6347**] to schedule an appointment.
|
[
"414.01",
"576.1",
"458.9",
"V64.1",
"530.81",
"401.9",
"V45.81",
"574.61",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.91",
"51.03",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
8317, 8394
|
4658, 7107
|
281, 416
|
8480, 8512
|
1719, 4635
|
10213, 10365
|
1338, 1394
|
7218, 8294
|
8415, 8459
|
7133, 7195
|
8536, 10190
|
1409, 1700
|
227, 243
|
444, 1151
|
1173, 1204
|
1220, 1322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,426
| 186,470
|
19330
|
Discharge summary
|
report
|
Admission Date: [**2116-4-6**] Discharge Date: [**2116-4-16**]
Date of Birth: [**2050-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Dynspnea and tachycardia.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This 66 year old white male is s/p Coronary artery bypass with
Dr. [**First Name (STitle) **] on [**3-24**]. Hw was discharged to home on POD #4 after
an uneventful postop course. On the AM of [**4-6**], he was noted by
the VNA to have dypnea, tachycardia and was hypertensive. He was
sent to the ER. CXR revealed a moderate left pleural effusion.
He had had stopped lasix the day previous per his discharge
instructions.
Past Medical History:
s/p Coronary artery bypass surgery x3 [**2116-3-24**]
Chronic diastolic heart failure
Hypertension
Hyperlipidemia
Gastroesophageal reflux disease
Hepatitis C
s/p bilateral rotator cuff repairs [**2113**]
s/p Left shoulder surgery [**10/2114**]
s/p right shoulder surgery in [**2095**]
s/p right knee surgery x 2
Social History:
He is married with one grown child. He is currently on
disability. He drinks socially and does not smoke.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death. His father had CABG x 4 in his 60??????s.
Physical Exam:
Admission:
T:102 SR 144/72 RR 21 94% on 1.5L O2
74" 97 kg
NAD
EOMI, HEENT unremarkable
decreased BS left base to mid, CTA on right
RRR no murmur
+ BS, soft, NT, ND
trace peripheral edema, 2+ bil. DP/PTs
sternal incision healing well, no drainage or erythema, sternum
stable
Pertinent Results:
[**2116-4-12**] 07:00AM BLOOD WBC-9.4 RBC-3.55* Hgb-10.7* Hct-32.3*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.0 Plt Ct-383
[**2116-4-13**] 05:30AM BLOOD PT-34.1* PTT-87.5* INR(PT)-3.6*
[**2116-4-12**] 07:00AM BLOOD PT-33.6* PTT-75.2* INR(PT)-3.5*
[**2116-4-12**] 03:20AM BLOOD PT-39.7* PTT-83.2* INR(PT)-4.3*
[**2116-4-11**] 04:05PM BLOOD PT-31.6* PTT-73.2* INR(PT)-3.3*
[**2116-4-11**] 09:44AM BLOOD PT-32.2* PTT-75.3* INR(PT)-3.3*
[**2116-4-11**] 03:17AM BLOOD PT-45.8* PTT-103.5* INR(PT)-5.1*
[**2116-4-13**] 05:30AM BLOOD PT-34.1* PTT-87.5* INR(PT)-3.6*
[**2116-4-14**] 05:40AM BLOOD PT-35.6* PTT-81.9* INR(PT)-3.8*
[**2116-4-16**] 05:45AM BLOOD WBC-9.6 RBC-4.07* Hgb-11.6* Hct-36.1*
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.1 Plt Ct-548*
[**2116-4-16**] 05:45AM BLOOD PT-27.6* PTT-38.4* INR(PT)-2.8*
[**2116-4-16**] 05:45AM BLOOD Glucose-96 UreaN-15 Creat-1.1 Na-139
K-4.7 Cl-104 HCO3-25 AnGap-15
Brief Hospital Course:
He was admitted [**4-6**] for workup and evaluation. IV lasix was
started and beta blockade was titrated. CTA of chest showed
bilateral pulmonary emboli. Heparin was started, however, on the
evening of [**4-7**], he developed rigors, dyspnea and decreasing O2
saturation. He became tachypneic with mottled extremities and
wheezing. A blood gas was sent. A CXR demonstrated no change
from the previous( LLL atelectasis with resolution of the
effusion). He was transferred to the CVICU for closer
monitoring. Heparin was vtopped for decreasing platelets and
argatroban started. A HIT panel was positive.
Argatroban was continued, the patient felt well in all regards.
His PTT was maintained between 60 and 90 seconds and Coumadin
was begun after several days. These were run concommitently for
5 days. By hospital day 11, his INR off argatroban was 2.8 and
he was therefore okayed to go home by hematology on coumadin. He
was discharged to home with the plan to have an INR drawn the
following day by the visiting nurses association with the
results sent to the office of Dr. [**Last Name (STitle) 11616**]. This plan was
confirmed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52621**] from Dr.[**Name (NI) 52622**] office.
Medications on Admission:
lopressor 75 mg TID
colace 100 mg [**Hospital1 **]
ASA 81 mg daily
MVI daily
HCTZ 25 mg daily
lipitor 10 mg daily
omperazole 20 mg daily
LD lasix [**4-5**]
LD KCl [**4-5**]
naprosyn 500 mg prn
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12
hours) as needed.
7. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4H (every 4 hours) as needed.
Disp:*1 mdi* Refills:*2*
8. Outpatient Lab Work
INR draw to be done [**2116-4-17**] and sent to the office of Dr. [**Last Name (STitle) 11616**]
at p([**Telephone/Fax (1) 13239**]/f([**Telephone/Fax (1) 52623**]. Plan confirmed with [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) 52621**] on [**2116-4-17**].
9. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
11. Coumadin 5 mg Tablet Sig: 1.5 Tablets PO once a day: take
7.5mg daily or as directed by the office of Dr. [**Last Name (STitle) 11616**] at
p([**Telephone/Fax (1) 13239**]. INR goal of 2.5-3 for pulmonary embolie per
hematology. INR draw to be done [**2116-4-17**] and sent to the office of
Dr. [**Last Name (STitle) 11616**]. .
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
bilateral pulmonary emboli
chronic diastolic heart failure
s/p Coronary artery bypass grafting [**2116-3-24**]
Hypertension
Hyperlipidemia
gastroesophageal reflux disease
Hepatitis C
Discharge Condition:
good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness of,
drainage from or increased pain of incisions.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision until it has healed.
Shower daily, no bathing or swimming for 1 month.
No lifting greater then 10 pounds for 10 weeks from date of
surgery.
No driving for 1 month or while taking narcotics for pain.
Take all medications as directed.
Followup Instructions:
Dr. [**First Name (STitle) **] in 2 weeks([**Telephone/Fax (1) 1504**]
Dr. [**Last Name (STitle) 73**] in 2 weeks.
Dr. [**Last Name (STitle) 11616**] (PCP)in [**2116-5-12**] 2:45 ([**Telephone/Fax (1) 7976**])
Nurse [**Last Name (Titles) **] ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52621**] for coumadin follow-up) [**2116-5-5**] 2:30
([**Telephone/Fax (1) 7976**])
INR draw to be done [**2116-4-17**] and sent to the office of Dr. [**Last Name (STitle) 11616**]
at p([**Telephone/Fax (1) 13239**]/f([**Telephone/Fax (1) 52623**]. INR goal of 2.5-3 for
pulmonary emboli. Plan confirmed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52621**] on [**2116-4-17**].
[**Hospital 17902**] clinic within the month ([**Telephone/Fax (1) 52624**].
Please call all providers to make appointments.
You have an appointment with Dr [**Last Name (STitle) **] [**7-14**] at 1100 hrs.
He will do NIVS at this time. His number is [**Telephone/Fax (1) 1241**]. [**Hospital Ward Name **]
Buiding. [**Location (un) 442**]. Suite A. [**Last Name (NamePattern1) 439**].
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2116-4-16**]
|
[
"530.81",
"276.8",
"428.0",
"453.41",
"415.19",
"289.84",
"414.01",
"272.4",
"401.9",
"070.70",
"356.9",
"453.42",
"511.9",
"428.32",
"E934.2",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5619, 5677
|
2594, 3845
|
305, 313
|
5905, 5912
|
1684, 2571
|
6454, 7670
|
1242, 1371
|
4089, 5596
|
5698, 5884
|
3871, 4066
|
5936, 6431
|
1386, 1665
|
239, 266
|
341, 764
|
786, 1102
|
1118, 1226
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,105
| 159,957
|
46621
|
Discharge summary
|
report
|
Admission Date: [**2105-11-13**] Discharge Date: [**2105-11-26**]
Service: MEDICINE
Allergies:
Darvon
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
Tracheal intubation
Central Line Placement
History of Present Illness:
[**Age over 90 **]-year-old man with dementia, hemolytic anemia, HTN, recent
UGIB, was transferred from [**Hospital3 2558**] nursing home after
being found on the floor with respiratory distress. BP 99/58, HR
106, O2 sat 90% -> improved to 94% with suctioning. Patient was
alert and oriented x 2, similar to baseline.
.
Of note, patient was discharged from [**Hospital1 18**] on [**2105-11-6**] after
6-day admission for duodenal bleed. Hct was in mid-20s on
discharge.
.
On presentation to [**Hospital1 18**] ED, rectal temp 100.6, HR 106, 97/58,
RR 17, O2 sat 100% on NRB. He was dyspneic with rhonchi
throughout on exam. CXR was unremarkable, but WBC was 13 with a
left shift. ABG was 7.51/28/207. Patient was intubated due to
increased work of breathing. Post-intubation CXR showed ET tube
in proper location. NGT was placed. SBP transiently dropped to
80s, improved quickly with IVF boluses. Was given vancomycin
1000 mg IV x 1 and pip-tazo 4.5 gm IV x 1.
Past Medical History:
Coombs negative hemolytic anemia
HTN
Degenerative disc disease
Anxiety, depression
Glaucoma
Duodenal ulcers
TURP [**2076**]
Cholecystectomy [**2076**]
Bilateral inguinal hernia repairs
Appendectomy
Arthrodesis T9-L1 [**6-/2105**]
Social History:
He is married and lived with his wife in [**Name (NI) 583**] up until
recent hospitalization and stay at rehab. He has no children. No
history of EtOH, tobacco, illicit drugs. Is a retired [**Hospital **]
hospital administrator.
Wife is on dialysis, [**Age over 90 **] yrs old, but very active and
independent.
Family History:
Mother with history of UC
Physical Exam:
GEN: elderly man, intubated
HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP
moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
ON ADMISSION:
[**2105-11-13**] 10:20AM BLOOD WBC-13.0*# RBC-2.40* Hgb-7.8* Hct-23.4*
MCV-98 MCH-32.4* MCHC-33.2 RDW-21.3* Plt Ct-397
[**2105-11-13**] 10:20AM BLOOD Neuts-91.6* Lymphs-3.7* Monos-4.1 Eos-0.5
Baso-0.1
[**2105-11-13**] 10:20AM BLOOD PT-12.6 PTT-29.2 INR(PT)-1.1
[**2105-11-13**] 10:20AM BLOOD Glucose-93 UreaN-37* Creat-2.2* Na-144
K-3.9 Cl-110* HCO3-22 AnGap-16
[**2105-11-13**] 10:20AM BLOOD ALT-23 AST-27 LD(LDH)-310* CK(CPK)-64
AlkPhos-50 TotBili-2.3*
[**2105-11-13**] 10:20AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.9
[**2105-11-13**] 10:20AM BLOOD Cortsol-24.6*
[**2105-11-13**] 11:27AM BLOOD Lactate-1.0
CARDIAC
[**2105-11-13**] 10:20AM BLOOD CK-MB-NotDone
[**2105-11-13**] 10:20AM BLOOD cTropnT-0.09*
[**2105-11-13**] 08:34PM BLOOD CK-MB-NotDone cTropnT-0.07*
[**2105-11-14**] 04:04AM BLOOD CK-MB-4 cTropnT-0.06*
RETICS
[**2105-11-16**] 04:24AM BLOOD Ret Aut-4.0*
DRUG MONITORING
[**2105-11-18**] 05:59AM BLOOD Vanco-21.7*
[**2105-11-13**] CT head 1. No acute intracranial hemorrhage. 2. Brain
atrophy.
3. Soft tissue density in bilateral external auditory canals,
likely reflects cerumen- recommend correlation with direct
visualization.
NOTE AT ATTENDING REVIEW: An alternative explanation for the
supratentorial ventricular dilatation is communicating
hydrocephalus. In any case, the ventricular dilatation, as noted
above, is stable since the earliest available scan, from [**2103-8-21**].
[**2105-11-13**] CXR:
Bibasilar atelectasis and pleural effusions with no evidence of
an acute
pulmonary process. There right humeral head appears inferiorly
subluxed,
unchaged from prior examination and clinical correlation is
recomended.
Brief Hospital Course:
1. Respiratory distress/sepsis: related to likely pulmonary
infection, though no evidence of pneumonia by chest xray.
Intubated and required pressors for several days, and ultimately
completed a 7 day course of Vancomycin/Zosyn. Mr. [**Known lastname **] had
significant difficulty managing and clearing secretions and had
several episodes of aspiration with respiratory diress/hypoxia
during his course. Aspiration pneumonia/pneumonitis is a likely
cause of his presentation. His suctioning requirement increased
toward the end of his course, and after discussion with his
wife, the decision was made to make him CMO rather than transfer
to the ICU for aggressive pulmonary care. Mr. [**Known lastname **] died on
[**2105-11-26**].
2. Agitation/delirium: due to medical illness, complicated by
recurrent aspiration events. Nonpharmacologic meaures were
employed, as well as antipsychotic medications. This worsened
despite attention to multiple medical conditions. Geriatrics
team consulted.
3. Tachycardia: intermittent runs of SVT and sinus with PACs.
Persistent over the last 48 hours of his course, associated with
hypovolemia, electrolyte abnormalities and agitation.
4. Anemia: had bleeding duodenal ulcers on previous
hospitalization. Presented with a low HCT and was transfused 3
units of prbc. Hemolysis parameters did not indicate ongoing
hemolysis as cause of anemia. He was continued on prednisone
and danazol as he was able to take. When unable to take po
prednisone, was given IV solumedrol at equivalent dose.
5. BPH/Yeast UTI: had traumatically inserted catheter with
cystoscopic guidance by urology at admission. Urine became
dark/cloudy with pyuria. Persistently grew yeast. Given ongoing
altered mental status, and decision made to treat with
fluconazole.
6. Positive troponin: during time of respiratory
distress/intubation--more likely the result of the acute insult,
not the cause given that CK remained normal. Not a candidate for
aspirin given ulcerations. ECG demonstrated <1mm STD in V4 only
at admission.
7. Acute renal failure on chronic renal insufficiency: during
the course, he remained volume sensitive. Improved with
resuscitation.
8. FEN: had video swallow on [**11-23**] which cleared him for
ground/thickened liquids. The patient was able to tolerate
applesauce/pills well. Despite this, he continued to aspirate
and could not clear secretions (see above)
9. Disposition: Mr. [**Known lastname **] was made CMO by his wife on [**2105-11-25**]
and expired on [**2105-11-26**].
Medications on Admission:
docusate
senna
hep SC
danazol 400 mg [**Hospital1 **]
prednisone 10 mg qday
fluoxetine 20 mg qday
timolol maleate 0.5% 1 drop [**Hospital1 **]
folate 5 mg qday
zolpidem 5 mg qhs prn
acetaminophen prn
pantoprazole 40 mg PO bid
amoxicillin 1000 mg Q12H until [**2105-11-17**]
clarithromycin 500 mg [**Hospital1 **] until [**2105-11-17**]
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Acute respiratory failure
Hypotension
Severe sepsis with organ dysfunction
Altered mental status
Acute blood loss anemia from GI bleed
Acute renal failure on chronic renal insufficiency
Secondary:
Hemolytic anemia
Benign prostatic hypertrophy
Duodenal Ulcers
Hypertension
Glaucoma
Anxiety
Depression
Discharge Condition:
Deceased
Discharge Instructions:
NA
Followup Instructions:
NA
|
[
"428.0",
"458.8",
"117.9",
"518.81",
"995.92",
"285.1",
"584.5",
"038.9",
"V58.67",
"507.0",
"403.90",
"E932.0",
"283.9",
"787.20",
"780.09",
"585.9",
"428.23",
"578.9",
"427.0",
"249.00",
"E928.9",
"294.8",
"867.0",
"600.00",
"276.3",
"V66.7",
"599.70",
"532.90",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.72",
"96.04",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6882, 6891
|
3932, 6463
|
236, 280
|
7245, 7256
|
2253, 2253
|
7307, 7313
|
1870, 1897
|
6850, 6859
|
6912, 7224
|
6489, 6827
|
7280, 7284
|
1912, 2234
|
176, 198
|
308, 1271
|
2267, 3909
|
1293, 1525
|
1541, 1854
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,095
| 193,118
|
33601
|
Discharge summary
|
report
|
Admission Date: [**2180-7-11**] Discharge Date: [**2180-7-20**]
Date of Birth: [**2118-8-18**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
T3N1 esophageal cancer
Major Surgical or Invasive Procedure:
esophagectomy
History of Present Illness:
The patient is a 61-year-old male
who was diagnosed with esophageal cancer going from around 35
cm from the incisors to around 45 cm, who was deemed to be a
radiological and clinical stage of T3N1 possibly N1BC. The
patient received preoperative chemo-radiation therapy and did
exhibit a very good sign of response and therefore was
elected to undergo a McCune procedure for a transthoracic
esophagectomy.
Past Medical History:
CAD s/p CABG [**11-19**](EF55% 12/07), hyperlipidemia, atrial
fibrillation(coumadin), HTN, IDDM, anemia
.
Social History:
Lives in two story house. Spouse and two youngest children live
on [**Location (un) 448**] while he lives on [**Location (un) 1773**] with stepson and
family friend. [**Name (NI) **] is a retired sportswriter with no history of
drug, alcohol or smoking problems.
Family History:
Noncontributory.
Physical Exam:
Afebrile, Vital Signs Stable
General-NAD, AAOx3
HEENT-PERRL
CVP-Regular rate and rhythm; no murmurs, rubs or gallops; lungs
clear to auscultation bilaterally.
Abdomen-soft, NT/ND, BS +
Wound incisions all clean, dry and intact.
Pertinent Results:
[**2180-7-11**] 05:52PM BLOOD WBC-11.7*# RBC-3.45* Hgb-9.9* Hct-29.5*
MCV-85 MCH-28.6 MCHC-33.4 RDW-16.5* Plt Ct-261
[**2180-7-19**] 06:45AM BLOOD WBC-9.8 RBC-3.23* Hgb-9.1* Hct-28.6*
MCV-89 MCH-28.2 MCHC-31.8 RDW-16.8* Plt Ct-270
[**2180-7-11**] 05:52PM BLOOD Glucose-180* UreaN-14 Creat-0.8 Na-138
K-4.0 Cl-104 HCO3-24 AnGap-14
[**2180-7-19**] 06:45AM BLOOD Glucose-216* UreaN-27* Creat-0.8 Na-134
K-4.1 Cl-97 HCO3-28 AnGap-13
[**2180-7-16**] 01:52AM BLOOD Type-ART pO2-104 pCO2-39 pH-7.47*
calTCO2-29 Base XS-4
Brief Hospital Course:
The patient is a 61 year old Male who is status post a
'three-hole' esophagectomy (R thoracotomy, L cervical [**Last Name (un) 1236**].,
upper midline incision) on [**7-11**] for esophageal cancer (stage
T3N1M1) s/p chemotherapy and radiation. On [**7-11**], the patient had
postoperative low urine output (10-15 cc/hr) and was bolused
with IV fluids. On [**7-12**], he was extubated with no immediate
complications. On [**7-13**], the patient went into atrial
fibrillation with rapid ventricular rate and was given lopressor
5mg IV x3 and Diltiazem gtt before rate control was achieved.
later that day the patient desaturated to 86% but improved with
facemask oxygen, nebulizers and suctioning. Dilt was d/c'd and
pt was treated w/ po amiodarone and diuresis. The patient also
had a fever of 101.8 overnight and was pancultured along with
being placed on Vancomycin and Zosyn which were d/c'd when the
cultures wer eneg. fver was attributed to atelectasis.
On [**7-14**], the patient received 1 unit of Packed Red Blood cells
and received lasix to prevent volume overload. On [**7-15**], further
transfusions were held due to suspected febrile transfusion
reaction-work up was negative for transfusion rxn.
On [**7-16**], the patient had his right chest tube removed and was
transferred to the floor for ongoing post op care.
For the rest of his hospital stay, the patient gradually
improved clinically, was [**Last Name (un) 1815**] full liquid diet and tube feeds
at goal. He remains below his baseline ambulatory function. He
will also need ongoing PT and assistance with feeding tube
management.
Medications on Admission:
ASA 81, Colace, Coumadin (held), Hytrin 5, novolog 12/lantus 32
am/pm, lasix 40 , prilosec, Toprol XL 150, Zetia, Zocor,
Simvastatin 80, neferex 150 (twice a day).
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (un) **]: One (1)
Injection TID (3 times a day).
2. Ipratropium Bromide 0.02 % Solution [**Last Name (un) **]: One (1) Inhalation
Q6H (every 6 hours).
3. Amiodarone 200 mg Tablet [**Last Name (un) **]: One (1) Tablet PO BID (2 times
a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (un) **]: One (1) Inhalation Q6H (every 6 hours).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (un) **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Ezetimibe 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
8. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
9. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: Twenty (20) ml PO Q6H
(every 6 hours) as needed for fever.
10. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: Three (3) ML
Miscellaneous Q6H (every 6 hours) as needed.
11. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: Ten (10) ml PO BID (2
times a day).
12. Polyethylene Glycol 3350 100 % Powder [**Last Name (STitle) **]: Seventeen (17) g
PO DAILY (Daily) as needed.
13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution [**Last Name (STitle) **]: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
14. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Fifteen (15) ML PO Q8H
(every 8 hours) as needed for constipation.
15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
[**Last Name (STitle) **]: 1.5 Tablet Sustained Release 24 hrs PO DAILY (Daily).
16. Terazosin 5 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO HS (at
bedtime).
17. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
18. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
19. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
Indwelling Port (e.g. Portacath), non-heparin dependent: Flush
with 10 mL Normal Saline daily, PRN, and when de-accessing, per
lumen.
20. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
21. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Indwelling Port (e.g. Portacath), heparin dependent: Flush with
10 mL Normal Saline followed by Heparin as above daily and PRN
per lumen.
22. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
23. Oxycodone 5 mg/5 mL Solution [**Last Name (STitle) **]: 5-10mls mg PO Q4H (every 4
hours) as needed.
24. tubefeeds
replete w/ fiber at 80cc/hr
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) **] Center - [**Location (un) 701**]
Discharge Diagnosis:
T3N1M1 esophageal adenocarcinoma status post chemotherapy and
radiation and status/post three hole esophagectomy.
Discharge Condition:
deconditioned
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if you develop chest pain,
shortness of breath, fever, chills, nausea, vomiting, diarrhea
or any symptoms that concern you.
If your J-tube sutures become loose or break, please tape
securely and call the office to be seen so the tube can be
re-sutured.
If the feeding tube clogs- please mix one tablespoon of meat
tenderizer dissolved in warm water and repeatedly try to instill
until unclogged.
Flush with 50cc of water every 8hrs and before and after each
feeding or medication.
Followup Instructions:
You have a barium swallow on thusday [**2180-7-27**] at 11am on the [**First Name9 (NamePattern2) 77858**] [**Location **] clinical cneter [**Location (un) **] radiology. DO NOT eat
after midnight on wednesday.
You have a follow up appointment with Dr. [**Last Name (STitle) **]/[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4129**]
NP on thursday [**2180-7-27**] 1:30pm on the [**Hospital Ward Name **] [**Hospital Ward Name **] [**Location (un) 8939**].
Completed by:[**2180-7-21**]
|
[
"414.00",
"V58.61",
"272.4",
"250.00",
"486",
"427.31",
"V45.81",
"401.9",
"276.6",
"285.9",
"150.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.29",
"44.29",
"45.13",
"40.3",
"99.04",
"42.40",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
6764, 6845
|
2045, 3651
|
344, 360
|
7003, 7019
|
1505, 2022
|
7620, 8123
|
1223, 1241
|
3866, 6741
|
6866, 6982
|
3677, 3843
|
7043, 7597
|
1256, 1486
|
282, 306
|
388, 797
|
819, 927
|
943, 1207
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,591
| 102,710
|
51679
|
Discharge summary
|
report
|
Admission Date: [**2116-10-2**] Discharge Date: [**2116-10-12**]
Date of Birth: [**2037-8-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 10842**]
Chief Complaint:
ICD Firing x4 times
Major Surgical or Invasive Procedure:
VT ablation
ICD interrogation
History of Present Illness:
HPI: 79M with CAD, ischemic cardiomyopathy EF = 20%, VT--s/p
ablation, BiV/ICD placement, CRI, hypertension and
hyperlipidemia p/w ICD firing. Pt admitted in [**2-1**] for ICD
firing, interrogation found to be ATP of SVT; ICD reset to avoid
ATP. Over past month, has felt weak, fatigued, and with
decreased PO intake. Today, felt slight fever, and vomited x 2
(watery, non-bloody) when attempted PO intake. No abd pain,
Nausea, LH, CP, or diarrhea. Pt has chronic SOB, and chronic
cough [**1-1**] COPD, unchanged. Last night, while laying in bed, ICD
fired at 10PM 1 time lightly, then 15 min later fired 3 more
times that were "sharp." Pt denied any symptoms following.
*
In ED, found to have Cr elevated at 5.2, with K 6.2, and Dig
3.9. Given CaGluc, Kayexelate 30mg, and D50/Insulin.
Past Medical History:
PMH:
-- CAD s/p CABG [**2109**]
-- CHF (Class II-III)
-- h/o VT s/p ablation AICD placement
-- HTN
-- hyperlipidemia
-- pAF (DCCV [**1-31**])
-- COPD(180 py tobacco)
-- GOUT
-- 3+ MR
-- CRI (bl cr 1.5-2.0)
Social History:
SOCHx:
180py tobacco, EtOH 1-2drinks/day, primary caretaker for
demented wife,
Family History:
NC
Physical Exam:
VS: Tm98.4 BP90-116/56-70 HR69-72 RR18-20 o2sat: 94-98%RA
Is/Os [**Telephone/Fax (1) 107065**]
GEN: NAD
HEENT: PERRL. EOMI.
NECK: O/P clear. No erythema/exudate
CV: Regular, nml s1,s2. +systolic murmur at RUSB.
RESP: CTAB. Moving air well.
ABD: Soft. NTND. +BS. No TTP
EXT: No edema bilat. +Chronic skin changes
SKIN: Resolving bruise on lower lip. Scattered healing bruises
on legs bilat.
Pertinent Results:
[**2116-10-7**] 06:35AM BLOOD WBC-8.3 RBC-3.57* Hgb-10.9* Hct-33.8*
MCV-95 MCH-30.6 MCHC-32.3 RDW-16.4* Plt Ct-163
[**2116-10-7**] 06:35AM BLOOD Plt Ct-163
[**2116-10-5**] 07:30PM BLOOD PT-13.3 PTT-44.8* INR(PT)-1.2
[**2116-10-7**] 06:35AM BLOOD Glucose-138* UreaN-55* Creat-2.0* Na-147*
K-4.8 Cl-112* HCO3-25 AnGap-15
[**2116-10-2**] 06:00AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2116-10-1**] 11:30PM BLOOD cTropnT-0.08*
[**2116-10-4**] 06:55AM BLOOD calTIBC-182* VitB12-256 Folate-5.8
Ferritn-67 TRF-140*
[**2116-10-7**] 06:35AM BLOOD Digoxin-1.3
.
Shoulder Xray [**10-2**]
RIGHT SHOULDER, THREE VIEWS: No fracture or dislocation is
identified. There is mild degenerative change of the
glenohumeral joint. Local evidence for several loose bodies in
the glenohumeral joint. There is mild calcific tendonitis of the
supraspinatus tendon. The visualized lung is clear.
.
IMPRESSION: No evidence of fracture.
.
CT Head [**10-2**]
IMPRESSION: No acute intracranial hemorrhage.
.
Renal U/S [**10-3**]
IMPRESSION: Multiple bilateral renal cysts. No hydronephrosis or
stones.
.
CXR [**10-3**]
Moderate cardiomegaly has progressed and maybe a slight increase
in atelectasis or new dependent left pleural effusion, but there
is not a substantial change in the radiographic appearance in
that area. Borderline interstitial edema is seen in the right
lower lung. The upper lungs are clear. Hyperinflation indicates
COPD. There is a calcified apical ventricular aneurysm. The
courses of the intended right atrial and left ventricular pacers
and right ventricular pacer defibrillator leads are unchanged.
There is no obvious discontinuity in any of the electrodes. No
pneumothorax or mediastinal widening.
Brief Hospital Course:
A/P: 79M PMH BiV/ICD, CHF--EF 20%, CAD--s/p CABG, CRI (BL Cr 1.5
- 2), p/w ICD firing in the setting of acute renal failure.
*
CARDIAC:
A. Cor: No chest pain throughout this admission.
--Continued ASA, Bblocker, statin, ACE
*
B. Pump: EF 20%, likely [**1-1**] CAD.
Pt with a h/o CHF with an EF of 20%. Pt on ASA/Bblocker,
statin, ACE, Aldactone, Digoxin, Lasix prior to admission. On
admission, digoxin level supratherapeutic and patient found to
be in ARF with a Cr of 5.2 likely due to dehydration/prerenal
azotemia. Held diuretics and Digoxin on admission. Bblocker
was initially held due to ? decompensated CHF but was quickly
restarted and titrated up to pre-admission levels.
IVFs were started for his prerenal ARF and patient's Cr rapidly
decreased over 3 days back to his baseline Cr of [**1-1**].2. Pt's
diuretics were restarted on HD#3, and patient continued to be
euvolemic until day of discharge.
Pt discharged on home dose of ASA, Bblocker, statin, Aldactone,
Lasix. Digoxin continued to be held on discharge.
*
C. Rhythm: Paced rhythm, with widened QRS likely due to
hyperkalemia/acidosis on admission. Pt felt ICD firing 4 times
at home, and called EMS to bring him to [**Hospital1 18**]. On interrogation
of his pacer by the EP team, pt was found to have been in Vfib
arrest s/p ICD firing x10 times, with the pacer timing out afte
10 shocks. Pt had been in vfib arrest after the 10th shock, but
spontaneously returned to NSR.
- Pt was continued on telemetry during admission. Pt had an
episode of asymptomatic 10 beat run of NSVT on HD#2. Pt was
counseled on his options and chose to go for VT Ablation as he
had had this procedure previously. On HD#6, pt was taken for VT
ablation which was unsuccessful, as in the [**Name (NI) 13042**] pt had 3 runs of
NSVT that were shocked back into NSR by the patient's ICD. Pt
at the time was on a low dose dopamine drip, and it was thought
the catecholamine action was causing the NSVT. The drip was
d/c'ed and a lidocaine drip was started, and patient was
transferred to the CCU to be observed overnight. There were no
issues overnight, and patient was weaned off the lidocaine drip
and transferred to the floor. On the floor over the weekend
prior to discharge, pt had an asymptomatic 40 beat of NSVT while
ambulating with PT. Pt was asymptomatical without any other
c/o's. EP evaluated the patient and it was decided to add
mexiletine 150mg po bid to his current regimen of amiodarone
400mg po qD and Toprol XL 50mg qD.
- EP did not think pt needed DFT evaluation as his ICD fired
successfully 3 times in the [**Name (NI) 13042**]. On discharge, pt was sent out
on Amiodarone 400mg po qD x2 weeks --> amiodarone 200mg qday
standing dose, mexiletine 150mg po qd, and Toprol XL 50mg qD.
*
RENAL FAILURE: No apparent etiology, but likely pre-renal due to
poor PO hydration and increased BUN/Cr ratio.
- Urine lytes c/w prerenal state. IVFs were started on
admission, and Cr decreased quickly back to baseline with his
hydration. On HD#3, pt's Cr back to 2.1 his baseline.
- Diuretics were restarted gingerly, and titrated up to
pre-admission levels. Creatinine increased s/p diuretic
addition to 2.7 on discharge. Pt will follow creatinine levels
as outpatient with PCP.
[**Name Initial (NameIs) **] [**Name11 (NameIs) **] sign of volume overload during this admission - euvolemic
on discharge.
*
ANEMIA:
- Pt's hct on admission 35, decreased to 30 on HD#2 thought
likely to hydration from a hemoconcentrated state. However on
HD#4, pt's hct decreased to 26 and with his CAD h/o, was
transfused 1u pRBC which increased his hct to 35 post
transfusion. Hct 28 on discharge.
- Pt had iron studies, vit b12, folate studies which showed MCV
97, Ferritin 67, on feso4 325 qd, nml vit b12, folate levels.
Iron was continued during this admission. It was thought that
likely CRI contributing to chronic anemia.
- Pt with hct of 28 on discharge, stable x3 days.
*
COPD: PRN albuterol, o2 as needed. No intervention needed this
admission.
*
DISPO: Full Code. Pt was evaluated by PT/OT who thought due to
his unsteadiness as well as his primary responsibility of caring
for his wife, who is currently in rehab herself, pt would
benefit from rehab stay. Pt was sent to rehab s/p EPS/VT
ablation.
Medications on Admission:
Amiodarone 200mg daily
Allopurinol 150mg daily
ASA 81mg daily
Aldactone 25mg daily
Coumadin 5mg daily
Digoxin .25mg daily
Flomax .4mg daily
Lasix 40mg daily
Lipitor 40mg daily
Toprol XL 50mg daily
Ferrous Sulfate 5gr tablets tid
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
7. Flomax 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO once a day.
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
8. Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO once a day.
Disp:*15 Tablet(s)* Refills:*2*
9. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Please start on [**10-23**] after completed course of amiodarone 400mg
qday x12days.
Disp:*30 Tablet(s)* Refills:*2*
11. Mexiletine 150 mg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) inhalation Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 6-8 hours as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
14. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Governor [**Location (un) 4628**] Nursing Center - [**Location (un) 4628**]
Discharge Diagnosis:
ICD firing due to V.fib
NSVT s/p VT ablation
ARF
.
CAD
CHF EF 20%
VT s/p ablation/ICD s/p re-VT ablation this admission
CRI
HTN
Hyperchol
Discharge Condition:
Afebrile, chest pain free, stable to be discharged to rehab.
Discharge Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 1147**] in 1 month after
discharge. Call ([**2116**] to scheduled that appointment.
Follow up with your device clinic appointment as below.
.
2. Please take your medications as below.
.
3. Monitor INR levels 2x/week until therapeutic on coumadin -
goal INR [**1-2**].
.
4. If develop chest pain, shortness of breath, fainting,
defibrillator firing, or any other sx's, please call your doctor
or report to the nearest ER.
.
5. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet. Fluid Restriction: <2L per day
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2117-1-18**]
1:00
Completed by:[**2116-10-12**]
|
[
"427.41",
"272.4",
"402.91",
"496",
"427.31",
"424.0",
"427.1",
"276.51",
"414.8",
"276.2",
"585.9",
"428.0",
"428.22",
"V58.61",
"276.7",
"584.9",
"274.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"99.04",
"00.17",
"37.34",
"37.27",
"37.26"
] |
icd9pcs
|
[
[
[]
]
] |
9935, 10037
|
3677, 7949
|
337, 369
|
10219, 10282
|
1959, 3654
|
10946, 11086
|
1529, 1533
|
8229, 9912
|
10058, 10198
|
7975, 8206
|
10306, 10923
|
1548, 1940
|
278, 299
|
397, 1186
|
1208, 1416
|
1432, 1513
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,188
| 116,218
|
15180
|
Discharge summary
|
report
|
Admission Date: [**2163-11-1**] Discharge Date: [**2163-11-7**]
Date of Birth: [**2085-4-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old man
with non-small cell lung cancer with a history of left
main stem stent and surrounding fibrosis and scarring, status
post multiple removals, who presents now with dyspnea on
exertion.
The patient is status post chemotherapy and XRT with stent
placement in his left main stem bronchus. This has migrated
and caused dyspnea on exertion on prior admissions. Patient
underwent bronchoscopy in [**9-/2162**] which demonstrated moderate
narrowing and distortion in the takeoff in the right main
stem bronchus. The metal stent in the left main stem
bronchus had moderate narrowing. The patient underwent
dilation of the left main stem bronchus.
Since then, the patient has undergone multiple
bronchoscopies. At baseline, he has clear white sputum, no
fever or chills, positive cough, worse on the left side. The
patient denies chest pain, minimal night sweats. His weight
has been stable. GI review of systems was negative. At
baseline, he can walk approximately 45 minutes and can climb
approximately three flights of stairs. The patient does note
hemoptysis, mild hoarseness.
PAST MEDICAL HISTORY:
1. Non-small cell lung cancer, diagnosed in [**2159**], status post
radiation, Taxol, and carboplatin x6 months, Navelbine and
carboplatin x12 months in [**2160**] for increased PET activity.
Patient is status post stent placement in the left main stem
bronchus with migration, fibrosis, scarring, now 90% removed,
status post multiple rigid bronchoscopies.
2. Colon cancer, diagnosed in [**2158**], status post resection of
polyp with positive lymph nodes, recurrent in [**2163**], treated
with laser.
3. Pericardial effusion, status post window in [**2161**].
4. Gastroesophageal reflux disease.
5. Benign prostatic hypertrophy status post transurethral
resection of the prostate x2.
6. Appendectomy.
7. Hernia repair.
ALLERGIES: Penicillin which causes rash and hives.
SOCIAL HISTORY: He is a retired General. He lives in
[**State 108**]. He has a remote history of tobacco with a 60 pack
year history, but has not smoked for 20 years. He drinks
approximately two drinks per week. Denies illicit drug use.
FAMILY HISTORY: [**Name (NI) **] mother died of heart disease in
her 40s. Father died at 54 of pneumonia and patient's sister
died of a cerebrovascular accident.
PHYSICAL EXAMINATION: Temperature 97.6, heart rate 95-99,
blood pressure 110-125/78-60. General: Patient is in no
apparent distress. Cardiovascular: Regular rate and rhythm
with no murmurs, rubs, or gallops appreciated on examination.
Pulmonary: Bilateral wheezes and rhonchi throughout.
Extremities: No edema, warm, 1+ DP and PT pulses.
Neurologic: Patient was alert and oriented times three.
HOSPITAL COURSE: The patient was admitted for bronchoscopy.
He underwent flexible rigid bronchoscopy. He underwent
balloon dilation of his lateral main stem bronchi to 12 mm in
maximum diameter. He underwent therapeutic aspiration of
secretions in both lower lobes with lavage of sterile saline
until clear. He underwent application of mitomycin-C, in his
right main stem bronchus. Bronchoscopy revealed benign
bronchial stenosis secondary to radiation and stent placement
at outside hospital.
The patient was then admitted to the MICU service, at which
time he was intubated on assist control. The patient was
treated with prednisone and antibiotics status post
bronchoscopy. The patient did have an episode of
hypertension in the MICU, which was treated with IV saline
bolus. However, overall, he was stable and was then
transferred to the Medicine floor for further management.
Patient was continued on a course of prednisone and
antibiotics. He remained stable and was discharged home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE DIAGNOSIS: Left bronchial main stem scarring,
status post debridement.
DISCHARGE MEDICATIONS:
1. Finasteride 5 mg p.o. q.d.
2. Guaifenesin 600 mg b.i.d.
3. Metronidazole 500 mg t.i.d. x3 days.
4. Prednisone 40 mg x1 day.
5. Levofloxacin 500 mg q.d. x1 day.
6. Prevacid 30 mg p.o. q.d.
7. Aspirin 81 mg p.o. q.d.
8. Combivent two puffs q.i.d.
[**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1775**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1776**]
Dictated By:[**Last Name (NamePattern1) 9725**]
MEDQUIST36
D: [**2164-2-15**] 14:49
T: [**2164-2-15**] 14:51
JOB#: [**Job Number 44222**]
|
[
"996.59",
"519.1",
"934.1",
"162.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"98.15",
"98.51",
"33.23",
"33.91"
] |
icd9pcs
|
[
[
[]
]
] |
2326, 2474
|
4019, 4577
|
3935, 3996
|
2895, 3879
|
2497, 2877
|
156, 1269
|
1291, 2066
|
2083, 2309
|
3904, 3913
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,637
| 114,342
|
11560
|
Discharge summary
|
report
|
Admission Date: [**2194-1-20**] Discharge Date: [**2194-1-28**]
Date of Birth: [**2109-7-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
aortic stenosis
Major Surgical or Invasive Procedure:
[**2194-1-21**]
TAVI-Aortic Valve Replacement via Right Thoracotomy ([**Company 1543**]
29 mm porcine CoreValve)
History of Present Illness:
Mr. [**Known lastname 36776**] is an 84 year old man with severe symptomatic aortic
stenosis a history of coronary bypass grafting in [**2185**] at the
[**Hospital1 18**] (LIMA to LAD, SVG-PDA,SVG-OMB),atrial fibrillation, severe
obstructive lung disease, peripheral vascular disease, carotid
artery disease, post-polio
syndrome, pulmonary hypertension.
He was seen approximately 6 months ago for aortic valve
treatment options. He was determined to be of prohibitively
extreme risk for surgical aortic valve replacement due to
frailty. He was undergoing evaluation for TAVI with incidental
findings of a pulmonary nodule. Workup included a repeat CT scan
of the chest which showed improvement of the nodule consistent
with resolving a infectious process.
He returned for Corevalve procedure via direct aortic approach.
He continues to be symptomatic with the ability ambulate bed to
bathroom before being limited by shortness of breath.
NYHA Class: III
Past Medical History:
aortic stenosis
s/p coronary artery bypass
noninsulin dependent diabetes mellitus
hyperlipidemia
s/p carotid stent
s/p carotid endarterectomies
h/o bladder cancer with neurogenic bladder
s/p pacemaker implant
chronic atrial fibrillation
post polio syndrome
Social History:
He lives with a caretaker and was a former venture capitalist.
He is a former smoker.
Family History:
- HTN, heart disease, stroke
- Mother died at 99 of old age
- Father died at 52 of an MI
- 1 sister with CHF
- 1 sister deceased from cancer (unknown type)
- Brother has ?stomach cancer
- 2 sisters are healthy
Physical Exam:
Pulse:77
B/P: 163/72
Resp: 20
O2 Sat: 976
Temp:98.4
Height: 68 inches Weight: 145lbs
General: frail, elderly male in wheelchair
Skin: color pale, turgor fair, warm and dry. Stage II
excoriation
left buttock.
HEENT: normocephalic, anicteric, oropharynx moist.
Neck:supple, trachea midline, bilat bruits vs referred murmer
Chest: mild kyphosis, well healed surgical scar, LS decreased
bases.
Heart: murmer throughout
Abdomen: soft, nontender, nondistended, hyperactive bowel
sounds,
last BM today. Foley insitu on arrival, clear yellow urine.
Extremities: 1+ lower extremity edema, prosthetic shoes, leg
lengths unequal, calves mild atrophy. Left foot deformity. No
femoral bruits.
Neuro: HOH, pleasant, vague at times, generalized weakness,
unsteady gait.
Pulses: weakly palpable peripheral pulses.
Pertinent Results:
[**2194-1-25**] 04:05AM BLOOD WBC-9.8 RBC-3.83* Hgb-10.4* Hct-32.1*
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.4 Plt Ct-226
[**2194-1-26**] 05:15AM BLOOD PT-21.0* INR(PT)-2.0*
[**2194-1-26**] 05:15AM BLOOD UreaN-28* Creat-1.3* Na-142 K-4.2 Cl-102
[**2194-1-21**] 08:05PM BLOOD CK(CPK)-387*
[**2194-1-20**] 12:40PM BLOOD ALT-21 AST-20 CK(CPK)-75 AlkPhos-75
TotBili-0.3
[**2194-1-25**] 04:05AM BLOOD proBNP-4948*
[**2194-1-25**] 04:05AM BLOOD Mg-2.1
[**2194-1-20**] 12:40PM BLOOD %HbA1c-6.9* eAG-151*
TTE [**2194-1-25**]: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). The estimated
cardiac index is normal (>=2.5L/min/m2). Right ventricular
chamber size and free wall motion are normal. An aortic
CoreValve prosthesis is present. The aortic valve prosthesis
appears well seated, with normal leaflet motion and
transvalvular gradients. Mild (1+) perivalvular aortic
regurgitation is seen. The mitral leaflets are mildly thickened.
Mild to moderate ([**1-13**]+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is an anterior space which
most likely represents a prominent fat pad.
IMPRESSION: Well seated CoreValve aortic prosthesis with normal
gradient Mild perivalvular aortic regurgitation. Mild symmetric
left ventricular hypertrophy with preserved global and regional
biventricular systolic function. Mild-moderate mitral
regurgtiation. Pulmonary artery hypertension.
Compared with the prior study (images reviewed) of [**2194-1-23**],
the severity of aortic regurgitation has increased/more
apparent. The severity of mitral regurgitation, tricuspid
regurgitation, and estimated PA systolic pressure are now
reduced.
CLINICAL IMPLICATIONS:
Based on [**2189**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis IS recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Electronically signed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4083**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2194-1-25**] 13:52
[**2194-1-25**] 04:05AM BLOOD WBC-9.8 RBC-3.83* Hgb-10.4* Hct-32.1*
MCV-84 MCH-27.1 MCHC-32.4 RDW-15.4 Plt Ct-226
[**2194-1-27**] 06:20AM BLOOD PT-27.2* INR(PT)-2.6*
[**2194-1-26**] 05:15AM BLOOD PT-21.0* INR(PT)-2.0*
[**2194-1-25**] 04:05AM BLOOD PT-18.3* INR(PT)-1.7*
[**2194-1-24**] 05:47AM BLOOD PT-15.6* INR(PT)-1.5*
[**2194-1-23**] 04:01AM BLOOD PT-13.4* INR(PT)-1.2*
[**2194-1-28**] 04:55AM BLOOD PT-25.7* INR(PT)-2.5*
Brief Hospital Course:
H e was admitted [**1-20**] and completed pre-op work up. He underwent
TAVI// CoreValve via mini right thoracotomy with Dr.[**Last Name (STitle) 914**] on
[**1-21**]. He was transferred to the CVICU in stable condition and
extubated later that day. He transferred to the floor on POD #1
to begin increasing his activity level.
The chest tubes were removed per protocol. He remains with his
chronic indwelling Foley. Coumadin was restarted for chronic
atrial fibrillation and Plavix was given and discontinued when
the INR reached 2. Beta blockade and ACE inhibitors were given.
he was diuresed towards his preoperative weight and edema had
essentially cleared by discharge. He continued to make good
progress and was cleared for discharge to [**Hospital **] Rehab on
[**2194-1-28**], POD 7. The atrial pacer lead was found to have a high
impedance on evaluation [**1-28**], having been normal on [**1-25**]. The
Electrophysiology Service felt this could be evaluated by his
primary cardiologist after rehab discharge.
He was walking with assistance and a walker at discharge and
Lisinopril and Lopressor were titrated to good blood pressure
control.
Medications on Admission:
BUMETANIDE - (Prescribed by Other Provider) - 1 mg Tablet -
Tablet(s) by mouth twice a day take 3 tablets in the am and 2
tablets in the afternoon
DIGOXIN - 125 mcg Tablet - one Tablet(s) by mouth every other
day
FINASTERIDE - (Prescribed by Other Provider) - 5 mg Tablet -
Tablet(s) by mouth once a day
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 0.5 (One half) Tablet(s) by mouth twice daily
NITROFURANTOIN MACROCRYSTAL - 100 mg Capsule - one Capsule(s) by
mouth daily
PAROXETINE HCL - 20 mg Tablet - one Tablet(s) by mouth in the
evening
PRAVASTATIN - 40 mg Tablet - one Tablet(s) by mouth daily
PREDNISONE - (Prescribed by Other Provider) - 5 mg Tablet - 1.5
Tablet(s) by mouth daily
RANITIDINE HCL - (Prescribed by Other Provider) - 150 mg
Capsule
- Capsule(s) by mouth twice a day
SITAGLIPTIN [JANUVIA] - (Prescribed by Other Provider) - 100 mg
Tablet - 1 Tablet(s) by mouth once a day
[**Month/Year (2) **] - 0.4 mg Capsule, Ext Release 24 hr - 2 Capsule(s) by
mouth daily
TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule,
w/Inhalation Device - one capsule orally daily
WARFARIN - 3 mg Tablet - one Tablet(s) by mouth daily - last
dose
[**2194-1-13**]
Medications - OTC
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth twice a day
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - one Tablet(s)
by
mouth daily
CHOLECALCIFEROL (VITAMIN D3) - 1,000 unit Tablet - two Tablet(s)
by mouth daily
DOCUSATE SODIUM [COLACE] - 100 mg Capsule - one Capsule(s) by
mouth daily
FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65
mg
iron) Tablet - Tablet(s) by mouth once a day
NPH INSULIN HUMAN RECOMB [HUMULIN N] - (Prescribed by Other
Provider) - 100 unit/mL Suspension - 15 units twice a day
VITAMIN E - 1,000 unit Capsule - one Capsule(s) by mouth daily
--------------- --------------- --------------- ---------------
Allergies: Penicillin - anaphylaxis
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. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
4. paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
7. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
10. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-13**]
Puffs Inhalation Q6H (every 6 hours) as needed for bronchospasm.
11. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. furosemide 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
16. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
17. warfarin 1 mg Tablet Sig: as directed Tablet PO once a day:
INR 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Severe Aortic stenosis
s/p Core Valve insertion
coronary artery disease
Asthma
noninsulin dependent diabetes mellitus
s/p right carotid stent
parosxymal atrial fibrillation
s/p dual chamber pacemaker ([**Company 1543**])
h/o stroke
Hypertension
Dyslipidemia
chronic obstructive pulminary disease
peripheral vascular disease
Post-polio syndrome with atrophy bilateral legs Pulmonary
hypertension
gastrointestinal reflux disease
h/o Bladder cancer - indwelling foley
Psoriasis
urinary tract infection
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Alert and oriented x3, nonfocal
Ambulating with assistance
Incisional pain managed with oral analgesics
Incisions:
mini Right thoracotomy - healing well, no erythema or drainage
Edema:trace lower extremeties
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Drs. [**Name5 (PTitle) 914**]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2194-2-24**]
@ 12:00,[**Hospital Ward Name **] 2A
DEVICE CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2194-2-24**] 10:00
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2194-2-24**] 9:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) **] in [**4-17**] weeks [**Telephone/Fax (1) 36783**]
**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 Afib
Goal INR 2.0-3.0
First draw day after discharge
****Coumadin follow up to be arranged prior to discharge from
rehab
Completed by:[**2194-1-28**]
|
[
"V70.7",
"696.1",
"305.1",
"599.0",
"707.05",
"443.9",
"416.8",
"V45.81",
"427.31",
"424.1",
"596.54",
"138",
"428.0",
"493.20",
"272.4",
"438.20",
"V10.51",
"428.30",
"041.49",
"250.00",
"V49.87",
"V53.31",
"294.20",
"293.0",
"707.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.05"
] |
icd9pcs
|
[
[
[]
]
] |
10292, 10394
|
5596, 6753
|
293, 408
|
10938, 11775
|
2842, 4710
|
12615, 13482
|
1797, 2008
|
8751, 10269
|
10415, 10916
|
6779, 8728
|
11799, 12592
|
2023, 2823
|
4733, 5573
|
238, 255
|
436, 1396
|
1418, 1677
|
1693, 1781
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,367
| 193,529
|
52707
|
Discharge summary
|
report
|
Admission Date: [**2130-11-21**] Discharge Date: [**2130-11-27**]
Date of Birth: [**2067-9-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea/Chest pain
Major Surgical or Invasive Procedure:
[**2130-11-21**] Redo sternotomy with AVR [**47**] mm CE pericardial tissue
valve/Aortic endarterectomy
History of Present Illness:
63 year old gentleman with progressive angina and dyspnea over
the past year. Symptoms occur mostly with exertion and
occassionally at rest. He also complains if 3 pillow orthopnea
and paroxysmal nocturnal dyspnea. ECHO revealed severe aortic
stenosis while a cardiac catheterization showed patenrt bypass
grafts. He is scheduled for a redo sternotomy and an aortic
valve replacement.
Past Medical History:
Aortic stenosis
CAD
HTN
CABG 4 years ago
Diabetes mellitus type II
Hyperlipidemia
Asbestosis
Social History:
Retired Carpenter. Quit smoking 15 years ago. Lives with
daughter.
Family History:
Mother died of MI at age 63. Sister died of MI at age 45.
Physical Exam:
GEN: WDWN in NAD
SKIN: Well healed sternotomy, no C/C/E
HEART: RRR< 4/6 systolic murmur
ABD: Benign
LUNGS: Clear
EXT: 1+ pulses, left saphenous vein suitable right surgically
absent
NEURO: Nonfocal
Pertinent Results:
[**2130-11-27**] 07:00AM BLOOD WBC-6.8 RBC-3.72* Hgb-11.5* Hct-32.4*
MCV-87 MCH-31.0 MCHC-35.6* RDW-13.8 Plt Ct-187
[**2130-11-27**] 07:00AM BLOOD Plt Ct-187
[**2130-11-27**] 07:00AM BLOOD Glucose-144* UreaN-26* Creat-0.9 Na-136
K-4.4 Cl-96 HCO3-30 AnGap-14
[**2130-11-27**] 07:00AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.0
[**2130-11-24**] CXR
1) Stable cardiomegaly.
2) Resolving right apical pneumothorax.
3) Low lung volumes. No change from previous radiograph.
[**2130-11-21**] EKG
Sinus bradycardia. Borderline first degree A-V block. Left
atrial abnormality.
Voltage criteria for left ventricular hypertrophy. Lateral ST-T
wave changes likely secondary to left ventricular hypertrophy.
Compared to the previous racing of [**2130-11-20**] no significant
diagnostic change
Brief Hospital Course:
Mr. [**Known lastname 108733**] was admitted to the [**Hospital1 18**] on [**2130-11-21**] for surgical
management of his aortic stenosis. He was taken directly to the
operating room where he underwent a redo sternotomy with an
aortic valve replacement utilizing a 23mm [**Last Name (un) 3843**] [**Doctor Last Name **]
tissue valve and an aortic endarterectomy. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname 108733**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. He was transfused with
packed red blood cells for postoperative anemia with good
effect. Beta blockade and aspirin were resumed. On postoperative
day two, he was transferred to the step down unit for further
recovery. Mr. [**Known lastname 108733**] was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility. His
drains and pacing wires were removed without difficulty. Mr.
[**Known lastname 108733**] continued to make steady progress and was discharged
home on postoperative day six. He will follow-up with Dr. [**Last Name (Prefixes) **], his cardiologist and his primary care physician as an
outpatient.
Medications on Admission:
Aspirin 81 mg daily
Lipitor 40mg daily
Atenolol 50mg daily
Altace 10mg daily
[**Doctor First Name **]
Norvasc 5mg daily
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. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
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:*0*
7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 1
weeks.
Disp:*14 Tablet(s)* Refills:*0*
10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO BID (2 times a day) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
caregroup
Discharge Diagnosis:
AS
CAD s/p CABG [**2126**]
HTN
hypercholesterolemia
DM2
Asbestosis
Right knee arhtroscopy
Chole
Discharge Condition:
Good.
Discharge Instructions:
Shower, wash incisions, pat dry. No lotions, creams or powders
to incisions.
Call with fever, redness or drainage from incisions, or weight
gain more than 2 pounds in one day or five in one week.
No lifting more than 10 pounds, no driving.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 6680**](PCP) 2 weeks
Dr. [**Last Name (STitle) 911**] (Cardiologist) 2 weeks
Completed by:[**2130-11-27**]
|
[
"272.4",
"716.96",
"V45.81",
"424.1",
"501",
"250.00",
"401.9",
"278.00",
"V17.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.14",
"00.40",
"88.72",
"39.61",
"99.04",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
4931, 4971
|
2168, 3456
|
342, 448
|
5111, 5119
|
1370, 2145
|
1078, 1137
|
3627, 4908
|
4992, 5090
|
3482, 3604
|
5143, 5384
|
5435, 5611
|
1152, 1351
|
284, 304
|
476, 862
|
884, 978
|
994, 1062
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,552
| 103,859
|
21973
|
Discharge summary
|
report
|
Admission Date: [**2115-11-17**] Discharge Date: [**2115-11-24**]
Date of Birth: [**2073-6-1**] Sex: F
Service: MEDICINE
Allergies:
Morphine / Latex
Attending:[**First Name3 (LF) 6180**]
Chief Complaint:
GIB, hematemesis
Major Surgical or Invasive Procedure:
EGD with esophageal varices sclerosis
History of Present Illness:
42 year old female with h/o cholangiocarcinoma dx in [**2112**] s/p
resection, with recent CT showing met cholangiocarcinoma in
9/[**2115**]. Pt was recently admitted for fever due to cholangitis on
[**11-8**] and had chemo (CDDP and Gemcitabine) on Monday, [**11-11**].
Since chemo pt has intermittent nausea adequately controlled by
zofran and compazine. Pt was doing well till night of admission
when she developed nausea/ vomitting and sizable amount of
hemoptysis and clots. Has low grade fever since chemo but
otherwise ROS was neg for shaking chills, chest pain, SOB,
coughing, constipation, diarrhea, tarry stools, abd pain. Pt
has reported gaining 30lbs since [**9-21**] due to ascites.
In ED: vitals: T98.8 P98 BP136/68 R29 Sat 98% RAPt had NG lavage
which evantually cleared up, also was transfused 1U PRBC, GI
consult called, also got zofran and iv protonix.
Past Medical History:
1. Ca Hx-Klatskin tumor originally diagnosed [**9-/2112**] after
presenting with painless jaundice. [**2112-10-21**] pt underwent ex. lap
with en bloc resection of L liver lobe, biliary tree, and portal
vein. Reconstructed portal vein followed by Roux-en-Y
hepaticojejunostomy. Per notes, pathology demonstrated biliary
ductal adenocarcinoma
(T3N0M0) stage [**Doctor First Name **]. Since presentation, patient had multiple
episodes of cholangitis([**8-27**] in past 3 years with last on
[**11-8**]), always short lived and treated with antimicrobial
therapy. She has been on
ciprofloxacin proph for about 1 year. Followed with yearly
abdominal CT without radiographic progression. CAT scan was
performed on [**2115-10-11**] at [**Hospital3 2358**], which revealed that she
had a recurrence of the tumor with occlusion of her portal vein
occluding bile ducts, hepatic artery nearly completely occluded,
and much ascites and was started on diuretics. She was was seen
at [**Hospital1 18**] heme/on clinic [**10-30**] and had repeat CT scan which
revealed metastatic
cholangiocarcinoma with mets to the ovaries, with tremendous
increase in metastatic disease. There was there was obstructive
uropathy on the right side, as well as questionable gastric
outlet obstruction and peritoneal carcinomatosis.
2. cholecystectomy at age 25
3. MVA-multiple orthopedic procedures
4. Strabismus
Social History:
She is a nurse [**First Name (Titles) **] [**Hospital6 204**]. She
denies any alcohol, drugs or tobacco. She lives in [**Hospital1 487**] with
her mom. She is single, no children.
Family History:
Her maternal grandmother had breast cancer in
her 80s and her dad's grandmother had stomach cancer and died in
her 50s. On her mom's side is an extensive family cardiac
history.
Physical Exam:
VITAL: afebrile, 96, 108/51, O2sat99%RA
GENERAL: pleasant female in no apparent distress, jaundiced
skin.
HEENT: sclera icteric, OP clear, EOMI, PERRL.
NECK: Supple.
NODES: No supraclavicular, submandibular, axillary or inguinal
lymphadenopathy.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate, s1 s2 .
ABDOMEN: soft and distended, but no actual tenderness. Guaiac
neg by ED
BACK: No CVA tenderness.
EXTREMITIES: No clubbing, cyanosis, but +edema.
Pertinent Results:
[**2115-11-17**] 01:30AM GLUCOSE-112* UREA N-14 CREAT-0.8 SODIUM-133
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-23 ANION GAP-17
[**2115-11-17**] 01:30AM ALT(SGPT)-149* AST(SGOT)-83* ALK PHOS-663*
AMYLASE-37 TOT BILI-8.2*
[**2115-11-17**] 01:30AM LIPASE-42
[**2115-11-17**] 01:30AM IRON-52
[**2115-11-17**] 01:30AM calTIBC-230* FERRITIN-197* TRF-177*
[**2115-11-17**] 01:30AM WBC-3.0* RBC-2.25* HGB-7.2* HCT-20.9* MCV-93
MCH-31.8 MCHC-34.3 RDW-14.7
[**2115-11-17**] 01:30AM NEUTS-79.7* BANDS-0 LYMPHS-13.3* MONOS-4.6
EOS-2.2 BASOS-0.2
[**2115-11-17**] 01:30AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2115-11-17**] 01:30AM PLT COUNT-88*
[**2115-11-17**] 01:30AM PT-13.4 PTT-25.9 INR(PT)-1.1
[**2115-11-17**] 01:30AM RET AUT-0.3*
[**2115-11-17**] 01:30AM URINE COLOR-Amber APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025
[**2115-11-17**] 01:30AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-LG UROBILNGN-0.2 PH-5.5 LEUK-NEG
[**2115-11-17**] 01:30AM URINE RBC-0-2 WBC-0-2 BACTERIA-MOD YEAST-NONE
EPI-[**3-22**] RENAL EPI-0-2
[**2115-11-17**] 01:30AM URINE HYALINE-0-2
CT abd on [**2115-11-7**] showed: 1. Recurrent cholangiocarcinoma, with
intrahepatic bile duct dilatation and gastric outlet
obstruction; exact extent of disease is unclear, but likely
extensive. No evidence of portal hypertension is seen. 2. Large,
cystic, multiseptated mass arising from the adnexa, worrisome
for second primary malignancy.
3. Ascites, and intraperitoneal carcinomatosis, which can arise
from either of the two processes described above. 4. Hiatal
hernia.
[**2115-11-24**] 07:30AM BLOOD WBC-2.2* RBC-3.09* Hgb-9.6* Hct-28.7*
MCV-93 MCH-31.2 MCHC-33.6 RDW-17.0* Plt Ct-89*
[**2115-11-21**] 06:00AM BLOOD Neuts-89.7* Bands-0 Lymphs-6.9* Monos-2.6
Eos-0.2 Baso-0.7
[**2115-11-24**] 07:30AM BLOOD PT-15.2* PTT-29.7 INR(PT)-1.5
[**2115-11-24**] 07:30AM BLOOD Glucose-117* UreaN-11 Creat-0.9 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
[**2115-11-24**] 07:30AM BLOOD AlkPhos-431* TotBili-7.8*
[**2115-11-24**] 07:30AM BLOOD Calcium-8.3* Phos-3.5 Mg-1.9
[**2115-11-17**] 01:30AM BLOOD calTIBC-230* Ferritn-197* TRF-177*
Brief Hospital Course:
1) GI - In the [**Name (NI) **] pt had Hct of 20 and bloody NG lavage which
did not clear. She was transfused 1U PRBC, GI consult called,
also got zofran and iv protonix and admitted to the [**Hospital Unit Name 153**]. On
arrival to unit pt had EGD which revealed grade III esophageal
varices with signs of old bleeding. She was started on
octreotide and nadolol to control portal htn. Pt was stable
and had appropriate Hct bump to 25 after 2U PRBC's.
She also had climbing bilirubin and low grade temp and was
started on Zosyn for suspected biliary obstruction and ascending
cholangitis coverage. She was rescoped on [**11-18**] and varices were
sclerosed(no banding due to latex allergy) and diuretics of
lasix and aldactone were readded for ascites since BP stable.
[**11-19**] she was transfused another 3U PRBC's with hct bump to 31.9
and antibiotic coverage broadend to Unasyn, Ceftriaxone, Flagyl
because she continued to spike, and for SBP prophylaxis.
Preprocedure of PTC on [**11-20**] she was transfused 1 unit PRBC's, 2
platelets and 2U FFP and procedure went without complication.
ON transfer to the floor she remained hemodynamically stable
with stable Hct and declining bilirubin. She remained afebrile
so on [**11-23**] antibiotic regimen was weaned to only levofloxacin.
Liver teams recommended to repeat EGD with non latex banding in
[**7-27**] days. She also went home on naldolol 20mg qd for portal
htn, and her home doses of diuretics to control her ascites.
2. US finding- Pt was incidentally found to have R
hydronephrosis and a R adenexal mass on her US. The
hydronephrosis was likely caused by blockage by her tumor.
Given her disease prognosis and the fact that her other kidney
is functioning well, no intervention was done. Also the
adenexal mass may represent a second primary maligancy. This
was seen on a prior CT scan and her [**Date Range 5564**] is aware. Again
given the patient's poor disease prognosis, there was no
intervention made at this time.
Medications on Admission:
MEDICATIONS: She is on Lasix 40 mg p.o. b.i.d., Aldactone 25 mg
p.o. b.i.d., Prilosec 20 mg p.o. daily, ciprofloxacin 250 mg
p.o.
daily, this is for prophylaxis for cholangitis and iron.
Discharge Medications:
1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 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. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
5. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
6. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) mL PO four
times a day: Swish and swallow.
Disp:*qs mL* Refills:*2*
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please have CBC and alkaline phosphatase and total bilirubin
checked on Monday [**11-25**]
Discharge Disposition:
Home With Service
Facility:
VNA of [**Hospital1 487**]
Discharge Diagnosis:
Cholangiocarcinoma
Biliary obstruction
Grade III esophageal varices
Discharge Condition:
Stable.
Discharge Instructions:
Call your primary care doctor, [**Hospital1 5564**], or return to the
Emergency Room if you have increasing nausea, vomiting, leg
swelling, confusion, or pain.
Followup Instructions:
Please follow up at all scheduled appointments including
Wednesday in [**Hospital **] clinic. Call the [**Hospital **] clinic on Monday to confirm
your appointment: [**Telephone/Fax (1) 53981**]. Ask to speak with [**Month (only) 116**] [**Doctor Last Name **], PA.
Call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) 5564**] for follow up
appointments. You will have a banding procedure in 9 days.
Please call the [**Hospital **] clinic and arrange to see Dr. [**Last Name (STitle) 2161**] for an
appointment: [**Telephone/Fax (1) 1954**].
|
[
"196.1",
"285.1",
"572.3",
"591",
"456.20",
"197.7",
"452",
"V10.09",
"198.6",
"197.6",
"287.5",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"51.98",
"87.51",
"42.33",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
9073, 9130
|
5760, 7757
|
295, 334
|
9242, 9251
|
3536, 5737
|
9459, 10033
|
2858, 3039
|
7994, 9050
|
9151, 9221
|
7783, 7971
|
9275, 9436
|
3054, 3517
|
239, 257
|
362, 1237
|
1259, 2643
|
2659, 2842
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,535
| 116,346
|
46286
|
Discharge summary
|
report
|
Admission Date: [**2176-10-14**] Discharge Date: [**2176-10-17**]
Date of Birth: [**2119-6-11**] Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Penicillins / Ivp Dye, Iodine Containing
/ Latex / Codeine / Tylenol/Codeine No.3 / Vancomycin
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
right leg infection
Major Surgical or Invasive Procedure:
right below knee guillotine amputation [**2176-10-16**]
History of Present Illness:
57 F with c/o one week of foot pain and distal wound, purulence
out of medial and lateral malleoli
Past Medical History:
ESRD: on hd x5 years, not able to recall what it is due to,
tunnelled rij placed with transplant surgery [**1-22**], HD t/t/sat
Congestive heart failure - last tte [**2171**] with ef 65%
Type II diabetes
Hypertension
Paranoid schizophrenia/delusions
s/p right tmt amputation
Social History:
She lives with her husband and her son. Retired high school
teacher. She denies alcohol, tobacco, or recreational drugs.
Family History:
DM
Physical Exam:
Deceased
Pertinent Results:
[**2176-10-16**] 11:20PM BLOOD
WBC-40.0* RBC-3.06* Hgb-9.5* Hct-35.1* MCV-115* MCH-31.2
MCHC-27.2* RDW-19.1* Plt Ct-147*
[**2176-10-16**] 08:30AM BLOOD
Neuts-73* Bands-6* Lymphs-8* Monos-4 Eos-0 Baso-0 Atyps-0
Metas-6* Myelos-3* NRBC-23*
[**2176-10-16**] 08:30AM BLOOD
Hypochr-NORMAL Anisocy-2+ Poiklo-2+ Macrocy-2+ Microcy-NORMAL
Polychr-2+ Spheroc-1+ Burr-2+
[**2176-10-16**] 11:20PM BLOOD
PT-43.3* PTT-150* INR(PT)-4.6*
[**2176-10-16**] 02:52PM BLOOD
Glucose-98 UreaN-40* Creat-5.2* Na-150* K-4.3 Cl-94* HCO3-10*
AnGap-50*
[**2176-10-16**] 11:20PM BLOOD
ALT-330* AST-1369* CK(CPK)-1598* AlkPhos-321* TotBili-1.0
[**2176-10-16**] 11:29PM BLOOD
Type-ART pO2-113* pCO2-32* pH-6.99* calTCO2-8* Base XS--23
[**2176-10-16**] 11:29PM BLOOD
freeCa-1.47*
[**2176-10-14**] 4:15 pm SWAB Site: ANKLE RIGHT ANKLE.
GRAM STAIN (Final [**2176-10-14**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2176-10-17**]):
SERRATIA MARCESCENS. HEAVY GROWTH.
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
SERRATIA MARCESCENS
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
Pt admitted for pedal sepsis. Stat antibiotics were intiated.
The team recommend a stat guillatine amp. Pt refused. A psych
consult was obtained. cxs taken.
Psychiatry met patient and concluded that patient was not able
to make decisions in her own best interest at this time.
The family was notified. No health care proxy. The [**Hospital1 18**] lawyer
was notified. The process was begun to make son the health care
proxy to make medical decisions.
[**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 9449**] from [**Hospital1 1388**] legal department notified. A
Social consult was obtained. SW began to coordinate
Guardianship information sheet and [**Name (NI) **] signatures from
patient's son.
SW then met with patient's two [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] and Rowan who have
agreed to be co-guardians and had them sign the [**Last Name (NamePattern4) **] necessary
to begin court proceeding for
emergency guardianship.
Am rounds nurse [**First Name (Titles) 13431**] [**Last Name (Titles) 98435**] breathing and lethargy. Pt only
responded to painfull stimuli. Anesthesia was called to intubate
patient. Anesthesia intubated patient. Transfered to the CVICU.
Family notified. Family agreed to stat guillatine AMP. Pt taken
emergently to the OR for Right pedal sepsis. Guillotine right
below-the-knee amputation was performed. No intra op
complications. Pt then transfered to the CVICU.
There it was noticed that the pt abd distention. A general
surgery consult was obtained. Bladder pressures, NPO/IV
resuscitation.
Serial labs were drawn. Multisystem organ failure from sepsis
occured. Pt put on multiple pressors. Family notified. Made CMO.
Pt deceased shortly aferwards.
Medications on Admission:
Norvasc 5', Sevelamer 800''', Tylenol, Aspirin, Minopehn
[**Telephone/Fax (1) 1999**] PRN, Colace, NPH, Hexavitamin, Senna
Discharge Medications:
[**Male First Name (un) **] - deceased
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
Completed by:[**2176-10-17**]
|
[
"362.01",
"403.91",
"250.40",
"428.0",
"728.84",
"785.52",
"250.60",
"428.32",
"997.62",
"995.92",
"785.4",
"424.0",
"443.81",
"585.6",
"357.2",
"276.2",
"682.7",
"707.14",
"038.9",
"682.6",
"250.50",
"V58.67",
"518.81",
"250.70",
"295.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.39",
"39.95",
"84.15",
"96.71",
"99.60",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
4642, 4651
|
2667, 4405
|
399, 456
|
4703, 4713
|
1086, 2583
|
4770, 4810
|
1038, 1042
|
4579, 4619
|
4672, 4682
|
4431, 4556
|
4737, 4747
|
1057, 1067
|
340, 361
|
484, 585
|
2619, 2644
|
607, 883
|
899, 1022
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,540
| 121,812
|
38586
|
Discharge summary
|
report
|
Admission Date: [**2134-2-24**] Discharge Date: [**2134-3-1**]
Date of Birth: [**2077-7-28**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Hydrochlorothiazide
Attending:[**First Name3 (LF) 13685**]
Chief Complaint:
DOE/angina
Major Surgical or Invasive Procedure:
[**2134-2-24**] cardiac cath
[**2134-2-25**] CABG x3 (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
56 yo M with history of hypertension
and hyperlipidemia who presented to PCP with complaints of
exertional shortness of breath and chest discomfort. He
underwent
stress test which was abnormal and was referred for elective
cardiac catheterization. Cardiac catheterization today showed
80%
Left main disease and cardiac surgery is asked to consult for
surgical revascularization.
Past Medical History:
coronary artery disease
s/p CABGx3
hypertension
hyperlipidemia
gastroesophageal reflux disease
Social History:
lives with wife
self-employed in photo lab
denies tobacco
ETOH: occasional on wkds
Family History:
father with CABG at 77; maternal/paternal uncles with premature
CAD
Physical Exam:
Pulse:74 Resp:20 O2 sat:100%RA
B/P Right:182/96 Left:192/92
Height:5'6" Weight:209 lbs
General: NAD, lying in bed comfortably
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur: no M/R/G
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema: none
Varicosities: None [x]
Neuro: Grossly intact, MAE, nonfocal exam
Pulses:
Femoral Right: cath site Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit none Right: Left:
Pertinent Results:
Conclusions
PRE-CPB:1. The left atrium is mildly dilated. No spontaneous
echo contrast is seen in the left atrial appendage.
2. A patent foramen ovale is present.
3. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. There is heavy calcification and leaflet restriction of
the RCC. Mild (1+) aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) 914**] was notified in person of the results.
POST-CPB: On infusion of phenylephrine. Sinus rhythm. Preserved
biventricular systolic function with LVEF = 60%. MR is 1+, AI is
1+. Aortic contour is normal post decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2134-2-25**] 13:34
[**2134-3-1**] 05:10AM BLOOD WBC-5.3 RBC-3.60* Hgb-9.7* Hct-28.3*
MCV-79* MCH-26.8* MCHC-34.1 RDW-13.5 Plt Ct-175
[**2134-2-25**] 02:43PM BLOOD PT-14.4* PTT-26.6 INR(PT)-1.3*
[**2134-2-28**] 07:10AM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-137
K-4.2 Cl-102 HCO3-29 AnGap-10
[**2134-3-1**] 05:10AM BLOOD UreaN-14 Creat-1.1 K-4.5
Brief Hospital Course:
Admitted for cath [**2-24**] which revealed severe left main and right
coronary artery disease. Referred for CABG and w/u completed.
Underwent surgery with Dr.[**Last Name (STitle) 914**] on [**2-25**] and transferred to the
CVICU in stable condition on titrated phenylephrine and propofol
drips. Cefazolin was used for surgical antibiotic prophylaxis.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable on no inotropic or vasopressor
support. Beta blocker was initiated and the patient was gently
diuresed toward the preoperative weight. The patient was
transferred to the telemetry floor for further recovery. Chest
tubes and pacing wires were discontinued without complication.
The patient was evaluated by the physical therapy service for
assistance with strength and mobility. By the time of discharge
on POD 4 the patient was ambulating freely, the wound was
healing and pain was controlled with oral analgesics. The
patient was discharged to home in good condition with
appropriate follow up instructions.
Medications on Admission:
ASA 325 mg daily
simvastatin 40 mg daily
prilosec 20 mg daily prn
metoprolol succinate 25 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 10
days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p CABGx3
hypertension
hyperlipidemia
gastroesophageal reflux disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**Last Name (STitle) 914**] [**4-6**] @ 1:00 pm [**Telephone/Fax (1) 170**]
Primary Care Dr.[**Last Name (STitle) 43785**] in [**12-5**] weeks [**Telephone/Fax (1) 31019**]
Cardiologist Dr. [**Last Name (STitle) **] in [**12-5**] weeks
Completed by:[**2134-3-1**]
|
[
"V17.3",
"424.1",
"530.81",
"272.4",
"338.12",
"411.1",
"401.1",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15",
"88.56",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
5651, 5726
|
3508, 4624
|
325, 419
|
5865, 5964
|
1862, 3485
|
6505, 6823
|
1063, 1132
|
4773, 5628
|
5747, 5844
|
4650, 4750
|
5988, 6482
|
1147, 1843
|
275, 287
|
447, 828
|
850, 947
|
963, 1047
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,165
| 102,323
|
51837
|
Discharge summary
|
report
|
Admission Date: [**2167-3-12**] Discharge Date: [**2167-3-18**]
Date of Birth: [**2096-3-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
cough, sob x 2days
Major Surgical or Invasive Procedure:
None
History of Present Illness:
70 year-old man w/ systolic CHF, CAD s/p 5V CABG, Afib
(coumadin/dig), type II DM, hypothyroidism, chronic renal
failure, who was transferred from an [**Hospital3 **] ED for
hypotension, coagulopathy, fever. He initially presented to
[**Location (un) 4444**] health clinic on [**3-12**] with 2 days of SOB, worsening
DOE, orthopnea, dry cough. At the clinic, the pt was given 80mg
IV lasix for presumed CHF exacerbation. He was then sent to
[**Hospital3 2783**] where he was found to have gross
coagulopathy (PT 215, PTT 109, INR 8.2), possible PNA, and fever
(?101). At the OSH, he became hypotensive w/ SBP of 50's. He was
given NS 250ml x 2 and levaquin 750mg for empiric tx of presumed
pna, although the CXR was read as normal. CE were neg. Lacate as
2.44. Blood cx were collected. Of note, pt. had 2 recent med
changes (metformin->actos, tricor -> [**Hospital3 107356**]).
In the [**Hospital1 18**] ED: initial vitals were- T 99.2 BP 92/56 HR 70 RR
20 02sat 99% on 4L. The pt again became hypotensive and was
given 2L of NS. After IVF, he developed SOB (02 sat 90% on 3L)
and was briefly required a NRB. He was given 2u of FFP and
started on peripheral levophed. He was given 1g of ceftrioxone
and admited to the MICU for further management. On arrival to
the MICU pt. had a new pruritic, erythematous rash on abdomen
chest and knees, which responded to benadryl/famotadine.
ROS: denies fevers, chill, sick contacts. Admits to dry cough.
denies urinary symptoms or diarrhea. Notes a recent fall with
fractured R 6th rib. DOE w/ 1 flight of stairs, orthopnea, PND
over the past 2 days. Denies poor wound healing or bleeding
recently.
Past Medical History:
CAD s/p CABG [**85**] years prior
CHF (unknown EF)
DMII
CRI
Afib
hypothyroidism (s/p ablation for multinodular goiter)
gout
Social History:
quit smoking 26 years ago (prior 1.5ppd x 20 years), occasional
alcohol, no drug use. Retired building maintenance engineer. 4
children. lives alone.
Family History:
Father- MI.
Physical Exam:
VS: Temp: 99.2 BP: 116/71 (on levophed) HR: 84 RR: 21 O2sat 94%
on 5L NC
GEN: NAD, laying in bed
HEENT: MMM, adentulous, NC in place, no JVD
RESP: fine crackles diffusely R>L
CV: irregularly, irregular, III/VI SEM best at LLSB
ABD: erythematous, pruritic papular rash. NT/ND, normoactive BS
EXT: 2+ DP, WWP, non edematous, well-healed RLE surgical scar
s/p bypass surgery. erythematous, papular rash in knees
bilaterally
SKIN: rash as described above.
NEURO: AAOx3.
Pertinent Results:
[**2167-3-12**] 03:00AM BLOOD WBC-5.8 RBC-4.06* Hgb-11.9* Hct-36.2*
MCV-89 MCH-29.4 MCHC-33.0 RDW-13.8 Plt Ct-154
[**2167-3-12**] 03:00AM BLOOD Neuts-72.9* Lymphs-15.3* Monos-9.6
Eos-1.6 Baso-0.5
[**2167-3-12**] 03:00AM BLOOD PT-150* PTT-63.6* INR(PT)-22.8*
[**2167-3-14**] 04:05AM BLOOD PT-15.3* PTT-26.8 INR(PT)-1.4*
[**2167-3-12**] 03:00AM BLOOD Glucose-149* UreaN-54* Creat-2.6* Na-137
K-5.0 Cl-100 HCO3-23 AnGap-19
[**2167-3-14**] 04:05AM BLOOD Glucose-60* UreaN-28* Creat-1.6* Na-136
K-4.3 Cl-99 HCO3-25 AnGap-16
[**2167-3-12**] 03:00AM BLOOD CK(CPK)-40
[**2167-3-12**] 03:00AM BLOOD CK-MB-NotDone proBNP-4439*
[**2167-3-12**] 03:00AM BLOOD cTropnT-0.03*
[**2167-3-14**] 04:05AM BLOOD Calcium-8.5 Phos-2.6* Mg-2.2
[**2167-3-12**] 09:45AM BLOOD Digoxin-0.8*
[**2167-3-12**] 03:08AM BLOOD Lactate-2.1*
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2167-3-13**]):
POSITIVE FOR INFLUENZA B VIRAL ANTIGEN.
REPORTED BY PHONE TO DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2167-3-13**] 125P.
[**2167-3-12**] Renal U/S: IMPRESSION:
1. No evidence of hydronephrosis. Nonobstructing 7 mm left renal
calculus.
2. 8-10 mm echogenic foci with tram tracking appearance in the
right kidney suggestive of an intraureteral stent but may also
represent renal calculi in the absence of such history. Clinical
correlation is recommended.
[**2167-3-12**] CXR: IMPRESSION:
1. Vague increased patchy opacity in the right lower lung. This
may be the area where prior pneumonia has been seen. Comparison
with prior would be helpful.
2. No evidence of congestive heart failure.
[**3-12**] ECG: Atrial fibrillation with moderate ventricular
response. Occasional ventricular
premature beats. Poor R wave progression suggests possible prior
old
anteroseptal myocardial infarction. Modest inferolateral ST-T
wave changes
which are non-specific. Compared to the previous tracing of
[**2153-2-28**] there is no significant diagnostic change.
[**2167-3-12**] ECHO: The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. Overall left ventricular systolic function is moderately
depressed (LVEF= 30-40 %). [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
depressed free wall contractility. [Intrinsic right ventricular
systolic function is likely more depressed given the severity of
tricuspid regurgitation.] The aortic root is moderately dilated
at the sinus level. The ascending aorta is moderately dilated.
The aortic valve leaflets are severely thickened/deformed. There
is moderate to severe aortic valve stenosis (area 0.8-1.0cm2).
No aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
severe mitral annular calcification. There is a minimally
increased gradient consistent with trivial mitral stenosis.
Moderate (2+) mitral regurgitation is seen. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] Moderate [2+] tricuspid
regurgitation is seen. There is no pericardial effusion.
-----------------
RADIOLOGY Final Report
CHEST (PA & LAT) [**2167-3-17**] 11:36 AM
CHEST (PA & LAT)
Reason: Please evaluate for interval change
[**Hospital 93**] MEDICAL CONDITION:
70 year old man with Aortic Stenosis, CAD, s/p CABG, a/w
influenza and pneumonia
REASON FOR THIS EXAMINATION:
Please evaluate for interval change
INDICATION: Aortic stenosis, now with influenza, and persistent
cough.
CHEST, TWO VIEWS: Comparison with [**2167-3-12**]. In the
interim, a small right pleural effusion has accumulated.
Cardiac, mediastinal, and hilar contours are unchanged, with
cardiomegaly again noted. The interstitial abnormality
throughout both lungs including [**Last Name (un) 16765**] B-lines and indistinct
pulmonary vasculature can represent interstitial changes from
chronic cardiac failure. There are no focal consolidations.
Osseous structures including midline sternotomy wires and CABG
staples are unchanged.
IMPRESSION: Small right pleural effusion and chronic
interstitial changes, which can be seen in chronic heart
failure. No focal consolidations. Findings discussed with Dr.
[**Last Name (STitle) **] by phone at 2:00 p.m., [**2167-3-17**].
ab
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: WED [**2167-3-18**] 6:07 AM
-------------
Brief Hospital Course:
A/P: 70 yo M w/ CHF, Afib, CAD s/p CABG, DMII, acute on chronic
RF, recent DOE and cough, transferred from OSH for hypotension,
fever, gross coagulopathy, acute on chronic RF.
.
# Fever and pneumonia due to influenza A: The patient's DFA was
positive for flu. In ICU started empirically on levaquin for
pneumonia and then transitioned to unasyn. After stabilization,
patient was transferred to the floor for management. Kept on
droplet precautions for influenza and continued on unasyn
overnight. Then transitioned to PO augmentin. Patient
subsequently developed low grade temperatures on a nightly basis
despite improvement in cough, shortness of breath, and overall
clinical status. Fever work-up was non-revealing with negative
blood cultures, and negative CXR. Augmentin was discontinued
and patient remained afebrile for 36 hours thereafter, so we
suspect that drug fever may have been the etiology.
# Hypotension due to cardiogenic shock: Pt presented to clinic
and was given IV lasix IV x 2 for presumed CHF. He has moderate
to severe AS by echo, and in setting of preload dependence may
have decompensated to the point of requiring both fluid
rescusitation and pressors. Was only transiently on pressors
once admitted and since SBPs have been stable in low 110s.
.
#Aortic Stenosis/CHF: TTE confirmed moderate to severe AS by
echo. Impression was for pre-load dependent AS that was overly
diuresed prior to admission and precipitated hypotension. Actos
was held due to concern it may exacerbate CHF. Patient advised
to to resume until discussing with PCP.
.
# Renal function elevated on admission and returned to baseline
prior to discharge.
.
# Coagulopathy: Initial coags here were PT 150 PTT 63 INR 22,
now coags are normalized (PT 20.5, PTT 31.5,INR 1.9). Pt.
received 2 units of FFP and vitamin K in ED. Per pt. he has his
INR checked every 4 weeks and has not had any problems in the
past. Of note, he has recently started [**Year (4 digits) **] which has
been reported to interact with warfarin. Coumadin was restarted
prior to discharge. INR was therapeutic on 2mg warfarin per day
and patient was advised to continue with this dose in the future
with further blood tests/monitoring to be conducted by his PCP.
[**Name10 (NameIs) **] was held on discharge.
.
# Rhythm: H/o afib. Per PCP [**Last Name (NamePattern4) **]. is very non-compliant with
coumadin compliance and checking his INR.
.
#:DMII: Covered with RISS while in house. Resumed glyburide on
discharge.
.
# gout: renally dosed allopurinol
.
# Hyperlipidemia:
- held [**Last Name (NamePattern4) 107356**] as this medication may interact with
warfarin.
.
# HTN: Resumed lisinopril at low dose of 2.5mg qd. Beta blocker
held and patient advised to resume after discussion with PCP.
Medications on Admission:
allopurinol 100mg qdaily
atenolol 100mg qdaily
digoxin 250mcg qdaily
lasix 40 qdaily
glyburide 10mg [**Hospital1 **]
lisinopril 10mg qdaily
potassium 20 meq qdaily
warfarin 3mg MWF 2mg STTS
nitro tabs
[**Hospital1 **] 600mg qdaily (recently changed from tricor)
actos 30mg qdaily (recently changed from metformin [**2-28**] to CRI)
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO once a day.
4. Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
Disp:*30 Tablet(s)* Refills:*0*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*18 Capsule(s)* Refills:*0*
8. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H
(every 6 hours) as needed for cough.
Disp:*320 ML(s)* Refills:*0*
9. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO once
a day.
11. Outpatient Lab Work
Please check PT, INR, Creatinine, Potassium, Sodium, and BUN and
have these lab results sent to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 107357**]. Phone:
([**Telephone/Fax (1) 25201**], Fax: ([**Telephone/Fax (1) 107358**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Influenza B
Hypotension
Aortic Stenosis
Elevated INR
Atrial Fibrillation
Discharge Condition:
Good, no oxygen requirement
Discharge Instructions:
You were admitted to the hospital for treatment of low blood
pressure, influenza and pneumonia. On admission it was found
that you had elevated levels of coumadin in your blood. You
were given Vitamin K and a plasma transfusion to correct the
levels. You were given fluids to treat your low blood pressure,
and you were given antibiotics to treat your pneumonia. While
in the hospital you were monitored and treated in the ICU and
then transferred to the floor for further care. With regards to
your pneumonia, it is believed that is developed as a
complication of influenza. With regards to your coumadin dose,
it is believed that [**Telephone/Fax (1) 107356**] may have interacted to cause
your dose to be too high. Please do not take [**Telephone/Fax (1) 107356**] when
you leave the hospital. Please take all other medications as
detailed below.
.
Please return to the hospital or call your physician if you
[**Name9 (PRE) 107359**] fever > 101, chest pain, shortness of breath, or any
other complaint concerning to you.
.
The following changes were made to your medications:
1. Actos - discontinued
2. [**Name9 (PRE) **] - discontinued
3. Warfarin 2mg per day only
4. Lisinopril 2.5mg daily - please discuss with your doctor
before resuming higher 10mg dose.
5. Atenolol - please do not resume taking until you discuss
with your PCP.
.
Recommended Follow-up Care:
1. Evaluation by Cardiologist for Moderate-Severe Aortic
Stenosis and possible valve replacement.
2. Please have your kidney function, and INR checked in the
next week and have the results sent to your PCP.
3. Repeat CXR in 4 weeks time to document resolution of your
pneumonia.
Followup Instructions:
1. Please follow-up in Cardiology: ([**Telephone/Fax (1) 2037**], Wednesday,
[**3-25**] at 1:20pm, Dr. [**Last Name (STitle) **], [**Hospital Ward Name 23**] [**Location (un) **], [**Hospital Ward Name 5074**] of [**Hospital1 69**].
2. Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 107357**], in [**Location (un) 2199**] for
an appointment in the next 1-2 weeks. Phone: ([**Telephone/Fax (1) 25201**],
Fax: ([**Telephone/Fax (1) 107358**].
3. Please have your Creatinine, potassium, PT, INR checked
prior to your next appointment and have the results sent to Dr.
[**Last Name (STitle) 107357**]. Pleaes have bloodwork done in next 3-5 days.
|
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47,746
| 138,095
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34330
|
Discharge summary
|
report
|
Admission Date: [**2143-8-30**] Discharge Date: [**2143-9-12**]
Date of Birth: [**2066-5-15**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4095**]
Chief Complaint:
hypotension, diarrhea, [**Last Name (un) **]
Major Surgical or Invasive Procedure:
CVL, PICC
History of Present Illness:
Ms. [**Known lastname 79000**] is a 77 yo female with h/o DMII and HTN who now
presents from clinic with hypotension. She went to her PCP's
office this morning bc she has been having diarrhea for the past
5 days and was complaining of feeling weak and dizzy. On Monday
her daughter brought her some roti, which she said tasted
strange but she continued to eat the meal. Since that time she
has had diarrhea, denies any blood in her stool along with
anorexia, lightheadedness and diffuse, vague abdominal pain
along with intermittent nausea. Denies vomiting or fevers. At
her PCPs office, and her BP was found 52/40 and HR 112, an
ambulance was called and pt was transferred to [**Hospital1 18**] ED. Of
note she walked to clinic this morning with her son-in-law and
throughout this time has continued to take her
anti-hypertensives. She also endorses having some leg cramping
and strange sensation in her tongue, and thing have been tasting
strangely. She says that she has had less urine output since
her diarrhea started on Monday.
.
In the ED, initial vs were: 96, 72/58, 18, labs were notable for
Cr 10.1 (baseline of 1.0). Lactate wnl at 1.8, LFT's were
within normal limits, with a mildly elevated lipase of 126. U/A
showed small blood, 100 protein, 15 ketones and few bacteria, 2
hyaline casts. She was mentating well, but noted to be anuric.
Pt was given total of 4LNS and received the 5th liter during
transport. BPs were labile initially in the mid 70s to 90s.
Bedside ultrasound showed that her IVC was collapsed, her CXR
did have any infiltrates, her EKG was NSR at 94bpm, without ST
changes. She was guaiac negative on exam. A foley was placed
and she was admitted to the MICU given her hypotension. On
transfer, VS were afebrile 87, 93/54, 12, 100% RA.
.
On arrival to the ICU her initial VS were: 96.4, 89, 101/56, 16,
98% on RA. She says that her tongue continues to feel strange
and the foley is uncomfortable. She denies any chest pain,
shortness of breath, dysuria, urinary frequency/urgency,
nausea/vomiting, abdominal pain, fever/chills, or current leg
cramps.
.
Past Medical History:
RECTAL BLEEDING [**2140**]
COLONIC POLYPS [**8-/2140**]
HYPERTENSION
DIABETES MELLITUS
<40% RIGHT ICA STENOSIS
DYSLIPIDEMIA
Social History:
The patient did smoke but quit approximately 10-15 years ago.
Alcohol, occasional wine. Drug use none.
Family History:
NC
Physical Exam:
Physical Exam on Admission:
Vitals T 99.3 BP 108/55 RR 19 O2 95% RA
General Appearance: Well nourished, No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: MMM
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Not assessed), (Left
radial pulse: Not assessed), (Right DP pulse: Not assessed),
(Left DP pulse: Not assessed)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : throughout )
Extremities: Right lower extremity edema: Absent, Left lower
extremity edema: Absent, No(t) Cyanosis, No(t) Clubbing
Skin: Warm
Neurologic: Attentive, Follows simple commands, Responds to:
Verbal stimuli, Movement: Purposeful, Tone: Normal
.
Discharge Exam:
AVSS
Otherwise unremarkable.
No stigmata of endocarditis.
Pertinent Results:
.
Imaging:
CXR [**8-30**]-IMPRESSION: No acute intrathoracic process. Right upper
mediastinal rounded fullness. This likely reflects a combination
of mediastinal fat and vessels, however in the absence of
comparisons other etiolgies cannot be fully excluded. If prior
studies are made available, direct comparison can be made.
Otherwise, non-emergent noncontrast chest CT is recommended.
This was discussed with Dr. [**Last Name (STitle) **] by Dr. [**First Name (STitle) **] by phone at [**Pager number **]
on [**2143-8-30**].
.
Renal Ultrasound-Unremarkable renal ultrasound with no evidence
of hydronephrosis
.
[**9-1**] CT abd/pelvis-IMPRESSION: No acute intra-abdominal process;
specifically no evidence of an organized fluid collection.
Sigmoid diverticulosis, but no evidence of diverticulitis
.
[**9-4**] ECHO-TTE
IMPRESSION: No valvular vegetations or abscesses identified.
Mild symmetric left ventricular hypertrophy with preserved
biventricular regional and global systolic function. Mild
dilatation of the aortic root and ascending aorta. Resting
tachycardia. EF 55%
.
[**9-5**] TEE-IMPRESSION: Aortic valve echodensity as described above,
consistent with possible aortic valve vegetation. Mild aortic
regurgitation. Extensive complex descending thoracic aorta
atheroma. Initiation of statin therapy may be considered. EF
>55%
.
LENI [**9-5**]-IMPRESSION: Non-occlusive thrombus within the left
brachial vein surrounding the antecubital fossa. No deep venous
thrombosis in the left arm
.
EKG: NSR at 94bpm with normal axis/intervals
.
MICRO:
[**2143-9-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-9-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-9-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-9-3**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-9-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-9-2**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-9-1**] BLOOD CULTURE Blood Culture,
Routine-PRELIMINARY {STAPH AUREUS COAG +}; Anaerobic Bottle Gram
Stain-FINAL INPATIENT
[**2143-9-1**] BLOOD CULTURE Blood Culture, Routine-FINAL
{STAPH AUREUS COAG +}; Anaerobic Bottle Gram Stain-FINAL;
Aerobic Bottle Gram Stain-FINAL INPATIENT
.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
[**2143-9-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2143-9-1**] URINE URINE CULTURE-PRELIMINARY {STAPH
AUREUS COAG +, STAPH AUREUS COAG +} INPATIENT
URINE CULTURE (Preliminary):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
STAPH AUREUS COAG +. ~1000/ML. 2ND MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
.
[**2143-9-1**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
[**2143-8-31**] STOOL OVA + PARASITES-FINAL INPATIENT
[**2143-8-31**] STOOL OVA + PARASITES-FINAL INPATIENT
[**2143-8-30**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; OVA + PARASITES-FINAL; FECAL CULTURE - R/O
VIBRIO-FINAL; FECAL CULTURE - R/O YERSINIA-FINAL; FECAL CULTURE
- R/O E.COLI 0157:H7-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2143-8-30**] URINE URINE CULTURE-FINAL INPATIENT
[**2143-8-30**] URINE NOT PROCESSED INPATIENT
[**2143-8-30**] MRSA SCREEN MRSA SCREEN-FINAL
.
[**2143-9-4**] 07:08AM BLOOD WBC-6.9 RBC-3.30* Hgb-9.9* Hct-29.2*
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.7 Plt Ct-230
[**2143-9-3**] 05:09AM BLOOD WBC-6.2 RBC-3.25* Hgb-9.7* Hct-28.9*
MCV-89 MCH-29.9 MCHC-33.6 RDW-13.0 Plt Ct-228
[**2143-9-2**] 05:24AM BLOOD WBC-7.3 RBC-3.37* Hgb-10.1* Hct-29.3*
MCV-87 MCH-30.0 MCHC-34.5 RDW-12.8 Plt Ct-213
[**2143-8-31**] 03:56AM BLOOD WBC-5.1 RBC-3.51* Hgb-10.5* Hct-31.4*
MCV-90 MCH-29.9 MCHC-33.4 RDW-13.3 Plt Ct-257
[**2143-8-30**] 11:00AM BLOOD WBC-5.3 RBC-3.84* Hgb-11.8* Hct-34.9*
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.4 Plt Ct-224
[**2143-9-2**] 05:24AM BLOOD PT-14.5* PTT-31.5 INR(PT)-1.3*
[**2143-9-1**] 04:45PM BLOOD PT-14.6* PTT-30.0 INR(PT)-1.3*
[**2143-9-4**] 07:08AM BLOOD Glucose-90 UreaN-13 Creat-1.3* Na-141
K-4.5 Cl-105 HCO3-29 AnGap-12
[**2143-9-3**] 05:09AM BLOOD Glucose-97 UreaN-12 Creat-1.2* Na-139
K-4.3 Cl-104 HCO3-29 AnGap-10
[**2143-9-2**] 05:24AM BLOOD Glucose-135* UreaN-15 Creat-1.3* Na-140
K-4.1 Cl-103 HCO3-30 AnGap-11
[**2143-9-1**] 04:45PM BLOOD Glucose-128* UreaN-22* Creat-1.3*# Na-137
K-3.3 Cl-98 HCO3-30 AnGap-12
[**2143-9-1**] 04:45PM BLOOD Glucose-130* UreaN-21* Creat-1.3*# Na-137
K-3.4 Cl-97 HCO3-30 AnGap-13
[**2143-8-31**] 03:56AM BLOOD Glucose-110* UreaN-54* Creat-5.1*# Na-139
K-3.4 Cl-108 HCO3-18* AnGap-16
[**2143-8-30**] 04:27PM BLOOD Glucose-109* UreaN-59* Creat-7.6*# Na-137
K-4.7 Cl-111* HCO3-13* AnGap-18
[**2143-8-30**] 11:00AM BLOOD Glucose-130* UreaN-71* Creat-10.1*#
Na-133 K-4.7 Cl-101 HCO3-15* AnGap-22*
[**2143-9-2**] 05:24AM BLOOD CK(CPK)-85
[**2143-9-1**] 04:45PM BLOOD ALT-12 AST-17 CK(CPK)-78 AlkPhos-54
TotBili-0.6
[**2143-9-2**] 05:24AM BLOOD Lipase-226*
[**2143-9-1**] 04:45PM BLOOD Lipase-299*
[**2143-9-2**] 05:24AM BLOOD CK-MB-2 cTropnT-0.06*
[**2143-9-1**] 04:45PM BLOOD CK-MB-2 cTropnT-0.05*
[**2143-8-31**] 04:27AM BLOOD Lactate-2.3*
[**2143-8-30**] 11:12AM BLOOD Lactate-1.8
Brief Hospital Course:
Ms. [**Known lastname 79000**] is a 77 y/o female with a h/o hypertension, DM who
presented from her PCP's office with 5 days of diarrhea,
hypotension and [**Last Name (un) **] with Cr to 10.1 from baseline of 1.
.
#) MSSA sepsis/endocarditis/UTI/fever-Source could be Staph food
poisoning, but this is very unlikely it is more likely that the
source was erythematous PIV on L.arm. Pt did have MSSA in her
urine and did have a foley, but this was likely seeding from
bacteremia. Abdominal CT negative for acute process. Pt was
initially started on Vanco and this was changed to Nafcillin
when cultures returned with MSSA. Pt underwent a TTE that was
negative, but a TEE did show evidence of aortic valve
endocarditis. ID was consulted and recommended 6 weeks of
nafcillin therapy. However, given patient's limited insurance
and lack of [**Hospital1 1501**] or IV antibiotic benefit made continuation of iv
treatment at [**Hospital1 1501**] an unviable option. As a result, ID had
suggested to switch to daptomycin for once a day regimen. She
will get daily infusions at [**Hospital1 18**] pheresis unit to conclude
[**10-15**] with ID follow-up.
#) Hypotension/Diarrhea/abdominal pain- Unclear etiology for
diarrhea, although she related it to the food that she ate from
a street fair prior to admit. Initially, pt did not have a
fever, leukocytosis, or tachycardia. Thought to be a viral
gastroenteritis. After aggressive fluid resuscitation with 1 L
LR and D5 with 150meq of bicarb at 250cc/hr for 2 liters, blood
pressure normalized. Stool studies for C.diff, although no
recent antibiotic use, stool culture, E.coli, Yersinia, vibrio,
viral culture and O&P were sent and results were negative. Pt
developed a fever on [**9-1**] and therefore, repeat cultures were
sent and abdominal imaging performed that did not show evidence
of any acute process. Pt's hypotension resolved during admission
and her anti-HTN meds (lisinopril and HCTZ) were restarted upon
discharge. Diarrhea, also resolved during admission.
.
#) Acute Kidney Injury: Creatinine significantly elevated to
10.1 on arrival to the ER, most recent baseline 1.1 in [**8-14**].
Patient also noted significantly decreased UOP since her
significant volume of diarrhea. Likely etiology was pre-renal
especially given the rapid improvement with fluid resuscitation,
however given her recent hypotension may have also had a
component of ATN. On her urine lytes she was not sodium avid
which supported a component of ATN on top of pre-renal azotemia.
A renal US was normal with no evidence of hydronephrosis. U/A
sediment was obtained and showed hyaline casts and crystals.
Urine culture was negative. ACE-i and HCTZ were held in setting
of hypotension as well as [**Last Name (un) **]. It was resumed prior to
discharge. Creatinine settled to 1.3-1.4 - her likely new
baseline. Urine eos was negative making AIN or atheroemboli
less likely. There was no evidence of active endocaritis
associated ARF.
#) Diabetes Mellitus: On metformin at home, despite her renal
failure her lactate was initially within normal limits. Held
home metformin, started a humalog sliding scale while in the
hospital. Resumed metformin upon discharge - although she is at
the cusp of the Cr cutoff for Metformin treatment.
.
#) Hypertension: on lisinopril-HCTZ at home, held given her
renal failure and hypotension. It was restarted on discharge
.
#) Anion Gap Metabolic Acidosis: anion gap was 17 on admission,
on repeat electrolytes anion gap down to 13 but now with
elevated chloride, so then likely had a non-gap acidosis likely
from aggressive IVF resuscitation with normal saline. Etiology
of gap acidosis could be lactic as well as uremic in nature.
Non-gap likely due to diarrhea and IV fluid repletion. This
resolved.
.
#normocytic anemia-unclear baseline. No current signs of active
bleeding. Stools ordered for guaiac. Hct trended. Pt should
continue workup in the outpatient setting. HCT was stable at
28-29 on day of discharge.
.
#INCIDENTAL RADIOGRAPHIC FINDINGS)apparent widened
mediastinum/extensive atheroma seen on TEE-seen on CXR-radiology
suggests likely due to tortuous vessels. Pt is currently HD
stable. Rads recommended non-emegent CT chest. Could be due to
extensive atheroma seen on TEE. Bilateral blood pressures were
obtained and found to be equal. Statin was restarted.
******************Pt will need a non-urgent CT scan of the chest
for further evaluation*******************
.
#)hyperlipidemia-ocntineud statin
Medications on Admission:
fluticasone 50 mcg 1 spray daily
lisinopril-hydrochlorothiazide 20 mg-12.5 mg Tablet 2 Tablets
daily metformin 500 mg once a day
pravastatin 20 mg hs
calcium carbonate-vitamin D3 600 mg-400 unit twice a day
loratadine 10 mg daily as needed for allergies
multivitamin-minerals-lutein [Centrum Silver] once a day
omega-3 fatty acids-vitamin E [Fish Oil] 1,000 mg once a day
Discharge Medications:
1. fluticasone 50 mcg/Actuation Disk with Device Sig: One (1)
Inhalation once a day.
2. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
3. Calcium 600 + D(3) 600 mg(1,500mg) -400 unit Tablet Sig: One
(1) Tablet PO twice a day.
4. loratadine 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
8. daptomycin 500 mg Recon Soln Sig: One (1) Intravenous once a
day: through [**2143-10-15**].
9. lisinopril-hydrochlorothiazide 20-12.5 mg Tablet Sig: One (1)
Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Endocarditis
- MSSA sepsis
- UTI
- Hypotension
- diarrhea
- Acute renal failure
fever
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fever, diarrhea, low blood pressure, and
kidney injury. You were found to have a bacterial infection in
your blood and urine (staph) as well as your heart. For this,
you were started on antibiotic therapy and will need to continue
antibiotics for an additional 4 week's time. You will be
regularly followed the infectious disease doctors [**First Name (Titles) **] [**Name5 (PTitle) 15968**]. Your symptoms improved during admission. Your blood
pressure medications were held during admission and restarted
upon discharge.
.
Please take all of your medications as prescribed and follow up
with the appointments below. You will be receiving daily
antibiotics at [**Hospital3 **] until [**2143-10-15**].
Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: SATURDAY [**2143-9-14**] at 9:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: BMT/ONCOLOGY UNIT
When: SUNDAY [**2143-9-15**] at 9:00 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST Best Parking: Main Garage
.
Department: [**Hospital 7975**] [**Hospital **] HEALTH CENTER
When: FRIDAY [**2143-9-27**] at 9:30 AM
With: [**First Name8 (NamePattern2) 23964**] [**Last Name (NamePattern1) 23965**], DPM [**Telephone/Fax (1) 7976**]
Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Free Parking on Site
.
Primary Care: Dr. [**First Name (STitle) 31365**]
Wednesday, [**9-25**], 6:15pm.
|
[
"599.0",
"562.10",
"787.91",
"038.11",
"285.9",
"250.00",
"E879.8",
"999.31",
"276.2",
"V12.72",
"584.5",
"272.4",
"451.82",
"421.0",
"458.8",
"401.9",
"276.51",
"041.11",
"995.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
15451, 15457
|
9720, 14213
|
349, 361
|
15608, 15608
|
3591, 6417
|
16508, 17534
|
2778, 2782
|
14637, 15428
|
15478, 15478
|
14239, 14614
|
15759, 16485
|
2797, 2811
|
3513, 3572
|
265, 311
|
6452, 9697
|
389, 2492
|
15497, 15587
|
2825, 3497
|
15623, 15735
|
2514, 2640
|
2656, 2762
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,870
| 167,183
|
15946
|
Discharge summary
|
report
|
Admission Date: [**2195-1-12**] Discharge Date: [**2195-1-19**]
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 79 year old
male with a past medical history known for hypertension who
was admitted to an outside hospital after having chest pain
early in the morning of the 17th. This lasted 15 minutes and
he transported himself to the Emergency Department. He
continued having some episodes of chest pain in the week
prior to which radiated to both arms and was relieved by
rest. At the time he said he had no shortness of breath,
diaphoresis, nausea or vomiting.
On arrival in the outside Emergency Department, he was
hypertensive and his systolic pressure was greater than 200.
He was treated with Aspirin, Nitroglycerin, Lopressor and
Ativan and had a good response. He ruled out for myocardial
infarction by enzymes but did show some T wave changes on
electrocardiogram.
Based on symptoms, the patient was taken for cardiac
catheterization which showed left main occlusion as well as
three vessel coronary disease. He denied having any past
orthopnea, paroxysmal nocturnal dyspnea or lower extremity
edema. He was transferred into [**Hospital6 2018**]. He was admitted on [**1-12**]. He had not had any
chest pain or shortness of breath for three days.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Gastritis.
3. Status post upper gastrointestinal bleed 28 years prior.
MEDICATIONS ON TRANSFER:
1. Lopressor 25 mg p.o. t.i.d.
2. Aspirin 325 mg p.o. q d.
3. Captopril 6.25 mg p.o. t.i.d.
4. Lipitor 10 mg p.o. q d.
5. Protonics 40 mg p.o. q d.
6. Potassium Chloride undetermined dose.
ALLERGIES: The patient had no known drug allergies.
SOCIAL HISTORY: He had smoked cigarettes four a day
approximately 60 years but quit six months prior to
admission. He also admits to two to three drinks daily with
his last drink five days prior to admission.
PHYSICAL EXAMINATION: He was in sinus rhythm at 80 with a
blood pressure of 168/88. He was in no distress. He was
anicteric but with moist mucous membranes. Neck was supple.
No jugular venous distention. Palpable carotid pulses and no
bruits. Cardiac examination, he had a regular rate and
rhythm. No murmurs, rubs or gallops. His lungs were clear
bilaterally. His abdomen was soft, nontender, nondistended
with no HSN and no palpable masses. On examination, he did
have a right groin sheath in good position, status post
cardiac catheterization. There was no peripheral edema. He
had pedal pulses bilaterally. Neurologic examination showed
no gross motor or sensory defects.
LABORATORY ON ADMISSION: White count, 6.9; hematocrit, 34.7;
sodium, 136; K, 3.7; chloride, 102; bicarbonate, 26; BUN, 9;
creatinine, 0.9. CK and troponin were each negative x 3
cyclings.
HOSPITAL COURSE: He was admitted to the CCU overnight on
Cardiology Service and started on Heparin and Nitroglycerin
drips. He remained pain free and stable overnight.
On[**Last Name (STitle) **]tal day #2, he was taken to the Catheterization
Laboratory where an intra-aortic balloon pump was placed
prior to surgery. Later that day on [**1-13**], he went to
the Operating Room and he underwent a coronary artery bypass
grafting x 3 by Dr. [**Last Name (Prefixes) **]. Please refer to the
Operative Note.
He tolerated this procedure well and was transferred to the
Cardiac Intensive Care Unit intubated in stable condition.
He remained intubated overnight and into postoperative day #1
on a Propofol drip for sedation as well as a Nitroglycerin
drip for blood pressure control.
He was given 2 units of fresh frozen plasma and one five pack
of platelets.
He remained in sinus for much of the day but did have one
episode of rapid atrial fibrillation with a heart rate in the
170s and hypotension. He converted back to normal sinus
spontaneously and was managed with a bolus of intravenous
Amiodarone and an Amiodarone drip. His pressure remained
labile requiring alternating drips of Nitroglycerin and
Nipride. He also required intermittent A pacing to maintain
his blood pressure.
He continued to improved and his intra-aortic balloon pump
was removed without incident. Later in the day he was weaned
from the ventilator and extubated without incident. He was
transfused two units of cells for a hematocrit of 24.1.
On postoperative day #2, he was off all drips and maintained
a stable heart rate and pressure and was transferred out of
the Intensive Care Unit to the Floor.
On postoperative day #3, his chest tubes were removed. His
drainage had subsided significantly. He remained
hemodynamically stable with no further ectopy. He worked
aggressively with Physical Therapy but continued to require
assistance for mobility. He was tolerating a regular diet.
His sternal incision was healing nicely.
On postoperative day #6, he was deemed stable and ready for
discharge but it was felt he would benefit from a short stay
in rehabilitation.
At the time of discharge, his heart rate was 89 and sinus;
blood pressure, 139/83 and a room air sat of 94%. His lungs
were clear bilaterally. His heart was regular rate with no
rhythm with no murmurs. His abdomen was soft, nontender and
nondistended. His lower extremities showed minimal
peripheral edema.
DISCHARGE MEDICATIONS AS FOLLOWS:
1. Lopressor 50 mg p.o. b.i.d.
2. Lasix 20 mg p.o. b.i.d. x 7 days.
3. KCl 20 mEq p.o. b.i.d. x 7 days.
4. Colace 100 mg p.o. b.i.d.
5. Zantac 150 mg p.o. b.i.d.
6. Enteric coated Aspirin 325 mg p.o. q d.
7. Amiodarone 400 mg b.i.d. x 3 days then Amiodarone 400 mg
p.o. q d x one month.
8. Thiamin 100 mg p.o. q d.
9. Folic Acid 1 mg q d.
10. Multivitamin one capsule q d.
11. Captopril 12.5 mg p.o. t.i.d.
12. Lipitor 10 mg p.o. q d.
DISPOSITION: On [**1-19**], the date of discharge, the
patient was stable and was discharged to extended care
rehabilitation facility.
DISCHARGE DIAGNOSIS:
1. Status post coronary artery bypass grafting x 3.
2. Postoperative atrial fibrillation which was brief and
self resolving.
3. Hypertension.
4. Hyperlipidemia.
5. Past upper gastrointestinal bleed 28 years ago.
He was discharged on a cardiac heart healthy diet.
FO[**Last Name (STitle) 996**]P: He was instructed to follow up with Dr. [**Last Name (Prefixes) 411**] in the office postoperatively in about four weeks and
to follow up with his Primary Care Physician and
Cardiologist.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 76**]
MEDQUIST36
D: [**2195-1-23**] 14:25
T: [**2195-1-23**] 16:32
JOB#: [**Job Number 45704**]
|
[
"414.01",
"413.9",
"458.2",
"427.31",
"401.9",
"396.3",
"794.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.68",
"36.12",
"39.61",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
5907, 6661
|
2813, 5886
|
1937, 2615
|
137, 1310
|
2630, 2795
|
1452, 1702
|
1332, 1427
|
1719, 1914
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,524
| 113,461
|
44067
|
Discharge summary
|
report
|
Admission Date: [**2134-4-6**] Discharge Date: [**2134-4-22**]
Date of Birth: [**2066-3-29**] Sex: F
Service: MEDICINE
Allergies:
Latex / Keflex / Codeine / Statins-Hmg-Coa Reductase Inhibitors
/ Ace Inhibitors / Ciprofloxacin / adhesive tape / Angiotensin
Receptor Antagonist / Tomato / morphine
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Left Carotid Endarterectomy
Diagnostic Cardiac Catheterization
History of Present Illness:
68 y/o F with hx of DMII, HTN, PVD, admitted for CEA of left now
POD #2 with SOB and EKG changes. Pt was dx with critical carotid
stensois >80 L and R, [**1-1**] at [**Hospital1 2177**] and was admitted for CEA of
left. Post op she was hypotensive and given IVF. She has been
having increased O2 needs since, now on face tent + NC 5 liters
and nitro gtt. Her wt increased from 90.7 on admission to 98kg.
CXR with pulm edema and BNP elevated to [**Numeric Identifier **]. Post op, she also
developed EKG changes with STD in lateral leads and CE are
elevated with MB peaked at 24 and Trop 0.67. She has worsened
renal function since admission, with Cr now 2.7. She was given
lasix 60mg IV last night and 20mg IV and 60mg IV today. Heparin
is being started at time of transfer without a bolus. [**Name (NI) 94597**]
pt is SOB with +orthopnea, with some CP with coughing in center
of chest. Cough is nonproductive. No fever, no n/v. No BM since
surgery, but passing flatus. No HA or vision changes. Pt has
chronic neuropathy in feet and leg claudication.
Past Medical History:
1. CARDIAC RISK FACTORS:
-Diabetes, on insulin and actos, with peripherial neuropathy
-Dyslipidemia, intolearant of statins due to severe cramps,
failed lipitor and pravastatin
-Hypertension, higher BP in left arm
2. CARDIAC HISTORY:
-Inferior MI seen on stress test, with EF 40% on stress echo
[**4-1**] with apical inferior and inferior lateral hypokinesis
-Heart murmur per pt
3. OTHER PAST MEDICAL HISTORY:
-CRF, stage II
-right and left internal carotid stenosis, >80%, dx [**2134-1-5**],
now s/p CEE on left
-GERD
-Osteo arthritis
-Asthma
-PVD with hx of thrombophlebitis
-Hypotension with anesthesia
-Epistaxis on left
-Endometeriosis
-Nephrolithiasis x 2
-UTIs
-Anemia
-Hyperplastic cells in right breast bx, ductal cyst removed [**7-1**]
rt; star angioma rmoved from right breast
-bilateral cataracts s/p surgery
-s/p chole [**2101**]
-s/p appy [**2121**]
-s/p removal of abscess in right groin [**2075**]
-hx of assault from pts including facial assault and back/rib
cage injury
-s/p right retinal laser surgery in [**2131**]
Social History:
No children, lives alone with cat. Semi-retired psych RN. Uses a
cane when there is ice.
- Tobacco history: former heavy smoker ([**3-26**] ppd), from age 20-35
- ETOH: social
- Illicit drugs: none
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: mesothelioma
- Father: unknown
- GF: asthma
- [**1-24**] Sister: breast CA in situ, HTN
- GM: [**Month/Day (2) 1106**] disease
Physical Exam:
Admission Exam:
VS: 99.8 144/64 100 26 93-97% 5L NC +face tent, I/O- yest
1800/[**2038**]; today 130/805
GENERAL: anxious. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP elevated at mid neck with sitting at 45
degrees, wound on left neck healing well
CARDIAC: RRR, No M, +2 radial pulses, 1+ DP pulses
LUNGS: Crackles bilaterally, [**2-25**] of the way up
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c, trace edema
.
Discharge Exam:
GENERAL: anxious. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP elevated at mid neck with sitting at 45
degrees, wound on left neck healing well
CARDIAC: RRR, No M, +2 radial pulses, 1+ DP pulses
LUNGS: Crackles bilaterally, [**2-25**] of the way up
ABDOMEN: Soft, NTND. No HSM or tenderness. +BS
EXTREMITIES: No c/c, trace edema
Pertinent Results:
Admission Labs ([**4-6**]):
WBC-8.4 RBC-3.48* Hgb-10.2* Hct-30.7* MCV-88 MCH-29.2 MCHC-33.2
RDW-14.6 Plt Ct-200
Glucose-154* UreaN-40* Creat-1.7* Na-145 K-3.9 Cl-111* HCO3-25
AnGap-13
CK-MB-3 cTropnT-<0.01
CK(CPK)-88
Calcium-8.4 Phos-3.7 Mg-1.7
Type-ART pO2-186* pCO2-39 pH-7.43 calTCO2-27 Base XS-2
Intubat-INTUBATED
freeCa-1.16
.
Cardiac Enzyme Trend:
[**2134-4-6**] 02:21PM BLOOD CK-MB-3 cTropnT-<0.01
[**2134-4-6**] 09:57PM BLOOD CK-MB-3 cTropnT-<0.01
[**2134-4-7**] 04:04AM BLOOD CK-MB-8 cTropnT-0.09*
[**2134-4-7**] 04:20PM BLOOD CK-MB-24* MB Indx-7.6* cTropnT-0.44*
proBNP-[**Numeric Identifier **]*
[**2134-4-7**] 10:17PM BLOOD CK-MB-24* MB Indx-6.8* cTropnT-0.55*
[**2134-4-8**] 03:57AM BLOOD CK-MB-21* cTropnT-0.67*
[**2134-4-8**] 01:55PM BLOOD CK-MB-15* MB Indx-4.9 cTropnT-0.83*
.
Imaging:
ECHO ([**2134-4-7**]):
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-15mmHg. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
infero-lateral akinesis (EF 45%). No masses or thrombi are seen
in the left ventricle. There is no ventricular septal defect.
Right ventricular chamber size and free wall motion are normal.
The aortic 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. An eccentric, posteriorly directed jet of
moderate to severe (3+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. Tricuspid
regurgitation is present but cannot be quantified. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
.
ECHO ([**2134-4-21**]):
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
severe hypokisis of the basal and mid inferior and inferolateral
walls. The remaining segments contract normally (LVEF = 45 %).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-24**]+) mitral regurgitation is seen.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal left ventricular cavity size with regional
systolic dysfunction c/w CAD. Mild-moderate mitral
regurgitation. Dilated aortic root. Compared with the prior
study (images reviewed) of [**2134-4-15**], the findings are similar.
.
CXR ([**2134-4-16**]):
IMPRESSION:
1. Significant interval improvement in severity of pulmonary
edema.
2. New mild lingular atelectasis.
Brief Hospital Course:
CCU Course:
68 yo female with hx of inferior MI, PVD, DMII, now s/p CEA on
left on [**2134-4-6**] transferred to the CCU on [**2134-4-8**] with s/s of
CHF secondary to iv fluid administration and new mitral
regurgitation.
# PUMP: Patient was admitted to the CCU with signs and symptoms
of CHF. Her echo on [**4-7**] showed EF 45% along with severe mitral
regurgitation. She also had an elevated BNP and CXR that showed
pulm edema. On admission to the CCU, her weight was up 8 kg from
admission. This weight gain was likely caused by IVF given for
hypotension post op. She was started on diuresis with iv lasix,
lasix drip and diuril with limited effect. Her diuresis was
improved when she was wearing her BIPAP mask but she had
difficulty tolerating this mask. Her severe mitral regurgitation
likely contributed to the difficulty with diuresis as she had
limited forward flow. She was intubated on [**2134-4-11**] for
persistent hypoxia, difficulty tolerating BIPAP mask. She was
also started on CVVH on [**2134-4-12**]. She became 6-7 liters negative
over 48 hours. Her oxygenation was improved and her CXR was much
improved. She was extubated and transitioned to 50% shovel mask
with good O2 saturations. Her weight also returned to baseline.
She was started on torsemide iv boluses with the goal to make
her fluid even. She had a repeat echo which showed improved [**1-24**]+
mitral regurgitation and resolution of pulmonary hypertension.
She was seen by CT surgery for evaluation of her mitral
regurgitation and they recommended she follow-up with them as an
outpatient. She has been intolerant of an ACE-I/[**Last Name (un) **] in the past.
She was started on imdur and hydralazine for afterload
reduction, but was founf to have orthostatic hypotension and so
it the hydralazine was discontinued and the Imdur was initially
lowered to 30mg PO Daily and then eventually discontinued. She
continued to be orthostatic with physical therapy, but her
symptoms of dizziness and nausea resolved. She will be
discharged to Rehab with a prescription for torsemide 5mg to be
given if Ms [**Known lastname **] is noted to be gaining weight on a daily
basis. However at this time, we held off on starting afterload
reducing agents given her orthostasis.
# CAD: Pt has a hx of a inferior MI seen on stress test last
fall and she was admitted to the CCU with new CE elevations and
lateral STD in post op setting, concerning to ACS vs demand
ischmia. Stress echo prior to surgery did not show ischemic
changes, but was at subopitimal exercise <4.5 METs. Pt was also
not on a BB perioperatively. She has not tolearted statins,
ACE-I or ARBs in the past. Also pt had hypotension post
operatively, which may have worsened any ischemia. Echo [**4-7**]
with new presumed MR, which may be from ischemia. She was
initially treated with heparin drip, plavix (loaded with 600 mg
po x1 then maintained on 75 mg po daily), metoprolol, nitro
drip, aspirin 325 mg po daily. She had a cardiac catheterization
on [**2134-4-12**] which showed diffuse coronary disease but did not
show any intervenable lesions. Her plavix was stoppped on [**4-12**]
given that she may need mitral valve surgery.
# Acute on Chronic Renal Failure: Patient has underlying CKD,
with creatinine of 1.8 on admission. She developed acute renal
failure in the setting of aggressive diuresis, cath and her
creatinine became elevated to a max of 4.0. This may also be
related to the poor forward flow from her severe mitral
regurgitation. She required CVVH for fluid removal. She was
treated with mucomyst prior to cath. Her creatinine eventually
began trending down and on discharge was 2.1. She will need
follow up labs to monitor whether she returns to baseline or
whether she will be at a new baseline of her kidney function
given this recent injury.
# RHYTHM: patient was in sinus rhythm. She developed bradycardia
along with hypotension after a femoral groin line was placed,
though to be a vagal response. Her metoprolol was stopped and
her bradycardia improved when the groin line was pulled on
[**2134-4-15**]. Her metoprolol was eventually restarted and she
tolerated it well. She will be discharged on metoprolol XL 50mg
PO Daily. She will continued to be monitored by her
cardiologist.
# HTN: Patient has hypertension and all blood pressures were
monitored on the left arm. Her right arm shows falsely low blood
pressure related to right sided subclavian stenosis. She was
initially managed on amlodipine, metoprolol, nitro gtt for goal
SBP 100-140. She was then transitioned to imdur and hydralazine
for afterload reduction. On hospital day 13, pt was orthostatic
lying BP 138/61 HR 88 to standing BP 80/48 HR 92. She was a
little dizzy and nuaseaus. Her Imdur and Hydralazine were held
and no diuretics started. She continued to be orthostatic, but
less symptomatic. Her orthostasis likely has some autonomic
component given her prolonged hospital stay and bedrest. She
will be discharged to rehab where she will likely improve. She
will be given a prescription for torsemide in the event that she
gains some weight and needs a diuretic, but her afterload
reducers are being held at this time.
# HLD: Patient has failed atrovastatin and pravastatin as an
outpatient due to severe cramps and she was resistant to retry a
statin. Her lipid panel was not at goal, but not severely
elevated- LDL 109, HDL 45, total cholesterol 175. Her fish oil
was held during her hospital stay but was restarted the day
prior to discharge. She was also started on Crestor 5mg PO
Daily. She will continue to be monitored in the outpatient
setting.
# Anemia: Iron studies are consistent with anemia of chronic
disease and may also be related to anemia [**2-24**] CKD. She required
1 unit of PRBC for HCT of 22.4 with an appropriate response. Her
HCT then remained stable in high 20s, low 30s.
.
# Carotid stenosis: stable, healing well s/p left CEA. She will
likely need a future procedure for right sided stenosis.
.
# DMII: Patient was treated with lantus 28 hs and humalog
sliding scale. Her A1c was 7.2. Her actos was held and was not
restarted as it may contribute to worsened CHF.
# Hypothyroidism: TSH within normal limits. She was continued on
her home dose of levothyroxine.
# Asthma: ? asthma vs COPD vs cardiac asthma due to heavy prior
tobacco use. She was continued on Albuteral nebs and Advair.
.
# Anxiety: patient has significant underlying anxiety and
becomes more anxious when she does not know her plan of care.
She was treated with lorazepam 1 mg iv prn.
#Code: FULL CODE (confirmed with patient)
Medications on Admission:
-Actos (pioglitazone) 45mg qday
-Levoxyl 150mcg qday
-Amlodipine 10mg qday
-Xalantan 1 drop each eye HS
-Alprazolam 0.25mg 1-2 tabs prn, none for last 4 months
-Humalog, 2 units for BS >250
-Lantus 28 units HS
-Protonix 40mg
-Lasix 10mg PO qday
-MV qday
-ASA 81mg qday
-Calcitrol 0.25mcg qday
-fluticasone-salmeterol 250 mcg-50 mcg/Dose 1 puff IH [**Hospital1 **]
-Montelukast 10 mg qday
-Calcium carbonate 600 mg
-Coenzyme Q10 100 mg
-Omega-3 fatty acids 1,200 mg-144 mg qd
-Salmon oil 1000mg qday
-Pen VK 500mg prn tooth infection
Discharge Medications:
1. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
5. alprazolam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for sleep.
6. insulin glargine 100 unit/mL Solution Sig: Twenty Eight (28)
units Subcutaneous at bedtime.
7. insulin lispro 100 unit/mL Solution Sig: 0-12 units
Subcutaneous four times a day: per sliding scale.
8. pramoxine-mineral oil-zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. hydrocortisone acetate 25 mg Suppository Sig: One (1)
Suppository Rectal DAILY (Daily).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. omega-3 fatty acids Capsule Sig: One (1) Capsule PO TID
(3 times a day).
18. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
20. Calcitrate 200 mg (950 mg) Tablet Sig: One (1) Tablet PO
twice a day.
21. torsemide 5 mg Tablet Sig: One (1) Tablet PO once a day.
22. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
23. Xalatan 0.005 % Drops Sig: One (1) gtt Ophthalmic at
bedtime: each eye.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 6594**] Rehabilitation & Nursing Center
Discharge Diagnosis:
Status-post Left Carotid Endarterectomy
Myocardial Infaction
Acute Systolic Congestive Heart Failure: allergy to ACEi and [**Last Name (un) **]
Mitral Regurgitation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted to the hospital for surgery of your left
carotid artery. Following your surgery, you developed a low
blood pressure with difficulty breathing and your lab tests and
EKG changes were concerning for a heart attack. You were
transfered to the cardiac intensive care unit where you were
evaluated and treated by the cardiology service. You were found
to have a significant excess of fluid throughout your body and
improtantly in your lungs that made it difficult for you to
breathe. You received medication to help your kidneys remove the
excess fluid, but your breathing continued to be difficult and
you required intubation and assistance from a breathing machine.
You also required temporary dialysis because your kidneys were
not able to remove enough fluid. Careful use of dialysis allowed
enough fluid to be removed and you were extubated with improved
breathing. You also received a cardiac catheterization that
revealed your known coronary disease but did not require
intervention. While your fluid volume was very high, you were
noted to have worsened heart valve disease (mitral
regurgitation) that improved after removing a large amount of
fluid. You will need to follow up with your outpatient doctors.
Please take your medications as prescribed and keep your
outpatient appointments.
The following changes have been made to your home medications:
1. Stop taking Actos, amlodipine, furosemide and co-enzyme Q10
2. Start Torsemide to prevent fluid buildup
3. Increase aspirin to 325 mg daily for one month
4. STart Tucks and hydrocortisone suppositories for your
hemmorrhoids
5. STart colace and senna to prevent constipation
6. STart metoprolol succincate to slow your heart rate and
improve your heart function
7. STart trazadone to help you sleep
8. STart crestor and zetia to lower your cholesterol. Please
talk to Dr. [**Last Name (STitle) 1836**] is you get leg cramps again
9. Start Plavix to prevent blood clots in your carotid artery
.
Please check your weight daily before breakfast. Call Dr. [**Last Name (STitle) **] if
your weight increases more than 3 pounds in 1 day or 5 pounds in
3 days.
Followup Instructions:
Department: [**Last Name (STitle) **] SURGERY
When: THURSDAY [**2134-5-6**] at 2:00 PM [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2134-5-6**] 2:00
Department: [**Month/Day/Year **] SURGERY
When: THURSDAY [**2134-5-6**] at 2:30 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**]
Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**]
Phone: [**Telephone/Fax (1) 7960**]
**Please contact Dr. [**Last Name (STitle) **] office on [**Last Name (LF) 766**], [**4-26**] to book a
follow up appointment. You will need to be seen by Dr. [**Last Name (STitle) **]
within 2-4 weeks of your discharge from the hospital.**
Name: [**Last Name (LF) 94598**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD
Location: [**Hospital3 **] CTR
Address: [**Location (un) **], 7TH FL, STE#7A
Phone: [**Telephone/Fax (1) 94599**]
Appointment: Tuesday [**5-18**] at 11:30AM
|
[
"584.9",
"433.10",
"244.9",
"585.2",
"285.9",
"410.91",
"997.1",
"250.60",
"403.90",
"428.0",
"530.81",
"357.2",
"428.21",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.12",
"96.04",
"00.40",
"96.72",
"38.95",
"88.56",
"88.72",
"39.95",
"37.23",
"88.45"
] |
icd9pcs
|
[
[
[]
]
] |
16313, 16391
|
7195, 13783
|
434, 499
|
16600, 16600
|
4214, 7172
|
18934, 20547
|
2872, 3127
|
14367, 16290
|
16412, 16579
|
13809, 14344
|
16751, 18136
|
3142, 3713
|
1835, 1981
|
18154, 18911
|
3729, 4195
|
387, 396
|
527, 1579
|
16615, 16727
|
2012, 2639
|
1601, 1815
|
2655, 2856
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,757
| 177,809
|
1260
|
Discharge summary
|
report
|
Admission Date: [**2136-1-3**] Discharge Date: [**2136-1-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6378**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Video assisted thoracoscopic surgery and pleural biopsy
Ultrasound guided pigtail catheter drainage of abdominal abscess
Endotracheal intubation and ventilation
Placement of central venous lines
History of Present Illness:
85 y.o M with an extensive past medical hx including MDS, colon
CA s/p resection, recent ileostomy revisions and takedown,
cholecystectomy c/b MRSA and klebsiella pna and prolonged
hospital course. Pt was hypotensive post-op requiring brief SICU
stay when found to have pna and arf [**1-11**] hypotension. Pt then
transfered to medicine team and received a course of Meropenem
and Vanco (completed1/11). Pt found to have b/l pleural
effusions R>L. Thorocentesis was negative for empyema. Pt also
afebrile for entire admission except one low grade temp to
100.5. Pt went to rehab on [**2135-12-19**] where he was doing quite well
until [**2136-1-3**] when pt awoke in resp distress. HE was transfered
to OSH where he was found to have large L sided pleural
effusion. Transferred to [**Hospital1 18**] for further treatment.
Past Medical History:
1. PERIPHERAL EDEMA
2. DYSPHAGIA
3. Immune thrombocytopenic purpura
4. GBS like peripheral neuropathy
5. GASTROESOPHAGEAL REFLUX
6. NECK PAIN
7. CHRONIC CONJUNCTIVITIS
8. PERIPHERAL VASCULAR DISEASE
9. Hemorrhoids
10. SEROUS OTITIS
11. BENIGN PROSTATIC HYPERTROPHY
12. HYPERTENSION
13. Right Colon Cancer
14. Rectal ulcers
15. Myelodysplastic syndrome
16. colon cancer s/p colectomy [**4-11**], complicated by ileal perf
leading to ileostomy placement
17. Chronic myelomonocytic leukemia on prednisone
18. adrenal insufficiency
19. abdominal abscess [**10-12**]
Social History:
Founder of Juliard String Quartet. No tobacco, no EtOH,
generally lives with wife, however, recently at rehab.
Family History:
No colon cancer history.
Physical Exam:
MICU c/o exam
VS 96.0 162/60 81 17 100% 4L NC
GENERAL: Pt sitting with bed at 60 degrees. Mild tachypnea,
speaking in ful sentences. NAD.
NECK: Supple, JVP flat
CARDIOVASCULAR: regular, nl S1, S2, II/VI systolic M
LUNGS: Decreased breath sounds bilaterally with crackles
ABDOMEN: Active bowel sounds, nontender, soft
dressing/wound CDI,
EXTREMITIES: Warm, 2+ pedal edema.
Pertinent Results:
[**2136-1-11**] 04:26AM BLOOD WBC-58.8* RBC-2.96* Hgb-9.0* Hct-26.8*
MCV-90 MCH-30.5 MCHC-33.7 RDW-16.2* Plt Ct-77*
[**2136-1-11**] 04:26AM BLOOD Neuts-59 Bands-2 Lymphs-6* Monos-17*
Eos-0 Baso-0 Atyps-2* Metas-8* Myelos-6*
[**2136-1-11**] 04:26AM BLOOD Plt Smr-VERY LOW Plt Ct-77*
[**2136-1-10**] 07:10AM BLOOD Fibrino-363#
[**2136-1-11**] 04:26AM BLOOD Glucose-124* UreaN-30* Creat-1.1 Na-146*
K-3.7 Cl-117* HCO3-24 AnGap-9
[**2136-1-10**] 04:04PM BLOOD CK(CPK)-33*
[**2136-1-10**] 02:44PM BLOOD ALT-12 AST-28 LD(LDH)-365* CK(CPK)-31*
AlkPhos-117 TotBili-0.6
[**2136-1-10**] 07:10AM BLOOD ALT-12 AST-30 LD(LDH)-385* CK(CPK)-23*
AlkPhos-137* TotBili-0.7
[**2136-1-6**] 01:53AM BLOOD Lipase-12
[**2136-1-10**] 04:04PM BLOOD cTropnT-0.08*
[**2136-1-11**] 04:26AM BLOOD Calcium-6.3* Phos-3.9 Mg-2.2
[**2136-1-10**] 07:10AM BLOOD Albumin-2.4* Calcium-7.1* Phos-2.9 Mg-1.8
[**2136-1-10**] 04:04PM BLOOD Cortsol-34.7*
[**2136-1-10**] 02:44PM BLOOD Cortsol-34.3*
[**2136-1-10**] 07:10AM BLOOD Cortsol-45.6*
[**2136-1-10**] 02:44PM BLOOD CRP-14.95*
[**2136-1-10**] 07:10AM BLOOD Vanco-18.3*
[**2136-1-11**] 04:28AM BLOOD Type-ART Temp-36.7 pO2-89 pCO2-42
pH-7.32* calHCO3-23 Base XS--4 Intubat-NOT INTUBA
[**2136-1-11**] 04:28AM BLOOD Lactate-1.0
[**2136-1-11**] 04:28AM BLOOD freeCa-1.00*
CT abd [**2136-1-11**]
1. Peribronchial consolidation which has developed since the
prior examination are consistent with aspiration, predominantly
involving the right middle lobe and the right lower lobe, but
also with atelectasis at the left lower lobe.
2. Interval decrease in size of right upper quadrant fluid
collection, with pigtail catheter in appropriate positioning.
3. Left-sided chest tube appears appropriately positioned in the
left pleural space.
GRAM STAIN (Final [**2136-1-9**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
PRESUMPTIVE IDENTIFICATION DEFINITIVE IDENTIFICATION TO
FOLLOW.
BEING ISOLATED FOR SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- PND
CEFTAZIDIME----------- PND
CEFTRIAXONE----------- PND
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 64 I
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- 2 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
86 yo male status post CCY/ileostomy takedown, MRSA/Klebsiella
PNA status post completed treatment with vancomycin/meropenem
returns with development of large left pleural effusion.
* PLEURAL EFFUSIONs: Patient had on previous admission had
known bilateral pleural effusions, R>L, and had undergone
thoracentesis with removal of 2L of fluid from the right pleural
space consistent with an exudate which was thought at the time
to be secondary to parapneumonic effusion as the patient was
still being treated for MRSA/Klebsiella pneumonia. Left-sided
pleural effusion was not intervened upon. During this
admission, patient underwent multiple procedures for removal of
pleural effusions, however was immediately restarted on
vancomycin/meropenem for empiric treatment of the previous
klebsiella/MRSA pneumonia. Initially, patient underwent bedside
thoracentesis, which was successful, but was only able to remove
~1.3L, secondary to loculation of the effusion. Serosanguinous
fluid, although consistent with exudative effusion was sterile.
A second attempt made under ultrasound guidance was only able to
obtain 250cc of fluid, and radiologists commented upon
loculations noted in the effusion, and repeat CT chest revealed
continued massive pleural effusion despite initial
thoracentesis.
Thoracic surgery consultants then placed a chest tube, which
drained an additional 1.2 liters, yielding an additional ~2L
after two administrations of intrathoracic tissue plasminogen
activator. Following placement of the chest tube, patient's
blood pressure, creatinine, and lactic acid improved
dramatically. However, patient continued to have return of
pleural effusions causing respiratory distress and returned to
OR for two additional chest tubes, complicated again by
hypotension requiring several liters of fluid and several units
of blood. Patient also underwent pleural biopsy which was
unrevealing for a source of continued effusions.
* LACTIC ACIDOSIS/HYPOTENSION: At the time of admission,
patient's systolic blood pressure was approximately 100, which
was significantly lower than his baseline, which normally
required anti-hypertensives for control. While patient was
initially given fluids for and blood to improve perfusion,
patient became acutely hypoxic and short of breath overnight,
concerning for congestive heart failure. Therefore, patient was
then treated with diuresis and fluid restriction, which in turn
induced hypotension and a rise in lactate, which peaked at 3.0.
Transthoracic echocardiogram revealed left ventricular
hypertrophy, with decreased filling, as well as possible
decreased filling secondary to increased intrathoracic pressure
due to the large left pleural effusion. Consistent with this,
following placement of chest tube and blood transfusion,
patient's blood pressures improved dramatically (to SBP 130's),
lactate dropped below 1, and creatinine improved, suggesting
that pleural effusion was impairing appropriate cardiac output.
However, following administration of second dose of
intrathoracic tPA and drainage of right upper quadrant abdominal
abscess, patient became acutely hypotensive, concerning for
sepsis. Patient was started on dopamine infusion and
transferred to the MICU for further management. There, patient
was found to have an extremely low central venous pressure, and
patient was repleted with blood and fluids and responded
appropriately.
* ACUTE ON CHRONIC RENAL FAILURE: Serum creatinine at the time
of admission was 2.2, which rose to a peak of 2.5 within the
same day. Of note, patient's FeNa at different times during
initial admission suggested both pre- and intra- renal failure.
Given the fact that patient's lactate began to rise, it was felt
that increased perfusion of tissues with fluid and blood support
was necessary. Indeed, patient's creatinine improved
dramatically (1.9->1.6) following placement of chest tube and
administration of blood. However, patient became hypotensive
secondary to blood loss following chest tube placement, and
patient's creatinine was elevated and became oliguric. This
responded well to fluid boluses and blood transfusion as
expected.
* ABDOMINAL ABSCESS: An air-fluid level was noted on multiple
chest xrays at the time of admission, but was initially thought
to be due to dilated loop of bowel on the right upper quadrant.
However, oral contrast CT did not opacify the air/fluid level,
and patient underwent ultrasound guided drainage. The fluid,
however, was significant for only neutrophils, but no
microorganisms. Ultimately, however, cultures grew out
Klebsiella and vancomycin resistant Enterococci, and patient was
treated with meropenem and linezolid with good effect. Cultures
remained clear throughout rest of hospital course.
On hospital day 24, following extensive invasive procedures,
patient requested comfort measures only and transfer to home
with hospice. Chest tubes were placed to water seal and removed
without complications. All medications except those required
for comfort were discontinued. Patient was discharged home with
hospice care including morphine and lorazepam for comfort.
Medications on Admission:
Prednisone 10 mg Po QOD
Latanoprost 0.005 % Drops
Tobramycin-Dexamethasone 0.3-0.1 % Ointment Sig: One (1) Appl
Ophthalmic 3X/WEEK (MO,WE,FR).
Percocet Q4-6.
Combivent Nebs
Dorzolamide-Timolol 2-0.5 % Drops
Protonix 40 PO QD
RISS
Lantus 5U SC Qhs
Lasix 80 mg QD
Potassium Chloride 40 meq QD
Discharge Medications:
Morphine
Ativan
Discharge Disposition:
Extended Care
Facility:
.
Discharge Diagnosis:
Chronic myelomonocytic leukemia
Bacterial abdominal abscess
Parapneumonic pleural effusions
Acute on Chronic renal failure
End-stage Myelodysplastic syndrome
Discharge Condition:
Poor
Discharge Instructions:
Comfort measures only. Continue Morphine and Ativan as needed
for comfort.
Followup Instructions:
None - call primary care physician as needed for assistance with
comfort medications
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6384**] MD, [**MD Number(3) 6385**]
|
[
"682.2",
"E878.8",
"998.59",
"458.9",
"511.0",
"285.1",
"E879.8",
"416.8",
"511.8",
"585",
"998.11",
"205.10",
"427.1",
"041.09",
"V10.05",
"428.0",
"507.0",
"518.81",
"600.00",
"584.9",
"041.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"00.14",
"34.24",
"96.04",
"34.03",
"99.10",
"33.24",
"34.91",
"96.72",
"99.04",
"34.51",
"38.93",
"34.04",
"54.91",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10881, 10909
|
5354, 10499
|
281, 478
|
11111, 11117
|
2497, 4382
|
11241, 11458
|
2061, 2087
|
10841, 10858
|
10930, 11090
|
10525, 10818
|
11141, 11218
|
2102, 2478
|
222, 243
|
4417, 5271
|
506, 1331
|
5307, 5331
|
1353, 1916
|
1932, 2045
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
74,818
| 171,908
|
49396
|
Discharge summary
|
report
|
Admission Date: [**2141-1-1**] Discharge Date: [**2141-1-11**]
Date of Birth: [**2085-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Fever
Chest pain
Shortness of Breath
Major Surgical or Invasive Procedure:
Transesophageal Echo
Oral Maxillo Facial surgery for teeth extraction
History of Present Illness:
55F with a history of rheumatic heart disease s/p mechanical
mitral valve on warfarin presented to the ED with 12 hours of
sudden onset fevers, HA, and chest pain. She reports that at
approximately 10pm the night prior to admission she developed
fevers and chills along with HA and CP. She had some
palpitations as well as SOB. She reports that she often gets CP,
palpitations, and SOB at random but not associated with
exertion. This CP was different somehow. She denies cough,
mylagias, rhinorrhea, or sick contacts. She reports a tooth ache
for some time as well as some dysuria. She took tylenol for her
symptoms, with no relief. She came to the ED for further
evaluation.
.
In the ED, initial vital signs were T 100.1 P 125 BP 144/69 RR
20 100 on RA. Given concern for influenza, was given a dose of
osteltamivir. A DFA for influenza was subsequently negative. She
complained of CP with radiation to the back, so was sent for CTA
to r/o dissection. CTA was negative for dissection, but she
became increasingly tachycardic after the scan. Received
lorazepam 0.5mg IV x 2 and morphine 4mg IV x 1 but continued to
be anxious and tachycardic. She then received lorazepam 1mg IV
without change in tachycardia, but became somnolent and was
placed on an NRB. Then spiked to 104.4 with rigors. BCx x2 were
sent as well as UA and UCx. UA was bland. Received vancomycin 1g
IV x1 and pip/tazo 4.5g IV x1 as antibiosis and ketoralac 30mg
on top of ASA 325. Of note, the patient had an INR of 4.4 on
arrival in the ED.
.
Past Medical History:
- Rheumatic heart disease complicated by mitral stenosis, s/p
mechanical valve replecement in [**2133**]. On warfarin with goal INR
2.5 to 3.5
- Hypertension
- Hyperlipidemia
Social History:
- Lives with boyfriend/?husband in [**Name (NI) **]. On [**Social Security Number 103429**]social security.
- Tobacco: Smoked age 22 to age 54, [**1-22**] PPD. Around 45 pack
years
- Alcohol: Denies
- Illitics: Denies
Family History:
- Father with CAD and DM
- Mother with CAD
- Brothers with CAD and [**Name (NI) 21418**]
Physical Exam:
GEN: Middle aged woman in NAD
HEENT: MMM, poor dentition with foul odor, rotten teeth
bilaterally on the lower jaw, mild R mandibular tenderness but
no erythema
CV: RR, loud S2, no MRG. JVP 12cm. Pulses 2+ of the radial and
DP arteries.
PULM: Bilateral crackles to the mid lungs bilaterally, dense on
percussion to the mid lungs, prolonged expiration.
ABD: BS+ NTND, no masses or HSM, gas on percussion.
LIMBS: No clubbing, tremors, or cyanosis. No LE edema.
SKIN: No rashes, splinter hemorrhages, or skin lesions. Dry skin
only.
NEURO: PERRLA, EOMI, moving all limbs, reflexes 2+ of the biceps
and patellar tendons, toes down bilaterally.
.
Pertinent Results:
[**2141-1-1**] 10:30 am URINE Site: CLEAN CATCH
**FINAL REPORT [**2141-1-3**]**
URINE CULTURE (Final [**2141-1-3**]):
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
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-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2141-1-1**] 9:00 am BLOOD CULTURE #1.
**FINAL REPORT [**2141-1-4**]**
Blood Culture, Routine (Final [**2141-1-4**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Aerobic Bottle Gram Stain (Final [**2141-1-2**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] ON [**2141-1-2**] AT
0050.
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2141-1-2**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**2141-1-1**] 9:10 am BLOOD CULTURE #2.
**FINAL REPORT [**2141-1-4**]**
Blood Culture, Routine (Final [**2141-1-4**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES PERFORMED ON CULTURE # 287-3595N
[**2141-1-1**].
Aerobic Bottle Gram Stain (Final [**2141-1-2**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2141-1-2**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Time Taken Not Noted Log-In Date/Time: [**2141-1-1**] 11:56 am
Influenza A/B by DFA Source: Nasopharyngeal swab.
**FINAL REPORT [**2141-1-1**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2141-1-1**]):
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2141-1-1**]):
Negative for Influenza B.
[**2141-1-1**] 3:30 pm BLOOD CULTURE LINE #3.
**FINAL REPORT [**2141-1-4**]**
Blood Culture, Routine (Final [**2141-1-4**]):
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES PERFORMED ON CULTURE # 287-3595N
[**2141-1-1**].
Aerobic Bottle Gram Stain (Final [**2141-1-2**]):
GRAM POSITIVE COCCI IN CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2141-1-2**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**1-2**], [**1-3**], [**1-5**] Blood cultures - negative
[**1-6**], [**1-7**] Blood cultures - still pending
Mandible XRAY
IMPRESSION:
1. There have been multiple extractions.
2. There is periapical lucency surrounding the roots of two
right-sided
molars, raising the possiblity of abscesses.
3. Dental caries is identified.
CT CHEST
MPRESSION:
1. No evidence of aortic dissection or pulmonary emboli.
2. Mild interlobular septal thickening could reflect mild
pulmonary edema. No
pleural effusion.
3. Hiatal hernia.
The study and the report were reviewed by the staff radiologist.
1st TEE-
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No mass or thrombus is seen in
the right atrium or right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. No aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The prosthetic
mitral leaflets appear normal. The transmitral gradient is
normal for this prosthesis. There is small linear echodensity at
the mitral prosthesis annulus (cine loop #16 and others). The
echodensity may represent a loose suture, although it is also
entirely consistent with a vegetation in the appropriate
clinical context. No mitral valve abscess is seen. Trivial
mitral regurgitation is seen. The degree of mitral regurgitation
seen is normal for this prosthesis. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Probable prosthetic mitral valve vegetation. No
other vegetations, paravalvular abscess or significant mitral
regurgitation seen.
[**2141-1-5**] TEE:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No mass or thrombus is seen in
the right atrium or right atrial appendage. No atrial septal
defect is seen by 2D or color Doppler. Right ventricular chamber
size and free wall motion are normal. There are simple atheroma
in the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion. No
masses or vegetations are seen on the aortic valve. No aortic
valve abscess is seen. No aortic regurgitation is seen. A
bileaflet mitral valve prosthesis is present. The prosthetic
mitral leaflets appear normal. The transmitral gradient is
normal for this prosthesis. There is small linear echodensity at
the mitral prosthesis annulus (cine loop #16 and others). The
echodensity may represent a loose suture, although it is also
entirely consistent with a vegetation in the appropriate
clinical context. No mitral valve abscess is seen. Trivial
mitral regurgitation is seen. The degree of mitral regurgitation
seen is normal for this prosthesis. The estimated pulmonary
artery systolic pressure is normal. No vegetation/mass is seen
on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Probable prosthetic mitral valve vegetation. No
other vegetations, paravalvular abscess or significant mitral
regurgitation seen.
[**2141-1-10**] Portable CXR:
INDICATION: 55-year-old female status post new right PICC.
COMPARISON: Chest radiograph available from [**2141-1-6**].
UPRIGHT AP VIEW OF THE CHEST: There is a new right-sided PICC
terminating at the low SVC. There is no pneumothorax. Cardiac
and mediastinal contours are unchanged.
IMPRESSION: New right-sided PICC terminating at the low SVC.
Brief Hospital Course:
55 y.o. F with history of rheumatic fever and mechanical mitral
valve who presented with fevers, chest pain, and shortness of
breath, found to have MSSA Bacteremia and endocarditis.
# MSSA Bacteremia / Endocarditis: This was initially a presumed
diagnosis based on her history of oral lesion with fevers and a
prosthetic mitral valve. She received vancomycin and pip/tazo
in the ED. Eventually blood cultures grew back MSSA, and
coverage was changed to gentamicin (2 weeks, lst day [**2141-1-16**]),
rifampin (6 weeks, last day [**2141-2-17**]), and nafcillin(6 weeks,
last day [**2141-2-17**]). TEE was performed which revealed a small
vegetation, and Cardiac Surgery was consulted and did not think
she was a surgical candidate at this time. During her course of
antibiotics, her rifampin was held due to elevated total
bilirubin, a known side effect; however, this normalized and
restarted per ID. Daily EKG's were checked which never revealed
concerning signs of abscess. Daily screening BCx x2 were never
positive after the initial set. The patient is scheduled for an
outpatient transesophageal echocardiogram in [**2141-2-13**] at
9 AM per her outpatient cardiologist.
.
# Poor dentition and possible dental abscesses: Ms [**Known lastname **] had a
mandible series and a panorex and was then seen by OMF who
pulled several teeth. Per patient, she has chronic poor
dentition and tooth aches. This is suspicious as a source for
her bacteremia, but is unlikely given that MSSA is an odd mouth
flora. Patient needs a general dentist for oral hygiene as
outpatient.
.
# Possible UTI: UCx grew out Gentamicin sensitive E. Coli.
Treatment decision was moot as the E. Coli was covered by
Gentamicin.
# Chest Pain: Had Chest pain in unit, ruled out, EKG changes
were stable. Had CTA which was negative for dissection.
Resolved with magic mouthwash and ativan.
.
# Prosthetic mitral valve: On warfarin with goal INR 2.5 to 3.5
as an outpatient. After several high and low periods of INR,
she became therapeutic, with heparin bridging when low.
.
# Anxiety: Minimize BZs as became somnolent in the ED with high
doses of lorazepam.
- Lorazepam 0.5mg PO Q6H PRN
.
# Pain: Low dose PO opiates for pain as became somnolent in the
ED from high doses of morphine IV.
- Morphine 15mg PO Q6H PRN
.
# Headache: Patient has been having a headache at home and
continues to complain of headache with fevers. Likely [**2-22**] to
fevers, as patient has normal neurologic exam, but given high
grade bacteremia and high risk, will r/o septic emboli. Had
normal head CT and MRI that were both negative.
.
# Anemia: She had labs consistent with [**Doctor First Name **] across her mitral
valve, and she did require 2 units PRBC on the day of her oral
surgery. Her MCV was low normal, and it was postulated that
chronic [**Doctor First Name **] might have led to iron deficiency anemia. Iron
studies showed were unrevealing.
Medications on Admission:
Fosamax 70 mg po weekly
Flonase 50 mcg spray 2 puffs daily
Metoprolal tartrate 25 mg po BID
Simvastatin 20 mg po daily
Warfarin 5 mg po daily
Discharge Medications:
1. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
2. Flonase 50 mcg/Actuation Spray, Suspension Sig: Two (2) puffs
Nasal once a day.
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
11. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: Three (3)
Tablet, Chewable PO BID (2 times a day).
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-22**] Sprays Nasal
QID (4 times a day) as needed for nasal congestion.
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
16. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
17. 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.
18. Morphine Sulfate 1-5 mg IV PRN PAIN Q5MIN
Maximum total dose not to exceed 0.3 mg/kg
PACU ONLY
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): last day [**2140-2-18**].
21. Nafcillin 2 g IV Q4H Duration: 6 Weeks
D1=[**1-2**]
22. Gentamicin 60 mg IV Q12H Duration: 7 Days
23. Outpatient Lab Work
Please draw weekly labs on Mondays with CBC/diff, BUN/Cr, LFTs.
Fax to attn: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1419**]
24. Outpatient Lab Work
Please draw INR 4 x weekly until INR therapeutic between 2.5 to
3.5
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Final Diagnosis:
Bacteremia
Endocarditis
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
You were admitted to the hospital with chest pain, and you were
subsequently found to have an infection in your blood that may
have landed on your mechanical mitral valve. You were seen by
CT surgery who deemed that you did not need surgery. You were
seen by infectious disease specialists who recommended a
prolonged course of IV antibiotics. You also had several teeth
removed by our dental surgery colleagues.
You were started on the following medications
Nafcillin 2 grams IV q4h (last day = [**2141-2-17**])
Rifampin 300 mg [**Hospital1 **] (last day = [**2141-2-17**])
Gentamicin 60 mg IV q12 hours (last day [**2141-1-16**])
Aspirin 81 mg daily
Please continue all your home medications as prescribed.
Please keep all your medical appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD (Infectious Disease)
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-1-25**] 11:20. [**Hospital **], [**Location (un) **], [**Hospital Ward Name 23**] Clinical Center
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD (Infectious Disease)
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2141-2-17**] 9:30 [**Hospital Unit Name **] ([**Doctor First Name **]), BASEMENT
Transespohageal Echocardiogram: [**2141-2-13**] at 9 AM, [**Hospital1 **] Hospital [**Hospital Ward Name **] ?????? [**Hospital1 7768**],
[**Location (un) 86**], and go to the fourth floor of the [**Hospital Unit Name 723**].
MD: Dr. [**First Name (STitle) **] [**Name (STitle) **]
Specialty: Cardiac Surgery
Date/ Time: [**2141-2-20**] 1:00pm
Location: [**Last Name (NamePattern1) 439**] [**Hospital Unit Name **] [**Location (un) 551**]
Phone number: [**Telephone/Fax (1) 170**]
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD (Cardiologist) Phone:[**Telephone/Fax (1) 1144**]
Date/Time:[**2141-3-9**] 3:00. [**Location (un) **] ([**Location (un) 2352**], MA), [**Location (un) **], [**Location (un) 2352**] - CARDIOLOGY (SB)
Provider: [**Name Initial (NameIs) 6436**] ([**Month (only) **]) [**Name8 (MD) **], MD (primary care)
Phone:[**Telephone/Fax (1) 1144**] Date/Time:[**2141-3-13**] 3:00
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
Completed by:[**2141-1-11**]
|
[
"041.4",
"790.92",
"584.9",
"V43.3",
"784.7",
"V58.61",
"996.61",
"038.11",
"521.00",
"421.0",
"428.33",
"401.9",
"E934.2",
"272.4",
"428.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"23.19"
] |
icd9pcs
|
[
[
[]
]
] |
16521, 16615
|
11087, 14012
|
350, 422
|
16700, 16700
|
3181, 11064
|
17626, 19184
|
2414, 2504
|
14204, 16498
|
16636, 16636
|
14038, 14181
|
16653, 16679
|
16845, 17603
|
2519, 3162
|
274, 312
|
450, 1964
|
16714, 16821
|
1986, 2162
|
2178, 2398
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,847
| 182,013
|
44722
|
Discharge summary
|
report
|
Admission Date: [**2177-7-27**] Discharge Date: [**2177-9-2**]
Date of Birth: [**2106-11-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
Endotracheal Intubation
Central Venous Catheter and Swan Ganz catheter placement
Arterial Line Placement
Right sided thoracentesis
History of Present Illness:
70 y/o male with h/o CAD s/p LAD PTCA [**92**] yrs ago, COPD, T2DM,
and AICD pocket infection who presented to the ED on [**2177-7-27**]
with worsening SOB x 5 days and feeling "cloudy." The patient
was currently at [**Hospital3 **] and began to develop worsening
SOB for the past 5 days. This AM while talking with his daughter
on the phone, he was noted to desaturate into the high 80s and
he was brought to the [**Hospital1 18**] ED for further evaluation. The
patient states that he has felt "cloudy" of late which seems to
relate to his worsening SOB. He is not ambulatory and is very
deconditioned secondary to several complications within the past
two months related to an AICD pocket infection. He denies any
CP, N/V/D, abdominal pain, or HA. He states that he only uses
one pillow to sleep but admits to sleeping at about 30 degrees
at rehab.
.
In the ED, his VS were 97.8 150/80 88 12 89-94% 3L NC. He
was given Percocet for back pain, Lasix 80 mg IV, and Combivent
neb. For unclear reasons, he was placed on a [**Name (NI) 597**] in the ED.
.
Upon arrival to the CCU, he was hemodynamically stable. He was
quickly weaned to 3L O2 via NC, O2 sats 100%.
Past Medical History:
-AICD Pocket infection c/b MSSA bacteremia, pericardial effusion
s/p mediastinal exploration, evacuation of pericardial effusion
& hematoma ([**2177-6-16**])
-Ischemic colitis and ischemic liver [**5-/2177**] (post air embolism
from post mediastinal exploration)
-CAD s/p LAD PTCA [**92**] years ago
-T2DM c/b neuropathy and nephropathy
-COPD
-Hypothyroidism
-CVA
-s/p Bovine AVR [**2169**]
-Hyperlipidemia
-GERD
-Chronic LBP
-Lumbar sympathectomy
Social History:
The patient is a retired truck driver. He is currently married,
has 10 children.
No smoking for last 5 years. Prior to that smoked 2 packs a day.
No EtOH or IVDU.
Family History:
Sister with diabetes. No other known family hx.
Physical Exam:
Vitals:
97.6 95/48 71 98% 4L NC
General: Oriented to person and time. Slight confustion with
place but oriented with some re-direction.
HEENT: NC/AT. MM dry. OP clear. PERRLA. EOMI.
Neck: JVD difficult to access [**1-16**] increased neck girth.
CV: S1, S2 with Grade II/VI SEM. +S3.
Pulm: Crackles halfway up lung fields B/L.
Abd: Soft, NT/ND with normoactive BS.
Ext: 2+ pitting edema to knees B/L.
Pertinent Results:
Admission Labs:
[**2177-7-27**] PT-13.8* PTT-33.1 INR(PT)-1.2*
[**2177-7-27**] PLT COUNT-124*
[**2177-7-27**] HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-2+
[**2177-7-27**] NEUTS-79.5* LYMPHS-9.9* MONOS-4.9 EOS-5.4* BASOS-0.2
[**2177-7-27**] WBC-9.1 RBC-2.77* HGB-8.8* HCT-27.2* MCV-99* MCH-31.9
MCHC-32.4 RDW-18.0*
[**2177-7-27**] CK-MB-NotDone proBNP-2656*
[**2177-7-27**] CK(CPK)-16*
[**2177-7-27**] GLUCOSE-206* UREA N-28* CREAT-1.8* SODIUM-135
POTASSIUM-4.1 CHLORIDE-85* TOTAL CO2-42* ANION GAP-12
[**2177-7-27**] CK-MB-NotDone cTropnT-0.22*
[**2177-7-27**] CK(CPK)-38
.
Discharge Labs:
[**2177-9-2**]: INR 3.5, PT 32.5, PTT 41
.
Imaging Studies:
1. CXR (PA/Lateral) [**2177-7-27**]
Congestive heart failure with bilateral effusions (R>L), with
possible underlying consolidation in the RLL and to a lesser
degree the RML and LLL.
.
2. CXR [**2177-7-28**]
Compared to PA and lateral chest of the prior day. Right-sided
PICC line with its tip in the distal SVC. The heart is markedly
enlarged. There remains a large right and small left pleural
effusion, not significantly changed. Patient remains in
congestive heart failure, though it may be slightly improved
compared to the prior study. Underlying infectious consolidation
in the right lower lobe not excluded.
.
3. Echo [**2177-7-28**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. LV systolic function appears depressed. Resting regional
wall motion abnormalities include inferior and inferolateral
hypokinesis. Right ventricular chamber size is normal and free
wall motion may be mildly impaired. The aortic root is mildly
dilated. The ascending aorta is mildly dilated. The aortic valve
leaflets are mildly thickened. A bioprosthetic aortic valve
prosthesis is present. The aortic prosthesis leaflets appear to
move normally. The transaortic gradient is normal for this
prosthesis. The mitral valve leaflets are mildly thickened. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. Transmitral
Doppler and tissue velocity imaging are consistent with Grade
III/IV (severe) left ventricular diastolic dysfunction. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion. Compared with the prior study (images reviewed) of
[**2177-7-7**], ventricular function is now similar. EF 35-40%.
.
4. Echo [**2177-8-7**]
The left atrium is mildly dilated. The left ventricular cavity
size is normal. Overall left ventricular systolic function
cannot be reliably assessed. 3l. The aortic valve leaflets are
mildly thickened. The mitral valve leaflets are mildly
thickened. There is no pericardial effusion. Compared with the
prior study (images reviewed) of [**2177-7-28**], there is
probably no significant change.
.
All cultures, including BCx, UCx, pleural fluid culture, and
wound culture have been negative.
.
5. CT Chest [**2177-8-9**]:
1. Increasing large right-sided pleural effusion and pulmonary
edema. Scattered parenchymal opacities in the left lower lobe
represent superimposed infection vs atelectasis. There is no
evidence of abscess.
.
6. [**2177-8-21**] Chest X Ray:
SINGLE AP VIEW OF THE CHEST. There has been almost complete
resolution of pulmonary edema. A small right pleural effusion
has decreased in size. Mild cardiomegaly is stable. There is no
pneumothorax. Right PIC catheter tip ends in the lower SVC.
Patient is post median sternotomy.
.
IMPRESSION: Almost complete resolution of pulmonary edema.
.
7. [**2177-8-22**] CT Head:
FINDINGS: There is no evidence of intraaxial or extraaxial
hemorrhage, mass effect, shift of normally midline structures,
or acute major or minor vascular territorial infarction. The
ventricles and sulci are mildly prominent, but stable in size
and appearance. The [**Doctor Last Name 352**]-white matter differentiation is
preserved. Again seen are subtle hypodensities within the
periventricular white matter which is an indication of chronic
microvascular ischemic changes, stable. Extensive carotid artery
calcifications are identified. The visualized paranasal sinuses
are clear. The surrounding osseous and soft tissue structures
are unremarkable.
.
IMPRESSION: No evidence of acute or chronic infarction. Stable
microvascular ischemic changes in the periventricular white
matter.
.
8. [**2177-8-23**] EEG:
IMPRESSION: Abnormal EEG due to the moderately slow posterior
background and occasional bursts of generalized slowing. These
findings
indicate a widespread encephalopathic condition affecting both
cortical
and subcortical structures. Medications, metabolic disturbances,
and
infection are among the most common causes. No prominent focal
abnormalities were evident, and there were no epileptiform
features.
The cardiac monitor showed occasional irregularities in a PACED
rhythm.
.
Brief Hospital Course:
A/P: 70 y/o male with h/o CAD, T2DM, hyperlipidemia, and COPD
who presented to the ED on [**2177-7-27**] with worsening SOB x 5 days
from [**Hospital3 **]. Pt. was initially admitted to CCU on
[**2177-7-27**], transferred to [**Hospital Ward Name 121**] 6 on [**2177-7-29**], triggered on [**2177-8-3**]
for hypotension with BP 67/38 and transferred back to CCU on
[**2177-8-3**]. He remained fluid overloaded and a swan catheter was
placed. The following issues were addressed during this hospital
admission:
.
1# Cardiac:
.
Pump
The patient was initially admitted for likely CHF exacerbation.
He was started on a lasix gtt the night of admission with a good
response. He continued to diurese and he was moved to the floor
since he no longer required intensive level care. While on the
floor, he continued to be diuresed. After several days, he
became hypotensive and triggered for BPs 60s/30s. He was given
IVF without an adequate response in his pressures. He was
transferred back to the CCU and started on a dopamine gtt. He
diuresed well on the dopamine gtt and his BP was supported.
Gradually, the dopamine gtt was weaned. However, he still
appeared volume overloaded with minimal improvement in his
oxygen requirement. A swan was placed for a more accurate
picture of his volume status and he was volume overloaded by
swan numbers with an elevated PAD and elevated CVP without an
obtainable wedge pressure. He also had a high CO and low SVR
suggestive of sepsis, but he never had an elevated WBC and was
afebrile during his entire hospital admission with negative
blood, urine, wound, and pleural fluid cultures. The Lasix drip
was eventually changed to IV Lasix boluses, with a net diuresis
of over 36 liters for the hospital stay. He was then
transitioned to oral Lasix for maintainence. The patient had an
echo on [**2177-7-28**] with the results above in detail. It was
unchanged in comparison to [**2177-7-7**] with similar ventricular
function and inferior and inferolateral hypokinesis. The patient
had another echo on [**2177-8-7**] with no new changes. At discharge
the patient was thought to be euvolemic, satting well on room
air and without peripheral edema. His dry weight is 70.4 kg.
.
Ischemia
The patient had an initial troponin bump on admission which was
most likely secondary to CHF exacerbation. He was continued on
Aspirin, Metoprolol and Lipitor with no further issues.
.
Rhythm
The patient is completely pacer-dependent, being epicardially
paced at 70. He is on Amiodarone for post-op afib and this was
continued this entire admission. His underlying rhythm is
atrial flutter; it was unclear whether he had previously been
cardioverted. Anti-coagulation was started with Warfarin 5 mg
with a goal of [**1-17**] and a plan for cardioversion in 6 weeks. The
patient's INR became supratherapeutic and Coumadin was held.
His coumadin was transitioned to 2mg and then 1mg. His INR
continued to flucuate. He was discharged on 1mg, but a stable
regimen had not been achieved. His INR will have to be
monitored closely unitl his levels are stable. His INR goal is
[**1-17**].
.
2# SOB on admission: Likely due to CHF exacerbation, with
diuresis of over 36 L during his admission. He had 4 surgeries
(3 cardiac surgeries) earlier in the summer, so it is likely
that he required copious IVF hydration surrounding these
procedures which may have been the cause of his massive fluid
overload. It appears that his diet was regulated at rehab but
there is concern for medication non-compliance at rehab, per
previous discharge summaries. On discharge, the patient was
maintained on standing diuretics as well as PRN nebs and INH
COPD meds.
.
3# Metabolic Alkalosis/Hypochloremia: Etiology most likely a
combination of contraction alkalosis and/or post-hypercapnia.
This acutely worsened on [**2177-8-11**], when the patient was found to
have mental status changes and an ABG revealed a CO2 of over
100, likley due to a depressed respiratory drive secondary to
sedatives given for agitation on top of a preexisting alkalosis.
The patient was therefore intubated for ventilation, and
continued to be diuresed. His CO2 improved and he was extubated
after a few days. All sedating medications were held and serial
ABGs were trended to follow the resolution of the metabolic
alkalosis.
.
4# Pleural effusions: s/p right thoracentesis on [**2177-7-30**], 1600
mL of serosanguinous fluid removed from right pleural space.
Gram stain and cultures were negative, cytology was negative.
The right pleural effusion slowly re-accumulated after tap but
resolved after continued diuresis. Repeat CXR showed
improvement of the effusion and on discharge he had been
breathing well on room air without complications
.
5# T2DM: The patient was started on Glargine for tighter
glycemic control and was covered with an insulin sliding scale.
He was monitored with QID fingersticks. His blood sugars were
in the 100s on discharge.
.
6# Hyperlipidemia: The patient was continued on his statin.
.
7# COPD: The patient was continued on nebs
.
8# MS changes: The patient has a history of baseline dementia
which was confounded by
delerium in the face of metabolic abnormalities. His mental
status improved as his metabolic process was resolved as
detailed above. Neurology was also consulted and a head CT
showed old lacunar infarcts but no acute causes for a change in
mental status. An EEG showed mild encephalopathy, but no other
findings. His mental status did clear somewhat with the addition
of standing lactulose; he was discharged on this medication.
.
9# Hypothyroidism: The patient was continued on his outpatient
dose of Levothyroxine.
.
10# ?UTI: The patient was started on levofloxacin at [**Hospital1 **] for a question of UTI based on U/A positive for WBC. UCx
during this hospitalization were negative and Levofloxacin was
d/c'd.
.
11# Chronic lower back pain: The patient was treated with a
Lidocaine patch and Percocet prn. Stronger narcotics were
avoided given somnolence and MS changes.
.
12# Wound Care: The patient has left chest wound and left
gluteal pressure ulcer. Wound care was consulted on [**2177-7-29**] and
they made several recommendations. For the left gluteal pressure
ulcer, they recommended gentle cleansing with normal saline or
commercial wound cleaner, thin layer of Duoderm gel, air dry,
allevyn foam adhesive over the site, and change every 2 days or
prn. For the left chest wound, they recommended cleansing with
commercial wound cleanser, pat dry, pack aquacel AG rope and
moisten with saline, cover with dry gauze and change daily.
These recommendations were followed throughout the admission.
.
13# Voiding: Pt. failed multiple attempts to void on his own.
Case was discussed with neurology. He was started on finsateride
on the day prior to admission. He is scheduled to follow up
with urology to address this issue. Until then, his foley
should remain in place.
.
14# Code: The patient was full code during admission.
Medications on Admission:
Levothyroxine 100 mcg PO daily
Duloxetine 20 mg PO QHS
Ondansetron PRN
Percocet 1 tab PRN
Senna PRN
Colace PRN
Lasix 80 mg PO BID
Lactulose PRN
Lidocaine patch
Nystatin powder
Gabapentin 300 mg PO TID
Alb nebs
Fluticasone/Salmeterol
Tiotropium Bromide
Spironolactone 25 mg PO daily
Epoetin 4000 units MWF
RISS
Amiodarone 200 mg PO daily
Calcium Acetate 667 mg PO TID
SubQ Heparin
Pantoprazole 40 mg PO daily
Simvastatin 40 mg PO QHS
ASA 81 mg PO daily
MVI
Tylenol PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for Constipation.
Disp:*90 Capsule(s)* Refills:*0*
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
4. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs Disk with Device(s)* Refills:*2*
6. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*qs * Refills:*2*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Capsule(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 tablets* Refills:*2*
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. 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*
13. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* 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. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*qs Adhesive Patch, Medicated(s)* Refills:*2*
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
17. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
18. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
Disp:*qs * Refills:*2*
19. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
20. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation
Q6H (every 6 hours).
Disp:*qs * Refills:*2*
21. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
22. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
23. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
24. Warfarin 1 mg Tablet Sig: One (1) Tablet PO at bedtime:
Please monitor INR with goal [**1-17**].
Discharge Disposition:
Extended Care
Facility:
Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**]
Discharge Diagnosis:
Primary: Congestive Heart Failure exacerbation
.
Secondary:
Coronary Artery Disease
Hypertension
Type 2 Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Discharge Condition:
The patient was discharged hemodynamicallly stable, afebrile
with appropriate follow up.
Discharge Instructions:
During this admission you have been treated for a CHF
exacerbation.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight increases by > 3
lbs in 2 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 mL
.
1. Please take all medications as prescribed.
2. Please keep all follow up appointments.
3. Please call your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8338**] or seek medical attention
in the ED if you experience worsening shortness of breath, chest
pain, dizziness, passing out, or any other concerning symptom.
Followup Instructions:
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8338**] ([**Telephone/Fax (1) 8340**]) on
[**9-2**] at 1:00 PM
.
Please follow up with Dr. [**Last Name (STitle) 8467**] in cardiology ([**Telephone/Fax (1) 95675**]) on
[**9-9**] at 4:45 PM
.
Please follow up with Dr. [**Last Name (STitle) 23651**] in cardiololgy
([**Telephone/Fax (1) 95675**]) on [**9-1**] at 2:15 PM.
.
Please follow up with Urology on [**9-8**] @ 1:50 PM on the
[**Location (un) 470**] of the [**Hospital Ward Name 23**] Building, [**Hospital Ward Name **] of [**Hospital1 771**]
|
[
"428.0",
"V45.81",
"496",
"V58.61",
"599.0",
"293.0",
"244.9",
"250.60",
"707.05",
"427.31",
"V42.2",
"583.81",
"276.3",
"357.2",
"250.40",
"998.83",
"584.9",
"511.9",
"518.81",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"00.17",
"34.91",
"96.71",
"38.93",
"89.64",
"38.91",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
18193, 18287
|
7766, 10881
|
335, 468
|
18491, 18582
|
2820, 2820
|
19180, 19770
|
2333, 2382
|
15261, 18170
|
18308, 18470
|
14768, 15238
|
18606, 19157
|
3402, 3445
|
2397, 2801
|
276, 297
|
13797, 14742
|
496, 1664
|
6448, 7743
|
2836, 3386
|
10895, 13785
|
1686, 2136
|
2152, 2317
|
3462, 6439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,579
| 177,529
|
34400
|
Discharge summary
|
report
|
Admission Date: [**2171-8-22**] Discharge Date: [**2171-8-29**]
Date of Birth: [**2125-11-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish Derived
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Throat tightness
Major Surgical or Invasive Procedure:
[**2171-8-23**] - CABGx5 (Left internal mammary->Left anterior
descending artery, Saphenous vein graft(SVG)->Diagonal artery,
SVG->Obtuse marginal artery, SVG->Ramus artery, SVG->Posterior
descending artery)
History of Present Illness:
This 45-year-old patient with a 1-month history of chest
tightness was investigated and was found to have severe
triple-vessel disease with diminished
left ventricular function with an ejection fraction of about 35%
with inferior hypokinesia. He also had a moderate to left
mainstem lesion. Based on anatomy and findings, he was
transferred for urgent coronary artery bypass grafting.
Past Medical History:
CAD
Dyslipidemia
HTN
Social History:
Custodian. Smokes 1 cigarette daily. Lives with wife. Drinks 3
[**Name2 (NI) 17963**] per week. last dental exam was 2 months ago.
Family History:
Father with CABG at age 45
Physical Exam:
76 123/89 98.6 RA sat 100%
GEN: WDWN in NAD
SKIN: Warm, dry, no clubbing or cyanosis.
HEENT: PERRL, Anicteric sclera, OP Benign
NECK: Supple, no JVD, FROM. No LAD.
LUNGS: CTA bilaterally
HEART: RRR, Nl S1-S2, No M/R/G
ABD: Soft, ND/NT/NABS
EXT:warm, well perfused, no bruits, no varicosities, No
peripheral edema
NEURO: No focal deficits.
Pertinent Results:
[**2171-8-22**] 04:35PM GLUCOSE-101 UREA N-10 CREAT-0.9 SODIUM-141
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-27 ANION GAP-16
[**2171-8-22**] 04:35PM %HbA1c-6.3*
[**2171-8-22**] 04:35PM WBC-7.7 RBC-5.29 HGB-15.3 HCT-46.0 MCV-87
MCH-29.0 MCHC-33.3 RDW-13.4
[**2171-8-22**] 04:17PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2171-8-22**] 04:35PM ALT(SGPT)-25 AST(SGOT)-23 LD(LDH)-166 ALK
PHOS-65 TOT BILI-0.9
[**2171-8-22**] Carotid duplex ultrasound
No hemodynamically significant stenosis in the internal carotid
arteries bilaterally. This is a baseline examination at the
[**Hospital1 18**].
[**2171-8-23**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Moderate LV systolic dysfxn. Akinesis of inferior, infero-septal
and infero-lateral walls. Akinesis of apex.
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**2-6**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
Patient is in SR on infusions of epinephrine and NTG.
The LV systolic fxn remains moderately depressed. The inferior,
lateral and infero-septal walls, and apex, are hypokinetic.
RV systolic fxn is preserved.
MR is 1+.
No AI. Aorta intact.
[**2171-8-24**] CXR
In comparison with study of [**8-23**], all tubes have been removed
except for the right IJ sheath. Specifically, no evidence of
pneumothorax. Low lung volumes accentuate the size of the heart
and fullness of the pulmonary vasculature. Some atelectatic
changes persist at the left base.
[**8-27**]:
PROCEDURE: CT head without contrast.
HISTORY: 45-year-old man with status post coronary artery bypass
graft.
Right-sided weakness with slurring of words. Please evaluate to
rule out
bleed.
TECHNIQUE: Contiguous axial images were obtained through the
brain. No
contrast was administrated.
COMPARISON: There are no previous studies for comparison done
before this CT.
FINDINGS: There is a hypodense area in the left side of the
pons,
representing acute infarct confirmed on MRI done subsequently.
There is no
evidence of edema, masses, and mass effect. The ventricles and
sulci are
normal in configuration and size. NO osseous lytic or sclerotic
lesions are
noted.
CONCLUSION: Hypodense area in left side of the pons,
representing acute
infarct confirmed on MRI done subsequently.
[**8-28**] echo:
Conclusions
The left atrium is mildly dilated. No thrombus/mass is seen in
the body of the left atrium. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is top
normal/borderline dilated. There is mild to moderate regional
left ventricular systolic dysfunction with basal to mid inferior
and infero-lateral akinesis. There is a basal infero-lateral
aneurysm. No masses or thrombi are seen in the left ventricle.
There is no ventricular septal defect. There is abnormal septal
motion/position. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. There is no aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**2-6**]+) mitral regurgitation is seen. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2171-8-27**],
the LVEF has improved.
IMPRESSION: No intracardiac thrombus seen.
Brief Hospital Course:
Mr. [**Known lastname 79109**] was admitted to the [**Hospital1 18**] via transfer from [**Hospital1 **] for surgical management of his coronary artery
disease. He was worked-up by the cardiac surgical service in the
usual preoperative manner. A carotid duplex ultrasound was
obtained which showed no significant disease. On [**2171-8-23**], Mr.
[**Known lastname 79109**] was taken to the operating room where he underwent
coronary artery bypass grafting to five vessels. Please see
separate dictated operative note for details. Postoperatively he
was taken to the cardiac surgical intensive care unit for
monitoring. Within 24 hours, Mr. [**Known lastname 79109**] [**Last Name (Titles) 5058**] neurologically
intact and was extubated. Beta blockade, aspirin and a statin
were resumed. He was then transferred to the step down unit for
further recovery. He was gently diuresed towards his
preoperative weight. The physical therapy service was consulted
for assistance with his postoperative strength and mobility.
The pt developed right sided weakness and slurred speech on the
morning of [**8-27**], POD 4. Neurology consult and subsequent workup
revealed acute embolic CVA in the left pons, confirmed by MRI.
The pt was treated with aspirin and statin as well as
anticoagulation. TEE and TTE were performed, intracardiac
thrombus was ruled out, and anticoagulation was discontinued.
Some improvements in motor function were made with physical
therapy. Additionally, speech improved within 24 hours. On
[**8-29**] he fell on his hip, grazing his head as he fell. No
hematoma was seen on his head and a subsequent wet read of a
head CT revealed no mass effect and no shift. He was seen in
consultation by physical therapy and was sent home with physical
therap, occupational therapy, speech tehrapy, skilled nursing,
and a nursing aide.
Medications on Admission:
Aspirin 81mg daily
Toprol XL 50mg daily
Zocor 40mg daily
TNG PRN
Discharge Medications:
1. Outpatient Physical Therapy
home physical therapy 5 times per week for two weeks with
transition to outpatient therapy when appropriate
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Ultram 50 mg Tablet Sig: 1-2 Tablets PO every four (4) hours
as needed for pain.
Disp:*60 Tablet(s)* Refills:*1*
8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
CAD s/p CABGx5
Dyslipidemia
HTN
CVA
Discharge Condition:
good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 79110**] in 2 weeks.
Follow-up with Dr. [**Last Name (STitle) **] in 2 weeks.
Follow-up with Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**] (stroke neurologist) in [**3-10**]
months [**Telephone/Fax (1) 1694**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2171-8-29**]
|
[
"414.01",
"E878.2",
"997.02",
"401.9",
"434.11",
"272.4",
"E849.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"36.14",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8046, 8108
|
5028, 6874
|
301, 511
|
8188, 8195
|
1538, 5005
|
8938, 9431
|
1135, 1163
|
6989, 8023
|
8129, 8167
|
6900, 6966
|
8219, 8915
|
1178, 1519
|
245, 263
|
539, 926
|
948, 970
|
986, 1119
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,799
| 175,814
|
49878
|
Discharge summary
|
report
|
Admission Date: [**2137-5-22**] Discharge Date: [**2137-5-27**]
Date of Birth: [**2059-8-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Enalapril / Lidocaine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Left main Coronary Artery disease
Major Surgical or Invasive Procedure:
Coronary artery bypass grafting x4 (left internal mammary artery
to left anterior descending coronary; reverse saphenous vein
graft to OM1,reverse saphenous vein graft first diagonal
coronary artery,saphenous vein graft to posterior descending
coronary artery.
History of Present Illness:
This is a 77 year old woman who presented to an outside hospital
with acute chest pain at rest, lasting 1/1/2 hrs. In retrospect
she had an episode of "indigestion" which was not persued by her
primary care provider [**Name Initial (PRE) **] week earlier. She went to the ED at [**Location (un) 21541**] Hospital where ECG showed ST depressions in anterolateral
leads and Heparin and ASA were given. Her initial troponin was
1.9. She had recurrent pain later in the day which led to
cardiac catheterization which revealed 75% LM,prox 95%LAD with
subsequent 40-50%s,99% osteal circumflex and significant,
diffuse RCA disease.Integrelin was begun. No LVgram wasdone. An
Intra-aortic balloon pump was placed due to anatomy and she
became pain free subsequently. Troponins peaked 9. A right
heart catheterization was normal (25/5,PCWP 10,CVP 2). She was
transferred to [**Hospital1 18**] for revascularization.
Past Medical History:
hyperlipidemia
hypertension
esophageal spasm
radical neck dissection and parathyroidectomy 10 yrs ago
Social History:
Race:caucasian
Last Dental Exam:3months
Lives with:husband
Occupation:
[**Name2 (NI) 1139**]:non smoker
ETOH:2 drinks/day
Family History:
noncontributory
Physical Exam:
Admission:
General:WDWN in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit Right:N Left:N
Pertinent Results:
[**2137-5-23**]
Pre-bypass: The left atrium and right atrium are normal in
cavity size. A patent foramen ovale is present. Overall left
ventricular systolic function is low normal (LVEF 50-55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Post-bypass: The patient is not receiving inotropic support
post-CPB. Biventricular systolic function is preserved and all
findings are consistent with pre-bypass findings. The aorta is
intact post-decannulation. All findings communicated to the
surgeon intraoperatively.
[**2137-5-26**] 06:00AM BLOOD WBC-9.0 RBC-2.86* Hgb-8.8* Hct-25.7*
MCV-90 MCH-30.8 MCHC-34.3 RDW-14.0 Plt Ct-179
[**2137-5-26**] 06:00AM BLOOD Glucose-110* UreaN-14 Creat-0.7 Na-139
K-3.5 Cl-102 HCO3-27 AnGap-14
[**2137-5-27**] 06:20AM BLOOD WBC-8.8 RBC-2.61* Hgb-8.2* Hct-23.3*
MCV-89 MCH-31.5 MCHC-35.2* RDW-14.1 Plt Ct-196
[**2137-5-27**] 06:20AM BLOOD UreaN-14 Creat-0.7 K-3.9
[**2137-5-27**] 06:20AM BLOOD Mg-2.3
[**2137-5-27**] 06:20AM BLOOD WBC-8.8 RBC-2.61* Hgb-8.2* Hct-23.3*
MCV-89 MCH-31.5 MCHC-35.2* RDW-14.1 Plt Ct-196
Brief Hospital Course:
She was transferred to [**Hospital1 69**] at
the request of her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1313**], for
surgical revascularization. She remained stable and painfree. On
[**2137-5-23**] she underwent coronary artery bypass graft surgery x 4.
See operative report for full details.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The intra-aortic balloon pump was removed on post operative day
1. The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and the patient was gently diuresed toward the
preoperative weight.
The patient was transferred to the telemetry floor for further
recovery on post operative day 2. Chest tubes and pacing wires
were discontinued without complication. She did develop a
maculopapular rash on her back, which was thought to be due to
allergic reaction to tape and sheets. She was treated with
Sarna lotion, hydrocortisone cream and Benadryl. Beta blockers
were titrated up secondary to tachycardia. Iron sulfate was
started for hematocrit of 23.3 (she was asymptomatic with this
level). The patient was evaluated by the Physical Therapy
service for assistance with strength and mobility. By the time
of discharge on POD 4 the patient was ambulating with assistance
and thought to benefit from a stay at a rehabilitation facility.
The wounds were healing and pain was controlled with oral
analgesics. The patient was discharged to the [**Hospital 1886**] rehab in
[**Location (un) **],MA in good condition with appropriate follow up
instructions.
Medications on Admission:
Lipitor 20mg HS,HCTZ,Quinapril 5mg
daily,Omeprazole 40mg daily,Ambien 5mg HS,Proventil,Nasonex
AT CCH added:Lopressor 25mg [**Hospital1 **],Heparin 1000units/hr,Integril;in
14u, ASA 325mg 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. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruitis.
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Hydrocortisone 0.5 % Ointment Sig: One (1) Appl Topical TID
(3 times a day) as needed for pruitis.
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every
twenty-four(24) hours for 7 days.
11. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime) as needed for pruitis.
12. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO twice a day for 1 months.
13. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for constipation for 1 months.
14. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
15. Sodium Chloride 0.9% Flush 3 ml IV DAILY:PRN line flush
Peripheral IV - Inspect site every shift
16. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 23638**]
Discharge Diagnosis:
Coronary Artery Disease
s/p coronary artery bypass grafts
hypertension
s/p radical neck dissection & parathyroidectomy
hyperlipidemia
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with unsteady gait and assist of one.
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage. 1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] ([**Telephone/Fax (1) 170**]) on [**6-25**] at 1:00 PM
Please call to schedule appointments with your
Primary Care: Dr. [**First Name (STitle) 1313**] ([**Telephone/Fax (1) 7318**]in [**1-26**] weeks
Cardiologist: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 34148**] in [**1-26**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2137-5-27**]
|
[
"785.0",
"411.1",
"692.9",
"401.9",
"410.71",
"272.4",
"414.01",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"97.44",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7467, 7556
|
3800, 5610
|
320, 584
|
7734, 7974
|
2390, 3777
|
8813, 9408
|
1804, 1822
|
5855, 7444
|
7577, 7713
|
5636, 5832
|
7998, 8790
|
1837, 2371
|
247, 282
|
612, 1522
|
1544, 1648
|
1664, 1788
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,363
| 113,705
|
52988
|
Discharge summary
|
report
|
Admission Date: [**2153-2-15**] Discharge Date: [**2153-2-19**]
Date of Birth: [**2086-3-24**] Sex: F
Service: MEDICINE
Allergies:
Flagyl / Iodine
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Acute Blood Loss Anemia due to Gastric Ulcers with Bleeding
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
66 year old Female with ESRD on peritoneal dialysis due to
hypertensive nephropathy, and h/o NSCLC on Tarceva and
nephrolithiasis who presents with symptomatic anemia. The
patient typically adjusts her weekly EPO injections between
4000-6000 units depending on her symptoms of fatigue and
dyspnea. Two and a half weeks ago her dialysis nurse had her
terminate EPO in the setting of an elevated hmg > 12 per her
report. She has been waiting to hear back from her dialysis
clinic regarding when to restart her EPO. She titrates her own
EPO, given a similar episode of severe symptomatic anemia. In
the interim she developed excruciating flank pain earlier this
week for which she presented to the ED, a CT demonstrated
bilateral stones. She was given toradol and vicodin and
discharged home with total resolution of her pain. However, as
the week progressed, she has become progressively constipated
and fatigued with suprapubic abdominal pain. She reports her PD
fluid has been clear. She had an episodic visit at [**Company 191**] on
Thursday which prompted referral to the ED. Her blood pressure
was 112/72 laying and 94/68 standing. Blood cultures were taken,
but patient denied any fevers or chills. She got IVF
(approximately 500 cc). Her labs were significant for a
hematocrit of 27, down from 36 on [**2-13**]. She was guiac negative.
Her potassium was elevated at 6, she was given kayexalate. She
had an abdominal CT which showed nothing acute. A CXR was
negative for acute processes. Repeat orthostatics were: lying HR
75 BP 135/63, standing HR 85 BP 127/61. On transfer to the
floor her abdominal pain had completely resolved in the setting
of a large dark brown bowel movement after receiving kayexalate.
She did not receive PD o/n.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, vomiting, diarrhea, BRBPR, hematochezia.
She makes trace amounts of urine. She notes acid reflux for the
past 3 days that has been constant. She has only been eating
peppermints do to her poor appetite.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- NSCLC on erlotinib
- ESRD on PD
- recurrent nephrolithiasis
- depression
- insomnia
- seasonal rhinitis
- papillary thyroid CA s/p excision
Social History:
Divorced, lives in same house as 3 friends ([**Name (NI) 11894**], [**First Name3 (LF) **],
[**Name (NI) **]). 2 adult sons.
Remote tobacco (quit 20 years ago)denies EtOH or illicit drug
use.
Family History:
Mother- diabetes
Father with kidney disease
Physical Exam:
ADMISSION:
VS: 98.7 143/69 85 18 100 RA
GENERAL - in NAD, comfortable, appropriate, pale
HEENT - NC/AT, MMM
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
HEART - RR, no MRG, nl S1-S2
ABDOMEN - soft/NT/slightly distended, no rebound/guarding, PD
catheter in lower abdomen with clean bandage, skin without
erythema, non-tender
EXTREMITIES - trace LE edema, WWP, 1+ peripheral pulses
NEURO - awake, A&Ox3, gait intact
DISCHARGE:
GENERAL: NAD, comfortable, upright in pain, returned color
LUNGS: Decreased breath sounds and mild crackles at left lower
lung base
HEART - RR, no MRG, nl S1-S2
ABDOMEN - soft/NT/slightly distended, no rebound/guarding, PD
catheter in lower abdomen with clean bandage, skin without
erythema, non-tender
EXTREMITIES - trace LE edema, WWP, 1+ peripheral pulses
Pertinent Results:
CHEST XRAY [**2153-2-15**]
PA AND LATERAL VIEWS OF THE CHEST: The cardiac silhouette is
normal in size. The mediastinal and hilar contours are stable.
Chain sutures within the left lower lobe are again demonstrated.
Pulmonary vascularity is not engorged. Left lower lobe mass is
again noted, better seen on the prior CT, but similar compared
to the prior study. Nodular opacity within the left upper lobe
appears relatively unchanged from prior. Small left pleural
effusion persists. The right lung is grossly clear. No
pneumothorax is identified. Multiple clips are demonstrated
within the thyroid bed. Left proximal humeral fracture appears
chronic.
IMPRESSION: No significant interval change in appearance of left
lower lobe lung mass, and nodule in the left upper lobe.
Persistent small left pleural effusion.
CT ABDOMEN w/out contrast [**2153-2-15**]
CT OF THE ABDOMEN:
There is unchanged left lower lobe round nodule with associated
surgical
material and small left pleural effusion and mild bibasilar
atelectasis.
Unchanged multiple pulmonary nodules at the right lung base.
Segment III liver hypodensity is stable and was previously
characterized as a hemangioma. Adjacent sub-cm hypodensity in
the left lobe is also unchanged. The gallbladder, spleen,
bilateral adrenal glands and pancreas are normal. Unchanged
splenic artery calcifications. The kidneys are atrophic with
numerous calcifications, likely vascular, and cysts, unchanged
from priors. The stomach, duodenum, small bowel are normal.
A peritoneal dialysis (PD) cathether is visualized in the left
lower quadrant with unchanged small 17 x 8 mm seroma in the
subcutaneous soft tissues and moderate amount of ascites.
Unchanged calcification of the aorta and its major branches.
There is no retroperitoneal or mesenteric lymphadenopathy.
CT OF THE PELVIS:
The urinary bladder is normal. There is no pelvic
lymphadenopathy, no pelvic hernias.
BONES: There are moderate degenerative change at L5-S1 with
intervertebral
disc disease.
.
IMPRESSION: No acute process or interval change from 2 days
prior, including no evidence of diverticulitis or appendicitis.
.
PORTABLE CHEST XRAY [**2153-2-18**]
IMPRESSION: AP chest compared to [**3-15**]:
Mild interstitial abnormality in the right lung is probably
edema. Moderate left pleural effusion is increasing. Large left
lung lesions also appear grown since [**2-15**], though this is
probably mostly a function of projection between the PA and AP
orientations. Heart size top normal. Mediastinal veins and upper
lobe pulmonary vessels are slightly dilated.
PERTINENT LABS
[**2153-2-19**] 06:55AM BLOOD WBC-8.3 RBC-3.48* Hgb-10.9* Hct-31.1*
MCV-90 MCH-31.5 MCHC-35.1* RDW-14.2 Plt Ct-227
[**2153-2-18**] 07:15AM BLOOD WBC-7.9 RBC-3.38* Hgb-10.6* Hct-29.5*
MCV-87 MCH-31.3 MCHC-35.9* RDW-14.5 Plt Ct-211
[**2153-2-17**] 07:10AM BLOOD WBC-8.4# RBC-3.23* Hgb-10.0* Hct-28.5*
MCV-88 MCH-31.1 MCHC-35.2* RDW-14.3 Plt Ct-231
[**2153-2-17**] 07:10AM BLOOD WBC-8.4# RBC-3.23* Hgb-10.0* Hct-28.5*
MCV-88 MCH-31.1 MCHC-35.2* RDW-14.3 Plt Ct-231
[**2153-2-16**] 04:15PM BLOOD WBC-17.0*# RBC-3.02* Hgb-9.3* Hct-26.8*
MCV-89 MCH-30.8 MCHC-34.8 RDW-14.1 Plt Ct-249
[**2153-2-16**] 09:00AM BLOOD WBC-8.4 RBC-2.59* Hgb-8.0* Hct-22.7*
MCV-88 MCH-31.1 MCHC-35.5* RDW-14.0 Plt Ct-295
[**2153-2-16**] 02:40AM BLOOD Hct-22.8*
[**2153-2-16**] 01:20AM BLOOD WBC-10.9 RBC-2.58* Hgb-7.9* Hct-22.5*
MCV-87 MCH-30.6 MCHC-35.2* RDW-14.1 Plt Ct-308
[**2153-2-15**] 05:27PM BLOOD WBC-10.9 RBC-3.09* Hgb-9.5* Hct-27.2*
MCV-88 MCH-30.8 MCHC-35.1* RDW-14.1 Plt Ct-347
[**2153-2-15**] 05:27PM BLOOD Neuts-83.7* Lymphs-12.1* Monos-1.3*
Eos-2.2 Baso-0.7
[**2153-2-17**] 07:10AM BLOOD PT-12.7 INR(PT)-1.1
[**2153-2-19**] 06:55AM BLOOD Glucose-88 UreaN-81* Creat-12.2* Na-140
K-5.4* Cl-100 HCO3-26 AnGap-19
[**2153-2-17**] 07:10AM BLOOD Glucose-83 UreaN-95* Creat-10.7*# Na-138
K-4.8 Cl-101 HCO3-25 AnGap-17
[**2153-2-16**] 01:20AM BLOOD Glucose-92 UreaN-108* Creat-11.5* Na-141
K-4.6 Cl-102 HCO3-24 AnGap-20
[**2153-2-18**] 07:15AM BLOOD ALT-22 AST-27 LD(LDH)-174 AlkPhos-218*
TotBili-0.4
[**2153-2-16**] 09:00AM BLOOD TotBili-0.2 DirBili-0.1 IndBili-0.1
[**2153-2-15**] 05:27PM BLOOD ALT-26 AST-23 AlkPhos-263* TotBili-0.2
[**2153-2-19**] 06:55AM BLOOD Calcium-7.8* Phos-5.2* Mg-2.1
[**2153-2-17**] 07:10AM BLOOD Calcium-7.9* Phos-5.2* Mg-2.1
[**2153-2-15**] 05:27PM BLOOD Albumin-3.3* Calcium-9.3 Phos-3.6# Mg-2.5
[**2153-2-16**] 09:00AM BLOOD Hapto-180
[**2153-2-16**] 02:40AM BLOOD Hapto-198
[**2153-2-18**] 03:17PM BLOOD IgA-122
[**2153-2-18**] 03:17PM BLOOD tTG-IgA-4
[**2153-2-15**] 07:45PM BLOOD Lactate-0.9 K-5.4*
[**2153-2-15**] 05:29PM BLOOD Lactate-1.1
[**2153-2-16**] 05:48AM OTHER BODY FLUID WBC-34* RBC-1* Polys-4*
Lymphs-16* Monos-0 Macro-79* Other-1*
[**2153-2-16**] 5:48 am DIALYSIS FLUID IMPROPER SPECIMEN
COLLECTION.
INTERPRET RESULTS WITH CAUTION.
**FINAL REPORT [**2153-2-19**]**
GRAM STAIN (Final [**2153-2-16**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2153-2-19**]): NO GROWTH.
[**2153-2-18**] 3:17 pm SEROLOGY/BLOOD
**FINAL REPORT [**2153-2-19**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2153-2-19**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
EGD: [**2153-2-16**]
Impression: Multiple superficial ulcers in the stomach antrum
Few cratered ulcers in the pre-pyloric region
A single cratered ulcer with stigmata of recent bleeding in the
pre-pyloric region (injection)
Bulbar duodenitis
Brunner's gland hyperplasia in the duodenal bulb
Scalloping folds on the mucosa of the second and third parts of
the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: The findings account for the symptoms, and the
distribution of the gastric ulcers suggests that they are
NSAID-induced.
Continue PPI, avoid all aspirin or NSAID products.
Follow serial Hcts, transfuse PRBCs to Hct >30. Consider DDAVP
and/or platelet transfusion for uremic platelets.
Check H.pylori serology, treat if positive.
Check TTG and IgA to exclude Celiac disease.
If re-bleeds will need repeat EGD.
Brief Hospital Course:
HOSPITAL COURSE
Ms. [**Known lastname 92380**] is a 66 year old woman with ESRD on PD, NSCLC, anemia,
and thyroid cancer who presented with an upper GI bleed. She
required multiple transfusions and transfer to the MICU where
upper endoscopy revealed bleeding gastric ulcers secondary to
recent NSAID use.
ACTIVE ISSUES
# Acute Blood Loss Anemia due to Gastric Ulcers with Bleeding,
Duodenitis:
Symptomatic anemia in the setting of a significant drop in Hct
over a three day period. (36->27->22) Etiology initially
concerning for discontinuation of weekly epogen in setting of
elevated hmg on routine lab draw. The patient has past history
of dramatic hct drop off epo. She received 1x dose of tordol
during ED visit on Monday. No other NSAID use or history of
GERD. Most recent colonscopy in [**2146**] demonstrated multiple
polyps. Follow up colonoscopy deferred given NSCLC. Initially no
evidence of acute bleed, guaic negative stool in the ED prior to
transfer, however on the morning of admission the patient passed
four melanolic stool, guaic positive. Her hct dropped to 22,
she was transfused 1 unit of pRBC and given desmopressin. Two
PIVs were placed, she was started on PPI gtt and 1 more unit
pRBC and transferred to MICU for EDG and further management. EGD
revealed multiple gastric ulcers in antrum, one of which had
stigmata of recent bleed with overlying dark area. This area was
injected. There was no evidence of active bleeding. The
duodenal bulb was acutely inflammed and edematous w/o discrete
ulcer or bleeding. Patient received additional 2 units pRBCS
after procedure, with subsequent stabilization in HCT and
hemodynamics. Her diet was advanced to clears, and she was
stable to be transferred back to the general medicine floor.
Her hematocrit continued to be stable. Pantoprazole was changed
to PO BID dosing which she will continue on for 6 weeks. She
will discuss further epoitin dosing with her outpatient
nephrologist. Hpylori negative. IgA at normal levels.
# Flank Pain:
The patient has was admitted to the ED prior to admission for
left sided plank pain for which she was prescribed vicodin for
pain managment. An episode of this flank pain recurred on
admission. Physical exam demonstrated left flank tenderness to
palpation. CT abdomen on [**2-13**] demonstrated bilateral stones and
CT abdomen two days later demonstrated calcified atrophic
kidneys. Unclear if pain is secondary to stones as patient is
PD dependant and almost anuric. Would consider outpatient MRI to
investigate for nerve impingement. Her pain was treated with
vicodin.
# Abdominal Pain Diffuse:
Completely resolved in setting of large bowel movement on night
of admission. She was afebrile, but given her history of
peritonitis and PD, fluid sent for culture and gram stain. Gram
stain revealed 1+ polys and no microorganisms, culture was
negative. Blood cultures were negative at the time of discharge.
# ESRD:
Renal fellow contact[**Name (NI) **] regarding admission. Peritoneal dialysis
was started per home regimen. Epoetin dosing to be discussed
with outpatient nephrologist. The patient became mildly fluid
overloaded in setting of multiple transfusions and clear diet.
CXR demonstrated small pleural effusion. Her PD dialsylate was
adjusted as indicated.
# Hyperkalemia:
Hyperkalemic on admission. She received kayexalate with
improvement in her potassium. No peaked T waves.
# Hypothyroidism:
Continued home levothyroxine dose.
# NSCLC: On Tarceva every three days. Patient stated she will
not take until appetite improved. Heme/onc was called, and
placed orders for patient to continue on Tarceva as per home
regimen.
TRANSITIONAL ISSUES
Medical Management: Pantoprazole 40mg [**Hospital1 **] for 6 weeks, Vicodin
for 3 days
Code Status: Full (Was DNR but do Intubate on admission.)
Medications on Admission:
CALCITRIOL - - 0.25 mcg Capsule - 1 Capsule(s) by mouth three
times a week (MWF)
EPOETIN ALFA [EPOGEN] - - 4,000 unit/mL Solution - 6000 weekly
ERLOTINIB [TARCEVA] - 25 mg Tablet - 1 Tablet(s) by mouth Q3
days on an empty stomach
LEVOTHYROXINE [LEVOXYL] - 150 mcg Tablet - 1 Tablet(s) by mouth
once a day and extra [**12-17**] tablet once weekly.
SEVELAMER CARBONATE [RENVELA] - 800 mg Tablet - 5 Tablet(s) by
mouth TID w/ food
ZOLPIDEM - 5 mg
B COMPLEX-VITAMIN C-FOLIC ACID [[**Doctor First Name **]-VITE] - 0.8 mg Tablet - 1
Tablet(s) by mouth once a day
CAMPHOR-MENTHOL [SARNA ANTI-ITCH] - 0.5 %-0.5 % Lotion - apply
on
the skin as needed for itch three to four times daily as needed
Discharge Medications:
1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO QMOWEFR
(Monday -Wednesday-Friday).
2. epoetin alfa 4,000 unit/mL Solution Sig: One (1) Injection
once a week.
3. erlotinib 25 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal twice a day.
5. levothyroxine 150 mcg Capsule Sig: One (1) Capsule PO once a
day.
6. sevelamer carbonate 800 mg Tablet Sig: Five (5) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. valsartan 80 mg Tablet Sig: One (1) Tablet PO once a day.
8. zolpidem 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours):
take for 6 weeks and then decreased to once daily.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets
PO Q6H (every 6 hours) as needed for pain for 3 days.
Disp:*qS Tablet(s)* Refills:*0*
11. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO every
six (6) hours as needed for itching.
Discharge Disposition:
Home
Discharge Diagnosis:
NSAID induced Gastric Ulcers
End Stage Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted for management of an upper GI bleed. An upper
endoscopy demonstrated multiple ulcers in your stomach. It is
likely that the tordol you received during your prior ED visit
precipitated the development of these ulcers. A small injection
of epinephrine in one of the bleeding ulcers was made which
stopped the bleeding. You required multiple blood transfusions.
You were started on pantoprazole twice daily. You will need to
continue this medication for six weeks and then may take it just
once daily.
You developed left sided flank pain that appears to be an
intermittant chronic issue. Please discuss with your primary
care physician, [**Name10 (NameIs) **] MRI to explore the cause of your intermittant
spasms.
Please discuss with your nephrologist how much epoetin you
should be taking.
Followup Instructions:
Department: [**Hospital3 249**]
When: WEDNESDAY [**2153-2-28**] at 10:10 AM
With: [**First Name4 (NamePattern1) 1060**] [**Last Name (NamePattern1) 1520**], MD. [**Company 191**] POST [**Hospital 894**] CLINIC
[**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
*This appointment is with a hospital-based doctor as part of
your transition from the hospital back to your primary care
provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary
care doctor in follow up.
Nephrology Appointment: PENDING
**We are working on a follow up appointmentt in the
NEPHROLOGY DEPARTMENT with DR.[**Last Name (STitle) **] [**Doctor Last Name **] for you to be seen
with in 2 weeks from your discharge. You will be called at home
with the appointment. If you have not heard from [**Doctor First Name **] in his
office by WED., [**2-21**] or have questions, please her at
[**Telephone/Fax (1) 721**].
|
[
"511.9",
"V10.87",
"244.0",
"403.91",
"285.21",
"162.9",
"585.6",
"285.1",
"V45.11",
"E935.7",
"535.60",
"531.40",
"276.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
15687, 15693
|
10001, 13821
|
336, 354
|
15790, 15790
|
3784, 9978
|
16777, 17813
|
2903, 2949
|
14559, 15664
|
15714, 15769
|
13847, 14536
|
15941, 16754
|
2964, 3765
|
237, 298
|
382, 2484
|
15805, 15917
|
2506, 2677
|
2693, 2887
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,652
| 151,829
|
40693
|
Discharge summary
|
report
|
Admission Date: [**2126-6-14**] Discharge Date: [**2126-6-17**]
Date of Birth: [**2040-4-21**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
endotracheal intubation and extubation
History of Present Illness:
86 yo M with h/o CHF, Afib on coumadin, CHF, AR s/p mechanical
AVR, severe MR, Alzheimer's disease p/w hypoxia. Unable to
obtain detailed history from patient or from rehab facility,
found to have sat of 81% and was transferred to [**Hospital1 18**] for
hypoxia. He was recently admitted to [**Hospital1 2177**] for mechanical fall,
from [**Date range (1) 40254**], during which he hit his head but did not lose
consciousness, no acute change on head CT. Course complicated by
wide complex tachycardia described as "Vtach" with rate in 140s,
broke without intervention. Prior to this admission, he had
slowly been declining over a period of weeks to months, with
increasing leg weakness and difficulty with walking. He was
discharged to [**Hospital **] Healthcare on 2L of O2 by NC, sat high
90s. He was there for one day, this morning was found to be
hypoxic with sat in low 80s, unable to get further history of
events immediately prior to discharge.
.
On arrival to the [**Name (NI) **], wife and patient unable to provide further
history. He was placed on a nonrebreather for O2 sat in the 70s
which dropped to 50% so he was intubated soon after arrival. He
was also noted to be febrile to 101, with HR 146, BP 133/87 and
was started on vancomycin, zosyn, and levofloxacin after
obtaining blood cx, CXR with bilateral infiltrates. L subclavian
central line was placed, R radial A line, and was started on
levophed. Also received 4L of IV normal saline. Lactate
initially 5.7, improved to 1.8 while in ED. Also noted on EKG to
have lateral depressions with sinus tachycardia so was given
rectal aspirin. On fentanyl and versed for sedation. Noted to
have Hct drop from 31.2 to 20.6 in the ED after receiving IVF,
type and screen sent. INR 4.8. VS on transfer: T 103 rectal HR
90 BP 129/67 CVP 14 sat 100% on vent (AC, Tv 500 mL, RR 18, PEEP
10, FiO2 100%), levophed at 0.13.
.
On the floor, pt is intubated and sedated, appears comfortable.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
Hodgkin's lymphoma (dx [**1-4**] at [**Hospital1 3278**]) for which he received no
treatment
Alzheimer's disease
Severe mitral regurgitation
Aortic regurgitation s/p mechanical AVR in [**2117**]
pAfib
HLD
HTN
hypothyroidism
esophageal ulcer [**2124**]
essential tremor
legally blind
Iron deficiency anemia (from [**Hospital1 2177**], serum iron 21, ferritin 46,
folate 2.3), last Hct from [**Hospital1 2177**] 25.9
.
Social History:
used to live with wife and had been independent with mobility
with walker and wheelchair, but has been getting weaker. was
discharged to rehab and has been there for one day. no smoking,
EtOH or illicit drugs
Family History:
noncontributory
Physical Exam:
ICU Admission Exam:
General: sedated, intubated no acute distress, poor skin turgor
HEENT: intubated, Sclera anicteric, dry MM oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: diffuse rhonchi
CV: irregular rhythm, normal S1 + S2, III/VI systolic murmur,
III/VI diastolic murmur, mechanical valve
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
[**2126-6-14**] 02:30PM BLOOD WBC-25.4* RBC-3.55* Hgb-10.2* Hct-31.2*
MCV-88 MCH-28.6 MCHC-32.6 RDW-18.9* Plt Ct-448*
[**2126-6-14**] 03:30PM BLOOD WBC-10.6# RBC-2.36*# Hgb-6.9*# Hct-20.6*#
MCV-87 MCH-29.4 MCHC-33.7 RDW-18.8* Plt Ct-228
[**2126-6-14**] 10:55PM BLOOD WBC-15.0* RBC-3.53*# Hgb-10.3*#
Hct-30.1*# MCV-85 MCH-29.2 MCHC-34.2 RDW-18.0* Plt Ct-288
[**2126-6-14**] 02:30PM BLOOD Neuts-78* Bands-0 Lymphs-17* Monos-3
Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2126-6-14**] 03:30PM BLOOD Neuts-94.4* Lymphs-3.6* Monos-1.7*
Eos-0.2 Baso-0.2
[**2126-6-14**] 02:30PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-1+ Polychr-NORMAL Ovalocy-1+
Acantho-OCCASIONAL
[**2126-6-14**] 02:30PM BLOOD Plt Smr-HIGH Plt Ct-448*
[**2126-6-14**] 03:30PM BLOOD PT-45.9* PTT-50.0* INR(PT)-4.8*
[**2126-6-14**] 03:30PM BLOOD Plt Ct-228
[**2126-6-14**] 10:55PM BLOOD Plt Ct-288
[**2126-6-14**] 02:30PM BLOOD Glucose-124* UreaN-32* Creat-1.6* Na-135
K-5.4* Cl-96 HCO3-21* AnGap-23*
[**2126-6-14**] 03:30PM BLOOD Glucose-119* UreaN-30* Creat-1.3* Na-139
K-3.8 Cl-105 HCO3-24 AnGap-14
[**2126-6-14**] 10:55PM BLOOD Glucose-123* UreaN-31* Creat-1.4* Na-141
K-4.4 Cl-107 HCO3-22 AnGap-16
[**2126-6-14**] 03:30PM BLOOD ALT-30 AST-83* LD(LDH)-365* AlkPhos-110
TotBili-0.5
[**2126-6-14**] 10:55PM BLOOD CK(CPK)-78
[**2126-6-14**] 03:30PM BLOOD cTropnT-0.02*
[**2126-6-14**] 10:55PM BLOOD CK-MB-3 cTropnT-0.04*
[**2126-6-14**] 03:30PM BLOOD Albumin-2.3* Calcium-6.9* Phos-3.4 Mg-1.6
[**2126-6-14**] 10:55PM BLOOD Calcium-7.2* Phos-4.2 Mg-1.7
[**2126-6-14**] 02:38PM BLOOD pH-7.29* Comment-GREEN TOP
[**2126-6-14**] 03:01PM BLOOD Type-ART Rates-/18 Tidal V-500 PEEP-10
FiO2-100 pO2-200* pCO2-41 pH-7.41 calTCO2-27 Base XS-1 AADO2-472
REQ O2-80 -ASSIST/CON Intubat-INTUBATED
[**2126-6-14**] 07:53PM BLOOD Type-ART Temp-37.4 Rates-18/2 Tidal V-500
PEEP-10 FiO2-100 pO2-260* pCO2-41 pH-7.37 calTCO2-25 Base XS--1
AADO2-415 REQ O2-72 Intubat-INTUBATED
[**2126-6-14**] 02:38PM BLOOD Glucose-122* Lactate-5.7* Na-136 K-5.3
Cl-95* calHCO3-25
[**2126-6-14**] 03:39PM BLOOD Lactate-2.3*
[**2126-6-14**] 04:57PM BLOOD Lactate-1.8
[**2126-6-14**] 06:01PM BLOOD Lactate-2.0
[**2126-6-14**] 02:38PM BLOOD Hgb-10.0* calcHCT-30
[**2126-6-14**] 02:38PM BLOOD freeCa-1.09*
.
MICRO:
[**2126-6-16**] 10:08 am SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2126-6-16**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Preliminary):
Legionella negative
Blood cultures NGTD
Urine cultures NGTD
IMAGING:
CHEST (PORTABLE AP) Study Date of [**2126-6-14**] 2:14 PM
FINDINGS: There is a dense right perihilar consolidation
consistent with
pneumonia. Blunting of bilateral costophrenic angles is present
suggesting
small effusions. The left lung is, otherwise, clear. Evidence of
prior
median sternotomy and CABG again are noted. An endotracheal tube
is present with the distal tip approximately 8 cm from the
carina. Consider advancing 2-3 cm for optimal placement. The
mediastinum otherwise is unremarkable. The cardiac silhouette is
borderline enlarged. There is no pneumothorax. A nasogastric
tube has been inserted and extends and coils in the left upper
quadrant, tip not identified.
IMPRESSION: Dense right perihilar consolidation most consistent
with
pneumonia in the acute setting. Followup radiographs after
appropriate
therapy recommended to document resolution.
CHEST (PORTABLE AP) Study Date of [**2126-6-15**] 5:21 AM
Significant interval progression of widespread parenchymal
consolidations may represent interval development of severe
pulmonary edema superimposed on pre-existing right lower lobe
consolidation. The bilateral pleural effusions have developed in
the interim, at least mild to moderate. The NG tube tip is not
clearly seen, most likely in the stomach. The replaced valve is
redemonstrated. The left subclavian line tip is at the level of
superior mid SVC.
Brief Hospital Course:
86 yo M with h/o CHF, Afib on coumadin, CHF, AR s/p mechanical
AVR, severe MR, Alzheimer's disease p/w hypoxia, respiratory
distress, bilateral infiltrates on CXR, elevated lactate and Cr
improving with IVF, hypotension now on pressors, also with
anemia
Patient with evidence of PNA on chest xray with bilateral
infiltrates, started on vanco/zosyn/levofloxacin in ED. On
admission he was on pressure support with norepinephrine for
hypotension and received several liters of IV normal saline.
Sputum cultre showed GNR preliminarily and urine legionella was
negative, blood cultures showed no growth to date. On day of
admission, patient was transfused 3 units of PRBC for a Hct 20
(unclear baseline but on discharge from [**Hospital1 2177**] 2 days prior to
admission Hct 25). IV PPI was started for concern for upper GI
bleed since he had esophageal ulcer in the past. INR elevated
on admission at 4.8 on coumadin and continued to be elvated to
7.8 in setting of anemia, so pt received PO vitamin K with
improvement in INR. Aspirin was continued considering trop
elevation and ischemic changes likely in setting of demand on
admission EKG, but discontinued when INR elevated to 7.8.
Amiodarone initially was held but restarted for Afib.
Patient was able to be weaned off pressors and appearance of CXR
showed mild improvement.
Discussion was had with family regarding goals of care and it
was decided that he would be DNR, and do not re-intubate after
extubation. After extubation, family decided that a focus on
comfort was more appropriate to pt's goals of care so all abx,
pressors, and agressive fluid support were discontinued and
patient was kept on fentanyl drip and scopolamine patch.
Patient died at 7:48 PM on [**6-17**], family was notified and autopsy
was declined.
Medications on Admission:
warfarin 2.5 mg wed/sun, 5 mg all other days
amiodarone 200 mg daily
lisinopril 5 mg daily
primidone 50 mg [**Hospital1 **]
lasix 40 mg [**Hospital1 **]
nexium 40 mg daily
levothyroxine 175 mcg daily
ambien 5 mg daily
vitamin D 1000 unit daily
acetaminophen [**Telephone/Fax (1) 1999**] mg Q4-6H PRN pain
nitroglycerin SL PRN
simvastatin 20 mg daily
folic acid 1 mg daily
ferrous sulfate 325 mg TID
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Pneumonia
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2126-6-17**]
|
[
"785.52",
"518.81",
"584.9",
"V43.3",
"486",
"799.02",
"428.0",
"038.9",
"244.9",
"V49.86",
"790.4",
"429.3",
"369.4",
"995.92",
"790.92",
"424.0",
"V66.7",
"201.90",
"427.31",
"272.0",
"280.9",
"331.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10237, 10246
|
7973, 9759
|
324, 364
|
10299, 10308
|
3986, 3986
|
10360, 10394
|
3420, 3437
|
10209, 10214
|
10267, 10278
|
9785, 10186
|
10332, 10337
|
3452, 3967
|
6499, 7950
|
264, 286
|
2357, 2737
|
392, 2339
|
4002, 6463
|
2759, 3178
|
3194, 3404
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,660
| 179,381
|
54078
|
Discharge summary
|
report
|
Admission Date: [**2116-3-11**] Discharge Date: [**2116-3-17**]
Date of Birth: [**2054-3-15**] Sex: F
Service: MEDICINE
Allergies:
Thorazine / Penicillins
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
BiPAP
History of Present Illness:
61 y.o. woman with pmh COPD, found by VNA in her home today to
be short of breath and somnolent. In ED Vitals were 97.6, 88,
108/38, 15 84% RA, 100% on NRB. She was wheezy and not moving
air. WBC 11.9 with Neutrophils 80%. Her ABG was 7.26/68/67/32.
Placed on BiPAP, new ABG 7.19/76/73/30. CXR showed new lingular
infiltrate. Got a dose of nebs, solumedrol 125mg IV, Levaquin
X1. Vitals prior to transfer 110/60, 80's, 95%, FiO2 40%. BiPAP
settings Pressure support 14, PEEP 6.
.
On arrival to ICU, the patient is awake, but does not remember
any events of the day. She is denying chest pain, abdominal
pain, but is reporting shortness of breath.
Past Medical History:
* COPD - patient denies h/o intubation, CO2s 60s
* Schizoaffective disorder, bipolar
* Chronic low back pain, followed at pain clinic
* duodenal polyp, adenoma on bx [**9-/2114**]
* esophageal stricture s/p dilatation
* h/o urinary retention
* h/o ovarian cysts
* s/p ccy
.
Social History:
Lives alone, long history of smoking ~1ppd since age 14. States
today she currently smokes 2ppd. Denies EtoH or ilict drug use.
Lives in senior housing. Has brother who lives nearby, is
involved and is HCP. Retired typist.
Family History:
Twin brother died of MI at 49 yo
Physical Exam:
Vitals: 97.1 109/54 88 18 95%2L-->88% 2L c exertion
Pain: denies
Access: PIV
Gen: mod distress at rest, coughing, audible wheezing, mild
accessory muscle use, able to speak full sentences
HEENT: mmm
CV: RRR, no m appreciated
Resp: bilateral wheezing, prolonged expiration, scattered
rhonchi, decent air movement
Abd; soft, obese, nontender, +BS
Ext; no edema
Neuro: A&OX3, grossly nonfocal
Skin: no changes
psych: strange affect, pleasant/cooperative.
.
Pertinent Results:
WBC 11.9->8.9
hgb 11s baseline
Chem panel unremarkable. BUN 9, creat 0.6\
Bicarb 35
Phos 0.5-->2.9
.
ABG [**3-12**]: 7.31/63/62 (baseline)
.
.
Imaging/results:
CXR [**2116-3-11**]: Probable lingular infiltrate. Radiographic followup
is recommended to clearance.
.
CXR [**2116-3-13**] In comparison with the study of [**3-11**], there is
increasing opacification at the left base silhouetting the
hemidiaphragm and consistent with a lower lung pneumonia.
Probable left pleural effusion and possible right effusion as
well.
CXR [**2116-3-15**]: Improving left retrocardiac consolidation and
improving small
left pleural effusion.
.
EKG: [**2116-3-11**]: NSR, rate 75, normal axis, No LVH, no ischemic
changes.
.
Brief Hospital Course:
61 y.o. woman with pmh COPD, found by VNA in her home on [**2116-3-11**]
with shortness of breath and somnolence. She was admitted to
[**Hospital1 18**] in [**Month (only) **] for SOB with PNA and then discharged to a rehab.
She improved remarkably at the rehab and was discharged from
there on [**2116-3-2**]. She was off oxygen supplementation and had
stopped smoking during her rehab stay. Upon returning home she
started smoking again. On the day of admission, she was unable
to get up from bed due to severe weakness and SOB. She was also
noted to be confused by her VNA with her O2 sats in mid 70's/RA.
On admission, had hypercapneic respiratory failure and was
admitted to MICU. CXR also with LLL PNA. Was started on IV
steroids, broad Abx, nebs. Tolerated brief BiPAP, but kept
pulling off. Her antibiotics were subsequently tapered to
levofloxacin alone on [**3-12**]. Transfered to Gen Med on [**3-13**]. While
on Gen Med, continued to be in COPD exacerbation and was treated
with duonebs q4, prednisone 40mg, levaquin. Repeat CXR showed
improved infiltrates and her Abx were stopped after a 7-day
course. Given frequency of exacerbations, decision made for slow
prednisone taper over 2weeks. The importance of smoking
cessation was repeatedly emphasized to her, and she acknowledged
understanding. Chantix was offered but she preferred to use
nicotine patches. Home O2 was arranged for her and increased VNA
services. When she is appropriately improved, she will be
referred to outpatient pulmonary rehab.
Medications on Admission:
Albuterol Inhaler 1-2 Puffs Q2H as needed
Chlordiazepoxide 10 mg PO BID
Mellarrill 200 mg PO BID
Topiramate 100 mg PO QAM
Topiramate 150mg PO QPM
Fluticasone-Salmeterol 250-50 mcg/Dose Disk Inhalation [**Hospital1 **]
Prilosec 20mg PO daily
Albuterol Nebulization Q4H as needed for shortness of breath
Atrovent 2 puffs [**Hospital1 **]
Discharge Medications:
1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Chlordiazepoxide HCl 5 mg Capsule Sig: Two (2) Capsule PO BID
(2 times a day).
3. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
4. Topiramate 50 mg Tablet Sig: Three (3) Tablet PO QPM (once a
day (in the evening)).
5. Thioridazine 100 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours).
9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: Two (2)
Inhalation twice a day.
10. Atrovent HFA 17 mcg/Actuation Aerosol Sig: Two (2)
Inhalation four times a day: when off atrovent nebs.
11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Inhalation
every four (4) hours as needed for shortness of breath or
wheezing.
12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB.
Disp:*1 month supply* Refills:*2*
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
Inhalation Q4 () as needed for shortness of breath or wheezing.
Disp:*1 month supply* Refills:*2*
14. Home O2
2-3 L/min continuous
O2 saturation 88% on RA [**2116-3-17**]
15. Nebulizer machine
16. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): Take three tablets (30mg total) daily for three days,
then two tablets (20mg total) daily for three days, then one
tablet (10mg) daily for three days, then stop.
Disp:*18 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
COPD exacerbation/hypercapneic resp failure
LLL pneumonia
Schizoaffective disorder
Tobacco abuse
Discharge Condition:
stable
Discharge Instructions:
You were admitted for another COPD exacerbation. You also have a
pneumonia and completed one week of antibiotics for this with
improvement in your symptoms and chest x-ray. Continue taking
steroids as directed.
It is VERY important that you stop smoking. You need oxygen at
home and it is extremely dangerous for you to smoke at home with
oxygen in the house.
If you have worsening shortness of breath, lightheadedness,
chest pain, fevers, chills, or any other concerning symptoms,
call your doctor.
Followup Instructions:
You have an appointment with your primary care physician [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] on Thursday [**3-26**] at 1:15pm. Call his office
at [**Telephone/Fax (1) 2205**] with any questions.
Please ask Dr. [**Last Name (STitle) 2903**] to refer you to Pulmonary clinic (lung
doctors)
Please keep your appointment or make one with Dr. [**First Name (STitle) **] in
psychiatry.
|
[
"338.29",
"296.80",
"486",
"491.21",
"518.81",
"295.72",
"276.1",
"305.1",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6436, 6507
|
2802, 4324
|
292, 300
|
6648, 6657
|
2066, 2779
|
7206, 7657
|
1538, 1572
|
4711, 6413
|
6528, 6627
|
4350, 4688
|
6681, 7183
|
1587, 2047
|
245, 254
|
328, 983
|
1005, 1281
|
1297, 1522
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,255
| 120,794
|
34324
|
Discharge summary
|
report
|
Admission Date: [**2115-8-14**] Discharge Date: [**2115-8-21**]
Date of Birth: [**2080-1-30**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ketorolac
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
s/p fall from ladder
Major Surgical or Invasive Procedure:
No surgical procedures, respiratory arrest in setting of
multiple narcotics that responded to naracan, was never
pulseless, and did not require intubation.
History of Present Illness:
35M s/p from a fall from ladder ([**6-4**] ft height) onto a wooden
plank and subsequently developed right LE numbness with severe
left LE pain. Accident occured at 1PM [**2115-8-13**]. From OSH, pt was
found to have neg CT c-spine, XR T and L spine which were all
neg. Noted to have right sided decrease in sensation from
sternum down to distal LE. At [**Hospital1 18**], evaluated by ortho spine
who did not think there was anything intervenable and did not
recommend steroids. MRI spine showed L5-S1 disc degeneration and
mild herniation but no other cord abnormalities. He was admitted
for further monitoring and pain control.
Past Medical History:
Anemia of unknown etiology on iron supplementation
Heart murmur
Social History:
Smoke around [**1-30**] pack a day, does not drink
Family History:
NC
Physical Exam:
Gen: complained of agonizing pain in LLE ad total loss of
sensation in RLE
HEENT: no neck tenderness, PERLA, EOMI
Heart: S1, S2, RRR
Lungs: CTAB
Abdomen: s/NT/ND
Neuro: limited by extreme pain
LLE: 5-/5 TA; [**5-4**] [**Last Name (un) 938**];
RLE: 0/5 TA; [**2-2**] [**Last Name (un) **]; 0/5 GS.
Sensory: no sensations below the navel
.
Pertinent Results:
[**2115-8-13**] 11:50PM BLOOD WBC-3.7* RBC-3.74* Hgb-12.6* Hct-34.2*
MCV-91 MCH-33.8* MCHC-37.0* RDW-13.0 Plt Ct-156
[**2115-8-15**] 06:36AM BLOOD WBC-2.8* RBC-3.68* Hgb-12.3* Hct-33.9*
MCV-92 MCH-33.4* MCHC-36.3* RDW-13.7 Plt Ct-134*
[**2115-8-16**] 06:40AM BLOOD WBC-2.5* RBC-3.53* Hgb-11.8* Hct-32.1*
MCV-91 MCH-33.4* MCHC-36.8* RDW-12.8 Plt Ct-132*
[**2115-8-19**] 05:15AM BLOOD WBC-3.2* RBC-3.43* Hgb-11.7* Hct-30.9*
MCV-90 MCH-34.1* MCHC-37.9* RDW-12.9 Plt Ct-141*
[**2115-8-19**] 06:41PM BLOOD WBC-5.4# RBC-3.60* Hgb-12.1* Hct-33.0*
MCV-92 MCH-33.6* MCHC-36.6* RDW-13.4 Plt Ct-135*
[**2115-8-20**] 04:32AM BLOOD WBC-3.2* RBC-2.90* Hgb-10.1* Hct-26.3*
MCV-91 MCH-34.7* MCHC-37.7* RDW-13.3 Plt Ct-115*
[**2115-8-13**] 11:50PM BLOOD Neuts-66.6 Lymphs-26.8 Monos-3.6 Eos-2.7
Baso-0.3
[**2115-8-19**] 06:41PM BLOOD Neuts-88.9* Lymphs-5.3* Monos-5.4 Eos-0.2
Baso-0.2
[**2115-8-19**] 06:41PM BLOOD PT-14.3* PTT-31.2 INR(PT)-1.2*
[**2115-8-13**] 11:50PM BLOOD Glucose-87 UreaN-18 Creat-1.2 Na-144
K-3.6 Cl-108 HCO3-23 AnGap-17
[**2115-8-15**] 06:36AM BLOOD Glucose-86 UreaN-13 Creat-0.8 Na-142
K-4.0 Cl-108 HCO3-25 AnGap-13
[**2115-8-16**] 06:40AM BLOOD Glucose-82 UreaN-13 Creat-0.9 Na-141
K-3.6 Cl-105 HCO3-24 AnGap-16
[**2115-8-18**] 08:45AM BLOOD Glucose-76 UreaN-7 Creat-0.9 Na-140 K-3.8
Cl-103 HCO3-27 AnGap-14
[**2115-8-19**] 05:15AM BLOOD Glucose-113* UreaN-6 Creat-0.9 Na-138
K-4.5 Cl-103 HCO3-25 AnGap-15
[**2115-8-19**] 06:41PM BLOOD Glucose-258* UreaN-6 Creat-0.9 Na-140
K-3.7 Cl-103 HCO3-28 AnGap-13
[**2115-8-20**] 04:32AM BLOOD Glucose-85 UreaN-4* Creat-0.8 Na-141
K-3.7 Cl-108 HCO3-27 AnGap-10
[**2115-8-13**] 11:50PM BLOOD ALT-66* AST-37 AlkPhos-62 Amylase-35
TotBili-1.0
[**2115-8-19**] 06:41PM BLOOD ALT-55* AST-32 LD(LDH)-168 CK(CPK)-38
AlkPhos-58 Amylase-41 TotBili-0.6
[**2115-8-20**] 04:32AM BLOOD CK(CPK)-32*
[**2115-8-13**] 11:50PM BLOOD Lipase-18
[**2115-8-19**] 06:41PM BLOOD Lipase-46
[**2115-8-15**] 06:36AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.9
[**2115-8-16**] 06:40AM BLOOD Calcium-9.1 Phos-4.5 Mg-1.7
[**2115-8-19**] 05:15AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8 Iron-103
[**2115-8-19**] 06:41PM BLOOD Albumin-3.9 Calcium-8.3* Phos-3.0 Mg-1.7
[**2115-8-20**] 04:32AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7
[**2115-8-19**] 05:15AM BLOOD calTIBC-233* VitB12-565 Folate-8.4
Ferritn-401* TRF-179*
[**2115-8-19**] 06:41PM BLOOD TSH-0.78
[**2115-8-19**] 06:41PM BLOOD Ethanol-NEG Bnzodzp-POS Barbitr-NEG
Tricycl-NEG
[**2115-8-19**] 05:29PM BLOOD Type-ART pO2-226* pCO2-44 pH-7.35
calTCO2-25 Base XS--1
-----------------
MRI L-Spine
IMPRESSION:
1. Overall normal appearance to the cervicothoracic spine, as
well as the
spinal cord through the level of the conus medullaris.
2. Unremarkable appearance of the cauda equina (on this
unenhanced study).
3. L5-S1: Disc degeneration with a broad-based but shallow
paracentral
protrusion only slightly displacing, without deforming, the
traversing left S1
nerve root, without overall canal stenosis. This finding should
be closely
correlated with the nature of the patient's symptoms.
4. L4-L5: Disc degeneration without significant bulge or focal
herniation.
COMMENT: These findings were discussed with Dr. [**Last Name (STitle) 65328**]
(Internal Medicine
houseofficer) at time of dictation.
.
CT L-Spine
IMPRESSION:
1. No evidence of fracture or malalignment.
2. Mild disc bulges at L4-5, L5-S1 levels, causing mild
indentation on the
ventral thecal sac, better evaluated on the recent MR of the
L-spine.
.
CT T-Spine:
IMPRESSION:
1. No fracture or dislocation.
2. Equivocal right suprarenal lesion, 3,5cm, can represent
complex cyst, mass or secondary to volume averaging. An
abdominal CT/ MR is recommended for further evaluation.
.
CT Pelvis: IMPRESSION: No fracture.
.
MR C/T-Spine: IMPRESSION:
1. Mild degenerative changes at the level of T8-9, without canal
stenosis or neural foraminal narrowing.
2. No significant change compared to the study done one day
earlier.
Evaluation for subtle cord abnormalities on the sagittal T2 or
STIR sequences is limited. No evidence of cord compression.
.
CTA Head/Neck: IMPRESSION: Normal study.
.
ECG: Sinus tachycardia. Left anterior fascicular block. No
previous tracing available for comparison.
.
CT Abdomen w/ Contrast: IMPRESSION:
1. There is no renal mass present. The previously described
abnormality can be attributed to respiratory motion on the
thoracic spine exam. Normal
kidneys. No evidence of hematoma.
2. Air within the bladder, likely related to instrumentation if
there is such a history. Please correlate clinically.
3. Scant atelectasis at the left lung base.
.
CXR: COMMENTS: Respiratory arrest on the floor, reversed with
Narcan. Acute process?
.
Normal aspect of the cardiopulmonary silhouette. No focal area
of
consolidation.
.
The study and the report were reviewed by the staff radiologist.
.
CTA Chest: IMPRESSION:
1. Negative examination for PE or aortic dissection.
2. Negative examination for pneumonia.
The study and the report were reviewed by the staff radiologist.
Brief Hospital Course:
Patient admitted to the medicine service for management.
.
#Leg Weakness and Pain: Concerning for fracture, disk
herniation, nerve entrapment. However, Neurology could find no
objective explanation for patient's symptoms. Imaging
unremarkable, and exam not consistent. Nevertheless, patient
complained of significant pain and started on MS Contin 75mg
TID, and dilaudid PCA while work-up on going. In addition,
given neurontin, diazepam, and cyclobenzaprine for nerve/muscle
pain. During hospital stay, on above regimen, patient found by
nursing this to be grey/blue and unresponsive, O2 sat reportedly
38% but then difficult to pick up [**Location (un) 1131**]. Code blue called.
Patient easily bag mask ventilated, no intubation attempted. SBP
initially measured at 70's but maintained good pulses. IVFs wide
open started. Patient had received PO and IV narcotics during
the day as well as diazepam; 0.4 mg narcan given with good
response. Switched to NRB, sats 100%. Persistently tachycardic
to 130's during/after code blue; also noted to be tachy to 120
earlier this afternoon, reportedly orthostatic VS and given IV
NS with response to HR 100. Previous HRs mainly in 60's - 70's.
O2 sats in mid-high 90s all day. [**Name8 (MD) **] RN reported he was
more sleepy than usual during day but arousable. In the ICU
patient did not require intubation or narcan gtt but did receive
one further dose of narcan. Of note did not have significant
complaints of pain with narcan. Was called out to the floor the
following day after CTA chest negative for PE. Patient with
stable vital signs, and without tachycardia, O2 requirement, or
neurological impairment. Thereafter pain was adequately
controlled with tylenol. Patient observed for 24 hours without
complication. New nursing staff than recognized patient from
previous admission when he presented with the same complaints
under a different name that resulted in his eloping from the
floor before he could be evaluated. Patient then eloped from
floor before he could be confronted.
.
#Pancytopenia: Has history of iron deficiency anemia by report.
Iron studies not c/w this diagnosis. Patient refused blood work
and further evaluation. Was instructed that he may have
malignancy, or serious infectious process involving his bone
marrow and taht this was a serious condition that required
further evaluation. Later that day he eloped from the floor.
.
Patient was non-compliant with care - refusing labs, meds - and
was believed to possibly have been taking opiates illicitly
given his respiratory arrest occurred in the afternoon without
having received any opiates since early morning. Is obvious
elopement risk.
Medications on Admission:
Ferrous sulphate
Discharge Medications:
Patient eloped.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p mechanical fall
respiratory arrest
pancytopenia NOS
anemia NOS
Discharge Condition:
Patient eloped from the floor.
Discharge Instructions:
Patient eloped from the floor.
Followup Instructions:
Patient eloped from the floor.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"E935.2",
"E881.0",
"799.1",
"427.89",
"722.52",
"564.09",
"458.0",
"284.1",
"729.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9493, 9499
|
6703, 9386
|
305, 463
|
9610, 9642
|
1672, 6680
|
9721, 9883
|
1295, 1299
|
9453, 9470
|
9520, 9589
|
9412, 9430
|
9666, 9698
|
1314, 1653
|
245, 267
|
491, 1123
|
1145, 1211
|
1227, 1279
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,536
| 118,799
|
43459
|
Discharge summary
|
report
|
Admission Date: [**2117-9-2**] Discharge Date: [**2117-9-20**]
Date of Birth: [**2060-1-2**] Sex: F
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 6088**]
Chief Complaint:
Acute onset of lower extremity paralysis
Major Surgical or Invasive Procedure:
Right axillo-bifemoral bypass, 8-mm PTFE, bilateral external
iliac thrombectomies, right femoral-popliteal thrombectomy, and
bilateral 4-compartment lower extremity fasciotomies [**2117-9-2**]
Flexible sigmoidoscopy [**2117-9-2**]
Flexible sigmoidoscopy [**2117-9-3**]
Exploratory laparotomy, transverse colectomy and colostomy along
Hartmann pouch and gastrostomy tube [**2117-9-4**]
Insertion of dialysis catheter [**2117-9-10**]
History of Present Illness:
57 yo F who presented to [**Hospital 1191**] hospital [**9-1**] for ambien
overdose was transferred to [**Hospital1 18**] ED for sudden onset bilateral
lower extremity paraplegia beginning yesterday afternoon.
Patient reported loss of sensory and motor function. CT
angiogram performed in the emergency department demonstrated
infrarenal aortic occlusion with reconstitution of flow in the
left common femoral and left profunda arteries. Pt was taken
emergently to the OR.
Past Medical History:
Depression s/p intentional Ambien overdose and subsequent
hospitalization at [**Doctor First Name 1191**], no previous known psych history.
Hypertension
Hypercholesterolemia
CAD - s/p AICD placement
[**Doctor First Name 2793**] insufficiency - s/p [**Doctor First Name **] artery stents
Chronic low back pain
Social History:
Lives in [**Location 3786**] with her husband, various jobs in past, but not
currently employed, one son who lives in the area. She smoked 1
ppd x 40 years. She denies any illicit or IV drug use.
Family History:
Father with diabetes mellitus and CAD
Physical Exam:
Gen: Thin, NAD, paraplegic
HEENT: NCAT, anicteric sclera, OP with dry MM, no lesions.
Neck: No carotid bruits B/L, no vertebral bruits. No nuchal
rigidity.
CV: RRR, no MRG, AICD in left chest.
Pulm: Course breath sounds bilaterally
Abd: Soft, NT, softly distended at lower abdomen, + BS, ostomy
draining liquid brown stool. groin wound exudative
Extr: Bilateral medial and fasciotomy wounds closed.
Vasc: DP/PT palpable bilaterally
Neuro:
PERRL 3 to 2mm and brisk. VFF to confrontation. There is no
ptosis bilaterally. no papilledema or hemorrhages. EOMI without
nystagmus. Normal saccades. Facial sensation intact to
pinprick.
No facial droop, facial musculature symmetric. Hearing intact to
finger-rub bilaterally. Palate elevates symmetrically. 5/5
strength in trapezii and SCM bilaterally. Tongue protrudes in
midline.
Brief Hospital Course:
Pt was admitted from the ER for aortic occlusion. Pt was
underwent right axillo-bifemoral bypass, bilateral external
iliac thrombectomies, right femoral-popliteal thrombectomy, and
prophylactic bilateral 4-compartment lower extremity
fasciotomies. Pt tolerated the procedure well, but was left
intubated anticipating reperfusion type issues. Her
postoperative course was complicated by multiple
episodes of hematochezia and moderate acidosis. Based upon the
concern for ischemic colitis, she underwent flexible
sigmoidoscopy. The colonic mucosa was essentially virtually
completely sloughed and there were multiple areas of
pseudomembranes and necrosis but the submucosa was all viable.
There was no evidence of transmural
necrosis or frank gangrenous changes. At this time the plan was
to repeat the colonoscopy in approximately 12 hours. A flexible
sigmoidoscopy on [**9-3**] noted areas of ischemic changes involving
the mucosa but no evidence of a transmural injury.
The submucosa was completely viable. There was no evidence of
perforation or active bleeding. At this time, the patient has
improved over the course of the evening. The pt off vasopressors
and a follow-up flexible sigmoidoscopy was planned in 24 hours.
Over the evening of [**2118-9-3**], the pt developed worsening
pressor requirements and increasing lactate. Based upon this,
the pt was taken to the operating for exploration. On [**2117-9-4**],
the pt underwent exploratory laparotomy, transverse
colectomy and colostomy along Hartmann pouch and gastrostomy
tube placement for mesenteric ischemia after which the patient
was taken to the cardiovascular intensive care unit in stable
condition.
During her CVICU stay, the pt was followed by social work for
continue to follow family for support and to work with pt’s
husband and son around issue of purposeful vs. accidental
overdose. Psychiatry was consulted to evaluate patient's
capacity [**Last Name (un) 93517**] code status from full code to DNR in context of
multiple medical problems and with recent suicide attempt.
Psych stated that the pt had significant deficits in her
capacity to make decisions about her code status at this
particular moment and recommended that the pt should be on
constant observer status due to risk of harming herself. Celexa
10 mg po q day was begun to treat depression.
Due to acute [**Last Name (un) **] failure from rhabdomyolysis and bilateral
[**Last Name (un) **] infarcts, pt underwent several week history of ongoing
dialysis (CVVD started on [**2117-9-3**]). On [**2117-9-8**], the pt was
switched from CVVD to HD as needed. On [**2117-9-10**], a tunneled
dialysis catheter was inserted. On [**2117-9-11**], pt received HD and
had 500 cc of fluid removed. As urine output had increased, on
[**2117-9-13**], HD was deferred.
Pt was transferred to the VICU. On [**2117-9-13**], psychiatry noted a
more hopefulness and future-orientation. Celexa was increased
to 20 mg po q day. Nutrition visited the pt and recommended
that diet be advanced as tolerated. As pt's hematocrit dropped
to 25.8, pt was transfused 1 unit of PRBC.
Physical therapy evaluated the pt. Pt recommended regular
physical therapy in-hospital with discharge to rehab.
On [**2117-9-14**], pt was transferred to the floor. On [**2117-9-15**], the
pt's creatinine continued to rise, but due to good urine output,
HD was delayed. Psychiatry visited the pt, increased her
Celexa, and discontinued the sitter. On [**2117-9-16**], wound vacs
were removed from the pt's medial fasciotomies which were then
closed. Nutrition reevaluated pt and recommended to add [**Date Range **]
CIB [**Hospital1 **] and beneprotein supplements. On [**2117-9-17**], ostomy care
visited the pt. They performed ostomy teaching and recommended
new wound care for the pt's partial thickness perianal ulcer.
On [**2117-9-17**], [**Date Range **] reevaluated the pt. HD was discontinued.
[**Date Range 2793**] recommended that [**Date Range **] function be followed q 3 days until
[**Date Range **] function reached baseline. On [**2117-9-18**], general surgery
removed the pt's abdominal staples and placed steristrips on the
wound. On [**2117-9-20**], the bilateral lateral fasciotomies were
closed and the HD catheter was removed. As the pt was stable
and afebrile, she was discharged to rehab with follow-up.
Medications on Admission:
Zestril 10mg daily
Simvastatin daily
Aspirin 81mg daily
Celexa (started 2 days ago at [**Doctor First Name 1191**]).
Pt was taking percocet and vicodin in the past for LBP, but none
recently.
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-23**]
Drops Ophthalmic PRN (as needed).
2. Beclomethasone Dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed for wheezesg/rhonchi.
4. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
8. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Metoprolol Tartrate 25 mg Tablet Sig: [**12-23**] Tablet PO twice a
day: Hold for BP <90 or HR <65.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
1 months.
11. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 1 weeks.
12. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO every six (6) hours as needed for pain for 20 days.
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for 1 months.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] AND REHABILITATION.
Discharge Diagnosis:
Acute aortic occlusion
Ischemic colitis
Paraplegia
Discharge Condition:
Stable
Discharge Instructions:
What to expect when you go home:
1. It is normal to feel weak and tired, this will last for [**5-30**]
weeks
?????? You should get up out of bed every day and gradually increase
?????? Increase your activities as you can tolerate - do not do too
much right away!
2. It is normal to have incisional and leg swelling:
?????? Wear loose fitting pants/clothing (this will be less
irritating to incision)
?????? Elevate your legs above the level of your heart (use [**1-24**]
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
?????? You should get up every day, get dressed, gradually increasing
your activity
?????? You may exercise as tolerated, 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 (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 101.5F for 24 hours
?????? Bleeding from incision
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
Followup Instructions:
Provider: [**Name10 (NameIs) 2793**] Clinic. [**Telephone/Fax (1) 60**] Follow-up appointment
should be in 3 weeks
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2117-10-13**] 10:15
Completed by:[**2117-9-20**]
|
[
"344.1",
"440.4",
"403.91",
"585.6",
"V45.02",
"707.03",
"707.05",
"276.6",
"721.3",
"584.9",
"728.88",
"414.01",
"557.0",
"440.20",
"444.0",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24",
"83.09",
"43.19",
"39.29",
"39.95",
"38.06",
"99.04",
"99.15",
"38.08",
"46.11",
"45.74",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
8862, 8925
|
2717, 7076
|
307, 741
|
9020, 9029
|
11578, 11871
|
1808, 1847
|
7319, 8839
|
8946, 8999
|
7102, 7296
|
9053, 11125
|
11151, 11555
|
1862, 2694
|
227, 269
|
769, 1244
|
1266, 1577
|
1593, 1792
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,543
| 109,236
|
25844
|
Discharge summary
|
report
|
Admission Date: [**2171-10-15**] Discharge Date: [**2171-11-14**]
Date of Birth: [**2109-12-29**] Sex: M
Service: MEDICINE
Allergies:
Beta-Adrenergic Blocking Agents / Zosyn
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
61 year old male with severe CAD, unrevascularizable, s/p
cardiac arrest with anoxic brain injury [**5-/2171**], chornic
bronchitis, osteomyelitis, trached and peged, living in extended
care, admitted to the MICU after presenting to the ED with
respiratory distress. Was reportedyl in USOH when had episode of
hypoxia, fevers to 101 and tachycardia. Was placed on NRB and
sating 90-100% on transfer to ED.
.
In ED - was able to be weaned to trach mask with good
saturations nad no respiratory distress. Got 1gm Vancomycin and
tylenol. Was per call-in reportedly was on Zosyn for pseudomonas
colonization. When on floor, BP noted to be 70s systolic,
responded well to IV fluid bolus.
.
Of note: recently admitted [**8-14**], discharge [**8-21**] for fevers,
tachycardia, tachypnea. Was discharged on a 5 week course of
vancomycin for osteo that was newly diagnosed on MRI imaging of
the hip, located @ ischial tuberosity and coccyx. - no biopsy
or debrediment performed.
Past Medical History:
# CAD - 3VD s/p cardiac arrest w/anoxic brain injury as above.
Arrest was in setting of left hip fracture and repair.
has 3VD not revascularizable
# ischemic cardiomyopathy (EF 25%)
# Osteomyelitis - recently diagnosed ([**7-/2171**]) during above
admission.
# Sensorimotor demyelinating polyneuropathy, confirmed by EMG
per the pt's brother. Pt. has resultant paraparesis
# suspected colonization of airway with pseudomonas (pan
sensative)
# UTIs
# chronic renal insufficiency, known horseshoe kidney
# chronic sacral and ischial decubitus ulcers
# H/O chronic indwelling foley
# h/o afib (currently not anticoagulated, not rate controlled,
and not in afib
# Hyperlipoidemia
# h/o AAA
# Schizophrenia
# prior strokes seen on CT head
# h/o dementia
Social History:
The pt. is a resident of a skilled nursing facility. There is no
history of alcohol use. The pt. quit smoking tobacco 2 years ago
after approximately 20 years of use. He is a former electrical
engineer. His Brother [**Name (NI) 11312**] [**Name (NI) 14714**] is actively involved in
his care.
Family History:
NC
Physical Exam:
Admit exam:
98.5 109 109/70 22 99-100%RA on trach mask
GEN: ill appearing, non responsive
HEENT: no rashes,
CV: rrr s1 s2, no M/G/R
RESP: CTA ant
ABD: soft, NT/ND
EXT: no edema or excoriations
NEURO: deffered
.
Discharge exam: (notable findings)
T 96.9 Tm 99.2 BP 95/74 HR 88-100 RR 20 94% trach mask 35%
General: minimally responsive elderly male with trach, NAD
Neuro: tracks people with eyes (EOMI PERRL), needs glasses on to
see, does not respond in meaningful way to questions, does
follow some commands (squeeze finger, spread fingers, blinks,
moves limbs spontaneously, L arm lightly contracted but able to
move passively, does not wiggle toes. Some days he waves hello
and some days he mouths words though unclear what he is trying
to say.
Respiratory: trach w/35% trach mask, white-light yellow sputum
requiring frequent suctioning, rhonchi heard throughout
CV: RRR no m/r/g, distant heart sounds
Abd: soft, NT/ND, PEG c/d/i, functioning well
Limbs/extremities: old excoriations on L arm, no edema, brown
mottling/discoloration of dorsal feet b/l, dopplerable pulses
Pertinent Results:
[**2171-10-15**] 08:55PM BLOOD WBC-21.8*# RBC-4.20*# Hgb-12.9*#
Hct-38.7*# MCV-92 MCH-30.6 MCHC-33.2 RDW-16.9* Plt Ct-287
[**2171-10-15**] 08:55PM BLOOD Neuts-93.3* Bands-0 Lymphs-4.2* Monos-2.0
Eos-0.4 Baso-0.1
[**2171-10-18**] 02:39AM BLOOD Hypochr-OCCASIONAL Anisocy-1+
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL
Polychr-OCCASIONAL Stipple-1+
[**2171-10-19**] 05:20AM BLOOD WBC-10.7 RBC-3.16* Hgb-9.7* Hct-29.1*
MCV-92 MCH-30.8 MCHC-33.5 RDW-17.0* Plt Ct-57*
[**2171-10-23**] 05:17AM BLOOD WBC-12.7* RBC-3.30* Hgb-10.5* Hct-30.8*
MCV-93 MCH-31.9 MCHC-34.2 RDW-18.2* Plt Ct-211
[**2171-10-31**] 04:31AM BLOOD WBC-8.3 RBC-2.99* Hgb-9.3* Hct-28.0*
MCV-94 MCH-31.1 MCHC-33.2 RDW-17.7* Plt Ct-289\
[**2171-11-2**] 10:57AM BLOOD Neuts-64.9 Lymphs-23.1 Monos-5.0 Eos-6.7*
Baso-0.3
[**2171-11-12**] 04:05AM BLOOD WBC-8.9 RBC-2.96* Hgb-9.4* Hct-27.9*
MCV-94 MCH-31.9 MCHC-33.8 RDW-17.6* Plt Ct-345
[**2171-11-14**] 04:30AM BLOOD WBC-10.7 RBC-3.36* Hgb-10.4* Hct-31.1*
MCV-93 MCH-31.0 MCHC-33.5 RDW-17.2* Plt Ct-308
.
[**2171-10-15**] 08:55PM BLOOD Glucose-206* UreaN-69* Creat-2.2* Na-135
K-4.8 Cl-101 HCO3-19* AnGap-20
[**2171-10-17**] 05:00AM BLOOD Glucose-94 UreaN-63* Creat-2.4* Na-142
K-4.2 Cl-111* HCO3-20* AnGap-15
[**2171-10-21**] 12:47PM BLOOD Glucose-113* UreaN-38* Creat-2.0* Na-138
K-4.4 Cl-108 HCO3-23 AnGap-11
[**2171-11-12**] 04:05AM BLOOD Glucose-93 UreaN-37* Creat-1.6* Na-141
K-4.0 Cl-111* HCO3-23 AnGap-11
[**2171-11-14**] 04:30AM BLOOD Glucose-89 UreaN-34* Creat-1.8* Na-139
K-4.5 Cl-106 HCO3-24 AnGap-14
.
[**2171-10-16**] 01:21AM BLOOD PT-14.8* PTT-26.9 INR(PT)-1.3*
[**2171-10-23**] 05:17AM BLOOD PT-13.2* PTT-27.3 INR(PT)-1.2*
[**2171-11-10**] 04:45AM BLOOD PT-14.6* PTT-28.0 INR(PT)-1.3*
[**2171-10-15**] 08:55PM BLOOD ALT-55* AST-43* AlkPhos-312* Amylase-76
TotBili-0.4
[**2171-10-16**] 04:00PM BLOOD ALT-54* AST-45* AlkPhos-257*
[**2171-10-23**] 05:17AM BLOOD ALT-40 AST-40 AlkPhos-268* TotBili-0.3
[**2171-10-15**] 08:55PM BLOOD Lipase-56
[**2171-10-22**] 04:57AM BLOOD Lipase-114*
[**2171-10-16**] 01:21AM BLOOD Albumin-2.6* Calcium-8.1* Phos-3.5 Mg-2.6
[**2171-11-14**] 04:30AM BLOOD Calcium-8.8 Phos-3.3 Mg-2.7*
[**2171-11-6**] 03:02AM BLOOD TSH-2.7
[**2171-11-2**] 11:32PM BLOOD Type-ART pO2-64* pCO2-40 pH-7.37
calTCO2-24 Base XS--1
[**2171-11-3**] 01:02AM BLOOD Type-ART pO2-80* pCO2-42 pH-7.36
calTCO2-25 Base XS--1
[**2171-10-15**] 09:08PM BLOOD Lactate-2.4*
[**2171-10-16**] 01:32AM BLOOD Lactate-2.0
[**2171-10-15**] 09:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2171-10-15**] 09:00PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-100 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
[**2171-10-15**] 09:00PM URINE RBC-0-2 WBC-[**3-4**] Bacteri-FEW Yeast-MOD
Epi-0
[**2171-11-8**] 03:13PM URINE RBC-[**6-9**]* WBC->50 Bacteri-MANY Yeast-MANY
Epi-0
[**2171-11-8**] 03:13PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.013
[**2171-11-8**] 03:13PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
[**2171-11-8**] 03:13PM URINE RBC-[**6-9**]* WBC->50 Bacteri-MANY Yeast-MANY
Epi-0
[**2171-10-18**] 06:06PM URINE Hours-RANDOM UreaN-660 Creat-37 Na-98
[**2171-10-18**] 06:06PM URINE Osmolal-502
[**2171-11-9**] 09:31PM URINE Color-S Appear-CL Sp [**Last Name (un) **]-1.010
[**2171-11-9**] 09:31PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-SM
[**2171-11-9**] 09:31PM URINE RBC-[**11-19**]* WBC-[**3-4**] Bacteri-MOD Yeast-MOD
Epi-<1
.
MICROBIOLOGY
[**2171-11-9**] 9:31 pm URINE Site: NOT SPECIFIED**FINAL REPORT
[**2171-11-11**]**
URINE CULTURE (Final [**2171-11-11**]): YEAST. >100,000
ORGANISMS/ML..
[**2171-11-9**] [**2171-11-9**] 4:28 pm SWAB Site: HIP LEFT HIP.
GRAM STAIN (Final [**2171-11-9**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
[**Month/Day/Year **] CULTURE (Final [**2171-11-11**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
[**2171-11-13**]**
GRAM STAIN (Final [**2171-11-9**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
SMEAR REVIEWED; RESULTS CONFIRMED.
[**Month/Day/Year **] CULTURE (Final [**2171-11-13**]):
Due to mixed bacterial types ( >= 3 colony types) an
abbreviated
workup is performed appropriate to the isolates recovered
from the
site (including a screen for Pseudomonas aeruginosa,
Staphylococcus
aureus and beta streptococcus).
ENTEROCOCCUS SP.. SPARSE GROWTH.
[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION. SPARSE
GROWTH.
YEAST. RARE GROWTH. 2ND TYPE.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN------------ =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final [**2171-11-13**]): NO ANAEROBES ISOLATED.
.
[**2171-11-8**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT
[**2171-11-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NG
[**2171-11-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT NG
[**2171-11-2**] GRAM STAIN (Final [**2171-11-3**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2171-11-6**]):
OROPHARYNGEAL FLORA ABSENT.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. 2ND COLONIAL
MORPHOLOGY.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| PSEUDOMONAS AERUGINOSA
| |
CEFEPIME-------------- 16 I 16 I
CEFTAZIDIME----------- =>64 R =>64 R
CIPROFLOXACIN--------- 1 S 1 S
GENTAMICIN------------ 2 S <=1 S
IMIPENEM-------------- =>16 R =>16 R
MEROPENEM------------- =>16 R =>16 R
PIPERACILLIN---------- 64 S =>128 R
PIPERACILLIN/TAZO----- 64 S =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
.
[**2171-11-2**] URINE Legionella Urinary Antigen NEGATIVE FOR
LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2171-11-2**] URINE URINE CULTURE-FINAL {YEAST} INPATIENT >100,000
ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES
[**2171-10-29**] STOOL FECAL CULTURE (Final [**2171-10-31**]): NO
SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final
[**2171-10-31**]): NO CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE
TOXIN ASSAY (Final [**2171-10-30**]): FECES NEGATIVE FOR C. DIFFICILE
TOXIN BY EIA.
[**2171-10-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT NG
[**2171-10-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL
INPATIENT NG
[**2171-10-16**] FECAL CULTURE (Final [**2171-10-19**]): NO SALMONELLA OR
SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2171-10-18**]): NO
CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final
[**2171-10-17**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2171-10-15**] URINE URINE CULTURE-FINAL {PSEUDOMONAS AERUGINOSA,
KLEBSIELLA PNEUMONIAE} EMERGENCY [**Hospital1 **] URINE CULTURE (Final
[**2171-10-21**]):
PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML..
OF TWO COLONIAL MORPHOLOGIES.
KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML..
Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- 8 S <=1 S
CEFTAZIDIME----------- 32 R <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 2 S
CIPROFLOXACIN--------- 2 I <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
IMIPENEM-------------- 8 I <=1 S
MEROPENEM------------- 4 S <=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN---------- R
PIPERACILLIN/TAZO----- 32 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2171-10-15**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **] NG
[**2171-10-15**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **] NG
.
[**10-15**] ECG Probable marked resting sinus tachycardia at about 136
beats per minute, although atrial tachycardia is not excluded.
Borderline left axis deviation. Possible right or biatrial
abnormality. Possible prior inferior wall myocardial infarction.
Left ventricular hypertrophy. Underlying anterior Q wave
myocardial infarction. Non-specific ST-T wave changes. Compared
to previous tracing of [**2171-8-16**] the heart rate is markedly
increased. QTc interval prolongation is not noted. Lateral T
wave inversions are normalized. Clinical correlation is
suggested.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
136 148 86 306/439 64 -24 143
.
IMAGING
[**10-15**]
PORTABLE UPRIGHT CHEST RADIOGRAPH: Minimal amount of linear
atelectasis is noted at the lung bases bilaterally with the
lungs appearing otherwise clear. Cardiomediastinal silhouette,
hilar contours, and pleural surfaces are within normal limits
and unchanged. Tracheostomy tube terminates approximately 4.8 cm
from the carina and left PICC terminates in the brachiocephalic
junction/superior SVC. Previously identified surgical/drainage
catheter projecting over the left upper quadrant is no longer
visualized.
.
[**10-16**] portable CXR- The tracheostomy tube is approximately 5 cm
above the carina. The left PICC line terminates in the upper
SVC/brachiocephalic junction. There are persistent low lung
volumes. There is increased right lower lobe linear opacities
likely consistent with atelectasis. There is no pneumothorax.
There are no focal consolidations or effusions.
.
[**10-16**] RUQ US FINDINGS: Grayscale and color ultrasound imaging of
the liver was performed with comparison made to CT examination
of [**2171-7-1**]. Again seen are multiple shadowing stones within the
gallbladder lumen. There is no gallbladder wall thickening or
pericholecystic fluid. Son[**Name (NI) 493**] [**Name2 (NI) 515**] sign was not
elicited. Body habitus limits thorough evaluation, however, no
definite focal hepatic lesions are seen. There is no ascites.
Two small hepatic cysts are seen, consistent with prior CT
findings. Portal vein remains hepatopetal in flow
direction.IMPRESSION: Cholelithiasis without son[**Name (NI) 493**]
evidence for acute cholecystitis.
.
Portable AP chest dated [**2171-11-1**] is compared to the prior from
[**2171-10-18**].
Tracheostomy tube is in stable position. The left PICC line has
migrated approximately 2.5 cm and is now positioned in the
distal left subclavian vein. The heart size and mediastinal
contours are unchanged given patient positioning. Lung volumes
are low, but there is no evidence of airspace consolidation,
pleural effusion, or pneumothorax.IMPRESSION: Interval
retraction of PICC approximately 2.5 cm, now terminating in the
distal left subclavian vein.
.
[**2171-11-7**] Portable AP chest radiograph compared to [**2171-11-5**]. The tracheostomy tube is in unchanged central position.
The mild-to-moderate cardiac enlargement is stable as well as
the mediastinal widening. The lungs are overall clear except for
right retrocardiac area where small opacity is demonstrated and
might represent either atelectasis or pneumonia, unchanged since
the previous study. There is no pleural effusion or
pneumothorax. Left PICC line tip terminates in left
brachiocephalic vein, unchanged since the previous study.
.
[**2171-11-11**] IMPRESSION: Successful declogging of G-tube using an
Amplatz wire and saline. The tube is ready for use.
Brief Hospital Course:
61 y/o man w/multiple medical problems including CAD complicated
by anoxic brain injury, with multiple infectious foci admitted
with an episode of hypoxia, tachycardia, fevers and hypotesion
likely secondary to urosepsis. Hospital course by problem:
.
# Hypotension/Sepsis: The patient's BP was in the 70s systolic
and he was admitted to ICU from the ED. He was occasionally
hypotensive to SBP in the 80s in the MICU, but he responded
quickly to fluids and antibiotics and he was soon called out to
the floor. On the floor he was continued on antibiotics and was
clinically improving, awaiting placement, but he had increased
secretions requiring frequent suctioning so he was transferred
back to the MICU and then back to the floors once secretions
were under better control. His blood pressures remained stable
with SBPs in the 90s-110s,
the patient is currently afebrile and normotensive. The
combination of fevers, hypotension, and elevated WBC count
support the diagnosis of sepsis. Possible sources included
pulmonary source, [**Month/Day/Year **], possible line infections(PICC x 6 wks),
urinary and abdominal source (cholecystitis as possibly
suggested by elevated LFT's). CXR was normal, [**Month/Day/Year **] cultures
from [**Hospital1 **] showed pseudomonas and proteus species, but blood
cultures have been negative. No obvious areas of erythema were
seen around the pick site or sacral decubitus ulcer. RUQ US
showed no cholecystitis or biliary disease. Urine cultures grew
klebsiella as a likely source. The patient was started on Zosyn
for pseudomonas and klebsiella coverage and switched to
meropenem due to thrombocytopenia. (See below).
.
# Hypoxia/Respiratory Secretions: His initial hypoxia was
thought to be due to transient mucus plugging. His hypoxia
resolved in the MICU with trach care and suctioning however when
he was on the floors he was noted to have increasing secretions
which appeared benign and related to the patient's inability to
manage secretions, however the nursing staff could not meet his
suctioning needs so he was transferred back to the MICU for more
frequent suctioning. In the ICU, he had more yellow and thick
secretions, so there was concern for possible pneumonia,
especially given that he developed a low grade fever and
tachycardia, however those have resolved. His chest x-rays have
not revealed any clear new consolidation, so it is felt at this
time he does not have a PNA. Patient is not hypoxic. With the
addition of tobramycin nebs [**Hospital1 **] and sublingual levsin, his
secretions decreased. The patient also completed a 4 day course
of Prednisone (60 mg PO x4 days) for possible COPD/bronchitis
component in the MICU. His sputum culture grew Pseudomonas
(meropenem resistant), but the consensus is that the patient is
likely colonized. He has been continued on Tobramycin nebs [**Hospital1 **]
to assist with mucous secretions for Pseudomonas colonization
(this is often given to patients with Cystic Fibrosis) with the
plan to continue Tobramycin nebs for 2 weeks, started on
[**2171-11-6**], to complete course on [**2171-11-20**]. He requires suctioning
to assist in clearing secretions (at least q3hrs) and
additionally receives atrovent, fluticasone, and xoponex in
place of albuterol (due to tachycardia) to manage COPD symptoms.
The patient may benefit from scopalamine patches in the future
if his secretions worsen and this may be discussed with his
family.
.
#UTI: In the MICU the patient was started on vanc/zosyn/flagyl
for sepsis. However, urine cultures grew pseudomonas and
klebsiella and [**Date Range **] cultures from [**Hospital1 **] grew proteus and
pseudomonas sensitive to imipenem, and he was colonized with
pseudomonus in the lungs, so vanc/zosyn/flagyl were discontinued
and he was started on meropenem (for pseudomonas both in the
urine and possibly in the bone- osteomyelitis- as pseudomonas
grew from the coccyx [**Hospital1 **] as well). The patient is being
treated for UTI and osteomyelitis (klebsiella and pseudomonas),
with meropenem for a 6wk course (day 1 = [**10-18**], the last day
will be [**11-29**]).
.
# History of sacral decubitus ulcer complicated by osteomyelitis
(MSSA+ s/p 6 weeks vancomycin at [**Hospital1 **]). As part of the
sepsis work up the patient was found to have pseudomonas
sensitive to imipenem in his sacral ulcer [**Hospital1 **] so was started
on meropenem as above. A sputum culture grew Pseudomonas
resistant to Meropenem, so there was concern that the sacral
[**Hospital1 **] could have pseudomonas resistant to Meropenem as well and
a repeat sacral [**Hospital1 **] culture was obtained on [**2171-11-9**] which did
not grow pseudomonas but is growing VRE. It is thought this is
likely contamination from feces as the clinical exam does not
support cellulitis. Osteomyelitis by VRE could be possible but
since the patient has been afebrile with no leukocytosis for the
past weeks, we chose not to treat and trend his fever curve and
WBC. One can consider adding linezolid to his antibiotics (14
days for cellulitis) or daptomycin (for longer course if suspect
osteo) if the patient develops signs of active infection. During
the hospital stay a [**Date Range **] nurse evaluated him and his [**Date Range **] was
managed per the [**Date Range **] nurse recommendations. Plastics was also
consulted and recommended continuing the current care, and to
maximize nutrition and blood glucose control to assist in
healing. The patient completed a 14 day course of Vit C and Zinc
for sacral decub care started on [**10-22**].
.
# Thrombocytopenia: The patient's platelets decreased over the
first 2 days of his hospital stay with a nadir on [**10-18**]. Zosyn
was discontinued (changed to meropenem) on [**10-18**] and his
platlets subsequently increased. HIT antibody was negative, so
heparin was restarted on [**10-19**]. Patelets continued to increase.
.
# CAD: Per past reports his coronary artery disease is
non-revascularizable, and he is allergic to betablockers. He was
continued on ASA 81 and a statin.
.
# CHF, systolic: The patient was bolused with gental IVF when
needed for hypotension in his initial few days of admission.
Also his ins and outs were monitored and he demonstrated equal
fluid balance. He did not demonstrate signs of fluid overload.
.
# DM: NPH was increased to 7 qAM and 8 qPM, FSBG under better
control, also with RISS.
.
# Acute on chronic renal failure: The patient's creatinine
varied widely in the past. On presentation his Cr was elevated,
thought to be due to hypovolemia. His Cr came back to baseline
at 1.6-1.8 with fluid resuscitation.
.
# History of atrial fibrillation: The patient is not rate
controlled or anticoagulated but he had a normal rhythm during
his stay. He occasionally becomes tachycardic with persistent
HRs in the 100s but this seems to have resolved with using
xopinex instead of albuterol for nebulizers. He tends to get
more tachycardic (120a) after suctioning and when he is
uncomfortable. His tachycardia is felt less likely to be due to
infection as he has been afebrile, and has a normal WBC count,
and is on Meropenem. He is still somewhat tachy with baseline HR
in the 80s-100s
.
# Altered MS - Multifactorial in etiology and chronic.
Contributants include: anoxic brain injury, demylenating
disease, known dementia, prior CVA,and h/o thought disorder. He
is able to follow some commands, and his mental status has
improved during the course of his admission.
.
# Agitation: Patient had been scratching his upper extremities
with multiple excoriations, likely due to agitation. He was
given Ativan 0.5 mg IV Q4H:PRN aggitation and was started on
Hydroxyzine 50 mg PO Q6H:PRN anxiety. He has fewer excoriations,
just on L arm now.
MICU, continue.
.
# Anemia- likely anemia of chronic disease, cont to trend
.
# FEN: tube feeds via peg, recently de-clogged, tube feeds at
goal.
.
# PPx: Heparin SQ, pneumoboots, sucralfate (as pt had
thrombocytopenia and was taken off PPI), bowel regimen
.
# CODE: FULL
.
# DISPO: To [**Hospital 3058**] rehab. placement has been a problem for
him due to insurance issues.
.
# Communication: Brother/HCP [**Name (NI) 11312**] [**Name (NI) 14714**]
Medications on Admission:
colace 100 mg po bid
bisacodyl suppositories prn for constipation
heparin 5,000 u sq q8hr
reglan 5 mg po tid
miconazole nitrate one application [**Hospital1 **]
amantadine 50 mg po bid
ascorbic acid 90 mcg [**Hospital1 **]
albuterol mdi q2hr prn
glycerine suppositories pr prn constipation
lactulose 30 ml qday prn constipation
senna 2 tabs [**Hospital1 **] pern constipaton
scopolamine patch 1.5 mg q2hr
simvastatin 10 mg po daily
zinc sulfate 220 mg po daily
tylenol 650 mg q6hr prn pain
asa 81 mg po daily
Discharge Medications:
Please see discharge summary for antibiotic course instructions.
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day) as needed for constipation.
5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
12. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
13. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: Five
(5) ml Inhalation [**Hospital1 **] (2 times a day).
14. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: Three (3) ML
Inhalation q4h ().
15. Hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for anxiety.
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
17. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
18. Meropenem 500 mg IV Q8H
19. Lorazepam 0.5 mg IV Q4H:PRN anxiety
hold for HR < 70 or SBP < 110
20. other Sig: see instructions for insulin n/a see below:
NPH 7 units bkfst NPH 8 units bedtime
Humolog ISS at bkfst, lunch, dinner and bedtime:
0-50 4 oz juice
51-149 0 units
150-199 2 units
200-249 4 units
250-299 6 units
300-349 8 units
350-399 10 units
>400 notify MD.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Primary
1. Urosepsis
Secondary
2. Coronary artery disease 3 vessel disease, status post cardiac
arrest CAD
3. Anoxic brain injury (from cardiac arrest)
4. ischemic cardiomyopathy (EF 25%)
5. Osteomyelitis - recently diagnosed ([**7-/2171**])
6. sacral decubitus ulcer- Methicillin Sensitive Staph aureus
positive
7. Sensorimotor demyelinating polyneuropathy
8. suspected colonization of airway with pseudomonas (pan
sensitive)
9. chronic renal insufficiency, known horseshoe kidney
10.chronic indwelling foley
11. history of atrial fibrillation (currently not
anticoagulated, not rate controlled, and not in atrial
fibrillation
12. Hyperlipidemia
13. history of abdominal aortic aneurysm
14. Schizophrenia
15. prior strokes seen on CT head
16. history of dementia
Discharge Condition:
Fair
Discharge Instructions:
You were admitted to the hospital for hypoxia, fevers, and
tachycardia. While in the hospital you were found to have a
urinary tract infection as well as organisms growing from your
sacral [**Year (4 digits) **] and from your sputum and were started on
antibiotics to treat these infections. While in the ICU your
blood pressure was low but came back up after receiving some IV
fluids. You were noted to have increased secretions from your
trach tube. Your sputum grew pseudomonas - we do not think this
is an infection, but rather colonization. We gave you levsin and
a scopolamine patch which helped decrease your secretions and
suctioned your trach regularly.
.
Please continue to take your antibiotic (Meropenem) to complete
a 6 week course.
.
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* [**Name2 (NI) **] have shaking chills or fevers greater than 102 degrees(F)
or lasting more than 24 hours.
* You aren't getting better within 48 hours, or you are getting
worse.
* New or worsening pain in your abdomen (belly) or your back.
* You are vomiting, especially if you are vomiting your
medications.
* Your symptoms come back after you complete treatment.
Followup Instructions:
You have an appointment with Dr. [**First Name8 (NamePattern2) 6923**] [**Name (STitle) 6924**] on Thursday
[**12-5**] at 2:10pm at the [**Hospital3 4262**] Group [**Street Address(1) 64339**]. If you need to reschedule, please call their office at
[**Telephone/Fax (1) 608**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2171-11-14**]
|
[
"585.9",
"V44.0",
"348.1",
"038.49",
"491.22",
"414.01",
"995.92",
"599.0",
"707.03",
"730.25",
"428.0",
"250.00",
"285.29",
"287.5",
"428.22",
"933.1",
"038.43",
"357.81",
"584.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
27124, 27203
|
16123, 16345
|
324, 330
|
28011, 28018
|
3555, 7539
|
29290, 29722
|
2432, 2436
|
24867, 27101
|
27224, 27990
|
24334, 24844
|
28042, 29267
|
2451, 2669
|
2685, 3536
|
264, 286
|
16373, 24308
|
359, 1332
|
7575, 16100
|
1354, 2104
|
2120, 2416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,897
| 137,443
|
45621
|
Discharge summary
|
report
|
Admission Date: [**2151-8-29**] Discharge Date: [**2151-9-4**]
Date of Birth: [**2104-11-16**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
"abnormal CT findings"
Major Surgical or Invasive Procedure:
Exploratory laparotomy; extensive lysis of adhesions (greater
than 2 hours); wedge resection of stomach; small-bowel
resection; reduction of internal hernia.
History of Present Illness:
PCP: [**Name10 (NameIs) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 6820**]
.
Patient is a 46 year old male with history of small bowel
obstruction and adhesions secondary to repair of gastroschisis
as an infant. He presented today to the emergency room with
crampy abdominal pain. Per his family, he had been having nausea
and vomiting for the last two weeks. Overnight and into the
morning of presentation, he was "doubled over" in abdominal
pain, and his roommate called 911. His work-up in the ED was
notable for an elevated lactate of 3.0 and leukocytosis of 11.1.
A CT scan was concerning for possible internal hernia.
Past Medical History:
gastroschisis s/p repair
prior large bowel obstruction
Social History:
The patient worked as a multimedia manager at [**Company 7709**] College.
He does not smoke. He drinks alcohol only socially and he
exercises on a regular basis.
Family History:
The patient is the youngest of four brothers and three sisters.
[**Name (NI) **] himself has no children. His parents died at the age of 85.
His father died from a stroke and his mother died from breast
and pancreatic cancer.
Physical Exam:
VS 100.2 98.8 78 122/70 20 99RA
Gen: NAD, alert
CV: RRR
Pulm: CTAB
Abd: soft, nontender, nondistended
Inc: clean/dry/intact, staples
Ext: no edema, wwp
Pertinent Results:
[**2151-8-29**] 09:00AM WBC-11.1* RBC-4.70 HGB-14.4 HCT-43.7 MCV-93
MCH-30.7 MCHC-33.0 RDW-13.5
[**2151-8-29**] 09:14AM LACTATE-3.0* K+-4.0
Brief Hospital Course:
OR course:
The patient was taken to the OR and underwent an exploratory
laparotomy; extensive lysis of adhesions (greater than 2 hours);
wedge resection of stomach; small-bowel resection; and reduction
of internal hernia.
.
[**Hospital Unit Name 153**] course:
Patient was initially admitted to the [**Hospital Unit Name 153**] for altered mental
status and inability to extubate. He still had an NGT, as well
as a foley catheter. His mental status improved, and he was
extubated later that day. Elevated bilirubin levels and
creatinine levels were noted at that time.
.
FLOOR course:
The patient was transferred to the floor once he was extubated
the same day of the operation. His foley catheter was removed
on [**8-31**], and the patient voided.
His NGT was removed, but the patient had a postop ileus. He
experienced flatus by [**9-2**], and his diet was advanced from NPO
to sips to clears on [**9-3**] and then to regular diet on [**9-4**].
.
His postoperative course was complicated by fever and elevated
bilirubin levels immediately postop. His preoperative abx of
kefzol and flagyl had been continued until [**8-30**]. The dosage of
kefzol was increased to 1g q8h. His LFTs were monitored, and
the Tbili rose to a high of 2.5 on [**8-31**]. His WBC rose to a high
of 11.6 on [**8-31**]. A RUQ U/S on [**9-1**] was unrevealing; there were
no GB stones or dilation of the ducts. Cultures were negative.
After [**8-31**], the bilirubin and WBC gradually trended back down to
normal. Simultaneously, the patient's hct trended down from
42.8 to 27.9 postoperatively. The patient was asymptomatic and
had no blood per rectum or hematemasis. Labs showed no evidence
of hemolysis. The team thought that it was possible that he had
bled internally. He was not transfused, and by [**9-4**], his Hct
was back up to 30.6.
.
At the time of discharge, the patient's pain was well-controlled
on PO pain medications, and he was ambulating, voiding to the
toilet, having flatus and bowel movements, and tolerating
regular diet. He had been afebrile for more than 24 hours
without medications.
Medications on Admission:
none
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
2 weeks.
Disp:*28 Capsule(s)* Refills:*1*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Small-bowel obstruction
(strangulating secondary to internal hernia).
Discharge Condition:
Stable
Tolerating a regular diet
Adequate pain control with oral medication
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow-up appointment with
Dr. [**Last Name (STitle) **].
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 9**] in [**12-18**]
weeks for removal of incisional staples.
2. Follow-up with your PCP as needed.
|
[
"780.62",
"997.39",
"511.9",
"560.81",
"518.0",
"285.1",
"593.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.42",
"45.62",
"54.59",
"53.9"
] |
icd9pcs
|
[
[
[]
]
] |
4459, 4465
|
2022, 4125
|
334, 494
|
4588, 4666
|
1854, 1999
|
6077, 6255
|
1433, 1662
|
4180, 4436
|
4486, 4567
|
4151, 4157
|
4690, 5727
|
5742, 6054
|
1677, 1835
|
272, 296
|
522, 1157
|
1179, 1236
|
1252, 1417
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,975
| 189,215
|
37096
|
Discharge summary
|
report
|
Admission Date: [**2146-11-25**] Discharge Date: [**2146-11-29**]
Date of Birth: [**2091-2-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
Post tracheostomy tracheal stenosis.
Major Surgical or Invasive Procedure:
[**2146-11-28**]
1. Rigid bronchoscopy using the Dumon black tracheoscope.
2. Flexible bronchoscopy.
[**2146-11-25**]
1. Percutaneous tracheostomy tube, 7-0 per Portex Per-Fit.
2. Bronchoscopy with aspiration.
History of Present Illness:
55 y/o, male with recurrent respiratory failure requiring
intubation and tracheostomy twice over the last year who was
decannulated about 2 months ago and since, has been experiencing
progressive hoarseness and dyspnea that is now affecting his
ADL's but not at rest. He's also experiencing a chronic
productive cough of white-yellow phlegm as well as intermittent
wheezing. He underwent a recent bronchoscopy in [**Hospital1 10478**]
which revealed a complex tracheal stenosis involving the cricoid
with the 60% circumferential narrowing of the lumen. He is now
s/p redo percutaneous tracheostomy
Past Medical History:
Recurrent respiratory failure
COPD (FEV1: 0.78 L. or 27%)
DM
PVD
? CVA
Chronic MRSA and VRE colonization
Social History:
Married, lives with his wife.
Former [**Name2 (NI) 1818**], quit~1 year ago after ~40 pack/year history
Former ETOH use, now sober
Family History:
Family History: Father died of CAD in his 40's
Physical Exam:
VS: T: 98.0 HR: 78 SR BP: 92/55 RR: 20 Sats: 100% 30% TM
General: walking in room no apparent distress
HEENT: normocephalic, muscus membranes moist
Neck: trach in place. site clean no ooz or erythema
Card: RRR
Resp: decreased breath sounds
GI: benign
Extr: warm no edema
Neuro: non-focal
Pertinent Results:
[**2146-11-28**] WBC-8.7 RBC-4.81 Hgb-13.4* Hct-40.3 Plt Ct-195
[**2146-11-26**] WBC-13.5* RBC-5.02 Hgb-13.5* Hct-41.2 Plt Ct-188
[**2146-11-27**] Glucose-183* UreaN-20 Creat-1.0 Na-135 K-4.7 Cl-92*
HCO3-35*
[**2146-11-26**] Glucose-111* UreaN-21* Creat-1.1 Na-137 K-4.3 Cl-102
HCO3-29
[**2146-11-27**] Calcium-9.4 Phos-4.3 Mg-2.2
[**2146-11-25**] MRSA negative
CXR:
[**2146-11-29**] PA AND LATERAL VIEWS OF THE CHEST
Cardiomediastinal contours are normal. Left perihilar opacity
and lingular
opacity consistent with multifocal pneumonia are unchanged.
There is no
pneumothorax or pleural effusion. Tracheostomy tube is in
standard position.
[**2146-11-25**] Tracheostomy tube terminates in the proximal
intrathoracic trachea, with no evidence of pneumothorax or
pneumomediastinum. Heart size is normal, and lungs are grossly
clear.
Brief Hospital Course:
Mr. [**Known lastname 83598**] was admitted on [**2146-11-25**] for Percutaneous
tracheostomy tube, 7-0 per Portex Per-Fit. Bronchoscopy with
aspiration. He tolerated the procedure transferred to the ICU
for airway and hemodynamic monitoring. He responded to fluid
challenges for SBP in the 80-90's. With aggressive pulmonary
toilet and nebs he titrated to TM Fi02 35% oxygen saturations in
the high 90's. POD 1 he transferred to the floor in stable
condition. On [**2146-11-28**] he was taken for Rigid and Flexible
bronchoscopy. Given the complexity of the stenosis as well as
the
patient's underlying co morbidities including his severe
obstructive respiratory disease, he is not amenable for any
further intervention or surgical approach at this time,
therefore, we would recommend keeping the tracheostomy tube
in place for the time being without any further intervention.
On [**2146-11-29**] he was seen by speech and swallow. At this time he
did not tolerate PMV as indicated by 02 de sats to 87-88%,
manometer pressures increased to +20 cm H20 and symptom ic. A
bedside swallow study was performed without signs or symptoms of
aspiration with all trialed consistencies. He was discharged to
home with VNA and on a regular solid thin liquid diet. He will
follow-up with Speech and Dr. [**First Name (STitle) 5586**] as an outpatient.
Medications on Admission:
Aggrenox 25/200 one tab PO BID (on hold x3 days)
Calcium
Lantus 45 units SQ daily
Metformin 1000 mg PO BID
Lisinopril 10 mg PO daily
Combivent 2 puffs QID
Prednisone 10 mg PO daily
Simvastatin 40 mg PO daily
Trazodone 100 mg PO QHS
Vitamin D weekly
Ativan PRN
Discharge Medications:
1. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-10**]
Puffs Inhalation Q6H (every 6 hours).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*2*
7. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Lantus 100 unit/mL Solution Sig: Forty Five (45) units
Subcutaneous once a day.
9. Calcium Carbonate 1,000 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO once a day.
10. Trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime.
11. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a
week.
12. Aggrenox 200-25 mg Cap, Multiphasic Release 12 hr Sig: One
(1) Cap, Multiphasic Release 12 hr PO twice a day.
13. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day as needed.
14. Humalog Insulin Sliding Scale
Continue previous insulin sliding scale
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] [**Hospital 107**] Home Health & Hospice
Discharge Diagnosis:
Complex tracheal and subglottic stenosis.
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
Call Dr. [**First Name (STitle) 5586**] office [**Telephone/Fax (1) 48380**] with questions or concerns
regarding trach.
-Trach cuff de-flated for speaking and eating.
-Complete 7 day course of Levofloxacin
Followup Instructions:
Provider: [**Name10 (NameIs) 12554**] CLINIC INTERVENTIONAL PULMONARY (SB)
Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2146-12-12**] 1:30pm in the Chest
Disease Center, [**Hospital Ward Name 121**] Building [**Hospital1 **] I
Follow-up with [**Doctor First Name 156**] WHITMILL, MS SLP Phone:[**Telephone/Fax (1) 3731**]
Date/Time:[**2146-12-12**] 3:30 on Span 106.
Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 83599**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
Completed by:[**2146-11-29**]
|
[
"443.9",
"786.2",
"250.00",
"496",
"519.02",
"V12.54",
"E878.3",
"V09.80",
"V02.54",
"V02.59",
"478.74"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.05",
"33.21",
"33.23"
] |
icd9pcs
|
[
[
[]
]
] |
5538, 5626
|
2686, 4039
|
313, 526
|
5712, 5712
|
1825, 2663
|
6089, 6691
|
1463, 1496
|
4350, 5515
|
5647, 5691
|
4065, 4327
|
5857, 6066
|
1511, 1806
|
236, 275
|
554, 1153
|
5726, 5833
|
1175, 1282
|
1298, 1431
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,090
| 175,043
|
50253
|
Discharge summary
|
report
|
Admission Date: [**2170-5-3**] Discharge Date: [**2170-5-6**]
Date of Birth: [**2098-10-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Left thoracotomy with left ventricular epicardial
lead placement times 2 on [**5-3**]
History of Present Illness:
Mr. [**Known lastname 38315**] is a 71 year old man with cardiomyopathy and
extensive cardiac history listed below. He has been seeing his
cardiologist and [**Known lastname 1834**] LV mapping during which it was felt
he might benefit from biventricular pacing. In addition, his
current device is "low on battery." He has a baseline dyspnea
with low level exersion but not at rest.
Past Medical History:
1. MI/CAD (CABG x2; LIMA-ramus, SVG-LADm 28mm CE [**Doctor Last Name 405**] band
in [**10-22**])
2. CHF (ECHO [**12-13**] EF<20%)
3. pacer VVI DCCV for WCT
4. RF ablation for VTach
5. gout
6. HTN
7. hypothyroidism
8. TIA
9. recent bronchitis
10.PAF
Social History:
Mr. [**Known lastname 38315**] lives at home with his wife. [**Name (NI) **] is retired.
Family History:
non-contributory
Physical Exam:
Pulse: 60 Resp: 12 O2 sat: 100% RA
B/P Right artm 135/81 left arm 147/89
General: awake, alert, oriented
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]; healed sternotomy scar;
Heart: RRR [x] Irregular [] Murmur 3/6 systolic ejection
murmur
Abdomen: Soft [x] non-distended [x] non-tender [x]
+ bowel sounds;
Extremities: Warm [x], well-perfused [x]
no Edema, no Varicosities
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right: no Left: no
Discharge
VS: 98.6 HR: 66-83 VP BP: 117-155/70-90 Sats: 100% RA
General: 71 year-old male in no apparent distress
HEENT: normocephalic
Card: RRR
Resp: clear breath sounds
GI: benign
Extr: warm no edema
Incision: Left axilla clean, dry intact
Neuro: awake,alert oriented.
Pertinent Results:
Date/Time: [**2170-5-3**] Test Type: TEE (Complete)
Left Ventricle - Septal Wall Thickness: *0.5 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *0.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *8.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 15% to 20% >= 55%
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. All four
pulmonary veins identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Severely
dilated LV cavity. Severely depressed LVEF. LV dysnchrony is
present.
RIGHT VENTRICLE: Moderately dilated RV cavity. Severe global RV
free wall hypokinesis.
AORTA: Normal ascending aorta diameter. Normal descending aorta
diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. No AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR).
Thickened MVR leaflets.. Moderate mitral annular calcification.
Moderate thickening of mitral valve chordae.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Moderate [2+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is moderately dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium or
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left ventricular cavity is severely dilated. Overall left
ventricular systolic function is severely depressed (LVEF=15-20
%). Left ventricular dysnchrony is present. The right
ventricular cavity is moderately dilated with severe global free
wall hypokinesis. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are mildly thickened . There is no aortic
valve stenosis. No aortic regurgitation is seen. A bioprosthetic
mitral valve prosthesis is present. The prosthetic mitral valve
leaflets are thickened. There is moderate thickening of the
mitral valve chordae. The tricuspid valve leaflets are mildly
thickened. Moderate [2+] tricuspid regurgitation is seen. There
is no pericardial effusion.
CXR:
[**2170-5-4**]:
FINDINGS: In comparison with the study of [**5-3**], there has been
removal of the endotracheal and nasogastric tubes. The Swan-Ganz
catheter also has been removed. Continued enlargement of the
cardiac silhouette without substantial vascular congestion. The
monitoring leads are otherwise intact. There has been
substantial clearing of the opacification in the region of the
aberrant nasogastric tube.
The left chest tube appears to have been removed. No evidence of
pneumothorax. Some subcutaneous gas is seen along the left
lateral chest
well.
Brief Hospital Course:
On [**5-3**] Mr. [**Known lastname 38315**] [**Last Name (Titles) 1834**] a lead placement. 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 extubated and his chest tubes were
removed. He progressed well and was transferred to the step
down floor. [**Company 1543**] ICD interrogated with normal device
funtion. A 7 day course of antibiotics was started [**2170-5-4**].
He will follow-up in the Device clinic in 1 week. His warfarin
was restarted [**2170-5-5**] and he will follow-up with his PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) 104795**] as an outpatient for further coumadin management.
Physical therapy saw him and deemed him safe for home. By
post-operative day 3 he was ready for discharge to home. All
follow-up appointments were advised.
Medications on Admission:
ALLOPURINOL 300 mg Tablet daily
DIGOXIN 125 mcg Tablet 3x/week - M, Wed, Fri
FUROSEMIDE 20 mg PRN (takes 1-2 times/week based on SOB)
LEVOTHYROXINE 100 mcg Q AM
LISINOPRIL 5 mg Tablet Q PM
TOPROL XL 50 mg Tablet alternating with 25 mg daily
SIMVASTATIN 40 mg daily
WARFARIN 2.5 mg Tablet daily - LD [**4-30**] - followed by [**Doctor Last Name 1270**]
ASPIRIN 81 mg Tablet daily
Discharge Medications:
1. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK
(MO,WE,FR).
4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
5. lisinopril 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
6. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO every other day alternate with
25 mg daily.
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
INR Goal 2.0-3.0.
9. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): take while taking narcotics.
11. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
12. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every [**2-21**]
hours as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
13. cephalexin 500 mg Tablet Sig: One (1) Tablet PO four times a
day for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
mitral regurgitation
Coronary Artery Disease s/p Anterior MI with LV aneurysm
Complete heart Block s/p Right sided PPM [**2137**]
VT ablation [**2153**]
ICD ([**Company **]) implant [**2164**] via left side with explant of right
PPM
Ischemic Cardiomyopathy and Congestive heart Failure (Systolic)
Atrial flutter s/p ablation [**2167**]
Atrial fibrillation on coumadin
Gout
Embolic CVA [**2137**] after boating accident
PSH
CABG/MVR (annuloplasty) [**2163**] complicated by Acute renal failure
TURP
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right/Left - healing well, no erythema or drainage. Edema
Discharge Instructions:
No showering for 1 week or until in Device clinic.
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 5 pounds, pulling or pushing with your left
arm for 6 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**
Complete the 7 day antibiotic course.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2170-5-8**]
11:00
Please call for an appointment in [**1-19**] weeks
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] call for a follow-up appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 1270**] [**0-0-**] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-3.0
First draw: Wednesday
Results to Dr. [**Last Name (STitle) 1270**] [**0-0-**]. Fax: [**Telephone/Fax (1) 8474**]
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2170-5-8**]
11:00
Please call for an appointment in [**1-19**] weeks
Surgeon: Dr. [**Last Name (STitle) 914**] [**Telephone/Fax (1) 170**]
Cardiologist: Dr. [**Last Name (STitle) **] call for a follow-up appointment
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 1270**] [**0-0-**] in [**2-20**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication Atrial fibrillation
Goal INR 2.0-3.0
First draw: Wednesday
Results to Dr. [**Last Name (STitle) 1270**] [**0-0-**]. Fax: [**Telephone/Fax (1) 8474**]
Completed by:[**2170-5-8**]
|
[
"V45.81",
"V15.82",
"412",
"V12.54",
"285.9",
"428.0",
"274.9",
"244.9",
"427.1",
"427.31",
"414.8",
"428.22",
"V45.02",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.74",
"99.62"
] |
icd9pcs
|
[
[
[]
]
] |
7829, 7904
|
5289, 6188
|
281, 369
|
8447, 8658
|
2177, 5266
|
9591, 11208
|
1178, 1196
|
6618, 7806
|
7925, 8426
|
6214, 6595
|
8682, 9568
|
1211, 2158
|
234, 243
|
397, 782
|
804, 1055
|
1071, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,314
| 153,946
|
12776
|
Discharge summary
|
report
|
Admission Date: [**2166-3-9**] Discharge Date: [**2166-3-19**]
Date of Birth: [**2088-10-19**] Sex: M
Service:
ADMISSION DIAGNOSIS: Severe gastrointestinal bleed.
HISTORY OF PRESENT ILLNESS: Patient is a 77-year-old male
who was transferred from [**Hospital 1562**] Hospital for ongoing
gastrointestinal bleeding which was refractory to any kind of
bleed despite bleeding scans, angiography, upper endoscopy,
colonoscopy. Patient has been transferred to the [**Hospital1 **] [**First Name (Titles) **] [**2166-3-9**]. Initially at the outside
hospital, he was admitted on [**3-5**] four days earlier
following a syncopal episode without abdominal pain, but
without hematochezia.
bleed, and upon presentation, he was transferred to the
Medical Intensive Care Unit, where he was continuing to have
a large volume of bright red blood and clots per his rectum,
and although his hematocrit was 30 at the outside hospital,
it was 26 upon his admission. With the ongoing bleeding, he
was aggressively resuscitated, and he had an arterial line as
well as a high volume central catheter placed immediately, in
addition packed red blood cells and fresh-frozen plasma was
pushed, and he was taken to the operating room after an
angiogram was without ability to localize the bleed.
On [**3-9**], he underwent exploratory laparotomy with
lysis of adhesions, a subtotal colectomy, an end ileostomy, a
J tube placement, and an intraoperative end ileostomy. The
findings in the case were that of an ischemic ulcerations
around his previous ileocolonic anastomosis and his distal
ileum with an internal hernia of the distal ileum.
He was then brought to the Surgical Intensive Care Unit
postoperatively, where he again needed to be volume
resuscitated. His hematocrit was stable after 30 units of
packed red cells, additional 5 of fresh-frozen plasma, 10 of
cryo, and 10 platelets.
His postoperative course was significant for ventilator
dependence, a troponin leak with slowly rising troponin,
which returned to [**Location 213**] after approximately 24 hours, a
pulmonary effusion, a depressed mental status. The patient
had a CT scan of his head which revealed a question of
infarct of unclear etiology. Subsequently had a MR scan of
his head which showed that the stroke was not of an acute
age, so was older, and all sedation was stopped and he woke
up and returned to his baseline mental status.
From a cardiovascular standpoint, he was resumed on Lopressor
once his blood pressure was stable and there was no further
episodes of gastrointestinal bleeding, and his heart rate
responded appropriately. No no longer had any problems with
low blood pressure. He was out of bed. He was tolerating
tube feeds and he was tolerating po, and his mental status
improved. His ileostomy was functional. His abdominal wound
had to be opened, and he grew out Enterobacter from his
abdominal wound swab. The site of the J tube which was
removed while he was in Intensive Care Unit grew out
Enterococcus. A sputum culture grew out Enterobacter and
Klebsiella, and the urine culture from [**3-11**] grew out
Enterococcus. He was started on Levaquin which covered
Enterococcus, Enterobacter, and Klebsiella.
He was making significant improvement, and on [**3-17**]
he was transferred from the Intensive Care Unit to the
Surgical floor. Within 24 hours of transfer, his
temperatures spiked to 102.4 and he became tachycardic along
with this and hypertensive. He did not have any further
gastrointestinal bleeding to precipitate this. At the time
it was thought that possibly he would have some type of
intraabdominal process causing his ascites for sepsis and his
blood pressure gradually declined. He had a subclavian
right-sided line placed at the bedside and was immediately
transferred to the Intensive Care Unit. There was a
temperature spike during the Intensive Care Unit transfer.
He had an arterial line placed as well. Full cultures were
drawn and his antibiotics was widened to Vancomycin and
Flagyl, so now he was on Vancomycin, levo, and Flagyl, and
this incidentally was on postoperative day nine on his
hospital course. A CT scan with contrast through his
nasogastric tube, and that showed a large intraabdominal
abscess in his pelvis. He also had evidence of lower pole of
his wound, the fascia was not intact. Therefore, we decided
to take him back to the operating room, where 1) we could
visualize the previous site of the jejunostomy tube, 2) to
clear off his intraabdominal abscess, and visualize if there
is any other etiology of where this is coming from, and 3)
reclose his abdominal wound.
The patient was then brought on [**3-19**], which is today
postoperative day #10, brought to the operating room,
approximately 6 o'clock pm, where he underwent exploratory
laparotomy and a washout of his abdomen, and clearing of his
pelvic abscess. There is evidence of ileus. There is no
perforation, and the wound looked infected, that was
debrided, and the fascia was reclosed. He also had lysis of
adhesions. Within 30 minutes of him being back to the
Surgical Intensive Care Unit postoperatively, the patient had
already been extubated, was conversant, and then suddenly
became hypotensive, blood pressure in the systolics in the
60s, and became completely unresponsive to verbal stimuli,
and an ACLS protocols were carried out, as he became
pulseless and without blood pressure, and for roughly 30
minutes, we were unable to regain a pulse or blood pressure.
He was unresponsive, although intubated, and he was
pronounced dead.
DISPOSITION: Death.
DIAGNOSES:
1. Status post severe gastrointestinal bleeding requiring
transfusions due to blood loss anemia
2. Status post ileocolectomy.
3. Status post end ileostomy.
4. Intra-abdominal sepsis.
5. Pneumonia.
6. Urinary tract infection.
7. Wound infection and abscess.
8. History of coronary artery disease with a coronary artery
bypass graft in [**2158**].
9. History of hypertension.
10. History of hyperlipidemia.
11. History of bilateral carotid stenosis.
12. History of a previous partial colectomy in [**2144**] for
polyps.
13. History of benign prostatic hypertrophy status post a
transurethral resection of the prostate.
14. History of three previous admissions for gastrointestinal
bleeding.
15. Status post cardiorespiratory arrest.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D.
Dictated By:[**Last Name (NamePattern1) 8344**]
MEDQUIST36
D: [**2166-3-19**] 21:49
T: [**2166-3-20**] 05:31
JOB#: [**Job Number 39398**]
|
[
"578.9",
"427.5",
"569.61",
"557.0",
"599.0",
"285.1",
"998.59",
"998.31",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.77",
"54.59",
"45.79",
"88.47",
"86.22",
"54.19",
"96.04",
"45.62",
"46.20",
"96.72",
"46.39",
"54.12"
] |
icd9pcs
|
[
[
[]
]
] |
152, 184
|
213, 6602
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,245
| 160,475
|
45610
|
Discharge summary
|
report
|
Admission Date: [**2200-10-27**] Discharge Date: [**2200-11-15**]
Date of Birth: [**2132-7-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Demerol / Ceftriaxone
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
nausea/diarrhea
Major Surgical or Invasive Procedure:
PICC line placement x 3
Arterial Line placement
History of Present Illness:
This is a 69 yo female with hx of chronic abdominal pain [**1-28**] to
radiation enteritis, chronic diarrhea recently admitted with
chronic diarrhea and abdominal and discharged on [**10-24**] to
[**Hospital 57609**] rehab presenting again for abdominal pain.
.
On last admission GI was consulted and that the diarrhea was
multifactorial with contribution from bile malabsorption,
bacterial overgrowth, and baseline radiation enteritis. She was
discharged on Rifaximin to complete the 10 day course, opium
tincture, lomotil and cholestyramine with close follow-up in the
[**Hospital **] clinic. Weight loss thought to be multifactorial, due to both
malabsorption and poor oral intake. Nutrition was consulted and
the patient was started on TPN cycled QHS. She was discharged on
this regimen.
.
At rehab, patient continue to have diarrhea, reduced PO intake,
and abdominal pain. Patient was unable to tolerate PO intake and
was brought in to the ED for further evaluation.
.
In ED VS were BP 198/104 HR 91 RR 16 98% on RA. Patient was
given labetolol 100mg, dilaudid 1mg, and ondasetron 2mg.
Past Medical History:
- multiple admissions for partial SBO, usually managed
conservatively, most recently [**2200-6-8**] - [**2200-6-15**]
- multiple small bowel obstructions
- Recent hip fracture [**1-28**] MSSA osteomyelitis on [**2200-3-31**],
on daptomycin for 6 weeks, recently discharged from
rehabilitation
in early [**Month (only) **]
-h/o MRSA bacteremia ([**4-4**]), ([**6-4**]), ([**11-4**]), complicated by
L2-L3 discitis/osteomyelitis, failed 4 month course of
vancomycin, resoved with surgical intervention with L2, L3
partial corpectomy/debridement on [**2199-11-19**] followed by 3 month
course of vancomycin
- C.diff colitis [**2200-4-7**], neg C.diff toxin [**2200-6-11**]
-C.parapsilosis line-associated BSI ([**8-/2199**])
-P.vulgaris pyelonephritis w/ bilat hydronephrosis dx [**12/2199**],
treated with meropenem-->ciproflox
-Ovarian cancer: Dx in [**2175**], stage IV metastatic to liver, s/p
TAH-BSO, adriamycin, and XRT
-Chemotherapy-associated cardiomyopathy, last ECHO in
[**11-4**] with EF of 50%
-Iron deficiency anemia
-Hyperlipidemia
-Chronic kidney disease
-Osteoporosis
-Hypothyroidism
-h/o RUE brachial thrombus, PICC associated, in [**2199-4-11**]
-Depression
-tonsillectomy, adenoidectomy
-appendectomy
Social History:
Patient lives with her husband, has 2 grown sons, and 3
grandchildren. She was a nurse until 6 months ago. She is a
remote smoker. No etoh, recreational drug use. Walks with a
walker at baseline secondary to hip pain.
Family History:
Breast cancer in maternal grandmother. Prostate cancer in
maternal grandfather.
Physical Exam:
Discharge Physical Exam:
VS: 96.9 153/83 (139-153/79-92) 66 (66-83) 100% RA
GA: NAD, comfortable
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No pain on
palpation of neck.
Cards: RRR S1/S2 heard. No murmurs appreciated today.
Pulm: CTAB no crackles or wheezes
Abd: soft, mildly tender, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, +[**12-28**] edema in Upper extremitites b/l. DPs, PTs
2+.
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Pertinent Results:
Admission Labs:
WBC-14.6* RBC-3.92*# Hgb-11.2*# Hct-34.4*# MCV-88 Plt Ct-581*#
PT-19.1* PTT-24.5 INR(PT)-1.7*
Glucose-117* UreaN-46* Creat-1.6* Na-135 K-5.2* Cl-102 HCO3-20*
Calcium-8.4 Phos-4.0 Mg-2.0
Discharge Labs:
[**2200-11-14**] 06:22AM BLOOD WBC-11.8* RBC-3.51* Hgb-10.1* Hct-30.5*
MCV-87 MCH-28.7 MCHC-33.0 RDW-15.6* Plt Ct-383
[**2200-11-14**] 06:22AM BLOOD PT-25.6* INR(PT)-2.5*
[**2200-11-13**] 06:01AM BLOOD Glucose-85 UreaN-17 Creat-1.4* Na-133
K-4.2 Cl-97 HCO3-25 AnGap-15
Other notable labs:
CK-MB-3 cTropnT-<0.01
CK-MB-3 cTropnT-<0.01
CK-MB-2 cTropnT-<0.01
Microbiology:
[**2200-10-28**] 2:23 pm URINE Source: Catheter.
**FINAL REPORT [**2200-11-2**]**
URINE CULTURE (Final [**2200-11-2**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
Daptomycin SENSITIVITY REQUESTED BY D. [**Doctor Last Name 18200**] [**2200-10-31**].
SENSITIVE TO Daptomycin @ 1.5MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
[**2200-10-31**] 12:15 am URINE Source: Catheter.
**FINAL REPORT [**2200-11-2**]**
URINE CULTURE (Final [**2200-11-2**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 97274**] [**2200-10-28**].
[**2200-11-4**] 9:10 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2200-11-12**]**
Blood Culture, Routine (Final [**2200-11-12**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance Oxacillin RESISTANT Staphylococci MUST be
reported as
also RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations
Rifampin
should not be used alone for therapy.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible resistance .
VANCOMYCIN PERFORMED BY SENSITITER.
[**Female First Name (un) **] (TORULOPSIS) GLABRATA.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus and [**Female First Name (un) 564**] species.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 1 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>8 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 4 R
VANCOMYCIN------------ 2 S
[**2200-11-5**] 2:20 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT [**2200-11-11**]**
Blood Culture, Routine (Final [**2200-11-11**]):
REPORTED BY PHONE TO [**Last Name (un) **] KHALIDA [**2200-11-7**] 11:25.
THIS IS A CORRECTED REPORT [**2200-11-8**].
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 12708**] [**Last Name (un) 12707**] #[**Numeric Identifier 97275**]; @1008,
[**2200-11-8**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. FINAL
SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BACILLUS SPECIES; NOT ANTHRACIS. ISOLATED FROM ONE SET
ONLY.
ENTEROCOCCUS FAECIUM. PREVIOUSLY REPORTED AS
([**2200-11-7**]).
STREPTOCOCCUS SPECIES. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
gentamicin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details.
HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to
1000mcg/ml of
streptomycin. Screen predicts possible synergy with
selected
penicillins or vancomycin. Consult ID for details..
Daptomycin NON SUSCEPTIBLE (MIC=6.0 MCG/ML).
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| ENTEROCOCCUS FAECIUM
| |
AMPICILLIN------------ =>32 R
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
LINEZOLID------------- 2 S
OXACILLIN-------------<=0.25 S
PENICILLIN G---------- 32 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 2 S =>32 R
Aerobic Bottle Gram Stain (Final [**2200-11-6**]):
GRAM POSITIVE COCCI IN CLUSTERS.
GRAM POSITIVE ROD(S).
[**2200-11-11**] 4:40 am URINE Source: Catheter.
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
[**2200-11-12**] 6:10 pm URINE Source: Catheter.
**FINAL REPORT [**2200-11-13**]**
URINE CULTURE (Final [**2200-11-13**]):
GRAM NEGATIVE ROD(S). ~1000/ML.
Studies:
CHEST (PORTABLE AP) Study Date of [**2200-10-27**] 3:18 PM
Right-sided PICC line terminates at the junction of the proximal
SVC and brachiocephalic vein on the right. Mild congestion.
CT HEAD W/ & W/O CONTRAST Study Date of [**2200-10-30**] 2:51 PM
Chronic-appearing left putamen infarction. No evidence of
hemorrhage or new infarction.
PORTABLE ABDOMEN Study Date of [**2200-10-30**] 11:02 PM
No evidence of small-bowel obstruction.
CHEST (PORTABLE AP) Study Date of [**2200-10-30**] 11:12 PM
1. Right PICC line has been advanced to the cavoatrial junction.
2. Mild pulmonary edema without focal consolidation.
TTE (Complete) Done [**2200-10-31**] at 12:02:00 PM
Normal biventricular cavity sizes with preserved global and
regional biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Compared with the
prior study (images reviewed) of [**2200-8-8**], left ventricular
systolic function has improved and the severity of mitral
regurgitation is now slightly reduced.
TTE (Complete) Done [**2200-11-6**] at 11:55:28 AM FINAL
The left atrium is dilated. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-28**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The supporting structures of the
tricuspid valve are thickened/fibrotic. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2200-10-31**],
mitral regurgitation is now slightly more prominent. Estimated
pulmonary artery systolic pressure is similar.
No definite vegetation seen (cannot definitively exclude).
Brief Hospital Course:
68F with left MCA CVA [**8-5**] on coumadin, remote history of
ovarian CA s/p TAH-BSO & chemoXRT complicated by radiation
enteritis and recurrent SBO, and h/o c diff colitis admitted
with worsening of chronic diarrhea.
.
# Bacteremia/Fungemia: Both likely from PICC line. TPN
predisposed patient to fungemia. Patient treated with daptomycin
for Staph coagulase negative and enterococcus and micafungin for
candidemia. PICC line was discontinued and patient was given
line holiday. Surveillance cultures were drawn. Daptomycin was
changed to linezolid given dapto resistance. Last Micafungin
dose will be on [**2200-11-18**] and last Linezolid dose will be on
[**2200-11-22**]. Of note, patient was stopped on sertraline given
concern for serotonin syndrome with linezolid. Patient will need
f/u CBC in 1 and 2 weeks after discharge to monitor for
myelosuppression.
.
# Urinary Tract Infection: On admission patient had unexplained
leukocytosis. UA was positive. Urine culture grew VRE on [**10-31**]
and was started on daptomycin. In setting culture turning
positive, patient became transiently hypotensive with SBPs in
70s. Patient was transferred to MICU, where she received several
liters of fluid and 2 units of pRBCs. Hypotension resolved and
patient sent back to medical floor. Enterococcus in blood was
daptomycin resistance and so dapto was discontinued and
linezolid was started. Patient also grew ESBL E.coli on 2
occasions while having a foley catheter in place. Concurrent
UA's were negative. Clean catch UA/culture were unremarkable so
treatment was deferred. ****PATIENT SHOULD NOT HAVE FOLEY IN AS
SHE IS AT RISK FOR URINARY INFECTION AND ASCENDING INFECTION****
.
# Diarrhea: Chronic and multifactorial in nature. GI was
consulted and recommended continuing course of opium tincture
and lomotil. Stool studies were sent and were negative. Patient
will likely need outpatient colonoscopy in future. Patient to be
followed by Dr. [**First Name (STitle) 10643**] as outpatient.
.
# Abdominal Pain/Nausea: Also appeared multifactorial in nature
with radiation enteritis being the major cause. Patient's pain
controlled with home dose dilaudid and started on PO compazine
for nausea with good effect. She had an episode of emesis which
subsequently led to hypotension. *** IT IS CRITICALLY IMPORTANT
FOR HER RECEIVE FLUIDS (PO OR IV) IF SHE VOMITS BECAUSE HER BP
[**Month (only) **] DROP. *** Patient may benefit from therapy with ativan for
anticipatory nausea however can be explored as an outpatient.
.
# Malnutrition: PICC line was replaced. Nutrition consult was
placed for calorie count. Calorie count should continue at rehab
and consideration for restarting TPN can occur while rehab if
necessary.
.
# Access: Patient has very difficult access. Multiples PICC's
have been placed in past and patient has sustained multiple line
infections. When patient is stable, Port should considered.***
.
# Chronic Renal Failure: Patient had AIN on last admission. Over
course of this hospital stay, creatinine continued to improve.
Cr should be trended as outpatient with adjusted of medications
for changing renal function.
.
# Anemia: Patient anemic at baseline. Patient transfused 3 units
of pRBCs while in MICU for falling hematocrit however that was
in setting of receiving large amounts of fluid. Patient was
hemodyamically stable at discharge with stable hematocrit of
28-30.
.
# s/p L MCA CVA: INR should be maintained between 2.0 and 3.0
Patient also residual right foot drop for which she needs a foot
brace while in bed to preserve ROM.
.
# Sacral decubitus: Stage 2 decubitus on coccyx. Wound care
consult placed.
Medications on Admission:
1. buspirone 10 mg PO BID
2. butorphanol tartrate 10 mg/mL Spray [**1-30**] Q4h prn pain.
3. carvedilol 25mg PO BID
4. diphenoxylate-atropine 2.5-0.025 mg/5 mL 9 drops PO BID PRN
diarrhea
5. furosemide 20 mg PO PRN edema
6. hydromorphone 4-8 mg PO Q8 hours.
7. levothyroxine 87.5 mcg Injection DAILY (Daily): IV.
8. omeprazole 40 mg PO once a day.
9. sertraline 150 mg PO DAILY
10. warfarin 5 mg PO once a day.
11. zolpidem 5 mg PO HS (at bedtime) prn insomnia
12. Bactrim DS 800-160 mg PO for 1 day
13. ondansetron prn nausea
14. folic acid 3 mg PO DAILY
15. cyanocobalamin (vitamin B-12) 1,000 mcg daily
16. cholestyramine-sucrose 4 gram [**Hospital1 **]
17. senna 8.6 mg [**Hospital1 **] prn constipation
18. hydrocortisone 1 % TP prn rash
19. opium tincture 10 mg/mL 10 drops PO Q4-6h prn diarrhea
Discharge Medications:
1. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. Levothyroxine Sodium 87.5 mcg IV DAILY
4. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1)
Tablet PO every other day.
6. opium tincture 10 mg/mL Tincture Sig: Ten (10) Drop PO Q4H
(every 4 hours) as needed for diarrhea.
7. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
8. hydromorphone 4 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day.
11. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: 1-2 Tablets
PO Q8H (every 8 hours) as needed for diarrhea.
12. Micafungin 100 mg IV Q24H
13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
14. Linezolid 600 mg IV Q12H
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Chronic diarrhea
Urinary Tract Infection
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 97260**],
You were admitted with nausea and abdominal pain. We were able
to control your nausea and abdominal pain with oral medications.
The GI doctors saw [**Name5 (PTitle) **] but no interventions are necessary at
this time. You also had a urinary tract infection, which was
treated with antibiotics. You developed a serious blood
infection that requires antibiotics through the IV. You will
require these antibiotics for at least 7 more days. You required
a short stay in the ICU because your blood pressure was low.
However after some fluid and 2 units of blood, your blood
pressure returned to its normal levels. You required another
unit of blood because your blood pressure was low. It is very
important that you remain hydrated all times so that your blood
pressure does not drop too low.
Please see the following list of medications for changes.
Followup Instructions:
Please be sure to make an appointment with Dr. [**First Name (STitle) **] for follow
up visit
Completed by:[**2200-11-17**]
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771
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50023
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Discharge summary
|
report
|
Admission Date: [**2166-3-3**] Discharge Date: [**2166-3-14**]
Date of Birth: [**2095-12-27**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS; This is a 70 year old man with a
complaint of increased shortness of breath over the past
several days prior to admission, positive cough with clear
sputum, no hemoptysis, increased right lower extremity edema
with erythema, pain. The patient was found to have a deep
vein thrombosis in his right lower extremity in the Emergency
Department by ultrasound. CTA in the Emergency Department
revealed a pulmonary embolus in the subsegmental branches of
the pulmonary arterial vasculature. This was considered a
small pulmonary embolus, however, the patient was
substantially dyspneic and had a large oxygen requirement.
The patient was reported to be on five liters of home oxygen
for his diagnosis of chronic obstructive pulmonary disease,
however, it was not clear whether the patient had been on his
oxygen prior to admission. Therefore, the patient was
transferred directly from the Emergency Department to the
[**Hospital Ward Name 12573**] Intensive Care Unit for close monitoring of his
respiratory status. The patient is a poor historian but does
complain of chronic constant shortness of breath and
occasional chest pain with occasional nausea, vomiting,
diarrhea, occasional dysuria and no fevers, chills or sweats.
The patient does report paroxysmal nocturnal dyspnea and
orthopnea and always has to sleep on at least three pillows.
The patient states that he has not taken his medications for
several days because he "ran out". The patient's home
situation is unclear. [**Name2 (NI) **] does not have his own home and
lives with various different relatives. Much of the history
was ascertained by the patient's wife who is known
schizophrenic and suffers from paranoid delusions.
PAST MEDICAL HISTORY:
1. Coronary artery disease, the patient's ejection fraction
is 20%.
2. Chronic obstructive pulmonary disease. The patient has
no pulmonary function tests done at this hospital, however,
he has been discharged in the past on five liters of home
oxygen.
3. Peripheral vascular disease, status post right femoral
popliteal in [**2159**], with chronic venous stasis.
4. Insulin dependent diabetes mellitus. The patient has
large insulin requirement.
5. Gastroesophageal reflux disease.
6. History of transient ischemic attack.
7. History of Methicillin resistant Staphylococcus aureus.
8. History of nonsustained supraventricular tachycardia.
ALLERGIES: Penicillin with rash.
MEDICATIONS ON ADMISSION:
1. Lasix 60 mg p.o. twice a day.
2. Lisinopril 3 mg p.o. once daily.
3. Lopressor 25 mg p.o. twice a day.
4. Glipizide 5 mg p.o. four times a day.
5. Combivent, Salmeterol, Flovent.
6. Oxygen five liters.
Note: Compliance with these medications is unknown,
SOCIAL HISTORY: The patient lives with various relatives at
different times. He does not have his own apartment. He
travels along with his wife who as mentioned before is
schizophrenic and suffers from paranoid delusions, however,
she is reporting that she is the [**Hospital 228**] health care proxy
and the patient confirms this. However, they have no
documentation of this. The patient denies alcohol or
intravenous drug abuse. Review of previous admission reveals
numerous hospitalizations during which patient refused various
recommended therapies and then left AMA.
PHYSICAL EXAMINATION: On admission, temperature is 97.6,
blood pressure 133/55, heart rate 83, respiratory rate 20
with oxygen saturation 93% on six liters. Generally, the
patient was in mild distress. Extraocular movements were
intact. The patient had no scleral icterus. Cardiovascular -
Distant heart sounds, regular rate and rhythm, no murmurs.
Pulmonary - He had diffuse breath sounds with occasional
wheezes and sporadic crackles at the bases, symmetric
expansion. The abdomen was soft, protuberant but nontender
with active bowel sounds. The patient was guaiac negative
in the Emergency Department. Extremities - The patient had
right lower extremity edema, greater than left, with
erythema, calor, and Charcot foot on the right. The patient
had significant 4+ pitting edema on the right lower extremity
where deep vein thrombosis had been noted on ultrasound. The
patient also had chronic venous stasis changes on the left
lower extremity with 2+ pitting edema.
LABORATORY DATA: On admission, white blood cell count was
13.2, hematocrit 35.8, platelet count 404,000, 83%
neutrophils, 0% bands, 10% lymphocytes. INR 1.4. Sodium
135, potassium 5.5, chloride 101, bicarbonate 24, blood urea
nitrogen 46, creatinine 1.3, glucose 354. Arterial blood
gases was 7.31, 54, 55.
Chest x-ray showed increased cardiac silhouette, no
opacities, no effusions, no active infiltrate. Ultrasound of
right lower extremity showed deep vein thrombosis in the
common femoral vein. CTA showed likely left upper lobe
subsegmental embolus and question right middle lobe tiny
embolus, no large pulmonary emboli, right basilar
atelectasis.
Electrocardiogram was sinus rhythm at 84 beats per minute,
normal axis, intraventricular conduction delay, no acute ST
changes, poor R wave progression consistent with old
electrocardiogram.
HOSPITAL COURSE:
1. Pulmonary embolus, deep vein thrombosis - The patient was
heparinized throughout his hospitalization. The patient and
his wife refused Coumadin treatment out of concern for
bleeding. The patient refused to be transitioned on the
Coumadin because it required taking Coumadin and Heparin at
the same time. The patient also refused discontinuing
Heparin and starting Coumadin because of concerns of
bleeding. It was also thought by the medical team that due
to the patient's poor social condition and poor compliance in
the past that going home with Coumadin may be quite unsafe
despite the very high risk of mortality without
anticoagulation for deep vein thrombosis and pulmonary
embolus in this setting. Ultimately, however, despite
medical team's advice and persistent attempts to convince the
patient otherwise, the patient refused to take Coumadin at
home. However, the patient was heparinized throughout his
hospitalization here. The patient also refused IVC filter
placement which was offered as an alternative to Coumadin
therapy even though it was considered suboptimal to
anticoagulation. The patient and his wife felt that he would
be at high risk for complications of this procedure despite
assurances to the contrary. The patient persistently refused
medical interventions by the medical team and was evaluated
by the psychiatry team and deemed to be competent to make his
medical decisions and competent to refuse various medical
interventions that were offered to him. Therefore, the
patient was discharged on Aspirin as the only form of
anticoagulation. Again, it should be reiterated the patient
refused Coumadin therapy at home despite his full
understanding that the one year mortality for untreated
pulmonary embolism is in excess of 50%.
2. Diabetic foot - The patient was seen by podiatry and the
vascular surgery team who felt that the patient was suffering
from acute cellulitis and diabetic foot. The patient had
plain films that revealed no signs of chronic osteomyelitis.
The patient was treated with intravenous Vancomycin,
Levofloxacin and Flagyl for the entirety of his
hospitalization which was a two week course. The patient
responded well clinically with significant improvement in
edema, swelling, erythema and pain in the right lower
extremity. The patient did have persistent right greater
than left lower extremity edema that was thought to be a
result of the known lower extremity deep vein thrombosis.
The patient had one blood culture out of four bottles
positive for Methicillin resistant Staphylococcus aureus at
admission and therefore had been treated for two weeks with
intravenous Vancomycin for Methicillin resistant
Staphylococcus aureus bacteremia that was thought to be
related to his diabetic foot. It is also possible that this
positive blood culture was a contaminant, however, he was
treated with a two week course for bacteremia nevertheless.
The patient was afebrile with a significant improvement in
his white blood cell count and left shift at the time of
discharge. The patient had no signs of active infection
throughout his admission and had a normal sedimentation rate
at the time of discharge.
3. Diabetes mellitus - The patient was treated with large
doses of NPH and regular insulin throughout his admission.
The patient and his wife continuously expressed concern that
the patient was receiving too much insulin despite
reassurance and despite fingerstick ranging from 90 to 150
throughout his hospitalization. The patient had good
glycemic control on the insulin regimen of NPH 30 units
q.a.m. and 20 units q.p.m. and regular insulin 15 units
q.breakfast and 10 units with dinner every day achieved good
glycemic control for this patient. The patient had no
evidence of diabetic ketoacidosis during his hospitalization.
4. Chronic obstructive pulmonary disease - The patient has a
known large oxygen requirement of over five liters per
minute. This is probably the result of his long smoking
history. The patient intermittently required more than five
liters of oxygen at various times and this was thought to be
related to his recent history of pulmonary embolus, however,
the patient was essentially stable through the latter part of
his hospitalization on five liters of oxygen. He did
desaturate to the 70s when his oxygen fell off his face or
was removed. Therefore, the patient was discharged with his
five liters of home oxygen which was the same regimen he was
admitted with. There was some question of whether or not the
patient had been getting proper oxygen therapy at home. The
patient's refused VNA services to insure that he was getting
his oxygen, but was set up with home oxygen prior to
discharge. The patient also was continued on Combivent
inhalers q6hours, Salmeterol q12hours and p.r.n. Albuterol.
5. Acute renal failure - The patient after being called out
to the floor after a 24 hour Intensive Care Unit stay was
bradycardic as a result of his Lopressor dosing which is
unclear if he had actually been taking at home. The patient
had pressure in the 80s to 90s and an appropriately low heart
rate of 50 to 60. The patient was closely monitored, given
aggressive fluid resuscitation and nevertheless suffered
oliguric acute renal failure. The patient's creatinine
peaked at 3.3, however, as the beta blocker wore off, the
patient's heart rate improved, blood pressure improved, renal
perfusion improved, and urine output improved with recovery
of his creatinine clearance and decrease in his creatinine to
1.2 which was actually better than reported baseline of 1.3
to 1.4. The patient had good urine output and was tolerating
his Lasix regimen at the time of discharge. The patient was
diuresed aggressively after his renal failure improved due to
the fluid overload state that occurred while he was oliguric.
The patient did suffer from some degree of renal
encephalopathy when his blood urea nitrogen approached 100,
however, the mental status improved with improvement of his
renal function. The patient was not discharged on a beta
blocker due to this history of bradycardia. He was sinus
bradycardic throughout the episode of bradycardia. No
evidence of conduction disease.
6. Congestive heart failure - The patient was discharged on
his doses of Lasix 40 mg once daily rather than the larger
dose due to his recent renal failure and his stable status on
40 mg a day. It would be recommended that the patient be
transitioned back onto his ace inhibitor in the future,
however, his pressure remained in the low 100s and we avoided
sending him home on ace inhibitor due to his renal failure.
DISPOSITION: The patient refused rehabilitation placement
because he felt that he did not need rehabilitation and that
he was at his baseline. The patient was discharged to home
which the patient and his wife reported was with relatives.
The patient refused VNA services because they were concerned
that living with relatives they would not be able to have a
nurse visit due to the preferences of the relatives. The
patient repeatedly refused most of what this medical team
tried to do, however, they also wanted to leave the hospital.
It was thought to be more safe to discharge the patient with
oxygen and with his various medications that he would agree
to take rather than letting him leave against medical advice
with none of the few things that the patient and his family
would agree to, however, the patient was discharged with
suboptimal medical regimen for his various medical problems.
Again, the patient had been seen by psychiatry. The
patient's case had been discussed at length with both the
legal counsel of the hospital and risk management division of
the hospital and it was felt that the patient was competent
to make his medical decisions, that he was competent to
refuse various medical interventions and that as long as he
was discharged with oxygen, he was not in immediate danger,
that is within 24 hours of life threatening illness by
leaving. The patient again was discharged with a suboptimal
medical regimen due to his refusal for various interventions
and medications.
DISCHARGE DIAGNOSES:
1. Deep vein thrombosis.
2. Pulmonary embolism.
3. Chronic obstructive pulmonary disease exacerbation.
4. Congestive heart failure exacerbation.
5. Acute renal failure.
6. Chronic renal insufficiency.
7. Methicillin resistant Staphylococcus aureus bacteremia.
8. Methicillin resistant Staphylococcus aureus sepsis.
9. Beta blocker induced bradycardia with hypotension.
10. Type 2 diabetes mellitus.
11. Diabetic foot ulcer with Methicillin resistant
Staphylococcus aureus.
MEDICATIONS ON DISCHARGE:
1. Lasix 40 mg p.o. once daily which could be titrated up in
the near future.
2. Albuterol Ipratropium inhaler one to two puffs q6hours.
3. NPH insulin 30 units q.a.m. and 20 units q.p.m.
4. Regular insulin 15 units q.breakfast and 10 units
q.dinner.
5. Protonix 40 mg p.o. once daily.
6. Albuterol p.r.n.
7. Multivitamin one tablet once daily.
8. Flovent two puffs twice a day.
9. Salmeterol two puffs twice a day.
10. Aspirin 325 mg p.o. once daily.
11. Coumadin was refused.
The patient was sent home with a new wheelchair to facilitate
his activities.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 7942**]
MEDQUIST36
D: [**2166-3-14**] 12:44
T: [**2166-3-14**] 14:09
JOB#: [**Job Number 104444**]
PLEASE SEE DISCHARGE LETTER AS PER DR. [**Last Name (STitle) **] FOR ADDITIONAL
DETAILS.
PATIENT WAS OFFERED NUMEROUS INTERVENTIONS FOR MANAGEMENT OF LIFE
THREATENING ILLNESSES, MANY OF WHICH WERE REFUSED. PATIENT WAS
FELT TO BE COMPETENT TO MAKE THESE DECISION AT THE TIME THAT
THESE OPTIONS AND RECOMMENDATIONS WERE DISCUSSED
|
[
"518.0",
"682.6",
"584.9",
"491.21",
"038.11",
"415.19",
"428.0",
"707.14",
"453.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22"
] |
icd9pcs
|
[
[
[]
]
] |
13437, 13920
|
13946, 15119
|
2590, 2855
|
5284, 13416
|
3456, 5267
|
1879, 2564
|
2872, 3433
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,163
| 176,993
|
22737
|
Discharge summary
|
report
|
Admission Date: [**2129-5-23**] Discharge Date: [**2129-5-27**]
Service: MEDICINE
Allergies:
Sulfur / Loperamide
Attending:[**First Name3 (LF) 6578**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is a [**Age over 90 **]yo woman with h/o CAD s/p NSTEMI in [**12/2128**] that
was medically managed in setting of melenic stools, HTN,
dyslipidemia, COPD on home oxygen, and CRI admitted with c/o
shortness of breath and left-sided chest pain.
Patient was in her usual state of health yesterday, but she
complained of some subjective dyspnea today at her nursing home.
She was noted to be pale and she c/o pain in her left breast.
She was not given NTG given her low BP but did receive 81mg ASA
x 2 en route to the ED.
In the ED, initial VS were 96.0 70 100/70 22 99% 4L. Soon after
triage, she was noted to be hypotensive to 80/40. She was given
an unclear amount of fluid and her pressures improved to
100s/30s. She was noted to be guaiac positive on exam. EKGs were
concerning for STE in V2 and V3 and the cardiology fellow was
contact[**Name (NI) **]. [**Name2 (NI) 6**] Echo done at the bedside showed newly depressed EF
of 50% as compared to 70% in [**1-29**] as well as possible
anteroseptal hypokinesis. After discussing the matter with the
patient and her daughter, it was decided to pursue medical
management, and she was admitted to the CCU. In addition, UA was
positive and there was a concern for infiltrate on CXR. She
received ceftriaxone and azithromycin as well as albuterol and
atrovent nebs. She was also given 1mg ativan IV.
Past Medical History:
CAD s/p NSTEMI
Hyperlipidemia
HTN
Left MCA in [**1-/2129**] treated with tPA
Dementia
CRI with baseline Cr 1.4
COPD on 2L oxygen at baseline
Anemia with baseline Hct 30
Severe sigmoid diverticulosis (per [**8-30**] colonoscopy)
Hemorrhoids
s/p Appendectomy
s/p bilateral carotid endarterectomy
Hypothyroid
Right breast cancer s/p R mastectomy many ago
Social History:
Alcohol and smoking history not available at this time; per
chart review, she was a previous smoker x 40 pack years. She
lives at [**Hospital1 599**] Senior Living at [**Location (un) 55**]. Her baseline
mental status (per daughter) is essentially no short term
memory; recognizes her children but gets their names wrong. Not
oriented to date.
Family History:
Family history not available at present.
Physical Exam:
VS: T 97.7, BP 101/32->122/67, HR 50->78, RR 17, O2 94-99% on 2L
Gen: Elderly woman in NAD, resp or otherwise. Oriented to
hospital and name, but reports year as [**2052**]. Somewhat nervous.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: Supple with flat neck veins.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. +systolic murmur at base. No S4, no S3.
Chest: s/p mastectomy on the right. Resp were unlabored, no
accessory muscle use. No crackles, wheeze, rhonchi.
Abd: Soft, NTND, No HSM or tenderness. No abdominial bruits.
Ext: Trace LE edema b/l at ankles. 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:
EKG demonstrated NSR with normal axis and prolonged QT (480)
with 1-2mm STE in V1-V4 and TWI in I, AVL, and V6; as compared
with prior dated [**2129-2-2**], the QTc has increased from 450 and
the STE in V2 and V3 and no longer upsloping. Of note, EKG done
upon arrival to CCU (at 21:38) demonstrates upsloping ST
elevations in V2 and V3 that are similar in appearance to her
baseline.
2D-ECHOCARDIOGRAM performed on [**2129-5-23**] in ED demonstrated
(PRELIM):
Suboptimal study with focused views. There is symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is low normal (LVEF 50%) with hypokinesis of the basal
anteroseptal and anterior wall. There are three aortic valve
leaflets. Mild (1+) mitral regurgitation is seen. There is a
small pericardial effusion.
IMPRESSION: Mild hypokinesis of basal anteroseptum and anterior
wall consistent with CAD. Overall EF mildly depressed, 50%. Mild
MR. Compared to prior echo dated [**2129-2-3**], the EF is decreased
and the wall motion is new.
CXR [**2129-5-23**]: RLL pneumonia (prelim)
LABORATORY DATA on admission:
Na 130
Cr 1.8
Hct 24
[**2129-5-27**] 06:15AM BLOOD WBC-9.3 RBC-3.95* Hgb-11.8* Hct-36.3
MCV-92 MCH-29.9 MCHC-32.6 RDW-15.3 Plt Ct-321
[**2129-5-23**] 06:35PM BLOOD Neuts-77.6* Lymphs-12.6* Monos-7.1
Eos-2.6 Baso-0.1
[**2129-5-27**] 06:15AM BLOOD Glucose-123* UreaN-21* Creat-1.3* Na-131*
K-4.3 Cl-94* HCO3-27 AnGap-14
[**2129-5-27**] 06:15AM BLOOD Calcium-8.9 Phos-2.9 Mg-2.0
[**2129-5-27**] 06:15AM BLOOD Vanco-15.4
[**2129-5-24**] 05:00AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2129-5-24**] 12:05AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2129-5-23**] 06:35PM BLOOD cTropnT-0.04*
Brief Hospital Course:
Mrs. [**Known lastname **] is a [**Age over 90 **] year old female with a PMH significant for
recent NSTEMI admitted after c/o CP and found to have pneumonia.
1. Pneumonia - Found to have a RLL consolidation consistent with
pneumonia. She was treated for healthcare associated pneumonia
with ceftriaxone, doxycycline, and vancomycin. She was treated
with doxycylcine instead of a azithromycin due to her prolonged
QT on admission. She will need to be treated with her antibiotic
regimen for a total of 10 days (currently day 4), and can stop
her antiobitic therapy on [**2129-6-2**]. For the patient's
vancomycin and ceftriaxone, a PICC line was placed.
2.Acute on chronic renal failure - The patient has a baseline
creatinine of 1.4. On admission, her creatinine was 1.8, which
trended down to 1.3 on day of discharge. Likely etiology was
prerenal azotemia with renal function that improved with IV
fluids. Unlikely to be UTI as urine culture was negative. The
patient's lasix was held due on admission, but was restarted on
discharge when her renal function returned to baseline.
Vancomycin was renally dosed at 1 gram Q48H with a random
vancomycin level of 15.4.
3.CAD - Recent NSTEMI that was medically managed due to chronic
guiaic positive stool. The patient's presenting symptoms are
unlikely to represent AMI as she has an unchanged ECG with CEx3
negative. Continue beta blocker, statin, and ASA therapy.
4.COPD - Currently has good O2 sats on 2L nc, which is at her
baseline. Continue advair, budesonide, and atrovent.
5.Prolonged QTc on admission. She is not taking any QT
prolonging drugs, and QT corrected with repeat ECG. She will be
treated with doxycycline instead of macrolide.
6. CHF with diastolic dysfunction. Patient's lasix was held
secondary to acute on chronic renal failure. She was continued
on her beta blocker, and lasix was restarted on admission after
renal function returned to baseline.
7. Anemia - Baseline HCT of 30, with HCT on admission of 24.4.
She received 2 units of PRBC, and on the day of discharge her
HCT was 36.3.
8. Dementia - Patient was disoriented throughout the course of
her stay. Per her records, she is at her baseline.
9. Hypothyroid - Continued on home levothyroxine.
Medications on Admission:
Colace 200mg daily
Budesonide 9mg daily
Furosemide 80mg daily
Levothyroxine 88mcg daily
Omeprazole 20mg daily
Simvastatin 20mg QHS
ASA 325mg daily
Celexa 20mg daily
Tylenol PRN
Bisacodyl PRN
Fleet Enema PRN
Milk of Magnesia PRN
Trazodone 12.5mg QHS PRN
Advair 250/50 [**Hospital1 **]
Atrovent q6h prn
MVI with minerals daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain or elevated temp.
2. Bisacodyl 10 mg Suppository Sig: One (1) 10 mg Rectal once a
day as needed for constipation.
3. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) enema Rectal
once a day as needed for constipation.
4. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) ml
PO once a day as needed for constipation.
5. Trazodone 50 mg Tablet Sig: QTR Tablet PO at bedtime as
needed for insomnia.
6. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO once a
day.
9. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Three (3)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
10. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day.
11. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day: Do no crush.
13. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
17. Ceftriaxone-Dextrose (Iso-osm) 1 gram/50 mL Piggyback Sig:
One (1) gram Intravenous Q24H (every 24 hours).
18. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q48H (every 48 hours).
19. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
20. Outpatient Lab Work
Vancomycin trough level on [**2129-5-29**] prior to administration of
vancomycin.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
Primary - Healthcare associated pneumonia
Secondary
1. CAD s/p NSTEMI
2. Hyperlipidemia
3. Hypertension
4. CVA - Left MCA in [**1-/2129**] treated with tPA
5. Dementia
6. CRI with baseline Cr 1.4
7. COPD on 2L oxygen at baseline
8. Anemia with baseline Hct 30
9. Severe sigmoid diverticulosis (per [**8-30**] colonoscopy)
10. Hemorrhoids
11. Hypothyroid
Discharge Condition:
The patient was discharged in good condition.
Discharge Instructions:
You were admitted for a pneumonia, which is an infection of your
lungs. You are being treated with antibiotics for your
infection. You will need to continue your antibiotics for a
total of 10 days. You can stop your antibiotics on [**2129-6-2**]. The instructions for your antibiotic regimen are:
Ceftriaxone 1 gm IV Q24H
Vancomycin 1 gm IV Q48H
Doxycycline 100 mg PO Q24H
For your intravenous medications, you a PICC line was placed in
your arm. This will need to be kept in place until you finish
your vancomycin and ceftriaxone. After [**2129-6-2**], your PICC
line can be removed.
You will need a blood draw on [**2129-5-29**] PRIOR to your vancomycin
dose administration in order to get a vancomycin level.
Weigh yourself every morning, call your physician if your weight
> 3 lbs.
It is very important that you take all of your medications as
prescribed.
It is very important that you make all of your doctor's
appointments.
If you develop any fevers, chills, sweats, chest pain, or
shortness of breath, go to your local emergency department
immediately.
Followup Instructions:
Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks after discharge
if possible.
Completed by:[**2129-5-27**]
|
[
"V12.54",
"272.4",
"414.00",
"584.9",
"403.90",
"728.88",
"496",
"486",
"276.1",
"285.21",
"294.8",
"428.0",
"V46.2",
"458.9",
"244.9",
"428.32",
"599.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9562, 9634
|
5063, 7306
|
247, 253
|
10033, 10081
|
3363, 4447
|
11201, 11331
|
2405, 2447
|
7681, 9539
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9655, 10012
|
7332, 7658
|
10105, 11178
|
2462, 3344
|
188, 209
|
281, 1652
|
4461, 5040
|
1674, 2027
|
2043, 2389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,693
| 180,938
|
6237
|
Discharge summary
|
report
|
Admission Date: [**2130-5-30**] Discharge Date: [**2130-6-2**]
Date of Birth: [**2073-4-22**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Darvon
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
MS changes
Major Surgical or Invasive Procedure:
None
History of Present Illness:
57F h/o CVA, depression c/b suicide attempts in past who was
brought to [**Hospital6 8283**] by husband [**2130-5-30**] for
decreased mental status. On presentation to the OSH, patient
found to have T 97.8, BP 63/47, RR 20, P 90, Pox 97% RA.
.
Per patient, takes oxycontin 40mg PO TID for chronic pain
syndrome thought [**3-8**] polycystic kidneys and on day PTA, patient
took multiple (cannot quantitate, keeps changing her mind) extra
pills. She denies intentional OD; says she took this because she
was having a lot of pain. She denies F/C; denies nasal
congestion, rhinorrhea, sore throat, ear pain, sinus pain, neck
pain/stiffness, rash, HA, photophobia. Denies cough/sputum,
CP/SOB. Denies abd pain, n/v, constipation. Says she had some
diarrhea 2d PTA, but could not elaborate. Had no specific
complaints.
.
Her labs at OSH were significant for BUN 39/Cr 3.0, K 7.7, HCO3
19, AST 70, ALT 85, Alk Phos 149, CK 1175 (TPN 0.14, nl by OSH
assay); WBC 28.3. Urine tox screen (+) morphine/benzos. U/A with
trace ketones, 1(+) protein.
.
Given findings on urine tox screen and h/o narcotics use,
patient was given narcan 0.4 mg IV x 1, narcan 1 mg IV x 1.
Given her hypotension and concern for ? infection, patient was
given ceftriaxone 1g IV x 1 and 2L NS. Her hyperkalemia was
treated with CaCl 10% 5 ml IV x 1.
.
In the ED at [**Hospital1 18**], patient found to be hypotensive with SBP
60s, bradycardic with T to 101 rectally. Initial WBC 17.9, Cr
2.6, K 5.5. ABG 7.08/62/69; started on NPPV and given almost 3L
NS and started on dopamine with significant improvement in her
BP.
.
Was given naloxone 2mg IV x 2, dolasetron 12.5 mg IV x 1,
dopamine IV gtt, levofloxacin 500 mg IV x 1, Metronidazole 500
mg IV x 1, Vancomycin 1 g IV x 1.
Past Medical History:
1. Depression with multiple suicide/OD attempts in the past
2. Bipolar Disorder
3. Chronic pain syndrome ? [**3-8**] polycystic kidney disease
4. HTN
5. Polycystic Kidney Disease
6. h/o sepsis [**2129-12-13**]
7. h/o CVA [**11-7**] with minimal residual defecits
Social History:
No tobacco, ETOH, IVDU.
Family History:
no family available, unknown for now
Physical Exam:
T 101.0 (R) HR 54 BP 60/P--> RR 20 O2 97%
General middle aged F appearing older than her stated age;
answering questions, although slow in her response, and
repeating answers
HEENT EOMI, PERRL, dry MM, no LAD, OP without lesions
Neck supple; no meningismus
Heart distant
Lungs diminished BS on R side; no accessory muscle use, no
paradoxical breathing
Abd soft, obese, NT, ND, BS(+)
Ext cool, no edema
Neuro oriented to person/place; MAE x 4
Skin no rash
Pertinent Results:
EKG: 60 bpm, sinus, nl axis, nl intervals, no atrial
enlargement/ventricular hypertrophy. Poor RWP. No acute ST-T
wave changes.
.
CXR: No infiltrate.
[**2130-5-30**] 05:50PM WBC-17.9* RBC-3.04*# HGB-9.1*# HCT-29.9*
MCV-98 MCH-29.9 MCHC-30.4* RDW-13.8
[**2130-5-30**] 05:50PM NEUTS-88.8* BANDS-0 LYMPHS-7.8* MONOS-3.3
EOS-0.1 BASOS-0
[**2130-5-30**] 05:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2130-5-30**] 05:50PM CRP-5.82*
[**2130-5-30**] 05:50PM CORTISOL-46.5*
[**2130-5-30**] 05:50PM CALCIUM-8.2* PHOSPHATE-7.5*# MAGNESIUM-2.0
[**2130-5-30**] 05:50PM CK-MB-20*
[**2130-5-30**] 05:50PM cTropnT-0.10*
[**2130-5-30**] 05:50PM LIPASE-37
[**2130-5-30**] 05:50PM ALT(SGPT)-79* AST(SGOT)-64* AMYLASE-53 TOT
BILI-0.8
[**2130-5-30**] 07:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-1 PH-5.0 LEUK-NEG
[**2130-5-30**] 07:00PM URINE RBC-[**7-14**]* WBC-[**4-8**] BACTERIA-OCC
YEAST-NONE EPI-[**7-14**] RENAL EPI-0-2
[**2130-5-30**] 09:34PM ASA-NEG ACETMNPHN-NEG
Brief Hospital Course:
1)Narcotic overdose: Pt admitted to ICU on Narcan drip. Mental
status improved over 1 day. All psych meds and narcotics held.
On [**6-1**], pt had severe nausea with dry heaves, and low-dose
methadone was started for presumed narcotic withdrawal. Pt
responded well to this, and she did not report any pain. She
will need to gradually be tapered off the methadone. She denied
that this was a suicide attempt. Psychiatry saw pt and
recommended holding all psych meds. They felt she was still a
danger to herself and would benefit from in-pt psych admit.
Patient was amenable to this.
2. Acidosis-Patient's ABG on admission 7.08/62/69, evidence of
an acute respiratory acidosis likely [**3-8**] narcotic
overdose/oversedation. She also had a primary metabolic
acidosis, likely from her renal failure. This completely
resolved with improved mental status and with improved renal
function.
3. Renal failure- On admission creatinine 2.6 from baseline 0.5,
likely [**3-8**] hypovolemia. Resolved with IVF, and on discharge,
creatinine 0.4.
4. Hyperkalemia-K 7.7 at OSH, no EKG changes; was treated en
route to [**Hospital1 18**] with insulin/D50, calcium etc. Likely all related
to renal failure, and was normal for several days at time of
discharge.
.
5. Leukocytosis-WBC persistently high WITHOUT bandemia, with no
focal source of infection. Pt was given ceftriaxone at outside
hospital and vancomycin/levofloxacin/flagyl here in the ED.
Multiple cultures showed no evidence of infection and
antibiotics were discontinued. Pt remained afebrile, with no
indication of ongoing infection. WBC 10 at discharge.
.
6. Hypotension- Was hypotensive on admission and transiently
required dopamine. Likely from hypovolemia and overdose.
Responded to fluids. BP 120/75 at time of discharge.
7. Decreased MS-likely related to narcotic overdose. Resolved.
8. CV-Elevated CK with nl MB index; mildly elevated TPN with no
EKG changes. Pt ruled out MI.
8. Anemia-Unknown if this is chronic or new. In house, was
stable in high 20's. Iron and vitamin studies revealed b12
deficiency and pt started on B12.
9. Depression/Bipolar-Apparently has h/o past OD in the past.
Followed by psych in house. [**Doctor Last Name **] psych meds held for now on their
advice. Will d/c pt to In pt Psych facility.
.
10. Transaminitis-? [**3-8**] hypotension and mild shock. Resolved
during hospitalization.
11. FEN-Tolerated low salt diet at discharge
.
12. FULL CODE
.
13. Comm-Husband ([**Telephone/Fax (1) 24283**]
Medications on Admission:
Meds (home), doses unclear
1. [**Name2 (NI) 24284**] 250 mg PO QD
2. Fioricet
3. Dilaudid
4. Topamax
5. Seroquel
6. Protonix 40 mg PO QD
7. Augmentin
8. Remeron 30 mg PO QD
9. Reglan 10 mg PO QD
10. Bupropion
11. Oxycontin 40 mg PO TID (per patient)
12. Gabapentin
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever, pain.
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000
(5000) units Injection TID (3 times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mg
Injection QD () for 7 days.
7. Methadone HCl 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] 4
Discharge Diagnosis:
Narcotic overdose
Depression
narcotic withdrawal
Hypertension
polycystic kidney disease
hypotension
Discharge Condition:
Good. Vitals stable, afebrile, normotensive, normal
oxygenation.
Discharge Instructions:
You are being discharged to a psychiatric facility to help you
with your depression and address any reasons for your overdose.
Followup Instructions:
Follow up with your PCP after discharge from psych facility.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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"281.9",
"276.5",
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icd9cm
|
[
[
[]
]
] |
[
"94.65"
] |
icd9pcs
|
[
[
[]
]
] |
7497, 7542
|
4024, 6531
|
286, 293
|
7686, 7753
|
2936, 4000
|
7928, 8113
|
2407, 2445
|
6847, 7474
|
7563, 7665
|
6557, 6824
|
7777, 7905
|
2460, 2917
|
236, 248
|
321, 2063
|
2085, 2350
|
2366, 2391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,214
| 185,919
|
38761
|
Discharge summary
|
report
|
Admission Date: [**2153-1-28**] Discharge Date: [**2153-2-13**]
Date of Birth: [**2074-7-30**] Sex: F
Service: SURGERY
Allergies:
Adhesive Tape / Amoxicillin / Mupirocin / Penicillins
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
pelvic fracture, pelvic hematoma
Major Surgical or Invasive Procedure:
1. IR coil (x4)-embolization within the distal right
pudendal/obturator artery.
2. Mechanical intubation and ventilation x2
3. placement of chest tubes bilaterally
4. Placement of right IJ central venous line
5. Placement of radial arterial line
History of Present Illness:
Ms. [**Known lastname **] is a 78 year old woman with a history of CAD s/p
distant MI, DVT/PE on coumadin, h/o pituitary tumor s/p
resection now with pan-hypopituitarism on chronic steroids who
was transferred to [**Hospital1 18**] for right pelvic ramus fracture. She
suffered what was reported to be a mechanical fall (question of
presyncope prior to fall), hitting coffee table with her right
hip. She was initially seen at [**Hospital3 **] and was found to have
a right pelvic ramus fracture w/ active extravasation in to the
R anterior abdomen extraperitoneal). She was given 1unit FFP
and 1unit pRBCs prior to transfer.
In the ED at [**Hospital1 18**], she was HD stable and received 1un FFP and
vit K for INR 2.0. She was admitted to T/SICU on [**1-28**]. She was
sent to IR for embolization where they coiled a right obdurator
or pudendal artery on [**1-29**] (4 coils). Repeat
imaging of her abdomen showed stability in hematoma in abdomen.
Past Medical History:
CAD w/ MI [**2130**], PE/DVT, pituitary tumor s/p removal (had caused
[**Location (un) 3484**]), L1 compression fx, OA, gout
Social History:
According to medical record, she is widowed. She lives with her
son. Was fully functioning with ADL's prior to fall. Denies
tob/ETOH/drugs.
Family History:
Non-contributory.
Physical Exam:
At discharge:
VS: 96.9 74 102/56 20 96%2L
Constitutional: Well appearing, no acute distress
Neck: No masses
CV: RRR, no murmurs
Resp: rhonchi bilat
Abd: Soft, nondistended, non-tender, +BS
Ext: Warm, distal pulses palpable bilaterally, LUE PICC without
erythema/drainage
Skin: Face, neck and chest is normal
Spine, Pelvis and Extremities: Stable
Pertinent Results:
141 104 29 AGap=23
-------------236
4.6 23 1.6
.
CK: 87 MB: Notdone Trop-T: 0.02
cTropnT: Ctropnt > 0.10 Ng/Ml Suggests Acute Mi
Ca: 8.1 Mg: 1.7 P: 8.1
.
ALT: 28 AP: 58 Tbili: 0.8 Alb: 3.7
AST: 47 LDH: Dbili: TProt:
[**Doctor First Name **]: Lip: 25
Na:140
K:8.3
Cl:103
TCO2:20
Glu:221 freeCa:0.57
Lactate:3.6
pH:7.19
Hgb:12.2
CalcHCT:37
.
COHb: 3 MetHb: 0 O2Sat: 73
.
11.9
9.5----102
35.4
N:91.9 L:4.9 M:2.9 E:0.3 Bas:0.1
.
PT: 21.1 PTT: 24.9 INR: 2.0
.
UA SpecGr 1.027 pH 5.0 Urobil Neg Bili Neg Leuk Sm Bld Lg
Nitr Neg Prot 75 Glu Neg Ket Neg RBC >50 WBC [**11-17**] Bact
Few Yeast
None Epi 0
.
Micro
[**2153-2-7**] UCx pending
[**2153-2-7**] sputum cx GS: [**10-22**] PMNs, no microorganisms
[**2153-2-7**] BCx pending
[**2153-2-7**] BCx pending
[**2153-2-6**] cath tip cx prelim - no significant growth
[**2153-2-6**] cath tip cx pending
[**2153-2-6**] pleural cx prelim - no growth
[**2153-2-6**] pleural cx prelim - no growth
[**2153-2-3**] cdiff neg
[**2153-2-1**] sputum MRSA
[**2153-2-1**] BCx NGTD
[**2153-2-1**] BCx NGTD
[**2153-2-1**] UCx NGTD
[**2153-2-1**] cdiff neg
[**2153-1-30**] cdiff neg
[**2153-1-29**] UCx klebsiella resistant to nitrofurantoin
[**2153-1-29**] BCx NGTD
[**2153-1-29**] BCx NGTD
[**2153-1-29**] UCx NGTD
.
Rads
[**2153-2-11**] CXR equivocal tiny L PTX; unchanged patchy opacity in
LLL
[**2153-1-30**] KUB no evid of pneumoperitoneum
[**2153-1-30**] CT abd/pelvis resolution of pneumoperitoneum; pelvic
hematoma unchanged
[**2153-1-30**] CT abd/pelvis New small-to-moderate R and small L pl
eff with bibasilar atel
[**2153-1-29**] angio right pudendal/obturator artery coiled
successfully
[**2153-1-29**] LENIs no DVT
[**2153-1-28**] EKG NSR @ 96; LBBB, L axis deviation
[**2153-1-28**] KUB non-specific gas pattern; no free air
[**2153-1-28**] CT torso multiple pelvic fx involving b/l sup rami & R
inf ramus
[**2153-1-28**] CT torso lg pelvic hematoma assoc'd w/ extravas'n
[**2153-1-28**] CT torso Multiple foci of intraperitoneal free air;
[**2153-1-28**] CT torso fatty 4.5 x 2.7 cm presacral mass likely
myelolipoma
[**2153-1-28**] CT torso Nonspecific ground-glass opacification in the
bilateral upper lobes
.
Brief Hospital Course:
The patient was admitted to the trauma surgery service on
[**2153-1-28**] for her right pubic fractures with active extravasation
and pelvic hematoma. She had a coil-embolization within the
distal right pudendal/obturator artery by IR. She was admitted
to the ICU for close monitoring. She had a very complicated
course including development of respiratory failure leading to
intubation x2, MRSA-ventilator associated pneumonia, acute renal
failure, hypoadrenalism, acute CHF, as well as likely non-ST
elevation MI.
.
[**1-28**] Admitted to the TSICU. Went to IR for embolization. Placed
NGT for abd decompression
[**1-29**]: LENIS negative, serial abd exams unchanged. changed
prednisone to hydrocortisone
[**1-30**]: spiked to 102, then 103. APAP no effective. abd exam
inconclusive. repeat CT with no free air. repeat cxr with
possible new infiltrate. also hypotensive. 2 x 500cc boluses.
started vanc and zosyn for presumed PNA vs infected pelvic
hematoma. intermittent tachycardia to the 130s.
[**1-31**]: Fevers continued although not quite as high as the day
before. Overnight, had worsening respiratory status, thought
perhaps due to pulm edema and tried nitro/lasix/bipap but pt's
distress continued so was intubated. Difficult to sedate. Pt
appeared more comfortable after her vent was changed from CMV to
CPAP/PSV. Pt dropped BPs at 5:30am and RIJ and an art line were
placed.
[**2-1**]: Neo weaned, cards consulted, CT Torso no obvious abd
pathology except for stable hematoma, bedside TTE - dilated LV,
no RV strain, hypokinetic septum
[**2-2**]: TTE: Severe left ventricular contractile dysfunction. LVEF=
20 %). per cards, no intervention at this point. CXR with
pleural effusions. diuresed with lasix gtt @ goal of -100cc/hr.
still on albumin 0.25% q6. TFs started. [**2-1**] Ucx neg.
[**2-3**]: transfused 1un pRBCs. D/c'd vanc, continued zosyn. K 2.7-
repleted. Increasing electrolyte abnormalities, including
contraction alkalosis, likely related to overdiuresis.
[**2-4**]: lasix gtt d/c, b/l pigtail placed in each pleural space
[**2-5**]: d/c zosyn, started vanc. holding sedation, started haldol
PRN. will attempt to run her even. reduced hydrocortisone to
[**12-30**], 25mg q8h, cont levo. will need to cont taper. got a PICC
line. getting 100cc D5 q6h for hypernatremia.
[**2-6**]: extubatd, failed, tachypneaic, wet sounding, CXR showed
worsening pulm edema, reintubated.
[**2-7**]: Lasix gtt, febrile and was pancx.
[**2-8**]: held another family meeting. it was decided she will be
DNR/DNI definitively. per family request, pt extubated, with
understanding she will be CMO if resp distress. pt tolerated
extubation very well. VSS, sats in high 90s on face mask. cont
medical regimen as planned. currently on lasix gtt @ 10,
responding well. Na this AM 152. free water deficit about
1800cc. ? hypervolemic hypernatremia. reduced lasix gtt to 5.
started free water flushes through NGT. BPs hypertensive. h/o
HTN vs. pain. on coreg and metoprolol and hydralazine prn. now
communicating that she has alot of back pain. @ home on: ultram,
neurontin, celebrex, oxycodone, dilaudid, xanax. also, febrile
to 102. APAP and ibuprofen.
[**2-9**]: passed speech and swallow eval, recs for ground solids and
thin liquids. pigtails d/c'd. A-line pulled.
[**2-10**]: transfered to floor.
[**2-11**]: PT saw pt and cleared for rehab. Started ensure
supplementation.
[**2-12**]: Rising WBC (11->18 over 3 days), sent C. Dificile.
.
Neuro: While intubated, the patient received pain control with
IV pain medication and drips. However, when cleared for oral
intake and transfered to the floor, the patient was transitioned
to oral pain medications, including ultram, percocet, and
dilaudid.
CV: Although the pt had some hemodynamic instability in the
TSICU, likely due to sepsis [**1-30**] pneumonia, she was eventually
weaned off of pressors and IV fluid boluses for resuscitation.
She had rising cardiac enzymes and an echo showing Severe left
ventricular contractile dysfunction, LVEF= 20 on [**2153-2-2**], and
cardiology consultation for possible cardiogenic shock. They
though sepsis was more likely the cause of her hypotension. She
did likely have an NSTEMI, but the patient could not receive
plavix or systemic anticoagulation due to pelvic fracture and
risk of rebleeding according. Our CV goal was managing causes of
increased cardiac demand. At discharge, CV meds included
hydralazine, Aspirin 325, Atorvastatin, Carvedilol, Isosorbide
Mononitrate (Extended Release), and Metoprolol.
Pulmonary: The patient developed respiratory failure during her
hospitalization, resulting in mechanical intubation and
ventilation x 2. She was eventually extubated and did well with
intense pulmonary toilet and Neb treatments.
GI/GU: The patient was aggressively resuscitated with IV fluids,
PRBCs, FFP and albumin. Although there was initially concern
for multiple foci of intraperitoneal free air seen on a CT scan,
this resolved on subsequent imaging, and was possibly mild
diverticulitis; the patient was managed conservatively without
an ex-lap and with IV abxs. Although given tube feeds during her
acute illness, when transfered to the floor she was cleared by
speech and swallow for a diet of Ground (dysphagia), Thin
liquids with Supplement: Boost Glucose Control breakfast, lunch,
dinner. She was also started on a bowel regimen to encourage
bowel movement. Intake and output were closely monitored. The
pt's creatinine was stable at 1.7-2 at discharge.
ID: Although she was treated with various IV antibiotics (vanc,
zosyn, cipro, flagyl) during her hospitalization, the only
culture that grew was sputum positive for MRSA. She needs to
complete a 14 day course of Vancomycin, ending [**2153-2-19**].
Endo: Endocrine was consulted, given the patient's complicated
endocrine past medical history in the setting of hypotension.
They recommended stress dose steroids as she was acutely ill. As
well as IV levothyroxine replacement. By discharge, she was
taking Prednisone 5mg daily, and will be discharged on 4mg daily
(her home dose).
Prophylaxis: The patient did not receive Subcut heparin due to
concern for repeat bleeding. She was encouraged to get up and
ambulate as early as possible with PT.
At the time of discharge on HD17 and POD15, the patient was
doing well, afebrile with stable vital signs, tolerating an
aspiration diet, ambulating with assistance, voiding without
assistance, and pain was well controlled.
Medications on Admission:
Colchicine 0.6', Fosamax 70 qweek, zantac 150", Fludrocortisone
0.1', Celebrex 200', Folic acid 1', Neurontin 1200", Kcl 20",
Ultram 50''', Xanax 0.5" PRN, Antivert 75', Coumadin 5 (pending
INR), Levoxyl 125', Prednisone 1'''', lasix 20", nitofurantoin
50', percocet PRN
Discharge Medications:
1. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO once a day.
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
9. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Acetaminophen Extra Strength 500 mg Tablet Sig: Two (2)
Tablet PO Q4H (every 4 hours) as needed for fever, discomfort.
13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
14. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
16. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
17. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours): Hold for SBP < 100.
18. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
19. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
21. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
22. Vancomycin 1000 mg IV Q48H
Day 1 [**2-5**], 14 day course, last day [**2-19**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] rehabilitation hospital
Discharge Diagnosis:
Primary: 1. right pubic ramus fracture with pelvic hematoma s/p
coil embolization; 2. diverticulitis; 3. ventilator associated
pneumonia; 4. NSTEMI, 5. hypoadrenalism, 6. Acute CHF, 7. mild
renal insufficiency
Secondary: 1. CAD w/ MI [**2130**], 2. PE/DVT, 3. pituitary tumor s/p
removal
Discharge Condition:
Mental Status:Confused - sometimes (baseline dementia)
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair
VS 96.9 74 102 118/56 20 96%2L
Discharge Instructions:
You were transferred to [**Hospital1 18**] after a fall while anti-coagulated
on Coumadin.
* You were found to have right-sided pubic rami fractures as
well as bleeding blood vessels in your pelvis causing a pelvic
hematoma. You underwent an interventional radiology procedure
with coil embolization of the bleeding vessels.
* You were admitted to the TSICU to the trauma team. Your had a
very complicated course in which you was developed respiratory
failure leading to intubation twice as well as MRSA-ventilator
associated pneumonia. You will need to take IV antibiotics
through your PICC line for a total of 14 days (last day [**2-19**]).
* While hospitalized, you also developed acute renal failure and
likely had an non-ST elevation MI.
Return to the ER or talk to your doctor at rehab if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
Followup Instructions:
Please follow up in Trauma clinic in 2-weeks. Call for
[**Telephone/Fax (1) 6429**] an appointment.
Please follow up in Cardiology clinic or with your private
cardiologist in 2-weeks. Call [**Telephone/Fax (1) 62**] for an appointment.
Location [**Hospital Ward Name 23**] 7.
You should also follow up with [**Hospital 6091**] clinic or with your
outpatient endocrinologist within 2-3 weeks. Call Phone
[**Telephone/Fax (1) 1803**] for an appointment. Location [**Hospital Ward Name 23**] 7.
Finally, please contact your regular doctor to let them know
about this hospitalization and follow up with them within 2
weeks.
|
[
"518.81",
"274.9",
"410.71",
"250.00",
"715.90",
"584.9",
"253.7",
"808.2",
"401.9",
"038.9",
"562.11",
"427.31",
"255.41",
"V58.65",
"428.0",
"782.3",
"414.00",
"276.0",
"511.9",
"902.89",
"995.91",
"997.31",
"041.12",
"E885.9",
"E878.6",
"V12.51",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.79",
"96.71",
"96.04",
"38.93",
"88.42",
"96.6",
"88.47",
"38.91",
"34.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
13229, 13295
|
4535, 10990
|
346, 594
|
13628, 13628
|
2309, 4512
|
15445, 16072
|
1902, 1921
|
11311, 13206
|
13316, 13607
|
11016, 11288
|
13859, 15422
|
1936, 1936
|
1950, 2290
|
274, 308
|
622, 1578
|
13642, 13835
|
1600, 1726
|
1742, 1886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,725
| 146,747
|
46543
|
Discharge summary
|
report
|
Admission Date: [**2116-8-12**] Discharge Date: [**2116-8-29**]
Date of Birth: [**2077-5-6**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
morbid obesity
Major Surgical or Invasive Procedure:
Status Post Laparoscopic converted to open gastric band with
spleenectomy [**8-12**]
History of Present Illness:
Mrs. [**Known lastname 98841**] is a 39-year-old woman with
longstanding morbid obesity refractory to attempts at weight
loss by nonoperative means.
Past Medical History:
polycystic ovary syndrome,
GERD,
dyslipidemia,
urinary stress incontinence,
osteoarthritis of
ankles, heels,
h/o ITP and gallbladder disease.
leg swelling,
anal fissure,
hemorrhoids,
abnormal hair
growth and menstrual irregularities (not on birth control).
Social History:
Factors contributing to her excess weight include
large portions, late night eating, grazing, too many
fats/carbohydrates, stress, compulsive eating and lack of
exercise. She denied history of eating disorders or depression.
Family History:
mother has Hx of several [**Name (NI) 4330**]
Physical Exam:
Her blood pressure was 130/82, pulse 107 and O2 saturation 100%
on room air. On physical examination [**Known firstname **] was casually dressed,
mildly anxious but in no distress. Her skin was warm, dry with
no
rashes, very mild acne, small cyst left breast recently on
antibiotic management (Keflex). Sclerae were anicteric,
conjunctiva clear, pupils were equal round and reactive to
light,
fundi difficult to assess fully, mucous membranes were moist,
tongue pink and the oropharynx was without exudates or
hyperemia.
Trachea was in the midline and the neck was supple without
adenopathy, thyromegaly or carotid bruits. Chest was symmetric
and the lungs were clear to auscultation bilaterally with good
air movement. Cardiac exam was slight tachycardic rate, regular
rhythm without murmurs, rubs or gallops. The abdomen was obese
but soft and non-tender, non-distended with normal bowel sounds
and no masses or hernias, there was a well-healed midline
vertical incision scar as well as healed trocar scars. There was
no spinal tenderness or flank pain. Lower extremities were
without edema, venous stasis or clubbing. There was no evidence
of joint swelling or inflammation of the joints. There were no
focal neurological deficits and her gait was normal.
Pertinent Results:
[**2116-8-12**] 11:25PM HCT-38.3
[**2116-8-12**] 03:08PM POTASSIUM-4.0
[**2116-8-12**] 03:08PM AMYLASE-112*
[**2116-8-12**] 03:08PM LIPASE-183*
[**2116-8-12**] 03:08PM MAGNESIUM-1.7
[**2116-8-12**] 03:08PM HCT-41.3
[**2116-8-27**] 05:27AM BLOOD WBC-15.5* RBC-2.87* Hgb-8.1* Hct-25.6*
MCV-89 MCH-28.2 MCHC-31.6 RDW-14.7 Plt Ct-1239*
[**2116-8-26**] 05:19AM BLOOD WBC-17.7* RBC-2.79* Hgb-8.1* Hct-25.2*
MCV-91 MCH-29.2 MCHC-32.3 RDW-14.3 Plt Ct-1062*
[**2116-8-25**] 05:59AM BLOOD WBC-22.1* RBC-2.90* Hgb-8.3* Hct-25.7*
MCV-89 MCH-28.7 MCHC-32.5 RDW-14.7 Plt Ct-1015*
[**2116-8-24**] 05:06AM BLOOD WBC-22.5* RBC-3.04* Hgb-8.7* Hct-26.8*
MCV-88 MCH-28.7 MCHC-32.5 RDW-14.4 Plt Ct-878*
[**2116-8-21**] 07:00AM BLOOD Neuts-85.5* Lymphs-10.9* Monos-2.3
Eos-0.9 Baso-0.4
[**2116-8-20**] 07:40AM BLOOD Neuts-56 Bands-19* Lymphs-20 Monos-5
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-4*
[**2116-8-28**] 04:29AM BLOOD PT-15.5* INR(PT)-1.4*
[**2116-8-27**] 05:27AM BLOOD Plt Ct-1239*
[**2116-8-27**] 05:27AM BLOOD PT-15.6* INR(PT)-1.4*
[**2116-8-20**] 07:40AM BLOOD Plt Smr-VERY HIGH Plt Ct-727*
[**2116-8-20**] 09:21AM BLOOD PT-14.0* PTT-24.6 INR(PT)-1.2*
[**2116-8-21**] 07:00AM BLOOD Plt Ct-716*
[**2116-8-18**] 05:00PM BLOOD Plt Ct-654*
[**2116-8-23**] 10:30AM BLOOD Glucose-227* UreaN-8 Creat-0.5 Na-140
K-4.4 Cl-98 HCO3-30 AnGap-16
[**2116-8-22**] 05:50AM BLOOD Glucose-140* UreaN-9 Creat-0.6 Na-142
K-3.0* Cl-102 HCO3-30 AnGap-13
[**2116-8-27**] 05:27AM BLOOD Lipase-198*
[**2116-8-26**] 05:19AM BLOOD Lipase-356*
[**2116-8-25**] 05:59AM BLOOD Lipase-374*
[**2116-8-22**] 10:37AM BLOOD Lipase-87*
[**2116-8-13**] 06:00AM BLOOD Lipase-1303*
[**2116-8-23**] 10:30AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2116-8-13**] 09:29PM BLOOD CK-MB-7 cTropnT-<0.01
[**2116-8-13**] 01:59PM BLOOD CK-MB-13* MB Indx-0.5 cTropnT-<0.01
[**2116-8-13**] 06:00AM BLOOD CK-MB-22* MB Indx-0.7 cTropnT-<0.01
[**2116-8-13**] 06:00AM BLOOD CK-MB-22* MB Indx-0.7 cTropnT-<0.01
[**2116-8-13**] 07:13AM BLOOD Type-ART pO2-68* pCO2-41 pH-7.35
calTCO2-24 Base XS--2 Intubat-NOT INTUBA
Brief Hospital Course:
[**8-13**] Patient was having pain begining around midnight, her PCA
dose was increased and her incisional pain was controlled. Pt
stated she was telling the nurse about her chest and back pain
throughout the night. Upon rounding in the morning (around 6
am) the patient appeared pale and complained about [**9-21**] sharp
nonradiating pain in a band like distribution across her chest
and in her back made worse with breathing. Yet she denies
shortness of breath. Her O2 sats were in the low 90's. Upon
exam, she did have some ronchi in the bases bilaterally and the
pain was not reproducible. She had 1+ bilat pedal edema. I
obtained a 12 lead ECG which was normal, cardiac enzymes were
cycled, ABG was drawn and showed PO2 of 68 on 3 L O2, she was
placed on non rebreather at 15 l/min and on telemetry, portable
xray was called. I took the patient to CT for a CT with PE
protocol and CT abd with oral contrast was performed. Patient
was transferred to the trauma ICU where I gave signout to the
ICU resident [**Doctor First Name **]. [**Last Name (NamePattern4) 98842**] [**MD Number(1) 98843**]
[**8-14**] Patient still tachycardic into 115-140, still on high oxygen
flows. She has a climbing white count up to 29 now. APS was
consulted and said: 1) trigger point injections
2) consider iv toradol although may be contraindicated by pt's
surgery
3) cont iv dilaudid pca
4) subscapular support w/pillow since it helps with pt's
ventilation
5) epidural if all above fail and pt's O2 sat continues to drop.
(pt's O2 sat in afternoon improved to 95-99% on open facemask).
Will remain in the ICU on close monitoring.
IMAGING:
CXR [**8-14**]: Bibasilar atelectasis. Mild dilatation left
hemidiaphragm
CTA CHEST [**8-13**]: No PE. Sm amt of intraop. air, C/W recent
surgery. sM amt of fluid tracking along gerota's fascia and
liver.
[**8-15**] Transferred from TICU back to the floor.
[**8-17**] Still encourage Inspiratory spirometer, pt stated she bacame
tachycardic and dizzy with albulterol thus was placed on
levoalbuterol, she is doing better with her insipiratory
spirometer and she is off oxygen with a good oxygen saturation.
[**8-18**] Unable to draw any labs or place any new intravenous
catheters, several people have tried.
[**8-19**] Pt is in more discomfort, white count keeps climbing, will
do CT scan and place PICC line to draw cultures from. ID recs
as follows:
1. Obtain blood cx, U/A + Cx, and stool for c.diff. OK to get
PICC line if needed as she has been afebrile x 48 hours.
2. Agree with stat abdominal imaging, consider CT chest as well
to rule out infectious pneumonic process
3. Would hold on antibiotics at this time but if she
decompensates or becomes febrile, would consider starting Zosyn
and Flagyl PO for possible abdominal process/c.diff
4. Will continue to follow.
5. Please d/c standing tylenol as it could mask fevers. [**Month (only) 116**] make
PRN.
6. Please obtain differential with next CBC
[**8-20**] Pt to go to IR for power PICC placement and left pleural
effusion drainage, CT from [**8-19**] showed large left pleural
effusion but the CT could not be read as the computer system was
not working. Will also get peripancreatic fluid collection
drained today at IR. The pleural effusion is small and the
patient is in so much pain from the peripancreatic fluid
collection that it is unsafe to proceed with the thoracentesis
today as felt by the radiologist. A drain was placed in the
fluid collection site.
Fluid collection gm stain: no microorganisms, no PMNs
[**8-21**] IP and thoracic were consulted, attempted bedside tap but
pts pain prevented this from happening. Pt was doing well in
the morning and then in the afternoon her drain site from [**8-20**]
peripancreatic draining is sevverly hurting her. She was given
1.5 mg IV dilaudid and 30 mg IV toridol, her CXR shows a much
worsened pleural effusion. We will attempt another tap in IR
under sedation to which the patient is agreeable and we will
transfer to the ICU as patients respiratory status is becoming
increasingly worse. IP fellow and thoracic attending do not feel
a need to do the procedure tonight and IR states they do not
perform thoracentesis only drainage of abdominal fluid
collections. She is in increasingly severe pain and her pain
cannot be controlled adequetly with the monitoring on the floor
due to high risk of respiratory depression. The attending
wanted the patient transferred to ICU, the ICU resident stated
the patient did not meet criteria for transfer to the ICU. We
will follow her closely overnight.
[**8-22**] TPN bag error by pharmacy, so had to give standard bag
PLEURAL FLUID
Other Body Fluid Chemistry:
TotProt: 3.8
Glucose: 113
LD(LDH): 792
PLEURAL FLUID
Other Body Fluid Hematology:
WBC: 4222
RBC: 2833
Polys: 51
Lymphs: 11
Monos: 16
Eos: 2
Mesothe: 2
Macro: 18
[**2116-8-24**] Pt went down for CTA which showed a PE. 1. Findings
consistent with acute segmental pulmonary embolism in the right
middle lobe.
2. Slight decrease in size of a left subphrenic fluid collection
with pigtail
catheter in place.
3. Small-to-moderate right-sided pleural effusion with adjacent
atelectasis.
Pt started on heparin drip and PTT was followed every 6 hours.
[**2116-8-25**] Patients heparin drip was changed to an enoxaparin drip.
[**2116-8-27**] Pt is having dyspnea, went for CXR which showed a
moderate to large left pleural effusion which is unchanged from
before. A small right pleural effusion. The left lower lobe is
almost completely collapsed. The PICC line is correctly
positioned in the SVC and there is no pneumothorax.
[**2116-8-28**] Spoke to Dr. [**Last Name (STitle) 84273**], the PCP, [**Name10 (NameIs) **] him about the
hospital course. He has agreed to follow her anticoagulation
therapy. She should stay therapeutic with an INR of [**3-17**], stay
on coumadin for 3 months. There is an acute change in the
pigtail from pus to blood overnight. There is minimal drainage
and there is no concern for bleed at this point. Removed pigtail
catheter due to minimal drainage over the past few days and
correlation with CT scan a few days ago. Spoke with IR who also
recommended removing the pigtail catheter.
Medications on Admission:
Tums
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*500 ML(s)* Refills:*0*
2. Colace 50 mg/5 mL Liquid Sig: Ten (10) ml PO at bedtime as
needed for constipation.
Disp:*500 ml* Refills:*0*
3. Respiratory Equipment
Nebulizer Machine with tubing
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
every twelve (12) hours as needed for shortness of breath or
wheezing: Place in nebulizer machine.
Disp:*60 units* Refills:*2*
5. Enoxaparin 150 mg/mL Syringe Sig: One (1) Subcutaneous Q12H
(every 12 hours): until bridged with coumadin to INR of [**3-17**].
Disp:*40 syringes* Refills:*0*
6. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 3
months: Dose will be adjusted by PCP to meet INR of [**3-17**]
requirement.
Disp:*90 Tablet(s)* Refills:*0*
7. Xopenex 0.63 mg/3 mL Solution for Nebulization Sig: One (1)
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
Disp:*60 nebs* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Obesity
Discharge Condition:
Stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
Diet: Stay on Stage III diet until your follow up appointment.
Do not self advance
diet, do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
No heavy lifting of items [**11-26**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.
Wound Care:
You may shower, no tub baths or swimming.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2116-8-27**] 9:45
Provider: [**Name10 (NameIs) 326**] UPPER GI (WEST) RADIOLOGY Phone:[**Telephone/Fax (1) 327**]
Date/Time:[**2116-8-27**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18800**], RD Phone:[**Telephone/Fax (1) 305**]
Date/Time:[**2116-8-27**] 11:00
Dr. [**Last Name (STitle) 4402**] [**2116-8-31**] at 11:15am, [**First Name8 (NamePattern2) **] [**Hospital1 **]
Completed by:[**2116-8-29**]
|
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"715.90",
"759.0",
"530.81",
"997.39",
"238.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.93",
"54.59",
"54.91",
"87.41",
"99.15",
"44.69",
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"34.91"
] |
icd9pcs
|
[
[
[]
]
] |
11828, 11834
|
4557, 10754
|
328, 415
|
11905, 11914
|
2474, 4534
|
13849, 14456
|
1132, 1179
|
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|
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|
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|
11962, 12528
|
1194, 2455
|
274, 290
|
13492, 13826
|
443, 593
|
11874, 11884
|
12553, 13480
|
615, 873
|
889, 1116
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,143
| 112,651
|
42451
|
Discharge summary
|
report
|
Admission Date: [**2183-12-6**] Discharge Date: [**2183-12-9**]
Date of Birth: [**2155-4-9**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
s/p stabbing
Major Surgical or Invasive Procedure:
Exploratory laparotomy, Takedown splenic flexure, Repair of
descending colon serosal tear, Evacuation of retroperitoneal
hematoma, Washout of stab wounds.
Exploratory laparotomy, retroperitoneal
exploration, evacuation of the retroperitoneal hematoma,
closure of Gerota's fascia over the left kidney
History of Present Illness:
Mr. [**Known lastname 91910**] is a 28 year old male who was transferred from
[**Hospital6 3105**] on [**2183-12-6**] after being stabbed in the
left flank/axilla with a box cutter during an argument.
According to report from the OSH, he was transferred for left
kidney injury and possible bowel injury. On arrival to [**Hospital1 18**], he
is alert, oriented and cooperative, and complaining of abdominal
pain.
Past Medical History:
PMH: polysubstance abuse s/p inpatient rehab
PSH: none
Social History:
+ ellicit drug, alcohol and tobacco use (+ETOH and cocaine at
time of trauma). Pt reports that he does not drink alcohol daily
but reports binge drinking when he does use. Pt reports using
approx.1 gram of cocaine on weekends, usually with alcohol.
Lives with father and father's girlfriend
Pt reports that he works full time in [**Location (un) 3844**] putting
together cable.
Family History:
noncontributory
Physical Exam:
On admission:
HR: 87 BP: 95/55 Resp: 19 O(2)Sat: 100 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: tender, distended abdomen
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: 3cm laceration to L flank and 2x 3cm lacerations to L
posterior shoulder, Warm and dry, No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
On discharge:
HR: 90 BP: 98/62 Resp: 18 O(2)Sat: 96 RA
Constitutional: Comfortable
HEENT: Araumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: abdomen soft, appropriately tender at incision site,
non distended
Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: Left flank wound with small to moderate amount serosang
drainage, packed with moist gauze. Abd and left axilla incisions
OTA with staples intact, no errythema or drainage.
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Heme/[**Last Name (un) **]/[**Last Name (un) **]: No petechiae
Pertinent Results:
[**2183-12-6**] CTA ABD W&W/O C & RECONS:
Patient is status post open laparotomy and evacuation of a
retroperitoneal
hematoma for a grade IV renal laceration. Stable laceration
noted in the
lower pole of the left kidney. However, the kidney demonstrates
normal prompt pelvicaliceal excretion with no evidence for
active contrast extravasation to suggest continued bleeding or
active urine leak.
[**2183-12-6**] 02:55AM PH-7.28* COMMENTS-GREEN TOP
[**2183-12-6**] 02:55AM GLUCOSE-125* LACTATE-2.6* NA+-138 K+-4.1
CL--105 TCO2-21
[**2183-12-6**] 02:55AM HGB-13.7* calcHCT-41 O2 SAT-89 CARBOXYHB-4.5
MET HGB-0.2
[**2183-12-6**] 02:55AM freeCa-1.06*
[**2183-12-6**] 02:35AM UREA N-11 CREAT-1.1
[**2183-12-6**] 02:35AM LIPASE-19
[**2183-12-6**] 02:35AM ASA-NEG ETHANOL-108* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-12-6**] 02:35AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2183-12-6**] 02:35AM WBC-21.2* RBC-4.11* HGB-13.0* HCT-37.3*
MCV-91 MCH-31.7 MCHC-34.9 RDW-14.7
[**2183-12-6**] 02:35AM PLT COUNT-204
[**2183-12-6**] 02:35AM PT-12.5 PTT-27.0 INR(PT)-1.2*
[**2183-12-6**] 02:35AM FIBRINOGE-123*
[**2183-12-6**] 02:35AM URINE COLOR-Red APPEAR-Hazy SP [**Last Name (un) 155**]-1.042*
[**2183-12-6**] 02:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM
[**2183-12-6**] 02:35AM URINE RBC->182* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
[**2183-12-6**] 02:35AM URINE MUCOUS-RARE
Brief Hospital Course:
28M transfer from OSH with multiple stab wounds to L
chest/flank. Trauma protocol activated on arrival to ED.
Received CT torso at OSH which showed L kidney laceration with
RP hematoma though no violation of thoracic cavity. Following
trauma evaluation, patient was taken to the OR for ex-lap,
evacuation of RP hematoma and repair of serosal tear to L colon.
Patient tolerated procedure well and was transferred to the
TSICU intubated for further management under ACS service.
Neuro: Post-operatively, the patient was brought to the TSICU
intubated/sedated. When extubated POD0 dilaudid PCA was
initiated. Due to refractory pain, patient was acute pain
service was consulted to place an epidural. Epidural was placed
successfully and patient was concurrently started on
supplementary iv->po pain regimen POD1-2. When tolerating oral
intake, the patient was transitioned to oral pain medications,
with which he reported adequate pain relief.
CV: Patient admitted with known recent cocaine use. Patient
demonstrated persistent tachycardia in setting of normotension.
Patient given clonidine patch in setting recent cocaine use,
which was discontinued prior to discharge.
***The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: Patient was extubated on POD0 and weaned supplemental
O2 appropriately. Pulmonary toilet including incentive
spirometry and early ambulation were encouraged. The patient
was stable from a pulmonary standpoint; vital signs were
routinely monitored.
GI/GU: Post-operatively, the patient was given IV fluids until
tolerating oral intake. His diet was advanced when appropriate,
which was tolerated well. He was also started on a bowel
regimen to encourage bowel movement. Foley was removed prior to
discharge, and he was able to void without difficulty. Intake
and output were closely monitored.
ID: Post-operatively, the patient was started on IV cefazolin
perioperatively. The patient's temperature was closely watched
for signs of infection. He remained afebrile without any
evidence of infection and antibiotics were discontinued.
Prophylaxis: The patient received subcutaneous heparin during
this
stay, and was encouraged to get up and ambulate as early as
possible.
At the time of discharge on POD#3, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
He was discharged to home with scheduled follow up in [**Hospital 2536**] clinic
on [**2183-12-16**] to have his staples removed. His family was
instructed on how to perform dressing changes, as well as signs
and symptoms of infection.
The patient was also seen by social work during his admission
for drug/etoh use, as well as given the trauma. He was provided
with referal information for resources.
Medications on Admission:
none
Discharge Medications:
1. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
5. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
s/p stabbing
1. Left renal laceration.
2. Descending colon serosal tear.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after be stabbed in the left
chest and flank. You sustained an injury to your left kidney and
a small tear to part of your colon. These injuries were repaired
in the operating room. You are recovering well and are now being
discharged home with the following instructions:
The dressing on your left side needs to be changed twice each
day, as instructed. Remove the dressing in place, including the
gauze packing and replace with a saline-moistened new piece of
gauze. Cover with a dry gauze and secure with tape. If you
notice any signs of infection such as pus/white/yellow drainage
or increased redness around the wound, please call the [**Hospital 2536**]
clinic ([**Telephone/Fax (1) 600**]) or come to the ED.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your [**Telephone/Fax (1) 5059**] at your next visit.
Don't lift more than [**10-11**] lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.)
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU [**Month (only) **] FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your [**Month (only) 5059**].
YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal. Your staples will be removed at your
follow up appointment.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important to take this medicine
as directied. Do not take it more frequently than prescribed. Do
not take more medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
[**Name2 (NI) 5059**] has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the folloiwng, please contact your
[**Name2 (NI) 5059**]:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].
DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: TUESDAY [**2183-12-16**] at 9:45 AM
With: ACUTE CARE CLINIC/ Dr. [**Last Name (STitle) 853**] [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
It is recommended that you establish care with a Primary Care
Physician. [**Name10 (NameIs) **] you need assistance finding a PCP outside the
[**Name9 (PRE) 86**] area, your local hospital or healthcare center can be a
resource.
If you are looking for a PCP in the [**Name9 (PRE) 86**] area or need further
assistance please call the [**Hospital1 18**] Find-A-Doc line at ([**Telephone/Fax (1) 91202**]. We are able to assist you between the hours of 8:30
AM- 5:00 PM Monday through Friday.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2183-12-9**]
|
[
"305.02",
"785.0",
"863.53",
"E966",
"292.0",
"305.60",
"V49.87",
"338.11",
"866.12"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.81",
"46.75"
] |
icd9pcs
|
[
[
[]
]
] |
8156, 8162
|
4515, 7379
|
323, 626
|
8280, 8280
|
2970, 4492
|
13757, 14770
|
1559, 1576
|
7434, 8133
|
8183, 8259
|
7405, 7411
|
8431, 13734
|
1591, 1591
|
2224, 2951
|
271, 285
|
654, 1067
|
1606, 2209
|
8295, 8407
|
1089, 1146
|
1162, 1543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,163
| 180,691
|
26153
|
Discharge summary
|
report
|
Admission Date: [**2107-11-17**] Discharge Date: [**2107-11-28**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
transfers for cath after presenting with acute CHF at [**Hospital **]
Hospital [**11-13**]
Major Surgical or Invasive Procedure:
Coronary artery bypass graft x2; saphenous vein
graft to left anterior descending artery, saphenous vein
graft to the obtuse marginal branch of circumflex.
History of Present Illness:
87 yo woman with no CAD hx reports episodes of dyspnea occurring
intermittently over the past few weeks. She was scheduled to see
her PCP for evaluation, however, on [**11-13**] she woke with acute
SOB, pink tinged sputum, and was transported to [**Hospital **]
Hospital. She R/I for NSTEMI with Trop peak 6.25, CPK 150. She
was diuresed for CHF. Remained without angina symptoms or CHF.
Cath [**11-16**] at [**Hospital1 **] and found to have mLAD, D1 lesion. Echo
shows EF 35% with ant/septal HK, no thrombus. Transferred for
PCI > LAD but on cath L main and 2 vessel CAD.
Past Medical History:
Breast CA ([**2041**]), s/p R mastectomy
HTN (prior treated with verapamil)
Diabetes
Social History:
lives independently in [**Hospital3 4634**] complex. Has one
family member (her grandson) to assist with any needs. She
reports he is supportive and anticipates he will assist wiht her
discharge.
Family History:
non contrib
Pertinent Results:
[**2107-11-17**] 03:45PM GLUCOSE-178* UREA N-39* CREAT-1.4* SODIUM-136
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-27 ANION GAP-14
[**2107-11-17**] 03:45PM ALT(SGPT)-15 AST(SGOT)-17 ALK PHOS-56
AMYLASE-43 TOT BILI-0.5
[**2107-11-17**] 03:45PM ALBUMIN-3.0* CHOLEST-168
[**2107-11-17**] 03:45PM %HbA1c-5.6 [Hgb]-DONE [A1c]-DONE
[**2107-11-17**] 03:45PM TRIGLYCER-123 HDL CHOL-34 CHOL/HDL-4.9
LDL(CALC)-109
[**2107-11-17**] 03:45PM WBC-9.0 RBC-4.05* HGB-12.1 HCT-34.8* MCV-86
MCH-29.8 MCHC-34.7 RDW-13.4
[**2107-11-17**] 03:45PM NEUTS-76.9* LYMPHS-14.5* MONOS-7.1 EOS-1.4
BASOS-0.2
[**2107-11-17**] 03:45PM PLT COUNT-231
Brief Hospital Course:
Mrs. [**Known lastname **] was tranferred from [**Hospital **] Hospital for complaints of
worsening CHF and upon catheterization was found to have left
main and 2 vessel CAD. Pt. underwent revascu;arization by Dr.
[**Last Name (STitle) **] on 12 /27/05. For details of the procedure, see
operative dictation.
Post-operatively, the patient did well and after a brief stay in
the Cardiac recovery unit, was transferred to the floor.
Patient has been actively diuresing for fluid mainatenance. On
postoperative day 6, patient was deemed stable enough to be
discharged to a rehabilitation facility for ongoing
convalescence. On [**2107-11-28**] she was therefore discharged in good
condition, ambulating with assistance and with good pain
control. She is asked to follow-up with Dr. [**Last Name (STitle) **] in [**12-30**] weeks
and her primary care physician this week.
Medications on Admission:
ASA 325 mg qd
plavix 75 mg qd
lasix 40 mg qd
lopressor 25 mg qd
lisinopril 10 mg qd
zocor 40 mg qd
zantac 150 mg qd
colace 100 mg qd
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*1*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
6. 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*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Disp:*20 Suppository(s)* Refills:*0*
9. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Monserret Nursing & Rehab
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Good
Discharge Instructions:
Go to an Emergency Room if you experience new and continuing
nausea,
vomiting, fevers (>101.5 F), chills, or shortness of breath.
Also go to the ER if your wound becomes red, swollen, warm, or
produces pus.
If you experience clear drainage from your wounds, cover them
with a
clean dressing and stop showering until the drainage subsides
for at
least 2 days.
No heavy lifting or exertion for at least 6 weeks.
No driving while taking pain medications.
Narcotics can cause constipation. Please take an over the
counter stool softener such as Colace or a gentle laxative such
as Milk of Magnesia if you experience constipation.
You may resume your regular diet as tolerated.
You may resume all of your previously prescribed medications.
You may take showers.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 2230**] in [**12-30**] weeks. [**Telephone/Fax (1) 64878**] Call Number
to make appointment.
Make appointment with Dr [**Last Name (STitle) **], this week.
|
[
"428.21",
"412",
"V10.3",
"584.9",
"250.00",
"414.01",
"401.9",
"585.9",
"428.0",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"37.22",
"88.55",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4302, 4354
|
2143, 3018
|
362, 520
|
4422, 4429
|
1493, 2120
|
5243, 5442
|
1461, 1474
|
3201, 4279
|
4375, 4401
|
3044, 3178
|
4453, 5220
|
231, 324
|
548, 1123
|
1145, 1231
|
1247, 1445
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,979
| 137,026
|
45274
|
Discharge summary
|
report
|
Admission Date: [**2176-3-22**] Discharge Date: [**2176-3-28**]
Date of Birth: [**2109-7-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 4679**]
Chief Complaint:
Right upper lobe mass
Major Surgical or Invasive Procedure:
Bronchoscopy: Right Thoracotomy with Right Upper Lobectomy
History of Present Illness:
The patient is a 66-year-old gentleman with a biopsy proven
cancer of the right upper lobe. He had undergone induction
chemoradiation therapy. It was felt that the lesion may involve
both the superior vena cava as well as the distal trachea. He
is being admitted for resection of this mass.
Past Medical History:
Hypertension
Hyperlipidemia
Glucose intolerance
NSCLC (dx [**2175-12-15**] via bronch)
AAA s/p repair
GERD
Social History:
Social History (per old records): He lives alone and is not
married. He is retired and used to work in the camera department
at the Lechmere store. He occasionally uses alcohol. He has a
100-pack-year history of smoking but quit 10 years ago. He has
no history of asbestos exposure.
Family History:
Family History (per old records): He has a father who died at
the age of 61 from a massive stroke. His mother died at the age
of 90 with lung cancer. His brother recently died at the age of
58 from sudden death. He has a sister who is 66 years old and
has ovarian cancer and he has another
brother who is living and otherwise healthy.
Physical Exam:
General: 66 year-old male in no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple no lymphadenopathy
Card: regular, rate & rhythm, normal S1,S2 no murmur/gallop or
rub
Resp: decreased breath sounds R>L with fine crackles on right
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Incision: right thoracotomy site C/D/I, no discharge or erythema
Extr warm 2+ edema bilateral lower extremities
Neuro: non-focal
Pertinent Results:
[**2176-3-22**] WBC-12.7*# RBC-3.06* Hgb-8.7* Hct-26.9 Plt Ct-358
[**2176-3-25**] WBC-11.7* RBC-2.57* Hgb-7.3* Hct-22.4 Plt Ct-352
[**2176-3-27**] WBC-5.8 RBC-3.44* Hgb-9.6* Hct-29.3 Plt Ct-307
[**2176-3-22**] Glucose-210* UreaN-15 Creat-0.5 Na-137 K-4.2 Cl-107
HCO3-24
[**2176-3-27**] Glucose-97 UreaN-15 Creat-0.6 Na-138 K-3.5 Cl-102
HCO3-31
[**2176-3-23**] 12:39 am MRSA SCREEN Site: RECTAL No MRSA
isolated.
Chest PA and lateral on [**2176-3-27**].
The left lung is clear.
IMPRESSION:
1) Stable small right apical pneumothorax with persistent
pleural thickening, and/or loculation and scarring.
2) The right basilar pneumothorax is no longer visualized.
3) Slight increase in interstitial edema in the right upper
lung.
Brief Hospital Course:
Mr. [**Known lastname 6330**] was taken to the operating room and underwent
successful Right thoracotomy, right upper lobectomy with
mediastinal lymph node dissection and en bloc resection of
azygos vein. The patient was then brought to the intensive care
unit, intubated, but hemodynamically stable. He had 2 right
chest tubes, foley and Epidural for pain managed by the acute
pain service. On POD #1 he was extubated and transferred to the
floor. He was seen by physical therapy who recommended home
when ready. On POD #2 he had a brief episode of atrial
fibrillation and responded well to beta-blockers. On chest-tube
was removed and follow-up CXR showed small right apical
pneumothorax. On POD #3 his HCT was found to be 23 and
transfused with 2 units of PRBC repeat HCT 32. On POD #4 the
remainder chest tube was removed and his CXR confirmed a stable
right apical airspace. The epidural was converted to PO pain
medication with good control. His foley was removed and he
voided without difficulty. He continued to ambulate in at the
[**Doctor Last Name **] and was discharged to home on POD #5. He will follow-up
with Dr. [**First Name (STitle) **] as an outpatient.
Medications on Admission:
Liptior 10 mg daily
Ranidine 150 mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take with narcotics.
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: Dr. [**First Name (STitle) **] will stop this medication on your next visit.
Disp:*60 Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*70 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Right Lung Mass s/p chemotherapy
COPD
Hyperlipidemia
Anemia (Hct 26)
CVA no deficit
PSH: hernia repair x 3; AAA repair;laser surgery of throat
lesion; bronchoscopy, mediastinoscopy [**2176-2-14**]
Discharge Condition:
good
Discharge Instructions:
Call Dr.[**Name (NI) 5067**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops increased redness, or drainage
Chest-tube site dressing remove Friday cover with bandaid until
healed
Should site begin to drain cover with clean dry dressing and
change as needed to keep site clean and dry.
You may shower
No bathing or swimming for 6 weeks
No driving while taking narcotics
Walk frequently throughout day increasing your distance daily
Followup Instructions:
Follow-up with Dr. [**First Name (STitle) **] [**2176-4-9**] 10:30 on the [**Hospital Ward Name 516**]
[**Hospital Ward Name 23**] Clinical Center, [**Location (un) **].
Report to the [**Location (un) 861**] Radiology Department for a Chest X-Ray
45 minutes before your appointment.
Completed by:[**2176-4-17**]
|
[
"276.1",
"162.3",
"997.1",
"276.3",
"508.1",
"272.4",
"E878.6",
"496",
"197.1",
"285.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"34.99",
"40.3",
"99.04",
"32.49"
] |
icd9pcs
|
[
[
[]
]
] |
4633, 4691
|
2711, 3896
|
299, 360
|
4933, 4940
|
1952, 2688
|
5535, 5849
|
1129, 1467
|
3989, 4610
|
4712, 4912
|
3922, 3966
|
4964, 5512
|
1482, 1933
|
237, 261
|
388, 682
|
704, 812
|
828, 1113
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,823
| 190,531
|
37524
|
Discharge summary
|
report
|
Admission Date: [**2179-12-2**] Discharge Date: [**2179-12-12**]
Date of Birth: [**2099-5-12**] Sex: F
Service: MEDICINE
Allergies:
Latex / Penicillins
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization [**2179-12-5**]
History of Present Illness:
80 yo female with hx of CHF (EF 25-30%), HLD, HTN, DMII who
presented to OSH with CP and was transferred to [**Hospital1 18**] for PCI
after catheterization found 70% LAD lesion and pt refused CABG.
Pt states that she has had CP for the last month, however her CP
got significantly worse 3 days PTA to OSH, prompting her
presentation. She describes it as substernal and radiating to
the arms and with associated nausea. Per pt, pain improved with
nitroglycerin. Pt denies any associated SOB, vomiting or
diaphoresis. On presentation to the OSH, she was ruled out for
MI however troponins were mildly elevated to 0.13. She was also
found to be hyperkalemic and was therefore given kayexalate, ARF
with creatinine to 1.5. She underwent cardiac cath which showed
80% proximal left main stenosis, 70% middle LAD stenosis, 60%
proximal circ stenosis and 60% mid-RCA stenosis and was
transferred to [**Hospital1 18**] for further management and PCI given pts
refusal of CABG.
Pt was transferred to [**Hospital1 18**] on heparin. In the ambulance, pt
complained of CP and pressures dropped to 80s systolic however
normalized without intervention. On arrival to [**Hospital1 18**], pt
required 4L to maintain sats in the 90s, however denied SOB, or
CP. Vitals were otherwise stable. She denied further CP or SOB
on arrival to the floor. Without complaints however wanting to
sit up in bed and somewhat agitated.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain
at present, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope. She
does have trouble lying flat because of SOB.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: DDD 60-140
3. OTHER PAST MEDICAL HISTORY:
-Anemia
-Hx Thrombocytopenia
-hypothyroidism
-diverticulosis
-osteopenia
-GERD
-bilateral cataract s/p laser surgery and implants
-CKD stage III
-cholecystectomy
-inguinal hernia repair
-ventral hernia repair
-TAH with bilateral salpingoophorectomy
-s/p lysis of small bowel adhesions
-s/p R knee surgery
Social History:
Pt worked as a nursing assistant. She has a son in TX and a
daughter in [**Name (NI) **], 6 grandchildren. She has been married for 60
yrs.
-Tobacco history: No current, quit in [**2152**]
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T=98.3 BP=118/66 HR=71 RR=26 O2 sat=92% 4L
GENERAL: Oriented x3. Mood, affect appropriate. Somewhat
uncomfortable and agitated appearing, wanting to sit up in bed.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis.
Breathing appears somewhat labored with use of accessory
muscles, pt coughing. Bibasilar crackles, no wheezes or rhonchi.
Poor air movement bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No calf tenderness. Small painful
hematoma on anterior lower leg
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ carotid bilaterally
Pertinent Results:
[**2179-12-2**] 07:31PM PT-13.0 PTT-37.3* INR(PT)-1.1
[**2179-12-2**] 07:31PM PLT COUNT-160
[**2179-12-2**] 07:31PM NEUTS-62.1 LYMPHS-26.7 MONOS-10.1 EOS-0.7
BASOS-0.5
[**2179-12-2**] 07:31PM WBC-15.3* RBC-3.02* HGB-8.8* HCT-27.0* MCV-89
MCH-29.2 MCHC-32.6 RDW-15.4
[**2179-12-2**] 07:31PM TRIGLYCER-104 HDL CHOL-46 CHOL/HDL-2.2
LDL(CALC)-34
[**2179-12-2**] 07:31PM CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-1.9
CHOLEST-101
[**2179-12-2**] 07:31PM GLUCOSE-285* UREA N-40* CREAT-1.6* SODIUM-142
POTASSIUM-5.3* CHLORIDE-105 TOTAL CO2-26 ANION GAP-16
TTE [**12-3**]:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated with severe global hypokinesis (LVEF = 25 %).
No masses or thrombi are seen in the left ventricle, but apical
images are suboptimal. Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). The
right ventricular cavity is mildly dilated with mild global free
wall hypokinesis. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**1-1**]+) mitral regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Left ventricular cavity
enlargement with severe global hypokinesis. Right ventricular
cavity enlargement with free wall hypokinesis. Moderate
pulmonary artery systolic hypertension. Mild-moderate mitral
regurgitation.
CXR [**12-5**]: As compared to the previous radiograph, there is no
relevant
change. The left basal retrocardiac parenchymal opacities,
unchanged in
extent and density. The left pectoral pacemaker obliterates the
left
costophrenic sinus, but an effusion may also be present on the
left. The
pre-existing right hilar enlargement is slightly less obvious
than on the
previous examination. The finding should nevertheless be
clarified with CT.
Unchanged right-sided PICC line, unchanged pacemaker wires. No
focal
parenchymal opacities have newly occurred. No signs of
overhydration.
ABI [**12-3**]:
Normal lower extremity arterial hemodynamics at rest. Note of
noncompressible vessels.
Cardiac Catheterization:
1. Three vessel coronary artery disease.
2. Sucecssful stenting of the LMCA into the LCX with two
overlapping Cypher DESs
3. Successful placement of TandemHeart assist device during LMCA
PCI
4. Successful removal of bilateral arterial sheaths (3 Perclose
devices
to the RCFA and one 6 F Angioseal to the LCFA).
5. Sucecssful removal of bilateral venous sheaths
6. Mild abdominal aortic plaquing without critical stenosis
7. Limited vagal event following closure of arterial
access,successfully treated
8. 2 weeks of 150 mg/d Plavix then 75 mg daily long term
9minimum of 1 year) and ASA indifinitely (325 mg daily x minimum
of 1 month then 162 mg daily)
9. Global cardiovascular risk reduction strategies to meet
recommended targets
Brief Hospital Course:
1. CORONARIES: Mrs [**Known lastname **] was found to have significant 3
vessel disease at the outside hospital and was transferred to
[**Hospital1 18**] for PCI. She developed chest pain and hypotension en
route to [**Hospital1 **] which resolved without intervention prior to
arrival. PCI was initally on hold given pts poor resp status,
however resp status improved with lasix and she underwent LMCA
stenting with DES using tandem heart support. She was
transferred to the CCU after stenting for further montioring,
however did well and was quickly transferred to the cardiology
floor. She was also maintained on aspirin, Imdur, heparin and
high dose statin. Plavix was started after intervention and
will be continued at 150 mg for 1 week, then pt will require
lifelong treatment of 75 mg/day. High dose aspirin 325mg should
be maintained for at least 1 month but thereafter may be down
titrated to 162mg daily if necessary.
2. Systolic heart failure/volume overload: Mrs [**Known lastname **] has a
baseline EF of 20%, was admitted in significant respiratory
distress and crackles on exam. She underwent diuresis with
lasix gtt and respiratory status improved with diuresis. She
was also continued on metoprolol at a decreased dose (50 mg [**Hospital1 **])
secondary to concern for her hypotension on admission.
3. HYPOTENSION: Pt was hypotensive on transport to the hospital,
however pressures stabilized in the low 100s on arrival to the
hospital. We also considerd septic physiology given
leukocytosis, ? PNA on CXR, 1 positive blood cxs growing gram -
staph, and pt was started on vanc/levofloxicin. Vancomycin was
discontinued after surveillance cultures remained negative after
48 hrs. Blood pressures stabilized and remained normotensive
through duration of hospital stay.
4. LEUKOCYTOSIS: Likely due to PNA, therefore pt was treated for
HCAP. While bacteremia was intially considered, vancomycin was
dc'd after 48 hrs of negative cultures. She was continued on a
5 day course of levofloxicin for CAP pneumonia.
5. CKD: Worsening renal function during this admission, with
FeNa<1 concerning for pre-renal etiology. Initially attributed
to aggresive lasix diuresis, given that renal function improved
after discontinuation of diuresis, however renal function
worsened again after cath, raising concern for contrast-related
nephropathy given that the pt received contrast 5 day prior at
OSH.
6 DM: sugars were poorly controlled and pt required uptitration
of her insulin during this admission.
7. THROMBOCYTOPENIA: Stable, low concern for HIT therefore
heparin was continued.
8. ANEMIA: Now WNL s/p transfusion and in the setting of
aggressive diuresis.
9. HYPONATREMIA: likely due to aggressive diuresis. Stable.
10. HYPOTHYROIDISM: continue home dose of levothyroxine
Medications on Admission:
At [**Hospital1 1501**]:
-Toprol XL 150 mg daily
-Aspirin 81 mg
-Lisinopril 20 mg
-Lipitor 10 mg q day
-Ranitidine 150 mg daily
-Humulin N insulin, unknown dose
-Lasix 40 mg daily
-Nitroglycerin 0.4 mg PRN CP
-Humulin R insulin to scale, 200 to 250, 6 units subcutaneously;
251 to 300, 8 units subcutaneously; and 301 to 350, 10 units
subutaneously
.
On Transfer:
-Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
-Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
-Amlodipine 10 mg PO/NG DAILY
-Isosorbide Mononitrate 20 mg PO BID
-Aspirin 325 mg PO/NG DAILY
-Levothyroxine Sodium 75 mcg PO/NG DAILY
-Atorvastatin 10 mg PO/NG DAILY Order
-Metoprolol Succinate XL 200 mg PO DAILY
-Miconazole Powder 2% 1 Appl TP TID
-Furosemide 40 mg PO/NG DAILY Order
-Nitroglycerin SL 0.3 mg SL PRN CP
-Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
-Pantoprazole 40 mg PO Q24H
-Heparin IV
-Glargine 8 U at breakfast and bedtime
-Novolog before meals, at bedtime and 0300
-Bactroban to nares
-ACE I held due to CKD
-Epogen 20-40K units q 2-4 wks for Hbg<10
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day): use in groin area and under breasts.
[**Hospital1 **]:*1 bottle* Refills:*0*
3. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
[**Hospital1 **]:*30 Tablet(s)* Refills:*2*
4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for CP: take up
to 3 tablets 5 miniutes apart for chest pain or indigestion.
Call Dr. [**Last Name (STitle) 84261**] if you take this medicine.
[**Last Name (STitle) **]:*30 Tablet, Sublingual(s)* Refills:*0*
5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
[**Last Name (STitle) **]:*30 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
[**Last Name (STitle) **]:*60 Capsule(s)* Refills:*2*
8. Clopidogrel 75 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): take Plavix 150 mg (double dose) until [**12-23**], then
decrease to 75 mg daily.
[**Month/Year (2) **]:*45 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
[**Month/Year (2) **]:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. Isosorbide Mononitrate 10 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
[**Month/Year (2) **]:*120 Tablet(s)* Refills:*2*
11. Ranitidine HCl 75 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Outpatient Lab Work
Please check chem-7 and monitor renal function. Please fax
results to your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 59323**] at [**Telephone/Fax (1) 64799**].
13. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
[**Telephone/Fax (1) **]:*30 Tablet(s)* Refills:*2*
14. Lantus 100 unit/mL Solution Sig: Seventeen (17) untis
Subcutaneous qam and qpm.
[**Telephone/Fax (1) **]:*1 vial* Refills:*2*
15. Insulin Lispro 100 unit/mL Solution Sig: according to scale
Subcutaneous qac: <100: none, 100-150: 2U,
151-200: 4U,
201-250: 6U,
251-300: 8U,
301-350: 10U,
351-400: 12U,
>401 [**Name8 (MD) 138**] MD.
[**Last Name (Titles) **]:*1 vial* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] regional VNA
Discharge Diagnosis:
Acute on chronic Renal Failure
Acute on chronic Systolic congestive Heart Failure
Insulin dependent Diabetes Mellitus
coronary artery disease
Hyperlipidemia
anemia on Fe
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 from an outside hospital after having
presented with chest pain and receiving a cardiac
catheterization which showed a very tight blockage in the main
artery that feeds blood to your heart. WE placed a drug eluting
stent in this artery and you will need to take Plavix 150 mg
(double dose) until [**12-23**], then decrease to 75 mg daily. You
need to take this every day for the rest of your life. Do not
stop taking Plavix unless Dr. [**Last Name (STitle) 11250**] tells you to. Your
kidney function deteriorated after the contrast during the
catheterization, they are improving now. You will need to have
your kidney function checked in a few days with results to Dr.
[**Last Name (STitle) 11250**].
Medication changes:
1. Increase Plavix to 150 mg daily until [**12-23**], then decrease to
75 mg daily for life.
2. Stop taking Lisinopril because of your kidney problems, Dr.
[**Last Name (STitle) 11250**] will restart this later
3. Increase your cholesterol medicine to 80 mg daily
(Simvastatin)
4. Take Imdur twice daily to prevent chest pain or indigestion
5. Continue lasix 40mg daily as previously to prevent excess
fluid
6. Your aspirin was increased to 325mg daily
7. Your insulin was changed to Lantus 17U in the morning and at
night. You will also follow a sliding scale with humolog insulin
for meals.
.
Check your weight daily before breakfast. Call Dr. [**Last Name (STitle) **] if
weight increases more than 3 pounds in 1 day or 6 pounds in 3
days.
Followup Instructions:
Cardiology:
[**Last Name (LF) **],[**First Name3 (LF) **]-[**Doctor First Name 10588**] S. Phone: [**Telephone/Fax (1) 11254**] Office will call
[**First Name5 (NamePattern1) 501**] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 84262**]) with an appt.
|
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"287.5",
"440.0",
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"244.9",
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icd9cm
|
[
[
[]
]
] |
[
"00.66",
"37.68",
"88.55",
"00.46",
"88.42",
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"00.41"
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icd9pcs
|
[
[
[]
]
] |
13685, 13749
|
7372, 10176
|
292, 333
|
13963, 13963
|
4232, 7349
|
15647, 15910
|
3139, 3254
|
11265, 13662
|
13770, 13942
|
10202, 11242
|
14140, 14860
|
3269, 4213
|
2466, 2545
|
14880, 15624
|
242, 254
|
361, 2358
|
13977, 14116
|
2576, 2883
|
2380, 2446
|
2899, 3123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,550
| 100,209
|
2057+55344+55345
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2155-7-22**] Discharge Date: [**2155-7-26**]
Service:
CHIEF COMPLAINT: Chest pain and shortness of breath
requiring BiPAP.
HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old
gentleman with a past medical history significant for
coronary artery disease with unrevascularized three-vessel
disease and ischemic cardiomyopathy with an ejection fraction
of 20% with also a history of VTs and sinus node dysfunction
and status post VT ablation and pacer ICD placement,
peripheral vascular disease, hypertension, and
hypercholesterolemia, who was admitted with acute onset of
substernal chest pain for one hour while at rest. The
patient reported associated symptoms of diaphoresis and
shortness of breath. The patient took six sublingual
nitroglycerins without relief and he was given Lasix 80 mg IV
en route to the Emergency Department. The patient refused
aspirin.
In the emergency room his heart rate was 96, blood pressure
194/88 and his oxygen saturation was 86% on a face mask,
which improved to 95% on BiPAP. Chest x-ray was consistent
with congestive heart failure and the EKG was uninterpretable
due to pacer. He was given aspirin, nitroglycerin and was
transferred to the coronary care unit where aggressive
diuresis was initiated for his congestive heart failure.
During his diuresis, he developed some abdominal pains and
laboratory studies showed an elevated amylase and lipase.
The patient is a poor historian, but reported vague abdominal
pain approximately two weeks ago when he went for a pacer
check with Dr. [**Last Name (STitle) **]. The patient in the coronary care
unit was given some gentle hydration in response to his acute
pancreatitis, and the patient was transferred to the floor
where his pancreatic enzymes were trending down, however he
developed a leukocytosis and a temperature to 101.1. On the
floor he was taking clear liquids without abdominal pain. He
denied any back or epigastric pain, but again the patient is
a very poor historian.
PAST MEDICAL HISTORY: 1. Coronary artery disease,
three-vessel disease in [**2150-3-8**]. He had a catheterization
that showed 30% stenosis of his LM and 30% of his PLAD and
30% of his D1. 2. Peripheral vascular disease, status post a
right iliofemoral bypass in [**10-9**] and status post
percutaneous transluminal coronary angioplasty of his left
iliac in [**7-9**]. 3. Ischemic congestive heart failure with an
ejection fraction of 20%. 4. History of VT sinus node
dysfunction, status post ablation and pacer placement in
[**2149**]. 5. Chronic obstructive pulmonary disease. 6. Chronic
renal insufficiency with a baseline creatinine of 2.1 to 3.6.
7. Hypertension. 8. Hypercholesterolemia. 9. History of
penile implant.
ALLERGIES: The patient states by report that he has no known
drug allergies, however review of computerized medical
records reports that he has an allergy to ACE inhibitors.
SOCIAL HISTORY: He is a previous smoker, 120-pack-year
history, quit 10 years ago, denies alcohol use, lives in [**Location 11206**], MA with his wife.
FAMILY HISTORY: His father died secondary to leukemia and
his mother died of liver disease; no further information was
provided.
MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg p.o. q.d. 2.
Lasix 80 mg p.o. q.d. 3. Isordil 30 mg p.o. q. day. 4.
Plavix 75 mg p.o. q. day. 5. Hydralazine 25 mg p.o. q. day.
6. Aspirin once a day.
PHYSICAL EXAMINATION: Vital signs on transfer to the floor
from the coronary care unit were temperature 101.2, blood
pressure 103/58, pulse 61, respiratory rate 28, and he was
saturating 95% on two liters. In general he was a confused
gentleman sitting in his chair in no apparent distress.
HEENT examination showed left pterygium, pupils minimally
reactive bilaterally. His oropharynx was clear. His mucous
membranes were dry. His neck was supple without jugular
venous distension. His chest had bilateral crackles one-half
way up the lung fields. His cardiac examination revealed a
2/6 systolic murmur best heard at the right upper sternal
border greater than the left upper sternal border. Abdominal
examination revealed positive bowel sounds, nontender with
palpation, and no tenderness in the epigastrium and right
upper quadrant with palpation. Extremities revealed no
edema. Neurologically, cranial nerves II-XII were grossly
intact. He had [**4-12**] right lower extremity strength, otherwise
5/5 strength in all extremities and his right lower extremity
was cooler than his left lower extremity.
LABORATORY DATA: On admission his white count was 17,
hematocrit 41, platelet count 781. Differential showed a
white blood cell count with 63.5 neutrophils, 26 lymphocytes,
7 monocytes, 3 eosinophils, 1 basophil. Sodium 139,
potassium 4.5, chloride 103, bicarbonate 24, BUN 38,
creatinine 3.0, glucose 155. He had a calcium of 9.1, a
magnesium of 2.2 and a phosphorous of 4.5. He had an INR of
1.1, a PTT of 24.0.
Laboratory studies on admission to the floor showed a white
count elevated to 21.3, hematocrit 36.6, sodium 139,
potassium 4.2, chloride 100, bicarbonate 26, BUN 48,
creatinine 3.2 and a glucose of 123. He had a phosphorous of
4.0 and a magnesium of 2.1. He had an ALT of 18, an AST of
24 and alkaline phosphatase of 84. His amylase, three
values, from 442 to 911 to 424; lipase 882 to 946 to 166.
His total bilirubin was 1.0. He had cardiac enzymes drawn, a
set of three, showing troponins 0.01, 0.04 and 0.03. The
patient also had an MCV of 63, a TIBC of 442, which was
elevated, and a ferritin of 11, which is increased.
HOSPITAL COURSE: 1. Pancreatitis: The patient had
experienced initial symptoms of abdominal pain while in the
coronary care unit during aggressive diuresis. An ultrasound
of the liver and gallbladder showed a gallbladder with stones
and sludge. There was no acute cholecystitis. There was a
nondilated biliary tree. He had an atrophic left kidney and
there was a limited view of the pancreas. To obtain better
imaging, we obtained an abdominal and pelvis CT without
contrast concerning his chronic renal insufficiency that
showed inflammation of his pancreas. The patient was
tolerating clears and then a full diet while on the floor
without abdominal pain. The patient's pain control was
purely on a p.r.n. basis. There were no standing medications
provided. We believe that his pancreatitis was secondary to
transient passage of gallstones. GI consult was not
appropriate at this time because the onset of his pain had
been for more than 24 hours, thus sphincterotomy was not
indicated.
2. Congestive heart failure: The patient was weaned off
oxygen and on the day before discharge he had an O2
saturation of 93% on room air. The patient's lung
examination improved with diminished crackles in both lungs.
The patient was kept off his diuretics while in the hospital
secondary to his chronic renal insufficiency, but more
importantly, secondary to his acute pancreatitis and his
fluid balance. The patient will be discharged on a smaller
dose of Lasix. He originally came in on 80 p.o. q. day and
will be discharged on 40 p.o. q. day with follow up with his
primary care physician in regards to adjustment of his Lasix
dosage.
3. Leukocytosis: The patient experienced an increase in his
white count from 17.0 to 21.3 with a bandemia once he was
transferred to the floor with neutrophils to 88. The patient
did have a left shift in a differential blood count that was
received while the patient was on the floor, with 88
neutrophils. We believe his leukocytosis is related to a
urinary tract infection. Urine cultures are pending, however
two urinalyses were consistent with a urinary tract infection
with elevated white blood cells and bacteria. The patient in
response to this was treated with levofloxacin 250 mg p.o. q.
48 hours for a total of seven days. This is the renal dosing
for levofloxacin. He will be discharged on this medication
to complete his course of therapy.
4. Chronic obstructive pulmonary disease: The patient was
given metered dose inhalers p.r.n. for his chronic renal
insufficiency. His creatinine was at the higher end of his
baseline and for his coronary artery disease we obtained
pressure control with hydralazine and rate control with
amiodarone.
5. Anemia: The patient has a microcytic anemia that is
consistent with iron deficiency anemia. He was started on
ferrous sulfate 325 mg while in the hospital and a hemoglobin
electrophoresis was sent out for analysis of possible
thalassemia.
CONDITION ON DISCHARGE: Fair.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Pancreatitis.
3. Urinary tract infection.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Amiodarone 200 mg p.o. q. day.
3. Hydralazine 10 mg p.o. q. 6 hours.
4. Iron 325 mg p.o. q. day.
5. Levofloxacin 250 mg p.o. q. 48 hours for a total of seven
day.
6. Clopidogrel 75 mg p.o. q. day.
7. Protonix 40 mg p.o. q. day.
8. Isosorbide dinitrate 30 mg p.o. q. day.
FOLLOW-UP PLANS: He is to call his primary care physician,
[**Last Name (NamePattern4) **]. [**Last Name (STitle) 6680**] for follow up in the next two weeks.
DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-953
Dictated By:[**Last Name (NamePattern1) 11207**]
MEDQUIST36
D: [**2155-7-25**] 17:53
T: [**2155-7-29**] 15:09
JOB#: [**Job Number 11208**]
Name: [**Known lastname 1563**], [**Known firstname **] Unit No: [**Numeric Identifier 1564**]
Admission Date: [**2155-7-22**] Discharge Date: [**2155-7-25**]
Date of Birth: [**2072-12-18**] Sex: M
Service: CMI
ADDENDUM: This is an addendum to job number [**Job Number 1565**]. Please
make change to post discharge medications. The patient is
not being discharged on hydralazine 10 mg p.o. q. six.
Instead, he is being discharged on hydralazine 25 mg p.o.
q.d.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**], M.D. [**MD Number(1) 1549**]
Dictated By:[**Last Name (NamePattern1) 1566**]
MEDQUIST36
D: [**2155-7-25**] 05:58
T: [**2155-7-25**] 22:26
JOB#: [**Job Number 1567**]
Name: [**Known lastname 1563**], [**Known firstname **] Unit No: [**Numeric Identifier 1564**]
Admission Date: [**2155-7-22**] Discharge Date: [**2155-7-29**]
Date of Birth: [**2072-12-18**] Sex: M
Service:
ADDENDUM: The patient remained in the hospital secondary to
an elevated white blood cell count with a white blood cell
count in the low 20,000. The patient did have one episode of
fever to a temperature of greater than 101.4 which was
approximately three days prior to discharge. Besides that
one episode, the patient remained afebrile.
We believe the leukocytosis to be possibly related to a
continuing urinary tract infection or Clostridium difficile
infection, possible pyelonephritis with a new right-sided
flank pain, or secondary to resolving pancreatitis.
The patient was started on Flagyl and was continued on his
levofloxacin. On the day of discharge, the patient had a
decrease in his white blood cell count from 24.3 to 22.9. He
remained afebrile, and he was discharged with completing a
7-day course of levofloxacin and a 14-day course of Flagyl
for presumed Clostridium difficile.
In terms of his second issue of pancreatitis, his amylase and
lipase had completely resolved with his values on the day of
discharge with an amylase of 35 and lipase of 39. The
patient was taking oral intake without difficulty. He denied
any abdominal, epigastric, or back pain. We believed his
pancreatitis to be related to transient gallstones in the
setting of an elevated alkaline phosphatase, lactate
dehydrogenase, and glutamyltransferase. It was recommended
that the patient follow up with a gastroenterologist as an
outpatient for evaluation of possible endoscopic retrograde
cholangiopancreatography and sphincterotomy.
In terms of his congestive heart failure, the patient did
have continued left basilar rales during the rest of his
hospital stay; however, his breathing was at baseline and he
was saturating well 97% to 98% oxygen saturations on room
air. The patient was maintained on 20 mg of Lasix and was
discharged on 40 mg of Lasix. His home dose prior to this
admission was 80 mg of Lasix p.o. once per day.
In terms of his fourth issue of iron deficiency anemia, the
patient was continued on ferrous sulfate 325 mg p.o. once per
day. He had a microcytic anemia, and hemoglobin
electrophoresis studies were sent off for possible evaluation
of thalassemia.
MEDICATIONS ON DISCHARGE: (The patient was discharged on the
following medications)
1. Aspirin 325 mg p.o. once per day.
2. Amiodarone 200 mg p.o. once per day.
3. Furosemide 20 mg p.o. once per day.
4. Ferrous sulfate 325 mg p.o. once per day.
5. Levofloxacin 250 mg p.o. q.48h. (for a total of seven
days).
6. Clopidogrel 75 mg p.o. once per day.
7. Protonix 40 mg p.o. once per day.
8. Isosorbide dinitrate 30 mg p.o. once per day.
9. Hydralazine 25 mg p.o. once per day.
10. Metronidazole 500 mg p.o. three times per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was arranged
for follow-up care with his primary care doctor (Dr.
[**Last Name (STitle) **].
DISCHARGE STATUS: The patient was discharged to home with
physical therapy and [**Hospital6 1346**].
DR.[**First Name (STitle) 684**],[**First Name3 (LF) 448**] 12-953
Dictated By:[**Name8 (MD) 1568**]
MEDQUIST36
D: [**2155-7-29**] 14:38
T: [**2155-7-29**] 16:36
JOB#: [**Job Number 1569**]
|
[
"577.0",
"008.45",
"599.0",
"428.0",
"401.9",
"414.8",
"496",
"272.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
3098, 3212
|
8589, 8664
|
8687, 8993
|
12617, 13138
|
3239, 3416
|
5601, 8536
|
13172, 13607
|
3439, 5583
|
9011, 12590
|
102, 155
|
184, 2017
|
2040, 2927
|
2944, 3081
|
8561, 8568
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,972
| 180,542
|
45923
|
Discharge summary
|
report
|
Admission Date: [**2178-9-10**] Discharge Date: [**2178-9-17**]
Date of Birth: [**2103-12-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vioxx / Celebrex / Lasix
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Intubated
Arterial Line
History of Present Illness:
74F morbid obese, history of severe COPD, obesity
hypoventilation syndrome, obstructive sleep apnea, diabetes,
hypertension, diastolic heart failure with recent diuretic
initiation and hypothyroidism BIBA from nursing home with
shortness of breath, depressed mental status. Her pOx was
reported to be 60 % on 2L NC and 90 % on 15L O2 NRB in triage.
She was scheduled to have ICU sleep study on Monday to titrate
O2/CO2 use due to severe OHVS. She was having a few day history
of cough - but uncertain if productive or not.
.
In the ED, initial vs were: 70 22 90% 15L nrb
She was initially tried on NIPPV in ER (15/10) but ABG
suggestive of hypercapneic respiratory failure (pH 7.16 pCO2 122
pO2 102 HCO3 46). She was also placed on nitro gtt. Given
declining mental status and ABG, she was intubated by anesthesia
secondary to obesity without complications with usage of
etomidate 8, succinycholine 120. She experienced brief period of
hypotenstion to SBP 80s after intubation in setting of
fentanyl/versed. She was noted to have thick secretions. She was
given 250 mL NS bolus x 1 with resultant pressure of SBP 103/49.
Repeat ABG pH 7.36 pCO2 70, pO2 161, HCO3 41 .
CXR performed showing mild to moderate congestive heart failure
with small bilateral pleural effusions and bibasilar airspace
opacities, possibly infection or atelectasis.
She was placed on vancomycin, cefepime, levofloxacin for
questionable pulmonic process on CXR. She was given bumex 1 mg
IV x 1 with poor urine output. Labs significant for WBC 17.5
with 78% N, 10 % L, Myelos 2 %, Cr 1.2 (baseline 0.8), HCO3 41
(baseline low to mid 30s), lactate 0.8. Blood cultures are
pending.
She was admitted for respiratory failure with possible component
of CHF vs. pneumonia and OHVS.
Past Medical History:
#. ?COPD/Restrictive disease due to obesity
- Recent admission [**Date range (1) 97789**] to MICU for COPD exacerbation
#. Hypertension
#. Diabetes mellitus - diet-controlled
#. Obstructive sleep apnea on BiPAP 15/? at home
#. Obesity hypoventilation syndrome
#. CHF
#. Hypothyroidism
#. Hypercholesterolemia
#. morbid obesity
#. osteoarthritis
#. gout
#. depression
#. GERD
Social History:
She has been non ambulatory since [**2175**]. Currently lives in
nursing home. 30-40 ppd smoking history; quit [**2156**]. No EtOH,
IVDU, or illicit drugs. Patient is not sexually active. Does not
excercise regularly.
Family History:
Mother with HTN
Physical Exam:
Admission Exam:
General Appearance: No acute distress
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic, Endotracheal tube
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: Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right lower extremity edema: Trace, Left lower
extremity edema: Trace
Skin: Warm
Neurologic: Responds to: Not assessed, Movement: Not assessed,
Sedated, Tone: Not assessed
Discharge Exam:
VS: 96.6 131/43 66 18 97%BIPAP
I/O: [**Telephone/Fax (1) 97791**]
GENERAL: morbidly obese woman in NAD, comfortable, appropriate,
immobolized in bed.
HEENT: PERRLA, EOMI, sclerae anicteric, dry MM
NECK: Supple, no JVD, no carotid bruits.
HEART: RRR, no MRG
LUNGS: decreased BS, CTAB.
ABDOMEN: Soft/mildly tender/ND, loud BS
EXTREMITIES: WWP, +1 edema
NEURO: Awake, A&Ox3, non-focal
Pertinent Results:
Admission Labs:
[**2178-9-10**] 04:40PM BLOOD WBC-17.5* RBC-4.12* Hgb-11.1* Hct-37.8
MCV-92 MCH-27.0 MCHC-29.4* RDW-18.4* Plt Ct-272
[**2178-9-10**] 04:40PM BLOOD Neuts-78* Bands-4 Lymphs-10* Monos-2
Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2178-9-10**] 04:40PM BLOOD PT-14.4* PTT-33.5 INR(PT)-1.2*
[**2178-9-10**] 04:40PM BLOOD Glucose-131* UreaN-36* Creat-1.2* Na-141
K-4.8 Cl-97 HCO3-41* AnGap-8
[**2178-9-10**] 06:02PM BLOOD Type-ART pO2-101 pCO2-122* pH-7.16*
calTCO2-46* Base XS-9
[**2178-9-10**] 04:51PM BLOOD Lactate-0.8
CEs:
[**2178-9-11**] 04:00AM BLOOD CK-MB-2 cTropnT-0.06*
[**2178-9-12**] 01:52AM BLOOD CK-MB-4 cTropnT-0.03*
ABGs:
[**2178-9-15**] 02:02AM BLOOD Type-ART pO2-129* pCO2-84* pH-7.29*
calTCO2-42* Base XS-10 Intubat-NOT INTUBA
Discharge Labs:
Reports:
[**9-12**] CTA: IMPRESSION:
1. No evidence of PE to the segmental level; no evidence of
aortic intramural hematoma or aortic dissection.
2. Moderate atelectasis of the right lower lobe and mild
atelectasis of the left lower lobe with small bilateral pleural
effusions.
3. Enlarged epicardial lymph node - 3 month follow-up is
recommended after
resolution of the current acute illness.
.
Shoulder x-ray ([**2178-9-17**]): per discussion with radiologist via
phone.
Severe degenerative changes in joing space between glenoid &
humerus, indicative of severe osteoarthritis. Also patient's
humerus is sitting high in joint space and could be indicative
of a rotator cuff injury. No fractures.
Brief Hospital Course:
74F morbid obese, history severe COPD, obesity hypoventilation
syndrome, obstructive sleep apnea, DM, HTN, dCHF, hypothyroidism
presenting with hypercarbic respiratory failure. She was
initially intubated for respiratory failure and hypercarbia but
was weaned, extubated and started on shovel mask with good
result.
.
# Hypercarbic respiratory failure: Likely multifactorial from
central apnea/ hypoventilation, COPD, ?pulmonary edema from CHF
exacerbation. ABG suggestive of reversible component with
ventilation. She was initially intubated, extubated easily and
successfully treated with BIPAP. She received a sleep study that
showed hypoventilation (C02 75-85) with oxygen-responsive
hypoxia. However, the patient had difficulty of air leak around
her mouth throughout the night. Even with air leak, CO2
continued to improve from 85 to 75. Oxygen saturations remained
88-93% on 50% face shovel. Patient's home BIPAP settings were
changed to 18/8 and she has been stable with these treatments.
-upon arrival to the floor, Patient's daytime requirement was
weaned to baseline of 2.5L NC.
.
# Leukocytosis: The patient was admitted with a mild
leukocytosis. CXR did not suggest discrete infiltrate. UA was
clean, pan cultures were negative. The patient received
vancomycin, cefepime, and levofloxacin on admission.
Antibiotics were discontinued with the absence of evidence of
infection. The patient's leukocytosis improved.
.
# new MRSA + status: While patient did not have pneumonia, she
was screened for MRSA and is found to be MRSA positive.
.
# Acute on chronic diastolic heart failure exacerbation - On
admission, CXR showed increased markings compatible with
possible CHF exacerbation. She was ruled out for MI by EKG and
cardiac enzymes. She received bumex in ER with unknown urine
output. On admission, diuresis was held due to elevated
creatinine. With improvement in renal function, patient was
given bumex 50 mg x 1, with good response.
-after arrival to the floor, patient was restarted on Toprol 50
XL daily & Bumex 1mg [**Hospital1 **].
.
# Shoulder pain - upon arrival to the floor, patient described
worsening of pain in L shoulder. Plain film of shoulder shows
osteoarthritis and possible rotator cuff injury. Pain was
controlled with Naproxen 250mg PO BID.
.
# CT finding: Patient had a chest CT in the ICU that should an
incidental epicardial lymph node which needs to be followed up
on by PCP as outpatient. Patient will need PCP to [**Name9 (PRE) 97792**] with
CT in 3 months and to follow up with patient on results.
.
# Acute renal failure - The patient was admitted with Cr 1.2
(baseline Cr 0.8). [**Last Name (un) **] on admission likely due to ATN in the
setting of hypovolemia. Blood pressures normalized and her
creatinine returned to baseline.
.
# COPD - Chronic. Patient did not have evidence of active flare
throughout admission. She was continued on duonebs. Advair was
held while intubated, but was restarted following extubation.
.
# Obesity hypoventilation syndrome and OSA - Patient underwent
sleep consult and sleep study in the ICU. Sleep recommended
BIPAP 18/8 with Mirage large face mask and chin strap
.
# DM - Chronic. Patient was maintained on insulin sliding scale
throughout admission.
.
# HTN - Anti-hypertensives held on admission in the setting of
mild hypovolemia. Patient's blood pressure returned to baseline
and she was restarted on home antihypertensives.
# Hypothyroidism - Chronic. Patient was continued on
levothyroxine.
.
# Gout - Chronic. Patient was continued on allopurinol
# Depression - Chronic. Patient was continued on bupropion,
paroxetine
# Neuropathy - Gabapentin held on admission.
.
# Code status: FULL
Medications on Admission:
From webOMR - unable to confirm
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth twice a day
AMLODIPINE - (Prescribed by Other Provider) - 5 mg Tablet - 1
Tablet(s) by mouth daily
BIPAP - - BIPAP 15/5 daily
BUPROPION HCL [WELLBUTRIN] - 100 mg Tablet - 1 Tablet(s) by
mouth
three times a day
ELECTRIC HOSPITAL BED - - One electric hospital bed
FLUTICASONE - (Prescribed by Other Provider) - 50 mcg Spray,
Suspension - 2 sprays daily
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose
Disk
with Device - 1 puff inh twice a day
GABAPENTIN - (Prescribed by Other Provider) - 300 mg Capsule -
1
Capsule(s) by mouth nightly
IPRATROPIUM-ALBUTEROL - (Prescribed by Other Provider) - 0.5
mg-3 mg (2.5 mg base)/3 mL Solution for Nebulization - 1 every
six (6) hours
LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth daily
PAROXETINE HCL - 40 mg Tablet - one Tablet(s) by mouth once a
day
TOBRAMYCIN-DEXAMETHASONE - 0.3 %-0.1 % Drops, Suspension - 1
drop(s) left eye three times a day
ACCU-CHEK - Strip - 2-3 TIMES A DAY FOR BLOOD GLUCOSE
MONITORING, DX; DIABETES
ASCORBIC ACID [VITAMIN C] - 500 mg Tablet - 1 Tablet(s) by mouth
once a day
ASPIRIN - (OTC; medication reconciliation) - 81 mg Tablet,
Delayed Release (E.C.) - 1 tablet daily
BISMUTH SUBSALICYLATE [MAALOX TOTAL RELIEF (BISMUTH)] -
(Prescribed by Other Provider) - Dosage uncertain
COLACE - 100MG Capsule - TAKE ONE PILL BY MOUTH QD-[**Hospital1 **]
MAGNESIUM HYDROXIDE [MILK OF MAGNESIA] - (Prescribed by Other
Provider) - Dosage uncertain
SENNOSIDES [SENNA] - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
a
day
SIMETHICONE - (Prescribed by Other Provider) - Dosage uncertain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. acetazolamide 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
7. bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
9. bumetanide 1 mg Tablet Sig: One (1) Tablet PO twice a day.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
12. ipratropium bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
14. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
15. paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO once a
day.
16. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily) as needed for constipation.
18. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
19. naproxen 250 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Rehab & Nursing Home
Discharge Diagnosis:
Hypercarbic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Discharge Instructions:
It was a pleasure taking care of you at the [**Hospital1 771**]. You were seen and evaluated for
symptoms of shortness of breath, decreased oxygen, and changes
in mental status. These symptoms were likely due to a number of
reasons including chronic conditions of sleep apnea, COPD, heart
failure, and decreased breathing. You were initially treated in
the ICU and then transferred to the medicine floor as you
stabilized. Changes were made to your BIPAP machine settings,
the mask you wear when you sleep to optimize your oxygenation.
You will follow up with the sleep doctors [**First Name (Titles) **] [**Last Name (Titles) 3816**] [**2178-10-6**] at
9am as an outpatient.
.
The following changes have been made to your medications:
--START acetazolamide 250mg by mouth twice daily
--START Naproxen 250mg by mouth twice daily for osteoarthritis
.
Continue all your other medications as previously prescribed.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You have the following appointment:
Department: MEDICAL SPECIALTIES
When: [**Name8 (MD) **] [**2178-10-6**] at 9:00 AM
With: DR. [**Last Name (STitle) **] / DR. [**Last Name (STitle) 3172**] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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icd9pcs
|
[
[
[]
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12491, 12563
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5376, 9072
|
328, 353
|
12639, 12639
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3880, 3880
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|
4654, 5353
|
2822, 3453
|
3469, 3861
|
281, 290
|
381, 2139
|
3897, 4637
|
12654, 12752
|
2161, 2538
|
2554, 2774
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,713
| 108,569
|
1689+55306
|
Discharge summary
|
report+addendum
|
Service: Date: [**2191-8-29**]
Date of Birth: [**2120-9-30**] Sex: M
Surgeon: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 9739**]
HISTORY OF THE PRESENT ILLNESS: This is a 70-year-old male
who presented with epigastric pain for several hours. The
pain migrated to the right upper quadrant. There no was
nausea, vomiting, or prior episodes.
PAST MEDICAL HISTORY:
1. History revealed brain metastasis secondary to renal
carcinoma.
2. Renal carcinoma, status post left nephrectomy [**2188-10-14**].
3. Status post MI, [**2181**].
MEDICATIONS:
1. Dilantin 200 mg p.o.b.i.d.
2. Lipitor 10 mg q.d.
3. Folic acid.
SOCIAL HISTORY: The patient is a former smoker. No alcohol.
PHYSICAL EXAMINATION: Examination revealed the temperature
of 97.3, heart rate 87, blood pressure 135/69, and
respiratory rate 20. The patient was alert, oriented times
three. CHEST: Chest was clear to auscultation. CARDIAC:
Regular rate and rhythm. ABDOMEN: Protuberant, right upper
quadrant tenderness, voluntary guarding, tap tenderness.
RECTAL: Guaiac negative.
LABORATORY DATA: Labs revealed the white count of 7.7;
hematocrit 37; platelets 224; sodium 139; potassium 4.8;
chloride 104; bicarbonate 28; BUN 19; creatinine .9; glucose
101; CK 27. Abdominal ultrasound revealed distended
gallbladder with stones. A son[**Name (NI) 493**] [**Name (NI) **] sign was
present. No wall thickening. Common bile duct was 7-mm. No
pericholecystic fluid.
HOSPITAL COURSE: The patient was admitted and started on
antibiotics and made NPO. On [**8-24**], the patient went
to the operating room to have a laparoscopic cholecystectomy
performed. The procedure was converted to an open
cholecystectomy. Postoperatively, he was started on
Lopressor 5 mg IV q.6h.; Levofloxacin; Flagyl for three
doses; and subcutaneous Heparin.
On [**8-25**], during the evening, Mr. [**Known lastname 9740**] was found
nonarousable. He became agitated and responded to Narcan.
Due to this episode, the patient was transferred to the
Intensive Care Unit for monitoring. He was rule out for MI
by cardiac enzymes. Chest x-ray revealed small bilateral
pleural effusion. An EKG revealed no acute ST and W changes.
On [**2191-8-26**], due to some shortness of breath, a VQ
scan was obtained, which revealed low probability. Lower
bilateral Doppler ultrasound was also obtained, which showed
no evidence of deep venous thrombosis.
Mr. [**Known lastname 9740**] became alert and oriented later on
[**8-26**], [**2190**]. The O2 saturation was 94% on 10 liter
face mask.
On [**8-27**], he was transferred to the floor. Repeat
white count was 9.3. A regular diet was started, which was
tolerated well. The oxygen saturation was 93% on four
liters.
On [**8-29**], [**2190**], Mr. [**Known lastname 9740**] was ready for discharge.
It was found that he was still dependent on O2 to maintain
his saturations above 90 on room air. Also, his ambulation
was slightly unsteady. It was thus felt that he should go to
a rehabilitation facility.
CONDITION ON DISCHARGE: Stable.
DISPOSITION: Rehabilitation Facility.
DISCHARGE STATUS: Mr. [**Known lastname 9740**] will followup with Dr. [**Last Name (STitle) 1305**]
in 10 to 14 days. He will go to a rehabilitation facility
with oxygen. Also, the Department of Physical Therapy will
work with him to improve his ambulation.
DISCHARGE MEDICATIONS:
1. Atenolol 50 mg p.o.q.d.
2. Percocet 1-2 tablets p.o.q.4-6h.p.r.n. pain.
3. Dilantin 200 mg p.o.b.i.d.
4. Lipitor 10 mg p.o.q.d.
5. Folic acid.
6. Combivent two puffs q.i.d.
7. Oxygen.
DISCHARGE DIAGNOSIS:
Cholecystitis.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] L. 02-164
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2191-8-29**] 12:38
T: [**2191-8-29**] 12:45
JOB#: [**Job Number 9741**]
Name: [**Known lastname 1318**], [**Known firstname 1319**] [**Known firstname 201**] Unit [**Name2 (NI) **]: [**Numeric Identifier 1320**]
Admission Date: [**2191-8-23**] Discharge Date:
Date of Birth: [**2120-9-30**] Sex: M
Service: Surgery
ADDENDUM: This is an addendum to the dictation of
Mr. [**Known lastname **]. He was discharged to rehabilitation on
[**2191-8-30**]. It was decided at that time that he did
not like the rehabilitation facility, and he came back to
[**Hospital1 536**].
At the hospital he had no events, and the course was
unremarkable. His oxygen saturation was 96% on room air. He
was discharged home with visiting nurses and home physical
therapy in stable condition. He was to follow up with
Dr. [**Last Name (STitle) **] in 10 to 14 days.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1255**], M.D. [**MD Number(1) 1256**]
Dictated By:[**Name8 (MD) 1321**]
MEDQUIST36
D: [**2191-8-31**] 09:33
T: [**2191-8-31**] 10:50
JOB#: [**Job Number 1322**]
(cclist)
|
[
"574.00",
"V10.52",
"198.3",
"V64.4",
"427.89",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.22"
] |
icd9pcs
|
[
[
[]
]
] |
3603, 3798
|
3819, 5145
|
434, 694
|
711, 3218
|
3243, 3580
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
940
| 111,612
|
8686
|
Discharge summary
|
report
|
Admission Date: [**2194-6-19**] Discharge Date: [**2194-6-25**]
Date of Birth: [**2131-4-19**] Sex: F
Service: MEDICINE
Allergies:
Cyclophosphamide
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
transient CP found to be hypotensive with evidence of UTI -->
code sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63f with cholangiocarcinoma and metastatic RCC with known liver
involvement who presented to ED with c/o CP found to be
hypotensive and jaundice. Pt reports 4 days of worsening
jaundice and abdominal pain. Pain is poorly described without
clear localization. Pt with worsening N/V and ability to
tolerate PO. Most recent BM several days ago was normal in color
without evidence of bleeding. No hematemesis. No
dysuria/frequency/urgency. Pt describes a 30 minute episode of
CP in the setting of nausea that resolved on its own. No
associated SOB. No DOE. No LE Edema. Mild dry/unproductive
cough. No fever/chills/sweats. Upon arrival in the ICU, Pt feels
a better after getting IVF.
.
ED Course: Triaged as urosepsis for which a central line was
placed and aggressive hydration initiated. Initial lactate 4.4
improved to 2.0 after 4 liters of NS. ABx -> Levo/Flagyl. Given
BB and ASA for CP protocol and became transiently hypotensive.
Pt admitted to [**Hospital Unit Name 153**] from ED with concerns of sepsis.
Past Medical History:
-? Cholangiocarcinoma
-Metastatic RCC: Dx [**2193**]. Pt not tx candidate, being seen by
hospice.
-HTN
-DM2
-CAD: Small fixed and reversible defects in [**2193**]
-CHF: [**2193**] echo with impaired relaxation, lvh, normal lvef
-COPD
-Pul fibrosis
-HCV
-Gout
-RA
Social History:
Lives at home with husband. [**Name (NI) 669**]. Former nursing aid. Smoked
for 40 yrs, quit 12 yrs ago. Has home health aide and VNA;
refused hospice.
Family History:
Mother with DM, father with CAD
Physical Exam:
gen- fatigued, jaundiced but comfortable
heent- PERRL, EOMI, icteric, op wnl, dry MM
neck- no jvd/lad; L-IJ in place
cv- rrr, s1s2, no m/r/g
pul- fair air movement
abd- soft, ND, diffuse tenderness worse RUQ. with + HM, no
rebound, no [**Doctor Last Name **] present, hypoactive BS
extrm- R>L 1+ nonpitting LE edema (chronic), WWP, ra changes in
hands/feet
neuro- a&ox3, no focal cn deficits, appropriate,
strength/sensation grossly intact
Pertinent Results:
ADMISSION LABS:
[**2194-6-19**] 03:45PM BLOOD WBC-1.3* RBC-4.52 Hgb-12.2 Hct-36.7
MCV-81* MCH-27.0 MCHC-33.3 RDW-22.4* Plt Ct-399
[**2194-6-19**] 03:45PM BLOOD Plt Smr-NORMAL Plt Ct-399
[**2194-6-19**] 05:10PM BLOOD PT-13.7* PTT-20.8* INR(PT)-1.2*
[**2194-6-19**] 05:10PM BLOOD Glucose-151* UreaN-61* Creat-2.2*# Na-138
K-3.9 Cl-93* HCO3-28 AnGap-21*
[**2194-6-19**] 05:10PM BLOOD ALT-9 AST-64* CK(CPK)-31 AlkPhos-288*
Amylase-18 TotBili-16.3*
[**2194-6-19**] 05:10PM BLOOD Lipase-11
[**2194-6-19**] 05:10PM BLOOD CK-MB-NotDone cTropnT-0.06*
[**2194-6-21**] 04:00AM BLOOD Albumin-2.3* Calcium-8.6 Phos-3.9 Mg-1.8
[**2194-6-19**] 05:10PM BLOOD Calcium-9.1 Phos-4.4 Mg-1.5*
[**2194-6-19**] 05:10PM BLOOD Cortsol-41.9*
[**2194-6-20**] 04:15AM BLOOD Cortsol-20.1*
[**2194-6-19**] 05:10PM BLOOD CRP-51.3*
[**2194-6-19**] 03:49PM BLOOD Lactate-4.4*
[**2194-6-19**] 07:45PM BLOOD Lactate-2.2*
[**2194-6-19**] 08:58PM BLOOD Lactate-2.0
[**2194-6-20**] 04:58AM BLOOD Lactate-1.4
[**2194-6-19**] 4:30 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2194-6-21**]**
URINE CULTURE (Final [**2194-6-21**]):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
IMAGING:
[**6-19**]: Liver US: 1. Multiple heterogeneous masses in the liver,
representing known cholangiocarcinoma. Bilateral mild
intrahepatic ductal dilation. 2. Sludge in gallbladder, and
possibly in CBD.
.
MRCP:
1. Widespread liver metastases, with findings more suggestive of
cholangiocarcinoma than metastatic renal cell cancer.
2. Findings consistent with extrinsic compression of the
extrahepatic common hepatic duct by a large metastasis in the
caudate lobe, including associated intrahepatic biliary ductal
dilatation.
3. Smooth appearance of the intra- and extra-hepatic ducts
without strictures or areas of focal abnormality.
4. Layering sludge within the gallbladder, but no evidence of
sludge or stones in the bile ducts.
5. Low signal lesion in the left kidney, previously
characterized as most likely representing a renal cell
carcinoma.
.
Renal US: No hydronephrosis. This cystic structure projected
within the renal sinus on some of the sagittal images is
consistent with the previously known large renal cyst. No
definite hydronephrosis. The urinary bladder was empty on
account of Foley catheter.
.
CXR on admission: Consolidation in bilateral lower lobes, which
may represent pneumonia or aspiration superimposed upon
underlying chronic lung disease. A component of pulmonary edema
is also possible. (FINAL READ CHANGED FROM THE PREVIOUSLY
WRITTEN PRELIM READ: The cardiac and mediastinal contours are
unchanged compared to the prior study. Note is made of increased
faint opacities in left lower lobe, with interstitial opacities,
which may represent pulmonary edema, however, superimposed
pneumonia especially in left lower lobe is also a possibility if
the patient has infectious symptoms. Note is made of opacity in
right lower lobe as well, which may represent atelectasis versus
pneumonia. Possible small pleural effusion is seen. Lung volumes
are small due to low inspiratory level. Note is made of somewhat
prominent colon gas with elevated left diaphragm.)
.
DISCHARGE LABS:
Brief Hospital Course:
# ? Sepsis: On admission the pt was noted to have a lactate of
>4, tachycardia, hypotension and a UA that was suggestive of
infection. Later, the urine culture grew GNR. The preliminary
read of the patient's CXR was atelectasis, however, subsequent
read suggested bibasilar infiltrates that could be consistent
with pneumonia. Initially the Biliary tree was suspected to be
another possible source of infection. Following MRCP, it was
felt that this was less likely. On arrival to the ICU, the pt
was afebrile without tachycardia or tachypnea. The lactate
improved with IVF. The pt was treated with Zosyn and was
initially on the sepsis protocol with a central line. The
sepsis protocol was discontinued on HD#2 as the pt was afebrile
with stable vital signs. Zosyn was continued to cover uti,
possible cholangitis (though unlikely), and possible aspiration
pneumonia.
.
# Jaundice: The pt had a bilirubin that was elevated markedly
from baseline, though alkaline phosphatase remained only
somewhat elevated from baseline. This raised concer for
extrinsic compression of the biliary tree from tumor. MRCP was
obtained and showed extrinsic compression from a mass in the
caudate lobe of the liver. It was felt that it would be
possible to stent this open via ERCP if the patient so desired.
.
# ARF: FENA was low, renal US was negative for hydronephrosis.
Creat decreased in the ICU from 2.2 to 1.7 with hydration.
(Baseline 1.0)
.
# ONC: Peripheral Cholangio-CA and Met RCC. Not a therapeutic
candidate. There were
.
# CAD: CP was not felt to be cardiac in nature. The pt had a
fixed defect on MIBI but initial enzymes were negative by CK.
ASA and BB were held in the ICU. Atorvastatin was continued.
.
# CHF: reported EF 50-65% ([**2192**]). Diuretic and Aldactone were
held given volume status and ARF.
.
# HTN: as above held anti-HTN
.
# Pain control: One of the patient's main complaints was pain.
She described diffuse pain that was bothersome constantly. She
was continued on her home dose of fentanyl patch. She became
nauseated and did not tolerate her oxycontin. Morphine worsened
her nausea. Dilaudid was used in conjunction with anzemet with
good result.
.
# COPD/pulm fibrosis: Felt to be stable. Nebs were used as
needed and azathioprine was held until creatinine decreased to
normal range.
.
Pt was transferred to the [**Hospital Unit Name 153**] on [**6-24**], required pressors and
IVFs to maintain pressure. Pt became progressively more
dyspneic and after extensive discussion with the family, the
patient was made comfort care only. Pt expired on [**6-25**] at 1700.
Family was present and requested an autopsy
Medications on Admission:
Bumetanide 3mg [**Hospital1 **]
ASA 325
Aldactone 25 qd
Lipitor 20
Protonix 40
Toprol XL 25
KCL 180 MEq [**Hospital1 **]
Colace
Ambien 10mg qhs
Azathioprine 10mg qd
Oxycodone 5mg q4hr prn
Discharge Medications:
n/a
Discharge Disposition:
Extended Care
Discharge Diagnosis:
urosepsis
pneumonia
cholangiocarcinoma
Discharge Condition:
expired
Discharge Instructions:
n/a
Followup Instructions:
n/a
Completed by:[**2194-6-25**]
|
[
"584.9",
"414.01",
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"189.0",
"401.9",
"155.1",
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"515",
"591",
"070.54",
"428.0",
"496",
"274.9",
"197.7",
"576.1",
"250.00"
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icd9cm
|
[
[
[]
]
] |
[
"51.85",
"45.13",
"51.11",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9160, 9175
|
6241, 8893
|
351, 357
|
9258, 9267
|
2380, 2380
|
9319, 9353
|
1871, 1904
|
9132, 9137
|
9196, 9237
|
8919, 9109
|
9291, 9296
|
6218, 6218
|
1919, 2361
|
238, 313
|
385, 1399
|
2396, 5335
|
5349, 6201
|
1421, 1686
|
1702, 1855
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,122
| 182,772
|
47073
|
Discharge summary
|
report
|
Admission Date: [**2115-4-24**] Discharge Date: [**2115-5-10**]
Date of Birth: Sex: F
Service: ICU
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 1395**] is a 79-year-old woman
with a severe history of chronic obstructive pulmonary
disease, a history of a benign lung tumor, with a left lower
lobe resection 20 years prior to admission who was initially
admitted to the A-Cove Service on [**4-24**] with a chronic
obstructive pulmonary disease exacerbation.
Six days prior to admission she had felt fatigued with
fevers. She had a temperature spike to 100 at home. Her
visiting nurse felt that she was breathing poorly, had a fast
heart rate, and appeared weak and had her evaluated in the
Emergency Room. The patient did not complain of cough,
hemoptysis, nausea, vomiting, or abdominal pain. She had
lost approximately seven pounds in the preceding six months.
In the Emergency Room, her temperature was 99.8. Her heart
rate was 107. Her blood pressure was 144/77, and her
respiratory rate was 20, with a saturation of 97%. She
appeared comfortable, spoke in full sentences. A chest x-ray
was remarkable for a left upper lobe spiculated opacity; new
since [**2114-8-4**] and concerning for pneumonia, tumor,
or tubercular infection.
A CT scan was obtained and was pending while she was
evaluated in the Emergency Room. She was initially treated
with normal saline, levofloxacin intravenously, albuterol,
and Atrovent and admitted to the A-Cove Service for further
management.
PAST MEDICAL HISTORY:
1. Chronic obstructive pulmonary disease.
2. A benign lung lesion; status post resection 20 years
prior.
3. Breast cancer, status post lumpectomy with radiation
therapy.
4. Rectal cancer, status post radiation therapy.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: (Medications on admission were)
1. Flovent 220 4 puffs b.i.d.
2. Albuterol 2 puffs q.4h.
3. Lasix 20 mg p.o. q.d.
4. Xanax 0.25 mg p.o. q.h.s.
5. Rhinocort.
6. Tylenol.
7. Home oxygen at 2 liters.
SOCIAL HISTORY: A nonsmoker currently, but with a
37-pack-year history.
PHYSICAL EXAMINATION ON PRESENTATION: On admission
temperature was 98.9, blood pressure was 126/62, heart rate
was 108, respiratory rate was 20, saturating at 99% on 2
liters. In general, a cachectic, frail, elderly woman
speaking in full sentences on 2 liters nasal cannula. Pupils
were equal, round and reactive to light. Sclerae were clear.
Heart rate and rhythm were regular with a normal first heart
sound and second heart sound. She had a high-pitched
inspiratory wheeze bilaterally in her upper lobes, left
greater than right. Her abdomen was soft and nondistended.
It was tender in the right upper quadrant to deep palpation.
She had multiple ecchymoses diffusely with peripheral tissue
wasting. She had no rash. Neurologically, she was alert and
oriented times three. Cranial nerves II through XII were
intact.
PERTINENT LABORATORY DATA ON PRESENTATION: Laboratory data
on admission revealed she had a white blood cell count
of 13.2 (which was elevated from a prior of 11.2), hematocrit
was 35 (down from the 40s), and a platelet count of 479.
Sodium was 1453,, potassium was 3.8, chloride was 99,
bicarbonate was 29, blood urea nitrogen was 22, creatinine
was 0.7, blood glucose was 92.
RADIOLOGY/IMAGING: Electrocardiogram revealed sinus
tachycardia at 123, normal axis. No ST changes.
A chest x-ray revealed increasing opacity with spiculated
appearance, chordae at the left apex in a region previously
described as scarring; worrisome for scar, carcinoma, or
recurrent tumor. Also concerning for infectious source.
HOSPITAL COURSE: Ms. [**Known lastname 1395**] was initially admitted to the
A-Cove Service for further management of pneumonia versus
chronic obstructive pulmonary disease exacerbation.
Given the findings on her chest x-ray, the Pulmonary Service
was consulted, and she underwent a diagnostic bronchoscopy
and lavage. She tolerated the procedure poorly and needed to
initially be placed on BiPAP and admitted to the Medical
Intensive Care Unit.
Shortly after being admitted to the Intensive Care Unit, she
had severe respiratory decompensation and required intubation
for management of her respiratory. She also had an A-line
placed.
Over the subsequent 12 days in the Intensive Care Unit,
Ms. [**Known lastname 1395**] was treated aggressively for presumed pneumonia;
although no infectious source was ever found. She was also
treated aggressively for a chronic obstructive pulmonary
disease exacerbation with high-dose steroids as well as
inhaled bronchodilators and Atrovent.
Despite these intense interventions, she remained ventilatory
dependent requiring pressor support at all times. She failed
to tolerate several attempts to wean. During this time, the
Medical Intensive Care Unit team was in close contact with
the patient's family including her daughters. The patient
did remain alert and able to interact and confirm her wishes
during this course.
Toward the end of her admission, it became evident that she
would require a tracheostomy to further maintain her
ventilatory status. This was discussed with her daughters
and with Ms. [**Known lastname 1395**] as well. Mr. [**Known lastname 1395**] made it quite clear
that she did not wish tracheostomy, and this was confirmed by
her daughters.
On [**2115-5-9**], Ms. [**Known lastname 1395**] deliberately self-extubated
herself. She was initially placed on a mask and CPAP. Her
attending and family were notified, and the decision not to
reintubate was confirmed.
She was started on a morphine drip for comfort, and her
family and sister were present. She ultimately expired on
[**5-10**]. An autopsy was declined.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation.
2. Pneumonia.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Name8 (MD) 4733**]
MEDQUIST36
D: [**2115-8-14**] 09:21
T: [**2115-8-20**] 16:14
JOB#: [**Job Number **]
|
[
"518.5",
"799.4",
"V10.06",
"V10.3",
"491.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"33.24",
"96.04",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5780, 6116
|
1834, 2039
|
3677, 5759
|
156, 1523
|
1545, 1807
|
2056, 3659
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,559
| 197,325
|
192
|
Discharge summary
|
report
|
Admission Date: [**2157-2-1**] Discharge Date: [**2157-2-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1928**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and biliary stent placement on [**2157-2-1**]
History of Present Illness:
Mrs. [**Known firstname 1929**] [**Known lastname 1930**] is a very nice 85 year-old woman with a
history of cholecystectomy and ampullar stenosis who presents
with RUQ abdominal pain. She states her pain started 2 days
prior to admission, was constant and radiated towards the back.
She had nausea, vomit, malaise. Denies fever, chills, changes
in her bowel movements, hematochezia or melena. Unable able to
tolerate oral intake.
Presenting vitals were T 101.5, HR 68, BP 152/76, RR 16, SpO2
95% RA. In ED, Unasyn 3gm given and a right IJ central line was
placed. She underwent ERCP that showed 1-cm stone in the common
bile duct. Patient became hypoxic from the conscious sedation,
so the stone was not removed to expedite the procedure. A
plastic biliary stent was successfully placed. Post-ERCP, she
was admitted to the ICU with a diagnosis of cholangitis.
ICU course: In the ICU, the patient was continued on Zosyn, her
RUQ pain significantly improved, and she began to tolerate
fluids. On [**2-3**], she developed shortness of breath that
improved with administration of furosemide. Nebulizer
treatments also given. At time of transfer to floor, O2 sat was
95% on 2L nasal canula. Lisinopril restarted, but Atenolol and
Nifedipine held for concern of lower heart rate.
She was transferred to the floor and felt improvement in her
abdominal pain. Denied shortness of breath, chest pain.
Past Medical History:
1. Hypertension
2. Ampullary stenosis
3. Status post cholecystectomy for gallstones
4. History of sphincterotomy (as described above)
5. Osteoporosis
6. Gastroesophageal reflux disease
7. External hemorrhoids
8. Cerebrovascular accident in [**2145**] (right pontine)
9. Parkinson's diseae
10. Chronic low back pain with sciatica
11. Urinary frequency and urge incontinence
12. Diverticulosis
13. Chronic pancreatitis
Social History:
She lives by herself. She came the US in [**2138**] from [**Country 1931**] and
is Russian-speaking. Denies alcohol, tobacco, and no drugs.
Family History:
No family of MI, stroke, son prostate cancer. Daughter with
[**Name2 (NI) 1932**].
Physical Exam:
Admission Exam:
VS: Temp 97.8 F, BP 108/30 mmHg, HR 78 BPM, RR 14 , O2-sat 93%
RA
GEN: Well-appearing woman in NAD, comfortable, jaundiced (skin,
mouth, conjuntiva)
HEENT: NC/AT, PERRLA, EOMI, sclerae icteric, 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
[**3-23**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Exam on transfer to floor on [**2157-2-3**]:
VS: 98.9, 154/56, 80, 18, 97% on 2L
GEN: NAD
HEENT: EOMI, MMM, anicteric sclerae, no oral lesions
NECK: Supple, R IJ s/p removal with bandage
CHEST: CTAB
CV: RRR, normal s1 and s2, no murmurs
ABD: Soft, nondistended, bowel sounds present, mild tenderness
in right upper/lower quadrants and midepigastrum, no rebound
tenderness, no guarding
EXT: No lower extremity edema
SKIN: No rash
NEURO: Awake, alert, oriented x3, CN 2-12 intact, strength 5/5
BUE/BLE, sensory intact throughout, fluent speech
PSYCH: Calm, appropriate
Pertinent Results:
Admission Labs:
WBC-13.8*# RBC-4.09* Hgb-12.9 Hct-39.2 MCV-96 Plt Ct-182
Neuts-77* Bands-14* Lymphs-6* Monos-3 Eos-0 Baso-0
PT-12.1 INR(PT)-1.0
Glucose-216* UreaN-23* Creat-1.1 Na-138 K-5.8* Cl-98 HCO3-26
AnGap-20
ALT-723* AST-979* LD(LDH)-1269* CK(CPK)-99 AlkPhos-120*
TotBili-3.5*
Lipase-44
HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE
Labs on transfer from ICU to floor [**2157-2-3**]:
WBC-8.6 RBC-3.12* Hgb-10.0* Hct-30.2* MCV-97 Plt Ct-83*
Glucose-193* UreaN-18 Creat-1.0 Na-138 K-3.0* Cl-103 HCO3-25
AnGap-13
ALT-51* AST-120* LD(LDH)-170 AlkPhos-65 Amylase-44 TotBili-1.5
Lipase-14
Calcium-8.0* Phos-2.2* Mg-1.6
Lactate-1.6
MICRO:
Blood Culture [**2157-2-1**]: +Ecoli and Enterococcus, susceptible to
ampicillin
Urine Culture [**2157-2-1**]: No growth
Blood cultures 3/17 x 2: Gram negative rods
Blood Culture [**2-3**]: No growth to date
Stool C-diff: Pending collection
Imaging:
CT Abdomen and Pelvis [**2157-2-1**]:
1. Stable pneumobilia and proximal biliary dilatation.
2. Left adnexal lesion, 2.6 cm. Recommend ultrasound for further
characterization, and to exclude a solid lesion/cyst with mural
nodule in this postmenopausal woman.
ERCP [**2157-2-1**]:
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Evidence of a previous wide open sphincterotomy
was noted in the major papilla. Pus was noted at the ampulla.
Cannulation: Cannulation of the biliary duct was successful and
deep using a free-hand technique. Contrast medium was injected
resulting in complete opacification.
Biliary Tree: A single 15 mm stone that was causing partial
obstruction was seen at the lower third of the common bile duct.
The bile duct was dilated to 15 mm. The rest of the biliary tree
was normal. Detailed cholangiogram was not obtained due to
suspicion of cholangitis.
Procedures: A 5cm by 10FR Double pig-tail biliary stent was
placed successfully.
Impression: S/P sphincterotomy - this was widely patent.
Pus noted at the ampulla.
Stone at the lower third of the common bile duct, dilation of
bile duct to 15 mm, other normal biliary tree.
A double pig-tail stent was placed in the bile duct.
Otherwise normal ercp to third part of the duodenum
TTE [**2-8**]
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No masses or vegetations are
seen on the aortic valve. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. Moderate (2+) mitral regurgitation is seen. The
left ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The tricuspid
valve leaflets are mildly thickened. There is moderate pulmonary
artery systolic hypertension. Significant pulmonic regurgitation
is seen. The end-diastolic pulmonic regurgitation velocity is
increased suggesting pulmonary artery diastolic hypertension.
There is a trivial/physiologic pericardial effusion.
Discharge labs:
[**2157-2-8**] 06:37AM BLOOD WBC-6.8 RBC-3.29* Hgb-10.4* Hct-31.5*
MCV-96 MCH-31.5 MCHC-32.8 RDW-13.8 Plt Ct-225
[**2157-2-8**] 06:37AM BLOOD Glucose-100 UreaN-14 Creat-0.9 Na-141
K-3.7 Cl-104 HCO3-30 AnGap-11
[**2157-2-8**] 06:37AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.8
Brief Hospital Course:
85 year-old woman presents with cholangitis [**12-21**]
choledocholithiasis s/p ERCP with biliary stent placement.
Gallstone was not removed because of the patient's tenous
condition. The plan will be to repeat the ERCP in one month to
remove the stone. Patient was also with bacteremia with E. Coli
and Enterococcus likely [**12-21**] biliary source. Patient initially
on Zosyn, but because of thrombocytopenia was changed over to
Vanco and Cipro. This was finally changed to ampicillin when
susceptibilities resulted.
# Cholangitis: RUQ pain, fever, leukocytosis with bandemia, AST
979, ALT 723, AP 120, TB 3.5 and direct of 2.4. ERCP was
performed and a double pigtail plastic stent was placed. Her
hemodynamics remained stable. Blood cultures were positive for
gram negative rods, and she was treated with IV Zosyn.
Hepatitis serologies demonstrated previous hepatitis A exposure.
She developed bacteremia (see below) and will continue
antibiotics until [**2-16**]. She will need ERCP follow up in 1 month
for repeat ERCP and stent placement.
# E. Coli and Enterococcus bacteremia both susceptible to
Ampicillin. Pt initially on Zosyn, then changed to Vanco and
Ciprofloxacin given thrombocytopenia. ID was consulted and did
not recommend cardiac imaging given that the likely source was
the biliary tree and surveillance cultures were negative. She
was converted to ampicillin and should continue a 14 day course
since last negative culture ([**Date range (3) 1933**]).
# Shortness of breath likely [**12-21**] fluid overload: Patient was
intermittently tachypneic and wheezing and was treated with
albuterol nebs and lasix with improvement. ECHO ordered to
evaluate for systolic or diastolic dysfunction. She was found
to have restrictive filling pressures and elevated [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1934**].
She will be discharged on lasix 10mg daily until she sees her
PMD. She will need cardiology follow up given her disease.
# Thrombocytopenia: PLTs decreased to 83 ([**2-3**]) from 182 on
admission. Pt not on heparin, thought to be [**12-21**] sepsis at
admission. Hemolysis labs not concerning for DIC, and less
likely thought to be due to ITP or TTP. After discontinuation of
Zosyn, the platelets increased and remained stable. On
discharge, her platelets were 252.
# Hypertension: Lisinopril restarted in ICU. Atenolol and
Nifedipine restarted on the floor. Blood pressures were well
controlled on the floor.
# GERD: Pantoprazole was started.
# Parkinson's disease: Continued Carbidopa-Levodopa
# Diverticulosis: Stable. Guaiac negative stools.
# DVT prophylaxis: mechanical
# Code status: Full Code
Medications on Admission:
Atenolol 75 mg PO Daily
Carbidopa-Levodopa 25/100 1 tab TID
Lidocaine 5% patch
Creon 10 249 mg EC 2 capsules with meals
Lisinopril 40 mg PO Daily
Nifedipine SR 60 mg PO Daily
Omeprazole 40 mg PO Daily
Detrol LA 2 mg PO Daily
Tramadol 50 mg PO BID
Zmbien 5 mg PO QHS
Aspirin 81 mg PO Daily
Discharge Medications:
1. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
2. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Tolterodine 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Atenolol 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours) for 9 days.
Disp:*27 Capsule(s)* Refills:*0*
9. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO every other day.
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Cholangitis
- Choledocholithiasis
- Bacteremia with E. Coli and Enterococcus
- Thrombocytopenia, possibly from Zosyn
- Hypoxia
SECONDARY DIAGNOSES:
- Hypertension
- Gastroesophageal reflux disease
- Parkinson's disease
- Chronic urinary incontinence
- Osteoporosis
- Diverticulosis
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Ambulatory and independent
Discharge Instructions:
You were admitted with abdominal pain. An ERCP was performed
which showed gallstones obstructing your bile ducts. A stent
was placed which improved the flow of bile. Blood tests showed
a blood infection, and you are being treated with antibiotics.
MEDICATION CHANGES:
1. START: Ampicillin 500mg one tablet three times daily until
[**2157-2-16**] to complete 14-day course of antibiotics (renally dosed)
2. CHANGE: Omeprazole to Pantoprazole 40mg one tablet daily
(your preference)
3. Start lasix 10mg daily.
4. Do NOT take aspirin for 5 days after your ERCP.
Followup Instructions:
Appointment #1
Department: [**Hospital3 249**]
When: FRIDAY [**2157-2-11**] at 12:10 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 544**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #2
Department: OPTHALMOLOGY
When: MONDAY [**2157-2-28**] at 1 PM [**Telephone/Fax (1) 253**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #3
Department: [**Hospital3 1935**] CENTER
When: TUESDAY [**2157-3-1**] at 9:30 AM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 252**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Appointment #4
ERCP: You will be contact[**Name (NI) **] by the Gastroenterology service to
schedule your biliary stent removal and gallstone extraction.
This will be in about one month.
|
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icd9cm
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11690, 11776
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,900
| 186,830
|
29228
|
Discharge summary
|
report
|
Admission Date: [**2171-12-13**] Discharge Date: [**2172-1-17**]
Date of Birth: [**2122-6-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
suspected HUS-[**Hospital 70289**] transfer from OSH
Major Surgical or Invasive Procedure:
1. Temporary Quinton catheter placement
2. PICC placement x 2
3. tunnelled Quinton catheter placement
4. Intubation and Bronchoscopy
5. Tranesophageal Echocardiogram
6. Renal biopsy
History of Present Illness:
49 yo M with a history of ESRD, secondary to kidney transplant
failure who was transferred from [**Hospital 1474**] Hospital for suspected
TTP-HUS. The patient reports that he has had six months of
increasing shortness of breath, fatigue and intermittent
blood-tinged productive cough. The shortness of breath has
become acutely worse over the last few days and he has had
symptoms of orthopnea.
.
The patient presented to the OSH and was noted to have bilateral
pleural effusions on chest CT, Hct 20.5, K 7.8 Cr 4.2 and
glucose > 400. He received several boluses of insulin and was
placed on an insulin gtt. He was also given an amp of D50,
calcium chloride, and kayexalate with subsequent decrease in K
to 5.9. He receieved 2 units of PRBCs which bumped his Hct to
24.7. He was placed on 4L NC for decreased O2 sat. Hematology
was consulted and felt that he needed plasmapheresis for
hemolytic uremic syndrome. He was transferred to [**Hospital1 18**] for
further management.
.
ROS: unable to obtain complete review, but denied CP or fevers
Past Medical History:
1. L cadavaric kidney transplant ([**2152**]) for renal failure [**1-31**]
presumed chronic glomerulonephritis
2. ESRD, baseline Cr 1.5 in [**5-3**]
3. DM
4. Restrictive lung disease
5. HTN
6. Interstitial pulmonary fibrosis
7. s/p L AV fistula
8. hypercholesterolemia
9. Gout
Social History:
lives by himself, divorced; no EtOH or tobacco
Family History:
diabetes mellitus
Physical Exam:
VS: 97.1 84 160/77 26 97% on 6L NC
GEN: tachypnic, using accessory muscles to breath
HEENT: PERRL, MM slightly dry
Cor: irregularly irregular
Lungs: b/l crackles, wheezes
Abd: +BS, s/distended/no TTP
Ext: trace pitting edema, WWP, 2+ pulses throughout
Neuro: alert, somnolent, responds to questions slowly, EOMI but
sluggish, 4/5 strength in UE b/l
Skin: 1.5 cm healing linear incision on L forehead
Pertinent Results:
OSH RECORDS:
[**2171-12-6**] CHEST CT: CHF, RLL infiltrate
[**2171-12-4**] BNP 896, Rheumatoid factor 17 (0-13)
[**2171-11-15**] PFTs: FVC moderately reduce, FEV1 mildly to moderately
reduced/ FEV1/FVC = normal, TLC moderately reduced. Diffusion
severely reduced. Moderate restrictive disease w/ severe
reduction in diffusion capacity.
[**2171-11-15**] ECHO: EF 60-65%, mild concentric LVH, oderate biatrial
enlargement; mildr tricuspid and trace pulmonic regurgitation.
.
Renal transplant u/s: No hydronephrosis. Normal vascularity
throughout the transplanted renal parenchyma.
.
Bronchial washings [**12-13**]: NEGATIVE FOR MALIGNANT CELLS. Reactive
bronchial epithelial cells, pulmonary macrophages, lymphocytes
and neutrophils.
.
CT chest: 1. Bilateral pleural effusions with atelectasis
involving large portions of both lower lobes. The possibility of
superimposed consolidation (reflecting pneumonia or aspiration)
is difficult to exclude.
2. Ascites and subcutaneous edema, consistent with diffuse third
spacing of fluid.
3. Small amount of hyperdense material within the gallbladder,
which may represent stones or sludge.
4. Tubes and lines positioned as described.
5. Three rounded soft tissue density structures between
posterior ribs near the spine as described, which may represent
lymph nodes.
TTE: The left atrium is dilated. There is mild symmetric left
ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is mild
to moderate aortic valve stenosis. Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension. There is a trivialpericardial
effusion.
.
Bone Marrow biopsy: Peripheral blood granulocytic dysplasia,
along with dysplasia of erythroid and megakaryocytic lineages in
the bone marrow aspirate raises the possibility of
myelodysplastic syndrome. Blasts (peripheral blood and marrow)
were enumerated at <1%. Ringed sideroblasts were not
identified. In the absence of myelotoxic or myelo-stimulatory
therapy, the findings are suspicious for refractory cytopenia
with multi-lineage dysplasia (RCMD) in the WHO classification.
However, we note that the patient is critically ill, has end
stage renal disease and is under several medications. Clinical,
pharmaco-therapeutic list and cytogenetic correlation is
recommended. We further recommend a repeat biopsy for
confirmation and evaluation for definitive diagnosis.
.
Bronchial washings [**12-19**]: NEGATIVE FOR MALIGNANT CELLS. Reactive
pulmonary macrophages and scattered yeast forms some of which
appear to be within cells.
.
R UE u/s: No evidence of deep vein thrombosis.
.
TEE [**1-6**]:
1 The left atrium is elongated. No atrial septal defect is seen
by 2D or color
Doppler.
2. Left ventricular wall thicknesses are normal.
3.The ascending, transverse and descending thoracic aorta are
normal in
diameter and free of atherosclerotic plaque.
4.The aortic valve leaflets are moderately thickened. No masses
or vegetations
are seen on the aortic valve. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. No mass or
vegetation is
seen on the mitral valve. Physiologic mitral regurgitation is
seen (within
normal limits).
6.There is no pericardial effusion.
.
CT torso:
1. No evidence of retroperitoneal hemorrhage.
2. Again seen are moderate sized bilateral pleural effusions
with associated atelectasis. There is also some ascites.
.
Renal u/s: No interval change in the appearance of the
transplanted kidney in the left lower quadrant. No
hydronephrosis. Normal vascularity of the transplanted kidney.
.
transplant biopsy:
1. Chronic allograft nephropathy.
2. Diabetic nephropathy.
3. Changes consistent with "acute tubular necrosis", see note.
.
Repeat TEE [**1-15**]:
The left atrium is normal in size. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness abnd cavity size
are normal. Right ventricular chamber size and free wall motion
are normal. There is a focal simple atheroma in the descending
thoracic aorta. The aortic valve leaflets are moderately
thickened. Mild-moderate aortic stenosis is suggested (not
quantified). Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a trivial/physiologic
pericardial effusion.
Brief Hospital Course:
49 yo M w/ ESRD s/p kidney transplant on chronic
immunosuppressive therapy, presenting with AMS,
thrombocytopenia, ARF, hemolytic anemia and pancytopenia, and
respiratory failure with bilateral pulmonary infiltrates, with
MDS on BM bx and persistent fevers of unknown origin, now on HD.
.
# Hypoxic respiratory failure/pulmonary edema: likely secondary
to volume overload in setting of ESRD +/- possible Ventilator
associated pneumonia. EF by [**2171-12-16**] TTE was normal at 60% so
CHF unlikely contributor. Cultures revealed no growth and he
completed a 7 day course of zosyn/vancomycin for possible
ventilator associated pneumonia. He had some difficulty weaning
off of PEEP believed to be secondary to volume overload in the
setting of renal failure and his HD was increased to QD.
Following increased HD, he was able to be switched to pressure
support on the ventilator and sedation was weaned. He was
extubated on [**2172-1-1**]. However, he failed extubation after 2
hours with tachypnea and low tidal volumes and was reintubated.
He underwent trach and PEG without complication. He was slowly
able to be weaned off the vent with gradual return of
respiratory muscle strength. Prior to discharge he had no
mechanical ventilation requirements and was maintained on trach
mask alone.
.
# Fever: Patient had been spiking fevers as high as 102 in the
ICU. He had a thorough work up for infection with all culture
and serology negative except for a weakly positive IgM for
Ehrlichia at IgM Ab + 1:80 titer. Further studies were sent and
he was started on doxycycline for presumed Ehrlichia infection.
Urine, blood, stool, respiratory cultures remained negative
except for some yeast which grew from BAL and sputum cultures.
Because of persistent fevers his temporary dialysis catheter as
well as his PICC were pulled and tip cultures were negative.
CMV serologies and viral load were drawn initially and were
negative. They were then resent because of persistent fevers
and were again negative. BK virus, cryptococcal Ag, and Babesia
PCR were also drawn. BK virus was strongly positive in the urine
but was negative in the serum suggesting renal transplant
colonization. Cryptococcus and Babesia were negative. LP was
negative for infection. TEE was negative for valve vegetation.
He completed a 7 day course of vancomycin/zosyn for possible
ventilator associated pneumonia. Following discontinuation of
broad spectrum antibiotics, he remained afebrile on only
doxycycline for presumed Ehrlichia infection. He completed a 14
day course of doxycycline and then again spiked a fever with
associated hypotension. He was restarted on vancomycin and
zosyn as well as stress dose steroids with concern for sepsis.
His hypotension responded to fluid boluses. Blood cultures grew
coag negative staph in [**1-4**] blood culture bottles and his Zosyn
was d/c'ed. His fevers rapidly recovered as did his mental
status. He completed a 7 day course of vancomycin and was then
off all antibiotics. His steroids were tapered to baseline
required for immunosuppresion for his renal transplant. A renal
biopsy did not suggest transplant rejection as a cause of
fevers. He also received a CT abdomen to evaluate for
intrabdominal abscess, lymphoma, or other malignancy which was
negative. There was no clear cause of his intermittent fevers
throughout admission. However, at the time of discharge, patient
had been afebrile off of all antibiotics.
.
# Pancytopenia: There was evidence of hemolytic anemia based on
admission Hct, haptoglobin, and peripheral smear. However, per
heme/onc and transfusion medicine, there were only few
schistocytes on peripheral smear and was not believed to be
consistent with TTP-HUS. A Direct Coombs was negative. There was
initially some concern that anemia could have been due to
Cyclosporin and it was stopped. However, bone marrow biopsy was
obtained and was suggestive of MDS and cyclosporin was
restarted. He received a total of 6 units PRBCs over the course
of admission as well as 5 units of platelets. Following
cyclosporin restart, cell lines remained stable. He required no
further transfusions after [**12-22**]. Parvovirus DNA and Ehrlichia
serologies were drawn as above to work up possible contribution
and Ehrlichia was only weakly positive. However, he still
completed a full course of doxycycline. His counts all
rebounded to normal values at the time of discharge. Hematology
Oncology recommended outpatient follow up to determine whether
he required any further evaluation or treatment for possible
MDS.
.
# Acute on CRI - s/p renal transplant. Patient has been on
chronic immunosuppressive therapy. Outside transplant physician
had been increasing doses of cyclosporin over past several
months. Cyclosporine level was 89 on admission but concern for
contribution to pancytopenia and was stopped as above.
Cyclosporin held briefly given concern that it was
causing/contributing to pancytopenia, but restarted once bone
marrow bx suggestive of MDS. Levels were followed and have
remained low since restart with goal level ~75. However, levels
never reached goal. He received a biopsy of his transplant
kidney which showed no evidence of acute rejection. It was
thought that his acute renal failure was most likely secondary
to ATN. Due to this, his cyclosporin was stopped given risk for
renal vasoconstriction. Immunosuppression was maintained with
prednisone and cellcept. He was initially managed with triweekly
dialysis which was increased to daily dialysis to help improve
respiratory status. His urine output eventually began to
improve and his dialysis was again decreased to ~ 3 times a week
as needed. He was initially dialyzed through his fistula.
However, this clotted off and could not be opened by
interventional radiology. Therefore, prior to discharge, he
received a tunneled Quinton line for further dialysis after
discharge while his ATN continued to resolve. He should have 24
hour urine studies checked intermittently to determine need for
further dialysis.
.
# Hypertension - Patient had been resistant to multiple
medications as outpatient previously. Prior to initiation of
daily dialysis, patient was also extremely hypertensive on the
floor. Possibly secondary to steroids, although required high
dose of beta blocker as outpatient. He was initially managed
with diltiazem, nifedipine, labetolol, and hydralazine. Blood
pressures improved with initiation of daily dialysis and he
blood pressure medications were cut back. Following a
hypotensive episode as described above, his BP medications were
stopped. Eventually he was restarted on labetolol with
hydralazine as needed with good blood pressure control.
Diltiazem was also added for atrial fibrillation as described
below.
.
# Atrial fibrillation - He was initially found to be in Atrial
fibrillation on admission believed to be most likely secondary
to adrenergic surge in the setting of sepsis. However, he
quickly returned to NSR. However, towards the end of his
admission, he once again converted to Afib with RVR which
required a diltiazem drip for adequate rate control. He was
eventually transitioned to po diltiazem in addition to his
labetolol with good heart rate control. He did not convert
spontaneously and was started on a heparin drip for
anticoagulation. He then had a repeat TEE which verified that
he had no clots in his atria. EP then recommended chemical
cardioversion as they felt he would be high risk of reverting to
Afib in the setting of acute illness. He was therefore loaded
with 6 grams of amiodarone at a dose of 400 mg po BID. Following
this loading dose he was decreased to 200 mg po BID which was
set to be continued for 1 months time. His HRs were monitored
with the start of amiodarone to determine the need for diltiazem
weaning as the amiodarone took effect. He was also started on
coumadin for transition off of heparin drip.
.
# Diabetes. - Patient was started on hydrocortisone for
immunosuppression and had significant elevation in his blood
sugars. Also believed to be some contribution of possible
infection. He required high doses of insulin sliding scale and
was started on lantus which was uptitrated as high as 34 units
QD. However, following resolution of his fevers, he had some
episodes of hypoglycemia and his insulin was cut back. With
return of his fevers and initiation of stress dose steroids in
the setting of hypotension, his blood sugars once again elevated
rapidly and he was started on an insulin drip. The drip was
continued until his steroids were weaned back down to his
maintenance dose for immunosuppression for his renal transplant.
He was then converted to a subQ regimen.
.
# Diarrhea: Patient had a significant amount of diarrhea
throughout his ICU stay. Stool studies were all negative
including cultures and C diff toxin A and B were negative
throughout admission. Banana flakes were added to be given in
between tube feeds with some improvement in diarrhea.
.
# FEN - Nutren Renal 3/4 strength; Additives: Beneprotein, 45
gm/day, Banana flakes, 3 packets per day. Goal: 40 ml/hr
.
# PPX - SC heparin followed by heparin drip followed by
coumadin. Pneumoboots. Lansoprazole while on steroids.
.
# Communication: HCP [**Name (NI) 56926**] [**Name (NI) 70290**] [**Telephone/Fax (1) 70291**]; other, [**First Name5 (NamePattern1) **]
[**Last Name (NamePattern1) 70292**] [**Telephone/Fax (1) 70293**]
.
# CODE: FULL CODE
Medications on Admission:
- Lasix 80mg PO qD
- Adalat 60mg PO BID
- Atenolol 200mg PO BID
- Lipitor 40mg PO qD
- Niaspan 500mg PO qD
- Gemfibrozil 600mg PO BID
- Zetia 10mg PO qD
- Neoral 175mg PO BID
- Prednisone 5mg PO qD
- Glipizide 20mg PO BID
- Metformin 500mg PO BID
- Sulindac 150mg PO qD
- Terazosin 2mg PO qD
- Allopurinol 100mg PO BID
- Neurontin 400mg PO qD
- Prilosec 20mg PO qD
- Azathioprine 25mg po qD
- Cyclosporin 175 MG po qD
.
MEDS on TRANSFER:
- Vanco 1g IV qD
- Zosyn 2.25g IV q6h
- Azithromycin 500mg IV q24h
- Zetia 10mg PO qD
- Lopid 600mg PO breakfast/dinner
- Protonix 40mg IV qD
- Simvistatin 80mg PO qhs
Discharge Medications:
1. Senna 8.8 mg/5 mL Syrup [**Telephone/Fax (1) **]: 1-2 Tablets PO BID (2 times a
day) as needed.
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
3. Cyanocobalamin 100 mcg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO DAILY
(Daily).
4. Camphor-Menthol 0.5-0.5 % Lotion [**Last Name (STitle) **]: One (1) Appl Topical
[**Hospital1 **] (2 times a day).
5. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day) as needed.
6. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: 10,000 units
Injection ASDIR (AS DIRECTED): to be administered during
dialysis.
7. Labetalol 300 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day): hold for SBP<110, HR<60.
8. Diltiazem HCl 90 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day): hold for SBP<110, HR<60.
9. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: [**2-2**]
Puffs Inhalation Q4H (every 4 hours).
10. Amiodarone 200 mg Tablet [**Month/Day (3) **]: Two (2) Tablet PO TID (3 times
a day) for 10 doses.
11. Amiodarone 200 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO TID (3 times
a day) for 1 months: to be started following completion of 400
mg po TID dosing of amiodarone.
12. Warfarin 5 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO HS (at bedtime).
13. Mycophenolate Mofetil 250 mg Capsule [**Month/Day (3) **]: Two (2) Capsule PO
BID (2 times a day).
14. Ascorbic Acid 500 mg Tablet [**Month/Day (3) **]: One (1) Tablet PO BID (2
times a day).
15. Zinc Sulfate 220 (50) mg Capsule [**Month/Day (3) **]: One (1) Capsule PO
DAILY (Daily).
16. Prednisone 5 mg Tablet [**Month/Day (3) **]: Three (3) Tablet PO DAILY
(Daily).
17. Insulin Glargine 100 unit/mL Solution [**Month/Day (3) **]: Thirty (30) units
Subcutaneous at bedtime.
Disp:*1000 units* Refills:*2*
18. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution
[**Month/Day (3) **]: Seven Hundred (700) units/hr Intravenous ASDIR (AS
DIRECTED): Currently at 700units per hour to be titrated to PTT
60-80 per weight based protocol until INR therapeutic on
coumadin.
Disp:*5000 units/hr* Refills:*2*
19. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Month/Day (3) **]: [**2-18**]
units Subcutaneous qid: Please refer to attached sliding scale.
Disp:*qs qs* Refills:*2*
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Year (2) **]: Two
(2) ML Intravenous DAILY (Daily) as needed: 10 mL NS followed by
2 mL of 100 Units/mL heparin (200 units heparin) each lumen
daily and prn. Inspect site every shift.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Center
Discharge Diagnosis:
Primary:
1. Respiratory failure
2. fever of unknown origin
3. acute tubular necrosis
4. critical illness neuropathy
5. myelodysplastic syndrome
6. Atrial fibrillation
Secondary:
1. End stage renal disease
2. Diabetes
3. hypertension
Discharge Condition:
Stable respiratory status on 40 % FiO2 via trach mask.
Tolerating po diet with PMV in place. Pleasant, conversant.
Full assist with transfers and ADLs.
Discharge Instructions:
Please continue to take all medications as prescribed. You
should be taking Prednisone and Cellcept once a day to protect
your kidney transplant. You will need to continue to use a
heparin drip until your coumadin levels are within goal. You are
also taking amiodarone to attempt and alter and abnormal rhythm
with your heart.
Please see below for follow up appointments.
Please continue with [**Hospital3 **] and dialysis at your
[**Hospital3 **] facility.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] of Cardiology on [**2171-2-6**] at 2:20
on the [**Hospital Ward Name **] of [**Hospital1 18**] on the [**Location (un) 436**] of the [**Hospital Ward Name 23**]
building. Phone: [**Telephone/Fax (1) 2934**]
You should follow up with your outpatient nephrologist Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in 1 month. You may call his office at ([**Telephone/Fax (1) 70294**] to
make an appointment. You will be working with the Dialysis
doctors at your [**Name5 (PTitle) **] facility.
Hematology/Oncology will call you to schedule a follow-up
appointment. You will be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6160**] and Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. You may call the clinic at [**Telephone/Fax (1) 6161**] with any
questions.
Please follow up with Dr. [**First Name (STitle) **] on [**2171-2-10**] at 3 pm for your
first new patient primary care appointment. Phone [**Telephone/Fax (1) 1247**]
|
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"486",
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icd9cm
|
[
[
[]
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[
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"96.6",
"39.95",
"38.93",
"31.1",
"43.11",
"33.24",
"96.72",
"55.23",
"38.95",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
20077, 20127
|
7317, 16766
|
367, 551
|
20405, 20560
|
2469, 7294
|
21070, 22130
|
2006, 2026
|
17423, 20054
|
20148, 20384
|
16792, 17212
|
20584, 21047
|
2041, 2450
|
275, 329
|
579, 1624
|
1646, 1925
|
1941, 1990
|
17230, 17400
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,572
| 149,117
|
3501
|
Discharge summary
|
report
|
Admission Date: [**2142-2-19**] Discharge Date: [**2142-2-26**]
Date of Birth: [**2055-7-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish / goldenrod in the Fall
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Redo Sternotomy, Aortic Valve Replacement (23mm St. [**Male First Name (un) 923**]
Tissue), Coronary Artery Bypass Grafting(SVG-LAD, SVG-OM)
History of Present Illness:
This 86 year old gentleman is status post coronary artery bypass
grafting in [**2133**] now with worsening dyspnea over the past year.
At the time of his surgery, he had mild aortic stenosis and
insufficiency. Since that time, he has had worsening aortic
stenosis which has been followed by serial echcardiograms. An
echocardiogram in [**2141-7-20**] showed severe aortic stenosis
with an aortic valve area of 0.6cm2 (Peak/Mean 52/24mmHg),
moderate aortic insufficiency, moderate tricuspid regurgitation
and trace mitral regurgitation. A cardiac catheterization was
performed [**2142-1-2**] to evaluate his coronaries which revealed
three vessel coronary disease with occluded vein grafts to his
left anterior descending and circumflex artery. His symptoms
include dyspnea on exertion which has worsened over the past
year. He is still able to split and carry firewood as well as
climb a flight of stairs. He denies chest pain, orthopnea,
dizziness or significant fatigue. Given the severity of his
disease and the
progression of his symptoms he has been referred for surgical
evaluation.
Past Medical History:
aortic stenosis
Coronary artery disease
s/p redo sternotomy, aortic valve replacement, coronary artery
bypass grafts
hypertension
Hyperlipidemia
Arthritis
Vitamin D defficiency
s/p Left total knee replacement
Social History:
Lives with: Wife
Contact: Phone #
Occupation: Retried Police officer
Cigarettes: Smoked no [] yes [] last cigarette _____ Hx:
Other Tobacco use: Cigar and pipe smoker in past
ETOH: < 1 drink/week [] [**12-26**] drinks/week [X] >8 drinks/week []
Illicit drug use
Family History:
No Premature coronary artery disease
Physical Exam:
Vital Signs sheet entries for [**2142-1-17**]:
BP: 134/67. Heart Rate: 54. Resp. Rate: 16. Pain Score: 0. O2
Saturation%: 99.
Height: 70" Weight: 164
General: WDWN in NAD
Skin: Warm, Dry and intact. No C/C/E. Well healed sternotomy.
HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP benign. 5
remaining lower teeth in good repair.
Neck: No JVD, Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, II/VI SEM, I/VI Diastolic rumble.
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: Right EVH incision at knee. Left GSV appears
suitable.
Neuro: Grossly intact [X]
Pulses:
Femoral Right:2 Left:2
DP Right:1 Left:1
PT [**Name (NI) 167**]:1 Left:1
Radial Right:2 Left:2
Carotid Bruit - Transmitted vs bruit
Pertinent Results:
[**2142-2-19**] ECHO
PRE-CPB:1. The left atrium is mildly dilated. The left atrial
appendage emptying velocity is depressed (<0.2m/s). No thrombus
is seen in the left atrial appendage.
2. A patent foramen ovale is present.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. The ascending, transverse and descending thoracic aorta are
normal in diameter and free of atherosclerotic plaque. There are
simple atheroma in the aortic arch. There are simple atheroma in
the descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic
regurgitation is seen.
7. Mild (1+) mitral regurgitation is seen.
Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) **] were notified in person of the
results.
POST-CPB: On infusion of phenylephrine. AV pacing for slow SR.
Well-seated bioprosthetic valve in the aortic position. Minimal
central AI. No paravalvular leak. The pfo remains small. MR
remains 1+. TR is 1+. LV systolic function is preserved post
cpb. Aortic contour is normal post decannulation.
Brief Hospital Course:
Mr. [**Known lastname 16068**] was admitted to the [**Hospital1 18**] on [**2142-2-19**] for surgical
management of his aortic valve and coronary artery disease. He
was taken directly to the Operating Room where he underwent redo
sternotomy, aortic valve replacement using a 23mm St. [**Male First Name (un) 923**]
tissue and coronary artery bypass grafting to two vessels.
Please see operative note for details. Postoperatively he was
taken to the intensive care unit for monitoring. On
postoperative day one, Mr. [**Known lastname 16068**] [**Last Name (Titles) 5058**] neurologically intact
and was extubated. He was later transferred to the step down
unit for further recovery. He was gently diuresed towards his
preoperative weight. The Physical Therapy service was consulted
for assistance with his postoperative strength and mobility.
CTs and wires were removed per protocol and he was diuresesd. On
POD 3 he developed atrial fibbrillation and Amiodaorne was added
to his treatment.
He had a 30 second episode of unresponsiveness after a walk on
POD 5. He remained hemodynamically stable, in sinus rhythm
during this episode and recovered to his baseline quickly. INR
became supra-therapeutic and the patient received FFP as well as
Vitamin K. When INR stabilized (3 on [**2-26**] after 2mg IV Vitamen
K), he was discharged to [**Location (un) **] Nursing & Rehabilitation on POD
7
All follow up was arranged.
Medications on Admission:
Aspirin 325mg daily
Metoprolol 50mg twice daily
Lisinopril 20mg daily
HCTZ 25mg daily
Zocor 80mg daily
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
3. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): 400mg(two tablets) twice daily for two weeks, then
200mg(one tablet) twice daily for two weeks, then 200mg (one
tablet) daily until directed to stop.
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
11. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO DAILY (Daily) for 7
days.
12. Outpatient Lab Work
INR [**2-26**] and daily until Coumadin dose set.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
aortic stenosis
Coronary artery disease
s/p redo sternotomy, aortic valve replacement, coronary artery
bypass grafts
hypertension
Hyperlipidemia
Arthritis
Vitamin D defficiency
s/p Left total knee replacement
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral medications
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema - trace
Discharge Instructions:
1) Please shower daily including washing incisions gently with
mild soap, no baths or swimming until cleared by surgeon. Look
at your incisions daily for redness or drainage.
2) Please NO lotions, cream, powder, or ointments to incisions.
3) Each morning you should weigh yourself and then in the
evening take your temperature, these should be written down on
the chart provided.
4) No driving for approximately one month and while taking
narcotics. Driving will be discussed at follow up appointment
with surgeon when you will likely be cleared to drive.
5) No lifting more than 10 pounds for 10 weeks
6) Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon:Dr. [**Last Name (STitle) **]([**Telephone/Fax (1) 170**]) on [**2142-3-28**] at 2:45pm
Cardiologist: Dr. [**First Name (STitle) 1075**] on [**2142-3-7**] @ 10:00 AM
Please call to schedule appointments with your
Primary Care Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]([**Telephone/Fax (1) 10096**]) in [**2-22**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Coumadin for atruila fibrillation Goal INR 2-2.5
needs Coumadin follow up arranged at discharge.
NO COUMADIN TODAY([**2-26**]) daily INRs until dose set.
Completed by:[**2142-2-26**]
|
[
"414.02",
"424.1",
"715.90",
"414.01",
"272.4",
"427.31",
"268.9",
"V43.65",
"E878.1",
"745.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"36.12"
] |
icd9pcs
|
[
[
[]
]
] |
7360, 7390
|
4463, 5888
|
319, 462
|
7643, 7871
|
3062, 4440
|
8760, 9515
|
2130, 2169
|
6042, 7337
|
7411, 7622
|
5914, 6019
|
7895, 8737
|
2184, 3043
|
260, 281
|
490, 1580
|
1602, 1812
|
1828, 2114
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,559
| 115,822
|
7802
|
Discharge summary
|
report
|
Admission Date: [**2139-9-6**] Discharge Date: [**2139-9-25**]
Service: CARDIOTHORACIC
Allergies:
Percocet / Penicillins / Sulfa (Sulfonamides) / Ertapenem
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
s/p Coronary Artery Bypass Graft x 4(LIMA->LAD, SVG->OM, Ramus,
PDA) [**2139-9-11**]
s/p pacer lead placement and generator change [**2139-9-18**]
History of Present Illness:
This is an 86 y/o male with multiple cardiac risk factors and
previous MI with evidence of CAD on prior cath who felt some
generalized weakness for several days. Also c/o shortness of
breath for one week. At OSH his troponin I was 7.4 and CK was
207 with MB 9.2. He then underwent a cardiac cath which
revealed three vessel coronary artery disease. He was then
transferred to [**Hospital1 18**] for surgical intervention.
Past Medical History:
s/p PCI, s/p perm. pacemaker placement, Diabetes Mellitus,
Hypertension, Dyslipidemia, Peripheral Vascular Disease s/p R
fem-distal BPG, s/p R 1st toe amp, Benign Prostatic Hypertrophy,
Chronic Renal Insufficiency, Anemia
Social History:
Lives with wife. [**Name (NI) **]. ETOH. +Tob but quit 50 yrs ago.
Family History:
Non-contributory
Physical Exam:
General: WD/WN elderly male in NAD
HEENT: EOMI, PERRL, NC/AT
Neck: Supple, FROM, -JVD
Cardiac: RRR -c/r/m/g
Lungs: CTAB -w/r/r
Abd: Soft, NT/ND, +BS
Ext: Warm, Dry -edema
Neuro: A&O x 3, MAE, non-focal
Pertinent Results:
CNIS/Vein Mapping [**9-7**]: Moderate-to-significant plaque with
bilateral 60-69% carotid stenosis. Duplex evaluation was
performed of the left lower extremity venous system. The left
lesser saphenous vein is patent, but somewhat calcified at range
in diameter from 0.17-0.24 cm. The left greater saphenous vein
is also patent with calcification approximately diameters ranges
from 0.18-0.24 cm.
CTA Neck [**9-9**]: 1. Substantial calcification and luminal
narrowing within the carotid artery bifurcation bilaterally. 2.
Diminutive right vertebral artery likely secondary to heavy
atherosclerotic disease versus congenital anomoly. 3. Small
right pleural effusion with bilateral calcification at the lung
apices.
Echo [**9-11**]: PRE-BYPASS: Overall left ventricular systolic
function is mildly depressed. There is an inferobasal left
ventricular aneurysm. There is mild regional left ventricular
systolic dysfunction with hypokinesis of inferobasal wall. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. The aortic valve leaflets
(3)are mildly thickened. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. Mild to moderate ([**11-24**]+)
mitral regurgitation is seen. The left atrium is mildly dilated.
There are simple atheroma in the descending thoracic aorta.
POST-BYPASS: Preserved right ventricular systolic function.
Overall LVEF 45%. Mild to moderate mitral regurgitation. Mild
aortic regurgitation.
[**2139-9-6**] 05:55PM BLOOD WBC-7.1 RBC-4.67 Hgb-12.9* Hct-38.6*
MCV-83 MCH-27.5 MCHC-33.4 RDW-17.6* Plt Ct-183
[**2139-9-10**] 07:00AM BLOOD WBC-6.2 RBC-4.04* Hgb-11.1* Hct-32.7*
MCV-81* MCH-27.4 MCHC-34.0 RDW-17.5* Plt Ct-174
[**2139-9-13**] 02:36AM BLOOD WBC-18.3* RBC-3.70* Hgb-10.5* Hct-30.3*
MCV-82 MCH-28.3 MCHC-34.6 RDW-17.7* Plt Ct-144*
[**2139-9-21**] 05:40AM BLOOD WBC-6.9 Hct-30.8*
[**2139-9-6**] 05:55PM BLOOD PT-13.0 PTT-35.2* INR(PT)-1.1
[**2139-9-22**] 06:25AM BLOOD PT-25.1* INR(PT)-2.5*
[**2139-9-6**] 05:55PM BLOOD Glucose-317* UreaN-29* Creat-1.5* Na-134
K-4.5 Cl-98 HCO3-23 AnGap-18
[**2139-9-22**] 06:25AM BLOOD Glucose-75 UreaN-46* Creat-1.9* Na-138
K-5.1 Cl-103 HCO3-27 AnGap-13
[**2139-9-19**] 04:30AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.1
[**2139-9-25**] 05:40AM BLOOD Hct-30.4*
[**2139-9-23**] 06:05AM BLOOD WBC-8.0 RBC-3.64* Hgb-10.2* Hct-30.5*
MCV-84 MCH-28.1 MCHC-33.6 RDW-17.2* Plt Ct-322#
[**2139-9-25**] 05:40AM BLOOD PT-30.0* INR(PT)-3.2*
[**2139-9-24**] 06:20AM BLOOD PT-27.0* INR(PT)-2.8*
[**2139-9-23**] 06:05AM BLOOD PT-25.1* INR(PT)-2.5*
[**2139-9-22**] 06:25AM BLOOD PT-25.1* INR(PT)-2.5*
[**2139-9-21**] 05:40AM BLOOD PT-17.7* INR(PT)-1.6*
[**2139-9-25**] 05:40AM BLOOD K-4.4
[**2139-9-24**] 06:20AM BLOOD Glucose-76 UreaN-44* Creat-1.8* Na-138
K-4.5 Cl-102 HCO3-29 AnGap-12
[**2139-9-23**] 06:05AM BLOOD Glucose-57* Creat-2.0* K-4.8
Brief Hospital Course:
As mentioned in HPI, Mr. [**Known lastname **] was transferred from OSH for
coronary artery bypass surgery. Upon admission Mr. [**Known lastname **] [**Last Name (Titles) 21110**] usual pre-operative work-up along with carotid
studies, vein mapping and echocardiogram. Vascular surgery was
consulted d/t his peripheral vascular disease. He remained in
hospital receiving medical management while undergoing
diagnostic studies and awaiting Plavix washout. He was finally
brought to the operating room on [**9-11**] where he underwent a
coronary artery bypass graft x 4. Please see operative report
for surgical details. He tolerated the procedure well and was
transferred to the CSRU for invasive monitoring in stable
condition. Patient received several blood products
post-operatively for bleeding. He was weaned from sedation on
post-op day two, awoke neurologically intact and was extubated.
Chest tubes were removed on post-op day two and EP was consulted
for pacemaker interrogation. Diuretics were initiated and he was
gently diuresed towards his pre-op weight. He remained in the
CSRU for several more days needing hemodynamic support with
Neo-Synephrine and epinephrine. Once he was weaned from theses
beta blockers were started. He also stayed in the CSRU d/t
aggressive pulmonary toilet therapy and confusion/delirium. On
post-op day six he was transfused with one unit of pRBCs and on
post-op day seven he underwent pacemaker lead placement and
generator change. There was evidence of underlying Atrial
Fibrillation. Later on this day he appeared to be doing quite
well and was transferred to the SDU. On post-op day eight his
epicardial pacing wires were removed and he was experiencing
some right upper extremity edema. He underwent u/s which
revealed acute vein thrombus. Coumadin was started for both AFIB
and DVT. He will be discharged with Coumadin with a goal INR of
[**12-25**].5. He remained stable over the next several days receiving
physical therapy for strength and mobility. He was discharged to
rehab facility on post-op day 14 with the appropriate follow-up
appointments.
Medications on Admission:
Lipitor, Norvasc, Doxazosin, Procrit, Aspirin, Insulin, Heparin
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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: then reassess need for diuresis.
8. Insulin Glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous q AM.
9. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Warfarin 1 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*QS Tablet(s)* Refills:*2*
12. Insulin Lispro (Human) 100 unit/mL Cartridge Sig: sliding
scale Subcutaneous four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Senior Healthcare - [**Location (un) 1887**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4
PMH: s/p PCI, s/p perm. pacemaker placement, Diabetes Mellitus,
Hypertension, Dyslipidemia, Peripheral Vascular Disease s/p R
fem-distal BPG, s/p R 1st toe amp, Benign Prostatic Hypertrophy,
Chronic Renal Insufficiency, Anemia
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
Do not drive for 4 weeks.
Do not lift more than 10 lbs. for 2 months.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use creams, lotions, or powders on wounds.
Call our office for temp>101.5, sternal drainage.
Followup Instructions:
Make an appointment with your primary care provider [**Last Name (NamePattern4) **] [**11-24**]
weeks.
Make an appointment with Dr. [**First Name (STitle) 1075**] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Appt. at [**Hospital **] Clinic [**2143-11-25**]:30 am, [**Hospital Ward Name 23**] 7
[**Telephone/Fax (1) 59**]
Completed by:[**2139-9-25**]
|
[
"285.9",
"453.8",
"250.00",
"414.01",
"585.9",
"427.31",
"996.01",
"410.71",
"998.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.75",
"38.93",
"36.15",
"37.87",
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
7745, 7833
|
4358, 6457
|
279, 427
|
8164, 8170
|
1479, 4335
|
8498, 8888
|
1224, 1242
|
6571, 7722
|
7854, 8143
|
6483, 6548
|
8194, 8475
|
1257, 1460
|
231, 241
|
455, 879
|
901, 1124
|
1140, 1208
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,102
| 173,980
|
41577
|
Discharge summary
|
report
|
Admission Date: [**2178-1-13**] Discharge Date: [**2178-2-10**]
Date of Birth: [**2131-3-22**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Bronchoscopy
Intubation
Mechanical Ventilation
History of Present Illness:
Mr. [**Known lastname 62558**] is a 46 year-old male with a history of HIV who
initially presented to [**Hospital1 18**] [**2178-1-13**] with SOB and nonbloody
diarrhea and a CD4 count of 19 (pt off HAART for 1.5 year).
Since admission he has been diagnosed with PCP (from BAL [**1-16**]
treated with bactrim and steroid taper), Giardia (finished
flaygl [**1-23**] with no residual diarrhea), KS with pulmonary
involvement(treated with Paclitaxel and high dose steroids on
[**1-20**]), thrush, HSV type II (lesion on left chin), and CMV
pnuemonitis growing from [**1-16**] BAL, as well as CMV bacteremia
(treated with gancyclovir). He also developed recurrent Hep B
infection and therefore was started on HAART therapy [**1-22**]
despite active PCP [**Name Initial (PRE) 2**]. Mr. [**Known lastname 90417**] hospital course is
also notable for developing bilateral apical pneumothoraces and
is s/p chest tube placement by IP. The Chest tube has since
been pulled [**1-28**] and his bilateral pneumothoraces were stable by
radiology report. However, also developed pneumomediastinum
which was present on [**1-27**] then dissappeared on [**1-30**] and now
present and worse on today's film. He also developed tachypnea
and hypoxia and was diagnosed with hospital acquired PNA and was
started on vanc/zosyn on [**1-30**]. Finally, his course has also been
c/b SIADH.
.
This morning Mr. [**Known lastname 62558**] [**Last Name (Titles) 7600**] for increasing oxygen
requirement. Per primary team, the pt has been stable on the
floor with O2 sats in the high 80s to low 90s on 5 L nc during
this hospitalization. This morning an NGT was placed for
nutrition given pt very malnourished and he was noted to be more
hypoxic. The NGT was removed and patient continued to have
decreasing O2 sats. He was somnolent and transiently not
oriented to place. He was placed on venturi mask and nasal
canula and his sats remained in the mid to low 80s. He was
tachypneic and complained of air hunger. He was pale on exam,
with poor air movement but otherwise no rhonchi or rhales.
Patient was placed on NRB and O2 sas improved to 92%. ABG at
this time revealed 7.4/32/51. He was then transferred to ICU.
.
In the ICU, patient was placed on nc with nonrebreather on hi
Flow. His O2 sats remained 89-90% despite this and he was
tachypneic to mid 30s. He was somnolent but oriented x 3.
Patient had no other complaints at that time.
.
Past Medical History:
Past Medical History:
HIV/AIDS - Last CD4 19. Has history of thrush and syphilis at
the
time of his diagnosis in [**2173**]. He was previously on Atripla but
has been off therapy for 1 1/2 years. No history of PCP
.
Social History:
.
Social History: Lives in [**Location 86**] with an occasional roommate.
Works in [**State 1727**] as Deputy Secretary of State, travels to [**State 1727**]
during week, back home during weekends. He used to smoke
cigarettes socially, quit 6 months ago, alcohol 1-2 times a
week. Former drug user predominantly with crystal meth,
including IV. MSM, although not currently in a relationship,
history of unprotected sex. Has lived in [**Location **] and [**Location (un) 511**] his
whole life, traveled across US, Europe in [**2173**], Bahamas last
year.
.
Family History:
Family Medical History: Asthma, Grandparents with strokes.
Father had MI at ages 45 and 50.
Physical Exam:
.
Physical Exam on ICU admission
VS: Temp: 97 BP: 101/70 HR:91 RR: 22 O2sat 80%
GEN: states he is anxious yet appears somnolent, cachectic
appearing, pale
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no
supraclavicular or cervical lymphadenopathy, no jvd
RESP: shallow breaths, no rhonchi or rhales
CV: RR, S1 and S2 wnl, no m/r/g
ABD: scaphoid abdomen, nd, +b/s, soft, nt, no masses or
hepatosplenomegaly
EXT: no c/c/e
SKIN: KS on scalp, HSV lesion on left chin
NEURO: AAOx3. Cn II-XII intact. moving all limbs but decreased
strength throughout
.
Pertinent Results:
Admission Labs:
[**2178-1-13**] 11:35AM BLOOD WBC-3.3* RBC-4.57* Hgb-13.6* Hct-40.9
MCV-90 MCH-29.7 MCHC-33.2 RDW-14.2 Plt Ct-731*
[**2178-1-14**] 07:20AM BLOOD WBC-2.7* RBC-3.76* Hgb-11.2* Hct-33.1*
MCV-88 MCH-29.8 MCHC-33.8 RDW-14.2 Plt Ct-562*
[**2178-1-13**] 11:35AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1
[**2178-1-13**] 11:35AM BLOOD Glucose-130* UreaN-14 Creat-0.6 Na-132*
K-3.7 Cl-98 HCO3-23 AnGap-15
[**2178-1-14**] 07:20AM BLOOD Glucose-114* UreaN-13 Creat-0.5 Na-132*
K-3.5 Cl-102 HCO3-23 AnGap-11
[**2178-1-14**] 07:20AM BLOOD ALT-29 AST-47* LD(LDH)-506* AlkPhos-105
TotBili-0.1
[**2178-1-13**] 11:35AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
[**2178-1-13**] 04:26PM BLOOD Type-ART pO2-63* pCO2-31* pH-7.46*
calTCO2-23 Base XS-0
[**2178-1-13**] 04:26PM BLOOD O2 Sat-91
[**2178-1-13**] 04:26PM BLOOD freeCa-1.11*
Legionella Urinary Antigen (Final [**2178-1-14**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
MICROSPORIDIA STAIN (Final [**2178-1-15**]): NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final [**2178-1-15**]): NO CYCLOSPORA SEEN.
FECAL CULTURE (Final [**2178-1-16**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2178-1-16**]): NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final [**2178-1-15**]):
This test does not reliably detect
Cryptosporidium,Cyclospora or
Microsporidium..
GIARDIA LAMBLIA. CYSTS AND TROPHOZOITES.
Cryptosporidium/Giardia (DFA) (Final [**2178-1-16**]):
NO CRYPTOSPORIDIUM SEEN.
GIARDIA LAMBLIA SEEN.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2178-1-15**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
Kaposi's Sarcoma - Skin, right scalp (A):
Dermal vascular proliferation consistent with Kaposi's sarcoma,
extending to the specimen margins (see note).
CT Torso:
IMPRESSION:
1. Diffuse ground-glass pulmonary infiltration, favoring the
central lungs
with a reticular pattern that suggests an acute-on-chronic
infection
consistent with pneumocystis jiroveci pneumonia. These findings
are not
characteristic of mycoplasma avium intracellulare infection.
2. Wedge-shaped hypodensity within the left kidney. This is most
characteristic of a renal infarct; however, differential
diagnosis includes
focal pyelonephritis and correlation with urinalysis is
suggested.
3. No appreciable lymphadenopathy.
CXR [**1-16**]:
FINDINGS: As compared to the previous radiograph, the
pre-described
parenchymal opacities at both lung bases and in the periphery of
the left
hilus are unchanged in severity and distribution. There is no
evidence of
pneumothorax. No newly occurred focal parenchymal opacities.
Normal size of the cardiac silhouette.
[**1-13**]: FINDINGS: There are ill-defined patchy opacities in the
lung bases
bilaterally, right greater than left. There is no pneumothorax
or pleural
effusion. The cardiomediastinal silhouette is unremarkable.
IMPRESSION: Ill-defined patchy bibasilar opacities, concerning
for infectious process. Given clinical context, pneumocystis
pneumonia not excluded.
On ICU admission:
Labs:
ABG 7.40/32/51
freeCa:1.06
Lactate:1.7
.
124 95 14
------------<53
5.2 19 0.4
.
Ca: 7.1 Mg: 1.6 P: 3.4
ALT: 56 AP: 241 Tbili: 0.2
AST: 108
MCV 88
11.1
1.9>----< 98
31.8
N:92 Band:0 L:4 M:4 E:0 Bas:0
.
.
EKG:
.
Imaging:
CXR Wet read
right PICC tip in the mid SVC. new since [**1-30**] tiny right apical
PTX and bilateral pneuomediastinum, but these findings similar
to [**1-27**] CXR. bilateral lung opacities, worse on the left,
unchanged since [**1-30**].
.
CXR [**1-30**]
IMPRESSION: AP chest compared to [**1-24**] through [**1-28**]:
There is no pneumothorax since [**1-28**] following removal of
the right pigtail pleural drain. A very small right pleural
effusion is little larger. Severe heterogeneous opacification of
much of the left lung and right lower lung has progressed over
the past three days, consistent with worsening infection,
including Pneumocystis. Heart is not enlarged. Pleural effusions
are small, if any. No pneumothorax.
.
CXR [**1-27**]
IMPRESSION: Portable upright AP chest radiograph compared with
multiple prior studies, most recent dated [**2178-1-25**].
A right-sided pigtail chest drain is in situ. No appreciable
pneumothorax is seen: There is moderate subcutaneous emphysema,
improved compared to the prior study. Multifocal bilateral mid
to lower zone consolidation is increased on the left side
compared to the prior study, concerning for infection.
.
[**1-19**] echo
The left atrium is normal in size. 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
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
leaflets are elongated. Mild bileaflet leaflet mitral valve
prolapse is suggested. Mild (1+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
.
[**1-15**] CT
IMPRESSION:
1. Diffuse ground-glass pulmonary infiltration, favoring the
central lungs with a reticular pattern that suggests an
acute-on-chronic infection consistent with pneumocystis jiroveci
pneumonia. These findings are not characteristic of mycoplasma
avium intracellulare infection.
2. Wedge-shaped hypodensity within the left kidney. This is most
characteristic of a renal infarct; however, differential
diagnosis includes focal pyelonephritis and correlation with
urinalysis is suggested.
3. No appreciable lymphadenopathy.
Brief Hospital Course:
Mr. [**Known lastname 62558**] was a 46 year-old male with a history of HIV who
initially presented to [**Hospital1 18**] [**2178-1-13**] with SOB and nonbloody
diarrhea and a CD4 count of 19 (pt off HAART for 1.5 year). He
[**Month/Day/Year **] underwent BAL with diagnosis of PJP and CMV
pneumonitis which were treated with bactrim and steroid taper
and Gancyclovir. KS with pulmonary involvement was treated with
Paclitaxel and high dose steroids. In addition he recieved
treatment for Giardia, thrush, HSV type II skin lesion and
hospital aquired pneumonia. He also developed recurrent Hep B
infection and was therefore started on HAART therapy. His
hospital course was complicated by bilateral apical
pneumothoraxes and pneumomediastinum. His pneumothoraxes were
treated by chest tube which was removed after bilateral
pneumothoraces were stable by radiology report. Unfortunately
Mr. [**Known lastname 62558**] [**Last Name (Titles) **] developed increasing oxygen requirement
and mental status change which required his transfer to the ICU.
In the ICU he was intubated for hypoxic respiratory failure,
mechanically ventilated and a right chest tube was placed to
prevent tension pneumothorax in the setting of known
pneumothorax and positive pressure ventilation. Mr. [**Known lastname 90417**] ICU
course was complicated by septic shock, renal failure, non
resolving right bronchopleural fistula, pancytopenia and ARDS.
Our attempts to wean off oxygen and pressors were to no avail.
Given his multi-organ failure, his profound immune supression
and his poor underlying nutritional status it was felt that he
no longer had realistic chance of recovery. On hospital day 29
after discussion with his family and HCP and in keeping with
their wishes Mr. [**Known lastname 90417**] goals of care were changed to focus on
comfort measures. He was extubated in the PM and expired shortly
thereafter with his mother and sister at his bedside. Death was
pronounced On 15th Febuary [**2177**] at 06:10 PM. The cheif cause of
death was Acquired Immune Deficiency Syndrome, the immediate
cause of death was Respiratory Failure.
Medications on Admission:
Medications:
Home:
None - Previously on Atripla
.
On transfer to ICU:
Sulfameth/Trimethoprim DS 2 TAB PO/NG TID (Day 1 = [**1-13**])
Vancomycin 1000 mg IV Q 24H (D1 [**2178-1-30**])
Piperacillin-Tazobactam 2.25 g IV Q6H (D1 [**2178-1-30**])
Raltegravir 400 mg PO BID
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
Ganciclovir 220 mg IV Q12H
Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Azithromycin 1200 mg PO/NG QMON ([**1-24**])
Cepacol (Menthol) 1 LOZ PO PRN cough
PredniSONE 40 mg PO/NG DAILY (started [**2-1**] ordered for 4 days)
OxycoDONE (Immediate Release) 5 mg PO/NG Q6H:PRN pain
Acetaminophen 325-650 mg PO/NG Q6H:PRN pain, fever
Ipratropium Bromide Neb 1 NEB IH Q4H:PRN SOB
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob/wheeze
Potassium Chloride Replacement (Oncology) IV Sliding Scale
Multivitamins 1 TAB PO/NG DAILY
Magnesium Sulfate Replacement (Oncology)
Potassium Phosphate Replacement (Oncology) IV Sliding Scale
Order Docusate Sodium 100 mg PO BID:PRN constipation
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Guaifenesin [**5-5**] mL PO/NG Q6H:PRN cough
Heparin 5000 UNIT SC TID Order date: [**1-24**] @ 1603 32.
.
Allergies: NKDA
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2178-2-11**]
|
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icd9cm
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[
[
[]
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[
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[
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13497, 13506
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10125, 12249
|
313, 362
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13552, 13556
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4343, 4343
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13607, 13640
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3653, 3747
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13527, 13531
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13580, 13584
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
870
| 109,361
|
46604
|
Discharge summary
|
report
|
Admission Date: [**2127-3-7**] Discharge Date: [**2127-3-14**]
Date of Birth: [**2064-4-1**] Sex: F
Service: MEDICINE
Allergies:
Bactrim Ds / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1974**]
Chief Complaint:
Shortness of breath, Left leg swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
62yo woman with history of hypertension presented to [**Hospital 191**] clinic
on day of admission with multiple complaints including chest
pain radiating to her left shoulder, shortness of breath on
exertion, cough, and worsening LLE swelling and pain x 2 days.
On initial exam, her vitals were stable: T 97.7, BP 126/84, P65,
RR10 98%RA. Her exam was notable for LLE swelling and warmth.
She was sent to the ED for further evaluation. In the ED, her
evaluation was notable for the following: clear chest film; CTA
demonstrating bilateral PE's; LLE LENI with extensive DVT in
left common femoral, superficial femoral, and popliteal veins,
also extending into greater saphenous; also found to have acute
coagulopathy, anemia, and thrombocytopenia.
She was also found to have BRBPR. GI was consulted, and
recommended to perform bowel prep in anticipation of colonoscopy
in AM. Surgery was consulted as well, and agreed with plan for
anticoagulation for PE's and further investigation for GI
bleeding by GI.
.
On interview on the floor she is alert, oriented, very pleasant,
and in no distress. She confirms that over the past several days
she has had exertional dyspnea, chest pain (described as dull
pressure, [**5-29**], mid-sternal with radiation to bilateral
shoulders, not clearly pleuritic) and worsening LLE swelling and
pain. She also reports several recent bouts of upper respiratory
symptoms after exposure to her grandson who is an infant in
daycare (reportedly had RSV bronchiolitis recently). Otherwise,
she denies any fever, chills, n/v, lymphadenopathy, night
sweats, unintentional weight loss, abdominal pain/increased
girth, or pruritus. She does report one episode of BRBPR on day
prior to admission after having bowel movement. ROS otherwise
negative. She also reports a worsening dry cough since she has
been in the hospital. She did not have a flu shot. She does not
report any long plane/car trips, no prolonged bed-rest. She
notes that the swelling in her L leg has improved since being in
the hospital.
Past Medical History:
Hypertension
Osteopenia
h/o pneumonia
liver hemangioma
psoriasis
rosacea
Diverticulosis
Social History:
Lives in [**Location 2624**], MA and summers on [**Location (un) 945**]. Married, two adult
children. Retired. No etoh/drugs/tobacco. Very active involved
in re-modelling her house. Babysits her grandson once per week.
Prior to onset of multiple viral illnesses last fall she did the
treadmill for 25 mins at speed 3.3 3-4 times per week.
Family History:
Father and mother with heart disease. Father had a triple A.
HTN. No blood clots. Father nieces with stomach cancer. Aunt
with lung cancer but was a smoker.
Physical Exam:
99.6, 92, 124/61, 18, 99% 2L nc
.
gen a/o, no distress, speaking in full sentences, no accessory
resp muscle use
heent moist mm, anicteric
neck supple, from, no meningeal signs, no JVD, no
lymphadenopathy
cv rrr, no m/r/g
resp CTA with decreased breath sounds in bilateral bases L>R
abd obese, soft, nabs, nt, no hepatosplenomegaly
extr asymmetric 2+ edema and erythema in LLE
neuro grossly non-focal
Pertinent Results:
[**2127-3-6**] 06:50PM WBC-11.7*# RBC-3.75* HGB-11.4* HCT-31.8*
MCV-85 MCH-30.2 MCHC-35.7* RDW-13.7
[**2127-3-6**] 06:50PM NEUTS-81.0* LYMPHS-13.3* MONOS-3.7 EOS-1.6
BASOS-0.3
[**2127-3-6**] 06:50PM PLT SMR-VERY LOW PLT COUNT-61*# LPLT-2+
[**2127-3-6**] 06:50PM PT-15.9* PTT-44.8* INR(PT)-1.4*
[**2127-3-6**] 06:50PM FIBRINOGE-65*
[**2127-3-6**] 06:50PM calTIBC-281 HAPTOGLOB-248* FERRITIN-192*
TRF-216
[**2127-3-6**] 06:50PM HOMOCYSTN-12.4
[**2127-3-6**] 06:50PM GLUCOSE-119* UREA N-27* CREAT-1.1 SODIUM-136
POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-23 ANION GAP-16
[**2127-3-6**] 06:50PM ALT(SGPT)-30 AST(SGOT)-24 LD(LDH)-333*
CK(CPK)-276* ALK PHOS-82 AMYLASE-38 TOT BILI-0.5
[**2127-3-6**] 06:50PM CK-MB-3
[**2127-3-6**] 06:50PM cTropnT-<0.01
[**2127-3-7**] 05:30AM D-DIMER-8945*
CTA CHEST:
1. Extensive bilateral pulmonary emboli, with probable
developing infarction in the left lingula.
2. Left pelvic vein clot from imaged portion of common femoral
to the confluence of the common iliac veins, likely the source
of pulmonary emboli. No definite extension to the right common
iliac vein or IVC.
3. Large hemangioma in liver.
4. Colonic diverticulosis without diverticulitis.
5. Left adnexal cyst, unusual in a postmenopausal patient. This
should be further evaluated with pelvic ultrasound on a
nonemergent basis.
LENI: Extensive acute DVT within the entire left lower
extremity deep venous systems. No right DVT.
ECG: Sinus rhythm. Non-specific junctional ST segment
depressions. Compared to the previous tracing this finding is
new.
TTE:
The left atrium is elongated. 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). Right ventricular
chamber size and
free wall motion are normal. The aortic arch is mildly dilated.
The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The left
ventricular inflow pattern suggests impaired relaxation. There
is borderline
pulmonary artery systolic hypertension. There is a
trivial/physiologic
pericardial effusion.
PELVIC US: Fibroids, follicular activity left ovary, right ovary
not seen, thrombus in the left iliac vein
Brief Hospital Course:
1) DVT/PE:
Patient was started on anticoagulation with heparin for
extensive PE/DVT (LLE). This was continued despite bleeding.
Once the bleeding has stabilized, she was started on coumadin.
She was discharged on a lovenox bridge to coumadin.
In terms of workup for cause of this thrombosis, pt had a pelvic
US to further evaluate mass since on CT as potential malignancy.
But there was no evidence of ovarian malignancy. She was up to
date on other cancer screening. Factor V leiden and prothrombin
gene mutation were pending at time of discharge. The rest of
the hypercoagulable workup will have to be done once acute
thrombosis resolves.
The left leg swelling improved throughout the admission. Pt was
instructed to keep the leg wrapped most of the day. And to keep
it elevated when lying in bed or sitting.
..
2) GI BLEED: Flex sig showed diverticulosis so this bleeding
was secondary to that. Pt did have blood loss anemia requiring
transfusions. During the last 5days of the admission, there was
no clinical bleeding and her Hct was stable to slightly
improving. Aspirin was held. Verapamil was also held and not
restarted as pt's BP was well controlled in house.
..
3) HTN: As above, verapamil was held.
..
4) COAGULOPATHY: On admission, pt had thromboctyopenia, low
fibrinogen. This was felt to be due to consumption and factors
improved once anticoagulation was started. There was no
evidence of frank DIC.
..
5) PNEUMONIA: Several days into the admission, pt developed a
low grade temperature and cough. Though this was most likely
due to pulmonary infarction, levaquin was started for pneumonia.
Pt's cough improved with this and she completed a 5d course of
levaquin before discharge.
Medications on Admission:
ASPIRIN 81 mg
BETAMETHASONE VALERATE 0.1 % to skin
METROGEL 1 % to skin
MULTIVITAMIN qD
VERAPAMIL HCL CR 240 MG qD
VIACTIV 500-100-40 mg-unit-mcg [**Hospital1 **]
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*0*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours) for 1 weeks.
Disp:*14 syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Deep Venous Thrombosis
Pulmonary embolism
Diverticular hemorrhage
Pneumonia
Discharge Condition:
Good.
Discharge Instructions:
Take medications as prescribed. You should not take aspirin or
verapamil until you are reassessed by Dr. [**First Name (STitle) 216**]. Do not take a
multivitamin or anything else with vitamin k as that will
counteract the coumadin.
For the next week, you can do basic daily activities but avoid
anything that requires prolonged standing, sitting (with legs
not elevated) ie driving, or walking. You can continue to use
the leg wrap during the night and part of the day. As your
swelling improves, you should not continue to need that.
Followup Instructions:
You will have your INR checked on monday with results sent to
Dr. [**First Name (STitle) 216**]. He will instruct you on whether you need to
continue lovenox and how to adjust your coumadin dose. Please
ask the VNA which lab the blood will be sent to.
Please follow up with Dr. [**First Name (STitle) 216**] late next week or early the
following week.
|
[
"562.12",
"287.5",
"486",
"453.41",
"401.9",
"415.19",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.24"
] |
icd9pcs
|
[
[
[]
]
] |
8382, 8431
|
5967, 7695
|
331, 339
|
8551, 8559
|
3474, 5944
|
9148, 9506
|
2879, 3037
|
7909, 8359
|
8452, 8530
|
7721, 7886
|
8583, 9125
|
3052, 3455
|
253, 293
|
367, 2395
|
2417, 2507
|
2523, 2863
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,514
| 109,641
|
54349
|
Discharge summary
|
report
|
Admission Date: [**2121-3-17**] Discharge Date: [**2121-3-19**]
Date of Birth: [**2039-3-20**] Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
81 y.o. male with history of colonic adenomatous polyp and grade
2 esophagitis in [**2118**] who presents with a chief complaint of
hematochezia x 1 day. Patient reports up to 6 grossly bloody,
loose BMs with ? melena and diaphoresis, but no hematemesis,
abdominal pain, fevers/chills, N/V, lightheadedness, CP, SOB,
palpitations. Given the ongoing symptoms, patient presented to
the ED for further evaluation.
.
In the [**Hospital1 18**] ED, vitals were: T - 97.4, BP - 111/57, HR - 90, RR
- 18, O2 - 99% RA. Hct was 26.7, down from 36.3 in in [**8-3**]. NGL
was negative, however, there was no bilious return. Though
patient was hemodynamically stable, he was admitted to the ICU
for close observation and GI follow-up.
Past Medical History:
Hypertension
Chronic Renal Insufficiency (baseline of 1.8 - 2)
CML
Gout
Chronic Low Back Pain
Carpal Tunnel Syndrome
BPH
Social History:
Patient denies tobacco or illicit drug use. He reports
occasional alcohol consumption. He is a tax attorney, married.
Family History:
NC
Physical Exam:
Vitals: T - 97.2, BP - 124/65, HR - 78, RR - 18, O2 - 95% RA
General: Awake, alert, NAD, resting comfortably in bed
HEENT: NC/AT; PERRLA, EOMI; OP clear, nonerythematous
Neck: Supple, no LAD
Chest/CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB
Abd: Soft, NT, ND, + BS
Rectal: Guaiac positive, maroon colored stool
Ext: No c/c/e
Neuro: Grossly intact
Skin: No lesions
Pertinent Results:
[**2121-3-16**] 11:50PM BLOOD WBC-15.7* RBC-2.52* Hgb-9.1*# Hct-26.7*#
MCV-106* MCH-36.3* MCHC-34.2 RDW-18.1* Plt Ct-484*
[**2121-3-16**] 11:50PM BLOOD Glucose-208* UreaN-39* Creat-2.4* Na-140
K-6.2* Cl-107 HCO3-21* AnGap-18
[**2121-3-17**] 06:45AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.8
Brief Hospital Course:
81 y.o. male with history of colonic polyps and esophagitis who
presented with hematochezia.
.
# Hematochezia: Pt presented with hematochezia and hct of 26.7.
Had a h/o diverticulosis and polyps which could have been the
source of the bleed. Patient intially admitted to the MICU. Hct
slowly trended down and pt initially reluctant to get
transfusions, but eventually agreed. Was prepped and had
colonoscopy that showed diverticulosis of the entier colon,
irregular site of previous polypectomy and otherwise nl
colonoscopy to cecum. Prep was noted to be poor. He was
hemodynamically stable, with stable hct and called out to the
floor. He then underwent an EGD, which showed a single
superficial non-bleeding 5mm ulcer was found on the posterior
wall of the antrum. No blood was found in the upper tract, and
the ulcer showed no stigmata of bleeding. This lesion is an
unlikely cause of hematochezia. It seems probably that the
event that precipitated this admission was a diverticular bleed.
As his colonoscopy prep was poor, and he had a previous polyp,
he should return for an elective colonoscopy sometime later this
year. With his previous history of esophagitis and the current
finding of an ulcer, it may be most prudent to continue acid
reduction therapy indefinitely.
.
# Chronic Renal Insufficiency: Increased at admit at 2.4 from
baseline of 1.8 - 2, possibly due to hypovolemia from GIB.
Improved with fluids and transfusions to baseline.
.
# Leukocytosis/Thrombocytosis: No localizing symptoms or
evidence of infection. UA was negative. Patient does have
myeloproliferative disease and WBC has been elevated in the
past, though more recently was normal. He was monitored for
fevers and remained afebrile.
.
# CML: No active issues> he was continued on hydrea
.
# Gout: He was continued on renally dosed allopurinol.
.
# BPH; Alpha blockers held in the setting of GIB
.
# Chronic Pain: He received Tylenol PRN andLow-dose narcotics
PRN for continued pain as BP tolerated
.
# Code status: FULL
Medications on Admission:
Allopurinol
Finasteride
Hydrea
Ambien
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Hydroxyurea 500 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Diverticular Bleed
Secondary Dx:
Acute Renal Failure
Chronic renal insufficiency
Myeloproliferative disease
Gout
BPH
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged from the hospital after admission for
gastrointestinal bleed. You required blood transfusion, and RBC
count has since held stable. Colonoscopy yesterday was normal.
Today's upper endoscopy today found a single superficial
non-bleeding 5mm ulcer. No blood was found in the upper tract,
and the ulcer showed no stigmata of bleeding. This lesion is an
unlikely cause of your bleeding. It seems probably that the
event that precipitated this admission was a diverticular bleed.
Your colonoscopy prep was poor, and he as you had a previous
polyp, you should return for an elective colonoscopy sometime
later this year.
With a previous history of esophagitis and the current
finding of an ulcer, it may be most prudent to continue acid
reduction therapy indefinitely.
Followup Instructions:
You should follow up with your PCP [**Last Name (NamePattern4) **] [**3-26**] at 130pm
You have a repeat colonoscopy set up for [**5-1**] at 8am Please call
([**Telephone/Fax (1) 2233**] with questions. Information will be mailed to
you in the mail.
|
[
"600.00",
"274.9",
"584.9",
"585.9",
"403.90",
"238.71",
"531.90",
"205.10",
"285.1",
"327.23",
"562.12",
"276.52",
"V12.72"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
4632, 4638
|
2050, 4067
|
273, 286
|
4818, 4827
|
1742, 2027
|
5674, 5929
|
1334, 1338
|
4156, 4609
|
4659, 4659
|
4093, 4133
|
4851, 5651
|
1353, 1723
|
228, 235
|
314, 1038
|
4678, 4797
|
1060, 1183
|
1199, 1318
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,657
| 177,550
|
13529
|
Discharge summary
|
report
|
Admission Date: [**2147-4-7**] Discharge Date: [**2147-4-9**]
Date of Birth: [**2112-11-14**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Watermelon / Almond Oil / Hydralazine / cefepime
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
hypoglycemia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
34 year-old man with hx brittle DM1 c/b HD-dependent ESRD now
admitted with sympomatic early-monrning hypoglycemia, BS 15.
.
Patient reports taking usual dose of lantus (10 units) at 11pm
on the night prior to admission and then he next remembers being
put in an ambulance. His girlfriend gave him glucose tablets
and called 911 because he he was "talking funny" and seemed
confused early that morning. He doesn't remember any of this.
EMS found the patient unresponsive with a FS of 15 - glucagon
and IV dextrose were administered.
.
In the ED the patient was hypertensive but otherwise had stable
VS. Initial FS was 179 & on repeat fell to 44. He was started on
D10W gtt. [**Last Name (un) **] was consulted in the ED and the patient was
admitted to the MICU for BS monitoring. Pt reports that he had
been taking his current insulin regimen for ~1 months without
hypoglycemia. Describes normal PO intake on the day prior to
admission (eats several small meals throughout the day to
prevent gastroparesis), perhaps less protein than usual. Denied
alcohol or drug use. No unusual exercise.
.
Of note, the patient was recently admitted from [**Date range (1) 1396**] for
CHF exacerbation that was notable for flash pulm edema due to
hypertension & required intubation for worsening mental status.
Patient also briefly required nitro drip and IV labetalol as
well as dialysis for blood pressure control. On that admission,
a bronchoscopy was concerning for alveolar hemorrhage, but [**Doctor First Name **],
ANCA and anti-GBM were negative and patient had no further
episodes of bleeding. Repeat echo on that admission showed an
improved EF of 55%. That hospital course was c/b initial
hyperglycemia then subsequent hypoglycemia requiring D20 gtt. On
the floor the patient was again hyperglycemic requiring high
doses of insulin prompting transfer bact to the MICU for insulin
gtt. [**Last Name (un) **] was consulted on that admission and recommended
increasing Lantus dose to 14units qAM and 12 units qPM. Patient
ultimately signed out AMA on [**3-2**].
Past Medical History:
- DM type I since age 19, followed at [**Last Name (un) **]. Complicated by
nephropathy, neuropathy, gastroparesis, retinopathy. Multiple
prior hospitalizations with DKA, nausea/vomiting [**2-9**]
gastroparesis
- ESRD on HD T/Th/S via right arm fistula @ [**Location (un) **] [**Location (un) **],
dry weight 73kg
- Hypoglycemia
- Hyperglycemia/DKA: requiring insulin gtt
- Hypertension
- Nonischemic cardiomyopathy with EF 30-35%
- Anemia: [**2-9**] iron deficiency and advanced CKD
- Depression
- Pulmonary hypertension
- Migraines
Social History:
Lives with girlfriend. Mother also local.
College degree in marketing, worked at [**Company 2475**] previously.
Tobacco: trying to quit; relapsed and smokes ~1 pack per week
EtOH: previously drank heavily (30-40 drinks/week) but has not
used alcohol since [**2144-11-14**]
Denies other drugs.
Family History:
Paternal grandfather had DM2. [**Name2 (NI) **] FH DM1. Hypertension in a few
family members. [**Name (NI) 6419**] [**Name2 (NI) **] and several siblings alive and
healthy, without known medical problems.
Physical Exam:
MICU 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-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact, no SI
.
DISCHARGE EXAM
VS 98.1 138/95 76 18 97/RA FS 104
GEN: well-appearing young man walking around comfortably, fully
dressed, NAD
HEENT: NCAT, MMM, oropharynx clear, EOMI, PERRL, no JVD
CV: RRR, normal S1/S2, no mrg
Lungs: good aeration throughout, no w/r/r
Abdomen: soft NT ND NABS
Ext: WWP, thin legs, 2+ palpable pulses no edema
Neuro: AOX3, CNII-XII intact, 5/5 strength throughout, gait
stable
Pertinent Results:
MICU ADMISSION LABS
[**2147-4-7**] 08:10AM BLOOD WBC-11.1*# RBC-3.82*# Hgb-11.7*#
Hct-37.5*# MCV-98# MCH-30.7 MCHC-31.2 RDW-14.7 Plt Ct-241
[**2147-4-7**] 08:10AM BLOOD Neuts-84.8* Lymphs-7.4* Monos-2.3
Eos-4.7* Baso-0.7
[**2147-4-7**] 08:10AM BLOOD Glucose-112* UreaN-19 Creat-6.6*# Na-137
K-3.6 Cl-94* HCO3-29 AnGap-18
.
OTHER PERTINENT LABS
[**2147-4-8**] 05:32AM BLOOD Cortsol-15.9
[**2147-4-7**] 08:10AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
DISCHARGE LABS
[**2147-4-9**] 06:40AM BLOOD WBC-4.5 RBC-3.42* Hgb-10.6* Hct-33.5*
MCV-98 MCH-30.9 MCHC-31.5 RDW-14.2 Plt Ct-282
[**2147-4-9**] 06:40AM BLOOD Glucose-69* UreaN-18 Creat-6.1*# Na-138
K-4.0 Cl-95* HCO3-32 AnGap-15
[**2147-4-9**] 06:40AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.1
.
MICRO - NONE
.
IMAGING
.
[**2147-4-7**] CXR
IMPRESSION:
1. Baseline cephalization of pulmonary vascularity and
cardiomegaly but no evidence for superimposed acute disease.
2. Suspected nipple shadow projecting over the left mid lung.
However, for confirmation, a repeat PA view with the nipple
markers is recommended when clinically appropriate.
Brief Hospital Course:
34M w/hx type 1 diabetes mellitus c/b gastroparesis,
HD-dependent ESRD and chronic systolic heart failure (with
recent documented recovery of EF) brought to the ED by EMS
after being found confused at home with a BS 15. Hospital course
was notable for hypo and hyperglycemia. Patient left AMA prior
to insulin regimen stabilization.
.
#SYMPTOMATIC HYPOGLYCEMIA/Diabetes mellitus type 1:
Patient was initially admitted to the MICU where he was
monitored and given D10 until blood sugars consistently above
100 (137-295). Pt reported no change in diet, alcohol
consumption or exercise to explain different response to usual
insulin dose. Pt history and OMR notes suggested long history of
difficulties controlling labile BS and admission for both hypo
and hyperglycemia. He was followed closely by the [**Last Name (un) **] consult
service in house, who recommended 8U lantus [**Hospital1 **] + humalog
sliding scale. This plan was applied for ~36h with no marked
change in lability of QACHS BS which ranged from 23 to >500.
Plan was for pt to stay inpatient for further insulin dose
adjustment, but pt decided to leave AMA prior to any further
changes. In addition, because pt was very uncomfortable using
*any* qHS lantus at home given his recent hypoglycemic episode,
[**Last Name (un) **] consult adjusted their regimen to 14U lantus qAM +
humalog sliding scale. Risks of leaving the hospital prior to
insulin regimen stabilization were discussed with the patient,
who understood. He was given a printout of final insulin scale
prior to leaving the hospital. Will need close outpatient
follow-up with [**Last Name (un) **] diabetologist and PCP.
.
# [**Name (NI) 40903**] ESRD
Pt's HD schedule is T/Th/S via right arm fistula (dry weight
73kg). Euvolemic on admission, underwent HD on [**4-8**]. All meds
were dosed renally.
# HTN
Hypertensive in MICU on admission. Home [**Month/Day (4) 40899**] patch,
labetalol, lisinopril, amlodipine were restarted.
# CARDIOMYOPATHY, CHRONIC SYSTOLIC HEART FAILURE EF 30-35%
Secondary to long-standing and poorly controlled hypertension.
Euvolemic on admission. Currently asymptomatic, without dyspnea,
hypoxia or exam evidence of volume overload. Continued on ASA
and Labetalol.
.
# HX DIABETIC GASTROPARESIS
On PRN zofran and dilaudid at home. No symptoms during this
admission. Ate regular meals.
.
TRANSITIONAL ISSUES
Pt needs close BS/insulin regimen follow-up. He was instructed
to call his PCP and [**Name9 (PRE) **] [**Name9 (PRE) 766**] morning - we will also attempt
to schedule these appointments for him and communicate details.
Medications on Admission:
amlodipine 10 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO once a day.
aspirin 81 mg Tablet, Chewable [**Name9 (PRE) **]: One (1) Tablet, Chewable PO
DAILY (Daily).
[**Name9 (PRE) 40899**] 0.3 mg/24 hr Patch Weekly [**Name9 (PRE) **]: One (1) Patch Weekly
Transdermal QMON (every [**Name9 (PRE) 766**]) - every friday per patient.
insulin glargine 100 unit/mL Solution [**Name9 (PRE) **]: Fourteen (14) units
Subcutaneous In the morning.
insulin lispro 100 unit/mL Solution [**Name9 (PRE) **]: Sliding scale units
Subcutaneous With meals and at bedtime: home sliding scale.
B complex-vitamin C-folic acid 1 mg Capsule [**Name9 (PRE) **]: One (1) Cap PO
DAILY (Daily).
lisinopril 40 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO once a day.
sevelamer carbonate 800 mg Tablet [**Name9 (PRE) **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
sertraline 100 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO once a day.
hydromorphone 4 mg Tablet [**Name9 (PRE) **]: One (1) Tablet PO every twelve
(12) hours as needed for pain.
ondansetron 4 mg Tablet, Rapid Dissolve [**Name9 (PRE) **]: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
labetalol per patient 600mg [**Hospital1 **], 300mg qhs
Discharge Medications:
1. amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. [**Hospital1 40899**] 0.3 mg/24 hr Patch Weekly [**Hospital1 **]: One (1) Patch Weekly
Transdermal qMONDAY.
4. insulin glargine 100 unit/mL Solution [**Hospital1 **]: Fourteen (14)
units Subcutaneous qAM.
5. insulin lispro 100 unit/mL Solution [**Hospital1 **]: as directed
Subcutaneous QACHS.
6. B complex-vitamin C-folic acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
7. lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
8. sevelamer carbonate 800 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. sertraline 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
10. hydromorphone 2 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day) as needed for pain.
11. ondansetron HCl 4 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
12. labetalol 200 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2
times a day).
13. labetalol 100 mg Tablet [**Hospital1 **]: Three (3) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
Hypoglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 21822**],
You were admitted to the hospital for blood sugar of 15. You
stayed overnight in the ICU for blood sugar monitoring. Your
blood sugars were very labile - ranging from the 70s to 500s.
Last night your blood sugar dropped from >500 to 29 over 5 hours
because of "insulin stacking" - taking too much insulin over a
few hours.
Because your blood sugars are so unstable, we recommended
staying in the hospital for further insulin dosing modification
and observation.
You are leaving against medical advice.
The attending physician discussed [**Name9 (PRE) 40904**] risks of high
and low blood sugars with you, including confusion, lethargy,
fainting and coma. You were aware of these risks and decided to
leave anyway.
We spoke with the [**Last Name (un) **] diabetes doctors before [**Name5 (PTitle) **] [**Name5 (PTitle) **].
Since you are not willing to take long-acting insulin at night,
they recommended taking 14 units of long-acting insulin (Lantus)
each morning. You should continue using a short-acting insulin
before meals and at bedtime.
We did not make any other changes to your medications.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You need to see your primary care doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] doctor
before Friday.
.
Please call Dr.[**Name (NI) 40905**] office [**Name (NI) 766**] morning to schedule an
appointment within the next week:
.
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 24385**] and/or Dr. [**First Name (STitle) **] RIND
Location: [**Hospital3 249**]
[**Hospital1 **]/EAST
Address: [**Location (un) **], E/CC-6, [**Location (un) **],[**Numeric Identifier 2260**]
Phone: [**Telephone/Fax (1) 2010**]
.
Please call [**Last Name (un) **] to schedule an appointment with Dr. [**Last Name (STitle) 978**].
We will also call them to ask them to call you with an
appointment, since you have had trouble scheduling appointments
there on short-notice in the past.
Name: [**Last Name (LF) 978**], [**First Name7 (NamePattern1) 7208**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
|
[
"311",
"250.83",
"416.8",
"428.0",
"250.53",
"536.3",
"305.1",
"403.91",
"250.43",
"583.81",
"425.4",
"428.22",
"250.63",
"V45.11",
"V58.67",
"285.21",
"362.01",
"357.2",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
10842, 10848
|
5709, 8296
|
334, 340
|
10905, 10905
|
4568, 5686
|
12309, 13427
|
3310, 3516
|
9581, 10819
|
10869, 10884
|
8322, 9558
|
11056, 12286
|
3531, 4549
|
282, 296
|
368, 2426
|
10920, 11032
|
2448, 2983
|
2999, 3294
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
755
| 127,323
|
51681
|
Discharge summary
|
report
|
Admission Date: [**2199-1-1**] Discharge Date: [**2199-1-7**]
Date of Birth: [**2127-4-25**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 71-year-old
woman status post a fall in [**2197-8-13**] resulting in severe
subdural hematoma with subarachnoid hemorrhage, eventually
requiring a ventriculoperitoneal pleural shunt. The patient
came back with recurrent pleural effusions requiring
thoracentesis x2 and on the 19th underwent a revision of a
ventricular pleural to a ventriculoperitoneal shunt secondary
to progressive dyspnea secondary to recurrent pleural
effusions. The patient tolerated the procedure well. There
were no intraoperative complications.
PAST MEDICAL HISTORY:
1. Traumatic brain injury
2. Chronic pulmonary embolus
3. Myocardial infarction with stenting in [**2198-10-14**]
4. Chronic right pleural effusion
5. Hypertension
She was admitted to the Surgical Intensive Care Unit
postoperative and had a thoracentesis done to tap the right
pleural effusion and that was done successfully without
complication. The patient was successfully extubated and was
weaned to room air and transferred to the regular floor post
thoracentesis. She has remained neurologically stable,
awake, alert and oriented x3, moving all extremities with
good strength. Her abdomen is soft, nontender, nondistended
with good bowel sounds. Her incisions are clean, dry and
intact. She is seen by physical therapy and occupational
therapy and found to require a short rehabilitation stay
prior to discharge to home.
DISCHARGE MEDICATIONS:
1. Colace 100 mg po bid
2. Protonix 40 mg po q 24 hours
3. Insulin sliding scale
4. Metoprolol 50 mg po bid
5. [**Year (4 digits) **] 10 mg po q day
6. Lorazepam 0.5 mg po bid
7. Trazodone 100 mg po q hs
8. Quetiapine fumarate 100 mg po q hs
The patient's condition was stable at the time of discharge.
Her incisions were clean, dry and intact. She will follow up
with Dr. [**First Name (STitle) **] in one month.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2199-1-7**] 09:42
T: [**2199-1-7**] 09:53
JOB#: [**Job Number 107068**]
|
[
"412",
"V45.82",
"331.4",
"511.9",
"996.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"02.42"
] |
icd9pcs
|
[
[
[]
]
] |
1583, 2286
|
158, 699
|
721, 1560
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,603
| 166,019
|
54833
|
Discharge summary
|
report
|
Admission Date: [**2178-4-15**] Discharge Date: [**2178-4-30**]
Date of Birth: [**2135-2-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Chief Complaint: cough
Reason for MICU transfer: septic shock
Major Surgical or Invasive Procedure:
PICC placement
Central Line Removal
History of Present Illness:
43 year old man who presented to [**Hospital3 4107**] on [**2178-4-13**] with
productive cough, fever and pleuritic chest pain. He was found
to be hypoxemic on arrival with sats 86% on RA, ABG
7.36/32/71/18. He reported associated pleuritic chest pain,
generalized weakness, diaphoresis and anorexia. Initially was
noted to be in SVT, given adenosine with conversion to sinus.
CXR showed moderate RLL consolidation, small RUL consolidation,
patchy infiltrates in LUL (differential included pneumonitis,
pulmonary hemorrhage versus ARDS). He was intubated for
respiratory failure and concern for ARDS. Sedation was difficult
and required fentanyl, ativan, propofol and vecuronium. He was
ventilated on pressure control. He had hypotension requiring
both norepinephrine and vasopressin for pressor support. He was
given ceftriaxone, azithromycin and vancomycin. Sputum culture
grew Strep pneumonia and [**Female First Name (un) **] albicans on [**2178-4-13**].
Bronchoscopy showed diffuse thick dark yellow secretions
throughout the entire tracheobronchial tree. BAL grew Strep
pneumonia (PCP and fungal cultures pending). Influenza negative.
Fungal cultures including acid fast bacilli cultures are
pending. Blood cultures were positive for Strep pneumonia on
[**2178-4-13**]. Opportunisitic infections were considered, but HIV
testing was not obtained. He was also noted to have acute kidney
injury with creatinine 3.7 and BUN 64. He was seen by nephrology
at the OSH who suspected ATN and recommended continued IV
hydration. Creatinine trended down to 1.9 prior to transfer.
.
On arrival to the MICU, he was intubated and sedated, on
pressure support ventilation, comfortable appearing. Pressors
weaned on arrival with MAP >65.
.
Review of systems:
unable to obtain due to sedation and intubation
Past Medical History:
ruptured appendix and appendectomy
Social History:
Works as a realtor, lives with a male partner. Smokes 1 pack/day
for past 20 years. Drinks one drink 4 times per week. Sexually
active with partner, has been HIV negative by report in past.
Family History:
Mother died age 73 of pancreatic cancer. Father had PMR, died
age 75.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.7 92 109/68 on pressure control, changed to AC 26
450mL 100% FIO2 and PEEP 10 on arrival, sedated with fentanyl
and propofol
General: intubated, sedated, not responding to voice
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, right subclavian line c/d/i
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: rhonchi anteriorly, no wheezes, rales, ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
DISCHARGE EXAM:
Pertinent Results:
ADMISSION LABS:
[**2178-4-15**] 07:37PM BLOOD WBC-13.3* RBC-3.31* Hgb-10.1* Hct-31.7*
MCV-96 MCH-30.6 MCHC-32.0 RDW-15.4 Plt Ct-169
[**2178-4-15**] 07:37PM BLOOD Neuts-84* Bands-7* Lymphs-1* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-1*
[**2178-4-15**] 07:37PM BLOOD PT-11.9 PTT-26.9 INR(PT)-1.1
[**2178-4-15**] 07:37PM BLOOD Glucose-112* UreaN-61* Creat-2.5* Na-145
K-3.9 Cl-121* HCO3-20* AnGap-8
[**2178-4-15**] 07:37PM BLOOD ALT-10 AST-45* LD(LDH)-340* TotBili-0.6
[**2178-4-15**] 07:37PM BLOOD Albumin-2.4* Calcium-7.1* Phos-6.7*
Mg-3.3* Iron-16*
[**2178-4-15**] 07:37PM BLOOD calTIBC-73* Hapto-447* Ferritn-1563*
TRF-56*
[**2178-4-15**] 07:48PM BLOOD Lactate-0.9
.
PERTINENT LABS:
.
MICRO:
.
IMAGING:
[**4-15**] CXR: The patient is intubated. The tip of the endotracheal
tube is located directly at the carina. The tube should be
pulled back by 2 to 3 cm. The patient has a right subclavian
line. The tip of the line projects over the lower SVC. There are
extensive areas of lung parenchymal opacities and
consolidations, slightly more extensive on the left than on the
right, with extensive air bronchograms but no evidence of
pleural effusions. Borderline size of the cardiac silhouette.
Despite the history of streptococcal infection, the possibility
of ARDS should be considered.
.
[**4-20**] ECHO: The left atrium and right atrium are normal in cavity
size. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is high (>4.0L/min/m2). Tissue Doppler imaging suggests a
normal left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Normal study. No valvular pathology or pathologic
flow identified.
.
[**4-21**] CT Chest w/o con:
1. Extensive ground-glass opacity is consistent with diffuse
infection. An
additional component of pulmonary edema is possible, given the
accompanying septal thickening.
2. Three large thick-walled cavitary lesions likely represent a
necrotizing pneumonia in this patient with prior streptococcal
bacteremia. A fourth smaller caviation and non-cavitary
consolidation are also present. Note that the plain radiographic
appearence of diffuse pulmonary opacity has improved since [**4-15**].
.
[**4-22**] CT Head w/o con:
1. No acute intracranial process.
2. Bilateral mastoid air cell fluid-opacification. Given the
documented Streptococcus pneumoniae infection, this may
represent infectious otomastoiditis, rather than simply
effusions due recent intubation and prolonged supine
positioning.
.
[**4-23**] MRI Head w/ and w/o con:
1. No evidence of infection, inflammation, infarction, or
hemorrhage within brain.
2. Pansinusitis and bilateral mastoid opacification.
Brief Hospital Course:
43 year man with history of etoh abuse who presented to [**Hospital1 2519**] on [**2178-4-13**] with productive cough, fever, bandemia and
respiratory failure, found to have Strep pneumonia with septic
shock and [**Hospital **] transferred to [**Hospital1 18**] for further evaluation.
.
# Septic shock: Secondary to Strep pneumonia with positive blood
and sputum cultures at [**Hospital3 4107**]. He was treated initially
with ceftriaxone, later broadened to cefepime and ciprofloxacin
due to lack of improvement on the ventilator. Blood cultures on
[**4-16**] revealed GPC in clusters, prompting intitiation of
vancomycin. Bronchoscopy with BAL was performed on [**4-18**] to
evaluate for additional pulmonary pathogens and was negative.
There was initial concern for HIV, however CD4 count was wnl and
HIV viral load was undetectable. He was initially improving on
the antibiotics but then spiked fevers on [**4-20**] and [**4-21**]. CT chest
on [**4-21**] revealed three large thick-walled cavitary lesions likely
represent a necrotizing pneumonia. ID was consulted and he was
treated empirically for VAP with linezolid, cefepime,
tobramycin, and flagyl. He continued to improve so antibiotics
were narrowed to ceftriaxone with transition to levofloxacin and
flagyl and the patient will complete a 14-day course of
levofloxacin and flagyl which will end on [**2178-5-5**].
.
# ARDS: Suspected due to underyling Strep pneumonia. He was
ventilated with ARDS net protocol although sedation was very
difficult (likely due to underlying alcohol use of 4+ drinks
daily). He was initially sedated with propofol, fentanyl and
versed. Propofol was stopped on [**4-16**] once hypertriglyceridemia
(TG 1000s) was noted. He was extubated on [**4-24**], and was able to
be weaned to room air on the floor with ambulatory O2
saturations >92% on room air.
.
# Acute renal failure: Suspected ATN secondary to septic shock.
Creatinine trended down and was 1.7 upon call-out from the MICU,
and was 1.2 upon discharge.
.
# Agitation: Patient was extremely agitation while on the
ventilator, rquiring large doses of fentanyl and versed. He was
started on seroquel, haldol prn, and methadone, with improvement
in agitation. His agitation also continued to improve
post-extubation. LP was negative for infection and CT and MRI
head were both negative for acute process. Psychiatry was
consulted and recommended tapering the above medications over
the next 4-5 days, starting from the day of MICU call-out
([**4-26**]). By [**4-28**], Mr. [**Known lastname 112056**] was off of methadone, and his
seroquel was PRN. He did not require haloperidol on the floor,
and became progressively more oriented to the point at which
upon discharge he was not disoriented at all and his attention
had returned nearly to baseline.
Medications on Admission:
Medications HOME:
none
Medications on transfer:
hydrocortisone 100mg q8H
lorazepam 2mg q6H
metoclopramide 10mg q6H
vasopressin drip
acetaminophen 650mg q4H PRN
vancomycin 1000mg IV BID
fentanyl drip
norepinephrine drip
azithromycin 500mg daily
heparin SQ 5000 units TID
NS continuous
artificial tears QID
chlorhexidine TID
Insulin regular sliding scale
levalbuterol 1.25mg nebs q4H
propofol drip
vecuronium PRN q8H
ceftriaxone 1g daily
pantoprazole 40mg daily
Discharge Medications:
1. Calcium Carbonate 500 mg PO QID:PRN heart burn
RX *Antacid 200 mg calcium (500 mg) every 4 hours Disp #*60
Tablet Refills:*0
2. Levofloxacin 750 mg PO DAILY Duration: 5 Days Start: In am
start [**4-29**], end [**5-5**]
RX *Levaquin 750 mg daily Disp #*5 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
last day of ABX will be on [**5-5**]
RX *Flagyl 500 mg every 8 hours Disp #*17 Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *Daily Multi-Vitamin daily Disp #*30 Tablet Refills:*0
5. Ondansetron 4 mg PO Q4H:PRN nausea
RX *ondansetron HCl 4 mg every 4 hours Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Severe Cavitary Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 112056**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were
admitted with a severe pneumonia, and were in the intensive care
unit for two weeks intubated. We were able to treat this serious
pneumonia with antibiotics, and your pneumonia improved. We were
able to wean you off of the ventilator and wake you up. While
you were intubated, you were quite agitated, and after you woke
up you were a fair bit disoriented. This improved over time.
Initially you were a bit weak on your feet after you woke up
from being intubated and sedated, but were able to improve to an
acceptable functional status for home once you worked with
physical therapy for a few days.
You were on no medications at home, we recommend that you start
the following medications:
Levofloxacin 750mg daily for 5 more days until [**5-5**]
Metronidazole (flagyl) 500mg every 8 hours for 5 more days until
[**5-5**]
Multivitamin ongoing for nutrition
Zofran as needed for nausea
Calcium Carbonate as needed for heartburn
It is very important that you continue to not smoke. Smoking
likely contributed to this very severe and life threatening
pneumonia. You have not smoked while you were admitted, and you
are no longer addicted to the nicotine. Don't smoke again! You
can do it! It is the single best thing you can do for your
health.
Followup Instructions:
We are working on a follow up appt in the Pulmonary department
in five weeks. You will be called at home with the appointment.
If you have not heard or have questions, please call
[**Telephone/Fax (1) 612**].
Name:[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],MD
Specialty: Primary Care
Address: [**Apartment Address(1) 99441**], [**Location (un) **],[**Numeric Identifier 4770**]
Phone: [**Telephone/Fax (1) 3149**]
When: We are working on a follow up appointment in the next
week. You will be called with an appointment. If you have not
heard in two days, please call above number for status.
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56,890
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Discharge summary
|
report
|
Admission Date: [**2113-11-26**] Discharge Date: [**2113-12-14**]
Date of Birth: [**2056-3-9**] Sex: F
Service: NEUROLOGY
Allergies:
Nafcillin / Penicillins
Attending:[**First Name3 (LF) 1032**]
Chief Complaint:
weakness, paresthesias
Major Surgical or Invasive Procedure:
Lumbar puncture
PICC line placement
Sural nerve biopsy
History of Present Illness:
per admitting resident:
57 RHF w/ hx MMP inlcuding morbid obesity, DM, HTN, OA,
chronic pain, multiple skin infections and UTI's, admitted twice
over the past ~month to [**Hospital3 **] Hosp. The first
admission
was for progressive weakness and parasthesiae initially only in
the LE with preserved UE strength and reflexes. She received MRI
of the C- and T-spine, initially without Gad, and then later
with, all of which were reportedly unremarkable. Both had to be
done at [**Hospital 1474**] Hosp to accommodate her girth. She received an
LP under fluoro that showed normal cell counts, protein, and
glucose. She received an EMG, which, although technically
difficult, demonstrated preserved F-waves, which was felt to
argue against an inflammatory neuropathy. She was diagnosed with
a presumptive transverse myelitis and was treated with 3 days IV
soumedrol (1 g per day), w/ perhaps mild improvement in
sensation, but no change in strength. She was discharged to
rehab
[**11-8**], but returned [**11-14**] with fever to 104 F and altered mental
status. LP was re-attempted but failed. UA was suggestive of
UTI,
and she was treated with Kefzol, Nystatin, and Macrobid. Blood
cx's have been neg to date. Mental status returned to [**Location 213**]
after she defeveresced, but when neurology was asked to
re-examine her, it seemed that her weakness had progressed and
involved her UE as well, and was described as a flaccid
quadraplegia. She was given a repeat trial of IV solumedrol 1 g
per day x 3 days without effect.
On ROS, she denied any HA or VC. She denied any GI or
respiratory
illness or any recent vaccines in the weeks to months prior to
the onset of this weakness. She does endorse hoarseness of her
voice which she feels has been present for about 10 days.
Past Medical History:
DM
HTN
recurrent cellulitis of the abdomen
an incarcerated ventral hernia requiring surgery followed by a
DVT in [**2103-6-12**], s/p IVC filter
osteoarthritis of the knee and back with chronic pain
chronic fungal infections of her pannus
obesity, s/p gastric bypass
GERD
folate deficiency
iron deficiency
Social History:
denies tobacco or drugs. Drinks ~3 beers per day on weekends.
Married, 2 grown kids.
Family History:
denies
Physical Exam:
Exam at time of admission:
T- 97.7F BP- 152/80 HR- 107 RR- 18 O2Sat 97% on 2L NC
Gen: morbidly obese woman, Lying in bed, NAD
HEENT: NC/AT, very dry oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no c/c/e; equal radial and pedal pulses B/L.
Skin: multiple hematomas thoughout UE B/L and Abd. Blistering
lesions on LE B/L with appearance of cellulitis changes on LE
B/L.
Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect. Oriented to person, place, and date. Attentive, says
DOW backwards. Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria. [**Location (un) **] intact. No
right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Retinas with sharp disc margins B/L. Visual fields
are full to confrontation via moving finger test. Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3. Facial movement symmetric. Hearing intact to finger rub
bilaterally. Palate elevation symmetrical. Sternocleidomastoid
and trapezius normal bilaterally. Tongue midline, movements
intact
Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 3 2 2 1 1 1 1 0 0 0 0 0 0 0
L 3 2 2 1 1 1 1 0 0 0 0 0 0 0
In LE, there is some subtle flickers of B/L ABduction movement,
but otherwise no mvmt whatsoever.
Sensation: Decreased to light touch and pinprick throughout with
some improvement superiorally (near shoulders and clavicle)
without clear sensory level. Very poor proprioception thoughout.
Reflexes:
0 and symmetric throughout.
Toes mute bilaterally
Pertinent Results:
Labs on admission:
[**2113-11-26**] 06:59PM BLOOD WBC-6.0 RBC-3.07*# Hgb-11.3* Hct-34.1*
MCV-111*# MCH-36.9*# MCHC-33.2 RDW-15.3 Plt Ct-523*#
[**2113-11-26**] 06:59PM BLOOD PT-12.4 PTT-22.6 INR(PT)-1.0
[**2113-11-26**] 06:59PM BLOOD Glucose-76 UreaN-15 Creat-0.4 Na-136
K-3.9 Cl-98 HCO3-31 AnGap-11
[**2113-11-26**] 06:59PM BLOOD CK(CPK)-39
[**2113-11-26**] 06:59PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2113-11-26**] 06:59PM BLOOD Calcium-8.4 Phos-2.4* Mg-2.3
[**2113-11-26**] 06:59PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2113-11-27**] 09:34AM BLOOD Type-ART Temp-37.2 O2 Flow-2 pO2-88
pCO2-43 pH-7.46* calTCO2-32* Base XS-5 Intubat-NOT INTUBA
Urine studies:
[**2113-11-26**] 06:38PM URINE RBC-9* WBC-31* Bacteri-MOD Yeast-MANY
Epi-1 TransE-<1
[**2113-11-26**] 06:38PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
[**2113-11-26**] 06:38PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
Microbiology:
UCx; yeast ([**12-2**])
BCx; 1/6 bottles MRSA. ([**12-3**])
Catheter tip culture neg
cdif neg x2
------
Labs during hospital course;
ESR 9
homocysteine 13
B12 297
folate 10.2
ferritin 342
TSH 6.6, T4 5.5, FT4 1.1
IgA 240
HIV Ab neg
U tox + opiates
Copper 77
Ceruloplasmin 16 (nl range 18-53)
Methylmalonic acid 518 (nl range 87-318)
vitamin k 689
vitamin A 20 (nl range 38-98)
vitamin D 1,25 13 (nl range 18-72)
vitamin B1 279 (normal)
porphyrins < 1
mycoplasma pneumonia IgG 3.18, IgA 19
Anti [**Doctor Last Name **] Antibody neg
CMV IgG +, IgM neg
Pending studies;
ACE, B6, B1, CV2 Ab, heavy metal screen
-------
CSF
Chemistry Protein 23 Glucose 57
Source: LP; #1
CSF
WBC 0 RBC 18
Poly 20 Lymph 52 Mono 28 EOs none
EMG [**2113-11-27**];
Limited, markedly abnormal study. There is electrophysiologic
evidence for a severe generalized denervating process of at
least three weeks in duration. Based on the single motor nerve
conduction study, there is no clear evidence for primary
demyelination, as would be expected in [**Month/Day/Year 7816**]-[**Location (un) **] syndrome.
Nonetheless, a primary demyelinating process cannot be entirely
excluded. There is also no evidence for a presynaptic disorder
of neuromuscular transmission.
-------
Results from outside hospital prior to admission;
Total prot 5.6
alb 2.8
T bili 1.7
alk phos 228
ALT 18
AST 28
LDH 213
Dbili 0.7
CSF [**2113-11-1**]; glucose 56, prot 16, 0 wbc, 90 rbc
RPR neg
Aldolase 5.7
ACE 52
[**Doctor First Name **] 1:40
Parvo B19 IgG 4.3, IgM 0.06
IgG serum 968, IgG CSF 1.3
Albumin CSF 7
Albumin 2.41
Alpha-1 0.53
Alpha-2 0.79
Gamma 1.03
Beta 0.74
IgG 926
IgA 563
IgM 71
MRI spine; unremarkable
Brief Hospital Course:
Ms. [**Known lastname 30064**] is a 57-year-old right-handed feamle with history
of morbid obesity s/p Roux-en-y gastric bypass in [**2104**], DM, HTN,
OA, chronic pain, multiple skin infections and UTI's, admitted
twice over the past month to [**Hospital3 **] Hosp for
progressive weakness and parasthesias. Her clinical course of
progressive weakness, sensory problems and loss of reflexes was
clinically most suggestive of a demyelinating polyneuropathy,
similar to [**First Name9 (NamePattern2) 7816**] [**Location (un) **]. Her prior negative LP and EMG
results were completed only 1 week into her symptoms. She was
treated for transverse myelitis at OSH wigh high dose solumedrol
without clinical improvement.
On admissiong to [**Hospital1 18**], patient was noted to be more tachypneic
and her NIFs and VCs declined to -30 and 1.0. Given this, she
was transferred to Neuro ICU.
NEURO. Her re-examination showed only minimal movements of her
fingers and no movements at wrist. She had proprioceptive loss
to hip b/l and to elbows in UEs, as well as loss of PP to L1 and
C4 in LEs and UEs respectively. She underwent a repeat LP which
showed normal protein, glucose and no cells. Repeat EMG showed
denervation, without ellicitable F waves due to no motor
response. Given all of the above, whe most likely had a
GBS-type polyneuropathy and was started on IVIG x 5 days on
[**2113-11-27**]. She completed 4 days of IVIG but developed fevers
prior to infusion on day #5 and this was not completed. She did
perhaps have slight improvement following the IVIG course.
Other studies investigating the etiology of her symptoms have
been negative including HIV, porphyrins, anti [**Doctor Last Name **] antibody,
etc... (please see results section for all studies). A CT torso
was also unrevealing for any underlying malignancy or
lymphoproliferative process. Current pending studies include
ACE level, B6, B1, CV2 Ab, and heavy metal screen as well as
vitamin B2, B7, carotene, vitamin C, and vitamin E. (Due to a
lab error the heavy metal screen was unable to be processed and
re-sent [**12-14**]). The patient underwent a sural nerve biposy [**12-5**]
which revealed widespread denervation and axonal loss but no
signs of inflammation. The final pathology report is still
pending at the time of discharge.
While the clinical course did appear consistent with an
acute-demyelinating polyneuropathy, several aspects of her
history did not appear consistent with [**First Name9 (NamePattern2) 30065**] [**Location (un) **]. Her
second EMG was more conistent with an axonal pathology and both
CSF analyses were unremarkable, and she had no proceeding
illness able to be identified. Given her history of a roux-en-y
gastric bypass in [**2104**], it was considered that her presentation
may be a manifestation of a nutritional deficiency complicated
by this procedure. Her B12 level was 297, methylamlonic acid
was elevated, Vitamin A and vitamin D levels were low. She was
started on multivitamins, thiamine, B12, folic acid, and vitamin
A and vitamin D supplements. Several cases of a similar
polyneuropathy years after a gastric bypass procedure have been
reported in the literatuere which is thought to mimic GBS
clinically. This is usually not identified with any specific
nutritional deficiencies. Case reports have not shown
conclusive improvement from nutritional repletion. It was
considered if reversing the patient's gastric bypass could be
considered and this was discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
(bariatric surgery) who did not believe she was a surgical
candidate and did not believe reversal of the bypass would
result in clinical improvement.
Further courses of IVIG and/or plasmapheresis were also
discussed. As she did not show much improvement from the first
course of IVIG and there was no evidence of an autoimmune
process, it was thought that the risks of further treatments
would outweight the benefits.
The patient also reported painful paresthesias intermittently
throughout the hospital course. Her neurontin was titrated up
and was continued on cymbalta for treatment of her neuropathic
pain. She was also admitted on amitryptiline which was weaned
off due to concern it may have been contributing to sedation and
trileptal was also weaned off during the hospital course.
Ultram was added as needed for breakthrough pain which has been
effective.
At the time of discharge the patient had shown moderate
improvement. Her facial weakness is only moderate and she is
less hypophonic. Her strength has improved, with what appears
to be 4-/5 triceps, [**3-16**] biceps, [**3-16**] wrist extension, [**2-16**] finger
extension and flexion bilaterally. Iliopsoas is [**2-16**], hip
abductors and adductors are [**3-16**], hamstrings and quads are [**3-16**],
dorsiflexors 0/5, plantarflexors [**2-16**].
PULM. ABG on admission showed metabolic alkalosis. Patient had
multiple NIFs and VC checked which were concerning for
respiratory muscle weakness. Her VC were consistently
800cc-1000cc early in the hospital course, promting several
transfers to the ICU. It was thought these values may have been
effort-dependent and also limited by her facial muscle weakness.
Her NIFs and VC remained poor however without showing other
evidence of respiratory compromise. She never required
intubation. She was however started on BIPAP at night for sleep
apnea and was tolerating this well.
CV. No active issues. She was treated with lasix for her
edema. Antihypertensive regimen (lisinopril) was held due to
intermittent hypotension and autonomic nervous system
instability, presumably due to her polyneuropathy. Her blood
pressure, pulse, and fluid balance have been stable for several
days at the time of discharge.
ID. The patient spiked a temperature of 102 prior to day #5 of
IVIG treatment. She ultimately grew out 1 of 6 bottles positive
for MRSA and was treated with a seven-day course of vancomycin.
No obvious infectious source was identified (including catheter
tip from PICC line which was subsequently removed).
F/E/N. The patient was started on continuous tube feeds and
also supplemented with multivitamins, thiamine, folate, vitamin
A, vitamin D, and B12. She was cleared for a nectar-thick
liquid and pureed diet. She was not taking in adeuqate PO
intake and therefore continuous feeds were changed to cycled
feeds at night from 6 PM to 6 AM in hopes of improving appetite
during the day. It is hoped that she will be able to transition
to PO intake over the next two weeks.
Medications on Admission:
(at time of transfer)
Tylenol 650 mg Q4hrs PRN pain, fever
MOM 30 mL Qday
Lisinopril 2.5 mg Qday
Lasix 20 mg [**Hospital1 **]
Morphine 1 mg IV PRN pain
Percocet 1 tab Q6hrs PRN pain
Miralax 17 g QHS PRN constipation
Amytriptyline 50 mg QHS
Gabapentin 600 mg QHS
Fentanyl 100 mcg patch Q72hrs
Cymbalta 60 mg Qday
Trileptal 300 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Protonix 40 mg Qday
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO
DAILY (Daily).
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
5. Papain Powder Sig: One (1) ML Miscellaneous MRX1 () as
needed for NGT clogging.
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Vitamin A 10,000 unit Capsule Sig: Five (5) Capsule PO DAILY
(Daily).
8. Acetaminophen 160 mg/5 mL Solution Sig: Twenty (20) mL PO Q6H
(every 6 hours) as needed for pain.
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for fungal infection.
10. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (TU).
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
12. Gabapentin 250 mg/5 mL Solution Sig: Twenty (20) ml PO Q8H
(every 8 hours).
13. Thiamine HCl 100 mg/mL Solution Sig: One (1) mL Injection
DAILY (Daily) for 7 days.
14. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL
Injection once a month.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Subacute motor and sensory polyneuropathy, possibly secondary to
nutritional deficiency and/or prior gastric bypass surgery
Discharge Condition:
Awake, alert, follows commands. Mild bifacial weakness. 4-/5
strength in triceps, [**3-16**] in biceps, [**3-16**] in wrist extensors, [**2-16**]
in finger extensors and flexors. [**3-16**] in hip adductors and
abductors, [**3-16**] in hamstrings, quadriceps, [**2-16**] in dorsiflexors,
[**3-16**] in plantarflexors, bilaterally. Sensation decreased to
light tough throughout.
Discharge Instructions:
Patient is to be discharged to rehabilitation facility for
further care. Please continue your medications as prescribed
and continue with physical therapy.
Followup Instructions:
Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (pulmonary) in the
Wednesday AM Sleep Clinic in [**2-14**] months. He can be reached at
([**Telephone/Fax (1) 9525**].
Please follow up in neurology clinic with Dr. [**Last Name (STitle) 21900**] and Dr.
[**Last Name (STitle) **]. At appointment has been scheduled for you on [**2-15**] at 2:30 PM at [**Hospital1 18**] [**Location (un) 8661**] Building ([**Hospital Ward Name **]) [**Location (un) **].
Please call ([**Telephone/Fax (1) 2528**] with any questions or concerns.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**MD Number(3) 1041**]
|
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8,485
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22810
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Discharge summary
|
report
|
Admission Date: [**2128-10-25**] Discharge Date: [**2128-11-4**]
Date of Birth: [**2051-3-8**] Sex: M
Service: MEDICINE
Allergies:
Altace
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
fever/chills and coffee ground emesis
Major Surgical or Invasive Procedure:
Percutaneous cholangiography with drain (external)
History of Present Illness:
77yo Man with h/o metastatic Huerthle cell cancer of thyroid
with known mets to pancreas and lung including s/p biliary
stricture that was stented via ERCP 4/[**2127**]. Complicated by
bleeding from mass in ampulla of Vater requiring EGD
cauterization. He presents to the ER today with CC of fever and
chills for two days as well as 1 day of coffee ground emesis and
weakness. Per OMR notes he has had recent transfusion-dependent
anemia from suspected upper GI source - pt states last
transfused about 2w ago.
.
In the ER the pt was febrile to 102. Blood and urine cultlures
were sent and UA was negative. CXR revealed bilateral nodules
and masses and a possible retrocardiac opacity. He received
vanc/levo/flagyl and 3L crystalloid. NG lavage revealed coffee
ground return. He was guaiac positive. A R IJ line was placed
and was adjusted after CXR showed poor positioning. He received
3u prbc and protonix IV. GI was notified and will follow
patient.
.
ROS: denies sob/cp/nausea/vomiting, notes decreased appetite
marginally better with marinol. constipation with no BM x 4
days. No change in his baseline cough, no phlegm.
Past Medical History:
1) Hurthle cell thyroid ca
- metastatic to lungs, pancreatic head-dx by EUS bx in [**9-16**],
neck)
- s/p total thyroidectomy on [**2127-1-15**] (8x7x6 cm mass extending to
the capsule. Follicular carcinoma, Hurthle cell variant with
clear cell features. Vascular invasion)
- s/p RAI rx in [**2-15**]
- s/p resection of neck recurrence ([**3-18**])
- s/p distal CBD stent [**1-15**] stricture from pancreatic head ([**3-18**])
2) Type II Diabetes mellitus
3) malignant melanoma: resected approximately 10-12 years ago
4) BPH
5) s/p inguinal herniorrhaphy
6) s/p right total knee replacement 6 or 8 years ago
Social History:
The patient is a dairy farmer from upstate [**State 531**]. He chews
tobacco, but has never smoked and consumes alcohol limited to
one beer a day.
Family History:
colon cancer in two siblings
Physical Exam:
On admission:
temp 100.4, HR 103, BP 111/57, RR 19, O2 99% RA
Gen: NAD, talkative, more interested in changing subject than
giving history
HEENT: NCAT, conjunctivae pale, OP not injected, dentures in
place, PERRL, EOMI, R eye ptosis, NG tube in place
Neck: R IJ in place , no LAD, supple
Cor: s1s2, high pitched holosystolic murmur heard best at apex,
nonradiating
Pulm: trace wheezes bilaterally
Abd: soft, scaphoid, NTND, no hsm, +bs
Ext: no c/c/e, w/w/p
Skin: no rashes
Pertinent Results:
[**2128-11-2**] 09:05AM BLOOD WBC-8.0 RBC-4.15* Hgb-12.5* Hct-37.3*
MCV-90 MCH-30.2 MCHC-33.6 RDW-17.8* Plt Ct-120*
[**2128-10-28**] 05:30AM BLOOD WBC-7.2 RBC-2.72* Hgb-8.4* Hct-24.4*
MCV-90 MCH-31.1 MCHC-34.6 RDW-17.4* Plt Ct-83*#
[**2128-10-25**] 01:15AM BLOOD WBC-10.8# RBC-2.64* Hgb-8.5* Hct-23.7*
MCV-90 MCH-32.4*# MCHC-36.0* RDW-18.0* Plt Ct-99*
[**2128-10-27**] 06:00AM BLOOD Neuts-89.0* Lymphs-5.0* Monos-3.0 Eos-3.0
Baso-0
[**2128-11-2**] 06:15AM BLOOD PT-21.9* PTT-49.8* INR(PT)-2.1*
[**2128-10-25**] 01:15AM BLOOD PT-12.8 PTT-25.1 INR(PT)-1.1
[**2128-11-2**] 09:05AM BLOOD Glucose-102 UreaN-10 Creat-1.0 Na-138
K-3.9 Cl-100 HCO3-23 AnGap-19
[**2128-10-25**] 01:15AM BLOOD Glucose-190* UreaN-16 Creat-0.7 Na-135
K-3.8 Cl-93* HCO3-24 AnGap-22
[**2128-11-2**] 09:05AM BLOOD ALT-24 AST-36 AlkPhos-253* TotBili-3.1*
[**2128-10-25**] 01:15AM BLOOD ALT-365* AST-842* AlkPhos-1389*
Amylase-36 TotBili-3.7*
[**2128-10-31**] 06:10AM BLOOD Lipase-9
[**2128-10-25**] 01:15AM BLOOD Lipase-50
[**2128-11-2**] 09:05AM BLOOD Mg-1.5*
[**2128-11-1**] 05:50AM BLOOD Calcium-8.0* Mg-1.6
[**2128-10-31**] 06:10AM BLOOD Albumin-2.4* Calcium-7.7* Phos-3.0
Mg-1.5*
[**2128-10-25**] 01:15AM BLOOD Albumin-3.4 Calcium-9.5 Phos-3.5 Mg-1.7
[**2128-10-30**] 12:50PM BLOOD Hapto-199
[**2128-10-25**] 02:50AM BLOOD Cortsol-41.5*
[**2128-10-25**] 02:50AM BLOOD CRP-255.8*
[**2128-11-2**] 05:45AM BLOOD Lactate-4.0*
[**2128-10-25**] 01:17AM BLOOD Lactate-5.4*
[**2128-10-26**] 12:13AM BLOOD Lactate-1.8
[**2128-10-25**] 01:17AM BLOOD Hgb-8.8* calcHCT-26
[**2128-10-28**] 02:56AM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.015
[**2128-10-28**] 02:56AM URINE Blood-LGE Nitrite-NEG Protein-100
Glucose-NEG Ketone-50 Bilirub-SM Urobiln-NEG pH-5.0 Leuks-SM
[**2128-10-28**] 02:56AM URINE RBC-292* WBC-42* Bacteri-NONE Yeast-NONE
Epi-<1
[**2128-10-27**] 05:47PM URINE WBC Clm-RARE
[**2128-11-2**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC
BOTTLE-PENDING INPATIENT
[**2128-10-30**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL
{CLOSTRIDIUM DIFFICILE} INPATIENT
[**2128-10-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2128-10-28**] BILE GRAM STAIN-FINAL; FLUID CULTURE-PRELIMINARY
{ENTEROCOCCUS SP., GRAM NEGATIVE ROD #1, GRAM NEGATIVE ROD #2,
GRAM POSITIVE BACTERIA} INPATIENT
[**2128-10-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2128-10-28**] URINE URINE CULTURE-FINAL INPATIENT
[**2128-10-27**] URINE URINE CULTURE-FINAL INPATIENT
[**2128-10-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2128-10-25**] SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
{ENTEROCOCCUS SP.} INPATIENT
[**2128-10-25**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2128-10-25**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **]
[**2128-10-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL EMERGENCY [**Hospital1 **]
[**2128-10-25**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {ESCHERICHIA
COLI}; ANAEROBIC BOTTLE-FINAL {ESCHERICHIA COLI} EMERGENCY [**Hospital1 **]
PORTABLE AP CHEST RADIOGRAPH: The study is limited secondary to
respiratory motion. Again seen are pleural opacities along the
right pleural surface, and nodular opacities within the right
upper lobe, corresponding to the patient's history of known
metastatic nodules. Additionally, there are bilateral pleural
effusions and an area of opacity at the right lung base which
may represent associated atelectasis and/or consolidation. The
cardiac and mediastinal contours are relatively stable. There is
an area of opacity in the left lung base, which may represent an
area of pleural thickening or atelectasis, though there is
limited evaluation secondary to motion. No definite pneumothorax
is seen. An internal external biliary stent is seen overlying
the right upper quadrant.
IMPRESSION:
1. Again seen are findings from the patient's known history of
metastatic malignancy, including areas of pleural opacity and
thickening within the right hemithorax.
2. Right pleural effusion and associated opacity which may
represent volume loss and/or consolidation.
3. Area of opacity in the left lower lobe which is not well
evaluated secondary to respiratory motion.
CT ABDOMEN:
Within the visualized lung bases, there are bilateral pleural
effusions with enhancing pleural metastases. Adjacent
compressive atelectasis is also evident, greater on the right.
Numerous parenchymal nodules are identified.
A percutaneous biliary drain is present and terminates within
the duodenum. Two plastic stents are identified within the
common bile duct and duodenum.
There is no significant intrahepatic biliary duct dilatation.
Multiple low attenuation lesions are identified scattered
throughout the liver. A small amount of perihepatic fluid is
identified, new from the previous examination.
The pancreatic head is enlarged, and a mass is identified within
the pancreatic tail. There is soft tissue within the porta
hepatis.
A 1 cm right adrenal nodule is again identified. The left
adrenal gland appears unremarkable. The kidneys show cysts, but
are otherwise unremarkable. There is no evidence of
hydronephrosis.
Note is made of small retroperitoneal lymph nodes. Free fluid is
identified within the pelvis, which is of increased attenuation,
and likely hemorrhagic. There is no evidence of colonic
obstruction.
There are multiple osseous metastases noted within the left
femoral head, right iliac crest, left L3 vertebral body. Note is
made of gas within the urinary bladder likely incident to
instrumentation.
IMPRESSION:
1. Other than a small increase in perihepatic fluid, there has
been no appreciable change compared to the [**2128-10-29**]
examination. The high- attenuation fluid within the pelvis
(likely hemorrhagic) has not appreciably increased in size.
2. Widespread metastatic disease.
CT OF THE ABDOMEN WITH IV CONTRAST: The lung bases show interval
progression of both parenchymal and pleural-based nodules,
consistent with metastatic disease. There are bilateral
low-density pleural effusions with adjacent areas of opacity
most likely to represent atelectasis. Numerous metastases in the
liver were much better demonstrated on the recent ultrasound
from [**2128-10-25**].
There is a new percutaneous biliary drain extending into the
right lobe of the liver and terminating in the duodenum. There
is interval improvement in the degree of intrahepatic biliary
ductal dilatation. There is again pneumobilia within the left
lobe. Ill-defined abnormal soft tissue is present in the hepatic
hilum.
A large mass in the head of the pancreas is perhaps minimally
increased in size, now measuring 6.2 x 4.8 cm in axial
dimensions, compared to 5.9 x 4.8 cm previously. A further mid
body metastasis which is new is seen also. A stent in the distal
common bile duct is in an unchanged position. There is a new
stent in the duodenum since the prior study with partial
opacification by contrast in its proximal course, although not
distally. However, contrast passes freely and is present in the
colon. The stomach is not dilated.
There is a new small right adrenal nodule of 10 mm in diameter
raising concern for metastatic disease. Otherwise, the adrenal
glands are unremarkable. The spleen is within normal limits. A
left-sided renal cyst is unchanged.A new left sided
retroperitoneal; deposit is seen-represewnting progressive mets.
The small and large bowel are within normal limits.
There is a small rim of high-density ascites about the liver
anteriorly. There are multiple small retroperitoneal lymph
nodes, not meeting size criteria for pathological enlargement.
CT OF THE PELVIS WITH IV CONTRAST: There is a small-to-moderate
amount of high- density ascites, up to 40 Hounsfield units in
the lower pelvis, most consistent with recent hemorrhage,
probably related to recent percutaneous drain placement.
The distal ureters and bladder are within normal limits,
although air is noted in the bladder. This appearance could be
seen in recent catheterization. There is sigmoid diverticulosis,
without diverticulitis. Contrast has passed to the rectum. There
is no pelvic or inguinal lymphadenopathy. Subcutaneous tissues
show edema.
BONE WINDOWS: There is a new lytic lesion in the left femoral
head. In fact, there are increased lucencies in both femoral
heads. There is also a new soft tissue mass along the right
iliac crest with bony destruction, measuring 2.8 x 2.0 cm in
axial dimensions, new since the prior study. There is also a new
soft tissue mass with bony destruction along the posterior
aspect of the left L3 vertebral body, also new since the prior
study. It is about 1 cm in diameter and extends slightly into
the spinal canal.
IMPRESSION:
1. Status post placement of percutaneous biliary catheter and
duodenal stent.
2. Hemoperitoneum in the pelvis, which may relate to recent
instrumentation, as well as small amount of hemoperitoneum
adjacent to liver.
3. Progressive metastatic disease, including new osseous
metastases, progressive lung nodules, and perhaps slightly
increased size of pancreatic mass. Possibly because of the phase
of contrast administration, the liver metastases are not as
conspicuous as on the recent ultrasound.
4. Bone metastases include a small mass in L3 with slight
posterior extension into the spinal canal. It is doubtful that
this lesion produces mass effect on the spinal cord at present,
although posterior extension into the canal may become a
consideration later if it were to become larger.
5. No evidence of obstruction, with free distal passage of
contrast.
Approved: SUN [**2128-10-31**] 9:59 AM
PTC:
IMPRESSION:
1. Cholangiogram demonstrating intrahepatic biliary ductal
dilation as well as dilation of the common bile duct; contrast
extended into the duodenum. Sludge and debris were seen within
the common bile duct. A common bile duct as well as a duodenal
stent were in situ.
2. Successful placement of a 10-French internal-external biliary
drain from the right approach. The catheter was connected to a
bag for gravity drainage. Approximately 30 mL of dark brown bile
and sanguinous material were extracted during the procedure.
ERCP
ERCP: Three fluoroscopic images were obtained in the ERCP suite
without the presence of a radiologist. Metallic stent is seen in
the region of the CBD. Duodenoscope could not be negotiated past
a reported extrinsic stenosis of the post-bulbar duodenum.
Subsequent image shows deployment of an incompletely expanded
metallic stent across the stenosis.
For further details, please see the ERCP report of the same day.
ECHO:
Conclusions:
The left atrium is elongated. No atrial septal defect is seen by
2D or color
Doppler. Left ventricular wall thickness, cavity size, and
systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal.
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 root is moderately dilated. The
ascending aorta
is mildly dilated. There are three aortic valve leaflets. The
aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic
pressure is normal. There is no pericardial effusion.
US:
CONCLUSION: Large pancreatic/portahepatus mass, which has
increased in size compared to the CT of [**2128-5-25**]. More
significantly, there has been blossoming of diffuse hepatic
metastatic disease with very extensive progression since the CT
scan.
There is also mild-to-moderate dilatation of the common hepatic
and intrahepatic bile ducts, despite the presence of biliary
stent.
Brief Hospital Course:
# Acute blood loss anemia: from GI bleeding - coffee ground
emesis/[**Last Name (un) 15557**]: with most likely source is bowel invasion of
tumor given pt's history. Was transfused as needed and also
given platelet transfusion. Treated with PPI.
The patient also had hemoperitoneum which could be from tumor
bleeding which was slightly increased on a subsequent CT. He was
managed conservatively with general surgery, GI and ERCP teams
followed.
# acute cholangitis - due to VRE - on culture from the bile. PTC
done by IR with external drain in place. LFT improved.
# C diff colitis - during the course in the hospital, pt
developed C diff diarrhea that was treated with flagyl.
# Pulmonay metastasis - caused intermittent hemoptysis.
# thrombocytopenia: pt is below baseline. Was possibly due to
bone marrow invasion by tumor. Required transfusion.
also has DM, hypothyroidism - medically managed.
During the ast few days, the patient developed severe
hypotension, tachycardia and severe abdminal pain. End of life
issues were discussed by Dr [**Last Name (STitle) **], [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] (palliative
care team) and me with the family and patient and given the very
poor long term prognosis of the patient, comfort measures were
maintained. The patient died on [**2128-11-4**] at 11-15 am. Family was
present at bedside and did not request an autopsy when offered.
Medications on Admission:
Synthroid 200 mcg po daily, metformin 500 mg po
daily, doxazosin .4 mg po daily, ferrous gluconate 324 mg po
daily, and Prilosec 1 tab po daily, ibuprofen 600mg po tid prn
arthritis pain. baby asa [**Name2 (NI) 24018**]. ( per pt never takes his
albuterol 1-2 puffs q6-8 prn. benzonatate capsules tid prn,
flovent 2 sprays per nostril [**Name2 (NI) 24018**])
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Death due to Metastatic thyroid cancer
C diff colitis
Acute cholangitis
Intestinal obstruction
Hypotension
Discharge Condition:
Died from metastatic thyroid cancer
Discharge Instructions:
Died from metastatic thyroid cancer
Followup Instructions:
Died from metastatic thyroid cancer
|
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16573, 16682
|
16130, 16491
|
16764, 16801
|
2372, 2372
|
228, 267
|
386, 1514
|
2387, 2848
|
1536, 2146
|
2162, 2311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,506
| 107,661
|
34386
|
Discharge summary
|
report
|
Admission Date: [**2138-7-3**] Discharge Date: [**2138-7-30**]
Date of Birth: [**2059-9-28**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain s/p fall
Major Surgical or Invasive Procedure:
1. Posterior cervical laminectomy C3-C7.
2. Posterior cervical arthrodesis C2-T1.
3. Posterior cervical instrumentation C2-T1
4. Allograft supplementation.
History of Present Illness:
Mr. [**Known lastname **] is a 78 year old male who fell out of bed and hit
cervical spine and loss function of both upper and lower
extremities. Mr. [**Known lastname **] was brought to [**Hospital1 18**] emergency via
ambulance.
Past Medical History:
Borderline Diabetes
Social History:
Currently lives with wife in [**Name (NI) 651**]
Family History:
None
Physical Exam:
A+O x3
Breathing on own and stable
Able to elevate shoulders.
C-spin in collar.
On admission: B/UE & B/LE 0/5 strength, no sensation
On discharge: B/LE: 4+/5 strength with mild decrease in
sensation. B/UE: Delt, tricept [**2-4**], bicep [**3-5**] left & [**2-4**] right,
decreased sensory throughout
rectal tone intact
distal pulses intact
Abd: soft non-tender
Pertinent Results:
[**7-3**] CT C-spine: IMPRESSION: Severe ossification of the posterior
longitudinal ligament at C2 through C4 with up to 75% narrowing
of the spinal canal. With the correct mechanism injury to the
spinal cord is likely and given the clinical scenario, MRI of
the cervical spine is strongly recommended to evaluate for
spinal cord injury.
[**7-3**] MRI C-spine:
IMPRESSION: 1. Severe spinal canal stenosis due to bulky
ossification of the posterior longitudinal ligament, with spinal
cord contusion extending from C2 through C4-5 level, with spinal
cord edema, but no evidence of hemorrhage. 2. No definite
evidence of ligamentous injury.
[**2138-7-3**] 06:19AM BLOOD WBC-12.5*# RBC-4.57* Hgb-14.6 Hct-41.9
MCV-92 MCH-31.9 MCHC-34.8 RDW-13.5 Plt Ct-234
[**2138-7-3**] 03:26PM BLOOD Hct-38.4*
[**2138-7-4**] 05:15AM BLOOD WBC-15.3* RBC-3.76* Hgb-11.8* Hct-34.1*
MCV-91 MCH-31.5 MCHC-34.7 RDW-13.7 Plt Ct-214
[**2138-7-5**] 02:45AM BLOOD WBC-12.8* RBC-3.34* Hgb-10.9* Hct-30.3*
MCV-91 MCH-32.7* MCHC-36.1* RDW-12.9 Plt Ct-176
[**2138-7-6**] 01:46AM BLOOD WBC-9.9 RBC-3.28* Hgb-10.7* Hct-29.8*
MCV-91 MCH-32.6* MCHC-35.9* RDW-12.7 Plt Ct-181
[**2138-7-7**] 02:00AM BLOOD WBC-10.4 RBC-3.43* Hgb-10.9* Hct-31.0*
MCV-91 MCH-31.9 MCHC-35.2* RDW-13.7 Plt Ct-214
[**2138-7-8**] 03:44AM BLOOD WBC-9.8 RBC-3.53* Hgb-11.2* Hct-32.0*
MCV-91 MCH-31.7 MCHC-35.0 RDW-12.8 Plt Ct-294
[**2138-7-9**] 06:00AM BLOOD WBC-11.0 RBC-3.60* Hgb-11.6* Hct-32.5*
MCV-90 MCH-32.3* MCHC-35.7* RDW-13.3 Plt Ct-284
[**2138-7-3**] 02:36AM BLOOD Glucose-193* UreaN-31* Creat-1.4* Na-139
K-4.0 Cl-106 HCO3-25 AnGap-12
[**2138-7-3**] 06:19AM BLOOD Glucose-187* UreaN-30* Creat-1.3* Na-137
K-4.4 Cl-106 HCO3-23 AnGap-12
[**2138-7-3**] 03:26PM BLOOD Glucose-183* UreaN-28* Creat-1.3* Na-138
K-4.4 Cl-105 HCO3-21* AnGap-16
[**2138-7-4**] 05:15AM BLOOD Glucose-155* UreaN-32* Creat-1.2 Na-139
K-4.3 Cl-108 HCO3-23 AnGap-12
[**2138-7-7**] 02:00AM BLOOD Glucose-168* UreaN-24* Creat-1.0 Na-138
K-4.2 Cl-105 HCO3-27 AnGap-10
[**2138-7-8**] 03:44AM BLOOD Glucose-166* UreaN-27* Creat-1.0 Na-135
K-4.3 Cl-102 HCO3-25 AnGap-12
[**2138-7-9**] 06:00AM BLOOD Glucose-134* UreaN-27* Creat-1.1 Na-139
K-4.3 Cl-104 HCO3-28 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was brought to [**Hospital1 18**] after a fall from bed resulting in
loss of function of both upper and lower extremities. He was
brought to the TSICU in stable condition and breathing on his
own. After explaining his situation to both his wife and his
daughter, he was consented for a posterior cervical
decompression and fusion. He tolerated the procedure well.
After his procedure he was brought back to the TSICU and then
transfered to the general floor five days post op.
1. Cervical cord compression: Mr [**Known lastname **] experienced cervical cord
compression s/p fall from bed. Cervical decompression and
fusion was performed to stabilize his cervical spine. He did
have a second procedure for removal of C2 cervical screw and
further decompression of C2 lamina. He tolerated the procedure
well.
2. Acute post operative anemia: Mr. [**Known lastname **] became acutely anemic
as the result of his surgical procedure. He was asymptomatic
and did not require blood transfusion.
3. IVC filter placement. Mr. [**Known lastname **] [**Last Name (Titles) 1834**] placement with IVC
filter for prevention of pulmonary embolism. He tolerated the
procedure well.
Mr. [**Known lastname **] did work with physical therapy who recommended
discharge to rehab facility. The rest of his course was
unremarkable.
Medications on Admission:
None
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
5. Oxycodone 5 mg/5 mL Solution Sig: One (1) PO Q6H (every 6
hours) as needed for pain.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
7. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed.
10. Glyburide Micronized-Metformin 2.5-500 mg Tablet Sig: Two
(2) Tablet PO BREAKFAST (Breakfast).
11. Glyburide Micronized-Metformin 2.5-500 mg Tablet Sig: One
(1) Tablet PO DINNER (Dinner).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Cervical spinal cord injury.
2. Ossification of the posterior longitudinal ligament (OPLL).
3. Cervical spine fracture C3-C4.
Discharge Condition:
Stable to ECF
Discharge Instructions:
Please keep incision clean and dry. You may shower in 48 hours,
but please do not soak the incision. Change the dressing daily
with clean dry gauze. If you notice drainage or redness around
the incision, or if you have a fever greater than 100.5, please
call the office at [**Telephone/Fax (1) **]. Please resume all home
mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **]
have been given additional medication to control pain. Please
allow 72 hours for refills of this medication. Please plan
accordingly. You can either have this prescription mailed to
your home or you may pick this up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for
narcotics to the pharmacy. If you have questions concerning
activity, please refer to the activity sheet.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1007**] at two weeks from the date of
discharge. You can call [**Telephone/Fax (1) **] to make this appointment.
Completed by:[**2138-7-29**]
|
[
"285.1",
"E878.1",
"806.00",
"996.49",
"723.7",
"E884.4",
"250.00",
"336.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"81.05",
"38.7",
"81.03",
"78.69",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
6072, 6142
|
3493, 4843
|
337, 495
|
6315, 6331
|
1285, 3470
|
7219, 7412
|
881, 887
|
4898, 6049
|
6163, 6294
|
4869, 4875
|
6355, 7196
|
902, 982
|
1049, 1266
|
279, 299
|
523, 756
|
996, 1035
|
778, 799
|
815, 865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,220
| 196,813
|
47449
|
Discharge summary
|
report
|
Admission Date: [**2175-1-1**] Discharge Date: [**2175-1-4**]
Date of Birth: [**2112-4-1**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Admitted for poor PO intake, anorexia, fatigue; transferred to
MICU for acute blood loss anemia due to gastric bleeding and
hematemesis
Major Surgical or Invasive Procedure:
Central Line Placement
Endoscopic GastroDuodenography (EGD)
History of Present Illness:
Ms. [**Known lastname 46**] is a 62 year old woman with h/o hepatitis C,
substance abuse, SBO s/p small bowel resection and GI bleed
transferred to the MICU in the setting of an acute GI bleed.
She was initially admitted to medicine on [**1-1**] with "failure to
thrive" in the setting of poor PO intake. Initial findings were
significant for tachycardia and hypertension with orthostatic
hypotension and guaiac positive stool. Labs revealed a lactate
of 4, a metabolic acidosis with anion gap of 24. Her Hct was
below baseline on admission (baseline 26-30, 24 on admission).
On the evening of [**1-1**], the patient developed coffee-ground
emesis. She had 2 episodes of 100-200cc red-tinged emesis with
maroon flecks. Her SBP dropped to 88 (although she returned to
SBP in 140s without fluids), and labs were significant for
7.40/27/109/17 with Hct of 20. As the team was attempting to
give her IV fluids, she lost her two PIVs. She was then
transferred to the unit because of GI bleed in the setting of
poor IV access.
Of note, the patient was admitted [**Date range (1) 12260**] with chest pain in
the setting of cocaine abuse. Enzymes were negative x 3. Also,
she had an episode of GI bleeding during an admission for
hypoglycemia in 07/[**2172**]. Work-up at the time revealed a small
gastric ulcer and a small colonic polyp that was not removed.
Upon arrival to the MICU from her brief stay on the medicine
floor, her vitals were T 97.1, HR 85, BP 119/70, RR 15, O2 sat
100%.
Past Medical History:
Diabetes Mellitus, type 2 - on insulin
Chronic Kidney Disease, baseline Cr 1.6-2.0
Hepatitis C-rebetron years ago discontinued after poor response
h/o acute hepatitis from tylenol overdose
Hypertension
h/o Chronic Pancreatitis
s/p TAH/BSO [**2155-1-26**]
Substance Abuse (Cocaine, EtOH)
h/o SBO with subsequent small bowel resection in [**7-1**] and again
[**11-1**]
Carpal Tunnel Syndrome
Depression
NSTEMI [**10-3**] in the context of cocaine use
Anemia with baseline Hct 26-30, but has dropped into low 20s in
past.
Social History:
Patient is known to abuse alcohol and cocaine. She reported that
her last drink was 2 weeks ago, which she had also reported in a
prior admission. She said her last cocaine use was 5 days before
admission. She smoked x 10 pack years and quit 20 years ago. She
lives with her boyfriend; he is her only sexual partner. She
denies IV drug use.
Family History:
Hypertension. No history of premature CAD. Father with lung
cancer who died in his early 60s, mother with sarcoid who died
in her early 50s. No family hx of breast CA.
Physical Exam:
MICU ADMISSION VITALS AND PE
Tmax: 36.4 ??????C (97.5 ??????F)
Tcurrent: 36.4 ??????C (97.5 ??????F)
HR: 106 (85 - 106) bpm
BP: 125/76(87) {119/59(74) - 136/76(90)} mmHg
RR: 19 (15 - 19) insp/min
SpO2: 100%
CVP: 4 (4 - 4)mmHg
IVF:
1,000 mL
Physical Examination
General Appearance: Thin
Head, Ears, Nose, Throat: Normocephalic, dry MM; no lesions in
OP
Cardiovascular: (PMI Normal), (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse:
Present)
Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds:
Clear : )
Abdominal: Soft, Non-tender, Bowel sounds present
Extremities: Right: Absent, Left: Absent
Skin: Warm, No(t) Rash:
Neurologic: Attentive, oriented, somewhat slow speech but fluent
and without slurring; some low frequency tremor with
outstretched hands, no apparent asterixis
Pertinent Results:
EMERGENCY DEPARTMENT LABS
[**2175-1-1**] 10:15AM WBC-5.3 RBC-2.48* HGB-8.1* HCT-23.9* MCV-96
MCH-32.8* MCHC-34.1 RDW-17.9*
[**2175-1-1**] 10:15AM NEUTS-41.3* BANDS-0 LYMPHS-55.2* MONOS-1.9*
EOS-0.5 BASOS-1.2
[**2175-1-1**] 10:15AM PLT COUNT-51*
[**2175-1-1**] 10:15AM GLUCOSE-130* UREA N-28* CREAT-2.2*
SODIUM-147* POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-18* ANION
GAP-29*
[**2175-1-1**] 10:15AM CK(CPK)-105
[**2175-1-1**] 10:15AM cTropnT-0.10*
[**2175-1-1**] 10:15AM CK-MB-4
[**2175-1-1**] 10:15AM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.6
.
[**2175-1-1**] 10:15AM ASA-NEG ETHANOL-313* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**2175-1-1**] 01:44PM LACTATE-4.0*
.
[**2175-1-1**] 01:50PM URINE HOURS-RANDOM
[**2175-1-1**] 01:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2175-1-1**] 01:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2175-1-1**] 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2175-1-1**] 01:50PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2175-1-1**] 01:50PM URINE HYALINE-[**3-30**]*
[**2175-1-1**] 01:50PM URINE MUCOUS-OCC
IN-HOUSE LABS, PRIOR TO MICU TRANSFER
[**2175-1-1**] 07:05PM UREA N-24* CREAT-1.7* SODIUM-142
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-14* ANION GAP-27*
[**2175-1-1**] 10:43PM HGB-6.8* calcHCT-20
[**2175-1-1**] 10:43PM LACTATE-3.9*
[**2175-1-1**] 10:43PM TYPE-ART PO2-109* PCO2-27* PH-7.40 TOTAL
CO2-17* BASE XS--5
[**2175-1-2**]: Liver ultrasound. IMPRESSION: Cirrhotic liver. No
evidence of portal vein thrombosis.
CXR [**2175-1-2**]: Right internal jugular line tip is in low SVC. No
pneumothorax, apical hematoma, or pleural effusion is
demonstrated. Cardiomediastinal contour is unremarkable. Lungs
are clear. Calcifications projecting over the left upper abdomen
correspond to pancreatic calcifications, most likely consistent
with chronic pancreatitis.
EGD [**2175-1-2**]: Findings: Esophagus:
Lumen: A small size hiatal hernia was seen.
Stomach:
Mucosa: Erythema and erosion of the mucosa were noted in the
whole stomach. These findings are compatible with gastritis.
Duodenum:
Mucosa: Erythema and congestion of the mucosa were noted in the
duodenal bulb compatible with duodenitis.
Impression: Small hiatal hernia
Erythema and erosion in the whole stomach compatible with
gastritis
Erythema and congestion in the duodenal bulb compatible with
duodenitis
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
62yo woman with h/o polysubstance abuse, hepatitis C, SBO s/p 2
small bowel resections, and GI bleed in the past transferred to
the MICU for care of GI bleed, stabilized and transferred to the
floor for monitoring of her anemia.
.
# Acute Blood Loss Anemia due to Acute Gastritis: She was
admitted to the MICU. After admission to the MICU she was seen
by the liver team who conducted an EGD in the unit. They saw
gastritis but no varices. She had no hemodynamic instability.
Hematocrit was stable x 24 hours after she received total 3U
PRBC, last on [**1-2**] AM. On the floor her hematocrit and
platelets remained low but were stable, however she was without
evidence of acute bleed or hemodynamic instability. She was
discharged with a PPI [**Hospital1 **], however H. pylori was negative
therefore abx were not started.
# Alcohol Withdrawal: Although patient denied recent alcohol
use, her alcohol level was 311 in ED. She did score on the CIWA
scale and was written for valium PRN for CIWA >10. Thiamine,
folate and multivitamin were continued. Addictions nurse [**First Name (Titles) **] [**Last Name (Titles) 17037**]d and patient was provided with resources for outpatient
assistance with her EtOH and drug use. She was not in ETOH
withdrawal for the last 48 hours of her admission.
# Cirrhosis, coagulopathy, Chronic hepatitis C, alcohol
dependence. No varices, encephalopathy, ascites. An abdominal
ultrasound confirmed cirrhosis but showed no portal flow
defects. Coagulopathy was treated with vitamin K 10 mg PO x 3
days. The liver service followed her and as above conducted an
EGD in the unit; pt is not currently a candidate for transplant
due to her alcoholism. A follow-up appointment was scheduled
for hepatology.
# Anion Gap Acidosis: Primary alcoholic/starvation ketosis and
renal failure. Lactate trended down. Renal function at
baseline.
# Thrombocytopenia: Baseline 60-200. Likely secondary to liver
disease. Ruled out for HIT in past and low T4 score therefore
unlikely HIT. Stable during the admission with plt of 24.
Discharge to rehab was recommended by PT as patient is at risk
for bleed with fall, however patient declined after a discussion
of the risks and benefits.
# Depression: On outpatient sertraline. Diazepam provided for
anxiety and CIWA while inpatient.
# Chronic pancreatitis: No acute issues. Her pancreatic enzymes
were continued for the hospitalization and at discharge.
# CKD stage III: Cr at baseline 1.6-2.0 during the admission.
Her calcium and vit D were continued inpatient and on discharge.
# Type 2 Diabetes Uncontrolled without complications: Pt
received insulin sliding scale while inpatient. She was
re-started on her home dose of lantus on discharge.
# Benign Hypertension: Her blood pressure meds were
discontinued while in the ICU, however she was restarted on
hydralazine in the ICU and verapamil on the floor. She was well
controlled on verapamil, therefore hydralazine was dc'd for ease
of dosing and she was discharged on her home dose of verapamil.
# Elevated troponin: Troponin elevation on admission was likely
due to CKD. Tox screen negative for cocaine. No symptoms of
cardiac ischemia. No indications of ACS. No CP while inpatient.
Medications on Admission:
1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS
2. Hydralazine 10 mg PO Q6H
3. Sertraline 50 mg PO DAILY
4. Multivitamin PO DAILY
5. Insulin Glargine 100 unit/mL (6) units Subcutaneous q9am.
6. Verapamil 180 mg SR PO Q24H
7. Cholecalciferol (Vitamin D3) 400 unit PO DAILY
8. Calcium Carbonate 500 mg Chewable PO DAILY
9. Oxycodone 5 mg PO Q6H as needed for pain.
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
4. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
9. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
10. 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*
11. Insulin Glargine 100 unit/mL Cartridge Sig: One (1) 6 units
Subcutaneous q9am.
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Blood Loss Anemia
Acute Gastritis with Hemmorhage
Acute Duodenitis with Hemmorhage
Cirrhosis due to Chronic Hepatitis C
Thrombocytopenia
Chronic Pancreatitis
Chronic Kidney Disease Stage II
Substance Dependence - Alcohol
Substance Dependence - Cocaine
Depression
Type 2 Diabetes Controlled without Complications
Benign Hypertension
Discharge Condition:
Good
Discharge Instructions:
You were admitted for a gastrointestinal bleed. You were
treated in the ICU for this bleed with blood products and
evaluation from the gastroenterology service who found no
evidence of an active bleed. Your hematocrit and blood
pressures were stable when you were transferred out of the ICU.
Please take all of your medications as directed on discharge.
Please return to the hospital if you notice new SOB, chest pain,
lightheadedness, blood in your stool or cough, or any other
symptoms that may be concerning to you. Please follow up with
your hepatologist, Dr [**Last Name (STitle) **], as scheduled below.
Followup Instructions:
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2175-11-29**] 11:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2175-2-2**] 8:00
|
[
"291.81",
"585.2",
"070.54",
"571.2",
"276.2",
"311",
"250.00",
"287.5",
"304.20",
"535.61",
"403.10",
"535.01",
"285.1",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"99.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11360, 11366
|
6578, 9805
|
404, 466
|
11748, 11755
|
3995, 6555
|
12417, 12661
|
2899, 3068
|
10287, 11337
|
11387, 11727
|
9831, 10264
|
11779, 12394
|
3083, 3976
|
229, 366
|
494, 1981
|
2003, 2525
|
2541, 2883
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,602
| 126,394
|
34956+57959
|
Discharge summary
|
report+addendum
|
Admission Date: [**2181-11-20**] Discharge Date: [**2181-11-30**]
Date of Birth: [**2136-1-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Chest pain/Sternal wound infection
Major Surgical or Invasive Procedure:
[**2182-11-25**] - Sternal debridement, plating with 4 plates,
osteosynthesis and bilateral pectoralis major advancement flap.
[**2181-11-22**] - Surgical Debridement of sternal wound
History of Present Illness:
Ms. [**Known lastname 7563**] is a 45-year-old woman who is status post a CABG x2
[**2181-11-5**]. She now presented with chest pain and fever
and an elevated white count.
Despite a negative CT, it was decided to take her to the OR for
sternal debridement.
Past Medical History:
Coronary artery disease s/p CABG [**2181-11-5**]
Hypertension
Family History of premature CAD
Cystic Breast Disease
Aspirin Allergy
Social History:
Native of [**Country 4194**]. She came to the US about eight years ago. She
smokes [**10-31**] cigarettes per day. She denies ETOH.
Family History:
Multiple family members have premature CAD.
Physical Exam:
Admission
T: 100.4 HR: 89 BP: 107/51 RR:20 O2sat 98%-RA
Gen NAD, alert, c/o pain & fatigue
HEENT PERRL/EOMI O/P dry neck supple, no LA, no JVD
CV RRR, no murmur. Sternum stable. Incision w/erythema at
superior pole, no drainage, no click.
Pulm CTA, no rhonchi-wheezes
Abdm soft, ND/NT, +BS
Ext warm, well perfused, no edema
Discharge
VS T 99 HR 67 SR BP 145/75 RR 20 O2sat 98%-RA Wt 69.6K
Gen NAD
Neuro A&O, nonfocal exam
Pulm CTA bilat
CV RRR, no murmur. Sternal wound-no eryhtema or drainage JP
drain x1 w/serosang drainage
Abdm soft, NT/+BS
Ext warm no CCE. palpable pulses. Rt arm PICC
Pertinent Results:
Discharge
[**2181-11-29**] 05:45AM BLOOD WBC-4.2 RBC-3.20* Hgb-8.5* Hct-25.5*
MCV-80* MCH-26.6* MCHC-33.4 RDW-17.2* Plt Ct-271
[**2181-11-29**] 05:45AM BLOOD Plt Ct-271
[**2181-11-26**] 02:46AM BLOOD PT-15.2* PTT-26.8 INR(PT)-1.3*
[**2181-11-29**] 05:45AM BLOOD Glucose-92 UreaN-7 Creat-0.7 Na-137 K-3.4
Cl-104 HCO3-26 AnGap-10
[**2181-11-25**] 02:33AM BLOOD ALT-13 AST-18 LD(LDH)-124 AlkPhos-104
Amylase-115* TotBili-0.6
Admission
[**2181-11-20**] 10:00PM PT-15.5* PTT-31.0 INR(PT)-1.4*
[**2181-11-20**] 10:00PM ALT(SGPT)-13 AST(SGOT)-15 CK(CPK)-25* ALK
PHOS-80 AMYLASE-92 TOT BILI-0.4
[**2181-11-20**] 10:00PM GLUCOSE-105 UREA N-7 CREAT-0.6 SODIUM-135
POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-21* ANION GAP-14
[**2181-11-20**] 11:04PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
[**2181-11-20**] 11:04PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006
[**2181-11-20**] 11:24PM WBC-17.7*# RBC-3.33* HGB-8.6* HCT-25.6*
MCV-77* MCH-25.9* MCHC-33.7 RDW-15.7*
[**2181-11-21**] Lower Extremity U/S
No evidence of deep vein thrombosis in the right arm. The study
and the report were reviewed by the staff radiologist.
[**2181-11-21**] CT Scan
1. Skin defect with infiltration of subcutaneous and anterior
mediastinal
fat, suggesting cellulitis. There is no bone erosion to suggest
osteomyelitis. Soft tissue opacity behind the sternum is
probably a
postoperative hematoma, infection cannot be excluded.
2. Signs of anemia.
3. Small bilateral pleural effusion and pericardial effusion.
4. 5-mm and less lung nodules, should be followed in 12 months
if no risk
factors for malignancy are present. If the patient has risk
factors, a
followup is warranted in six months.
[**2181-11-25**] ECHO
1. The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the left atrial appendage. No thrombus is
seen in the left atrial appendage.
2. No spontaneous echo contrast is seen in the body of the right
atrium or right atrial appendage. No atrial septal defect is
seen by 2D or color Doppler.
3. Left ventricular wall thicknesses and cavity size are normal.
Overall left ventricular systolic function is normal (LVEF>55%).
4. Right ventricular chamber size and free wall motion are
normal.
5. There are simple atheroma in the aortic root. There are
simple atheroma in the ascending aorta. There are simple
atheroma in the aortic arch. There are simple atheroma in the
descending thoracic aorta.
6. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen.
[**2181-11-26**] UE Ultrasound
Thrombus in the right basilic vein which is a superficial vein.
No deep vein thrombosis seen.
CHEST PORT. LINE PLACEMENT Clip # [**0-0-**]
[**Hospital 93**] MEDICAL CONDITION:
45 year old woman with
REASON FOR THIS EXAMINATION:
r picc 47cm
Final Report
CHEST RADIOGRAPH
INDICATION: Status post PICC line placement.
COMPARISON: [**2181-11-25**].
FINDINGS: As compared to the previous radiograph, the PICC line
has been
inserted over the right upper extremity. The tip of the line
projects over
the right atrium. The line should be pulled back by roughly 5
cm. The
nasogastric tube and the endotracheal tube as well as the
right-sided central venous access line has been removed. There
is partial resolution of the pre-existing retrocardiac
atelectasis. Otherwise, the radiograph is
unchanged.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: [**Doctor First Name **] [**2181-11-29**] 10:40 PM
Brief Hospital Course:
Ms. [**Known lastname 7563**] was admitted to the [**Hospital1 18**] on [**2181-11-20**] for management
of her chest discomfort and fever. Vancomycin and ciprofloxacin
were started as she had signs of a sternal wound infection on
exam. A debridement was performed on [**2181-11-22**] and cultures were
sent which grew coagulase positive staph aureus. A VAC dressing
was placed and the pastic surgery service was consulted. The
infectious disease service was also consulted and recommended
that nafcillin be used for antibiotic coverage. On [**2181-11-26**], she
was taken back to the operating room where she underwent sternal
plating and bilateral pectoralis flap coverage by the plastic
surgery service. Postoperatively she was returned to the
intensive care unit for monitoring. She later awoke
neurologically intact and was extubated. She was then
transferred to the step down unit for further recovery. Over the
next several days she was followed by cardiac surgery, plastic
surgery and Infectious disease service. Her activity was
advanced and her medical regime tailored. On POD [**9-22**] she was
discharged home with home infusion for antibiotics and VNA for
woound care. She is to be followed by Dr [**Last Name (STitle) **] in the cardiac
surgery clinic at [**Hospital1 **], the plastic surgery and ID clinics
here at [**Hospital1 18**].
Medications on Admission:
Atenolol 100', HCTZ 25', Omeprazole 20', Lipitor 80'
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*2*
6. Nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) gms
Intravenous Q4H (every 4 hours): until stoppd by ID service.
Expected 6-8 weeks course.
Disp:*qs gms* Refills:*2*
7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush: Heparin
Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
Disp:*qs ML(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
s/p Sternal wound debridement([**11-22**]) and plating ([**11-25**])
CAD s/p CABGx2 [**2181-11-5**]
HTN
Hyperlipidemia
PICC line placeement [**11-29**]
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] Thursday 9:30AM at [**Hospital1 **].
([**Telephone/Fax (1) 1504**] for questions
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-18**] weeks.
Follow-up at Plastic surgery clinic (Dr [**First Name (STitle) **] every Monday.
Please call ([**Telephone/Fax (1) 65943**] to [**Last Name (un) 21610**] appointment
Scheduled appointments:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 9316**] Date/Time:[**2181-12-19**]
8:15
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2182-1-31**] 10:30
Completed by:[**2181-11-30**] Name: [**Known lastname 12248**],[**Known firstname 1463**] Unit No: [**Numeric Identifier 12841**]
Admission Date: [**2181-11-20**] Discharge Date: [**2181-11-30**]
Date of Birth: [**2136-1-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 741**]
Addendum:
Appointment schedule for Dr [**First Name (STitle) 735**] to be scheduled by his
office. they will call patient directly withtime of 1st
appointment. office informed of intended ongoing
Monday(plastics)-Thursday(cardiac surgery) clinic appointments
until wound healed.
Please follow-up with Dr. [**Last Name (STitle) **] Thursday 9:30AM at [**Hospital1 2057**].
([**Telephone/Fax (1) 2092**] for questions
Please follow-up with Dr. [**Last Name (STitle) 12842**] in [**2-18**] weeks.
Follow-up at Plastic surgery clinic (Dr [**First Name (STitle) 735**] every Monday.
please call([**Telephone/Fax (1) 12843**] for questions. Dr [**Last Name (STitle) **] office will
call you with time of first appt.
Scheduled appointments:
Provider: [**First Name8 (NamePattern2) 12844**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 12845**] Date/Time:[**2181-12-19**]
8:15
Provider: [**First Name4 (NamePattern1) 12846**] [**Last Name (NamePattern1) 12847**], MD Phone:[**Telephone/Fax (1) 496**]
Date/Time:[**2182-1-31**] 10:30
Discharge Disposition:
Home With Service
Facility:
Home Solutions
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2181-11-30**]
|
[
"V45.81",
"401.9",
"272.4",
"414.00",
"998.59",
"041.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"34.79",
"38.93",
"86.74"
] |
icd9pcs
|
[
[
[]
]
] |
11333, 11502
|
5568, 6918
|
358, 544
|
8373, 8382
|
1837, 4747
|
9160, 11310
|
1152, 1197
|
7021, 8109
|
4787, 4810
|
8198, 8352
|
6944, 6998
|
8406, 9137
|
1212, 1818
|
284, 320
|
4842, 5545
|
572, 831
|
853, 986
|
1002, 1136
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,441
| 110,153
|
37079
|
Discharge summary
|
report
|
Admission Date: [**2150-11-25**] Discharge Date: [**2150-12-1**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 8587**]
Chief Complaint:
Right femur fracture with vascular compromise
Major Surgical or Invasive Procedure:
[**2150-11-25**]: Right lower extremity angiogram, right above knee
to below knee popliteal bypass graft with reversed saphenous
vein, lower extremity fasciotomy. (Vascular surgery)
[**2150-11-25**]: ORIF Left distal femur fracture with [**Last Name (un) 101**] plate
(orthopaedics)
[**2150-11-27**]: I&D with closure right leg wound (orthopaedics)
History of Present Illness:
Ms. [**Known lastname **] is an 86 year old female who had a fall at home. She
was taken to [**Hospital3 79628**] and found to
have a right femur fracture and no distal pulses and a cool leg.
She was then transferred to the [**Hospital1 18**] for further evaluation.
Past Medical History:
HTN
osteoporosis
s/p appy
Right hip fracture
Social History:
Lives at home
Family History:
n/a
Physical Exam:
Upon admission
Alert and oriented
Cardiac: Regular rate rhythm
Chest: Lungs clear bilaterally
Abdomen: Soft non-tender non-distended
Extremities: RLE thigh with deformity, skin intact, no pulses
DP/PT on doppler, toes blue/cold
Pertinent Results:
[**2150-11-25**] 05:55PM PTT-143.5*
[**2150-11-25**] 04:23PM TYPE-ART PO2-200* PCO2-35 PH-7.35 TOTAL
CO2-20* BASE XS--5
[**2150-11-25**] 04:23PM LACTATE-3.0*
[**2150-11-25**] 04:05PM GLUCOSE-175* UREA N-10 CREAT-0.5 SODIUM-135
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-20* ANION GAP-11
[**2150-11-25**] 04:05PM CK(CPK)-402*
[**2150-11-25**] 04:05PM CK-MB-9
[**2150-11-25**] 04:05PM CALCIUM-7.6* PHOSPHATE-3.4 MAGNESIUM-3.0*
[**2150-11-25**] 04:05PM WBC-10.8# RBC-3.68*# HGB-11.0* HCT-30.8*#
MCV-84 MCH-30.0 MCHC-35.8* RDW-17.7*
[**2150-11-25**] 04:05PM PLT COUNT-229
[**2150-12-1**] 06:15AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.9* Hct-32.3*
MCV-88 MCH-29.8 MCHC-33.7 RDW-16.0* Plt Ct-266
[**2150-12-1**] 06:15AM BLOOD Plt Ct-266
[**2150-12-1**] 06:15AM BLOOD Glucose-94 UreaN-14 Creat-0.4 Na-140
K-4.6 Cl-104 HCO3-29 AnGap-12
[**2150-12-1**] 06:15AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.0
Brief Hospital Course:
Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2150-11-25**] via transfer from
[**Hospital3 79628**] with a right femur
fracture and with no distal pulses (DP/PT). She was evaluated
by the orthopaedic and vascular surgery services. She was then
taken to the operating room and underwent an ORIF of her right
femur fracture with orthopaedics and a right lower extremity
angiogram, right above knee
to below knee popliteal bypass graft with reversed saphenous
vein, 2 right lower extremity fasciotomies, lateral performed by
orthopaedics and medial performed by vascular surgery. She was
then transferred to the Trauma ICU for further monitoring. On
[**2150-11-26**] she was transfused with 2 units of packed red blood
cells due to acute blood loss anemia. She was also started on
Cipro for her urinary tract infection. On [**2150-11-27**] she was
taken to the operating room and underwent an I&D with fasciotomy
closure of her right leg. A drain was left in her medial
incision. She tolerated the procedure well, was extubated,
transferred to the recovery room, and then to the floor. On the
floor she was seen by physical therapy to improve her strength
and mobility. On [**2150-11-29**] she was transfused with 2 units of
packed red blood cells due to acute blood loss anemia. On
[**2150-11-30**] her JP drain was removed since it had put out less than
20cc in one day. Her wound remained intact. Her lab data and
vital signs were within acceptable range, her pain was well
controlled, and she was tolerating a regular diet. On [**2150-12-1**]
she was considered medically stable and was discharged to rehab
in stable condition.
Medications on Admission:
asa 81mg daily
colace 100mg [**Hospital1 **]
cozaar 50mg daily
Toprol 25mg
norvasc 10mg
lexapro 5mg daily
senna
iron
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Right femur fracture
Acute blood loss anemia
Right SFA disruption
Urinary Tract Infection
Discharge Condition:
Stable/Good
Discharge Instructions:
Continue to be touchdown weight bearing on your right leg
Continue your lovenox injections as instructed
Please take all medication as prescribed
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
Physical Therapy:
Activity: As tolerated
Right lower extremity: Touchdown weight bearing
Treatments Frequency:
Staples/sutures out on [**2150-12-11**], 14 days after last surgery
([**2150-11-27**]), or at orthopaedic follow up visit
Change dressings daily, or as needed for drainage, on right leg
(dry gauze)
Followup Instructions:
Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP in orthopaedic
clinic in 2 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that
appointment
[**2150-12-9**] at 11:45am Please follow up with Dr [**Last Name (STitle) 1391**] in
vascular surgery. Please call [**Telephone/Fax (1) 1393**] if needed to change
appointment.
|
[
"821.23",
"904.1",
"V54.13",
"599.0",
"958.92",
"401.9",
"E885.9",
"733.00",
"458.29",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.09",
"86.59",
"38.93",
"79.35",
"96.71",
"39.29",
"86.28",
"88.48",
"79.05"
] |
icd9pcs
|
[
[
[]
]
] |
4103, 4219
|
2269, 3935
|
313, 666
|
4353, 4367
|
1352, 2246
|
5979, 6357
|
1079, 1084
|
4240, 4332
|
3961, 4080
|
4391, 5642
|
1099, 1333
|
5660, 5734
|
5756, 5956
|
228, 275
|
694, 964
|
986, 1032
|
1048, 1063
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,154
| 106,342
|
32517
|
Discharge summary
|
report
|
Admission Date: [**2101-1-13**] Discharge Date: [**2101-2-11**]
Date of Birth: [**2030-1-26**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2969**]
Chief Complaint:
Right hydrothorax, fluid overload, fever
Major Surgical or Invasive Procedure:
[**2101-1-13**]: right ultrasound-guided thoracentesis
[**2101-1-14**]: flexible bronchoscopy
[**2101-1-18**]: bronchoscopy, thorascoscopy video-assisted right
drainage of effusion, decortication, removal of gortex mesh
History of Present Illness:
Mr. [**Known lastname 75713**] is a 71 year-old male with history of right upper
lobe lung cancer s/p right thoracotomy with right upper
lobectomy and en-block chest wall resection with decortication
of the middle and lower lobes. The procedure was difficult
procedure and complicated by prolonged hospital stay due to
bronchopleural fistula. He returned for followup on [**2101-1-13**] with
improving
postoperative chest discomfort, yet reported shortness of
breath, nonproductive cough, and bilateral lower extremity
edema, despite being recently placed on lasix by his PCP. [**Name10 (NameIs) **] had
a low-grade fever to 100.1 the evening prior to his followup
appointment. CXR ([**2101-1-13**]) revealed right hydropneumothorax. He
was subsequently admitted to the Thoracic Surgery service for
further workup and management.
Past Medical History:
PMH:
Traumatic blindness (left eye)
Hypertension
Alcohol-induced gastric ulcers (alcohol-free x20yr)
Lung CA, R chest wall ([**4-11**]), s/p carboplatin, taxol with
avastin
h/o serratia marascens VAP
PSH:
s/p appendectomy, date unknown
[**2100-12-22**]: Bronchoscopy, Reoperative right thoracotomy with right
upper lobectomy and en bloc right chest wall resection (ribs 3,4
and 5) with [**Doctor Last Name 4726**]-Tex chest wall reconstruction and decortication
of right middle and right lower lobes.
.
[**2100-12-25**]: Flexible bronchoscopy with therapeutic aspiration and
bronchoalveolar lavage.
.
[**2100-12-26**], [**2100-12-27**], [**2100-12-28**], [**2101-1-19**]:
Flexible bronchoscopy with therapeutic aspiration.
.
[**2101-1-13**]: Right sided thoracentesis under ultrasound guidance.
Social History:
Lives with wife
EtOH: {x}N { }Y Quit
Tobacco: {x}N { }Y Quit 20 years ago
Drugs: {x}N { }Y Amount:
Married: { } N {x}Y
Occupations: Construction worker
Exposures: Asbestos, chemical / construction materials
Diabetes: N
Immunodeficiency: N
Cancer: Y
Family History:
Notable for cerebral hemorrhage. Father with lung cancer.
Brother with gastric cancer and another brother with emphysema.
Sister with cystic fibrosis.
Physical Exam:
General: NAD, thin-appearing male, awake, alert
HEENT: NC/AT, mucous membranes moist, OP clear, no lesions
Neck: Supple, no lymphadenopathy
Cardiovascular: RRR no murmurs
Respiratory: Significantly decreased right base, slightly
decreased on left base. Empyema tubes x3.
Back: Well-healed thoracotomy scar
Gastrointestinal: soft, nontender, nondistended, normoactive
bowel sounds
Musculoskeletal: [**2-6**]+ pitting edema LE bilaterally
Skin: Right port without erythema, bilateral splinter
hemorrhages
Pertinent Results:
[**2101-1-13**]: CXR (on admit)
No evidence of remaining aerated pulmonary tissue in right-sided
hemithorax and central right-sided airways only followed 2-3 cm
distal to the bifurcation. A hydropneumothorax is present on the
right side with an air-fluid level above thoracic arch. Multiple
right-sided upper rib defects consistent with chest wall
reconstruction. Mild-to-moderate mediastinal shift towards right
side indicative of volume loss. The left-sided hemithorax shows
grossly normal appearance of the lung without evidence of acute
infiltrates or congestive pattern.
.
[**2101-1-13**]: Pleural fluid:
NEGATIVE FOR MALIGNANT CELLS
.
[**2101-1-25**]: ECHO:
Left atrium is mildly dilated. Mild symmetric left ventricular
hypertrophy. Left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. There is a small
pericardial effusion.
.
[**2101-1-27**]: CT Chest
IMPRESSION:
1. New, large hematoma in the right upper chest, predominantly
pleural, despite two apical pleural tubes; new submuscular, R
chest wall hematoma.
2. Persistent right pleural thickening and worsening
atelectasis.
3. New small left pleural effusion.
.
[**2101-2-3**]: CT Chest
IMPRESSION:
1. Resolving large hematoma in the right upper chest with
reexpansion of the right upper lobe volume.
2. Persistent right extrathoracic hematoma with less gas.
3. Resolving left pleural effusion.
.
[**2101-2-9**]: Renal U/S: No evidence of hydronephrosis
.
[**2101-2-10**]: CXR (prior to discharge)
IMPRESSION: No relevant changes in right hemithorax. Minimal
increase in a subtle perihilar, but diffuse opacity in the left
lung.
Brief Hospital Course:
Neuro: On admit, the patient was given oral pain medication, on
which he reported adequate pain relief. Following right VATS and
post-operative intubation, he was placed on propofol gtt and
given dilaudid IV until extubated. When able to tolerate po, he
was placed on oral pain medication. Prior to discharge, his pain
was adequately controlled on tylenol.
.
Cardiopulmonary: Following admission, the patient underwent a
bronchoscopy on [**2101-1-14**] which revealed a small amount of
granulation tissue at the base of cords c/w prior intubation
trauma, healthy appearing surgical stump, mucous in RLL, and
edematous RML/RLL bronchi. Based on the right hydropneumothorax
revealed on CXR, a right apical chest tube was inserted (drained
~1000cc serosanginous) at the bedside and pleural fluid cultures
were obtained. tPA was placed through the tube prior to
obtaining CT Chest on [**2101-1-17**]. On [**2101-1-18**], due to the persistent
right effusion, the patient underwent a flexible bronchoscopy,
right video-assisted thoracoscopy with drainage, and
decortication. Two additional right chest tubes were placed
while in the operating room. The patient tolerated the procedure
well, yet post-operatively, was electively intubated following
right hemithorax whiteout demonstrated on CXR. He was
subsequently transferred to the ICU and underwent bronchoscopy
which revealed moderate inflammation and edema in the distal
trachea and mainstem bronchi with a mucous plug in the bronchus
intermedius and right middle lobe takeoff. Repeat bronchoscopy
on [**2101-1-19**] revealed a small amount thick mucoid secretions in
the LLL, with an intact RUL stump. Following bronchoscopy, he
was weaned to extubate without incident. On [**2101-1-20**], he was
transferred to [**Hospital Ward Name 121**] 7. He had multiple CT scans during the
remainder of the hospitalization, results aforementioned. On
[**2101-1-26**] he was transferred to the TICU for hypotension and
decreased hemocrit. After stabilization of hemocrit (received 6
units pRBCs) and blood pressure stabilization, he was
transferred to [**Hospital Ward Name 121**] 7 on [**2101-1-28**]. Once on the floor, tPA was
placed through the chest tubes. He became hypertensive (SBP
180s) intermittently, and was administered hydralazine IV prn in
addition to atenolol and lisinopril (home medications). On
[**2101-2-7**], all three chest tubes were placed to waterseal. The
anterior CT was subsequently converted to an empyema tube. Prior
to discharge, the posterior and basilar tubes were converted to
empyema tubes. CXR on [**2101-2-11**] revealed no relevant changes in the
right hemithorax.
.
FEN/GI: Following admit, the patient tolerated a regular diet.
He was given Ensure supplements and calorie counts were
initiated per nutritional recommendations. Over 3 days, calorie
were 1403 and protein 47 grams. Lasix 40mg daily was continued
for diuresis and electrolytes were repleted as appropriate. On
discharge, he was tolerating a regular diet; denied nausea or
vomiting.
.
ID: On admit, patient had temperature of 101.2, WBC=8.5. He was
initially placed on vancomycin and levofloxacin IV while
awaiting culture results. Diflucan was started on [**2101-1-15**] due to
[**Female First Name (un) **] albicans growth in pleural fluid from [**2101-1-13**] and
subsequently [**2101-1-18**]. Levofloxacin was discontinued on [**2101-1-24**].
Infectious disease was consulted for antibiotic management.
Recommendations included: checking TEE to r/o endocarditis,
continuing diflucan from [**Date range (1) 75840**], checking LFTs every
2weeks while on diflucan, and obtaining f/u CT scan at end of
treatment course to determine resolution of effusion. On
discharge, the patient was afebrile, WBC=9.9. He was discharged
on vancomycin, to continue until all empyema tubes removed, and
fluconazole, to continue until [**2101-2-28**].
.
Renal: On [**2101-2-9**], the patient's creatinine increased to 1.7
(from 1.3 on admit). Fractional excretion of sodium was 0.9.
Renal ultrasound revealed right kidney 11.6 cm, left kidney 10.7
cm, with no evidence of hydronephrosis, nephrolithiasis, or
renal mass. Urinalysis was negative; no eosinophils. Renal team
was consulted and thought acute renal failure was likely
drug-related. Renal recommmendations included holding lisinopril
and renally dosing antibiotics. Creatinine was closely followed;
on discharge, creatinine was 1.9.
.
Endo: Blood sugars were closely monitored. The patient was
placed on an insulin sliding scale. On [**2101-2-4**], the patient was
triggered for a blood sugar of 26. He was confused and
disoriented, yet improved with 1/2 amp D50 x2 and [**Location (un) 2452**] juice.
He subsequently received D10W, insulin was held, and
fingersticks were closely monitoring. He did not have any
further low blood sugars during the remainder of his
hospitalization.
.
Heme: He was given heparin SQ 5000U TID for DVT prophylaxis. He
received 2 units pRBC on [**2101-1-26**] for Hct drop (28.6 to 23.8).
Post-tranfusion Hct was 25.9, and he subsequently received 4
more units pRBC, with resulting Hct of 33.0. On discharge, Hct
was 26.6.
Medications on Admission:
Atenolol 100 mg daily
Oxycodone-Acetaminophen 5-325 mg, 1-2 tabs po q4-6hr prn pain
Docusate Sodium 100 mg [**Hospital1 **]
Lisinopril 20 mg [**Hospital1 **]
Hydrochlorothiazide 25 mg daily
Doxazosin 6mg qhs
Lasix 40mg daily
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
2. Doxazosin 4 mg Tablet [**Hospital1 **]: 1.5 Tablets PO HS (at bedtime).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
4. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Fluconazole 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every
24 hours): Dr. [**Doctor Last Name 75841**] disease will stop this medication.
Disp:*30 Tablet(s)* Refills:*1*
7. Atenolol 100 mg Tablet [**Doctor Last Name **]: One (1) Tablet PO once a day:
Hold for
SBP<100, HR<60.
8. Diazepam 5 mg Tablet [**Doctor Last Name **]: [**1-5**] to 1 [**1-5**] Tablet PO Q12H (every
12 hours) as needed.
9. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Month/Day (2) **]: One (1)
gm Intravenous Q 24H (Every 24 Hours).
Disp:*30 gm* Refills:*1*
10. Atenolol 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO q pm.
11. Outpatient Lab Work
check vanco level, liver function tests, and bun/creat on monday
[**2101-2-14**] and call to Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**]
12. Heparin Lock Flush (Porcine) 10 unit/mL Solution [**Telephone/Fax (1) **]: One
(1) ML Intravenous DAILY (Daily) as needed.
Disp:*qs unit/ml* Refills:*0*
13. Tylenol 325 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO every four (4)
hours.
14. Saline Flush 0.9 % Syringe [**Telephone/Fax (1) **]: One (1) Injection prn.
Disp:*qs syringe* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Lung CA, right chest wall s/p carboplatin, taxol with avastin,
s/p right thoracotomy with right upper lobectomy and enblock
right chest wall resection with [**Doctor Last Name 4726**]-Tex chest wall
reconstruction
Secondary:
Hypertension
Gastric Ulcers
COPD
CRI (baseline Cr 1.5)
Traumatic blindness L eye
Discharge Condition:
Good
Discharge Instructions:
Call Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] if experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or sputum production
-Chest pain
-Incision develops discharge
Cover chest tube site with a clean dry dressing daily. The gauze
at the end of the chest tubes can changed as often as needed. If
the chest tube falls out- cover the site with a gauze and call
Dr.[**Doctor Last Name 4738**] office [**Telephone/Fax (1) 170**] immediately.
Complete Diflucan through [**2101-2-28**]
LFT's every 2 weeks while on Diflucan: Fax results to Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 432**]
You may only [**Last Name (un) 41829**] bathe until the chest tubes are removed.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] on thursday [**2101-2-17**] at 3pm in the
[**Hospital Ward Name **] clinical center [**Location (un) **]. Please arrive 45 minutes
prior to your follow up appointment and report to the [**Location (un) **]
radiology for a chest xray.
Follow-up with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2101-2-28**] 11:00 in the [**Last Name (un) 2577**] Building basement [**Last Name (NamePattern1) 10357**]
|
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"511.8",
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"403.90",
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"117.9",
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icd9cm
|
[
[
[]
]
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[
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"99.10",
"34.04",
"96.05",
"34.06",
"34.91",
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icd9pcs
|
[
[
[]
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12196, 12245
|
5079, 10219
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319, 541
|
12604, 12611
|
3236, 5056
|
13381, 13909
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2544, 2698
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10495, 12173
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12266, 12583
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10245, 10472
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12635, 13358
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2713, 3217
|
239, 281
|
569, 1401
|
1423, 2221
|
2237, 2528
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,181
| 117,239
|
55164+55165
|
Discharge summary
|
report+report
|
Admission Date: [**2166-8-16**] Discharge Date: [**2166-8-18**]
Date of Birth: [**2103-6-9**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
63F with recently diagnosed stage I lobular breast cancer who
presents from home, brought in by ambulance, after 2 syncopal
episodes this morning. The patient reports that she was in her
usual state of health until the afternoon/evening prior to
admission when she developed a headache. Of note, the patient
received her first of four planned cycles of chemotherapy with
Taxotere/Cytoxan three days prior to admission ([**8-13**]). On the
day prior to admission, she had some nausea and took zofran,
colace and 2 senna tabs; she also received her first Neulasta
injection ([**8-15**]). On the morning of admission, the patient's and
her husband report that she fell at approximately 6:15am. The
patient does not remember the events surrounding the fall and
states that she believes she passed out on the way to the
bathroom. Her husband helped her back to bed and she took a
zofran for nausea. He did note that she had some urinary
incontinence after getting back to bed. At approximately 8:00am,
the patient's husband reports that he heard her fall again in
the bathroom. Patient states that she felt as if she was about
to have diarrhea, however, husband reports that she had a formed
stool. Again the patient does not remember passing out, and this
time her husband was unsure of whether she hit her head. She
reports feeling clammy and complained of worsening headache, as
well as thirst and abdominal cramping. Her husband called her
PCPs office who recommended that she go to the ED.
In the ED, initial VS were: 97 157 89/73 16 98% 2L NC. ECG
revealed new atrial fibrillation with rapid ventricular response
@ ~140 beats per minute, as well as an incomplete RBBB and
inferolateral STD. Although patient's initial SpO2 is recorded
at 98%, repeat was in the mid to high 80%s and she was placed on
a non-rebreather for an unclear amount of time. Labs were
notable for WBC 11.6 w/left shift and no bands, lactate 1.6,
troponin <0.01, BNP 608, and negative U/A. Blood and urine
cultures were sent and the patient received vancomycin and
cefepime. CT head was negative. Preliminary read of CTA/CT
abdomen and pelvis showed no pulmonary embolism or acute process
in the chest, but possible very early diverticulitis involving
the mid-to-distal descending colon, as well as evidence of
chronic inflammatory bowel disease involving the right
hemi-colon. In light of these findings, as well as two episodes
of foul-smelling diarrhea in the ED, the patient was started on
metronidazole. She received a total of 2L NS and converted to
normal sinus rhythm without any medications. Repeat ECG showed
sinus rhythm with rSr' in V1 and resolution the ST depressions.
She was able to be weaned down to 2L NC and blood pressure and
heart rate remained stable.
On arrival to the MICU, patient's VS were 97.5, 79, 101/59, 14,
93%RA. She appeared uncomfortable and complained of headache,
thirst, and stomach cramping. Denied any chest pain or shortness
of breath.
Past Medical History:
- Stage I invasive lobular breast cancer s/p left lumpectomy
[**2166-7-1**] with re-excision [**2166-7-22**]; started cycle 1 of
chemotherapy with Taxotere/Cytoxan [**8-13**], received Neulasta [**8-15**]
- Asthma
- Meralgia paresthetica
- Depression
- Hypercholesterolemia
- H/o alcohol dependence
- Umbilical hernia
- Colonic adenoma
- Bilateral bunions
- ?Restless legs syndrome
Social History:
Patient quit smoking cigarettes [**2141-12-17**]. Drinks ~1 beer/day.
Reports a history of alcohol dependence; used to drink 2 bottles
of wine/day. No longer drinks wine. Denies any illicit drug use.
Married, no children. Works for [**Street Address(1) 59974**] Service as a
museum collections conservator. Lives on the [**Location (un) **] of house
and walks up the stairs unassisted with no difficulty.
Family History:
Mother with CHF. Father with early-onset Alzheimer's disease.
Denies any family history of breast or ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL
General: Alert, oriented, appears uncomfortable
HEENT: Sclera anicteric, dry MM, 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,
rhonchi
Abdomen: soft, endorses tenderness in bilateral lower quadrants
& epigastrum -- not particularly exacerbated by palpation,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, bunions bilaterally
Neuro: CNII-XII intact, no focal abnormalities
Pertinent Results:
[**8-16**] CT CHEST ABDOMEN:
TECHNIQUE: MDCT axial images were acquired through the chest
without
administration of intravenous contrast material. Subsequently,
rapid axial
images were acquired through the chest during infusion of 130 ml
of
intravenous water-soluble contrast material. Rapid axial images
were then
acquired through the abdomen and pelvis in the portal venous
phase.
Multiplanar reformats were performed.
CHEST CT: The thoracic aorta is normal in caliber, and
unremarkable in
appearance, without evidence of dissection. There is no
evidence of pulmonary
embolism to the subsegmental levels bilaterally. The heart is
unremarkable.
The visualized portion of the thyroid gland is normal. Small
mediastinal
lymph nodes do not meet CT size criteria. There are no
pathologically
enlarged hilar or axillary lymph nodes.
There is mild centrilobular emphysema, most prominent at the
apices. There is
also paraseptal emphysema along the posteromedial right lung
apex. No
pulmonary nodules are identified. Minimal atelectasis is seen
along the
posterior portion of the upper and lower lungs bilaterally. No
consolidations
are identified. The airways are patent to the subsegmental
levels
bilaterally.
ABDOMEN CT: Centered within hepatic segment VI is a 9.0 x 7.6
cm simple cyst.
There are scattered subcentimeter hypodensities throughout the
remainder of
the liver, all of which are too small to characterize, also
likely
representing simple cysts. There is no intrahepatic biliary
duct dilatation.
The portal vein is patent. Minimal sludge or tiny stones are
seen within the
dependent portion of an otherwise unremarkable gallbladder. The
spleen is
unremarkable. There is mild fatty atrophy of the pancreas,
which is otherwise
normal in appearance. The adrenal glands are unremarkable. The
kidneys are
normal in appearance. The stomach is unremarkable. There is a
small 2.2 cm
duodenal diverticulum. The small bowel is otherwise
unremarkable. There is
moderate colonic wall thickening involving the cecum, ascending
colon, and
proximal portion of the transverse colon, with evidence of
submucosal fat
deposition, findings that can be seen in the setting of chronic
inflammatory
bowel disease, (3B:109-128). There is no pericolonic vascular
injection or
fat stranding adjacent to the thickened segment of bowel to
suggest acute
inflammation. The terminal ileum is unremarkable. There is
extensive
diverticulosis, predominantly involving the sigmoid colon but
also seen
scattered throughout the descending colon. There is minimal fat
stranding
along the mid to distal descending colon (3B:128), likely
secondary to early
colitis versus diverticulitis. There is no free fluid or free
air in the
abdomen. No pathologically enlarged abdominal lymph nodes are
seen. The
abdominal aorta is normal in caliber. Note is made of scattered
aortic and
[**Hospital1 **]-iliac artery calcifications. There is a small fat containing
umbilical
hernia.
PELVIS CT: A Foley catheter is seen within the bladder, which
is otherwise
unremarkable. There is no free fluid in the pelvis. No
pathologically
enlarged pelvic lymph nodes are seen.
BONE WINDOW: No suspicious lytic or blastic lesions are
identified.
Multilevel degenerative changes of the thoracolumbar spine are
seen.
IMPRESSION:
1. Mild fat stranding adjacent to the mid-to-distal descending
colon, likely
secondary to early colitis, less likely diverticulitis.
2. Colonic wall thickening and submucosal fat deposition along
the cecum,
ascending colon, and proximal transverse colon, suggestive of
chronic colitis.
There is no pericolonic fat stranding or vascular injection
along this bowel
distribution to suggest active disease.
3. No evidence of pulmonary embolism.
4. Large right hepatic lobe simple cyst with additional
scattered tiny
hepatic hypodensities, also likely simple cyst but too small to
characterize.
5. Small duodenal diverticulum.
6. Minimal gallbladder sludge versus tiny stones.
The study and the report were reviewed by the staff radiologist.
CT HEAD [**8-16**]
FINDINGS: There is no evidence of intracranial hemorrhage,
edema, shift of
normally midline structures, hydrocephalus, or acute large
vascular
territorial infarction. Mild prominence of the ventricles and
sulci is
consistent with age-related involutional change.There is focal
hypodensity in
the corona radiata bilaterally( left > right) which could
represent small
vessel ischemic disease but consider MRI for further evaluation
. Minimal
calcifications are seen of the bilateral cavernous carotid
arteries and left
vertebral artery. The orbits are unremarkable. Scattered mucus
retention
cysts are seen throughout both maxillary sinuses. The remainder
of the
paranasal sinuses are well aerated. The mastoid air cells are
well aerated
bilaterally. The imaged osseous structures are unremarkable.
IMPRESSION:
1. No acute intracranial process.
2. Scattered bilateral maxillary sinus mucus retention cysts.
3. There is focal hypodensity in the corona radiata bilaterally
, left greater
than right which could represent small vessel ischemic disease
but consider
MRI for further evaluation .
[**2166-8-16**] 09:53AM BLOOD WBC-11.6* RBC-3.91* Hgb-12.7 Hct-37.2
MCV-95 MCH-32.5* MCHC-34.2 RDW-12.2 Plt Ct-136*
[**2166-8-17**] 02:51AM BLOOD WBC-5.4# RBC-3.21* Hgb-10.4* Hct-30.9*
MCV-96 MCH-32.3* MCHC-33.6 RDW-12.2 Plt Ct-102*
[**2166-8-16**] 09:53AM BLOOD Glucose-119* UreaN-22* Creat-0.7 Na-142
K-3.7 Cl-105 HCO3-26 AnGap-15
[**2166-8-16**] 09:53AM BLOOD Albumin-3.8 Calcium-7.7* Phos-4.2 Mg-2.4
[**2166-8-16**] 10:01AM BLOOD Lactate-1.6
[**2166-8-17**] 05:06AM BLOOD Lactate-0.8
Brief Hospital Course:
MICU COURSE
# Syncope: Patient presented with 2 syncopal episodes and was
found to be in new afib with RVR. She had no memory of the
events surrounding the syncopal episodes, but her husband found
her on the ground twice on the morning of admission. Given that
she complained of lightheadedness, as well as her history of
decreased PO intake and nausea since receiving chemo on [**8-13**], it
was thought to be that both hypovolemia as well as new afib
contributed to these episodes. Seizure was thought to be less
likely given presentation. Troponins were cycled, which were
negative. Patient was volume resuscitated and monitored on
telemetry. Had no further events during the hospitalization.
She received a total of 8 L during this hospitalization with
good recovery of her blood pressure. To work up her atrial
fibrillation, she was ruled out, TSH was checked (normal), and
echocardiogram performed. The Echocardiogram revealed nl EF
(55-60%) with mod [**Last Name (un) **] and mild LAE, no LV motion abnormality.
SHe was kept in telemetry and had no subsequent atrial
fibrillation during this admission.
She was able to ambulate without any orthostatic signs. The
original syncope was attributed to significant nausea and
decreased PO intake from the chemotherapy.
# Abdominal pain: Patient presented with a leukocytosis with
left-shift; read of CT abdomen, in conjunction with crampy
abdominal pain, was suggestive of possible acute on chronic
colitis. Chemotherapy side-effect was another etiology to
consider. She had two episodes of diarrhea in the ED, but this
was in the context of taking prophylactic colace and senna. The
diarrhea resolved. However, given evidence of new onset
abdominal pain with white count, inflammatory findings on CT
scan, patient was covered empirically for GI flora with
cipro/flagyl. She will complete a total of ~ 14 day course.
Prescription for the medications were provided and she may
follow up with her PCP/oncologists to see how she has responded
to antibiotics. She was instructed to increase fiber intake
(within limits of what is allowed of chemo and risk of
neutropenia) and to optimize regularity of bowel movement.
# Headache: Ms. [**Known lastname **] also complained of significant
headache. Head CT on admission revealed no evidence of bleed.
She was treated with tylenol and oxycodone PRN. ALthough, she
has very little recollection of what occurred in the bathroom,
it appears that she was found with her head on the bathroom
scale. The headache is likely posttraumatic related and can be
followed up as an outpt with her PCP/oncologist.
She was able to ambulate and eat solids without problems. [**Name (NI) **]
husband was present and made aware of the existing diagnosis,
workup, and discharge plans. She was discharged in good
condition.
Medications on Admission:
- Albuterol inhaler (uses approx 1x/week)
- Ondansetron 8mg PO q8h prn nausea
- Lorazepam 1mg PO q8h prn mild nausea or anxiety
- Neulasta 6mg/0.6mL sq syringe injected 24-48 hrs after chemo
every 21 days (last dose 8/24)
- Dexamethasone 8mg [**Hospital1 **] on the day prior to, of, and after chemo
- Colace
- Senna
- States that she self-discontinued Prozac, Ritalin, and
gabapentin, and was told to stop taking multivitamins/calcium by
her oncologist
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain or fever
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Hold for oversedation or RR < 12
RX *oxycodone 5 mg [**12-23**] capsule(s) by mouth every four (4) hours
Disp #*20 Capsule Refills:*0
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
7. Lorazepam 1 mg PO Q8H:PRN mild nausea, anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
- atrial fibrillation with rapid ventricular response
- dehydration
- colitis/diverticulitis
- headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with low blood pressure and rapid heart beat
due to atrial fibrillation. You were found to be significantly
dehydrated. After hydration, your rhythm normalized and your
pressure returned to [**Location 213**]. You received 8L of iv fluids to
help you become hydrated. A surface echocardiogram was
performed and showed a normal ejection fraction (pumping
function) for the heart.
Also, abdominal CT revealed mild colitis/diverticulitis on
the left side. For this, you were given antibiotics.
Prescriptions for antibiotics is provided for you to complete a
10 day course.
In addition, you complained of a headache. Head CT showed no
evidence of bleed. The headache should improve with time and
can be treated with tylenol +/- oxycodone as needed.
Followup Instructions:
Please follow up with your oncologist in [**12-23**] weeks.
Admission Date: [**2166-8-19**] Discharge Date: [**2166-8-20**]
Date of Birth: [**2103-6-9**] Sex: F
Service: MEDICINE
Allergies:
House Dust
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Neutropenia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
63 year old female with recent hospital admission ([**2166-8-18**]) with
diverticulitis, recent chemo on [**8-13**], found to have rigors and
be neutropenic in PCP office this am. She was diagnosed in [**Month (only) **]
with breast cancer, s/p lumpectomy and reexcision, w/ negative
nodes. Started chemo 6 fdays ago:started cycle 1 of chemotherapy
with Taxotere/Cytoxan [**8-13**], received Neulasta [**8-15**]. On [**8-16**], she
presented to [**Hospital1 18**] with head trauma after syncopal episode, in
the setting of diarrhea, found to have diverticulitis and new
AFib with RVR. She spontaneously cardioverted following Iv
hydration. She was treated in the MICU with fluids and
cipro/flagyl, and discharged on [**8-18**]. Echo revealed normal EF
with moderate [**Last Name (un) **] and mild LAE, no LV motion abnormality. CT
head at the time showed no acute intracranial pathology, but she
has had a waxing/[**Doctor Last Name 688**] headache in the temporal/peri-orbital
region since, which persists today. She denies any visual
changes, nausea, visual changes. Does not wake up from sleep
with headache. She does have intermittent waxing/[**Doctor Last Name 688**]
abdominal pain, chronic for years, located in bilateral lower
quadrants. worse since saturday. The pain is crampy and
debilitating but resolves with bowel movement. She is continuing
on oral cipro/flagyl since hosptial discharge. Lat BM was in
hospital, no nausea/vomiting/hematochezia/ melena since
discharge.
Today she went to her PCP's office for followup, and was found
to have rigors/chills whilst there. No fevers. CBC was notable
for pancytopenia (today is day 5 post-chemotherapy). Denies any
fevers, chest pain, dyspnea, dysuria, hematuria, neck stiffness,
photophocia.
In the ED, initial vital signs were 98.2 78 107/63 16 97% RA.
She was given 500 cc NS bolus, Zofran 4mg IV, Morphine 5mg IV
total as well as Toradol 30mg IV for headache. Given soft blood
pressure and neutropenia, the decision was made to admit her to
medicine for observation, wth concern for bacteremia
Past Medical History:
- Stage I invasive lobular breast cancer s/p left lumpectomy
[**2166-7-1**] with re-excision [**2166-7-22**]; started cycle 1 of
chemotherapy with Taxotere/Cytoxan [**8-13**], received Neulasta [**8-15**]
- Asthma
- Meralgia paresthetica
- Depression
- Hypercholesterolemia
- H/o alcohol dependence
- Umbilical hernia
- Colonic adenoma
- Bilateral bunions
- ?Restless legs syndrome
Social History:
Patient quit smoking cigarettes [**2141-12-17**]. Drinks ~1 beer/day.
Reports a history of alcohol dependence; used to drink 2 bottles
of wine/day. No longer drinks wine. Denies any illicit drug use.
Married, no children. Works for [**Street Address(1) 59974**] Service as a
museum collections conservator. Lives on the [**Location (un) **] of house
and walks up the stairs unassisted with no difficulty.
Family History:
Mother with CHF. Father with early-onset Alzheimer's disease.
Denies any family history of breast or ovarian cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 97.8, 118/68, 76, 20, 94% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD distended, soft NT normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Discharge PE
VS 98.3 108/68 68 20 93% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs
[**2166-8-19**] 06:45PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2166-8-19**] 06:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
[**2166-8-19**] 04:32PM LACTATE-1.4
[**2166-8-19**] 04:10PM GLUCOSE-91 UREA N-6 CREAT-0.7 SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-29 ANION GAP-12
[**2166-8-19**] 04:10PM ALT(SGPT)-23 AST(SGOT)-34 ALK PHOS-68 TOT
BILI-0.8
[**2166-8-19**] 04:10PM LIPASE-13
[**2166-8-19**] 04:10PM ALBUMIN-3.9
[**2166-8-19**] 04:10PM WBC-2.7* RBC-3.72* HGB-12.3 HCT-35.4* MCV-95
MCH-33.0* MCHC-34.7 RDW-12.0
[**2166-8-19**] 04:10PM NEUTS-9* BANDS-0 LYMPHS-72* MONOS-10 EOS-3
BASOS-1 ATYPS-1* METAS-3* MYELOS-1*
[**2166-8-19**] 04:10PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2166-8-19**] 04:10PM PLT SMR-LOW PLT COUNT-128*
[**2166-8-18**] 06:25AM GLUCOSE-81 UREA N-7 CREAT-0.5 SODIUM-139
POTASSIUM-3.6 CHLORIDE-107 TOTAL CO2-25 ANION GAP-11
[**2166-8-18**] 06:25AM CALCIUM-7.7* PHOSPHATE-2.4* MAGNESIUM-1.9
[**2166-8-18**] 06:25AM TSH-3.4
[**2166-8-18**] 06:25AM WBC-2.3*# RBC-3.39* HGB-11.1* HCT-32.2*
MCV-95 MCH-32.8* MCHC-34.6 RDW-12.9
[**2166-8-18**] 06:25AM PLT SMR-LOW PLT COUNT-99*
Discharge Labs
[**2166-8-20**] 10:35AM BLOOD WBC-7.8 RBC-3.72* Hgb-12.1 Hct-35.6*
MCV-96 MCH-32.4* MCHC-33.9 RDW-12.3 Plt Ct-130*
[**2166-8-20**] 10:35AM BLOOD Neuts-36* Bands-16* Lymphs-23 Monos-17*
Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-3* Promyel-1*
Micro
[**2166-8-20**] STOOL
C. difficile DNA amplification assay-PENDING;
FECAL CULTURE-PENDING;
CAMPYLOBACTER CULTURE-PENDING;
OVA + PARASITES-PENDING
URINE URINE CULTURE-PENDING I
Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **]
[**2166-8-19**]
BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **]
CXR [**8-19**]
FINDINGS:
The heart size is top normal and unchanged. The mediastinal and
hilar
contours are stable and within normal limits. The pulmonary
vascularity is
not engorged. A trace left pleural effusion is likely present.
There is
minimal bibasilar atelectasis. No pneumothorax is present, and
no acute
osseous abnormalities seen.
IMPRESSION:
Small left pleural effusion and mild bibasilar atelectasis.
Brief Hospital Course:
This is a 63F C1D6 following Taxotere/Cyclophosphamide, reent
MICU admission for diverticulitis, on cipro/flagyl, now presents
with rigors in PCP office, soft blood pressures and neutropenia.
# Neutropenia/Abdominal pain/Hypotension: The patient was
recently discharged from the MIcu after hospital stay for
diverticulitis and continued on ciprofloxacin/metronidazole. She
presented to her PCP pancytopenic following chemotherapy (ANC
243). Given she was previously diagnosed with diverticulitis
during the past admission, the initial concern for bacteremia
vs. colitis with comlicatons such as abscess vs. other
infection. Abdominal exam was benign, patent's GI symptoms have
not worsened. CXR benign, no history of dysuria.
She was resuscitated with 2L IVF and responded adequately with
pressures going from 80s-90s systolic to 110s systolic. A
repeat CBC shows uptrending WBC at 5.8 with 36% neutrophils, no
longer neutropenic. Her vitals were closely monitored and
serial abdominal exams were performed. She was afebrile and
never met SIRS criteria and her belly was soft and nontender
during the entire admission.
I spoke extensively with Dr. [**Last Name (STitle) **], the atrius attending
covering heme/onc today, and he agreed with my assessment that
the patient likely is not acutely infected and is not at
increased risk for infection as her WBC recovered. Dr. [**Last Name (STitle) 849**],
her PCP was [**Name (NI) 653**] and her case was discussed. She agreed to
see the patient in her clinic the following day for close
monitoring.
# Headache: Her headache symptoms were minimal during this
hospital admission. The etiology is likely post-traumatic as
she denied photophobia/visual changes/neck stiffness/ altere
mental status to suggest meningitis/encephalitis, and past CT
scan of head showed no acute abnormalities. We continued her
percocet which adequately managed her pain
Chronic Issues: These issues were not active during this
hospital admission
- Stage I invasive lobular breast cancer s/p left lumpectomy
[**2166-7-1**] with re-excision [**2166-7-22**]; started cycle 1 of
chemotherapy with Taxotere/Cytoxan [**8-13**], received Neulasta [**8-15**]
- Asthma- she was contined on her albuterol inhaler
- Meralgia paresthetica
- Depression- was continued on lorazepam
- Hypercholesterolemia
- H/o alcohol dependence
- Umbilical hernia
- Colonic adenoma
- Bilateral bunions
- ?Restless legs syndrome
TRANSITIONAL ISSUES
-Patient needs follow up on the following labs: Stool culture,
campylobacter culture, stool ova and parasites, C.Diff, Urine
culture, Blood culture
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain or fever
2. Ciprofloxacin HCl 500 mg PO Q12H
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
4. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Hold for oversedation or RR < 12
5. Ondansetron 8 mg PO Q8H:PRN nausea
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
7. Lorazepam 1 mg PO Q8H:PRN mild nausea, anxiety
Discharge Medications:
1. Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q8H:PRN pain or fever
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheezing, SOB
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Lorazepam 1 mg PO Q8H:PRN mild nausea, anxiety
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
6. OxycoDONE (Immediate Release) 5-10 mg PO Q4H:PRN pain
Hold for oversedation or RR < 12
7. Ondansetron 8 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenia (recovered)
Diverticulitis
Headache
Secondary
-Breast Cancer s/p lumpectomy, node excision, and cycle 1 day 6
chemotherapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. [**Known lastname **],
You were admitted to [**Hospital1 18**] for low white blood cell counts,
abdominal pain, and headache. Since you were here, we gave you
several liters of IV fluids as your blood pressures were a bit
low. Additionally, we redrew your blood counts which showed you
to have recovered your white blood cell numbers. We continued
the cipro and flagyl for the diverticulitis you were diagnosed
with earlier in the week. Fortunately, it did not look like you
have a separate acute infection. We concluded that your
headache was due to your fall a few days back and we continued
your Percocet and Tylenol for pain.
CHANGES TO MEDICATIONS
NONE
It was a pleasure taking care of you while you were here.
Followup Instructions:
Talked with PCP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 849**] and she has agreed to see the
patient tomorrow, [**2166-8-21**] at 2:10 pm for close follow up.
PCP also plans on rescheduling the patients GI appointment with
a different provider (TBD)
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83,099
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53010
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Discharge summary
|
report
|
Admission Date: [**2155-8-21**] Discharge Date: [**2155-9-1**]
Date of Birth: [**2107-5-11**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48 yo female with T1DM with neuropathy, hypothyroidism, recent
presumptive diagnosis of C. difficile (day 6 of 10 of po
flaygyl), recent admission to podiatry [**Date range (1) 109272**] for
left foot cellulitis, where she was treated with Vancomycin 1 gm
IV x 2 doses and cipro and then discharged with po bactrim DS
800-160 mg 1 po BID. She presents due to fever (Tmax 102 at
home) and vomiting all day today.
In ED:
VS: 99.0 103 96/58 24 100
Received in ED:
22:30 MetRONIDAZOLE (FLagyl) 250 mg
22:30 Vancomycin 1g
23:10 Acetaminophen 500mg
1/2 NS x 1L
On floor, she reports that her husband noted the denuded skin on
the ball of her left foot before she did due to her neuropathy.
She denies cp, sob, cough, abdominal pain, skin problems other
than above, dysuria, diarrhea;
ROS: + headache and BM in past few days; otherwise wnl for all
systems
Past Medical History:
PMH: Type 1 diabetes since [**2117**], on an Ace inhibitor to
protection of kidneys not for HTN.
PSx: Previous left hallux debridement for osteomyelitis in [**2149**]
Social History:
Denies current tobacco use
Social alcohol use
Denies drug use
Family History:
Non-contributory
no early (50 years or less) deaths in family
Physical Exam:
VS: 99.2 151/78 96 18 98%RA
GEN: Alert and oriented to person, place and situation; no
apperent distress
HEENT: no trauma, pupils round and reactive to light and
accomodation, no LAD, oropharynx clear, no exudates
CV: regular rate and rhythm, no murmurs/gallops/rubs
PULM: clear to auscultation bilaterally, no
rales/crackles/rhonchi
GI: soft, non-tender, non-distended; no guarding/rebound
EXT: no clubbing/cyanosis/edema; 2+ distal pulses
NEURO: CN II-XII intact, [**5-21**] motor function globally, decreased
sensation in bilateral feet up to ankles, otherwise intact
DERM:
Left foot plantar surface: 4x5cm denuded skin at ball; 2x2cm
denuded at heel
Left foot dorsal surface: 4x4 L-shaped echymosis with intact
erythmatous skin
Bilateral feet/legs: non-pruritic, erythematous petechia up to
mid ankles
Pertinent Results:
[**2155-8-21**] 09:35PM WBC-5.7 RBC-4.11* HGB-11.7* HCT-35.5* MCV-87
MCH-28.5 MCHC-33.0 RDW-14.9
[**2155-8-21**] 09:35PM NEUTS-84.3* LYMPHS-7.9* MONOS-2.0 EOS-5.2*
BASOS-0.5
[**2155-8-21**] 09:35PM PLT COUNT-235
[**2155-8-20**] 07:00AM GLUCOSE-85 UREA N-11 CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-29 ANION GAP-11
[**2155-8-20**] 07:00AM CALCIUM-8.4 PHOSPHATE-3.4 MAGNESIUM-1.8
[**2155-8-21**] 09:45PM LACTATE-2.3*
[**2155-8-21**] 09:35PM GLUCOSE-93 UREA N-10 CREAT-1.2* SODIUM-131*
POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-24 ANION GAP-16
[**8-23**] CTA Chest
IMPRESSION:
1. Patchy ground-glass opacities throughout both lungs, with
neighboring
prominent mediastinal lymph nodes, is compatible with an
inflammatory process.
An atypical or viral pneumonia is a strong consideration.
Pulmonary
hemorrhage can have a similar appearance in the appropriate
clinical context.
2. Moderate-sized bilateral pleural effusions with adjacent
compressive
atelectasis.
3. No PE detected to the subsegmental levels.
[**8-25**] TTE
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Doppler parameters are
indeterminate for left ventricular diastolic function. There is
no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The aortic
valve leaflets are mildly thickened (?#). There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Normal regional and global left ventricular systolic
function. The right ventricle is not well seen but is probably
mildly dilated. No pathologic valvular abnormality seen.
Discharge Labs: [**2155-9-1**] 05:56AM
BLOOD WBC-3.0* RBC-3.15* Hgb-9.0* Hct-27.6* MCV-88 Plt Ct-388
Glucose-215* UreaN-17 Creat-0.8 Na-136 K-3.7 Cl-100 HCO3-32
AnGap-8
AlkPhos-146*
[**2155-8-25**] 10:39AM BLOOD BLASTOMYCOSIS ANTIBODY (BY CF AND ID)-PND
Brief Hospital Course:
48 F h/o DM1 with pedal neuropathy, hypothyroidism, LLE
cellulitis, C diff, presenting with nausea, vomiting and ARF.
# Atypical PNA: The patient was found to have bilateral ground
glass opacities on admission CXR and required 70% O2 to maintain
saturations > 93%, for which she was sent to the ICU. She
clinically and symptomatically improved on Levofloxacin, with O2
requirement decreasing to 2L to maintain saturations in the
mid-90s and CXR showing interval improvement on transfer to the
medical floor compared to admission. It was also thought that
hypoxia and symptoms could be due a component of [**Last Name (LF) 105496**], [**First Name3 (LF) **] viral
and fungal studies were sent; her improvement without steroids
argued against these etiologies. Beta-glucan was negative;
blastomycosis was still pending at the time of discharge. She
completed a 7 day course of Levofloxacin and will complete a 10
day course Vancomycin. She was on room air with no respiratory
complaints for over 72 hours prior to discharge.
# Decompensated CHF: A component of her hypoxia was thought to
be due to decompensated CHF, although ECHO as detailed in the
pertinent results was not suggestive of diastolic failure. She
was diuresed during her ICU stay and showed symptomatic
improvement and decreased pulmonary effusion on CXR. Lasix was
discontinued on [**2155-8-30**], but given an increase in lower
extremity edema she was re-started on Lasix 20mg PO daily with
instructions to weigh herself each morning and administer one
dose of Lasix 20mg if her weight increases 2 pounds above her
baseline or if she notes significantly increased lower extremity
edema.
# Acute renal failure: Likely due to intravascular volume
depletion from nausea with vomiting. Medications were renally
dosed and creatinine quickly normalized to baseline with
intravascular repletion.
# Nausea and vomiting, poor PO intake: Likely due to infection
+/- antibiotics. Managed symptomatically with ondansetron 4 mg
IV q4h prn. Flagyl changed to PO vanco on [**8-29**]; stool studies
were negative. Her oral intake improved significantly prior to
discharge.
# Cellulitis Diabetic foot ulcers: Non-limb threatening
infection in a diabetic with complications and history of
osteomyelitis. Covered broadly with IV vancomycin and Flagyl for
gram + and anaerobic microbes. She will complete the final three
doses of Vancomycin as an outpatient.
# Clostridium difficile: Initially treated with metronidazole
500 mg po TID. Changed to PO Vanco due to abdominal symptoms on
[**8-29**]. Repeat stool studies [**8-29**] were negative. She will complete
14 days of PO Vancomycin following completion of Levofloxacin,
the last dose of which was given [**2155-8-30**].
# Diabetes mellitus, type 1: Blood sugars were treated by the
patient through adjustments of her insulin pump and a sliding
scale for coverage [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations. She had elevated
sugars during the 24 hours prior to discharge as her diet was
advanced, which she managed to good effect.
# Elevated alkaline phosphatase: Noted three days prior to
admission; GGT also elevated, suggesting a hepatic source. Cause
unclear, but thought to potentially be related to re-feeding.
Alk phos peaked in the low 200's on [**2155-8-31**], and decreased to
140 on [**2155-9-1**].
# Leukopenia: Stable for four days prior to discharge, thought
to be secondary to inflammatory/infectious processes. Would
recommend a repeat check one week after discharge.
Medications on Admission:
1. Bactrim DS 800-160 mg 1 Tablet PO BID x 10 days. Disp:*20
Tablet(s)
2. Aspirin 81 mg Tablet 1 Tablet PO DAILY
3. Levothyroxine 100 mcg 2 Tablet PO DAILY
4. Quinapril 20 mg 1 PO DAILY
5. Omeprazole 20 mg (E.C.) 1 PO DAILY
6. Hydrochlorothiazide 12.5 mg 1 PO DAILY
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times
a day) as needed for muscle spasm.
Disp:*1 month's supply* Refills:*0*
4. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*1 month's supply* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
6. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
7. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 13 days.
Disp:*52 Capsule(s)* Refills:*0*
8. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 3 doses.
Disp:*3 doses* Refills:*0*
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. Quinapril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Insulin Aspart 100 unit/mL Solution Sig: Take as directed
units Subcutaneous at bedtime.
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as
needed.
Disp:*30 Tablet(s)* Refills:*0*
13. Heparin flush
Please flush PICC with heparin and saline per NEHP protocol.
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
Diabetic foot ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a diabetic foot ulcer and pneumonia. You
were treated with Vancomycin and Levofloxacin, as well as pain
medications for your neuropathy. You need to complete three
additional doses of antibiotics, which will be supplied by a
visiting nurse.
You also had symptoms of volume overload, and are being sent
home on Lasix. You should weigh yourself immediately after using
the restroom each morning, and take one dose of Lasix 20mg if
your weight has increased >2 pounds above your baseline or if
you have increased lower extremity edema. Please discuss this
plan with your primary care physician.
Followup Instructions:
Please follow-up with your primary care physician as scheduled
below to address the issues raised during this hospitalization.
You should have a repeat CBC and alkaline phosphatase checked at
that time.
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: MONDAY [**2155-9-8**] at 10:30 AM
With: [**First Name8 (NamePattern2) 278**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Department: DERMATOLOGY
When: WEDNESDAY [**2156-7-21**] at 8:30 AM
With: [**Doctor Last Name 3833**] [**Telephone/Fax (1) 1971**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"250.83",
"536.3",
"682.7",
"682.6",
"486",
"357.2",
"276.2",
"V45.85",
"401.9",
"518.81",
"530.81",
"707.14",
"250.63",
"008.45",
"276.1",
"428.0",
"244.9",
"428.31",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
9877, 9883
|
4617, 8142
|
320, 326
|
9956, 9956
|
2401, 4337
|
10746, 11567
|
1495, 1559
|
8459, 9854
|
9904, 9935
|
8168, 8436
|
10106, 10723
|
4354, 4594
|
1574, 2382
|
275, 282
|
354, 1207
|
9971, 10082
|
1229, 1399
|
1415, 1479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,835
| 132,980
|
9157+56003
|
Discharge summary
|
report+addendum
|
Admission Date: [**2178-12-27**] Discharge Date: [**2179-1-1**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
[**Age over 90 **]M with afib on coumadin, CAD, CHF, who presented to the ED
after family became concerned for progressive lethargy and then
acute development of word finding difficulty. The pt's
granddaughter, who lives with him, called the PCP this evening
to say pt is very sleepy since this afternoon. does not
complaints about any other S/S but does not wish to wake up. He
has been increasingly groggy
over the past week but today is most pronounced. PCP thought it
might be side effect of remeron, which was recently started, so
recommended stopping remeron, but when patient became markedly
confused after awaking from a nap, family brought him to the ED
and Code Stroke was called for concern of aphasia.
In the ED, he was alert, speech production was similar to
baseline according to the family. Neurology/stroke team saw
patient but exam was nonfocal. Labs, however, were remarkable
for Hct 18 and INR 5.8. Pt received 2 units of PRBCs and vitamin
k 5mg IV. Nurse's notes do report an episode of melena. The
family refused foley placement, citing difficulty with voiding
upon removal of foley in the past. VS prior to transfer were
97.6, 134/40, 46, 16, 100% 2L.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
hematochezia, chest pain, shortness of breath, orthopnea, PND,
lower extremity oedema, [**Age over 90 **], urinary frequency, urgency,
dysuria, lightheadedness, gait unsteadiness, focal weakness,
vision changes, headache, rash or skin changes.
Past Medical History:
Hypertension
CAD: [**1-11**] stress-MIBI showing ischemic EKG changes in inferior
and lateral leads, medical management only
CHF: ischemic cardiomyopathy (mildly depressed EF 50-55%)
Upper GI Bleed, known h/o duodenal ulcer
Diverticulosis
Aspiration pneumonia [**10/2177**]
Hyperglycemia without diagnosis of DM, [**10/2177**] (on modified
diet)
Melanoma: s/p excision [**4-12**] & [**2174-10-3**] R posterior auricular
region, s/p XRT (last in [**12-14**]), concern for recurrence in [**3-14**]
but pt refused further w/u
Basal cell carcinoma: s/p excision on [**12-12**] & [**4-12**]
Anemia--baseline Hct 30, macrocytosis
Sacral Wound--punch biopsies done [**10/2177**], pending
Glaucoma
Venous insufficiency longstanding with frequent ulcers
Hearing impairment (left ear with hearing aid)
Irritable bowel syndrome
Macular degeneration
Bradycardia, HR 40's
Urinary retention/BPH-flomax/proscar, sees DR. [**Last Name (STitle) **]
Social History:
From [**Country 4754**], moved to states in [**2117**], lives with granddaughters
who assist with [**Name (NI) 4461**]; used to smoke x 20 years, quit 25 years
ago; denies EtOH or drugs. Used to work for [**Location (un) 86**] Gas company
Per OMR:
ADLS: Independent of dressing, ambulating with cane, hygiene,
eating, toileting
[**Location (un) **]: grand dtr - shopping, dtr- accounting, [**Name2 (NI) **] telephone
use, indepently makes breakfast and lunch. Gdtr takes care of
dinner.
No Dentures, L ear hearing Aides
Family History:
Brothers died of CAD. Positive for DM, htn. Sister died of
unknown cancer.
Physical Exam:
On Presentation:
Vitals: T 97 HR 55 BP 153/52 RR 17 SAt 100% RA
GEN: elderly white male, very HoH
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: irreg, III/VI holosystolic murmur at the apex, normal S1
S2, radial pulses +2
PULM: Lungs CTAB except some transmitted upper airway sounds, no
W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses. Guiaic positive stool
in vault.
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis. No ecchymoses. + Stasis dermatitis
of BLE, R > L.
.
Discharge:
TC 97.8 118/46 p49 R18 93RA
GEN: elderly male with thick Irish accent, non-toxic, NAD.
HEENT: eomi, mmm.
Neck: No elevated JVP.
RESP: Mild rales bases B. Some scattered rhonchi, improve with
several coughs. No egophony.
Abd: NT/ND
Ext: 1+ LE edema B. skin changes c/w chronic venous stasis.
Neuro: non-focal. alert. CN2-12 intact.
Pertinent Results:
EGD: [**2178-12-27**]
Esophagus:
-Lumen: A small size hiatal hernia was seen, displacing the
Z-line to 40cm from the incisors, with hiatal narrowing at 42cm
from the incisors.
Stomach:
-Mucosa: Patchy erythema, granularity and congestion of the
mucosa with no bleeding were noted in the antrum and fundus.
These findings are compatible with mild gastritis.
-Flat Lesions: A few small angioectasias that were not bleeding
were seen in the stomach body. [**Hospital1 **]-CAP Electrocautery was applied
for hemostasis successfully.
-Other: There was no blood seen in the stomach or duodenum.
-Duodenum: Normal duodenum.
IMPRESSIONS:
Small hiatal hernia
Angioectasias in the stomach body (thermal therapy)
Erythema, granularity and congestion in the antrum and fundus
compatible with gastritis
There was no blood seen in the stomach or duodenum.
Otherwise normal EGD to third part of the duodenum
.
CT HEAD:
No acute intracranial hemorrhage.
.
Cardiac echo:
The left atrium is dilated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
moderately thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-4-29**],
the degrees of tricuspid regurgitation and aortic stenosis have
increased slightly. The other findings are similar.
.
CXR [**12-29**]:
FINDINGS: In comparison with the earlier study of this date, the
cardiac
silhouette is somewhat more prominent, given that this
represents a PA rather than AP view. There is also increased
prominence and indistinctness of the pulmonary vessels,
consistent with elevated pulmonary venous pressure. No definite
acute pneumonia.
.
[**2178-12-27**] 01:43AM BLOOD WBC-4.0 RBC-1.96*# Hgb-5.7*# Hct-18.6*#
MCV-95 MCH-29.2 MCHC-30.7* RDW-15.4 Plt Ct-139*
[**2178-12-28**] 08:06PM BLOOD Hct-24.2*
[**2178-12-29**] 04:03AM BLOOD WBC-4.8 RBC-2.70* Hgb-7.8* Hct-25.3*
MCV-94 MCH-29.0 MCHC-30.9* RDW-17.3* Plt Ct-84*
[**2178-12-31**] 06:20AM BLOOD WBC-3.8* RBC-2.67* Hgb-7.7* Hct-25.3*
MCV-95 MCH-28.8 MCHC-30.4* RDW-16.6* Plt Ct-99*
[**2178-12-27**] 01:43AM BLOOD PT-46.9* PTT-43.2* INR(PT)-5.3*
[**2178-12-27**] 03:00AM BLOOD PT-50.6* PTT-44.5* INR(PT)-5.8*
[**2178-12-31**] 06:20AM BLOOD PT-14.8* PTT-30.5 INR(PT)-1.3*
[**2178-12-31**] 06:20AM BLOOD Glucose-106* UreaN-42* Creat-1.4* Na-142
K-4.8 Cl-105 HCO3-33* AnGap-9
[**2178-12-27**] 10:41AM BLOOD ALT-18 AST-21 CK(CPK)-49 AlkPhos-200*
TotBili-1.1
[**2178-12-27**] 01:43AM BLOOD cTropnT-0.07*
[**2178-12-27**] 10:41AM BLOOD CK-MB-3 cTropnT-0.07*
[**2178-12-31**] 06:20AM BLOOD Calcium-8.0* Phos-3.4 Mg-2.2
.
MRSA screen negative
Brief Hospital Course:
[**Age over 90 **] year old male with medical history pertinent for afib, CAD,
Chronic Diastolic CHF who presented with lethargy and GI Bleed.
.
#. GI Bleed, upper: Patient presented with Hct drop and melena
in setting of supratherapeutic INR. EGD revealing for
angiodysplasia although no stigmata of recent bleeding as well
as gastritis. Patient received 4U PRBC total, stable Hct without
additional transfusion, INR reversed on admission. Continued to
monitor patient throughout hospitalization, and H/H remained
stable. Patient was continued on PPI PO once daily. Patient
may restart aspirin 5 days post-bleed, ([**2179-1-1**]).
Per discussion with PCP, [**Name10 (NameIs) **] to restart coumadin 1 month
post-bleed as an outpatient. Patient will f/u with PCP prior to
resuming coumadin.
.
#. Lethargy/Altered Mental Status: Code stroke called in ED but
neuro exam non-focal at that time. Patient's lethargy improved
with management of GI bleed. ICU team deferred MRI given low
suspicion for stroke or TIA on presentation in setting of
supratherapeutic INR and alternative explanation. Although small
stroke not absolutely ruled out without MRI, management unlikey
to change at this time.
.
#. Afib with Bradycardia: Patient has known afib and per
discussion with her daughter has persistently had heart rates in
the 30s to 40s. Per ICU signout the patient was discussed with
EP with unofficial recommendation that PPM was not indicated if
patient asymptomatic. More importantly the patient was offered
PPM as an outpatient previously and declined this. Patients
declining of interventions seems to be in keeping with past
history including declining further evaluation of possible
recurrent melanoma in [**2174**].
Patient was monitored on telemetry, and no betablockers or
calcium channel blockers were given.
.
#. Hypoxemia:
On transfer out of the ICU, there was some concern that patient
may have a new oxygen requirement. Does have occas [**Year (4 digits) **], but
clinically not c/w bacterial pneumonia; possibly viral. This was
thought due to acute on chronic diastolic heart failure, and
patient was resumed on Lasix. Oxygen requirement was noted to
improve. Pt remained without fevers or SOB. His WBC was noted
to dip on [**12-31**]. Geriatrics recommended 7 days of guiafenasin
and encourage [**Month/Year (2) **]. Antibiotics were not provided, and
recommend outpt follow up.
.
#. Thrombocytopenia:
Patient was noted to have a thrombocytopenia, which began to
improve prior to discharge. No culprit medications were
identified, and patient was not receiving heparin products.
Recommend outpt follow up at next visit.
.
#. CAD, native vessel: Patient with indeterminant Trop x 2,
ruled out for MI during admission. No chest pain.
- hold Aspirin until [**2179-1-1**] as above
- no beta-blocker given bradycardia
- continue ACE and Statin
.
#. Acute on Chronic Diastolic CHF:
Patient's Lasix was initially held during admission, considering
GI bleed. Patient received 4 units of blood, and at time of
transfer from ICU to the floor, pt was noted to have mild oxygen
requirement and CXR c/w mild overload. Patient was resumed on
lasix with improvement.
- Lasix 20mg PO daily
- continue ACE
.
#. Hypertension, benign: Well controlled
- continue Lisinopril
.
#. Chronic Kidney Disease, Stage III: Stable
- stable
.
#. Anemia, acute blood loss: Improved s/p transfusion and
Endoscopy
- stable
.
#. BPH: Pt had been on Tamsulosin and Finasteride.
Per Geriatrics recs: will change to flomax 0.8 mg po qhs and
finasteride was discontinued d/t concerns for orthostasis.
Recommend follow up with patient's symptoms to ensure patient
does not retain urine on monotherapy.
- f/u with PCP and [**Name9 (PRE) **] as outpt
.
#. FEN - Regular; Consistency: Soft; Thin liquids
PPx: per Geriatrics recommendations, colace was changed to 100
mg po qam (instead of [**Hospital1 **]). If patient needs more softeners at
home, recommend change to 250 mg po q am.
.
#. Ppx - Pneumoboots, PPI
.
#. Code - DNR/DNI - Per Dr. [**Last Name (STitle) 31518**]: Code status was discussed
with patient and daughter [**Name (NI) **] at bedside. Patient was very clear
he would not want to be resuscitated. He is alert, oriented,
expressed understanding of what this implies and ramifications
of not resuscitating him during a code. The patient's daughter
reports she and her sister/HCP would like him full code and
tried to convince father of this, patient maintained his opinion
to remain DNR/DNI. I explained to patient's daughter that
despite her wishes, the patient has capacity to make this
decision and is very clear on his desire. I recommended to the
patient and his daughter that he and his daughters discuss this
together to make sure they are understanding of this as it is
concerning that the patient and his family (including HCP per
daughter's report) have wishes that differ from that of the
patient.
.
Dispo - to home with services. Recommended [**Hospital 1501**] rehab, however pt
declined.
HCP: Daughter [**Name (NI) 501**] [**Telephone/Fax (1) 31515**]
[**Name2 (NI) **]ter [**Name (NI) **]: [**Telephone/Fax (1) 31510**]
C- [**Telephone/Fax (1) 31511**]
Medications on Admission:
1. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
5. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
6. Imdur 30 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
7. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day:
8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
10. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day.
12. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Discharge Medications:
1. Docusate Sodium 100 mg Tablet Sig: One (1) Capsule PO once a
day.
2. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO at bedtime.
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Imiquimod 5 % Packet Sig: One (1) Packet Topical 5xWEEK ().
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin EC 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day for 7 days.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
# Gastrointestinal bleed, upper
# Anemia due to acute blood loss
# Altered mental status
# Atrial fibrillation with bradycardia
# Acute on chronic diastolic heart failure
# CAD, native vessel
# Hypertension, benign
# Chronic kidney disease, Stage III
# Benign prostatic hypertrophy
Discharge Condition:
Stable
Discharge Instructions:
Please take your medications as prescribed. Do not take your
coumadin until instructed to do so by your primary care
physician. [**Name10 (NameIs) 357**] seek medical attention if you develop fevers,
chills, worsened [**Name10 (NameIs) **], bloody stools, black tarry stools,
vomiting blood, lightheadedness, dizziness, increased fatigue,
or any other concerns.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2179-1-27**] 3:30
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**]
Date/Time:[**2179-4-8**] 1:00
.
Name: [**Known lastname 3567**],[**Known firstname 3206**] Unit No: [**Numeric Identifier 5433**]
Admission Date: [**2178-12-27**] Discharge Date: [**2179-1-1**]
Date of Birth: [**2088-1-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 128**]
Addendum:
Pt was intended to be discharged on evening of [**1-1**], however,
pt's daughter never came to pick up patient as planned. This
however provided additional opportunity to follow H/H; which
improved slightly overnight.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 136**] Homecare
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 131**] MD [**Last Name (un) 132**]
Completed by:[**2179-1-1**]
|
[
"428.0",
"585.3",
"790.92",
"428.33",
"427.31",
"600.01",
"287.5",
"414.01",
"285.1",
"414.8",
"459.81",
"E934.2",
"788.20",
"403.10",
"535.50",
"V10.82",
"427.89",
"V58.61",
"537.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"43.41"
] |
icd9pcs
|
[
[
[]
]
] |
16900, 17114
|
7883, 8699
|
271, 276
|
15533, 15542
|
4675, 5572
|
15954, 16877
|
3357, 3433
|
14066, 15126
|
15228, 15512
|
13079, 14043
|
15566, 15931
|
3448, 4656
|
223, 233
|
304, 1843
|
5581, 7860
|
8714, 13053
|
1865, 2799
|
2815, 3341
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,036
| 108,465
|
7723+55870+55871
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-18**]
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
bilateral claudication and rest pain
Major Surgical or Invasive Procedure:
[**2130-4-12**]: B femoral patch endarterectomy, B iliac stents (7
stents)
History of Present Illness:
This elderly lady well known to [**Month/Day/Year 1106**]/Dr. [**Last Name (STitle) **] and has
developed severe disabling claudication progressively worsening
to the point now where she will only walk a few steps without
pain and probably a mild ischemic
rest pain as well. She underwent an MRA because of renal
insufficiency which showed extensive iliac disease bilaterally.
There were high-grade stenoses at the origin of both common
iliac arteries and diffuse disease throughout
both external iliac arteries involving the common femoral
arteries as well with occlusion of her superficial femoral
arteries.
Past Medical History:
1. Coronary artery disease:
- s/p CABG [**2124**] (SVG to OM, SVG to PLV, SVG to LAD)
- Cardiac cath on [**12-13**] showed patent grafts
2. Peripheral [**Month/Year (2) 1106**] disease
3. Diabetes mellitus, type II
4. Hypertension
5. Chronic renal insufficiency (baseline creatinine 1.6-1.9)
6. s/p Right CEA
7. Macular degeneration
8. h/o GI bleed
9. s/p bladder suspension
Social History:
Lives alone. husband died 2 months ago. daughter lives nearby.
activity limited by severe PVD.
Tob: smoked for 30yrs; quit 15yrs ago
EtOH: none
Illicits: none
Family History:
NC
Physical Exam:
VSS: 99.1, 130/80, 86 94%RA
GEN: NAD
CARD: RR, [**2-7**] STEM
Lungs: [**Month/Day (4) **]
EXT: no edema, incisions c/d/i steri-strip
RT DP palp, PT dopp, LT DP/PT dopp
Pertinent Results:
[**2130-4-17**] 06:20AM BLOOD WBC-6.4 RBC-3.23* Hgb-9.5* Hct-27.8*
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.0 Plt Ct-136*
[**2130-4-17**] 06:20AM BLOOD Plt Ct-136*
[**2130-4-17**] 06:20AM BLOOD Glucose-106* UreaN-39* Creat-1.6* Na-138
K-4.3 Cl-103 HCO3-30 AnGap-9
[**2130-4-17**] 06:20AM BLOOD Calcium-7.8* Phos-2.6* Mg-2.6
Brief Hospital Course:
Underwent uneventful bilateral common femoral endarterectomies
and distal external iliac endarterectomies with Dacron patch
angioplasties and balloon angioplasty and stenting of both
common and external iliac arteries. Extubated in OR and
transferred to PACU. B/L DP/PT dopplerable. pain controlled. UO
at 22 cc/hr. BP 125/43, off nitro gtt.
POD1- Hypotension overnight BP 86/42 CVP 3-4. Fluid bolus given
with improvement in BP to 114/48. Second event of hypotension to
SBP 50 HCT 28.4. Received 2 units PRBCs. Non contrast CT
negative for retroperitoneal bleed. Hypertensive meds held.
Dopamine gtt started, 5% albumin given for support. Swan
catheter placed. Denies chest pain, abdominal pain. ECG WNL,
cardiac enzymes cycled. Cardiology consult obtained.
POD2-Intermittent hypotensive events, BP 69-110/32-47. Off
Dopamine. Troponins elevated, likely demand ischemia per
cardiology.
POD3-No overnight events. VSS On heparin gtt. RT DP palp, B/L
DP/PT dop
Cardiology following patient with acute MI:Troponin 0.23, peak
CK 154 with pos MB. Exam negative for CHF.
POD4- No overnight events. OOB to chair. diet advanced to
regular. PA cath discontinued.
POD5- VSS. No overnight events. Cr 1.6. Physical therapy
consulted. transferred from VICU to [**Wardname **] floor bed.
POD6- VSS. No overnight events. Physical therapy cleared for
discharge home with PT/home safety eval. Patient will follow up
with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] next week.
Medications on Admission:
ASA 81', Imdur 30', lisinopril 20", zestoril', metoprolol 50",
MVI' zocor 40, lantus 8hs with Humalog sliding scale
Discharge Medications:
1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Lantus 100 unit/mL Solution Sig: 8 units at bedtime
Subcutaneous at bedtime: Follow normal Humalog sliding scale
with meals.
9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
B/L claudication s/p B femoral patch endarterectomy, B iliac
stents (7 stents)
Elevated Troponin-demand ischemia
PMH: CAD, PVD, IDDM, CRI, HTN, macular degeneration, h/o GI
bleed
PSH: CABG '[**24**] x3, cardiac cath [**12-7**] shows patent grafts, R CEA
'[**27**], bladder suspension
Discharge Condition:
Good. VSS
Cr 1.6
Discharge Instructions:
Division of [**Year (2 digits) **] and Endovascular Surgery
Lower Extremity 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 [**2-4**]
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:
Call Dr.[**Initials (NamePattern4) 5695**] [**Last Name (NamePattern4) 28043**] at [**Telephone/Fax (1) 3121**] to schedule office
visit to be seen next week.
Call Dr. [**Last Name (STitle) **] (Cardiology) at ([**Telephone/Fax (1) 10085**] to schedule
office visit to be seen next week.
Completed by:[**2130-4-18**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 4892**]
Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-18**]
Date of Birth: [**2045-7-12**] Sex: F
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 1546**]
Addendum:
Patient discharged with prescription for Percocet for pain.
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2130-4-18**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 4892**]
Admission Date: [**2130-4-12**] Discharge Date: [**2130-4-18**]
Date of Birth: [**2045-7-12**] Sex: F
Service: SURGERY
Allergies:
Iodine
Attending:[**First Name3 (LF) 1546**]
Addendum:
Patient discharged on Dilaudid instead of Percocet per patient
request
Discharge Disposition:
Home With Service
Facility:
[**Company 720**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1548**] MD [**MD Number(1) 1549**]
Completed by:[**2130-4-18**]
|
[
"585.9",
"416.8",
"250.00",
"V58.67",
"V45.81",
"447.1",
"403.90",
"410.91",
"396.8",
"458.29",
"414.00",
"440.1",
"440.22",
"433.10"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.46",
"38.93",
"00.44",
"00.41",
"38.18"
] |
icd9pcs
|
[
[
[]
]
] |
9174, 9379
|
2107, 3587
|
250, 327
|
4930, 4949
|
1767, 2084
|
7799, 8515
|
1559, 1563
|
3753, 4529
|
4622, 4909
|
3613, 3730
|
4973, 7366
|
7392, 7776
|
1578, 1748
|
174, 212
|
355, 967
|
989, 1366
|
1382, 1543
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,882
| 126,543
|
3765+55504
|
Discharge summary
|
report+addendum
|
Admission Date: [**2195-6-11**] Discharge Date: [**2195-7-10**]
Date of Birth: [**2141-8-28**] Sex: M
Service: MEDICINE
Allergies:
Tylenol / Penicillins
Attending:[**First Name3 (LF) 6114**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy
Upper Endoscopy
Endoscopic ultrasound
History of Present Illness:
53 y/o M s/p self-inflicted gunshot injury to face in [**2187**] with
resulting tracheostomy, who presented to [**Hospital6 14576**]
in [**Location (un) 8973**] [**6-6**] c/o increased secretions from tracheostomy.
They were yellowish, and this had been going on x 3 weeks. He
reportedly didn't feel his breathing was worse than usual. He
denied fevers or chills. He had been seen in the ED one day
prior to this with the same complaint and was sent home with
Levaquin. He continued to require more frequent suctioning and
so returned to the OSH ED the next day. He also was having
coffee-grounds aspirate from G tube, and BRBPR. At that time, he
was afebrile, bp 140/80, RR 20, and O2 sat 95% on 40% trach
mask. He was felt to have bronchospasm, and begun on frequent
nebulizers, steroid taper, and IV levofloxacin. GI felt that his
GI bleeding was [**3-4**] gastritis and hemorrhoids. On HD1 at the
OSH, he was noted to be in resp distress and tube feeds were
suctioned from his lungs. His ABG was 7.22/78/64 and he was
transferred to the ICU. He was tachypneic in the 30s and c/o
respiratory fatigue so was placed on the vent in the early
morning [**6-7**]. In the ICU, his uncuffed trach was changed to a
cuffed trach with a fair amount of difficulty. He was placed on
PCV due to high peak pressures. He was emergently bronchoscoped
which revealed severe hemorrhagic bronchitis but was difficult
because the bronchoscope that was used was unable to suction. He
was changed to Zosyn upon arrival in the ICU, and was also
placed on flagyl when he developed a distended abdomen with a
lot of gas on the RUQ (CDiff pending). He also was begun on
vancomycin when staph grew from his sputum. He had a neck CT
done to evaluate the degree of his tracheal stenosis, which was
severe. At this point he was transferred to [**Hospital1 18**] for further
management of his tracheal stenosis, for IP procedure. In the
MICU patient initially put on ventilator and was switched to
trach mask the following day.
Past Medical History:
-bronchiectasis s/p R pneumonectomy [**2180**]
-seizure [**2182**] with anoxic encephalopathy
-gunshot wound to face [**2187**] requiring multiple facial
reconstructions, trach/G tube
-gastritis
-gastric ulcer
-esophagitis
Social History:
Lives with wife, from [**Name (NI) 6257**] originally.
Remote tobacco history. Denies etoh.
Family History:
Noncontributory
Physical Exam:
Upon transfer to the floor:
PE: T 96.3 HR 85 BP 135-164/80-87 RR 23 O2sat 100%
Gen: NAD, with trach mask
Heent: Disfigured mouth, PERRL, OP clear
Lungs: Upper airway sound b/L, diffuse rhonchi
Cardiac: RRR S1/S2 no murmurs
Abd: soft, distended, NABS, tender to palpation diffuse, no
guarding or rebound
Ext: no edema
Neuro: AAOx3
Pertinent Results:
Micro:
[**2195-7-7**] BLOOD CULTURE INPATIENT Pending
[**2195-7-6**] STOOL INPATIENT toxin A negative
[**2195-7-6**] BLOOD CULTURE INPATIENT Pending
[**2195-7-6**] URINE INPATIENT <10,000 organisms/ml
[**2195-7-6**] BLOOD CULTURE INPATIENT Pending
[**2195-7-2**] CATHETER TIP-IV INPATIENT no growth
[**2195-7-2**] BLOOD CULTURE INPATIENT no growth
[**2195-7-2**] SEROLOGY/BLOOD INPATIENT RPR nonreactive
[**2195-7-2**] BLOOD CULTURE INPATIENT no growth
[**2195-6-27**] BLOOD CULTURE INPATIENT no growth
[**2195-6-27**] BLOOD CULTURE INPATIENT no growth
[**2195-6-26**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) INPATIENT
Pending
[**2195-6-24**] SEROLOGY/BLOOD INPATIENT H. pylori Ab negative
[**2195-6-21**] BLOOD CULTURE INPATIENT no growth
[**2195-6-21**] BLOOD CULTURE INPATIENT no growth
[**2195-6-19**] BLOOD CULTURE INPATIENT no growth
[**2195-6-19**] BLOOD CULTURE INPATIENT no growth
[**2195-6-19**] STOOL INPATIENT toxin A negative
[**2195-6-15**] BRONCHOALVEOLAR LAVAGE INPATIENT
GRAM STAIN (Final [**2195-6-15**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
RESPIRATORY CULTURE (Final [**2195-6-19**]):
10,000-100,000 ORGANISMS/ML. OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
OF THREE COLONIAL MORPHOLOGIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN------------ =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
[**2195-6-13**] STOOL INPATIENT toxin A negative
[**2195-6-12**] STOOL INPATIENT toxin A negative
Pertinent reports:
[**2195-7-6**] Radiology CTA ABD PELVIS
IMPRESSION:
1) No new pseudoaneurysms identified.
2) No significant change in soft tissue mass surrounding the
hepatic artery branches, though the proper hepatic artery is now
somewhat attenuated when compared with the prior study, though
still patent.
3) Slightly decreased size of retrogastric soft tissue density.
[**2195-7-3**] Cardiology STRESS INTERPRETATION: 53 year old male with
IDDM and vascular aneurysms presents to the laboratory for
evaluation of coronary artery disease. The patient received
0.142 mg/kg/min of dipyridamole over three minutes. No anginal
symptoms were reported by the patient. The dipyridamole was
reversed with 125 mg of amiophylline IV. No significant ST
segment changes during the procedure. Rhythm was sinus with rare
APBs.
Hemodynamic response was appropriate. IMPRESSION: No ischemic
ECG changes or anginal symptoms. Nuclear report sent separately.
[**2195-7-3**] Radiology PERSANTINE MIBI
IMPRESSION: 1.Normal myocardial perfusion study. 2. Normal left
ventricular
size and function.
[**2195-7-2**] Cardiology ECG Sinus rhythm Poor R wave progression -
is nonspecific and may be within normal limits but clinical
correlation is suggested Since previous tracing of [**2195-6-24**], no
significant change
[**2195-7-2**] Cardiology ECHO Conclusions:
No spontaneous echo contrast or thrombus is seen in the body of
the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. A small, mobile echodensity (about 5 mm) is attached
to a catheter seen in the right atrium (probable thrombus). No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve leaflets are structurally normal. No
mass or vegetation is seen on the mitral valve. No mitral
regurgitation is seen. There is no pericardial effusion.
Impression: 1. No cardiac source for systemic embolization
seen. 2. A small, mobile echodensity is seen on the tip of a
catheter in the right atrium. This likely represents a small
catheter-associated thrombus.
[**2195-7-2**] Radiology CHEST (PORTABLE AP) IMPRESSION:
1) Right subclavian central venous catheter is seen with the tip
extending into the right IJ, beyond the image margin. The
results were discussed with Dr. [**Last Name (STitle) **] at 10:15 a.m. on
[**2195-7-3**].
2) Stable post pneumonectomy changes are again noted.
[**2195-7-1**] EGD/EUS
Impression: Abnormal splenic artery
At the level of the celiac axis a 17x17mm soft tissue mass
identified
Normal pancreas, CBD and PD.
Using the radial and linear echoendoscopes the pancreas,
mesenteric vessels and surrounding structures were examined in
real time. The celiac axis was identified and the proximal take
off appeared normal. Splenic artery however had markedly
thickened walls with pronounced peri-arterial soft tissue and
possible small thrombus. The pancreatic head, body and tail
appeared normal and the CBD and PD were also normal without
dilatation or filling defects. At the level of the celiac axis
take-off a soft tissue mass 17 x 17 mm was identified. This may
relate to a lymph node. It was irregular in outline with a tiny
cystic component but otherwise solid throughout. It was 4 mm
from the celiac axis on EUS.
[**2195-6-30**] Cardiology ECHO Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall
motion abnormality cannot be fully excluded. Overall systolic
function is
mild-moderately depressed (LVEF ~35%). The right ventricular
cavity size is normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
There is no pericardial effusion. If clinically indicated, a
radionuclide study may be better able to define biventricular
systolic function.
[**2195-6-30**] Radiology CTA ABD PELVIS IMPRESSION:
1) Interval presumed thrombosis of the previously noted
aneurysms nvolving the splenic artery and hepatic arteries, with
stable gastroduodenal artery aneurysm and 2 new tiny
intrahepatic aneurysms within the right lobe. No evidence of
arterial occlusion. Stable peri-arterial soft tissue densities
as described.
2) New infarcts within the left kidney as described. Given the
normal renal arteries, this raises the possibility of embolic
etiology, for example, from a cardiac source. Clinical
correlation is advised.
3) Stable retrogastric soft tissue density.
[**2195-6-26**] Cardiology ECG Sinus rhythm. Since the previous tracing
of [**2195-6-26**] the rate has slowed and atrial ectopy is no longer
seen. The tracing is now normal.
[**2195-6-26**] Cardiology ECG Sinus tachycardia with premature
supraventricular beats. Compared to the previous tracing of
[**2195-6-23**] premature beats are now present.
[**2195-6-25**] Radiology CTA ABD PELVIS
CTA Abdomen [**6-25**]: The patient is status post right pneumonectomy
with an unchanged appearance. The left lung base is clear. The
liver and gallbladder appear normal. The pancreas appears
normal. However, adjacent to the pancreas, in the lesser sac,
but not definitely associated with either the stomach or the
pancreas, is an area of soft tissue density with minimal if any
enhancement of unclear etiology. The spleen has a similar
appearance with an area of peripheral hypodensity likely
representing an infarct. The kidneys and adrenal glands are
within normal limits. The appearance of the gastrostomy tube in
the stomach and the small and large bowel are within normal
limits. There is no retroperitoneal or mesenteric
lymphadenopathy or free fluid. Again noted on the arterial phase
images is extensive wall thickening of the entire celiac axis
with multiple regions of contrast collection which may represent
ulcerations into the surrounding soft tissue density. The
appearance is not significantly changed since the prior study.
The splenic artery may be somewhat stenotic as before but is
opacified. More inferior images are available on this CT and
these demonstrate a separate small focus over about 1 cm of
mural thickening of a major branch of the superior mesenteric
artery, although contrast again appears to pass distally. The
major mesenteric veins appear open. IMPRESSION: Vascular
process involving the celiac axis and its branches (Splenic,
hepatic to intrahepatic branches and GDA) and at least one right
branch (ileocolic) of the SMA, associated with splenic infarct
and soft tissue retrogastric density. These findings are new,
developed after [**6-14**]. Mural hematoma vs dissection is
considered. Focal gastric perforation with secondary vascular
changes is less likely. Finally pancreatitis is unlikely due to
otherwise normal pancreas.
[**2195-6-23**] Cardiology ECG Sinus tachycardia
Normal for tracing except for rate
Since previous tracing of [**2195-6-22**], no atrial premature complex
[**2195-6-23**] EGD
Impression: Erosion in the stomach body (opposite the peg tube)
PEG tube noted in body
Otherwise normal egd to second part of the duodenum
Recommendations: PPI therapy
Serological H pylori testing. Treat if positive
[**2195-6-23**] Radiology CTA CHEST IMPRESSION:
1) Status post right pneumonectomy.
2) No evidence of pulmonary embolism.
3) Patchy parenchymal densities in the left lung, suggesting
atypical pneumonia or inflammatory changes.
4) New peripancreatic fluid, raising a question of pancreatitis.
5) EXTENSIVE Soft tissue density or edema tracking along the
entire celiac axis, and ivolving the hepatic artery, including
the intrahepatic branches and the splenic artery. Although this
appearance could represent sequelae of pancreatitis, a primary
vasculitis is felt more likely.
6) New splenic infarct.
[**2195-6-22**] Cardiology ECG Sinus tachycardia. Atrial premature
beats. Probable right atrial abnormality. Since the previous
tracing of [**2189-4-6**] atrial ectopy is present and the sinus
tachycardia rate has increased.
[**2195-6-20**] Radiology CHEST (PORTABLE AP) PORTABLE CHEST:
Comparison is made to prior film dated [**2195-6-16**]. Previously
noted PICC catheter and tracheostomy tube remain in place,
without significant change. Changes of prior right pneumonectomy
are again identified. There is associated rightward shift of
midline structures. There is stable pleural based density in the
left apex. No acute changes are seen within the parenchyma of
the left lung. IMPRESSION: No acute change.
[**2195-6-19**] Radiology ABDOMEN (SUPINE ONLY) IMPRESSION: No evidence
of bowel obstruction or significant ileus.
[**2195-6-16**] Radiology CHEST (PORTABLE AP) IMPRESSION: PICC tip in
the lower SVC.
[**2195-6-14**] Radiology CT ABDOMEN PELVIS
CT abdomen/pelvis [**2195-6-14**]:IMPRESSION:
1) No CT evidence of colitis or other intraabdominal source for
the patient's abdominal pain.
2) Pulmonary parenchymal opacity within the left lower lobe,
raising the question of aspiration or other
infectious/inflammatory processes in this patient status post
right-sided pneumonectomy.
Rigid [**Last Name (un) **] Findings [**2195-6-15**]:
The right side was absent surgically. The stoma seems to be very
clean. The left main stem was patent. The left lower lobe showed
evidence of some very thick, greenish mucous secretions.
Bronchoalveolar lavage was done at that side. At that moment, a
rigid bronchoscope was retrieved to the subglottic area. Under
direct visualization, tumor excision with the use microdebrider
was done to the granulation tissue. At that moment, a 6 Portex,
cuffless, nonfenestrated tracheostomy was placed under direct
visualization. There were no complications. The patient
tolerated the procedure well, and he was transferred to
recovery.
[**2195-6-12**] Radiology CHEST (PORTABLE AP) IMPRESSION:
Status post right pneumonectomy. Suggestion of bronchiectasis at
the left lung base. No pneumonia
[**2195-6-12**] Radiology ABDOMEN (SUPINE ONLY) IMPRESSION: No evidence
of obstruction and no free air. Prominent loop of large bowel in
the right mid/upper abdomen, which appears to represent a
prominent cecum. If clinical symptoms continue, repeat KUB or CT
may be helpful.
Pertinent labs:
[**2195-7-9**] 06:16AM BLOOD WBC-11.0 RBC-4.05* Hgb-12.3* Hct-36.9*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.1 Plt Ct-400
[**2195-6-12**] 12:56AM BLOOD WBC-9.8# RBC-4.72# Hgb-14.4# Hct-43.6#
MCV-92 MCH-30.6 MCHC-33.1 RDW-12.3 Plt Ct-181
[**2195-6-12**] 12:56AM BLOOD Neuts-90.0* Lymphs-6.2* Monos-3.7 Eos-0.1
Baso-0
[**2195-7-6**] 01:03PM BLOOD Neuts-90.8* Lymphs-5.4* Monos-3.7 Eos-0
Baso-0.1
[**2195-7-7**] 06:01AM BLOOD PT-13.4* PTT-89.6* INR(PT)-1.2
[**2195-6-24**] 05:45AM BLOOD ESR-65*
[**2195-6-29**] 08:42AM BLOOD ESR-60*
[**2195-6-12**] 12:56AM BLOOD Glucose-89 UreaN-24* Creat-0.6 Na-141
K-4.3 Cl-101 HCO3-35* AnGap-9
[**2195-7-9**] 06:16AM BLOOD Glucose-112* UreaN-21* Creat-0.5 Na-137
K-3.9 Cl-98 HCO3-34* AnGap-9
[**2195-6-12**] 12:56AM BLOOD ALT-32 AST-32 AlkPhos-48 Amylase-72
TotBili-0.6
[**2195-6-24**] 05:45AM BLOOD ALT-22 AST-16 LD(LDH)-255* AlkPhos-76
Amylase-56 TotBili-0.6
[**2195-6-12**] 12:56AM BLOOD Calcium-8.3* Phos-3.9# Mg-2.1
[**2195-7-9**] 06:16AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.9
[**2195-6-19**] 04:47AM BLOOD Albumin-3.5
[**2195-7-2**] 06:06AM BLOOD Cryoglb-NO CRYOGLO
[**2195-6-26**] 05:48AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2195-6-24**] 05:45AM BLOOD ANCA-NEGATIVE B
[**2195-7-1**] 06:19AM BLOOD PSA-4.8*
[**2195-6-29**] 08:42AM BLOOD CRP-3.46*
[**2195-6-26**] 05:48AM BLOOD [**Doctor First Name **]-NEGATIVE
[**2195-6-26**] 05:48AM BLOOD RheuFac-5
[**2195-6-26**] 05:48AM BLOOD C3-164 C4-49*
[**2195-7-9**] 11:57AM BLOOD HIV Ab-PND
[**2195-7-8**] 10:14PM BLOOD Vanco-10.7*
[**2195-6-19**] 10:00PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2195-6-19**] 10:00PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
[**2195-7-6**] 06:15PM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.050*
[**2195-7-6**] 06:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
Brief Hospital Course:
## Tracheal Stenosis: Based on CT results patient has severe
tracheal stenosis. Patient underwent rigid bronch with excision
of granulation tissue and change of cuff. No residual problems
throughout rest of hospital course.
.
## Hemoptysis: Pt initially transferred to [**Hospital1 18**] MICU. Had rigid
bronch to assess tracheomalacia. HD stable and weaned off vent.
He was transferred to the floor [**6-12**]. On the night of [**6-13**], he
began to have episodes of hemoptysis, necessitating emergent
[**Last Name (un) 1066**] and transfer back to the MICU. Bronch revealed that pt was
bleeding from granulation tissue on upper stoma. Anticoagulation
was stopped and his bleeding resolved. Pt was HD stable and was
transferred back to the floor for further management. While on
floor patient continued to have minimal bleeding from trach and
bronch was performed again and trach cuff was changed. No
further bleeding from trach site.
.
## Respiratory Failure: Initially on transfer patient felt to
possbily have aspiration PNA. In the ICU he was kept on a
ventilator overnight and was quickly extubated the following day
put on trach mask. Patient continued to have many secretions so
given 7 day course of Zosyn which was completed in the hospital.
The OSH reported that sputum aspirate showed MRSA and patient
was started on IV vanco. Patient underwent BAL during fisrt
bronch which came back possitive for MRSA which was consistant
with results from OSH. Treated with IV vancomycin total 14 days.
Once on floor, secretions decreased, had no further episodes of
respiratory distress.
.
## Abdominal Pain - While in the ICU, patient complained of
abdominal pain. A KUB was done which came back normal. When
transferred to the floor patient still had abdominal pain so
underwent a CT abdomen which was negative. Patient was started
on Flagyl for presumed C diff which was stopped after 4 days
when patient's diarrhea and abdominal pain resolved and first
set on C. diff toxin came back negative. After a few days being
pain free, diarrhea and abdominal pain returned along with
increased WBC. Patient was started on PO vancomycin for C. diff
colitis. Another set of C. diff toxins were sent which again
came back negative however felt that 14 day PO vancomycin course
should be completed. Patients abdominal pain and diarrhea
resolved. Patient put on PPI [**Hospital1 **]. GI saw patient in ICU for
blood in PEG, which was felt to be secondary to hemoptysis.
While on the floor patient found to have blood mixed with tube
feeds (bright red, no clots); Hct stable but EGD was done to
rule out active bleeding. EGD showed no active bleeding and
mild gastritis opposite PEG site. On CTA of abdomen to further
eval the multiple aneurysms discovered on CTA chest, a
retrogastric mass as well as a splenic infart was found, which
was thought to possibly be the cause of the patient's pain. The
pain resolved over 2d after transfer to the floor.
.
## Abdominal aneurysms - On a chest CTA done to r/o PE, multiple
abdominal aneurysms were seen along celiac trunk, and a 2x2cm
retrogastric mass was noted. Patient had CTA abdomen which
revealed what appears to be a vasculitis picture affecting the
hepatic artery, splenic artery, gastroduodenal artery, with
multiple aneurysms. Rheumatology was consulted and sent HepB and
HepC, Rh factor, complement, [**Doctor First Name **]. Rh factor and C3, C4 WNL.
Patient ESR slightly elevated and ANCA neagative. Consulted GI
who performed EUS with intention of getting FNA of soft tissue
mass, but given proximity (4mm away) of celiac artery this was
deferred. Vascular was also consulted who felt aneurysms were
likely infectious in etiology given the rapid time course of
onset, as they were not seen on the abd CT [**2195-6-14**]. ID felt
that there was unlikely to be an infectious cause of the
aneurysms. Multiple mycotic and bacterial blood cultures were
sent with no growth. Patient also had a TTE and then TEE to r/o
embolic cause of splenic and renal infarct, especially as there
was no aneursym or thrombosis proximal to the L kidney which had
an infarct. A 4mm clot vs. bacterial growth was found off the
end of the pt's PICC line, which was subsequently removed and
cultured without growth. Double lumen PICC placed thereafter.
.
A second CTA of abd/pelv showed thromboses of aneurysms, two new
small intrahepatic aneurysms, new renal infarcts. Steroids were
started in case of PAN or similar vasculitis, and repeat CTA
(#3) showed stabilization/improvement of the aneurysms. Vasc rec
no anticoag, cont abx x 6 week course, f/u CTA and clinic appt
in 6 mths. Rheum recommended high dose prednisone, f/u CTA in 2
wks and appt with Dr. [**First Name4 (NamePattern1) 16931**] [**Last Name (NamePattern1) 16932**] in 3 weeks, as well as
Bactrim, calcium, Vit D, Fosamax, HIV test which is pending.
Presumptive diagnosis is vasculitis, likely PAN however
consensus among multiple consultants was that empiric six weeks
of antibiotics given the lack of biospy proven diagnosis and the
rare chance of an infectious etiology which could prove fatal if
treated with steroids alone.
.
## Retrogastric mass - Was initially 17mm x 17mm per EUS. FNA
was felt to be too risky given proximity to celiac axis. Gen
[**Doctor First Name **] was consulted for possible lap bx. Pt had repeat CTA after
abx/steroids that showed mass had shrunk. Gen [**Doctor First Name **] holding off
on lap bx at this time, want to re-evaluate mass by CT in 2
weeks
.
## Sinus tachycardia - After patient returned to floor from ICU
for the second time he was found to be tachycardic. Felt that
tachycardia was due to aggressive albuterol nebulizer
treatments. A CTA of the chest was done to make sure
tachycardia was not secondary to pulmonary embolism, which was
ruled out. Tachycardia went away after nebs decreased.
.
## Depression - maintained on Zoloft, mood fluctuated but was
overall appropriate
.
## Diarrhea - while on abx and steroids near the end of
hospitalization for vasculitis, developed multiple loose stools
with no pain but increased WBC count that seemed to far out from
initiation of steroids to be from demargination; had no fever; C
diff toxin A negative, toxin B sent but still pending; did not
restart Flagyl or PO Vanc; likely from abx themselves, with WBC
elev from steroids.
His diarrhea improved spontaneously.
Medications on Admission:
prevacid 30 mg per G tube [**Hospital1 **]
Sucralfate 1 mg per G tube 4x/day
zoloft 50 mg daily
albuterol 25 mg with atrovent [**Age over 90 **]m g nebs q4hours
decadron 10 IV bid
xopenex neb 0.63 mg tid
colace
zosyn 3.37 g IV q8h (day 1= [**6-7**])
Humulin sliding scale
reglan 10 mg IV q8h
flagyl 500 mg IV q8h (day 1= [**6-10**])
vancomycin 1 gm IV q12h (day 1= [**6-11**])
versed 2-4 mg IV q1h
Discharge Medications:
1. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-1**]
Puffs Inhalation every six (6) hours.
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
6. Flovent 44 mcg/Actuation Aerosol Sig: Two (2) Inhalation
twice a day.
7. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1)
injection Intravenous Q24H (every 24 hours) for 27 days.
8. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1)
injection Intravenous Q 12H (Every 12 Hours) for 27 days.
9. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
10. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): continue at current dose until pt sees Rheumatologist
on [**2195-7-29**].
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): per sliding scale,
while on steroids.
12. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig:
Thirty (30) mg PO DAILY (Daily).
13. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
QDAY ().
14. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. Alendronate Sodium 10 mg Tablet Sig: One (1) Tablet PO QSAT
(every Saturday).
16. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day:
cont while on steroids.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] Rehab
Discharge Diagnosis:
Respiratory Failure
Tracheal stenosis
MRSA pneumonia
Abdominal aneurysms: hepatic, splenic, gastroduodenal arteries
Associated arterial thromboses
Splenic and renal infarcts
Retrogastric mass of unclear etiology
PICC line clot
C diff colitis
Depression
Discharge Condition:
Patient breathing well on trach mask, hemodynamically stable, no
abdominal or chest pain, no shortness of breath
Discharge Instructions:
Please continue to take all medications as directed and follow
up with your doctors. Inform your doctors if [**Name5 (PTitle) **] have bleeding
from trach site, abdominal pain, chest pain, shortness of
breath, increased secretions or any other concerning symptoms.
Followup Instructions:
Please follow up with the following appointments:
1. Please have the following lab values checked each week for
the next 6 weeks while you are at the rehab facility: CBC, Chem
10, Vanc trough. You should have a physician view the results
each week and adjust your medications accordingly.
2. You have a repeat CT scan of your abdomen scheduled as well.
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2195-7-24**] 9:00
3. You have the following Rheumatology appt scheduled:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 16933**]
Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2195-7-29**] 11:00
4. Vascular Surgery follow up: please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
office in the next several days to set up a follow up
appointment after your CT scan. Her office # is [**Telephone/Fax (1) 2395**].
Name: [**Known lastname 2687**],[**Known firstname **] Unit No: [**Numeric Identifier 2688**]
Admission Date: [**2195-6-11**] Discharge Date: [**2195-7-10**]
Date of Birth: [**2141-8-28**] Sex: M
Service: MEDICINE
Allergies:
Tylenol / Penicillins
Attending:[**First Name3 (LF) 1513**]
Addendum:
Update:
[**First Name3 (LF) **] Surgery follow up: Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) 798**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 282**]
SURGERY Where: [**Last Name (NamePattern4) 282**] SURGERY Date/Time:[**2195-8-19**] 1:15pm
Alendronate 10mg po qd (not qweek as originally written)
Discharge Disposition:
Extended Care
Facility:
[**Hospital 2653**] Rehab
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1514**] MD [**MD Number(2) 1515**]
Completed by:[**2195-7-10**]
|
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"427.89",
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] |
icd9cm
|
[
[
[]
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[
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"33.21",
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icd9pcs
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[
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29040, 29249
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18117, 24493
|
302, 361
|
26939, 27053
|
3144, 16159
|
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2762, 2779
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|
24519, 24919
|
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|
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|
243, 264
|
389, 2390
|
16175, 18094
|
2412, 2637
|
2653, 2746
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,750
| 188,700
|
2080
|
Discharge summary
|
report
|
Admission Date: [**2141-5-1**] Discharge Date: [**2141-5-5**]
Date of Birth: [**2097-12-5**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Latex
Attending:[**First Name3 (LF) 11291**]
Chief Complaint:
?seizure / agitation
Major Surgical or Invasive Procedure:
intubation and extubation
History of Present Illness:
[**Known firstname 6423**] is a 43 yo F with history of epileptic and
nonepileptic seizures who presents today with behavioral
decompensation and possibly more seizures. Her developmental
director who visits her several times a week helps relay the
story. Patient lives alone and was taken to her therapist's
office in [**Hospital1 **]. While in therapy she began smacking her head
against the wall repeatedly and was inconsolable, she fell to
the
floor but did not loose consciousness. They told her she needed
to come to the hospital for psychiatric evaluation. While in a
taxi she was reportedly communicative but upon arrival she had
an
episode of generalized body shaking that lasted reportedly 5
minutes. While in the ED she was reportedly very vocal and
combative with staff, while she was in the CT scanner she
reportedly turned "blue" and was apnic and had an arched back,
eyes rolled back, and generalized shaking for less than a
minute.
There was incontinence associated with this incident. She was
very combative after requiring a total of 15 mg of haldol, 4 mg
of lorazepam, and had to be intubated for agitation. Unclear if
she missed any doses of her medications. She recently had a
cold
which may have also been a trigger for a potential event.
Past Medical History:
1) Symptomatic generalized epilepsy and nonepileptic psychogenic
events- currently followed by Dr. [**First Name (STitle) **]. Has received care
also
for a period of time at [**Hospital1 756**] Woman's Hospital.
EVENTS: (described in Dr.[**Name (NI) 7029**] previous notes)
Type 1: Aura
Aura: flashing colors, some lightheadness
Ictal: no LOC or confusion, wax and wane over several minutes,
may last up to full day
TB/incont: None
Postictal: none
First: unclear
Frequency: once a month
Precipitants: none
Type 2: Nonepileptic psychogenic events (probable almost all)
Aura: nausea, sometimes preceded by colors as above.
Ictal: generalized shaking, loss of awareness, falls to ground
sometimes.
TB/incont: none
Postictal: sleepy, may nap for 1-2 hours
First: unclear
Frequency: 2-3 per week (increased)
Precipitants: stress, but recently occur without stress
Type 3: Generalized tonic-clonic
Aura: nausea, sometimes preceded by colors as above.
Ictal: generalized shaking, loss of awareness, falls to ground
sometimes.
TB/incont: none
Postictal: sleepy, may nap for 1-2 hours
First: unclear
Frequency: 2-3 per week
Precipitants: none; difficult to distinguish from [**Last Name (un) **].
Type 4. Undetermined, probably nonepileptic
Aura: None
Ictal: Staring / spacing, lasts 1 min. Sometimes has twitching
of limbs during these.
TB/incont: none
Postictal: Confused
First: Unclear
Frequency: Now occur daily.
Precipitants: None
Type 5. Stress related, tingling in the body, lasts [**3-20**]
minutes.
No loss of consciousness or confusion
AED HISTORY: She had been treated for a long time with Depakote
which was discontinued at some point over the past year, and
Lamictal was added to her Zonegran. She has also stopped
Lamictal for unclear reasons.
PREVIOUS EEGS:
1) She underwent video-EEG monitoring at [**Hospital6 8866**], which showed nonepileptic events.
2) There are numerous VEEGs since [**2124**] that have all captured
various pushbuttons that have not have epileptiform correlate.
She has had spehnoidal electrodes in the past.
3) There is an EEG in [**2126**] that is abnormal EEG in the waking
and
drowsy states due to the prominent bursts of generalized theta
slowing which can be a non-specific abnormality.
4) There are several EEGs which show characteristics of mild
encephalopathy.
2) Mild developmental delay/static encephalopathy.
3) migraine headaches
4) chronic back pain.
5) chronic right knee pain.
6) right adnexal cyst.
7) mild to moderate obstructive sleep apnea, but does not use
CPAP.
8) History of depression and anxiety, followed by Dr. [**Last Name (STitle) 6496**].
Past Surgical History:
1) left eye surgery for exotropia as a child
2) left knee surgery in [**2135**].
3) repair of an umbilicus hernia.
Social History:
She is currently living in an appartment building. She
completed
high school. She is now living in appartments at [**Location (un) 11292**] [**Location (un) 745**].
She does not have any roommates. She has an attendant for most
of
the evening hours who helps with cleaning, bills, preparing
meals
and with medication preparation. [**Known firstname 6423**] is not supervised with
taking her medications.
She is currently working 6 hours per day 3 days per week, at
project triangle. Her current tasks are to roll wires for
[**Company 11293**]
cable.
She denies cigarette smoking, alcohol use, drug use.
She does not drive.
She has a cane but her director reports that she has never seen
her use it and mostly keeps it on her elbow.
Family History:
There is no history of seizures or epilepsy.
Physical Exam:
On admission:
Temp: 98.8 HR: 111 BP: 118/65 Resp: 18 O(2)Sat: 96 Normal
General: intubated, with paralytics
HEENT: lump on left occiput .
Chest: Clear to auscultation
Cardiovascular: +S, S2, rrr, no murmur
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, + pulses Complaining
of pain with movement of right knee. There is large ecchymosis
over right fibular head.
Skin: No rash. There are multiple ecchymosis over varying
staged
over body.
Neurological exam:
Mental Status: intubated, sedated with paralytics, grimaces to
pain, does not open her eyes to noxious
Cranial nerves: PERRL, +dolls, +gag, + corneals
Motor/ sensory: Normal tone. withdrew to noxious in all 4
extremities
Reflexes, contracting and agitated, but toes were down
On transfer out of ICU:
Drowsy, arousable to voice. Speaks in phrases - typically "No, I
don't want to", agitated. Follows commands. Moves all
extremities with what appears full strength but then often has
functional findings on formal testing. Reacts to light touch
throughout. Pupils asymmetric, R > L by 0.5-1mm, both reactive.
No nystagmus.
Pertinent Results:
[**2141-5-1**] 06:13PM WBC-11.9* RBC-4.41 HGB-12.9 HCT-40.7 MCV-92
MCH-29.3 MCHC-31.8 RDW-13.2
[**2141-5-1**] 06:13PM NEUTS-81.4* LYMPHS-14.6* MONOS-2.5 EOS-1.2
BASOS-0.2
[**2141-5-1**] 06:13PM PLT COUNT-328
[**2141-5-1**] 06:13PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2141-5-1**] 06:13PM GLUCOSE-126* UREA N-16 CREAT-1.1 SODIUM-139
POTASSIUM-7.2* CHLORIDE-105 TOTAL CO2-18* ANION GAP-23*
[**2141-5-1**] 06:33PM URINE RBC-5* WBC-22* BACTERIA-NONE YEAST-NONE
EPI-18 TRANS EPI-2
[**2141-5-1**] 06:33PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-6.5 LEUK-MOD
[**2141-5-1**] 06:33PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.018
[**2141-5-1**] 06:33PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
NCHCT:
IMPRESSION:
No acute intracranial process.
PORTABLE AP CHEST RADIOGRAPH: The ET tube is 3.9 cm above the
carina.
Feeding tube passes below the diaphragm with side port within
the expected
region of the stomach and tip not clearly visualized in the
field of view
provided. Bilateral low lung volumes are noted with crowding of
bronchovascular markings. No focal consolidation, pleural
effusion or
pneumothorax is noted. Cardiomediastinal and hilar contours are
unchanged.
Brief Hospital Course:
Ms. [**Known lastname **] was initially admitted to the ICU as she needed
intubation in the emergency room after receiving ativan and
haldol
She was extubated without complications 8 hours later, and
transferred to the regular floor the next day.
Neuro/psych:
We did not make any medication changes. She had one of her usual
events on [**2141-5-4**], which consisted of agitation and her bumping
her head against her pillow. An EEG done on [**2141-5-4**] did not
show any epileptiform abnormalities (done before her episode).
She was seen by psychiatry who did not have any further
recommendations regarding her non-epileptic events.
ID:
She had an elevated white count on [**2141-5-3**]. Her urine analysis
was positive but the urine culture showed no growth. She had
been on bactrim but given the elevated white count she was
switched to ceftriaxone on [**2141-5-4**] with a plan to treat for a
presumed UTI. Her white count improved on [**2141-5-5**].
Renal:
Her CK was elevated to 700's initially, most likely due to her
combattive behavior. We checked it daily and it trended down.
Her renal function remained normal.
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - 2 puffs po q
[**4-21**]
as needed for cough
AZELASTINE - 137 mcg (0.1 %) Aerosol, Spray - 2 spray each
nostril twice a day as needed for post nasal drip
FLUOXETINE - 40 mg Capsule - two Capsule(s) by mouth in the
morning
FLUTICASONE - 50 mcg Spray, Suspension - 2 spray each nostril
daily daily
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs
qd once a day with spacer
INHALATIONAL SPACING DEVICE - Spacer - Use as directed with
Flovent and albuterol inhalers
INVACARE AT'M POWER CHAIR - - use as directed
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - one
Tablet(s) by mouth once a day
ZONISAMIDE - 100 mg Capsule - 1 Capsule(s) by mouth in the
morning, 3 capsules at night
Medications - OTC
ASPIRIN [[**Doctor Last Name **] ASPIRIN] - (Prescribed by Other Provider) - 325
mg Tablet - 2 Tablet(s) by mouth at night as needed for pain
CALCIUM CARBONATE [CALCIUM ANTACID] - (Not Taking as
Prescribed:
didn't restart, told to do so) - 500 mg Tablet, Chewable - 1
Tablet(s) by mouth twice a day
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - 1,000 unit Capsule -
1 Capsule(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) (Not Taking as
Prescribed: stopped a while ago, doesn't know if should be
taking) - Dosage uncertain
MULTIVITAMIN - (OTC) (Not Taking as Prescribed: not consistent,
forgets dose) - Tablet - 1 Tablet(s) by mouth once daily
WALKER - (Prescribed by Other Provider; Dose adjustment - no
new
Rx) - Misc - used at home as needed as needed for for
imblance
WHEELCHAIR - Device - use as directed daily
Discharge Disposition:
Home
Discharge Diagnosis:
Non-epileptic events
Discharge Condition:
Condition: Good
Mental status: alert and oriented
Ambulatory: independent.
Discharge Instructions:
Ms. [**Known lastname **],
You were admitted after you had an episode concerning for a
seizure. You had to receive medications to calm down your
agitation, and because of that, you required some help with your
breathing and therefore you were intubated and taken to the ICU.
The tube was taken out without complications and you were
transferred to the neurology floor.
Your CT scan was negative. We also obtained an EEG and it did
not show any seizures.
Our final diagnosis is that your events are most likely not
seizures. They are probably due to the stressors you are under
and represent your body's reaction to these stressors.
We treated you for a possible urinary tract infection, and you
will continue antibiotics for 3 more days.
we would like you to follow up with Dr. [**Last Name (STitle) 11294**] until Dr. [**Last Name (STitle) **]
has returned and discussed your case with him.
Followup Instructions:
Provider: [**Name10 (NameIs) 191**] CLINICAL NURSE Phone:[**Telephone/Fax (1) 2010**]
Date/Time:[**2141-5-16**] 2:30
Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 590**] Date/Time:[**2141-5-31**] 1:15
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2141-6-1**] 2:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 3294**]
Date/Time:[**2141-5-25**] 9:30
|
[
"317",
"307.9",
"308.9",
"599.0",
"311",
"345.90",
"781.0",
"300.00",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10637, 10643
|
7808, 8935
|
302, 329
|
10708, 10724
|
6454, 7785
|
11725, 12223
|
5197, 5244
|
10664, 10687
|
8961, 10614
|
10809, 11702
|
4311, 4428
|
5259, 5259
|
5804, 5804
|
241, 264
|
357, 1629
|
5926, 6435
|
5273, 5785
|
10739, 10785
|
1651, 4288
|
4444, 5181
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,981
| 100,870
|
43102
|
Discharge summary
|
report
|
Admission Date: [**2200-7-27**] Discharge Date: [**2200-7-29**]
Service: MEDICINE
Allergies:
Barbiturates / Sulfonamides / Opioid Analgesics / Novocain
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
fall off toilet
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a [**Age over 90 **] yo woman who fell off the commode on the day of
admission. Denies hitting head or losing consciousness. Found
down by home aide [**Doctor Last Name **] and was brought to ED at [**Hospital1 18**] for eval.
Past Medical History:
1. CAD s/p CABG in [**2193**] residual deficits
2. PM for bradycardia in [**2184**]
3. s/p partial colon resection in [**2183**] for diverticulitis
4. HTN
5. hypothyroidism
6. h/o Zoster
7. CVA s/p CABG with residual left hemiparesis
8. hx of recurrent falls
9. urinary incontinence
10. OA
11. bilat hearing loss
12. hx of post herpetic neuralgia with residual right shoulder
weakness
13. dep
14. cognitive impairment
15. s/p TAH BSO, cataract surgery,
16. s/p ileorectal [**Doctor First Name **] for diverticulitis in [**2173**]
17 cognitive impairment x 3 yrs
Social History:
Lives at [**Hospital3 537**]. Remote history of tobacco use. Denies
etoh or illicit drug use. Avid tennis player in past. Close to
family. When asked what the secret of longevity was, she said a
supportive and loving family.
Family History:
non contributory
Physical Exam:
admission
96.1 140/46 60 97% RA
hard of hearing
dry membranes, op clear
supple neck
no jvd
no thyroidmegaly
RRR, no murmur
decreased breath sounds, minimal crackles LLL
nbs, soft, ND
ext - no c/c/e
multiple ecchymoses and bandages over left arm and left lat shin
neuro - no aware of location or yr; 5/5 strength throughout
except [**5-22**] left shoulder
Pertinent Results:
[**2200-7-27**] 01:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2200-7-27**] 01:30PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-MOD
[**2200-7-27**] 01:30PM URINE RBC-[**4-21**]* WBC-[**7-27**]* BACTERIA-NONE
YEAST-NONE EPI-[**4-21**]
[**2200-7-27**] 11:41AM URINE HOURS-RANDOM
[**2200-7-27**] 11:41AM URINE GR HOLD-HOLD
[**2200-7-27**] 11:41AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
[**2200-7-27**] 11:41AM URINE RBC-[**4-21**]* WBC-21-50* BACTERIA-FEW
YEAST-NONE EPI-[**7-27**]
[**2200-7-27**] 10:00AM GLUCOSE-102 UREA N-24* CREAT-0.9 SODIUM-143
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-29 ANION GAP-13
[**2200-7-27**] 10:00AM CK(CPK)-147*
[**2200-7-27**] 10:00AM CK-MB-7 cTropnT-0.01
[**2200-7-27**] 10:00AM WBC-5.9 RBC-4.34 HGB-13.5 HCT-39.0 MCV-90
MCH-31.2 MCHC-34.7 RDW-16.1*
[**2200-7-27**] 10:00AM NEUTS-69.6 LYMPHS-20.2 MONOS-6.2 EOS-3.1
BASOS-1.0
[**2200-7-27**] 10:00AM PLT COUNT-202
[**2200-7-27**] 10:00AM PT-11.8 PTT-25.1 INR(PT)-1.0
Brief Hospital Course:
Pt was borderline hypotensive in the ED so was admitted to the
[**Hospital Unit Name 153**]. Cause of fall uncertain. They attributed it to increased
dose of Ditropan vs UTI. She was placed on teletry and cardiarc
enzymes were checked. Given abx for ques of UTI with
levofloxacin. Given tetanus shot for laceration to right shin.
Pt was in ICU x 1 day and then tx'ed to 11 [**Hospital Ward Name **]. She had no
complaints and demanded to go back to [**Hospital3 537**]. I spoke
with her outpt provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who agreed with not
giving the Ditropan or Cipro. Discharged pt back to [**Hospital **].
Medications on Admission:
ASA 325mg daily
ditropan XL 5mg q hs
Ditropan 2.5mg q hs
Effexor XR 75 mg daily
synthroid 100mcg daily
metoprolol 12.5mg [**Hospital1 **]
carafate 1g [**Hospital1 **]
vit D 800 units daily
MVI tab once daily
calcium 500mg tid
tylenol prn
immodium prn
metamucil prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2
times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Fall
hypotension
UTI
decreased hearing
CAD
Discharge Condition:
stable
Discharge Instructions:
seek medical attention if you do not feel well
Followup Instructions:
followup with your primary care doctor Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 31517**]
|
[
"V45.81",
"V45.01",
"414.00",
"E945.1",
"599.0",
"891.0",
"401.9",
"458.9",
"788.30",
"244.9",
"438.20",
"276.52",
"923.00",
"E884.6",
"389.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4604, 4619
|
2957, 3649
|
282, 289
|
4706, 4715
|
1815, 2934
|
4810, 4927
|
1407, 1425
|
3964, 4581
|
4640, 4685
|
3675, 3941
|
4739, 4787
|
1440, 1796
|
227, 244
|
317, 552
|
574, 1145
|
1161, 1391
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,191
| 156,167
|
48501
|
Discharge summary
|
report
|
Admission Date: [**2123-12-19**] Discharge Date: [**2123-12-28**]
Date of Birth: [**2043-5-15**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Carbapenem / Aztreonam
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
wheezing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. [**Known lastname **] is an 80 yo female with h/o DM and HTN who presents
with wheezing since last night. Per patient she had acute onset
of SOB and wheezing that was not associated with rest or
exertion. She states she has had episodes like this in the past,
but they resolved in a few hours. Her symptoms did not resolve
by this afternoon so she presented to the ER. She denies fevers,
cough, chest pain, abdominal pain, recent change in salt intake
or increased swelling in her legs.
.
Upon arrival to the ER she was not hypoxic. Sats were 95% on RA
and were 98-100% on 4 L NC. She was started on a nitro gtt for
SBPs in the 200s. CXR showed CHF, BNP was 2281 and she was
treated with 40 IV lasix. She was placed on bipap for comfort.
She also received an ASA. EKG was done and did not show
significant changes. Her labs were significant for a Cr of 3.5.
While in the ER pt stated she had a several month h/o of
intermittent abd pulsations "like my heart is beating in my
stomach". Retroperitoneal ultrasound was done to evaluate for
AAA and was negative, but exam was limited.
.
Upon arrival to the ICU the patient was satting well on 5L NC
O2. Her breathing was improved.
.
Of note, pt recently had a fall out of bed 5 days ago. She notes
she has had bilateral knee pain, left shoulder pain and pain in
her right hand, with visible bruising, since that time.
.
ROS: Denies fevers, nasal congestion, cough, chest pain,abd
pain, diarrhea, constipation, mental status changes, increased
edema.
(+) pain in right hand, left shoulder and bilateral knees since
her fall.
(+) chills occasionally
(+) has peripheral edema at baseline, but this has not gotten
any worse recently
Past Medical History:
h/o poorly controlled HTN
DM x 20 yrs
Chronic renal insufficiency that has recently been worsening
Social History:
Lives by herself, but daughter lives upstairs
Denies ETOH, tobacco or drugs
Family History:
Father with HTN
Mother died from "uremia" in her 40s
Physical Exam:
VS: T 97.8 HR 58 BP 146/49 O2 sat 99% on 5L NC RR 18
GEN: well appearing, obese female in NAD on NC 02
HEENT: anicteric sclera, dry MMM
Neck: supple, JVP 7 cm
Cardio: RRR, 3/6 systolic murmur loudest LUSB
Pulm: decreased BS at bases, slight end expiratory wheeze
Abd: distended, soft, NT, hypoactive BS, no masses
Ext: 2+ pitting edema b/l
Bruise on left shoulder
bruising over right knuckles
Scrapes and effusion in right knee
Scrape over right shin
Neuro: A&Ox3
Full range of motion in extremities
Pertinent Results:
[**2123-12-19**] 06:00PM URINE HOURS-RANDOM
[**2123-12-19**] 06:00PM URINE UHOLD-HOLD
[**2123-12-19**] 06:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2123-12-19**] 06:00PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2123-12-19**] 06:00PM URINE RBC-[**4-18**]* WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2123-12-19**] 04:00PM GLUCOSE-264* UREA N-82* CREAT-3.5* SODIUM-139
POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-20* ANION GAP-20
[**2123-12-19**] 04:00PM CK(CPK)-59
[**2123-12-19**] 04:00PM cTropnT-0.02*
[**2123-12-19**] 04:00PM CK-MB-NotDone proBNP-2281*
[**2123-12-19**] 04:00PM CALCIUM-9.7 PHOSPHATE-6.4* MAGNESIUM-2.6
[**2123-12-19**] 04:00PM WBC-12.1*# RBC-3.36*# HGB-9.7*# HCT-28.1*#
MCV-84 MCH-28.9 MCHC-34.5 RDW-15.7*
[**2123-12-19**] 04:00PM NEUTS-86.5* LYMPHS-8.0* MONOS-3.3 EOS-2.0
BASOS-0.2
[**2123-12-19**] 04:00PM MICROCYT-1+
[**2123-12-19**] 04:00PM PLT COUNT-240
.
MRI knee:
1. Tear of the posterior [**Doctor Last Name 534**] of the medial meniscus extending
to the junction with the body.
2. Tear of the free edge of the body of the lateral meniscus.
3. Joint effusion and [**Hospital Ward Name 4675**] cyst.
.
CXR:
Stable, significant cardiomegaly. Stable vascular congestion
with ill-defined areas of infiltrate, predominantly in the right
lung, which may represent atypical pulmonary edema in a patient
with underlying COPD. The possibility of a new pneumonia,
however, is not completely excluded, and short-term followup is
recommended to rule out a developing pneumonia.
.
Video swallow: Penetration with thin consistency without
aspiration. For dietary recommendations, please refer to the
speech pathology note that can be found on CareWeb.
Brief Hospital Course:
*CHF: DDx includes CHF [**3-18**] transient cardiac ischemia worsening
mitral regurg or diastolic filling vs uncontrolled HTN causing
flash pulm edema vs ACS (less likely given flat CKs) vs
worsening renal function and volume overload vs dietary
indiscretion. Also pt with transient episode of AV block
overnight and this could be precipitant for CHF
- echo with normal EF 55%, mild [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1915**], mild LVH, no AR,
mild AS, and trivial MR
- beta blocker held as pt. developed transient Wenchebach block,
asymptomatic, resolved with holding BB
- hold ACEI for worsening renal function
- consider outpt holter monitor to evaluate possible short
episodes trigeminy
- now euvolemic, lasix being held, Cr stable at 3.7-4
.
*Renal insufficiency: Followed at [**Last Name (un) **] for her renal
insufficiency by Dr. [**First Name (STitle) 10083**]. Cr today is up to 4.0 up from 3.5
on admission after Lasix diuresis. Has had progressively
declining renal function, which could possibly be contributing
to her volume overload. Renal insufficiency likely [**3-18**] to DM and
HTN.
Renal following, phoslo increased, didn't tolerate renagel.
follow up with Dr. [**First Name (STitle) 10083**] after d/c from rehab.
.
*DM: Patient states she is on 68 units of NPH QAM and 5 QPM, as
well as a sliding scale. She had a few BS so she was adjusted to
60/4 of NPH, follow up with [**Last Name (un) **].
.
*HTN:
- cont. hydral and imdur increased to 60 mg, didn't tolerate BB
.
*UTI: UCx grew entercoccus, vanc [**Last Name (un) 36**] but tetracycline
resistant, started on linezolid to complete 7 day course, will
need UA followed up when finished.
.
*L medial meniscal tear: seen by ortho, declined steroid
injection, no surgery, WBAT, cont. PT
.
*FEN: regular, diabetic, low salt diet
.
*PPx:bowel regimen, PPI, sc heparin
.
*Access: PIVS
.
*Code status: DNR/DNI, confirmed with patient and her daughters
on [**12-19**]
.
*Communication: With patient and her daughters
[**First Name8 (NamePattern2) 102092**] [**Name (NI) 8789**], [**Telephone/Fax (1) 102093**]
.
*Dispo: to rehab
.
Medications on Admission:
calcitriol 0.5 mcg daily
enalapril 20mg PO daily
lasix 40mg Po daily
atenolol 50mg PO daily
avapro 300mg po daily
lipitor 20mg Po daily
folic acid-vit b 1mg po daily
ecotrin 81mg po daily
catapres 0.2mg po qweek
humalog sliding scale
humulin
NPH 68 units QAM
ultrafine syr 1cc
ultrafine syr 1/2 cc
hydralazine 50mg QID
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QSAT (every Saturday).
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: as dir as
dir Subcutaneous twice a day: Please give 60 units sc w
breakfast and 4 units hs.
10. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: as dir
as dir Subcutaneous four times a day: Continue sliding scale 4
times daily as in hospital.
11. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every
6 hours).
12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed.
13. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4-6H (every 4 to 6 hours) as needed.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
17. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
18. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
19. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38**] Landing
Discharge Diagnosis:
Diastolic Congestive Heart Failure
Chronic Renal Insufficiency
Mechanical Fall
Left Medial Meniscus Tear
Urinary Tract Infection
Discharge Condition:
stable
Discharge Instructions:
Take medications as listed below. Please follow up with your PCP
in the next 1-2 weeks.
Followup Instructions:
1. Please have a doctor at your rehab or your PCP have your
urine cx rechecked when you finish your antibiotic.
2. Please follow up with your PCP in the next 1-2 weeks.
3. Please also f/u with Dr. [**First Name (STitle) 10083**] after d/c from rehab.
|
[
"585.9",
"285.21",
"250.60",
"428.30",
"426.10",
"599.0",
"836.0",
"564.00",
"E884.4",
"041.04",
"428.0",
"V58.67",
"787.2",
"403.90",
"357.2",
"718.44",
"518.82",
"250.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8987, 9044
|
4669, 6789
|
325, 332
|
9217, 9226
|
2865, 4646
|
9362, 9617
|
2274, 2329
|
7159, 8964
|
9065, 9196
|
6815, 7136
|
9250, 9339
|
2344, 2846
|
277, 287
|
360, 2041
|
2063, 2164
|
2180, 2258
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,975
| 175,984
|
20031
|
Discharge summary
|
report
|
Admission Date: [**2182-1-3**] Discharge Date: [**2182-1-7**]
Date of Birth: [**2099-9-16**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 2840**]
Chief Complaint:
Hypertensive Emergency/UTI
Major Surgical or Invasive Procedure:
R arm PICC line placed
History of Present Illness:
The pt. is a 81 y/o M with an extensive past medical history
including 3vessel CAD, Parkinson's disease, recurrent Klebsiella
ESBL UTIs admitted to MICU from urology clinic with hypertensive
urgency. The patient was sent to the ED from [**Hospital 159**] clinic this
pm after being found to have a BP of 220/130 following
cystoscopy. Per report, the patient had too much
bleeding/clotting in bladder to complete the exam, on routine VS
screen was found to have elevated BP. At the time the patient
complained of headache and was sent to ED for eval. He denied
chest pain, N/V. On arrival to the ED vitals T 98.9, BP 214/116,
HR 106, RR 18, 97% RA. He was given labetalol 10mg IV X2
followed by a labetalol gtt. Morphine 2mg IVX1. ECG with TWI
laterally. Cardiology was consulted, felt likely strain pattern
related to HTN. Also given Vancomycin 1gm IV for concern of
cellulitis. He was given 1L NS.
.
The patient has been evaluated by urology at [**Hospital1 18**] for hematuria
with history of negative cystoscopy, felt related to
UTI/prostatitis per notes. The patient does not recall the last
time he received antibiotics for UTI.
.
He has been previously admitted in [**2-10**] for NSTEMI and
hypertensive urgency, treated with nitro and labetalol gtts.
.
On the floor, the patient stated he was feeling improved but has
mild headache. No vision changes. No CP/SOB. His low back pain
is at his baseline. He relates he likely missed both his BP and
pain medications earlier today pre-procedure. Pt states his
lower extremity swelling and skin changes are at his baseline.
Denies fever/chills.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
1)Parkinson's disease
2)3-Vessel Coronary Artery Disease - medically managed-[**2180**] for
NSTEMI
3)Hypertension - hypertensive urgency in [**2180**] with NSTEMI
4)Hx of recurrent ESBL - Klebsiella Urinary Tract Infection with
hx of Sepsis in [**11-9**]
5)Chronic renal insufficiency (baseline creat 1.2-1.5)
6)Chronic lower back pain
7)h/o melanoma s/p resection 20yrs ago
7)GERD
8)BPH
9)Chronic Systolic Heart Failure, EF~50%.
10)Hyperlipidemia.
11)4.4 X 4.2 X 4.1 cm Left Renal Cyst.
12)Dysautonomia with Syncope.
13)Hx MRSA Pneumonia.
14)Depression.
15)S/P Open Cholecystectomy.
16)Spinal Stenosis partial paralysis. Poor Functional Status
Social History:
Lives at [**Hospital 100**] Rehab with his wife. A former\International
Relations professor. Walks with a walker. Smoked previously,
but quit 45 years ago, had 5 years of 1ppd. Occasional alcohol
at special occasions, dinner. No IVDA.
Family History:
son and daughter have renal cysts.
Physical Exam:
Vitals - T: 99.1 BP:176/60 HR:76 RR: 18 02 sat:99%RA
GENERAL: Pleasant, well appearing in NAD but with evidence of
resting tremor
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP=unable to assess [**1-7**] to habitus
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: 1+ pitting pretibial edema with evidence of chronic
venous stasi, 1+ dorsalis pedis/ posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses, seborrheic keratosis of
scalp
NEURO: A&Ox3. Appropriate. Resting tremor and intention tremor.
CN 2-12 grossly intact. Decreased sensation bilateral lower
extremities. 5/5 strength throughout. [**12-7**]+ reflexes, equal BL.
Normal coordination. Gait assessment deferred as pt is
wheelchair bound but can walk with PT with walker.
PSYCH: Listens and responds to questions appropriately, pleasant
Discharge Exam:
Afebrile, BP 170s/70s, HR 60-80
GENERAL: NAD
HEENT: NO JVD, MMM., OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2
LUNGS: CTAB
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: 1+ pitting pretibial edema with evidence of chronic
venous stasi, 1+ dorsalis pedis/ posterior tibial pulses.
NEURO: A&Ox3. Appropriate. Resting tremor and intention tremor.
CN 2-12 grossly intact.
Pertinent Results:
[**2182-1-3**] 03:50PM GLUCOSE-132* UREA N-23* CREAT-1.3* SODIUM-133
POTASSIUM-3.9 CHLORIDE-93* TOTAL CO2-32 ANION GAP-12
[**2182-1-3**] 03:50PM estGFR-Using this
[**2182-1-3**] 03:50PM CK(CPK)-64
[**2182-1-3**] 03:50PM cTropnT-0.18*
[**2182-1-3**] 03:50PM CK-MB-4
[**2182-1-3**] 03:50PM WBC-8.8 RBC-3.81* HGB-11.3* HCT-32.5* MCV-85#
MCH-29.6 MCHC-34.7 RDW-15.3
[**2182-1-3**] 03:50PM NEUTS-75.2* LYMPHS-16.4* MONOS-4.6 EOS-3.5
BASOS-0.4
[**2182-1-3**] 03:50PM PLT COUNT-180
[**2182-1-3**] 03:50PM PT-12.6 PTT-26.0 INR(PT)-1.1
.
[**2182-1-3**] CT head: No intracranial hemorrahge or other acute
intracranial
abnormality.
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMIKACIN-------------- 16 S
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFUROXIME------------ =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Cystoscopy Operative Report:
Upon entering the bladder, there was quite a bit of hematuria
and
debris making a full evaluation and pan cystoscopy difficult.
There were no obvious filling defects in the bladder, but again
the bleeding thorough inspection impossible.
Brief Hospital Course:
Patient's MICU course: In brief, Mr. [**Known lastname 4901**] is a 81 y/o M 3
vessel CAD, Parkinson's disease, recurrent Klebsiella ESBL UTIs
admitted to MICU with hypertensive urgency. He was admitted with
BP 220/130 following cystoscopy performed for hematuria that was
too extensive to complete the procedure. He was also at the time
c/o of headache, CT head here was normal. He was given labetalol
10mg IV X2 followed by a labetalol gtt. Had trop leak and cards
was called for ECG had with TWI laterally. Cardiology was
consulted, felt likely strain pattern related to HTN. Urology
was consulted felt related to UTI/prostatitis per notes in OMR
and recommended treating.
Once on the floor,
#. Hypertensive emergency - BP better controlled now on floor,
ECG with no acute ischemic changes but strain pattern which may
have accounted for trop leak but down trending(CKs flat), not
likely having ACS. Started lisinopril for BP control. Can
continue to titrate up in creatinine is stable. In addition,
could try PO hydralazine. Beta blockers avoided because of AV
block. He was monitored on tele, continued on Imdur, statin,
aspirin, lasix 40mg PO qday. The patient has been started on
Norvasc 5mg [**1-6**] to uptitrated as necessary. Please follow weekly
K/Cr for lisinopril adverse effects.
#. Hematuria - urology following, concern for ongoing UTI
causing hematuria, continued with condom catheter as he was not
retaining urine. Started Meropenem for Klebsiells UTI(ESBL)
500mg IV Q8 for 2 weeks ending [**2182-1-16**]. The patient has an
appointment scheduled with Dr. [**Last Name (STitle) 3748**].
#Chronic venous stasis changes. No current systemic signs of
infection. Continued lasix for LE edema.
# CHF: mildly depressed systolic function only, pt w/ LE edema
on exam but clear lungs, continued home dose lasix
#. Anemia - down to 28 - baseline 32-35, microcytic, likely iron
deficiency and ongoing losses from hematuria. Pt was
hemodynamically stable. Trended hct.
# Hyperlipidemia: continued statin
# Parkinson's disease - continued Pramipexole, Primidone and
carbidopa/levodopa
#. Chronic renal insufficiency (baseline creat 1.2-1.5) - at
baseline, continued to monitor.
#. Chronic lower back pain - at baseline continue home dose
oxycontin
#. BPH - continued tamsulosin and finasteride
Medications on Admission:
Coreg 12.5 mg Tab 1 Tablet(s) by mouth twice daily
Lasix 40 mg Tab 1 Tablet(s) by mouth daily
Imdur 60 mg 24 hr Tab 1 Tablet(s) by mouth daily
Sinemet 25 mg-100 mg Tab 1 Tablet(s) by mouth twice a day please
alternate with 1.5 tablet dose
Aspirin 81mg daily
Vit D 1000U daily
Colace
Finasteride 5mg daily
Gabapentin 300mg QHS
Omeprazole 20mg daily
oxycontin 20mg [**Hospital1 **]
oxycodone 15mg Q4 PRN
PEG every other day
Primidone 25mg QHS
Senna
Simvastain 40mg daily
Tamulosin 0.4mg QHS
Discharge Medications:
1. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
3. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
11. 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.
12. Primidone 50 mg Tablet Sig: .5 Tablet PO at bedtime.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
14. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
15. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
16. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
17. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
19. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Pramipexole 0.125 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
22. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
23. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
24. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
25. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q8H (every 8 hours) for 9 days: Continue until
[**2182-1-16**]. PICC line may be removed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
hypertensive emergency
hematuria
urinary tract infection
coronary artery disease
Discharge Condition:
stable, afebrile, hemodynamically insignficant hematuria, PICC
line in place
Discharge Instructions:
You were admitted for increased blood pressure. You were
treated in the ICU and given medications to lower your blood
pressure. You were also noted to have blood in your urine and
an urinary tract infection. You were examined by the urologists
and the hematuria was thought to be from the urinary infection.
We started you on two medications to lower your blood pressure
and the doctors at rehab [**Name5 (PTitle) **] continue to increase this
medication as needed to control your blood. These medications
are Lisinopril and Amlodipine.
We also started you on an IV antibiotics to treat your urinary
infection. Meropenem, for a 2 weeks course
Do not restart your plavix until instructed to do so by a
physician.
We are not sending you home on subcutaneous heparin but we
recommend pneumoboots to prevent deep venous thrombosis.
Subcutaneous heparin should be restarted one hematuria improves.
Please continue to follow up with your primary care doctor and
the doctors [**First Name (Titles) **] [**Last Name (Titles) 100**] rehab. Please follow with Dr. [**Last Name (STitle) 3748**] in
3 weeks as scheduled below.
If you develop worsening bleeding, chest pain, shortness of
breath, headache, dizziness, or back pain, please let your
doctors at rehab know.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2182-3-14**] 11:45
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**]
Date/Time:[**2182-1-31**] 9:15
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 3752**]
Date/Time:[**2182-3-14**] 1:00
|
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"600.00",
"459.81",
"285.1",
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"585.9",
"530.81",
"599.0",
"788.30",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11615, 11681
|
6471, 8785
|
297, 322
|
11806, 11885
|
4832, 5394
|
13201, 13628
|
3271, 3307
|
9324, 11592
|
11702, 11785
|
8811, 9301
|
11909, 13178
|
3322, 4372
|
4388, 4813
|
231, 259
|
5508, 6448
|
1966, 2335
|
350, 1948
|
5403, 5473
|
2357, 3003
|
3019, 3255
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,241
| 191,546
|
19368
|
Discharge summary
|
report
|
Admission Date: [**2122-5-4**] Discharge Date: [**2122-5-12**]
Date of Birth: [**2044-9-27**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Sulfa (Sulfonamides) / Penicillins /
Darvon / Ativan / Ambien
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Transfer for NSTEMI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
Placement and removal of temp. dialysis line
History of Present Illness:
This is a 77 year old female with h/o MI, PVD and stage V CKD.
She was recently hospitalized in early [**Month (only) 547**] at [**Hospital3 3583**]
for a perforated gastic ulcer s/p surgical repair with a
complicated post-op course with MI and repiratory failure
requiring intubation. She was discharged to [**Hospital **] Rehab on
[**4-24**]. On [**5-2**], she developed respiratory distress
and was brought to Good samarita. She became hypotensive and was
placed on Neo briefly. Thought was that she was septic from PNA
and UTI, treated with ceftriaxone and vancomycin. She was placed
on BIPAP for respiratory distress. Then she developed chest pain
and EKG was interpreted as STEMI in the precordial leads, which
was later read as J pt elevations by the consultant
cardiologist. She had CK's to 30's, MB 7.8 and troponins was
0.66 and 0.56. She had recurrent chest pain, and was sent to
[**Hospital1 18**] for cath.
.
At Catheterization, she had an 80% LCx that was fixed with a
BMS. She has a totally occluded RCA that was fed by collaterals.
LM and LAD had minimal dz. Wedge pressure was 20.
.
ROS: Denies chest pain, SOB, orthopnea, PNA, claudications,
peripheral edema. Denies fevers, chills, abd pain, n/v/d. + back
and shoulder pain which is chronic.
Past Medical History:
# Hypertension.
# Hyperlipidemia.
# History of coronary artery disease, mild angina, history of
MI, unclear documentation.
# History of CVA with mild residual left sided symptoms.
# s/p L and R carotid stent
# s/p stenting of the distal aorta and both iliac arteries
# Renal insufficiency (baseline cr 4) with renal stone and renal
dysfunction and a solitary kidney.
# h/o perforated gastric ulcer s/p surgery [**2122-4-9**]
.
Cardiac History:
CABG: none
Percutaneous coronary intervention: none
Pacemaker/ICD placed: none
Social History:
Lives at home with husband. Distant smoking history. Social
alcohol use. No illicit drug use now or in the past.
Family History:
Noncontributory.
Physical Exam:
VITALS: 96.7, 99/79, 102, 20, 99% 4LNC
GEN: A+Ox3, NAD, pleasant
HEENT: Pupils equal and round, EOMI, OP clear, MMM
NECK: JVP about 7 cm, carotid bruits bilaterally, R>L
CV: Tachy, regular, S1 and S2, no M/G/R
PULM: CTAB, no W/R/R
ABD: Midline scar healing, soft, NT, ND, +BS
EXT: No peripheral edema, bruit femoral bilaterally
PULSES: 2+ DP pulse, 1+ PT pulse bilaterally
Pertinent Results:
[**2122-5-4**] 02:45PM TYPE-ART O2 FLOW-4 PO2-86 PCO2-33* PH-7.38
TOTAL CO2-20* BASE XS--4 INTUBATED-NOT INTUBA COMMENTS-NASAL
PRON
[**2122-5-4**] 02:45PM GLUCOSE-133* K+-4.2
[**2122-5-4**] 02:45PM HGB-9.4* calcHCT-28 O2 SAT-96
[**2122-5-4**] 01:50PM GLUCOSE-143* UREA N-78* CREAT-3.9*#
SODIUM-134 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-17* ANION GAP-20
[**2122-5-4**] 01:50PM estGFR-Using this
[**2122-5-4**] 01:50PM ALT(SGPT)-9 AST(SGOT)-10 CK(CPK)-20* ALK
PHOS-86 AMYLASE-100 TOT BILI-0.2 DIR BILI-0.1 INDIR BIL-0.1
[**2122-5-4**] 01:50PM CK-MB-NotDone
[**2122-5-4**] 01:50PM ALBUMIN-2.6*
[**2122-5-4**] 01:50PM %HbA1c-5.6
[**2122-5-4**] 01:50PM WBC-5.2 RBC-2.98* HGB-8.9* HCT-26.0* MCV-87
MCH-30.0 MCHC-34.4 RDW-15.9*
[**2122-5-4**] 01:50PM NEUTS-94.9* BANDS-0 LYMPHS-3.7* MONOS-0.9*
EOS-0.5 BASOS-0
[**2122-5-4**] 01:50PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2122-5-4**] 01:50PM PLT SMR-NORMAL PLT COUNT-245
.
.
EKG:
OSH EKG [**5-2**]: sinus tach 120 BPM, NA, NI, J-pt elevations vs STE
V1 to V2 3mm, STD V5, V6, I, AVL 1-2mm.
[**Hospital1 18**] EKG post cath: sinus tach 100 BPM, NA, NI, J-pt elevations
vs STE V1 to V2 2mm, STD V6, I 1mm.
.
TELEMETRY:
.
2D-ECHOCARDIOGRAM: none
.
ETT: none
.
CARDIAC CATH:
RHC: PAP 42/15/6, PCW 20 (30 at beginning of case, then got
lasix)
LHC:
LM no dz
LAD minimal dz
Lcx 80% thrombotic stenosis then severe diffuse dz beyond,
stented with BMS
RCA occluded proximally and fills by collaterals from LAD
Brief Hospital Course:
#NSTEMI - Patient was transfered from OSH for chest pain and
elevated troponins. Catheterization here showed occluded Left
Circumflex and occluded Right Coronary Artery filled by
collaterals. A Bare Metal Stent was placed to the Left
Circumflex artery. She was chest pain free after the procedure.
She was maintained on ASA, plavix, Beta-blocker, and statin.
An ACE-inhibitor was held because of her poor renal function.
# Acute Systolic Heart Failure: Patient presented to OSH with
CHF exacerbation and shortness of breath. Here her EF was
decreased at 30-40%, and unknown previous. She was diuresed and
her blood pressure was aggressively controlled. She was weaned
from oxygen and did well. She is not on Lasix currently given
her renal failure and euvolemic status. ***Her volume status
should be monitored at the rehab facility and her lasix should
be administered as needed.*** Creatinine should be monitored if
she is placed back on lasix therapy.
#Severe MR: Patient was noted to have severe Mitral
Regurtitation on Echo. The chronicity of this was unknown. She
does not seem to be a good surgical candidate for valvular
repair or replacement. Her blood pressure was controlled. She
should follow up with her outpatient cardiologist regarding this
matter.
.
# CKD: Stage V kidney disease from hypertension. Her outpatient
nephrologist anticipated that it likely progressing to renal
failure requiring Hemodialysis. After cardiac cath. she did
recieve one session of dialysis after placement of a temporary
dialysis line. She did not require other dialysis session and
it seems her serum Creatinine is at her baseline. She will
still likely need dialysis at some point in the future. The
renal team made a note that a fistula should not be place on the
left given left subclavian steel syndrome. She will need to be
monitored as before by her nephrologist.
#Mental Status Changes - At times during the hospitalization,
the patient appeared confused. This was thought related to pain
and psychiatric medications. The doses of these medications
were decreased and she seemed to improve. She did continue to
complain of anxiety; a balance is needed between treating her
anxiety and making her somulent with medications. It is also
likely that a UTI was contributing to her mental status changes.
The UTI will be treated with a 7day course of Ciprofloxacin.
Her foley was removed.
.
#UTI - Associated with a chronic indwelling foley. She will be
treated with Ciprofloxacin 500mg daily and is to complete a 7
day course. The foley was removed and voiding should be
encouraged rather than replacement of the foley. Urine culture
at the time of discharge was pending. Rehab facility should
follow up urine culture to assure proper antibiotic coverage.
# HTN: The patient did have labile blood pressures while in the
hospital that were difficult to control at times. We believe
that her blood pressure was a likely precipitant of her initial
presentation with heart failure. Pressures were controlled with
the addition and titration of amlodipine and carvedilol.
.
# PVD: s/p bilateral carotid stenting. It was necessary to take
blood pressures in her legs because of her known subclavian
stenosis.
Medications on Admission:
Lipitor 80
Lasix 20 IV
Aspirin 325
Metoproolol 25 q6
Heparin
Insulin
Nexium
Zofran
Ceftriaxone
Vancomycin
Risperdal
Tramadol
Xalantan eye drops
.
ALLERGIES:
Iodine; Iodine Containing / Sulfa (Sulfonamides) / Penicillins /
Darvon / Ativan / Ambien
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
8. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8 hours)
as needed for pain.
9. Risperidone 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day) as needed.
10. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days: Last day [**2122-5-16**].
13. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): 12
hours on and 12 hours off. Apply to back area.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
NSTEMI, s/p cath and placement of BMS
Pneumonia
Acute Systolic and Diastolic heart failure
Stage 5 chronic kidney disease
peripheral vascular disease
Discharge Condition:
stable
Discharge Instructions:
You were seen in the hospital for treatment of a heart attack,
pnuemonia and CHF exacerbation. You had a cardiac
catheterization which showed a blockage of an artery in your
heart. A bare metal stent was placed. You have been placed on
Aspirin and Plavix to prevent further clotting of your arteries.
These two medications will also prevent your stent from
clotting. Please DO NOT stop taking these medications unless
otherwise directed by your cardiologist.
You have also been placed on Ciprofloxacin 500mg daily for
treatment of a Urinary Tract Infection, please complete a 7 day
course of this medication, last day is [**2122-5-16**].
Your renal function was also closely monitored while in the
hospital. You required 1 session of dialysis. Please follow up
with your outpatient nephrologist to discuss any further need
for dialysis in the future.
For your congestive heart failure, Please weigh yourself daily,
if you increase by > 3lbs then notify your doctor as you may
need to be placed back on lasix for diuretic therapy and removal
of excess fluid. Please adhere to a 2gm Sodium diet.
Please take your medications as prescribed and follow up as
indicated below
If you experience worsening chest pain, shortness of breath,
fevers, chills, fainting, nausea, vomiting, palpitations or any
other concerning symptoms then please call your doctor or report
to the nearest emergency room.
Followup Instructions:
Please call Cardiologist, Dr. [**Last Name (STitle) 7047**] at ([**Telephone/Fax (1) 18658**] and make
a follow up appointment within 1-2 weeks from your rehab
discharge.
Please call your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17025**] at [**Telephone/Fax (1) 3183**] to
make a follow up appointment within 1-2 weeks from your rehab
discharge.
Please call your outpatient nephrologist, Dr. [**Last Name (STitle) 52684**] [**Name (STitle) **] at
([**Telephone/Fax (1) 52685**] to make a follow up appointment within 1-2 weeks
from your rehab discharge.
|
[
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"599.0",
"414.01",
"443.9",
"300.00",
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"428.0",
"403.91",
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"428.41",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
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icd9pcs
|
[
[
[]
]
] |
9245, 9312
|
4409, 7644
|
369, 439
|
9506, 9515
|
2851, 4386
|
10968, 11586
|
2424, 2442
|
7942, 9222
|
9333, 9485
|
7670, 7919
|
9539, 10945
|
2457, 2832
|
309, 331
|
467, 1730
|
1752, 2277
|
2293, 2408
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,374
| 132,956
|
23125
|
Discharge summary
|
report
|
Admission Date: [**2108-12-24**] Discharge Date: [**2109-1-3**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
upper endoscopy
colonoscopy
History of Present Illness:
Pt is a 87 yo male , with a history of PUD, EtOH abuse,
dementia, mitral regurgitation s/p recent admission for
bradycardia/hypotension secondary to hypovolemia presents to ED
with BRBPR from rehab. On the morning of admission, pt was noted
to have increased lethargy and hematemesis at his nursing home.
HCT found to be 21 (from 35 [**2108-12-18**]) and pt was sent to [**Hospital1 18**].
Past Medical History:
1) HTN
2) Paget's disease
3) MR and AS: TTE [**2108-12-13**]: LEF > 55%, 2+ MR, [**12-2**]+ TR, moderate
AS
4) PUD
5) HAV
6) ERCP s/p sphincterotomy in [**2099**] for CBD stone
-- c/b choledochalduodenal fistula [**2103**]
7) s/p appy
8) Depression
9) H/o EtOH abuse
10) Dementia
11) External capsule infarcts- shown on recent MRI to be old
Social History:
Pt lives at the [**Hospital3 4414**] Rehab Center for one month (previously
he lived alone). He has two sons and twelve grandchildren.
Retired worker at paper company. Quit smoking at 35. History of
EtOH [**3-5**] whiskeys x 4-5 days per week but none since moved to
NH. No history of black outs. No IVDU.
Family History:
Non-contributory
Physical Exam:
T: 96.4; HR: 58; BP: 113/34; RR:13; O2: 96 RA
Gen: Elderly male, hard of hearing in NAD
HEENT: PERRLA 3-->2; EOMI.
Neck: JVD could not be seen.
CV: II/VI holosystolic murmur at apex--> axilla and at LUSB. RRR
S1S2.
Lungs: Fine crackles at bases b/l.
Abd: +BS. Soft, nt, nd.
Ext: DP 1+ b/l. No edema. Clubbing on fingernails.
Neuro: CN II-XII tested and intact. MS [**4-4**]. Reflexes
brachioradialis/biceps [**1-2**]. Patellar [**12-1**].
Rectal: normal prostate without tenderness, no blood
Pertinent Results:
Labs on admission:
[**2108-12-24**] 02:30PM PT-13.8* PTT-25.8 INR(PT)-1.2
[**2108-12-24**] 02:30PM PLT COUNT-287
[**2108-12-24**] 02:30PM NEUTS-87.2* BANDS-0 LYMPHS-10.7* MONOS-1.7*
EOS-0.3 BASOS-0.2
[**2108-12-24**] 02:30PM WBC-11.2*# RBC-2.62*# HGB-7.9*# HCT-24.3*#
MCV-92 MCH-30.1 MCHC-32.5 RDW-15.3
[**2108-12-24**] 02:30PM calTIBC-363 FERRITIN-57 TRF-279
[**2108-12-24**] 02:30PM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.0
IRON-66
[**2108-12-24**] 02:30PM CK-MB-NotDone
[**2108-12-24**] 02:30PM cTropnT-<0.01
[**2108-12-24**] 02:30PM cTropnT-<0.01
[**2108-12-24**] 02:30PM GLUCOSE-148* UREA N-31* CREAT-0.6 SODIUM-139
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-15
[**2108-12-24**] 02:30PM CK(CPK)-22*
.
.
URINE CULTURE (Final [**2108-12-31**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
.
.
Upper endoscopy- Dieulafoy lesion in stomach was noted with
adherant clot
Second upper endoscopy- clips in place no active bleeding
Colonoscopy- grade 2 internal hemorrhoids, erythema at the
recto-sigmoid junction
Brief Hospital Course:
In the ED, he had BRBPR and NG lavage was bright red and did not
clearing with 500 cc NS. Pt continued to have multiple episodes
of melena. EGD in done in the MICU showed with oozing Dieulafoy
lesion in stomach body with a visible clot. It was injected w/
epinephrine, cauterized, and 3 endoclips were placed. Pt
received a total of 5 units of pRBCs. 4 units upon initial
presentation with lasix in between and one unit [**2108-12-25**]. Pt was
then transferred to the medicine floor.Pt came to the regular
medicine floor on [**2108-12-26**] after having >24 hours of stable Hct.
That night, however, pt had BRBPR and was sent back to the unit
for fear of Dieulafoy lesion opening up. He got one unit pRBCs
upon transfer. NG lavage in MICU was negative. Pt was had
another upper endoscopy that showed clips in place, and no
source of bleeding seen.
1. UTI: Pt with coagulase negative staph in urine with
urinalysis positive for infection. He had an episode of CoNS in
the urine during the previous hospitalization but was not
treated as he was asymptomatic at the time. During this
hospitalization the patient became delerious and so the UTI was
treated with Levaquin which resulted in clearing of sensorium.
He had no signs of prostatitis by exam and it was felt that this
was not a recurrence but rather due to the fact that previous
episodes of UTI had not been treated, and an episide prior to
last hospitalization received inadequate length of treatment (7
days).
2. UGIB:
Pt had an oozing Dieulafoy lesion visualized in stomach body on
EGD ([**2108-12-24**]) treated by epinephrine injection, cautery, and 3
endoclips. Pt received 5 units of pRBCs. 4 units initially with
furosemide in ([**Date range (3) 59532**]). Last [**2108-12-26**]. Due to BRBPR
[**2108-12-26**] he had a second upper endoscopy on [**2108-12-27**] with no
source of bleeding and clips in place. On [**2109-1-1**] he had an
episode of BRPPR but with stable hct. He was taken for
colonoscopy on [**2109-1-2**] and was found to have grade 2 internal
hemorrhoids, likely responsible for the recent BRBPR. He also
had erythema at the recto-sigmoid junction but was otherwise
clear.
3. HTN/[**Name (NI) 4964**] Pt has HTN and diastolic CHF (EF 70%, E:A 1.6).
Lasix was held during acute period but as he stabilized he
developed small pleural effusions and was restarted on Lasix
with good results. His only antihypertensive on admission was
Zestril, which was held through most of his hospital course due
to the GIB.
4. H/O EtOH abuse- Pt not actively drinking now as in nursing
home but was continued on MVI, thiamine, folate.
5. H/O anemia- Pt has chronic iron deficiency anemia.
6. Dementia/[**Name (NI) 1068**] Pt is on Lexapro, Donepezil, and
seroquel.
Medications on Admission:
Medications on transfer:
Thiamine
Folic acid
Tylenol prn
Protonix 40 po bid
Donezepil 5 mg qday
Lexapro 10 mg qday
MVI
Quietiapin 12.5 mg [**Hospital1 **]
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 20847**] Home - [**Location (un) 86**]
Discharge Diagnosis:
Dieulafoy Lesion
Grade 2 Internal Hemorrhoids
Urinary Tract Infection
Congestive Heart Failure
Delerium
Dementia
Discharge Condition:
stable
Discharge Instructions:
Return to the ED or call your doctor if you develop chest pain,
problems breathing, bloody stool or other concerning symptoms.
Followup Instructions:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital3 4414**] Nuring Facility will follow up on
your medical care issues once you leave [**Hospital1 827**].
Completed by:[**2109-1-7**]
|
[
"293.0",
"041.19",
"401.9",
"398.91",
"396.3",
"294.8",
"280.0",
"455.2",
"599.0",
"537.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.34",
"44.43",
"99.04",
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
6028, 6106
|
3077, 5823
|
290, 320
|
6263, 6271
|
1989, 1994
|
6446, 6665
|
1444, 1462
|
6127, 6242
|
5849, 5849
|
6295, 6423
|
1477, 1970
|
223, 252
|
348, 740
|
2008, 3054
|
5874, 6005
|
762, 1105
|
1121, 1428
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,992
| 183,320
|
15769
|
Discharge summary
|
report
|
Admission Date: [**2117-2-1**] Discharge Date: [**2117-2-5**]
Date of Birth: [**2070-1-13**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 47-year-old man with a
past medical history significant for multiple myocardial
infarctions in the past, hypertension, obesity, insulin
dependent-diabetes mellitus, gastroesophageal reflux disease,
history of cerebrovascular accident, high cholesterol,
chronic renal insufficiency with a baseline creatinine of
1.2-1.5, bilateral foot peripheral neuropathy, trigeminal
neuralgia, and past surgical history significant for hernia
and appendectomy in [**2111**] as well as bilateral laser surgery
of the eyes for his retinopathy.
Patient's preoperative medications included Nexium 20 mg q
day, aspirin 325 mg q day, lisinopril 40 mg q day, atenolol
100 mg q day, Simvastatin 40 mg q day, Plavix which was
discontinued the prior Tuesday, multivitamins, lente insulin.
The patient has no known drug allergies.
Patient is a 47-year-old man who has had his first myocardial
infarction in [**2105**], another myocardial infarction in [**2106**] who
began having increased chest pain and shortness of breath
since the fall of [**2115**]. He had another myocardial infarction
in [**2116-9-25**] at which time he underwent PTCA and stent
of his circumflex. He then underwent an exercise stress test
later on which was positive, and in [**2116-12-26**] again
underwent PTCA of his restenosed circumflex.
Cardiac catheterization on [**2116-12-28**] revealed three
vessel coronary artery disease with a left main coronary
artery being normal, left anterior descending artery with a
50% proximal lesion and a 60% mid lesion, 80% disease in the
first diagonal, and 80% diffuse restenosis of the OM that was
stented earlier, which was then successfully PTCA'd at the
time of this cardiac catheterization. The right coronary
artery also had a 70% lesion, the posterior descending artery
with a 70% lesion.
Due to the patient's discomfort in the supine position, a
right femoral arteriotomy closure was performed using a 6
French Angio-Seal device. Patient was then admitted [**2117-2-1**] at which time patient underwent coronary artery
bypass grafting x4 with a left internal mammary artery to
left anterior descending artery, saphenous vein graft to the
obtuse marginal and ramus intermedius sequential, and
saphenous vein graft to the right posterolateral. Total
cardiopulmonary bypass time was 118 minutes, total
cross-clamp time was 105 minutes. The patient was
transferred to the Cardiac Surgery Recovery Unit in stable
condition in normal sinus rhythm at 77 beats per minute on
propofol 30 mcg/kg/minute, nitroglycerin at 0.5 mcg/kg/min,
Neo-Synephrine at 0.7 mcg/kg/min, and an insulin drip of 2
units/hour.
The patient was extubated the same day at 6:30 pm at which
time the patient was easily arousable and oriented x3.
Postoperative day one, no 24 hour events. Patient in sinus
rhythm at 100 beats per minute with a CVP of 9 and a cardiac
index of 3.42, making adequate urine with a low grade
temperature of 99.5, white count of 10.3, hematocrit of 30.8,
platelet count of 216. Sodium 141, potassium 5.1, BUN 24,
creatinine 1.1, and a glucose of 126. Still on an insulin
drip of 2.
On physical exam, the patient was alert and oriented times
three, moving all of his extremities and following commands
correctly, complaining of pain which was relieved by
Morphine. Patient was transferred to the floor about the
same day. However, the patient needed to be transferred back
to the Cardiac Surgery Recovery Unit for an insulin drip due
to the patient's hyperglycemia with a blood sugar up to 348.
Postoperative day two, significant overnight events including
the patient's hyperglycemic event for which the patient
needed to be transferred to the unit. The patient still in
sinus rhythm at 100 beats per minute on his po medications of
Plavix, Imdur, Lopressor, and Simvastatin, making good urine,
afebrile. White count of 13.6, hematocrit down from 31-25.3,
BUN 42, creatinine of 1.8.
On physical exam, the patient is still complaining of pain
which was relieved with the Percocet. Otherwise, examination
was benign. Plan was to continue to monitor the patient's
blood sugar, and to continue the patient's insulin drip.
[**Last Name (un) **] came by to see the patient that same day at which time
they recommended to continue the insulin drip for now. They
also recommended Lente 30 units q hs and 35 units q am,
titrate the insulin starting 30 minutes after the pm dose of
Lente beginning that night, and they also gave a sliding
scale for the Intensive Care Unit to follow.
Patient was again transferred to the floor postoperative day
two [**2117-2-3**] in stable condition. Postoperative day
three, 24 hour events including patient's Foley catheter
being discontinued. Insulin drip being turned down to 1
cc/hour, and around 1:45 in the morning a blood sugar of 77.
The insulin drip was turned off, and the patient was given
150 cc of [**Location (un) 2452**] juice.
Patient also had complaints early in the morning of right
shoulder pain which was localized and reproducible for which
the patient was given Percocet. Patient had a low grade
temperature of 100, in normal sinus rhythm, vital signs
stable, fingersticks ranging between now 100-172. Physical
examination was benign.
[**Last Name (un) **] came by to see the patient again at which time they
recommended to increase regular and NPH to 36 regular, 50
lente. They stated that the patient did not receive regular
presupper insulin yesterday as recommended, so they stated
that the would start today, and to consider the insulin drip
as a supplement to the subQ in order to achieve the target
blood sugar of 100-120.
Postoperative day four, patient still with a low grade
temperature of 99.2 and normal sinus rhythm at 97. Vital
signs stable, sating at 95% on room air. Physical
examination benign. Patient still with complaints of right
shoulder pain, however, feeling better. [**Last Name (un) **] came by to
see the patient again, at which time they wrote in their
notes that the patient was low after supper last night, and
the sliding scale at breakfast and supper reduced. The
patient did not receive any regular insulin as ordered.
Consequently, the patient's prelunch blood sugar was
elevated. The patient was discontinued on a new sliding
scale and was told to continue the patient's Lente insulin.
The patient was discharged home that same day on [**2117-2-5**] in good stable condition.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg [**Hospital1 **].
2. Oxycodone 10 mg [**Hospital1 **].
3. Imdur 60 mg q day.
4. Percocet 1-2 tablets po q3-4h prn.
5. Iron sulfate 325 q day.
6. Ascorbic acid 500 mg [**Hospital1 **].
7. Simvastatin 40 mg q day.
8. Plavix 75 mg q day.
9. Tylenol 650 mg po q4h prn.
10. Aspirin 325 mg q day.
11. Zantac 150 mg [**Hospital1 **].
12. Colace 100 mg po bid.
13. Lasix 20 mg [**Hospital1 **] for seven days.
14. Potassium chloride 20 mEq [**Hospital1 **] for seven days.
15. Insulin sliding scale.
16. Milk of magnesia 30 mg q hs prn.
DISCHARGE INSTRUCTIONS: The patient was discharged to make
an appointment with Dr. [**Last Name (STitle) 1537**] in four weeks, his PCP [**Last Name (NamePattern4) **] [**11-26**]
weeks, Dr. [**Last Name (STitle) 11493**] the cardiologist in [**12-28**] weeks, Dr. [**Last Name (STitle) 3761**],
the patient's diabetes doctor this week, to adjust the
patient's insulin regimen.
DISCHARGE DIAGNOSIS: Coronary artery disease status post
coronary artery bypass grafting x4.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Doctor Last Name 2011**]
MEDQUIST36
D: [**2117-3-2**] 14:22
T: [**2117-3-3**] 06:24
JOB#: [**Job Number 45415**]
|
[
"357.2",
"593.9",
"250.61",
"362.01",
"414.01",
"411.1",
"412",
"250.51",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"36.15",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6604, 7153
|
7555, 7898
|
7178, 7533
|
178, 6581
|
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