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49,453
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Discharge summary
|
report
|
Admission Date: [**2105-1-30**] Discharge Date: [**2105-2-9**]
Date of Birth: [**2033-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11552**]
Chief Complaint:
syncope, UGIB
Major Surgical or Invasive Procedure:
colonoscopy
History of Present Illness:
71M with a history of ESRD [**3-10**] GN and HTN s/p transplant in [**2102**]
with chronic rejection recently admitted for hyperkalemia and
found to have gastric and duodenal ulcer after melena x1 in the
hospital admitted after being found on the floor of his home
surrounded by melenotic stool. He reports that he remembers
having the urge to have diarrhea, heading to the bathroom, and
waking up with his family over him. He denies chest pain,
palpitations, dizziness, or focal weakness. He has a L black eye
from his fall which is sore. He also reports mild chronic SOB
more or less unchanged. He was taken by EMS to the ED.
.
In the ED, initial vs were T 97.8 P 100 BP 151/68 R 18 O2 sat
100% on 4L NC. Head, neck, and torso CTs showed no acute
fratures or bleeds. Initial HCT was 30, but fell to 20 four
hours later. A R femoral line was placed, he received
pantoprazole 40mg IV x 1, 1L NS, and 1 unit of pRBCs. ECG showed
deepened ST-depressions in II, III, aVF, and V5-6 but initial
CEs were negative. GI and surgery were consulted. He was
hemodynamically stable in the ED with SBPs of 108-144 with
pulses of 88-91. Also in the MICU his K was 5.2 and rose to 5.5.
Of note, he takes tacrolimus for his transplanted kidney. He was
admitted to the MICU for further management.
.
On the floor he gives the above history. He denies chest pain,
palpitations, chest pressure, HA, dizziness, weakness, or
worsened SOB.
Past Medical History:
end stage renal disease due to chronic glomerulonephritis on
hemodialysis
hypertension
hypercholesterolemia
gout
Social History:
The patient is originally from [**Location (un) 4708**]. He smoked one to two
pack of cigarettes for a year or so and has now quit. Denies any
alcohol right now, but used to drink approximately four to five
drinks, usually on the weekends, for a total of five years.
Patient is divorced and is remarried. He currently lives with
his 16-y/o son. [**Name (NI) **] works for GE.
Family History:
Mother has [**Name (NI) 2481**]. Brother has diabetes and gout. There is
no family history of any renal failure, diabetes, or any
coronary artery disease.
Physical Exam:
On admission:
GEN: NAD, pleasant, conversant
HEENT: MMM, no OP lesions, palpable jugular briuts from AV
fistula
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+ NTND, no masses or HSM
LIMBS: No LE edema, no clubbing, RIJ c/d/i
SKIN: No rashes or skin breakdown
NEURO: CN II-XII intact, grossly non-focal
Pertinent Results:
Images:
- CT C-SPINE W/O CONTRAST Study Date of [**2105-1-30**] 10:34 AM
FINDINGS: There is slight, possible anterior wedging of the C5
vertebral body without prevertebral soft tissue swelling, but in
association with a large anterior bridging osteophyte arising
off its anteroinferior aspect. Thus, these findings probably are
chronic in nature, as is the narrowed C5-6 disc space. There is
moderate narrowing of the C6-7 disc space, with smaller anterior
but a moderate posterior osteophytic ridge, the latter causing
mild impression upon the ventral margin of the thecal sac. No
other cervical spine fractures are seen. There is moderately
prominent degenerative narrowing of the atlanto- dental
articulation, with a small superiorly situated osteophyte
arising from the anterior arch of the dens. There are no other
osseous abnormalities detected. There is a moderate
atherosclerotic calcification of the right common carotid
bifurcation. CONCLUSION: Mild anterior wedging of the C5
vertebral body which is probably chronic, in association with
degenerative changes at this as well as the C6-7 levels. No sign
of subluxation or prevertebral soft tissue swelling.
.
- CT ABDOMEN W/O CONTRAST Study Date of [**2105-1-30**] 10:34 AM
Preliminary Report !! PFI !! No evidence of acute abdominal
process. Left adrenal lesion again seen, incompletely
characterized on single phase CT.
.
- CT HEAD W/O CONTRAST Study Date of [**2105-1-30**] 10:33 AM FINDINGS:
There is no intracranial hemorrhage, mass effect or shift of
normally midline structures. There is mild diffuse cerebral
atrophy. There is moderate atherosclerotic calcification of the
cavernous internal carotid arteries. There is a prominent,
likely dystrophic dural calcification adjacent to the falx
cerebri in the vertex region, to the right of midline. No other
osseous abnormality is seen. There is prominent left
premaxillary soft tissue swelling which is incompletely
delineated on this head CT scan. CONCLUSION: No intracranial
hemorrhage. Other findings noted above. COMMENT: The above-noted
findings were indicated in the preliminary report section of the
electronic requisition.
.
- EGD [**2105-1-26**]: Findings: Esophagus: Normal esophagus. Stomach:
Excavated Lesions A single chronic cratered non-bleeding 8 mm
ulcer was found in the antrum. Additional findings include
heaped-up margins with clean based ulcer. Two cold forceps
biopsies were performed for histology at the stomach antrum.
Duodenum: Mucosa: Localized erythema of the mucosa with no
bleeding was noted in the duodenal bulb compatible with
duodenitis. Excavated Lesions Multiple chronic superficial
non-bleeding 5mm ulcers were found in the duodenal bulb.
Impression: Ulcer in the antrum (biopsy) Ulcers in the duodenal
bulb Erythema in the duodenal bulb compatible with duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations: follow-up biopsy results Please check H.Pylori
Ab.
Please check serum gastrin level Pt should repeat EGD in 8 weeks
continue high dose PPI
.
- EGD [**2105-1-30**]: Clotted blood was seen in the stomach.
Excavated Lesions A single cratered oozing 12 mm ulcer was found
in the pre-pylorus. A gold probe was applied for hemostasis
successfully after 3 clips could not be sucessfully applied due
to the depth of the lesion.
Duodenum: Excavated Lesions A few superficial non-bleeding
ulcers were found in the duodenum. Impression: Normal mucosa in
the esophagus;
Blood in the stomach; Ulcer in the pre-pylorus (thermal
therapy); Ulcers in the duodenum ; Recommendations: serial
hematocrits EGD in [**9-17**] weeks;
[**Hospital1 **] proton pump inhibitor; Repeat EGD if acutely rebleeds
.
EKG: Sinus, 98/min, L axis deviation, LVH by wave criteria, ST-D
in II, III, aVF, V5-6, no ST-E
Brief Hospital Course:
# Melena: Initially felt to be [**3-10**] UGIB from known duodenal and
gastric ulcers. EGD revealed an oozing pre-pyloric ulcer which
was cauterized. In the ED HCT dropped 10 points over 4 hours;
however, patient remained HD stable. A right femoral line was
placed and patient was transferred to the MICU for further
evaluation. Patient was transfused 2 units initially and then
another 3 units. HCT bumped appropriately and remained stable.
Following discharge to floor, HCTs continued to remain stable.
Continued to be guiaic positive. Colonoscopy showed multiple
polyps and an anal mass. Surgery was consulted and the mass was
biopsied. Biopsy results showed invasive adenocarcinoma with
mucinous features most consistent with perianal mucinous
(colloid) adenocarcinoma. The tumor was present at deep
margins. Outpatient appointments with Dr [**Last Name (STitle) 1120**] were set up for
outpatient surgical follow up, as well as an MRI for
investigation for metastatic disease. At time of discharge, HCT
was stable. The patient was offered a social work consult for
his new diagnosis. Sucralfate and a PPI were started for his
upper GI ulcers. Iron replacement was provided for his low HCTs
given low intake of iron and continued guiaic positive blood in
stool. Given his history of renal failure and immunosupression,
the tissue obtained from the ulcers in the duodenum were also
checked for CMV + staining. These were pending at the time of
discharge. GI follow up was scheduled.
.
# Hyperkalemia: This was felt to be [**3-10**] chronic renal failure
vs. tacrolimus. Patient was initially treated with dextrose and
insulin. Potassium normalized. Tacrolimus level was followed
daily and dosed accordingly.
.
# Chronic renal insufficiency: Due to history GN and
hypertension. S/p transplant in [**2102**] complicated by chronic
rejection. Patient was continued on Tacrolimus with daily levels
and mycophenolate.
.
# ECG changes: Has subtle deepening of chronic ST depressions in
II, III, aVF, V5-6. No CP. ECG changes resolved without any
elevation on serial cardiac enzymes.
. Likely will need an outpatient stress prior to any surgical
interventions for further investigation/treatment of his anal
mass.
.
# HTN: BP meds were intially held [**3-10**] to GIB then home
Metoprolol restarted at time of transfer to floor. On the
floor, his pressures were stable and within normal range.
.
# Fevers: Had several fevers of 100.5 -101.5 while on floor.
Was pan-cultured; blood grew out 1 positive Enterococcus in 1 of
4 bottles. Urine also grew out enterococcus. Endorsed dysuria
and flank pain. Enterococcus was sensitive to vancomycin,
however, given difficulty with access, was started on PO
[**Month/Day (2) 11958**] with instruction to continue it for a 2 wk course to
be continued on [**2-17**]. A TTE echo was performed which showed no
vegetations. Infectious disease follow up was set up for
evaluation of CBC on day 7 and day 10 of [**Month/Year (2) 11958**] treatment
given possibility of inducing pancytopenias. At time of
discharge, fevers, dysuria, flank pain had resolved.
.
Was discharged with follow up set up with Transplant ID,
Transplant Hepatology, General surgery, and gastroenterology.
Medications on Admission:
- Amlodipine 10 mg PO DAILY
- Metoprolol Tartrate 12.5 mg PO BID
- Tamsulosin 0.8 mg PO HS
- Fludrocortisone 0.1 mg PO DAILY
- Cholecalciferol 800 unit PO BID
- Pantoprazole 40 mg PO Q12H
- Trimethoprim-Sulfamethoxazole 80-400 mg PO DAILY
- Tacrolimus 5 mg PO Q12H
- Senna 8.6 mg PO BID PRN: constipation
- Docusate Sodium 100 mg PO BID PRN: constipation
- Mycophenolate Mofetil 1000 mg PO BID
Discharge Medications:
1. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
3. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2)
Capsule, Sust. Release 24 hr PO at bedtime.
7. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
9. Tacrolimus 5 mg Capsule Sig: One (1) Capsule PO every twelve
(12) hours for 1 doses.
10. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
11. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. Outpatient Lab Work
please obtain CBC and differential on day [**2105-2-12**] and [**2105-2-15**] and
send results to [**Telephone/Fax (1) 11959**] care of [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], transplant [**Hospital **]
clinic.
13. [**Hospital **] 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 8 days: last dose on [**2105-2-17**].
Disp:*16 Tablet(s)* Refills:*0*
14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO three times a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
1. Bleeding pyloric ulcer
2. Anal adenocarcinoma
3. Chronic kidney disease secondary to failed renal transplant
4. Hypertension
Discharge Condition:
Stable for home. Alert and oriented, ambulating on room air.
Discharge Instructions:
Dear Mr [**Known lastname 11952**],
It was a pleasure taking care of you while you were here.
You were admitted because you were bleeding in your stomach. To
find out exactly where the bleed was, we placed a scope inside
you which found that you had a small ulcer that was actively
bleeding. We treated this ulcer by cauterizing it and the
bleeding stopped. We also started you on a new medicine
(sucralfate) which can help prevent these ulcers from forming
and bleeding again. Following the procedure, your blood counts
remained stable. You will need to be seen by gastroenterology in
follow-up; this has been scheduled for you below. You should
avoid taking any medicines like ibuprofen, motrin, advil, or
other NSAIDs which can make ulcers worse. If you feel stomach
pain in the interim, you can try over the counter Zantac or
Mylanta.
.
While you were here, we received the results of the biopsy from
the mass near your anus. As discussed with you, this mass is
concerning for cancer. You will need further investigation to
figure out the best way to treat this cancer. For this reason,
you will have to see the surgery team as an outpatient as noted
below. Prior to going to this appointment, you will need to
have an MRI, which is an imaging test similar to a CT scan. You
will need to call radiology to schedule an appointment for this,
and this should be done in late [**Month (only) 1096**] prior to your surgery
appointment. You should call: [**Telephone/Fax (1) 327**] (radiology
scheduling office) to schedule this MRI.
.
We also found that you had a urinary tract infection caused by
bacteria that were also found in your blood. For this, we
started you on [**Last Name (LF) 11958**], [**First Name3 (LF) **] antibiotic that you should continue
to take to complete a two week course. You should continue to
take [**First Name3 (LF) 11958**] until [**2104-2-18**]. You will also need to be seen by
the infectious disease clinic. An appointment has been
scheduled for you below.
.
Medication changes made during this hospitalization:
(1) Started sucralfate, a medicine that helps protect your
stomach. You should take 1 gm four times a day.
(2) Increased your dose of sodium bicarbonate to 1300 mg three
times a day.
(3) Started [**Month/Day/Year 11958**] which you should take daily 600 twice a
day until [**2104-2-18**] to complete a 2 wk course.
(4) Started ferrous sulfate (iron replacement) which you should
take 325 mg three times a day.
.
You will need outpatient lab work done on [**2105-2-12**] and [**2105-2-15**]
(your VNA will help to draw this).
.
Please call your primary care doctor or return to the emergency
department if you notice blood in the toilet bowl again, if you
vomit up blood, if you feel increasingly dizzy or lightheaded,
or if you have any worsening fevers, chills, or any other
concerning symptoms.
.
See follow up appointments below.
Followup Instructions:
1. Appointment with your kidney doctor: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**],
MD Phone:[**Telephone/Fax (1) 673**] On: [**3-9**], Monday at 1 PM.
.
2. Appointment with your gastroenterologist: DR. [**First Name (STitle) **] [**Doctor Last Name **]
Phone:[**Telephone/Fax (1) 3752**] On:[**2105-2-12**] at 8:30 AM
.
3. Appointment with your surgeon: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2105-2-17**] at 345 PM
.
4. Please call the radiology scheduling office as noted above
to schedule your MRI at [**Telephone/Fax (1) 327**]. You should schedule this
prior to your surgery appointment (ideally within the next
week).
.
5. Please schedule an appointment with infectious disease clinic
tomorrow morning. You need to call [**Telephone/Fax (1) 11486**] and ask to
schedule an appointment with Transplant Infectious Disease with
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. He will need to see you in two weeks to review
your lab work (so try to get something between [**2-17**] and
[**2-20**]).
Your visiting nurse will draw labs that he will review.
|
[
"285.1",
"E878.0",
"272.0",
"154.3",
"276.2",
"V15.82",
"274.9",
"276.0",
"996.81",
"585.9",
"041.04",
"532.90",
"276.7",
"403.90",
"531.40",
"599.0",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11871, 11929
|
6623, 9850
|
328, 341
|
12101, 12165
|
2829, 6600
|
15111, 16314
|
2335, 2491
|
10294, 11848
|
11950, 12080
|
9876, 10271
|
12189, 15088
|
2506, 2506
|
275, 290
|
369, 1789
|
2520, 2810
|
1811, 1925
|
1941, 2319
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,568
| 119,600
|
50110
|
Discharge summary
|
report
|
Admission Date: [**2182-12-15**] Discharge Date: [**2182-12-23**]
Service: MEDICINE
Allergies:
Bactrim / Nsaids
Attending:[**First Name3 (LF) 19684**]
Chief Complaint:
Nausea and abdominal pain
Major Surgical or Invasive Procedure:
Intubation
TEE
History of Present Illness:
Pt is a [**Age over 90 **] yo F with a h/o Afib/flutter, CHF(diastolic dysfxn),
HOCM who presented to [**Hospital1 18**] on [**12-15**] with episode of chest pain
radiating to her back, shoulders, and abdomen. Per the pt's
daughter, patient had gone back into afib about 3 weeks ago.
Since that time she has had problems with CHF and fatigue. She
was recently started on diltiazem for rate control and coumadin
for anti-coagulation. Patient was doing okay until the day of
admission when the daughter gave her mother some Mg citrate for
constipation. After taking this she became acutely ill with
nausea and abdominal pain. She was nauseous all day and could
not tolerate PO's and had significant diarrhea. Per the daughter
the patient was not complaining of any chest pain during the
day. However in the ED they noted the patient as having chest
pain for about 1 hour PTA with radiation to the back/shoulders.
The daughter denied that her mother had any recent fevers,
cough, dysuria, or sick contacts.
.
Past Medical History:
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 141**]
Cardiologist: Dr. [**Last Name (STitle) 104615**]
1. A-flutter, non-Q wave MI [**2176**], cardiac cath as above.
2. Hypertension and hyperlipidemia.
3. Hypothyroid.
4. Arthritis.
5. Diverticulosis.
6. Status post GI bleed secondary to nonsteroidal
anti-inflammatories.
7. History of bradycardia, for which a pacer was considered
8. Peripheral vascular disease.
9. Status post cataract repair.
10. s/p MVA 15 years ago
11. h/o pelvic fx
Social History:
Retired bacteriologist. Daughter who is an attending neurologist
at the [**Hospital 789**] [**Hospital **] Hospital. Lives alone, daughter nearby,
health aide 2h/day, 7days/week. Walks with a walker. She is
widowed. There is no history of alcohol or tobacco or
recreational drug use.
Family History:
4 sisters all died of cancer, various causes including lung ca
and possibly ovarian ca. One daughter died of metastatic cancer
in [**2173**] primary site unknown, presumed to be ovarian.
Physical Exam:
Discharge physical Exam
PE: Tm= 98.9 HR 80-113 irregular BP 95-120s/50-60
O2 sat 93-97% (2L)
Gen: interactive, appropriate
HEENT: PERRL, dry mm, R IJ
CV: brady, distant S1, S2, LUSB murmur [**3-31**] r/g
Lungs: [**Hospital1 **]-basilar rales, mild wheezes(improve with nebs)
Abd: soft, mild tender on R, mildly distended
Ext: trace LE edema bilaterally
Neuro: CN 2-12 intact, 4/5 strength
Pertinent Results:
Admission lAbs:
[**2182-12-15**] 11:25PM TYPE-ART PO2-556* PCO2-38 PH-7.45 TOTAL
CO2-27 BASE XS-3
[**2182-12-15**] 11:25PM LACTATE-1.0
[**2182-12-15**] 08:40PM POTASSIUM-5.6*
[**2182-12-15**] 08:05PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2182-12-15**] 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 [**2182-12-15**] 07:41PM LACTATE-2.0
[**2182-12-15**] 04:18PM GLUCOSE-166* UREA N-40* CREAT-1.7*
SODIUM-126* POTASSIUM-6.3* CHLORIDE-86* TOTAL CO2-30 ANION
GAP-16
[**2182-12-15**] 04:18PM ALT(SGPT)-25 AST(SGOT)-33 CK(CPK)-55 ALK
PHOS-137* AMYLASE-116* TOT BILI-0.3
[**2182-12-15**] 04:18PM LIPASE-84*
[**2182-12-15**] 04:18PM cTropnT-0.01
[**2182-12-15**] 04:18PM CK-MB-NotDone
[**2182-12-15**] 04:18PM ALBUMIN-4.5 CALCIUM-9.7 PHOSPHATE-5.2*
MAGNESIUM-2.6
[**2182-12-15**] 04:18PM WBC-17.3*# RBC-4.64 HGB-13.0 HCT-38.8 MCV-84
MCH-27.9 MCHC-33.4 RDW-13.2
[**2182-12-15**] 04:18PM NEUTS-88.4* LYMPHS-9.3* MONOS-1.8* EOS-0.3
BASOS-0.2
[**2182-12-15**] 04:18PM PLT COUNT-298
[**2182-12-15**] 04:18PM PT-14.2* PTT-24.5 INR(PT)-1.4
.
CBC:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt
[**2182-12-22**] 07:00AM 10.1 3.67* 10.3* 30.5* 83 28.0 33.8 13.4
169
[**2182-12-21**] 07:00AM 10.7 3.71* 10.6* 31.4* 85 28.5 33.7 13.4
166
[**2182-12-19**] 05:11AM 12.8* 3.53* 9.7* 29.8* 84 27.5 32.6 13.4
132*
[**2182-12-18**] 09:20PM 11.5* 3.53* 10.0* 29.7* 84 28.3 33.7 13.4
142*
[**2182-12-18**] 03:23AM 13.2* 3.46* 10.0* 28.9* 84 28.9 34.6 13.3
132*
[**2182-12-17**] 04:57AM 10.2 3.30* 9.8* 27.8* 84 29.7 35.3 13.4
145*
[**2182-12-16**] 05:59AM 13.8* 3.40* 9.4* 28.1* 83 27.8 33.6 13.3
158
[**2182-12-16**] 12:44AM 15.0* 3.62* 10.4* 29.1* 80 28.6 35.6 13.1
172
[**2182-12-15**] 04:18PM 17.3* 4.64 13.0 38.8 84 27.9 33.4 13.2
298
.
Coags:
BASIC COAGULATION PT PTT INR(PT)
[**2182-12-22**] 07:00AM 18.8* 27.5 2.5
[**2182-12-21**] 06:04PM 16.6* 24.2 1.9
[**2182-12-20**] 05:04AM 19.1* 27.3 2.6
[**2182-12-19**] 05:11AM 17.5* 26.2 2.1
[**2182-12-18**] 03:23AM 16.2* 25.8 1.8
[**2182-12-17**] 04:57AM 16.0* 26.1 1.8
[**2182-12-16**] 05:59AM 15.9* 27.4 1.7
[**2182-12-16**] 12:44AM 16.8*122.4 1.9
.
SMA 7:
RENAL & GLUCOSE Glu BUN Cr Na K Cl HCO3 AnGap
[**2182-12-22**] 07:00AM 121* 21 1.1 139 4.7 98 301 16
[**2182-12-21**] 07:00AM 119* 19 1.1 136 4.7 97 311 13
[**2182-12-20**] 09:30AM 146* 16 1.0 138 4.3 100 291 13
[**2182-12-20**] 05:04AM 125* 18 1.1 141 4.3 103 281 14
[**2182-12-19**] 05:11AM 125* 18 1.1 139 3.6 100 301 13
[**2182-12-18**] 03:23AM 131* 20 1.0 138 3.6 100 291 13
[**2182-12-17**] 04:57AM 106* 19 1.1 135 3.7 100 281 11
[**2182-12-16**] 05:59AM 115* 30*1.2*135 3.5 100 261 13
[**2182-12-16**] 12:44AM 126* 33*1.4*134 3.5 96 281 14
.
CXR- [**12-15**]: Cardiomegaly, increased pulmonary vasculature
consistent with CHF, round density in right lung base correlates
with old granuloma on CT , s/p intubation ETT 3 cm above carina,
NGT in place
Rt IJ in SVC, decreased pulmonary vasculature engorgement
.
CXR ([**12-18**]): Improving CHF, small B effusions, can't r/o LLL
infiltrate
.
CXR ([**12-19**]): IMPRESSION: Resolution of pulmonary edema.
Bilateral pleural effusions, left greater. Right paracardiac and
left basilar subsegmental atelectasis
.
CXR ([**12-21**]): IMPRESSION: Left effusion. No other evidence of
failure
.
CT abd/pelvis ([**12-15**]):
1) cardiomegaly with small bilateral pleural effusions. sigmoid
diverticulosis without evidence of diverticulitis, otherwise,
unremarkable CT Abd/Pelvis without evidence for bowel
abnormality, free air or free fluid.
.
ABD US ([**12-15**]): unremarkable GB, liver, pancreas. CBD 4mm
.
ECG Afib, 97 bpm, nl axis, LVH, TWI V3-4 (old)
.
TEE ([**12-16**]): no aortic dissection, no thrombus/clot in the left
atria, EF>55%, [**1-27**]+ MR, symmetric LVH
.
Cardiac Cath [**2182-9-25**]- 30% LCx, elevated LVEDP at 15, no aortic
gradient
.
ECHO [**2182-8-20**]- EF 70%, E/A ratio 0.75, TR gradient 39, Mod LAE.
Asymmetric LVH. [**1-27**]+ MR 1+ TR
Brief Hospital Course:
Upon arrival to the hospital, in the ED, she was initially
hypotensive and dropped her pressures into the 70's/80's. She
was given 2 L of IVF and went into acute pulmonary edema. At
this time she also became hypertensive. She was given lasix and
started on nitro gtt. Her BP and respiratory status gradually
improved, but she was intubated in anticipation of MRI/A to rule
out aortic dissection. In the MR machine she became transiently
hypotensive. She was given fluid bolus and since then her BP
recovered. She was found to have an elevated WBC and was
empirically given levo/flagyl.
.
MICU course was significant for empiric Abx (discontinued on
transfer to the floor since no clear infection), diuresis, rate
control with BB, CCB. Had one day of stridor thought secondary
to airway edema post-extubation that resolved after a dose of
racemic epi. Was started on 240mg dilt and has became brady to
high 30's -> thus dilt was readjusted to 120mg daily.
.
On transfer to the floor:
# Respiratory [**Name (NI) 13115**] Pt had decreasing O2 requirements from 4L
to 2L via NC on the floor. Continued O2 requirement was
attributed due to pleural effusion and atelectasis. She was
gently diuresed with a goal of 500-1L negative w/ 20 po lasix
daily. The pt was thought to have a very tenous fluid and
hemodynamic status and overdiuresis was carefully avoided.
Incentive spirometry was continued. At discharge the pt was
considered close to her euvolemic status. She developed a
contraction alkalosis in the days prior to discharge but did not
have episodes of hypotension or an increase in her
BUN/Creatinine. Further diuresis should be adjusted cautiously
based on clinical exam. The pt should be slowly weaned of O2 as
tolerated.
.
# Atrial fibrillation was rate controlled with acebutolol and
dilt 120 ER initially.
Due to repeated episodes of rapid ventricular response diltiazem
was titrated up to 180mg qAM on [**12-22**]. The Pt was anticoagulated
with a goal of INR between 1.8-2.0.
The INR on [**12-21**] was 1.9. 3mg of Coumadin was given on [**12-21**],
but it was held on the [**12-22**] because of an INR of 2.5. We
recommend to give 2mg of Coumadin today in the evening as the
INR on the day of discharge was 1.6. Coumadin will need to be
adjusted according to INR measurements.
.
# Hypotension: See MICU course. Likely multifactorial and now
stable. Was Empirically started on steroids for questionable
sepsis and relative adrenal insufficiency but steroids were
discontinued on the floor and the pt was able to maintain a good
BP.
.
# [**Name (NI) **] Pt with white count of 17 and left shift on admission
without clear source of infection. Was empirically treated with
levo/flagyl but these were stopped on transfer to the floor
since no clear signs of infection were found. Blood and urine Cx
were negative. A CXR from the [**2182-12-19**] showed resolved pulmonary
edema; with b/l pleural effusions with L>R; there is also R
paracardiac and l basilar subsegmental atelectasis which
correlates with physical exam (pt with decreased BS at bases
with crackles). Repeating CXR on [**12-21**] showed remaining L
effusion. Effusion was thought to be unlikely from other causes
then cardiac disease and no further interventions or imaging was
done.
.
# Abdominal pain resolved upon admission to the floor. Previous
CT showed sigmoid diverticulosis without evidence for
diverticulitis, but was negative for other processes. The pt has
been having daily bowel movements until discharge.
.
# CKD- Baseline creatinine reportedly 1.4-1.5, came in at 1.7
likely from decreased forward flow from the afib and CHF or
hypovolemia. Creatinine now 1.1 on discharge.
.
# CAD/Chest pain- Pt with recent cardiac cath which demonstarted
clean coronaries, only had 30% lesion in LCx. In the ED there
was a concern for aortic dissection given the nature of her
symptoms, which was ruled out by TEE. Cardiac enzymes with mild
troponin leak, nml CK likely represented demand ischemia. The pt
was continued on the betablocker Acebutolol 200mg [**Hospital1 **].
.
#Hypothyroid: Thyroid replacement was continued. TSH wnl.
.
# FEN- Diet:low Na/Heart healthy. The pt was gently diuresed
with a goal of I/O is -500-1000cc/day. Electrolytes were
repleted as necessary.
.
# Prophylaxis: PPI, coumadin, bowel regimen. PT service saw the
patient and recommended further rehab.
.
# Code- Per discussion with daughter patient is DNR, but not
DNI.
.
# Communication- [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 104616**] (daughter)- cell ([**Telephone/Fax (1) 104617**] or beeper ([**Telephone/Fax (1) 104618**]
Medications on Admission:
Diltiazem 120mg [**Hospital1 **], acebutolol 200mg [**Hospital1 **], warfarin 4mg qday,
Atorvastatin 10 mg qday, Levothyroxine 100 mcg qday,
Nitroglycerin 0.3 mg Tablet SL prn, Docusate Sodium 100 mg [**Hospital1 **],
Pantoprazole 40 mg qday, Furosemide 20 mg qday
Discharge Medications:
1. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Acebutolol 200 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Senna 8.6 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. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*2*
12. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime):
adjust for INR between 1.8-2.0.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
Primary diagnosis:
1. Pulmonary Edema
.
Secondary Diagnoses:
- constipation
- CHF/diastolic dysfunction
- COPD
Discharge Condition:
AAOx3
Ambulating with walker
having BMs
A little hard of hearing
Discharge Instructions:
Please continue to take the medications as listed on this
discharge sheet. Ensure that you keep taking laxatives so that
you do not become obstructed. Avoid Magnesium citrate enemas.
.
If you develop any chest pain, shortness of breath, fevers, or
any concerning symptoms, please call your primary care
physician.
Followup Instructions:
You have the following premade appointments. you can call the
number below if you have any questions.
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 8754**] DERMATOLOGY GEN-[**Doctor First Name 8754**] (NHB)
Date/Time:[**2183-1-3**] 9:30
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2183-2-17**] 1:00
Provider: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD Phone:[**Telephone/Fax (1) 5003**]
Date/Time:[**2183-2-24**] 10:00
|
[
"564.00",
"401.9",
"428.33",
"496",
"427.31",
"585.9",
"425.1",
"276.1",
"428.0",
"272.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13100, 13173
|
6926, 11537
|
253, 270
|
13328, 13395
|
2786, 2786
|
13757, 14317
|
2171, 2360
|
11852, 13077
|
13194, 13194
|
11563, 11829
|
13419, 13734
|
2375, 2767
|
13255, 13307
|
188, 215
|
298, 1306
|
2802, 6903
|
13213, 13234
|
1328, 1849
|
1865, 2155
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,207
| 117,111
|
54356
|
Discharge summary
|
report
|
Admission Date: [**2185-5-24**] Discharge Date: [**2185-6-10**]
Date of Birth: [**2124-1-16**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3619**]
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Endoscopy s/p cauterization
Intubation x 2
Central line placement
History of Present Illness:
The Pt is a 61y/o M with a PMH of primary sclerosing cholangitis
dx w/ cholangiocarcinoma [**8-28**] during routine change of stent
placed for recurrent biliary obstruction (CA19-9 at diagnosis
about 3). Cholangiocarcinoma found when CT scan [**9-27**]
demonstrated a 2.4 x 3.2 cm diameter low attenuation mass
surrounding the common duct, extending into the region of the
pancreatic head and through the retroperitoneum down to the
renal vein and encasing the proximal portal vein as well as the
hepatic artery. There was evidence also that the duodenum was
encroached upon by the tumor, although not circumferentially.
Based on the CT findings he was deemed unresectable. Received 6
cycles of Gemcitabine/oxaliplatin [**10-28**] to [**4-28**]. Pt found to
have progression of pulmonary disease and chemo regimen was
changed to second line of cisplatin/5FU [**4-28**]. Course complicated
by thrush and fatigue.
.
Pt presented to ED with hematochezia and hematemesis with BRB.
Hct 19 at OSH from 26 yesterday. Here hemodyamically stable. S/p
2U PRBC, 2LIVF at OSH in the setting of SBPs of 70s-->90s.
Past Medical History:
Onc history:
Dx [**8-28**] with cholangiocarcinoma
-- local extension including encasing the portal vein and
hepatic artery, extending into the head of the pancreas and
encircling the duodenum. (Not surgical candidate)
-- Chemotherapy: 6 cycles Gemcitabine/Oxaliplatin with
progression ([**Date range (1) 111295**]), 1 cycle 5FU and cisplatin (Currently
day 16 cycle 1)
Other PMHx:
-Primary sclerosing cholangitis (followed by Dr. [**Last Name (STitle) 497**]
-melanoma resection mid back approx 10 years ago with negative
sentinel node
-Cholecystectomy >20 years ago
Social History:
Physics teacher at [**Location (un) 5028**] High School.
Family History:
Married x
30 years. 2 children. No smoking, no etoh
Physical Exam:
afebrile, HR 90s, BP 110s/60s, 100% RA
NAD- alert and talkative, jaundiced
lungs clear
RRR, soft SM
abdomen protuberant, liver edge palpable just below costal
margin, splenomegaly not detected
no peripheral edema
Pertinent Results:
[**2185-5-23**] 03:35PM BLOOD WBC-5.2 RBC-3.17* Hgb-8.8* Hct-26.2*
MCV-83 MCH-27.7 MCHC-33.6 RDW-18.3* Plt Ct-82*#
[**2185-5-24**] 03:20AM BLOOD WBC-4.5 RBC-2.57* Hgb-7.4* Hct-22.0*
MCV-86 MCH-29.0 MCHC-33.9 RDW-17.7* Plt Ct-74*
[**2185-5-24**] 07:41AM BLOOD WBC-3.7* RBC-2.78* Hgb-8.4* Hct-23.4*
MCV-84 MCH-30.1 MCHC-35.7* RDW-16.3* Plt Ct-80*
[**2185-5-24**] 10:25AM BLOOD WBC-3.9* RBC-3.14* Hgb-9.6* Hct-26.4*
MCV-84 MCH-30.6 MCHC-36.4* RDW-15.4 Plt Ct-72*
[**2185-5-24**] 09:50PM BLOOD Hct-30.7*
[**2185-5-27**] 05:39AM BLOOD WBC-2.4* RBC-3.31* Hgb-10.2* Hct-28.8*
MCV-87 MCH-30.8 MCHC-35.4* RDW-16.1* Plt Ct-245
[**2185-5-27**] 01:15PM BLOOD WBC-2.8* RBC-4.07* Hgb-12.1* Hct-34.7*
MCV-85 MCH-29.8 MCHC-35.0 RDW-15.6* Plt Ct-215
[**2185-5-23**] 03:35PM BLOOD Neuts-84* Bands-2 Lymphs-4* Monos-9 Eos-0
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2185-5-27**] 05:39AM BLOOD Neuts-67 Bands-0 Lymphs-18 Monos-9 Eos-4
Baso-0 Atyps-2* Metas-0 Myelos-0
[**2185-6-2**] 12:00AM BLOOD PT-12.9 PTT-25.4 INR(PT)-1.1
[**2185-5-24**] 03:20AM BLOOD PT-15.7* PTT-27.9 INR(PT)-1.4*
[**2185-5-24**] 03:20AM BLOOD Glucose-181* UreaN-22* Creat-0.9 Na-135
K-3.7 Cl-103 HCO3-24 AnGap-12
[**2185-5-27**] 09:55AM BLOOD Glucose-112* UreaN-33* Creat-0.9 Na-137
K-3.4 Cl-108 HCO3-21* AnGap-11
[**2185-5-27**] 05:39AM BLOOD ALT-39 AST-45* LD(LDH)-228 AlkPhos-442*
TotBili-1.9*
[**2185-5-24**] 03:20AM BLOOD ALT-64* AST-53* CK(CPK)-42 AlkPhos-322*
TotBili-1.0
[**2185-5-24**] 03:20AM BLOOD Lipase-15
[**2185-5-25**] 04:36AM BLOOD Lipase-7
[**2185-5-24**] 03:20AM BLOOD Albumin-2.5* Calcium-7.2* Phos-3.2 Mg-1.7
[**2185-5-27**] 09:55AM BLOOD Calcium-7.5* Phos-2.2* Mg-2.0
[**2185-5-27**] 04:11PM BLOOD Type-ART pO2-152* pCO2-40 pH-7.35
calTCO2-23 Base XS--3
[**2185-5-24**] 03:20AM BLOOD Glucose-166* Lactate-1.5 Na-132* K-3.6
Cl-103 calHCO3-24
[**2185-5-27**] 04:35PM BLOOD freeCa-1.06*
[**2185-5-24**] 01:57PM BLOOD freeCa-1.12
Angiogram #1
Selective arteriograms were performed within the celiac trunk
and SMA without signs of active bleeding.
Embolization of the gastroduodenal artery was performed with one
3-mm coil, four 4-mm coils and one 5-mm coil.
Delayed images demonstrated no opacification of the portal vein,
suggesting occlusion of this vessel.
Note: The patient has been stable with no further bleeding over
a 24 hour
period.
The study and the report were reviewed by the staff radiologist.
Angiogram # 2
IMPRESSION: Selective arteriograms were performed in the celiac,
SMA and [**Female First Name (un) 899**] without signs of active bleeding.
There is no flow within the GDA that was previously embolized
with coils.
The study and the report were reviewed by the staff radiologist
CT Abd/Pelvis:
1. Marked interval increase in intra-abdominal and intrapelvic
ascites with anasarca.
2. Bilateral pleural effusions, right greater than left.
3. Small bowel loops are dilated up to 4.2 cm with air seen
distally,
suggestive of an ileus. No evidence of free air.
4. Evaluation of vasculature could not be performed due to lack
of IV
contrast.
5. Sigmoid colonic wall thickening could be suggestive of
procto-sigmoiditis.
Abdominal Ultrasound [**6-2**]:
IMPRESSION: Large amount of ascites in all four abdominal
quadrants with
marking of right lower quadrant for paracentesis to be performed
by clinical staff.
Abdominal Ultrasound [**6-6**]:
Limited evaluation of the four abdominal quadrants was
performed. Small
pockets of ascites were identified in each quadrant with a
moderate-sized
pocket above the bladder. No site was large enough to mark for
paracentesis.
IMPRESSION: Moderate ascites without adequate spot for
paracentesis marking
Brief Hospital Course:
61M w/ primary sclerosing cholangitis diagnosed with
cholongiocarcinoma who presented hematemsis and BRBPR. This
stopped by the time he came to the ER. Endoscopy saw a clot in
the second portion of the duodenum, and during the procedure a
large amount of bleeding began apparently out of the second part
of the duodenum. The procedure was stopped and the patient was
transfused ~8-10U PRBC. An emergent angio did not find the
source of bleeding. The gastroduodenal artery was embolized as
the most likely source. 24 hours later the patient rebled and
was intubated for airway protection. ERCP found a bleeding
vessel in an ulcerated part of the tumor in the second part of
the duodenum. This was injected w/ epi and cauterized. A repeat
angio showed no clear target for embolization as the tumor was
well-vascularized, so given that the patient was likely to
rebleed and that the next bleed would be untreatable, the
decision was made to make the patient CMO. He was extubated and
actually did well. He remained hemodynamically stable and was
transferred to the floor.
On the floor, his only complaint was his abdominal distension
from his ascites. This was drained for palliative purposes on
[**6-2**] by paracentesis. This made him feel much better and allowed
him to eat. He had an abdominal port placed by interventional
radiology on [**6-9**] without incidence for repeat paracenteses.
Mr. [**Known lastname **] has a very high chance of the bleeding vessel
rebleeding and there is no medical intervention that can be done
to alleviate it at this time. In discussion with the family, the
patient, his primary oncologist, and the palliative care team,
the decision was made to focus on his comfort. His daily needs
are minimal but when his bleeding starts again, he will likely
need an NGT quickly for managment of bleeding as well as
possible associated nausea/hematemesis. He may also need a
flexiseal or other similar stool management system if he begins
having bright red blood per rectum.
Medications on Admission:
pancrease suppl qac
ursodiol 300mg tid
Dexamethasone
Compazine
Clotrimazole
Zofran
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
3. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold for diarrhea.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) 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. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
9. 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.
10. 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.
11. Morphine Sulfate 2-6 mg IV Q1H:PRN
12. Lorazepam 0.5-2 mg IV Q1H:PRN anxiety, tachypnea
13. Ondansetron 4 mg IV Q8H:PRN
Discharge Disposition:
Extended Care
Facility:
The [**Hospital1 656**] Family Hospice House
Discharge Diagnosis:
Upper gastrointestinal bleed
Cholangiocarcinoma
Primary Sclerosing Cholangitis
Discharge Condition:
All vital signs stable, comfortable.
Discharge Instructions:
You were admitted with a severe gastrointestinal bleed. It was
stabilized temporarily but will bleed again and at that time
there is no treatment available to stop it.
You also have acculmulations of fluid in your abdomen. You
underwent one drainage procedure and then had an abdominal port
placed to allow for easier drainage procedures in the future.
We have stopped all medications that do not contribute to your
comfort.
Followup Instructions:
None. Please call Dr. [**Last Name (STitle) **] (primary oncologist) at ([**Telephone/Fax (1) 83254**] with any questions.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 3621**]
|
[
"E933.1",
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"401.9",
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"041.3",
"156.9",
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"452",
"584.9",
"288.50",
"197.4",
"287.5",
"578.9",
"572.3",
"456.21",
"197.0"
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icd9cm
|
[
[
[]
]
] |
[
"45.30",
"38.93",
"86.07",
"45.13",
"96.04",
"99.04",
"54.91",
"99.29",
"96.71",
"88.47",
"99.05",
"44.44",
"51.10",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9547, 9618
|
6163, 8165
|
324, 391
|
9741, 9780
|
2507, 6140
|
10256, 10504
|
2204, 2258
|
8299, 9524
|
9639, 9720
|
8191, 8276
|
9804, 10233
|
2273, 2488
|
276, 286
|
419, 1522
|
1544, 2114
|
2130, 2188
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,620
| 135,871
|
16482
|
Discharge summary
|
report
|
Admission Date: [**2170-12-28**] Discharge Date: [**2171-1-1**]
Date of Birth: [**2106-8-8**] Sex: M
CHIEF COMPLAINT: Left upper quadrant abdominal mass and
abdominal pain.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 64-year-old
abdominal mass. This mass was suggestive of adenocarcinoma
of the transverse colon or possible lymphoma.
The patient is status post abscess drainage and diverting
loop colostomy at an outside hospital; this outside hospital
being [**Hospital3 **] in [**Location (un) 7658**]. The patient was transferred to
the [**Hospital1 69**] Emergency Department
pain. His loop colostomy was done about six weeks ago. At
that time, a 12-cm left upper quadrant mass near the splenic
flexure was identified. Serial computed tomographies at [**Hospital3 14565**] showed stability of this mass but development of an
apparent gastric colic fistula. Of note, the patient has
been complaining of persistent left upper quadrant and left
flank pain and recently completed a course of antibiotics for
his phlegmon without development of bacterial sepsis.
Currently, he is complaining of left upper quadrant and left
flank pain. No fevers, chills, sweats, nausea, vomiting,
dysuria, or hematuria. He is taking oral intake well. His
ostomy is pink and viable. He has no melena, hematochezia,
and no acute changes in the quality of his stool.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Myocardial infarction.
3. Status post catheterization; no stent with a negative
stress test four months ago.
MEDICATIONS ON ADMISSION: Diovan, Lopressor, Lipitor.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He quit smoking about 14 months ago. He
occasionally drinks wine.
PHYSICAL EXAMINATION ON PRESENTATION: Initial physical
examination revealed vital signs with a temperature of 100.6,
heart rate was 120, blood pressure was 111/87, respiratory
rate was 18, oxygen saturation was 95% on room air. His
heart was regular in rate and rhythm. No murmurs, rubs, or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was soft and nontender. He had positive left
upper quadrant tenderness. No rebound. No rigidity. No
guarding. His extremities were warm and well perfused.
RADIOLOGY/IMAGING: Pertinent x-rays revealed a computed
tomography scan upon admission which showed a large low
attenuating mass in the left upper quadrant encasing the
splenic flexure, stomach, spleen, and pancreatic tail;
invading the chest wall and diaphragm with a large left
pleural effusion, and a small amount of fluid in the left
paracolic gutter; tumor probably arose from the splenic
flexure of the colon. There was a fistula from the stomach
to the transverse colon, but no evidence of free
extravasation of contrast in the abdomen. There was no
evidence of small-bowel obstruction or perforation in the
abdomen.
HOSPITAL COURSE: The patient was admitted to the floor,
made nothing by mouth, and given intravenous fluids and
antibiotics. The patient was to have a Gastrointestinal
consultation and an esophagogastroduodenoscopy for biopsies,
as the mass was most likely not operable; however, if it
turned out to be lymphoma we could possibly start
chemotherapy.
The patient started his preparation on hospital day two of
GoLYTELY and Fleet enemas and was ready for his
esophagogastroduodenoscopy and colonoscopy on hospital day
four.
On hospital day four, the patient acutely had bright red
blood per ostomy and hematemesis. The patient also had left
upper quadrant pain with this, and the nurses found his blood
pressures at this time to be 70/50 and 80/60. The patient
was awake and responsive at this time. He was emergently
intubated, put in a right subclavian triple lumen and a left
groin cordis with blood and fluid resuscitation. The patient
was then transferred to the Intensive Care Unit for
management.
In the Intensive Care Unit, the patient underwent an emergent
endoscopy which showed a large blood clot in the stomach;
most likely a bleeding source from the invasion of the tumor.
A chest x-ray also showed a large left pleural effusion
compressing the right side of the lung with mediastinal
shift, so a chest tube was placed at that time.
After discussion with the family, and because of the poor
prognosis, and ongoing transfusion requirement, and the
inability to control the bleeding, the family discussions
moved toward withdrawing intervention. The wife wished to
stop transfusions and further intervention.
The decision was made to have no chest compressions or
chemical resuscitation, and soon after that the family
decided to extubate the patient and have comfort measures
only.
The patient was transferred from the Intensive Care Unit to
the floor with comfort measures only. On hospital day five,
the patient expired on the floor.
CONDITION AT DISCHARGE: The patient deceased.
DISCHARGE STATUS: Discussion still ongoing with family as to
whether postmortem will be performed.
DISCHARGE DIAGNOSES: Death secondary to hemorrhagic shock
caused by large left upper quadrant abdominal tumor.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3799**], M.D. [**MD Number(1) 3800**]
Dictated By:[**Name8 (MD) 1750**]
MEDQUIST36
D: [**2171-1-1**] 15:39
T: [**2171-1-4**] 09:46
JOB#: [**Job Number **]
|
[
"V10.05",
"511.8",
"197.2",
"578.9",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"34.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5020, 5369
|
1577, 1644
|
2905, 4858
|
4873, 4997
|
135, 191
|
220, 1394
|
1416, 1549
|
1661, 2886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,570
| 183,034
|
27025
|
Discharge summary
|
report
|
Admission Date: [**2182-12-27**] Discharge Date: [**2183-1-24**]
Date of Birth: [**2114-12-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
SOB, Orthopnea and DOE
Major Surgical or Invasive Procedure:
Intubation
Tracheostomy
PEG tube placement
Cardiac Catheterization
History of Present Illness:
Patient is a 67 year old male with history of DM-II, CKD, MI,
CAD, CHF, A-fib, who was transferred from an OSH [**2182-12-27**] with
reported fluid overload. Pt was initially referred to OSH with
sxs of SOB, orthopnea, and DOE as well as a R thigh abscess at
donor saphenous graft site. US performed @ OSH showed 7cm fluid
collection in the right mid thigh, for which he was started on
Vancomycin and Zosyn ([**2182-12-26**]). At [**Hospital1 18**], abx regimen was
switched to Vancomycin/Levofloxacin/Flagyl ([**12-28**]). Vancomycin was
discontinued and levofloxacin switched to cipro on [**12-31**]. Pt was
on the vascular servive aduring this admission but was being
followed by cardiology and diuresed on the floor since [**12-28**] for
gross total body fluid overload. The patient decompensated early
am on the day of transfer with sats in the mid 80s, requiring
Dopamine gtt to maintain MAP > 65. The patient was initially
transferred to SICU on [**1-2**] for further diuresis, continuation of
Dopamine gtt, and commencement of BiPap. In the SICU, the
patient had worsening SOB and hypercapnia that was not
responding to diuresis. The patient was transferred to CCU for
management of above.
In the CCU, the pt had worsening SOB, hypoxia, hypercapnia
that was not responding to diuresis so he was tried on bipap and
then intubated. Pt was switched from dopa to neo to levophed.
Initially diuresed to -3.3L, but didn't tolerated less PS
despite this. Now LOS ~even. Pt has had low-grade F (to 100.0)
from [**1-3**], then up to 102 on [**1-5**]. Pt was also given
inhaled NO x ~1 day with reported decrease in PA BPs, then
transitioned to Viagra.
Upon transfer to MICU ([**1-6**]), pt denies pain. Continues to
require levophed for BP support. Tolerating PS mechanical
ventilation. CCU team gave pt 80 IV lasix today x1 for diuresis.
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD s/p MI
2. DM-II w/neuropathy and nephropathy
3. CAD s/p CABG x 5 ([**7-29**])
4. CHF
5. CRI (Cr 1.3)
6. A-fib
7. PVD
8. CVA
9. Hypercholesterolemia
PAST SURGICAL HISTORY:
1. CABG ([**7-29**])
2. R fem-peroneal bypass ([**9-28**])
Social History:
Retired policeman. Lives in FL, former smoker (15-20pack year),
occasional EtOH
Family History:
non-contributory
Physical Exam:
Vitals: BP 77/48 HR 75 RR 20
Gen: A/O x3, cooperative with commands, on BiPAP
HEENT: PERRLA, NC/AT
Neck: JVD
COR: S1 S2 regular rate, rhythm. 2/6 SEM heard left
parasternal border. no S3, S4. Carotid bruit exam not possible
[**12-26**] BiPAP.
Pulm: wet crackles 2/3 up bilaterally, R>L.
Abd: soft, nt, nd. + BS. no abdominal masses palpated.
Ext: WWP bilaterally. 1+ DP bil. gross interstitial and
pitting edema observed in [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 6816**]. R saphenous vein
graft donor site indurated, with 4"x2" irregular patchy erythema
surrounding incision site. Bil extremities w ACE wrap per
vascular.
MS: A/O x 3
(Upon transfer from CCU to MICU on [**1-6**])
-VS: T 101.3, HR 57-73, BP 104/54 (SBP 84-117), Sat 98-100% on
vent
-Vent: PS 15, PEEP 10, 40% FiO2
-I/O: 3800/1600 to MN; 1800/1400 since MN
-PCWP 7-14 ([**September 2182**])
-Swan ([**1-2**]): CVP 13-16, RA 15-20; RV 75/7; PA 75/24 (69-80 PA
systolic); wedge 15, CO 6.5, CI 2.5, SVR 665 (on dopa).
-Swan ([**1-5**]): CVP 14-19, PA 69/27, wedge 17-18, CO 5.9, CI
2.3, SVR 637 (on neo).
-Gen: elder M sitting in bed, intubated, calm
-Skin: bilat LEs in dressings; L-toe dry gangrene
-HEENT: OP w/ETT, EOMI, anicteric sclera
-Heart: S1S2 RRR, no M apprec
-Lungs: coarse upper airway sounds bilat; fine crackles bilat
lower lobes; fair air movement
-Abdom: soft, obese, NT, ND, NABS
-Genital: edematous penis & scrotum
-Extrem: trace bilat LE pulses, 2+ bilat pitting edema
-Neuro/Psych: alert, follows simple commands, moves all
extremities
Pertinent Results:
Admission labs:
.
[**2182-12-27**] 06:30PM PT-48.9* PTT-39.3* INR(PT)-5.7*
[**2182-12-27**] 06:30PM PLT COUNT-215
[**2182-12-27**] 06:30PM HYPOCHROM-2+ ANISOCYT-1+ MACROCYT-1+
[**2182-12-27**] 06:30PM NEUTS-77.6* LYMPHS-13.5* MONOS-5.5 EOS-3.1
BASOS-0.3
[**2182-12-27**] 06:30PM WBC-10.1 RBC-4.81# HGB-14.0# HCT-44.2# MCV-92
MCH-29.1 MCHC-31.7 RDW-17.4*
[**2182-12-27**] 06:30PM CALCIUM-9.0 PHOSPHATE-4.2# MAGNESIUM-2.2
[**2182-12-27**] 06:30PM CK-MB-NotDone cTropnT-0.09*
[**2182-12-27**] 06:30PM CK(CPK)-23*
[**2182-12-27**] 06:30PM GLUCOSE-90 UREA N-35* CREAT-1.5* SODIUM-144
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-34* ANION GAP-12
.
[**2183-1-2**]: proBNP-[**Numeric Identifier 66437**]*
[**2183-1-3**]: proBNP-[**Numeric Identifier 27500**]*
.
[**2182-12-31**] Iron binding studies: calTIBC-264 Ferritn-80 TRF-203
[**2183-1-3**] [**Last Name (un) **] Stim: 21.4 -> 27.3 -> 30.9
.
.
STUDIES PERTAINING TO RLE FLUID COLLECTION:
[**2183-1-5**]: Right Noninvasive LE ultrasound - repeat imaging
IMPRESSION: 1) Fluid collection tracking deep to the
subcutaneous tissues; significantly smaller but more organized
compared to the ultrasound of [**2182-12-30**]. Superficial to and
distinct from the bypass graft. No flow to suggest
pseudoaneurysm.
2) Subcutaneous tissue edema consistent with cellulitis.
.
[**2182-12-30**]: Right Noninvasive LE ultrasound
There is evidence of extensive subcutaneous infiltration and
induration
consistent with cellulitis. In addition, there is a linear
tract extending from the superficial surface - corresponding to
the scar site that extends to a deeper collection that measures
a maximum of 7 x 2 cm. This collection runs along the
undersurface of the thigh, but lies superficial to the patient's
graft site. The graft is identified and is patent (see separate
report). The graft is separated from the superficial collection
by a distance of 1.3 cm. This superficial collection contains no
flow and is not thought to represent a pseudoaneurysm.
.
.
Pulmonary Hypertension Work-up:
[**2183-1-3**] [**Doctor First Name **]-NEG
[**2183-1-3**] RheuFac-<3
[**2183-1-4**] HIV Ab-NEG
[**2183-1-3**] SCLERODERMA ANTIBODY-NEG
.
[**2183-1-2**]: Swann Ganz Catheter Placement: RA 15-20 mmHg (A wave);
RV 75/7; PA 75/24; PCWP 15
.
.
[**2183-1-5**]: CTA Chest: There is no CT evidence for pulmonary
embolism. Specifically, the questionable filling defects seen
in the left lower lobe on the prior CT are now well opacified.
This pulmonary branches demonstrate normal enhancement without
filling defects. There are moderate bilateral pleural effusions
and bibasilar atelectasis. There is mild diffuse ground glass
opacities as well as septal thickening. There is enlargement of
the cardiac silhouette with increase in size of both left and
right side [**Doctor Last Name 1754**]. In addition, there is mild enlargement of
the coronary sinus. All these findings suggest congestive heart
failure.
IMPRESSION:
1. Congestive heart failure with bibasilar atelectases and
moderate pleural effusions.
2. No evidence for pulmonary embolism.
.
[**2183-1-3**]: Echocardiogram
Left Atrium - Long Axis Dimension: *4.2 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: *5.8 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.4 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.2 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.1 cm (nl <= 5.6 cm)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: 1.4 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 0.88
Mitral Valve - E Wave Deceleration Time: 224 msec
TR Gradient (+ RA = PASP): *32 to 36 mm Hg (nl <= 25 mm Hg)
.
INTERPRETATION:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter
or pacing wire is seen in the RA. No ASD or PFO by 2D, color
Doppler or saline contrast with maneuvers.
LEFT VENTRICLE: Normal LV cavity size. Suboptimal technical
quality, a focal LV wall motion abnormality cannot be fully
excluded. Cannot assess LVEF.
RIGHT VENTRICLE: Moderately dilated RV cavity. RV function
depressed.
AORTIC VALVE: Moderately thickened aortic valve leaflets. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. Mild (1+) MR. LV inflow pattern c/w impaired
relaxation.
TRICUSPID VALVE: Mild PA systolic hypertension.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: Compared with the findings of the prior study,
there has been no significant change.
.
.
MICROBIOLOGY DATA:
.
Blood Cultures:
[**2182-12-27**]: NGTD
[**2182-12-30**]: NGTD
[**2182-12-31**]: NGTD
[**2183-1-3**]: NGTD
[**2183-1-4**]: NGTD
[**2183-1-5**]: NGTD
.
[**2183-1-11**]: Stool - C.diff Neg
.
Catheter Tips
[**2183-1-4**]: PICC - No significant growth
[**2183-1-5**]: Swann Ganz - No significant growth
.
Wound:
[**2182-12-27**]: Right Thigh - Sparse growth SERRATIA MARCESCENS,
pan-sensitive
.
Urine Cultures:
[**2183-1-4**]: NGTD
[**2183-1-5**]: NGTD
.
Sputum:
[**2183-1-3**]: GRAM STAIN :[**9-17**] PMNs <10 epis, NO MICROORGANISMS
SEEN. RESPIRATORY Cx: SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2183-1-4**]: Gram Stain: >25 PMNs , <10 epis
3+ GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
3+ GRAM POSITIVE RODS
RESPIRATORY CULTURE: MODERATE GROWTH OROPHARYNGEAL FLORA.
SPARSE GROWTH GRAM NEGATIVE ROD(S)
[**2183-1-5**]: Gram Stain: > 25 PMNs, < 10 Epis
1+ MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE: ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
BAL [**2183-1-7**]:
GRAM STAIN (Final [**2183-1-7**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final [**2183-1-9**]): ~8OOO/ML OROPHARYNGEAL
FLORA.
.
[**2183-1-11**]: Lyme:
POSITIVE BY EIA.
NEGATIVE BY WESTERN BLOT.
Brief Hospital Course:
A/P: Patient is a 57 year old male with multiple medical
comorbidities found to have severe pulmonary hypertension
without known cause with hospital course complicated by right
heart failure and respiratory failure.
.
1. Respiratory Failure: The pt was initially intubated on [**2183-1-2**], for hypoxic and hypercarbic respiratory failure. The
etiology of the respiratory failure was felt to be
multifactorial with contributions from fluid overload, PNA,
diaphragmatic dysfunction (later diagnosed after intubation) on
top of possible baseline chronic pulmonary disease (as pt was
tobacco smoker). The pt was overtly fluid overloaded and
difficult to diurese in the CCU leading to the original
intubation. The difficulty diuresing was felt to be due to
hypotension from [**Month (only) **]. intravascarul volume from septic
physiology (vasodilatory). He was transferred to the MICU where
he was treated with abx (as below) and gradually he demonstrated
recovery from his PNA. However he remained difficult to wean
and on physical examination was found to have parodoxical
breathing pattern. This was further investigated with a bedside
US and the pt was found to have a left sided diaphragmatic
paralysis resulting in paradoxical motion of the diaphragm.
After he had recovered from his infectious insult he was slowly
diuresed with a lasix gtt maintaining goal diuresis of negative
500 to 1000cc/day. On [**2183-1-20**], he was doing well from a
respiratory perspective, breathing on PS with 5/5. His RSBI in
the AM was found to be 70 and after repeat was 56. ABG
demonstrated good ventilation and oxygenation and the pt was
extubated. However several hours after extubation, the pt
became short of breath with worsening ventilation by ABG. This
was felt to be due to his diaphragmatic dysfunction and the pt
was re-intubated the same day. He was evaluated by the
interventional pulmonary team and received a tracheostomy and
PEG tube placement on [**2183-1-21**]. The following day, the pt was
doing well on PS of [**8-28**] without any difficulty. He was
transferred to rehabiliation facility for further weaning and
potential tracheostomy removal after improvement in his
diaphragmatic function and further diuresis.
.
2. Diaphragmatic dysfunction: The pt was not previously not
known to have any signficant neuropathy and the dx of
diaphragment dysfunction was further investigated. During his
MICU stay, the neurology team was consulted to further assist in
management of this problem. Unilateral diaphragmatic
dysfunction/weakness are usually asymptomatic unless the pt is
otherwise comprised (ie with pneumonia and heart failure). His
physical examination was consistent with some amount of lower
motor neuron weakness in his right leg, which was found to be
fairly severe. Differential diagnosis includes: peripheral
neuropathy affecting the phrenic nerve (diabetes, CIDP,
vasculitis, connective tissue disease given + [**Doctor First Name **], possibly
motor neuron disease) vs. prior injury during CABG in [**7-29**] (can
be injured during
cooling) vs. spinal cord injury (C 3,4, 5), less likely given
his arms are
strong and nutritional deficits causing injury to nerves. Aside
from treating the underlying cause, the only other treatment for
this condition is surgical plication. The neurology service
recommended supportive care at this moment with investigation
into treatment later on after recovery from his acute insults
(PNA, CHF, Pulm HTN). They recommended an EMG/NCS to help
diagnose a neuropathy, and if the results demonstrate a
demyelinating disorder then he may benefit from treatment with
IVIG. This should be followed up as an outpt.
.
3. Infectious Disease: The patient arrived at the OSH with
suspected cellulitis/abscess at the saphenous donor site on his
R medial upper thigh. Vancomycin and Zosyn were initiated on
[**12-26**]. Blood cultures from [**12-27**] revealed no growth, but wound
cultures grew pan-sensitive serratia marscens. On [**12-28**], abx
regimen was switched to Vancomycin/Levofloxacin/Flagyl. On [**12-30**],
U/S of the R thigh collection revealed a 7.0 x 2.0 cm collection
superficial to the saphenous donor graft site; although the skin
over the R thigh donor site collection was indurated and
erythematous, vascular surgery did not consider the collection
to represent an abscess. It was instead felt to be a residual
fluid collection from post-op and not pathologically relevant.
Blood cultures from [**12-30**] and [**12-31**] showed no growth. Vancomycin
was discontinued and levofloxacin was switched to cipro on [**12-31**];
flagyl was continued. Although the patient was afebrile and had
a normal WBC count since admission, broad-spectrum antibiotics
were continued given concern for early sepsis in light of low
SVR measured with the swan-ganz catheter and repeated episodes
of hypotension. Potential sources included: (1) a peristent LLL
infiltrate that was poorly characterized on CXRs taken
throughout the hospital course, possibly representing PNA, (2)
peripheral spread from the potential R thigh abscess, and (3)
line infection.
.
The patient developed fever and had increasing WBC to 13.9 on
[**1-4**]. Blood, urine, lung, abscess, and line sources were
considered. Blood and urine cultures were drawn on [**2-14**],
and [**1-5**], and have shown no growth to date. Both PICC lines and
Swann Ganz catheters were removed and tips were cultured, and
showed no sinigicant growth to date. Repeat U/S of the R thigh
collection revealed a shrinking collection of fluid but
persistent cellulitis. Vascular surgery reiterated their
contention that the fluid collection did not represent an
abscess. Sputum gr st from [**1-3**] showed GNR and GPC, but
cultures showed no growth. Repeat sputum gr st and cx on [**1-5**]
were clean. At the time of tranfer from the CCU, the most
likely etiologies for the patient's fevers included: line infxn
vs. PNA vs. cellulitis. On [**1-6**], ID service was consulted, and
abx were changed to meropenem/vanc/flagyl. The pt completed a
two week course of antibiotics without further complication. He
was afebrile during the remainder of his MICU stay and his
septic physiology (vasodilatory) resolved with continuation of
antibiotics. All of his antibiotics were discontinued on [**1-20**], [**2182**] and he remained afebrile without significant concern
for further infection.
.
4. Congestive Heart Failure: The pt was transferred from the
OSH with initial complaints of SOB and DOE. On arrival to
[**Hospital1 18**], the pt was felt to be volume overloaded, during the
first 6 hospital days, the patient was agressively diuresed with
transient improvement in SOB, dyspnea, and orthopnea. However,
though pulmonary edema was minimal on CXR upon arrival to CCU,
peripheral edema and JVD were still markedly increased.
Diuresis also did not improve heart function as measured by
persistent hypotension and requirement for pressor support. The
patient arrived at the CCU on dopamine gtt, then was switched to
neosynepherine and finally levophed; attempts to wean were
unsuccessful. Given the evidence for a diagnosis of primary
pulmonary hypertension (see below) and the clinical picture of
right-sided heart failure, the persistent CHF sxs in this
patient were attributed to pulmonary hypertension resulting in
right-sided heart failure.
.
Complicating the picture of this patient's CHF is his
pre-existing LV dysfunction. Echocardiography from [**12-30**] showed a
LVEF of 40-45%, but qualitatively described LV function as
mildly depressed with inferior and infero-lateral hypokinesis.
Repeat echocariography on [**1-3**] was not able to assess LV
function due to technical considerations. Although it is
possible that some degree of LV dysfunction could also be
abetting the CHF picture in this patient, the CCU team
considered it to be a secondary concern given the overwhelming
evidence for R sided failure.
.
After transfer to the MICU, the pt was stabilized from an
infection/sepsis standpoint and with resultant improvement in
his blood pressure, he was able to be diuresed more
aggressively. He was started on a lasix gtt with good urine
output (>100cc/hour) and after several days was transitioned to
lasix IV bolus [**Hospital1 **]-TID with good diuresis. The pt should
continue to be diuresed to achieve a goal of neg 500cc to
1000cc/day until he regained his dry body weight or until his
creatinine and/or bicarbonate demonstrated signs of increase.
Until then, he should have routine electrolytes monitored to
better assess his renal function and his body weight as well as
daily ins and outs should be monitored to verify appropriate
diuresis.
.
5. Cardiac Ischemia: The patient arrived at [**Hospital1 18**] with CEs
under threshold levels for acute MI, but by [**1-1**], the patient's
troponin reached 0.12. However his EKGs were not consistent
with sigificant ichemic changes. He was continued on
ASA/plavix/statin which he was on as an outpatient. CEs again
increased to their peak of TrT of 1.5 and CK-MB of 15 on [**1-2**].
EKG again showed no significant ST changes and the patient was
asymptomatic. CEs decreased thereafter and daily EKGs
thereafter revealed no further ischemia. His plavix was
disontinued one week prior to his Trach/PEG placement after
consultation with his vascular surgeon Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**].
After the Trach/PEG, the plavix was not re-started given his
prior episode of GI bleed while in the MICU. He should be
continued on his ASA and statin. A decision re: re-initiation
of plavix should be made in consultation with his PCP,
[**Name10 (NameIs) 2085**] and vascular surgeon as an outpt.
.
6. Cardiac Rhythm: The patient arrived at [**Hospital1 18**] with a
pre-existing diagnosis of atrial fibrillation, which was
controlled at home with digoxin and sotalol. The patient was
also on chronic anticoagulation at home with coumadin with a
goal INR of [**12-27**]. Digoxin was discontinued upon arrival at [**Hospital1 18**]
given a lack of evidence for significant LV pump dysfunction.
The sotalol was continued, with good control of the atrial
fibrillation; telemetry revealed only infrequent bouts of
paroxysmal a fib. Temporary discontinuation of sotalol resulted
in episodes of PVCs and occasional runs of SVT. The sotalol was
therefore maintained during this admission. The pt's
anticoagulation was initially held until [**1-6**] given a
supratherapeutic INR. However with an episode of GIB, the
anticoagulation was discontinued all together. Decision re:
re-initiation of his anticoagulation should be made as an outpt
after consultation with his PCP and cardiologist.
.
7. Primary Pulmonary Hypertension: The patient was initially
trasnferred to the CCU for indication of fluid overload and
respiratory distress with intention to perform pulmonary artery
catheterization to investigate etiology of patient's symptoms.
On admission the patient was maintained on non-invasive
ventilation as he was noted to become increasingly hypercarbic,
hypoxic and acidemic when off BiPap. Once relatively stabilized
from a respiratory status, the patient underwent placement of a
Swann Ganz catheter which was remarkable for severe pulmonary
hypertension: RA 15-20 mmHg (A wave); RV 75/7; PA 75/24, with
relatively low PCWP suggesting that the patient's right heart
failure on admission was secondary to a primary pulmonary
process rather than secondary to left heart failure. Prior to
admission to the CCU the patient has been undergoing aggressive
diuresis given evidence of decompensated CHF. However, given the
PA cath results it became evident that the patient was actually
relatively [**Name2 (NI) 66438**] the LA/LV which was likely contributing
to the patient's hypotension and pressor requirements.
Additionally, blood gas analysis revealed likely a chronic
respiratory acidosis with compensatory metabolic alkalosis as
well as a primary metabolic alkalosis, likely a contraction
alkalosis secondary to aggressive diuresis. It was thought that
the patient's metabolic alkalosis was liekly contributing to his
impaired respiratory drive and resultant hypercarbic respiratory
failure. Given this, the patient was aggressively repleted with
KCl to correct the underlying metabolic alkalosis. In addition
to LV [**Name2 (NI) 66438**], swan tracings were noteable for a SVR
ranging from 500 to 600. In the setting of hypotension it would
be expected that the patient's SVR would reflect a state of
increased vascular resistance with an elevated SVR. Given that
the patient's SVR was relatively depressed compared to it's
expected values, there was additional concern for potential
distributive shock, likely secondary to sepsis although the
infectious source was not immediately obvious. As the patient's
severe right heart failure appeared to be secondary to a primary
pulmonary process, a pulmonary consult was requested. Pulmonary
consult team recommended a number of studies that might identify
the cause of primary pulm HTN including HIV Ab, Scleroderma Ab,
[**Doctor First Name **], and RF (all neg). The pulmonary consult team suggested
inhaled nitric oxide as an initial empiric treatment for
suspected pulm HTN. In response to iNO rx, BP increased and PAP
decreased, which was taken as a verification of the diagnosis of
pulm HTN. After two days of iNO therapy, the patient was
started on sildenafil, dose escalating from 25mg PO TID to 100mg
PO TID over several days. The patient initially tolerated this
treatment well, with peripheral BP remaining stable or
increasing. PAP improved slightly with sildenafil rx, but the
PA catheter was removed on [**1-5**] due to concern for a line
infection.
.
Later in his CCU course, the pt developed hypotension and
fevers concerning for worsening sepsis/infection. He was
therefore transferred to the MICU where he was worked up for
sepsis. After completion of his antibiotic course as above, his
septic physiology resolved and he slowly regained appropriate BP
and hemodynamics. After careful review of his records, the
pulmonary hypertension was thought to be either primary in
origin as above or secondary due to LVF. Prior to his CABG, the
pt was known to have signficant CHF with compromised LVEF. This
may have led to the development of Pulmonary HTN over time.
However after his CABG, his LVEF was significantly improved.
The pulmonary HTN may not have had time to resolve after the
return of cardiac function. Howevever as he is currently
hemodynamically stable with good diuresis, decision to start
either CCB, prostacyclins or inhaled NO for management of his
pumonary HTN was deferred until further discussion with his PCP
and pulmonologist.
.
8. GIB: The pt was maintained on anticoagulation as noted above
for his atrial fibrillation during most of his hospital stay.
While in the MICU, the pt had one episode of coffee ground
emesis which cleared with NGL. Given his concern for
hemodynamic instability at the time, the anticoagulation was
discontinued. Since that one episode, the pt was also found to
have some coffee ground from his OG tube after re-placement of
his ETT tube on [**1-20**]'[**82**]. In addition, the patient has
displayed a slowly decreasing HCT over the time of his CCU
course. Stools have been guaiac'd and have not been positive to
date. It was planned to transfuse the patient if HCT drops
below 21. At time of discharge a decision as made to
discontinue his anticoagulation. A decision re: re-initiation
of anticoagulation for atrial fibrillation should be made after
discussion with his PCP and cardiologist as an outpt.
.
9. Vascular: The patient is followed as an outpatient by Dr.
[**Last Name (STitle) 1391**]. He had a R fem-peroneal bypass operation in [**9-28**].
In addition to the R thigh fluid collection mentioned above, the
patient's post-operative course was complicated by wound
breakdown at the bypass site on the R calf. Vascular service
has managed wound dressing changes thoughout the hospital course
and plans to place a vac dressing once the immediate issues have
resolved. Most currently, the vascular service has recommended
wet to dry dressing changes on the right calf wound. His wound
appear to heal well with almost aproxmiation/filling at time of
dischage. The pt will follow up with Dr. [**Last Name (STitle) 1391**] as an outpt.
.
10. Renal: The patient has mild pre-existing CKD, with a
baseline Cr of 1.0-1.4. During this admission, the patient has
shown acute on chronic renal insufficiency, likely secondary to
aggressive diuresis and potentially impaired perfusion given
hypotension. Throughout the hospital course, meds have been
renally dosed as appropriate. Mucomyst and hydration have been
given prior to any administration of contrast [**Doctor Last Name 360**]. The pt did
demonstrate improvements in his creatinine and at time of
discharge his renal function was back at baseline.
.
11. Endocrine: The patient has DM, which has been managed with
an insulin sliding scale throughout his hospital course. Sugars
have been kept under good control with 8units of NPH [**Hospital1 **] in
addition to RISS.
.
12. FEN: After the patient was intubated, tube feeds were given
through an NG tube. He received a tracheostomy as well as a PEG
tube placement on [**2183-1-21**] without complications. The TF
were given through the PEG tube and the pt was subsequently
evaluated by Speech and Swallow for ability to take POs.
.
13. PPx: The pt was maintained on DVT ppx with either a heparin
gtt or heparin sub Q TID (After the episode of GIB, the gtt was
stopped as above). In addition, the pt also recieved GI ppx
with PPI and bowel regimen.
.
14. Code Status: Full code
Medications on Admission:
1. Sotalol 80mg [**Hospital1 **]
2. Colace 100mg [**Hospital1 **]
3. Dig 250mcg qd
4. Atorvastatin 20mg QD
5. Plavix 75mg QD
6. Coumadin
7. Amaryl
8. Lasix 40mg po bid
9. Senna
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 1121**] - [**Location (un) 1456**]
Discharge Diagnosis:
pneumonia
respiratory failure s/p intubation
s/p tracheostomy
s/p PEG placement
paroxysmal AFib
CHF
pulmonary HTN
PVD
Discharge Condition:
stable
Discharge Instructions:
Please continue diuresis with goal net negative 500cc to 1L
daily until edema resolves or Cr increases. Can dose 80mg IV
lasix daily to twice daily to achieve this. Please check
electrolytes daily while diuresing.
Please continue to work with patient to wean ventilator.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 66439**] in the next 2
weeks (or when able to travel for appointment). Call
[**Telephone/Fax (1) 65735**] to make an appointment.
Please make an appointment to follow up with your cardiologist
in the next few weeks.
Please also follow up with your vascular surgeon, Dr. [**Last Name (STitle) 1391**]
in the next month. Call ([**Telephone/Fax (1) 31602**] to make an appointment.
Completed by:[**2183-1-24**]
|
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60,897
| 177,937
|
11809
|
Discharge summary
|
report
|
Admission Date: [**2188-9-10**] Discharge Date: [**2188-10-24**]
Date of Birth: [**2120-10-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation
Central Line placement
Axillary Arterial Line Placement
PICC placement ([**10-7**])
NG tube placement
TIPs dilatation
Cardioversion
paracentesis x 3
EGD
History of Present Illness:
Mr. [**Known firstname **] [**Known lastname 487**] is a 67-year-old man with a history of CHF,
cirrhosis s/p TIPS, and Afib (off coumadin) was brought in the
the [**Hospital6 17032**] by ambulance after his
daughter found him to be short of breath, confused, and
incontinent. At the [**Hospital3 17031**] he was found to be febrile
to 105, HR 137, BP 72/31 RR 28 SpO2 98%. EKG reveal afib with
RVR and ST depressions in V4-6. Labs were notable for a WBC
27.6, PLT 45, INR 2.3, creatinine 4.1 digoxin 0.5. A femoral
line was placed and he was given levaquin and zosyn for presumed
urosepsis given a positive UA (packed WBC, 4+ bacteria). CT
abd/pelvis without contrast showed no free air and no bowel wall
thickening. He received 6 L IVF and was started on dopamine and
levophed prior to transfer to [**Hospital1 18**] for further evaluation.
.
On arrival to [**Hospital1 18**] ED VS were 98.9 130 77/49 28 100% 3L
Dopamine was discontinued due to tachycardia and levophed was
titrated up. He was given decadron 10 mg IV and 1 L IVF.
Transplant surgery was consulted to evaluate for mesenteric
ischemia given elevated lactate, WBC and intermittent abdominal
pain. They recommended admission to MICU.
.
Of note, records from OSH mention admission on [**2188-8-13**] for SBP
and recent Klebsiella infection.
.
Review of systems: Unable to assess due to confusion.
Past Medical History:
Paroxysmal atrial fibrillation (not on coumadin due to
cirrhosis)
Cirrhosis s/p TIPS
Dilated cardiomyopathy
CAD
Obesity
Social History:
Patient lives alone. He is retired. He reports smoking 2
cigarettes per day. He admits to a history of alcohol abuse but
denies any recent alcohol use. He denies use of herbal
medications or illicit drugs (including IVDU).
Family History:
Noncontributory. Denies family history of liver disease.
Physical Exam:
ADMISSION EXAM
GA: AAOx3, NAD
HEENT: PERRLA. dryMM. Poor dentition. No LAD. No JVD. Neck
supple.
Cards: Tachycardic, 2/6 systolic murmur heard at LUSB.
Pulm: Moderately labored breathing. Crackles at bilateral bases.
Abd: soft, NT, decreased bowel sounds. No rebound, guarding
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: dry skin, no rashes
Neuro/Psych: Awake, alert, but disoriented. Follows commands,
answers questions appropriately.
Pertinent Results:
I. Labs
A. Admission
[**2188-9-10**] 05:30PM BLOOD WBC-15.5* RBC-4.40* Hgb-13.4*# Hct-41.3
MCV-94 MCH-30.5 MCHC-32.5 RDW-15.1 Plt Ct-41*#
[**2188-9-10**] 05:30PM BLOOD Neuts-76* Bands-20* Lymphs-2* Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2188-9-10**] 05:30PM BLOOD PT-22.3* PTT-47.0* INR(PT)-2.1*
[**2188-9-10**] 05:30PM BLOOD Glucose-164* UreaN-42* Creat-3.6*# Na-139
K-3.7 Cl-103 HCO3-15* AnGap-25*
[**2188-9-10**] 05:30PM BLOOD ALT-13 AST-27 AlkPhos-116 TotBili-3.7*
[**2188-9-10**] 05:30PM BLOOD cTropnT-0.03*
[**2188-9-10**] 05:30PM BLOOD Albumin-2.5*
[**2188-10-11**] 05:48AM BLOOD Ammonia-26
[**2188-10-11**] 05:48AM BLOOD TSH-3.5
[**2188-9-11**] 05:34AM BLOOD Cortsol-78.0*
[**2188-9-10**] 05:37PM BLOOD Lactate-11.8*
B. Discharge ([**2188-10-25**])
WBC 6.2 Hgb 10.9 Hct 32.5 Plt 156
Na 140 K 3.9 Cl 107 HCO3 29 BUN 7 Cr 0.8 Glc 85 Ca 8.8 Ph 2.5 Mg
1.9
C. Other
[**2188-10-11**] 05:48AM BLOOD VitB12-941*
[**2188-10-9**] 03:23AM BLOOD calTIBC-122* Hapto-14* Ferritn-384
TRF-94*
[**2188-10-11**] 05:48AM BLOOD Digoxin-0.9
D. Urine
[**2188-9-10**] 09:21PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015
[**2188-9-10**] 09:21PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-4* pH-5.5 Leuks-LG
[**2188-9-10**] 09:21PM URINE RBC-56* WBC-94* Bacteri-FEW Yeast-NONE
Epi-0
[**2188-9-11**] 04:10AM URINE Hours-RANDOM UreaN-156 Creat-164 Na-38
K-82 Cl-12
[**2188-9-11**] 03:38PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG
E. Ascites
[**2188-10-8**] 08:57AM ASCITES WBC-15* RBC-20* Polys-4* Lymphs-91*
Monos-4* Mesothe-1*
[**2188-9-29**] 06:45AM ASCITES WBC-135* RBC-245* Polys-40* Lymphs-43*
Monos-7* Mesothe-6* Macroph-4*
[**2188-10-8**] 08:57AM ASCITES Albumin-LESS THAN
[**2188-9-29**] 06:45AM ASCITES Glucose-126 LD(LDH)-63
II. Microbiology
[**2188-10-20**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2188-10-20**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2188-10-19**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; FECAL CULTURE - R/O E.COLI 0157:H7-FINAL;
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL INPATIENT
[**2188-10-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2188-10-18**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-10-18**] 1:30 am BLOOD CULTURE
**FINAL REPORT [**2188-10-20**]**
Blood Culture, Routine (Final [**2188-10-20**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
WARNING! This isolate is an extended-spectrum
beta-lactamase
(ESBL) producer and should be considered resistant to
all
penicillins, cephalosporins, and aztreonam. Consider
Infectious
Disease consultation for serious infections caused by
ESBL-producing species.
BACTRIM (=SEPTRA=SULFA X TRIMETH) AND TETRACYCLINE
Sensitivity
testing per DR.[**Last Name (STitle) 10000**],[**First Name3 (LF) **] PAGER [**Numeric Identifier 37310**] [**2188-10-19**].
Piperacillin/Tazobactam sensitivity testing confirmed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. TETRACYCLINE sensitivity testing performed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TETRACYCLINE---------- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2188-10-18**]):
GRAM NEGATIVE ROD(S).
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 26**] [**Last Name (NamePattern1) 37311**] -ICU- @ 12:45 [**2188-10-18**].
Anaerobic Bottle Gram Stain (Final [**2188-10-18**]): GRAM
NEGATIVE ROD(S).
Time Taken Not Noted Log-In Date/Time: [**2188-10-17**] 4:12 pm
PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2188-10-23**]**
GRAM STAIN (Final [**2188-10-17**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2188-10-20**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2188-10-23**]): NO GROWTH.
[**2188-10-17**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-10-17**] FLUID RECEIVED IN BLOOD CULTURE BOTTLES
Fluid Culture in Bottles-FINAL INPATIENT
[**2188-10-16**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2188-10-16**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2188-10-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2188-10-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2188-10-14**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2188-10-14**] BLOOD CULTURE Blood Culture,
Routine-PENDING INPATIENT
[**2188-10-11**] SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT
[**2188-10-10**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-10-10**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-10-10**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-10-8**] BLOOD CULTURE Blood Culture,
Routine-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic
Bottle Gram Stain-FINAL INPATIENT
[**2188-10-8**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-10-8**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT
[**2188-10-5**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2188-10-1**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-10-1**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-29**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT
[**2188-9-29**] STOOL FECAL CULTURE-FINAL; CAMPYLOBACTER
CULTURE-FINAL; CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
INPATIENT
[**2188-9-29**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-29**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-28**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2188-9-28**] URINE URINE CULTURE-FINAL {YEAST}
INPATIENT
[**2188-9-28**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram
Stain-FINAL; Aerobic Bottle Gram Stain-FINAL INPATIENT
[**2188-9-23**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2188-9-22**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-9-22**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-22**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-20**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-20**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-19**] URINE URINE CULTURE-FINAL INPATIENT
[**2188-9-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2188-9-17**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL INPATIENT
[**2188-9-16**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-15**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-14**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-12**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram
Stain-FINAL INPATIENT
[**2188-9-12**] BLOOD CULTURE Blood Culture,
Routine-FINAL INPATIENT
[**2188-9-11**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Anaerobic Bottle Gram
Stain-FINAL INPATIENT
[**2188-9-11**] CATHETER TIP-IV WOUND CULTURE-FINAL
INPATIENT
[**2188-9-11**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B
TEST-FINAL INPATIENT
[**2188-9-10**] URINE URINE CULTURE-FINAL {ESCHERICHIA
COLI} INPATIENT
[**2188-9-10**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram
Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL INPATIENT
[**2188-9-10**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
[**2188-9-10**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram
Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
[**2188-9-10**] BLOOD CULTURE Blood Culture,
Routine-FINAL {ESCHERICHIA COLI}; Aerobic Bottle Gram
Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **]
III. Radiology
***** A. Redo TIPS
B. Doppler LUE
IMPRESSION: No evidence of deep vein thrombosis in the left arm.
C. Liver US ([**2188-10-10**])
IMPRESSION:
1. Patent TIPS, however, the flow is not satisfactory on color
Doppler
imaging due to lack of wall-to-wall appearance. Additionally,
flow in the
left and right portal veins is noted to be away from the TIPS
shunt. The
appearance may represent neointimal proliferation and a consult
with
interventional radiology is suggested.
2. Gallstones.
3. Splenomegaly.
4. Ascites and left pleural effusion.
D. Bone scan ([**2188-10-10**])
CONCLUSION: Normal bone scan. No evidence of focal abnormality
in the bone as described above. Gallium scan to follow.
E. Gallium scan
IMPRESSION: Normal gallium scan. Specifically no evidence of
infection in the lumbar spine.
F. Tib/fib
Two views of the tibia and fibula demonstrate edema within the
soft tissues of the calf. No abnormal findings in the fibula. Of
note, there is a faint region of lucency with indistinct cortex
at the medial proximal tibial shaft. This is best seen on the
frontal view. It is unclear if this area correlates to the
wound. Further assessment with MRI may be helpful to ascertain
for osteomyelitis.
G. MRI spine
HISTORY: Urosepsis with ESBL E. coli and now bacteremia with
unknown source.
Now with worsening lower extremity weakness concerning for cord
compression.
Rule out cord compression.
TECHNIQUE: MRI of the cervical, thoracic and lumbar spine was
performed
utilizing sagittal T2, sagittal T1, sagittal STIR without
intravenous
contrast. Due to patient's inability to cooperate axial T1 and
T2 sequences
were only obtained through L3-S1. After the administration of
contrast
sagittal and axial T1-weighted sequences were obtained.
COMPARISON: None.
FINDINGS:
CERVICAL SPINE: Evaluation of the cervical spine is limited as
only sagittal
T1- and T2-weighted sequences could be performed due to
patient's inability to
cooperate. The cervical alignment and vertebral body height are
maintained.
The T1 signal of the vertebral bodies is mildly hypointense
diffusely. Small
disc protrusions are present at C5-C6 and C6-C7 without
significant spinal
canal narrowing. No gross neural foraminal narrowing although
this is limited
without axial images. The cervical cord is normal in signal and
caliber. No
intradural or extradural fluid collections are noted. The
prevertebral soft
tissues are normal.
THORACIC SPINE: The thoracic spine vertebral body heights and
alignment are
maintained. Diffuse T1 hypointensity of the vertebral body
marrow signal is
noted as seen in the cervical spine. Multilevel mild
degenerative changes are
noted with mild indentation on the adjacent end-plates. There is
no spinal
canal or neural foraminal narrowing. The thoracic cord is normal
in signal
and caliber. No epidural or soft tissue fluid collections are
noted. The
prevertebral soft tissues are normal.
LUMBAR SPINE: The lumbar spine vertebral body heights are
maintained. Mild
decrease in the T1 signal of the vertebral body marrow is noted
similar to
that seen in the cervical and thoracic spine. Approximately 4 mm
of grade 1
retrolisthesis of L4 on L5 is present.
L1-L2: No gross spinal canal or neural foraminal narrowing.
L2-L3: A broad-based disc bulge is present asymmetric to the
right without
significant spinal canal or neural foraminal narrowing.
L3-L4: Minimal disc bulge is present without spinal canal
narrowing. Moderate
facet degenerative changes are noted with mild bilateral neural
foraminal
narrowing.
L4-L5: 4 mm of retrolisthesis of L4 on L5 along with disc
protrusion,
posterior osteophytes, facet arthrosis and ligamentum flavum
infolding produce
moderate spinal canal narrowing. Mild-to-moderate right neural
foraminal
narrowing is present.
L5-S1: A broad-based right paracentral disc protrusion is
present
superimposed upon a diffuse disc bulge resulting in mild spinal
canal
narrowing and moderate bilateral neural foraminal narrowing.
Mild increase in the discs at L4/5, L5/S1 levels may be normal/
related to
superimposed inflammation/infection. Correlate with labs.
The lower cord and cauda equina are not well assessed due to
suboptimal
quality of the L spine study. This may be due to technical
factors although
clumping of nerve roots cannot be excluded in this region. No
epidural or
intradural fluid collection is identified. The paravertebral
soft tissues are
grossly normal.
No obvious foci of enhancement are noted within the limitations
of motion.
IMPRESSION:
1. The study is significantly limited as the patient could not
tolerate a
complete exam and there is significant motion on multiple
sequences. No gross
evidence for cord compression or gross evidence of
spondylodiscitis. Mild
increased T2 signal in the L4/5 and L5/S1 levels may be within
normal limits
or superimposed mild inflammtion/infection. Correlate clinically
and with labs
and if necessary nuclear medicine studies.
2. The cauda equina is not readily discernable from the conus
medullaris and
is difficult to evaluate which may be technical due to the above
limitations
although, abnormality of the cauda equina and conus cannot be
excluded such as
clumping of nerve roots and arachnoiditis. A repeat examination
when the
patient is able to tolerate would be helpful for further
evaluation.
3. Diffuse diminished T1 signal of the vertebral body marrow
signal is
present suggesting such processes as myeloproliferative
disorders, chronic
anemia and marrow replacement. Clinical correlation recommended.
4. Multilevel, multifactorial degenerative changes in the lumbar
spine from
L3-S1; can be assessed better on repeat study.
H. CT Abdomen
INDICATION: 67-year-old male with congestive heart failure,
cirrhosis, status
post TIPS, presents with bacteremia with failed antibiotics,
here for
evaluation of source of infection.
COMPARISON: [**2188-9-10**].
TECHNIQUE: MDCT images were acquired from the lung bases through
the pubic
symphysis following administration of oral contrast, without IV
contrast.
Multiplanar reformations were generated.
G. CT ABDOMEN: Small bilateral pleural effusions are new since
[**2188-9-10**]. There is atelectasis and/or scarring in the lung bases. A
12-mm
subpleural nodularity (2, 4) is similar to [**2188-9-10**].
The heart is
top normal in size without pericardial effusion.
A large abdominal ascites is new since [**2188-9-10**].
Patient is status
post TIPS, which is in stable position. The liver is small and
nodular in
contour. There is splenomegaly to 15 cm. Along the splenic hilum
is an
ovoid structure isoattenuating to the spleen, most likely a
large splenule,
although this may be confirmed by nuclear study if desired.
Gallstones are
redemonstrated. There is no definite evidence to suggest
cholecystitis. The
pancreas, adrenal glands, and bilateral kidneys appear within
normal limits.
A small hiatal hernia is noted. The stomach, duodenum, small and
large bowel
loops are normal in caliber. The appendix is normal. A duodenal
diverticulum
may be present. There is no free air. No mesenteric or
retroperitoneal
lymphadenopathy. Mild atherosclerotic disease is seen in the
infrarenal
aorta.
CT PELVIS: The bladder is partially collapsed, containing air
along the
nondependent portion, likely related to recent instrumentation.
A Foley
catheter is in place. The rectum and sigmoid colon are
unremarkable.
BONE WINDOW: Multilevel degenerative disease is seen in the
lumbar spine,
with spondylosis, most pronounced at L2-3, L4-L5 and L5-S1.
There is grade 1
anterolisthesis of L5 with respect to L4 and S1. A sclerotic
focus within L3
vertebral body is redemonstrated, liekly a bone island.
IMPRESSION:
1. No drainable collection.
2. Bilateral small pleural effusions with atelectasis and/or
scarring.
3. Cirrhosis status post TIPS. New large abdominal ascites.
4. Probable large splenule, which could be confirmed by
scintigraphy if
desired.
5. Mild anasarca, new since [**2188-9-10**].
I. INDICATION: 67-year-old man with hypotension, cirrhosis and
diffuse abdominal
pain, to assess for colitis.
COMPARISON: No prior study is available for comparison.
TECHNIQUE: Outside hospital images done at [**Hospital3 18201**] have
been uploaded to the [**Hospital1 18**] PACS for a second opinion.
The visualized lung bases demonstrate linear atelectasis. Trace
pleural
effusions are seen bilaterally.
This study is limited without intravenous contrast for
assessment of
mesenteric ischemia. The liver demonstrates a nodular contour. A
TIPS is in
place. Multiple gallstones are present in a mildly distended
gallbladder, but
no other evidence of acute cholecystitis is present. Both
adrenal glands are
normal. Both kidneys are unremarkable without evidence of
nephrolithiasis or
hydronephrosis. The pancreas is unremarkable.
A large round lobulated soft tissue mass measuring 5.4 x 4.6 cm
is seen in the
left upper quadrant, and is not well characterized in this
non-contrast study.
The adjacent presumed spleen is slightly abnormal in morphology
and a
well-defined hilum is absent. No stigmata of splenectomy noted.
The stomach and small bowel loops are unremarkable without
evidence of bowel
wall thickening or obstruction. The study is limited for
assessment of
mesenteric ischemia without intravenous contrast. Within this
limitation no
pneumatosis or portal venous gas is identified. The visualized
large bowel is
decompressed and unremarkable. Incidental note is made of a
lipoma of the
ileocecal valve. A small focus of gas in the retroperitoneum
adjacent to
L2-L3 intervertebral disc space, could represent extension of
air from the
disc degeneration.
A small amount of pelvic free fluid is present, of unclear
clinical
significance. The bladder is empty with a Foley catheter in
place. The
rectum and sigmoid colon are normal. No significant pelvic
lymphadenopathy is
detected. Prostate is unremarkable.
OSSEOUS STRUCTURES AND SOFT TISSUES: Multilevel degenerative
changes of the
lumbar spine are noted with mild grade 1 anterolisthesis of L5
on S1. A
rounded sclerotic focus in L3 vertebral body likely represents a
bone island.
IMPRESSION:
1. Limited study without intravenous contrast. No portal venous
gas or
pneumatosis is detected to suggest bowel ischemia.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Left upper quadrant soft tissue mass. Unclear etiology. [**Month (only) 116**]
represent a
splenule adjacent to large native spleen. No history given or
stigmata
present of prior splenectomy. Nuclear spleen scan can help
confrim splenic
origin of mass to exclude neoplasm.
4. A trace amount of pelvic free fluid of unclear clinical
significance.
5. Small amount of gas in the retroperitoneum adjacent to the
L3-L4 disc
space could represent extension of the gas from the degenerating
disc at that
level.
CT Chest with contrast
CHEST CT ON [**10-22**]
HISTORY: Pleural nodularity right apex and mediastinal
adenopathy.
TECHNIQUE: Multidetector helical scanning of the chest was
coordinated with
intravenous infusion of 100 cc Optiray 250 nonionic iodinated
contrast [**Doctor Last Name 360**]
reconstructed as contiguous 5- and 1.25-mm thick axial and 5-mm
thick coronal
and paramedian sagittal images compared to torso CT [**2188-10-18**].
FINDINGS: The mediastinum is markedly widened with fat. Lymph
node
enlargement is greatest in the prevascular station where 10 and
13 mm wide
nodes were previously 14.6 and 13.5 mm. A 10mm right
paraesophageal node,
2:29, was 12 mm on [**10-18**] and right lower paratracheal lymph
nodes, though
numerous are neither pathologically enlarged nor changed. The
interval
involution in node size probably reflects decreased edema since
previous
mediastinal edema and mild anasarca in the upper chest on the
prior study have
also cleared. Small nonhemorrhagic bilateral pleural effusions
layer
posteriorly, slightly smaller today than on [**10-18**]. There is
mild
thickening of parietal pleura on both sides of the chest and the
radiodensity
of the effusions is higher than one would expect from serous
fluid, but since
the patient has a history of chronic and recurrent pleural
effusion, this need
not represent an active exudate such as infection. There is no
pericardial
effusion. All cardiac [**Doctor Last Name 1754**] are chronically, moderately
enlarged.
Atelectasis at the lung bases is probably due to chronic pleural
abnormality.
There is no bronchial obstruction. Previous mass-like
atelectasis at the
right apex has cleared. A new region of mild peribronchial
infiltration in
the anterior segment of the right upper lobe is probably
atelectasis.
Relatively symmetric areas of discrete demineralization in the
tips of both
scapulae are most likely due to osteoporosis. If patient has
known
malignancy, a bone scan would be prudent to exclude lytic
metastasis.
Thoracic spine is unremarkable except for a focal sclerotic
nodule in T11, a
benign finding.
The thyroid gland is mildly enlarged diffusely, particularly the
right lobe
and isthmus, but there is no focal heterogeneity to suggest
malignancy.
This study is not designed for subdiaphragmatic diagnosis except
to note
chronic calcified gallstone, interval increase in moderate
ascites and a
portosystemic shunt in the right lobe of the liver.
IMPRESSION:
1. Decreasing reactive mediastinal lymph nodes, probably a
reflection of
improved fluid status given concurrent resolution of previous
mediastinal
edema and mild anasarca and smaller chronic, bilateral pleural
effusions,
responsible for pleural thickening and basal atelectasis.
2. No focal pulmonary lesion of concern.
3. Chronic cardiomegaly. Chronic calcific cholelithiasis.
4. Left PIC line ends in the upper SVC.
5. Mild thyromegaly. No discrete mass.
6. Increased moderate ascites.
7. Focal lytic lesions in both scapulae, most likely focal
osteoporosis.
Further attention would be indicated only if patient has known
malignancy or
other indication of osseous malignancy.
INDICATION: Assess left basilic vein PICC line placement.
COMPARISON: Upright PA portable chest x-ray from [**2188-10-15**].
TECHNIQUE: Upright AP portable chest x-ray.
FINDINGS: The tip of the left basilic PICC line is in the right
atrium. PICC
line nurse, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was called concerning this finding
and we suggested
that she withdraw the PICC line 5 cm to the distal superior vena
cava.
Interval mediastinal widening and cephalization of lung
vasculature suggest of
worsening heart failure. Bilateral pleural effusions are small,
but there is
no pulmonary edema.. Retrocardiac atelectasis appears unchanged.
IMPRESSION:
1. PICC line ends in the right atrium, suggest withdrawing 5 cm.
2. Mild CHF increased since [**2188-10-15**].
INDICATION: Left greater than right swelling, rule out DVT.
COMPARISON: None.
FINDINGS: Grayscale and Doppler evaluation of bilateral common
femoral,
superficial femoral, popliteal veins demonstrate normal
compressibility, flow,
response to augmentation. The peroneal and posterior tibial
veins were
suboptimally visualized; however, demonstrated normal
compressibility on
real-time evaluation.
IMPRESSION: No evidence of DVT in bilateral lower extremities.
IV. Cardiology
A. 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 atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is no pericardial effusion.
IMPRESSION: No evidence of spontaneous echo contrast or
intracardiac thrombus. Good left atrial appendage emptying
velocities.
B. EKG
Atrial fibrillation with a ventricular rate of 122. ST-T wave
changes
in leads I, II, III, aVL, aVF and V4-V6. Compared to the
previous tracing
of [**2188-9-25**], when the patient was also in atrial fibrillation,
there are no
longer ventricular premature beats. The rate is faster. The
non-specific
ST-T wave changes are unchanged. The possible flutter waves seen
previously in lead V1 are no longer seen on the current tracing.
Otherwise, no diagnostic interval change.
# Pending
Above blood cultures
Brief Hospital Course:
67-year-old man with a history of secondary to
tachycardia-induced dilated CM, alcoholic cirrhosis s/p TIPS
([**2182**]), and paroxysmal atrial fibrillation (off coumadin)
presented from OSH with ESBL E. coli urosepsis and recurrent
bacteremia with possible TIPs infection.
# Septic Shock: Initially presented with altered mental status,
elevated creatinine, decreased urine output, and persistent
hypotension after aggressive fluid resuscitation requiring three
pressors. Lactate initially elevated to 11. Intubated for
altered mental status, acidosis, and aggressive volume
rescitation. Empirically started on vancomycin, cipro and zosyn.
Cultures ultimately grew ESBL E. coli in both urine and blood.
.
# Respiratory Failure/Intubation: Pt required intubation on
admission given respiratory distress. He was ultimately
extubated [**2188-9-18**], HD#8. Respiratory status has been stable over
the last few weeks.
.
# ESBL E.Coli Bacteremia: Presumed to be secondary to TIPS
infection. Infectious work-up included TTE, MRI spine to r/o
osteo, multiple paracentesis, and multiple CT scans of abdomen
and pelvis. He was started on meropenem on [**2188-9-11**]. Given
recurrent bacteremeia after an initial 14 day course of
meropenem another 14 day course given which again resulted in
positive blood cxs shortly after the abx was stopped. Given
presumed TIPS he will likely need long term suppressive abx
therapy. plan is to dc him on meropenem 1g Q8 until he follows
up in [**Hospital **] clinic on [**2188-11-12**]. His ID physicians will determine
whether he can be transitioned to an oral abx. At time of
discharge cxs had been negative since [**2188-10-18**].
.
# Atrial Fibrillation/Atrial Flutter: Pt with long h/o difficult
to control afib/aflutter. While septic in MICU developed SVT
with rates in the 160s. He was started on an amiodarone drip
with minimal decrease in his rates and without conversion to
sinus rhythm. Electrophysiology was consulted and ultimately he
was cardioverted and started on flecainide 75 mg [**Hospital1 **] on [**2188-9-25**].
He was cont on digoxin as well.He had rhythm and rate control
during the rest of his hospitalization with some limited
episodes of atrial fibrillation with RVR to 130s. Given multiple
procedures, and recurrent hematocrit drops, coumadin was
deferred until outpatient colonoscopy could be performed. Risk
of remaining off coumadin was discussed with pt and family.
.
# Volume Overload: Pt was 18L positive following fluid
resucitation from sepsis. He required slow diuresis with lasix
gtt. Currently, he is near euvolemia and should restart home
regimen of lasix and spironolactone.
.
# Altered Mental Status: Delirium during much of initial
hospitalization likely related to illness and encephalopathy. He
was restarted home lactuose, resolution of infection, avoidance
of narcotics all improved patient's mental status.
.
# Acute renal failure: Creatinine 4.0 on presentation. Muddy
brown casts shown demonstrated ATN, either secondary to
hypoperfusion given inital low blood pressures vs. direct effect
of sepsis. His renal function returned to ~ 0.9 after treatment
of his infection and diuresis.
.
# Cirrhosis (MELD 13): Patient with history of cirrhosis s/p
TIPS for ascites. Per patient's hepatologist, cirrhosis is
likely secondary to alcohol abuse. Denies recent alcohol use.
Hepatology followed the patient while in house. Should continue
lactulose, furosemide and spironolactone.
.
# Ascites
The patient had interval development of abdominal swelling
likely secondary to increased hydrostatic pressure from portal
hypertension. He had multiple RUQ and two therapeutic and
diagnostic paracenteses to rule out SBP. Given continuing
ascites despite paracentesis, his TIPS was explored with
dopplers and found to have stenosis. IR performed a TIPs
venogram with successful dilitation on [**10-16**].
# Congestion Heart Failure, diastolic, chronic: Patient with
history of dilated cardiomyopathy (presumably secondary to
alcohol abuse). Cardiology note from [**2186**] suggests EF of 50% up
from prior estimates of [**10-24**]%. No known coronary disease. Echo
performed during admission did not show any focal wall motion
abnormalities, and did show a normal EF. It is of note, his echo
was performed with pressor support, so his ejection fraction may
be over-estimated. Patient was total body positive in terms of
fluid status given his aggressive fluid resuscitation initially.
No active signs or symptoms of heart failure at discharge.
# Thrombocytopenia: Unknown baseline. Likely chronic or chronic
in setting of hepatic disease. He had a platelet nadir at 10 and
was given one transfusion of a pack of platelets with
improvement in numbers. No episodes of bleeding. DIC labs
negative. He subsequent had platelets in 60s-100s.
# Diabetes
The patient was placed on SSI in house and Lantus 25. Due to
persistent hypoglycemia in the morning, he was discharged on
Lantus 12 units. He should also be on a humalog SS.
.
# Diarrhea
The patient developed diarrhea on [**10-14**]. Differential includes
medication side effect secondary to lactulose, excessive juice
intake with sorbitol, and C. diff with the later being negative
three times. No longer having diarrhea at time of discharge.
.
# Hemoccult positive stool with anemia
The patient has no gross blood per stool. His stools were dark
at times. He had a post-procedural hematocrit drop on [**10-8**] to
22.9 and was subsequently transfused. Hepatology was consulted
and performed an EGD on [**10-10**] for upper tract causes with EGD
showing grade I varices, portal gastropathy, and erosions in the
stomach/cardia. He was started on a PPI, and his anemia
gradually stabilized. He had some variable fluctuations that on
repeat were near baseline. Outpatient colonoscopy is advised.
# Loss of bilateral foot function, resolved
On [**10-7**], patient reported loss of bilateral foot function with
sensory lossin the lower extremities. Stat MRI showed L2 signal
abnormality,No gross
evidence for cord compression or gross evidence of
spondylodiscitis. Following MRI he was able to move both LE
again. He denied any bowel/bladder incontinence or saddle
anesthesia. Rectal exam was performed with normal tone and
enlarged prostate with any nodules or discrete masses. He
continues to have adequate extremity movement on discharge.
.
# Left UE swelling
Given concern for L>R UE swelling, UE dopper was performed to
r/o DVT. Doppler was negative for DVT on both [**10-4**] and [**10-14**].
.
# Joint pain
The patient endorses joint pains throughout the hospital. There
was a history of early joint pains per his daughter. [**Name (NI) **] took
prednisone at home, which was held secondary to issues with
infection. Given that his back pain was variably controlled,
bone and gallium scans as above were performed showing no
osteomyelitis. He was discharged with oral pain medication.
.
# Insomnia
The patient was continued on home trazodone. Given habitus and
snoring noted during rounds, outpatient sleep study may be
indicated given underlying heart disease. Would avoid ativan for
insomnia given risk of confusion.
.
# Adjustment disorder
Given multiple medical problems, the patient had a flat affected
and endorses passive SI that seemed to correlate with his
medical condition and progress. Social work was consulted for
coping in addition to psychiatry. A family meeting was held with
subsequent better spirits, expansive affected, and interval
denial of SI or HI. The patient does have guns given his history
as a police officer and an antique knife at home. His daughter
was notified that these items should be removed from his home
after he returns and stabilizes.
.
# Nutrition
The patient had poor PO intake on the floor with excessive
consumption of juice. Nutrition was consulted with suggestion
for a feeding tube, but the patient refused. His appetite
subsequently improved, and he was given ensure supplementation
as well. Would continue to monitor.
.
# Left upper tooth Disease:
Patient has severe dental disease with upper left tooth with
severe decay. Advise outpatient dentist follow-up
# Incidentals on imaging
--Large splenule noted on abdominal CT scan.
--CT chest with contrast revealed focal lytic lesions in both
scapulae, most likely focal osteoporosis. Further attention
would be indicated only if patient has known malignancy or other
indication of osseous malignancy.
--MRI spine showing Diffuse diminished T1 signal of the
vertebral body marrow signal is present suggesting such
processes as myeloproliferative disorders, chronic
anemia and marrow replacement.
# Code status: Full Code
# Contact Information:
1. **[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]** [**Telephone/Fax (1) 37312**]
2. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 37313**]
3. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22633**] [**Telephone/Fax (1) 37314**] (not preferred for contact)
# Access: L PICC placed [**10-22**]
# Pending - Blood cultures per lab section
Outpatient considerations:
1. Patient will need outpatient ID visit to manage meropenem
therapy and plan for suppressive therapy.
2. Consider outpatient colonoscopy given recurrent hematocrit
drops.
3. Atrial fibrillation: He will need to follow-up with Dr. [**Last Name (STitle) 11493**]
to manage rhythm control medications (flecainide and digoxin)
4. Patient will need outpatient hepatology follow-up given liver
disease.
Medications on Admission:
Digoxin 0.125 mg po daily
Metoprolol 50 mg po daily
Lasix 40 mg po bid
Prednisone 2.5 mg daily
KCl 20 meq po daily
Trazodone 50 mg daily
Ativan unknown
Lactulose unknown
Discharge Medications:
1. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-12**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
2. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for back/bottom.
3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours): Titrate to two bowel movements per day.
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. flecainide 50 mg Tablet Sig: 1.5 Tablets PO Q12H (every 12
hours).
6. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
12. insulin glargine 100 unit/mL Solution Sig: Twelve (12) units
Subcutaneous at bedtime.
13. 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.
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. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. meropenem 500 mg Recon Soln Sig: 1000 (1000) mg Intravenous
every eight (8) hours: ** Please infuse over 3 hours **
Stop date: [**2188-11-30**].
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. spironolactone 25 mg Tablet Sig: One (1) Tablet PO twice a
day.
19. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain: Do not exceed greater than 2 grams of
APAP/daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Care and Rehab Woodmill in [**Known lastname 487**]
Discharge Diagnosis:
PRIMARY: ESBL E. Coli bacteremia, Septic Shock, Acute renal
failure, Atrial Fibrillation with Rapid Ventricular Response,
Portal Gastropathy
SECONDARY: Cirrhosis, Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname 487**],
You were treated at [**Hospital1 18**] for a blood infection that required
you to be admitted to the ICU. Your infection has resolved,
though you will continue to need IV antibiotics and to follow up
closely with your infectious disease physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **].
.
Medications
----------------
STOP Toprol
STOP potassium supplement
STOP prednisone
STOP lorazepam
STOP tylenol with codeine
.
START ferrous sulfate, flecainide, folic acid, lidocaine patch,
meropenenm, multivitamin, oxycodone, omeprazole, thiamine,
spironolactone
.
CHANGE Lasix 20 mg by mouth daily instead of 40 mg by mouth
twice daily
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital6 **]
Address: [**Apartment Address(1) 37315**], [**Location (un) **],[**Numeric Identifier 28704**]
Phone: [**Telephone/Fax (1) 37316**]
Appointment: Thursday [**2188-10-30**] 4:00pm
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2188-11-12**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 249**]
When: WEDNESDAY [**2188-12-3**] at 11:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 288**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Please make an appointment for pt to follow up with his
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] ([**Telephone/Fax (1) 29810**] within 2 weeks of
leaving rehab.
|
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|
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|
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|
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,325
| 103,883
|
30539+57700+57701+57703
|
Discharge summary
|
report+addendum+addendum+addendum
|
Admission Date: [**2138-5-5**] Discharge Date: [**2138-5-15**]
Date of Birth: [**2070-2-18**] Sex: M
Service: VSU
CHIEF COMPLAINT: Left ankle-foot nonhealing ulceration.
HISTORY OF PRESENT ILLNESS: This patient was hospitalized
from [**2138-4-9**] to [**2138-4-11**], for his nonhealing
ulceration. He underwent a diagnostic lower extremity
angiogram. Patient was determined to be a surgical candidate.
He now returns for elective revascularization.
PAST MEDICAL HISTORY: Type 2 diabetes with triopathy, end-
stage renal disease, hemodialysis Monday, Wednesday, Friday,
history of coronary artery disease with cardiomyopathy,
history of systolic congestive heart failure, pulmonary edema
compensated, status post coronary artery bypasses x2 with
vein complicated by respiratory failure requiring a
tracheostomy, history of pneumonia, history of catheter
sepsis, MRSA; history of atrial fibrillation, history of
bilateral DVTs with pulmonary embolus anticoagulated, history
of depression, history of hypertension, history of GERD,
history of gastroparesis, history of morbid obesity.
SOCIAL HISTORY: Patient lives at rehab. He does not smoke or
drink.
PHYSICAL EXAM: Patient was in no acute distress, oriented
x3. He had an irregularly, irregular rhythm without murmur,
gallop, or rub. Lungs were clear to auscultation bilaterally.
Abdominal exam was unremarkable except for obese,
protuberant, soft, nontender belly. The left ankle had a 2.5-
cm nonhealing ulceration with purulence. There was dry eschar
with an erythematous rim. The pulse exam showed palpable DP
and PTs bilaterally.
MEDICATIONS ON ADMISSION: Bupropion 100 mg daily, donepezil
5 mg at bedtime, lactulose 10 grams in 15 cc, 30 cc Tuesdays,
Sundays, and Thursdays, Reglan 5 mg b.i.d., calcium acetate
tablets, atorvastatin 20 mg at bedtime, Nephrocaps daily,
mirtazapine 45 mg at bedtime, niacin 500 mg at bedtime,
levothyroxine 50 mcg daily, Prozac 20 mg daily, fluconazole
110 mcg inhaler puffs 2 b.i.d., sublingual nitroglycerin 0.04
p.r.n.
HOSPITAL COURSE: Patient was admitted to the vascular
service. Vancomycin, ciprofloxacin, and Flagyl were
instituted. The patient was prepared for surgery and prior to
surgery, underwent dialysis. Patient proceeded to surgery on
[**2138-5-6**]. He had a redo left mid SFA to BK-[**Doctor Last Name **] bypass with
nonreverse saphenous vein left, angioscopy and valve lysis.
Urology was consulted intraoperatively to place a Foley. The
patient underwent a cystoscopy which showed slight narrowing
at the bulbar urethra. Patient was dilated, and a Foley
catheter was placed. This remained in for 7 days
postoperatively.
Patient was transferred to the PACU in stable condition.
Postoperative day 1, there were no acute events.
Postoperative day 2, patient's T. max was 101. Blood cultures
were obtained which were no growth. The patient remained in
the VICU. On physical exam, he had a left Dopplerable DP and
PT. Potassium was 7.2. Patient went to dialysis.
Wound care service was requested to see the patient for a
type stage I pressure ulceration on the sacrum.
Recommendations were turn frequently. Keep heels off of bed
surface at all times and apply protective ointment to the
area after cleaning the area carefully.
Postoperative day 3, patient's T. max was 98.0. His potassium
improved postdialysis. He was sent to the regular nursing
floor for continued care. Patient had very poor venous
access, and a PICC was recommended. It was determined at this
time that his antibiotics will be converted to oral agents,
and the vancomycin would be dosed at dialysis.
Postoperative day 5, patient continued to progress. He
remained afebrile and ambulation to chair was begun.
Postoperative day 6, the patient was afebrile. He complained
of mild dyspnea with desaturation which responded to face
mask. The chest x-ray demonstrated near white of the left
chest. The CT was considered. CT scan was done which showed
collapse of the left lung. Patient was transferred to the
ICU, where he underwent a bronchoscopy. Was intubated and
ventilator support overnight.
Postoperative day 7, patient remained in the unit, intubated,
and bronchoscopy was repeated with improvement in left lung
aeration. At this point, they felt the patient, from
pulmonary standpoint, had improved enough to be extubated and
transferred back to the regular nursing floor. Patient did
require transfusion for a hematocrit of 23.7.
Pulmonary was consulted on postoperative day 9 for continued
left lower lobe changes, concerns for pneumonia and
appropriate treatment. Their recommendations were to continue
aggressive pulmonary PT. Discontinue the Mucomyst as this can
increase secretion thickness. Discontinue the Tylenol since
it may be hiding a fever. Recommend fluid removal at dialysis
if blood pressure will tolerate. Will avoid sedating
medications. Begin albuterol nebulizers q.4 hours standing
and q.2 hours p.r.n. with Atrovent nebulizers q.6 hours. Felt
he did not need to be rebronched at this time to consider
starting CPAP for possible OSA at night. Continue his
antibiotics, vancomycin and levofloxacin. Add cefepime for
concerns for hospital-acquired pneumonia. Maintain
saturations greater than 91%. Keep patient on right side as
much as possible for postural drainage. Continue to monitor
pulmonary status by daily x-rays.
Sputum culture was obtained which showed no microorganisms on
Gram stain and it was finalized of rare growth of
oropharyngeal flora. This cefepime was discontinued. The
patient will be continued on vancomycin and levofloxacin for
total of 7 more days. The vancomycin will be given at
hemodialysis when the level is less than 15. Vancomycin will
be orally. Patient was made n.p.o. for potential rebronch on
[**2138-5-15**]. Patient will return to his nursing home once
patient is medically stable.
DISCHARGE INSTRUCTIONS: Patient may ambulate essential
distances. Please elevate the leg when patient is sitting in
a chair. Please call us if he develops a fever greater than
101.5 or the leg wounds become erythematous, drain, or he has
groin swelling. The patient may shower, but no tub baths.
Please continue all medications as ordered. Random levels on
a daily basis to determine when to dose at dialysis of
vancomycin. Sacral decubitus care should be continued with
adequate cleansing and protective ointment to the skin.
DISCHARGE MEDICATIONS: Miconazole powder to effected area
p.r.n., senna tablets 8.6 mg tablets 1 b.i.d., fluconazole
110 mcg actuation aerosol +2 b.i.d., paroxetine 20 mg daily,
niacin 500 mg daily, levothyroxine 50 mcg daily, mirtazapine
15 mg tablets 3 at bedtime, calcium acetate 667 mg capsules 1
t.i.d. with meals, donepezil 5 mg at bedtime, B complex,
vitamin C, folic acid, capsule 1 mg daily, lactulose 30 cc
daily, atorvastatin 20 mg daily, Reglan 5 mg a.c. and at
bedtime, bupropion 100 mg sustained release q.a.m.,
amiodarone 200 mg daily, lansoprazole 30 mg daily, Colace 50
mg in 5 cc b.i.d., metoprolol 25 mg b.i.d., albuterol sulfate
0.083% solution inhalation q.2 hours, ipratropium bromide
0.02% solution inhalation q.6 hours, levofloxacin 500 mg q.48
hours for a total of 7 days, acetaminophen 325 mg tablets [**1-7**]
q.4-6 hours p.r.n., vancomycin 1 gram at dialysis when random
level is less than 15 for a total of 7 days, glargine U100
eight units subcutaneously daily at breakfast. Humalog
sliding scale before meals: Glucoses less than 150: No
insulin, 151-200: 1 unit, 201-250: 2 units, 251-300: 3 units,
301-350: 4 units, 351-400: 5 units, greater than 400: Notify
physician. [**Name10 (NameIs) **] bedtime sliding scale glucoses less than 250:
No insulin, 251-300: 2 units; 351-400: 3 units; glucoses
greater than 400: Notify physician.
DISCHARGE DIAGNOSES: Ischemic left foot ulceration,
nonhealing; peripheral vascular disease status post
diagnostic arteriogram on [**2138-4-10**], history of type 2
diabetes with triopathy, controlled; history of end-stage
renal disease on hemodialysis Monday, Wednesday, Friday,
history of coronary artery disease with cardiomyopathy,
status post coronary artery bypass graft x2 complicated by
congestive heart failure, systolic; respiratory failure,
pneumonia, status post tracheostomy, history of methicillin-
resistant Staphylococcus aureus catheter sepsis, history of
pneumonia, history of atrial fibrillation, history of
pulmonary embolus secondary to deep venous thrombosis,
anticoagulated, history of depression, history of
hypertension, history of gastroparesis, history of gastric
reflux, history of morbid obesity, urethral stenosis status
post cystoscopy with dilatation and Foley placement on [**5-6**],
postoperative blood loss anemia, transfused; postoperative
left lower lobe collapse secondary to bronchial mucus
plugging, status post bronchoscopy x2.
MAJOR SURGICAL PROCEDURES: Cystoscopy with urethral
dilatation and Foley placement on [**2138-5-6**], redo left mid
SFA BK-[**Doctor Last Name **] with nonreverse saphenous vein, left angioscopy
and valve lysis, [**2138-5-6**], status post bronchoscopy x2 [**5-13**] and [**5-14**].
FOLLOW UP: Patient should follow up with Dr. [**Last Name (STitle) 1391**] in 2
weeks' time. He should call for an appointment at ([**Telephone/Fax (1) 72527**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2380**], [**MD Number(1) 2381**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2138-5-15**] 09:50:29
T: [**2138-5-15**] 10:33:22
Job#: [**Job Number 72528**]
Name: [**Known lastname **],[**Known firstname 63**] C Unit No: [**Numeric Identifier 12083**]
Admission Date: [**2138-5-5**] Discharge Date: [**2138-5-17**]
Date of Birth: [**2070-2-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**5-15**] patient's schedualed bronch was canelled by pulmonary
secondary to patient's clinical improvment and improved chest
xray. Will d/c to his rehab residence today.
Discharge Disposition:
Extended Care
Facility:
[**Location 12084**] [**Hospital 12085**] rehabilitation centre
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2138-5-15**] Name: [**Known lastname **],[**Known firstname 63**] C Unit No: [**Numeric Identifier 12083**]
Admission Date: [**2138-5-5**] Discharge Date: [**2138-5-17**]
Date of Birth: [**2070-2-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**5-16**] - patient feels well, vital signs and physical exam stable
CXR stable and unchanged.
[**Month (only) 412**] go to rehab
Discharge Disposition:
Extended Care
Facility:
[**Location 12084**] [**Hospital 12085**] rehabilitation centre
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2138-5-17**] Name: [**Known lastname **],[**Known firstname 63**] C Unit No: [**Numeric Identifier 12083**]
Admission Date: [**2138-5-5**] Discharge Date: [**2138-5-17**]
Date of Birth: [**2070-2-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 231**]
Addendum:
[**5-17**] patient is stable,
cxr stable and unchanged.
may go to rehab
Discharge Disposition:
Extended Care
Facility:
[**Location 12084**] [**Hospital 12085**] rehabilitation centre
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern1) 237**] MD [**MD Number(1) 238**]
Completed by:[**2138-5-17**]
|
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icd9cm
|
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[
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icd9pcs
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[
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|
1127, 1180
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,182
| 119,847
|
3835
|
Discharge summary
|
report
|
Admission Date: [**2135-5-2**] Discharge Date: [**2135-5-8**]
Date of Birth: [**2083-9-8**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: The patient was recently
diagnosed with a right sided breast cancer and presents for
mastectomy and TRAM reconstruction. The pathology of the
patient's breast cancer shows an infiltrating ductal
carcinoma, grade I out of III.
PAST MEDICAL HISTORY: Hypertension.
MEDICATIONS ON ADMISSION:
1. Zestril 10 mg p.o. q.d.
2. Multivitamin.
3. Aspirin.
ALLERGIES: Sulfa.
HOSPITAL COURSE: On the first hospital day, the patient was
taken to the operating room where she underwent a right skin
sparing mastectomy with axillary dissection performed by Dr.
[**Last Name (STitle) 364**], followed by bilateral oophorectomy as performed by
Dr. [**Last Name (STitle) 5166**], and finally a free TRAM right breast
reconstruction by Dr. [**First Name (STitle) **] and the plastic surgery team.
The patient tolerated the procedure well and there were no
intraoperative complications.
Postoperatively, the patient was taken to the Surgical
Intensive Care Unit for close monitoring of the free flap.
The patient's pain was initially managed with an epidural. A
Foley catheter was placed. The patient was given Kefzol and
deep vein thrombosis prophylaxis.
On postoperative day number one, the patient had no problems
and was begun on a p.o. diet, however, on postoperative day
number two, the patient began showing signs of confusion and
inappropriate behavior. She appeared shaky and agitated.
The symptoms were attributed to the patient's history of
alcohol use and in consultation with the psychiatry team, the
patient was begun on CIWA Valium protocol. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] workup
was performed which revealed no other etiologies. The
patient's symptoms resolved over the next day and the patient
required no further intervention.
On postoperative day number three, the patient was stabilized
to the point that she was ready for transfer to the floor.
She began taking adequate p.o. and her intravenous fluids
were discontinued. With adequate p.o. intake, the patient's
epidural was removed by the acute pain service and Foley
catheter was removed as well. Throughout this time, the
patient's flap continued to have a strong dopplerable signal
and had no concerning signs for failure.
On postoperative day number six, the [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) 1661**]-[**Location (un) 1662**]
drain had decreased to a point where they could all be
removed. At this time, the patient was ambulating well,
tolerating regular diet and had adequate pain control. The
patient was afebrile with stable vital signs and no further
signs of any delirium or alcohol withdrawal.
At this point, it was decided the patient was ready for
discharge.
CONDITION ON DISCHARGE: The patient was stable at the time
of discharge.
DISCHARGE DISPOSITION: The patient was discharged home
without need for VNA services.
MEDICATIONS ON DISCHARGE:
1. Percocet one to two tablets q4-6hours p.r.n.
2. Keflex 500 mg p.o. q.i.d.
3. Zestril 10 mg p.o. q.d.
4. Effexor 75 mg p.o. q.d.
FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) **], Dr.
[**Last Name (STitle) 364**] and Dr. [**Last Name (STitle) 5166**] as previously scheduled.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8332**], M.D. [**MD Number(1) 8333**]
Dictated By:[**Last Name (NamePattern1) 17228**]
MEDQUIST36
D: [**2135-6-15**] 11:51
T: [**2135-6-19**] 10:29
JOB#: [**Job Number 17229**]
|
[
"291.81",
"174.9",
"250.00",
"614.6",
"401.9",
"620.1",
"614.1",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"65.61",
"85.43",
"40.3",
"85.7"
] |
icd9pcs
|
[
[
[]
]
] |
2961, 3025
|
3051, 3639
|
445, 525
|
543, 2862
|
153, 381
|
404, 419
|
2887, 2937
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,807
| 125,879
|
16627
|
Discharge summary
|
report
|
Admission Date: [**2147-5-22**] Discharge Date: [**2147-6-5**]
Date of Birth: [**2070-11-20**] Sex: F
Service: ORTHOPEDIC
HISTORY OF PRESENT ILLNESS: This is a 76 year-old white
female who presented with a chronic history of low back pain
and lower extremity discomfort. The patient states that the
pain has become progressively worse thus limiting her
activities of daily living.
PHYSICAL EXAMINATION: The patient's lower extremities were
warm, good sensation, fairly good strength.
Radiographic findings revealed a degenerative scoliosis with
significant spinal stenosis from L1-S1. Considering the
patient's persistent symptoms, radiographic findings it was
decided the patient's best option would consist of an L1-S1
laminectomy and fusion. The risks and benefits of the
procedure were explained to the patient. The patient has
complete understanding of these risks and wished to proceed
with the aforementioned surgical intervention.
HOSPITAL COURSE: On [**2147-5-22**] the patient underwent L1-S1
revision laminectomy and fusion with the use of
instrumentation and local autograft and allograft. Because
of significant intraoperative blood loss the patient after
the surgery was sent to trauma SICU for further medical
management. The patient was appropriately stabilized. The
patient's hematocrit remained stable at 34. The patient was
extubated later on postoperative day number one. On
postoperative day number two the patient remained in the
trauma SICU. Her pain was adequately controlled. She was
tolerating out of bed to the chair. Hemovac put out 180 cc.
Hematocrit remained stable at 37.8. For pain management her
epidural was discontinued. Her Hemovac was continued. She
was slowly mobilized with the use of her EBI brace. Deep
venous thrombosis prophylaxis was maintained with bilateral
OCDs. The patient was later transferred to the floor on
postoperative day number two. On postoperative day number
three the patient complained of significant incisional back
pain during the evening. She had minimal po intake. She was
mobilized slowly with her EBI brace. Her Hemovac put out 100
cc. For pain management her PCA pump was discontinued with
transition to po analgesia. Her Hemovac was continued.
On postoperative day number four the patient had some
confusion secondary to narcotics and significant somnolence
secondary to narcotics later on postoperative day number
three. On postoperative day number four she still had
persistent incisional low back pain. She was eating fairly
well. She was ambulating with significant difficulty.
Hemovac was minimal. Hemovac was thus discontinued. Her
Foley was discontinued. The medical service was subsequently
consulted
secondary to the patient's elevated blood pressure and
inability to have adequate control with the Lopressor. On
postoperative day number six, X-rays acquired including AP and
lateral views of the
lumbar spine, showed a possible dislodgement of the
proximal L1 screws. Flexion and extension views were taken,
which showed slight motion at the L1 pedicle screw region.
Considering the failure of instrumentation of L1 it was
decided the patient's best option consisted of a revision
posterior fusion with extension up to T10. The risks and
benefits were explained to the patient. The patient has
complete understanding of these risks and wished to proceed
with the aforementioned surgical intervention.
On [**2147-5-30**] the patient underwent a revision of T10- S1 fusion.
The patient tolerated the procedure well. For further
details of the procedure please refer to the previously
dictated operative report. On postoperative day number one
from the second procedure the patient complained of some
incisional low back pain. The patient
had one episode of chest pain, which the patient attributed
to movement and low back pain and spasms. Electrocardiogram
performed showed no acute changes. The patient denied any
shortness of breath. Hemovac put out 125 cc. For pain
management her epidural was continued. Her Foley was
continued. Her cardiac status was
continued to be monitored. She was mobilized with the TLSO
in place. Deep venous thrombosis prophylaxis was maintained
with bilateral compression stockings. On postoperative day
number two the
patient had better pain control. She had flatus and no bowel
movement. Her Hemovac put out 20 cc. Her hematocrit and
electrolytes were fairly stable. Her Hemovac was discontinued.
Her Foley was discontinued when she was mobilized better. On
postoperative day number three the patient had much better
pain control. She had slight difficulty mobilizing with the
use of the TLSO brace. The patient's abdomen was soft,
nontender, slightly distended with active bowel sounds. She
was started on an appropriate bowel regimen consisting of
Fleet's enema.
On postoperative day number four the patient complained of
significant loose bowel movements during the previous
evening. She had adequate pain control. She was eating
well. She was urinating without difficulty. Clostridium
difficile culture was taken, which subsequently came back
negative. On postoperative day number five the patient again
continued to do very well. She was ambulating with slight
difficulty with the use of TLSO. She was urinating without
difficulty. She noted slight improvement of her loose bowel
movements. She also noted significant improvement of her
abdominal distention. On postoperative day number six the
patient's pain was doing much better. Her pain was
adequately controlled. She was ambulating with the use of
the TLSO with minimal difficulty. She had no episodes of
chest pain or shortness of breath. Her hematocrit was stable
at 31.6. Her electrolytes were also stable. The patient was
subsequently transferred to rehab on postoperative day number
six.
DISPOSITION/CONDITION ON DISCHARGE: Upon discharge the
patient's pain was adequately controlled. She was eating
well. She was ambulating with minimal difficulty with the
use of TLSO brace. She was urinating without difficulty.
Her incisions showed no signs of infection.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
Lumbar spondylosis.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 3863**]
Dictated By:[**Last Name (NamePattern1) 43864**]
MEDQUIST36
D: [**2147-6-5**] 06:54
T: [**2147-6-5**] 07:05
JOB#: [**Job Number 47108**]
|
[
"292.81",
"733.00",
"998.11",
"737.34",
"996.4",
"724.02",
"427.31",
"E935.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.90",
"81.08",
"78.59",
"03.09"
] |
icd9pcs
|
[
[
[]
]
] |
6186, 6483
|
987, 5873
|
428, 969
|
172, 405
|
5898, 6165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,013
| 116,051
|
7279
|
Discharge summary
|
report
|
Admission Date: [**2177-4-2**] Discharge Date: [**2177-4-7**]
Service: CCU
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with a history of AFib that has been difficult to rate
control, who is scheduled for elective pacemaker placement
and AVJ ablation on day of admission. After completion of
pacemaker placement, patient's blood pressure dropped to
50/palpable. Volume resuscitation was begun and
echocardiogram showed a large effusion with tamponade.
Emergent pericardiocentesis was 300 cc of frank blood and
improved blood pressure.
Blood pressure decreased again and another 400 cc blood was
pulled off. Pacing wire was repositioned successfully in the
right ventricle and pacer was set at DDD at 90.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hypothyroidism.
3. Hypercholesterolemia.
4. Atrial fibrillation.
5. Atrial flutter.
6. Status post right atrial isthmus ablation in summer of
[**2175**]. Was on amiodarone, but discontinued secondary to
nausea and headache. Status post several admissions with
AFib with RVR with rates in the 160s. Referred for pacer and
AVJ ablation. Stress echocardiogram in [**2175-4-17**] showed
an ejection fraction of 65%, mild AS and AI, mild MR [**First Name (Titles) **] [**Last Name (Titles) **].
ALLERGIES: Amiodarone causes headache and nausea.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 b.i.d.
2. Univasc 15 mg q.d.
3. Lescol 80 mg p.o. q.d.
4. Cartia 120 mg p.o. b.i.d.
5. Coumadin.
6. Levoxyl 75 mg p.o. q.d.
7. Vitamin E.
8. Vitamin C.
9. Calcium.
10. Magnesium citrate.
11. Calcium citrate.
FAMILY HISTORY: Negative for diabetes and otherwise
noncontributory.
SOCIAL HISTORY: Denies drugs, tobacco, and alcohol. Lives
in [**Location **] with friend.
PHYSICAL EXAM ON ADMISSION: Temperature 97.3, blood pressure
120/59, heart rate 90, respiratory rate 16, and sats 100% on
room air. Height is 5'5.5", weight 128 pounds. HEENT was
moist mucous membranes. Clear oropharynx. Neck was supple.
Jugular venous pressure is 6 cm. Cardiovascularly: S1, S2
with a 2/6 systolic ejection murmur at the right upper
sternal border, and pericardial drain that was clean, dry,
and intact. Lungs were clear to auscultation bilaterally.
Abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremities: No cyanosis, clubbing, or edema.
Neurologic examination: Awake, alert, and oriented times
three. Cranial nerves II through XII are grossly intact.
Intact strength and motor function, normal sensation. Skin:
No rashes or lesions.
LABORATORIES ON ADMISSION: White count 16.1, hematocrit
30.4, platelets 222. Potassium 4.2, creatinine 0.7, INR 1.3,
PTT 25.1.
Echocardiogram at 11:18 on day of admission showed
moderate-to-large sized pericardial effusion with RV
diastolic collapse. This is impaired filling and tamponade
physiology. At 11:21 a.m. status post pericardiocentesis,
just trivial physiologic pericardial effusion.
HOSPITAL COURSE: This was an 81-year-old woman with a
history of atrial fibrillation, atrial flutter, status post
right atrial isthmus ablation in the summer of [**2175**] admitted
for pacer placement. Procedure complicated by RV perforation
requiring pericardiocentesis with removal of 700 cc of blood.
1. Hemorrhagic pericardial effusion with tamponade: Patient's
drain output
continued to decline and patient's drain was eventually
removed with good results. Patient remained hemodynamically
stable. She got 2 units of packed red blood cells in the
Cath Lab, but was otherwise stable. Patient had follow-up
echocardiogram with no recurrence of the effusion even after
Coumadin was removed. Plans were to stay off Coumadin for at
least one month secondary to this bleed.
Otherwise, patient was started on Ancef 1 gram q.8 initially
and then titrated off.
2. Atrial fibrillation: Patient continued to have episodes
of tachycardia. Patient was continued on her outpatient
regimen eventually and titrated up as tolerated. Patient's
diltiazem dose was titrated up to 180 b.i.d. at time of
discharge. Her atenolol at her home b.i.d. dose regimen was
titrated up to 50 mg b.i.d. Patient was started on aspirin
to which she is to continue especially while she is off
Coumadin. Otherwise, patient was doing well and was planned
for EP study as an outpatient. Patient will follow up with
[**Hospital **] Clinic, on [**4-9**] for Device Clinic and then will
return on [**4-29**] for AVJ ablation.
3. Pneumothorax: Patient had a small pneumothorax after her pacer
placement. Leads were in place and pneumothorax had resolved by
the time of dischar ge on follow-up chest x-ray.
3. Hypothyroidism: The patient was continued on her home
dose of Levoxyl. Patient's TSH was elevated, but her free T4
was in the normal range, and this was likely secondary to
subacute hypothyroid picture. No changes were made during
this acute setting.
DISCHARGE DIAGNOSES:
1. Right ventricle perforation.
2. Atrial fibrillation.
3. Atrial flutter.
4. Hypertension.
5. Hypothyroidism.
6. Pericardial effusion and tamponade.
7. Pneumothorax.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. once a day.
2. Atenolol 50 mg p.o. b.i.d.
3. Diltiazem extended release 180 mg p.o. b.i.d.
4. Ascorbic acid 500 mg p.o. b.i.d.
5. Vitamin E 400 units p.o. q.d.
6. Levothyroxine 75 mcg p.o. q.d.
DISCHARGE CONDITION: Good. Patient is ambulating without
difficulty. Chest pain free at present, no oxygen
requirement.
DISCHARGE STATUS: Discharged to home with followup.
FOLLOW-UP INSTRUCTIONS: The patient is to see her PCP [**Last Name (NamePattern4) **] [**1-17**]
weeks. Patient is to followup in Device Clinic on [**4-9**]
at 9:30 and then for return on [**2177-4-29**] for an AVJ
ablation.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 8227**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2177-4-7**] 13:50
T: [**2177-4-8**] 08:58
JOB#: [**Job Number 26913**]
|
[
"512.1",
"998.2",
"997.1",
"244.9",
"401.9",
"427.31",
"272.0",
"423.9",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"37.72",
"37.83",
"37.0",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
5327, 5483
|
1588, 1642
|
4896, 5064
|
5087, 5305
|
1347, 1571
|
2948, 4875
|
114, 732
|
2557, 2930
|
5508, 5969
|
2354, 2542
|
754, 1321
|
1659, 1749
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,106
| 169,306
|
28916
|
Discharge summary
|
report
|
Admission Date: [**2103-7-6**] Discharge Date: [**2103-7-12**]
Date of Birth: [**2022-10-12**] Sex: F
Service: NEUROLOGY
Allergies:
Pergolide Mesylate
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
unresponsive
Major Surgical or Invasive Procedure:
cerebral angiography and intraarterial tPA administration
History of Present Illness:
The patient is a 81 yo woman with recent diagnosis of Afib, HTN,
recent partial splenic rupture, who is brought to the ED after
she became unresponsive.
.
The patient was recently diagnosed with Afib (this week, when
she developed SOB, HR in the 140's and CP). She underwent a
workup at [**Hospital3 **], including a thyroid biopsy. The plan
was to start her on coumadin and she received lovenox x2 days
(Monday and Tuesday per daughter), but she developed abdominal
pains and was found to have a partial splenic rupture (likely
due a fall [**6-20**] or 2 months earlier). So, she was not started
on coumadin.
.
She was at home with her daughter, when she told her daughter
that she had a headache. She then became unresponsive. This
happened around 3.15 pm. EMS found her to be flaccid on the R
(face, arm and leg). PB was 118/72 and FS was in the 80's.
.
In the ED, her NIHSS was 24 (see below). She is in Afibb. A STAT
CT head showed L-MCA sign.
.
NIHSS: 25
1a. Level of consciousness: 2
1b. LOC questions: 2 (age and month)
1c. LOC commands: 2
2. Best gaze: 1
3. Visual: 2
4. Facial Palsy: 2
5. Motor Arm: 0/4
6. Motor Leg: 0/4
7. Limb ataxia: 0
8. Sensory: 1
9. Best Language: 3
10. Dysarthria: 0
11. Extinction: 2
.
ROS:
-unable
Past Medical History:
- recent AFib; not on coumadin
- thyroid nodules: biopsy on [**7-5**] at [**Hospital **] Hosp
- HTN
-proteinuria
-restless legs
-partial splenic rupture
-multiple falls
-hearing loss on the L
Social History:
lives with her daugther. Former smoking, not much, stopped in
'[**78**]. 3 kids. No alcohol. Does not drive. Some memory problems at
baseline.
Family History:
- MI and strokes; no ca
Physical Exam:
VITALS: Tafebrile HR BP120/49 RR sO2100% FM
GEN: pale
HEENT: mmm
NECK: no carotid bruits
LUNGS: Clear to auscultation bilaterally
HEART: [**Last Name (un) 3526**] [**Last Name (un) 3526**], normal S1 and S2, no murmurs
ABDOMEN: normal bowel sounds, soft, nontender, nondistended
EXTREMITIES: no clubbing, cyanosis, ecchymosis, or edema
.
MENTAL STATUS:
Awake, eyes open, not following commands, non-verbal.
.
CRANIAL NERVES:
No blink to threat from the R, does blink from the L. PERRL.
Dolls across midline. Responds to nose tickle. R-facial droop.
Has gag.
.
MOTOR SYSTEM: Decreased bulk. Tone flaccid in RLE and RUA,
normal LLE, some gegenhalten LUE. Spontaneous movements of LUE
and LLE antigravity. No spontaneous movement on the R, but
triple flexion on the RLE.
.
SENSORY SYSTEM: Triple flexion to noxious in RLE; no response
RUE; withdrawal on the L (UE and LE)
.
REFLEXES:
B T Br Pa Pl
Right 1 1 1 2 -
Left 1 1 1 2 -
upgoing bilaterally.
.
COORDINATION: deferred
.
GAIT: deferred
Pertinent Results:
Admission Labs:
[**2103-7-6**] 04:24PM FIBRINOGE-604*
[**2103-7-6**] 04:24PM PT-12.7 PTT-28.1 INR(PT)-1.1
[**2103-7-6**] 04:24PM WBC-5.2 RBC-4.06* HGB-13.3 HCT-37.7 MCV-93
MCH-32.7* MCHC-35.2* RDW-14.1 PLT COUNT-254
[**2103-7-6**] 04:24PM ASA-7 ETHANOL-NEG ACETMNPHN-7.5 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2103-7-6**] 04:24PM CK-MB-NotDone cTropnT-<0.01
[**2103-7-6**] 04:24PM CK(CPK)-43 AMYLASE-40
[**2103-7-6**] 04:24PM UREA N-24* CREAT-1.1
[**2103-7-6**] 04:26PM freeCa-1.24
[**2103-7-6**] 04:26PM GLUCOSE-84 LACTATE-1.2 NA+-139 K+-5.0 CL--102
TCO2-27
[**2103-7-6**] 04:26PM PH-7.35 COMMENTS-GREEN TOP
[**2103-7-6**] 08:48PM PT-13.0 PTT-37.0* INR(PT)-1.1
[**2103-7-6**] 08:48PM WBC-5.8 RBC-4.33 HGB-13.5 HCT-40.3 MCV-93
MCH-31.2 MCHC-33.6 RDW-14.0 PLT COUNT-286
[**2103-7-6**] 08:48PM CALCIUM-9.2 PHOSPHATE-4.1 MAGNESIUM-2.2
[**2103-7-6**] 08:48PM CK-MB-NotDone cTropnT-<0.01
[**2103-7-6**] 08:48PM CK(CPK)-24*
[**2103-7-6**] 08:48PM GLUCOSE-110* UREA N-23* CREAT-0.9 SODIUM-136
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2103-7-6**] 08:56PM TYPE-ART PO2-163* PCO2-40 PH-7.41 TOTAL
CO2-26 BASE XS-1
.
CTA Head [**7-6**]:
ADDENDUM: Perfusion images were performed. They demonstrate
slow transit
times throughout the entire left hemisphere (including ACA and
PCA
territories) as well as in the right ACA distribution. The
decreased slow
transit time in the right ACA distribution and also in the left
PCA
distribution are thought to be related to collateral attempt.
.
There is also severe decrease in blood volume in the right MCA
distribution. This has been shown to correlate with the ischemic
core. However, no definitive studies are available to support
this information.
.
Preliminary CTA results are also available and they demonstrate
complete
occlusion of the left internal carotid artery at the level of
the bifurcation by likely emboli.
.
The final CTA images confirm the initial impression of left ICA
occlusion
without other significant stenoses.
.
CT Head [**7-7**]:
FINDINGS: There is hypodensity involving the left frontal and
parietal lobe [**Doctor Last Name 352**] and white matter with mild focal effacement
consistent with continued evolution of the patient's known left
MCA infarct. Hypodensity also notably involves the insular
cortex and underlying white matter, with also possible
involvement of the basal ganglia on the left. There is no
evidence of acute intra- or extra-axial hemorrhage. There is
slight mass effect producing slight compression of the left
lateral ventricle without midline shift. The basal cisterns
appear patent. Periventricular white matter hypodensity is also
again seen and unchanged compared to the previous exam
consistent with chronic microangiopathic disease.
.
The visualized paranasal sinuses appear well pneumatized and
well aerated.
.
IMPRESSION: Continued evolution of infarction in the
distribution of the left middle cerebral arterial.
.
Brief Hospital Course:
Pt. was admitted to the Neuro ICU after administration of
intraaterial tPA. Her exam was stable (not improved) overnight,
and she still had dense right sided hemiplegia with no movement
on that side in the morning. She opened her eyes to voice but
produced no speech and followed no commands. Repeat imaging in
the AM showed evolution of the stroke but no evidence of midline
shift. BP was controlled with Labetalol drip initially, then
transitioned to metoprolol PO, and pt. was given ASA and Statin
for secondary stroke prevention. An NGT was placed and pt was
administed tube feeds. We discussed with family starting
Heparin and Coumadin given her A fib and likely embolic source
of ischemia, however family did not want these given her risk of
hemorrhagic conversion of her stroke. In further discussions
with pt's family they felt that she would not have wanted
aggresive care in these circumstances, and elected to follow her
wishes and focus her care on comfort. ASA, Statin, BB, tube
feeds, and IVF were therefore discontinued, and Morphine and
Ativan were administered as needed for anxiety and pain. Pt.
was transferred to inpatient hospice for further comfort care.
Medications on Admission:
-colace
-MOM
-nitro 0.4mg PRN
-fosamax 70mg q week
-salsalate 750mg [**Hospital1 **] PO
-neurontin 600mg PO BID
-cardizem 240mg PO daily
Discharge Medications:
1. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: One (1)
Tablet, Sublingual Sublingual QID (4 times a day) as needed for
PRN secretions.
2. Scopolamine Base 1.5 mg Patch 72HR Sig: [**11-20**] Patch 72HRs
Transdermal Q72H (every 72 hours) as needed for PRN secretions.
3. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
Q1-2H () as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] House Rehabilitation & Nursing Center - [**Location (un) 5087**]
Discharge Diagnosis:
Large left MCA ischemic stroke
Atrial fibrillation
Discharge Condition:
Appears comfortable. No movement right arm or leg, does not
open eyes to voice.
Discharge Instructions:
Please continue comfort care.
Followup Instructions:
per hospice physicians
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2103-7-12**]
|
[
"401.9",
"241.0",
"427.31",
"507.0",
"434.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"96.6",
"96.71",
"96.04",
"99.10"
] |
icd9pcs
|
[
[
[]
]
] |
7820, 7928
|
6054, 7241
|
293, 353
|
8023, 8106
|
3062, 3062
|
8184, 8353
|
2010, 2035
|
7428, 7797
|
7949, 8002
|
7267, 7405
|
8130, 8161
|
2050, 2389
|
241, 255
|
381, 1618
|
2476, 3043
|
3079, 6031
|
2404, 2460
|
1640, 1834
|
1850, 1994
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,739
| 132,843
|
39433
|
Discharge summary
|
report
|
Admission Date: [**2166-7-21**] Discharge Date: [**2166-8-1**]
Date of Birth: [**2096-11-18**] Sex: M
Service: MEDICINE
Allergies:
Percodan
Attending:[**First Name3 (LF) 1943**]
Chief Complaint:
need for possible esophageal and Y-stent placement
Major Surgical or Invasive Procedure:
Radiation therapy to lung mass
History of Present Illness:
Mr. [**Known lastname 87136**] is a 69 year-old man with COPD and newly diagnosed
right lower lobe poorly differentiated NSCLC w/ bulky
mediastinal lymphadenopathy and obstruction of the esophagus and
distal trachea and bilateral mainstem bronchi. He was initially
transferred to the MICU from [**Hospital 8641**] Hospital after being
admitted on [**2166-7-16**] for evaluation for esophageal and Y-stent
placement for compressive lung mass. VS on arrival were T 97.0,
BP 130/60, HR 110, RR 24 with sat 94 on 10LNC.
About two months ago, he presented with hemoptysis and, with the
workup, ultimatley had a biopsy around 3 weeks ago. He has lost
35 lbs due to anorexia and difficulty getting food down. He had
a PEG tube placed on [**2166-7-17**]. MRI head at OSH was negative for
mets. He was managed with duonebs, IV solumedrol and
azithromycin at the OSH, though his respiratory status continued
to decline.
In the MICU, he was started empirically on vanc/unasyn for
aspiration pneumonia and seen by IP. They felt that his hypoxia
was most likely secondary to right pulmonary artery compression
from the mediastinal mass/LAD, and did not feel that he would
benefit from Y-stent placement. However, if one were placed,
they recommended evaluation for simultaneous esophageal stent
placement. They also recommended chest CTA to rule out PE (he
previously had chest CT with contrast at OSH but was not
protocoled for PE per report), and urgent rad onc consult.
He is transferred to the [**Hospital Unit Name 153**] today for initiation of radiation
simulation and with first session of XRT to begin this
afternoon. Vitals immediately prior to transfer were 97.3 99-110
20 147/62 95%NRB, up from 10L nasal canula on arrival to the
MICU.
ROS is notable for dyspnea, back pain, headache, occ cough. It
is negative for FC, abd pain, change in BM.
Past Medical History:
-PEG tube placed on [**2166-7-17**]
-COPD
-HTN
-Transitional cell Bladder CA
-Spermatic cord liposarcoma, [**2160**], RP nodal resection; no
chemo/XRT
-Poorly differentiated NSCLC -- RLL; needle bx [**2166-6-19**]
-Cholecystectomy
Social History:
50 pack year smoking history; drinks 1 drink per day; prior
asbestos exposure. No IVDU.
Family History:
Mother-- breast CA; father-- diabetes
Physical Exam:
VS on arrival were T 97.0, BP 130/60, HR 110, RR 24 with sat 94
on 10LNC
GENERAL: appears somewhat uncomfortable with face mask but NAD
HEENT: bearded, conjunctiva nonicteric, OP clear
LUNGS: rhonchorous esp at right base; wheezing throughout
CARDIO: tachycardic, rate regular, no murmurs appreciated
ABD: + BS, soft, NTND
EXT: no [**Location (un) **], WWP
SKIN: no rashes, no petechiae
NEURO: AA, Ox3, CN II - XII normal; strength 5/5 throughout
Pertinent Results:
Admission Labs:
[**2166-7-21**] 07:24PM BLOOD WBC-22.2* RBC-3.77* Hgb-11.4* Hct-33.3*
MCV-88 MCH-30.3 MCHC-34.3 RDW-13.2 Plt Ct-313
[**2166-7-21**] 07:24PM BLOOD Neuts-94.6* Lymphs-3.0* Monos-2.3 Eos-0.1
Baso-0.1
[**2166-7-21**] 07:24PM BLOOD PT-13.3 PTT-24.9 INR(PT)-1.1
[**2166-7-21**] 07:24PM BLOOD Glucose-203* UreaN-22* Creat-0.6 Na-136
K-4.4 Cl-100 HCO3-24 AnGap-16
[**2166-7-21**] 07:24PM BLOOD Calcium-9.2 Phos-3.0 Mg-2.1
Chest CT [**7-25**]:
IMPRESSION:
1. Extensive mediastinal, hilar lymphadenopathy involving the
entire
mediastinum and hila bilaterally, with minimal change within the
right hilum compared to prior study. The lymphadenopathy encases
aorta, right main pulmonary artery and SVC as described in
details in the body of the report. Interval increase in
pericardial effusion is noted, small-to-moderate.
2. Right lower lobe mass, unchanged.
3. Bilateral pleural effusion, unchanged.
4. Large right adrenal mass, no comparison with prior studies is
available
and this area was not included on the prior outside study.
5. Multiple mesenteric lymph nodes most likely representing a
similar
process.
6. Hypodense pancreatic lesion, significance is unknown, might
represent IPMN or involvement of the pancreas by metastatic
process as well.
7. Status post PEG insertion due to significant compromise of
the esophagus by lymphadenopathy.
8. Metastasis involvement of L1 by lytic lesion with soft tissue
component. No involvement of posterior endplate and spinal
canal is seen at this point.
Brief Hospital Course:
69 y/o gentleman with RLL NSCLC and extensive mediastinal
lymphadenopathy that is compressing the esophagus, left lower
lobe segmental bronchi, and right pulmonary artery; he was
admitted to the [**Hospital Unit Name 153**] while he completed his radiation course.
The patient did develop atrial fibrillation and rapid
ventricular rate that was controlled with Metoprolol.
PROBLEM LIST:
#. [**Name2 (NI) 87137**]/Hypoxia: New diagnosis of lung cancer with involvement
of mediastinum and compression of right pulmonary artery, distal
trachea, bilateral mainstem bronchi, and esophagus. Transferred
to [**Hospital Unit Name 153**] for expedited XRT and monitoring during therapy.
Hypoxia likely multifactorial with right pulmonary artery
compression, ? of post-obstructive pneumonia, and airway
compression. Pt was given 5 days of XRT to fairly wide area in
chest. After few days started having difficulty with substernal
chest pain likely [**12-24**] to mass effect and post-radiation
changes/inflammation. He was also treated with a 7 day course of
vanc/unasyn for emperic coverage of post-obstructive pna. All
micro culture was negative. DNR/DNI status was established at
initial presentation. A palliative care consult was obtained due
to the nature of the disease process. Pain control recs were
left and followed and a discussion was started about long term
plans. Family expressed interest in having pt with son in [**Name (NI) 86**]
area with home hospice. Pt expressing interest in going home to
[**Location (un) 3844**]. Dr.[**Name (NI) 8949**] office called to schedule f/u
appointment in case pt stays in [**Location (un) 86**] area on D/C.
#. Pain, right chest, tumor-related: Fentanyl patch, as needed
morphine.
#. Atrial Fibrillation: Pt with new onset of Afib during the
evening of [**9-2**]. Also with RVR tachy to 150s. EKG showed no
signs ischemia. 5mg of IV metoprolol x 2 slowed rate to 110-120s
but not further and BP bottomed to 90s/60s. Metoprolol was
changed to QID. HR slowly increased again to 150s over next [**12-25**]
hrs but pt spontaneously convereted to sinus early in AM with no
further intervention. It is thought that a combination of atrial
compression from the mass and radiation change to the atrial
area precipitated the Afib which did not reoccur while in the
[**Hospital Unit Name 153**]. Discharged on Metoprolol 50mg PO Q8hrs. Recommend
increasing to 50mg PO Q6hrs if patient has recurrent rapid
ventricular response.
#. RUE swelling/erythema: noted on [**7-26**]. Concern for DVT or SVC
syndrome as come evidence of SVC compression on chest CT. U/S
RUE showed occlusive clot of cephalic vein (superficial vein)
but no DVT.
#. COPD: Initially treated for COPD exacerbation at OSH with
azithro and solumedrol. Pt was kept on standing
ipratropium/albuterol + PRN albuterol for SOB but steroids were
discontinued per rad onc request while on XRT.
#. Back pain: History of distant back surgery and patient
reports chronic back pain x decades, no worsening in last
several months. Rad Onc okayed NSAIDs during therapy so high
dose Ibuprofen was started in addition to standing opiods.
#. HTN: On metoprolol mostly for rate control.
#. DVT prophylaxis: Heparin subcutaneous
#. Code status: DNR/DNI
#. Communication: [**Name (NI) **] [**Name (NI) 87136**] (Son) [**Telephone/Fax (1) 87138**]
Medications on Admission:
Atenolol 25mg PO Daily
Vicodin
Pravachol 40mg Daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Telephone/Fax (1) **]: One (1) unit dose Inhalation Q4H (every 4
hours) as needed for SOB.
4. Lorazepam 0.5 mg Tablet [**Telephone/Fax (1) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for anxiety.
5. Benzonatate 100 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO TID (3
times a day).
6. Fexofenadine 60 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times
a day).
7. Fluticasone 50 mcg/Actuation Spray, Suspension [**Telephone/Fax (1) **]: Two (2)
Spray Nasal DAILY (Daily).
8. Heparin (Porcine) 5,000 unit/mL Solution [**Telephone/Fax (1) **]: 5000 (5000)
unit Injection TID (3 times a day): For DVT prophylaxis.
9. Morphine 10 mg/5 mL Solution [**Telephone/Fax (1) **]: Five (5) mg PO Q4H (every 4
hours) as needed for pain.
10. Acetaminophen 650 mg/20.3 mL Solution [**Telephone/Fax (1) **]: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for fever or pain.
11. Ipratropium Bromide 0.02 % Solution [**Age over 90 **]: One (1) unit dose
Inhalation Q6H (every 6 hours) as needed for wheezing.
12. Fentanyl 12 mcg/hr Patch 72 hr [**Age over 90 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
13. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia: [**Month (only) 116**] repeat x1 as needed.
15. Metoprolol Tartrate 50 mg Tablet [**Month (only) **]: One (1) Tablet PO TID
(3 times a day): Hold for SBP<90 or HR<60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3137**] Care Center - [**Location (un) 1468**]
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Non small cell lung cancer
- Atrial fibrillation
- Hypoxemia
- Pain, right chest, tumor-related
SECONDARY DIAGNOSES:
- G-tube placed [**2166-7-17**]
- Chronic obstructive pulmonary disease
- Hypertension
- Transitional cell cancer of the bladder
- Spermatic cord liposarcoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were managed at the [**Hospital1 69**]
with radiation therapy for your Lung Cancer. You developed
complication with an irregular heart rhythm called Atrial
Fibrillation that is controlled with a medication called
Metoprolol. We decided to leave in the gastric tube that you
use for supplemental tube feeding because it may be useful for
medicine administration and food supplementation and because you
did not mind having it left in. You will transition to a
skilled nursing facility to continue receiving care and support
for your medical issues.
Followup Instructions:
Dr [**Last Name (STitle) **] - Pulmonary [**Hospital **] Clinic - Please call
[**0-0-**] after Tuesday [**7-29**] to make appointment as desired.
|
[
"785.6",
"492.8",
"V66.7",
"459.2",
"443.9",
"162.5",
"453.81",
"V10.47",
"507.0",
"338.29",
"724.5",
"401.9",
"V44.1",
"787.20",
"427.31",
"427.89",
"530.3",
"V10.51",
"519.19",
"198.5",
"276.50"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
10056, 10141
|
4658, 5032
|
320, 353
|
10481, 10481
|
3124, 3124
|
11235, 11383
|
2603, 2642
|
8104, 10033
|
10162, 10280
|
8028, 8081
|
10656, 11212
|
2657, 3105
|
10301, 10460
|
230, 282
|
381, 2228
|
3140, 4635
|
5046, 8002
|
10496, 10632
|
2250, 2482
|
2498, 2587
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,787
| 120,913
|
2527
|
Discharge summary
|
report
|
Admission Date: [**2124-1-12**] Discharge Date: [**2124-1-17**]
Date of Birth: [**2044-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
80 M with previous BRBRP [**7-24**] and [**9-23**] attributed to colitis,
severe diverticulosis, h/o C-diff colitis, EGD with no bleeding
source [**9-23**], recent MICU discharge for ESBL Klebsiella
urosepsis [**2123-12-18**], bilateral urolithiasis with R ureteral stent
and L perc nephrostomy tube, CHF EF 60%, here with BRBPR x 1
day. He has been in rehab since his recent MICU discharge, and
had recovered well, being able to move from a wheelchair to a
walker. He has been feeling well over the past several days, no
fever, no chills, no CP, no SOB, no abd pain, no N/V, no
dizziness, just bright red bleeding that has not stopped since
yesterday. No melena.
.
He has presented in [**7-24**] and [**9-23**] for BRBPR, attributed to
friability and edema of mucosa of sigmoid colon and descending
colon, compatible with colitis. Patient was hemodynamically
stable with Hct around 30s throughout [**9-23**] admission. Stool cx
were negative, C diff was negative, and colon biopsies showed
active colitis. Colonoscopy showed severe diverticulosis which
appeared to be nonbleeding.
.
He had ESBL Klebsiella urosepsis that was [**Last Name (un) 36**] to Meropenem. On
his last admission, he had been treated with [**Last Name (un) **] for several
days, and then was switched to Ceftriaxone for 2 weeks, stopped
on [**12-30**]. He had also been positive for Cdiff on [**11-23**], treated
with flagyl for 2 weeks and stopped on [**12-30**].
Past Medical History:
CVA - [**2117**] with residual right-sided weakness
OSA - on 2L NC during day and night; refused home CPAP
CAD - s/p MI 3 yrs ago
CHF - diastolic dysfunction
Anemia - [**8-23**] EGD with gastritis, colonoscopy with
diverticulosis, with GI bleeding
C diff colitis [**8-24**], [**11-23**]
Depression
s/p right shoulder surgery
s/p knee replacement
h/o right ureteral stent placement and left nephrostomy tube
placement for obstructive nephrolithiasis - removed [**7-24**]
right subcapsular perinephric hematoma
Social History:
Married, currently lives at Rehab. History of 30 pky smoking
history, quit 20 years ago. Drinks 2 drinks/week. No IVDU
Family History:
Noncontributory
Physical Exam:
VS: 97.3 / 139/93 / 108 / 13 / 95% RA
GEN: Alert, speaks articulately and answers questions
appropriately
HEENT: JVD flat, no LAD, OP clear
LUNGS: CTA B
HEART: RRR, no m/r/g
ABD: Soft, +BS, ND NT
EXTR: Warm, no c/c/e, 2+ DP bl
NEURO: L pupil surgical, can move all extremities, has R sided
weakness
SKIN: No rash
Pertinent Results:
[**2124-1-12**] 10:50AM PT-12.8 PTT-24.5 INR(PT)-1.1
[**2124-1-12**] 10:50AM PLT COUNT-144*#
[**2124-1-12**] 10:50AM WBC-5.8 RBC-3.69* HGB-10.7* HCT-32.0* MCV-87
MCH-29.0 MCHC-33.5 RDW-16.9*
[**2124-1-12**] 10:50AM NEUTS-56.2 LYMPHS-33.0 MONOS-4.8 EOS-4.6*
BASOS-1.4
[**2124-1-12**] 10:50AM GLUCOSE-95 UREA N-26* CREAT-1.6* SODIUM-138
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-26 ANION GAP-13
[**2124-1-12**] 11:55PM calTIBC-137* VIT B12-402 FOLATE-10.7
FERRITIN-338 TRF-105*
[**2124-1-12**] 08:15PM URINE RBC-145* WBC-116* Bacteri-NONE Yeast-NONE
Epi-<1
[**2124-1-12**] 08:15PM URINE Blood-LGE Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
[**2124-1-12**] 08:15PM URINE Color-Yellow Appear-SlCloudy Sp
[**Last Name (un) **]-1.016
.
CDIFF NEGATIVE X 1
.
URINE CULTURE (Final [**2124-1-15**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
NITROFURANTOIN-------- 256 R
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
.
Blood cultures pending
.
[**2124-1-13**] Colonoscopy:
1. Diverticulosis of the sigmoid colon, descending colon,
transverse colon and ascending colon, with clotted blood in the
diverticuli in the left colon
2. Small patch of abnormal mucosa in the rectum
3. Polyp in the rectum
4. Otherwise normal colonoscopy to cecum
[**2124-1-17**] 08:35AM BLOOD WBC-5.2 RBC-3.85* Hgb-11.1* Hct-31.4*
MCV-82 MCH-28.8 MCHC-35.3* RDW-16.5* Plt Ct-113*
Brief Hospital Course:
80 M with previous BRBRP [**7-24**] and [**9-23**] attributed to colitis,
severe diverticulosis, Cdiff colitis, EGD with no bleeding
source [**9-23**], recent MICU discharge for ESBL Klebsiella
urosepsis [**2123-12-18**], bilateral urolithiasis with R ureteral stent
and L perc nephrostomy tube, CHF, here with BRBPR x 1 day.
.
# BRBPR/LGIB:
Colonoscopy revealed diverticulosis with clots in diverticuli,
but no evidence of active bleed. He received a total of 4 U
prbcs and his hct has stabilized. He has had no addtional
episodes of BRBPR since colonoscopy but continues to have guaic
positive stools. Furthermore, he has remained hemodynamically
stable. In terms of previous GI evaluation, he does have a
history of gastritis and was started on a PPI. He was admitted
on an H2 blocker and most recent EGD did not reveal any evidence
of gastritis. Both PPIs and H2 blockers can potentiate
thrombocytopenia, and although not thought to be the cause of
his thrombocytopenia (given he has been on both prior to
developing low platelets), we will currently keep him off PPI
and H2 blocker and start him on sucralfate.
.
# UTI: On admission, UA showed numerous WBC and RBCs, but no
organisms. He has known urolithiasis and has recent
hospitalization for Klebsiella urosepsis. He was started on
meropenem in the ICU and received 3 days for ? adequate
treatment previously. His culture subsequently grew
enterococcus, resistant to ampicillin but sensitive to
vancomycin. Plan to treat with a total of 7 days vancomycin
with follow-up urinalysis and urine culture off antibiotics. He
has follow-up scheduled with urology on [**1-27**].
.
# h/o C. diff: Previously treated for full 2 week course of
flagyl. Reports no additional diarrhea except in the setting of
his GI bleed. C. diff negative x 1 this admission and no
further diarrhea. C diff B pending.
.
# CAD: s/p MI. Holding aspirin in setting of GIB. He reamined
HD stable so his beta blocker was reinstituted. Would consider
restarting ASA in one month.
.
# CHF: Diastolic dysfunction. EF 60%. No evidence of CHF on
exam.
.
# Anemia: Previous studies c/w Fe deficiency likely from chronic
GIB. Iron normal on this admission, low TIBC, normal ferritin
and transferrin.
.
# Thrombocytopenia: Recent platelet baseline low 100s, but prior
to [**2123-11-19**] appears to have had normal platelet count. Unclear
etiology as he does not appear to have been started on any new
medications. Suspect BM suppression due to prior episode of
sepsis. DIC panel without significant abnormalities this
admission and platelets remain stable. Holding off on
PPI/Famotidine as above.
.
# CRI: Most recent creatinine has range 1.5-1.7. He is
currently below this baseline at 1.3.
.
# COPD: No wheezing on exam. Bibasilar crackles but CXR without
infiltrate. Continued on tiotropium.
.
# Liver cysts: Incidental finding on abdominal CT. Will need
outpatient workup.
.
# History of CVA [**2117**] with R sided weakness: Aggrenox and ASA
have been held in the setting of his GI bleed. This will need
to further evaluated in the setting of recurrent GI bleeds.
.
Medications on Admission:
1. MVI 1 Cap PO daily
2. Ferrous Sulfate 325 three times daily
3. Aspirin 81 mg daily
4. Metoprolol Tartrate 25 mg twice daily
5. Tiotropium Bromide 1 cap IH daily
6. Famotidine 40 mg daily
7. Tramadol 25 mg twice daily
Discharge Medications:
1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gm
Intravenous Q 12H (Every 12 Hours) for 5 days: course to end
evening of [**1-22**].
4. FerrouSul 325 (65) mg Tablet Sig: One (1) Tablet PO once a
day.
5. Multi-Vit 55 Plus Tablet Sig: One (1) Tablet PO once a
day.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
7. Carafate 1 g Tablet Sig: One (1) Tablet PO four times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
1. Acute Blood Loss Anemia
2. GI bleed, likely secondary to diverticulosis
3. Thrombocytopenia; suspect med effect
4. Enterococcus Urinary Tract Infection
Secondary Diagnoses:
CVA - [**2117**] with residual right-sided weakness
OSA - on 2L NC during day and night; refused home CPAP
CAD - s/p MI 3 yrs ago
CHF - diastolic dysfunction
Anemia - [**8-23**] EGD with gastritis ([**9-23**] with no gastritis),
[**9-23**] colonoscopy with non-bleeding diverticulosis
C diff colitis [**8-24**], [**11-23**]
Depression
s/p right shoulder surgery
s/p knee replacement
h/o right ureteral stent placement and left nephrostomy tube
placement for obstructive nephrolithiasis - removed [**7-24**]
h/o right subcapsular perinephric hematoma
Secondary Diagnoses
Discharge Condition:
Stable
Discharge Instructions:
Please come back to the ED should you have any blood in your
stools, black stools, chest pain, abdominal pain, fevers,
chills, or any other complaints.
Please hold your aspirin for one month. It can then be
restarted.
Followup Instructions:
Provider: [**Name10 (NameIs) **],PCC PROSTATE CANCER CARE (SB) Phone:[**Telephone/Fax (1) 6317**]
Date/Time:[**2124-2-1**] 1:00
|
[
"041.04",
"287.5",
"428.30",
"285.1",
"562.12",
"585.9",
"496",
"428.0",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
8580, 8674
|
4539, 7656
|
321, 334
|
9474, 9483
|
2855, 4516
|
9751, 9882
|
2489, 2506
|
7927, 8557
|
8695, 8855
|
7682, 7904
|
9507, 9728
|
2521, 2836
|
8876, 9453
|
275, 283
|
362, 1803
|
1825, 2336
|
2352, 2473
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,710
| 183,957
|
42375
|
Discharge summary
|
report
|
Admission Date: [**2169-1-6**] Discharge Date: [**2169-2-6**]
Date of Birth: [**2110-8-20**] Sex: M
Service: MEDICINE
Allergies:
Unasyn
Attending:[**First Name3 (LF) 5141**]
Chief Complaint:
Fatigue, lightheadedness, dysphagia
Major Surgical or Invasive Procedure:
1. Rigid bronchoscopy
2. EGD with 15cm stent placement
3. Bedside bronchoscopy
4. PICC placement
5. CT guided placement of PEG tube
6. arthrocentesis right knee
History of Present Illness:
58 year old male with recent diagnosis of esophageal cancer,
gout who presents with fatigue and lightheadedness. Per the
patient and his son-in-law, via [**Name (NI) 8230**] interpreter, the
patient has been hungry but unable to tolerate POs X 3 days.
The patient has tried buns and fluids but generally vomits
everything up (5-6X daily); also endorses some difficulty
swallowing. No coffee grounds or hematemesis. Also no diarrhea,
mostly small formed/firm stools. He does endorse some chronic
left leg pain and intermittent fevers X months; 50 pound weight
loss over the last several weeks. No chest pain, shortness of
breath, abdominal pain, pleuritic chest pain, dyuria.
.
In the ED inital vitals were, T98.6, HR81, BP67/48, RR20, 96% on
RA. The patient was triggered and received 4 L IVF and
levofloxacin 750mg IV X1. Because of persistent low blood
pressures, he was broadened to Ceftriaxone 1 gram X1 as well.
His labs were notable for a lactate 3.0, sodium 133 and
creatinine 1.5; his WBC 25.3 with 4% bands and INR 1.4. CXR
suggestive of RML infiltrate and urinalysis with trace leuks, 24
WBC, moderate bacteria (no nitrites). Blood cultures were drawn.
.
On arrival to the ICU, the patient is resting comfortably in
bed. He denies current symptoms but requesting the head of his
bed to be lowered.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, headache, rhinorrhea or congestion.
Denies cough, shortness of breath, or wheezing. Denies chest
pain, chest pressure, palpitations, diarrhea, constipation
(although small stools, minimal PO intake), abdominal pain, or
changes in bowel habits. Denies dysuria, frequency, or urgency.
Past Medical History:
* Esophageal cancer (diagnosed last week) - ?squamous cell
carcinoma
* Gout
Social History:
[**Name (NI) 8230**] speaking only. Understands some Mandarin. Lives with
daughter and son-in-law. Drank and smoked heavily when younger.
Denies illicits.
Family History:
noncontributory
Physical Exam:
Physical Exam on admission:
Vitals: T: 96.0 BP: 85/62 P: 60 R: 16 O2: 96% on RA
General: Alert, oriented, no acute distress, cachectic
HEENT: Sclera anicteric, dry mucus membranes, oropharynx clear
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: Foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; symmetric
Discharge PE
G tube c/d/i, mild effusion still present in suprapatellar
region of right knee but both kneed nontender
Pertinent Results:
Admission Labs:
[**2169-1-6**] 06:50PM BLOOD WBC-25.3*# RBC-3.87* Hgb-10.1* Hct-32.2*
MCV-83 MCH-26.1* MCHC-31.3 RDW-13.6 Plt Ct-604*
[**2169-1-6**] 06:50PM BLOOD Neuts-84* Bands-4 Lymphs-10* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2169-1-6**] 06:50PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2169-1-6**] 06:50PM BLOOD PT-14.6* PTT-30.1 INR(PT)-1.4*
[**2169-1-6**] 06:50PM BLOOD Glucose-192* UreaN-48* Creat-1.5* Na-133
K-4.8 Cl-93* HCO3-23 AnGap-22*
[**2169-1-6**] 06:59PM BLOOD Lactate-3.0*
[**2169-1-6**] 09:25PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2169-1-6**] 09:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-TR
[**2169-1-6**] 09:25PM URINE RBC-5* WBC-24* Bacteri-MOD Yeast-NONE
Epi-3
[**2169-1-6**] 09:25PM URINE CastHy-98*
Pertinent Labs
[**2169-1-7**] 04:30AM URINE Osmolal-602
[**2169-2-1**] 08:55AM URINE Osmolal-642
[**2169-1-7**] 04:30AM URINE Hours-RANDOM UreaN-714 Creat-44 Na-122
K-26 Cl-147
[**2169-2-1**] 08:55AM URINE Hours-RANDOM Creat-83 Na-122 K-61 Cl-103
[**2169-1-6**] 09:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.5 Leuks-TR
[**2169-2-1**] 08:55AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
[**2169-1-6**] 09:25PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2169-2-1**] 08:55AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018
.
[**2169-1-11**] 06:05AM BLOOD Hapto-309*
[**2169-1-7**] 04:30AM BLOOD calTIBC-113 Ferritn-1295* TRF-87*
[**2169-1-11**] 06:05AM BLOOD Triglyc-118
[**2169-2-1**] 08:54AM BLOOD Osmolal-278
.
[**2169-1-23**] 06:00AM BLOOD Cortsol-21.4*
[**2169-1-7**] 04:30AM BLOOD Cortsol-26.5*
.
[**2169-1-12**] 04:55PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HBc-NEGATIVE
[**2169-1-7**] 04:58AM BLOOD Lactate-1.2
[**2169-1-16**] 12:03PM BLOOD QUANTIFERON-TB GOLD-Test
.
Micro:
[**2169-1-8**] 8:00 am ABSCESS Site: LUNG
RIGHT LOWER ABSCESS LUNG MASS. R/O ACTINOMYCES.
GRAM STAIN (Final [**2169-1-8**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ (5-10 per 1000X FIELD): THIN BRANCHING GRAM POSITIVE
ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
Reported to and read back by VILLARENZI (NURSE) AND INTERN
MD [**Last Name (Titles) **]
# [**Numeric Identifier 91765**].
MODIFIED ACID-FAST STAIN FOR NOCARDIA (Final [**2169-1-8**]):
No thin, branching, partially acid fast rods seen.
WOUND CULTURE (Final [**2169-1-14**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ANAEROBIC CULTURE (Preliminary):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
GRAM POSITIVE RODS. MODERATE GROWTH.
ISOLATE BEING SENT TO [**Hospital1 4534**] LABORATORIES FOR FURTHER
IDENTIFICATION.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2169-1-9**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
NOCARDIA CULTURE (Final [**2169-2-2**]): NO NOCARDIA ISOLATED.
FUNGAL CULTURE (Final [**2169-1-30**]): NO FUNGUS ISOLATED.
[**2169-1-8**] 12:45 pm SPUTUM Source: Endotracheal.
GRAM STAIN (Final [**2169-1-8**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2169-1-10**]):
SPARSE GROWTH Commensal Respiratory Flora.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
ACID FAST SMEAR (Final [**2169-1-9**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
NOCARDIA CULTURE (Final [**2169-1-30**]): NO NOCARDIA ISOLATED.
FUNGAL CULTURE (Final [**2169-1-23**]): NO FUNGUS ISOLATED
[**2169-1-12**] 4:55 pm IMMUNOLOGY Source: Line-PICC.
**FINAL REPORT [**2169-1-17**]**
HBV Viral Load (Final [**2169-1-17**]):
HBV DNA not detected.
Performed using the Cobas Ampliprep / Cobas Taqman HBV
Test.
Linear range of quantification: 40 IU/mL - 110million
IU/mL.
Limit of detection: 10 IU/mL.
[**2169-2-1**] 8:54 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2169-2-7**]**
Blood Culture, Routine (Final [**2169-2-7**]): NO GROWTH.
[**2169-2-1**] 8:55 am URINE Source: CVS.
**FINAL REPORT [**2169-2-3**]**
URINE CULTURE (Final [**2169-2-3**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
[**2169-2-2**] 8:10 am JOINT FLUID
Source: Knee BURSA AND INTRA-ARTICULAR.
GRAM STAIN (Final [**2169-2-2**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
Reported to and read back by TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**2169-2-2**] @1045.
FLUID CULTURE (Final [**2169-2-5**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2169-2-3**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
[**2169-2-2**] 08:10AM JOINT FLUID WBC-[**Numeric Identifier 20686**]* RBC-5000* Polys-92*
Lymphs-7 Monos-1
[**2169-2-2**] 08:10AM JOINT FLUID Crystal-MOD Shape-NEEDLE
Locatio-I/E Birefri-NEG Comment-c/w monoso
Imaging:
CXR [**2169-1-6**]:
IMPRESSION: Findings consistent with pneumonia in the right
lower lobe.
Follow-up radiographs are recommended following treatment in
order to ensure resolution.
[**2169-1-7**] Radiology CT CHEST/Abdomen W/CONTRAST:
IMPRESSION:
1. Perforation of the lower thoracic esophagus with evidence of
active oral contrast extravasation in to a large multiloculated
fluid- and air-containing collection extending from the
posterior mediastinum into the majority of the posterior aspect
of the right lower lobe of the lung.
2. Ground-glass and more confluent opacities throughout the
right lower lobe, consistent with an infectious process.
3. Necrotic right paratracheal lymph node, measuring up to 13 mm
in short
axis.
4. The stomach is grossly unremarkable aside from a 3.8 cm
segment of
concentric wall thickening at the level of the pylorus (3:63),
which could
still represent hypertrophic muscle. EGD correlation is
recommended.
5. Cystic 1.6 cm partially enhancing lesion superior to the
pancreatic tail is concerning for a necrotic lymph node .
6. Moderate quantity of simple free fluid in the pelvis is a
nonspecific but abnormal finding, possibly related to the
esophageal perforation.
7. Enlargement of the main pulmonary artery with ectasia of the
ascending
thoracic aorta, as described above.
8. Moderate right and small left nonhemorrhagic pleural
effusions.
9. Simple left renal cyst with additional tiny bilateral renal
hypodensities that are too small to characterize but also
statistically represent simple cysts.
.
CT NECK W/ CONTRAST [**2169-1-7**]:
IMPRESSION:
1. No pathologically enlarged cervical lymph nodes. A necrotic
right
paratracheal node could relate to known squamous cell esophageal
cancer.
2. Dilation with debris within the upper thoracic esophagus.
Please see the accompanying CT torso from [**2169-1-7**] for a
full description regarding lower thoracic esophageal perforation
into the right lower lobe of the lung.
3. Moderate non-hemorrhagic right pleural effusion.
4. Ectasia of the ascending thoracic aorta.
5. Periapical lucencies scattered throughout the maxillary
dentition could
represent odontogenic disease.
.
CXR [**2169-1-9**]:
FINDINGS: Homogeneous opacity extends from the minor fissure to
a partially obscured right hemidiaphragm, with associated signs
of volume loss. Observed findings likely represent collapse of
the right middle lobe and partial atelectasis of the right lower
lobe, the latter coexisting with known complex fluid collection
and consolidation based on review of recent CT. Moderate right
pleural effusion has increased in size in the interval. New
bilateral asymmetrical perihilar opacities worse on the left
than the right could reflect pulmonary edema or new sites of
aspiration or infection. Dense left retrocardiac opacity and a
small left pleural effusion are also new. Since the prior study,
esophageal stent has been placed, and the patient has been
intubated, with tip of endotracheal tube terminating at the
level of the medial clavicles, about 7.7 cm above the carina.
.
EGD with Stent [**2169-1-9**]:
There was an extensive ulcerated mass from 29 cm to 41 cm from
the incisors. There was an opening at 31 cm from the incisors
suspicious for the fistula. The lumen was severely narrowed. The
regular gastroscope was not able to traverse. A pediatric
gastroscope was used. It traversed and reached the antrum. A
biliary guidewire was placed and the scope was withdrawn. Under
the fluoroscopic guidance, a 15cm by 18mm UltraFlex partially
covered metal stent was placed successfully over the wire. The
upper end of stent was confirmed endoscopically at 27 cm from
the incisors. The exam of the stomach was normal.
.
CXR [**2169-1-10**]:
AP radiograph of the chest was compared to [**2169-1-9**] and
multiple prior
studies dating back to [**2169-1-6**].
.
Since the prior radiograph, there is overall minimal change in
the right lower lobe consolidation, right pleural effusion.
Since [**2169-1-7**], there is interval progression of left mid and
lower lung consolidation. Mild pulmonary edema is also present
contributing to the parenchymal opacification. Stenting of the
esophagus is in place. The patient was extubated in the meantime
interval.
.
Esophagram [**2169-1-10**]:
CONCLUSION: Esophageal stent in place and there was no evidence
for contrast extravasation or fistula to the bronchial tree.
.
LLE DUPLEX U/S [**2169-1-12**]:
IMPRESSION: No evidence of deep venous thrombosis
.
PET CT [**2169-1-13**]:
IMPRESSION:
1) Extensive FDG-avid disease in the chest. Because of the known
esophageal perforation, the FDG uptake in the right lung may be
secondary to infection/inflammation OR tumor involvement.
2) FDG-avid sub-carinal mass extending distally along the
esophagus as described above, consistent with neoplastic
disease. Again, because of the esophageal perforation,
involvement with infection/inflammation can not be ruled out.
3) Right paratracheal lymph node with minimal FDG uptake may be
reactive.
4) Focus of FDG uptake at the GE junction, distal to the
esophageal stent which is non-specific and may be related to
local inflammatory disease, but can not rule out a rest of
neoplastic disease.
5) No evidence of abnormal FDG uptake between the stomach and
pancreatic tail at the site of the questioned node on the recent
CT.
6) No evidence of distant metastatic disease.
7) Bilateral pleural effusions and extensive focal FDG-avid
ground glass
opacities, throughout the lungs, new since the recent CT and
therefore likely secondary to infection/inflammation.
8) Elevated serum glucose, decreasing the sensitivity of this
study for small foci of neoplastic disease.
.
CXR [**2169-1-14**]:
IMPRESSION: Considerable improvement over prior chest x-ray.
.
LEFT KNEE PLAIN FILM [**2169-1-16**]:
IMPRESSION: No fracture or significant degenerative changes.
.
CT GUIDED PEG PLACEMENT [**2169-1-20**]:
IMPRESSION: Successful uncomplicated insertion of a 12 French
Wills-Ogles by G-tube under CT guidance.
.
CT Chest [**2-1**]:
1. Multiple pulmonary emboli, as detailed above. No evidence of
right-sided heart strain at this time.
2. Large abscess formation at right lung base related to
esophageal rupture seen on [**2169-1-7**] exam, has substantially
improved. There is residual right lung base consolidation at the
site of prior abscess formation.
3. Moderate-to-large right pleural effusion has resolved.
4. Interval placement of an esophageal stent with large amount
of secretions within its lumen. Large soft tissue mass
surrounding the stent, likely correspond to patient's known
history of esophageal carcinoma.
5. Ill-defined bilateral ground-glass opacities predominantly in
upper lung zones, are most likely related to recurrent
aspirations given large amount of secretions within the
esophagus.
.
R knee xray [**2-2**]: Mild tricompartmental degenerative changes with
a joint effusion.
.
.
DISCHARGE LABS:
.
[**2169-2-6**] 05:47AM BLOOD WBC-4.6 RBC-3.16* Hgb-8.9* Hct-27.0*
MCV-86 MCH-28.3 MCHC-33.1 RDW-19.5* Plt Ct-246
[**2169-2-5**] 05:33AM BLOOD WBC-5.5 RBC-2.85* Hgb-8.1* Hct-24.2*
MCV-85 MCH-28.5 MCHC-33.5 RDW-19.3* Plt Ct-228
[**2169-2-4**] 06:00AM BLOOD WBC-10.0 RBC-2.99* Hgb-8.5* Hct-25.9*
MCV-87 MCH-28.4 MCHC-32.8 RDW-19.7* Plt Ct-154
[**2169-2-6**] 05:47AM BLOOD Glucose-124* UreaN-14 Creat-0.7 Na-138
K-5.1 Cl-100 HCO3-29 AnGap-14
[**2169-2-5**] 05:33AM BLOOD Glucose-108* UreaN-15 Creat-0.6 Na-134
K-4.6 Cl-99 HCO3-28 AnGap-12
[**2169-2-4**] 05:35PM BLOOD Na-134 K-4.5 Cl-98
[**2169-2-4**] 06:00AM BLOOD Glucose-150* UreaN-12 Creat-0.6 Na-132*
K-5.5* Cl-99 HCO3-28 AnGap-11
[**2169-2-3**] 02:44PM BLOOD Glucose-126* UreaN-14 Creat-0.6 Na-130*
K-3.8 Cl-96 HCO3-29 AnGap-9
[**2169-2-1**] 06:16AM BLOOD PT-13.2* PTT-29.7 INR(PT)-1.2*
[**2169-2-2**] 07:56AM BLOOD PT-27.4* INR(PT)-2.6*
[**2169-2-3**] 06:16AM BLOOD PT-41.9* PTT-41.9* INR(PT)-4.1*
[**2169-2-4**] 06:00AM BLOOD PT-24.6* PTT-29.5 INR(PT)-2.4*
[**2169-2-5**] 05:33AM BLOOD PT-18.5* PTT-41.6* INR(PT)-1.7*
[**2169-2-6**] 05:47AM BLOOD PT-24.6* PTT-44.2* INR(PT)-2.4*
Brief Hospital Course:
Mr. [**Known lastname **] is a 58 year old male with recent diagnosis of esophageal
cancer, gout, who presents with fatigue and lightheadedness
secondary to inability to tolerate [**Hospital **] transferred to the ICU
for hypotension, with eventual transfer to OMED after
stabilization for continued workup and treatment.
.
# Esophageal fistula: On arrival to [**Hospital Unit Name 153**], patient was
comfortable without complaints. CT torso, CT neck showed
esophageal perforation, active contrast extravasation into
parenchyma of RLL lung, which has multiple loculated fluid
collections including one 11x7x10cm, bilateral simple pleural
effusions, simple fluid in the pelvis, also 2x1x1 cm cystic mass
on pancreas. Patient made NPO and transferred to MICU
[**Location (un) **]/[**Hospital Ward Name 517**] for a rigid and flexible bronchoscopy by IP
with therapeutic aspiration of tracheobronchial secretions and
diagnostic upper GI endoscopy without identification of fistula.
He was intubated for the procedure, and subsequently
transferred to MICU [**Location (un) 2452**] post-procedure where he was extubated
without issue. Pt had initially been on vanc/zosyn in the [**Hospital Unit Name 153**]
and was narrowed to unasyn in MICU [**Location (un) 2452**]. While in MICU
[**Location (un) 2452**], microbiology notified team that abscess was growing thin
branching gram + rods concerning for norcardia. ID was
consulted who recommended continuing unasyn and adding high-dose
bactrim for nocardia coverage. Patient was then transferred to
[**Hospital Unit Name 153**], ERCP team performed an EGD which showed an extensive
ulcerated mass from 29 cm to 41 cm and narrowed lumen. There was
an opening at 31 cm from the incisors suspicious for the
fistula. A 15cm by 18mm UltraFlex partially covered metal stent
was placed successfully over the wire and barium esophogram
showed showed patency of the stent. Patient was started on a
PPI. His diet as advanced to full liquids and he tolerated this
well. The Bactrim was eventually DC'ed with continuation of
Unasyn. On Day 10 of Unasyn the patient developed a diffuse
morbilliform rash covering the torso and back, non-pruritic,
non-painful and most c/w with a drug reaction. His Unasyn was
changed to Clindamycin.
# Hypotension: Thought to be secondary to hypovolemia from poor
PO intake although sepsis also possibility given given
esophageal fistula and lung abscess. Blood pressure was fluid
responsive in the ICU and required no pressors. He was initially
placed on Levofloxacin and CTX. However, given CT chest findings
with concern for necrotic abscess and esophageal perforation,
his abx were broadended initially to Zosyn/Levofloxacin, then to
unasyn/bactrim. Patient was temporarily on pressors during EGD
given sedation and paralysis, but quickly weaned off after
procedure. Since EGD, BP's were stable, low 100's to 90's
systolic.
# Necrotic right lung abscess: CT torso showed a large necrotic
mass with extravasation of oral contrast, suggestive of
esophageal perforation. Pt was made strict NPO. Thoracics
surgery was consulted, who recommended no acute surgery and to
consult IP and ERCP. IP was consulted, and recommended rigid
bronchoscopy. He was transferred across campus for rigid bronch
where the abscess was sampled and grew thin branching GPR's,
suspicious for nocardia. ID was consulted and recommended
empiric IV Bactrim until further data was obtained. Culture from
abscess revealing thin branching G+ rods and G+ cocci in pairs
and chains, no nocardia. Bactrim was stopped, unasyn continued.
CXR the day after rigid bronch showed collapsed RLL. After ERCP,
patient was still intubated so prior to extubation, patient
underwent repeat bronch with mucous pluggings removed. Follow up
CXR improved. Patient transferred to OMED on 2L NC satting in
the mid-90s. On day 10 of unasyn, patient developed diffuse
morbilliform rash on torso and back, c/w with drug reaction.
Unasyn was stopped and patient was transitioned to Clindamycin.
In addition to this patient had his Quantiferon gold checked
prior to starting his chemo treatment which was positive. ID
recommended starting INH which was started on [**1-20**] and patient
will continue to take this with monitoring of LFT's until [**9-21**].
Patient is to have repeat imaging on [**2-3**] and should
have follow up with ID for eval of progression/resolution of
abscess.
# Acute renal failure: Cr up to 1.4 on admission. Most likely
pre-renal given hypotension, recent inability to tolerate POs.
With fluid resuscitation his creatinine normalized.
# Anemia: Normocytic, likely secondary to chronic
disease/malignancy. He had an initial Hct drop, though thought
in part to be dilutional given volume rescuscitation. He had no
s/s bleeding.
# Esophageal cancer: Squamous cell carcinoma on pathology from
[**2168-12-31**] EGD by PCP. [**Name10 (NameIs) **] is likely cause of patient's low grade
fevers, dysphagea and possibly his current nausea/vomiting. He
underwent CT neck/chest that showed esophageal-pulmonary fistula
(see above), which has been stented. Patient then underwent a
PET CT for staging which did not show any diffuse metastatic
disease. Rad/Onc was consulted and the patient started rad tx on
[**1-19**] with a plan for a total of 28 days worth of treatment. In
addition, patient has been setup with primary oncologist Dr.
[**Last Name (STitle) **]. He started his chemo treatment on Monday [**1-21**]. In
anticipation of [**Month/Year (2) 74384**] induced esophagitis, and poor
tolerance to chemo treatment, patient had a CT guided PEG tube
placed by IR on [**1-19**]. Nutrition was consulted and patient was
started on nepro TFs boluses. He will continue his rad treatment
as an outpatient.
.
# L Knee Pain: Patient complains of left knee pain for the past
several months. Attributes it to arthritis. On exam patient has
small effusion, no erythema. Patient does have history of gout,
but exam and history is inconsistent with this. Unasysn can
cause increased uric acid levels, but again, patient has had
this problem for several months. Now resolving.
- XRAY [**1-16**] no acute fracture
- defer on arthrocentesis given no obvious collection to tap,
will clinically monitor
- tylenol and oxycodone PRN for pain
- uric acid wnl
.
# L Calf Pain: Patient working with PT today had pain in the L
calf and difficulty ambulating
- LENI Negative, will continue to monitor
.
# Latent Tuburculosis: Quantiferon gold positive. ID following.
- Isoniazid 300mg QD started [**1-20**], will need 9 months until
[**2169-10-21**].
- Monitor LFT's
To recap, The patient was transferred to the MICU for rigid
bronch on [**1-8**] for evaluation of a lung abscess and was started
on IV clindamycin, and back to the [**Hospital Unit Name 153**] for esophageal stent
[**1-9**] for an esophageal fistula, and then transferred to the OMED
service for further oncologic workup and therapy. The patient
had a G tube placed on [**1-20**] by IR. The patient started his
[**Month/Year (2) 74384**] therapy on [**1-19**] (planned for a total of 28
treatments). The patient was noted to be anemic Hb 7 so he was
transfused 2 units PRBC's on [**1-18**] prior to rad treatment to
increase sensitivity of treatment with appropriate response Hb
7->9. Hemolysis labs were negative. The patient received
cisplatin on [**1-23**] and 5-FU from [**Date range (1) 91766**].
The patient had a repeat CT scan of his chest on [**1-31**] which
showed improvement of his abscess, ? apiration, and also a LLL
PE. The patient was switched from IV clindamycin to PO
clindamycin on [**2-1**]. Treatment for the PE was started on [**1-31**] with
a lovenox bridge for coumadin. On [**2-1**], the patient noted
moderate to severe R knee pain. There was swelling superior and
lateral to his R patella and he was very tender to palpation in
this area. Later in the evening the patient spiked to 101. He
was pancultured and Rheumatology was consulted. Labwork showed
ESR 86 and CRP 117.5. After a joint tap of his knee and fluid
analysis, WBC was found to be 180k w/ 93% polys and negatively
birefringement crystals c/w gout were seen. The patient was
started on indomethacin and vancomycin was added. The patient
also received oxycodone for pain. Colchicine was added for a few
days, and the vancomycin was d/c'ed. Rheumatology was alright
with stopping the vancomycin since no organisms grew from the
joint fluid, and it was likely only a gout flare.
The patient had issues with hyponatremia during his stay. This
was thought to be caused by SIADH. We tried to fluid restrict to
1.5L/day. At the time of discharge his sodium had normalized.
The patient's INR was 2.6 on [**2-2**] after 2 doses of 5mg warfarin,
so the [**2-2**] and [**2-3**] doses were held. The patient was restarted
on coumadin 2.5mg daily on [**2-4**] and [**2-5**] with a d/c INR of 2.4.
The patient will followup with ID, Rheumatology, Oncology, and
his PCP. [**Name10 (NameIs) **] therapy will continue during weekdays until
early [**Month (only) 958**] (28 days total). He will be scheduled for his second
cycle of chemotherapy in two weeks. He will continue his
clindamycin indefinitely until Infectious Disease instructs him
otherwise. He should continue coumadin for at least 6 months
with a goal INR of [**1-27**]. He will continue getting bolus tube
feeds at home and remain on a full liquid diet. The patient
should restrict his fluid intake to less than 1.5 liters per
day.
Although discharge instructions were discussed extensively with
the patient and the patient's son-in-law, [**Name (NI) **] (HCP), there was a
language barrier and their insight into his disease is limited.
Since the patient does not have insurance, he will only receive
2 VNA visits. Extensive instructions were given to the patient
both verbally and written, but it is difficult to know how
compliant the patient and his son-in-law will be with
medications and attending followup appointments.
Medications on Admission:
Gout medication PRN flares (?colchicine)
Discharge Medications:
1. insulin lispro 100 unit/mL Solution Sig: per sliding scale
Subcutaneous ASDIR (AS DIRECTED). -> the patient will not take
this as an outpatient.
2. isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. acetaminophen 650 mg/20.3 mL Solution Sig: Twenty (20) ml PO
Q6H (every 6 hours) as needed for fever.
Disp:*400 ml* Refills:*0*
5. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
Disp:*84 Tablet(s)* Refills:*0*
6. Nepro 0.08-1.80 gram-kcal/mL Liquid Sig: One (1) can PO four
times a day: Bolus feeds: Nepro Full strength; 240cc per
feeding: feedings/day: QID Residual Check: Before each feeding
Hold feeding for residual >= : 200 ml
.
Disp:*120 cans* Refills:*2*
7. clindamycin HCl 300 mg Capsule Sig: Three (3) Capsule PO
every eight (8) hours.
Disp:*180 Capsule(s)* Refills:*2*
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
9. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day
as needed for gout flare: Please use only for gout flare, and
continue only until pain resolves. Disp:*5 Tablet(s)*
Refills:*0* -> this medication was not approved for coverage and
the patient was unable to fill prescription
11. indomethacin 75 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO twice a day as needed for gout
flare: Please use only for gout flare, and continue only until
pain resolves.
Disp:*10 Capsule, Extended Release(s)* Refills:*0* -> this
medication was not approved for coverage and the patient was
unable to fill prescription
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary Diagnosis: Squamous Cell Esophageal Cancer, Right Lower
Lobe Pneumonia, Latent Tuburculosis
Secondary Diagnosis: Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
due to nausea/vomiting and problems eating and drinking. You had
a CT scan which showed a mass in your esophagus. A biopsy was
taken of the mass and consistent with a cancer. You also had
large lung infection in your right lung, and we started you on
antibiotics for this. In addition, we checked your blood for
signs of tuburcolosis and this was positive for an inactive
infection. We started you on an antibiotic for this as well. A
stent was placed in your esophagus to help you swallow
liquids/food. Also a tube was placed in your stomach to help
your feeding. You were seen by the [**Hospital1 74384**] oncology team who
started [**Hospital1 74384**] treatment on you which will continue when you
leave the hospital. We also started you on chemotherapy for
treatment of your cancer, and you tolerated this well.
You were found to have a blood clot in your lung during your
stay. You were started on coumadin as treatment for the clot.
You also had a gout flare during your stay and received
colchicine and indomethacin as treatment. We also had the
rheumatology service (joint doctors) see you during your stay.
You will have followup with them as an outpatient.
You also had low sodium levels during your stay. We believe your
body is holding onto too much water. The treatment of this is to
limit your free water intake to less than 1.5 liters per day.
Drinks such as gatorade are fine.
MEDICATION CHANGES:
START Guaifensein take 5-10ml by mouth every 6 hours as needed
for cough
START Isoniazid 300mg table take one by mouth daily
START Pantoprazole 40mg take one tablet by mouth twice daily
START Aceteminophen syrup take 20ml by mouth every 6 hours as
needed for pain
START oxycodone 5mg as needed for pain
START Clindamycin take 900mg PO every 8 hours - this is ongoing
until told to stop by an Infectious Disease doctor (see
appointment below)
START Zofran 8mg tablet take one tablet by mouth every 8 hours
as needed for nausea
Start Coumadin 2.5mg daily
Start Endomethacin 75mg twice a day for gout flare
Start Colchicine 0.6mg daily for gout flare
You have several followup appointments as shown below.
Thank you for allowing us at the [**Hospital1 18**] to participate in your
care.
Followup Instructions:
[**Hospital1 **] Oncology Appoitnments - weekdays as listed below. All
appointments are at 3:30pm, please arrive 5-10 minutes early
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 332**] Basement
Dates: [**Date range (1) 84712**], [**Date range (1) 88292**], [**Date range (1) 91767**], [**Date range (1) 90093**]
Department: Primary Care
Name: Dr. [**First Name (STitle) **] [**Name (STitle) **]
When: Wednesday [**2169-2-8**] at 10:15 AM
Location: [**Hospital3 8233**]
Address: [**State 8234**], [**Location (un) **],[**Numeric Identifier 8235**]
Phone: [**Telephone/Fax (1) 8236**]
Department: Thoracic Surgery
When: TUESDAY [**2169-3-7**] at 9:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: RHEUMATOLOGY
When: WEDNESDAY [**2169-3-8**] at 1 PM
With: [**First Name8 (NamePattern2) 674**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: Hematology/ Oncology
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
When: Dr. [**First Name (STitle) 91768**] office is working on a follow up appointment
for you 4-8 days after your hospital discharge. You will be
notified by Dr. [**First Name (STitle) 91768**] office with your appointment date and
time. If you have not heard from the office in 2 business days
please call the office number listed below.
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 15512**]
[**2169-3-7**] 11:00a ID,[**Doctor Last Name 4091**],[**Doctor First Name **]
LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT
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icd9cm
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[
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icd9pcs
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[
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] |
29208, 29291
|
17240, 27203
|
301, 464
|
29461, 29461
|
3177, 3177
|
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|
2434, 2451
|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
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|
2167, 2245
|
2261, 2418
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,327
| 135,984
|
48716
|
Discharge summary
|
report
|
Admission Date: [**2188-9-9**] Discharge Date: [**2188-9-14**]
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is an 89 year-old male with
a past medical history significant for hypertension,
diabetes, gastroesophageal reflux disease, amyloid angiopathy
and questionable [**Last Name **] problem and dementia. The patient
presented to the Emergency Department the day prior to
admission with a chief complaint of change in mental status
and status post multiple falls. Per the patient's family
there was no loss of consciousness and no head trauma. The
CT scan in the Emergency Department showed subacute subdural
hematoma, but no evidence of trauma. The patient was to be
admitted to neurosurgery for observation and then drainage,
but while in the MRI waiting for the scan the patient had an
episode of unresponsiveness with bradycardia and relative
hypotension. The patient was urgently intubated and repeated
CT was read as showing no acute change. The patient was then
admitted to the MICU Service.
PAST MEDICAL HISTORY:
1. Amyloid angiopathy.
2. Hypertension.
3. Diabetes.
4. Gastroesophageal reflux disease.
5. Cervical spondylitis.
6. Dementia.
SOCIAL HISTORY: No tobacco and no alcohol use.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs the patient
was afebrile with a heart rate of 51, blood pressure 126/66.
The patient was intubated and sedated elderly gentleman. The
patient's eye was closed, reactive. Pupils are equal, round
and reactive to light, though small pupil. Heart rate was
regular, bradycardia in the low 50s. No murmurs, rubs or
gallops. Lungs are clear bilaterally to auscultation. No
wheezes or rhonchi. Abdomen soft, nontender, nondistended.
Positive bowel sounds. Extremities was warm and well
perfuse. No edema.
LABORATORIES ON ADMISSION: The patient's white blood cell
count was 8.4, hematocrit 31.2, platelets 156. Electrolytes
were within normal limits. INR was 1.1 and normal TSH level.
Cardiac enzymes were negative. CT scan showed subdural
hematoma. MRA showed left ventricular artery had severe
stenosis and there is multiple infarct in white matter area
unchanged from previous study.
HOSPITAL COURSE: The patient was admitted to the MICU on the
day of admission and his condition stabilized. The patient
though was intubated, but soon was stable enough to be
extubated and there is no recurrence of bradycardia and no
recurrence of hypotensive episodes. Therefore the patient
was transferred out to the regular floor on [**9-12**] from
the MICU. While on the floor the patient's mental status was
waxing and [**Doctor Last Name 688**]. The patient has questionable underlying
Alzheimer's disease/dementia. We took off all of the
psychiatric medications and the patient has been experiencing
steady mental status decline per his neuropsychiatric doctor
Dr. [**Last Name (STitle) 1693**] and the patient has been quite confused for at
least several months prior to being admitted when Dr. [**Last Name (STitle) 1693**]
saw the patient. The patient also had word finding
difficulties and especially confused at night. The patient
required one to one sitter while in the floor to prevent him
from going to bathroom or getting out of bed by himself given
that he has a high fall risk due to his underlying dementia
as well as his poor muscle coordination.
As for his diabetes he was being covered on regular insulin
sliding scale. His sugar has been quite stable throughout
the hospital stay. There is no active issues.
As for his hypotensive episode while in the Emergency
Department it has not been recurred and his blood pressure
returned to his baseline and he eventually required his
antihypertensive medications Metoprolol b.i.d. after his
blood pressure returned to the baseline of high normal level.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home with services including physical
therapy and home safety evaluation.
DISCHARGE DIAGNOSES:
1. Confusion.
2. Subdural hematoma.
DISCHARGE MEDICATIONS:
1. Atenolol 25 mg po q.d.
2. Atorvastatin 10 mg po q.d.
3. Tylenol 325 mg take one to two tablets q 4 to 6 hours as
needed.
4. Pantoprazole 40 mg po q.d.
5. Lisinopril 5 mg po q.d.
FOLLOW UP PLANS: The patient was instructed to follow up
with Dr. [**Last Name (STitle) 2204**] in one to two weeks for a blood pressure
check and also the patient was instructed to have a repeated
CAT scan of the head to evaluate the progression of hematoma.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**First Name (STitle) 102416**]
MEDQUIST36
D: [**2188-10-7**] 01:25
T: [**2188-10-8**] 09:42
JOB#: [**Job Number 102417**]
|
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
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3992, 4031
|
4054, 4749
|
2226, 3840
|
120, 1025
|
1849, 2208
|
1047, 1181
|
1198, 1289
|
3865, 3971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,126
| 134,007
|
35006
|
Discharge summary
|
report
|
Admission Date: [**2140-12-21**] Discharge Date: [**2141-1-10**]
Date of Birth: [**2061-2-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
Hypotension, hematemesis.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a 79 year-old male with a history of DM, pancreatic
cancer s/p chemoradiation complicated by recent ascending
cholangitis and malnutrition on TPN, who presents with weakness
and abdominal pain, found to have multiple/bilateral PEs and
also hematemesis in the ED. He initially presented for
evaluation of abd pain, nausea, 3-4 episodes of non-bloody,
non-bilious emesis in the last day to day and a half, and
subjective fevers at home.
In the ED, his initial vitals were remarkable for tachycardia to
130s, SBP 90s; he was afebrile. Because he had reported
subjective fever and was hypotensive, broad spectrum Abx (vanc
and zosyn) were started and, because of his ascites and known
pancreatic CA, CT torso was performed. A CT torso showed that
the patient had b/l PEs, and heparin gtt was started. Shortly
thereafter, he had hematemesis x2 (~1L total) of mixed bright
and dark red blood. Heparin was then stopped, he was transfused
two units of blood, and gen surgery and GI were consulted about
bleeding and thoracics consulted about possible thrombectomy of
PEs. Surgery did not recommend any operative management for
upper GI bleeding and GI recommended supportive care until
morning, when EGD could be performed if pt stabilizes. Thoracics
did not think patient was a good candidate for thrombectomy. In
total, he received 7 liters of NS in the ED, and remained
hypotensive, so he was started on dopamine.
ROS: The patient denies any shaking chills, diarrhea,
constipation, melena, hematochezia, chest pain, shortness of
breath, orthopnea, PND, cough, urinary frequency, urgency,
dysuria, lightheadedness, gait unsteadiness, focal weakness,
vision changes, headache, rash or skin changes.
Past Medical History:
- Pancreatic Ca: Diagnosed in [**8-8**]. He was started on
protocol treatment with TNFerade (injected directly into the
tumor by EGD weekly), 5-FU and Radiation.
- Hx of ascending cholangitis during his last hospital admission
([**Date range (1) 77005**])
- Dysphagia on a pureed and thin liquid diet
- Malnutrition on ensure shakes and megestrol. Recently started
on TPN.
- Hyperlipidemia
- Diabetes II
- BPH
- Depression
Social History:
Denies tobacco use, occasional wine with meals, no prior drugs.
Lives with wife, retired.
Family History:
Mother with pancreatitic CA at age 67.
Physical Exam:
On admission:
Vitals: T:97.5 BP:108/55 HR:118 RR:20 O2Sat:100% RA
GEN: cachectic, elderly man
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: tense ascites with bulging flanks, min tender, +BS, no HSM,
no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
On discharge:
Vitals: T 98.1, BP 107/60, HR 98, RR 18, 97% on room air.
Tm 98.1, 107-108/60-62, 98-100, 16-18, 97-98% RA
GEN: Cachectic male, awake, alert, NAD
HEENT: EOMI, sclera anicteric, MMM, OP Clear
CAR: regular
Lungs: CTAB anteriorly
EXT: no edema
NEURO: A and O x3
Pertinent Results:
Labs on admission:
[**2140-12-20**] 09:03PM GLUCOSE-363* UREA N-35* CREAT-1.1 SODIUM-130*
POTASSIUM-5.1 CHLORIDE-97 TOTAL CO2-16* ANION GAP-22*
[**2140-12-20**] 09:03PM ALT(SGPT)-49* AST(SGOT)-42* ALK PHOS-275* TOT
BILI-0.7
[**2140-12-20**] 09:03PM LIPASE-9
[**2140-12-20**] 09:03PM WBC-14.6*# RBC-4.15* HGB-13.2* HCT-39.2*
MCV-94 MCH-31.9 MCHC-33.8 RDW-17.4*
[**2140-12-20**] 09:03PM NEUTS-80* BANDS-8* LYMPHS-6* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2140-12-20**] 09:03PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+
[**2140-12-20**] 09:03PM PLT SMR-HIGH PLT COUNT-455*
[**2140-12-20**] 09:18PM LACTATE-5.9*
[**2140-12-20**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-12-20**] 09:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2140-12-20**] 09:30PM PT-14.4* PTT-29.1 INR(PT)-1.3*
Labs on discharge:
[**2141-1-9**] 12:00AM BLOOD WBC-6.7 RBC-2.98* Hgb-9.1* Hct-27.3*
MCV-92 MCH-30.7 MCHC-33.5 RDW-17.3* Plt Ct-621*
[**2141-1-9**] 12:00AM BLOOD Glucose-134* UreaN-14 Creat-0.6 Na-130*
K-4.5 Cl-99 HCO3-25 AnGap-11
[**2141-1-9**] 12:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-1.8
ECG: Sinus tach at 140, nml axis, nml intervals. No ST-T wave
abnormalities.
Imaging:
CXR ([**12-20**]): 1. Interval improvement in aeration of the left
lower lobe, with residual patchy opacity likely representing
residual atelectasis. Please note, however, that developing
infection cannot be excluded on this examination, and clinical
correlation is recommended. No sizable residual left-sided
pleural effusion seen.
2. Mild prominence of the interstitial markings within the right
upper lobe, but no evidence of overt pulmonary edema.
CT torso ([**12-20**]):
1. Pulmonary emboli of the right and left main pulmonary
arteries extending into the segmental and subsegmental branches.
2. Bilateral common femoral vein deep venous thrombosis.
3. Unchanged left pleural effusion with underlying atelectasis.
Resolution of right pleural effusion.
4. Large volume ascites, unchanged.
5. Stable mass of the pancreatic head with vascular involvement.
6. Unchanged mild intrahepatic biliary ductal dilation with
common bile duct stent in place.
7. Pulmonary nodules unchanged in comparison to [**2140-11-29**].
Head CT ([**12-21**]): No intracranial hemorrhage or edema
Chest x-ray [**2140-12-29**]: Small left-sided pleural effusion with
subsequent small left basal hypoventilation. No newly occurred
focal parenchymal opacity suggestive of pneumonia. Unchanged
size of the cardiac silhouette, bilaterally reduced lung
volumes.
Brief Hospital Course:
79 year-old male with a history of DM, pancreatic cancer
status-post chemoradiation complicated by recent ascending
cholangitis and malnutrition on TPN, who presented with weakness
and abdominal pain, found to have multiple/bilateral PEs and
also hematemesis in the ED.
# Pancreatic cancer: The patient completed a course of
chemoradiation with 5-FU and EBRT on [**11-11**] which included 5
endoscopic US-guided intratumoral injections of TNFerade. Given
his issues with malnutrition and poor functional status further
chemo had been deferred. After discussion with the patient and
his family given the new diagnosis of bilateral PEs, recent
hematemesis, he initially chose to be made CMO. Dr. [**Last Name (STitle) 4613**], his
outpatient oncologist, met with him as well while he was
hospitalized. His pain was treated with morphine as needed, his
nausea with zofran and prochlorperazine prn. Palliative care
was consulted. The patient preferred to remain in the hospital.
When transferred to the floor, the primary oncology team and
the palliative care team had another family meeting, reiterating
that there was not further treatment for the patient's
pancreatic cancer. The family members had a very difficult time
accepting this. Ultimately, the patient decided to change status
back to full code and chose to be discharged with VNA services.
# Hypotension/Shock: The patient presented with shock in the ED.
Possible etiologies included obstruction from his submassive
PEs; sepsis, from possibly a GI (SBP or gastroenteritis) source;
vs hypovolemic from bleeding. He was volume resuscitated with 7L
NS + 2 units PRBCs in the ED. He was initially placed on
levophed, however this was weaned off. His SBPs have been
stable since this was weaned.
# Acute Blood loss anemia due to GI bleed: The patient vomited
almost 1 L of blood in the ED. General surgery reviewed his CT
scans with radiology and did not see any compelling signs of
vascular invasion or varices that would explain his massive
hematemesis, although CT has low sensitivity for this diagnosis.
The heparin gtt which had been started for his PEs was stopped
and he was transfused with two units of PRBC. GI evaluated him
and were going to scope him in the morning, however he was made
CMO so further diagnosis was not pursued. On the floor, the
patient had 3 bloody bowel movements, his family reversed his
CMO status, he received 3 units of blood and had no further
episodes of bleeding. We consulted GI who said the risks of EGD
outweighed the benefit.
# Bilateral PE: The patient was found on chest CT to have
bilateral PE. This was likely secondary to his procoagulant
state secondary to pancreatic cancer (Trousseau's syndrome).
Anticoagulation is contraindicated secondary to his recent
massive hematemesis. The patient developed cough and this was
treated with tussinex.
# Diabetes: The patient is on glipizide as an outpatient. In
the ED his serum glucose was 363 and he had glucose in his
urine, although no ketones. He was initally covered with SSI,
however as he is CMO, fingerstick monitoring and insulin have
been stopped.
# Depression: The patient was continued on his outpatient
remeron.
# Sacral dcubitus ulcuer: The patient has a known decubitus
ulcer and received VNA-wound care services at home. A wound
consult was obtained and supportive care was given.
# Anasarca: The patient was on aldactone and lasix as an
outpatient for anasarca that was thought to be related to
malnutrition. His diuretics were held given his recent
hypotension. He had no anasarca on the floor.
# FEN: The patient was started on TPN as dysphagia has been a
significant problem for him. His dysphagia is thought to be due
to malnutrition-related oropharyngeal myopahty. He is now given
food upon request as tolerated.
# Code: The patient was initally DNR/DNI on admission, but was
made CMO given the worsening of his clinical status as above. As
above, this was then reversed to DNR/DNI. The family refused
several different hospice companies. We arranged for hospice to
come and speak with the family while in the hospital, but they
were very resistant to having the patient leave the hospital.
Ultimately, the patient and family felt that VNA services would
be the acceptable option to them at this point.
Medications on Admission:
Medications: (per last discharge summary on OMR)
Spironolactone 100 mg daily
Glyburide 5 mg daily
Omeprazole 20 mg daily
Remeron 7.5 mg po daily
Trazodone 50 mg qHS prn insomnia
Megestrol 400 mg po bid
Discharge Medications:
1. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
2. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*30 Tablet(s)* Refills:*2*
3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
4. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. Glyburide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Codeine Sulfate 15 mg Tablet Sig: 1-2 Tablets PO HS as needed
for cough.
Disp:*30 Tablet(s)* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
8. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day) as needed.
Disp:*500 ML(s)* Refills:*2*
9. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) g
PO BID (2 times a day) as needed for constipation.
Disp:*500 g* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
11. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous PRN (as needed) as needed for DE-ACCESSING
port.
Disp:*10 ML(s)* Refills:*0*
12. Heparin Flush 10 unit/mL Kit Sig: Five (5) mL Intravenous
PRN as needed for 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. .
Disp:*50 mL* Refills:*0*
13. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
14. Megestrol 400 mg/10 mL Suspension Sig: One (1) PO twice a
day as needed.
15. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 0.25-0.5 mL
PO q3H:PRN as needed for pain.
Disp:*1 vial* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Angels
Discharge Diagnosis:
Primary Diagnosis:
Bilateral Acute Pulmonary Embolus
Acute blood loss anemia from GI bleeding
Pancreatic cancer
Constipation
Discharge Condition:
Stable.
Discharge Instructions:
You came to the hospital with difficulty breathing. We found
you had clots in your lungs. We treated you with blood thinners
but then you developed bleeding in your GI tract so we had to
stop the blood thinners. You were stabilized in the ICU and
transferred to the floor. You had one more bleeding episode and
required a blood transfusion. We believe the bleeding is from
erosion of your tumor into your GI tract and no further
interventions are indicated.
You are being given several medications for constipation. These
include Colace and Senna which you should take every day. You
should take Miralax or Lactulose as needed if you have not had a
bowel movement in two days. You are being given Morphine for
pain. Please be aware that this can cause further constipation.
You are also being given Codeine and Benzonatate (Tessalon
Perles) which help with cough. Please resume taking your other
medications as before. Your Omeprazole dose was increased to
40mg daily.
Please call your doctor or return to the hospital for any
symptoms that you are concerned about.
Followup Instructions:
Please follow up as needed. Dr.[**Name (NI) 21829**] office can be reached at
([**Telephone/Fax (1) 694**].
Completed by:[**2141-1-25**]
|
[
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"785.50",
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icd9cm
|
[
[
[]
]
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[
"38.91",
"99.15"
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icd9pcs
|
[
[
[]
]
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12919, 12956
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6468, 10774
|
342, 349
|
13125, 13134
|
3764, 3769
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4746, 6445
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3783, 4727
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2102, 2528
|
2544, 2636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,094
| 182,915
|
48290
|
Discharge summary
|
report
|
Admission Date: [**2152-4-21**] Discharge Date: [**2152-4-24**]
Date of Birth: [**2080-11-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
This is a 71 year old gentleman with past medical history
significant for alcohol abuse and motor vehicle accident
complicated by below the knee amputation and jaw trauma who
presented to an outside hospital on the day of admission with
altered mental status. Per Mr [**Known lastname 2093**], who admitted to being
unclear on the details, and his daughter's report he had been in
his normal state of health until a week prior to presentation
when he went into an outside hospital for jaw pain. He reported
he has been having right jaw and cheek pain for months that is
exacerbation of his chronic jaw and cheek pain since his
accident. He has been taking a great deal acetaminophen and
aspirin with some improvement in symptoms, but as he did not
feel these results were completely adequate a few days before
his presentation he visited an outside hospital where he was
given oxycodone-acetaminophen and Penicillin. He returned to his
PCP's office on the day of presentation and apparently got a
prescription for more oxycodone-acetaminophen as his pain
persisted. He took [**3-14**] of these pills and was noted to have
altered mental status on his return from his PCP's office. His
daughter and wife brought him to the outside hospital for
further evaluation.
Per report at the outside hospital the patient had a GCS of 12
and a temperature of 101 on presentation there. Labs were
remarkable for WBC of 10.6, Na of 129, and a negative alcohol
level. Toxicology screen was positive for opiates consistent
with oxycodone use, acetaminophen level was 31.4, and aspirin
level was 10.3. He was intubated for increasing agitation and
had an LP performed with 3 WBC, 3 RBC, Glucose of 59, Protein of
53, and a negative gram stain. CT head and chest radiograph were
reportedly negative. Ceftriaxone, vancomycin, and acyclovir were
given empirically before the LP. The patient was transferred to
the [**Hospital1 18**] MICU intubated.
REVIEW OF SYSTEMS (obtained after extubation): The patient
reports chronic jaw pain over the past months leading up to
admission but really since his MVA in [**2144**]. He denies any
headache, worsened cough, or respiratory distress. He reports
being completely in his normal state of health until he received
the oxycodone.
Past Medical History:
-History of alcohol abuse, last drink 3 years ago
-MVA complicated by BKA and jaw trauma secondary to MVA ([**2144**])
Social History:
History of alcohol abuse but no alcohol in three years. He tries
to limit himself to one pack per day but has smoked more in the
past and has smoked since his teens. He was formerly a clam
digger and has worked other odd jobs but is now retired.
Family History:
Non-contributory. He denies any family history of heart
problems or diabetes.
Physical Exam:
On Admission to the ICU:
GEN: Intubated/sedated.
HEENT: Pupils 4mm->3mm
CV: Regular. No obvious murmurs.
PULM: Clear anteriorly.
ABD: Soft; no apparent tenderness
EXT: Warm. No edema. No lesions; right BKA
SKIN: No rash noted.
NEURO: Pupils as above; sedated so unable to assess further
On Transfer to Floor:
VS: T 98.3, BP 139/76, HR 95, RR 18, O2 95% on 2L
Gen: Well appearing elderly male in NAD
HEENT: Normocephalic, anicteric, PERRL, OP edentulous
Neck: Supple, no masses or lymphadenopathy
CV: RRR, no M/R/G; JVP not visible with patient sitting upright
Pulm: Extremely poor air movement bilaterally; no wheezes,
rhonchi, or rales.
Abd: Soft, NT, ND, BS+, no organomegaly or masses appreciated
Extrem: Right BKA, left lower extremity warm and well perfused,
no C/C/E
Neuro: A and O*3, can answer questions about current events with
ease and converse reasonably, CNII-XII grossly intact, strength
[**6-13**] in all extremities
Psych: Pleasant, cooperative
Pertinent Results:
LABORATORY RESULTS
==================
On Presentation:
WBC-10.2 RBC-4.07* Hgb-10.4* Hct-32.9* MCV-81* RDW-14.4 Plt
Ct-273
---Neuts-72.3* Lymphs-20.8 Monos-6.0 Eos-0.7 Baso-0.3
PT-12.6 PTT-26.0 INR(PT)-1.1
Glucose-88 UreaN-15 Creat-0.9 Na-131* K-4.0 Cl-98 HCO3-25
Calcium-7.9* Phos-3.0 Mg-1.9
ALT-17 AST-21 AlkPhos-55 TotBili-0.4 Lipase-20
On Discharge:
WBC-7.9 RBC-3.61* Hgb-9.3* Hct-29.3* MCV-81* RDW-14.6 Plt Ct-307
PT-12.1 PTT-30.4 INR(PT)-1.0
Glucose-99 UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-103 HCO3-30
Calcium-8.5 Phos-3.3 Mg-2.0
Other Values:
Ammonia-34, Acetone-Sm
Serum tox: ASA-6 Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Parasite smears-NEGATIVE FOR INTRA AND EXTRA CELLULAR PARASITES
Urine:
UA: Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018 Blood-LG Nitrite-NEG
Protein-TR Glucose-NEG Ketone-15 Bilirub-NEG Urobiln-NEG pH-5.0
Leuks-TR
RBC->50 WBC-0-2 Bacteri-MOD Yeast-NONE Epi-0
Urine tox:E bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
OTHER STUDIES:
Chest Radiograph [**4-21**]:
IMPRESSION: 1. ETT tip 6 cm from the carina; standard position
of OG tube. 2. No acute cardiopulmonary process.
CT neck w/contrast [**4-21**]:
IMPRESSION: No evidence for abscess.
CT head w/contrast [**4-21**]:
IMPRESSION: No evidence for intracranial abscess. Fluid level in
the left maxillary sinus and mild mucosal thickening in
bilateral ethmoid, sphenoid and frontal sinuses.
Radiograph mandible [**4-21**]: FINDINGS: There is hardware in the
right mandibular rami. No hardware-related complications are
seen. The patient is edentulous. There is no [**Known lastname **] bony
destruction on these limited images. Endotracheal and
nasogastric tubes are identified. If there is high clinical
concern for subtle cortical abnormalities of the facial bones,
dedicated CT mandibular series is recommended.
Radiograph elbow [**4-21**]: Impression: Old post-traumatic deformity
of the distal left humerus. Two metallic screws are present at
that site.
MRI/MRA/MRV head [**4-22**]:
FINDINGS: Diffusion-weighted images of the brain are normal.
Suboptimal study unable to fully evaluate mandible. Some
suggestion of chronic small vessel ischemic changes.
Chest Radiograph [**4-23**]:
IMPRESSION: Worsening of the left basal aeration with signs of
volume loss suggesting atelectasis but the progression of
infection can also not be excluded. Increase in left pleural
effusion.
Brief Hospital Course:
71 year old male with history of alcohol abuse, presenting with
mental status change and fever.
1) Altered Mental Status: Given the patient's initial
presentation with fever and altered mental status primary
concern was for infectious etiology. Tox screen was negative
for any medications not expected in this patient who was
intubated and sedated. Given the patient's jaw complaints and
history of being on [**Hospital3 **] he was initially treated
empirically for dental abscess and ricksettial disease. After
he remained afebrile, parasite smears were negative, and further
examination revealed no teeth or likely abscess these were
stopped. He was never febrile after that. Blood cultures
remained negative as did CSF culture from the outside hospital.
After extubation on his second hospital day his mental status
was restored to baseline and he never developed confusion
therafter. Ultimately, most likely etiology of his mental
status changes was thought to be
2) Hematuria: The patient had hematuria of unclear etiology
noted while he had a foley in place. Foley was removed an he
urinated without problems. Presumed etiology of hematuria was
foley trauma and this resolved without particular management.
Urine cultures eventually negative for growth.
2) Decreased breath sounds: The patient has a long history of
smoking and no clear infiltrate or pneumonia on chest
radiograph. Presuming a likely diagnosis of COPD he receieved
ipratroprium and albuterol nebulizers with better air movement.
He was able to be weaned off supplementary O2 without event. He
was discharged on scheduled ipratroprium and PRN albuterol and
urged to follow up with his primary care doctor and establish
care for management of probable COPD and other issues.
The patient was maintained on SC heparin for DVT prophylaxis.
He had no indications for GI prophylaxis. He was full code. He
was tolerating a full diet prior to discharge.
Medications on Admission:
Magnesium Oxide 400 mg [**Hospital1 **]
Nicoderm patch 14 mg daily
Vitamin K PO daily
Thiamine 100 mg daily
Folic acid 1 mg daily
Multivitamin 1 table daily
Lactobacillus 2 tablets TID
Discharge Medications:
1. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
Disp:*1 inhaler* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*1 inhaler* Refills:*0*
3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: Please do not exceed 4,000 mg per day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Delirium secondary to narcotic medications
Secondary Diagnoses:
Chronic obstructive pulmonary disease
Discharge Condition:
No complaints of pain, afebrile, O2 sat 94% on RA, amb O2 sat
89-92%
Discharge Instructions:
You were taken to the hospital due to confusion felt to be due
to the Percocet. There you required a breathing tube to protect
your airways. You were then transferred to [**Hospital1 771**]. You had an extensive infectious
work-up, which was completely negative. You do NOT need any
antibiotics.
Please continue to take your medications as prescribed. DO NOT
take Percocet anymore. You may take acetaminophen (Tylenol) for
pain instead, but do NOT take more than 4,000 mg a day.
You were also noted to have shortness of breath. This is likely
due to chronic obstructive pulmonary disease from smoking
cigarettes. We strongly encourage you to stop smoking. We have
also prescribed two different types of inhalers to help your
breathing. Please take the ipratropium inhaler EVERY day.
Please take the albuterol inhaler when you feel short of breath.
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. You have an appointment with Dr. [**Last Name (STitle) **] at 10:30AM on
Wednesday, [**4-26**]. His clinic number is [**Telephone/Fax (1) 41478**].
If you develop worsening facial pain, confusion, fevers,
shortness of breath, chest pain, or any other concerning
symptoms, please call your primary care physician.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. You have an appointment with Dr. [**Last Name (STitle) **] at 10:30AM on
Wednesday, [**4-26**]. His clinic number is [**Telephone/Fax (1) 41478**].
|
[
"E937.9",
"518.81",
"292.81",
"401.9",
"E849.8",
"V15.81",
"491.21",
"599.70",
"303.93"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
9210, 9216
|
6601, 6709
|
338, 363
|
9382, 9453
|
4150, 4490
|
10829, 11133
|
3072, 3153
|
8771, 9187
|
9237, 9237
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8562, 8748
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9477, 10806
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3168, 4131
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4504, 6578
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277, 300
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391, 2650
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9256, 9300
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6724, 8536
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2672, 2793
|
2809, 3056
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,614
| 116,703
|
11+12
|
Discharge summary
|
report+report
|
Admission Date: [**2175-9-27**] Discharge Date: [**2175-9-28**]
Date of Birth: [**2101-11-11**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 158**]
Chief Complaint:
rectal bleeding following prostate biopsy
Major Surgical or Invasive Procedure:
1. prostate biopsy
2. exam under anesthesia
3. ligation of post-prostate biopsy bleeding
History of Present Illness:
The patient is a 73-year-old man who underwent a prostate biopsy
in [**Hospital 159**] clinic complicated by immediate significant bright
red blood bleeding. Attempts were made to stop the bleeding with
a dilating Foley balloon and Surgicel packing without success.
He was admitted for surgical management of bleeding.
Past Medical History:
hyperlipidemia, coronary artery disease, prostate cancer, gout
Social History:
Retired as a waiter in a Chinese restaurant. Patient is an
accomplished poet who has published works in Chinese. Daughter
is nurse. Tobacco none ETOH: None Drugs: None
Family History:
non-contributory
Physical Exam:
VS T 98.5 HR 68 BP 91/52 RR 18 SpO2 98%RA\
Gen: NAD, AOx3
Cv: RRR
Pulm: CTAB
Abd: soft, non-tender
Rectal: no gross blood
Ext: warm
Pertinent Results:
[**2175-9-27**] 05:16PM BLOOD WBC-13.0*# RBC-3.64* Hgb-11.8* Hct-33.7*
MCV-93 MCH-32.5* MCHC-35.1* RDW-13.0 Plt Ct-138*
[**2175-9-27**] 08:54PM BLOOD WBC-11.9* RBC-3.61* Hgb-11.8* Hct-33.7*
MCV-93 MCH-32.7* MCHC-35.0 RDW-12.9 Plt Ct-143*
[**2175-9-28**] 01:45AM BLOOD Hct-29.6*
[**2175-9-28**] 05:30AM BLOOD WBC-10.1 RBC-3.07* Hgb-10.1* Hct-28.6*
MCV-93 MCH-32.9* MCHC-35.3* RDW-13.4 Plt Ct-144*
Brief Hospital Course:
The patient was admitted to the surgery service for management
of rectal bleeding following prostate biopsy. He underwent a
rectal exam under anesthesia followed by ligation of the
bleeding biopsy site. He tolerated the procedure well and
recovered briefly in the PACU before being transferred to the
floor. Please see the operative report for further details. His
hospital course was relatively uneventful.
N: His pain was managed initially with IV pain medicines and
then transitioned to po medicines with issue
Cv: stable, no issues
Pulm: Excellent oxygen saturations on room air
GI: overnight the patient passed clotted blood per rectum
several times. This resolved on POD #1 and no bright red blood
was observed. Serial hematocrit values were obtained and shown
to be stable in the AM compared to the post-operative value. He
was started on a clear liquid diet and was advanced to a regular
diet without issues.
GU: voided without difficulty
HEME: stable as described above. No transfusions required.
ID: afebrile without issues
DISPO: The patient was no longer bleeding and felt to be stable.
He was tolerating a regular diet, voiding, and ambulating
appropriately. He was discharged home with follow-up
instructions.
Medications on Admission:
allopurinol, finasteride, metoprolol, simvastatin
Discharge Medications:
1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
3. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
5. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
rectal bleeding
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.
Followup Instructions:
Please call the surgery clinic at [**Telephone/Fax (1) 160**] to schedule
follow-up with Dr. [**Last Name (STitle) **] in [**1-15**] weeks or as necessary. Please
also follow-up with your primary care physician.
Provider [**First Name8 (NamePattern2) 161**] [**Name9 (PRE) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 164**]
Date/Time:[**2175-10-11**] 1:00
Completed by:[**2175-9-28**] Admission Date: [**2175-9-29**] Discharge Date: [**2175-10-4**]
Date of Birth: [**2101-11-11**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
angina and STEMI
Major Surgical or Invasive Procedure:
[**2175-9-29**] cardiac cath
[**2175-9-29**] CABG X5 (LIMA to LAD, SVG to DIAG, SVG to OM1>OM2; SVG
to PDA) with pre-op IABP
History of Present Illness:
Mr. [**Known lastname 166**] is a 73 yo who underwent a
prostate biopsy and OR for ligation of post prostate biopsy
bleeding on [**9-27**] and was discharged on [**9-28**]. He awoke in the
morning of [**9-29**] about 2am with crushing substernal chest pain.
He presented to the ED with a STEMI and was taken emergently to
the cath lab. He was found to have severe 3 vessel CAD. IABP
was placed to support hemodynamics. Cardiac Surgery is
consulted
for surgical revascularization.
Past Medical History:
hyperlipidemia, coronary artery disease, prostate cancer, gout
Social History:
Retired as a waiter in a Chinese restaurant. Patient is an
accomplished poet who has published works in Chinese. Daughter
is nurse. Tobacco none ETOH: None Drugs: None
Family History:
non-contributory
Physical Exam:
Pulse: 81 SR Resp: 16 O2 sat: 98%
B/P Right: Left: 118/59
Height: 5'4" Weight: 65lb
Five Meter Walk Test: Bedrest (IABP)
General: NAD, WGWN, supine with IABP
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema [] none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]: 1+ Left:1+
Radial Right: 2+ Left:2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
Conclusions
PRE-BYPASS:
-No spontaneous echo contrast or thrombus is seen in the body of
the left atrium or left atrial appendage.
-No atrial septal defect is seen by 2D or color Doppler.
- Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Left ventricular systolic
function is hyperdynamic (EF>75%).
-There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta.
-There is an intra-aortic balloon pump in the descending aorta
with the tip termintating 3cm distal to the left subclavian
artery.
-The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. There is no aortic valve stenosis. Mild
to moderate ([**1-15**]+) aortic regurgitation is seen.
-The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen.
-There is a small pericardial effusion.
-There is a left pleural effusion.
POSTBYPASS:
I certify that I was present for this procedure in compliance
with HCFA regulations.
Interpretation assigned to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting
physician
[**2175-10-4**] 05:42AM BLOOD WBC-6.8 RBC-3.50* Hgb-11.0* Hct-30.7*
MCV-88 MCH-31.5 MCHC-36.0* RDW-15.1 Plt Ct-130*
[**2175-10-3**] 04:12AM BLOOD WBC-8.4 RBC-3.74* Hgb-11.3* Hct-32.5*
MCV-87 MCH-30.3 MCHC-34.9 RDW-15.1 Plt Ct-128*
[**2175-10-2**] 01:25AM BLOOD PT-12.4 PTT-30.7 INR(PT)-1.0
[**2175-10-1**] 01:28PM BLOOD PT-13.1 PTT-34.3 INR(PT)-1.1
[**2175-10-4**] 05:42AM BLOOD Glucose-120* UreaN-39* Creat-1.1 Na-141
K-3.7 Cl-105 HCO3-28 AnGap-12
[**2175-10-3**] 08:16PM BLOOD Na-144 K-3.4 Cl-106
[**2175-10-3**] 04:12AM BLOOD Glucose-131* UreaN-39* Creat-1.3* Na-146*
K-3.6 Cl-106 HCO3-30 AnGap-14
Brief Hospital Course:
Admitted to CCU after emergency cardiac cath/IABP placement.
Pre-op w/u completed and taken to the OR directly for surgery
with Dr. [**First Name (STitle) **]. Transferred to the CVICU in stable condition on
titrated phenylephrine and propofol drips. The patient was
loaded with Plavix pre-cath, on the day of surgery. Out of the
OR, he was coagulopathic, requiring multiple blood products.
Hemodynamics improved and vasoactive drips were weaned by POD 1.
The IABP was weaned and discontinued on POD 2. The patient was
aggressively diuresed and extubated on POD 3. Beta blocker was
initiated and titrated as tolerated. 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. Norvasc and Lisinopril
were added for hypertension. The patient has poor targets, and
Plavix was initiated. By the time of discharge on POD 5 the
patient was ambulating with assistance, the wound was healing
and pain was controlled with oral analgesics. The patient was
discharged to [**Hospital 169**] Center of [**Location (un) 55**] in good
condition with appropriate follow up instructions.
Medications on Admission:
allopurinol 300mg daily
finasteride 5mg daily
metoprolol succinate 50mg daily
simvastatin 80mg daily
aspirin
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for poor targets.
2. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain, fever.
6. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
12. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 10 days.
14. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day for 10 days.
Discharge Disposition:
Extended Care
Facility:
tba
Discharge Diagnosis:
coronary artery disease s/p cabg x5
hyperlipidemia
prostate CA
gout
Past Surgical History
s/p prostate biopsy and surgery for ligation of bleeding [**9-27**]
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 1+
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. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2175-11-6**] 1:00
Cardiologist:Dr. [**Last Name (STitle) 171**] [**Telephone/Fax (1) 62**] Date/Time:[**2175-12-11**] 8:00
Please call to schedule appointments with your
Primary Care Dr. [**Last Name (STitle) 172**] [**Telephone/Fax (1) 133**] in [**4-18**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2175-10-4**]
|
[
"286.9",
"185",
"401.9",
"285.1",
"410.11",
"274.9",
"276.69",
"458.9",
"287.5",
"780.62",
"272.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.61",
"36.15",
"37.23",
"36.14",
"88.56",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
11428, 11458
|
8769, 10037
|
5288, 5415
|
11660, 11882
|
6991, 8746
|
12722, 13402
|
6219, 6237
|
10197, 11405
|
11479, 11639
|
10063, 10174
|
11906, 12699
|
6252, 6972
|
5232, 5250
|
5443, 5929
|
3650, 3762
|
5951, 6015
|
6031, 6203
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,478
| 136,904
|
39049
|
Discharge summary
|
report
|
Admission Date: [**2137-4-15**] Discharge Date: [**2137-4-17**]
Date of Birth: [**2069-9-8**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Declining Hct; Orthostatic and transient hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
67 yo F with CHF, ischemic cardiomyopathy s/p ICD, CAD s/p
multiple NSTEMI, who presents with a drop in HCT below her
baseline from [**Hospital 86574**] Rehabilitation Center. Patient was
recently hospitalized a week ago for bare metal stent to
proximal LCX, complicated by the developement of a R
pseudoaneurysm and groin hematoma. At rehab, patient denies any
overt signs of bleeding, red brown or back output in her ostomy
bag, or hematoma enlargement but does recall being lightheaded
and dizzy upon standing or walking more than 30 feet in rehab.
She denies chest pain, palpitations, and shortness of breath.
Of note, patient has an extensive history of [**Hospital 1106**] disease.
She is s/p NSTEMI x2 and stents to circumflex diag and RCA. She
has PVD s/p aortobifem bypass and R CEA (with 99% restenosis).
Additionally, the patient was also hospitalized in [**February 2137**] for
ischemic colitis s/p colectomy. She does note a gradual 10 lb
weight loss over the past month due to recent colectomy and
decrease in her appetitie. She was transiently put on TPN s/p
colectomy. At rehab, she denies nausea but confirms taking in
less PO. She has not been seen by nutrition at rehab.
.
On arrival to the ED, HCT= 28.5 (compared to 23.8 at the time of
discharge last week). Orthostatics were not done in the ED; the
pt became transiently hypotensive with systolics in the 70s from
110s on arrival. She was asymptomatic and recovered with NS
bolus x1. She was guiaic positive int he ED. CT of the abdomen
and R groing ultrasound was ordered to assess for interval
change in her right groin hematoma.
.
Review of Systems:
(+) As per HPI
(-) Denies fever, chills, night sweats, recent weight gain.
Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies chest pain or tightness, palpitations. Denies cough,
shortness of breath, or wheezes. Denied nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies No numbness/tingling in extremities.
Past Medical History:
-CAD s/p NSTEMI x2 including inferior infarct and stents to
circumflex diag and RCA; most recently (last week) had a BMS
placed in the proximal LCX for EKG changes and borderline trops
post-operatively (no sxs). This was c/b post cath hematoma
.
-Aorto-bifem bypass s/p left leg thrombosis requiring
thrombectomy from graft. Followed by OSH [**Year (2 digits) 1106**] surgeon ?Dr.
[**Last Name (STitle) **]
.
-Ischemic Cardiomyopathy s/p ICD and PPM with EF 25% several
months ago but 55% on repeat echo (not in our system)
.
-Ischemic colitis c/b post op ileus, was on TPN
-Right [**Name (NI) 86575**] unclear if still occluded
-COPD
-HTN - seemingly resolved, not on medication, baseline BP
90s/50s per patient
-CKD baseline Cr 1.3-1.4
-Chronic back pain
-Chronic anemia
Social History:
Tobacco history: 40 pack year history, not currently a smoker
-ETOH:none
-Illicit drugs:none
-Is divorced and lives in [**Location 86576**] with sons [**Name (NI) **] and [**Name (NI) **]
nearby. Daughter [**Name (NI) **] lives in [**Hospital3 **].
Family History:
Father died of MI at 35, Mother contracted TB while working as
[**Name8 (MD) **] RN
Physical Exam:
VS: T=98.6 BP=103/69 HR=82 RR=16 O2 sat=98%ra
GENERAL: thin, NAD. Oriented x3. Mood, affect appropriate.
HEENT: PERRLA, EMOI, Sclera anicteric. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at clavicle
CARDIAC: RR, distant S1, S2. II/VI sys at LSB. No thrills,
lifts. No S3 or S4.
LUNGS: No chest wall deformities. Unlabored breathing. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits. Bilateral ostomy
bags intact; skin tender and friable around ostomy.
EXTREMITIES: No femoral bruits. Right greenish non-tender
hematoma. 1+ weak pulses PT, DP bilaterally.
SKIN: No stasis dermatitis or ulcers.
Pertinent Results:
[**2137-4-15**] 10:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.019
BLOOD-SM NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR RBC-0 WBC-[**3-29**]
BACTERIA-MOD YEAST-NONE EPI-[**3-29**] TRANS EPI-0-2
[**2137-4-15**] 06:07PM GLUCOSE-106* UREA N-31* CREAT-1.4* SODIUM-135
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-17* ANION GAP-19
[**2137-4-15**] 06:07PM CK(CPK)-13*
[**2137-4-15**] 06:07PM CK-MB-2 cTropnT-0.02*
[**2137-4-15**] 06:07PM WBC-11.9* RBC-3.34* HGB-9.0* HCT-28.5* MCV-85
MCH-26.8* MCHC-31.5 RDW-21.6* NEUTS-76.7* LYMPHS-14.5* MONOS-4.8
EOS-3.8 BASOS-0.2 PLT COUNT-625*
COMPLETE BLOOD COUNT WBC Hgb Hct
[**2137-4-17**] 05:15AM 9.8 7.9* 24.9*
[**2137-4-16**] 05:03PM 26.1*
[**2137-4-16**] 12:40PM 25.7*
[**2137-4-16**] 06:42AM 11.7* 7.8* 24.3*
[**2137-4-15**] 06:07PM 11.9* 9.0* 28.5*
CT abdomen and pelvis [**4-15**]:
1. Medial right superior thigh/lower perineum hematoma Multiple
more
superior rounded lesions may represent additional hematomas or
nodal masses. Evaluation is limited due to lack of IV contrast
and active extravasation can not be excluded. There was a
hematoma and pseudoaneurysm at this location on prior ultrasound
from [**2137-4-8**]. This area is partially imaged and a repeat CT of
the pelvis extending more inferior along the right proximal
lower extremity is suggested for better evaluation.
2. Trace free pelvic fluid.
3. Small bowel wall thickening may be secondary to
underdistension; however, mild enteritis cannot be excluded.
4. Aneurysmal dilatation of bilateral femoral graft as well the
suprarenal
aorta.
CT pelvis [**4-16**]:
IMPRESSION: Right medial thigh-groin hematoma, size is difficult
to compare to prior ultrasound from [**2137-4-8**] due to difference in
technique but likely slightly enlarged.
U/S [**4-16**]:
Ultrasound evaluation of the right groin was performed with B
mode,
color and spectral Doppler ultrasound. A thrombosed
pseudoaneurysm measuring at least 4 x 3.7 x 3.1 cm is visualized
within the right groin. There is no evidence of flow within the
pseudoaneurysm, status post thrombin injection. IMPRESSION:
Thrombosed pseudoaneurysm in the right groin with no evidence of
residual flow.
ECG [**4-15**]:
Sinus rhythm. Left ventricular hypertrophy with ST-T wave
abnormalities.
Consider prior inferior myocardial infarction. Since the
previous tracing
of [**2137-4-3**] no significant change.
Brief Hospital Course:
67 yo F with CHF, ischemic cardiomyopathy s/p ICD, CAD s/p
multiple NSTEMI, who presented from [**Hospital 86577**] Rehabilitation
center thought to have a Hct drop but Hct unchanged from
baseline during her recent admission to [**Hospital1 18**].
.
# Hypotension: Pt had sporadic orthostasis symptoms at rehab for
one week prior to presenation. This prompted a repeat Hct which
was actually higher than HCT at discharge one week prior. She
had no signs of bleeding and an am cortisol was within normal
limits. Orthostatics were not checked in the ED, but she was
volume resusitated and orthostatics were negative on the floor.
Her "transient hypotension" to systolic 70s normalized her BP
back to 100's. She had 2 more "episodes" of BPs in the 70s which
were asymptomatic and it was found that her right arm pressures
were normal (110s) while her left-arm pressures were in the
70s-80s suggesting a [**Hospital1 1106**] stenosis, likely at the
subclavian. She was asked to have bps always checked on her
right arm. Given that she was asymptomatic, she was asked to
discuss further with her [**Hospital1 1106**] surgeon as an outpatient. She
did have watery ostomy output and irritated skin around her
stoma. She was seen by an ostomy nurse who recommended using a
wafer between her bag and stoma as well as taking banana flakes
or benefiber to bulk her stools.
.
# Groin hematoma/pseudoaneurysm: Doppler of the right groin
showed a thrombosed pseudoaneurysm without flow. [**Hospital1 **]
surgery saw the patient and recommended 2 week f/u ultrasound.
.
# Left femoral aneurysm: Seen on CT abdomen and pelvis. Patient
was asked to follow up with her primary [**Hospital1 1106**] surgeon.
.
# Normocytic Anemia: Mixed inflammatory and decreased
production. Remained stable throughout her stay.
.
# Non-anion gap metabolic Acidosis: Remained stable. Attributed
to ostomy output.
.
# Eosinophilia: Unclear etiology. No clearly offending meds. Am
cortisol normal.
.
# CAD: no sxs, no EKG changes. Home aspirin, plavix, and statin
were continued. Metoprolol was initially held due to hypotension
but was restarted prior to discharge without event.
.
# CHF: No echo in our system, but reported severe ischemic CMP
s/p ICD. Appeared euvolemic to mildly hypovolemic. Her
metoprolol was given as above. Lisinopril and spironolactone
continued to be held as they were on prior discharge. Restarting
the meds was deferred to her primary cardiologist, Dr [**Last Name (STitle) 23097**].
.
# Back pain: Stable lumbar back pain: Continued home pain
management of [**2-26**].5mg oxycodone prn pain.
Medications on Admission:
ASA 325'
plavix 75'
toprol 25'
ranitidine 150''
atorvastatin 80'
spironolactone 25
lisinopril 40
oxycodone 2.5-5 q4h prn
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO every six (6)
hours as needed for pain.
8. Benefiber (Guar Gum) Packet Sig: One (1) packet PO once a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 1293**] - [**Location (un) 1294**]
Discharge Diagnosis:
Primary:
Stable anemia, secondary to inflammation and poor bone marrow
production
Non-anion gap metabolic acidosis
Cachexia
Left femoral pseudoaneurysm, 2.5cm
Right groin hematoma
Secondary:
Coronary Artery Disease
Peripheral [**Location (un) **] disease
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)
Discharge Instructions:
You were admitted to the hospital due to concern for a drop in
your blood count. It did not appear that your blood count had
actually dropped after trending your blood count and comparing
to prior values. You were monitored overnight and your blood
count remained stable.
You had a CT scan of your abdomen and pelvis which showed your
thrombosed pseudoaneurysm on the right side. You had an
ultrasound to see if there were any signs that the
pseudoaneurysm would expand further. The ultrasound suggested
that the prior thrombosis procedure worked and that your
pseudoaneurysm should re-aborb on its own over time but should
be followed up with another ultrasound in 2 weeks time.
Your CT scan also showed a left-sided aneurysm in your femoral
artery. The [**Location (un) 1106**] surgeons felt that there was nothing acute
to be done for this but did think you should address this
finding as an outpatient with your regular [**Location (un) 1106**] surgeon.
You were found to have a larger than normal amount of acid in
your blood. This may be related to watery output from your
ostomy. It is important that you care for your ostomy as
directed by the ostomy nurse who saw you while you were in the
hospital. You should use a wafer between your skin and ostomy
bag to prevent further irritation and eat banana flakes or use
benefiber to firm up your stools. You should also discuss this
with your surgeon at your upcoming appointment.
You were also noted to have low left-sided blood pressures. This
may be due to blockages/stenosis in your arteries. This should
be discussed further with your [**Location (un) 1106**] surgeon and you should
ask your providers to only take your blood pressures on the
right side.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
You have the following scheduled appointments:
Dr [**First Name4 (NamePattern1) 518**] [**Last Name (NamePattern1) 86578**] at St [**Hospital 107**] Hospital on [**4-19**] at
10:15 am. His phone number is [**Telephone/Fax (1) 78935**] should you need to
reschedule.
Dr [**Last Name (STitle) **] ([**Last Name (STitle) **] Surgery) on [**4-29**] at 1:45pm. His phone
number is [**Telephone/Fax (1) 86579**] should you need to reschedule.
Dr [**Last Name (STitle) 23097**] (Cardiology) on [**4-26**] at 8:30am for a pacer
check and on [**5-2**] at 4:45pm for follow up.
Please call to cancel the following [**Month (only) 1106**] surgery appointment
with Dr [**Last Name (STitle) **] at [**Hospital1 18**] if you are following up on all of your
[**Hospital1 1106**] issues with your regular [**Hospital1 1106**] surgeon.
[**Hospital1 **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2137-4-24**] 11:00
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2137-4-24**] 11:45
Completed by:[**2137-4-17**]
|
[
"276.2",
"288.3",
"414.8",
"V45.72",
"998.12",
"403.90",
"V45.82",
"585.3",
"E879.0",
"285.9",
"458.0",
"442.3",
"V45.01",
"V44.2",
"414.01",
"V45.02"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10300, 10374
|
6915, 9502
|
367, 374
|
10674, 10674
|
4404, 6892
|
12686, 13847
|
3539, 3624
|
9674, 10277
|
10395, 10653
|
9528, 9651
|
10854, 12663
|
3639, 4385
|
2028, 2459
|
275, 329
|
402, 2009
|
10689, 10830
|
2481, 3256
|
3272, 3523
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,225
| 199,948
|
39163
|
Discharge summary
|
report
|
Admission Date: [**2102-2-22**] Discharge Date: [**2102-3-2**]
Date of Birth: [**2027-10-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
Recurrent Rectal prolapse
Major Surgical or Invasive Procedure:
Laproscopic to Open sigmoid Colectomy and Suture Rectopexy [**2-24**].
History of Present Illness:
74 year old female transferred from [**Hospital1 **] [**Location (un) 620**] after presenting
there with a 36 hour history of rectal pressure. At [**Hospital1 **] [**Location (un) 620**],
she was found to have severely edematous mucosal prolapse to
about 4-5 cm. The rectal prolapse was reduced at the bedside
however would frequently reoccur.
Past Medical History:
PMH: anxiety
PSH: hysterectomy
Social History:
Current Smoker
Family History:
Daughter very involved with care.
Physical Exam:
On Discharge:
General: The patient appears well, behavior is appropriate,
ambulating the floor with rolling walker.
VS: 98.0, 100/60, 71, 18
Neuro: A&Ox3
CV:RRR
Resp: Left lung base deminished to ascultation, all other lung
fields clear throughout.
Abd: Surgical midline incision intact with staples, well
approximated, without drainage. Surgical incision on left lower
quadrant intact with staples, well approximated, no drainage.
+BS, non tender, patient reports some gas pain.
GU: Adequate urine output, 275cc 0700-1130
Extremities: no edema noted
Pertinent Results:
[**2102-2-27**] 06:25AM BLOOD WBC-11.9* RBC-3.65* Hgb-11.6* Hct-34.2*
MCV-94 MCH-31.9 MCHC-34.0 RDW-13.6 Plt Ct-147*
[**2102-2-26**] 04:03AM BLOOD WBC-8.2 RBC-3.62* Hgb-11.5* Hct-33.9*
MCV-93 MCH-31.8 MCHC-34.0 RDW-13.7 Plt Ct-121*
[**2102-2-25**] 03:41AM BLOOD WBC-9.7 RBC-4.07* Hgb-12.6 Hct-38.3
MCV-94 MCH-30.8 MCHC-32.8 RDW-13.6 Plt Ct-139*
[**2102-2-27**] 06:25AM BLOOD Glucose-78 UreaN-12 Creat-0.6 Na-135
K-3.9 Cl-98 HCO3-28 AnGap-13
[**2102-2-26**] 04:03AM BLOOD Glucose-89 UreaN-10 Creat-0.6 Na-138
K-4.2 Cl-104 HCO3-26 AnGap-12
[**2102-2-25**] 03:41AM BLOOD Glucose-130* UreaN-7 Creat-0.6 Na-137
K-4.1 Cl-103 HCO3-27 AnGap-11
[**2102-2-25**] 09:33AM BLOOD CK(CPK)-226*
[**2102-2-24**] 09:05PM BLOOD CK(CPK)-101
[**2102-2-27**] 06:25AM BLOOD Calcium-8.4 Phos-2.8 Mg-2.0
[**2102-2-25**] 03:41AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.0
[**2102-2-25**] 04:57AM BLOOD Type-ART Temp-37.2 Rates-/18 PEEP-5
FiO2-50 pO2-158* pCO2-38 pH-7.42 calTCO2-25 Base XS-0
Intubat-INTUBATED Vent-SPONTANEOU
[**2102-2-24**] 11:53PM BLOOD Type-ART Temp-36.8 Rates-15/3 Tidal V-400
PEEP-5 FiO2-50 pO2-109* pCO2-40 pH-7.39 calTCO2-25 Base XS-0
-ASSIST/CON Intubat-INTUBATED
[**2102-2-24**] 09:13PM BLOOD Type-ART Temp-36.3 Rates-15/0 Tidal V-400
PEEP-5 FiO2-50 pO2-84* pCO2-45 pH-7.33* calTCO2-25 Base XS--2
-ASSIST/CON Intubat-INTUBATED
[**2102-2-24**] 07:32PM BLOOD Type-ART FiO2-100 pO2-220* pCO2-57*
pH-7.25* calTCO2-26 Base XS--3 AADO2-436 REQ O2-75
Intubat-INTUBATED
[**2102-2-24**] 07:57PM BLOOD Glucose-151* Lactate-1.0 Na-139 K-4.3
Cl-107
[**2102-2-24**] 07:32PM BLOOD Glucose-149* Lactate-0.8 Na-138 K-4.1
Cl-107
[**2102-2-24**] 07:57PM BLOOD freeCa-1.05*
Brief Hospital Course:
The patient was admitted to the inpatient floor for surgical
treatment of her recurrent rectal prolapse. She remained stable
on the floor preoperatively and given pain medication as needed.
Anesthesia and Oral, maxillary, facial surgery were consulted on
the patients arrival to the floor to evaluate the patients tooth
which had become loose after intubation at the outside hospital.
Pre-operatively the tooth was removed. The day prior to surgery
the patient underwent a colonoscopy which revealed
diverticulosis of the sigmoid colon but otherwise, the study was
normal.
The patient was taken to the operating room for a
Laparoscopically-assisted sigmoidectomy and rectopexy. During
the case, the patient developed subcutaneous emphysema and
retained CO2. She also required pressors intraoperatively and
was taken to the ICU postoperatively for close monitoring. She
remained intubated in the ICU but stable. Postoperatively the
patients urine output dropped which was believed to be related
to pre-operative bowel preparation. This was monitored closely.
The patient was stabilized and was extubated on post-op day 2
and her urine output improved. She was transferred to the
inpatient floor for further monitoring.
On the inpatient floor the patient continued to have low-normal
systolic blood pressure, and her oxygen saturation remained
lower than baseline. The patients bowel function improved and
she was able to tolerate a regular diet. Physical therapy and
social work were consulted during the patients hospital stay and
it was recommended that the patient be transferred to inpatient
rehab at discharge. The patient continued to require nasal
cannula oxygen and will be weaned from this during her rehab
stay. On day of discharge, she was able to ambulate the
inpatient floor with assistance of a walker and was stable for
discharge.
Medications on Admission:
None
Discharge Medications:
1. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain. Tablet(s)
2. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for headache or pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Recurrent rectal prolapse
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 for treatment of rectal
prolapse. You had a procedure called a open sigmoid colectomy
and suture rectopexy on [**2-23**]. The surgery to repair your
rectum has been successful. It is important that you monitor
your bowel function closely. If you develop: nausea, vomiting,
worsened abdominal bloating, pain not controled with medication,
rectal bleeding or your rectum become prolapsed once again
please seek medical attention.
You unfortunately had a low oxygen level in the operating room
and you were transfered to the intensive care unit for close
monitoring. You have been stable on the floor and it has been
decided that you are ready to be transferred to a inpatient
rehabilitation hospital for continued physical therapy. Also,
during your stay the staff at the rehabilitation hospital will
be working with you to improve your oxygen saturation. For now,
you will traveling to the rehabilitation hospital with nasal
canula oxygen.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1120**] in 1 week. Call ([**Telephone/Fax (1) 3378**]
to make an appointment.
Completed by:[**2102-3-2**]
|
[
"518.81",
"569.1",
"041.4",
"300.00",
"562.10",
"599.0",
"424.0",
"V64.41",
"276.2",
"525.8",
"305.1",
"511.9",
"998.81",
"E878.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.76",
"48.75",
"45.23",
"23.09"
] |
icd9pcs
|
[
[
[]
]
] |
5444, 5528
|
3182, 5030
|
339, 412
|
5598, 5598
|
1511, 3159
|
6780, 6936
|
888, 923
|
5085, 5421
|
5549, 5577
|
5056, 5062
|
5781, 6757
|
938, 938
|
953, 1492
|
274, 301
|
440, 785
|
5613, 5757
|
807, 840
|
856, 872
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,028
| 166,028
|
609
|
Discharge summary
|
report
|
Admission Date: [**2186-9-29**] Discharge Date: [**2186-10-13**]
Date of Birth: [**2133-2-21**] Sex: F
Service:
CHIEF COMPLAINT: Metastatic thyroid cancer to the lungs.
HISTORY OF THE PRESENT ILLNESS: The patient is a 53-year-old
female with a history of hypertension, non-insulin-dependent
diabetes mellitus, and a long history of multinodular goiter,
which has doubled in size recently. The patient was admitted
on [**8-/2186**] and found to have D-differential papillary
carcinoma on fine-needle aspiration. The patient was also
found to have multiple pulmonary nodules on chest CT and
chest x-ray at that time, and the patient was admitted on
[**2186-9-13**] with shortness of breath and aspirate of right
lower lobe nodule at that time revealed malignant cells. The
patient was scheduled for total thyroidectomy with the
surgery team on [**9-29**] with plan to pursue adjuvant
chemotherapy and XRT to the surgical bed. The patient was to
receive carboplatinum and Taxol as the chemotherapeutic
regimen. The patient had a CAT scan at that time, which
revealed multiple pulmonary nodules. The patient presented
with progressive shortness of breath, nonproductive cough,
right sided chest discomfort. Postoperatively, the patient
had increased hypoxia. The patient was found to have small
PEs on CT angiogram. The patient was heparinized and
coumadinized at that time. The patient was started on
decadron prechemotherapy and the course was complicated by
possible pneumonia on chest x-ray. There was no complaints
of chest pain, nausea, vomiting, abdominal pain, or pleuritic
chest pain that the patient recalls.
PAST MEDICAL HISTORY:
1. Thyroid cancer, tissue biopsy awaiting diagnosis with
pulmonary metastasis, diagnosed by FMA as D-differentiated
papillary carcinoma versus medullary carcinoma.
2. Multinodular goiter times 34 years.
3. Hypertension.
4. Non-insulin-dependent diabetes mellitus on oral
hypoglycemics.
MEDICATIONS ON ADMISSION:
1. Glucophage b.i.d.
2. Uniretic 25/15 q.d.
ALLERGIES: No known drug allergies.
MEDICATIONS ON TRANSFER: Medications upon transfer to the
medicine service were as follows:
1. Regular insulin sliding scale.
2. Tums 500 mg t.i.d.
3. Albuterol nebs q.6 hours p.r.n.
4. Levofloxacin 500 mg q.d.
5. Levoxyl 100 mg q.d.
6. Lopressor 50 mg b.i.d.
7. ....................20 mg PO q.d.
8. Protonix 40 mg q.d.
9. Oxycodone p.r.n.
10. Morphine IV q.4h. to q.6.p.r.n.
11. Albuterol and Atrovent MDIs.
SOCIAL HISTORY: The patient lives with her daughter. T was
born in [**Location (un) 4708**]. The patient was a day care provider and
has three children. The patient denies tobacco or alcohol
use.
FAMILY HISTORY:
1. Hypertension.
2. "Thyroid disease."
3. No history of cancer, of which the patient is aware.
PHYSICAL EXAMINATION: Examination upon presentation revealed
the following: Temperature 99.1, heart rate 110,
respirations 20, 130/70, 96% on 3?????? liters. GENERAL: The
patient is a fairly ill-appearing female in no apparent
distress. HEENT: Extraocular muscles are intact. Pupils
equal, round, and reactive to light. No bruits. Upon
palpation of the thyroid, tongue is midline. Neck incision
present, palate rises symmetrically. CARDIAC: Normal S1 and
S2, no murmurs, rubs, or gallops. PULMONARY: Clear to
auscultation bilaterally. ABDOMEN: Soft, nontender,
nondistended, positive bowel sounds. EXTREMITIES: Trace
edema, vascular good peripheral pulses. NEUROLOGICAL: The
patient was alert, oriented and grossly intact.
LABORATORY DATA: Labs upon admission revealed the following:
White blood cell count 24.5, hematocrit 30.2, platelet count
639,000. Sodium 136, potassium 4.0, chloride 93, bicarbonate
30, BUN 14, creatinine 0.5, platelets 125,000, calcium 8.4,
phosphorus 3.8, magnesium 1.7, INR 2.
STUDIES: CT angiogram revealed multiple small segmental PEs.
CT of the body revealed increased side of pulmonary nodules,
large heterogenous goiter.
HOSPITAL COURSE: The patient was admitted to the Surgical
Service, where she had a resection of the thyroid and she was
transferred to the medical service for administration of
chemotherapy and further medical management. While the
patient was on the Oncology Service at [**Hospital1 190**], the pulmonary status remained tenuous
initially, requiring q.4h. nebs, Albuterol and Atrovent MDIs
and Flovent MDIs, as well as aggressive chest PT. The
patient was also placed Levaquin and Flagyl due to possible
pneumonia given low-grade temperatures, increased white blood
cell count and a chest x-ray, which was equivocable for lower
lobe atelectasis versus pneumonia. The patient's pulmonary
status progressively improved over time and the patient was
followed very closely by the Department of Physical Therapy,
as well as the Pulmonary Therapist who believed that the
patient's standing q.4h. medications at the time of discharge
could actually be tapered down to p.r.n. since she was doing
so well. The patient was also placed on a rapid Prednisone
taper to increase the pulmonary reserves, as well. There was
no evidence of volume overload, and the patient was not
diuresed for reasons of CHF.
ONCOLOGY: The patient was administered Taxol and Carboplatin
with premedication on [**10-6**] with XRT to be followed up in
three weeks. The patient tolerated this regimen fairly well,
even though she had subsequent decrease in the hematocrit
possibly due to this chemotherapy.
From the hematologic standpoint, the patient was converted
from coumadin to low-molecular weight heparin with good
therapeutic effect for her PEs. The patient's low-molecular
weight heparin level was 0.78 when checked and within the
therapeutic range. The patient complained of no pleuritic
chest pain. The patient had a negative [**Last Name (un) 4709**] sign and no
palpable cords during her admission and stay on the
Hematology Service. The patient had guaiac time three
negative and hemolysis labs, which were negative, but the
hematocrit continued to drift downwards and eventually had to
be transfused two units of packed red blood cells. Of note,
the patient is not a Jehovah Witness, but she was raised in
the Jehovah Witness family and held off for transfusion until
her hematocrit reached 22. The patient was also started on
q. week Procrit and iron as well. The patient's PT remained
high around 1.8 during the admission, which was thought to be
due to poor nutritional status and after her nutrition picked
up the INR drifted downwards to 1.1.
The patient also had hyponatremia, thought to be due to SIADH
secondary to pulmonary metastasis, which improved gradually
with the administration of salt tablets and Lasix, which were
given as a standing dose. At the time of discharge, the
sodium was 133. The patient had no neurological
manifestations of hyponatremia, such as decreased mental
status or confusion. The patient, at the time of discharge,
had decreased PO intake of solid foods and remained in fluid
restriction.
From an endocrine standpoint, the patient remained on her
regular insulin sliding scale, which was adequate, even
though while she was on her Prednisone taper, the glucose
levels ran consistently around 150 to 170.
During this admission, the patient was changed over from full
code to DNR/DNI. This was done after extensive discussion
with the hematology and oncology attending, Dr. [**Last Name (STitle) 4710**], as
well as the oncology fellow and Dr. [**First Name (STitle) 4702**], the patient's
PMD. The patient consistently stated that she does not want
heroic measures to be taken and, therefore, change in code
status was consistent with this long-held view. The
patient's family members were also present during her
conversations and agreed with the plan.
DISCHARGE DIAGNOSES:
1. Metastatic thyroid carcinoma with metastasis to lung.
2. Syndrome of inappropriate secretion of antidiuretic
hormone secondary to pulmonary metastasis.
3. Recent PE during this admission secondary to
hypercoagulable state.
4. Anemia secondary to chemotherapeutic agents.
5. Hypertension.
6. Insulin dependent diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Lovenox 70 mg subcutaneously q.12h.
2. Protonix 40 mg PO/IV q.d.
3. Colace 100 mg PO b.i.d.
4. Senna two tablets PO q.h.s.
5. Albuterol two puffs MDI q.4h.
6. Levoxyl 100 mcg PO q.d.
7. Tums 500 mg PO t.i.d. between meals.
8. Lopressor 50 mg PO b.i.d.
9. Trazodone 50 mg PO q.h.s.p.r.n.
10. Flagyl 500 mg PO t.i.d. times 7 days.
11. Levaquin 500 mg PO q.d. times 7 days.
12. Prednisone 40 mg q.d. times two more days, 20 mg q.d.
times three more days, then discontinue.
13. Flovent 110 mcg MDI four puffs b.i.d.
14. Albuterol and Atrovent nebulizers q.4h. inhaled around
the clock (this may be able to be tapered if pulmonary
function continues to be good off Prednisone).
15. Regular insulin sliding scale.
16. Lasix 20 mg PO q.d.
17. Ferrous sulfate 325 mg PO t.i.d.
18. Procrit 40,000 units q.week.
19. Dulcolax 10 mg PO p.r.n.q.d.
20. Sodium chloride one gram PO b.i.d.
21. Ibuprofen 600 mg q.4h.p.r.n.
22. Zofran 8 mg IV q.8h.p.r.n.
23. Robitussin p.r.n. cough.
DISCHARGE PLAN:
1. The patient was to be discharged to [**Hospital3 7**] for
further management of her pulmonary complications secondary
to pulmonary metastasis.
2. The patient was to follow up with her
hematologist/oncologist, Dr. [**Last Name (STitle) 4711**] next Tuesday at which
time it would be reconsidered if she needed further
chemotherapeutic interventions, as well as XRT.
3. The patient was to follow up with her primary care
physician in two weeks.
CONDITION ON DISCHARGE: Stable.
[**Name6 (MD) **] [**Name8 (MD) **] m.d.02-333
Dictated By:[**Name8 (MD) 4712**]
MEDQUIST36
D: [**2186-10-13**] 10:03
T: [**2186-10-13**] 10:42
JOB#: [**Job Number 4713**]
|
[
"250.00",
"415.11",
"198.89",
"401.9",
"253.6",
"486",
"285.9",
"193",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"06.95",
"40.41",
"38.93",
"99.25",
"96.71",
"06.4"
] |
icd9pcs
|
[
[
[]
]
] |
2711, 2810
|
7808, 8146
|
8169, 9149
|
1989, 2074
|
4007, 7787
|
2833, 3989
|
150, 1650
|
9165, 9615
|
2100, 2494
|
1672, 1963
|
2511, 2695
|
9640, 9854
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,448
| 128,127
|
18600
|
Discharge summary
|
report
|
Admission Date: [**2180-5-2**] Discharge Date: [**2180-5-10**]
Date of Birth: [**2122-7-2**] Sex: M
Service: Transplant Surgery
HISTORY OF PRESENT ILLNESS: Patient is a 57-year-old male
with a past medical history significant for end-stage renal
disease secondary to type 2 diabetes mellitus. He also has a
history of peripheral vascular disease and had a left above
the knee amputation done as a result of a gunshot wound
suffered in the [**Country 3992**] war in [**2145**] as well as an
aortobifemoral bypass graft performed approximately 20 years
ago. The patient does have a history of known carotid artery
disease and coronary artery disease, and had a four vessel
coronary artery bypass graft performed in [**2175**]. The patient
presents to this institution today for elective living
related renal transplantation from his brother, [**Name (NI) 449**].
At the time of admission, the patient denies fever, chills,
nausea, vomiting, anorexia, diarrhea, and constipation. He
does state that he does have mild peripheral edema in the
right lower extremity at baseline.
PAST MEDICAL HISTORY:
1. End-stage renal disease.
2. Insulin dependent-diabetes mellitus.
3. Hypertension.
4. Coronary artery disease status post CABG.
5. Peripheral vascular disease status post aortobifemoral
bypass graft.
6. History of traumatic left above the knee amputation.
7. History of osteomyelitis.
8. History of nephrolithiasis.
MEDICATIONS:
1. Neurontin 200 mg p.o. t.i.d.
2. Metoprolol 50 mg p.o. t.i.d.
3. Clonidine 0.2 mg p.o. b.i.d.
4. Hydrochlorothiazide 12.5 mg p.o. q.d.
5. Tums 1000 mg p.o. q.i.d.
6. Ativan 2 mg p.o. q.h.s. prn.
7. Aranesp 25 mcg q week.
8. Norvasc 5 mg p.o. b.i.d.
9. Lasix 160 mg p.o. q.d.
10. Lipitor 80 mg p.o. q.d.
11. Aspirin 325 mg p.o. q.d.
12. Vitamin E 400 units q.d.
13. Humalog insulin-sliding scale.
14. Insulin glargine 18 units subcutaneously q.h.s.
PHYSICAL EXAM: Vital signs: Temperature 98.3, blood
pressure 138/70, pulse 76, respiratory rate 18, and oxygen
saturation 100% on room air. In general, the patient is a
healthy appearing white male, who is comfortable and in no
apparent distress. His oropharynx is clear. His mucous
membranes are moist. His sclerae are anicteric. The neck is
supple without lymphadenopathy or JVD. His heart was regular
rate and rhythm without murmurs. His lungs are clear to
auscultation bilaterally. His abdomen is soft, nontender,
and nondistended with no palpable masses. His left lower
extremity reveals an above the knee amputation. His right
lower extremity has 1+ pedal edema with a 2+ femoral pulse
and capillary refill less than two seconds to all digits.
HOSPITAL COURSE: On the date of admission, patient was taken
to the operating room, where he underwent a living related
kidney transplant. The surgery was complicated by a 6 unit
intraoperative blood loss along with thromboembolism of the
right superficial femoral artery requiring groin exploration
and embolectomy by the Vascular Surgery service.
The postoperative hematocrit was 32.8 with a creatinine of
4.1 and a potassium of 5.3. The patient was monitored in the
recovery room until postoperative day #2 at which time he was
transferred to the regular hospital floor. The patient had
adequate urine output postoperatively making 7 liters on
postoperative day #1, 4 liters on postoperative day #2, and 3
liters on postoperative days #3 and four. A renal transplant
ultrasound was performed postoperatively, which demonstrated
normal arterial and venous flow without hydronephrosis or
leak. The [**Location (un) 1661**]-[**Location (un) 1662**] drain did, however, put out a
significant amount on postoperative day #2. The specimen was
sent for a creatinine level, which returned at 2.7.
On postoperative day #3, the drain output was 350 cc and #4
was 600 cc. At this time, a renal scan was performed in the
Nuclear Medicine Department, which did not demonstrate a
leak. The patient was doing well at this time with stable
hematocrits and urine output. He was ambulating with the
assistance of Physical Therapy. His immunosuppressant
regimen included three doses of antithymocyte globulin along
with CellCept, Prograf, and a prednisone taper. The
patient's right lower extremity was warm throughout his stay
with Dopplerable pulses of the posterior tibial and anterior
tibial arteries. His Foley catheter was removed on
postoperative day #6, and he was able to void without
difficulty.
On postoperative day #7, the [**Location (un) 1661**]-[**Location (un) 1662**] drain was removed,
and on postoperative day #8, the patient was discharged to
home with the visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with blood draws and
physical therapy. The creatinine at the time of discharge
was 1.2.
DISCHARGE CONDITION: Good.
DISCHARGE DISPOSITION: The patient was discharged to home
with visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] with wound care, blood draws,
and physical therapy.
DISCHARGE DIAGNOSES:
1. End-stage renal disease.
2. Status post living related renal transplantation.
3. Status post right superficial femoral artery thrombectomy.
4. Status post traumatic left above the knee amputation.
5. Peripheral vascular disease.
6. Status post aortobifemoral bypass graft.
7. Insulin dependent-diabetes mellitus.
8. Coronary artery disease status post coronary artery bypass
graft.
9. Hypertension.
10. History of osteomyelitis.
11. History of nephrolithiasis.
DISCHARGE MEDICATIONS:
1. Bactrim single strength one tablet p.o. q.d.
2. Valganciclovir 450 mg p.o. q.d.
3. Colace 100 mg p.o. b.i.d.
4. Neurontin 200 mg p.o. t.i.d.
5. Metoprolol 50 mg p.o. t.i.d.
6. Clonidine 0.2 mg p.o. b.i.d.
7. Lorazepam 1-2 mg p.o. q.h.s. prn.
8. Nystatin 5 mL p.o. q.i.d.
9. Percocet 5/325 1-2 tablets p.o. q4-6h prn pain.
10. Protonix 40 mg p.o. b.i.d.
11. CellCept [**Pager number **] mg p.o. q.i.d.
12. Lasix 20 mg p.o. b.i.d.
13. Prednisone 20 mg p.o. q.d.
14. Amlodipine 10 mg p.o. b.i.d.
15. Tacrolimus 5 mg p.o. b.i.d.
16. Insulin glargine 20 units subcutaneously q.h.s.
17. Humalog insulin-sliding scale as directed.
FOLLOW-UP PLANS: The patient was instructed to followup with
Dr. [**Last Name (STitle) **] in the Transplant Center in approximately 1-2
weeks for staple removal. He was also instructed to followup
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] from the Department of Vascular
Surgery in two weeks. He will be having his blood drawn
every Monday and Thursday with a CBC, Chem-7, and tacrolimus
levels to be checked and faxed to the Transplant Center for
monitoring.
DISCHARGE INSTRUCTIONS: Patient was instructed to followup
sooner if he develops fevers greater than 101.5 F, vomiting,
severe abdominal pain, or if he had any other questions or
concerns.
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 26023**]
MEDQUIST36
D: [**2180-5-10**] 18:44
T: [**2180-5-11**] 10:11
JOB#: [**Job Number 51080**]
|
[
"414.01",
"287.4",
"V49.76",
"998.11",
"996.74",
"997.2",
"250.40",
"583.81",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.08",
"39.49",
"55.69",
"55.24"
] |
icd9pcs
|
[
[
[]
]
] |
4853, 5014
|
4822, 4829
|
5035, 5500
|
5523, 6151
|
2683, 4800
|
6674, 7090
|
1918, 2665
|
6169, 6649
|
174, 1097
|
1119, 1902
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,592
| 148,161
|
8803
|
Discharge summary
|
report
|
Admission Date: [**2152-8-16**] Discharge Date: [**2152-8-19**]
Date of Birth: [**2091-4-17**] Sex: F
Service: SURGERY
Allergies:
Sulfonamides / Dilaudid
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
swollen tongue, respiratory compromise
Major Surgical or Invasive Procedure:
umbilical hernia repair, nasopharyngeal intubation
History of Present Illness:
61yo F w/ PMH of CKD, breast cancer s/p R mastectomy, and HTN
presented to [**Hospital1 18**] for elective outpatient umbilical hernia
repair. The procedure went well, without any complications. She
underwent GETA and it was a somewhat difficult intubation in the
OR, with 2-3 attempts at laryngoscopy and intubation. EBL of
5mL. She received 2mg midazolam, 200mg propofol, 100mg
succinylcholine, 4mg ondansetron, 100mcg fentanyl, 80mg
lidocaine, and 8mg dexamethasone intraop. She was extubated
successfully and brought to the PACU. In the PACU, she was
initially given phenergan and haldol IV for nausea, then was
medicated with vicodin PO for pain. She swallowed the pill w/o
difficulty. At 1610, she was noted to have a swollen tongue,
L>R. There was a reddened area along L side of tongue that was
also tender per report. Her sats remained stable, at 100% on RA.
She denied any SOB, no wheezes or stridor. She had had no
difficutly swallowing fluids earlier, but was no longer able to
swallow her own saliva. Cold packs were applied to her tongue
and she was given racemic epi, benadryl and decadron. Further
examination revealed that she also had a small bruise under R
side of her tongue. Her speech was difficult to understand and
the swelling seemed to be most prominent in anterior aspect of
tongue. It was also felt that the redness under her tongue was
progressing. ENT was consulted and performed a fiberoptic exam
which showed "no edema of the posterior pharyngeal wall, tongue
base enlarged w/ complete effacement of bil valleculae and
encroachment onto epiglottis, mild edema on right tracks onto
lateral pharyngeal wall, visible surfaces of epiglottis appear
crisp, bilateral good VF motion without edema, clear piriforms".
Based on their findings, the decision was made to electively
intubate the patient fiberoptically via L nares. She was started
on propofol for sedation and transferred to the [**Hospital Unit Name 153**] for
continuous O2 monitoring.
.
ROS: prior to OR - noted heartburn, [**2-19**] pain in abdomen, and
had a h/o murmur
Past Medical History:
# Polycystic kidney disease - baseline Cr [**2-13**]
# Hypothyroidism
# Hypertension
# Breast cancer, s/p R total mastectomy for DCIS
Social History:
(per OMR) Married, lives w/ husband. She formally owned her own
business in the sheet metal cutting industry. She and her
husband are in the process of retiring up in [**Location (un) 3844**].
Former smoker, quit in [**2114**]. Rare EtOH.
Family History:
unknown - nothing documented in OMR
Physical Exam:
VS - T 99.3, BP 109-165/67-85, HR 78-88, RR 18-22, sats 100%
SIMV + PS 500x14, FiO2 50%, PEEP 5, PS 10
ht 5'2", wt 124#
Gen: WDWN middled aged female, intubated and sedated.
HEENT: Sclera anicteric, pupils 2mm -> 1mm bilaterally.
Nasotracheal tube in L nares. Tongue swollen and ecchymotic,
obliterating view into oropharynx.
CV: RR, normal S1, S2. No m/r/g.
Lungs: CTA anteriorly and at bases, no crackles appreciated. s/p
R breast mastectomy.
Abd: Soft, mildly distended, NT. + BS throughout. Umbilical
hernia surgical site c/d/i.
Ext: RUE w/ chronic lymphedema. No LE edema. 2+ DP, PT, radial
pulses bilaterally.
Neuro: Opens eyes to voice, but not following commands. MAFE to
painful stimuli. Toes equivocal bilaterally.
.
Pertinent Results:
Admission Laboratories:
Chemistries:
GLUCOSE-103 UREA N-43* CREAT-3.4* SODIUM-145 POTASSIUM-5.0
CHLORIDE-108 TOTAL CO2-21* ANION GAP-21*
CALCIUM-9.7 PHOSPHATE-4.1 MAGNESIUM-2.2
Hematology:
PT-12.2 PTT-23.6 INR(PT)-1.0
.
Other:
[**2152-8-17**] 05:51AM BLOOD C4-22
.
Discharge Laboratories:
Chemistries:
Glucose-110* UreaN-50* Creat-3.4* Na-146* K-4.9 Cl-113* HCO3-19*
AnGap-19
Calcium-8.7 Phos-4.8* Mg-2.4
.
Hematology:
WBC-10.4 RBC-4.08* Hgb-12.0 Hct-35.7* MCV-88 MCH-29.5 MCHC-33.7
RDW-14.0 Plt Ct-140*
.
Imaging:
CXR: no acute cardiopulmonary process
.
CT Head:
1. No evidence of intracranial hemorrhage.
2. Findings consistent with chronic ischemic microvascular
disease.
3. A large area of hypodensity in the right frontal lobe may
represent ischemia of uncertain chronicity. This could represent
chronic small vessel disease. Comparison with prior studies
would be most helpful. If there is a clinical suspicion for
acute ischemic infarction, MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**]- weighted imaging
is more sensitive.
.
MRI Brain: Wet read on discharge, no acute process, chronic
microvascular disease.
Brief Hospital Course:
A/P: 61yo F w/ hypothyroidism, HTN, and h/o breast cancer who
presents with anaphylaxis vs. angioedema after elective
umbilical hernia repair.
.
# Umbilical Hernia Repair: Patient underwent umbilical hernia
repair on [**2152-8-16**]. Procedure was uncomplicated with minimal
blood loss. Incision closed with staples. Her post operative
course was complicated by the development of angioedema of the
tongue which required elective nasopharyngeal intubation and
subsequent MICU stay as described below. Patient was followed
by surgery throughout her hospitalization. Her wound appeared
clean and dry without any evidence of erythema or discharge. On
discharge her pain was well controlled with Tylenol. She was
tolerating a regular diet. She will follow up with her surgeon
Dr. [**Last Name (STitle) **] in [**12-14**] weeks for follow up and suture removal.
.
# Angioedema: Patient developed acute tongue swelling
post-operatively which was felt to be consistent with
angioedema. The swelling began in the PACU approximately 2
hours post-operatively. Temporally it occurred 30 minutes after
receiving Vicodin for pain. Given concern for airway compromise
an elective nasopharyngeal intubation was performed and she was
transferred to the medical ICU for further management. She
received high dose steroids, Benadryl and famotidine for her
tongue swelling with rapid improvement over post-operative days
1 and 2. She was extubated without difficulty on post-operative
day 2. The etiology of her angioedema is not clear but potential
offending agents included Vicodin, lisinopril and latex. Her
lisinopril was discontinued and she received no further Viocin.
A number of laboratory tests were sent to workup her angioedema
including C1 esterase, C1 esterase inhibitor, IgE and tryptase
which were pending at time of discharge. C4 was found to be
normal. She will continue on oral steroids for three days
post-discharge. She will follow up with ENT as an outpatient.
She will also follow up with allergy/immunology for further
workup.
.
# Fall: On post-operative day 1 the patient suffered a fall
from bed. She was restrained at the time and was intubated and
sedated and it is unclear how the fall took place. She
remembers hitting her head and subsequently waking up.
Neurologic exam at the time was completely intact. She
underwent CT scan of her head on post-operative day 3 which was
negative for acute intracranial hemorrhage but did show an area
of hypodensity in the frontal lobe concerning for ischemic
injury. She subsequently underwent MRI scan of the brain. Wet
read of the MRI showed no evidence of acute ischemia and showed
chronic microvascular changes. She will follow up with her
primary care physician in early this week and neurology follow
up can be considered if her primary care physician feels this is
appropriate.
.
# Polycystic Kidney Disease: Patient's creatinine throughout
this hospital admission was stable at 3.4 which is her baseline.
Her lisinopril was discontinued during this admission secondary
to concern for angioedema. Her outpatient nephrologist was
notified of this change. She will follow up with her primary
care doctor the week of discharge to discuss further management
of her hypertension and renal disease. She will also follow up
with her primary nephrologist.
.
# Hypertension: As above, her lisinopril was discontinued during
this admission. Her blood pressures were stable ranging from
130s to 160s systolic. She will follow up with her primary care
physician and nephrologist.
.
# Hypothyroidism: Stable, she was continued on her home dose of
levothyroxine.
.
# Prophylaxis: She received heparin subcutaneously for DVT
prophylaxis.
.
# Code: Full
Medications on Admission:
tramadol 50mg PO QD (? if this is correct dose, listed as 500mg)
cipro 500mg PO QD
levothyroxine 100mcg PO QD
lisinopril 1 tab PO QD, dose unknown (in [**2150**], dose was 10mg QD)
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*20 Capsule(s)* Refills:*0*
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
4. Prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for 3
days: Please take two tablets on [**8-20**]. Please take on tablet on
[**8-21**] and [**8-22**]. .
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Umbilical Hernia Repair
Angioedema
.
Secondary:
Polycystic Kidney Disease
Hypertension
Hypothyroidism
Discharge Condition:
Stable
Tolerating regular diet
Pain well controlled
Discharge Instructions:
You underwent umbilical hernia repair. Your surgery went well
but was complicated by swelling of your tongue for which you had
a breathing tube placed to allow you to breath. You were also
given steroids to help with inflammation. It was thought that
you suffered an allergic reaction to one of your medications.
Lisinopril and vicodin were thought to be the most likely
causes. You should not take either of these medications again.
Please inform all your physicians of this reaction. You also
suffered from a fall while you were in the hospital and hit your
head. You had a CT scan of your head which showed a small area
in the front of your brain which was concerning for a stroke.
You had an MRI which showed some chronic changes but did not
show evidence of stroke.
.
Please take all your medications as prescribed. The following
changes were made to your medication regimen:
1. Please discontinue your lisinopril until you follow up with
your primary care physician.
2. Please take 20 mg prednisone on [**8-20**], and 10 mg on [**8-21**] and
[**8-22**]
3. Please take tylenol as needed for pain at your surgical
incision site.
.
Please keep all your follow up appointments.
.
If you experience any increased tongue swelling, fevers above
101.5 degress, severe nausea and vomiting, shortness of breath,
worsening pain at your incision site, slurring of your speech,
numbness or weakness or your arms or legs or any other
concerning symptoms please seek immediate medical attention.
Followup Instructions:
Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] within three days of discharge. The office phone
number is [**Telephone/Fax (1) 30738**].
.
Please follow up with ENT in two weeks. Their phone number is
[**Telephone/Fax (1) 2349**].
.
Please follow up with the allergy clinic. Their phone number is
[**Telephone/Fax (1) 1723**]. We recommend Dr. [**First Name8 (NamePattern2) 2602**] [**Name (STitle) 2603**] but you can be seen
by any physician in this practice.
.
Please follow up with your nephrologist Dr. [**Last Name (STitle) **] within [**1-15**]
weeks to ([**Telephone/Fax (1) 773**].
.
Please follow up with Dr. [**Last Name (STitle) **], surgery, in [**12-14**] weeks at
[**Telephone/Fax (1) 9**].
|
[
"585.9",
"403.90",
"518.81",
"V10.3",
"995.1",
"244.9",
"553.1",
"753.13"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"53.49"
] |
icd9pcs
|
[
[
[]
]
] |
9296, 9302
|
4852, 8580
|
319, 371
|
9457, 9511
|
3694, 4249
|
11051, 11866
|
2894, 2931
|
8812, 9273
|
9323, 9436
|
8606, 8789
|
9535, 11028
|
2946, 3675
|
241, 281
|
399, 2462
|
4258, 4829
|
2484, 2620
|
2636, 2878
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,589
| 184,246
|
30995
|
Discharge summary
|
report
|
Admission Date: [**2152-5-9**] Discharge Date: [**2152-5-10**]
Date of Birth: [**2088-5-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 11040**]
Chief Complaint:
weakness, fever
Major Surgical or Invasive Procedure:
Endotracheal intubation; ERCP; CVVHD
History of Present Illness:
63f with prior Hodgkin's lymphoma and recently appreciated liver
masses presented to OSH with weakness, fever to 102, and
leukocytosis to 39 starting 1-2d prior to admission. Her course
began in early [**4-/2152**] when she developed jaundice and malaise;
an evaluation disclosed liver masses, ascites, and pleural
effusions, with further working demonstrating NHL. She was
scheduled to receive her first round of chemotherapy [**5-8**], but
was noted to be weak and febrile with an elevated WBC, so she
was admitted to [**Hospital3 15402**]. Felt to have cholangitis, an ERCP was
attempted but failed, so she was transferred to [**Hospital1 18**] for ERCP
versus percutaneous intervention. Before transfer, she became
hypotensive to the 70's; she was started on dopamine and
transferred to [**Hospital1 18**].
Past Medical History:
PMHX/SHX:
Hodgkins Lymphoma status post radiation and splenectomy
HTN
Peptic Ulcer Disease
Herniated disk
Osteoporosis
Hypercholesterolemia
Social History:
Widowed, supportive family (daughters); no etoh or recent
tobacco
Family History:
non-contributory
Physical Exam:
V/S: BP 107/73 CVP 12 P 98 RR 28 100% on Vent 5/450/24/70%
GEN: Cachetic, jaundiced, woman. Drowsy, moving spontaneously.
Oriented.
HEENT: NC/AT. Icterus
CHEST: SC line in left upper chest. Clear anteriorly
CV: S1 and S2 normal intensity. No m/r/g
ABD: Distended. Soft NT.
EXT: Dusky fingers bilaterally. Cool extremities. TLC in R
groin.
Pertinent Results:
[**2152-5-9**] 04:24AM WBC-41.0* HCT-42.5
[**2152-5-9**] 04:24AM NEUTS-52 BANDS-25* LYMPHS-2* MONOS-5 EOS-0
BASOS-2 ATYPS-0 METAS-10* MYELOS-4* NUC RBCS-14*
[**2152-5-9**] 04:24AM ALT(SGPT)-304* AST(SGOT)-[**2141**]* LD(LDH)-3210*
ALK PHOS-508* AMYLASE-132* TOT BILI-7.2*
[**2152-5-9**] 04:24AM LIPASE-244*
[**2152-5-9**] 04:24AM GLUCOSE-391* UREA N-38* CREAT-2.3*
SODIUM-120* POTASSIUM-9.0* CHLORIDE-100 TOTAL CO2-7* ANION
GAP-22*
.
Abdominal U/S:
IMPRESSION:
1. Minor biliary dilatation in left lobe. No biliary stent or
overt biliary dilatation identified.
2. Markedly heterogeneous hepatic echotexture, with appearance
most consistent with diffuse metastatic disease.
3. Additional soft tissue structure in left upper quadrant
(history of prior splenectomy). Differential diagnosis includes
an enlarged splenule or lymphadenopathy given history of
lymphoma and prior splenectomy..
4. Small-to-moderate amount of ascites. Bilateral pleural
effusions.
.
ERCP [**2152-5-9**]:
Biliary stricture in the middle and upper third of the bile
duct, with post-obstructive dilation. A biliary stent was
placed.
Brief Hospital Course:
63yo woman with non-hodgkins lymphoma and liver massess admitted
to OSH where she underwent unsuccessful biliary stenting & ERCP,
now transferred with evidence of severe sepsis. Biliary source
of sepsis most likely given recent instrumentation of biliary
tree. Blood cultures with Gram Negative Rods. Pt treated with
with vancomycin, meropenem and gentamycin. Received aggressive
fluid resuscitation as well as pressors. ERCP performed at
[**Hospital1 18**], showing biliary stricture. Stent was placed.
Pt developed multi-organ failure including ARF with severe
metablolic acidosis. likely due to ATN. Required CVVH in MICU
for dialysis and ultra-filtration given fluid overload
subsequent to fluid resuscitation. Pt intubated for worsening
mental status as well as improved control of respiratory
mechanics in setting of severe acidosis & volume overload. Pt
showed signs of pancreatitis likely secondary to ERCP.
Pt seen by hematology regarding her NHL.
Discussion with family revealed that pt would not want such
aggressive measures of care. Thus, she was made CMO and
measures were withdrawn. She died within hours of this change
of care.
Medications on Admission:
n/a
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary:
Sepsis
Non-hodgkins lymphoma
Acute renal failure
Pancreatitis
Metabolic acidosis
.
Secondary:
Hypertension
Peptic Ulcer Disease
Herniated disk
Osteoporosis
Hypercholesterolemia
Discharge Condition:
Dead
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"785.52",
"038.40",
"V45.79",
"276.2",
"576.1",
"789.5",
"518.81",
"570",
"584.5",
"272.0",
"401.9",
"202.83",
"576.2",
"250.00",
"995.92",
"286.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"38.95",
"99.21",
"96.71",
"38.91",
"99.07",
"39.95",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
4245, 4254
|
3006, 4163
|
331, 369
|
4483, 4489
|
1868, 2983
|
4541, 4547
|
1473, 1491
|
4217, 4222
|
4275, 4462
|
4189, 4194
|
4513, 4518
|
1506, 1849
|
276, 293
|
397, 1210
|
1232, 1374
|
1390, 1457
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,511
| 152,627
|
36560
|
Discharge summary
|
report
|
Admission Date: [**2121-3-25**] Discharge Date: [**2121-3-29**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Seizures
Major Surgical or Invasive Procedure:
Lumbar puncture
Intubation/Extubation
History of Present Illness:
86 F with hx of dementia, HTN, AF not on coumadin, prior stroke,
had been living at a NH, and was noted to have a GTC seizure
x3-4 minutes at about 4:30 pm [**2121-3-24**]. This was noted to be
preceded by right gaze deviation. She received ativan at the NH
after the seizure. Afterward her eyes were open but she was
non-verbal. She was transported via EMS to an OSH ER, where she
proceded to have a second GTC seizure, also lasting minutes. She
was intubated for airway protection, given more ativan and
started on a propofol gtt. She was subsequently transferred to
[**Hospital1 18**]. She had been on Leqaquin for a UTI. Though there is no hx
of seizure per se. She is DNR, but not DNI.
Past Medical History:
HTN
dementia
prior stroke
(likely prior seizure as came in on Keppra)
AF - not on coumadin
Social History:
Does not walk or talk at baseline, sings to herself, and does
not recognize her sons. She lives in [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Nursing Home.
Family History:
Non-contributory
Physical Exam:
T- 97.4 F BP- 150/90 HR- 85 RR- 14 O2Sat 98% intubated
Gen: Lying in bed, intubated, NAD
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation, normal ROM, supple, no carotid
or vertebral bruit
CV: irreg irreg, 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
Neurologic examination:
Mental status: off propofol for 10 minutes, she remains
non-responsive to verbal stim; some mvmt of LE to tactile stim,
Cranial Nerves:
Pupils equally round and reactive to light, 5 to 2 mm
bilaterally. Left retina with sharp disc margin, right poorly
visualized. Corneals present B/L, very weak on L (weaker than
R). No BTT B/L. (+) VOR. (+) cough.
Motor:
Normal bulk bilaterally. increased tone in the UE B/L, left
greater than right. No mvmt of UE at all, even to noxious.
Mildly withdraws LE B/L to noxious
Sensation: withdraws LE to noxious in LE. In UE, noxious stim
causes withdrawal of LE.
Reflexes:
+2 and symmetric throughout the UE. At the Patellae, L is far
brisker than R (3 vs 1). 0 at Achilles B/L. Toes upgoing
bilaterally
Pertinent Results:
LABS:
[**2121-3-25**] 02:45AM BLOOD WBC-11.8* RBC-4.43 Hgb-13.3 Hct-40.5
MCV-92 MCH-29.9 MCHC-32.7 RDW-14.0 Plt Ct-343
[**2121-3-26**] 03:09AM BLOOD WBC-12.0* RBC-4.37 Hgb-13.2 Hct-39.5
MCV-91 MCH-30.1 MCHC-33.3 RDW-14.0 Plt Ct-310
[**2121-3-25**] 02:45AM BLOOD Neuts-78.4* Lymphs-15.8* Monos-4.8
Eos-0.3 Baso-0.7
[**2121-3-25**] 02:05AM BLOOD PT-14.0* PTT-21.2* INR(PT)-1.2*
[**2121-3-25**] 02:05AM BLOOD Glucose-149* UreaN-32* Creat-1.3* Na-150*
K-3.5 Cl-114* HCO3-25 AnGap-15
[**2121-3-26**] 03:09AM BLOOD Glucose-135* UreaN-23* Creat-1.1 Na-146*
K-3.2* Cl-114* HCO3-23 AnGap-12
[**2121-3-25**] 08:11AM BLOOD ALT-12 AST-20 CK(CPK)-67 AlkPhos-106
TotBili-0.6
[**2121-3-25**] 02:43PM BLOOD CK(CPK)-56
[**2121-3-25**] 10:29PM BLOOD CK(CPK)-42
[**2121-3-25**] 08:11AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-3-25**] 02:43PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-3-25**] 10:29PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2121-3-25**] 08:11AM BLOOD TotProt-6.6 Albumin-3.8 Globuln-2.8
Calcium-9.0 Phos-3.1 Mg-2.4
[**2121-3-25**] 08:11AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2121-3-25**] 08:11AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2121-3-25**] 08:11AM URINE Blood-LG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2121-3-25**] 08:11AM URINE RBC-[**1-23**]* WBC-[**4-30**]* Bacteri-FEW Yeast-NONE
Epi-0 TransE-[**1-23**]
[**2121-3-25**] 05:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028
[**2121-3-25**] 05:15PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2121-3-25**] 05:15PM URINE RBC-0-2 WBC-[**4-30**]* Bacteri-FEW Yeast-NONE
Epi-0-2
[**2121-3-25**] 08:11AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2121-3-25**] 06:11PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-3* Polys-0
Lymphs-56 Monos-42 Basos-2
[**2121-3-25**] 06:11PM CEREBROSPINAL FLUID (CSF) TotProt-113*
Glucose-97
CSF HSV [**11-22**] PCR not detected
MICRO:
Blood Cx ([**3-25**]): NGTD x2
Urine Cx ([**3-25**]): ESCHERICHIA COLI. 10,000-100,000
ORGANISMS/ML.
CSF Cx ([**3-25**]):
GRAM STAIN (Final [**2121-3-25**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
IMAGING:
Head CT ([**3-25**]): IMPRESSION:
1. Diffuse white matter hypodensity for which the differential
includes
vasogenic edema secondary to metastases, posterior reversible
encephalopathy syndrome (associated with seizures), reversible
leukoencephalopathy syndrome (associated with hypertension), or
a diffuse demyelinating process. Correlate clinically. Recommend
MR for further characterization.
2. Small hyperdense foci in the posterior parietal region may be
small
hemorrhagic foci vs. calcifications.
3. Right parietal hyperdense lesion at the convexity possibly
consistent with a hemorrhagic focus vs. meningioma correlation
with MRI of the head with and without contrast is recommended.
EEG ([**3-25**]): IMPRESSION: This is an abnormal portable EEG
recording due to the slow background which was not reactive to
different stimuli and the runs of somewhat more rhythmic
triphasic waves. The first abnormality suggests a moderate to
severe encephalopathy. Metabolic disturbances, medications, and
infection are the most common causes. The second abnormality may
be part of the same pattern of encephalopathy described above
but it may also evolve into a build-up of rhythmic activity
suggestive of epileptic activity. Long-term monitoring of this
patient for 24-48 hours may reveal the existence of subclinical
seizures. Of note is that although lateralized features were not
seen in this recording, this may be obscured by the severe
slowing of the background.
CXR ([**3-25**]): IMPRESSION:
1. ET tube in right mainstem bronchus. Needs retraction.
Orogastric tube
standard postion.
2. Likely right lower lobe atelectasis
MR [**Name13 (STitle) 430**] ([**3-25**]): IMPRESSION:
1. Multiple foci of magnetic susceptibility as described above,
raising the possibility of amyloid angiopathy, and multiple
microbleeds. No diffusion abnormalities are detected, the
subcortical white matter is diffusely hyperintense on T2 and
FLAIR, raising the possibility of chronic hypertensive
leukoencephalopathy or severe chronic microangiopathy. Mild
mucosal thickening identified in the mastoid and ethmoidal air
cells.
2. The right parietal lesion is not enhancing and demonstrates
hemorrhagic changes on the gradient echo sequence.
Brief Hospital Course:
The patient is an 86 year old woman with a history of dementia,
atrial fibrillation not on Coumadin, and hypertension who
presented with new onset seizures. She was intubated at an OSH,
placed on propofol, and started on Keppra. Physical exam on
admission showed that she was intubated, no eye opening, did not
follow any simple commands, PERRL but roving eye movements. Head
CT on admission showed diffuse white matter hypodensity for
which the differential includes vasogenic edema secondary to
metastases, posterior reversible encephalopathy syndrome
(associated with seizures), reversible leukoencephalopathy
syndrome (associated with hypertension), or a diffuse
demyelinating process. MRI brain showed multiple foci of
magnetic susceptibility
raising the possibility of amyloid angiopathy, and multiple
microbleeds, no diffusion abnormalities are detected, the
subcortical white matter is diffusely hyperintense on T2 and
FLAIR raising the possibility of chronic hypertensive
leukoencephalopathy or severe chronic microangiopathy. EEG
showed slow background suggestive of moderate to severe
encephalopathy, and runs of somewhat more rhythmic triphasic
waves consistent with encephalopathy or epileptic activity. LP
showed 2 WBC, CSF culture showed no growth (prelim), and HSV 1
and 2 were negative.
While in the NeuroICU, the team spoke with [**First Name8 (NamePattern2) 717**] [**Last Name (NamePattern1) 9449**], NP at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] NH, who mentioned that at baseline the patient needed
1:1 assistance, did not talk, had recurrent UTIs, sodiums were
around 147, she also had HTN and anxiety. Recently, her Prozac
had been weaned down, she also had swelling in her hands. She
was DNR/DNI and [**Last Name (NamePattern1) 3225**] in light of her advanced dementia, however,
her sons reversed the [**Name (NI) 3225**] after the new onset seizures.
After being admitted to the neuro ICU service for 24 hours, she
spontaneously opened her eyes but did not move her limbs in any
purposeful manner. After further discussions with both Mrs. [**Known lastname 82750**] sons [**Name2 (NI) **] and [**Name (NI) **]), her sons decided to make her
comfort measures only in light of her advanced dementia, and her
physical deterioration.
Palliative care was consulted, and recommended Morphine SL and
Tylenol PR prn. She was also prescribed Scopolamine patch.
Medications on Admission:
Levaquin 250 mg Qday x 9 days started [**2121-3-18**]
Keppra 500 mg [**Hospital1 **]
Ativan 0.5 mg PRN
Nitropaste PRN
Seroquel 25 mg [**Hospital1 **] and 25 mg PRN agitation
Simvastatin 20 mg Qday
ASA 81 mg Qday
Prevacid 15 mg Qday
Dulcolax 10 mg PR PRN constipation
MOM 30 mL PRN constipation
Colace 100 mg TID
Neutraphos 4 packets Qday
MVI
Vit D
Discharge Medications:
1. Morphine Concentrate 5 mg/0.25 mL Solution Sig: 5-10 mg PO
Q1H (every hour) as needed for pain, agitation: to be given
sublingual.
2. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72 HOURS PRN () as needed for excess secretions.
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain: TO BE GIVEN PR.
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name **] [**Doctor First Name **] nursing care center
Discharge Diagnosis:
PRIMARY
Seizure likely due to underlying strokes, hypertension, or
amyloid angiopathy
PRES
Hypertension
Dementia
SECONDARY
Atrial fibrillation
Recurrent UTI
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital with seizures, which was
likely due to your prior strokes, hypertension, or underlying
amyloid angiopathy. After discussion with your family, you were
made [**Doctor First Name 3225**]. Palliative care was consulted, and gave
recommendations to help keep you comfortable. You will be
discharged back to your nursing home.
Followup Instructions:
None
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
|
[
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"041.4",
"599.0",
"294.8",
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icd9cm
|
[
[
[]
]
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[
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|
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[
[]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,867
| 117,221
|
34852
|
Discharge summary
|
report
|
Admission Date: [**2143-9-19**] Discharge Date: [**2143-10-24**]
Date of Birth: [**2080-1-4**] Sex: M
Service: SURGERY
Allergies:
Simvastatin / Colchicine / Roxicet
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Mr. [**Known lastname 5850**] is a 63yo man with h/o CKD, HTN, and PVD who was
transferred to [**Hospital1 18**] from an outside hospital for continued care
of his intra-abdominal issues.
Major Surgical or Invasive Procedure:
[**10-4**] - Total abdominal colectomy with ileostomy.
History of Present Illness:
Mr. [**Known lastname 5850**] is a 63yo man with h/o CKD, HTN, and PVD who was
transferred to [**Hospital1 18**] from an outside hospital today for
continued care of his intra-abdominal issues. Per the patient,
he was admitted to the hospital in [**Month (only) 205**] of this year for a left
lower extremity angioplasty and femoral endarterectomy. He
recovered from the procedure and was discharged to home in [**Month (only) 205**],
only to return several days later with diarrhea and was
re-admitted and found to have [**Last Name (un) 4584**]-[**Location (un) **] syndrome which
affected his arms and legs bilaterally. During this
hospitalization he also suffered from intractible diarrhea but
did recover full function of his arms and legs. After being
discharged briefly to a rehab center, Mr. [**Known lastname 5850**] was
re-admitted to the outside hospital on [**2143-8-20**] for diarrhea and
fever and found to have ischemic colitis. He underwent right
colectomy on [**2143-8-22**] and his postoperative course was
complicated by ARDS, AVNRT and paroxysmal Afib, for which he
remained in the ICU. During this hospitalization he received a
G-tube for feeding and was started on tube feeds as his
condition improved. Of note, patient is transferred with
VRE/MRSA precautions from OSH, source unknown at this time. In
the past several days, Mr.
[**Known lastname 5850**] reports increased abdominal distention and general
malaise. He was reported to have c.dificile colitis and is
currently treated with PO vancomycin. He [**Known lastname **] nausea or
vomiting. He has been NPO and started on perenteral nutrition
at the outside hospital, and the patient requested that his care
be transferred to [**Hospital1 18**] under Dr. [**Last Name (STitle) **].
Upon arrival, Mr. [**Known lastname 5850**] [**Last Name (Titles) **] abdominal pain and ROS is
negative except as noted above. He is comfortable in bed and
his G-tube is clamped on arrival.
Past Medical History:
HTN
CAD s/p MI (EF 52%)
PVD
CKD (bl Cr 2.5-3)
Gout
Depression
[**Last Name (un) 4584**]-[**Location (un) **] in [**7-/2143**] complicated by rhabdomyolysis and right
ischemic colitis
Klebsiella UTI [**9-8**].
Social History:
remote smoking history, currently nonsmoker; works as a
bartender, drinks 3 beers per day
Family History:
Non contributory
Physical Exam:
On day of admission:
98.7 130/50 68 24 99%2L
Gen: NAD
CV: RRR
Chest: CTAB
Abd: distended, tympanic, +BS, nontender, G tube in LUQ
Ext: 2+ DPs, PTs palpable b/l
Pertinent Results:
[**2143-9-19**] 10:05PM GLUCOSE-100 UREA N-89* CREAT-2.5* SODIUM-130*
POTASSIUM-4.5 CHLORIDE-97 TOTAL CO2-20* ANION GAP-18
[**2143-9-19**] 10:05PM estGFR-Using this
[**2143-9-19**] 10:05PM CALCIUM-8.2* PHOSPHATE-3.7 MAGNESIUM-2.6
IRON-21*
[**2143-9-19**] 10:05PM calTIBC-146* FERRITIN-GREATER TH TRF-112*
[**2143-9-19**] 10:05PM TRIGLYCER-90
[**2143-9-19**] 10:05PM WBC-12.1* RBC-3.48* HGB-10.5* HCT-31.1*
MCV-89 MCH-30.2 MCHC-33.8 RDW-16.9*
[**2143-9-19**] 10:05PM PLT COUNT-286
IMAGING:
[**9-24**] KUB: Increased distention of the transverse colon 12.4cm
[**10-1**] Renal U/S: Grade I hydronephrosis R kidney, likely UPJ
obstruction, Partially atrophic L kidney
[**10-8**] Renal U/S: No hydronephrosis
[**10-8**] CXR: Whiteout left lung
[**10-15**] CXR: Remaining LLL post. segment atelectasis/infiltrate. No
new infiltrates, no signs of pulmonary vascular congestion
.
MICRO
[**9-3**] OSH C.diff: (+)
[**9-20**] Stool: no growth
[**9-26**] UCx: 10-100K yeast
[**10-8**] Sputum: OPF
[**10-9**] BAL: OPF, 10K yeast
[**10-12**] UCx: No growth
[**10-14**] Stool Cx: C.diff(-), campylobacter/salmonella/shigella(-)
[**10-14**] BCx: Pending
[**10-15**] Cathtip Cx: No growth
[**10-15**] BCx x 2: Pending
[**10-15**] UCx: No growth
[**10-16**] UCx: <10K micros
Brief Hospital Course:
The patient was admitted to the surgical service from an OSH on
[**2143-8-20**] for shock and [**Last Name (un) **] [**1-12**] ischemic colitis, s/p partial
colectomy on [**8-22**], post-op course c/b ARDS, AVNRT, Afib w/RVR.
During hosp course, Rx with Zosyn and linzolid for VRE & Ecoli
in perit fluid, PO Vanco for +CDiff w/?megacolon, Ceftaz for
Klebsiella UTI, and levoflox for PNA. Kept NPO with TPN. Also
rec'd steroids for acute gout. He was transferred to [**Hospital1 18**] on
[**9-19**] for further management of colitis.
On transfer, cont'd on iv flagyl and po vanco for CDiff.
levofloxacin added for ?PNA. TPN cont'd. Mental status per notes
intact. Patient afebrile through initial course of stay. renal
consulted for increasing Cr & pt's acute on CRF. Renal felt
patient with AIN [**1-12**] medication (levo, ppi) or obstruction.
Renal followed throughout.
Had total colectomy with end ileostomy on [**10-4**] for failed
colonic motility. Pre-op had AFib wtih RVR controlled with
metoprolol. Post-op, transferred to ICU [**1-12**] arrythmia &
intra&postop acidosis. Had episodic recurrent AFib wtih RVR, and
hypotension. Urine Cx +yeast. Extubated on [**10-6**], Xferred to
floor on [**10-7**], noted to be lethargic. Started on TF. Volume
overloaded and diuresed. Noted to have delusions &
hallucinations. CXR on [**10-8**] showed L-side white-out. Triggered
on [**10-9**] for tachypnea and desat, thought to be [**1-12**] mucous plug,
Xferred to ICU. Bronchoscopy performed on [**10-9**] showed copious
think white secretions in L side LMS>RMS. Patient continued to
be delirious with lethargy, agitation, hallucinations, and
requiring restraints and sitter. Episode of bilious emesis
[**10-11**], TFs held, restarted on [**10-12**]. Pt transferred back to
floor. Vanc d/ced on [**10-13**]. Increasing confusion and agitation
noted on [**12-11**]. O/N on [**10-15**], pt required 2 pt restraints.
Geriatrics consult called [**1-12**] confusion on [**10-15**]. Recommended
workup for delirium w/ hallucinations. Overnight, started on
Ceftriaxone for UTI, and Foley changed. Pt's delirium noted to
clear over following days. ID consult also called, recommended
infectious workup. Delirium largely resolved by [**10-17**]. [**10-19**],
started loperamide to slow ostomy output. Pt tolerating soft
foods and liquids for most part, with some episodes of emesis.
Tube feeds cycled on [**10-20**]. Stopped abx because UCx clear. PT
following pt, and pt [**Name (NI) 79810**] for rehab when medically stable.
Planned d/c to rehab on [**10-24**].
Medications on Admission:
ASA 81mg QDaily
Citalopram 40mg QDaily
Metoprolol 5mg IV q4
Morphine PRN
Zofran 4mg q8 PRN
Protonix
Vancomycin 250 PO q6H
Insulin SS
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours).
4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
5. Loperamide 1 mg/5 mL Liquid Sig: Three (3) mg PO Q 8H (Every
8 Hours).
6. Sodium Bicarbonate 650 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) ml PO Q6H (every 6 hours).
9. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED): Glucose Insulin
51-150 0 Units
151-200 2 Units
201-250 4 Units
251-300 6 Units
301-350 8 Units
351-400 10 Units
> 400 12 Units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 1110**]
Discharge Diagnosis:
Primary Diagnosis:
Ischemic colitis
Secondary:
Post operative delirium
Acute Respiratory Insufficiency
Atrial Fibrillation
Acute interstitial nephritis
Chronic Renal Failure
Discharge Condition:
Stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* 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 becoming
progressively worse, or inadequately controlled with the
prescribed pain medication.
* 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.
Incision Care:
*You may shower. Pat incision dry.
*Avoid swimming and baths until further instruction at your
followup appointment.
*Leave the steri-strips on. They will fall off on their own, or
be removed during your followup.
*Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call the office of Dr. [**Last Name (STitle) **] to arrange a follow up
appointment in [**1-13**] weeks at [**Telephone/Fax (1) 2981**]
Please follow up with your primary care physician as needed
|
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icd9cm
|
[
[
[]
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[
"38.93",
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icd9pcs
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[
[
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8080, 8163
|
4403, 6959
|
482, 539
|
8382, 8391
|
3106, 4380
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,225
| 156,813
|
39164
|
Discharge summary
|
report
|
Admission Date: [**2102-3-4**] Discharge Date: [**2102-3-29**]
Date of Birth: [**2027-10-4**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
s/p PPM-[**2102-3-28**]
mitral valve replacement with 29mm [**Company 1543**] porcine, tricuspid
valve annuloplasty [**2102-3-17**]
left heart catheterization, coronary angiogram
rectopexy/sigmoidectomy
dental extractions
right thoracentesis
History of Present Illness:
Mrs. [**Known lastname 732**] is a 74-year-old woman with mitral valve prolapse
who recently underwent laparoscopy-assisted sigmoidectomy and
rectopexy on [**2102-2-24**] and was subsequently discharged to rehab on
[**2102-3-2**]. She was re-admitted on [**2102-3-4**] with recurrent rectal
prolapse. She is scheduled to undergo hemorrhoidectomy. However,
she was noted to have new ECG changes and cardiology was
consulted. An echocardiogram was performed which revealed
severe mitral and tricuspidregurgitaion with a question of a
flail posterior mitral leaflet.
She was transferred to the cardiology service for further
management of acute heart failure.
Of note, the patient reported a significant worsening in dyspnea
on exertion since her recent surgery. At this time, she gets
short of breath with mild exertion. She also reports mild
bipedal edema that has started since the surgery. Dr.[**First Name (STitle) **] was
consulted for surgical repair.
Past Medical History:
mitral valve prolapse with regurgitation
tricuspid valve regurgitation
Anxiety
Rectal prolapse
s/p hysterectomy
Social History:
One quarter pack per day smoker x 50 years, denies EtOH or
illicits drug use.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission:
VS: T=99.9F BP=127/77 HR=70 RR=20 O2 sat= 94% 2L (90% RA)
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5 cm.
CARDIAC: RRR, normal S1, S2. No thrills, lifts. No S3 or S4.
III/VI holosystolic murmur heard throughout the precordium but
loudest at apex.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi. Decreased breath sounds at bases.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ pedal edema b/l. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2102-3-21**] 02:58AM BLOOD WBC-8.3 RBC-3.47* Hgb-10.4* Hct-30.9*
MCV-89 MCH-30.1 MCHC-33.8 RDW-15.6* Plt Ct-211
[**2102-3-21**] 02:58AM BLOOD Glucose-103* UreaN-13 Creat-0.5 Na-137
K-3.6 Cl-98 HCO3-31 AnGap-12
[**2102-3-27**] 05:05AM BLOOD WBC-6.9 RBC-3.57* Hgb-10.3* Hct-32.2*
MCV-90 MCH-29.0 MCHC-32.1 RDW-14.9 Plt Ct-444*
[**2102-3-27**] 05:05AM BLOOD UreaN-13 Creat-0.6 K-3.5
[**2102-3-24**] 08:10AM BLOOD Glucose-93 UreaN-14 Creat-0.5 Na-139
K-4.6 Cl-99 HCO3-33* AnGap-12
[**2102-3-27**] 05:05AM BLOOD WBC-6.9 RBC-3.57* Hgb-10.3* Hct-32.2*
MCV-90 MCH-29.0 MCHC-32.1 RDW-14.9 Plt Ct-444*
[**2102-3-29**] 05:15AM BLOOD WBC-7.9 RBC-3.39* Hgb-9.7* Hct-30.5*
MCV-90 MCH-28.7 MCHC-31.8 RDW-14.8 Plt Ct-438
[**2102-3-29**] 05:15AM BLOOD Plt Ct-438
[**2102-3-29**] 05:15AM BLOOD Glucose-83 UreaN-14 Creat-0.4 Na-136
K-3.8 Cl-97 HCO3-33* AnGap-10
[**2102-3-17**] Intra-op Echo:
PRE-CPB:1. The left atrium is markedly dilated. The left atrium
is elongated. Mild spontaneous echo contrast is seen in the body
of the left atrium. The left atrial appendage emptying velocity
is depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. The coronary sinus is dilated (diameter >15mm). No evidence
of LSVC following bolus of iv fluid in left arm iv.
4. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
5. Right ventricular chamber size and free wall motion are
normal.
6. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen.
7. Severe (4+) mitral regurgitation is seen. There is an
eccentric jet directed anteriorly with significant prolapse and
flail of P2 and moderate anterior leaflet retraction.
8. Moderate to severe [3+] tricuspid regurgitation is seen. The
tricuspid annulus measures 4 cm.
9. There is a very small pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-CPB: On infusion of epi, neo, milrinone. AV pacing.
Well-seated bioprosthetic valve in the mitral position. Poor
images due to air in esophagus. Small amount of MR. [**Name14 (STitle) 86748**]
annuloplasty ring in the tricuspid position. TR is now mild.
Preserved biventricular systolic function on inotropic support.
Aortic contour is normal post decannulation.
Brief Hospital Course:
The patient was brought to the Operating Room on [**2102-3-17**] where
she underwent mitral valve replacement and tricuspid valve
repair. Please refer to Dr.[**Name (NI) 86749**] operative report for
further details. She weaned from bypasss on propofol and neo
Synephrine infusions. Vancomycin was used for surgical
antibiotic prophylaxis, given the preoperative stay of longer
than 24 hours. She was weaned form sedation and awoke
neurologically intact and was extubated without difficulty. Over
the next 24 hours she was weaned off pressors. All lines and
drains were discontinued in a timely fashion.
Diuresis was begun towards her preoperative weight and beta
blockade begun. She continued to progress and was transferred
to the step down unit for further monitoring on POD# 5. Physical
Therapy was consulted for strength and mobility evaluation.
Serial chest x-rays and a chest CT scan was done to evaluate
postoperative pleural effusions. A moderate left effusion and a
large right effusion were noted. A right thoracentesis was
performed which yielded 1600cc of serosanguinous fluid was
obtained uneventfully. The post procedure CXR revealed no
residual apical pneumothoraces, small left pleural effusion,
full resolution of right pleural effusion.
EP was consulted POD#9 to evaluate heart rhythm after an episode
of bradycardia-AV nodal dysfunction occurred. Beta-blocker was
discontinued. It was determined by EP after following several
days of her electrical activity that due to paroxysmal AVblock a
PPM was warranted. [**3-28**] PPM was placed.
POD#11 she was cleared by Dr.[**First Name (STitle) **] for discharge to [**Location (un) 582**] at
[**Hospital 620**] rehabilitation for further strength and mobility. All
follow up appointments were advised.
Medications on Admission:
Trimethoprim-sulfamethoxazole 800-160 [**Hospital1 **]
Oxycodone prn
Docusate
Polyethylene Glycol
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 4 weeks.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-19**] Sprays Nasal
QID (4 times a day) as needed for dry nares .
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours).
12. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
mitral valve prolapse with regurgitation
tricuspid valve regurgitation
Anxiety
Rectal prolapse
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Surgeon: Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 170**]on [**2102-5-8**] at 1pm
Please call to [**Year (4 digits) **] appointments
Primary Care: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**] in [**11-19**] weeks
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**11-19**] weeks
Wound Check in 1 week - Your nurse [**First Name (Titles) **] [**Last Name (Titles) **]
Device Clinic in 1 week [**Telephone/Fax (1) 62**]
**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:[**2102-3-29**]
|
[
"455.2",
"428.0",
"300.00",
"424.2",
"426.0",
"521.00",
"511.9",
"428.33",
"424.0",
"569.1",
"311"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"23.09",
"48.79",
"49.46",
"35.14",
"34.91",
"88.56",
"37.72",
"37.83",
"35.23",
"39.61",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
8621, 8705
|
5452, 7228
|
339, 583
|
8844, 9001
|
2843, 5429
|
9787, 10569
|
1822, 1938
|
7376, 8598
|
8726, 8823
|
7254, 7353
|
9025, 9764
|
1953, 2824
|
280, 301
|
611, 1573
|
1595, 1709
|
1725, 1805
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,321
| 161,002
|
24169
|
Discharge summary
|
report
|
Admission Date: [**2135-4-4**] Discharge Date: [**2135-4-25**]
Date of Birth: [**2080-7-23**] Sex: M
Service: SURGERY
Allergies:
Beta-Blockers (Beta-Adrenergic Blocking Agts)
Attending:[**Doctor Last Name 19844**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2135-4-4**] ERCP with sphincterotomy
[**2135-4-6**] decompressive laparotomy for abdominal compartment
syndrome
[**2135-4-7**] decompressive laparotomy for sedondary abdominal
compartment syndrome
[**2135-4-11**] abdominal washout
[**2135-4-14**] abdominal washout
[**2135-4-17**] abdominal washout
[**2135-4-19**] perc tracheostomy
[**2135-4-22**] abdominal washout
History of Present Illness:
54M Burmese-speaking with h/o dilated cardiomyopathy and pHTN
admitted for sudden onset epigastric pain associated with
nonbloody emesis x2 and hypotension. In ED, lipase levels
19,540, and CT demonstrating cholelithiasis, 9mm CBD, nl caliber
PD, significant pancreatic inflammation with associated
pseudocapsule and fat-stranding. Pt denied recent change in
medication, EtOH use, jaundice, pale stools, dark urine, and
unintentional weight loss.
Past Medical History:
Nonischemic dilated cardiomyopathy (15-20%) h/o tandem heart
[**2132**], hypertension, HTN, DM2 A1c 8.0, Hyperlipidemia (TAG 171
[**1-8**]), Hepatitis B (dx [**2128**]), pAF (on coumadin), hx LV wall
thrombus-completed anticoagulation tx, Hx PEA arrest following
beta-blocker administration
PSH: ICD placement, single chamber [**Location (un) 86**] Sci Teligen.
Indication: preventative for severely depressed EF (Scd-HeFT
criteria) single chamber (VVI@40, shock if >170) Right common
iliac artery stent ([**2132**])
Social History:
He moved from [**Country 16225**] to the US and lives in [**Hospital1 392**] with his wife
and son. [**Name (NI) **] is retired from the shipping industry. He formerly
smoked one pack per day x30 years and quit when he began feeling
unwell. Prior [**4-3**] shots of vodka daily. No other drugs or IVDU.
Family History:
His parents and siblings have type 2 diabetes and brother had
CAD diagnosed at age 53.
Physical Exam:
Resp: no audible breath sounds
CV: no cardiac activity
Abd: open abdomen,surgical dressing and drains in place
Ext: 2+ edema b/l U&L extremities
Brief Hospital Course:
[**4-4**]: Admitted early AM. Transferred East for ERCP. impacted
stone stone in the major papilla. Sphincterotomy performed.
Returned from procedure with abd distension and pain. pCXR
without free air. NGT placed. Bolused 250 cc in the setting of
elevated lactate and Cr. BP stable. MAP 75-90. Trop 0.14,
lactate trending down (peak 5.1). PR ASA. Insulin gtt. Glucose
trending down. Hyper K resolved. Bolused again with albuminx2
overnight. UOP sluggish. Down to 5cc/hr. Urine lytes sent. FeNa
0.7%
5/8: Cardiology consulted- possible non-ischemic CM and inferior
septal ischemia, recommended start milrinone, repeat TTE in AM;
Renal consulted- starting CVVH;family meeting- continue
aggressive care for now; placed R IJ HD catheter and R
subclavian CVL. Started neo, levo, milrinone. Changed neo to
vaso. Received 2.5L IVF during code event. Bolused 500cc NS x4
overnight for hypoTN and gave calcium chloride x1. Transfused 1u
PRBC's for hypoTN and hct 26, post-transfusion Hct 24.
Transfused additional 2u PRBC's. Abdominal distention and peak
pressures increases, so decided to paralyze.
[**4-5**] CODE: developed respiratory distress ~245pm, associated with
rhythm abnormalities (likely vtach) on telemetry; patient's AICD
fired, with return to NSR; elected to intubate [**12-30**] respiratory
distress; uncomplicated intubation, though hypotensive with
induction, requiring neo; back in vtach/vfib without pulses,
started ACLS; multiple firings of patient's AICD and 2 shocks
from defibrilator, 2 rounds epi, 300 amiodarone, ROSC at 16
minutes
[**4-6**]: Peak pressures improved with paralysis, but MAP dropped to
58-62. Gave calcium chloride and hydrocort 100 x1. Family
discussion re:goals of care/prognosis. Echo-no interval change.
Bedside laparotomy for decompression. Milrinone d/c'd. Weaning
NE.
[**4-7**]: Weaning vasopressin. Titrating levophed. Bedside
laparotomy, washout. Secondary compartment syndrome. No necrotic
bowel but did have white "studs" throguhout (? saponification).
Abdominal wound to wall suction. CVVH running even. Cis on for
procedure and then off.
[**4-8**]: Off paralysis. Weaned levo to 0.1 and turned off vaso. Ran
even on CVVH during day, then 50/hr negative. Decreased MAP goal
to >55. Cultured for temp 101.5.
[**4-9**]: D/c Foley. Sputum cx sent. D/c midaz gtt, start prn
boluses. HD line cultured. Transfused 1u pRBC (26.3->29.8). WBC
up to 22K. Family meeting held to discuss prognosis-interpreter,
Dr. [**Last Name (STitle) 26687**], eldest son and majority of family present. NGT
replaced by OGT because of deep tissue injury at nare.
[**4-10**]: Transfused 2 unit pRBC without appropriate bump. WBC
trending up, bandemia. Vasopressor weaned off. plan for OR [**4-11**]
for washout. Family meeting held (update). Abdominal dressing
oozing. WBC up to ~40. Levo down to 0.08. Transfused 1 unit pRBC
for Hgb 9 in the setting of increasing wound output.
[**4-11**]: Intermittently on/off levo. CT torso with extensive
inflammation; no abscess/collection. CT head unremarkable. OR
for wash-out. Transfused 1u PRBC's post-op for Hct 24.4-> 27.7.
WBC to 40: abx broadened to Vanc/[**Last Name (un) **]/Flagyl, bronch
(unremarkable).
[**4-12**]: WBC increased to 46.2, then 50K. Rectal tube placed for
decompression. Started on po vancomycin for wbc 50K. Started
Zyprexa.
[**4-13**]: PSV 5/5. Peripheral smear sent. Washout/Jtube/closure
planned for [**4-14**]. WBC still in the 40s. Neg 5.7 liters for the
day without incr in levophed requirement (0.08)
[**4-14**]: OR for washout; unable to do cholecystectomy or J-tube [**12-30**]
hemodynamic instability. Back from OR on levo/neo.
[**4-15**]: TBili 9.1 (DBili 6.8) post-op, up from 7.0 pre-op.
Phenylephrine d/c'd. Propofol weaned. CVVH run negative
initially but --> even per primary team. Hepatology consulted
and recommended RUQ ultrasound-not performed due to lack of
view. Spiked, cultured.
[**4-16**]: CVVH running even to try and avoid intra-op HD issues. No
further episodes of VT. OR planned for [**Doctor First Name **]. for washout, ? ccy,
? mesh. Bolused for hypotension in early AM.
[**4-17**]: Ran even/positive on CVVH to avoid increasing pressors.
Taken for wash-out, unable to do ccy, J-tube, or closure due to
hemodynamic instability. Returned from OR on increased levo and
back on neo. Changed vanco to 750".
[**4-18**]: Abx d/c'd (discussed w/ACS). Will hold TFs at midnight for
possible trach tomorrow. Transfused 1u pRBCs for Hct 23.7.
Pan-cultured. Dextrose gtt d/c'd. Attempting to run even.
[**4-19**]: Trach done at bedside. No J-tube placement per ACS. went
into vtach >5x, aicd broke rhythm. cards rec amio 150 bolus and
1mg/hr gtt x6 hours then 0.5mg/hr for 24 hours and repeat echo
tomorrow
[**4-20**]: Family meeting with interpreter. Transfused 2u PRBC's for
Hct 24 and continued pressor requirement. Tolerated -50cc/hr
CVVH for -1L for the day. Echo relatively unchanged from
previous. Amio gtt completed, started po.
[**4-21**]: Trach collar yesterday. Issues with CVVH this AM; renal
will see. Will go to IR today for tunneled dialysis catheter
placement. ISS started; will attempt to wean off insulin drip.
Minimal residuals; will consider d/c'ing NGT if remain low.
[**4-22**]: HD line d/c'd, tunneled line placed. Back to OR for
washout.
[**4-23**]: Episode of Vtach with hypotension, on max dose of levo,
started vaso and epi.
[**4-24**]: Unable to wean pressors, worsening hypotension. Patient
expired at 11.45 pm, family present at bedside.
Medications on Admission:
Digoxin .125,
Sitagliptin 50
Glipizide 5
Lisinopril 20
Sildenafil 40'''
Simvastatin 40
Torsemide 80
Wararin 2.5SSTuWF/5MTh
ASA 325
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute pancreatitis
Multi-organ failure
Discharge Condition:
Death
Completed by:[**2135-4-25**]
|
[
"V17.3",
"V18.0",
"789.59",
"567.89",
"V58.61",
"785.52",
"V64.1",
"995.92",
"412",
"576.1",
"287.49",
"729.73",
"276.7",
"427.31",
"518.81",
"403.90",
"038.9",
"070.30",
"276.2",
"272.4",
"410.71",
"414.01",
"425.4",
"416.8",
"428.40",
"584.5",
"585.4",
"285.9",
"V66.7",
"577.0",
"V15.82",
"V45.02",
"250.40",
"574.91",
"V11.3",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"96.08",
"54.12",
"39.95",
"54.11",
"54.25",
"51.85",
"31.1",
"96.04",
"33.21",
"38.95",
"51.88",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
8006, 8015
|
2318, 7796
|
320, 691
|
8097, 8133
|
2046, 2134
|
7978, 7983
|
8036, 8076
|
7822, 7955
|
2149, 2295
|
266, 282
|
719, 1167
|
1189, 1709
|
1725, 2030
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,560
| 178,211
|
36558
|
Discharge summary
|
report
|
Admission Date: [**2195-7-29**] Discharge Date: [**2195-8-17**]
Date of Birth: [**2139-1-6**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Metformin
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
CVL placement
Midline access placement
Intubation
Thrombolysis of submassive PE
EGD and Colonoscopy
IVC filter placement
History of Present Illness:
56 yo [**Male First Name (un) 4746**] male with Crohn's disease, diverticulosis s/p
hemicolectomy times 2, type 2 diabetes, and obesity who
initially presented to OSH for shortness of breath of one week
duration and found to have bilateraly submassive PEs and
intubated for respiratory failure.
.
Transferred to [**Hospital1 18**] on [**2195-7-29**]. Echo showed RB strain. Received
TPA for thrombolysis and heparin gtt was started. Vital signs
were stable and was extubated on [**2195-7-30**]. After the heparin gtt
was initiated, pt developed maroon stools mixed with BRBPR,
thought likely secondary to underlying crohn's disease. Hcts
were measured closely and fell from 40 on admission to 30
following heparin initiation. GI was consulted and pt underwent
upper endoscopy which showed no active source of bleeding.
Steroids were increased from 20mg daily to 40mg daily and pt was
continued on pentasa.
.
Called out to the floor on [**2195-8-2**] with stable vital signs, but
hct dropped from 30->26 requiring transfusion of 2 units prbcs.
With bowel prep for colonoscopy planned for the next day, it was
decided to readmit patient to ICU for better monitoring of Hcts
and vital signs. Patient was never hemodynamically unstable. In
total, he has needed 4 units of PRBCs.
.
In the ICU, patient underwent colonoscopy, showing diffuse
crohn's disease consistent with a flare but no intervention was
warranted. IVC filter was placed on [**2195-8-4**], should the patient
require emergent cessation of anticoagulation secondary to large
GI bleed. Hcts and vitals signs stable during this admission.
Bridge to coumadin has been initiated.
.
Upon reaching the floor, patient reports that he is feeling
good. Denies lightheadedness, weakness, shortness of breath,
chest pain, acute change in abdominal pain.
Past Medical History:
Type 2 Diabetes
Obestiy
Crohn's disease, with history of GI bleed
Hypertension
Diverticulitis s/p Partial Colectomy x 2
s/p Multiple Herniorraphy's
Arthritis
Social History:
Patient is not married but lives with significant other (female)
and lives in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]. He only drinks alcohol 2x year
currently, but reports heavy alcohol use that stopped
approximately 20 years ago. He denies tobacco use. He reports
using cocaine with cessation approximately 25 years ago. He is a
former mechanic.
Family History:
No family history of blood clots, malignancy, or sudden cardiac
death. No family history of Crohn's disease. His mother passed
away from pneumonia, but also had hypertension.
Physical Exam:
Physical exam: ([**2195-8-5**])
VS: T: 97.3 (97.5-98.6), HR 61 (61-76) BP 139/80
(133-139/80-90), 97% RA, RR: 18
Gen: NAD, comfortable.
HEENT: PERRLA, EOMI, MMM, oropharynx clear
CV: distant heart sounds, RRR with nl S1, S2. No m/r/g.
Pulm: CTA B with no w/r/r.
Abd: obese, midline scar and lateral scars on left and right
with herniations visible. Nontender, positive bowel sounds in
all 4 quadrants. Right femoral site has dressing from IVC
placement - c/d/i.
Ext: ecchymosis noted on the arms bilaterally, no pedal edema,
no calf tenderness, no palpable cord.
Neuro: A+OX3, 5/5 strength in all 4 extremities
Pertinent Results:
Selected Labs:
[**2195-7-29**] 02:15PM BLOOD WBC-16.7* RBC-4.72 Hgb-13.2* Hct-40.8
MCV-86 MCH-27.9 MCHC-32.3 RDW-15.1 Plt Ct-338
[**2195-7-30**] 03:04AM BLOOD WBC-17.1* RBC-4.31* Hgb-11.7* Hct-37.3*
MCV-87 MCH-27.2 MCHC-31.4 RDW-14.3 Plt Ct-267
[**2195-7-31**] 03:14AM BLOOD WBC-10.8 RBC-3.67* Hgb-10.2* Hct-30.5*
MCV-83 MCH-28.0 MCHC-33.6 RDW-15.1 Plt Ct-240
[**2195-8-1**] 03:02AM BLOOD WBC-8.2 RBC-3.29* Hgb-9.1* Hct-27.6*
MCV-84 MCH-27.8 MCHC-33.1 RDW-15.0 Plt Ct-261
[**2195-8-2**] 08:09AM BLOOD WBC-7.2 RBC-3.21* Hgb-9.0* Hct-26.6*
MCV-83 MCH-28.0 MCHC-33.7 RDW-14.9 Plt Ct-273
[**2195-8-3**] 04:05AM BLOOD WBC-9.5 RBC-3.68* Hgb-10.0* Hct-30.3*
MCV-82 MCH-27.1 MCHC-32.9 RDW-15.0 Plt Ct-309
[**2195-8-4**] 04:52AM BLOOD WBC-9.0 RBC-3.62* Hgb-10.2* Hct-30.1*
MCV-83 MCH-28.1 MCHC-33.7 RDW-14.6 Plt Ct-317
[**2195-8-5**] 06:04AM BLOOD WBC-10.5 RBC-3.70* Hgb-10.1* Hct-30.9*
MCV-84 MCH-27.3 MCHC-32.7 RDW-14.6 Plt Ct-362
[**2195-8-13**] 07:10AM BLOOD WBC-14.1* RBC-4.27* Hgb-11.4* Hct-36.0*
MCV-84 MCH-26.6* MCHC-31.5 RDW-15.3 Plt Ct-441*
[**2195-8-14**] 07:00AM BLOOD WBC-14.1* RBC-4.17* Hgb-11.3* Hct-35.0*
MCV-84 MCH-27.1 MCHC-32.3 RDW-15.4 Plt Ct-411
[**2195-8-15**] 07:22AM BLOOD WBC-13.9* RBC-4.34* Hgb-11.5* Hct-37.1*
MCV-86 MCH-26.6* MCHC-31.1 RDW-14.5 Plt Ct-416
[**2195-8-16**] 06:47AM BLOOD WBC-13.6* RBC-4.29* Hgb-11.5* Hct-36.0*
MCV-84
.
[**2195-7-29**] 02:15PM BLOOD Glucose-265* UreaN-22* Creat-1.4* Na-139
K-5.6* Cl-106 HCO3-23 AnGap-16
[**2195-8-16**] 06:47AM BLOOD Glucose-145* UreaN-23* Creat-1.2 Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
.
[**2195-7-29**] 02:15PM BLOOD PT-12.8 PTT-27.8 INR(PT)-1.1
[**2195-8-7**] 06:39AM BLOOD PT-13.6* PTT-82.7* INR(PT)-1.2*
[**2195-8-8**] 05:27AM BLOOD PT-15.9* PTT-66.9* INR(PT)-1.4*
[**2195-8-9**] 05:22AM BLOOD PT-17.2* PTT-62.5* INR(PT)-1.5*
[**2195-8-10**] 05:55AM BLOOD PT-17.3* PTT-78.4* INR(PT)-1.6*
[**2195-8-10**] 05:09PM BLOOD PT-16.7* PTT-45.0* INR(PT)-1.5*
[**2195-8-11**] 02:51AM BLOOD PT-17.3* PTT-101.6* INR(PT)-1.6*
[**2195-8-11**] 09:10AM BLOOD PT-18.3* PTT-66.3* INR(PT)-1.7*
[**2195-8-11**] 04:32PM BLOOD PT-17.6* PTT-49.1* INR(PT)-1.6*
[**2195-8-12**] 06:38AM BLOOD PT-17.0* PTT-58.4* INR(PT)-1.5*
[**2195-8-12**] 10:00AM BLOOD PT-16.7* PTT-52.5* INR(PT)-1.5*
[**2195-8-15**] 01:25AM BLOOD PT-24.4* PTT-58.3* INR(PT)-2.3*
[**2195-8-14**] 04:25PM BLOOD PT-23.9* PTT-43.7* INR(PT)-2.3*
[**2195-8-14**] 07:00AM BLOOD Plt Ct-411
[**2195-8-14**] 07:00AM BLOOD PT-23.4* PTT-83.9* INR(PT)-2.2*
[**2195-8-13**] 07:10AM BLOOD PT-20.0* PTT-77.1* INR(PT)-1.8*
[**2195-8-13**] 01:40AM BLOOD PT-18.4* PTT-71.9* INR(PT)-1.7*
[**2195-8-14**] 07:00AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
[**2195-8-13**] 07:10AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.1
[**2195-8-12**] 06:38AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
[**2195-8-16**] 06:47AM BLOOD PT-30.5* PTT-87.6* INR(PT)-3.0*
[**2195-8-15**] 04:55PM BLOOD PT-27.4* PTT-61.2* INR(PT)-2.7*
.
[**2195-7-29**] 02:15PM BLOOD Calcium-8.6 Phos-6.1* Mg-2.0
[**2195-8-12**] 06:38AM BLOOD Calcium-9.6 Phos-5.0* Mg-2.1
.
Upon reaching the floor on [**2195-8-5**] until discharge, patient's
hematocrit remained between 30.4 and 37.3.
.
ECG ([**2195-7-29**]): Tracing 1. Sinus tachycardia. Non-specific
intraventricular conduction delay. Non-specific ST-T wave
changes. No previous tracing available for comparison.
.
TTE ([**2195-7-29**]): IMPRESSION: RV strain c/w acute pulmonary
embolism.
.
CTA Chest, Abdomen, Pelvis ([**2195-7-29**]): IMPRESSION: 1. Extensive
bilateral pulmonary emboli involving the bilateral main
pulmonary arteries with extension through to the lobar,
segmental, lower lobe subsegmental branches bilaterally, as
above. Associated findings of right heart strain. 2. No evidence
of acute aortic injury. 3. Bilateral dependent
atelectasis/aspiration. 4. Small left-sided ventral abdominal
hernia containing non-obstructed loop of small bowel. Suggestion
of right-sided spigelian hernia, incompletely assessed as right
lateral aspect of the abdomen fully included.
.
ECG ([**2195-7-30**]): Tracing 2. Sinus tachycardia. Non-specific T wave
changes. Low QRS voltage in the limb leads. Compared to the
previous tracing of [**2195-7-29**] the QRS voltage has decreased in the
limb leads. ST segment depression is less pronounced and the
ventricular rate is slower.
.
ECG ([**2195-7-31**]): Tracing 3. Sinus rhythm. T wave inversions in
leads V1-V3. Cannot exclude ischemia. Low QRS voltage in the
limb leads. Compared to the previous tracing of [**2195-7-31**] artifact
is present. T wave inversions are less pronounced in lead V3 and
the T waves are more upright and normal appearing in leads
V4-V5.
.
CXR ([**2195-7-30**]): The ET tube tip is 4.5 cm above the carina. The
right internal jugular line tip is at the level of mid low SVC.
There is no change in the cardiomediastinal contour with the
mediastinal widening being due to extensive mediastinal
lipomatosis. Bibasilar atelectasis have developed in the
interim, new, but note is made that the lung bases cannot be
entirely evaluated since they were not entirely included in the
field of view. No evidence of pulmonary edema. No pneumothorax.
.
Bilateral Lower Extremity Vein Ultrasound ([**2195-7-31**]): IMPRESSION:
1. Non-occlusive thrombosis of the right popliteal (deep) vein.
Non- visualization of right posterior tibial veins, can not
exclude thrombosis
within these veins. 2. No evidence of deep venous thrombosis in
the left lower extremity.
.
ECG ([**2195-8-5**]): Sinus tachycardia. Possible left atrial
abnormality. There is one ventricular premature contraction.
Non-specific inferior ST-T wave changes. Compared to the
previous tracing of [**2195-8-5**] there is no significant change.
Brief Hospital Course:
56 yo [**Male First Name (un) 4746**] with DMII, HTN, crohn's disease on steroids,
diverticulosis s/p colectomy X 2, who was admitted to the MICU
on [**7-29**] for respiratory failure requiring intubation secondary to
submassive PE.
.
# Pulmonary Embolism. Patient presented to [**Hospital1 18**] and found to
have submassive clot burden on CTA with significant hypoxia
(PAO2 only 130 in spite of 100% oxygen). He required intubation
for respiratory failure and also had evidence of right heart
strain from bedside echo. He was lysed with TPA and extubated
afteward. He was begun on heparin gtt. Shortly after the
initiation of heparin, pt developed maroon stools with BRBPR and
required transfusion of 4 u PRBC. Hematocrits were measured
closely and fell from 40 on admission to 30 following heparin
initiation. GI was consulted and pt underwent upper endoscopy
which showed no active source of bleeding. Steroids were
increased from 20mg daily to 40mg daily and pt was continued on
pentasa. Patient was called out to the floor on [**2195-8-2**], but
given persistence of maroon stools with BRBPR, patient returned
to the MICU the following morning for bowel prep for anticipated
colonoscopy with close monitoring of vitals and hematocrit. He
underwent colonoscopy and was found to have evidence of active
Crohns disease, though no active bleeding was identified. His
hematocrit stabilized but because he had a clot in his lower
extremities in combination with concerns regarding his ability
to tolerate anticoauglation in the short term, an IVC filter was
placed on [**2195-8-4**]. Patient was called out to floor on [**2195-8-5**]
with a stable hematocrit greater than 30. Vital signs remained
stable without any requirement for supplemental oxygen.
.
On the floor, heparin gtt was continued with bridge to
therapeutic INR with Coumadin. Hematocrits were monitored
closely and remained stable. The option to be discharged home
on lovenox therapy was presented to the patient on several
occasions but given the gravity of his presentation and his
underlying anxiety, pt preferred to remain hospitalized until
his INR was therapeutic. Patient never developed hypoxia and
never complained of shortness of breath on the floor. Patient's
INR slowly elevated over the course of this admission, reaching
therapeutic INR (2.2) on [**2195-8-14**]. In order to reach this INR,
coumadin doses were increased as tolerated, with daily doses
between 5-15 mg daily depending on the INR. On [**2195-8-10**], patient
reported that central line was accidentally removed during
showering, and occlusive dressing was placed. Patient was given
midline access and was without anticoagulation for approximately
3-4 hours. Patient was bridged for 48 hours upon reaching
therapeutic INR. The duration of his anticoagulation therapy
remains unclear, but patient has been instructed to follow up
with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], for further guidance.
He will likely need anticoagulation for at least 3 months, with
repeat LENIs to determine if clot burden is still present. If
clots are present, he will need to continue anticoagulation. If
clots are absent, stopping of anticoagulation may be considered.
However, if his underlying crohn's disease is the etiology of
his increased susceptibility to hypercoagulability, patient may
require life-long anticoagulation with coordinated care between
his PCP and gastroenterologist. In regards to patient's IVC
filter, it was not removed during this admission due to
persistent clot burden and the necessity to continue heparin
gtt. He will follow up with interventional radiology at [**Hospital1 18**]
and will have it removed within the next year, as per IR.
.
# acute blood blood loss anemia: Likely secondary to underlying
crohn's disease with flare in the setting of anticoagulation.
Patient developed maroon stools with BRBPR in response to
initiation of heparin gtt, with concurrent drop in hematocrit
from 40 on admission to 26 on [**2195-8-2**]. Patient was transfused
with 4 units PRBC in the MICU. EGD showed no acute bleeding but
colonoscopy showed diffuse crohn's disease. Hematocrit was
measured frequently, stabilized around 30 on [**2195-8-3**] and
remained at or above this level throughout this admission. On
[**2195-8-15**], Hct was noted to be 37.2. Active type and screen was
maintained. Patient continued to have BRBPR/maroon stools until
[**2195-8-9**], which may have been due to the passing of clots. All
other vital signs remained stable and patient did not experience
any signs of hypotension or anemia.
.
# Crohns. Diagnosed in [**5-2**] but patient reported chronic
symptoms for many years. Prior to admission, patient was on
20mg PO prednisone taper for prior crohn's flare. As above,
following administration of tpa lysis and heparin gtt for PE,
patient developed BRBPR and maroon stools. In the MICU, an EGD
showed no upper GI bleeding and a colonoscopy showed an active
crohn's flare with no intervenable bleeding areas. GI followed
patient during this admission and increased PO steroid dose to
40mg PO in the MICU. He was continued on mesalamine 500mg PO
BID. On [**2195-8-9**], patient reported that his stools were brown,
formed, without blood. On [**2195-8-10**], GI was re-consulted and his
prednisone was tapered down. He will be discharged on 30mg PO
daily with a goal taper of 5mg per week. Remained
hemodynamically stable and asx. Patient will follow up with his
gastroenterologist, Dr. [**Last Name (STitle) **], for further management as an
outpatient.
.
# Type 2 Diabetes: With the administration of increased
steroids, it was suspected that blood sugars would run higher.
It was difficult to control dinner and evening sugars, which
spiked in the 300's. During this admission, patient was
continued on HISS with long acting glargine. The scale was
continually uptitrated with goals of containing sugars under
300. Patient will be discharged on his home insulin regimen,
which he reports was effective in controlling his sugars. The
tapering of steroids will help with better sugar control.
.
# HTN. Patient's outpatient medication for hypertension included
lisinopril. In the MICU and in the setting of his lower GI
bleeding, this medication was held. After several days of
continued stabilized of the hematocrits and vital signs,
lisinopril was restarted. Blood pressures remained stable
following re-initiation of this medication.
.
# Acute Renal failure. Patient was noted to have a creatinine
of 1.4 on presentation. Likely secondary to decreased volume
status in the setting of lower GI bleeding. Creatinine improved
in response to fluids and remained stable over the course of
this admission.
.
# Disposition: There were several obstacles to the discharge of
this patient. Patient is from [**Hospital3 4298**] and
transportation was an initial problem. [**Name (NI) **] was originally
agreeable to discharge on lovenox therapy, provided that his
significant other could pick him up from the hospital. Primary
team and social work contact[**Name (NI) **] pt's significant other, who
reported that she was not ready to have patient back home. She
initially reported that the weekend traffic at [**Hospital3 4298**]
was too overwhelming for her to travel. Upon further
conversation, she revealed that in the last year, patient had
become increasingly angry and had become more threatening
(though not physically). Patient believed that he was not
medically stable, was anxious, and demanded to stay on heparin
gtt until he was therapeutic. Denied several offers to leave on
lovenox therapy.
.
Patient if FULL code. HCP is long-time girlfriend, [**Name (NI) **]
[**Name (NI) **] ([**Telephone/Fax (1) 82747**].
Medications on Admission:
Medications at Home: (as per initial note)
Lisinopril 10 mg daily
Humalog ISS
Lantus 30 qhs
NPH 30 qam
Tramadol 50 mg PO daily
Pentasa 500 mg [**Hospital1 **]
.
Medications on Transfer:
Pantoprazole 40 mg PO Q24H
Warfarin 5 mg PO DAILY
Hydrocortisone Acetate Ointment 1% 1 Appl PR DAILY
Heparin IV Sliding Scale
Insulin SC (per Insulin Flowsheet)
Mesalamine 500 mg PO BID
PredniSONE 40 mg PO DAILY
Cepacol (Menthol) 1 LOZ PO PRN
Morphine Sulfate 1-2 mg IV Q4H:PRN pain
Acetaminophen 325-650 mg PO Q6H:PRN
Docusate Sodium (Liquid) 100 mg PO BID
Senna 1 TAB PO BID:PRN
Bisacodyl 10 mg PO/PR DAILY:PRN
Discharge Medications:
1. Mesalamine 250 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO BID (2 times a day).
Disp:*120 Capsule, Sustained Release(s)* Refills:*2*
2. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
Subcutaneous at bedtime: please continue to take your humalog
sliding scale as prior to hospitalization.
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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*0*
6. Tramadol 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for pain.
7. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM: Please follow up with your PCP as scheduled to check your
INR, with goal INR of [**1-27**].
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Submassive Pulmonary Embolus
Acute Blood loss anemia from lower GI bleed
Crohns Disease
Type 2 Diabetes
Hypertension
Arthritis
Discharge Condition:
Stable, hematocrit 30-33, stools brown and formed.
Discharge Instructions:
You initially went to an outside hospital with difficulty
breathing. After getting transferred to [**Hospital1 18**], we found that you
had a large blood clot in your lung. We treated your with
medication to dissolve your clot and this caused you to have
lower GI bleeding. We then put a filter in your IVC, put you on
blood thinners, and your bleeding has improved. Your vital
signs and hematocrit continue to remain stable. You were given
coumadin to thin your blood and now your INR levels are
therapeutic. Your stools are no longer bloody or maroon in
color.
.
We made the following changes to your medications:
-ADDED Coumadin 7.5mg by mouth daily. Your dose of this
medication may vary. Your primary care doctor, Dr. [**Last Name (STitle) **], [**First Name3 (LF) **]
tell you whether to increase or decrease this medication to keep
your INR between 2 and 3
-ADDED Prednisone 30mg by mouth daily. You should continue to
take this medication until you follow up with your GI doctor.
-ADDED Pantoprozole 40mg by mouth daily. You can speak with
your GI doctor about when to stop this medication.
.
Please follow up with your GI doctor and your PCP as below. You
will need to have your blood levels monitored closely over the
next few weeks.
.
If you have any abdominal pain, fevers, chills, increase in your
bloody bowel movements, please contact your primary care
physician or visit the emergency room.
Followup Instructions:
GI doctor: Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **]. Thursday [**8-20**] at 4pm.
[**Telephone/Fax (1) 82746**]. Please talk to your doctor about starting Bactrim
for prophylaxis if you will require long term steroids. Please
follow up with him regarding the tapering of your steroid doses.
.
Primary Care Doctor: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], check INR Wednesday [**8-19**] at 12:00pm. [**Telephone/Fax (1) 29822**]. Please go to the clinic on
Wednesday morning to have your labs drawn. The clinic will call
you in the afternoon and tell you if you need to adjust your
coumadin dose. Your primary care physician will order you a
repeat ultrasound at 3 months after discharge to see if you
still have a blood clot in your leg. If this ultrasound is
negative, you may consider stopping anticoagulation and schedule
to remove your IVC filter. You can call the interventional
radiology department at [**Hospital1 18**] to remove your IVC filter within 1
year. Phone: [**Telephone/Fax (1) 8243**]
.
You may ask your primary care physician to set you up with a
hematologist to determine if you are at risk for any future
clots.
|
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19,952
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49763
|
Discharge summary
|
report
|
Admission Date: [**2118-5-10**] Discharge Date: [**2118-5-14**]
Service: MED
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old female
with multiple medical problems including dementia,
transferred from [**Hospital3 **] for bright red blood
per rectum. Per nursing notes in the [**Hospital3 **]
chart the patient has had at least two prior episodes of
bright red blood per rectum, smaller amount however, on the
day of transfer the patient had greater than 150 cc's bright
red blood per rectum. On arrival to the emergency room her
temperature was noted to be 100.6 with a blood pressure of
88/25, heart rate 86, 92% on room air. Following two liters
normal saline the patient's blood pressure remained 90/30,
she was placed on a sepsis protocol and admitted to the
intensive care unit.
Per history the patient had no history of vomiting and no
abdominal pain noted in the emergency room. Nasogastric
lavage was negative for blood or clots. The patient received
Ceftriaxone, Flagyl in the emergency room.
PAST MEDICAL HISTORY: Diabetes mellitus.
Status post aortic and mitral valve replacement secondary to
rheumatic heart disease.
Atrial fibrillation.
Coronary artery disease.
Cerebrovascular accident with residual left hemiplegia.
Urinary incontinence.
Gastroesophageal reflux disease.
Dementia.
Hemorrhoids.
Severe hearing loss.
Status post CCY.
MEDICATIONS:
1. Sorbitol.
2. Folate.
3. NPH 12 units twice a day.
4. Prevacid.
5. Zestril 2.5 mg p.o. q day.
6. Micro-K
7. Coumadin per INR.
8. Lasix 120 mg p.o. q day.
9. Zoloft 75 mg p.o. q day.
ALLERGIES: Norpace, Atropine, aspirin, non-steroidal anti-
inflammatory drugs. Erythromycin.
FAMILY HISTORY: Noncontributory.
SOCIAL HISTORY: No alcohol, tobacco or drugs. The patient
has two sons both of whom are physicians. Her official
health care proxy is currently in [**Country 3594**] as we are
communicating with [**First Name4 (NamePattern1) **] [**Known lastname 29919**] her son.
PHYSICAL EXAMINATION: Temperature 97.7, blood pressure
133/28, heart rate 81, respiratory rate 19, O2 98% on room
air. Those are at the point of her MICU call up. In general
she is in no apparent distress. Head, eyes, ears, nose and
throat: Pupils equal, round and reactive to light and
accommodation. Extraocular movements intact. Sclera
anicteric. Moist mucous membranes. Neck: A right IJ is in
place. Thorax: Bibasilar crackles, one third of the way up.
No wheeze. Cardiovascular: Regular, irregular rate with no
murmurs, rubs or gallops. Abdomen: Note is made of an S2
click consistent with artifical valves. Abdomen: Normal
active bowel sounds, soft, distended, tender in the right
lower quadrant and right upper quadrant, no rebound or
guarding. Extremities: Trace lower extremity edema
bilaterally, no clubbing or cyanosis. Neurological: Alert,
severely hard of hearing, note is made of left hemiparesis.
LABORATORY FINDINGS: Chest X-ray from [**2118-5-11**] - stable
cardiomegaly with a left small left pleural effusion.
General impression: Mild congestive heart failure.
Blood cultures from [**2118-5-10**] pending at the time of this
dictation. Urine culture: Mixed flora. Abdominal CT: Small
bilateral pleural effusions. Note is made of slight
prominence of the rectum and distal sigmoid colon.
Concerning for bowel wall thickening with minimal surrounding
fat stranding.
Admission white blood cells 19.5. Hematocrit 37.7 dropped to
29.2 with hydration. INR on admission 2.9. Cortisol 32.
HOSPITAL COURSE: This is a [**Age over 90 **]-year-old demented female from
[**Hospital3 **] with history of diabetes, status post
mitral valve and aortic valve repair, coronary artery
disease, status post cerebrovascular accident, in atrial
fibrillation admitted with gastrointestinal bleed concerning
for ischemic colitis. Secondary to hypotension from acute
blood loss due to question diverticular bleed or ischemic
colitis.
Bright red blood per rectum: The patient presents with
history of prior episodes of small amount of bright red blood
per rectum followed by a significant episode of greater than
150 cc's blood loss from the rectum. This history is
concerning for possible arteriovenous malformation,
diverticular bleed or hemorrhoidal bleed. The patient's son,
[**Name (NI) **] [**Name (NI) 111**] was involved in discussions regarding possible
endoscopy. Decision was made to defer endoscopy and to
continue to monitor hematocrit and avoid colonoscopy. If
hematocrit remained stable as the suspicion for a polyp or
colon cancer is the source of the patient's bleeding was
extremely low on the differential. The patient's hematocrit
remained relatively stable. She only required single unit of
packed red blood cells for transfusion following a drop in
her hematocrit with hydration following her initial
presentation. However, she developed diffuse abdominal pain
and an abdominal CT was concerning for ischemic colitis
likely secondary to her hypertensive event.
She was kept NPO and received intravenous Ceftriaxone and
Flagyl for presumed ischemic colitis. Her abdominal pain has
since improved and she is currently tolerating a low residue
diet. Stool cultures were not sent however C. Diff negative
times one however, the presentation is quite unusual for an
infectious colitis. Her hematocrit has remained stable
despite reinitiation of anti-coagulation. Plan to discharge
to [**Hospital3 **] as hematocrit has been stable times
48 hours, and after INR returns to therapeutic range.
Cardiovascular: Coronary artery disease. The patient was
not given aspirin considering her history of allergy to
aspirin in the context of a gastrointestinal bleed. Her Ace
inhibitor was initially held however, re-started once she was
transferred out of the Intensive care unit with the stable
hematocrit. Would consider adding a beta-blocker to her
medication regimen as this has been shown to decrease
mortality. We have deferred doing so while in the hospital
due to the potential for masking a compensatory tachycardia
in the context of her current bleeding.
Congestive heart failure. The patient received a total of
one unit packed red blood cells. Upon transfer out of the
intensive care unit she was noted to have persistent crackles
bilaterally with a recent chest x-ray with evidence of a
small left effusion. Her blood pressure remained stable with
no further gastrointestinal bleeding thus her home dose of
Lasix was reinitiated.
Rhythm. The patient currently in atrial fibrillation. Her
INR was initially reversed with p.o. Vitamin K in the context
of acute gastrointestinal bleed. She has since then started
on a Heparin drip and we are currently loading her with
Coumadin to re-anticoagulate for history of atrial
fibrillation with artificial aortic and mitral valve. Plan
to continue Heparin drip 24 hours beyond therapeutic INR
goal, INR 3 to 4 considering multiple valves. In addition to
concurrent atrial fibrillation.
Diabetes mellitus. The patient was maintained on one half of
her home dose of NPH due to her NPO status and in the context
of a gastrointestinal bleed. She will be restarted on her
home dose of 12 units twice a day upon discharge.
DNR/DNI
DISCHARGE DIAGNOSIS: Ischemic colitis.
Lower gastrointestinal bleed.
DISCHARGE CONDITION: Good. Tolerating low residue diet. No
further bleeding. Hematocrit stable times 48 hours.
.
DISCHARGE STATUS: Patient is to be discharged to [**Hospital3 1761**], [**Location (un) 550**] until off Heparin drip at which time she
will return to her regular unit.
DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o. q day times seven more days.
2. Flagyl 500 mg p.o. three times a day times seven more
days.
3. Zoloft 75 mg p.o. q day.
4. Lisinopril 2.5 mg p.o. q day.
5. Nystatin suspension 5 mls p.o. four times a day times six
more days.
6. Colace 100 mg p.o. twice a day.
7. Senna two tablets p.o. q h.s. p.r.n.
8. Dulcolax 10 mg p.o. q day p.r.n. constipation.
9. Insulin NPH 12 units subcutaneously q AM.
10. Insulin NPH 12 units subcutaneously q PM.
11. Coumadin 10 mg p.o.q h.s, continue times three days
or until INR greater than 2 and then either continue or
decrease dose according to INR, goal INR 3 to 4.
12. Heparin drip 700 units per hour continuous to be
continued 24 hours beyond therapeutic INR. Please check
PTT q 6 hours until stable within range of 60 to 80 times
two and then can follow q day. Adjust according to
provided slow scale. Goal PTT 60 to 80.
13. Lasix 120 mg p.o. q day.
14. Prevacid 30 mg p.o.q day.
15. Folate 1 mg p.o. q day.
16. Micro K, please continue home dose.
FOLLOW UP: The patient will be followed by her physician at
[**Name9 (PRE) 5595**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 104026**]
Dictated By:[**Last Name (NamePattern1) 19957**]
MEDQUIST36
D: [**2118-5-13**] 17:03:51
T: [**2118-5-13**] 18:08:48
Job#: [**Job Number **]
|
[
"578.9",
"584.9",
"557.9",
"285.1",
"398.91",
"276.0",
"458.0",
"427.31",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7336, 7604
|
1708, 1726
|
7627, 8707
|
7264, 7314
|
3547, 7242
|
8719, 9061
|
2018, 3529
|
118, 1040
|
1063, 1691
|
1743, 1995
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,611
| 135,993
|
40375
|
Discharge summary
|
report
|
Admission Date: [**2174-11-27**] Discharge Date: [**2174-12-12**]
Date of Birth: [**2139-9-23**] Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
IPH
Major Surgical or Invasive Procedure:
[**2174-11-27**] Right Craniotomy for evacuation of hemorrhage/AVM
History of Present Illness:
35 yo F found down at home w/ slowed MS [**First Name (Titles) **] [**Last Name (Titles) 15410**] L
hemiparesis. Pt was drinking caffeinated beer at home when she
was found down by her sister. [**Name (NI) **] one witnessed the fall and pt
reportedly had 2 carinated beers. Pt was minimally responsive w/
sluggish speech and complete flaccidity of her L extremities.
She
was taken by ambulance to OSH where she was found to have a L
hemiparesis and L lower facial droop. CT at that time
demonstrated a large IPH in the R frontal lobe with 10mm of
subfalcine herniation. Pt was transferred to [**Hospital1 18**] for
neurosurgical evaluation.
On arrival to the [**Hospital1 18**] [**Name (NI) **], pt was hemodynamically stable and
sluggishly responsive (GCS 14). CTA/CT demonstrated no interval
enlargement of the hemorrhage nor the herniation. Neurosurgery
was consulted.
On initial evaluation pt was responsive and denied any blurred
vision, dizziness, or numbness. Pt was complaining of an
inability to move her L arm and leg and endorsed a frontal
headache. No n/v, no fever or chills, no SoB,
Past Medical History:
Anxiety
Social History:
lives w/ sister, [**Name (NI) **] EtOH, [**Name (NI) **] tobac,
Family History:
noncontributory
Physical Exam:
On Admission:
Hunt and [**Doctor Last Name 9381**]: 3 [**Doctor Last Name **]: 4 GCS E:3 V:5 Motor: 6
O: T:98.4 BP: 115/67 HR:104 R 18 98% 2L
Gen: WD/WN, NAD, somnolent
HEENT: Pupils: anisocoric w/ R:5 to 3, L 3 to 2 EOMs grossly
intact
Neck: Supple. no LAD
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Somnolent, opens eyes to loud voice, cooperative
with exam but requires frequent stimuli.
Orientation: Oriented to person, place, and date.
Language: Speech slurred with good comprehension and repetition.
Cranial Nerves:
I: Not tested
II: Pupils anisocoric R>L (5 vs 3), round and reactive to light,
5 to 3mm in R, 3 to 2 in L. Visual fields are grossly full to
confrontation.
III, IV, VI: Extraocular movements grossly intact bilaterally.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-20**] throughout. No pronator drift
Stength:
D B T WE WF IP Q H AT [**Last Name (un) 938**] G
R 3 5 5 4 4 5 5 5 5 5 5
L 1 1 1 0 0 0 0 0 0 1 1
Sensation: Intact to light touch and pinprick bilaterally.
Reflexes: B T Br Pa Ac
Right 2 - - 2 -
Left 2 - - 3 -
Upgoing toe on L
Downgoing on R
Upon Discharge:
awake, alert + oriented x3
PERRL, EOM- restricted to left (passes midline though)
left facial droop, tongue deviates left
Left hemiparesis ( R IP 2+/5 )
Right UE and LE full strengths
sensation intact to light touch and symmetric
incision- sutures/staples removed, well healing
R groin- angioseal. C/D/I
Pertinent Results:
CTA HEAD [**2174-11-27**]:
No contrast extravasation to suggest active arterial hemorrhage.
Vascular
malformation such as cavernoma or AVM likely. Stable right
frontal
intraparenchymal hemorrhage with subarachnoid and
intraventricular extension. 11 mm leftward subfalcine herniation
as before.
CT HEAD [**2174-11-27**]:
Status post right frontal craniotomy for evacuation of
underlying hematoma, but expected post-surgical change. No new
hemorrhage is identified. There is persistent edema within the
right frontal lobe, though overall decreased mass effect
compared to study performed preoperatively.
CT Head [**2174-11-27**]:
Status post right frontal craniotomy, with expected
post-surgical change. No new hemorrhage is identified. There is
persistent edema within the right frontal lobe and associated
mass effect, though the degree of midline shift has decreased
from 8 to 6 mm over the prior 6 hours.
Right upper extremity ultrasound [**12-2**]: IMPRESSION: No evidence
of DVT.
[**12-7**] LE DVT: IMPRESSION: No evidence of DVT.
[**12-12**] Cerebral angiogram: no evidence of vascular malformation
or residual source of hemorrhage.
Brief Hospital Course:
Patient presented to [**Hospital1 18**] from an OSH and was admitted to the
neurosurgery service for intracranial hemorrhage. She recieved a
STAT cerebral angiogram and it was found that she had a AVM of
the parietal branch of the right MCA. Prior to the angiogram she
had an episode of seziure which consisted of her extensor
posturing her LUE and flexing her RUE towards her face. she
went to the OR for evacuation vis craniotomy on the mornign of
[**11-27**]. post-operatively she remained intubated and was
trasnferred back to the ICU. she had 2 episodes of presumed
seizure in the post-op period similar in nature to the one she
ahd prior to her angiogram. For this reason, she was placed on
dilantin.
On [**11-28**] she remained in the ICU for Q2 neuro checks. Her exam
remained stable.
On [**11-29**] she was transferred out of the ICU to the Step down
unit. She was able to maintain a SBP of 100-140 without
medications. Her Dilantin level was corrected to greater than
10. She was seen by Speech and swallow, who recommended she was
safe for a liquid diet with soft solids.
Dilantin level on [**12-4**] was 10.6 and she was continued on 100mg
TID. Her exam continued to improve and she had some voluntary
movement of her left leg.
On [**12-5**], she complained of increased muscle spasms to her neck
and arm. She was placed on Robaxin 100mg QID. She continued to
work with PT for mobility.
[**12-6**] the muscle spasms were improving and she was tolerating
the robaxin. Sutures and staples were removed.
On [**12-7**] she had LENIs which were negative and continued to be
OOB to chair with PT.
On [**12-8**] & [**12-9**] she continued to complain of pain and muscle
spasm throughout her body. It was noted that her spasticity had
gotten worse again. She was very tearful throughout the day and
stated that she just couldn't sleep at night. She was started on
Ambien QHS as well as Zoloft. Baclofen was added and the robaxin
was continued. Dilatin was 8.7 therefore she was bolused and her
standing dose was increased.
Her exam remained stable [**12-10**] through [**12-11**] and she underwent a
cerebral angiogram on [**12-12**] which showed no vascular
malformation. This was via right femoral artery which was
successfully angiosealed. After remaining neurologically and
hemodynamically stable for 3 hours she was cleared for discharge
to rehab.
Medications on Admission:
None
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever/pain.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. miconazole nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
9. methocarbamol 500 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. phenytoin 50 mg Tablet, Chewable Sig: Four (4) Tablet,
Chewable PO BID (2 times a day).
12. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
St. [**Hospital 11042**] Hospital Rehabilitation Unit
Discharge Diagnosis:
Right MCA AVM
Cellulitis
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:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? 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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
??????Please call ([**Telephone/Fax (1) 9403**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
Completed by:[**2174-12-12**]
|
[
"348.5",
"781.94",
"780.39",
"682.3",
"300.00",
"348.4",
"430",
"342.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.12",
"01.59",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
8373, 8453
|
4750, 7121
|
314, 383
|
8522, 8522
|
3582, 4727
|
10508, 10735
|
1639, 1656
|
7176, 8350
|
8474, 8501
|
7147, 7153
|
8698, 10485
|
1671, 1671
|
271, 276
|
3257, 3563
|
411, 1510
|
2232, 3241
|
1686, 1995
|
8537, 8674
|
1532, 1541
|
1557, 1623
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,500
| 162,473
|
42398
|
Discharge summary
|
report
|
Admission Date: [**2180-3-4**] Discharge Date: [**2180-3-10**]
Date of Birth: [**2128-3-9**] Sex: F
Service: MEDICINE
Allergies:
vancomycin / Sulfa(Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
Acute Aletered Mental Status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
51 yo female with h/o multiple sclerosis, seizure disorder,
dementia, frequent [**Hospital **] transferred from [**Hospital 91805**] Hospital with
elevated troponin and depressed ejection fraction (45%) in the
context of a recently seizure occurring during a prep for a
colonoscopy, which resulted in subsequent [**Last Name (un) **] and bilateral
DVT's. Patient initially presented to the OSH on [**2-29**] with a
hematocrit of 26.5 with a ? slow Hct drop, upon which she
received 3 units PRBCs, and underwent EGD and colonoscopy, with
reportedly no noted active bleeding, and a small ulcer and polyp
(unclear location). On [**3-2**] the patient experienced seizure-like
activity, was found to be in status epilepticus and loaded with
valium and dilantin. She was subsequently found to be flaccid
on her right side with a right facial droop. Head CT was
performed and reportedly negative. LENIs were done and showed
bilateral clots in the common femoral vein, and patient was
started on Lovenox. In addition, patient was found to have a
troponin of 1.12 and a BNP of 1600, for which an ECG, which
showed normal sinus rhythm with no ECG changes, and
echocardiogram was performed and showed an EF of 45% and
decreased wall motion. There was some concern for possible PFO
causing embolism from legs to the brain, and is being
transferred to [**Hospital1 18**] for catheterization on Monday, accepted by
Dr. [**Last Name (STitle) **]. Patient also has an E.coli UTI and is currently on
IV piperacillin/tazobactam. Patient has also received an
unclear amount of [**Name (NI) 91806**] for hypernatremia.
.
Pt was then transferred to [**Hospital1 18**] to further evaluate elevated
troponin with plan for left heart cath and evaluation for PFO as
a cause for stroke. Trops here ~0.3 persistently, CKMB normal,
so cath was not pursued; cardiac enzymes thought to be due to
demand ischemia plus renal failure. Pt was also treated with
pip/tazo x5 days for UTI, which may have lowered her seizure
threshold. She had a 24hr video EEG, which was negative for
seizure activity. She also had MRA/MRI of head/neck which
showed possible new L hippocampus lesion seen on DWI but not
FLAIR. She developed new significant right sided hemiparesis
and word-finding difficulty. Pt was evaluated by neurology;
symptoms thought to be due to [**Doctor Last Name 555**] paralysis secondary to
seizure. She is currently minimally verbal, but alert and
responsive, withdrawals all limbs to pain. Per her family, Pt's
post-ictal states generally last for 2-3 days. Pt was initially
monitored in cardiac care unit but transferred to medical floor
for further management after ACS was felt to be unlikely and
cardiac cath not to be indicated.
On review of systems, s/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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Vitals prior to transfer: 98.8 92 124/78 17 97% RA.
Past Medical History:
1. Multiple sclerosis - primary progressive, diagnosed in [**2151**].
Had
a severe flare and deterioriation in [**2156**] with onset of
seizures.
Has been steadily deteriorating since then, has been wheelchair
bound for the last 10 years. On maintenance methotrexate
therapy.
Followed by a neurologist at [**Hospital1 756**].
2. Seizure disorder - had first "big seizure" in [**2156**] and has
subsequently had a few "smaller" ones consisting of staring
spells occasionally with some facial twitching. Last one was 12
years ago, 3 episodes total. Has never been in status
epilepticus. Has always been maintained on Dilantin, which was
recently increased from 400mg total daily to 500mg total daily
within the last week due to a low level (5).
3. Hemorrhagic cystitis due to chronic cytoxin therapy
4. Deep vein thrombosis [**2172**]
5. Anemia
6. Neurogenic bladder
7. Bilateral hydronephrosis
8. Tonsillectomy
9. Appendectomy
10.Multiple cystocopies with ureteral stent placement in [**2172**]
11. Cauterization of her hemorrhagic points in her urinary
bladder
12. Breast bx in [**2-/2180**]
Social History:
- Tobacco history: denies
- ETOH: denies
- Illicit drugs: denies
lives with husband and has no children
Family History:
non-contributatory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T= 98.6 BP=100/60 HR= 97 RR= 24 O2 sat= 98%
GENERAL: Oriented x0. head rotated to left
HEENT: NCAT. Sclera anicteric. PEERL. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa.
NECK: Supple with no JVP
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. otomy site on R lower
abdomin drain red to clear fluid.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: AAOx0, head rotated to left, facial droop on R. moving L
arm and leg. Moans to painful stimuli in all 4 extremities.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Physical Exam:
General: middle-aged woman resting in bed in no acute distress
Vitals:
HEENT - PERRLA, EOMI, MMM, OP clear
LUNGS - clear to auscultation
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, hypoactive bowel sounds, RLQ ileal conduit
in place, yellow urine with white material and clumps
EXTREMITIES - 2+ peripheral pulses (radials, DPs), no edema
NEURO - awake, A&O x name, hospital, CNs II-XII grossly intact,
muscle strength 4/5 on RUE, [**4-6**] in LUE, [**3-6**] in LLE, [**3-6**] RLE, but
unclear if inattentive.
Pertinent Results:
ADMISSION LABS:
[**2180-3-4**] 05:45PM BLOOD WBC-5.0 RBC-3.75* Hgb-11.8* Hct-34.2*
MCV-91 MCH-31.5 MCHC-34.5 RDW-15.0 Plt Ct-181
[**2180-3-4**] 05:45PM BLOOD Neuts-69.5 Lymphs-18.6 Monos-6.1 Eos-5.1*
Baso-0.8
[**2180-3-4**] 05:45PM BLOOD PT-13.0* PTT-35.2 INR(PT)-1.2*
[**2180-3-4**] 05:45PM BLOOD Glucose-90 UreaN-39* Creat-2.0* Na-141
K-3.4 Cl-104 HCO3-27 AnGap-13
[**2180-3-4**] 05:45PM BLOOD ALT-26 AST-25 CK(CPK)-87 AlkPhos-104
TotBili-0.3
[**2180-3-4**] 05:45PM BLOOD CK-MB-3 cTropnT-0.37*
[**2180-3-4**] 11:50PM BLOOD CK-MB-2 cTropnT-0.28*
[**2180-3-4**] 05:45PM BLOOD Albumin-2.6* Calcium-7.2* Phos-1.7*
Mg-2.4 Iron-81
[**2180-3-4**] 05:45PM BLOOD calTIBC-125* Ferritn-2907* TRF-96*
[**2180-3-4**] 05:45PM BLOOD Phenyto-15.3
[**2180-3-5**] 08:10PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-LAMP
[**2180-3-4**] 04:56PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015
[**2180-3-4**] 04:56PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-7.0 Leuks-LG
[**2180-3-4**] 04:56PM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
[**2180-3-4**] 04:56PM URINE WBC Clm-FEW
[**2180-3-4**] 06:53PM URINE Hours-RANDOM UreaN-473 Creat-97 Na-49
K-22 Cl-<10
IMAGING / Studies:
OSH: [**2180-3-1**] EGD/[**Last Name (un) **] Pathology report:
-distal esophagus biopsy: severe monilial (candidal) esophagitis
w/ numerous exudates continaing abundant fungal pseudohyphae
highlighted on AB PAS stain. No intestinal metaplasia.
-proximal esophagus. Mild monilial esophagitis w/ few fungal
pseudohyphae on PAS-D stain.
-gastric polyp. Fundic gland polyp.
OSH: [**2180-3-1**] EGD/[**Last Name (un) **] procedure report:
-EGD: small hiatal hernia, patchy grade I candidiasis in whole
esophagus, erythema and edema w/ early linearl ulcerations in
the antrum, stomach body, and fundus, compatible w/ diffuse
gastritis and ulcerations, but no active bleeding. Erythema,
erosion, congestion and irregular margins w/ inflammatory polyp
in distal esophagus in the GE junction and lower [**1-4**] of
esophagus compatible w/ esophagitis and GERD. Several
semi-pedunculated non-bleeding polyps of benign appearance in
gastric body consistent w/ fundic gland polyps. Normal duodenum.
-[**Last Name (un) **]: normal terminal ileum, small grade 2 non-bleeding
internal hemorrhoids
[**3-5**] Video EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of the continued presence of slowing over the left
lateral temporal region suggestive of a structural abnormality
with superimposed interictal epileptic activity. Compared to the
prior day's recording, there was some improvement over the
previous days' recording with less interictal epileptic activity
and improvement of frequencies across the left hemisphere.
[**2180-3-4**] MR brain, MRA neck:
1. MRI brain shows extensive atrophy and chronic changes from
multiple sclerosis. Increased signal in the left hippocampus
could be due to ischemia or due to post-seizure changes. It does
not appear to be artifactual given the asymmetry, a followup
study can help.
2. MRA of the head and neck are unremarkable without stenosis,
occlusion or aneurysm.
[**2180-3-4**] Radiology PORTABLE ABDOMEN
There are no ureteral stents. There are multiple bilateral
kidney stones larger and greater in number on the right side.
Osseous structures are unremarkable. Multiple surgical clips
project in the pelvis. There is nonspecific bowel gas pattern.
[**2180-3-7**] 9:56 AM # [**Telephone/Fax (1) 91807**] COMPLETE GU U.S.
1. Massive left hydronephrosis with hydroureter to the UPJ. The
left kidney contains several large shadowing gallstones and
debris with [**Doctor Last Name 5691**] is seen in the left renal collecting system
and may be present within the left ureter. 2. Minimal
hydronephrosis seen in the right kidney with multiple shadowing
stones seen in the right renal collecting system. 3. Echogenic
kidneys consistent with chronic parenchymal disease.
Additionally, the left kidney demonstrates some cortical
thinning which may be related to the hydronephrosis.
[**2180-3-7**] 4:09 PM CTU (ABD/PEL) W/&W/O CO
IMPRESSION: 1. Massive hydronephrosis of the left kidney which
demonstrates delayed nephrogram and no excretion of contrast.
Cortical thinning suggests a chronic process. Multiple calculi
layering within the distended calices. There is significant
inflammatory fat stranding around the left kidney in addition to
an ill-defined 2.9 x 1.3 cm heterogeneous region adjacent to the
anterior cortex which is of uncertain etiology. This may
represent an area of phlegmonous change from possible prior
calyceal rupture, however, neoplasm or infection are not
excluded. If prior imaging is available, this would be
beneficial for comparison. 2. Transition at the left
ureteropelvic junction with urothelial hyperenhancement in the
normal-caliber left ureter. There is no stone or eccentric
enhancement. In addition to periureteral fat stranding, there
are multiple enlarged enhancing abnormal lymph nodes in the left
periaortic region. Findings may relate to inflammatory changes
secondary to reflux and stricture, however urothelial tumor
cannot be excluded. If retrograde urologic evaluation and
stenting is not able to be performed due to ileal loop anatomy,
consider antegrade left renal decompression and brushings via
percutaneous nephrostomy. 3. Mild-to-moderate right
hydronephrosis. There are multiple layering stones within the
collecting system on the right. There is no ureteral calculus.
Mild inflammatory stranding around the proximal ureter noted.
There are multiple areas of cortical thinning on the right
suggesting prior infection/insult. Results regarding the severe
left hydronephrosis and associated findings were discussed with
Dr. [**First Name (STitle) **] by Dr. [**Last Name (STitle) 53899**] on [**2180-3-7**] at 1700 via telephone. 4.
Bilateral central hypodense regions in the common femoral and
external iliac veins. Given symmetry, flow-related artifact is
suggested. However, if the patient has risk factors for DVT or
symptoms to suggest DVT, further imaging could be considered.
ECG: Scooped/upsloping 1-[**Street Address(2) 1766**] depressions in the
inferior/lateral precordial leads. 1 mm STE in V1. Similar to
prior ECG from 12 hours prior at OSH. No other ECGs for
comparison.
MICRO:
[**2180-3-4**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2180-3-4**] URINE URINE CULTURE-FINAL {ESCHERICHIA COLI}
URINE CULTURE (Final [**2180-3-9**]):
WORK-UP PER DR [**Last Name (STitle) **] ([**Numeric Identifier 17776**]).
ESCHERICHIA COLI. ~7000/ML. PRESUMPTIVE
IDENTIFICATION.
Piperacillin/tazobactam sensitivity testing available
on request.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2180-3-5**] URINE URINE CULTURE-FINAL -
URINE CULTURE (Final [**2180-3-6**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
[**2180-3-7**] URINE URINE CULTURE-FINAL - no growth
[**2180-3-8**] URINE URINE CULTURE-MIXED FLORA
[**2180-3-4**] MRSA SCREEN MRSA SCREEN-FINAL - negative
[**2180-3-4**] 06:53PM URINE Hours-RANDOM UreaN-473 Creat-97 Na-49
K-22 Cl-<10
[**2180-3-4**] 04:56PM URINE RBC->182* WBC->182* Bacteri-MANY
Yeast-NONE Epi-0
[**2180-3-4**] 04:56PM URINE Blood-LG Nitrite-POS Protein->300
Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-0.2 pH-7.0 Leuks-LG
[**2180-3-4**] 04:56PM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.015
DISCHARGE LABS:
[**2180-3-10**] 06:20AM BLOOD WBC-9.4 RBC-3.70* Hgb-11.4* Hct-35.9*
MCV-97 MCH-30.8 MCHC-31.8 RDW-15.5 Plt Ct-371
[**2180-3-10**] 06:20AM BLOOD Plt Ct-371
[**2180-3-10**] 06:20AM BLOOD PT-18.5* INR(PT)-1.7*
[**2180-3-10**] 06:20AM BLOOD Creat-1.5* Na-145 K-4.5 Cl-112*
[**2180-3-10**] 06:20AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.0
[**2180-3-10**] 06:20AM BLOOD Phenyto-13.1 Phenyfr-2.0 %Phenyf-15
Brief Hospital Course:
51F w/ PMH multiple sclerosis c/b dementia and neurogenic
bladder, seizure disorder, and frequent [**Hospital **] transferred from
[**Hospital 91805**] Hospital after developing a seizure on [**3-2**], AMS, and
acute renal insufficiency.
#Toxic-metabolic encephalopathy: Pt developed significant new
right hemiplegia and word finding difficulty after her seizure
on [**3-2**]. Per her family, she generally has a [**2-4**] day post-ictal
state after her seizures. Pt had a CT at OSH, which was read by
in-house rads showing no acute process. Pt was seen by
neurology, who recommended 24 hr video EEG, which showed
continued presence of slowing over the left lateral temporal
region suggestive of a structural abnormality with superimposed
interictal epileptic activity, and MRA/MRI which prelim showed
chronic MS, and MRA with left hippocampus changes consistent
with ischemia lesion seen on DWI, but not on FLAIR. Currently
feel that symptoms most likely due to post-ictal state ([**Doctor Last Name 555**]
paralysis) vs infection vs toxic metabolic state from renal
failure. Neurology feels that [**Doctor Last Name 555**] paralysis vs continuing
seizures are most likely, especially since Pt has waxing [**Doctor Last Name 688**]
course. Pt has been doing better overall and continues to
improve daily, becoming more interactive and gaining strength.
Pt will need intensive physical therapy, but expect steady
improvement.
# seizure: Pt developed seizure whilst on phenytoin at OSH, but
per husband, level was steadily decreasing, down to 5 when goal
is [**10-21**]. Also, Pt was getting bowel prep for colonoscopy, which
may have altered electrolytes, also received amp and pip/tazo
for UTI, also getting methotrexate, any of which may lower
seizure threshold. Pt's phenytoin level currently
supratherapeutic at 24.7 (corrected for albumin). However, 24 hr
video EEG, showed continued presence of slowing over the left
lateral temporal region suggestive of a structural abnormality
with superimposed interictal epileptic activity. MRA/MRI showed
chronic MS, and MRA with left hippocampus changes consistent
with ischemia lesion seen on DWI, but not on FLAIR. Neurology
feels that hippocampal lesion most consistent with post-ictal
change, but concerning for continuing seizures. Will repeat
video EEG. Decreased phenytoin to 200 [**Hospital1 **] because Pt was
supratherapeutic, which may actually induce seizures and
confusion. Pt had a repeat video EEG on [**3-7**], which did not
show any seizure activity.
Free phenytoin level very high at 2.8 on [**3-7**]. Held phenytoin on
[**3-8**]. Based on 22.6% free to total phenytoin ratio, will hold
phenytoin until free phenytoin is < 2, which correlates to total
phenytoin of 8.86 in this patient. Per her outpatient
neurologist's coverage, pharmacy, and husband, Pt has never been
tried on levetiracetam. Neurology agrees with adding
levetiracetam at 20mg/kg divided into 2 daily doses. Follow-up
has been scheduled in the [**Hospital1 18**] neurology [**Hospital1 **] with Dr.
[**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] (phone [**Telephone/Fax (1) 2100**], fax [**Telephone/Fax (1) 91808**]). They will follow Pt's phenytoin levels and adjust as
needed. Pt was discharged on levetiracetam 500mg po bid (D1 =
[**2180-3-10**]), phenytoin at 100mg po tid (discharge level total
phenytoin 13.1, Free 2.0, % free 15%). Pt will need repeat serum
phenytoin level checked on [**3-20**], faxed to [**Telephone/Fax (1) 91809**]. Levels
will be adjusted by Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **].
#bilateral lower extremity deep vein thromboses: Pt was
incidentally found to have bilateral DVTs at OSH after reporting
calf pain. DVTs considered provoked given wheelchair bound. Pt
was started on heparin drip and transitioned to warfarin.
Heparin drip was discontinued on [**3-8**] after INR was above 2.0
for 2 days, but INR dropped to 1.7 likely due to lower dose of
warfarin and possibly several interacting medications. Pt was
restarted on enoxaparin 70mg sc bid bridge and warfarin was
increased to 4 mg po daily. Pt will need daily INR check until
therapeutic and stable, at which point enoxparin may be
discontinued. This should be monitored by facility MD.
# UTI: patient has long standing h/o of neurogenic bladder.
Underwent a ileal loop urinary diversion in [**2172-5-2**] and has
urostomy in place. Has had multiple UTI. Currently, had UCx at
OSH that grew >100k colonies pan-sensitive enterococcus and >
10k colonies of pan-sensitive E.coli, which was initially
treated with oral ampicillin then switched to zosyn (unclear
when switched) for UTI. Per husband, was treated for 1 week w/
amp prior to OSH admission. Enterococcus is typically resistant
to piperacillin, so not clear if was adequately treated,
although repeat UCx from [**3-4**] showed < 10k colonies. Pt
currently afebrile w/ normal WBC and diff, but urine does have
significant white sediment. OSH renal ultrasound showed
echogenic material in L renal pelvis, concerning for possible
infectious material. Sent repeat UA, UCx on [**3-5**]. UA dirty,
UCx showed mixed flora. Repeat ultrasound showed massive L
hydronephrosis and hydroureter, several gallstones and debris in
L renal collecting system, minimal R hydronephrosis, multiple
stones in R collecting system. Given that multiple urine
cultures showed mixed flora or low growth, in the future, no
need to treat unless there is a predominance of one organism and
Pt is symptomatic.
# Acute renal failure: likely pre-renal in the setting of colon
prep, FeNa 0.68, received fluids, Cr improved to 1.7 from 2.1.
Unclear what baseline is. Per OSH renal ultrasound, Pt has
severe L hydronephrosis w/ possible infectious material in L
renal pelvis and moderate right hydronephrosis. Repeat renal
ultrasound on [**3-6**] showed massive L hydronephrosis, several
stones in bilateral kidneys, and cortical thinning on L. Urology
was consulted, who wanted CT urogram, which showed massive L
hydronephrosis w/ no excretion of contrast, cortical thinning,
multiple calculi, significant inflammatory fat stranding around
L kidney, and ill-defined 2.9 x 1.3 cm heterogeneous region next
to anterior cortex of unclear etiology. Also multiple enlarged
enhancing abnormal lymph nodes in left periaortic region, which
may be reactive inflammatory changes due to reflux and stricture
(but urothelial tumor cannot be excluded). Also showed mild
moderate right hydronephrosis w/ multiple layering stones.
Urology did not feel that there was any need to intervene due to
the likely chronic nature of these processes; wanted urine
cultures from bladder reminant and ileal urostomy. They were not
concerned about the ill-defined lesion adjacent to left anterior
cortex and suggested outpatient urological follow-up. Repeat
urine culture from bladder reminant shows no growth. Repeat
urine culture from ileal urostomy showed mixed flora consistent
with fecal contamination. Contact[**Name (NI) **] and updated outpatient
urologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31365**] [**Telephone/Fax (1) 91810**] about Pt's imaging
findings and concern for possible L ureter urothelial
malignancy. Will have [**Hospital1 1501**] arrange follow-up in [**2-5**] wks w/ Dr.
[**First Name (STitle) 31365**]. Urine cytology was ordered and will need to be followed
up. Pt should have repeat Cr check in 1 week to ensure no major
changes.
.
# [**Female First Name (un) **] esophagitis: Per OSH EGD biopsy path report from [**3-1**], [**2180**], Pt had extensive distal and mild proximal candidal
esophagitis w/ numerous exudates continaing abundant fungal
pseudohyphae on PAS. Unclear if this may have been the source of
fever / infection after her [**3-1**] EGD at the OSH. Pt currently
not voicing symptoms and eating well, but will treat given
description of extensive disease. Pt was started fluconazole
400mg po daily and should continue a 3 wk course ending [**3-28**].
Further assessment to be guided by Pt symptoms.
.
# Elevated troponin: Per cardiology, Pt's troponin was likely
due to seizures and renal failure, very low suspicion of ACS.
Apparently, her troponin of 1.1 at OSH was a troponin I, so not
comparable to our troponins. Here troponin 0.37 -> 0.28 -> 0.18.
CKs flat. Would not characterize Pt has having a NSTEMI.
Cardiology fellow felt that Pt should have repeat Echo given
abnormal findings at OSH. Pt's repeat Echo at [**Hospital1 18**] on [**3-7**]
does show mild regional left ventricular systolic dysfunction
with basal to mid septal and inferior hypokinesis. Repeat ECG
showed normal sinus rhythm, HR 96, normal axis, no q waves, ST
changes, or T wave changes, no evidence of ischemia. Cardiology
feels that wall motion abnormality may have been due to a prior
silent MI or non-coronary cardiomyopathy. Suggested starting a
beta blocker and ACE-inhibitor once creatinine improves. Pt was
started on metoprolol tartrate, which was uptitrated to 25mg po
bid due to high heart rate to 100s with good response and HR in
70s-80s on discharge. Pt was not started on an ACE inhibitor due
to low normal SBP in 100s. Outpatient cardiology follow-up was
arranged with Dr. [**First Name (STitle) 437**] at [**Hospital1 18**], who may consider pharmalogical
stress w/ imaging.
# Anemia: likely anemia of chronic disease vs effect of
methotrexate given normocytic, normal iron 81, ferritin 2907.
Unclear baseline. Pt had an EGD and colonoscopy, with reportedly
no noted active bleeding, and a small ulcer and polyp (unclear
location). No report included in OSH records, but Pt apparently
had distal esophagitis gastritis, and erosions on [**2179-11-8**]
EGD, also history of colonic and gastric polyps. Continue PPI
and monitor Hcts. EGD/[**Last Name (un) **] performed at [**Hospital3 24768**] in
[**State 792**]showed small hiatal hernia, patchy grade I
candidiasis in whole esophagus, erythema and edema w/ early
linearl ulcerations in the antrum, stomach body, and fundus,
compatible w/ diffuse gastritis and ulcerations, but no active
bleeding. Erythema, erosion, congestion and irregular margins w/
inflammatory polyp in distal esophagus in the GE junction and
lower [**1-4**] of esophagus compatible w/ esophagitis and GERD. Pt
was started on omeprazole 40mg po daily, which should be
continued until patient is evaluated by her outpatient
gastroenterologist. This will need to be arranged by PCP once
her other medical conditions stabilize. PCP may also pursue
further anemia workup.
.
# Multiple Sclerosis: stable, rx w/ methotrexate complicated by
hemorrhagic cystitis. Pt typically gets methotrexate 20mg po
qSaturday (but did not receive it during this admission). Spoke
with covering [**Hospital 112**] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **], [**Last Name (NamePattern4) **]. [**Last Name (STitle) 91811**] [**Name (STitle) **], who
advised holding methotrexate until Hct stabilizes and seizures
are under control since methotrexate may lower seizure
threshold. She also advised to give methylprednisolone 1g iv
bolus on [**3-10**] (on monthly schedule). Pt will follow-up with
her MS specialist and discuss when to resume methotraxate. We
tried to arrange MS [**Name13 (STitle) 702**] with [**Hospital 112**] [**Hospital **] [**Hospital **], but Dr. [**Last Name (STitle) 91811**]
[**Name (STitle) **] did not allow this to be scheduled and suggested that Pt
follow-up with an epilepsy specialist. Given stability of blood
counts, Pt was discharged with instruction to resume her prior
regimen of methotrexate 20mg po qSaturday and
methylprednisolone 1g iv bolus on the 9th of each month pending
appointment with her MS caregivers at [**Name (NI) 112**].
.
# Prolonged Qtc - chronic, typically 500s, would need serial
ECGs if giving any meds that would prolong it further
.
TRANSITIONAL ISSUES:
-phenytoin levels need to be followed and dosing adjusted as
necessary; may be able to transition off phenytoin w/
levetiracetam monotherapy to be determined by [**Hospital1 18**] neurology
-INR needs to be checked regularly and warfarin dose adjusted
for goal INR 2.0-3.0. Needs anticoagulation for at least 6
months for provoked bilateral lower extremity DVTs
-possible L ureter urothelial malignancy and L massive
hydronephrosis, mild-moderate right hydronephrosis and extensive
renal calculi needs to be evaluated by outpatient urologist.
Urine cytology was ordered and will need to be followed-up by
urologist / PCP. [**Name10 (NameIs) **] needs regular Cr check to assess make sure
renal function is not worsening
-continued outpatient workup of anemia
-need to clarify multiple sclerosis care with [**Hospital 112**] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) 91812**]s. Should clarify whether her current regimen of
methotrexate 20mg po qSaturday and methylprednisolone 1g iv
bolus on the 9th of each month needs to be adjusted or changed.
Medications on Admission:
HOME MEDICATIONS:
Dilantin 300mg AM, 200mg PM
aricept 10mg daily
methorexate 2.5mg. 8 tablets q saturday
fosamax 70mg on sunday
calcium 600mg [**Hospital1 **]
Vitamin C 500mg daily
Vitamin E 400 IU daily
MVI
iron 65mg TID
ampicillin 500mg TID for UTI
.
Transfer Medications:
Phenytoin 300 mg PO QAM
Phenytoin 200 mg PO QPM
Zosyn 2.25 gm IV Q6H
Lovenox 70 mg SC Q12H
Aricept 10 mg PO daily
Discharge Medications:
1. donepezil 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
3. multivitamin 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. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, fever.
6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 3 weeks: end [**3-28**].
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day: hold
for sbp < 100, hr < 60.
11. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
12. warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM: adjust dose for goal INR 2.0-3.0.
13. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 1 weeks: as bridge until warfarin is >
2.0 for 2 days.
14. phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg
PO Q8H (every 8 hours): goal total phenytoin (dilantin) level
[**10-21**].
15. methotrexate sodium 2.5 mg Tablet Sig: Eight (8) Tablet PO
once a week: every Saturday.
16. methylprednisolone sodium succ 1,000 mg Recon Soln Sig: 1000
(1000) mg Intravenous once a month: on the 9th, monthly.
17. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
18. iron 325 mg (65 mg iron) Capsule, Extended Release Sig: One
(1) Capsule, Extended Release PO three times a day.
19. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week:
on Sundays.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] nursing and rehab
Discharge Diagnosis:
Primary:
toxic metabolic encephalopathy / [**Doctor Last Name 555**] paralysis
epilepsy
bilateral lower extremity deep vein thromboses
acute on chronic renal insufficiency
massive left hydronephrosis
left hydroureter
moderate right hydronephrosis
bilateral renal calculi
[**Female First Name (un) **] esophagitis
cardiomyopathy (congestive heart failure)
Secondary:
chronic anemia
multiple sclerosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Ms. [**Known lastname 91813**],
You were transferred to our hospital because your doctors [**First Name (Titles) **] [**Name5 (PTitle) 91814**] [**Name5 (PTitle) 2985**] that you were having a heart attack. Your heart
specialists at [**Hospital1 18**] did not feel that you were having a heart
attack, but your heart scan showed that it was pumping less
effectively than normal. We have arranged for you to see our
heart specialists. You had weakness on the right side of your
body and trouble speaking after your seizures. You were
evaluated by our neurologists, who felt that you had a "[**Doctor Last Name 555**]
paralysis", or post-seizure disorder. Your scans did not show
any evidence of new strokes. Your seizure medications were
adjusted and you were started on a new medication. Your seizure
medications will be followed by our neurologists at [**Hospital1 18**]. You
had massive enlargement of your left kidney and left ureter. Our
urologists felt that this was chronic and suggested that you
follow-up with your outpatient urologist because of concern of a
possible cancer in the ureter. We have contact[**Name (NI) **] Dr. [**First Name (STitle) 31365**] and
made an appointment for you. You also had a fungus infection in
your esophagus and you were started on medication for this,
which you will need to continue for 3 weeks. You were found to
have blood clots in your legs, and you were started on
medication to thin your blood, which you will need to continue
for 6 months. This will be adjusted by your facility's doctor.
Your multiple sclerosis was felt to be stable, we gave you your
monthly methylprednisilone injection on [**3-10**].
We have made the following changes to your medications:
-DECREASE your phenytoin (Dilantin) to 100mg by mouth three
times daily
-START taking levetiracetam 500mg tablets, 1 tab by mouth twice
daily
-START taking warfarin 4 mg tabs, 1 tab by mouth daily
-START taking enoxaparin 70mg subcutaneous injections, twice
daily until instructed to stop by your facility doctors
-START taking fluconazole 400mg tabs, 1 tab by mouth daily,
ending on [**3-28**]
-START taking omeprazole 40mg tabs, 1 tab by mouth daily
-START taking metoprolol succinate 50 mg tabs, 1 tab by mouth
daily
We have not made any other changes to your medications. Please
continue to take them as previously prescribed.
Followup Instructions:
Name: [**First Name8 (NamePattern2) 6930**] [**Last Name (NamePattern1) 31365**], MD./UROLOGY
Address: [**Doctor Last Name 91815**]., [**Location (un) 11790**], [**Numeric Identifier 91816**]
Phone: [**Telephone/Fax (1) 91817**]
When: Friday, [**2179-3-31**]:00 AM
Department: CARDIAC SERVICES
When: MONDAY [**2180-4-10**] at 9:00 AM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: WEDNESDAY [**2180-4-5**] at 12:30 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD and Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 2100**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital6 13753**]/Neurology
Phone: [**Telephone/Fax (1) 91818**]
*It is recommended that you follow up with your neurologist for
multiple sclerosis. We tried to schedule an appointment for you
but Dr. [**Last Name (STitle) 91811**] [**Name (STitle) **] did not allow this and wanted to you
follow-up with an epilepsy specialist.
Completed by:[**2180-3-10**]
|
[
"345.90",
"591",
"344.89",
"340",
"585.9",
"411.89",
"453.40",
"112.84",
"596.54",
"349.82",
"592.0",
"276.0",
"784.51",
"425.4",
"584.9",
"280.0",
"403.90",
"041.49",
"285.21",
"V44.6",
"784.3",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
30081, 30146
|
14756, 26608
|
330, 336
|
30591, 30591
|
6186, 6186
|
33140, 34442
|
4761, 4782
|
28141, 30058
|
30167, 30570
|
27727, 27727
|
30769, 32453
|
14338, 14733
|
5648, 6167
|
27745, 27980
|
26629, 27701
|
32483, 33117
|
262, 292
|
28002, 28118
|
364, 3504
|
6203, 14321
|
4832, 5633
|
30606, 30745
|
3526, 4620
|
4636, 4745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,877
| 126,290
|
8122
|
Discharge summary
|
report
|
Admission Date: [**2188-2-6**] Discharge Date: [**2188-2-22**]
Date of Birth: [**2135-2-12**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Zestril
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Shortness of Breath on exertion
Major Surgical or Invasive Procedure:
[**2188-2-11**] Pericardectomy
History of Present Illness:
52 year old woman wiht history of HTN and depression, with known
pericardial effusion and pericardial constriction attributed to
an antecedant viral illness, who reports worsening exercise
tolerance and LE edema (Rt. greater than Lt.) since [**Holiday **].
She had previously been evaluated on the CMI service for
elective RHC on [**12-17**]. Catheterization at that time showed
moderate diastolic left and right ventricular dysfunction and
constrictive physiology.
Shortly after her cardiac catherization she developed R leg pain
and noted an increase in swelling of the both legs but right
greater than left. She also noted that her dyspnea on exertion
also worsened shortly after her catherization.
.
Pericardial effusion attributed to viral illness as follows:
.
Diagnosed initially in [**2187-8-30**] after what was
described as "the flu" (note: there was no antecedent travel,
tick bite) - this was likely a viral URI or other, but very
unlikely to have been influenza per se given timing. She had a
negative PPD and CXR, negative [**Doctor First Name **] and ?negative RF. She did
well until [**12-12**] per pt when she was started on lasix w/o
effect. She then underwent RHC on [**2187-12-19**].
She went to her outpatient cardiologist (Dr.[**Last Name (STitle) 11493**]) Wed [**12-24**],
complaining of the above noted, worsening LE edema and SOB etc.
Dr. [**Last Name (STitle) 11493**] [**Name (NI) 653**] Dr. [**Last Name (STitle) **] of cardiac surgery here who
asked for her to be admitted to [**Hospital Unit Name 196**] for evaluation for surgery
(pericardial stripping).
Past Medical History:
PMH/PSH: pericardial effusion/pericarditis ([**1-4**] TTE: EF55%,
small effusion; [**1-4**] cath: CI 1.9, no coronary dz; OSH workup
for SLE/TB negative, presumed viral etiology), [**12-2**] PE in
RUL/RML/LUL, Bilateral DVTs, depression, HTN
Social History:
Lives w/ husband. Denies substance use, tob, etoh.
Family History:
Father with aneurysm of right iliac artery, spinal stenosis,
normal pressure hydrocephalus. Father also had a DVT in the
setting of decreased mobility.
Physical Exam:
On admission:
99.1, 110, 156/98, 20, 95 room air, 195 pounds
General: no acute distress, well-developed
HEENT: moist mucous membranes, EOMI
Neck: no lymphadenopathy
Lungs: decreased right breath sounds
Cardiac: sinus tachycardia, no murmur or rubs
Abd: soft, nontender/nondistended, normoactive bowel sounds
Ext: warm, 2+ edema
Neuro: grossly intact
Pertinent Results:
CARDIOLOGY:
[**2188-2-7**] Echo:
1. The left atrium is mildly dilated.
2. The left ventricular cavity size is normal. Overall left
ventricular systolic function cannot be reliably assessed.
3. There is a trivial pericardial effusion.
4. Compared with the findings of the prior study (images
reviewed) of [**2188-1-1**], the estimated pulmonary artery pressure has
decreased.
[**2188-2-15**] Echo:
Left ventricular wall thicknesses are normal. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The right ventricular cavity is
dilated. There is severe global right ventricular free wall
hypokinesis. There is abnormal septal motion/position consistent
with right ventricular pressure/volume overload. The aortic
valve leaflets (3) are mildly thickened. The mitral valve
leaflets are mildly thickened. There is a small posterior
pericardial effusion.
Compared with the prior study (images reviewed) of [**2187-2-7**], the
right ventricle is now markedly dilated and hypokinetic and the
left ventricular cavity is now small.
[**2188-2-6**] 05:00PM GLUCOSE-102 UREA N-13 CREAT-0.6 SODIUM-140
POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-20
[**2188-2-6**] 05:00PM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-1.7
[**2188-2-6**] 05:00PM WBC-10.8# RBC-5.76*# HGB-15.0 HCT-44.3#
MCV-77* MCH-26.0* MCHC-33.8 RDW-17.9*
[**2188-2-6**] 05:00PM PLT COUNT-281
[**2188-2-6**] 05:00PM PT-26.3* PTT-32.2 INR(PT)-2.7*
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2188-2-18**] 05:36AM 7.5 4.05* 10.6* 31.5* 78* 26.2* 33.7
17.3* 353
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Ct INR(PT)
[**2188-2-20**] 05:55AM 15.6*1 37.6* 1.4*
1 NOTE NEW NORMAL RANGE AS OF 12:00AM [**2188-1-23**].;ABNORMAL
PROTHROMBIN TIME (PT) INCREASED DUE TO;LABORATORY CHANGE TO A
MORE SENSITIVE PT [**Name (NI) 25013**].;INR VALUES REMAIN THE SAME. MONITOR
WARFARIN BASED ON INR ONLY!
[**2188-2-21**]: INR 1.6
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2188-2-20**] 05:55AM 93 22* 1.3* 137 4.0 97 30 14
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2188-2-14**] 03:08AM 29 30 123* 0.7
GREEN TOP
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2188-2-20**] 05:55AM 8.2* 4.2 1.8
RADIOLOGY:
[**2188-2-6**] CXR: The bilateral pleural effusions are similar-to-
slightly larger since the prior study. The cardiac contour is
difficult to evaluate, but there is probably again associated
bibasilar atelectasis, as
seen on a recent CT. There is no pneumothorax. Leftward conve
thoracolumbar scoliosis is again noted, with a similar
appearance.
[**2188-2-13**] CXR: There is slightly increased moderate-sized
bilateral pleural effusion with atelectasis in both lower lobes.
The lung volume is small. There is continued mild cardiomegaly.
The patient is status post pericardiectomy with median
sternotomy and multiple drains overlying the mediastinum and
bilateral chest tubes.
No evidence for pneumothorax is identified
[**2188-2-19**] CXR: Comparison is made with the next previous similar
study of [**2188-2-18**]. During the interval, the right
internal jugular vein central venous line has been removed. A
right-sided chest tube located at the right base also has been
removed. No other interval changes can be identified and no
pneumothorax has developed after the tube removal. With the
exception of some linear densities on the left base, no other
pulmonary abnormalities are identified.
PATHOLOGY:
[**2188-2-12**] I. "Pericardium for frozen section":
Fibrosis and chronic inflammation; no evidence of malignancy.
II. "Pericardium":
Fibrosis and chronic inflammation; no evidence of malignancy.
MICROBIOLOGY:
[**2188-2-12**] Pericardial fluid: PRESUMPTIVE PROPIONIBACTERIUM ACNES.
RARE GROWTH.
Brief Hospital Course:
This is a 53 year old female with a history of restrictive
pericarditis who presented for operative repair. She had a prior
recently diagnosed pulmonary embolus and was therefore admitted
several days prior to her operation and started on a heparin
drip while coumadin was held. She was taken for a
transesophageal echocardiogram on [**2188-2-7**] for evaluation and
planned possible tapping of pericardial fluid; she was found to
have a restrictive pattern with no significant fluid to tap
(please see full report in the results section). She was then
taken to the operating room on [**2188-2-12**] with Dr. [**Last Name (STitle) **] and
Dr. [**Last Name (STitle) 28946**] for repair (please see the operative note for full
details).
The patient had an essentially uncomplicated postoperative
course which was prolonged due to acute renal failure and
resumption of coumadin anticoagulation. She was extubated upon
arrival to the intensive care unit after her operation. Her pain
was well controlled in the post-operative course, initially with
a morphine PCA and eventually with oral narcotics. She was
started on a clear liquids diet on post-op day 1 which was
advanced to a regular diet without complication. She had 4 chest
tubes placed during the operation-- 2 pleural tubes and 2
mediastinal tubes. The mediastinal drians were removed on [**2-15**].
The pleural drains were removed on [**2-18**] and [**2-19**]. There was
minimal residual effusion and no pneumothorax.
Heparin drip was restarted on post-operative day 2 for
anticoagulation for her known PE; coumadin was held for several
days until her INR drifted down to sub-therapeutic range at
which point it was resumed, with 2 mg given from [**Date range (1) 28947**], 5 mg
given on [**2-20**] and 2.5 mg given on [**2-21**]. Heparin was stopped and
Lovenox was commenced on [**2-19**].
From a renal standpoint, the patient initially had several days
of low urine output after her operation. This was presumed to be
due to some residual restrictive physiology/low-outflow state,
with a transthoracic echo on [**2-15**] revealing some hypokinesis
(please see the full report in the results section). Renal
consultation was obtained and it was felt that she had some
prerenal physiology. Therefore, a dopamine drip was started for
several days during the intial post-operative course. Eventually
this was discontinued and Lasix diuresis was started to which
she responded quite well. She lost approximately 10 kilograms in
her 2 week in-hospital post-operative course, placing her at
about [**8-7**] kilograms above her baseline weight from several
months ago. Lasix was continued in her outpatient regimen.
The patient was discharged in good condition after her 2-week
post-operative course. Her outpatient regimen included oral
narcotics, lasix, potassium chloride, and coumadin. She
ambulated with physical therapy and was found safe for home. She
had planned follow-up with Cardiac and Thoracic Surgery. All
questions were answered to her satisfaction upon discharge.
Medications on Admission:
prozac 20'
coumadin 5'
Discharge Medications:
1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*10 Tablet(s)* Refills:*0*
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.8 ml Subcutaneous [**Hospital1 **]
(2 times a day): subcutaneous injection; injections can stop
once your INR is in therapeutic range ([**2-1**]).
Disp:*20 ml* Refills:*2*
4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day:
Diuretic pill.
Disp:*30 Tablet(s)* Refills:*2*
7. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO once
a day: to be taken while you are taking Lasix.
Disp:*60 Packet(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*10 Capsule(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: You
should have your INR checked every 3 days to adjust dose towards
therapeutic range 2-3.
Disp:*30 Tablet(s)* Refills:*2*
10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
Disp:*12 Tablet(s)* Refills:*0*
11. Outpatient Lab Work
You should have your INR checked within 2-3 days of discharge
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary: Pericardial effusion and restrictive pericarditis
Secondary: Pulmonary embolus in Right upper lobe/Right middle
lobe/Left upper lobe, Bilateral Deep vein thrombus, depression,
Hypertension
Discharge Condition:
Stable. Tolerating POs. Good Pain control.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**]/Thoracic Surgery office([**Telephone/Fax (1) 170**])
for: fever, shortness of breath, chest pain, excessive foul
smelling drainage from incision sites.
Take regular medications as directed.
Resume coumadin dose as directed w/ discharge instructions. Have
coumadin/INR/blood test checked Monday [**2-25**] as previous to
hospital.
Monitor weights daily. If [**2-1**] lb weight gain over 1-2 days, call
office.
Take new medications- pain medication as directed and as needed.
You may shower when you get home. No tub baths/hot tubs/
swimming for 2-3 weeks.
Ambulate 4-6 times per day, gradual increase in duration w/
episodes as able. 10-20 minutes each episode.
Do not lift more than 10lbs for 10 weeks (do not lift more than
a gallon of milk.
Followup Instructions:
You should see your primary care physician [**Name Initial (PRE) 176**] 2-3 days of
your discharge to have your INR checked.
Call Dr.[**Name (NI) 2347**]/Thoracic Surgery office([**Telephone/Fax (1) 170**]for
an appointment in [**10-11**] days. Prior to your appointment you
should have an x-ray of the chest taken at 4 [**Hospital Ward Name 23**] Radiology--
call for an appointment at [**Telephone/Fax (1) 327**].
Follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **] (cardiac surgery) in [**12-31**] weeks
as well. Call [**Telephone/Fax (1) 170**] for an appointment.
Completed by:[**2188-2-21**]
|
[
"415.19",
"511.9",
"428.0",
"584.9",
"423.1",
"311",
"401.9",
"518.0",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.31"
] |
icd9pcs
|
[
[
[]
]
] |
11423, 11442
|
6863, 9900
|
305, 338
|
11684, 11729
|
2849, 6840
|
12550, 13167
|
2309, 2462
|
9973, 11400
|
11463, 11663
|
9926, 9950
|
11753, 12527
|
2477, 2477
|
234, 267
|
366, 1958
|
2491, 2830
|
1980, 2224
|
2240, 2293
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,757
| 150,001
|
52120
|
Discharge summary
|
report
|
Admission Date: [**2115-5-21**] Discharge Date: [**2115-6-1**]
Date of Birth: [**2053-3-2**] Sex: F
Service: MEDICINE
Allergies:
Talwin
Attending:[**First Name3 (LF) 9240**]
Chief Complaint:
failure to thrive, as per patient "ultrasensitive to taste,
other senses"
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 62 year-old woman with IDDM, COPD, interstitial lung
disease, h/o IVDU on methadone maintenance, hepatitis C, gastric
varices, depression, anxiety with recent 40 lb weight loss in
setting of dysphagia with thus far unremarkable work up, also
with falls, incontinence and hypersensitivity to all 5 senses.
.
When asked, the patient's chief concern is a feeling of
hypersensitivity to smells, tastes, touch. She says she can
taste what individuals with home she talks have eaten, she can
feel the alarm sounds from rooms away, she can smell things from
down the [**Doctor Last Name **]. She reports feeling as though specks are coming
from me as I talk to her and entering her eyes and mouth. She
denies auditory or visual hallucinations but rather reports a
hyperawareness of her senses. Denies depressive symtpoms
including anhedonia, sleep or appetite changes.
.
She says her weight loss is due to her food getting stuck in her
throat around her voice box. Good appetite. No abdominal pain,
diarrhea, nausea, vomiting or constipation.
.
Also reports urinary incontinence and gait instability. Denies
weakness or sensory deficits but rather says she just sometimes
falls without understanding why. Of note, she reported to
emergency room providers that she had wet herself when in fact
she had dry diaper.
.
Work up for weight loss and dysphagia thus far have included
recent EGD which demonstrated gastritis and Barrett's esophagus,
CT abdomen which demonstrated an isolated pulmonary nodule,
gastric varices and a renal cyst. Follow up renal ultrasound
confirmed large cyst. Additionally, barium swallow done in
early [**Month (only) 404**] demonstrated only hiatal hernia. CT chest also
performed and confirmed isolated pulmonary nodule. Because of
the patient's recent gait instability, MR head to assess for
mass or multiple sclerosis performed a few days ago demonstrated
likely chronic vascular occlusions. Recent labs remarkable for
leukopenia and thrombocytopenia(chronic), recent hypernatremia
now resolved, hypokalemia and albumin of 4.
.
New medications over this period appear to be citalopram,
reglan, prilosec and urecholine, but would need to confirm with
Dr. [**Last Name (STitle) **] as patient unsure.
Past Medical History:
Past Medical History:
1. IDDM
2. COPD
3. ?Interstitial Lung Disease
4. Hepatitis C
5. Gastric Varices
5. Hypothyroidism
4. Former IVDU now on methadone
5. Anxiety
6. Depression
7. Chronic Constipation-sigmoidocele
8. Nonhealing decubitus ulcer
9. Hyperlipidemia
10. Lower extremity edema
11. Incontinence
12. Chronic Low Back Pain
13. Falls
14. Weight loss-40 pounds in 6 months
15. Dysphagia
Social History:
Heavy smoking, alcohol history. Former IVDU on methadone.
Worked for commission for blind long ago. Married.
Family History:
non-contributory
Physical Exam:
VS: Temp: 98.6 BP:140/80 HR:87 RR:18 100% 3 litersO2sat
.
general: frustrated with me examining her, continually wiping
her eyes to remove specks, difficulty with history, cachectic
and frail, non-toxic
HEENT: PERLLA, EOMI, anicteric, no sinus tenderness, MMdry, op
without lesions, no supraclavicular or cervical lymphadenopathy,
no jvd, no carotid bruits, no thyromegaly or thyroid nodules
lungs: CTA b/l with good air movement throughout
heart: RR, S1 and S2 wnl, no murmurs, rubs or gallops
appreciated
abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
extremities: trace ankle edema
skin/nails: no rashes/no jaundice/, some excoriation over
bilateral calf area
back: stage 2 sacral decub.
neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. MMSE: would not
cooperate for assessment, fixated on my wearing a mask and
specks emanating from my mouth
Pertinent Results:
[**2115-5-21**] 09:15PM GLUCOSE-182* UREA N-22* CREAT-1.0 SODIUM-140
POTASSIUM-3.2* CHLORIDE-98 TOTAL CO2-34* ANION GAP-11
[**2115-5-21**] 09:15PM ALT(SGPT)-32 AST(SGOT)-52* LD(LDH)-258* ALK
PHOS-55 AMYLASE-62 TOT BILI-0.7
[**2115-5-21**] 09:15PM LIPASE-17
[**2115-5-21**] 09:15PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.1
MAGNESIUM-1.8 IRON-56
[**2115-5-21**] 09:15PM calTIBC-225* FERRITIN-377* TRF-173*
[**2115-5-21**] 06:00PM WBC-3.9* RBC-4.49 HGB-14.1 HCT-41.1 MCV-92
MCH-31.4 MCHC-34.2 RDW-14.6
[**2115-5-21**] 06:00PM NEUTS-53.5 LYMPHS-37.0 MONOS-7.5 EOS-1.7
BASOS-0.3
[**2115-5-21**] 06:00PM PLT COUNT-135*
.
CT neck: 1. No overt masses in the neck, causing luminal
narrowing of the [**Last Name (un) **]-, oro-, or hypopharynx, to explain the
patient's symptoms. Consider barium swallow, based on clinical
symptoms (dysphagia).
2. Please see the report of the CT scan of the chest, done on
[**2115-5-15**] for further details concerning the lungs.
.
Bone scan: Nonspecific focus of increased activity at the
costovertebral
junction of the left 10th rib.
.
Video swallow: Delayed pharyngeal swallow initiation, and slow
oral bolus transit time. Trace penetration with thin liquids
only. No aspiration.
.
MR C spine: Mild changes of cervical spondylosis from C4-5 to
C6-7. No evidence of spinal stenosis. Mild foraminal narrowing
at C5-6 level. No evidence of extrinsic spinal cord compression
or intrinsic spinal cord signal abnormalities.
.
pCXR: Allowing for rotation, cardiac and mediastinal contours
are stable in appearance with prominence of the right cardiac
border without change from older studies. Slight upper zone
vascular redistribution and vascular indistinctness suggest
early fluid overload, and there is a questionable small right
pleural effusion.
.
CT abd/pelvis:
IMPRESSION:
1. Evidence of cirrhosis with portal hypertension, varices, and
ascites.
2. No evidence of bowel obstruction.
3. Moderately distended rectum containing stool and retained
contrast from earlier studies, with mild wall thickening, which
may be inflammatory or due to venous congestion. Correlation
with physical examination is suggested.
.
Head CT: Normal study, including no sign of intracranial
hemorrhage.
.
TTE: The left atrium is mildly dilated. No atrial septal defect
is seen by 2D or
color Doppler. The estimated right atrial pressure is 5-10 mmHg.
Left
ventricular wall thickness, cavity size, and systolic function
are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
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
appears
structurally normal with trivial mitral regurgitation. The
pulmonary artery
systolic pressure could not be determined. There is a
trivial/physiologic
pericardial effusion.
Brief Hospital Course:
1)Weight Loss: Extensive work up thus far has included MRI
head, CT chest/abdomen, EGD, barium swallow within past six
months, labs including cbc, chem-10, b12, rpr, tsh, free t4,
spep/upep, hepatitis panel. To summarize, patient has Barrett's
esophagus, gastritis, gastric varices, isolated pulmonary
nodule, treated hypothyroidism and diabetes, hepatitis C.
--[**Last Name (un) **]/[**Last Name (un) 3907**] as outpatient
--follow up with outpatient psychiatrist as dysphagi may have
functional component as patient seems severely limited by her
numeroud delusions.
.
2)Hypersensitivity to senses: No clinical evidence of seizures.
Patient declined EEG. Seen by psychiatry and started on
risperdal 1 mg hs for delusions. Will follow up with Dr.
[**Last Name (STitle) **], her psychiatrist.
.
3) UTI with possible sepsis: Had brief episode of hypotension
and was discovered to have a UTI with MSSA. She will complete a
14 day course of dicloxacillin.
3)Neuro: Incontinence/gait instability/neuropathy history: No
clear evidence of actual incontinence, this appears to be a
delusion to some degree. although she does retain urine as
demonstarted after a voiding trial with a PVR of 500 cc. She was
seen by neurology who recommended a C spine MRI which showed no
spinal stenosis or cord impingement.
.
5)DM: well controlled with poor eating--recent A1C of 6.6
--continue lantus, sliding scale, care given poor PO
.
6)Hypothyroidism: recent free t4 wnl although TSH elevated
--continue levoxyl 50 for now
.
7)Psych: Changed to 2 mg hs of clonapin and risperdal 1 mg hs.
She will follow up with her outpatient psychiatrist. Psychaitry
was asked if patient might benefit from psyche inpatient
admission, given her numerous delusions, but they felt she did
not meet criteria for psychiatric admission at this time.
.
GI prophylaxis: protonix
.
DVT prophylaxis:hold subcu heparin given thrombocytopenia
.
Code:full
.
Medications on Admission:
1. alprazolam 1mg QID
2. Citalopram 30mg daily
3. Conjugated estrogens 625 mcg daily
4. Humulin N 22qam, 5-8qpm
5. Lantus 6U qbedtime
6. Levoxyl 50 mcg daily
7. methadone 130mg daily
8. Prilosec 40 mg daily
9. Reglan 5-10mg TID with meals
10. Simvastatin 40mg daily
11. Trazadone 150mg qhs
12. Urecholine 50mg TID
13/14. propanolol 20mg [**Hospital1 **] and lisinopril 5mg recently
discontinued given hypotension with weight loss
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Methadone 10 mg Tablet Sig: Thirteen (13) Tablet PO DAILY
(Daily).
7. Conjugated Estrogens 0.625 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Clonazepam 1 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
Disp:*60 Tablet(s)* Refills:*0*
9. Risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
10. Dicloxacillin 500 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) for 10 days.
Disp:*40 Capsule(s)* Refills:*0*
11. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
14. Insulin Glargine 100 unit/mL Solution Sig: Six (6) units
Subcutaneous at bedtime.
15. Humulin N 100 unit/mL Suspension Sig: as directed as
directed Subcutaneous twice a day: Resume your home insulin dose
of 22 units qam and 5-8 units qpm.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Urinary Tract Infection
Sepsis
Urinary Retention
Dysphagia
Discharge Condition:
stable
Discharge Instructions:
Continue medications as listed. Follow up with Dr. [**Last Name (STitle) **], your
urologist, and your psychiatrist.
Followup Instructions:
1. Follow up with Dr. [**Last Name (STitle) **] in [**1-22**] weeks. You will need a f/u CT
1 year for pulmonary nodule. You are also due for a mammogram.
2. Please follow up with Dr. [**Last Name (STitle) **] your psychiatrist on [**6-18**]
at 11:40 am. Provider: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7676**] Phone:[**Telephone/Fax (1) 1387**]
Date/Time:[**2115-6-18**] 11:40
3. Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2115-6-19**]
10:30
4. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5014**], MD Phone:[**Telephone/Fax (1) 5015**]
Date/Time:[**2115-6-3**] 3:00
|
[
"263.9",
"276.51",
"287.5",
"599.0",
"250.00",
"V58.67",
"530.85",
"787.2",
"707.03",
"496",
"781.2",
"244.9",
"300.4",
"515",
"304.01",
"038.9",
"788.20",
"995.91",
"288.50",
"070.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10948, 11006
|
7111, 9026
|
340, 347
|
11109, 11118
|
4162, 6315
|
11283, 11985
|
3181, 3199
|
9507, 10925
|
11027, 11088
|
9052, 9484
|
11142, 11260
|
3214, 4143
|
226, 302
|
375, 2620
|
6324, 7088
|
2664, 3036
|
3052, 3165
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,801
| 116,066
|
26871
|
Discharge summary
|
report
|
Admission Date: [**2129-10-17**] Discharge Date: [**2129-11-2**]
Date of Birth: [**2082-3-8**] Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending:[**First Name3 (LF) 11415**]
Chief Complaint:
Motorcycle collision
Major Surgical or Invasive Procedure:
Open reduction internal fixation ABC to pelvic fracture with
plating of the symphysis.
History of Present Illness:
[**Known firstname **] [**Known lastname 1968**] is a 47-year-old gentleman who was involved in a
motorcycle accident on [**2129-10-17**] resulting in anterior posterior
compression type 2 pelvic fracture with symphyseal diastasis.
Past Medical History:
HTN, NIDDM
Social History:
NA
Family History:
NA
Physical Exam:
GCS: 15
HEENT: normocephalic, atraumatic; PERRLA, TM's clear
NECK: nontender, in cervical collar
CV: RRR, no M/R/G
RESP: CTA b/l
ABD: obese, NT
PELVIS: TTP, ecchymosis to b/l thighs,
NEURO: nl rectal tone, sensation and motor grossly intact
strength 5/5 b/l UE, 4+/5 b/l LE secondary to pain
Pertinent Results:
[**2129-10-17**] 08:00PM NEUTS-75* BANDS-8* LYMPHS-10* MONOS-5 EOS-0
BASOS-0 ATYPS-2* METAS-0 MYELOS-0
[**2129-10-17**] 08:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2129-10-17**] 08:00PM PT-13.3 PTT-24.3 INR(PT)-1.2
[**2129-10-17**] 08:00PM PLT SMR-NORMAL PLT COUNT-395
[**2129-10-17**] 08:00PM FIBRINOGE-380
[**2129-10-17**] 08:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.035
[**2129-10-17**] 08:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2129-10-17**] 08:00PM URINE RBC-[**2-5**]* WBC-[**5-13**]* BACTERIA-FEW
YEAST-NONE EPI-[**2-5**]
Brief Hospital Course:
Upon admission, on [**2129-10-17**] the symphysis was widely malplaced
at least 4 cm and the patient was significantly symptomatic and
required a pelvic bandage to relieve comfort. He remained
hemodynamically stable on the day of admission. He now
([**2129-10-19**]) presents for open reduction internal fixation ABC to
pelvic fracture with plating of the symphysis. The patient
tolerated the procedure well and was taken to the recovery room
without incident. Dr. [**Last Name (STitle) 1005**] was present through the entire
procedure. The patient was brought to CC6 and placed on lovenox
for DVT prophylaxis. He was evaluated by physical therapy and
occupational therapy and did well. His diabetes was kept in
good control. On [**2129-10-24**] the patient's potassium was low at
3.0, so it was replaced with 40 mEq IV potassium. It was found
to be low again on [**2129-10-25**] and another 40 mEq of potassium was
given. His potassium stabilized with po. Hospital course was
otherwise without incident. He is being discharged today to his
home in stable condition. he was cleared by pt and was okay to
be dc'd home with pt and ot
Medications on Admission:
Glucophage
HTN medication
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*0*
2. Enoxaparin 40 mg/0.4mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily) for 4 weeks.
Disp:*30 syringes* Refills:*0*
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
Indigestion.
4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. Metformin 850 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Anterior posterior compression type 2 pelvic fracture with
symphyseal diastasis
Discharge Condition:
Stable
Discharge Instructions:
Keep your incision clean and dry. You may shower, but do not
tub bathe or immerse in water. Watch for signs of infection as
written in the nursing discharge sheet. If you notice any
fever, increased pain, swelling, or redness report to the
emergency room. If you have any questions you may call the
orthopaedic clinic. Do not bear weight on your legs for [**5-11**]
wks. Take your medications as prescribed. Please follow up with
Dr [**Last Name (STitle) 1005**] in 2 weeks.
Physical Therapy:
Strict NWB bilateral lower extremities
Treatments Frequency:
Staple removal at orthopaedic clinic with Dr. [**Last Name (STitle) 1005**]
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1005**] at the [**Hospital1 18**] orthopaedic
clinic in 2 weeks. You may call [**Telephone/Fax (1) **] to make an
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**]
Completed by:[**2129-11-2**]
|
[
"278.00",
"250.00",
"276.8",
"808.2",
"E812.2",
"458.9",
"401.9",
"V13.01",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"79.39",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3824, 3830
|
1787, 2930
|
298, 387
|
3954, 3963
|
1056, 1764
|
4647, 4984
|
718, 722
|
3006, 3801
|
3851, 3933
|
2956, 2983
|
3987, 4468
|
737, 1037
|
4486, 4525
|
4547, 4624
|
238, 260
|
415, 648
|
670, 682
|
698, 702
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,525
| 132,331
|
52672
|
Discharge summary
|
report
|
Admission Date: [**2116-5-10**] Discharge Date: [**2116-5-18**]
Date of Birth: [**2050-4-3**] Sex: M
Service: MEDICINE
Allergies:
Neupogen / Neurontin / Dilaudid
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
R foot TMA ulcer
Major Surgical or Invasive Procedure:
Debridement of R TMA site ulcer and vac placement
History of Present Illness:
Pt is 66 y/o M with h/o ESRD on HD and peripheral [**First Name3 (LF) 1106**]
disease s/p right transmetatarsal amputation one month ago for
gangrene who presents with right TMA site ulcer. Patient has a
history of occlusion of his popliteal artery and embolus to his
distal vessels, which caused the grangrene for which required
the TMA. He is s/p angioplasty and stenting of his R popliteal
artery. Howver, he still developed necrosis of his TMA site.
He currently denies pain, redness, or drainage from TMA site.
No fevers, chills, chest pain, shortness of breath, abd pain, or
nausea/vomiting.
He will undergo debridement of his R foot TMA site on [**5-11**].
Past Medical History:
PMH:
1) Atrial Fibrillation - s/p cardioversion in [**10-13**]. Was
maintained on coumadin for 6 months. Currently not
anticoagulated due to fall risk.
2) Pericardial effusion - s/p drainage, unclear etiology
3) ESRD from ATN in setting of acute gastroenteritis, s/p failed
cadaveric kidney transplant in [**2109**]. Dialyzed at [**Location (un) **] Tues,
Thurs, Sat.
4) Abdominal wall hernia - s/p repair after transplant
5) Multiple knee surgeries 20 years ago
6) Poor access, Right Tunnelled line
7) Baseline SBP's in 90s
9) Hypercapnia due to obesity hypoventilation syndrome
10) non-melanoma skin cancer
11) septic knee
Social History:
Denies any history of Tobacco use, no EtOh use for [**Last Name (un) **] than 20
years, no drug use. Lives with his wife, now on disability. Used
to work as a spray painter. Has 3 children and multiple
grandchildren.
Family History:
History of CAD (mother died at age 70), cancer
Physical Exam:
VS: T 99.5, HR 88, BP 96/62, RR 18, 96% RA
GEN: NAD, A&O x 3
LUNGS: Decreased BS B/L
CV: irregularly irregular
Abd: soft, NT, ND
EXT: R TMA site with 4 x 6 cm black eschar, no active purulent
drainage, slight surrounding erythema
VASC: 1+ fem B/L, dopp [**Doctor Last Name **] B/L, dopp PT B/L, dopp DP B/L
Pertinent Results:
Portable TTE (Complete) Done [**2116-5-13**] at 3:22:07 PM: The left
atrium is mildly dilated. Left ventricular wall thicknesses and
cavity size are normal. Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. Overall
left ventricular systolic function is low normal (LVEF 50%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Physiologic mitral regurgitation is seen
(within normal limits). There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
[**2116-5-10**] 04:10PM BLOOD WBC-4.9 RBC-2.87* Hgb-8.6* Hct-28.6*
MCV-100* MCH-30.0 MCHC-30.1* RDW-17.6* Plt Ct-149*
[**2116-5-16**] 07:20AM BLOOD WBC-6.1 RBC-3.05* Hgb-9.4* Hct-31.0*
MCV-102* MCH-30.8 MCHC-30.3* RDW-19.1* Plt Ct-137*
[**2116-5-13**] 01:12PM BLOOD Neuts-74.5* Bands-0 Lymphs-21.6 Monos-2.6
Eos-1.1 Baso-0.2
[**2116-5-10**] 04:10PM BLOOD PT-15.3* PTT-32.8 INR(PT)-1.3*
[**2116-5-10**] 04:10PM BLOOD Plt Ct-149*
[**2116-5-16**] 07:20AM BLOOD PT-14.5* PTT-32.7 INR(PT)-1.3*
[**2116-5-16**] 07:20AM BLOOD Plt Ct-137*
[**2116-5-10**] 04:10PM BLOOD Glucose-88 UreaN-16 Creat-4.0*# Na-140
K-3.4 Cl-103 HCO3-28 AnGap-12
[**2116-5-16**] 07:20AM BLOOD Glucose-37* UreaN-19 Creat-4.8*# Na-141
K-3.6 Cl-101 HCO3-29 AnGap-15
[**2116-5-12**] 08:52AM BLOOD CK(CPK)-20*
[**2116-5-11**] 09:40PM BLOOD CK(CPK)-19*
[**2116-5-11**] 02:26PM BLOOD CK(CPK)-19*
[**2116-5-12**] 08:52AM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2116-5-11**] 09:40PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2116-5-11**] 02:26PM BLOOD CK-MB-NotDone cTropnT-0.12*
[**2116-5-16**] 07:20AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.0
[**2116-5-15**] 06:55AM BLOOD VitB12-278 Folate-16.5
[**2116-5-13**] 01:12PM BLOOD Digoxin-0.8*
[**2116-5-11**] 09:17AM BLOOD Type-[**Last Name (un) **] Temp-36.1 Rates-/22 FiO2-97 O2
Flow-6 pO2-50* pCO2-89* pH-7.10* calTCO2-29 Base XS--5 AADO2-556
REQ O2-91 Intubat-NOT INTUBA Comment-OFF THE DI
[**2116-5-15**] 10:40AM BLOOD Type-[**Last Name (un) **] pO2-148* pCO2-50* pH-7.39
calTCO2-31* Base XS-4 Comment-GREEN TOP
.
TISSUE Site: FOOT RT FOOT TMA DEBRIDEMENT.
GRAM STAIN (Final [**2116-5-11**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2116-5-14**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
.
[**2116-5-13**] 3:22 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
.
[**2116-5-13**] 1:13 pm MRSA SCREEN
**FINAL REPORT [**2116-5-16**]**
MRSA SCREEN (Final [**2116-5-16**]): No MRSA isolated.
.
[**5-10**] CXR: 1) Probable small focus of atelectasis and pleural
fluid or thickening
posteriorly. The overall appearance is similar to prior lateral
CXRs from
[**2116-3-3**] and [**2116-3-17**]. In the absence of acute symptoms, this is
unlikely to
represent a focal infiltrate.
2) COPD, cardiomegaly, and ? pulmonary hypertension. No CHF.
.
Path: Right TMA debridement:
Gangrenous necrosis of skin and soft tissue.
.
EKG [**5-11**] Atrial fibrillation with rapid ventricular response.
Diffuse low voltage and
non-specific ST-T wave changes. Compared to the previous tracing
of [**2116-5-10**]
no diagnostic interim change.
.
US [**5-14**]: IMPRESSION: No right upper extremity DVT.
Brief Hospital Course:
Patient was admitted to the [**Month/Day (4) 1106**] service on [**2116-5-10**] and was
pre-op for R TMA debridement. He was started on broad spectrum
Abx (Vanc, cipro, flagyl) for TMA ulcer.
On [**5-11**], the patient went to the OR for debridement of R TMA site
and vac placement. There were no complications
intra-operatively, and the patient was extubated without
difficulty. In the PACU, the patient dropped his blood pressure
to the 70s diastolic, and his HR was in the 130s in an atrial
fib/RVR rhythm. The patient was bolused with Neo and started on
a drip at 0.8. He also received a pulse dose of steroids. The
patient responded with systolic pressures in the 90s.
Cardiology was contact[**Name (NI) **] to determine if the patient was a
candidate for cardioversion, however they declined. They
recommended to keep the patient on digoxin and lopressor for his
arrhthymia, as long as the patient could handle it. The patient
was then transferred to the CVICU for close monitoring. The
patient was ruled out for an MI with troponins. Of note, the
patient had fluid and pressor adminstered through his [**Name (NI) 2286**]
catheter, as he had no other IV access. The patient's
antibiotics were switched to Vanc/gent with HD for empiric
coverage.
On [**5-12**], the patient was weaned off the Neo gtt. He was evaluated
by renal, who dialyzed the patient after administration of 25g
of albumin. The patient received 1 pack of pRBCs postop for HCT
of 27. His blood pressure was then maintained in the 90s-120s
systolic.
On [**5-13**], POD2, the [**Month/Day (4) 1106**] team took down the patient's vac -
his TMA site appeared to be clean and healing very well. The
plan was to change the vac again in [**3-11**] days and to start
looking for rehab placement. However, the [**Date Range 1106**] surgery team
was notified in the morning that the patient's SBP was in the
high 60s and low 70s systolic, with HR in the 130s. The patient
was evaluated by the [**Date Range 1106**] service, who felt the patient
would be best served by being monitored in the MICU, as the only
active issues for the patient were renal and cardiologic in
nature. Of note, the patient was evaluated by the renal service
as well, who felt that the patient's blood pressure did not need
to be treated if the MAP remained above 50 and if the patient
was mentating well. The patient was then transferred to the
MICU.
MICU Course: Patient was started on antibiotics as per [**Date Range 1106**]
surgery, and received his HD on the ICU floor. Patient received
an echo which demonstrated no significant change from previous,
with no pericardial effusion. In addition, the patient was
complaining of some right arm pain and received an upper
extremity ultrasound which was negative for DVT.
Medicine floor course: transfered on [**5-15**].
.
# Hypotension: Pt with baseline low blood pressure in 90-100
without any symptoms. Hypotension requiring ICU care throught to
be due to afib with RVR and improved back to baseline with rate
control. TTE nl without pericardial effusion and no evidence of
infection; abx discontinued on [**5-15**]. Was hypotensive to 80s on
[**5-17**] with hypothermia to 95.5 but no evidence of infection still
on CXR or blood cultures to date. BP improved [**5-18**] and
metoprolol restarted at low dose, to be uptitrated as tolerated.
***[**5-13**] and [**5-17**] blood cultures pending at discharge.***
.
# Afib with RVR: Has h/o failed cardioversion. Cardiology
consulted and recommended medical management. He is not on
coumadin [**2-10**] fall risk but continued on Asirin 325mg PO daily.
Rate control between 80s and 100s was achieved with digoxin
0.125mg PO QOD and metoprolol 25mg tid. However, metoprolol
discontinued and then restarted at lower dose of 12.5mg [**Hospital1 **] in
setting of lower-running BP. Would increase beta blockade for
more optimal rate control as BP tolerates.
.
# Hypoglycemia: On [**5-16**] am the patient had a BG of 37, improved
to 190 on FS after [**1-10**] amp D50. Unclear etiology. He is not
diabetic, and on no meds which would cause hypoglyemia. No signs
of infection. Pt had been receiving prednisone in AM but changed
to qHS dosing as this has helped him avoid late evening and
early AM hypoglycemic episodes in the past. Continue evening
snacks and qid FSG monitoring.
.
# Obesity hypoventilation syndrome: Questionable history of
obesity hypoventilation syndrome. [**5-11**] ABG showed respiratory
acidosis with 7.10/89/50 but hypercarbia improved on [**5-15**] VBG of
7.39/50/148. Could consider outpatient pulmonary evaluation of
hypercapnia.
.
# PVD s/p LMA revision: No evidence of infection on arrival to
the floor. Vancomycin and Zosyn discontinued on [**5-15**] given the
negative cultures. Pt to continue wound vac until re-evaluation
by Dr. [**Last Name (STitle) **]. He was continued on ASA and plavix (course to be
determined by [**Last Name (STitle) **] surgery). Pain controlled with tylenol
and oral morphine. Follow-up scheduled with Dr. [**Last Name (STitle) **] on
[**2116-5-22**] at 10am.
.
# Right arm pain: C/o right arm pain over the last few weeks
after being pulled by the right arm. RUE Doppler U/S was done
and negative for a DVT. Pain contrlled with prn pain meds,
phyical therapy.
.
# Anemia: Likely [**2-10**] ESRD; receives epo with HD. Hct currently
at his baseline. Noted to be macrocytic, and B12 levels were
borderline low. Given the low toxicity and expense of Vitamin
B12 the patient was started on 1000mcg daily PO Vitamin B 12
supplementation. B12 levels showed be followed for improvement.
.
# ESRD s/p failed renal transplant: On HD T/Th/Sa. Continued on
nephrocaps and vitamin A; sevelamer discontinued as phosphate
low; to be restarted as needed. Continued on home prednisone
dose. He did receive stress dose steroids in the setting of
hypotension but now back on home dose. Adrenal insufficiency
workup not pursued due to clear association of hypotension with
Afib with RVR and 5mg dose unlikely to suppress HPA axis. Should
receive prednisone at night to avoid hypoglycemic episodes at
night and early AM.
.
# Mental status: Alert and oreinted x 3 throughout floor course.
.
# FEN: IVF prn, replete electrolytes - restart sevelamer prn,
Renal diet
.
# Prophylaxis: Subcutaneous heparin, PPI, bowel regimen.
.
# Access: R SC tunneled HD line
.
# Code: Full
.
# Communication: With patient. HCP is wife [**Name (NI) **]
([**Telephone/Fax (1) 108688**]).
Medications on Admission:
Albuterol
Plavix 75mg PO daily
Metoprolol 50mg PO TID
Prilosec 20mg PO daily
Prednisone 5mg PO daily
Sevelamer 2400mg PO TID with meals
Simvastatin 10mg PO daily
Nephro-vite 1 capsule PO daily
Vit A [**Numeric Identifier 961**] units PO daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for wheezing.
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Prednisone 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
Tablet(s)
5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Vitamin A 10,000 unit Tablet Sig: One (1) Tablet PO once a
day.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
(5000 Units) Injection TID (3 times a day).
8. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**]
unit dwell Injection PRN (as needed) as needed for line flush:
[**Numeric Identifier **] Catheter (Tunneled 2-Lumen): [**Numeric Identifier **] NURSE ONLY:
Withdraw 4 mL prior to flushing with 10 mL NS followed by
Heparin as above according to volume per lumen. .
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
16. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
17. Nephro-Vite 0.8 mg Tablet Sig: One (1) Tablet PO once a day.
18. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: Hold for SBP <90 or HR <60.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Peripheral [**Location (un) 1106**] disease s/p right foot debridement
Atrial fibrillation with RVR
ESRD s/p transplant on HD
Anemia
B12 deficiency
Discharge Condition:
Good, BP stable, HR stable
Discharge Instructions:
You were admitted to [**Hospital1 18**] for surgery on your Right foot. Your
blood flow to your foot was poor and dead tissue had to be
removed. After the surgery you developed low blood presure in
the setting of a rapid irregular heart rate (atrial
fibrillation). You were supported in the ICU. Your heart rate
was controled with medications and your blood pressure improved.
There was a concern for an infection in your foot but all
cultures were negative and all antibiotics have been
discontinued. Your foot pain was treated with pain medicine and
vac. You will continue to need intense wound care and physical
therapy at the rehabilitation center as well as follow-up with
[**Hospital1 **] Surgery.
.
The following changes were made to your medication regimen:
Metoprolol Tartrate was decreased to 12.5mg two times a day
Digoxin was added for heart rate control
Aspirin was started to thin the blood
Cyanocobalamin was started to replete vitamin B12
Colace, Senna, and Bisacodyl were added for constipation
Sevelamer was discontinued
Tylenol and immediate release morphine were added for foot and
shoulder pain
.
Please follow up with your doctors as detailed below.
.
If you develop fevers, chills, dizziness, chest pain,
palpatations, vomitting, diarrhea, shortness of breath, severe
foot pain, or any other worrisome symptoms please call your
doctor or go to the emergency room.
Followup Instructions:
PCP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2204**]. [**Telephone/Fax (1) 2205**]. Please call to make an
appointment within 1 week of discharge from the rehabilitation
facility.
.
[**Telephone/Fax (1) **] surgery: [**2116-5-22**] at 10am with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. ([**Hospital Unit Name 108689**].
|
[
"427.31",
"458.29",
"287.5",
"440.24",
"997.62",
"585.6",
"251.2",
"997.1",
"266.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"77.69"
] |
icd9pcs
|
[
[
[]
]
] |
14546, 14616
|
5911, 12034
|
307, 358
|
14808, 14837
|
2349, 4884
|
16273, 16647
|
1956, 2006
|
12670, 14523
|
14637, 14787
|
12403, 12647
|
14861, 16250
|
2021, 2330
|
5036, 5888
|
251, 269
|
386, 1054
|
4920, 5002
|
12049, 12377
|
1076, 1705
|
1721, 1940
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,008
| 155,908
|
10566+10581+10567+56162
|
Discharge summary
|
report+report+report+addendum
|
Admission Date: [**2182-12-2**] Discharge Date: [**2182-12-23**]
Date of Birth: [**2113-10-3**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a 69 year-old female
with history of aortic stenosis and peripheral vascular
disease referred for cardiac catheterization after complaints
of increased dyspnea on exertion over the past several
months. The history of aortic stenosis has been followed by
echocardiogram with most recent aortic valve area of 0.7 and
a peak gradient of 118 and a mean of 82 with a normal
ejection fraction.
PHYSICAL EXAMINATION ON ADMISSION: General, no acute
distress. HEENT pupils are equal, round and reactive to
light. Extraocular movements intact. Anicteric, injected.
Mucous membranes are moist. Supple, no lesions. No JVD. NO
radiating murmurs. Cardiovascular regular rate and rhythm.
S1 and S2. 4 out of 6 systolic ejection murmur. Pulmonary
diffuse wheezes. Abdomen soft, nontender, nondistended.
Well healed midline scar. Extremities cool left foot digits
one through three necrotic/blistering lesions. Pulse
examination, radial and femoral pulses are 1+ bilaterally.
Dorsalis pedis pulse and posterior tibial pulse are
dopplerable bilaterally. Carotids have murmurs bilaterally.
HOSPITAL COURSE: The patient was admitted on the day of
surgery on [**2182-12-2**]. The patient was seen by the stroke
attending consult.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2182-12-23**] 09:31
T: [**2182-12-23**] 09:39
JOB#: [**Job Number 34771**]
Admission Date: [**2182-12-2**] Discharge Date: [**2156-3-1**]
Date of Birth: [**2113-10-3**] Sex: F
Service:
ADDENDUM:
HOSPITAL COURSE: The patient was admitted on [**2182-12-2**] and taken to the Operating Room for her aortic stenosis
and coronary artery disease, at which time a coronary artery
bypass graft times one was performed which brought the CVTA
to the LAD and an aortic valve was replaced using a 21 mm CE
RSR. The cross-clamp time was 120 minutes and the
cardiopulmonary bypass time was 140 minutes.
Upon waking, the patient was noted to be unable to move her
left arm and her left leg movement was weaker than the right.
CT of the head immediately done postoperatively revealed a
negative hemorrhagic event.
Neurology was in to assess the patient and felt that there
was a question of thrombotic event with left-sided neglect.
This was presumed right MCA territory by examination.
On postoperative day number two, the patient had a repeat
head CT which continued to be negative for hemorrhagic event
or any other focal findings. She was also extubated and then
reintubated and she seemed to have some seizure activity at
that time.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1477**], M.D. [**MD Number(1) 1478**]
Dictated By:[**Last Name (NamePattern1) 14176**]
MEDQUIST36
D: [**2182-12-23**] 10:11
T: [**2182-12-23**] 10:30
JOB#: [**Job Number 34811**]
Admission Date: [**2182-12-22**] Discharge Date: [**2182-12-26**]
Date of Birth: [**2113-10-3**] Sex: F
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a 69 year-old woman who
has a history of aortic stenosis and chronic interstitial
pulmonary disease. Her most recent echocardiogram was from
[**2182-10-31**] where her peak aortic gradient was noted to be 118
mmHg, mean of 82 with a valve area of 0.7 cm squared. She
had mild MR, mild left ventricular hypertrophy and a normal
EF. In terms of symptoms, the patient had a continued
progression of dyspnea on exertion. She is short of breath
after walking from room to room in her home. There are times
when she finds she is short of breath at rest or talking.
This past [**Month (only) 547**] the patient noted a small ulcer on her left
foot. She states it has progressed in severity so that she
has now involvement of the great toe, along with two other
toes right next to it. She states that they are red,
blistered and some areas that are black. She has severe pain
and has been under evaluation by her physician and vascular
surgery on how to proceed with treatment. She is taking
Percocet several times a day for pain control. She states
there has been some discussion regarding amputation. There
is much concern regarding how she might handle any type of
anesthesia for surgery, because of her severe pulmonary
status and her aortic stenosis. She will be coming to [**Hospital1 1444**] with a copy of her
arteriogram from one month ago, along with other vascular
studies.
PAST MEDICAL HISTORY: Hypertension, hyperlipidemia, aortic
stenosis, osteoarthritis, chronic interstitial pulmonary
disease, peripheral vascular disease of the left leg. Also
status post treatment in her 50s for a spot on her lung, 1+
AFB (inhaler/PAF).
PERTINENT LABORATORIES ON ADMISSION: White blood cell 12.1,
hematocrit 44, platelets 299, sodium 138, potassium 4.8,
chloride 101, bicarb 26, BUN 14, creatinine 1.0.
HOSPITAL COURSE: The patient was admitted to the CMI Service
at which time a cardiac catheterization was performed.
Catheterization showed proximal 80% tubular lesion in the
left anterior descending coronary artery and left circumflex
and right coronary artery both without critical lesions. In
addition, left ventricular ejection fraction was 60% and the
aortic valve area was .41 cm squared. The patient was
subsequently recommended for cardiac surgery with a valve
replacement and coronary artery bypass graft. She was
brought to the Operating Room on [**2182-12-2**] where an aortic
valve replacement using a 21 mm GE valve was used and
coronary artery bypass graft times one was performed.
Cardiopulmonary bypass time was 140 minutes and cross clamp
time was 120 minutes. Upon awakening the patient was not
moving her left arm, left leg movement was weaker then right.
CT of the head revealed negative for hemorrhagic event.
Neurology felt that this was a thrombolic event with left
side neglect. When not on Propofol the patient would open
her eyes up to commands and squeeze a hand with her right
hand, move her right leg, but left leg movement was clearly
weaker. Neurology presumed that this was a right MCA
territory thrombolic event by examination.
On postop day three an electroencephalogram was performed and
seizure activity was detected. The patient was started on
Dilantin and kept on the vent for studies. Repeat CT scan
was negative for hemorrhagic or any large cortical infarct.
Hematocrit was maintained at 30 and optimized O2 delivery.
On postop day four the patient was in rapid atrial
fibrillation into the 180s and spontaneously converted to
normal sinus rhythm. She was started on Amiodarone and on
postoperative day six Levofloxacin was started for sputum
that was positive for 3+gram negative diplococci and 1+ gram
negative rods. Ciprofloxacin and Cefepime were also started
on postoperative day six and Levofloxacin was discontinued.
Secondary to recurrence of atrial fibrillation the patient
was started on a heparin drip as well as Amiodarone that she
was previously on and Lopressor. Bronchoscopy done on
postoperative day eight was consistent with [**Female First Name (un) **]
tracheobronchitis. Fluconazole was subsequently started. On
postop day ten tracheostomy and PEG were placed by Dr.
[**Last Name (STitle) 952**]. On postop day eleven the patient got a PICC line and
a consult from Vascular Medicine determined that after
reviewing the angiogram determined that the patient had left
iliac common femoral artery. On postop day fifteen the
patient got a Passy Muir valve and at this point she was able
to move all extremities with equal strength. She was able to
be moved out of bed to her chair with a two person assist.
On [**2182-12-20**], which is postop day eighteen the patient went
back to the Operating Room where an amputation of the left
first, second and third toes were performed by Dr. [**Last Name (STitle) 1476**].
The patient tolerated the procedure well and was transferred
to the SICU in stable condition. On [**2182-12-23**] the patient
was transferred to the Cardiovascular Surgical Floor in
stable condition. She had a bedside swallowing evaluation,
which recommended advancing the patient's po diet to a ground
diet with nectar thick liquids and pills crushed or broken in
pureed food. It was also recommended that the patient begin
to be weaned from trach by using a cap instead of a Passy
Muir valve. It was felt by the consult at this time that her
swallow will improve significantly when the trach is removed.
The patient otherwise continued in stable condition sating 96
to 98% on 4 liters trach mask. Pulmonary toilet was
continued and the patient's diet was advanced. At this point
all antibiotics were discontinued secondary to stable white
blood cell count and the fact that the patient has been
afebrile for more then a week. The patient was subsequently
transferred to an acute care rehab facility. It is
recommended that she follow up with Dr. [**Last Name (STitle) 952**] in two weeks
for further trach evaluation.
DISCHARGE STATUS: To acute care rehab.
DISCHARGE DIAGNOSES:
1. Aortic stenosis status post aortic valve replacement.
2. Coronary artery disease, status post coronary artery
bypass graft times one.
3. Aspiration pneumonia, now resolved.
4. Stroke.
5. Peripheral vascular disease, status post left first,
second and third toe amputation on [**2182-12-20**].
DISCHARGE MEDICATIONS: To follow.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 8455**]
MEDQUIST36
D: [**2182-12-26**] 11:18
T: [**2182-12-26**] 11:24
JOB#: [**Job Number 34772**]
Name: [**Known lastname 6187**], [**Known firstname **] Unit No: [**Numeric Identifier 6188**]
Admission Date: [**2182-12-2**] Discharge Date: [**2182-12-27**]
Date of Birth: [**2113-10-3**] Sex: F
Service:
HOSPITAL COURSE: The patient was kept another day in order
to continue chest physical therapy and respiratory therapy.
In addition, the patient's bed at rehab was not ready for
her.
DISCHARGE MEDICATIONS:
1. Albuterol nebs q.four hours (do not administer while
asleep).
2. Atrovent nebs q.four hours (do not administer while
asleep).
3. Roxicet 5 to 10 ml per PEG q.four hours, hold for
sedation (do not administer when asleep).
4. Lopressor 50 mg p.o. b.i.d.
5. Subcu heparin 5000 units b.i.d.
6. Phenytoin 200 mg p.o. q.eight.
7. Fluconazole 400 mg p.o. q.day.
8. Fluticasone 110 mcg two puffs inhaler b.i.d.
9. Colace 100 mg p.o. b.i.d.
10. Methylprednisolone 40 mg p.o. q.o.d.
11. Aspirin 325 mg p.o. q.day.
12. Reglan 10 mg p.o. q.six hours.
13. Tylenol 650 mg p.r.n. p.o.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 143**], M.D. [**MD Number(1) 144**]
Dictated By:[**Last Name (NamePattern1) 6189**]
MEDQUIST36
D: [**2182-12-27**] 11:04
T: [**2182-12-27**] 11:08
JOB#: [**Job Number 6190**]
|
[
"515",
"440.24",
"424.1",
"507.0",
"707.15",
"414.01",
"427.31",
"997.02",
"780.39"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"39.61",
"36.15",
"84.11",
"43.11",
"96.04",
"33.24",
"35.21",
"96.72",
"31.1"
] |
icd9pcs
|
[
[
[]
]
] |
9320, 9622
|
10378, 11240
|
10189, 10355
|
3318, 4716
|
5011, 5141
|
4739, 4996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,110
| 116,215
|
1424+1425
|
Discharge summary
|
report+report
|
Admission Date: [**2164-7-30**] Discharge Date: [**2164-8-11**]
Date of Birth: [**2097-8-29**] Sex: M
Service: CSURG
Allergies:
Codeine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Who presents to the cardiovascular surgery service for MVR.
Major Surgical or Invasive Procedure:
s/p redo sternotomy,MVR 27mm mosaic porcine, MAZE [**7-30**]
reoperation for bleeding
History of Present Illness:
This is a 66 y/o white male with an extensive hx of cardiac dz
(s/p CABG x 4 [**2152**], mitral valve disease) and COPD who presents
with sob x 1.5 months. Patient has had extensive cardiology
workup including catheterization and echo.
Past Medical History:
1. CAD s/p MI and CABGx4 [**2152**]
2. afib
3. MS/MR
4. COPD/Asthma
5. PUD
6. s/p inguinal hernia repair [**2149**]
Social History:
lives in [**Location **], married. retired UPS driver. smoked 1.5 ppd
x 35 yrs but quit in [**2151**]. 1 drink/wk
Family History:
mother, sister, brother with "heart problems"
Physical Exam:
Gen: alert and oriented pleasant white male, sitting up in
chair, in NAD
HEENT: perrl, OP clr, MMM
Lungs: lungs CTA bilaterally without w/c/r
CV: RRR,S1S2, no M/R/G
Abd: soft, nt/nd. +bs. liver edge percussed, no HSM, no
rebound, no guarding
Ext: no edema. 2+ distal pulses. no cyanosis.
Nuero:AAO x3
Pertinent Results:
[**2164-8-10**] 07:24AM BLOOD WBC-10.5 RBC-3.16* Hgb-9.5* Hct-27.7*
MCV-88 MCH-30.0 MCHC-34.2 RDW-14.6 Plt Ct-404
[**2164-7-30**] 12:51PM BLOOD WBC-12.6*# RBC-3.39*# Hgb-10.2*#
Hct-30.4*# MCV-90 MCH-30.1 MCHC-33.5 RDW-13.1 Plt Ct-121*
[**2164-8-11**] 07:16AM BLOOD PT-16.2* INR(PT)-1.7
[**2164-7-30**] 12:51PM BLOOD PT-17.6* PTT-46.4* INR(PT)-2.1
[**2164-7-30**] 05:37PM BLOOD Fibrino-141*
[**2164-8-10**] 07:24AM BLOOD Glucose-101 UreaN-15 Creat-1.2 Na-140
K-4.1 Cl-99 HCO3-32* AnGap-13
[**2164-7-30**] 12:51PM BLOOD Glucose-70 UreaN-10 Creat-0.6 Na-156*
K-2.9* Cl-125* HCO3-16* AnGap-18
[**2164-8-10**] 07:24AM BLOOD Mg-2.2
[**2164-7-30**] 02:34PM BLOOD Mg-3.0*
Brief Hospital Course:
The patient was admitted to the CRSU following a redo MVR and
take back to OR for bleeding and MAZE on [**2164-7-30**] please see
operative report for further detail. On postoperative day one
the patient was neurologically stable, weaned from epinepherine,
weaned from a ventilator and extubated. Additionally he recieved
one unit of packed RBCs and was kept on kefzol for antimicrobial
protection. On postop day two the patient remained
neurologically stable, epinepherine was discontinued, diet was
advanced, lasix was held and the patient was transferred to from
the cardiac ICU to a regular hopital floor room. On postop day
three the patient's chest tubes were kept to wall suction,
physical therapy was started and diuresis with lasix 20mg IV
twice a day was given. The patient had minor air leaks that were
seen on chest x-ray and via his chest tubes on forceful
expiration through the pleurovac. On postop day four the patient
was doing well had no complaints, his pacing wires were
discontinued as was his right chest tube. The patient had a
chest xray post right chest tube removal showing a small apical
pneumothorax. On postop day five the patient experienced some
nausea that was treated with zofran his potassium was repleted,
while his pain was controlled with tylenol and toradol. The
patient's left chest tube was dicontinued on postop day seven as
well his toradol. The patient recieved ambien in the evening as
a sleeping aid. The patient did well on postop day eight his
mediastinal chest tube had a small air leak. His anxiety and
night time sleeping improved. Previously mentioned nausea was
also better. The patient worked well with physical therapy and
his ability to ambulate was better. On postop day nine the
patient's mediastinal chest tube was placed to water seal. On
postop day ten his mediastinal chest tube was discontinued. The
chest xray that followed showed improved lung expansion and a
very small effusion. Oxygen therapy was arranged for the patient
to go home with. The patient's lasix dosage was decreased from
20mg twice a day to once per day. The patient did well overnight
and had no complaints in the morning of postop day eleven.
[**Hospital **] nursing care was arranged during the [**Hospital 228**] hospital
stay and he was happy to be going home.
Medications on Admission:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO QD (once a day).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours).
5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for SOB.
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for anxiety.
8. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QHS (once
a day (at bedtime)).
9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): Take 5 mg PO 5 days a week and 2.5 mg PO 2 days a
week.
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. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day): take 325mg
when INR<2.0, otherwise take 81mg .
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QD (once a
day).
5. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO QD (once
a day) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
6. Fluticasone-Salmeterol 100-50 mcg/DOSE Disk with Device Sig:
One (1) Puff Inhalation [**Hospital1 **] ().
7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
9. Warfarin Sodium 7.5 mg Tablet Sig: One (1) Tablet PO QD (once
a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO QD (once a
day) for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
11. oxygen
use prn with exertion
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
mitral stenosis
redo sternotomy
s/p MVR 27mm Mosaic porcine valve
prolonged air leak from chest tubes
pre operative atrial fibrillation
Discharge Condition:
good
Discharge Instructions:
keep wounds clean and dry. OK to shower, no bathing or swimming.
take all medications as prescribed
call for any fever, redness or drainage from wounds
no heavy lifting
do not apply lotions, creams ointments or powders to any
incisions
Followup Instructions:
follow up with Dr. [**Last Name (STitle) **] in [**2-7**] weeks
follow up with Dr. [**Last Name (STitle) **] in [**1-6**] weeks
follow up with Dr. [**Last Name (STitle) 8521**] in [**1-6**] weeks in the office and on
Monday [**8-13**] by phone for results of PT/INR
follow up with Dr. [**Last Name (STitle) 1290**] in [**2-7**] weeks
follow up with Dr. [**Last Name (STitle) 8522**] in 1 month
Admission Date: [**2164-7-30**] Discharge Date: [**2164-8-11**]
Date of Birth: [**2097-8-29**] Sex: M
Service: CSU
HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 65-year-old gentleman
with a known history of coronary artery disease who underwent
a coronary artery bypass graft times four in [**2152**], had been
doing well with history of worsening mitral regurgitation and
dyspnea on exertion. Patient had an episode of atrial
fibrillation in [**4-/2164**] for which he underwent subsequent
cardioversion, and patient had an echocardiogram done in
[**5-/2164**] which showed moderate mitral stenosis and mitral
regurgitation. Cardiac catheterization in [**5-/2164**] showed
native three-vessel coronary artery disease with three patent
bypass grafts, globally hyperkinetic left ventricle with an
ejection fraction of 42 percent, 2 plus mitral regurgitation,
mild aortic insufficiency. Patient was referred to Dr. [**Last Name (Prefixes) **] for redo sternotomy and mitral valve replacement.
PAST MEDICAL HISTORY: Coronary artery disease.
Status post CABG in [**2152**].
Mitral stenosis and mitral regurgitation.
History of atrial fibrillation.
Asthma.
COPD.
Rheumatic heart disease.
Status post myocardial infarction in [**2152**].
Status post right inguinal hernia repair.
ALLERGIES: Patient is allergic to Codeine, which he reports
gives him GI upset.
PREOPERATIVE MEDICATIONS:
1. Zocor 10 mg p.o. q. day.
2. Cardizem 240 mg p.o. q. day.
3. Advair inhaler one puff twice a day.
4. Coumadin 7.5 mg p.o. q. day.
5. Combivent p.r.n.
As part of the patient's preoperative workup patient was
noted to have an abnormal chest x-ray. Patient underwent an
evaluation for this by Dr. [**Last Name (STitle) 952**], [**First Name3 (LF) 1092**] Surgery. Workup
was subsequently negative for any evidence of malignancy and
patient's surgery was rescheduled.
HO[**Last Name (STitle) **] COURSE: Patient was admitted on [**2164-7-30**] and
taken to the Operating Room with Dr. [**Last Name (Prefixes) **] for a redo
sternotomy, a mitral valve replacement with a 27 mm mosaic
porcine valve, and a MAVE procedure. Patient tolerated the
procedure well. Patient was transferred to the Intensive
Care Unit in stable condition on 0.5 mcg/kg per minute
Amiodarone as well as propofol.
Upon leaving the Operating Room patient was noted to have a
fair amount of chest tube output. Patient's coagulation
factors were repleted. Patient was treated with blood
products. However, patient continued to have large amount of
chest tube output. Within a few hours postoperatively
patient was noted to have a decreasing blood pressure in
spite of increasing pressor requirements as well as
increasing filling pressures. Echocardiogram was performed
at the bedside which showed a pericardial effusion.
Patient was taken back to the Operating Room for evacuation
of moderate amount of clot with improvement in the blood
pressure and decrease in the filling pressures. Patient was
returned to the Intensive Care Unit in stable condition on
low-dose epinephrine. Patient was weaned and extubated from
mechanical ventilation on postoperative day number one.
Patient was noted postoperatively to have significant air
leak from all of his chest tubes. This did not cause him any
respiratory compromise. Patient's epinephrine was weaned off
and patient was started on diuretics with good response.
Upon extubation patient was noted to have moderate amount of
wheezing and shortness of breath which responded to chest
physiotherapy as well as diuretic.
Over the next day patient continued to receive diuresis and
chest physiotherapy, and patient was determined to be stable
and transferred from the Intensive Care Unit to a regular
part of the hospital on postoperative day number two.
Patient continued to have significant air leaks in his chest
tubes. Patient began working with Physical Therapy.
Patient's pacing wires were removed on postoperative day
number four. The next several days patient's chest tubes
were removed one at a time. The patient continued to have
air leak in the remaining chest tubes. By postoperative day
number the patient had one remaining chest tube with
continued air leak on water seal. Recommendation was to
clamp the chest tube and reevaluate for evidence of
pneumothorax. This was done, clamped overnight, and in the
morning there was no evidence of pneumothorax. The chest
tube was removed without incident.
Patient had been evaluated by the Electrophysiology service
preoperatively for his atrial fibrillation. Postoperatively
patient had not had any atrial fibrillation, but it was
recommendation of Dr. [**Last Name (STitle) **] to continue patient on 200 mg
a day of Amiodarone for one month as well as anticoagulate
with Coumadin for one month, at which time he would be
reevaluated for discontinuation of the therapy and determine
success of the MAVE procedure.
By postoperative day number 10 patient was able to ambulate
500 feet with Physical Therapy and climb one flight of
stairs. However, patient was noted to desaturate with oxygen
saturations in the mid 80s upon ambulation, and it was
discussed with the Cardiac Surgery team and it was decided
that patient would be discharged to home with oxygen as
needed by the patient during ambulation with the thought that
the patient would be able to be weaned to off over the next
several days. So, by postoperative day number 11 patient was
cleared for discharge with plans to discharge the patient on
postoperative day number 12.
DISCHARGE CONDITION: T-max 98.4 F, pulse 76, sinus rhythm,
blood pressure 108/50, respiratory rate 16, room air oxygen
saturation 95 percent at rest with oxygen saturation in the
high 80s with ambulation on room air and high 90s on 2 liters
nasal cannula with ambulation. Patient's weight on
[**2164-8-10**] is 78.6 kg; preoperatively patient was 77 kg.
Neurologically, patient is awake, alert, oriented times
three, nonfocal. Cardiovascular: Regular rate and rhythm
without rub or murmur. Respiratory: Breath sounds are clear
bilaterally, decreased at the left lung base. GI: Positive
bowel sounds; soft, nontender, nondistended. Patient is
tolerating a regular diet and having normal bowel movement.
Extremities: Left lower extremity has 1 plus edema, right
lower extremity with trace edema. Sternal incision is clean,
dry, and intact without any erythema or drainage. The right
mediastinal chest tube site has mild erythema with minimal
amount of serosanguineous drainage.
LABORATORY DATA: White blood cell count 10.5, hematocrit
27.7, platelet count 404, sodium 140, potassium 4.1, chloride
99, bicarbonate 32, BUN 15, creatinine 1.2, glucose 101,
patient's PT is 14.2 with an INR of 1.3 and PTT of 29.5.
Patient's chest x-ray on [**2164-8-10**] showed almost complete
resolution of what had been persistent small right apical
pneumothorax, significant decrease and almost resolution of
the subcutaneous air in the patient's neck, a small loculated
right pleural effusion, no pneumothorax on the left, no
evidence of CHF.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg p.o. q. day times five days.
2. Colace 100 mg p.o. b.i.d.
3. Protonix 40 mg p.o. q. day.
4. Enteric-coated aspirin 325 mg p.o. q. day.
5. Simvastatin 10 mg p.o. q. day.
6. Amiodarone 200 mg p.o. q. day.
7. Advair one puff b.i.d.
8. Combivent two puffs q. 6 hours.
9. Lopressor 12.5 mg p.o. b.i.d.
10. Coumadin 7.5 mg p.o. q. day. Goal INR 2.0 to 2.5.
Patient is to have his INR checked on Monday, [**2164-8-13**],
by the visiting nurse with results called to patient's
primary care physician, [**Last Name (NamePattern4) **].[**Name (NI) 8523**], office.
DISCHARGE DIAGNOSES: Mitral stenosis and mitral
regurgitation.
Status post redo sternotomy, mitral valve replacement, and
MAVE procedure.
Reoperation for bleeding.
Prolonged air leak from chest tubes.
Preoperative atrial fibrillation.
Chronic obstructive pulmonary disease.
DISPOSITION: Patient is to be discharged to home.
DISCHARGE CONDITION: Stable.
DI[**Last Name (STitle) 408**]E INSTRUCTIONS: He is to have oxygen as needed for
ambulation and weaned to off for an oxygen saturation greater
than 90 percent with ambulation. Patient should follow up
with his cardiologist, Dr. [**Last Name (STitle) **], in one to two weeks. He
should follow up with Dr. [**Last Name (STitle) **] from Electrophysiology in
two to three weeks. He should follow up with Dr. [**Last Name (Prefixes) **]
in two to three weeks. He should follow up with his
pulmonologist, Dr. [**Last Name (STitle) 8522**], in two to three weeks. He should
follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8521**], in one
to two weeks in the office and Dr. [**Last Name (STitle) 8521**] by phone on Monday,
[**2164-8-13**], for results of the PT INR and for Coumadin dosing
and for further lab draws.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 8524**]
MEDQUIST36
D: [**2164-8-10**] 17:55:59
T: [**2164-8-10**] 21:59:34
Job#: [**Job Number 8525**]
|
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42,367
| 139,932
|
9102
|
Discharge summary
|
report
|
Admission Date: [**2147-10-3**] Discharge Date: [**2147-11-4**]
Service: NEUROSURGERY
Allergies:
Bactrim Ds / Ciprofloxacin
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
CC:[**CC Contact Info 31392**]
Major Surgical or Invasive Procedure:
Craniotomy for Bilat SDH [**10-9**]
Re-evacuation of SDH on [**10-14**]
tracheostomy
History of Present Illness:
HPI: Patient is a 87F who is s/p right burr hole evacuation of
SDH on [**9-28**]. She was discharged on [**10-2**] from [**Hospital1 18**] to [**Hospital 100**]
Rehab. This morning while visiting with her husband, she was
observed to have several(approx 5 per husband's report) episodes
of seizure activity. Per the husband's report, the seizures
seemed to be localized to the right side of her head and neck,
and described as muscle twitching. The husband denies observing
any further activity in alternate areas of her body.
Past Medical History:
- SDH b/l frontal
- L hip fx s/p ORIF in [**8-/2147**]
- recent cellulitis LLE
- diastolic CHF (TTE [**8-/2147**])
-dementia
-NPH s/p VP shunt
-gait disorder of unclear etiology; uses walker
-h/o prior lacunar strokes with residual left sided weakness
-GERD
-depression
-anemia
-diabetes type 2
--urinary incontinence
--falls
Social History:
- lives with husband usually but currently at [**Hospital 100**] Rehab s/p
ORIF for hip fx
- distant tobacco use, quit 30 years ago
- retired hair dresser
Family History:
-no history of seizures or strokes prior to this admission
Physical Exam:
PHYSICAL EXAM on Admission:
O: T:100.8(rectal) BP:192/112 HR:77 RR:31
O2Sats:100%NRB
Gen: WD/WN, fine tremor noted on the right side of her head.
HEENT:normocephalic, healing surgical wound to right side of
head
from previous surgery
Pupils: PERRL EOMs:unable to assess
Extrem: Warm and well-perfused.
Neuro:
Mental status: Not responsive, no eye opening. Lower extremities
withdrawing symmetrically to noxious stimulus. Pupils 3/2mm
equally round and reactive to light. Upper extremity assessment
deferred for bilateral IV assessments.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to
2 mm bilaterally.
III, IV, VI-XII: unable to assess
Toes downgoing bilaterally
Physical Exam on Discharge:
The patient has been pronounced dead. There is no heartbeat or
pulse. There is no respiration. There are no breath sounds.
Pertinent Results:
Labs on Admission:
[**2147-10-2**] 06:45AM GLUCOSE-115* UREA N-9 CREAT-0.4 SODIUM-141
POTASSIUM-3.5 CHLORIDE-106 TOTAL CO2-22 ANION GAP-17
[**2147-10-2**] 06:45AM CALCIUM-8.2* PHOSPHATE-2.6* MAGNESIUM-1.6
[**2147-10-2**] 06:45AM VANCO-<1.7
[**2147-10-2**] 06:45AM PHENYTOIN-5.1*
[**2147-10-2**] 06:45AM WBC-5.0 RBC-3.66* HGB-10.6* HCT-31.4* MCV-86
MCH-28.8 MCHC-33.6 RDW-17.4*
[**2147-10-2**] 06:45AM PLT COUNT-210
Imaging:
Head CT ([**10-11**]):
IMPRESSION:
1. Interval right frontal craniotomy, with a persistent right
subdural
hematoma, and a moderate degree of pneumocephalus surrounding
the right
frontal lobe which is likely related to recent surgery.
2. Stable small left subdural hematoma.
3. Slightly improved appearance of the right lateral ventricle
compared to
[**2147-10-4**], when it was completely effaced.
Head CT ([**10-12**]):
IMPRESSION:
1. Unchanged right subdural collection with component of
pneumocephalus and heterogeneous density.
2. Significant, but unchanged, mass effect with compression of
the right
lateral and third ventricles and approximately 9 mm of leftward
midline shift with subfalcine herniation.
3. Unchanged opacification of the paranasal sinuses and mastoid
air cells as described above.
Head CT ([**10-13**]):
IMPRESSION:
1. No significant change in the appearance of right subdural
collection
residual following evacuation of subdural hematoma. There is no
increase in mass effect. There is no new edema, new hemorrhage,
or new infarction.
2. Stable opacification of the paranasal sinuses and mastoid air
cells as
described above.
Head CT ([**10-15**]):
IMPRESSION:
1. Status post evacuation of the right frontoparietal subdural
hematoma with decrease in the shift of midline structures.
2. Decreasing falcing subdural hematoma and stable appearance of
the intra-
intraventricular shunt and opacification of the paranasal
sinuses.
3. New subcentimeter intra-parenchymal hemorrhage of the right
superior
frontal lobe.
Head CT([**10-16**]):
IMPRESSION:
1. Unchanged appearance of postoperative subdural evacuation
site with recent insertion of drainage catheter.
2. No increase in mild mass effect.
3. Stable small superior right frontal intraparenchymal
hemorrhage.
4. Persistent opacification of the paranasal sinuses and mastoid
air cells.
Head CT([**10-18**]):
IMPRESSION: Little interval change after removal of right
frontal extra-axial drainage catheter. No evidence of new
hemorrhage or mass effect.
Head CT([**10-23**]):
MPRESSION:
1. Slight dilation of the ventricular system since prior study.
2. No evidence for new hemorrhage, edema, mass effect or
infarction.
EEG Monitoring:
([**10-12**]):IMPRESSION: This is a markedly abnormal 24-hour video EEG
telemetry in the waking and sleeping states due to the
occasional runs of up to 30
seconds of right posterior quadrant [**2-26**] Hz rhythmic slowing
without a
clinical correlate suggestive of an electrographic seizure.
Furthermore, there were frequent spike or polyspike and slow
wave discharges seen at a frequency of approximately 1 Hz
primarily over the right hemisphere suggestive of periodic
lateralized epileptiform discharges. This may be seen with a
stroke, hemorrhages, infectious etiologies (e.g. HSV) or after
status epilepticus. Clinical correlation is advised. In
addition, there was a slow and disorganized background rhythm
seen primarily over the left hemisphere suggestive of a mild to
moderate encephalopathy which may be seen with medication
effect, toxic metabolic abnormalities, or infections
EEG([**10-13**]):IMPRESSION: This is a markedly abnormal 24-hour video
EEG telemetry in the waking and sleeping states due to the
frequent sharp and slow wave discharges seen over the right
hemisphere particularly the right
posterior quadrant. In addition, there were frequent runs of up
to 30
seconds of 3 Hz sharp and slow wave discharges seen in the right
posterior quadrant consistent with electrographic seizures. The
right hemisphere, and particularly right posterior quadrant
sharp and slow wave discharges, are suggestive of periodic
lateralized epileptiform discharges which may be seen with
infections, hemorrhages, infarcts, or after status epilepticus.
The slow background rhythm of [**5-30**] Hz is suggestive of a moderate
encephalopathy which may be seen with medication effect, toxic
metabolic abnormalities, or infections.
EEG([**10-14**]):
IMPRESSION: This is a markedly abnormal 24-hour video EEG
telemetry in
the waking and sleeping states due to the numerous
electrographic seizures recorded with focus in the right
posterior quadrant. In addition, there were frequent sharp and
slow wave discharges seen over the right hemisphere but
primarily in the right posterior quadrant with a frequency of
approximately 1 Hz. These periodic lateralized epileptiform
discharges may be seen as a consequence of stroke, hemorrhages,
infections, or after status epilepticus. Finally, the slow
background rhythms seen over the left hemisphere is suggestive
of a moderate encephalopathy which may be seen with medications,
toxic metabolic abnormalities, and infections.
EEG([**10-16**]):
IMPRESSION: This is an abnormal 24-hour video EEG telemetry in
the
waking and sleeping states due to the frequent right posterior
quadrant
discharges seen occasionally with a frequency of once every two
seconds.
These periodic lateralized epileptiform discharges may be seen
as a
consequence of infarcts, hemorrhages, or rarely infections. It
may also
be seen after status epilepticus. There were no electrographic
seizures
noted on this recording and there were no pushbutton
activations. In
addition, there was infrequent left temporal mixed frequency
slowing
suggestive of subcortical dysfunction in this region. Finally,
the slow
background rhythm is suggestive of a mild to moderate
encephalopathy
which may be seen with medication effect, toxic metabolic
abnormalities,
or infections.
EEG([**10-17**]):IMPRESSION: This is an abnormal 24-hour video EEG
telemetry in the waking and sleeping states. There were a few
runs of up to 20 seconds
of C4 or T4 sharp and slow wave discharges at a frequency of [**3-28**]
Hz with
no clear clinical correlate. These are suggestive of
electrographic
seizures. However, in these regions, there was also frequent
electrode
artifact. In addition, there continue to be right posterior
quadrant
epileptiform discharges suggestive of a potential focus of
pileptogenesis. However, the frequency of these discharges is
decreased compared to prior recordings. In addition, there was
left mid-temporal theta frequency slowing and sharp waves seen
suggestive of a potential focus of epileptogenesis and
subcortical dysfunction in this region. Finally, there was a
slow and disorganized background rhythm suggestive of a moderate
encephalopathy which may be seen with medication effect, toxic
metabolic abnormalities, or infections.
EEG([**10-18**]):
IMPRESSION: This is an abnormal 24-hour video EEG telemetry in
the
waking and sleeping states due to the single electrographic
seizure
recorded in the right posterior quadrant with 3-4 Hz rhythmic
slowing
and occasional embedded sharp waves lasting up to 90 seconds
without
clinical correlate. In addition, there continued to be right
posterior
quadrant spike or sharp and slow wave discharges suggestive of a
potential focus of epileptogenesis. The occasional frequency at
1 Hz is
suggestive of periodic lateralized epileptiform discharges which
may be
seen as sequelae of stroke, infections, or hemorrhages.
Fortunately,
the frequency of these discharges is diminished compared to
prior
recordings. There also continued to be left mid-temporal theta
frequency slowing suggestive of subcortical dysfunction in this
region and there were rare left temporal sharp waves suggestive
of a second potential focus of epileptogenesis. Finally, there
was a slow and disorganized background rhythm suggestive of a
moderate encephalopathy which may be seen with medications,
toxic metabolic abnormalities, or infections.
EEG([**10-19**]):MPRESSION: This is an abnormal 24-hour video EEG
telemetry due to the five electrographic seizures noted on
routine sampling and automatic seizure detection files. These
had a foci in either left or right posterior quadrants.
Interictally, there were additional left and right posterior
quadrant sharp and slow wave discharges seen suggestive of
potential foci of epileptogenesis. Finally, a slow and
disorganized
background rhythm of approximately 5 Hz was seen suggestive of a
moderate encephalopathy which may be seen with medication
effect, toxic metabolic abnormalities, or infections. In
addition, there was infrequent left mid-temporal mixed frequency
slowing suggestive of subcortical dysfunction in this region.
EEG([**10-20**]):IMPRESSION: This is an abnormal 24-hour video EEG
telemetry in the waking and sleeping states due to the single
electrographic seizure
noted over the central electrodes. On prior recordings, this was
associated with left temporal electrographic seizure; however,
at the
time of the recording, the left temporal electrodes did not
appear to be
functioning as well. In addition, there were bilateral
independent left
mid-temporal and right posterior quadrant sharp and slow wave
discharges
at best at a frequency of once every two seconds. This is an
improvement from prior recordings. These are suggestive of
potential foci of epileptogenesis. Finally, there was a markedly
slow and disorganized background rhythm suggestive of a moderate
encephalopathy which may be seen with medication effect, toxic
metabolic abnormalities, or infections
EEG ([**10-22**]):IMPRESSION: This is an abnormal 24-hour video EEG
telemetry in the waking and sleeping states due to the right
posterior quadrant,
occasionally right hemisphere sharp and slow wave discharges
suggestive
of potential focus of epileptogenesis. In addition, the slow and
disorganized background rhythm is suggestive of a moderate
encephalopathy which may be seen with medication effect, toxic
metabolic abnormalities, or infections. Nonetheless, this
recording is improved from last week's recording with a decrease
in the frequency of the discharges and a slight improvement in
the background rhythm. There were no electrographic seizures and
no pushbutton activations noted.
Upper Extremity Venous Duplex([**10-16**]):IMPRESSION: Occlusive
thrombus in the right cephalic vein which is a superficial vein.
No evidence of deep vein thrombosis in the deep veins of either
arm.
CT Head ([**2147-10-30**]):
IMPRESSION: Stable small bilateral hypodense extra-axial
collections, without evidence of new hemorrhage.
Brief Hospital Course:
This 87 yo woman was readmitted [**2147-10-3**] after a recent discharge
to rehab following an uncomplicated burrhole evacuation of a
right SDH which occurred [**2147-9-28**]. Repeated imaging in the ED
revealed stable SDH with no new or acute changes from previous
imaging. She was thought to have had seizures because her
consciouness was altered and she was noted to initially have
rhythmic RUE jerking movements as well as right facial and jaw
twitching. She was intubated and admitted to the ICU, EEG was
done which showed encephalopathy, and due to unchaged poor
mental status she was brought to the OR for craniotomy and
evacuation. Seizures controlled with Dilantin later switched to
Keppra, no benzodiazepines per family. She continued to have
questionable seizure activity and continuous EEG monitoring
restarted. On [**10-11**] CT showed reaccumulation of SDH and evidence
of seizures on EEG. Family meeting was arranged and patient
induced into Pentobarb coma. On [**10-14**] patient returned to the OR
for re-evaciation of SDH with drain placement. The drain was
removed on POD#1, and EEG monitoring continued. Per reports,
less seizure activity was noted, however was still having
seizure activity. A third anti-epileptic [**Doctor Last Name 360**] was then added
for additional control. EEG monitoring again ensued, revealing
ongoing seizure activity. Again noted to be improved since
evacuation, however still present. On [**10-22**],EEG determined that
she was now without seizure, but coma state persisted.
Phenobarbital was slowly weaned to off, and she was given
several day for all the drugs to metabolize to optimize mental
status.
On [**10-30**], a family meeting was conducted with Dr.
[**Last Name (STitle) 31393**] and the patient was made CMO the following day
after the family had some time to discuss the patient's
condition overnight. All of her medications and feeding were
stopped with the exception of a morphine drip and she continued
to be suctioned per the family's request. When a bed became
available, she was transferred to the floor. On [**2147-11-2**] the
patient was restarted on phenobarbital to reduce visible seizure
activity. However, the following day the phenobarbital was
stopped due to the palliative care team's request. She was
receiving to much IV fluid with the medication.
The patient went into respiratory failure on [**2147-11-4**] and was
pronounced dead at shortly thereafter. Time of death was 19:30.
Medications on Admission:
1. Acetaminophen 325 mg Tablet [**Date Range **]: Two (2) Tablet PO Q6H (every
6 hours).
2. Amlodipine 5 mg Tablet [**Date Range **]: Two (2) Tablet PO DAILY (Daily).
3. Atorvastatin 80 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY
(Daily).
4. Insulin Regular Human 100 unit/mL Solution [**Date Range **]: One (1)
Injection ASDIR (AS DIRECTED).
5. Lisinopril 10 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
7. Nystatin 100,000 unit/g Cream [**Date Range **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal infection.
8. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2
times a day).
9. Oxycodone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q4H (every 4
hours) as needed.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as
needed.
11. Dilantin Extended 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO
three times a day.
12. Lasix 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO twice a day.
13. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
14. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID
(2 times a day).
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
SDH
Seizure
Respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
NA
NA
Followup Instructions:
NA
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2147-11-4**]
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[]
]
] |
17039, 17048
|
13100, 15565
|
268, 355
|
17124, 17134
|
2419, 2424
|
17188, 17316
|
1454, 1514
|
17010, 17016
|
17069, 17103
|
15591, 16987
|
17158, 17165
|
1529, 1543
|
2276, 2400
|
199, 230
|
383, 915
|
2098, 2248
|
2438, 13077
|
1867, 2082
|
937, 1265
|
1281, 1438
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,413
| 163,363
|
53175
|
Discharge summary
|
report
|
Admission Date: [**2121-2-24**] Discharge Date: [**2121-3-15**]
Date of Birth: [**2062-10-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**Known firstname 1055**]
Chief Complaint:
Jaundice
Major Surgical or Invasive Procedure:
Paracentesis [**2-27**], [**3-2**]
Left subclavian central venous line [**2-27**]
History of Present Illness:
This is a 58 y/o M with recently diagnosed alcoholic cirrhosis
who is being called out of the ICU where he was admitted
overnight for monitoring post-ERCP.
.
Initially transferred from [**Hospital6 **] on [**2-24**] for
diagnosis of obstructive jaundice with radiographic evidence of
dilated intra-hepatic duct on the left lobe of liver. Presented
with several days of fatigue, lethargy and ?ruq pain. At OSH,
noted to be hypotensive to 80's with leukocytosis to 22K and
elevated bilirubin to 23. Abdominal u/s demonstrated evidence of
perihepatic/perisplenic ascites, ?cirrhosis and focal biliary
ductal dilation on left lobe liver. MRI confirmed these findings
and ERCP at OSH showed suggestion of polyp at bifurcation of
CHD.
.
Transferred to [**Hospital1 18**] for further evaluation via repeat ERCP but
procedure limited by bowel wall edema and unable to cannulate
ampulla. Hemodymically stable in procedure and PACU but
transferred to MICU for further montioring. In MICU overnight,
blood pressure low/stable in 90's with prn NS boluses.
Maintaining urine output at 30cc per hour. Mentating but with
mild encephalopathy. lactate 1.4.
OSH demonstrated GPC in blood cx. Blood, urine cultures repeated
here. In addition CXR was performed which demonstrated
?infiltrate.
.
He underwent repeat ultrasound on [**2-25**] which did not show intra
or extra hepatic ductal dilatation. A 1.7 cm hypoechoic lesion
was seen in the central portion of the liver which was thought
to possibly represent hepatoma. Of note there was normal
hepatopedal flow and non-distended sludge was visualized in
gallbladder. Initial discussion in regards to percutaneous
decompression of dilated duct, however hepatology was consulted
and recommeded holding off on this procedure. Felt that findings
most consistent with acute on chronic ETOH cirrhosis. Recommend
continued work-up for underlying infection and MRCP/repeat ERCP
for further evaluation. (See consult note for formal
recommendations).
.
Given hemodynamic stability overnight, called out to floor ([**Hospital Ward Name 121**]
10) on [**2121-2-25**].
Past Medical History:
No major medical history prior to this hospitalization, was not
taking any medications.
1. ? Hilar tumor on abdominal ct
2. Obstructive jaundice
3. Alcoholism
4. Cirrhosis as per hpi
5. Anemia at osh
Social History:
Maternal grandmother with gastric Ca.
Family History:
- Divorced, used to be truck driver until 6mos ago.
- smokes 1 ppd x years, [**1-3**] vodka tonics/day since age 23 (no
EtOH x 2 weeks), no IVDU, lives alone
Physical Exam:
vitals- T 96.4, L arm 96/52, R arm 82/38, P 94, R 16, 100% on
RA
gen- Sleepy but arousable, cachectic.
heent- Icteric sclerae, jaundice, OP clear
pulm- CTA bilaterally
CV- RRR, nl S1, S2, no extra sounds
ABD- Distended, soft, NT, ND
ext- trace pedal edema
neuro- A&O x 4, no asterixis
Pertinent Results:
Labs:
Admission labs:
wbc 32.2, hct 27.6 (mcv 108), plt 206
na 133, k 5.3, cl 105, hco3 16, bun 38, cr 0.9
alt 107, ast 250, alk phos 295, LDH 266, t bili 24.5
Hepatitis serologies: negative.
AFP: <1.0.
CA [**33**]/9:
HIV: negative.
[**Doctor First Name **]: negative.
AMA: positive at 1:160.
Microbiology:
[**2-24**] Blood cultures at OSH - 2/4 bottles (one from each set)
positive for coag. negative staph aureus, resistant to
oxacillin, sensitive to vancomycin.
[**2-25**], 29 Blood cultures: pending.
[**2-25**] Urine culture: negative.
[**2-26**], [**2-28**], [**3-1**] Stool: c. difficile negative.
.
[**2-25**] Paracentecis:
WBC RBC Polys Lymphs Monos Eos Basos Mesothe Macroph
39 572 47 27 0 1 1 6 18
.
Studies at [**Hospital1 18**]:
[**2-25**] RUQ Liver U/S:
FINDINGS: The liver has a nodular surface contour in keeping
with underlying cirrhotic change. In the central portion of the
right lobe of liver, there is an ovoid hypoechoic nodular lesion
measuring up to 1.7 cm in size. Some vascular flow demonstrated
along its anterior aspect on color Doppler assessment. This
lesion could represent a small hepatoma and as such, further
evaluation with MRI of the liver is advised. Normal hepatopetal
direction of flow is demonstrated in the right portal vein.
Normal venous flow demonstrated in the middle hepatic vein.
Assessment of the left lobe of liver and main portal vein was
difficult due to the presence of a larger amout of
intra-abdominal ascites. An ink mark was placed over the largest
depth of ascites in the right lower quadrant to facilitate any
planned paracentesis. Non-distended sludge containing
gallbladder. No intra- or extra-hepatic biliary dilatation.
.
CONCLUSION:
1. Cirrhotic liver.
2. A 1.7-cm hypoechoic nodule in the central portion of the
right lobe, could represent a small hepatoma. Further evaluation
with MRI of the liver advised.
3. Large amount of intra-abdominal ascites (ink mark placed over
the largest area in the right lower quadrant. Preferably
paracentesis should be performed prior to any liver MRI).
.
[**2-25**] CXR:
Lung volumes are low. Consolidation at the medial aspect of the
left lung base could be pneumonia. Configuration of the
diaphragmatic pleural contour suggests small bilateral pleural
effusions. Opacified structure in the right upper abdominal
quadrant looks more like a gallbladder than kidney. If the
patient has not received any contrast agents, this finding
suggests biliary obstruction.
.
[**2-24**] ERCP:
1. Portal hypertensive gastropathy was present. Scant coffee
grounds were present.
2. The bowel wall was edematous.
3. The ampulla was extremely edematous. The papilla was
intermittently visualized behind collapsing mucosal folds, but
cannulation was not successful due to this limitation.
.
[**3-3**] MRCP:
1. Extensive peribiliary cysts within the hepatic hilum and
left hepatic lobe greater than the right. Mild-moderate
peripheral left hepatic biliary ductal dilatation suggests a
compressive effect of the cysts on the drainage of left biliary
system. Right biliary system does not show dilation.
2. Narrow common hepatic duct near its origin with lack of
visualization of the confluence from the right and left hepatic
ducts. This is likely from compression by peribiliary cysts.
No filling defects within the common hepatic duct or common bile
duct evident, though the common hepatic duct is not completely
visualized.
3. Cirrhosis and portal hypertension without evidence of HCC.
4. Splenic infarcts.
.
[**3-5**] EGD:
1. Medium hiatal hernia. Linear erosion in hernia sac.
2. Mosaic appearance in the antrum and stomach body compatible
with portal gastropathy.
3. Erythema in the gastroesophageal junction.
4. Varices at the gastroesophageal junction and lower third of
the esophagus.
5. Otherwise normal egd to second part of the duodenum.
.
[**3-7**] ERCP:
1. Grade I esophageal varices were seen. A small hiatal hernia
was noted.
2. Changes of portal hypertensive gastropathy were seen
involving the stomach.
3. Duodenal bulb erosions were seen.
4. Cannulation of the pancreatic duct was performed with a
sphincterotome using a free-hand technique. Contrast medium was
injected resulting in partial opacification of the distal PD.
Limited pancreatogram revealed a normal distal pancreatic duct.
5. Selective cannulation of the biliary duct was difficult with
a sphincterotome. Therefore, a pre-cut sphincterotomy was
performed with a needle knife to gain access to the bile duct.
6. Cholangiogram revealed a dilated bile duct with extrinsic
compression at the hilum. The left intrahepatic duct filled with
contrast preferentially and appeared mildly dilated.
7. A 10 Fr 12 cm Cotton [**Doctor Last Name **] biliary stent was placed
successfully across the hilum into the left hepatic duct and
bile was seen draining into the duodenum.
Brief Hospital Course:
Mr. [**Known lastname 31966**] is a 58 y/o M with recently diagnosed alcoholic
cirrhosis, w/?obstructive jaundice, who was transferred from
[**Hospital6 33**] to [**Hospital1 18**].
.
# Leukocytosis:
His white blood cell count was initially elevated near 30,000.
Although he did not have a fever or focal signs, he did have
positive blood cultures from [**Hospital6 33**] (coagulase
negative staph in [**1-4**] bottles - one from each set).
Surveillance blood cultures were negative at [**Hospital1 18**]. Urine
cultures and stool tests for c. difficile were negative as well.
A diagnostic paracentecis was done at [**Hospital1 18**] which was negative
but was performed while he was already on antibiotics.
Initially he was broadly covered with vancomycin, levofloxacin,
and flagyl. As his white count began to come down and his
cultures remained negative, vancomycin was discontinued and he
was continued on levofloxacin and flagyl.
.
# Cirrhosis:
This was thought most likely due to EtOH given his history of
heavy EtOH use. Hepatitis serologies were negative as were [**First Name8 (NamePattern2) **]
[**Doctor First Name **] and HIV test. An AMA was positive at 1:160. He was treated
supportively with nutrition, folate, MVI, and vitamin K and
multiple therapeutic paracenteces for dyspnea. Complications
included hematemesis which an associated fall in hematocrit. An
EGD showed no active site of bleeding but did show grade 2
varices, portal gastropathy, and linear erosions. He also had a
persistently elevated bilirubin. An MRCP revealed multiple
peribiliary cysts some of which were extrinsically compressing
the biliary system. An ERCP was performed and a stent was
placed into the left hepatic duct. Following this his bilirubin
remained elevated and at discharge was around 40.
.
# Hypotension:
He was initially hypotensive to the 70s and required to be in
the MICU for one night following his ERCP. His blood pressure
stabilized into the mid 90s and he was called out to the floor.
The differential for his hypotension included hypoalbuminemia
due to his cirrhosis vs. sepsis due to his staph bacteremia. He
had persistent hypotension with systolics in the 70s to 90s but
he had good mentation through this and this was thought to be
due to his underlying liver disease. He was supported with
intermittent albumin.
.
# Heme:
He had a baseline macrocytic anemia due to his alcoholism. He
also had a few episodes of hematemesis and an EGD showed grade 2
varices, portal gastropathy, and linear erosions but no active
site of bleeding. He required intermittent support with red
blood cell transfusions. He also had thrombocytopenia thought
secondary to his liver disease and alcoholism and he required
intermittent platelet transfusions.
.
# Hyponatremia:
This was thought to be secondary to his cirrhosis and he was
fluid restricted.
.
# Non-gap metabolic acidosis:
This was thought most likely due to diarrhea as his renal
function was normal.
.
# Dispo:
After several weeks of supportive treatment, he felt
subjectively about the same but, given the severity of his
disease and his poor prognosis, he wished to orient his care
towards comfort measures. At this point non-essential
medications were stopped and he was treated supportively with
pain medications and anti-emetics as needed. On [**3-14**] he passed
away.
Medications on Admission:
Was not taking any medications prior to hospitalization.
Meds on Transfer:
Levaquin 500mg IV q24
Flagyl 500mg IV q8
Vanco 1g IV q12
Midodrine 5 mg po TID
Vit K 5mg SC x 3 days
folic acid
valium CIWA scale
Discharge Medications:
N/A
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Alcoholic hepatitis/cirrhosis.
Discharge Condition:
expired.
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2121-3-16**]
|
[
"303.90",
"571.2",
"456.21",
"571.1",
"578.0",
"576.8",
"281.2",
"287.5",
"276.1",
"570",
"584.9",
"790.7",
"305.1",
"576.1",
"553.3",
"576.2",
"273.8",
"286.7",
"537.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"54.91",
"99.05",
"99.07",
"51.87",
"51.85",
"99.04",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11792, 11807
|
8156, 11509
|
280, 363
|
11885, 11895
|
3259, 3265
|
11947, 11981
|
2778, 2937
|
11764, 11769
|
11828, 11864
|
11535, 11592
|
11919, 11924
|
2952, 3240
|
232, 242
|
391, 2482
|
3281, 8133
|
2504, 2706
|
2722, 2762
|
11610, 11741
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,638
| 120,002
|
35762+58031
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-3-7**] Discharge Date: [**2182-3-19**]
Date of Birth: [**2116-1-28**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Naprosyn
Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Low Back Pain
Major Surgical or Invasive Procedure:
[**2182-3-7**]: L2 Transpedicular Corpectomy, Posterior Spinal
Instrumentation & Posterolateral Fusion T10-L5, Open L2 Biopsy,
ICBG
History of Present Illness:
[**Known firstname **] [**Known lastname 81322**] is a 66-year-old female who had the onset of back
pain associated with leg weakness, numbness, tingling and pain
caused difficulty with ambulation. The interfered with habits of
daily living as well as all activities requiring walking. She
was evaluated clinically and radiographically and found to have
a vertebra plana fracture of L2. An MRI demonstrated
infiltrative lesion within the vertebral body. Additionally, the
MRI demonstrated high-grade central and foraminal stenosis L2 on
the left. For these reasons in part, the patient elected to
undergo surgical treatment in the setting of high-grade
neurological compression and spinal instability.
Past Medical History:
1. s/p recent L TKA c/b infection
2. chronic LLE lymphedema
Social History:
Denies regular tobacco or EtOH use.
Family History:
N/C
Physical Exam:
AVSS
Well appearing, obese, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: [**5-21**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative [**Doctor Last Name 937**], 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: [**5-21**] B TA/GS/[**Last Name (un) 938**]/FHL/Per, 4-/5 L IP/Qu/HS, [**5-21**] R IP/Qu/HS
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Pertinent Results:
[**2182-3-7**] 09:53PM WBC-9.2 HGB-9.5* HCT-27.8* PLT COUNT-357
[**2182-3-7**] 09:53PM PT-14.0* PTT-28.8 INR(PT)-1.2*
[**2182-3-7**] 09:53PM GLUCOSE-161* UREA N-13 CREAT-0.7 SODIUM-141
POTASSIUM-4.7 CHLORIDE-109* TOTAL CO2-25
[**2182-3-8**] 02:42AM Hct-29.3*
[**2182-3-8**] 09:56PM Hct-23.7*
[**2182-3-9**] 04:15AM Hct-25.5*
[**2182-3-10**] 05:46AM Hct-25.6*
[**2182-3-11**] 06:25AM Hct-26.7*
[**2182-3-12**] 06:28AM Hct-27.8*
Brief Hospital Course:
Ms. [**Known lastname 81322**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2182-3-7**] and taken to the Operating Room for the above
procedure performed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] in conjunctions with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]. Please refer to the dictated operative note for
further details. The surgery was very complicated. Due to the
patient's body habitus and extent of disease with considerable
tumor adherent to the dura, two dural tears with spinal fluid
leaks were encountered. These were repaired with the microscope.
The procedure duration was approximately 10.5 hours with EBL
2500cc. She received 3U PRBCs intraoperatively. A lumbar drain
was placed at the conclusion of the surgical procedure. She was
transferred to the SICU intubated postoperatively but in a
stable condition. On POD#1 she was extubated without incident
and was able to be transferred to the floor. She received 1U
PRBC for HCT 23 on POD#1. HCT bumped appropriately to HCT 25.5
after transfusion but she continued to be tachycardia and
slightly hypotensive. An additional 2U PRBCs were transfused.
Serial HCT were followed until stable. She received 6U RBCs
total during the hospital course.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Initial postop pain was controlled with a PCA. Diet was advanced
as tolerated. The patient was gradually transitioned to oral
pain medication when tolerating PO diet. Oxycontin and Oxycodone
were used for oral pain control. A wound care consult was
obtained for assistance in managing a chin abrasion sustained
that developed postoperatively as well as several chronic pannus
ulcers. A CT Lspine was obtained on POD#4 and showed appropriate
pedicle screw position at all sites and acceptable spinal
alignment. Intravenous Ancef was continued for infection
prophylaxis while the lumbar drain was in place. On POD#5 the
lumbar drain was clamped and a HOB elevation trial was
performed. She did well without headache or other signs
concerning for continued dural leak. On POD#6 the lumbar drain
was removed and a purse-string suture was used to close the
drain hole to prevent fistula formation. The surgical wound
remained CDI throughout the hospitalization without erythema or
drainage.
After removal of the lumbar drain, physical therapy was
consulted for mobilization OOB. She was not braced
postoperatively. Foley was removed on POD#7. Xrays of the L
spine were obtained prior to discharge and confirmed appropriate
hardware position and spinal alignement. Hospital course was
otherwise unremarkable. Final pathology on her L2 biopsy was
still pending at the time of discharge. On the day of discharge
the patient was afebrile with stable vital signs, comfortable on
oral pain control and tolerating a regular diet.
Medications on Admission:
1. Vicodin prn
2. MVI
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
7. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for rash.
11. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for spasms.
12. Oxycodone 15 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
13. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
L2 lesion
Discharge Condition:
Stable
Discharge Instructions:
You have undergone the following operation:
L2 Transpedicular Corpectomy, Posterior Spinal Instrumentation &
Posterolateral Fusion T10-L5
Immediately after the operation:
- Activity: You should not lift anything greater than 10 lbs.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting. No deep back bending.
- Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
- Brace: None
- Wound Care: If the incision is draining cover it with a new
sterile dressing. If it is dry then you can leave the incision
open to the air. Do not get wound wet until cleared to do so at
follow up appointment. Do not soak the incision in a bath or
pool. Sutures stay in place until follow up. If the incision
starts draining at anytime cover it with a sterile dressing &
call the office.
- You should resume taking your normal home medications.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
- Activity: You should not lift anything greater than 10 lbs.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without getting up and walking around.
- Rehabilitation/ Physical Therapy:
o 2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can
tolerate.
o Limit any kind of lifting. No deep back bending.
- Brace: None
Treatments Frequency:
- Wound Care: If the incision is draining cover it with a new
sterile dressing. If it is dry then you can leave the incision
open to the air. Do not get wound wet until cleared to do so at
follow up appointment. Do not soak the incision in a bath or
pool. Sutures stay in place until follow up. If the incision
starts draining at anytime cover it with a sterile dressing &
call the office.
Please call the office for fever>101.5 degrees Fahrenheit and/or
drainage from your wound.
Followup Instructions:
o Please Call the office ([**Telephone/Fax (1) 1228**]) and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
o At the 2-week visit we will check your incision, take baseline
X-rays and answer any questions.
o We will then see you at 6 weeks from the day of the operation.
Completed by:[**2182-3-15**] Name: [**Known lastname 13038**],[**Known firstname 3650**] L. Unit No: [**Numeric Identifier 13039**]
Admission Date: [**2182-3-7**] Discharge Date: [**2182-3-19**]
Date of Birth: [**2116-1-28**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Naprosyn
Attending:[**Doctor Last Name 147**]
Addendum:
[**2182-3-17**]: BLE Lower Extremity U/S: NEGATIVE. Due to decreased
mobility, SC Heparin 5000U TID was started for DVT prophylaxis.
This will be continued until she is cleared by PT for discharge
to home from rehab.
[**2182-3-18**]: No events
[**2182-3-19**]: Foley removed. U/A sent which was positive. Started on 7
day course of ciprofloxacin for UTI. No other events.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] Northeast - [**Location (un) 50**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**]
Completed by:[**2182-3-19**]
|
[
"707.25",
"457.1",
"785.0",
"111.9",
"737.10",
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"707.09",
"349.31",
"719.7",
"202.80",
"733.13",
"E870.0",
"199.1",
"599.0",
"707.8",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.53",
"03.59",
"80.99",
"81.05",
"81.63",
"77.49",
"77.79",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
10451, 10688
|
2348, 5227
|
286, 420
|
6595, 6604
|
1890, 2325
|
9351, 10428
|
1304, 1309
|
5299, 6436
|
6562, 6574
|
5253, 5276
|
6628, 6768
|
1324, 1871
|
8626, 8822
|
8844, 8846
|
6801, 6999
|
233, 248
|
8858, 9328
|
448, 1152
|
1174, 1235
|
1251, 1288
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
80,411
| 159,737
|
50339
|
Discharge summary
|
report
|
Admission Date: [**2131-6-27**] Discharge Date: [**2131-7-2**]
Date of Birth: [**2074-6-26**] Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7575**]
Chief Complaint:
Admitted for the management of seizures
Major Surgical or Invasive Procedure:
intubation followed by extubation; lumbar puncture
History of Present Illness:
Patient is a 66 year-old female who presents with seizures.
Her history is unknown. However from outside hospital reports,
she arrived at the hospital with concerns of shortness of breath
and an inhaler in her hand. She then became unresponsive going
into respiratory distress. She was intubated. Following this
she developed tonic and then clonic movements. It is unclear
how
long this lasted for, however she was given 1300 mg of
fosphenytoin, 250 mg of Keppra, 10 mg of ativan. As she had a
fever she was given 4.5 grams of zosyn, 1 gram of vancomycin,
and
fentanyl. Upon arrival she continued to have intermittent
episodes of jerking.
Past Medical History:
Asthma, HCV, Hx of TBI (MVA) many years ago requiring drain (s/p
removal) and craniotomy, history of opioid dependence
Social History:
Active IV cocaine use, currently enrolled in a methadone clinic
(confirmed dose of methadone 35mg daily) for hx of opioid
dependence (IV heroin). Also sister reports she abuses
presciption medicines and drinks wine. Recently released from
jail after being incarcerated for 5 yrs, currently living in a
motel on [**Hospital3 **].
Family History:
No family hx of seizures
Physical Exam:
Vitals: T:98.4 P:76-91 R:17-25 BP:96-124/62-75 SaO2: 93-97%
on RA
General: awake, lying in bed
HEENT: NC/AT, MMM, no lesions noted in oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity,
track marks
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses
Extremities:warm and well perfused
Skin: no rashes or lesions noted. Numerous track marks along
antecubital fossa bilaterally as well as neck.
Neurologic:
-Mental Status: awake, alert, drowsy but easily arousable,
speaking in full sentences, comprehension intact.
-Cranial Nerves:
I: Olfaction not tested.
II: left eye reactive 3 to 2mm and brisk. Right eye opacified,
nonreactive
III, IV, VI: EOMI
V: facial sensation intact, jaw motor symmetric
VII: No facial droop, facial musculature intact and symmetric.
IX, X: symmetric palate elevation
[**Doctor First Name 81**]: shoulder shrug [**4-26**] b/l
XII: tongue midline
-Motor:
spontaneously moving all 4 extremities purposefully. normal tone
throughout
Sensory:
Intact to light touch throughout
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was extensor bilaterally.
MRI of Spine:
Degenerative disc disease with moderate-to-severe bilateral
neural foraminal
narrowing at C3-4, C4-5, and C5-6. No cord compression seen.
Degenerative disc disease seen in the lumbar spine as described
with subacute Schmorl's node at L4-5 interspace. Note made of
bilateral pleural effusions with underlying lung atelectasis. A
2-cm cystic lesion, possibly arising from left ovary. An MRI of
the pelvis may be performed if clinically indicated.
MRI of Brain: Post-craniotomy changes in the frontal bone with
focal
encephalomalacia and right inferior frontal region.
Pertinent Results:
[**2131-6-27**] 04:26PM CEREBROSPINAL FLUID (CSF) PROTEIN-41
GLUCOSE-87
[**2131-6-27**] 04:26PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-15 LYMPHS-38 MONOS-46
[**2131-6-27**] 05:09AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-POS
[**2131-6-27**] 05:09AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM
[**2131-6-27**] 05:09AM cTropnT-<0.01
[**2131-6-27**] 12:00PM SED RATE-3
[**2131-6-27**] 01:49PM ALBUMIN-3.2* CALCIUM-7.1* MAGNESIUM-2.1
[**2131-6-27**] 01:49PM ALT(SGPT)-21 AST(SGOT)-29 LD(LDH)-211
CK(CPK)-117 ALK PHOS-61 TOT BILI-0.2
Brief Hospital Course:
Ms. [**Known lastname 41507**] was admitted to the [**Hospital1 18**] neuro-ICU for closer
monitoring. She was initiated on broad spectrum anti-infective
medications to cover for viral/bacterial forms of meningitis,
treated with IV keppra for her seizures, and remained on
continuous video EEG monitoring. She was seen and examined by
one of our senior epilpetologists, Dr. [**Last Name (STitle) 104943**]. After
extubation, she did well, and was subsequently transferred to
the floor. Her MRI showed postcraniotomy changes of the right
frontal bone with underlying encephalomalacia, and her EEG did
not show obvious seizure events. Re: postcraniotomy changes, I
am told by her PCP that she has a history of brain trauma and
recent release from incarceration.
Ultimately, it was thought that her seizures were provoked and
secondary to cocaine abuse (her UTOX was positive for cocaine
metabolites). On the floor, she did well and did not suffer from
any more seizures. Her acyclovir was continued until her HSV-PCR
returned negative, although we had a low suspicion for a viral
process to begin with. She was discharged with instructions to
follow up with her PCP at [**Name9 (PRE) 5239**] Medical Center in [**Hospital3 **]. I
spoke with her NP[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**] and made her aware that a 2cm
ovarian cyst was incidentally discovered on her L-spine MRI and
likely can be followed up with either TVUS or abdominal CT/MRI.
On discharge, the patient's physical exam was such that she was
alert, awake and oriented with normal speech, comprehension and
intact short term memory. Her right pupil is fixed with an
anterior opacity, but her left pupil reacts to light well. Other
cranial nerves are unremarkable; there is no facial droop,
tongue is midline, sensation is grossly intact and her SCMs are
symmetric. Strength and sensation is symmetric and nonfocal, and
her gait is normal.
Medications on Admission:
Methadone 35mg [**Hospital1 **]
Xanax 0.25mg TID
Ambien 5mg QHS PRN
Discharge Medications:
1. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for anxiety.
Disp:*1 Tablet(s)* Refills:*0*
2. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 tablets* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cocaine abuse
Opiate dependence
Asthma
Discharge Condition:
Discharge Condition: stable
Mental Status: Alert and oriented, comprehension is intact,
speech is fluent without paraphasic errors, intact short term
memory and attention
Neurological exam: right pupil is nonreactive (chronically) [**1-24**]
cataract, otherwise left pupil is 6-4mm, strength is full and no
sensory deficits, coordination and gait is stable
Discharge Instructions:
You were treated for seizures during this hospitalization. You
were treated with medications to reduce seizure frequency, and
were subsequently discontinued.
Followup Instructions:
Please follow up with your primary care provider in one week
Completed by:[**2131-7-3**]
|
[
"345.3",
"304.00",
"970.81",
"305.60",
"518.81",
"493.90",
"070.70",
"780.60",
"E854.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
6467, 6473
|
4168, 6103
|
344, 396
|
6577, 6584
|
3499, 4145
|
7121, 7212
|
1578, 1604
|
6222, 6444
|
6494, 6535
|
6129, 6199
|
6939, 7098
|
2272, 3480
|
1619, 2146
|
6746, 6915
|
265, 306
|
424, 1073
|
6599, 6727
|
1095, 1216
|
1232, 1562
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,385
| 124,462
|
30622
|
Discharge summary
|
report
|
Admission Date: [**2146-10-3**] Discharge Date: [**2146-10-10**]
Service: CARDIOTHORACIC
Allergies:
Percocet
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
AVR/CABG x1 [**2146-10-3**] (19mm CE pericardial valve, SVG to RCA)
pacemaker insertion [**2146-10-7**]
History of Present Illness:
83 yo female with long-standing AS and history of CHF. First
seen in [**5-19**]. Surgery delayed secondary to MRSA bacteremia
(completed 6 week course of vanco), mesenetyeric schemia
(SMA/celiac stenting), and leukopenia ( resolved when plavix and
immunosuppressive stopped). Underwent repeat celiac stneting for
a fractured stent 2 weeks ago. Cath revealed RCA disease.
Past Medical History:
AS/CAD
MI [**5-19**]
PVD with SMA/celiac stents [**5-19**] and [**9-18**];mesenteric ischemia
left popliteal atherectomy
HTN
NIDDM
elev. chol.
CHF
hypothyroid
depression
prior MRSA bcteremia
prior leukopenia
PMR
giant cell arteritis
glaucoma
anemia
s/p colon ca with colectomy
Social History:
Independent senior, lives alone in [**Hospital1 1562**] ([**Hospital3 **]). Has one
daughter in the area, another daughter in [**Name (NI) 7349**]. One son in
[**Name (NI) 4565**]. Quit tobacco many years ago. Denies ETOH.
Family History:
Denies premature coronary artery disease
Physical Exam:
HR 76 reg right 139/53 left 121/42
5'2" 137#
NAD
large ecchymotic area left brachial cath site
PERRLA,EOMI, anicteric, OP unremarkable
neck supple, no JVD
murmur transmitted bil. to carotids
CTAb
RRR with 3/6 SEM throughout precordium to carotids
abd soft, NT, ND, + BS
no CVA tenderness or HSM
extrems warm, well-perfused, no edema, small BLE spider veins
neuro nonfocal exam, MAE [**3-17**] strengths
2+ bil. DP/radials
1+ bil. PTs
2+ right fem/1+ left fem
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **]
[**Last Name (NamePattern1) 2325**] Ventricle - Ejection Fraction: >= 55% >= 55%
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aortic Valve - Peak Gradient: *68 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 47 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Mildly dilated RV cavity. Focal apical
hypokinesis of RV free wall.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. Severe AS (AoVA
<0.8cm2). Mild to moderate ([**12-14**]+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of mitral valve chordae. Mild to moderate ([**12-14**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
Physiologic (normal) PR.
PRE BYPASS
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). The right ventricular
cavity is mildly dilated. There is focal hypokinesis of the
apical free wall of the right ventricle. There are complex
(>4mm) atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is severe aortic valve
stenosis (area <0.8cm2). Mild to moderate ([**12-14**]+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild to moderate ([**12-14**]+) mitral regurgitation is seen.
POST BYPASS
Preserved biventricular systolic function. There is a well
seated well functioning bioprostheisi in the aortic position. No
AI is visualized. MR remains mild to moderate.
I certify that I was present for this procedure in compliance
with HCFA regulations.
CHEST (PA & LAT) PORT [**2146-10-8**] 1:38 PM
PA AND LATERAL CHEST ON [**2146-10-8**] AT 13:39
INDICATION: New pacemaker.
FINDINGS: A pacemaker hardware of a dual-chamber device is
visualized over the left anterior soft tissues. The wires are
intact and the tips are appropriately located. Note is made of
prior aortic valve replacement. There are bilateral pleural
effusions similar to that noted on the prior film from [**2146-10-6**].
No airspace consolidations.
[**2146-10-9**] 05:40AM BLOOD WBC-6.7 RBC-2.74* Hgb-8.9* Hct-26.7*
MCV-98 MCH-32.4* MCHC-33.2 RDW-16.8* Plt Ct-174
[**2146-10-9**] 05:40AM BLOOD Plt Ct-174
[**2146-10-7**] 11:57PM BLOOD PT-12.9 PTT-28.7 INR(PT)-1.1
[**2146-10-9**] 05:40AM BLOOD Glucose-152* UreaN-21* Creat-1.1 Na-140
K-4.3 Cl-106 HCO3-25 AnGap-13
Brief Hospital Course:
Admitted [**10-3**] and underwent AVR/CABG x1 with Dr. [**Last Name (STitle) 1290**].
Transferred to the CSRU in stable condition on titrated propofol
and phenylephrine drips.Extubated that evening and transferred
to the floor on POD #1 to begin increasing her activity level.
She was gently diuresed toward her preoperative weight. On
[**10-6**], she suffered a bradycardic cardiac arrest with full code
in the early AM hours. Paced via epicardial wires with no
neurologic deficit apparent. Transferred intubated back to the
CVICU, and extubated later that day. EP consult done to plan for
pacer, and pt. went into Afib in the interim. Treated with
amiodarone. Pacer inserted [**10-7**], and interrogated on the 27th .
Epicardial wires removed and transferred to the floor on POD #6.
Continued to make good progress and cleared for discharge to
rehab on POD #7. She was started on coumadin for paroxysmal post
op atrial fibrillation. Pt. is to make all followup appts. as
per discharge instructions.
Medications on Admission:
metformin 500 mg [**Hospital1 **]
ASA 81 mg daily
folate 1 mg daily
simvastatin 20 mg daily
prilosec 20 mg daily
levothyroxine 75 mcg daily
atenolol 12.5 mg daily
lasix 20 mg daily
citalopram 40 mg daily
latanoprost 0.005% one gtt QHS OU
bromonidine 0.15% one gtt [**Hospital1 **] OU
dorzolamide/tomolol 2-0.5% one gtt [**Hospital1 **] OU
MVI daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime): both eyes.
9. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H
(Every 12 Hours): both eyes.
10. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day): both eyes.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) for 1 months.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: until [**10-14**], then 400 mg daily until [**10-21**],
then 200 mg daily ongoing until discontinued by Dr. [**Last Name (STitle) 6254**].
13. Ferrous Gluconate 300 (35) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
15. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 5 days.
17. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for
5 days: hold for K > 4.5.
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0*
19. Warfarin 1 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: check INR [**10-11**].
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 14468**] Nursing & Rehabilitation Center - [**Location (un) 1456**]
Discharge Diagnosis:
AS/CAD s/p AVR/cabg x1
postop bradycardic arrest
pacemaker insertion
postop A Fib
MI [**5-19**]
PVD with SMA/celiac stents [**5-19**] and [**9-18**];mesenteric ischemia
left popliteal atherectomy
HTN
NIDDM
elev. chol.
CHF
hypothyroid
depression
prior MRSA bcteremia
prior leukopenia
PMR
giant cell arteritis
glaucoma
anemia
s/p colon ca with colectomy
Discharge Condition:
good
Discharge Instructions:
SHOWER daily, and pat incisons dry
no lotions, creams or powders on any incision
no driving until cleared by surgeon and PCP
no lifting greater than 10 pounds for 10 weeks
call surgeon for fever greater than 100.5, redness , or drainage
Followup Instructions:
see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 72601**] in [**12-14**] weeks
see Dr. [**Last Name (STitle) **] in [**1-15**] weeks
see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2146-10-10**]
|
[
"412",
"428.32",
"414.01",
"424.1",
"V10.05",
"244.9",
"725",
"401.9",
"272.0",
"250.00",
"440.0",
"997.1",
"427.81",
"427.31",
"427.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"96.04",
"39.61",
"88.72",
"37.78",
"35.21",
"37.83",
"96.71",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
8177, 8288
|
4813, 5815
|
227, 336
|
8685, 8692
|
1839, 4790
|
8977, 9241
|
1297, 1339
|
6215, 8154
|
8309, 8664
|
5841, 6192
|
8716, 8954
|
1354, 1820
|
184, 189
|
364, 736
|
758, 1037
|
1053, 1281
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,895
| 105,955
|
8048
|
Discharge summary
|
report
|
Admission Date: [**2171-9-26**] Discharge Date: [**2171-10-4**]
Date of Birth: [**2086-5-11**] Sex: F
Service: MEDICINE
Allergies:
Allopurinol / Levaquin
Attending:[**First Name3 (LF) 4980**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 85 year old female with a h/o symptomatic
bradycardia s/p recent pacemaker placement, COPD, A.fib on ASA,
vascular dementia who presented from rehab with a complaint of
worsening cough throughout the day, shortness of breath, chest
pain and increasing confusion per her home health aid. She
denied any n/v, diaphoresis. Upon arrival to the ER, her initial
VS were: 96.9, 100, 100/56, 18, 96%. CXR was done with no
evidence of infiltrate, EKG with A.fib in the 100's, however
given her symptoms she was empirically treated with ceftriaxone
and azithromycin. Later during her course in the ER she became
hypotensive with a temperature of 100, had a CTA that ruled out
a PE, at CT head that did not show an acute process, an
abdominal ultrasound was done that did not show any
intra-abdominal pathology, but did show a pericardial effusion.
As a result cardiology did a bedside echo, which showed a small
pericardial effusion, no evidence of tamponade. Blood and urine
cultures were also sent. She then had a right IJ placed for SBP
low of 65, and then persistent SBP's in the 70's, and was
started on levophed at 0.03, with an improvement in her blood
pressures to a systolic in the 100's. Her antibiotic coverage
was also broadened to vancomycin and zosyn. For fluid
resuscitation she received a total of 2LNS during her stay in
the ER.
.
On the floor, initial VS were: 98.3, 127, 128/55, 21, 95% on
3LNC. She is currently denying any pain, denies any CP, SOB,
n/v/d, dysuria, back pain or palpitations. She does say that she
continues to have a cough, that is sometimes productive. She was
oriented times [**2-16**], and somewhat lethargic, falling asleep
during the examination.
.
Review of systems: Unable to obtain a full ROS due to mental
status
(+) Per HPI
(-) Denies headache, congestion. Denies nausea, vomiting,
dysuria.
Past Medical History:
Symptomatic Bradycardia s/p Pacemaker Placement [**8-24**]
Diabetes
Dyslipidemia
Hypertension
Chronic noncardiac chest pain
Anxiety
Gait disorder
Atrial fibrillation on aspirin
Asthma and COPD
History of CVA
Dementia (multi-vascular)
Diabetes mellitus type 2
Hyperlipidemia
Hypertension
Hypothyroidism
Osteoporosis
Gout
Edema
DJD
Social History:
Denies any alcohol. Quit smoking 23 years ago, used to have one
20-pack-year smoking history, and three packs for 40 years.
Lives in [**Location **] Place [**Hospital3 400**] Facility. She never
finished high school and then went to [**University/College **] Extension School
matriculated from there and then went to learn about psychology
and social work from [**University/College **]. She has currently 24-hour social
caregiver with only time that is during mealtime that she will
be by herself.
Family History:
Two sisters died from lung cancer
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2171-9-25**] 08:15PM BLOOD WBC-11.0# RBC-3.28* Hgb-9.5* Hct-28.9*
MCV-88 MCH-28.9 MCHC-32.8 RDW-14.7 Plt Ct-288#
[**2171-9-25**] 08:15PM BLOOD Neuts-74.7* Lymphs-17.5* Monos-7.3
Eos-0.2 Baso-0.2
[**2171-9-25**] 08:15PM BLOOD Plt Ct-288#
[**2171-9-25**] 08:15PM BLOOD PT-14.6* PTT-28.1 INR(PT)-1.3*
[**2171-9-25**] 08:15PM BLOOD Glucose-162* UreaN-30* Creat-1.0 Na-142
K-4.3 Cl-103 HCO3-30 AnGap-13
[**2171-9-26**] 03:41AM BLOOD ALT-8 AST-13 LD(LDH)-238 CK(CPK)-23*
AlkPhos-78 Amylase-21 TotBili-0.4
[**2171-9-26**] 03:41AM BLOOD Lipase-18
[**2171-9-25**] 08:15PM BLOOD cTropnT-<0.01
[**2171-9-26**] 03:41AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-3945*
[**2171-9-26**] 04:09PM BLOOD CK-MB-1 cTropnT-<0.01
[**2171-9-26**] 03:41AM BLOOD Calcium-7.2* Phos-3.3 Mg-1.5*
[**2171-9-26**] 03:41AM BLOOD Hapto-224*
[**2171-9-26**] 03:41AM BLOOD TSH-0.94
[**2171-9-26**] 03:41AM BLOOD Cortsol-20.4*
[**2171-10-3**] 06:49AM BLOOD calTIBC-290 Ferritn-112 TRF-223
.
Micro:
[**2171-9-25**] Blood culture- No growth.
[**2171-9-25**] Urine culture- <10,000 organisms.
[**2171-9-26**] MRSA screen- no MRSA isolated.
[**2171-9-29**] Blood culture- No growth.
[**2171-9-30**] Blood culture- No growth.
[**2171-9-30**] Urine culture- No growth.
........
Studies:
[**2171-9-25**] CXR: Low lung volumes, but no acute cardiopulmonary
abnormality.
.
[**2171-9-25**] CT Head W/Out Contrast: 1. No acute intracranial
hemorrhage or mass effect. 2. Extensive encephalomalacia in the
right frontal and left parietal lobes,compatible with old
infarcts. Comparison with prior studies would be helpful. Given
the lack of priors and presence of pacemaker, consider followup
CT without and with contrast to exclude mass lesions
.
[**2171-9-25**] CTA Chest: 1. No acute pulmonary embolism or aortic
pathology. Small right-sided pleural effusion. 2. Severe
anterior wedge T6 compression fracture, chronic in appearance.
3. Moderate-sized hiatal hernia.
.
[**2171-9-26**] TTE: Small LV cavity size with mild symmetric LVH and
hyperdynamic LV systolic function. Mild resting LVOT gradient.
Probable diastolic dysfunction. Mild pulmonary artery systolic
hypertension. Calcified mitral and aortic valve. Mild mitral
regurgitation.
.
[**2171-9-29**] EKG: Atrial fibrillation with rapid ventricular response
and ventricular paced beat. Left axis deviation may be due to
left anterior fascicular block and/or possible prior inferior
myocardial infarction. ST-T wave changes are non-specific. Since
the previous tracing of [**2171-9-26**] atrial fibrillation has replaced
sinus tachycardia.
.
[**2171-10-2**] EKG: Atrial fibrillation and paced beats at 71 beats per
minute. Compared to the previous tracing of [**2171-9-29**] the patient
is now in a paced rhythm at 71 beats per minute. The atria
remain in fibrillation.
.
[**2171-10-2**] CXR: There is opacification at both bases consistent
with
moderate pleural effusions and compressive atelectasis. Fullness
of pulmonary vessels is consistent with elevated pulmonary
venous pressure in patient with some enlargement of the cardiac
silhouette. Pacemaker device remains in place.
Brief Hospital Course:
Ms. [**Known lastname **] is an 85 year old female with h/o A.fib on ASA,
tachybrady syndrome s/p PPM placement, COPD, hypothyroid who
presented with hypotension, cough, chest pain and worsening
mental status. Her hospital course by problem is as follows:
# Hypotension: Patient was admitted to the medical intensive
care unit. She was initially started on levophed but weaned off
without difficulty shortly after admission. Her stool was
guaiaic negative and transfusion was deferred as the patient was
asymptomatic from her anemia. TSH and cortisol were within
normal limits. She was ruled out for MI. She did not appear
septic as there was no identifiable infectious source- blood and
urine cultures from [**9-25**] were negative. Blood cultures from [**9-29**]
and [**9-30**] were pending on discharge. While in the MICU, the
patient went into afib with tachycardia and developed transient
hypotension - possibly this was a contributing factor to her
initial presentation. There was no evidence of heart failure on
her initial CXR and no discrete cause for her hypotension on
ECHO. Patient's hypotension was responsive to fluid boluses and
she was transferred to the floor where she did not require any
further pressure support or fluid boluses, maintaining pressures
in the 130s-140s.
# Shortness of Breath: Upon admission, patient was maintained on
O2 and nebulizers, and it as thought her symptoms were most
likely [**3-19**] volume overload. The pt was diuresed aggressively
(to the point of some hypotension). However, she remained SOB
at times. She spiked a fever two days prior to transfer to the
wards, and her CXR, although not grossly different, still showed
some RLL process concerning for [**Month/Day (2) 10540**]. She was treated with vanc
and cefepime as above. At the same time, we thought a COPD
exacerbation was contributing, so she was started on steroids,
the [**Month/Day (2) 10540**] abx, and continued on nebulizers (xopenex, given her
AF, and atrovent). A PICC was placed for antibiotic treatment
and blood draws; this was discontinued on the day of discharge.
On the day of transfer to the wards, we were less convinced of
the [**Name (NI) 10540**] (pt was afebrile, without a WBC elevation, and numerous
cultures negative to date), so vanc and cefepime were changed to
abx for COPD exacerbation (azithromycin, as patient is allergic
to levofloxacin). On the wards, patient was sat-ing in the mid
90s on room air and was continued on this regimen (azithromycin
and prednisone) for 4 days. Diuresis for presumed diastolic
heart failure was restarted with IV lasix as patient sounded
crackly on exam and a repeat CXR showed engorged pulmonary
vasculature. Patient was discharged home with instructions to
continue her nebs as needed and to go back to her home dose of
lasix 40 mg PO to continue her diuresis until she followed up
with her PCP at her scheduled appointment the following week.
She will require a check of her electrolytes including BUN and
creatinine at the time of follow up.
.
# Atrial Fibrillation: Patient went into AF with RVR while in
the MICU. At that time her metoprolol dose was increased to 25
TID. Given her hypotension she was started on digoxin with the
goal of tapering down her metoprolol dose. Her digoxin level was
checked and was therapeutic on a qOD dosing schedule. She should
have this level rechecked as an outpatient. For the rest of her
hospitalization, the patient was monitored on telemetry and
remained largely in AF with ventricular pacing at a rate in the
60s-70s. She was discharged with instructions to continue her
digoxin, taper down and eventually discontinue her metoprolol,
and follow up with her primary care doctor.
.
# Anemia: The patient was anemic during this hospitalization
with a low hct close to 24. She received 1 unit PRBCs for
symptomatic treatment and her hematocrit improved over the
course of her hospitalization. Iron studies were sent and seemed
consistent with an anemia of chronic disease picture. Her hct on
discharge was 27.7 and patient was hemodynamically stable.
.
# Hypothyroidism: TSH was checked on [**9-26**] and was 0.94. Patient
was continued on her home levothyroxine.
# Diabetes: Patient's glipizide was held while she was an
inpatient, but she was continued on her home metformin and put
on an insulin sliding scale with QID finger stick blood sugar
checks.
.
# Depression/Anxiety: Patient was continued on her home regimen
of celexa/ativan. She remained stable on this regimen.
.
# Dementia: Patient was continued her home namenda.
.
# Goals of care: Palliative care was consulted and met with the
patient and her family to discuss goals of care. They decided to
pursue hospice after discharge and try to minimize unnecessary
interventions while an inpatient. Patient and family expressed
that they will likely not want to pursue future
hospitalizations. Social work was consulted for family coping.
.
# Code: DNR/DNI
.
Pending on Discharge:
Blood cultures from [**9-29**] and [**9-30**]
Medications on Admission:
CITALOPRAM - 20 mg at night
FUROSEMIDE - 40 mg daily
GLIPIZIDE - 5 mg daily
LEVOTHYROXINE - 75 mcg daily
LORAZEPAM - 0.5 mg [**Hospital1 **] prn
MEMANTINE [NAMENDA] - 5 mg twice a day
METFORMIN - 500 mg twice a day
METOPROLOL SUCCINATE - 50 mg Sustained Release once a day
NITROGLYCERIN - 0.4 mg sublingually prn
SIMVASTATIN - 80 mg at bedtime
TRAMADOL - 50 mg TID as needed
ACETAMINOPHEN - 500 mg Tablet 2 Tablet(s) by mouth Q 8 hours
ASPIRIN - 325 mg daily
CALCIUM CARBONATE-VITAMIN D3 - 600mg-400 unit - [**Unit Number **] Tablet(s) by
mouth twice a day
GUAIFENESIN [MUCINEX]- 600 mg Tablet Sustained Release - 2
Tablet(s) by mouth daily
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
2. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO once a day as needed for cough .
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID ().
5. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for anxiety, agitation .
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Calcium 600 with Vitamin D3 600 mg(1,500mg) -400 unit
Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day.
11. Tramadol 50 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
12. Acetaminophen 500 mg Capsule Sig: [**2-16**] Capsules PO every
eight (8) hours as needed for pain.
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*1*
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
Disp:*30 Tablet(s)* Refills:*0*
16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day for 2 days: Please take 1 tablet twice daily on Saturday
and one tablet once on Sunday.
Disp:*3 Tablet(s)* Refills:*0*
17. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation Q4h PRN () as needed for SOB.
Disp:*30 neb* Refills:*0*
18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb
Inhalation Q4H (every 4 hours) as needed for SOB.
Disp:*30 Neb* Refills:*0*
19. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Tachy-Brady Syndrome status post pacemaker placement
Atrial fibrillation
Diastolic heart failure
Hypertension
Anxiety/depression
Chronic obstructive pulmonary disease/asthma
Dementia (multi-vascular)
Diabetes mellitus type 2
Hyperlipidemia
Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital because you had trouble
breathing. While you were in the hospital your blood pressure
was low and you were admitted to the medical intensive care
unit. You were treated with medications to improve your blood
pressure and the function of your lungs. You were transferred to
the medical wards where you were continued on treatments for
your chronic lung disease and your heart disease.
We have made the following changes to your medications:
- Please start taking digoxin every other day as indicated
- Please change your metoprolol from metoprolol succinate to
metoprolol tartrate and take it as indicated on Saturday and
Sunday and then stop taking any kind of metoprolol until you
follow up with your doctor
- Please take xopenex and ipratropium nebulization treatments as
needed for your shortness of breath
You may continue taking your other medications as you were
previously.
Please follow up with your primary care doctor and cardiologist
at the appointments below.
It was a pleasure taking care of you at the [**Hospital1 18**].
Followup Instructions:
Please follow up at your previously scheduled appointments and
with Dr. [**Last Name (STitle) **] at the appointment we scheduled for you next
week:
Department: CARDIAC SERVICES
When: MONDAY [**2171-10-14**] at 3:20 PM
With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2172-3-23**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GERONTOLOGY
When: THURSDAY [**2171-10-10**] at 3:30 PM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 13171**], MD [**Telephone/Fax (1) 719**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2171-10-4**]
|
[
"428.0",
"437.0",
"V45.01",
"493.22",
"272.4",
"428.30",
"290.40",
"274.9",
"401.9",
"285.29",
"250.00",
"244.9",
"458.9",
"733.00",
"518.81",
"427.31",
"486",
"423.9",
"300.00",
"490"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14329, 14407
|
6734, 11687
|
303, 309
|
14706, 14706
|
3624, 6711
|
15982, 17045
|
3089, 3124
|
12444, 14306
|
14428, 14685
|
11774, 12421
|
14884, 15330
|
3139, 3605
|
11701, 11748
|
15359, 15959
|
2070, 2200
|
244, 265
|
337, 2051
|
14721, 14860
|
2222, 2554
|
2570, 3073
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,936
| 115,652
|
20897
|
Discharge summary
|
report
|
Admission Date: [**2157-3-23**] Discharge Date: [**2157-4-5**]
Date of Birth: [**2099-11-5**] Sex: M
Service: MEDICINE
Allergies:
Tetracyclines
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
Cardiac Catheterization, PTCA with stenting of LMCA/LCX
History of Present Illness:
Pt is a 57m with HTN, DM hyperlipidemia, CAD, CHF, ESRD on
coumadin who presents to ED w/ R nare epistaxis x 12 hours. He
reports that the epistaxis started at 1PM on day PTA when he was
doing ??????gymnastics.?????? He denies any trauma to the nose, though
states he may have picked at it. Despite applying pressure, it
continued to bleed for a period of 12 hours, and he was brought
to ED @ 1 AM on the day of admission.
In the ED, his R nare was packed.
Past Medical History:
CAD s/p CABG in [**2137**](LIMA-LAD, SVG-RCA), s/p 2 stents RCA [**6-/2155**]
with 3VD with occluded SVG grafts and patent LIMA, NSTEMI [**11-20**].
Last Cath 6/[**2155**].
CHF with EF 40% on [**2156-12-21**] echo with: Mod LV dysfunction, EF 40%
with mildly dilated RV and mild pulm htn, global HK, 2+MR [**First Name (Titles) **] [**Last Name (Titles) **]R.
Hypertension
Hyperlipidemia
Insulin-dependent diabetes mellitus
morbid obesity
hypothyroidism
s/p Hartmann's procedure for diverticular bleed
recurrent bilateral pleural effusions R>L-- last tapped under
USG guidance [**12-24**]
depression
Social History:
forty-five pack year history, quit 15 years ago. No EtOH in 3
years, never a heavy drinker.
Family History:
two brothers with DM. Mother died at age 5 of a stroke. Father
died at 55 of an MI.
Physical Exam:
On physical exam, obese man, anxious, lying in bed, slightly
tachypneic, but does not appear to be tiring.
Vital signs:
Temp: Pulse: BP: RR: O2 Sat:
98.4 97 81/65 25 97% RA
Skin:
Multiple scars on abdomen, legs, chest. No rash, petechiae, or
ecchymoses.
HEENT:
Head NC/AT. Sclerae anicteric, conjunctiva pink. PERRLA, EOMs
intact. Nasal mucosa pink. Oropharynx dry, nonerythematous. .
Neck supple. No LAD.
Cardiac:
JVP difficult to assess. Carotid pulses 1+ bilat.; moderately
brisk upstroke; without bruits. II-III/VI holosystolic ejection
murmur, most prominent at LSB.
Pulmonary:
Decreased breath sounds at bases. Bibasilar crackles.
Abdomen:
Colostomy bag ?????? stump pink, non-erythematous. BS present in all
4 quadrants. Obese, soft. No tenderness No hepatosplenomegaly.
-black stool, guiac positive.
Extremities:
Slightly cool extremities bilaterally. Symmetric 1+ radial and
DP pulses. 1+ edema.
Neuro:
MMSE: AOx3. Rest of MMSE not performed.
CNs: II-XII intact to direct testing.
Pertinent Results:
Admission Labs:
BLOOD WBC-9.0 RBC-3.24* Hgb-10.2* Hct-32.4* MCV-100* MCH-31.3
MCHC-31.4 RDW-18.6* Plt Ct-473*
PT-22.9* PTT-30.2 INR(PT)-2.3*
Glucose-158* UreaN-41* Creat-2.0* Na-128* K-5.4* Cl-91* HCO3-26
AnGap-16
Calcium-8.2* Phos-3.5 Mg-1.5* Iron-31* Cholest-157
[**2157-3-26**] 06:19AM BLOOD WBC-9.4 RBC-2.69* Hgb-8.5* Hct-26.9*
MCV-100* MCH-31.4 MCHC-31.4 RDW-18.1* Plt Ct-464*
Cardiac Enzymes:
CK(CPK)-30* CK-MB-3 cTropnT-0.35*
CK(CPK)-25* cTropnT-0.32*
CK(CPK)-27* CK-MB-NotDone cTropnT-0.29*
CK(CPK)-31* CK-MB-NotDone cTropnT-0.35*
Other Laboratory Studies:
Triglyc-170* HDL-36 CHOL/HD-4.4 LDLcalc-87
calTIBC-280 Ferritn-945* TRF-215
PTH-99*
Digoxin-0.6*
PT-15.9* PTT-26.5 INR(PT)-1.4*
[**2157-3-26**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE
[**2157-3-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE
[**2157-3-24**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-NEGATIVE
CHEST (PORTABLE AP) [**2157-3-23**] 10:22 AM
IMPRESSION: Congestive heart failure with pulmonary edema and
bilateral pleural effusions. Opacity at the right lung base may
represent pneumonia versus atelectasis.
ECG Study Date of [**2157-3-23**] 2:14:20 AM
NOTE: patient on digoxin
Sinus rhythm. First degree A-V delay. Left atrial abnormality.
Modest
non-specific intraventricular conduction delay. Probable
infero-posterior myocardial infarction, age indeterminate.
Diffuse ST-T wave abnormalities are non-specific but cannot
exclude ischemia. Clinical correlation is suggested for possible
right ventricular overload. Since the previous tracing of
[**2157-1-29**] ST-T wave changes appear more prominent
ECG Study Date of [**2157-3-24**] 10:50:40 AM
Sinus rhythm Right axis deviation Inferolateral/posterior
myocardial infarct Since previous tracing, no significant
change
ECHO Study Date of [**2157-3-29**]
The left atrium is mildly dilated. The right atrium is markedly
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is mildly dilated. There is severe
global left ventricular hypokinesis (ejection fraction [**11-4**]
percent). 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 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. The mitral valve leaflets are structurally normal.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen. There is no
pericardial effusion. Compared with the findings of the prior
study (images reviewed) of [**2157-1-20**], the left ventricular
ejection fraction is further reduced.
Cardiac Catheterization [**2157-4-1**]:
COMMENTS:
1. Selective coronary angiography revealed a right dominant
syetm with
severe three vessel disease. RCA stents were patent but the
distal vessel and the R-PDA were diffusely severely diseased.
The LMCA was totally occluded as were the proximal LCX and the
LAD. LIMA to the LAD graft was patent but did not backfill the
LCX. SVG grafts were know occluded and were not engaged.
2. Left vetriculography was deferred.
3. Hemodynamic assessment showed markedly elevated left and
right sided
filling pressures (PCWP 29 mm Hg and RAp 34 mm Hg) consistent
with severe volume overload. RA pressure tracing and LVEDP
tracing had accentuated X and Y descents and square root sign
configuration consistent with interventricular interdependence
due to volume overload. Cardiac index was 2.0.
4. Successful PTCA and stenting of the LMCA and the LCX with
two 2.5 mm Cypher drug-eluting stents, proximally post-dilated
to 3.0 mm. 5. The right CFA arteriotomy site was closed with a
6 French Angioseal.
Brief Hospital Course:
In summary this is a 57 year old man with HTN, DM
hyperlipidemia, CAD, CHF, ESRD on anticoagulation who presents
to ED w/ epistaxis x 12 hours.
Following transfer to the floor, the pt appeared volume
overloaded on CXR. He subsequently [**Month/Day/Year 1834**] HD on [**3-23**] and had
2 kg ultrafiltration. During the next few days, the pt had
several intermittent episodes of chest pain with EKGs showing
deepened ST depression anterolaterally with peak troponins of
0.38 and CKs in 30s. The ST changes persisted even after
resolution of the CP (relieved with metoprolol). He again
received HD on [**3-24**] and [**3-26**] with 2L ultrafiltrated both
times. The medicine team contact[**Name (NI) **] the pt's outpatient
cardiologist who stated that pt's last cath was in [**6-19**] at
[**Hospital1 18**]. He had not had a cath at [**Hospital1 2025**] as was erronously stated in
a prior discharge summary. The pt's outpt cardiologist agreed
with continuing ASA and coumadin and discontinuing plavix since
the taxol stent was placed over 19 months ago. The pt was also
re-started on a statin. Given the episodes of chest pain with
unclear etiology and EKG changes, the plan was made to proceed
with P-MIBI on [**3-29**]. In further events, the pt was transfused 2
units of PRBCs over the hospital course for a goal Hct of 30
given concern for demand ischemia.
.
On [**3-28**], the pt [**Month/Year (2) 1834**] HD during which he had 2 L
untrafiltrated. He tolerated this well but did receive 0.5 mg of
IV ativan for anxiety. Following arrival back on the floor, the
pt was found to be hypotensive at 78/doppler and was more
lethargic then his baseline. At that time, the pt reported the
presence of chest pain but stated that had been present for
months. In addition, her reported mild SOB and nausea. No
abdominal pain or vomiting. The pt received a total of 750 cc of
NS (250 cc x3) but his SBP remained in the 80s and his mental
status did not improve. VBG was significant for a lactate of
5.2. An ABG could not be obtained and it was difficult to
maintain an oxygen sat per finger probe. EKG was essentially
unchanged with ST depressions persistent in 1, V1-V3, and V5-V6
with RBBB pattern. CXR showed bilateral pleural effusions and
?RLL opacity essentially unchanged from prior. At that time, the
pt was transferred to MICU for concern for sepsis and further
management.
.
MICU course:
For hypotension after dialysis, the patient was started on vanco
and ceftriaxone initially as there was a concern for sepsis.
Nasal packing was removed by ENT and PICC line was discontinued
and sent for culture. When all cultures were negative x
48hours, antibiotics were discontinued. The patient did not
have any further episodes of hypotension during his MICU stay
and even after HD, he remained hemodynamically stable. His
blood pressure ranged 90-100s. As a part of hypotension w/u,
TTE was done which showed decreased EF of [**11-4**]% as compared to
TTE done in [**1-21**] (EF of 25%). Given his ST depression and chest
pain hx, it was felt that his worsening EF was secondary to
ischemia. The patient was continued on ASA and lipitor, but
given his hypotension, BB was not started in MICU but should be
restarted once BP persistently stable. Dr. [**Last Name (STitle) **] was made aware
of the new findings on echo, and it was decided that patient
should undergo cardiac cath for intervention. Dr. [**Last Name (STitle) **] also
recommended started carvedilol 3.125 [**Hospital1 **], spironolactone 25 qday
and Zestril 5 qday as BP tolerates. For afib, his
anticoagulation was held for cardiac cath and digioxin was held
per Dr. [**Last Name (STitle) **] as it is unlikely improve his mortality.
.
Mr. [**Known lastname **] [**Last Name (Titles) 1834**] cardiac catheterization on [**2157-4-1**] and found
to have 3VD with complete occlusion of the LMCA, proximal LCX
and the LAD. PTCA and stenting was performed for the LMCA and
the LCX with two 2.5 mm Cypher drug-eluting stents. Hemodynamic
assessment also showed elevated left and right sided filling
pressures consistent with severe volume overload.
.
Consequently, Mr. [**Known lastname **] [**Last Name (Titles) 1834**] 3 days of hemodialysis in order
to make him more euvolemic. He was restarted on coumadin.
.
Following cardiac catheterization Mr. [**Known lastname 55603**] BP seemed to
improve slightly (high 90s-110s SBP) and Coreg 3.125 mg [**Hospital1 **] was
re-initiated. He should be followed by Cardiology after
discharge for further tailoring of his CHF regimen (titrating BB
up and adding ACEI as tolerated).
.
.
Additional hospital course by issues:
1. Epistaxis: Mr. [**Known lastname 55603**] nose was packed in the ED. On
admission, his stool was notable for being guaic positive. His
warfarin and coumadin were held on the day of admission, then
restarted the following day when there was no evidence of
continued epistaxis. His hematocrit was followed throughout his
hospital stay and he periodically received transfusions of PRBCs
during dialysis. Nasal packing was removed by ENT after 6 days.
Keflex was prescribed to prophylax against toxic shock
syndrome.
2. C.Difficile: Per [**Hospital **] Rehab his stool was positive for
C.Diff on [**2157-2-24**], [**2157-3-14**], and [**2157-3-15**]. On admission he was
taking PO vancomycin (presumably for C.Diff failing to clear on
metronidazole). PO vancomycin was continued during
hospitalization until he was C.Diff negative x 3 and hand
complated a 14 day course of PO vancomycin.
Medications on Admission:
1. Lansoprazole 30 mg PO DAILY
2. Acetaminophen 325-650 mg PO Q4-6H:PRN
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Albuterol-Ipratropium [**1-17**] PUFF IH Q6H:PRN
5. Nephrocaps 1 CAP PO DAILY
6. Aspirin 325 mg PO DAILY
7. Quetiapine Fumarate 50 mg PO QHS
8. Clopidogrel Bisulfate 75 mg PO DAILY
9. Quetiapine Fumarate 25 mg PO Q12H:PRN
10. Digoxin 0.125 mg PO DAILY
11. Sertraline 50 mg PO DAILY
12. Zofran 4 mg IV Q6H:PRN nausea
13. Senna 1 TAB PO BID:PRN
14. Docusate Sodium 100 mg PO BID
15. Sucralfate 1 gm PO BID
16. Epoetin Alfa
17. Vancomycin Oral Liquid 250 mg PO Q6H
18. Gabapentin 100 mg PO DAILY EXCEPT SUNDAY
19. Warfarin 6 mg PO DAILY
20. Insulin SC (per Insulin Flowsheet) Sliding
21. Toprol XL 50mg PO daily
22. Ocean 0.65% nose spray 2 sprays/nostril QID PRN
23. Glycerin suppository
24. Ducolax
25. lactulose
26. cepacol lozenges
27. robitussin AC syrup
28. Imodium
29. albuterol sulfate nebs
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-17**]
Puffs Inhalation Q6H (every 6 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
7. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) as needed.
9. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
EXCEPT SUNDAY ().
10. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
prn.
12. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
14. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Warfarin 2 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
18. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-17**] Sprays Nasal
5X/D (5 times a day) for 1 weeks.
19. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
21. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
Coronary Artery Disease s/p PTCA and stent placement
Congestive Heart Failure
Secondary Diagnoses:
Epistaxis
Diabetes Mellitus
ESRD on Hemodialysis
Hypothyroidism
Hypertension
Hypercholestolemia
s/p colostomy for diverticular bleed
Discharge Condition:
Stable, BP improved, without chest pain
Discharge Instructions:
You were admitted to [**Hospital1 18**] for uncontrolled bleeding from your
right nostril. Packing was placed in your nostril and remained
in place for 5 days, at which point it was removed. You
received several transfusions of blood for decreased blood
counts.
On [**3-28**] following dialysis your blood pressure dropped low,
and you were transferred to the Intensive Care Unit for close
monitoring. An echocardiogram of your heart was performed,
which demonstrated that the heart was not squeezing as
effectively as prior. Accordingly, on [**4-1**] you were taken to
cardiac catheterization where the blood vessels in your heart
were imaged and stents (metal scaffolding) were placed to open
up several vessels that were very narrow.
After the cardiac catheterization and aggressive dialysis to
remove excess fluid, your blood pressure improved slightly.
1. Please take all medications as prescribed. Please be aware
that your medications have changed while you have been
hospitalized. Some medications have been added, some have been
changed, and some have been removed.
2. Please keep all appointments with medical care providers.
You should follow-up with your Cardiologist, your kidney doctor,
and your primary care doctor.
3. You should contact your doctor or return to the hospital if
you experience:
-chest pain that does not resolve (particularly if it is
associated with shortness of breath, palpitations, sweating,
N/V)
-uncontrollable bleeding (if bleeding persists despite keeping
pressure on the site of bleeding for 15-30 minutes)
-for lightheadedness, confusion, decreased level of
consciousness
-for high fevers, uncontrollable shaking chills
- shortness of breath
- abdominal pain
- or any other concerning symptoms
Followup Instructions:
Cardiology Follow-up:
Dr. [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] on [**4-25**] @ 3PM. One [**Location (un) **] Place,
[**Apartment Address(1) 19746**]. ([**Telephone/Fax (1) 47597**]
Nephrology (Kidney):
Dr. [**First Name (STitle) 4102**] [**Name (STitle) 4090**], [**4-12**] @12:30 PM. [**Hospital **] Clinic, [**Location (un) 1385**].([**Telephone/Fax (1) 817**]
You should contact your Primary Care Physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 807**] ([**Telephone/Fax (1) 823**]) and arrange to be seen by him
approximately 2 weeks after you are discharged from the
rehabilitation center.
|
[
"428.0",
"403.91",
"280.0",
"427.31",
"276.1",
"585.6",
"272.0",
"411.1",
"414.01",
"008.45",
"414.02",
"784.7",
"250.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"21.01",
"00.66",
"37.23",
"39.95",
"88.56",
"99.04",
"00.46",
"36.07",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
14835, 14906
|
6554, 12085
|
282, 340
|
15202, 15244
|
2725, 2725
|
17036, 17733
|
1581, 1666
|
13046, 14812
|
14927, 14927
|
12111, 13023
|
15268, 17013
|
1681, 2706
|
15046, 15181
|
3126, 6531
|
233, 244
|
368, 830
|
2741, 3109
|
14946, 15025
|
852, 1455
|
1471, 1565
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,623
| 157,468
|
755
|
Discharge summary
|
report
|
Admission Date: [**2123-4-6**] Discharge Date: [**2123-4-9**]
Date of Birth: [**2081-1-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
Patient is a 42 year-old male with past medical history
significant for alcoholism and depression. Patient presented to
ED earlier this evening complaining of having fell off of a pole
and fell backwards [**Location 5491**]in [**Location (un) 86**]. He had a scalp
laceration which was not initially able to be repaired due to
c-spine precautions. The patient had a head CT which was
negative for any intracranial bleeds. CT neck also negative for
any fractures.
In the ED, initial vs were: T P 88, BP 89/58, RR 14 and O2 sat
100% RA. While in the ED the patient appeared anxious and
confused initially. ETOH level was 105 and the rest of
toxicology screen was negative.
.
In the ED he then had a witnessed apneic episode and then went
unresponsive for a few seconds per ED resdient but he had a
palpable pulse and blood pressures remained stable. During this
episode he had dropping oxygen saturations (drop not recorded)
and he was clinching his jaw to the point where he chipped his
tooth. Patient then went into rapid bilateral upper extremity
myoclonic jerking followed by partial proning of his arms
bilaterally. He was given Ativan 2mg IV x2, then 5mg IV Ativan,
then 6mg IV Ativan, followed by 7mg IV Ativan in ED.
.
Minutes later he developed SVT to 200 range which appeared to be
atrial fibrillation vs. flutter per ED resident. He was
intubated rapidly and then cardioverted in the ED with good
response as HR returned to NSR with rate in 70-90 range.
.
EKG was significant for borderline long QRS at .122 as well.
Toxicology was called and suggested patient be given bicarbonate
fluid to cover for possible TCA overdose given EKG findings.
While in ED he was given tetanus shot given new scalp
laceration, 3L NS IVFs and then 3Amps bicarbonate were given in
D5. He also got 1g IV Dilantin load and he was placed on
Propofol and a Versed drip started after intubation.
.
On arrival to the MICU patient was intubated and sedated. He was
on AC mode with Tv 600 x RR 16, FiO2 40% and PEEP 5. HR was 90,
BP 132/88 and patient was afebrile. He had dry dressings packed
over right sided head laceration and he was in a c-spine collar.
Past Medical History:
-alcoholism
-depression
Social History:
Unable to obtain as intubated, sedated
Family History:
NC
Physical Exam:
Vitals: AC mode with Tv 600 x RR 16, FiO2 40% and PEEP 5.
saturations 100%. HR 90, BP 132/88, Temp 99.9 F.
General: sedated, intubated, pale skin, very warm
HEENT: Sclera anicteric, MMM, oropharynx with some evidence of
dried blood over right buccal mucosa
Skin: pale skin, scalp with right posterior laceration, crusted
dry blood over hair, about 1" superficial
Neck: supple, JVP not elevated, no LAD, in a c-spine collar
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,
unable to assess guarding, no organomegaly noted
GU: foley in place, draining yellow fluid
Ext: warm, well perfused, 2+ pulses over upper/lower ext, no
clubbing, cyanosis or edema
Neuro : deferred as patiet intubated but PERRLA
Pertinent Results:
CT neck: no evidence of any fractures
CT head: prelim with no acute ICP
.
EKG: sinus tachycardia to 150s, RBBB, QRS 122; QTc 423
Brief Hospital Course:
42yo male with past medical history of alcoholism and depression
who had recent fall and is now status post seizure with
associated hypoxia and SVT episode in ED.
.
#) Alcohol intoxication with withdrawal syndrome: per patient's
report, last drink was on [**Location (un) 766**] [**4-5**] and he consumed 1.5 pints
of vodka. He had a seizure that was though to be multifactorial
in the ER but denied any prior episodes of visual hallucinations
in the context of Etoh withdrawal. Patient was initially
intubated and managed in the ICU, in the setting of concern
about protecting his airway during the seizure in the ER. He
was started on CIWA scale in the ICU and was extubated within 24
hours. After extubation his vital signs remained stable and he
was able to be weaned to q3h CIWA's so he was transferred to the
floor. On the floor he was able to be weaned to q4h CIWA's, and
watched until he was out of the danger zone for another seizure.
He had social work consult for help with outpatient alcohol
abuse programs and maintained on a multivitamin, thiamine and
folate.
.
#) Seizure: Patient initially presented to the ER s/p a fall,
but then had a witnessed seizure in the ER thought to be due to
ETOH withdrawal in combination with wellbutrin use which lowered
his seizure threshold. Patient was initially dilantin loaded in
the ER and neurology was consulted. An EEG was done with no
evidence of seizure activity, so dilantin was discontinued as
per neurology recommendations.
.
#) Supraventricular tachycardia: EKGs and telemetry in ED
consistent with rapid SVT to 280 at peak with etiology possibly
atrial fibrillation/flutter or AVNRT as some of the tracings
appear more regular vs. irregular. He was cardioverted in the
ER with no further episodes during his hospital stay. His
troponins remained flat, his CK was elevated but in the setting
of his fall, was thought to be due to possible rhabdomyolysis.
.
#) Elevated CK: patient with CK elevated to around 1000, given
recent fall concerning for possible rhabdomyolysis. He was
continued on IVF hydration to help prevent kidney damage, and
his CK's trended down.
.
#) Depression/anxiety: patient has been followed by a
psychiatrist in [**Last Name (LF) 8**], [**First Name3 (LF) **] continue to hold home wellbutrin
given concern about seizure threshold. Neurology team contact[**Name (NI) **]
patient's psychiatrist to discuss concerns about wellbutrin, and
his wellbutrin was not restarted. At the time of discharge he
had outpatient follow up with his psychiatrist.
Medications on Admission:
Medications: Confirmed per last fill at pharmacy
CVS [**Location (un) 5492**], [**Location (un) 86**] - ([**Telephone/Fax (1) 5493**]
Last filled [**2123-3-17**]
gabapentin 800mg [**Hospital1 **]
alprazolam 0.5 [**Hospital1 **] prn anxiety (#30)
tylenol codeine 2 Q4-6hr prn pain (#50)
buproprion XL 300mg daily
.
prior: lexapro 20mg (last filled [**7-/2122**])
celexa 60mg daily (last filled in spring [**2121**])
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Alcohol Withdrawal
2. Fall
3. Seizure
4. Depression/Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 5239**], it was a pleasure caring for you during your stay at
[**Hospital1 18**]. You were admitted after you had a fall [**Last Name (un) 5494**]. In the ER you were witnessed having a seizure and then
went into a fast heart rhythm that required your heart to be
shocked to stop, during this time you were intbuated and
transferred to our intensive care unit. The next morning you
were able to be extubated and transferred to the medicine floor,
we monitored you on the medicine floor for signs of alcohol
withdrawal. After you were out of the danger period for
withdrawal we felt you were medically stable for discharge.
During your stay we also made some changes to your psychiatric
medication regimen, due to concern about some the medications
contributing to your seizure. The most important thing you
could do to help keep yourself safe, and benefit your health
would be to stop drinking alcohol. Please consider following up
with one of the outpatient program options given to you by the
social workers from the hospital. Please make sure you drink
plenty of fluids after you leave the hospital.
.
Changes made to your medication regimen:
1. STOPPED Wellbutrin 300mg daily
2. STOPPED Alprazolam 0.5mg prn anxiety
3. DECREASED Seroquel dose to 50mg at night as needed for
anxiety/insomnia
4. STARTED Folic Acid 1mg daily
5. STARTED Multivitamin 1 tablet daily
6. STARTED Thiamine 100mg daily
Followup Instructions:
Psychiatry:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5495**]
[**Last Name (LF) 766**], [**4-12**] at 1pm
.
Please call 1-[**Telephone/Fax (1) 5496**] to talk with your insurance company
about what plan you have. Then once you have the policy number
please call [**Telephone/Fax (1) 798**] to book an appointment. You are all
registered through [**Hospital1 778**] and they will book the appointment for
you within 2 weeks. They just want to make sure you have active
insurance so you [**Last Name (un) 5497**] stuck with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] for the appointment.
|
[
"799.1",
"300.4",
"780.39",
"287.5",
"728.88",
"291.81",
"E885.9",
"285.9",
"427.1",
"873.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6680, 6686
|
3673, 6215
|
321, 333
|
6802, 6802
|
3519, 3557
|
8404, 9037
|
2625, 2629
|
6707, 6781
|
6241, 6657
|
6953, 8381
|
2644, 3500
|
274, 283
|
361, 2506
|
3566, 3650
|
6817, 6929
|
2528, 2553
|
2569, 2609
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,843
| 194,297
|
2813
|
Discharge summary
|
report
|
Admission Date: [**2156-7-30**] Discharge Date: [**2156-8-9**]
Service: SURGERY
Allergies:
Vancomycin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Lower abdominal pain. "Feels like gas". Wife reports marked
dyspnea after bowel movement with feet turning blue.
Major Surgical or Invasive Procedure:
IR placement of PICC line
[**8-2**] UGI endoscope performed
[**8-6**] EGD with multiple biopsies
History of Present Illness:
Mr. [**Known lastname 1352**] is a [**Age over 90 **]yo male with a past medical history of
hyptertension, CAD with [**Age over 90 4448**], DVT, pulmomary embolism,
osteoarthritis, & chronic lower back pain who presented to
[**Hospital1 18**] ED accompanied by his wife with c/o lower abdominal pain
for the past few days. His wife also reports that he became
increasingly short of breath after having a bowel movment, and
his lower extremeties turned blue.
Past Medical History:
- GERD/hiatal hernia
- Osteoarthritis
- Chronic LBP x 6 months - likely sciatica
- Varicose veins s/p stripping in RLE
- Type IIb heart block, asymptomatic bradycardia during sleep
- h/o PE in [**12-5**] with IVC filter [**3-4**]
Social History:
.
Married. Lives with wife. [**Name (NI) **] etoh. Quit smoking 30 years ago,
no illicit drug use. Pt is a retired jazz pianist. He likes to
swim but has not done so for several months.
.
Family History:
Non Contributory
Physical Exam:
Vitals: T-94.1, HR-79, BP-106/66, O2 sat 99% RA
Gen: NAD
Cardiac: RRR
Resp: coarse vs. bilateral crackles, diminished @bases
ABD: soft, nondistended with epigastric discomfort
Rectal: guaiac negative
Pertinent Results:
[**2156-8-9**] 09:29AM BLOOD WBC-12.6* RBC-UNABLE TO Hgb-9.5*#
Hct-31.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-25.4*# RDW-UNABLE
TO Plt Ct-342
[**2156-8-7**] 09:09AM BLOOD WBC-12.4* RBC-4.41* Hgb-12.7* Hct-38.2*
MCV-87 MCH-28.9 MCHC-33.3 RDW-14.2 Plt Ct-320
[**2156-7-30**] 02:30PM BLOOD WBC-14.0*# RBC-4.84 Hgb-14.4 Hct-42.8
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.6 Plt Ct-188
[**2156-8-8**] 07:10AM BLOOD PTT-73.4*
[**2156-8-6**] 06:15AM BLOOD PT-12.7 PTT-39.2* INR(PT)-1.1
[**2156-8-8**] 07:10AM BLOOD Glucose-138* UreaN-27* Creat-1.1 Na-140
K-4.1 Cl-109* HCO3-23 AnGap-12
[**2156-7-30**] 02:30PM BLOOD Glucose-133* UreaN-24* Creat-1.5* Na-140
K-3.1* Cl-103 HCO3-24 AnGap-16
[**2156-8-3**] 07:00AM BLOOD Amylase-127* TotBili-0.7
[**2156-7-30**] 02:30PM BLOOD ALT-74* AST-108* LD(LDH)-209 AlkPhos-83
Amylase-2621* TotBili-1.0
[**2156-8-3**] 07:00AM BLOOD Lipase-79*
[**2156-7-30**] 02:30PM BLOOD Lipase-2382*
[**2156-8-8**] 07:10AM BLOOD Albumin-3.1* Calcium-8.8 Phos-3.7 Mg-2.1
Iron-39*
[**2156-7-30**] 02:30PM BLOOD Albumin-4.3 Calcium-10.1 Phos-2.0* Mg-1.9
[**2156-8-8**] 07:10AM BLOOD calTIBC-231* Ferritn-277 TRF-178*
[**2156-8-8**] 07:10AM BLOOD Triglyc-67
[**2156-8-6**] 06:15AM BLOOD Triglyc-112
.
RADIOLOGY Final Report
CT ABDOMEN W/CONTRAST [**2156-7-30**] 3:51 PM
Reason: r/o obstruction-GASTROGRAFFIN please
ABDOMEN AND PELVIS CT WITH CONTRAST, [**2156-7-30**] AT 18:36
HOURS
HISTORY: On Coumadin with abdominal pain, nausea, and distended
abdomen.
IMPRESSION:
1. Distended stomach. Patient would likely benefit from
nasogastric tube decompression. There is also dilated duodenum
and proximal jejunum. No clear transition point is identified in
part because of poor oral preparation. However, more distal
small bowel loops are collapsed. There is extensive stool
throughout the colon including the rectal vault. An early
high-grade obstruction cannot be entirely excluded.
2. Markedly distended edematous gallbladder as above. While
pericholecystic inflammatory stranding is not present to a
significant degree, the wall edema is quite impressive and acute
cholecystitis cannot be excluded. To confirm or refute this
diagnosis, consider HIDA scan for further evaluation. US will
likely not provide further data.
3. Enlarged prostate without definite focal mass lesion.
Findings most consistent with benign prostatic hypertrophy;
however, CT is not sensitive to detect subtle prostate tumors.
If indicated, consider ultrasound or MRI for further evaluation.
4. Infrarenal IVC filter
.
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2156-7-31**] 5:14 AM
INDICATION: Acute pancreatitis. Gastric dilatation on CT.
COMPARISON: No previous plain film available for comparison.
FINDINGS: An IVC filter is in situ.
IMPRESSION: Some prominent loops of small bowel which may
represent an ileus.
.
RADIOLOGY Final Report
US ABD LIMIT, SINGLE ORGAN [**2156-8-1**] 11:16 AM
Reason: Please evaluate RUQ and gallbladder changes
INDICATION: Acute pancreatitis, possible gallbladder problem
since right upper quadrant pain.
IMPRESSION: Equivocal findings for acute cholecystitis with
gallbladder wall edema and distended gallbladder although no
pericholecystic fluid or stone is identified. A HIDA scan is
recommended for further evaluation.
.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2156-8-2**] 12:44 PM
Reason: evaluate for obstruction
IMPRESSION:
1. No free intraperitoneal air identified.
2. Marked gaseous distension of the stomach. Is there concern
for outlet obstruction.
3. Non-dilated colonic and small bowel segments filled with air.
.
RADIOLOGY Final Report
SMALL BOWEL ONLY (BARIUM) [**2156-8-3**] 1:15 PM
Reason: UGI series w/ sm bowel follow-through to evaluate for
SBO
HISTORY: [**Age over 90 **]-year-old male with gastric distention, sliding
hiatal hernia, pancreatitis. Evaluate for small bowel
obstruction.
COMPARISON: Abdomen supine and erect, [**2156-8-2**].
IMPRESSION: There is no evidence for anatomical obstruction.
There was retained contrast within the stomach after
approximately three hours, which may represent an ileus. There
was mild fold thickening of the third portion of the duodenum.
.
RADIOLOGY Final Report
UNILAT UP EXT VEINS US LEFT [**2156-8-5**] 4:55 PM
Reason: rule/out LUE DVT at PICC site.
LEFT UPPER EXTREMITY VENOUS ULTRASOUND STUDY.
CLINICAL HISTORY: [**Age over 90 **]-year-old man with pancreatitis and gastric
dilatation. Left-sided PICC line. Evaluate for left upper
extremity DVT at PICC line site.
IMPRESSION:
Extensive deep venous thrombosis extending from the distal left
subclavian to the left axillary and the left basilic veins.
.
Date: [**Last Name (LF) 2974**], [**2156-8-6**] Endoscopist
Indications: abnormal CT with duodenal thickening
upto proximal jejunum.
Impression: Medium hiatal hernia
Erythema and congestion in the antrum compatible with mild
gastritis (biopsy)
Normal mucosa in the first part of the duodenum, second part of
the duodenum, third part of the duodenum and fourth part of the
duodenum (biopsy, biopsy)
No luminal narrowing was noted upto proximal jejunum.
Otherwise normal EGD to second part of the duodenum
Recommendations: 1. Follow biopsy results
2. Follow up clinically.
Brief Hospital Course:
Mr. [**Known lastname 1352**] was evaluated in the ED. His labwork indicated an
acute pancreatitis, and possible cholecystitis. He underwent
diagnostics which revealed a small bowel obstruction. He was
admitted under the General Surgery service for further
management.
.
CARDIAC-His heart rate and blood pressure remained stable during
this admission.
.
RESP-His lungs sounds are decreased bilaterally with coarse
crackles which have improved. His oxygen saturation remains >95%
on RA.
.
NUT-He was NPO upon admission, and started on TPN for
nutritional support. His NGT was removed, and his diet was
advanced as his bowel function resumed. He was placed on
Aspiration Precautions prophylactically due to his frail
condition. He has shown no signs of aspiration. He is tolerating
a regular diet with Ensure supplements.
.
EXTREM-He developed a thrombus of the LUE where the PICC line
was inserted. He was treated with IV heparin, and transitioned
to Lovenox. He has a strong history of coagulpathies. He will
transitioned back to Coumadin under the supervision of his PCP
(Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **]) once he is discharged from Rehab. This
information was discussed with Dr.[**Name8 (MD) 13763**] RN at [**Hospital1 **] Health
Center. He continues with bilateral [**Location (un) **] with positive pedal
pulses bilaterally.
.
GI/ABD-There were multiple attempts to insert an NGT in the ED,
but was unsuccessful. He was admitted to the ICU on [**2156-7-30**] for
observation and insertion of NGT under IV conscious sedation,
intravenous resuscitation, and insertion of a Foley catheter.
The NGT was inserted successfully. He remained stable, and was
transferred to [**Wardname 13764**]. According to RUQ U/S, his gallbladder
appeared distended with no evidence of stones. His labwork
indicating pancreatitis resolved gradually. The etiology
remained unknown. He had multiple loose BM's. The CDIFF culture
was negative. GI was consulted. An EGD was completed x2 with
collection of multiple biopsies which are presently pending.
First revealed a hiatal hernia, and the second a hiatal hernia,
erythema. Please refer to pertinent lab result section. He also
underwent a small bowel follow through that indicated no
evidence of anatomical obstruction.
.
ID-He received IV levaquin & flagyl x 1 in the ED. He has
remained afebrile, and has not required additional antimicrobial
treatment.
.
NEURO-He became confused after IVCS in the ICU. He was managed
medically, and had hand mitts applied to prevent removal of NGT
and other devices. His mental status cleared, and he returned to
his baseline which was confirmed by his wife who remained at his
bedside. He is hard of hearing, but pleasant & cooperative.
.
Mobility-He was evaluated per physical therapy due to his
weakened condition. He ambulates with a walker and assist. He
requires monitoring for safety. He will continue rehabilitation
in [**Hospital 6669**] Rehab.
Medications on Admission:
Coumadin 6 mg, HCTZ 25 mg, aspirin 81 mg, multivitamin, calcium
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) 90mg Subcutaneous
Q12H (every 12 hours): Please expel 10mg for 90mg dose.
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) 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).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] Hospital
Discharge Diagnosis:
Primary:
Acute Pancreatitis treated with intravenous hydration
Small bowel obstruction treated with NGT & intravenous hydration
Hyperglycemia treated with regular insulin sliding scale
Left upper extremity thrombosis treated with intravenous heparin
.
Secondary:
1. PE in [**2153**], s/p IVC filter
2.HTN
3.complete heart block s/p pacer in [**2154**]
4. GERD
5.Hiatal hernia
6.Osteoarthritis
7.LBP
8. Parkinson disease diagnosed [**2156-7-29**]
Discharge Condition:
Good
Tolerating a regular diet with supplements
Denies pain.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
.
Lovenox to Coumadin:
-Follow-up with your PCP after discharge from Rehab to be
transitioned from Lovenox back to your Coumadin.
Followup Instructions:
Please call Dr.[**Name (NI) 1482**] office at [**Telephone/Fax (1) **] for a
follow-up appointment in 2 weeks.
Please follow-up with Dr. [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) **] after
dissharge from Rehab.
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2156-10-12**]
11:30
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2157-1-14**]
1:00
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Phone:[**Telephone/Fax (1) 2934**]
Date/Time:[**2157-7-20**] 2:40
Completed by:[**2156-8-9**]
|
[
"V45.01",
"401.9",
"715.90",
"724.2",
"575.12",
"553.3",
"V12.59",
"530.81",
"577.0",
"996.74",
"569.89",
"V58.61",
"332.0",
"V15.82",
"444.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"44.13",
"45.16",
"96.07",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10306, 10360
|
6846, 9814
|
329, 428
|
10850, 10913
|
1648, 6823
|
12134, 12779
|
1394, 1412
|
9928, 10283
|
10381, 10829
|
9840, 9905
|
10937, 12111
|
1427, 1629
|
177, 291
|
456, 915
|
937, 1169
|
1185, 1378
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,594
| 183,180
|
11783
|
Discharge summary
|
report
|
Admission Date: [**2118-10-20**] Discharge Date: [**2118-10-28**]
Date of Birth: [**2060-2-14**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Headaches and fevers.
Major Surgical or Invasive Procedure:
Placement of a VP shunt.
History of Present Illness:
This is a pleasant 58 year old man who came to the ED for a
3-day history of headaches and fevers. His headaches are
described as constant, rated [**11-8**], and recently associated with
nausea and vomiting (2-3 episodes of vomiting in the last
24hrs).
His headaches are aggrvated by coughing or straining. Of note,
he
has a hx of metastatic rectal ca (mets to liver/lungs/bone) and
has been treated with radiation.
Past Medical History:
PMHx:
- carcinoma of the rectosigmoid junction and rectum s/p low
anterior resection in [**2115**]
- Neo adjuvant chemo radiation ([**2115**])
- Six cycles of CPT-11, 5-FU and leucovorin ([**2116**])
- Ostomy reversal ([**2116**])
- seven cycles of the [**Doctor Last Name **] regimen with Avastin ([**2116**])
- 6 week cycles of FLOX chemotherapy ([**2118**])
Social History:
Patient accompanied by his mother.
Family History:
Noncontributory.
Physical Exam:
-----> PHYSICAL EXAM:
Gen: WD/WN, comfortable, NAD. Mother present with patient in
room
(speaks minimal english)
HEENT: Pupils: 4 to 2mm on the right, 3 to 2mm on the left. EOMs
intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+. Evidence of well-healed prior surgical
scars.
Extrem: Warm and well-perfused. No C/C/E.
.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect. [**Last Name (un) **], responds to questions appropriately.
Orientation: Oriented to person, place, and date.
Recall: [**4-1**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4 to 2mm on the
right, 3 to 2mm on the left. Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations. Of note, there are
some superficial tongue changes (dermatological changes).
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-3**] throughout. No pronator drift
.
Sensation: Intact to light touch bilaterally. Other sensory
modalities not tested.
.
Toes downgoing bilaterally
.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin intact.
Pertinent Results:
[**2118-10-20**] 11:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2118-10-20**] 11:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2118-10-20**] 09:22PM COMMENTS-GREEN TOP
[**2118-10-20**] 09:22PM LACTATE-2.8*
[**2118-10-20**] 09:02PM GLUCOSE-142* UREA N-10 CREAT-0.8 SODIUM-138
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-30 ANION GAP-16
[**2118-10-20**] 09:02PM CALCIUM-10.2 PHOSPHATE-4.0 MAGNESIUM-1.9
[**2118-10-20**] 09:02PM WBC-9.8 RBC-4.48* HGB-13.5* HCT-39.8* MCV-89
MCH-30.0 MCHC-33.8 RDW-14.0
[**2118-10-20**] 09:02PM NEUTS-83.5* LYMPHS-11.7* MONOS-4.3 EOS-0.4
BASOS-0.2
[**2118-10-20**] 09:02PM PLT COUNT-384
[**2118-10-20**] 09:00PM PT-13.0 PTT-26.0 INR(PT)-1.1
.
.
CT HEAD W/O CONTRAST [**2118-10-20**] 10:12 PM
IMPRESSION: Several large ring-enhancing lesions in the
cerebellum. In the setting of advanced metastatic colon cancer,
as this patient is known to have, these probably represent colon
cancer metastases. No definite hemorrhage, although there is
moderately dense material surrounding the lesions on the
pre-contrast imaging. Non-communicating hydrocephalus is
present, associated with either occlusion or high-grade
obstruction of the ventricular system. Findings discussed with
the covering team shortly after the study and put to the ER
dashboard as well.
NOTE ADDED AT ATTENDING REVIEW: As above, there is considerable
mass effect within the posterior fossa with inferior herniation
of the cerebellar tonsils.
.
.
CHEST (PA & LAT)
IMPRESSION: PA and lateral chest compared to [**2115-6-14**]:
Lung volumes are lower and multiple pulmonary nodules most
likely metastases are new. There is also generalized
interstitial abnormality which may represent lymphatic tumor
invasion. Small left pleural effusion is present. Heart is
normal size. Tip of the right subclavian infusion port projects
over the SVC. No pneumothorax.
.
.
CT ABD W&W/O C [**2118-10-22**] 4:39 PM
CT CHEST W/CONTRAST; CT ABD W&W/O C
IMPRESSION:
1. Substantial progression of disease with interval increase in
size and number of pulmonary lesions and more extensive
metastatic involvement of the liver. Increased mediastinal
lymphadenopathy.
2. New, small left pleural effusion.
.
.
MR HEAD W & W/O CONTRAST [**2118-10-22**] 2:12 AM
IMPRESSION: Rim-enhancing lesion in both cerebellar hemispheres
consistent with metastatic disease. Moderate obstructive
hydrocephalus. Edema involving the cerebellar hemispheres with
slightly low position of the cerebellar tonsils.
.
.
Brief Hospital Course:
This patient was admitted to the Neurosurgery service on [**2118-10-20**]. He was initially in the ICU for close monitoring of his
neurological status, although his clinical examination was
neurologically intact. The following morning on [**10-21**], he was
transfered to the floor in a stable condition.
.
The patient received repeat abdominal and chest imaging over the
course of the next few days, which showed disease progression
(please see radiology reports for furthur details). He was
prepared and consented per standard to go into the OR on [**10-26**].
From time of admission until VP shunt placement, he was
neurologically intact and did not have any issues on the floor.
.
Postoperatively, he was neurologically intact. Incisions were
clean and dry. His diet was advanced. He was ambulating on
discharge.
.
He started XRT prior to discharge and completed 2 sessions. He
was scheduled for outpatient XRT. His primary oncologist was
notified.
Medications on Admission:
Hydrochlorothiazide 25 mg daily for hypertension
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
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. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic rectal cancer
Discharge Condition:
Neurologically stable
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
Keep sutures dry.
Remove steristrips in 10 days.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 100.4 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] for suture removal in 10 -14 days.
Continue with Radiation Therapy.
Follow up with General Surgery for any problems with abdomen.
Follow up with oncologist for steroid taper.
Completed by:[**2118-10-28**]
|
[
"198.3",
"197.7",
"198.5",
"331.4",
"197.0",
"V10.06"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29",
"38.93",
"02.34"
] |
icd9pcs
|
[
[
[]
]
] |
7157, 7163
|
5549, 6504
|
343, 369
|
7232, 7256
|
2952, 5526
|
8270, 8522
|
1269, 1287
|
6603, 7134
|
7184, 7211
|
6530, 6580
|
7280, 8247
|
1324, 1663
|
282, 305
|
397, 815
|
2016, 2933
|
1678, 2000
|
837, 1201
|
1217, 1253
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,446
| 104,538
|
39879
|
Discharge summary
|
report
|
Admission Date: [**2144-12-7**] Discharge Date: [**2144-12-14**]
Date of Birth: [**2058-12-29**] Sex: M
Service: OTOLARYNGOLOGY
Allergies:
Bee Pollens / Lisinopril
Attending:[**First Name3 (LF) 7729**]
Chief Complaint:
squamous cell carcinoma of tongue
Major Surgical or Invasive Procedure:
1. Direct laryngoscopy and biopsy of left lateral tongue
1. tumor and left anterior tonsillar pillar.
2. Left modified radical neck dissection.
3. Hemiglossectomy.
History of Present Illness:
85 year old man with T2(possibly T4 if invading into base of
tongue musculature) probable N2c (bilateral uptake) squamous
cell carcinoma of the left lateral tongue and newly identified
mid-esophageal squamous cell carcinoma at least in situ. For
left SCC of tongue patient underwent left partial glossectomy,
left neck dissection and direct laryngoscopy [**2143-12-8**] by ENT. .
As patient is currently intubated history obtained through OMR.
Patient first noticed a painful swollen tongue in [**2144-8-5**]
- progressed to difficulty swallowing accompanied by a 25-pound
weight loss over the course of three months. This prompted an
evaluation at the [**Hospital 882**] Hospital where he had a biopsy
performed of the left lateral tongue on [**2144-9-4**] that revealed
squamous cell carcinoma in situ extending to the specimen
margins. There was no invasive carcinoma identified in the
biopsy specimen. PEG tube placed [**2144-9-25**] in preparation for
treatment of tongue cancer. As part of work-up patient had EGD
[**2144-3-5**], [**2144-9-25**] that demonstrated no abnormalities
however EGD [**10-21**] which revealed a visible abnormality in his
mid-esophagus with biopsy consistent with at least in situ
squamous cell carcinoma. This EGD was preformed on recent
admission [**2144-10-19**] for weight loss and fatigue felt to be
secondary to malignancy and PMR flare was consequently started
on course of prednisone.
Past Medical History:
Squamous cell carcinoma of the left lateral tongue
Squamous cell carcinoma of the esophagus
Hypertension
GERD
Polymyalgia rheumatica: Diagnosed about 2.5 years ago for the
symptoms of hand swelling/stiffness. Started on steroid 15-20 mg
daily and was slowly tapered off over couple years. Pt was on
1mg prednisone until [**Month (only) 359**] - then recently re-started last
[**Month (only) **] admission.
.
Social History:
The patient performs his own ADL's. He used to drink about 4oz
of alcohol a day and smoke a pipe, but quit both when he was
diagnosed with cancer. He began smoking a pipe at the age of 17.
.
Family History:
No family history of oral or GI cancers
Physical Exam:
On discharge:
AVSS
GEN: eldery male, NAD
HEENT: PERRL, anicteric, dry mucosa, tongue s/p left partial
glossectomy.
Neck: Left neck wound with steri-strips over incision, c/d/i
RESP: CTA b/l with good air movement throughout anteriorly
CV: S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, + PEG
in use
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
.
Pertinent Results:
[**2144-12-9**] 04:16AM BLOOD WBC-11.8* RBC-3.89* Hgb-12.0* Hct-36.3*
MCV-93 MCH-30.8 MCHC-33.0 RDW-15.3 Plt Ct-218
[**2144-12-9**] 04:16AM BLOOD Glucose-151* UreaN-13 Creat-0.7 Na-141
K-4.0 Cl-103 HCO3-29 AnGap-13
[**2144-12-9**] 04:16AM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.4* Mg-2.3
[**2144-12-12**] 09:45AM OTHER BODY FLUID Triglyc-1475
.
CXR: [**12-7**]
FINDINGS: In comparison with the study of [**10-19**], there has been
placement of
an endotracheal tube with its tip approximately 7.5 cm above the
carina.
Hyperexpansion of the lungs persists suggestive of chronic
pulmonary disease.
However, no acute focal pneumonia, vascular congestion, or
pleural effusion.
CXR: [**12-9**]
Aside from mild left basal atelectasis lungs are clear. Heart
size top
normal, increased since [**12-7**], but no pulmonary vascular
congestion or
edema. Small left pleural effusion may be present. No
pneumothorax.
.
Micro:
URINE CULTURE (Final [**2144-12-9**]): NO GROWTH.
Brief Hospital Course:
A/P: 85 yo male PMH oral SCC s/p left partial hemiglossectomy,
left neck dissection.
The patient was admitted to the ENT Service on
[**2144-12-7**] for treatment. On [**2144-12-7**], the
patient underwent left partial hemiglossectomy, left neck
dissection and direct laryngoscopy, which went well without
complication (reader referred
to the Operative Note for details). The patient remained
intubated after the procedure due to concern for postoperative
edema, and was kept in the ICU. The patient was hemodynamically
stable. He was extubated on POD#1. The patient was
hemodynamically stable. He was transferred to the floor on
POD#2, where speech and swallow service saw the patient, and he
was transitioned to thin liquids on POD#3 and also began
supplemental tube feeds. His Foley catheter was D/Ced on POD#4,
and he voided without difficulty. His diet was advanced further
to pureed solids on POD#4, and his tube feeds were cycled
overnight. The patient tolerated these well, however on POD#4
developed cloudy output from his JP drain which was found to
contain elevated triglycerides and a chyle leak was suspected.
His diet was reduced to clear liquids, and his tube feeding
formula changed. By POD#7, his drain output became
serosanguinous again, and his drain and staples were removed.
The remainder of the [**Hospital 228**] hospital course was uneventful.
Post-operative pain
was initially well controlled with IV pain medications, which
was converted to oral pain medication when tolerating clear
liquids.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated.
At the time of discharge on [**2144-12-14**], the patient was doing well,
afebrile with stable vital signs. The patient was tolerating a
clear liquid diet, ambulating, voiding without assistance, and
pain
was well controlled. The patient was discharged home with
services for tube feeding. The patient received discharge
teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
ATENOLOL - 50 mg Tablet - 1Tablet(s) by mouth daily
PREDNISONE - 30 mg daily
MS CONTIN - 15 mg [**Hospital1 **]
EPINEPHRINE [EPIPEN] - Dosage uncertain
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 (One)
Capsule(s) by mouth once a day
OXYCODONE-ACETAMINOPHEN [ROXICET] - (Prescribed by Other
Provider) - Dosage uncertain
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
2. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
3. prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
4. morphine 10 mg/5 mL Solution Sig: [**4-13**] mL PO Q4H (every 4
hours) as needed for pain.
Disp:*150 mL* Refills:*0*
5. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
squamous cell carcinoma of the left lateral tongue
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**4-13**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1837**] as scheduled:
Provider: [**First Name4 (NamePattern1) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2144-12-18**] 10:40
|
[
"401.9",
"V15.82",
"V49.86",
"530.81",
"518.5",
"725",
"141.8",
"274.9",
"230.0",
"285.9",
"997.99",
"150.4",
"E878.8",
"V58.65",
"716.90",
"V85.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"28.11",
"25.2",
"96.71",
"40.41",
"96.6",
"31.42",
"25.01"
] |
icd9pcs
|
[
[
[]
]
] |
7370, 7428
|
4070, 6429
|
327, 493
|
7523, 7523
|
3078, 4047
|
8778, 9001
|
2610, 2651
|
6813, 7347
|
7449, 7502
|
6455, 6790
|
7674, 8251
|
8266, 8755
|
2666, 2666
|
2680, 3059
|
254, 289
|
521, 1952
|
7538, 7650
|
1974, 2384
|
2400, 2594
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,683
| 103,609
|
10656
|
Discharge summary
|
report
|
Admission Date: [**2112-5-30**] Discharge Date: [**2112-6-17**]
Date of Birth: [**2052-9-2**] Sex: M
Service: SURGERY
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
Acute renal failure
Hepatitis C Cirrhosis, decompensated liver failure
Major Surgical or Invasive Procedure:
[**2112-6-2**]: Temporary right internal jugular double lumen dialysis
catheter
[**2112-6-6**]: [**Last Name (un) 1372**]-duodenal tube replacement
[**2112-6-10**]: OLT
History of Present Illness:
59 M with h/o hepC cirrhosis, s/p renal and pancreatic
transplant for DM, and recent admission for ARF (not thought to
be HRS, [**Date range (1) 34961**], admit creat 3.1 and d/c creat 2.3 on [**5-12**])
who presented for routine paracentesis on day of admission, and
was found to have elevated creatinine of 3.6. At Day Care
Clinic, pt had paracentesis removing 3 L of ascitic fluid which
was negative for SBP. Pt stayed hemodynamically stable
throughout the procedure with SBP in 90s-100s. Pt received 50
gm of albumin (concentrated) after paracentesis. Pt reports he
has not been eating or drinking much fluid due to abdominal
distension for the past several days. He reported intermittent
nausea and vomiting up food soon after eating. Denied any
hematemasis, melena, worsening diarrhea (has bm [**12-15**]/day),
hematochezia, decreased urinary stream or urine output (goes 3
times a day). Denied any cough, fevers, but reports chills all
the time. Denied sob, chest pain, abdominal pain, n/v, or
urinary symptoms. Denied any recent NSAIDS use. Stopped taking
ASA recently for easy bruising/bleeding. Has been getting tube
feeding at home at night and has been tolerating it well (60cc
goal).
Past Medical History:
1. Hepatitis C cirrhosis, genotype 1. s/p biopsy [**2-17**] (stage 2-3
fibrosis). HepC VL 965,000 [**2-17**]. +h/o SBP [**4-18**], +h/o
encephalopathy, EGD [**2-17**] no varices, +portal gastropathy. no
colonoscopy. +recurrent ascites on diuretics.
2. s/p cadaveric renal transplant in [**2107**] for presumed
diabetic nephropathy
3. s/p pancreas transplant in [**2108**] now with resolved diabetes
4. HTN
5. Asthma
6. Encephalopathy
Social History:
He lives at home with his wife. Ex-[**Name2 (NI) 1818**], quit 15 years ago. He
used to work as a cabinet maker in the past.
Family History:
Mother deceased MI [**69**], h/o kidney CA, dad alive at 87 yr old.
Otherwise NC.
Physical Exam:
VS: 98.3 98.3 116/54 88 18 97%RA
GEN: NAD, pleasant male.
HEENT: PERRLA, EOMI, sclera icteric, OP clear, MM dry, no LAD.
left side carotid radiation of murmur. 8cm JVP at 45
degrees.
CV: regular, nl s1, s2, 3/6 SEM radiating to carotids and
holosystolic murmur at base radiating to axilla, no r/g.
PULM: CTA B, no r/r/w.
ABD: soft, NT, +distended, + BS, + fluid wave, no HSM.
paracentesis dressing in LLQ c/d/i.
EXT: warm, 2+ dp/radial pulses BL. [**12-15**]+ edema to mid-calf L>R
(not new per pt).
NEURO: alert & oriented to place and [**2112-5-11**], CN II-XII grossly
intact. + mild L asterixis.
Pertinent Results:
On Admission: [**2112-5-30**]
WBC-5.0 RBC-3.58* Hgb-11.6* Hct-33.5* MCV-94# MCH-32.5*
MCHC-34.7 RDW-20.8* Plt Ct-181
PT-21.7* PTT-51.0* INR(PT)-2.1*
Glucose-90 UreaN-102* Creat-3.6*# Na-132* K-4.3 Cl-104 HCO3-16*
AnGap-16
ALT-46* AST-158* AlkPhos-134* Amylase-40 TotBili-8.4* Lipase-45
Calcium-8.4 Phos-5.7* Mg-2.9*
On discharge: [**2112-6-16**]
WBC-3.8* RBC-2.96* Hgb-9.5* Hct-28.4* MCV-96 MCH-32.0 MCHC-33.4
RDW-17.7* Plt Ct-116*
PT-11.8 PTT-29.1 INR(PT)-1.0
Glucose-130* UreaN-57* Creat-1.4* Na-135 K-3.1* Cl-102 HCO3-24
AnGap-12
ALT-223* AST-84* AlkPhos-114 Amylase-50 TotBili-1.4 Lipase-30
Albumin-2.7* Calcium-7.5* Phos-1.3* Mg-1.4*
[**2112-6-17**] 04:30AM BLOOD FK506-14.8
[**2112-6-15**] 04:25AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE >450
Brief Hospital Course:
59yo M with HCV cirrhosis, s/p renal/pancreas transplant a/w
ARF.
Initially admitted with ARF (Cr 3.3 today) s/p renal transplant
in [**2108**], creatinine rising from 0.8 one year ago, worsening over
the past year. This is likely hepatorenal syndrome. Transplant
renal U/S with lack of diastolic flow, a non-specific finding.
Started hemodialysis using temporary dialysis catheter
(Successful placement of temporary right internal jugular double
lumen dialysis catheter on [**2112-6-2**]).
It was felt that this was Hepatorenal syndrome and he was
started on midodrine, octreotide and albumin.
[**Date Range 13808**], awaiting transplant, EGD with no varices [**2112-3-2**]. Last
paracentesis [**2112-6-1**], no SBP, though has previous h/o SBP. He
was continued on lactulose, rifaxamin, ursodiol, levofloxacin
for SBP ppx.
In addition he continued his immunosuppression of tacrolimus and
prednisone as well as Bactrim. He has not required insulin since
his pancreas transplant in [**2108**].
He had a very poor nutritional status with low Na diet with
ensure, tube feeding for supplement, this was continued from
home. The [**Last Name (un) **]-intestinal tube was replaced on [**2112-6-6**].
Stress MIBI was performed on [**6-7**] in anticipation of liver
transplant, EF 67% Other blood serologies had been previously
reported.
On [**6-10**] the patient was able to undergo Orthotopic liver
transplant. Of note the patient was HBcAb positive, received
10,000 units HBIG intra-op in additon to routine induction
immunosuppression. He was started on Vanco and Zosyn for
presumed UTI (10-100,00 yeast in urine)
Please see the operative note for surgical details. OLT from
when the clamps were removed, there was excellent flow and good
thrill through the artery. The liver began making bile and its
color improved. There was a size discrepancy at the bile duct,
recipient bile duct was oversewn. He received CVVH while in the
OR
Patient followed pathway post-op, was extubated on POD 1 and
transferred to [**Hospital Ward Name 121**] 10 on POD 2.
He continued to make excellent progress, liver function tests
improved as did renal function. He did not require hemodialysis
following the transplant.
He received 5000 units HBIG daily for 5 days post op. HBsAb was
>450 daily.
He was continued on tube feeds, his ND tube was exchanged early
in the hospitalization. He will continue tube feeds at home,
having only a fair appetite.
He did have an insulin requirement while hospitalized, and will
go home on insulin at least in the short term. Seen by [**Last Name (un) **]
during the hospitalization.
He is ambulating using a walker.
Medications on Admission:
1. Gemfibrozil 600 mg [**Hospital1 **]
2. Hydroxyzine HCl 25 mg QHS
3. Tacrolimus 0.5 mg PO QDAILY at 8 PM
4. Prednisone 5 mg Daily
5. Trimethoprim-Sulfamethoxazole 80-400 mg DAILY (Daily).
7. Pantoprazole 40 mg Tablet PO Q24H
8. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
9. Hexavitamin 1 Tablet PO DAILY
10. Calcium Carbonate 500 mg PO TID
11. Cholecalciferol (Vitamin D3) 400 unit PO DAILY
12. Sodium Bicarbonate 650 mg Two (2) Tablet PO BID
13. Rifaximin 200 mg PO TID
14. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO BID (2
times a day).
15. Levofloxacin 250 mg Tablet PO Q24H
16. Simethacone 80mg po QID/PRN
17. Ursodiol 600mg [**Hospital1 **]
Discharge Medications:
1. Nutrition
Tubefeeding: Nutren 2.0 3/4 strength
Starting rate: 80 ml/hr; Do not advance rate
Goal rate: 80 ml/hr
Cycle start: 1800 Cycle end: 1000
Residual Check: q4h Hold feeding for residual >= : 100 ml
Flush w/ 30 ml water q6h
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Prednisone 20 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. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12)
Subcutaneous once a day.
12. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day.
13. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*qs inhaler* Refills:*2*
14. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed.
Disp:*20 Tablet(s)* Refills:*0*
15. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Medical Resources Home Health Corp
Discharge Diagnosis:
Acute renal failure: now resolved
[**Hospital1 13808**] s/p orthotopic liver transplant
Discharge Condition:
Good
Discharge Instructions:
Call the transplant office at [**Telephone/Fax (1) 673**] if you experience any
of the following symptoms: fever >101.4, chills, nausea,
vomiting, diarrhea, inability to eat, pain over the incision
site or liver, yellowing of the skin or eyes, an increase in
abdominal girth. Monitor incision for redness, drainage or
bleeding.
Do not drive if you are taking narcotics.
Take your medications exactly as directed.
Have labs drawn every Monday and Thursday and have them faxed to
[**Telephone/Fax (1) 697**]. CBC, Chem 10, AST, ALT, Alk Phos, Albumin, T Bili
and trough Prograf Level
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2112-6-20**]
10:00AM
Completed by:[**2112-6-17**]
|
[
"V42.83",
"276.8",
"V42.0",
"285.21",
"493.90",
"401.9",
"572.4",
"571.5",
"070.70",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"54.91",
"99.05",
"99.04",
"00.93",
"39.95",
"96.6",
"99.09",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
8772, 8837
|
3873, 6508
|
354, 536
|
8969, 8976
|
3103, 3103
|
9607, 9782
|
2385, 2468
|
7267, 8749
|
8858, 8948
|
6534, 7244
|
9000, 9584
|
2483, 3084
|
3433, 3850
|
244, 316
|
564, 1767
|
3117, 3419
|
1789, 2226
|
2242, 2369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,186
| 141,894
|
47874
|
Discharge summary
|
report
|
Admission Date: [**2158-10-3**] Discharge Date: [**2158-10-13**]
Date of Birth: [**2097-8-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Abdominal pain, swelling
Major Surgical or Invasive Procedure:
-Paracentesis, [**2158-10-3**]
-Right heart catheterization, [**2158-10-5**]
Swan Ganz Catheter
Central Venous Line
History of Present Illness:
Briefly, this is a 61 yo male w/ ESRD on hemodialysis, h/o MSSA
bacteremia and resultant endocarditis with AR/MR and right heart
dysfunction, A-fib, s/p colostomy for ischemic bowel who
presents with months of abdominal swelling, and days of
abdominal pain and nausea. On day of admission, pt began to
have midline LQ crampy abdominal pain coming in waves with
nausea, no emesis at first. However, after drinking PO contrast
for CT abdomen, then vomited. No blood. No changes in ostomy
output, but pt stating that hasn't had movement since Sunday and
not passing gas. Had [**Month/Day/Year 2286**] yesterday without complications.
.
On the [**Hospital1 1516**] floor, pt would like NGT removed, but otherwise
without complaints. No CP, SOB, nausea (at this time). Pt
would like fluid removed from his abdomen, as he is still
complaining of abdominal pressure. Denies F/C, rash, HA, cough,
sore throat, joint pain, blood in stool. Endorses constant
palpitations.
.
SBPs 80s-90s in ED, at HD, and on floor since admission. Per
[**Location (un) **] Dyalisis center where he get's dyalisis, pt tends to run
94/63 pre, 96/62 post, and 70s-80s during [**Location (un) 2286**].
Past Medical History:
++ Post-strep glomerulonpehritis
- LUE AV fistula, [**2135**]; surgical repairs [**2153**]
- renal transplant [**2137**], failed
- transplant nephrectomy, [**2145**]
- ESRD on HD
-----
[Admission [**Date range (2) 101021**]]
++ L wrist infective arthritis
- Left wrist incision and drainage [**2156-12-10**]
- MSSA on Cx [**12-10**], [**12-19**]
- s/p Cefazolin x6 weeks
++ Endocarditis
- BCx [**Date range (1) 31005**] MSSA; BCx [**Date range (1) 101022**] neg
- TEE [**12-22**] = No valvular vegetations; mod-severe eccentric MR
- TTE [**1-5**] = mobile bright post MV veg, old > new?
- TTE [**1-19**], [**2-2**] = no veg seen
++ Right hip fracture
- Right hip hemiarthroplasty, [**2157-1-11**]
- Revision right hemiarthroplasty, femoral component, [**2157-1-26**]
- septic hematoma; I&D, evacuation of hematoma, [**2157-2-3**]
- infective arthritis; removal R hip, abx spacer, VAC, [**2157-2-18**]
- I&D hematoma + abscess, VAC, [**2157-2-22**]
- Cx [**12-18**], [**1-4**], [**1-26**] = NEG
- Cx/tissue [**2-3**] = K.oxytoca, E.cloacae
- Cx [**2-18**] = VRE (linez-[**Last Name (un) 36**])
- s/p >8 weeks daptomycin, ciprofloxacin
++ Ischemic colitis/ileitis
- ex lap, subtotal colectomy, terminal ileectomy, [**2157-1-13**]
- repeat OR [**2157-1-14**]
- g-tube, ileocolonic [**Last Name (un) 1236**], diverting loop ileostomy, [**2157-1-15**]
- d/c with ant abd wound vac (Cx = B.fragilis)
-----
++ Hypertension
++ Coronary artery disease (unspecified)
++ prior diastolic heart failure
++ Pneumonia, multiple (unknown etiology)
++ Pulmonary nodules, stable
++ Hyperparathyroidism
++ ? Amyloid lesions of wrist and metacarpals
+ Right endoscopic carpal tunnel release, [**2-/2155**]
+ Right trigger thumb release, [**2-/2155**]
+ Ring finger flexor tenosynovectomy, [**2-/2155**]
+ Left carpal tunnel release, [**12/2155**]
+ left index, long and ring finger trigger releases, [**12/2155**]
+ Right ring finger closed reduction percut pinning, [**2-/2156**]
Social History:
Owner of a clothing store in [**Location (un) 4398**]. Patient has been
hospitalized/in rehab since [**2156-12-10**]. Prior to this, he lived in
[**Location **] with his mother and brother. [**Name (NI) **] current tobacco and
alcohol use but notes intermittent tobacco use in the past (~3
pack-years). Denies illicit drug use. HIV negative [**2156-12-27**]
Family History:
Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother).
Father deceased. Brother has fibromyalgia. Daughter in good
health.
Physical Exam:
Physical Exam on Admission:
PHYSICAL EXAMINATION:
GENERAL: cachectic extremities, but no acute distress, very
pleasant. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink
NECK: Supple with JVP elevated to ear, no LAD, no carotid bruits
CARDIAC: PMI displaced laterally. irreg irreg. 3/6 systolic
murmur heard best at apex with radiation to axilla and to back.
[**3-18**] diastolic murmur heard best at RUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. scattered crackles at
bases.
ABDOMEN: +bowel sounds. significantly distended. Could not
assess HSM due to large amount of ascites. + fluid wave. Tender
to palpation in Left upper and lower quadrant, no guarding or
rebound. Ostomy intact without blood and minimal output. Plug in
feeding tube hole. Ostomy site C/D/I. Midline abdominal scars
from prior surgeries.
EXTREMITIES: Cool legs, DP/PT pulses easily dopplered. AV
fistula present on LUE, faint thrill, no bruit appreciated.
NEURO: grossly intact
.
PHYSICAL EXAMINATION on Discharge:
VS 98.1 79/47 (79-88/47-50) 76 (76-78) 18 96% RA
I- 200cc (popsicles)
O- --ostomy
I- 730
O-400 ostomy +2 stool small soft
GENERAL: cachectic extremities, but no acute distress, very
pleasant. Oriented x3. Mood, affect appropriate.
HEENT: Sclera anicteric. PERRL, EOMI. Conjunctiva were pink
NECK: Supple with JVP elevated to ear, no LAD, no carotid bruits
CARDIAC: PMI displaced laterally. irreg irreg. 3/6 systolic
murmur heard best at apex with radiation to axilla and to back.
[**3-18**] diastolic murmur heard best at RUSB.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. scattered crackles at
bases.
ABDOMEN: +bowel sounds. much less distended than on admission.
nontender to palpation, no guarding or rebound. Ostomy intact
without blood and minimal output. Plug in feeding tube hole.
Ostomy site C/D/I. Midline abdominal scars from prior surgeries.
EXTREMITIES: Cool legs, DP/PT pulses easily dopplered. AV
fistula present on LUE, faint thrill, no bruit appreciated.
NEURO: grossly intact
Pertinent Results:
[**2158-10-13**] 04:40AM BLOOD WBC-2.9* RBC-4.24* Hgb-11.8* Hct-38.0*
MCV-90 MCH-27.7 MCHC-31.0 RDW-18.9* Plt Ct-107*
[**2158-10-12**] 05:20AM BLOOD WBC-3.5* RBC-4.03* Hgb-11.3* Hct-35.5*
MCV-88 MCH-28.1 MCHC-31.9 RDW-18.8* Plt Ct-96*
[**2158-10-11**] 03:25AM BLOOD WBC-4.2 RBC-3.96* Hgb-10.6* Hct-34.9*
MCV-88 MCH-26.7* MCHC-30.4* RDW-19.2* Plt Ct-98*
[**2158-10-10**] 04:19AM BLOOD WBC-6.9 RBC-4.20* Hgb-11.7* Hct-37.6*
MCV-89 MCH-27.9 MCHC-31.3 RDW-19.2* Plt Ct-129*
[**2158-10-9**] 04:01AM BLOOD WBC-6.8 RBC-4.07* Hgb-11.3* Hct-36.4*
MCV-89 MCH-27.8 MCHC-31.2 RDW-19.2* Plt Ct-147*
[**2158-10-8**] 04:04PM BLOOD WBC-6.2 RBC-4.34* Hgb-12.4* Hct-38.7*
MCV-89 MCH-28.5 MCHC-32.0 RDW-19.5* Plt Ct-160#
[**2158-10-8**] 05:17AM BLOOD WBC-4.5 RBC-4.08* Hgb-11.4* Hct-36.3*
MCV-89 MCH-27.9 MCHC-31.3 RDW-19.1* Plt Ct-106*
[**2158-10-7**] 09:44PM BLOOD WBC-3.2* RBC-4.00* Hgb-11.1* Hct-35.2*
MCV-88 MCH-27.8 MCHC-31.6 RDW-19.1* Plt Ct-94*
[**2158-10-7**] 01:30PM BLOOD Hct-38.3*
[**2158-10-7**] 03:08AM BLOOD WBC-2.6* RBC-4.09* Hgb-11.4* Hct-36.3*
MCV-89 MCH-27.8 MCHC-31.4 RDW-19.4* Plt Ct-90*
[**2158-10-6**] 07:30AM BLOOD WBC-3.0*# RBC-4.36* Hgb-12.1* Hct-37.7*
MCV-87 MCH-27.8 MCHC-32.1 RDW-19.0* Plt Ct-95*
[**2158-10-4**] 03:15AM BLOOD WBC-4.3 RBC-4.03* Hgb-11.0* Hct-36.2*
MCV-90 MCH-27.4 MCHC-30.5* RDW-19.1* Plt Ct-117*
[**2158-10-3**] 03:00PM BLOOD WBC-3.6* RBC-3.97* Hgb-10.9* Hct-35.6*
MCV-90 MCH-27.5 MCHC-30.7* RDW-19.3* Plt Ct-113*
[**2158-10-2**] 11:10PM BLOOD WBC-3.3* RBC-3.87* Hgb-10.7* Hct-33.8*
MCV-87 MCH-27.7 MCHC-31.7 RDW-19.3* Plt Ct-88*
[**2158-10-5**] 08:50PM BLOOD Neuts-69 Bands-3 Lymphs-8* Monos-8
Eos-11* Baso-1 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2158-10-2**] 11:10PM BLOOD Neuts-65.7 Lymphs-20.8 Monos-5.3 Eos-8.0*
Baso-0.3
[**2158-10-5**] 08:50PM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-NORMAL
Macrocy-1+ Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+ Target-1+
[**2158-10-13**] 04:40AM BLOOD Plt Ct-107*
[**2158-10-13**] 04:40AM BLOOD PT-22.9* PTT-34.6 INR(PT)-2.2*
[**2158-10-12**] 05:20AM BLOOD Plt Ct-96*
[**2158-10-12**] 05:20AM BLOOD PT-22.3* PTT-36.9* INR(PT)-2.1*
[**2158-10-11**] 03:25AM BLOOD Plt Ct-98*
[**2158-10-11**] 03:25AM BLOOD PT-24.7* PTT-49.6* INR(PT)-2.4*
[**2158-10-10**] 04:19AM BLOOD Plt Ct-129*
[**2158-10-10**] 04:19AM BLOOD PT-20.5* PTT-42.8* INR(PT)-1.9*
[**2158-10-9**] 04:01AM BLOOD Plt Ct-147*
[**2158-10-9**] 04:01AM BLOOD PT-19.7* PTT-34.1 INR(PT)-1.8*
[**2158-10-3**] 03:00PM BLOOD PT-33.2* PTT-36.0* INR(PT)-3.4*
[**2158-10-2**] 11:10PM BLOOD Plt Smr-LOW Plt Ct-88*
[**2158-10-2**] 11:10PM BLOOD PT-28.9* PTT-34.8 INR(PT)-2.9*
[**2158-10-2**] 11:30AM BLOOD PT-26.0* INR(PT)-2.5*
[**2158-10-13**] 04:40AM BLOOD Glucose-75 UreaN-14 Creat-3.8*# Na-138
K-4.0 Cl-96 HCO3-32 AnGap-14
[**2158-10-11**] 03:25AM BLOOD Glucose-89 UreaN-13 Creat-2.9* Na-136
K-4.7 Cl-102 HCO3-25 AnGap-14
[**2158-10-10**] 01:14PM BLOOD Glucose-97 UreaN-8 Creat-2.2* Na-136
K-4.5 Cl-102 HCO3-22 AnGap-17
[**2158-10-10**] 08:24AM BLOOD Glucose-102* UreaN-8 Creat-2.0* Na-135
K-4.6 Cl-101 HCO3-24 AnGap-15
[**2158-10-9**] 10:06PM BLOOD Glucose-102* UreaN-11 Creat-2.5* Na-136
K-4.3 Cl-101 HCO3-22 AnGap-17
[**2158-10-9**] 04:30PM BLOOD Glucose-108* UreaN-12 Creat-2.7* Na-136
K-4.2 Cl-103 HCO3-22 AnGap-15
[**2158-10-7**] 03:08AM BLOOD Glucose-50* UreaN-18 Creat-4.5*# Na-138
K-4.0 Cl-93* HCO3-32 AnGap-17
[**2158-10-6**] 07:30AM BLOOD Glucose-82 UreaN-20 Creat-5.8* Na-140
K-4.1 Cl-95* HCO3-31 AnGap-18
[**2158-10-5**] 11:30PM BLOOD Glucose-97 UreaN-16 Creat-5.6* Na-139
K-4.0 Cl-93* HCO3-33* AnGap-17
[**2158-10-4**] 03:15AM BLOOD Glucose-51* UreaN-23* Creat-6.4*# Na-141
K-4.7 Cl-95* HCO3-31 AnGap-20
[**2158-10-2**] 11:10PM BLOOD Glucose-81 UreaN-14 Creat-4.9* Na-140
K-4.0 Cl-98 HCO3-30 AnGap-16
[**2158-10-4**] 03:15AM BLOOD ALT-9 AST-25 LD(LDH)-155 AlkPhos-172*
TotBili-1.0
[**2158-10-2**] 11:10PM BLOOD ALT-7 AST-21 LD(LDH)-130 AlkPhos-188*
TotBili-1.1
[**2158-10-13**] 04:40AM BLOOD Calcium-8.7 Phos-1.9* Mg-1.8
[**2158-10-12**] 05:20AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.9
[**2158-10-11**] 03:25AM BLOOD Calcium-9.5 Phos-2.3* Mg-1.8
[**2158-10-10**] 08:24AM BLOOD Calcium-10.2 Phos-2.1* Mg-2.1
[**2158-10-10**] 04:19AM BLOOD Calcium-10.4* Phos-2.2* Mg-2.2
[**2158-10-7**] 03:08AM BLOOD Calcium-9.3 Phos-4.5 Mg-1.9 Cholest-103
[**2158-10-6**] 07:30AM BLOOD Calcium-9.2 Phos-5.1* Mg-1.9
[**2158-10-5**] 11:30PM BLOOD Calcium-10.0 Phos-4.6* Mg-2.0
[**2158-10-4**] 03:15AM BLOOD Albumin-4.0 Calcium-10.6* Phos-5.0*
Mg-1.7
[**2158-10-2**] 11:10PM BLOOD Albumin-3.6
[**2158-10-7**] 03:08AM BLOOD %HbA1c-5.0 eAG-97
[**2158-10-7**] 03:08AM BLOOD Triglyc-79 HDL-43 CHOL/HD-2.4 LDLcalc-44
[**2158-10-7**] 03:08AM BLOOD TSH-1.6
[**2158-10-13**] 04:40AM BLOOD Testost-97*
[**2158-10-6**] 07:30AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2158-10-8**] 07:10PM BLOOD Vanco-10.5
[**2158-10-13**] 04:40AM BLOOD Digoxin-1.5
[**2158-10-12**] 05:20AM BLOOD Digoxin-2.5*
[**2158-10-11**] 03:25AM BLOOD Digoxin-2.9*
[**2158-10-11**] 03:43AM BLOOD Type-ART Temp-36.9 pO2-100 pCO2-34*
pH-7.45 calTCO2-24 Base XS-0
[**2158-10-10**] 09:08AM BLOOD Type-ART pO2-89 pCO2-41 pH-7.41
calTCO2-27 Base XS-0
[**2158-10-10**] 04:34AM BLOOD Type-ART pO2-86 pCO2-40 pH-7.40
calTCO2-26 Base XS-0 Intubat-NOT INTUBA
[**2158-10-9**] 10:17PM BLOOD Type-ART Temp-36.1 pO2-80* pCO2-34*
pH-7.44 calTCO2-24 Base XS-0
[**2158-10-9**] 04:40PM BLOOD Type-ART Temp-36.4 pO2-87 pCO2-37 pH-7.42
calTCO2-25 Base XS-0
[**2158-10-9**] 10:29AM BLOOD Type-ART Temp-37.1 Rates-/13 pO2-74*
pCO2-41 pH-7.42 calTCO2-28 Base XS-1 Intubat-NOT INTUBA
Vent-CONTROLLED
[**2158-10-9**] 04:17AM BLOOD Type-ART Temp-37.3 pO2-84* pCO2-37
pH-7.44 calTCO2-26 Base XS-0
[**2158-10-8**] 07:15PM BLOOD Type-ART pO2-74* pCO2-38 pH-7.45
calTCO2-27 Base XS-2
[**2158-10-8**] 05:03PM BLOOD Type-ART Temp-37 pO2-65* pCO2-38 pH-7.45
calTCO2-27 Base XS-2 Intubat-NOT INTUBA
[**2158-10-7**] 10:00PM BLOOD Type-ART Temp-37.0 O2 Flow-3 pO2-136*
pCO2-48* pH-7.46* calTCO2-35* Base XS-9 Intubat-NOT INTUBA
[**2158-10-11**] 03:45AM BLOOD Lactate-0.7
[**2158-10-10**] 01:40PM BLOOD Lactate-1.0
[**2158-10-10**] 09:08AM BLOOD Lactate-1.2
[**2158-10-10**] 04:34AM BLOOD Lactate-0.9
[**2158-10-8**] 01:46AM BLOOD Glucose-80 Lactate-0.7
[**2158-10-7**] 10:00PM BLOOD Lactate-0.8
[**2158-10-7**] 03:36AM BLOOD Lactate-1.4
[**2158-10-3**] 12:03AM BLOOD Lactate-1.6
[**2158-10-11**] 03:45AM BLOOD O2 Sat-78
[**2158-10-10**] 01:44PM BLOOD Hgb-11.9* calcHCT-36 O2 Sat-96
[**2158-10-10**] 01:40PM BLOOD O2 Sat-70
[**2158-10-9**] 04:40PM BLOOD Hgb-12.1* calcHCT-36 O2 Sat-95
[**2158-10-9**] 10:38AM BLOOD O2 Sat-63
[**2158-10-10**] 01:44PM BLOOD freeCa-1.09*
[**2158-10-10**] 09:08AM BLOOD freeCa-1.12
[**2158-10-9**] 10:17PM BLOOD freeCa-1.08*
[**2158-10-9**] 04:17AM BLOOD freeCa-1.18
[**2158-10-8**] 12:18PM BLOOD freeCa-1.08*
[**2158-10-7**] 10:00PM BLOOD freeCa-1.08*
.
ECG Study Date of [**2158-10-3**] 9:39:32 PM
Atrial fibrillation with a single ventricular premature beat.
Delayed
precordial R wave progression. Compared to the previous tracing
of [**2157-9-6**] the findings are similar.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 0 116 400/459 0 -98 102
.
TTE (Complete) Done [**2158-10-3**]
Conclusions
The atria markedly dilated. The estimated right atrial pressure
is 10-20mmHg. Left ventricular wall thicknesses and cavity size
are normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is mildly depressed
(LVEF= 50%). The right ventricular cavity is markedly dilated
with moderate to severe global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic valve leaflets
(3) are mildly thickened. There is no valvular aortic stenosis.
The increased transaortic velocity is likely related to
increased stroke volume due to aortic regurgitation. Moderate
(2+) aortic regurgitation is seen. The mitral valve leaflets are
moderately thickened. No mass or vegetation is seen on the
mitral valve. Severe (4+) mitral regurgitation is seen. Moderate
[2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. The main pulmonary
artery is dilated. There is no pericardial effusion.
IMPRESSION: Markedly dilated right ventricle with moderate to
severe global systolic dysfunction. Mild global left ventricular
systolic dysfunction. Moderate aortic regurgitation. Severe
eccentric mitral regurgitation. Moderate pulmonary hypertension.
Ascites and bilateral pleural effusions.
Compared with the prior study (images reviewed) of [**2158-3-30**], LV
function is slightly more depressed and RV is larger yet. The
other findings are similar.
.
CT PELVIS AND ABDOMEN W/CONTRAST Study Date of [**2158-10-3**]
IMPRESSION:
1. New large volume ascites.
2. Dilated small bowel at the stoma has an unusual configuration
and may
reflect early or partial bowel obstruction. The significance of
this finding is uncertain given reportedly normal ostomy output,
however, and clinical correlation is recommended.
2. Slightly prominent loops of small bowel in the mid abdomen,
which may
reflect ileus.
3. Chronic right hip dislocation and prior removal of hardware,
little
changed from [**2157-5-11**] CT except for increased density of
contents of the
acetabular cavity that might reflect resolution of acetabular
fluid
collection.
4. Cardiomegaly.
5. Diffuse atherosclerotic disease.
6. Atrophic native kidneys.
7. Splenic hemangioma.
.
CHEST (PORTABLE AP) Study Date of [**2158-10-3**]
IMPRESSION:
Severe cardiomegaly with probable alveolar edema.
Satisfactory position of nasogastric tube.
.
Cardiac Cath Study Date of [**2158-10-5**]
COMMENTS:
1. Resting hemodynamics revealed mild elevation of right and
left
ventricular filling pressures, with a RVEDP of 11mmHg and a mean
PCWP of
19mmHg. There was no prominent V waves on the PCWP tracing to
support
severe mitral regurgitation. The patient has moderate pulmonary
hypertension, with a mean PA pressure of 41 mmHg. The cardiac
index was
preserved, with a calculated FICK of 2.06 L/min/m2 (which is
inaccurate
due to AV fistula.) No step-up of oxygen saturation to suggest
intracardiac shunt.
2. The PCWP increased to 24 mmHg with inhaled 100% O2 and
remained at
23 with NO at 40 ppm. There was no significant change in the PA
pressures with 100% O2 or NO therapy. The patients cardiac
output did
increase from 2.0 L/min/m2 to 2.4 L/min/m2, but values
inaccurate by
Fick due to AV fistula.
FINAL DIAGNOSIS:
1. Moderatly elevated right and midly elevated left-sided
filling
pressures.
2. Moderate pulmonary hypertension, with no significant change
in
pulmonary pressure with inhaled nitric oxide therapy.
3. Inaccurate assessment of cardiac output in the setting of AV
fisula.
.
ABD COMPL INCLUDING LAT DECUB Study Date of [**2158-10-6**]
IMPRESSION:
1. Prominent small bowel loops that may represent ileus or
obstruction. No
evidence of free intraperitoneal air.
2. Retrocardiac opacity that will be better evaluated on
PA/Lateral chest
radiographs.
.
MANDIBLE (PA, [**Last Name (un) **] & BOTH OBLS) PORT Study Date of [**2158-10-11**]
FINDINGS: Limited evaluation of the mandible, absent dentition.
No definite focal lucencies, however, the mandible is
incompletely visualized.
IMPRESSION: Limited evaluation of the mandible. Recommend
evaluation with
CT
Brief Hospital Course:
61 yo male w/ ESRD on hemodialysis, h/o MSSA bacteremia and
resultant endocarditis with AR/MR and right heart dysfunction,
A-fib, s/p colostomy for ischemic bowel who presents with months
of abdominal swelling, and days of abdominal pain and nausea who
is found to have ascites and ileus on admission, as well as
significant R heart failure presumably [**3-14**] known valvular
disease.
.
#. Abdominal pain and ascites with sx of ileus vs obstruction:
CT abd on admission showed normal hepatic structures and LFTs
were wnl, so preseumed secondary to heart failure. Pt had
paracentesis with removal of 7.7L of fluid on [**2158-10-4**] -->
transudate with SAAG 0.3. Sx of obstruction vs ileus resolved
transiently s/p paracentesis, and pt transitioned to regular
diet as tolerate. Intitially, did very well without abd pain,
N/V, and passing flatus/small amount of stool. However,
obstruction sx of N/V/abd pain returned [**10-5**] with
re-accumulation of ascites. KUB with possible obstruction, and
U/S abd showed moderate amount of free intra-abdominal fluid and
dilated small bowel loops. NGT placed. Stool studies sent, and
C.diff negative. While in the CCU, the patients NGT output
decreased and it was able to be clamped. He had copious amounts
of brown stool into his ostomy bag.
.
# GI bleed as evidenced by blood in ostomy bag and ?bloody
aspirate from NG tube: pt had H/H trended, which was stable. GI
consult placed, but no recommendations for urgent scoping in
context of small amount of serosangineous ostomy output and
stable H/H. Also started on Protonix 40mg [**Hospital1 **]. GI signed off
on the patient and his output was non-bloody while in the CCU.
.
#. R Heart failure likely cause of ascites, in context of aortic
and mitral regurg: Was being evaluated as outpatient for valve
replacement. Since ascites is likely related to increased
decompenastion of heart disease, may need replacement sooner.
Had paracentesis to remove ascites fluid (transudative) and then
had R heart catheterization to evaluate reversibility of
pulmonary hypertension. Minimal response of pulmonary HTN to
NO, so patient was transfered to CCU with throught that may be
able to inotropically aid forward flow, and thus be able to
diurese extra fluid off patient. Patient was started on
dobutamine and phenylephrine and started on CVVH with removal of
1L a day. His cardiac status improved and he was able to be
weaned off of his pressors and was able to start [**Hospital1 2286**].
.
#. Supratherapeutic INR: INR 4.3 on [**10-4**], now s/p 4U FFP and Vit
K. Coumadin held since [**2158-10-3**].
.
# A fib with intermittent RVR (140s): initially, cardiology
consult placed, resulting in transfer of care to cardiology
medicine team. The patient was started on digoxin for its rate
controlling and inotropic support.
.
#. Hypotension: SBPs in 80s-90s at baseline, and decreases to
70s during [**Month/Day/Year 2286**]. Renal consulted, and recommended keeping
SBP>75, but if low SBP and asymptomatic, no need to fluid bolus.
Lisinopril 2.5 daily held while hypotensive. He kept good
metation with SBP in the 70's during admission.
.
#. ESRD: Pt gets [**Month/Day/Year 2286**] M,W,F at [**Hospital **] clinic and [**Hospital 2286**]
schedule initially continued while pt hospitalized. He was
switched to CVVH for right heart failure and need for diuresis.
He was then converted back to [**Hospital 2286**] and converted back to his
normal schedule. Cont nephrocaps, Cinacalcer, epogien.
.
Pt clinical status improved. Pt was able to take in POs and
advance diet. Additional workup for possible future valve
replacement was conducted including panorex which showed need
for removal of 3 teeth. This was felt could be performed as an
outpt. Pt was discharged in stable condition w/instruction to
eat a robust diet to improve nutritional status. Pt also had
close outpt follow-up planned for further workup and management
w/respect to heart issues and possible valve replacement.
.
Pt was full code during this admission.
Medications on Admission:
- LISINOPRIL 2.5mg PO daily
- WARFARIN - 2 mg Tablet - up to 3 (three) Tablet(s) by mouth
once
a day to maintain INR
- B COMPLEX-VITAMIN C-FOLIC ACID [NEPHROCAPS] - 1 mg Capsule - 1
Capsule(s) by mouth once a day
- CINACALCET [SENSIPAR] - (Prescribed by Other Provider) - 60 mg
Tablet - 1 Tablet(s) by mouth once a day
- CIPROFLOXACIN - 500 mg Tablet - 1 Tablet(s) by mouth once a
day
- EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider: [**Name10 (NameIs) **] HD
TIW; med rec from rehab) - Dosage uncertain
- PROTONIX 40mg daily
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
3. Epoetin Alfa Injection
4. Cinacalcet 60 mg Tablet Sig: One (1) Tablet PO once a day.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO M, W, F after
hemodialysis: Digoxin level should be checked at [**Name10 (NameIs) 2286**]
sessions for dosing.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Diastolic Heart Failure
Hypotension
Ascites
Malnutrition
Abdominal Pain
End Stage Renal Disease
Guiac Positive Stools
Secondary Diagnosis:
Atrial fibrillation
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 [**Hospital1 18**] because you were nauseus and having
abdominal pain. Because of your heart condition, fluid built up
in your abdomen making your belly swell with fluid. Because of
that you were not having bowel movements. We controlled your
pain, and removed the fluid from your abdomen. Because of the
nausea and vomiting you couldn't eat for multiple days.
Your blood pressures were low while you were in the CCU, so we
used medication to help keep your blood pressures at an
acceptable level. We used a catheter called a Swan, to measure
the pressure coming from your heart. We also needed to place a
large IV in the vein in your neck for your [**Hospital1 2286**]. There was
concern that the fistula in your arm was not working, but it was
evaluated and it was accessed and worked fine at the end of your
stay. We used [**Hospital1 2286**] to remove fluid as well, in order to help
your heart function and to stop the fluid from backing up in
your abdomen.
After the fluid was removed, your pain got better, and slowly,
your bowels started putting out stool, so we started you back on
a diet consisting of liquids to test your nausea. You were able
to tolerate those, so we increased your diet before you were
discharged.
While you were here, we had you evaluated by cardiac surgery
and a dentist to help evaluate you for a potential surgery to
replace the valves in your heart that are damaged.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
In summary, we made the following changes to your medications:
We STOPPED Lisinopril because of low blood pressure
We STOPPED your coumadin, this will need to be restarted by your
primary care doctor, or Dr. [**Last Name (STitle) 4883**]
We STARTED Digoxin 0.125mg MWF after [**Last Name (STitle) 2286**]
.
You are unable to be on a beta blocker or calcium channel
blocker at this time because of your low blood pressure
Followup Instructions:
Provider: [**Name10 (NameIs) **],SCHEDULE HEMODIALYSIS UNIT Date/Time:[**2158-10-14**]
12:00
Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2158-10-17**]
1:00
Provider: [**Known firstname 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2158-10-24**] 1:30
Provider: [**Name Initial (NameIs) **]CC7 [**2158-11-27**] 8:40am [**Hospital Ward Name **] CENTER, [**Location (un) **]
Please call Dr. [**Last Name (STitle) 4883**] for a follow-up appointment in one week
at [**Telephone/Fax (1) 721**]
.
Please have your Digoxin level checked at [**Telephone/Fax (1) 2286**] every MWF for
a goal level of [**2-10**].5
.
Please have your coumadin restarted by your primary care doctor
or Dr. [**Last Name (STitle) 4883**]
Completed by:[**2158-10-15**]
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26,187
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10253
|
Discharge summary
|
report
|
Admission Date: [**2119-3-2**] Discharge Date: [**2119-3-6**]
Date of Birth: [**2054-9-28**] Sex: M
Service: [**Hospital1 212**]-MEDICINE
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 7086**] is a 64-year-old
male with a past medical history significant for paroxysmal
atrial fibrillation, history of left atrial appendage
thrombus (shown on an echocardiogram on [**2119-2-1**]),
hypertension, congestive heart failure, noninsulin dependent
diabetes mellitus, who presented to the Emergency Department
with a two day history of melena.
Upon admission, the patient stated that he was well until the
day before his admission. At presentation, he complained of
a diffuse abdominal "fullness." Additionally he complained
of chest pain mostly on the left side with radiation towards
his back. He, however, denied chest pain at the time of
admission. There was some association of shortness of breath
but no nausea or vomiting.
Additionally the patient complained of a black stool the
night before admission as well as one on the a.m. of
admission. He denies bright red blood per rectum.
On review of systems, the patient states that he had good
p.o. intake. There was no nausea or vomiting. Review of
systems also was positive for a bifrontal headache. He
denied lightheadedness or dizziness. He denied any history
of anemia in the past.
PAST MEDICAL HISTORY: The past medical history revealed
paroxysmal atrial fibrillation; history of left atrial
appendage thrombus (by echocardiogram on [**2119-2-1**]);
hypertension; congestive heart failure (echocardiogram also
showed ejection fraction of less than 20%); noninsulin
dependent diabetes mellitus; status post cerebrovascular
accident, 15 years prior; right lower lobe lung opacity by CT
scan; recent echocardiogram on [**2119-2-1**] showing
ejection fraction less than 20%, severely decreased left
ventricular function, thrombus in the left atrial appendage,
and depressed right ventricular systolic function; chest CT
in [**2119-1-26**] showing right lower lobe lung mass/opacity
measuring 3.6 x 4.6 cm, also two ground-glass nodules within
the lung apices.
MEDICATIONS: Amiodarone 200 mg p.o. q. day, Lisinopril 10 mg
p.o. q. day, Lasix 20 mg p.o. q.o.d., Coumadin 2 mg p.o. q.
day, enteric coated aspirin 325 mg p.o. q.d., Zantac 75 mg
p.o. b.i.d., Glipizide 10 mg p.o. q. day, Atrovent MDI 2
puffs p.r.n., Motrin 500 mg p.o. q. day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient recently moved from [**Country 7192**].
He was a smoker. He quit tobacco 35 years ago. There is no
alcohol use. The patient walks with a walker.
PHYSICAL EXAMINATION: Initially heart rate was 75, blood
pressure 90/40, respirations 16, O2 saturation 99% on room
air. In general, the patient was awake and alert. He was
Spanish-speaking only. He demonstrated rolling head movement
as well as persistent eye closing movements which according
to the family were baseline for the patient. HEENT
examination revealed normocephalic, atraumatic. The right
pupil was status post surgical intervention. The left pupil
was equal, round, and reactive to light. Sclerae were
nonicteric. The neck showed no carotid bruits and 2+ pulses.
There was positive jugular venous distention. Cardiac
examination revealed regular rate and rhythm with a 2/6
systolic ejection murmur heard best at the left lower sternal
border. The lungs showed rales one-third of the way up in
both lung fields with dull bases, the right being greater
than the left. The abdomen was soft, slightly distended, and
nontender with positive bowel sounds. Rectal examination was
significant for black stools that were guaiac positive. The
extremities revealed 2+ bilateral pitting edema up to the
knees. Neurologically, the cranial nerves were intact.
Motor was [**4-29**] bilaterally with slightly weak interosseous
muscles.
SIGNIFICANT LABORATORY DATA: White blood cell count was 6.1,
hematocrit 18, platelets 544,000. (Of note, the patient's
last hematocrit was 32.0 on [**2119-2-15**].) Sodium was
132, potassium 4.7, chloride 97, bicarbonate 25, BUN 35,
creatinine 0.6, glucose 319. INR was 4.1, PTT 34, ALT 15,
AST 14, LDH 200, alkaline phosphatase 138, amylase 34, lipase
17, total bilirubin 0.2. Electrocardiogram showed normal
sinus rhythm at a rate of 73 beats per minute, possible
criteria for left ventricular hypertrophy, flattened T wave
in lead I as well as nonspecific biphasic T wave
abnormalities in lead aVL and across the precordium. There
were considered to be more marked repolarization changes than
a previous EKG done on [**2119-2-17**]. Chest x-ray showed
cardiomegaly and interval increase of a left dependent
pleural effusion, loculated right pleural effusion slightly
improved from early [**2119-1-26**], and rounded opacity at the
peripheral right lung base which either represented
atelectasis or discreet nodular mass.
BRIEF HOSPITAL COURSE: In summary, the patient is a
64-year-old male with a past medical history significant for
paroxysmal atrial fibrillation, left atrial appendage
thrombus, hypertension, congestive heart failure, and
noninsulin dependent diabetes mellitus who was admitted for
gastrointestinal bleed and anemia. A review of the [**Hospital 228**]
hospital course by systems revealed the following.
Gastrointestinal: Shortly after admission, the patient had
an nasogastric lavage which was negative. Given the
patient's recent gastrointestinal bleed, a gastroenterology
consultation was obtained on the morning after admission.
EGD done on [**2119-3-3**] showed a normal esophagus, normal
stomach, normal duodenum, and no evidence of bleeding.
Following EGD, the decision was made to observe the patient.
He continued to have guaiac positive black stools, however,
hematocrits were monitored and were stable. On [**2119-3-6**], the patient underwent colonoscopy which showed the
following: Non-bleeding grade I internal hemorrhoid and
three superficial ulcers ranging in size from 3-6 mm in the
distal transverse colon as well as proximal transverse colon.
They were not actively bleeding. These ulcers were thought
to be most likely NSAID induced or possibly ischemic colitis.
Recommendations were for the patient to discontinue all use
of aspirin as well as nonsteroidal anti-inflammatory drugs.
Following colonoscopy which showed no active bleeding as well
as upper endoscopy which showed no active bleeding, further
workup for gastrointestinal bleed was not to be pursued at
the time of discharge. The patient was, however, to undergo
a repeat colonoscopy six weeks following the colonoscopy done
on [**2119-3-6**].
Hematology: Given the patient's initial hematocrit of 18.0
as well as an elevated INR of 4.1, the patient received
packed red blood cells and fresh frozen plasma to normalize
both abnormalities. Initially the patient was transfused
four units of packed red blood cells and three units of fresh
frozen plasma. Additionally the patient's aspirin as well as
Coumadin were both discontinued.
After being transfused to a level of near 30.0 on [**2119-3-4**], the patient maintained a similar hematocrit and upon
discharge the hematocrit was 31.0 with no additional units of
packed red blood cells given. Additionally with the
discontinuation of the Coumadin as well as the fresh frozen
plasma, the patient's INR level decreased towards baseline at
1.8. The patient no longer demonstrated any evidence of
active bleeding. To followup such values, the patient is to
have a CBC as well as INR drawn two days following the
discharge date.
Cardiac: Because of the patient's chest pain by history
before his admission, the patient underwent rule out
myocardial infarction protocol. Serial CKs were negative for
any evidence of myocardial infarction and troponin was less
than 0.3.
As mentioned earlier, the patient had a severely depressed
ejection fraction as well as evidence of left atrial
appendage thrombus. Because of the complicated nature of
these matters, the cardiology team including Dr. [**Last Name (STitle) **]
was consulted. The decision was made to keep the patient on
his normal dose of Amiodarone as well as Lisinopril. It was
also thought that because of the patient's history of left
atrial appendage thrombus, the patient would still require
anticoagulation upon discharge. Therefore the patient was
restarted on Coumadin at his pre-hospitalization levels.
Pulmonary: As noted earlier, the patient does have a history
of a right lower lobe lung nodule which has not been
extensively worked up. However two days after discharge, the
patient does have an appointment with his primary care
physician including [**Name Initial (PRE) **] scan to determine the likely etiologies
of the mass.
Endocrine: The patient was admitted on a regimen of
Glipizide. He will be continued on this as an outpatient.
Disposition: The patient is to be discharged home with his
family members. A home physical therapy evaluation will be
pursued. He will also have VNA services to help insure
medication compliance.
CONDITION ON DISCHARGE: Stable.
DISCHARGE MEDICATIONS: Amiodarone 200 mg p.o. q. day,
Prilosec 40 mg p.o. b.i.d., Lisinopril 10 mg p.o. q. day,
Coumadin 3 mg on Monday, Wednesday, Friday, and Sunday, and
then Coumadin 2 mg on Tuesday, Thursday, and Saturday.
DISCHARGE INSTRUCTIONS: The patient is to avoid the use of
aspirin as well as Motrin or Advil or for that matter any
other nonsteroidal anti-inflammatory drugs.
The patient is to have followup as follows: On Wednesday,
[**2119-3-8**], he is to have PT, PTT, and INR as well as CBC
checked. On the same date, Wednesday, [**2119-3-8**], he is
to have a followup appointment with Dr. [**First Name (STitle) **] as well as PET
scan of the lungs. Additionally on the same day, he is to
followup with the [**Hospital **] Clinic. I spoke extensively
with them in regards to the patient's previous doses of
anticoagulation and the decision was made to continue the
patient on his pre-hospital regimen. The patient is to also
pursue colonoscopy in six weeks. He was instructed to return
for any recurrence of gastrointestinal bleed, chest pain, or
shortness of breath.
DISCHARGE DIAGNOSES: Gastrointestinal bleed (likely
nonsteroidal anti-inflammatory drug induced); paroxysmal
atrial fibrillation; congestive heart failure; hypertension;
noninsulin dependent diabetes mellitus; status post
cerebrovascular accident; left atrial appendage thrombus.
[**Name6 (MD) 2415**] [**Last Name (NamePattern4) 3474**], M.D.
Dictated By:[**Last Name (NamePattern1) 34142**]
MEDQUIST36
D: [**2119-3-6**] 17:09
T: [**2119-3-6**] 19:33
JOB#: [**Job Number **]
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|
[
[
[]
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[
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] |
icd9pcs
|
[
[
[]
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4948, 9085
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9143, 9348
|
9373, 10217
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2664, 4924
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2480, 2641
|
9110, 9119
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,508
| 164,807
|
54605
|
Discharge summary
|
report
|
Admission Date: [**2150-3-8**] Discharge Date: [**2150-3-19**]
Date of Birth: [**2076-6-29**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Doctor First Name 3298**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
ERCP WITH AMPULLARY BIOPSY
TRANSHEPATIC BILIARY DRAIN PLACEMENT
TRANSHEPATIC BILIARY METAL STENT PLACEMENT
ESOPHAGOGASTRODUODENOSCOPY
History of Present Illness:
73-year-old male with h/o previous cholecystectomy, GERD, HTN,
HLD, NIDDM who presents to ED with acute abdominal pain and
found to have coffee ground emesis by NG lavage, elevated LFTs
and pancreatitis by imaging. Patient brought in by ambulance
with acute onset [**11-11**] non-radiating abdominal pain starting
[**2150-3-8**] at 0400 and awakening him from sleep. This is in the
context of anorexia, daily bilious frothy vomiting x4 weeks.
Unable to tolerate PO intake, unable to sleep. Endorses nausea,
vomiting and vomiting with any type of PO intake. Pain
non-radiating, no dysuria, no back pain, no diarrhea, no BRBPR
or black tarry stools per patient. He denies fever, chills,
chest pain, SOB, DOE. Patient may have some baseline cognitive
deficits and is on Donepezil as an outpatient. Patient denies
any recent weight loss or use of recent NSAIDS.
In the ED inital vitals were, 07:57 10 97.9 60 134/53 20 100%.
Patient had a CT of the abdomen/ pelvis remarkable for Acute
Pancreatitis, subtle hyperdensity in gastric fundus (?small
active bleed), focal edema in 2 areas of gastric wall, greater
curve. Free fluid likely related to pancreatitis. Mild
intrahepatic biliary ductule dilation, stricture in area of
pancreatic head, no stones.
Patient had a NG tube placed with NG lavage and 500cc. Patient
started on Protonix 80mg IV boluse and started infusion.
Vitals on transfer: 98.1 hr 68 b/p 139/55 rr 20
On arrival to the ICU, patient is comfortable and non-toxic
appearing.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies diarrhea, constipation, abdominal pain, or changes in
bowel habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
-H pylori + gastritis diagnosed and treated per notes in OMR
[**10-13**].
-Acute on chronic cholecystitis treated by cholecystostomy
followed by open cholecystectomy (converted from laparoscopic
approach) [**4-10**].
-BPH
-Coronary Arthery Disease (ETthal [**8-9**] with reversible inferior
ischemia at high workload, but asymptomatic; medically managed)
echo) without signs of ischemia.
-Dementia
-Diabetes Mellitus
-Herpes Zoster
-Hyperlipidemia
-Hypertension
-Obstructive Sleep Apnea
-PVD
-Plantar fasciitis
-Nephrolithiasis
-Retinal vein occlusion
-Subarachnoid hemorrhage [**2-/2147**]
PAST SURGICAL HISTORY:
-septal deviation and R inf turbinate repair at MEEI
-cholecystitis with perc drain, then open cholecystectomy [**4-10**]
-Abdominal Hernia Repair [**11-10**]
Social History:
Retired taxi driver. Lives with his wife in [**Name (NI) **]. From
[**Country 532**], came to U.S. in [**2125**]. Quit smoking. Denies EtOH or IVDU
Family History:
Sister with breast CA. Mother had diabetes
Physical Exam:
Admission:
Vitals: T:97.2 BP:153/62 P:63 O2: 98%
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
On Discharge:
VS: T 97.8, BP 149/73, P 84, RR 20, O2 94% on RA
Gen: NAD
HEENT: Anicteric sclera, MMM
CV: RRR, no M/R/G
Pulm: Clear to auscultation bilaterally, no wheezes, rhonchi, or
rales
Abd: Soft, nontender, nondistended, bowel sounds present, no
guard/rebound, bandaged site of removal of perc drain on right
upper quadrant
Ext: Warm and well perfused, no C/C/E
Neuro: Alert, fluent speech
Psych: Somewhat flattened, down affect
Pertinent Results:
===================
LABORATORY RESULTS
===================
On Admission:
WBC-7.1 RBC-3.26* Hgb-9.8* Hct-29.6*# MCV-91 RDW-13.8 Plt Ct-231
---Neuts-78.7* Lymphs-12.3* Monos-6.0 Eos-2.3 Baso-0.7
Glucose-170* UreaN-28* Creat-1.1 Na-136 K-4.3 Cl-98 HCO3-27
ALT-484* AST-465* AlkPhos-1002* Amylase-563* TotBili-1.7*
Lipase-1610*
Albumin-3.6 Calcium-9.1 Phos-3.4 Mg-1.6
BLOOD Acetmnp-NEG
Lactate-0.8
Important Inpatient Labs:
CA [**57**]-9 202, HCV Ab-NEGATIVE, HBsAg-NEGATIVE, HBcAb-NEGATIVE,
HAV Ab-POSITIVE
CEA-3.2 AFP-3.1
Triglyc-136 HDL-38 CHOL/HD-5.7 LDLcalc-152*
On Discharge:
WBC-6.8 RBC-2.99* Hgb-8.8* Hct-26.4* MCV-88 RDW-14.0 Plt Ct-213
Glucose-123* UreaN-12 Creat-0.8 Na-135 K-4.3 Cl-101 HCO3-27 AnGa
ALT-143* AST-37 AlkPhos-688* TotBili-1.8*
Calcium-8.4 Phos-3.5 Mg-1.8
=============
MICROBIOLOGY
=============
H Pylori Serology [**2150-3-8**]:
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2150-3-9**]):
POSITIVE BY EIA.
==============
OTHER STUDIES
==============
ECG [**2150-3-8**]:
Sinus rhythm. Compared to tracing #1 an RSR' pattern in leads
V1-V2 is no
longer present
EGD [**2150-3-8**]:
Impression: Ulcer in the stomach body
Otherwise normal EGD to third part of the duodenum
CT Abd and Pelvis [**2150-3-8**]:
IMPRESSION:
1. Extensive soft tissue stranding, mesenteric and omental
nodularity and
lymphadenopathy in the upper abdomen consistent with malignancy.
Considerations for the site of primary neoplasm include a
pancreatic neoplasm (centered likely at the margin of the
pancreatic head with extensive local invasive disease including
vascular encasement and liver involvement), or alternatively
gastric carcinoma. If of pancreatic origin, pancreatic
adenocarcinoma would be considered most likely although in the
setting of elevated lipase, acinar cell carcinoma could be
considered as well (versus lipase elevation due to superimposed
pancreatitis). Cholangiocarcinoma is considered though felt less
likely.
2. Abnormal appearance of the posterior wall of the gastric
body, concerning for ulceration, possibly secondary to
underlying mass. Possible focus of hyperdensity within the
stomach on pre-contrast images with slight increase on arterial
phase images, might suggest a correlate for active bleeding.
Endoscopy is recommended.
3. Peripancreatic stranding and fluid, compatible with a
component of
superimposed acute pancreatitis, though possibly secondary to
other processes as described above without evidence for necrosis
or abscess.
4. Bilateral lower lobe lung nodules, left adrenal mass, omental
nodularity, and mesenteric and retroperitoneal
nodularity/lymphadenopathy, concerning for metastatic disease.
5. Lytic lesion in the left transverse process of T10,
concerning for
metastasis.
6. Grade 2 anterolisthesis of L5 on S1 with bilateral
spondylolysis.
Chest Radiograph [**2150-3-8**]:
IMPRESSION:
1. Mild interstitial pulmonary edema.
2. Micronodularity in the right mid-to-upper lung could be
vessels on end.
ERCP [**2150-3-10**]:
Impression:
Limited exam of the stomach using the side viewing scope
revealed diffusely edematous and friable mucosa throughout the
stomach.
A large non bleeding ulcer was visualized within the stomach
body.
A malignant appearing highly friable 2 cm mass was seen at the
major papilla. Cold forceps biopsies were performed for
histology at the mass at the ampulla.
Cannulation of the biliary duct was attempted with a
sphincterotome using a free-hand technique. However cannulation
of the bile duct was unsuccessful despite multiple attempts.
The pancreatic duct was cannulated and limited pancreatogram was
obtained. The distal PD within the head of the pancreas
appeared unremarkable.
Otherwise normal ercp to third part of the duodenum
CT Chest W/O Constrast [**2150-3-14**]:
IMPRESSION:
1. Exam limited by patient motion.
2. Septal thickening with reticular nodular infiltrates
scattered throughout all lobes concerning for lymphangitic
carcinomatosis in the setting of known metastatic gastric
cancer.
3. Superimposed mild pulmonary edema. Small bilateral pleural
effusions.
4. 8-mm metastatic lesion within the T8 vertebral body.
5. Unchanged metastatic lesion at the left transverse process
T10.
6. Diffuse abnormal gastric wall thickening, concerning for
primary gastric adenocarcinoma.
7. Bilateral adrenal nodules/masses.
8. Trace ascites.
9. Mild pneumatosis and stable intrahepatic bile duct dilation,
now status
post percutaneous biliary drainage.
PTC [**2150-3-16**]:
IMPRESSION:
1. Pre-existing drain was occluded accounting for rising LFTs
2. Uncomplicated fluoroscopy-guided cholangioplasty and 10 x 80
mm CBD stent placement. An 8 French Anchor catheter left in
place and connected to a bag for overnight external drainage
after which it may be capped. The plan is to have the patient
come back for check cholangiogram: if the stent is patent the
anchor catheter may be removed.
ERCP [**2150-3-19**]:
Impression: A large, infiltrative mass involving the stomach
fundus and body likely linitus plastica - this is most likely
the primary site of metastatic cancer. (biopsy)
Mass lesion was noted in the duodenum concerning for malignancy
- this had been previously seen on ERCP.
Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
73-year-old male with h/o previous cholecystectomy, GERD, HTN,
HLD, NIDDM who presents to ED with acute abdominal pain and
found to have coffee ground emesis by NG lavage, elevated LFTs
and pancreatitis by imaging.
#Pancreatic vs Gastric Adenocarcinoma/Cholestasis: Found after
workup of biliary ductal dilatation and rising LFTs consistent
with cholestasis from an obstructive ampullary mass. He
underwent ERCP which was not successful at cannulating the
ampulla, but a ampullary biopsy was performed that showed poorly
differentiated adenocarcinoma. Given the presence of local
invasion and evidence of thickened stomach wall and abnormal
findings at EGD, there is also a possiblity that the primary
tumor could be pancreatic vs duodenal vs. gastric. Ampullary
biopsy revealed poorly differentiated adenocarcinoma. It is
stage 4 because there are evidence of lung, bone, adrenal,
omental lesions consistent with dissmeninated metastasis. He
does not have resecectable disease per pancreatico-biliary
surgery and medical oncology. He had a trans-hepatic biliary
drain placed via IR to decompress his biliary tree but LFT's
rose again so he had an internal stent placement on [**3-16**].
Bilirubin started to fall again and was 1.8 on day of discharge.
He has follow up scheduled for the week after discharge with
Dr. [**Last Name (STitle) **] in oncology. By that time gastric biopsy pathology
should be available.
# Upper GI bleed due to ulcer: Initial EGD only showed friable
large ulcer that bled on contact but no frank blood. Limited
study as scope had to be withdrawn due to patient intolerance.
CT with induration of wall concerning for malignancy either
metastatic or primary. The patient was treated with PPI as well
as clarithromycin/amoxicillin for H pylori as serologies
positive(course to finish on [**3-26**]). Hct dropped from 40-->29
soon after admission (received one unit of pRBC's) but then no
further signs of bleeding and Hct relatively stable. EGD on day
of discharge continued to slow ulcer and induration concerning
for linea plastica. Stomach biopsies pending at discharge.
# Acute pancreatitis: Also unclear etiology: question
obstruction from a mass versus other etiology, not likely
alcohol, donepizil and depakote can possibly cause. Patient
without pain radiating to back, lipase 1610 and CT scan positive
for pancreatitis preliminarly. BISAP score of 2 for age and BUN
giving low mortality (<2%). Calcium is normal at 9.1. Lipid
panel unremarkable. Patient was given at least 5L LR initially
for fluid resuscitation and initially kept NPO. Then diet
advanced without issue. He was tolerating a full diet at
discharge.
# Elevated Liver transaminases (hepatocellular and cholestatic
without markedly elevated bilis), also with intrahepatic biliary
ductal dilation with focal narrowing of the distal common bile
duct. Patient is s/p cholecystectomy [**4-10**]. LFTs were normal in
[**2148**] and [**2149**]. ? cholangiocarcinoma with mets also possible is
vascular lesion. Tylenol level negative and hepatitis
serologies unremarkable.
INACTIVE ISSUES:
1)CAD: [**7-10**] Nuclear perfusion stress test: Probably abnormal
perfusion study with mild reversible defect in the inferior
wall. Managed medically: [**9-11**] stress echo with excellent
functional exercise capacity. Metoprolol was initially held but
then restarted on discharge. Simvastatin was held given LFT
abnormality. ASA should be held until 7 days after last IR
procedure (due to bleeding risk) and restarted [**3-26**].
2) Hypertension: Hydrochlorothiazide was held. Lisinopril was
continued at reduced dose. Terazosin held briefly but restarted
prior to discharge.
3) Diabetes: Patient was kept on ISS in house. He will be
restarted on metformin at discharge.
4)Dementia: His divalproex and donazepil were initially held
due to concern they promoted pancreatitis but were restarted and
tolerated prior to discharge. Patient is usually lucid but
occasionally disoriented and with labile affect.
5) BPH with hematuria on foley placement: On presentation.
Urine cleared after irrigation and patient then had foley
removed with no further hematuria.
6) Communication: Discussion held between patient, primary
hospitalist, and family with Russian interpreter present.
Patient previously informed he had cancer but family concerned
large amounts of information were burdensome to him. Therefore,
we discussed this and patient expressed that he would prefer new
or complex information be primarily conveyed to his wife and son
who would then help decided how to convey information to him.
Transitional Issues:
-Patient will follow up with oncology to discuss plan of
treatment for his malignancy
-Pathology of stomach biopsies are pending but should be
available by time of oncology follow up
-Patient code status was full
-Primary Family members [**Name (NI) **] [**Name (NI) 111699**] (Wife-HCP) cell :
[**Telephone/Fax (1) 111700**]
[**Name (NI) **] [**Name (NI) 111699**] (Son): [**Telephone/Fax (1) 111701**]
Medications on Admission:
Per OMR, patient verifies names but unsure of doses:
- Divalproex 500mg qhs
- Donepezil 10mg qd
- HCTZ 25mg qd
- Lisinopril 40mg qd
- Metformin 1000 [**Hospital1 **]
- Metop Succ 200mg qd
- Simvastatin 40mg qd
- Terazosin 2mg qhs
- ASA 81mg qd
- B12 1000mcg qd
Discharge Medications:
1. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
2. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO HS (at bedtime).
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
4. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 7 days: END DATE [**3-26**].
5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO
DAILY (Daily) as needed for constipation.
6. amoxicillin 250 mg Capsule Sig: Four (4) Capsule PO Q12H
(every 12 hours) for 7 days: END 2/ 23
.
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
9. terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
10. donepezil 10 mg Tablet Sig: One (1) Tablet PO once a day.
11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
14. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day: hold until
[**2150-3-26**].
15. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for pain: do not exceed 2 gm/day.
16. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnoses:
Metastatic carcinoma (pancreatic vs gastric)
Cholestasis
Transaminitis
Pancreatitis
Secondary Diagnoses:
Dementia
Hypertension
Benign Prostatic Hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with abdominal pain and found to have GI
bleeding as well as a cancer involving your stomach and
pancreas. It is unclear if this tumor originated in the stomach
or pancreas. You had biopsies taken through an ERCP and from a
endoscopy of the stomach and ampulla of the intestine. These
are being processed and final results will be available when you
return for oncology follow up next week.
Your medications have been changed. Please continue to take all
medications as prescribed.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2150-3-27**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7634**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2150-3-27**] at 11:00 AM
With: DR. [**First Name8 (NamePattern2) 610**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"285.1",
"532.40",
"790.4",
"577.0",
"599.70",
"272.4",
"250.00",
"414.01",
"600.01",
"576.8",
"156.2",
"199.1",
"401.1",
"294.10",
"331.0",
"041.86"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.54",
"44.14",
"51.10",
"45.16",
"51.98",
"97.55",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
16679, 16745
|
9689, 12775
|
319, 455
|
16965, 16965
|
4430, 4489
|
17645, 18278
|
3401, 3445
|
15064, 16656
|
16766, 16870
|
14779, 15041
|
17116, 17622
|
3060, 3220
|
3460, 3976
|
16891, 16944
|
5010, 9666
|
14324, 14753
|
1994, 2423
|
265, 281
|
483, 1975
|
12792, 14303
|
4503, 4996
|
16980, 17092
|
2445, 3037
|
3236, 3385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,776
| 133,370
|
48996
|
Discharge summary
|
report
|
Admission Date: [**2178-2-8**] Discharge Date: [**2178-2-11**]
Date of Birth: [**2106-11-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Pre-cath hydration
Major Surgical or Invasive Procedure:
Cartotid angiogram
History of Present Illness:
71 yo F with history of CAD, severe PVD, DM, HTN who presents
for pre-cath hydration prior to carotid angiogram. Patient has a
history of severe PVD with recent admission for PCI on L deep
femoral artery. Recent U/S of carotids shows 50-79% right ICA
and 70-79% left ICA stenosis. Here for evaluation and possible
stenting by Dr. [**First Name (STitle) **] and Dr. [**Last Name (STitle) **]. She denies any history
of stroke and has never had any episodes of focal weakness,
numbness, loss of vision, speech difficulties or any other TIA
symptoms. She has had only one brief episode of chest pain since
her prior admission which was non-exertional and lasted a few
minutes, alleviated with one SL nitro. She cannot remember other
details about the CP. She is able to walk multiple blocks
without chest pain or shortness of breath. She denies orthopnea,
PND, N/V, diaphoresis, LE edema, or syncope. She does note a
mild dry cough over the last few days. No associated congestion
or shortness of breath, no recent fevers or chills. On further
ROS she also notes mild occasional occipital HA, relieved by
tylenol and baseline pain in upper thighs at rest [**3-7**] PVD and
worse in LE with exertion. She also notes increased fatigue over
the last few weeks but denies any palpitations, lightheadedness
or syncope.
Past Medical History:
CAD - s/p 3 MIs, did not experience chest pain at the time. She
has a known occluded RCA
CHF- EF 20-25%, ischemic cardiomyopathy, s/p ICD placement in
[**2174**] for primary prevention. Has only discharged once 2 years
ago
PVD - has symptoms of claudication s/p POBA to L profunda
femoral artery, known 99% R SFA and 100% L SFA occulusions
small AAA
Hypothyroidism
DM
HTN
HLD
COPD
Asthma
history of Bladder Ca - had tumor excision without chemo or
radiation
Carotid Stenosis: 50-79% right ICA and 70-79% left ICA stenosis
on U/S
.
Surgical history
Appendectomy
hysterectomy
.
Social History:
Quit smoking 4 years ago, s/p [**Age over 90 **] year pack history, no EtOH
use.
Family History:
Strong family history of CAD, in brothers, sister, father and
mother
Physical Exam:
VS - T: 98.2 P: 64 BP: 141/58 RR: 18 O2: 100% RA
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP not elevated. Possible bruit on R carotid
CV: PMI located in 5th intercostal space, midclavicular line.
irregular rhythm, normal S1, S2. No m/r/g appreciated. No
thrills, lifts. ? S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, very mild
bibasilar 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. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 0+ DP 0+ PT 0+
Left: Carotid 0+ Femoral 2+ Popliteal 0+ DP 0+ PT 0+
Pertinent Results:
[**2178-2-8**] 05:17PM BLOOD WBC-8.1 RBC-3.87* Hgb-11.2* Hct-31.9*
MCV-83 MCH-29.0 MCHC-35.1* RDW-13.9 Plt Ct-233
[**2178-2-8**] 05:17PM BLOOD Glucose-280* UreaN-40* Creat-1.8* Na-134
K-3.9 Cl-93* HCO3-30 AnGap-15
[**2178-2-10**] 06:05AM BLOOD Glucose-280* UreaN-46* Creat-1.8* Na-139
K-5.0 Cl-99 HCO3-32 AnGap-13
[**2178-2-10**] 06:05AM BLOOD CK(CPK)-93
[**2178-2-9**] 05:40AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2178-2-8**] 05:17PM BLOOD Calcium-9.8 Phos-3.2 Mg-2.3
[**2178-2-9**] 05:40AM BLOOD %HbA1c-10.1*
[**2178-2-9**] 05:40AM BLOOD Triglyc-582* HDL-30 CHOL/HD-5.9
LDLmeas-70
[**2178-2-8**] 05:17PM BLOOD Digoxin-2.5*
[**2178-2-9**] 05:40AM BLOOD Digoxin-3.5*
LENIS [**2178-2-9**]:
FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of bilateral common
femoral, superficial femoral and popliteal veins were performed.
There is normal compressibility, flow and augmentation. Flow in
the visualized superficial calf veins is normal.
IMPRESSION: No evidence of DVT.
.
Cath [**2178-2-10**]:
COMMENTS: 1. Initial angiography of the aortic arch was
obtained
revealing a type 1 aortic arch without critical stenosis atthe
level of
the arch. Images were ovbtained non-selectively via a 5 french
tennis
racquet catheter. Selective images were then obtained of the
right and
then the left carotid arteries with a 5fr [**Doctor Last Name **] 1 catheter.
The right
common carotid: minimal disease, right ICA has a 65% lesion
proximally
just distal to the CCA bulb. The right ICA fills the ipsilateral
AC and
MCA intracerebrally with cross-filling noted of the
contralateral ACA.
The Left common carotid artery is normal. The Left ICA has a
tubular 80%
stenosis present involving the bulb and extending into the
proximal left
ica. The ICA fills the ipsilateral ACA and MCA as well as
providing some
cross-filling to the contralateral ACA.
2. Successful ptca and stenting of the left ICA utilizing spider
filter
for distal protection. Successful deployment of a self-expanding
tapering 6-8x40mm protege carotid stent which was post dilated
to 4.5mm.
Final angiography revealed a 10% residual stenosis, no
angiographically
apparent dissection and brisk flow (see ptca comments). The
patient left
the lab free of angina and in stable condition.
3. Limited hemodynamics revealed a central aortic pressure of
196/69.
FINAL DIAGNOSIS:
1. Left internal carotd disease
Brief Hospital Course:
#Carotid Stenosis: Pt with Carotid stenosis found on screening
US. Relatively high risk of stroke based on the degree of
stenosis. She was evaluated by cardiovascular medicine and
underwent cath on [**2178-2-10**]. Angiography demonstrated: right
common carotid: minimal disease, right ICA has a 65% lesion
proximally
just distal to the CCA bulb. The Left common carotid artery is
normal. The Left ICA has a tubular 80% stenosis present
involving the bulb and extending into the proximal left ica. The
ICA fills the ipsilateral ACA and MCA as well as providing some
cross-filling to the contralateral ACA. Left ICA was successful
ptca and stented utilizing spider filter for distal protection.
Final angiography revealed a 10% residual stenosis, no
angiographically apparent dissection and brisk flow. The patient
was observed in CCU overnight. Required phenyleprine to maintain
BP systolic range 100-140. Normal neuro exam post stenting. Her
PCM backup rate was increased from 40bpm to 50bpm givnen her
symptomatic bradycardia. Her pressor was weaned the morning
following admission. Her digoxin, amlodipine, lisnopril, lasix
and imdur were discontinued until her scheduled outpatient
follow up with cardiology. Her carvedilol was held pre-cath and
she was instructed to restart this medication on the day
following discharge.
.
#Bradycardia/Mobitz 1: The Mobitz 1 heart block is new since her
last admission and she descibes increased fatigue. The AV block
with slightly sccoped ST segments and new fatigue all suggest
possible digoxin toxicity. Her digoxin level was elevated and
her medication was held. Her carvedilol was held pre-cath and
she was instructed to restart her home dose on the day following
discharge. Concern because mobitz [**6-4**] worsen with vagal
stimulation (and carotid stents frequently complicated by high
vagal tone so her PCM backup rate was increased to 50bpm as
above.
.
#. CAD: Cardiac cath on [**1-17**] showed stable coronary anatomy
with known RCA occlusion supplied by collaterals. No other
significant coronary disease. She was continued on aspirin and
plavix. Continued on statin. Her lisinopril, amlodipine, and
imdur were held as above.
.
#. Chronic Kidney Disease: Baseline Cr. of 1.7. Estimated GFR of
approximately 30. The patient received pre-cath hydration with
NS at 60cc/hr ON, more gentle given decreased EF. Then 150meq
Bicarb at 120cc 1 hour prior to cath and 60cc/hr for 6hr after.
Also given NAC 600mg PO BID before and after.
.
#PVD: Hx of claudication S/P POBA to L profunda femoral artery.
Continued on ASA, Plavix, and pentoxifylline.
.
#HTN: Mildly hypertensive on admit. Improved today. Blood
pressure medications held as above.
.
#DM: Continued home glipizide and RISS.
.
#Hyperlipidemia: Continued on atorvastatin, fenofibrate, and
Zetia.
.
# COPD: Continued Fluticasone and PRN albuterol
.
Medications on Admission:
1. Digoxin 250 mcg PO DAILY
2. Atorvastatin 60 mg PO DAILY
3. Levothyroxine 50 mcg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Fenofibrate Micronized 145 mg PO daily
6. Glyburide 10mg 2 tabs in AM and 1 tab in PM
7. Furosemide 120mg in AM and 80 in PM
8. Lisinopril 20 mg PO DAILY
9. Ezetimibe 10 mg PO DAILY
10. Pentoxifylline 400 mg Sustained Release PO TID
11. Nitroglycerin 0.4 mg Tablet Sublingual PRN.
12. Fluticasone-Salmeterol 250-50 mcg/Dose One INH [**Hospital1 **]
13. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
every eight (8) hours as needed for shortness of breath or
wheezing.
15. Clopidogrel 75 mg PO DAILY
16. Aspirin 325 mg PO DAILY
17. Carvedilol 25 mg PO twice a day.
18. Isosorbide Mononitrate Sustained Release 24 hr 60mg qAM,
30mg qhs
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
Daily ().
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Pentoxifylline 400 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO TID (3 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Glyburide 5 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)).
11. Glyburide 5 mg Tablet Sig: Two (2) Tablet PO qPM.
12. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual prn chest pain: take one tablet under toungue every 5
minutes, up to 3 tablets, if still having chest pain, call 911.
.
13. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day:
start on [**2178-2-12**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. L internal carotid stenosis s/p carotid stenting
2. Peripheral Vascular Disease
3. Bradycardia
4. Ischemic Cardiomyopathy
Secondary:
1. Diabetes Mellitus
2. Hypertension
3. Hyperlipidemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital for carotid artery stent
placement.
.
Your digoxin, amlodipine, lisnopril, lasix and imdur were
discontinued. You should discuss restarting these with your
usual cardiolgist dr. [**Last Name (STitle) **]. You should restart your
carvedilol tomorrow morning ([**2178-2-12**]).
.
However, do not take the following medications until directed to
do so by your cardiologist:
Digoxin
Amlodipine
Imdur
.
You have started the medication Plavix. You must continue to
take this medication to prevent a blot clot formation in your
carotid stent. You should never stop this medication unless
directed to by your cardiologist. You should also continue to
take your aspirin daily.
.
Please contact your doctor or return to the emergency room if
you develop worrisome symptoms such as dizziness,
lightheadedness, shortness of breath or chest pain.
.
Please maintain your scheduled follow up appointments listed
below.
Followup Instructions:
You should follow up with your Cardiologist Dr. [**Last Name (STitle) **] on
Friday [**2178-2-13**] at 1:15pm. Please call [**Telephone/Fax (1) 102870**] with any
questions about your appointment. Dr. [**Last Name (STitle) **] will discuss
restarting your blood pressure medications at this time.
.
You should follow up with Dr. [**First Name (STitle) **] and [**Last Name (LF) **], [**First Name3 (LF) **]
appointment has been made for you withdr. [**Doctor Last Name **] on [**2178-3-9**] @
10:30AM. call ([**Telephone/Fax (1) 1703**] with any questions or concerns.
.
You should then follow-up with Dr. [**First Name (STitle) **] on [**2178-3-9**] @ 11:30AM.
call ([**Telephone/Fax (1) 7236**] with any questions or concerns.
.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6403**], MD Phone:[**Telephone/Fax (1) 1690**]
Date/Time:[**2178-3-9**] 10:30
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (2) 1690**]Provider:
[**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 4022**]
|
[
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"493.20",
"780.79",
"244.9",
"E942.1",
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"V45.02",
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] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.41",
"00.45",
"00.63",
"00.61",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
10811, 10817
|
5837, 8691
|
334, 354
|
11061, 11068
|
3444, 5763
|
12056, 13149
|
2415, 2485
|
9514, 10788
|
10838, 11040
|
8717, 9491
|
5780, 5814
|
11092, 12033
|
2500, 3425
|
276, 296
|
382, 1697
|
1719, 2300
|
2316, 2399
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,388
| 169,392
|
18545
|
Discharge summary
|
report
|
Admission Date: [**2157-4-20**] Discharge Date: [**2157-5-5**]
Date of Birth: [**2099-12-5**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Lisinopril
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
Fever, rigors, hyperglycemia
Major Surgical or Invasive Procedure:
PICC Line placement.
History of Present Illness:
57 yo M with h/o autoimmune disease NOS s/p splenectomy presents
with fevers to 104 for 5 days and hyperglycemia. Patient reports
3 high fevers/day a/w severe rigors and chills. He had noticed
feeling slight chills and sweats couple weeks ago, and had
increased prednisone from baseline 10mg to 20mg. In discussion
with his rheumatologist last weekend, he increased to 30mg
prednisone and then to 50 for past two days. Patient states
similar episodes have occured, but not for a couple years. On
all of these occasions, despite extensive w/u, no etiology has
been determined. He has been stable on 10mg prednisone during
this time.
.
Patient denies any localizing symptoms including URI sx, N/V/D,
SOB, CP, joint pain/swelling, headache, neck stiffness,
photophobia. He endorses urinary frequency for a few days, but
reports this is now resolved and that it may have been
associated with trying to hydrate himself. He has had some
abdominal pain that he feels is musculoskeletal and occured with
the rigors. He denies pain now.
.
In terms of DM, pt diagnosed couple yrs ago, had been controlled
on diet and oral medications until recently. About 1 month ago,
he noticed leg swelling L>R, which was attributed to Actos. He
was taken off Actos, and due to poor glycemic control, was
started on Lantus and Humalog.
.
In the ED, initial vs were: 97.1, 81, 117/71, 18 99RA. FS >500,
AG 14.
EKG no ischemic changes, no T wave peak. Trop elevated, CKMB 4
and CK 49. His creatinine is 3.2, baseline is 1.7. Patient was
given cefepime, placed on insulin gtt 7u/hr, no bolus and 2L NS.
.
Review of sytems:
(+) Per HPI
(-) Denies 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
dysuria. Denied arthralgias or myalgias.
Past Medical History:
(1) Splenectomy in [**2151-11-24**] when he had resection of a
pancreatic mass at [**Hospital1 2025**].
(2) Thrombocythemia: 800,000 - 1,000,000. No clotting or
bleeding. bone marrow biopsy on [**2153-3-1**] consistent with
myeloproliferative disorder...abnormal karyotype with deletion
20q in 3 out of 20 metaphases.
(3) Immune-mediated granulomatous disease. He is followed by Dr.
[**Last Name (STitle) 50954**] at [**Hospital1 112**].
(4) Hypertension.
(5) Chronic renal insufficiency of unclear etiology.
(6) High-risk adenocarcinoma of the prostate treated with
radical prostatectomy on [**2151-5-31**], with no evidence of disease
recurrence since that time. Path revealed granulomas.
(7) Diabetes mellitus (no recent A1C).
(8) Gastritis, detected on EGD in [**2153-6-30**].
(9) In [**5-31**], he developed a perianal abscess with bacteremia.
(10) h/o thrombophlebitis in left leg
(11) uveitis
(12) C4-C5 radiculopathy
(13) HLD
(14) HTN
(15) recurrent autoimmune pericarditis
(16) h/o benign pancreatic cyst s/p resection
Social History:
Lives with wife, has grown children. Has pet dog, always getting
scratched but nothing concerning for infection, no bites. Recent
travel to [**Location (un) 50955**] (last Thurs-Sun, illness began while
there). Works as a trial attorney.
Family History:
pancreatic cancer
Physical Exam:
Exam on Admission:
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
===========================================
Exam on discharge:
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, PICC line in place with no surrounding erythema or
induration.
Pertinent Results:
OUTSIDE RECORDS:
creatinine [**2157-3-15**]: 1.71 (baseline)
ADMISSION LABS:
[**2157-4-20**] 01:45PM BLOOD WBC-7.6 RBC-2.90* Hgb-9.4* Hct-31.1*
MCV-107* MCH-32.3* MCHC-30.1* RDW-19.0* Plt Ct-319
[**2157-4-20**] 01:45PM BLOOD Neuts-99* Bands-0 Lymphs-0 Monos-1* Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-6*
[**2157-4-20**] 01:45PM BLOOD ESR-98*
[**2157-4-20**] 01:45PM BLOOD Glucose-724* UreaN-73* Creat-3.3*#
Na-120* K-5.8* Cl-87* HCO3-19* AnGap-20
[**2157-4-20**] 01:45PM BLOOD ALT-61* AST-30 AlkPhos-203* TotBili-0.6
[**2157-4-20**] 01:45PM BLOOD cTropnT-0.26*
[**2157-4-20**] 01:45PM BLOOD CK-MB-4
[**2157-4-20**] 04:25PM BLOOD CK(CPK)-49
[**2157-4-20**] 04:06PM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-45 pH-7.31*
calTCO2-24
[**2157-4-20**] 01:50PM BLOOD Lactate-2.3*
.
DISCHARGE LABS:
[**2157-5-5**] 05:00AM BLOOD WBC-5.9 RBC-3.42* Hgb-10.7* Hct-34.5*
MCV-101* MCH-31.2 MCHC-31.0 RDW-18.7* Plt Ct-584*
[**2157-5-5**] 05:00AM BLOOD PT-24.6* PTT-107.7* INR(PT)-2.4*
[**2157-5-5**] 05:00AM BLOOD Glucose-101* UreaN-24* Creat-1.8* Na-139
K-4.7 Cl-98 HCO3-28 AnGap-18
=================
MICROBIOLOGY
Blood Cultures:
[**4-24**], [**4-25**], [**4-26**], [**4-27**]: NEGATIVE
[**4-23**]: E.Coli
[**4-22**]: BACTEROIDES FRAGILIS GROUP
[**4-21**]: BACTEROIDES FRAGILIS GROUP, CLOSTRIDIUM SPECIES NOT C.
PERFRINGENS OR C. SEPTICUM
[**4-20**]: ESCHERICHIA COLI, BACTEROIDES FRAGILIS GROUP
[**4-20**]: ESCHERICHIA COLI, CLOSTRIDIUM SPECIES NOT C. PERFRINGENS
OR C. SEPTICUM, CLOSTRIDIUM SPECIES NOT C. PERFRINGENS OR C.
SEPTICUM, BACTEROIDES FRAGILIS GROUP
.
Urine Cx [**4-20**]: NEGATIVE
.
Stool Cx [**4-25**] and [**4-26**]: NEGATIVE
===================
Imaging:
[**4-21**] CT non-contrast abdomen and pelvis:
Mild acute diverticulitis of the proximal sigmoid colon with no
evidence of perforation or surrounding collection. Exophytic
lesion arising off the lower pole of the right kidney which is
incompletely evaluated; neoplasm cannot be excluded. Suggest
further evaluation with a triphasic CT scan or MRI for further
characterization. Calcified left pelvic side wall node and two
surgical clips which is concerning for prostate cancer
recurrence.
.
[**4-23**] CT non-contrast abdomen and pelvis:
Mural thickening at descending/signoid colon junction, with
associated
diverticulae and pericolic fat stranding, mildly progressed from
prior study. A follow-up colonoscopy to exclude neoplasm is
recommended. Bilateral renal lesions are indeterminate and can
be further evaluated with ultrasound. Left pelvic side wall soft
tissue is worrisome for nodal reccurence of prostate cancer.
Two non-specific tiny pulmonary nodules could be followed up
with chest CT in six months.
.
[**4-23**] RUQ U/S:
Notable for 2 cm mildly hypoechoic lesion along the right
hepatic dome, with suggestion of vascularity seen on color
Doppler imaging, does not have son[**Name (NI) 493**] features of a simple
cyst or hemangioma and is concerning for metastasis. This lesion
was not seen on remote MRI from [**2150**].
.
[**4-26**] Liver Spleen sulfur colloid scan:
No focal liver abnormalities identified within the limits of
resolution of liver/spleen scan. Absence of focal defect favors
focal nodular hyperplasia for the lesion seen on prior
ultrasound.
.
[**4-29**] CT w/contrast abdomen and pelvis:
Portal vein thrombosis involving the right posterior and
anterior portal
venous branches and partially extending into the main portal
vein. Small ill-defined hepatic hypodensities. Given the
provided history and
the presence of portal venous thrombosis, these are concerning
for early
developing abscesses. Acute uncomplicated sigmoid
diverticulitis.
.
[**5-4**] CT w/contrast abdomen and pelvis:
Interval progression of portal venous clot into the left portal
vein. Interval resolution of multiple hepatic microabscesses.
Persistent thickening of the sigmoid colon likely represents
resolving diverticulitis.
Brief Hospital Course:
#. POLYMICROBIAL BACTEREMIA/ACUTE DIVERTICULITIS/LIVER
MICROABSCESSES: Patient determined to have polymicrobial
bacteremia--E.Coli, bacteroides fragilis and clostridium. This
was felt to be secondary to acute diverticultitis given
thickening of the rectosigmoid colon and mild mesenteric
stranding seen on CT. He was treated with cefepime and flagyl
which was changed to ceftriaxone and flagyl. Cultures became
positive of [**4-24**]. On [**4-29**] he underwent repeat Abd CT given
intermittent low grade temps to 100.4 and was found to have
multiple liver microabscesses and a new portal vein thrombosis.
ABX course subsequently extended from 2 weeks to total 4 weeks
from [**4-29**]. Patient followed closely by ID consult team who will
continue to follow him as an outpatient. Pt had PICC line placed
for IV CTX and will go home with Home Solutions infusion
services. He was afebrile for >72 hrs at time of discharge.
.
# PORTAL VEIN THROMBOSIS. CT scan on [**4-29**] demonstrated portal
vein thrombosis involving the right anterior and posterior
divisions and extending into the main portal vein. The patient
has a history of polycythemia [**Doctor First Name **] MPD associated with JAK2
V617F mutation making him more susceptible to splanchnic and
portal vein thrombosis. It was felt that this underlying
susceptibility in the setting of bacteremia contributed to
thrombosis. He was started on heparin gtt (given renal failure
and recent GI bleed) bridge to coumadin. Following 2 days of INR
> 2.0 heparin gtt was discontinued and the patient was
discharged with [**Hospital 191**] [**Hospital **] clinic follow-up. Because
of his underlying MPD, he will likely require lifelong
anticoagulation.
.
# LOWER GI BLEED: Etiology unclear. [**Name2 (NI) **] lavage negative thus
considered more likelly to be lower GI bleed. Possible sources
thought to be diverticulitis, ischemia or malignancy. Due to
falling Hct he received a total of 2 units PRBCs and Hct
responded appropriately. He was seen by the gastroenterology
consult service recommends a colonscopy which could not be done
as an inpt given acute diverticulitis. Patient will have
colonscopy as outpatient and will require warfarin reversal with
inpt heparin gtt and total 2 day prep. He is scheduled to follow
up with Dr. [**Last Name (STitle) 1940**].
.
# ACUTE ON CHRONIC RENAL FAILURE: Likely pre-renal from sepsis
and hyperglycemia induced osmotic diuresis. Improved with IVF,
treatment of infection, and improved regulation of blood sugars.
Cr improved from 3.3 on admission to 1.8 at time of discharge.
[**Last Name (un) **] held throughout this admission.
.
# LIVER LESION: A 2 cm mildly hypoechoic lesion along the right
hepatic dome noted on abdominal ultrasound. Patient underwent
liver spleen sulfur colloid scan which showed no focal liver
abnormalities suggesting this lesion represents focal nodular
hyperplasia. Given initial concern this could represent a
malignancy CEA, AFP and Ca19-9 checked: CEA was mildly elevated
at 8.0, AFP wnl at 1.8, Ca19-9 wnl at 33.
.
# ENLARGED PELVIC NODULE: Seen on ABD CT [**4-23**] and described as
1.8 short axis soft tissue nodule in the left pelvic side wall.
Given history of prostate cancer a PSA was checked and found to
be undetectable. This nodule should continue to be followed on
CT. As noted above, patient undergoing screening colonscopy. He
has follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] who follow
him for his myeloproliferative condition and history of prostate
cancer respectively.
.
# INDETERMINATE RENAL LESIONS: Seen on abdominal CT from [**4-23**]. It
is recommended that patient have a renal ultrasound to further
evaluate.
.
# PULMONARY NODULES: Seen on CT ABD [**4-23**] and described as two
tiny non-specific pulmonary nodules. It is suggested that these
are followed up by chest CT in six months.
.
# HYPERGLYCEMIA/DM II: Regimen changed from metformin,
pioglitazone and glyburide to lantus 20 units qHS and humalog
sliding scale before meals and at bedtime. Glycemic control
improved with this regimen. Patient scheduled to follow up with
[**Last Name (un) **] as an outpatient.
.
# Hyponatremia: Serum sodium trended down to 130. This was in
the setting of elevated blood sugars and what was likely
autodiuresis in setting of recovering renal function. Patient
treated with IVF and serum sodium trended up to a normal range.
.
# Non-Caseating Granulomatous Disease of Unclear Etiology: Prior
to admission patient had uptitrated prednisone to 50mg daily
given he was attributing his symptoms of fever, chills, abd pain
and malaise to this condition. Patient followed by rheumatology
consult service who assisted team with titrating down prednisone
eventually to 10mg daily. Patient has scheduled follow up with
[**Hospital1 18**] rheumatology.
.
#. Hx of THROMBOCYTOSIS/ERYTHROCYTOSIS. His hydroxyurea was
held in the setting of infection and anemia. This medication
continued to be held at time of discharge per Dr. [**Last Name (STitle) **],
patient's hematologist. Patient has follow up with Dr. [**Last Name (STitle) **] on
[**5-12**].
Medications on Admission:
prednisone 10 mg (recently 30mg, then 50) daily
simvastatin 40 mg daily
metformin 1000 mg daily
glyburide 20 mg daily (unsure if 10 [**Hospital1 **])
Cozaar 100 mg daily
Lantus 10 U QHS
Humalog 4 U at dinner
Prilosec OTC
Fosamax 70 mg qmonth (due [**4-23**])
Lexapro 10 mg daily
hydroxyurea 1000 mg daily
colace
iron
MVI
ASA 81
Discharge Medications:
1. PICC Care
Flush PICC per home solutions protocol
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): Last dose [**2157-5-26**].
Disp:*65 Tablet(s)* Refills:*0*
3. Simvastatin 40 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Prednisone 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
8. Insulin Glargine 100 unit/mL Solution Sig: Twenty (20) units
Subcutaneous at bedtime.
Disp:*QS u/mL* Refills:*0*
9. Insulin Lispro 100 unit/mL Solution Sig: dose per sliding
scale Units Subcutaneous four times a day.
Disp:*QS U/mL* Refills:*0*
10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a month.
11. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
13. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
One dose (2grams) Intravenous Q24H (every 24 hours) for 21
doses: Last dose on [**2157-5-26**].
Disp:*21 doses* Refills:*0*
14. Warfarin 2.5 mg Tablet Sig: 2-3 Tablets PO Once Daily at 4
PM: 7.5mg on [**5-5**]-
and then 5mg daily after that .
Disp:*90 Tablet(s)* Refills:*2*
15. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Topical once a day: apply only once per day for no more
than 12 hours.
Disp:*30 patches* Refills:*2*
16. Outpatient Lab Work
Please draw weekly CBC with differential, BUN, Cr, AST, ALT, Alk
phos, Tbili. All laboratory results should be faxed to
Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**].
17. Outpatient Lab Work
Please check PT/INR on [**2157-5-9**] and call results to [**Hospital1 18**] [**Hospital 191**]
[**Hospital3 271**] ([**Telephone/Fax (1) 10844**].
Discharge Disposition:
Home With Service
Facility:
Home solutions
Discharge Diagnosis:
PRIMARY: Escheria Coli and Bacteroides fragilis and Clostridium
Bacteremia, Lower gastrointestinal bleeding, Diverticulitis,
Acute on chronic renal failure, Hyperglycemia, Hyponatremia
.
SECONDARY: Granulomatous auto-immune disease, polycythemia [**Doctor First Name **],
type two diabetes mellitus, history of prostate cancer, history
of benign pancreatic lesion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **], it was a pleasure caring for you during your
hospitalization. When you arrived you were shaking and had a
fever. Blood test showed a bacterial infection in your blood
(bacteremia) and you were treated with antibiotics. Your blood
sugar was significantly elevated and you were treated with
intravenous fluids and insulin. During the course of your
hospitalization you were found to have blood in your stools. You
were given two blood transfusions. Over the course of your
hospitalization your fevers subsided and you appeared to
clinically improve with antibiotic treatment. The blood in your
stools also resolved. While you appeared to clinically improve
on these antibiotics, you continued to spike a occasional
fevers. Because of this we did a repeat CT scan of your abdomen
on [**2157-4-29**] which showed small abscesses in your liver and a clot
in the portal vein to the liver. Under the direction of our
infectious disease specialists we therefore again switched your
antibiotic regimen (to IV ceftriaxone and oral metronidazole).
We also started you on blood "thinner" medications (heparin and
coumadin) and monitored your blood levels until the activity of
coumadin was therapeutic for two days (goal INR = 2.0 - 3.0). On
the day prior to discharge we obtained a repeat abdominal CT
scan to assess intereval changes in the liver micro-abscesses
and portal vein clot. This scan demonstrated decreased size of
the abscesses but increased size of the portal vein clot.
New Medications:
-Ceftriaxone 2g IV Every 24 hours (last dose [**2157-5-26**])
-Metronidazole 500mg Every 8 hours (last dose [**2157-5-26**])
-Warfarin: you will need to take 7.5mg tonight and then 5mg
daily starting on Friday (tablets are 2.5mg each).
-Lidoderm patch
.
Medication Changes:
- Lantus (glargine) increased to 20 Units before bed
- Use sliding scale for dosing of humalog insulin prior to meals
and bedtime rather than only dosing before dinner
- Prednisone now 10mg tablet daily.
.
Stopped medications:
-glyburide
-metformin
-pioglitazone
-iron
-hydroxyurea
-losartan (speak with your primary care physician about
restarting this medication, your blood pressure did not require
this medication while you were in the hospital)
Followup Instructions:
You will need to have your blood drawn tomorrow [**2157-5-6**] when you
come for appointment w/ Dr. [**Last Name (STitle) **] and on [**2157-5-9**] at [**Hospital1 18**] in
[**Location (un) 1439**]. We have given you a prescription that you should take to
[**Location (un) 1439**]. Please do not take your coumadin on [**2157-5-9**] until you
receive a call from the anti-coagulation nurses. These nurses
will let you know when your next blood draw will be.
.
APPOINTMENTS:
=============
.
DEPARTMENT: Internal Medicine
When: Friday [**2157-5-6**] at 11:10 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: Endocrinology ([**Hospital **] CLINIC)
When: Friday [**2157-5-6**] at 10:00AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7280**], NP ([**Telephone/Fax (1) 20881**]
Building)
Department: [**Hospital3 249**]
.
Department: RHEUMATOLOGY
When: MONDAY [**2157-5-9**] at 9:15 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
**Please request referral from your Primary Care Dr., to be
faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], ([**Telephone/Fax (1) 50956**]
.
Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2157-5-12**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 647**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 48006**] from [**Hospital 3278**] Medical Center
Tuesday [**2157-5-17**] at 10:15am. If you need to reschedule his
office phone number is [**Telephone/Fax (1) 50957**].
.
CT Abdomen with Contrast at [**2157-5-24**] at 12:45pm. The
location is [**Hospital Ward Name 516**], [**Hospital Unit Name 1825**], [**Location (un) **]. Please do not
eat or drink anything 3 hours prior to this test. If you need to
reschedule this appointment the radiology phone number is ([**Telephone/Fax (1) 18969**]. Note that scan needs to be done before you see Dr.
[**First Name (STitle) **] in Infectious Disease.
.
Department: INFECTIOUS DISEASE
When: WEDNESDAY [**2157-5-25**] 9:30 AM
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
DEPARTMENT: Hematology/Oncology
Physician: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Name (STitle) **]
Date: [**2157-5-26**]
Time: 12:00p
Location: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
.
DEPARTMENT: Infectious Disease
When: [**2157-6-8**] at 11:00 am
With: [**Name6 (MD) 1423**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
.
Department: Gastroenterology
When: [**2157-6-3**] at 2:45 PM
With: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1940**], MD [**Telephone/Fax (1) 463**]
Building: LM 8E
.
You will need to have a colonscopy as an outpatient which Dr.
[**Last Name (STitle) 1940**] will schedule for you.
Completed by:[**2157-5-5**]
|
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icd9cm
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[
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28,959
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34140
|
Discharge summary
|
report
|
Admission Date: [**2129-5-2**] Discharge Date: [**2129-5-15**]
Date of Birth: [**2060-12-5**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2129-5-9**] - CABGx3 (Left internal mammary-> Left anterior
descending artery, Saphenous vein graft->Right coronary artery)
[**2129-5-2**] - Cardiac Catheterization
History of Present Illness:
68 y/o male with ESRD on HD, HTN, and bipolar disorder who was
admitted to an OSH on [**2129-4-29**] with chest pain, SOB, and new
onset atrial fibrillation. He was transferred to [**Hospital1 18**] for
cardiac catherization.
He awoke on [**2129-4-29**] around 3AM and could not catch his breah. He
then started having chest pressure. He took two nitros with
relief of the chest pressure but he continued to have SOB. He
presented to the OSH ED and was noted to be in atrial
fibrillation and to be volume overloaded. He was admitted for
further evaluation.
Patient reports DOE, orthopnea, and PND. He attributes these
symptoms to fluid overload as a result of insufficient
hemodialysis. He also reports episodes of substernal chest
pressure associated with feeling clammy and wet and relieved by
NTG. He denies associate nausea. He experiences the pressure
when he is at rest and with exertion. He is currently symptom
free.
At the OSH, he was ruled out for acute MI with serial cardiac
enzymes. EKGs showed diffuse ST/T changes. Upon transfer, he was
loaded with plavix 600mg and sent to the cath lab, where he was
found to have several RCA lesions and a focal LAD lesion. Of
note, he also had a dilated aortic arch that was concerning for
aortic aneurysm. Given the possibility of aortic aneurysm and
the thought that he might be eligible for renal transplant soon,
the cath team opted not to place stents.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis. 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
palpitations, syncope or presyncope.
Past Medical History:
ESRD on HD MWF
HTN
Bipolar disorder
Depression
"s/p bowel resection 10 yrs ago"--per report, though patient
denies (states he had shrapnel removed in [**Country 3992**])
Peritonitis while on peritoneal dialysis
GERD
ALLERGIES: Lisinopril ---> angioedema
Social History:
He used to work as a chef and is retired. He is divorced and
currently lives with his girlfriend. [**Name (NI) **] has a h/o alcohol abuse
(per chart, not patient) in the remote past but currently does
not drink. Smoked x 3 years, but only has a very occasional
cigarette since 1 year. Sometimes uses a cane.
Family History:
Father had an MI at 81. No premature CAD.
Physical Exam:
VS - 97.2 149/90 64 16 97% RA
Gen: WDWN middle aged male in NAD. Oriented x3. Mood, affect
appropriate. Pleasant
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Irreg irreg but not tachy, normal S1, S2. No m/r/g. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were mildly labored with conversation, but no accessory muscle
use. Good air movement with crackles at bases b/l.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+
Pertinent Results:
EKG demonstrated AFib with rate of 50 and normal axis. Flate T
waves in lateral and inferior leads and TWI in V5-V6 with no
significant change compared with prior dated [**2129-4-29**].
2D-ECHOCARDIOGRAM performed on [**2129-4-29**] demonstrated:
Dilated LV with concentric LVH, global hypokinesis in the
inferior segment, EF 35-40%. Biatrial enlargement. Dilated
ascending aorta. Dilated right ventricle, right ventricular
hypokinesis. Trace to mild MI. Trace AI. Mild TI with moderate
pulmonary HTN.
CARDIAC CATH performed on [**2129-5-2**] demonstrated:
1. Coronary angiography of this right dominant system
demonstrated 2
vessel coronary artery disease. The LMCA had no angiographically
apparent flow-limiting disease. The LAD had a 95% mid-vessel
stenosis. The LCx was small in caliber and without significant
disease. The RCA was calcified and had serial 80% stenoses in
the proximal and mid-segments. The distal RCA had a 20%
stenosis.
2. Limited resting hemodynamics revealed elevated left sided
filling
pressure with a LVEDP of 24 mmHg. Systemic arterial pressure was
normal at 124/70 mmHg. There was no transaortic valve gradient
on pullback of the catheter from the LV to the aorta.
3. Left ventriculography demonstrated no mitral regurgitation.
The
estimated LVEF was 45% with global hypokinesis. The ascending
aorta
was calcified and appeared dilated.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease.
2. Left ventricular diastolic dysfunction.
3. Moderate left ventricular contractile dysfunction.
4. Dilated ascending aorta.
HEMODYNAMICS:
elevated left sided filling pressure with a LVEDP of 24 mmHg.
Systemic arterial pressure was normal at 124/70 mmHg. There was
no transaortic valve gradient on pullback of the catheter from
the LV to the aorta.
[**2129-5-9**] ECHO
PRE-BYPASS:
1. The left atrium is markedly dilated. Mild spontaneous echo
contrast is seen in the body of the left atrium. Mild
spontaneous echo contrast is present in the left atrial
appendage. The left atrial appendage emptying velocity is
depressed (<0.2m/s). No thrombus is seen in the left atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity is moderately dilated. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
moderately depressed (LVEF= 30-35 %).
3. The right ventricular cavity is mildly dilated with
borderline normal free wall function.
4. The aortic root is moderately dilated at the sinus level. The
ascending aorta is moderately dilated. There are simple atheroma
in the aortic arch. The descending thoracic aorta is mildly
dilated. There are complex (>4mm) atheroma in the descending
thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Trace aortic regurgitation is seen. A small mobile
echoenicity is noted on the ventricular surface of the left
coronary cusp.
6. There is severe mitral annular calcification. Mild (1+)
mitral regurgitation is seen.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including epinephrine and
phenylephrine and is being AV paced.
1. Biventricular function is unchanged.
2. Aorta is intact post decannulation.
3. Other findings are unchanged.
[**2129-5-5**] Carotid Duplex Ultrasound
There is less than 40% stenosis within the internal carotid
arteries bilaterally.
Brief Hospital Course:
Mr. [**Known lastname 732**] was admitted to the [**Hospital1 18**] on [**2129-5-2**] for further
management of his chest pain. He underwent a cardiac
catheterization which revealed severe two vessel coronary artery
disease and a slightly dilated ascending aorta. Please see
separated dictated catheterization report. Given the severity of
his disease, the cardiac surgical service was consulted for
surgical revascularization. Mr. [**Known lastname 732**] was worked-up in the
usual preoperative manner including a carotid duplex ultrasound
which revealed a less then 40% bilateral internal carotid artery
stenosis. A CT scan was obtained to evaluate his aorta which
revealed an enlarged ascending aorta measuring 4.4cm, a
uestionable nodular contour of the liver for which ultrasound is
recommended if there is clinical suspicion of underlying liver
disease, a hiatal hernia, and multiple lymph nodes seen within
the mediastinum at the upper limits of
normal in size. Over the next few days, plavix was allowed to
clear from his system. He continued his hemodialysis schedule
with close following by the renal service. Intravenous heparin
was given for anticoagulation for rate controlled atrial
fibrillation. On [**2129-5-9**], Mr. [**Known lastname 732**] was taken to the operating
rooom where he underwent coronary artery bypass grafting to two
vessels. Postoperatively he was taken to the intensive care unit
for monitoring. Within 24 hours, he awoke neurologically intact
and was extubated. He developed respiratory acidosis and was
reintubated. later on postoperative day one, he was again
extubated without complication. Aspirin and a statin were
resumed. Hemodialysis was resumed on postoperative day one.
Coumadin was resumed for his chronic atrial fibrillation. On
postoperative day two, he was transferred to the step down unit
for further recovery. He worked with physical therapy daily to
improve his strength and mobility. He was transfused for
postoperative anemia. On DC his inr is stable 1t 2.2 on
coumadin. Recieving HD on his scheduled days. He is cleared to
go home with VNA. INR is being followed as a out patient. HCT is
stable. Pt has low EF, not started on ACE. Pt has allergy, BP to
low to start [**Last Name (un) **].
Medications on Admission:
Medications on transfer (pt unable to confirm; home pharmacy is
[**Company **] in [**Location (un) 3236**], NH):
Norvasc 10 mg PO daily
ASA 325 mg PO daily
Clonidine 0.2 mg PO BID
Prozac 10 mg PO daily
Lopressor 100 mg PO BID
Nephrocaps 1 capsule daily
Heparin gtt
Depakote ER 1500 mg PO daily
Renagel 1600 mg PO TID w/meals
Zaroxolyn 5 mg PO daily (TThSatSun)
Demadex 100 mg PO daily
Torsemide 10 mg PO daily
confirmed with pharmacy in [**Location (un) 15961**], NH:
Furosemide 80mg TID / Torsemide 100mg [**Hospital1 **]
Lopressor 100mg [**Hospital1 **]
Depakote ER 1500mg daily
Prozac 10mg daily
Clonidine 0.2mg [**Hospital1 **]
Nephrocaps daily
Norvasc 10mg daily
Nitroquick 0.4mg (not filled since [**Month (only) **])
Discharge Medications:
1. Outpatient Lab Work
Please draw an INR for on Monday [**2129-5-16**] with results faxed to
the office of Dr. [**Last Name (STitle) 59323**] at ([**Telephone/Fax (1) 72972**]. Plan confirmed
with [**First Name5 (NamePattern1) 4457**] [**Last Name (NamePattern1) **]. Goal INR for atrial fibrillation is [**12-19**].
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Divalproex 500 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
9. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Sevelamer HCl 800 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*180 Tablet(s)* Refills:*2*
12. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
14. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: INR
goal is [**12-19**] .
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
wollfboro vna
Discharge Diagnosis:
CAD
HTN
ESRD
AF
GERD
CHF LVEF 35-45%
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.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 78538**]
Please follow-up with Dr. [**Last Name (STitle) 59323**] in 2 weeks. ([**Telephone/Fax (1) 1504**]
Please draw an INR for on Monday [**2129-5-16**] with results faxed to
the office of Dr. [**Last Name (STitle) 59323**] at ([**Telephone/Fax (1) 72972**]. Plan confirmed
with [**First Name5 (NamePattern1) 4457**] [**Last Name (NamePattern1) **]. Goal INR for atrial fibrillation is [**12-19**].
Completed by:[**2129-5-15**]
|
[
"585.6",
"285.1",
"428.43",
"403.91",
"414.2",
"530.81",
"296.80",
"428.0",
"276.2",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"39.61",
"39.95",
"96.04",
"37.22",
"88.56",
"36.15",
"88.53",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
12478, 12523
|
7541, 9792
|
287, 457
|
12604, 12613
|
3906, 5276
|
13356, 13878
|
2930, 2973
|
10567, 12455
|
12544, 12583
|
9818, 10544
|
5293, 7518
|
12637, 13333
|
2988, 3887
|
237, 249
|
485, 2310
|
2332, 2588
|
2604, 2914
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,042
| 130,732
|
22567
|
Discharge summary
|
report
|
Admission Date: [**2166-6-20**] Discharge Date: [**2166-7-4**]
Date of Birth: [**2129-5-22**] Sex: M
Service: SURGERY
Allergies:
Morphine
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Hepatitis C cirrhosis, ascited, encephalopathy
Major Surgical or Invasive Procedure:
Liver transplant for Hepatitis C cirrhosis and hemochromatosis
[**2166-6-21**]
History of Present Illness:
37 y.o. male with h/o cirrhosis [**2-5**] HCV. Admitted from [**Date range (1) 58540**]
for abd pain ? cholecystitis, but had negative HIDA and was
discharged. Admitted [**4-18**] -51 for ATN renal failure. Not on HD
yet. Presents for liver transplant.
Past Medical History:
1) Cirrhosis secondary to hepatitis C, diagnosed in [**2162**].
Intolerance to IFN/ribaviran therapy. Genotype 1. On transplant
list.
2) H/o of IVDA [**2152**]-[**2159**], + cocaine use. Last + tox in [**2-/2166**]
3) Iron overload syndrome. Genotyping for hemochromatosis
negative, per report liver biopsy at outside hospital with
normal HIC.
4) BCC removed in [**2162**]
5) Hernia repair
6) Recent scalp furuncle, + MRSA, treated with Bactrim
8) SBP [**1-8**], on Cipro prophylaxis
10) Depression
11) Anemia
12) Chronic hyperkalemia
Social History:
Mr. [**Known lastname 46**] was diagnosed w/ HCV cirrhosis in [**2162**]. He used IV
heroin for [**8-12**] yrs starting at 20, but quit in [**2159**] after
multiple incarcerations. When he became acutely ill with
jaundice and ascites in [**9-7**], he moved back to [**Location (un) 8973**], MA,
and currenly lives with his mother who has power of attorney. He
quit drinking in [**2160**], and drank heavily intermittently before
that. Ex-smoker, quit recently. 10 pack-year [**Year (4 digits) **] history.
Family History:
Cousin with hemochromatosis
Physical Exam:
CV: II/VI SEM
Ch: quiet throughout but clear
Abd: mildly tender on R side, soft. liver enlarged but difficult
to clearly measure. neg [**Doctor Last Name 515**] sign
Heent: grossly icteric, skin and sclerae, OP clear. Small lesion
on left cheek. Ext: 2+ distal pulses, cap refill ~1 sec.
Brief Hospital Course:
Taken to OR [**2166-6-20**] for orthotopic (piggyback)deceased donor
liver transplant pv-pv, cbd-cbd, no t-tube. He received 3,300 of
crystalloid, 3units FFP, 2units of RBC, 2 units of plts and 1
cryo. EBL was 300. See operative report. Given induction
immunosuppression (Simulect, Cellcept, and Solumedrol). A duplex
of the liver demonstrated "Unremarkable post-transplant liver
ultrasound and Doppler." He was transferred to SICU postop
intubated and stable.
On POD 1 sedation was decreased with goal to extubate. Lungs
were clear. Hct was 25.4. He was transfused with 4 units of PRBC
and 1 unit of plts. JP 1 drained 385 and JP # 2 110cc.
Solumedrol [**Age over 90 **]m and Cellcept 1gram [**Hospital1 **] were given. On POD 2,
temperature was 101.7. Blood and urine cultures were done and
subsequently negative. JP 1 drained 1245 and #2 55. He was
extubated. Prograf was initiated in addition to cellcept and a
daily solumedrol tapering dose for immunosuppression. Liver
duplex was normal. Pain was managed with dilaudid prn. Alt 222,
ast 191, alk phos 98 and t.bili 3.7.
LFTs trended down until POD 4 when alk phos started to increase
to 368. On POD 4, he received Simulect 20mg IV. The lateral JP
and NG were removed and diet was advanced to sips of clears. He
became dyspneic and dropped 02 sat to 88% on RA. A 70% face mask
was applied with O2 sat that increased to 98%. Wheezing and
decreased breath sounds were noted on the right. ABGs,CXR and
EKG were done. He was given albuterol neb treatment with
improvement of O2 sat. ABG was 7.32/48/75/26/-1. CXR revealed
small bilateral pleural effusions that were stable. EKG was
stable. He was treated with IV lasix 40 [**Hospital1 **] for volume
overload. O2 remained at 92% on 5L face tent.He continued to
receive albuterol neb treatments every 2-4 hours. He diuresed,
but PAO2 continued at 68 and PC02 53. Diamox was added. He
diuresed 4290cc with repeat ABG of 7.35/54/83/31/12 and
decreased wheezing. He required hand restraints for some
confusion and pulling off O2.
On POD 5, alk phos increased to 572 and t.bili to 3.1. A duplex
of the liver demonstrated " interval development of a new fluid
collection just deep to the left lobe of the liver extending
into the left porta. The collection contains fluid and solid
components, with septations. It measures 5.9 x 5.7 x 3.2 cm.
Aside from this collection, the left lobe parenchyma is normal
in appearance. There is no intrahepatic biliary ductal
dilatation. In addition, there is a second collection found in
the right subhepatic region. This collection contains fluid and
some echogenic material that may represent clot. This collection
measures 7.5 x 3.0 x 4.7 cm. The parenchyma of the right lobe is
normal in appearance, without biliary ductal dilatation. A right
pleural effusion with associated atelectasis is noted."
Arterial/venous flow and resistive indices were normal. Prograf
level was 19.4 and prograf was held x 4 doses. Repeat prograf
level was 7.8 and prograf was resumed at 1mg [**Hospital1 **] on POD7. He was
given 2 bags of platelets for a plt count of 68. A HIT antibody
was sent. Medial JP was removed.
On POD 7, he was coughing and raising thick, green sputum. He
remained in the SICU for close management of respiratory and
mental status. He had episodes of somnolence and confusion. At
times, he appeared to be hallucinating. Pain medication was
decreased.
On POD 8, he was transferred to the transplant unit. Diet was
advanced and PT continued to work with him. He required a 1:1
sitter as he was agitated, and pulling at IV lines and removing
O2 tubing. Foley was removed. Percocet was decreased for
sedation.
On POD 9, he received Pamidronate x1. Calcium and vitamin D were
started. Alk phos increased to 566. A repeat duplex revealed ".
Patent portal vein, with most probably slight narrowing in the
anastomotic site, demonstrating velocity gradient of uncertain
significance.
2. Unchanged subhepatic and left intrahepatic small fluid
collections." Prograf was increased for a level of 10.4.
ON POD 11 ([**7-2**]), a liver biopsy was performed. This
demonstrated "Features indeterminate for acute cellular
rejection.
Focal minimal lobular inflammation, nonspecific.
Focal poorly formed histiocytic aggregate, suggestive of
granuloma". Prograf was decreased to 1.5mg [**Hospital1 **] for a level of
13.5. Prednisone remained at 20mg and cellcept at 1gram [**Hospital1 **]. A
[**Last Name (un) **] consult was obtained for elevated glucoses. These were
treated with sliding scale insulin. [**First Name8 (NamePattern2) **] [**Last Name (un) **] recommendations,
Prandin 1mg [**Hospital1 **] prior to meals was started.
On POD 13, he was alert and ambulatory. O2 sats were in the high
90's on room air. Lungs were clear. He was tolerating a regular
diet and vital signs were stable. Hct trended down to 25.1. AST
was 24, alt 40, alk phos 340 and t.bili 1.5. VNA ([**Location (un) 6138**]
Home Care) was set up to assist with medication and
insulin/glucose management as well as PT for strengthening and
safety training. A rolling walker was provided for unsteady
gait. His mother arranged for time off from work in order to
provide 24 hour supervision as he did display poor safety
awareness and judgement. Incision was clean and dry. There was
extensive ecchymosis on right side of abdomen and flank. He was
discharged home [**2166-7-4**] with scheduled f/u appointments at the
Transplant office.
Medications on Admission:
Protonix, quinine, actigall, ultram, lactulose, bumex, and cipro
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
4. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q8H (every 8 hours) as needed for PRN: give only [**1-5**] tablet
every 8 hours if needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
9. Repaglinide 1 mg Tablet Sig: One (1) Tablet PO BEFORE LUNCH
AND BEFORE DINNER () as needed for hyperglycemia.
Disp:*60 Tablet(s)* Refills:*0*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12
hours).
11. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO 2X
(TIMES 2): 1.5mg twice daily.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 6136**] Home Services
Discharge Diagnosis:
Liver transplant for Hepatitis C cirrhosis and hemochromatosis
[**2166-6-21**]
Discharge Condition:
stable
Discharge Instructions:
Call [**Telephone/Fax (1) 673**] if nausea, vomiting, inability to take
medication, redness/bleeding from incision, jaundice, or
confusion
Labs every Monday and Thursday for cbc, chem 10, ast,alt, alk
phos, t.bili, albumin and trough prograf level. Results to be
fax'd to [**Hospital1 18**] [**Telephone/Fax (1) 18623**]
No driving while taking pain medication
No heavy lifting
[**Month (only) 116**] shower
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-7-9**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-7-16**] 9:50
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) **]: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2166-7-23**] 11:20
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2166-7-17**]
|
[
"293.0",
"571.5",
"070.54",
"790.29",
"789.5",
"E933.1",
"276.6",
"V09.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"00.93",
"50.11",
"99.04",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
8849, 8914
|
2132, 7579
|
313, 394
|
9037, 9045
|
9501, 10305
|
1774, 1804
|
7694, 8826
|
8935, 9016
|
7605, 7671
|
9069, 9478
|
1819, 2109
|
227, 275
|
422, 676
|
698, 1234
|
1250, 1758
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,943
| 118,412
|
7198
|
Discharge summary
|
report
|
Admission Date: [**2154-12-16**] Discharge Date: [**2154-12-24**]
Date of Birth: [**2076-3-19**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Aspirin
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
Pelvic mass
Major Surgical or Invasive Procedure:
Exploratory Laparotomy
Pelvic washings
Extensive lysis of adhesions
Radical resection of pelvic mass
Total abdominal hysterectomy
Bilateral salpingo-oophorectomy
History of Present Illness:
The patient is a 78 y.o. female who was referred for a 12.3 X 9
cm pelvic mass seen on CT [**2154-11-25**]. She has a h/o small bowel
obstruction in 8/99. At that time she underwent small bowel
resection and was found to have a gastrointestinal stromal tumor
of high malignant potential. She then developed liver recurrence
in [**2149**]. She was treated with chemoembolization and
radiofrequency ablation. She has currently been on Gleevac and
has a generally stable tumor in the liver. She presented to the
gynecology/oncology team for surgical management.
Past Medical History:
PMH: COPD, Bronchitis, SBO, gastrointestinal stroma tumor, gout,
portal HTN
PSH: Small bowel sarcoma s/p resection (99/01), mastecomy in
[**2152**] (pathology benign), partial liver resection [**2150**].
Gyn History: Last pap smear unknown. Last mammogram was normal
last year.
OB History: Negative
Social History:
The patient does not smoke, but she is a former heavy smoker who
quit in [**2147**]. She drinks occasionally.
Family History:
Brother with pancreatic cancer.
Physical Exam:
HEENT: sclerae anicteric, no LAD.
Lungs: scattered expiratory wheezes and distant breath sounds.
CV: RRR, no murmurs.
Breasts: no masses.
Abd: soft, NT, suggestion of a mass in the lower abdomen which
was difficult to define.
Pelvic exam: Normal vulva, vagina and cervix. Bimanual and
rectovaginal examination revealed a suggestion of a large pelvic
mass which again was difficult to define. This mass seemed to be
more anterior and high up in the pelvis. The rectum was
intrinsically normal and there was no cul-de-sac nodularity. The
uterus and adnexa were not separately palpable.
Extremities without edema.
Pertinent Results:
[**2154-12-16**] 11:57AM WBC-4.2 RBC-3.46* HGB-10.9* HCT-32.3* MCV-93#
MCH-31.5 MCHC-33.8 RDW-15.1
[**2154-12-16**] 11:57AM NEUTS-85* BANDS-0 LYMPHS-9* MONOS-4 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2154-12-16**] 11:57AM ALBUMIN-2.4* CALCIUM-8.6 PHOSPHATE-5.8*#
MAGNESIUM-1.1*
[**2154-12-16**] 11:57AM CK-MB-5 cTropnT-0.02*
[**2154-12-16**] 11:57AM CK(CPK)-116
[**2154-12-16**] 11:57AM GLUCOSE-184* UREA N-41* CREAT-1.6* SODIUM-137
POTASSIUM-4.5 CHLORIDE-109* TOTAL CO2-21* ANION GAP-12
[**2154-12-16**] 10:11PM FIBRINOGE-271
[**2154-12-16**] 10:11PM PLT COUNT-151
[**2154-12-16**] 10:11PM PTT-24.4
[**2154-12-16**] 10:11PM HCT-30.9*
[**2154-12-16**] 10:11PM MAGNESIUM-2.6
[**2154-12-16**] 10:11PM CK-MB-10 MB INDX-3.2 cTropnT-0.02*
[**2154-12-16**] 10:11PM CK(CPK)-312*
[**2154-12-16**] 10:11PM UREA N-41* CREAT-1.6* SODIUM-139
POTASSIUM-5.1
Brief Hospital Course:
On [**2154-12-16**] the patient underwent an exploratory laparotomy,
total abdominal hysterectomy, bilateral salpingo-oophorectomy,
radical resection of a pelvic mass, extensive lysis of
adhesions, and RIJ placement. She received 4500 LR and 3 units
PRBCs intraoperatively for a 1500ml blood loss. She also
experienced three episodes of desaturation to 73%.
Intraoperative findings included a large left adnexal mass with
extensive adhesions. The mass was found to be sarcoma on frozen
section. Final pathology is pending.
Post-operative course:
HEME: The patient had a pre-operative HCT of 27, she received 2u
PRBC's intraoperatively for a ~1500 ml blood loss. On POD#1 she
received an additional u PRBC for a HCT of 26.4. An additional 1
u PRBC (for a total of 5 units) was given on POD #2 for a HCT of
28.9. This raised her HCT to 35.5. It remained stable for the
remainder of her hospital stay.
Neuro: The patient became disoriented following the operation.
On POD #1 she was put on soft restraints to prevent her from
pulling out her lines. She was transferred to the unit on POD#1.
She was treated with Haldol for agitation. Her pain continued
to be controlled with Dilaudid. Her agitation was felt to be due
to post-op delirium with pain medications from surgery and
resolved on POD#2 with minimization of narcotics. She was
transitioned to oral Oxycodone from Dilaudid on POD#3.
Respiratory: The patient had three episodes of acute
desaturation during the operation. She was maintained on
supplemental O2 post-operatively and her respiratoy status
remained stable. She had course breath sounds bilaterally and a
chest X-ray performed on POD #1 showed fluid overload she was
treated with Lasix. Incentive spirometry and aggressive
pulmonary toilet were encouraged. She also received chest PT.
The patient remained on home medications of Advair and Combivent
for her history of COPD.
Cardiovascular: Cardiac enzymes were checked post-operatively
due to the intra-operative desaturations and she ruled out for a
myocardial infarction. The patient had 2 episodes of rapid
ectopic beats on POD #2; these were asymptomatic and electolytes
were wnl. An echo showed likely normal LV systolic function,
trace aortic regurgitation, slightly thickened mitral valve with
mild mitral regurgitation and pulmonary artery hypertension.
Renal: The patient had low urine output post-operatively. She
was thought to have acute-on-chronic renal failure, with an FeNa
of <1%. Her urine ouput increased on POD #2 with administration
of fluids and Lasix. A urine analysis and culture were sent and
found to be positive for yeast. The patient was started on
fluconazole. Her foley was D/C'd on POD#5 and the patient
experienced nocturia, similar to the symptoms she had prior to
the operation.
Gastrointestinal: The patient was started on a diet of clear
fluids and it was advanced as tolerated. She began experiencing
diarrhea over night on POD #3. Her C. Diff toxin was negative.
The diarrhea resolved on POD #6. The patient was found to be
slightly jaundiced with elevated LFT's on POD#4. These resolved
over her hospital course. The LFT elevation was thought to be
consistent with a brief hemolytic picture.
The patient's incision remained clean, dry and intact. By the
time of discharge the patient was tolerating a regular diet,
ambulating with assistance, voiding spontaneously, passing
flatus, and her pain was well-controlled.
Medications on Admission:
Gleevac, Inderal, Diovan HCT, Ranitidine, Quinine sulfate,
Allopurinol, Iron pills, Combivant, Advair.
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-8**]
Puffs Inhalation [**Hospital1 **] (2 times a day) as needed.
5. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. Albuterol Sulfate 0.083 % Solution Sig: [**12-8**] Inhalation Q4-6H
(every 4 to 6 hours) as needed.
7. Imatinib Mesylate 100 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)) as needed for sarcoma.
8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 14 days.
Disp:*14 Tablet(s)* Refills:*0*
10. Propranolol HCl 80 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
11. Valsartan 80 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
12. Hydrochlorothiazide 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Rehab & Nursing Center - [**Location (un) 47**]
Discharge Diagnosis:
Pelvic mass
Discharge Condition:
Good
Discharge Instructions:
1) No heavy lifting, exercise or intercourse for 8 weeks.
2) No Driving for 2 weeks.
3) Please call your doctor if you experience fever/chills,
nausea/vomiting, increasing abdominal pain, or other symptoms
that are concerning to you.
Followup Instructions:
1) Please call Dr.[**Name (NI) 2989**] office to have your staples removed in
1 week.
2) Provider: [**Name10 (NameIs) **],[**First Name3 (LF) **] B. GYN ONC PPS (SB) Where: GYN ONC PPS
(SB) Date/Time:[**2155-1-22**] 2:00
3) Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2155-3-24**] 9:30
4) Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital6 29**]
HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2155-3-24**] 10:30
|
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"198.89",
"787.91",
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"293.0",
"568.0",
"V10.00",
"585",
"198.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"59.02",
"54.3",
"54.25",
"68.4",
"54.59",
"99.04",
"65.61"
] |
icd9pcs
|
[
[
[]
]
] |
8082, 8222
|
3089, 6516
|
295, 459
|
8278, 8284
|
2191, 3066
|
8566, 9138
|
1512, 1545
|
6669, 8059
|
8243, 8257
|
6542, 6646
|
8308, 8543
|
1560, 2172
|
244, 257
|
487, 1047
|
1069, 1369
|
1385, 1496
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,357
| 128,240
|
32008
|
Discharge summary
|
report
|
Admission Date: [**2165-10-23**] Discharge Date: [**2165-11-1**]
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
pelvic mass, abdominal pain
Major Surgical or Invasive Procedure:
3 unit blood transfusion
Exam under anesthesia
Exploratory laparotomy
Cyst drainage
Peritoneal washings
Bilateral salpingo-oophorectomy
History of Present Illness:
84yo G3P3 transferred from [**Hospital3 **] with a new diagnosis
of a pelvic mass. The pt reports being in usual state of health
until [**10-20**], when she woke with severe lower abdominal pain and
experienced prolonged nausea and emesis. She presented to
[**Hospital1 **] on [**10-21**] and was admitted. During her hospital course she
was treated for a presumed UTI and was kept NPO. A CT scan of
her abdomen revealed a large (>20cm) pelvic mass arising from
the L ovary. She was transferred for further evaluation and
management. She reports an unquantified weight gain over the
past year associated with increased abdominal girth. No changes
in appetite, bowel or bladder habits.
Past Medical History:
ObHx: SVD x3
GynHx: menopause ~30y ago, no postmenopausal bleeding; underwent
vaginal hysterectomy with ?unilateral salpingo-oophorectomy for
prolapse at age 50; no abnl Paps or STIs
MedHx: CAD s/p CABG x5; dyslipidemia; GERD; osteoarthritis
SurgHx: CABG; Vaginal Hysterectomy
Social History:
married; lives with husband for whom pt is primary caregiver;
denies T/E/D
Family History:
no hx gyn, breast, colon malignancy
Physical Exam:
At admission:
VS 101.3 122/52 100 20 90% on RA -> 97% on 4L via NC
Gen mild distress, uncomfortable-appearing
Chest bibasilar crackles, decreased breath sounds overall
Heart RRR
Abd firm, markedly distended, dull to percussion throughout,
+BS, diffusely tender without guarding or rebound
Extr NT, no erythema, 1+ LE edema
Pelvic not performed due to pt immobility
Pertinent Results:
[**2165-10-23**] 06:35PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG
[**2165-10-28**] 07:50AM BLOOD WBC-8.1 RBC-3.67* Hgb-9.1* Hct-27.0*
MCV-74* MCH-24.7* MCHC-33.6 RDW-19.2* Plt Ct-458*
[**2165-10-27**] 03:19PM BLOOD WBC-10.7 RBC-3.73* Hgb-9.1* Hct-27.7*
MCV-74* MCH-24.4* MCHC-32.8 RDW-18.7* Plt Ct-457*
[**2165-10-27**] 04:00AM BLOOD WBC-11.2* RBC-3.27* Hgb-7.8* Hct-23.6*
MCV-72* MCH-23.8* MCHC-32.9 RDW-18.2* Plt Ct-445*
[**2165-10-26**] 03:53AM BLOOD WBC-17.0* RBC-3.56* Hgb-8.5* Hct-25.5*
MCV-72* MCH-23.9* MCHC-33.4 RDW-18.1* Plt Ct-436
[**2165-10-25**] 08:48PM BLOOD WBC-20.4* RBC-3.62* Hgb-8.6* Hct-25.8*
MCV-71* MCH-23.6* MCHC-33.1 RDW-18.0* Plt Ct-422
[**2165-10-25**] 07:30AM BLOOD WBC-25.7* RBC-3.90* Hgb-8.9* Hct-27.6*
MCV-71* MCH-22.8* MCHC-32.2 RDW-16.1* Plt Ct-517*
[**2165-10-24**] 06:00AM BLOOD WBC-27.4* RBC-3.59* Hgb-8.2* Hct-25.7*
MCV-72* MCH-22.9* MCHC-32.0 RDW-16.0* Plt Ct-408
[**2165-10-23**] 03:41PM BLOOD WBC-23.85* RBC-4.02* Hgb-9.1* Hct-28.0*
MCV-70* MCH-22.7* MCHC-32.7 RDW-15.8* Plt Ct-389
[**2165-10-25**] 08:48PM BLOOD Neuts-91.5* Bands-0 Lymphs-4.8* Monos-3.5
Eos-0.1 Baso-0
[**2165-10-28**] 07:50AM BLOOD Plt Ct-458*
[**2165-10-29**] 07:20AM BLOOD Glucose-106* UreaN-9 Creat-0.5 Na-137
K-3.5 Cl-105 HCO3-25 AnGap-11
[**2165-10-28**] 07:50AM BLOOD Glucose-115* UreaN-15 Creat-0.5 Na-134
K-3.6 Cl-101 HCO3-24 AnGap-13
[**2165-10-27**] 04:00AM BLOOD Glucose-73 UreaN-17 Creat-0.6 Na-138
K-3.5 Cl-107 HCO3-22 AnGap-13
[**2165-10-26**] 03:53AM BLOOD Glucose-106* UreaN-12 Creat-0.5 Na-134
K-3.7 Cl-104 HCO3-21* AnGap-13
[**2165-10-25**] 08:48PM BLOOD Glucose-115* UreaN-13 Creat-0.5 Na-132*
K-4.0 Cl-104 HCO3-19* AnGap-13
[**2165-10-23**] 03:41PM BLOOD Glucose-70 UreaN-18 Creat-0.8 Na-133
K-3.9 Cl-98 HCO3-22 AnGap-17
[**2165-10-29**] 07:20AM BLOOD Calcium-8.1* Phos-3.1 Mg-2.2
[**2165-10-23**] 03:41PM BLOOD calTIBC-329 VitB12-240 Folate-10.5
Ferritn-94 TRF-253
[**2165-10-23**] 03:41PM BLOOD CEA-2.3 CA125-62*
[**2165-10-26**] 12:09 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2165-10-29**]**
GRAM STAIN (Final [**2165-10-26**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND SINGLY.
RESPIRATORY CULTURE (Final [**2165-10-29**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CIPROFLOXACIN--------- =>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
[**2165-10-23**] 6:35 pm URINE Source: Catheter.
**FINAL REPORT [**2165-10-24**]**
URINE CULTURE (Final [**2165-10-24**]): NO GROWTH.
**FINAL REPORT [**2165-10-30**]**
AEROBIC BOTTLE (Final [**2165-10-30**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2165-10-30**]): NO GROWTH.
[**2165-10-24**] 6:00 pm BLOOD CULTURE
**FINAL REPORT [**2165-10-30**]**
AEROBIC BOTTLE (Final [**2165-10-30**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2165-10-30**]): NO GROWTH.
[**10-29**] CXR:
TWO VIEWS OF THE CHEST: Small bilateral pleural effusions
obscure the costophrenic angles, left greater than right. A left
basilar vague opacity is present likely seconday to the
underlying effusion and/or atelectasis. The lungs are otherwise
clear. There is left ventricular enlargement. The bony thorax is
normal.
BILAT LOWER EXT VEINS [**2165-10-28**] 10:18 AM
IMPRESSION: No evidence of DVT.
Echocardiogram [**2165-10-24**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Left ventricular systolic function is hyperdynamic (EF
70-80%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic arch is mildly dilated. There are focal calcifications in
the aortic arch. The aortic valve leaflets (3) are mildly
thickened and display slightly reduced systolic excursion. There
is no valvular aortic stenosis. The increased transaortic
velocity is likely related to high stroke volume. Mild (1+)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate ([**1-29**]+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The supporting structures
of the tricuspid valve are thickened/fibrotic. Moderate to
severe [3+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
CT Abdomen/Pelvis and CTA Chest [**10-23**]
IMPRESSION:
1. No pulmonary embolism.
1. Large, 20-cm complex, cystic pelvic mass with features highly
worrisome for neoplasm. Differential diagnosis would include
such entities as ovarian cystadenocarcinoma. No uterus or
ovaries are specifically identified. Clinical correlation with
surgical history is recommended. Other etiologies such as a
benign, post-surgical peritoneal inclusion cyst are also
possible, but considered less likely. A least one, enlarged,
mildly enhancing lymph node is noted. No evidence of peritoneal
carcinomatosis.
3. There is extensive sigmoid diverticulosis. Mild thickening of
a small segment of the sigmoid colon just inferior and posterior
to the large cystic mass could represent a focal area of
diverticulitis. This area is incompletely characterized
secondary to lack of intraluminal oral contrast. Clinical
correlation is recommended. There is no evidence of bowel
obstruction.
4. Bibasilar atelectasis, right greater than left. No focal
areas of consolidation is identified. A 6-mm, rounded focus in
the right upper lobe of the lung could represent a focal area of
atelectasis or represent a focal nodule. Attention to this area
should be paid on subsequent examinations.
5. Mild anterior wedging of the L1 vertebral body could
represent a compression fracture of indeterminate chronicity.
Clinical correlation is recommended.
6. Cholelithiasis without evidence of cholecystitis.
7. Bilateral renal low attenuation lesions, most too small to
characterize but most likely simple cysts.
Brief Hospital Course:
The patient was admitted with four day history of abdominal
pain, shortness of breath, nausea/vomiting and a new diagnosis
of a pelvic mass arising from the left ovary. The patient was
transferred from an outside hospital.
Pelvic Mass: The patient was evaluated with CT scan which
demonstrated large pelvic complex cystic mass 20 cm. No
peritoneal carcinomatosis was seen. A medicine consult was
obtained for preoperative clearance. An Echocardiogram was
obtained to evaluate the patient's heart function and ejection
fraction. CEA, Ca [**77**]-9 and Ca-125 were obtained.
The patient was taken to the operating room on [**2165-10-25**]. Please
see operative note for details. Her intraoperative course was
complicated by emesis following intubation of 600cc of fluid.
Following initial extubation, the patient was reintubated due to
concern for aspiration pneumonia and an elevated respiratory
rate. A CXR was obtained in the postoperative area which could
not rule out aspiration pneumonia. The patient was transported
to the ICU intubated. She was transferred to the floor on
postoperative day 2.
ID: The patient presented with elevated WBC of 23.8 which
increased to 27 on hospital day 2. The patient was initially
started on Levofloxacin for empiric treatment of a UTI diagnosed
at outside hospital. Urine culture at [**Hospital1 18**] returned negative.
Blood cultures were obtained and negative/no growth to date at
time of discharge. The patient was febrile upon presentation and
respiked on hospital day 2 preoperatively. A CT scan obtained
showed diverticulosis but could not rule out a small foci of
diverticulitis. Flagyl was added to the antibiotic regimen on
hospital day 2.
Following surgery on hospital day 2, during which a necrotic
torsed 20 cm ovarian cyst was found along with diffuse
peritonitis, antibiotics were discontinued. She was restarted on
Levofloxacin/Flagyl when the patient spiked a temperature on
post-operative day 0 to 101. The patient's WBC improved and
normal on postoperative day [**5-4**]. She remained afebrile since
[**10-26**] 0400.
Sputum cultures returned positive for sparse growth of MRSA on
[**10-29**]. The patient remained afebrile and had no symptoms or
signs of pneumonia. A repeat CXR showed no evidence of pneumonia
and significant for small bilateral pleural effusions vs
atelectasis. Per discussion with infectious disease team, no
further treatment was indicated as the patient was improving
without treatment for MRSA and the patient was clinically well.
The MRSA was thought to be from colonization and not evidence of
an acute infection. The patient received 7 days of Levofloxacin
and Flagyl.
Blood cultures returned negative on [**10-23**] and some remained
pending at discharge.
Pulmonary: The patient presented with oxygen desaturation to 90%
room air; the patient symptomatically was short of breath.
Oxygen was titrated. A CTA angiogram demonstrated no evidence of
pulmonary embolism on admission.
The patient was transported intubated to the ICU given some
concern for aspiration pneumonia and an increased respiratory
rate following surgery. She was extubated on postoperative day
1. Her oxygen requirement resolved on post-operative day 3.
Serial CXR were followed. On [**10-30**], the CXR showed no evidence of
infiltrate. Small bilateral pleural effusions versus atelectasis
were seen.
GI: The patient had significant ileus caused by the diffuse
peritonitis from the torsed, necrotic ovary. The patient was
made NPO upon admission. IV Fluids were maintained until the
patient's diet was advanced. Her electrolytes were checked daily
and repleted appropriately until tolerating diet. The patient
passed flatus on [**10-28**]. Her diet was advanced slowly. She had
bowel movement on [**10-29**]. She was tolerating regular diet x 3 days
at time of discharge.
Arthritis: The patient received 1 dose of 100 mg of
hydrocortisone stress dose steroids prior to incision as
recommended by the Medicine consult. She was maintained on her
normal dose of steroids for Rheumatoid arthritis following
surgery.
Cardiovascular: A Medicine consult was obtained upon admission
to help manage the patient and provide guidance for clearance
for surgery. An EKG showed no changes from baseline. An
echocardiogram was performed (see reports). The patient was
maintained on a beta blocker.
Anemia: The patient's initial hematocrit was 28.0. Guiac exam
negative. CT scan showed no evidence of intraabdominal bleeding.
The patient's HCT was followed daily until surgery. She received
1 unit blood transfusion intraoperatively. Postoperatively her
HCT was 25. On postoperative day 1, her HCT dropped to 23.6.
The decision was made to transfuse the patient 2 additional
units of blood. Her HCT responded appropriately to 27.7 and
stable at discharge 27.9. Iron studies and Folic acid/B12 were
normal. Anemia contributed to anemia of chronic disease.
Prophylaxis: The patient was started on Heparin sc 5000 mg TID
and pneumoboots/TEDs which were continued until discharge. She
received Pepcid IV and incentive spirometer for use.
LENIs were performed on [**10-27**] for bilateral symmetrical leg pain
which were negative.
Rehab: The patient received physical therapy
treatment/evaluation daily. The patient's family desired
rehabilitation facility given the lack of help at home for the
patient. She was discharged on POD 7 to a rehabilitation
facility.
Medications on Admission:
Atenolol 50mg qd
Prednisone 4mg qd
Darvocet-N 1 tab tid prn
Salsalate 500mg qd
Protonix 40mg qd
Lipitor 20mg qd
Hydroxychloroquine 200mg qd
Meds on transfer:
Morphine 4mg SC q4h
Zofran 4mg IV q6h
Protonix 40mg IV qd
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Acetaminophen 500 mg Capsule Sig: [**1-29**] Capsules PO Q6H (every
6 hours) as needed.
Disp:*60 Capsule(s)* Refills:*0*
4. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*40 Tablet(s)* Refills:*2*
5. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*50 Tablet(s)* Refills:*2*
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*40 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. Salsalate 500 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay - [**Hospital1 392**]
Discharge Diagnosis:
Primary Diagnosis:
20 cm Ovarian cyst with torsion and necrosis
Final pathology pending
Secondary Diagnosis:
Dyslipidemia
Arthritis
CAD s/p CABG x 5
GERD
Chronic Leg edema s/p CABG vein harvesting
Discharge Condition:
Tolerating regular diet, afebrile, vital signs stable. Voiding
and moving bowels.
Discharge Instructions:
Call Dr. [**First Name (STitle) 1022**] or Dr. [**Last Name (STitle) 2028**] if fever > 100.4, severe abdominal
pain not relieved by medicine, nausea/vomiting or inability to
eat regular diet, chest pain, shortness of breath or other
concerns, redness around incision or other worrisome signs.
For pain: you may take Tylenol or Percocet. Do not take these
medicines together.
Tylenol: 1-2 tablets every 6 hours
Percocet: 1 tablet every 6 hours
You may take Colace as a stool softener and Senna as bowel
motility [**Doctor Last Name 360**].
You should walk every day with assistance and your walker.
You may go up the stairs.
No heavy lifting for 6 weeks.
You may restart all your home medications:
Prenisone 4 mg daily
Atenolol 50 mg daily
Protonix 40 mg daily
Lipitor 20 mg daily
Hydroxychlroquine (Plaquenil) 200 mg daily
Salsalate 500 mg daily
Do not take Darvocet and Percocet together! They are both
narcotic pain medicines.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2165-12-5**] 2:30
[**Hospital Ward Name **] [**Location (un) **] [**Hospital Ward Name 23**] Clinical Center
[**Hospital1 69**]
You should follow up with Dr. [**Last Name (STitle) **] after discharge from the
rehab facility to check on your blood count.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
[
"518.5",
"560.1",
"272.0",
"414.00",
"V45.81",
"799.02",
"786.06",
"530.81",
"714.0",
"428.43",
"401.9",
"518.0",
"620.2",
"614.2",
"285.9",
"511.9",
"428.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"96.6",
"65.61",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
15457, 15537
|
8627, 14048
|
304, 442
|
15779, 15863
|
2015, 8604
|
16847, 17348
|
1574, 1611
|
14315, 15434
|
15558, 15558
|
14074, 14215
|
15887, 16571
|
1626, 1996
|
16589, 16824
|
237, 266
|
470, 1163
|
15668, 15758
|
15577, 15647
|
1185, 1466
|
1482, 1558
|
14233, 14292
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,569
| 120,139
|
23189
|
Discharge summary
|
report
|
Admission Date: [**2173-9-4**] Discharge Date: [**2173-9-17**]
Date of Birth: [**2089-12-9**] Sex: F
Service: NEUROLOGY
Allergies:
Aricept
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Disorientation with Right temporal lobe hemorrhage
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 83 yo LH F with h/o HTN, HLD, dCHF, mild
dementia and AFib (on Coumadin with Lovenox bridge) who presents
to [**Hospital1 18**] ED with disorientation and HTN to 190. Neuro is
consulted for intraparenchymal hemorrhage on head CT. Her
history was obtained from her son and granddaughter, as patient
is confused and unable to give a coherent history.
Of note, patient was recently admitted to [**Hospital1 18**] from [**Date range (1) 59633**]
for dyspnea and was found to have new-onset AFib. She was on a
heparin gtt while in the hospital, and discharged on Coumadin
5mg daily with Lovenox bridge.
Following hospitalization, patient was in her usual state of
health when her son last spoke with her 4 days ago. She has had
no recent falls. Today at 3pm, the nursing staff [**Street Address(1) 19140**] where she lives noted that she was newly disoriented and
did not know where she was (normally AAOx3 and lucid, per son,
although she does have mild dementia). They checked her
temperature which
was 100.3. They called EMS out of concern for altered mental
status.
On arrival to the ED, vitals were BP 192/74, P 53, RR 16, SaO2
95% RA, T 98.7. ED staff noted irregular respirations and were
concerned for [**Location (un) **] response. Labs notable for INR 2.0.
Noncontrast head CT showed 4.0x2.3 right temporal lobe IPH with
small intraventricular extension, with mild surrounding edema
but
no midline shift. Patient was given 2 units FFP and 10 units
vitamin K.
On exam currently, patient has no complaints and does not know
why she is in the hospital. She is alert to person only. She is
intermittently somnolent but awakens quickly to voice. She
becomes agitated with questioning, asking examiner "what do you
want?" repeatedly.
Neuro and general ROS were unable to be obtained from patient
given patient's poor cooperation. Per her family, ROS is
negative except for anorexia and significant (30 lb) weight loss
over the past year after a prolonged rehab stay for a fall last
year.
Past Medical History:
-HTN
-HLD
-diastolic CHF (LVEF>55%)
-AFib on Coumadin/Lovenox
-Cervical spondylosis and myelopathy
-Mild dementia (on rivastigmine)
-Glaucoma
-GERD
-Rheumatoid arthritis
-Left femur fracture
-Osteoarthritis
-Osteopenia
Social History:
-Tobacco history: remote
-ETOH: negative
-Illicit drugs: negative
-Housing: lives an [**Hospital3 **] in a 2 room apartment
-ADLs: able to shower, washing her hair, taking her medications
and ambulates with a walker at baseline. Does not drive or
manage her own finances.
Family History:
No family history of stroke. Father died of heart disease in his
50's. Mother had osteoporosis and died at 82.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 170/71 68 29 94% RA
General: thin elderly woman in NAD. Intermittently somnolent but
arouses easily to voice.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 1.5 (person, year [**2172**], does
not know she is in hospital even when given choices). Unable to
relate coherent history, repeatedly asks "why am I here?" and
"what do you want?". Inattentive, unable to name [**Doctor Last Name 1841**] backward.
Language: intact repetition, but poor comprehension (unable to
follow commands without visual prompting). Many paraphasic
errors with [**Location (un) 1131**]. Poor naming: unable to identify high or low
frequency objects. Able to read without difficulty. Able to
register 3 objects but recalled 0/5 at 5 minutes. Seemed to be
neglecting the left at times.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk (right pupil surgical). Visual
fields grossly full to confrontation. Funduscopic exam revealed
no papilledema, exudates, or hemorrhages.
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**]: does not cooperate.
XII: Tongue protrudes in midline and is strong.
-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**] EDB
L 4 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally (likely secondary to
cervical spondylopathy).
-Coordination: No intention tremor. Unable to cooperate with
FNF.
-Gait: not tested
================================
DISCHARGE PHYSICAL EXAM:
Vitals: 98.0 (max 98.3) BP: 135/79 (range 90-146/52-91), HR 93
in AFib (range 90-118); RR 20; O2 sat: 95 RA
General: thin elderly woman in NAD. Laying comfortably in bed.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. JVP not visualized
at 30 degrees No nuchal rigidity.
Pulmonary: Bibasilar crackles unchanged from baseline
Cardiac: RRR, no murmurs, rubs or gallops
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, disoriented to person, place and time.
Able to recognize her son and daughter in law and recalled their
names after a few seconds delay.
Language: intact repetition. Many paraphasic errors and
neologisms. Naming was poor with inability to name pen, glasses;
called a plastic spoon a "plastic fork." Knew what to do with
eyeglasses but could not name them.
Able to read without difficulty. Writing intact.
Digit span to 4 numbers going forward.
Follows midline and appendicular commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Visual fields grossly full 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**]: trapezii and SCM 5/5 strength
XII: Tongue protrudes in midline and is strong.
-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**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was extensor bilaterally (likely secondary to
cervical spondylopathy).
-Coordination: No intention tremor. Unable to cooperate with
FNF.
-Gait: not tested
Pertinent Results:
ADMISSION LABS:
[**2173-9-4**] 05:20PM BLOOD WBC-6.9 RBC-3.86* Hgb-12.4 Hct-37.8
MCV-98 MCH-32.1* MCHC-32.8 RDW-12.6 Plt Ct-190
[**2173-9-4**] 05:20PM BLOOD Neuts-75.4* Lymphs-17.9* Monos-6.2
Eos-0.3 Baso-0.3
[**2173-9-4**] 06:12PM BLOOD PT-21.4* PTT-50.1* INR(PT)-2.0*
[**2173-9-4**] 05:20PM BLOOD Glucose-92 UreaN-18 Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-30 AnGap-12
[**2173-9-4**] 05:20PM BLOOD Calcium-10.5* Phos-2.5* Mg-2.3
[**2173-9-4**] 05:52PM BLOOD Lactate-1.0
[**2173-9-4**] 08:30PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.010
[**2173-9-4**] 08:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
[**2173-9-4**] 08:30PM URINE RBC-<1 WBC-20* Bacteri-FEW Yeast-NONE
Epi-<1
DISCHARGE LABS:
[**2173-9-15**] 05:45AM BLOOD WBC-8.5 RBC-4.06* Hgb-13.0 Hct-38.8
MCV-96 MCH-31.9 MCHC-33.4 RDW-12.2 Plt Ct-289
[**2173-9-6**] 01:52AM BLOOD PT-11.5 PTT-29.0 INR(PT)-1.1
[**2173-9-15**] 05:45AM BLOOD Glucose-108* UreaN-22* Creat-0.8 Na-143
K-3.9 Cl-104 HCO3-33* AnGap-10
[**2173-9-15**] 05:45AM BLOOD Calcium-10.8* Phos-2.8 Mg-2.0
EKG ([**9-4**]): Sinus bradycardia. Borderline left axis deviation.
Left atrial abnormality. Non-diagnostic anterolateral T wave
inversions raising question of ischemia, left ventricular
hypertrophy, etc. Probable underlying left ventricular
hypertrophy. Compared to the previous tracing of [**2173-8-27**] atrial
and ventricular ectopy not seen. T wave inversions are more
apparent. Clinical correlation is suggested.
ECG [**2173-9-7**]
Atrial fibrillation with rapid ventricular response. Compared to
the previous tracing of [**2173-9-5**] the rate and rhythm have
changed.
IMAGING:
NCHCT ([**9-4**]): 4.0 x 2.3 cm right temporal lobe intraparenchymal
hemorrhage with small intraventricular extension into the right
lateral ventricle. Location of this bleed would be compatible
with provided history of anticoagulation.
REPEAT NCHCT ([**9-4**]):
1. Stable 4.4-cm right temporal lobar hemorrhage.
2. Transependymal xtension of hemorrhage into the occipital
horns of the
lateral ventricles, which may be new on the left.
3. No evidence of significant ventricular enlargement.
4. No new intra- or extra-axial hemorrhage and no evidence of
central
herniation.
5. NOTE ADDED IN ATTENDING REVIEW: The presence of prominent
blood/fluid levels, at time of presentation, is concordant with
previously-provided history of anticoagulation. Of note, the GRE
sequence from the remote MR study of [**2168-8-6**] demonstrates
several foci of "blooming" susceptibility artifact, particularly
adjacent to the splenium of the corpus callosum (that study
6:15-15); absent a previous history of head trauma (with
possible [**Doctor First Name **]), this raises the possible contribution of
underlying amyloid angiopathy.
PORTABLE NCHCT ([**9-6**], FINAL):
1. Stable right temporal lobe intraparenchymal hemorrhage, with
increased
overlying edema as described above.
2. No evidence of new hemorrhage or acute infarction.
3. No evidence of ventricular enlargement to suggest
hydrocephalus.
CHEST (PORTABLE AP) [**2173-9-8**]: FINAL
Small left pleural effusion has increased. There are low lung
volumes. The aorta is tortuous. Cardiomegaly is unchanged.
Increased peripheral opacity in the right upper lobe is most
likely due to pleural thickening in the setting of multiple old
rib fractures. There is mild interstitial edema. There is no
pneumothorax.
Brief Hospital Course:
82 yo LH F with h/o HTN, HLD, mild dementia, cervical
spondylopathy and newly-diagnosed AFib on Coumadin/Lovenox
presents with acute onset of confusion and speech problems,
found to have right temporal lobe IPH with small
intraventricular extension.
# NEURO: In the ED, patient was somnolent with a significant
expressive and receptive aphasia. Her blood pressure on arrival
was 190/70, so she was started on nicardepime drip. She was
given activated factor IX, FFP and vitamin K to reverse her
anticoagulation. She was admitted to the neuro ICU for close
monitoring and BP control with nicardepime drip. On HD #2 her
somnolence was improved but she developed a more marked global
aphasia. Repeat head CT on HD #3 showed some edema around IPH,
but no extension of bleed. Comparison with prior MRI from [**2167**]
showed evidence of ?underlying cerebral amyloid angiopathy (vs.
head trauma). She was transferred to the step-down unit for
close BP and neuro monitoring (given ongoing risk for cerebral
edema after her bleed). Her aphasia and confusion improved over
the course of her admission but she had significant residual
deficits on discharge.
# CARDIOVASCULAR
(1) AFib: Patient was in sinus rhythm on admission and while in
ICU. Given h/o symptomatic AFib, her home metoprolol was
restarted at lower dose during hospitalization. She then went
into asymptomatic AFib with RVR, which required IV metoprolol
and diltiazem (including drip) for rate control. At discharge,
her metoprolol had been increased from daily to TID and she was
on PO diltiazem 120mg QID. Her anticoagulation was stopped given
head bleed, as risks clearly outweighed benefits, and ASA 81mg
daily was started for clot prevention.
(2) HTN: On metoprolol only at home, previously on valsartan
before prior hospitalization. BP initially controlled with
nicardipine drip, then metoprolol.
(3) diastolic CHF: Made home Lasix PRN. Remained euvolemic.
Lisinopril discontinued per cardiology, can be restarted at
their follow-up.
# ID: UA on admission showed 20 WBCs so received single dose of
ceftriaxone in ED. This was discontinued in ICU. UCx with no
growth, CXR with small bibasilar pleural effusions (stable from
prior imaging).
# ENDOCRINE: On ISS for tight glycemic control while
hospitalized. Home statin was held in post-hemorrhage period
given risk of increased vessel friability.
# CODE STATUS: Patient is DNR/DNI (confirmed).
Medications on Admission:
- Alprazolam 0.25mg PO TID
- Calcium carbonate 500mg PO BID
- Rivastigmine 4.6mg/24 hr TD patch daily
- Latanoprost 0.005% ophth sol'n 1 drop both eyes daily
- Multivitamin 1 tab PO daily
- Sertraline 100mg PO BID
- Vitamin D 400mg PO daily
- Ezetimibe-simvastatin 10-40mg PO qHS
- Metoprolol succinate 50mg PO daily
- Enoxaparin 60mg SC q12 hrs
- Warfarin 5mg PO daily
- Furosemide 60mg PO daily
Discharge Medications:
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Multivitamins 1 TAB PO DAILY
3. Sertraline 100 mg PO BID
4. Vitamin D 400 UNIT PO DAILY
5. Calcium Carbonate 500 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Diltiazem 120 mg PO QID
8. ALPRAZolam 0.25 mg PO TID:PRN anxiety
hold for sedation, rr < 12
9. Metoprolol Tartrate 50 mg PO TID
hold for sbp <95, hr <50
10. Furosemide 60 mg PO DAILY as needed for increased fluid
balance, goal even
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
ACUTE ISSUES:
1. Right temporal lobe hemorrhage
CHRONIC ISSUES:
1. Hypertension
2. Hyperlipidemia
3. Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname **],
Thank you for choosing [**Hospital1 69**] for
your care.
You were admitted to the hospital with confusion and difficulty
with speech. You were found to have a hemorrhage (bleeding) on
the right side of your brain. This was most likely due to being
on blood thinning medications and having high blood pressure. In
the hospital we gave you medications to reverse your blood
thinners and control your blood pressure. You are being
discharged to rehab where you will have speech therapy to help
with stroke recovery.
.
Please attend the follow up appointment listed below.
.
We made the following changes to your medications:
1. STOPPED warfarin
2. STOPPED enoxaparin (lovenox)
3. STARTED Diltiazem 120 mg four times per day.
4. INCREASED metoprolol to 50mg three times daily
5. CHANGED furosemide to as needed from standing
Followup Instructions:
Neurology
Provider: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD
Phone:[**Telephone/Fax (1) 2574**]
Date/Time: [**2173-11-10**] 1:30
[**Hospital 43084**] clinic
Date/Time: Thursday [**2173-10-14**] 2PM
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5448**]
Location: [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] 7 Cardiac Services
Telephone: [**Telephone/Fax (1) 62**]
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
Completed by:[**2173-9-17**]
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icd9cm
|
[
[
[]
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[
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47,473
| 110,683
|
52803
|
Discharge summary
|
report
|
Admission Date: [**2190-3-15**] Discharge Date: [**2190-3-23**]
Date of Birth: [**2109-1-23**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**Known firstname 1406**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2190-3-15**] - Coronary artery bypass grafting x3(LIMA-LAD,SVG-OM-PDA
sequentially)
History of Present Illness:
This 81 year old male recently presented with heart failure, an
indeterminate troponin check and a significant drop in his EF to
25% by nuclear study which also demononstrated an inferorapical
infarct with a small area of inferior apical ischemia. He states
he has been experiencing increasing shortness of breath with
minimal exertion. He was then referred for coronary angiogram.
He was found to have progression of left main disease and was
referred to cardiac surgery for revascularization.
He was admitted for elective operation.
Past Medical History:
coronary artery disease
s/p stent [**11-22**]
Ischemic Cardiomyopathy EF 34%
Peripheral vascular disease
Hypertension
Hyperlipidemia
Asthma
chronic obstructive pulmonary disease on home oxygenation
[**Company 1543**] pacemaker secondary to complete heart block
Noninsulin dependent Diabetes Mellitus
gastroesophageal refluxAnxiety
Arthritis in back
s/p Right lung resection for benign disease
Social History:
Last Dental Exam:edentulous
Lives with:wife, Partners nurse [**First Name (Titles) 2176**] [**Last Name (Titles) 20515**]
Contact: [**Name (NI) **] (wife) cell# [**Telephone/Fax (1) 108888**]
Occupation:retired Iron worker
Cigarettes: Smoked no [] yes [x] Hx:quit 14 years ago and smoked
[**1-15**] ppd x50 years
Other Tobacco use:occasional cigars years ago
ETOH: < 1 drink/week [x] [**1-19**] drinks/week [] >8 drinks/week []
Illicit drug use:Denies
Family History:
Premature coronary artery disease- Grandfather had multiple MI's
Physical Exam:
Pulse:85 Resp:18 O2 sat:95/RA
B/P Right:129/83 Left:134/94
Height:5'[**88**].5" Weight:202 lbs
General: NAD, AAOx3
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x]
Extremities: Warm [x], well-perfused [x] Edema []
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right: none Left: none
Pertinent Results:
[**2190-3-15**] ECHO
PRE BYPASS The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. The left ventricular cavity is moderately dilated.
There is severe regional left ventricular systolic dysfunction
with apical akinesis, and severe hypokinesis of the mid to
distal anterior, anterolateral, and anteroseptal walls. There is
mild to moderate global hypokinesis on top of that. Overall
ejection fraction is about 25%. No masses or thrombi are seen in
the left ventricle. The right ventricular cavity is dilated with
mild global free wall hypokinesis and focal severe hypokinesis
of the apical free wall. [Intrinsic right ventricular systolic
function is likely more depressed given the severity of
tricuspid regurgitation.] There are simple atheroma in the
ascending aorta. There are complex (>4mm) atheroma in the aortic
arch. The descending thoracic aorta is mildly dilated. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly to modertaely thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**12-14**]+) mitral regurgitation is seen. The mitral
regurgitation has a slight anterior lean to it suggesting
slightly worse poterior leaflet restriction. Moderate to severe
[3+] tricuspid regurgitation is seen. Significant pulmonic
regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **]
was notified in person of the results in the operating room at
the time of the study.
POST BYPASS The patient is AV paced and receiving norepinephrine
and milrinone by infusion. Biventricular systolic function is
globally improved from the pre-bypass period. The apical right
ventricular free was is improved but mild global RV hypokineis
remains. The left ventricle has improvement in global function
but regional wall motion abnormalities noted pre-bypass persist.
EF is about 35%. The tricuspid regurgitation is somewhat
improved - now moderate. The rest of valvular function appears
unchanged from pre-bypass. The thoracic aorta is intact after
decannulation.
[**2190-3-22**] 03:13AM BLOOD WBC-4.9 RBC-3.60* Hgb-9.6* Hct-31.2*
MCV-87 MCH-26.8* MCHC-30.9* RDW-17.0* Plt Ct-145*
[**2190-3-15**] 11:39AM BLOOD WBC-9.2# RBC-3.28*# Hgb-8.4*# Hct-28.4*#
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.5* Plt Ct-146*
[**2190-3-22**] 03:13AM BLOOD Glucose-89 UreaN-35* Creat-1.6* Na-131*
K-3.2* Cl-90* HCO3-32 AnGap-12
[**2190-3-19**] 02:25AM BLOOD Glucose-71 UreaN-32* Creat-1.7* Na-131*
K-3.6 Cl-94* HCO3-26 AnGap-15
[**2190-3-22**] 03:13AM BLOOD WBC-4.9 RBC-3.60* Hgb-9.6* Hct-31.2*
MCV-87 MCH-26.8* MCHC-30.9* RDW-17.0* Plt Ct-145*
[**2190-3-15**] 11:39AM BLOOD WBC-9.2# RBC-3.28*# Hgb-8.4*# Hct-28.4*#
MCV-87 MCH-25.5* MCHC-29.4* RDW-16.5* Plt Ct-146*
[**2190-3-20**] 02:55AM BLOOD PT-12.0 PTT-25.8 INR(PT)-1.1
[**2190-3-15**] 11:39AM BLOOD PT-15.1* PTT-29.9 INR(PT)-1.4*
[**2190-3-23**] 04:41AM BLOOD Glucose-78 UreaN-36* Creat-1.5* Na-132*
K-3.4 Cl-94* HCO3-31 AnGap-10
[**2190-3-15**] 12:45PM BLOOD UreaN-23* Creat-1.0 Na-138 K-4.5 Cl-111*
HCO3-21* AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 12303**] was admitted to the [**Hospital1 18**] on [**2190-3-15**] for surgical
management of his coronary artery disease. He was taken directly
to the Operating Room where he underwent coronary artery bypass
grafting x3(LIMA-LAD,SVG-OM-PDA sequentially)
with Dr.[**Last Name (STitle) **]. Cardiopulmonary Bypass time=78 minutes. Cross Clamp
time=63 minutes. Please see operative note for details.
Postoperatively he was taken to the intensive care unit for
monitoring.
He required several days of Milrinone and pressor support due to
left ventricular dysfunction. These were weaned over several
days and after load reductuion with hydralazine substituted.
Post operatively he awoke neurologically intact and was
extubated. He developed atrial fibrillation for which Amiodarone
was started, with restoration of sinus rhythm.
He was seen by Physical Therapy for mobility and strength and
he was transferred to the step down unit for further recovery.
He was aggressively diuresed and developed a contraction
alkalosis which was treated with potassium chloride and
acetazolamide.
Mr. [**Known lastname 12303**] continued to make steady progress. He desired to
return home as he has home oxygen, the VNA already sees him
twice a week and his sons will stay with him around the clock.
On POD# 8 he was cleared by Dr.[**Last Name (STitle) **] for discharge to home with
VNA. All follow up appointments were advised.
Medications on Admission:
ALBUTEROL SULFATE nebulizer PRN, PLAVIX 75',FLUTICASONE FUROATE
Dose uncertain,FUROSEMIDE 40', GLIPIZIDE 5', LORAZEPAM 0.5" PRN,
METFORMIN 500", METOPROLOL 25', NTG 0.4 prn, SIMVASTATIN 20',
SPIRIVA 18 mcg Cap daily, ASPIRIN 325', Prilosec dose unknown
[**Hospital1 **] (otc)
Discharge Medications:
1. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
2. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temperature >38.0.
4. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for
wheeze.
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 discontinue.
Disp:*100 Tablet(s)* Refills:*2*
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO four times a
day.
11. metoprolol succinate 25 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
12. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 2255**] [**Name (NI) 2256**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
s/p coronary stent [**9-23**]
Ischemic Cardiomyopathy EF 34%
Peripheral vascular disease
Hypertension
Hyperlipidemia
Asthma
Chronic obstructive pulmonary disease- on home Oxygen
s/p pacemaker secondary to complete heart block
noninsulin dependent diabetes mellitus
gastroesophageal reflux
Anxiety
Arthritis in back
s/p [**Hospital1 **];ateral total knee replacements
hyperlipidemia
s/p Right lung resection for benign lesion
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Incisional pain managed with oral analgesics
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema : none
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) **] on ([**Telephone/Fax (1) 170**]) on [**2190-4-15**] at 1:15pm
Please call to schedule appointments with your:
Cardiologist: Dr. [**Last Name (STitle) 10543**]
Primary Care: Dr. [**Last Name (STitle) 29117**] ([**Telephone/Fax (1) 70698**]) in [**3-18**] 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:[**2190-3-23**]
|
[
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"428.23",
"V15.82",
"414.01",
"414.8",
"428.0",
"250.00",
"287.49",
"V43.65",
"272.4",
"E942.1",
"493.20",
"276.3",
"427.31",
"276.1",
"412",
"443.9",
"401.9",
"530.81",
"416.8",
"300.00",
"V45.01",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"89.61",
"36.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9322, 9393
|
5945, 7385
|
297, 386
|
9920, 10146
|
2612, 5922
|
11035, 11578
|
1855, 1922
|
7711, 9299
|
9414, 9899
|
7411, 7688
|
10170, 11012
|
1937, 2593
|
237, 259
|
414, 951
|
973, 1367
|
1383, 1839
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,474
| 176,612
|
7496
|
Discharge summary
|
report
|
Admission Date: [**2117-11-30**] Discharge Date: [**2117-12-10**]
Date of Birth: [**2054-3-12**] Sex: F
Service: MEDICINE
Allergies:
Inderal
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Dyspnea, chest pain
Major Surgical or Invasive Procedure:
Cardiac Catheterization with bare matal stents to left
circumflex artery and right coronary artery
PICC line placement and removal
History of Present Illness:
SOURCE: Patient, interviewed with her adult son translating.
([**Name2 (NI) **] cambodian interpreter available except via telephone). Son
speaks excellent English and appears to speak fluently with his
mother.
.
Ms [**Known lastname **] is a 63 year old woman with a history of asthma, who was
in her usual state of health, able to be up and about her house,
rode here stationary bike etc on Sunday. Yesterday, she didn't
feel as well, developed some dyspnea on awakening that persisted
through the day. She had chest pain thru the day as well, though
it waxed and waned, with her dyspnea worsening. She took her
nebulizers and her other medications and this helped her
shortness of breath and her chest pain. She has not had any
fevers. Has a sore throat but she says she has had his for a
long time. Says at least one month, where it is worse in the
morning and improves with the albuterol nebs and resolves by
midday.
She presented to the ED where she was noted to be dyspneic and
was treated for PNA +/- asthma flare with levofloxacin,
nebulizers and steroids. She also received an aspirin. She is
now admitted to the Medicine service for further evaluation and
management.
.
ROS
She later describes her pain as in her chest, extending across
upper abdomen doesn't know how long she's really had this, seems
to come and go, and patient is not really able to describe for
how long she's had it. Says her medications make it better.
No diarrhea, constipation. Decrease energy with acute illness.
+ dark stools x a long time (is on iron supplement).
.
All other ROS are otherwise negative
Past Medical History:
FROM OMR
1. Diabetes Mellitus, Type 2: She was diagnosed in [**2104**] and has
been followed by Dr. [**Last Name (STitle) 9006**] since that time. She is controlled on
insulin. Here most recent HbA1c was < 7%.
2. Chronic Hepatitis B.
3. Stage 2 - Chronic kidney disease (hyperparathyroidism [**2-9**]
renal issues).
4. Nephrotic Syndrome.
5. Hypertension.
6. Asthma.
7. Hypertriglyceridemia.
8. CVA/TIA.
9. Raynaud's phenomena.
10. Generalized anxiety disorder.
Social History:
She lives with her daughter, son and husband. She has 9
children, 3 are deceased. Her occupation was as a housewife.
She was born in [**Country **] living in a rural area. She denies ever
smoking cigarettes but does continue to chew betel. She denies
alcohol abuse. She came to the United States in [**2090**].
Independent of ADLS. Has help with some IADLS. No recent
falls.
Son = [**Name (NI) **] [**Name (NI) 27411**] [**Telephone/Fax (1) 27413**] (son). HCP = [**Name (NI) 27414**] [**Name (NI) 27411**]
[**Telephone/Fax (1) 27415**] (daughter).
.
CODE STATUS CONFIRMED as FULL
Family History:
Per OMR:
Daughter and son with asthma; no strokes or seizures in family
per granddaughter.
Physical Exam:
98.6 162/90 100 24-28 98% on 2L, FS 254
GEN: Obese woman, dyspneic, appears somewhat tired
[**Telephone/Fax (1) 4459**]: Anicteric, MMM
NECK: Unable to visualize JVP
CV: Reg rate, tachycardic, distant
LUNGS: Distant lung sounds, markedly diminished air entry,
increased I:E ratio
ABD: obese, some mild tenderness across upper abdomen, +
distended, soft, otherwise no abnl, no HSM appreciated due to
habitus
EXT: warm, DPs palp
NEURO: Alert, appropriate, follows commands, speech fluent
.
At discharge: same as above except:
GEN: not dyspneic, comfortable, not tired-appearing
LUNGS: CTAB
Pertinent Results:
[**2117-11-30**] 10:10AM GLUCOSE-245* UREA N-24* CREAT-1.3* SODIUM-141
POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-23 ANION GAP-17
[**2117-11-30**] 03:26PM LACTATE-3.4*
[**2117-11-30**] 10:10AM cTropnT-0.03*
[**2117-11-30**] 10:10AM WBC-8.2 RBC-3.73* HGB-11.5* HCT-36.0 MCV-96
MCH-30.8 MCHC-31.9 RDW-13.6
[**2117-11-30**] 10:10AM PLT COUNT-248
[**2117-11-30**] 10:10AM PT-12.4 PTT-26.4 INR(PT)-1.0
EKGs reviewed (as described below)
TTE: from [**3-16**]
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Mild (1+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is an anterior
space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2113-7-14**], the
findings are similar.
.
Cardiac Catheterization [**12-6**]:
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Moderate systemic hypertension.
3. Successful PCI of LCx with BMS
4. Successful PCI of RCA with BMS
5. Successful RRA TR band
6. [**Hospital 27416**] medical regimen.
.
Discharge Labs:
[**2117-12-10**] 06:53AM BLOOD WBC-11.2* RBC-2.82* Hgb-8.9* Hct-26.3*
MCV-94 MCH-31.5 MCHC-33.7 RDW-13.9 Plt Ct-198
[**2117-12-10**] 03:39PM BLOOD Hct-29.0*
[**2117-12-10**] 06:53AM BLOOD Glucose-110* UreaN-32* Creat-1.3* Na-140
K-4.6 Cl-108 HCO3-27 AnGap-10
[**2117-12-10**] 06:53AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.5
[**2117-12-2**] 06:09AM BLOOD %HbA1c-7.9* eAG-180*
Enzymes:
[**2117-11-30**] 10:10AM BLOOD cTropnT-0.03*
[**2117-12-1**] 02:30AM BLOOD CK-MB-18* MB Indx-6.9* cTropnT-0.11*
proBNP-2431*
[**2117-12-1**] 04:45AM BLOOD CK-MB-24* MB Indx-7.2* cTropnT-0.25*
proBNP-2808*
[**2117-12-2**] 06:09AM BLOOD CK-MB-33* MB Indx-5.7 cTropnT-2.87*
[**2117-12-3**] 06:15AM BLOOD CK-MB-13* MB Indx-4.8 cTropnT-1.41*
[**2117-12-6**] 10:18PM BLOOD CK-MB-5
[**2117-12-7**] 04:02AM BLOOD CK-MB-5
Brief Hospital Course:
63 yo F with DM II, HTN, DL and CKD who presents after multiple
episodes of chest pain and SOB. Admitted initially for asthma
exacerbation but later found to have an NSTEMI and found to have
3VD on cath [**12-1**].
.
# CAD: S/P NSTEMI. Currently stable without CP. Received Cardiac
Catheterization with bare matal stents to left circumflex artery
and right coronary artery on [**12-1**]. She has done well post
catheterization with a resolving small hematoma on the left
radial site. She should have a full dose 325 mg aspirin and
Plavix 75 mg every day for at least one month and possibly
longer. she will also need to be on Atorvastatin 80 mg. Her
Lisnopril was restarted on [**12-8**]. Her beta blocker was held and
not restarted because of her severe asthma. She was rate
controlled with increased dose of long acting Diltiazem. She has
remained in a normal sinus rhythm. Her heart function is stable
with a preserved EF at 60-65%, no significant valvular
abnormality. She will see Dr. [**Last Name (STitle) **] in cardiology here at [**Hospital1 18**]
in 1 month.
.
# ASTHMA EXACERBATION: History of Asthma with exacerbations
several times per year, but no history of intubations who
presents with 2 day history of worsening shortness of breath, no
URI symptoms, and intermittent chest pain. Started on standing
nebs and prednisone pulse in the MICU, now on prednisone taper.
Leukocytosis likely [**2-9**] prednisone. She has baseline DOE and
tight breath sounds with no audible wheezes on exam. She also
has a dry cough. Her Adviar dose was increased from home dose
and she has no O2 requirement (also no home O2)
.
# Diabetes Mellitus: She is followed by Dr. [**Last Name (STitle) 3617**] at [**Last Name (un) **] and
has had high insulin requirements, started on u500 insulin as
outpt. Her blood sugars have been labile and she will likely
need more insulin given prednisone. She was transitioned to
glargine with a humalog sliding scale.
.
# HTN: Currently well controlled on diltiazem and Lisinopril.
.
# Hyperlipidemia: restarted home simvastatin 40mg daily
.
# CKD: Patient with baseline 1.4-2.4. Cr rising slightly after
contrast load with catheterization, should be monitored after
discharge and avoid nephrotoxins.
.
# Chronic HBV infection with gastric varices. Viread was
decreased to 300mg q 72 hours for renal function. Her MELD score
is 12. Seen by hepatology during hospital stay and has an
upoming outpt appt.
.
# Social: pt has a large family and her son is the HCP. She was
previously living at home with her husband and son and was
independent. She is deconditioned with some gait instability,
should be on fall precautions until she is stonger.
Medications on Admission:
Viread 1 tab q72 hours
albuterol mdi
diltiazem 300 mg/d
[**Last Name (un) 12457**] 1 tab po bid
advair 100 mcg-50 mcg 1 inh [**Hospital1 **]
furosemide 80 mg po bid
duoneb q4-6 hrs prn
lisinopril 40 mg po bid
metoprolol 25 mg po bid
omeprazole 20 mg po daily
simvastatin 40 mg po daily
valsartan 320 mg po daily
aspirin 81 mg po daily
docusate 100 mg po bid
iron 325 daily --> will hold given acute illness
Vit D
Omega 3 Fatty acids
Humulin R as per Sliding Scale
Discharge Medications:
1. tenofovir disoproxil fumarate 300 mg Tablet Sig: One (1)
Tablet PO Q72H (every 72 hours).
2. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO every
other week.
3. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) ML Inhalation Q4h () as needed for wheezing/SOB.
4. ipratropium bromide 0.02 % Solution Sig: One (1) vial
Inhalation every six (6) hours.
5. ferrous sulfate 325 mg (65 mg Iron) 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. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. diltiazem HCl 180 mg Capsule, Sustained Release Sig: Two (2)
Capsule, Sustained Release PO DAILY (Daily).
9. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): Hold SBP < 100.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO QID (4 times a day) as needed for abdominal pain.
15. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
17. guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for coughing.
18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
syringe Injection twice a day.
19. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed for pruritis.
20. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for pruritis.
21. hydrocortisone 0.5 % Cream Sig: One (1) Appl Topical TID (3
times a day) as needed for pruritis.
22. insulin glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous QPM.
23. insulin aspart 100 unit/mL Solution Sig: 2-14 units
Subcutaneous four times a day.
24. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO TID
(3 times a day).
25. ipratropium bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
26. prednisone 5 mg Tablet Sig: 0.5 to 2 Tablet PO once a day:
TAPER: 10mg daily until [**12-11**], 5mg daily 12/5-7, 2.5mg daily
[**2117-12-15**] then DC. .
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Rehabilitation & Nursing Center - [**Location (un) 538**]
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Diabetes mellitus
Asthma Exacerbation
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You had chest pain and a heart attack. You had a cardiac
catheterization and needed to bare metal stents to two of your
heart arteries to open blockages. You were also treated for a
severe asthma exacerbation with prednisone, nebulizer treatments
and a long acting controller medicine called Advair.
.
We made the following changes in your medicines:
1. Stop taking Albuterol, [**Location (un) **], Metoprolol and Valsartan
2. Increase aspirin to 325 mg daily
3. Increase Diltiazem long acting to 360 mg daily
4. Increase Advair to 250/50 mg twice daily
5. Start taking Plavix to keep the stent open. Do not stop
taking Plavix for any reason or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) **]
tells you to.
6. Start taking senna and Miralax to prevent constipation
7. Start taking Guaifenesin for your cough
8. Start taking Levalbuterol nebulizers as needed for your
breathing
9. Start taking Benadryl as needed for your itching
10. Start using Sarna lotion and hydrocortisone cream as needed
for your itching.
Followup Instructions:
Department: [**Hospital3 249**]: pls d/c if pt goes to ECF
When: TUESDAY [**2117-12-14**] at 9:10 AM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 250**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: TUESDAY [**2118-1-11**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: THURSDAY [**2118-1-20**] at 9:20 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"428.32",
"272.4",
"403.90",
"584.9",
"443.0",
"493.22",
"708.0",
"585.3",
"V12.54",
"070.32",
"456.8",
"799.02",
"272.1",
"276.7",
"300.02",
"288.60",
"410.71",
"428.0",
"414.01",
"581.9",
"250.00",
"V58.67",
"588.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.41",
"37.22",
"00.66",
"88.56",
"38.93",
"00.46",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
11868, 12022
|
6187, 8859
|
290, 422
|
12158, 12158
|
3878, 5125
|
13422, 14376
|
3156, 3249
|
9373, 11845
|
12043, 12137
|
8885, 9350
|
5142, 5355
|
12333, 13399
|
5371, 6164
|
3264, 3757
|
3771, 3859
|
231, 252
|
450, 2049
|
12173, 12309
|
2071, 2536
|
2552, 3140
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,845
| 176,231
|
6363
|
Discharge summary
|
report
|
Admission Date: [**2173-7-2**] Discharge Date: [**2173-7-10**]
Date of Birth: [**2113-11-21**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ativan / Erythromycin Base / Statins-Hmg-Coa Reductase
Inhibitors / [**Female First Name (un) 504**] Type Anesthetics
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Shortness of breath, cough - from tracheobronchomalacia
Major Surgical or Invasive Procedure:
Right thoracotomy and tracheoplasty with mesh,
bronchoplasty of the bronchus intermedius and right main stem
bronchus with mesh; left main stem bronchoplasty with mesh;
bronchoscopy with bronchoalveolar lavage
History of Present Illness:
59 yo female with h/o of persistent and disabling cough found to
have TBM. Symptoms began in [**2152**] after exposure to chemical
fumes--and anaphylactic shock to chemical fumes. In [**4-/2173**]
dyspnea/cough have been ongoing and
disabling--antibiotics/steroids not helpful. Bronch [**5-/2173**]
showed 80% proximal trachea, 100% occlusion (distal bronchi);
Y-stent trial yielded improvement (placed [**6-8**] and removed [**6-14**])
with some granulation tissue; pH Bravo study showed GERD/distal
reflux.
Past Medical History:
TBM, CAD (LAD w/ < 30% stenosis), migraines, colonovaginal
fistula, vaginitis,
PSH: cesarean sections x 3, left lumpectomy
Social History:
Denies tobacco, ethanol and drug use. Has exposure to cleaning
agents.
Works for an electrical company.
She is married and lives with family
Family History:
Mother pancreas ca
Father
Siblings ovarian ca
Offspring
Other lung ca
Physical Exam:
VS: Temp 97.2 HR 108 BP 110/60 RR 18 O2 sat 98% on 3L O2 via N/C
PE:
Gen: NAD, A&O x 3
Lungs: CTAB, decreased breath sounds L>R, no w/c/r, L
thoracotomy incisions s/d/i w/ serosang drainage
CV: RRR
Pertinent Results:
[**2173-7-2**]:
CK(CPK)-1237
GLUCOSE-203 UREA N-13 CREAT-0.6 SODIUM-140 POTASSIUM-4.1
CHLORIDE-108 TOTAL CO2-21 ANION GAP-15 CALCIUM-9.2 PHOSPHATE-4.0
MAGNESIUM-1.4
WBC-10.1 HGB-11.8 HCT-35.2 PLT COUNT-289
ABG: PO2-215* PCO2-37 PH-7.33* TOTAL CO2-20* BASE XS--5
Brief Hospital Course:
[**2173-7-2**]: Admitted to thoracic surgery service after
tracheobrochoplasty for tracheobronchomalacia. Was slightly
tachycardic in the PACU to 105, but asymptomatic and BP normal.
Admitted to ICU for respiratory status monitoring. Thoracic
epidural function declined, likely paramedian. Epidural split to
bupivicaine with dilaudid PCA.
[**2173-7-3**]: Improved pain control with addition of Toradol.
Epidural with minimal effect. Patient stable and out of bed to
chair. No acute events. Right chest tube removed.
[**2173-7-4**]: No acute events, tolerating clears, epidural removed,
PCA dilaudid switched to intermittent IV dilaudid as patient was
highly sedated and had questionable respiratory drive.
[**2173-7-5**]: Foley catheter removed and IV fluids were stopped.
Tolerated full liquid diet. Given oxycontin for pain. Begun on
toradol for a 3 day period. Dilaudid PCA restarted, and
lidocaine patch over the incision site was applied. Given lasix
for diuresis, recent CXR showed mild fluid overload with a small
left sided pleural effusion.
[**2173-7-6**]: Continue diruesis given >3L positive yesterday -> lasix
20mg x1. Transferred from the ICU to the floor. Begun on a
regular diet, which she tolerated well.
[**2173-7-7**]: Has not taken topiramate during this admission.
Developed nausea after going down for a CXR. Upon questioning,
pt sts she is somewhat dizzy and that this exact same problem
occured on her previous post surgical admission. Likely
withdrawal from topiramate. Begun on standing topiramate.
Morphine PCA stopped and oral morphine begun, with better pain
control.
[**2173-7-8**]: Mild pleuritic pain, O2 sat's stable, tolerating PO's
well, and pain is well controlled. Was made NPO and placed on
IVF in preparation for bronchoscopy on [**2173-7-9**].
[**2173-7-9**] - Patient underwent flexible bronchoscopy, which was
within normal limits. She is alert, oriented, and ambulating
independently.
[**2173-7-10**]- Patient was afebrile, saturating 98% on room air, and
normotensive. Pain was well controlled and she was ambulating
independently. Cough was productive and clearing mucous
effectively. Patient was discharged home.
Medications on Admission:
Albuterol inhaler
Singulair 10 mg daily
Topiramate 100 mg PO qHS
Discharge Medications:
1. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Topiramate 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for migraine.
3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) Inhalation Q4H (every 4 hours) as
needed for wheezing/sob.
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
Indigestion.
5. Morphine 15 mg Tablet Sig: One (2) Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
scoop PO DAILY (Daily).
Disp:*1 can* Refills:*2*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain: take with food and water.
Disp:*90 Tablet(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
10. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): cut in
[**12-19**] place either side of incision.
Disp:*15 Adhesive Patch, Medicated(s)* Refills:*2*
11. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*30 Tablet(s)* Refills:*0*
12. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous
membrane QID (4 times a day).
Disp:*40 Troche(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Tracheobronchomalacia.
CAD (LAD w/ < 30% stenosis),
Migraines
Colonovaginal fistula
vaginitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fever > 101 or chills
-Increased shortness of breath, cough or stridor
-Chest pain
-Incision develops drainage.
-No driving while taking narcotics. Take stool softners with
narcotics
-Walk 4-5 times a day for 10-15 minutes to a goal of 30 minutes
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) 24620**] [**Telephone/Fax (1) 3020**] Date/Time:[**2173-7-27**]
9:30
in the [**Hospital Ward Name 121**] Building [**Location (un) 591**], [**Hospital1 **] I
Chest X-Ray [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology 30
minutes before your appointment
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2173-7-27**] 9:30
Completed by:[**2173-7-10**]
|
[
"346.90",
"530.81",
"519.19",
"V45.82",
"414.01",
"511.9",
"276.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.48",
"31.79",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
5949, 5955
|
2112, 4288
|
440, 651
|
6093, 6093
|
1823, 2089
|
6601, 7097
|
1516, 1588
|
4403, 5926
|
5976, 6072
|
4314, 4380
|
6244, 6578
|
1603, 1804
|
345, 402
|
679, 1190
|
6108, 6220
|
1212, 1338
|
1354, 1500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,961
| 160,874
|
38086
|
Discharge summary
|
report
|
Admission Date: [**2140-7-28**] Discharge Date: [**2140-9-2**]
Date of Birth: [**2073-7-28**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
rising creatinine
Major Surgical or Invasive Procedure:
paracentesis
[**2140-8-11**]: ABO incompatible orthotopic liver transplant
[**2140-8-15**]: Chest tube placement
[**2140-8-25**]: Liver Biopsy
[**2140-8-26**]: ERCP
Hemodialysis q Monday, Wednesday, Friday
History of Present Illness:
Ms. [**Known lastname 85025**] is a 66 year old woman with h/o HCV cirrhosis on
transplant wating list who was admitted from rehab with rising
creatinine concerning for HRS.
.
She was recently discharged on [**7-17**] after an admission for Hct
drop and hyperK in the setting of aldactone. Admission was
complicated by refractory ascites and hepatic encephalopathy
requiring a paracentesis which drained 4.5 L. She has been
scheduled for serial weekly paracentesis most recently done on
[**7-22**], and scheduled again for [**7-29**].
.
She is now being admitted today from [**Hospital3 **] today after
being seen in clinic yesterday with labs at that time revealing
rise in her creat to 2.1 (1.5, 1.3, 1.4) and T. bili 7.1 (3.2)
bringing her MELD up to 29. She is not on diuretics. She was
scheduled for repeat paracentesis tomorrow as an outpatient and
was to have PICC line placed at that time due to poor IV access.
.
On the floor, she reports abdominal pain and distension, as well
as LE edema. She is having diarrhea at baseline from her
lactulose. She reports occasional BRB on the toilet paper with
BMs which has been attributed to hemorrhoids. VS T: 99.2 131/77
96 18 100% RA.
.
Past Medical History:
- HCV cirrhosis type 1a c/b ascites, jaundice, encephalopathy, 1
cm enhancing focus in liver, diagnosed 12 years ago, likely
secondary to blood transfusion in [**2103**], she has never received
antiviral therapy, she was diagnosed with cirrhosis 8 years ago,
received ABO incompatible liver transplant [**2140-8-11**]
- HTN
- DM2
- Left cataract surgery
- Hysterectomy for fibroids
- s/p bladder prolapse surgery
Social History:
She is divorced with 3 children. She was living with her
daughter and 3 grandchildren, has a commode her in bedroom, and
lives on the [**Location (un) 1773**]. She is a retired nursing assistant.
She gave up smoking approximately 4 years ago. She does not
drink alcohol and never used recreational drugs. She was
discharged to [**Hospital3 **] after last admission.
Family History:
Her maternal aunt had congestive cardiac failure. Her mother
had [**Name (NI) 5895**], diabetes and hypertension. Two sisters have
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 99.2 131/77 96 18 100% RA
General: Pleasant female, A/O x3, somewhat somenelent, reporting
mild abd pain
HEENT: NCAT, OP clear, no LAD
Neck: Supple
Heart: RRR, harsh 2/6 systolic murmur throughout precordium
Lungs: CTAB
Abdomen: Distended, taught. Tenderness worse in LLQ without
rebound or [**Last Name (un) **]. BS present
Extremities: 2+ pulses, 2+ edema
Neurological: A/O x3, + asterixis, CN2-12 intact, motor and
sensory exams normal
Rectal: hemorrhoids (bleeding) with guaic positive mucous.
Prolapsed uterus.
Pertinent Results:
ADMISSION LABS: [**2140-7-27**]
WBC-11.2*# RBC-2.55* Hgb-8.5* Hct-25.8* MCV-101* MCH-33.3*
MCHC-33.0 RDW-17.2* Plt Ct-51*
Neuts-76* Bands-1 Lymphs-11* Monos-10 Eos-1 Baso-0 Atyps-0
Metas-1*
PT-21.4* INR(PT)-2.0*
UreaN-43* Creat-2.1* Na-129* K-4.3 Cl-99 HCO3-18* AnGap-16
ALT-44* AST-81* AlkPhos-82 TotBili-7.1*
Albumin-3.9 Calcium-9.1 Phos-2.6* Mg-2.3 Iron-97
AFP-10.4*
DISCHARGE LABS: [**2140-9-2**]
WBC-15.9* RBC-3.40* Hgb-10.0* Hct-30.3* MCV-89 MCH-29.5
MCHC-33.1 RDW-15.2 Plt Ct-578*
PT-13.3 PTT-24.8 INR(PT)-1.1
Glucose-111* UreaN-59* Creat-2.6* Na-139 K-4.7 Cl-97 HCO3-30
AnGap-17
ALT-26 AST-24 AlkPhos-336* TotBili-0.6
Calcium-9.7 Mg-2.2 Albumin-3.2* Phos-3.9
tacroFK-8.3
Brief Hospital Course:
66-year-old woman with hepatitis C decompensated cirrhosis with
ascites, recurrent hepatic encephalopathy on transplant list,
now presenting with elevated creatinine and concern for HRS,
found to have SBP.
.
# SBP/Decompensated cirrhosis: Pt with a MELD of 30. She is on
transplant waiting list currently. She has been receiving weekly
serial therapeutic paracenteses and is due for her next one on
[**7-29**], but we canceled this in the setting of her acute illness.
Diagnostic tap confirmed SBP (760 WBC and 64% poly's) and she
was started on ceftriaxone, increased outpatient midodrine
regimen and added octreotide as well as albumin. She was
continued on rifaximin and lactulose. On [**2140-8-11**] she was cleared
for liver transplant and underwent ABO incompatible liver
transplant.
.
# Acute on Chronic Renal Failure: Cr up to 2.3 at presentation
from baseline of 1.5 on [**7-19**] raising concern for HRS. She has
been off diuretics since her prior discharge. At the time of
transplant she underwent CVVH in the operating room and then was
continued on CVVH in the ICU post transplant. She has been
continued on intermittent hemodialysis using a tunneled HD
catheter q Monday, Wednesday Friday and will continue on this
regimen. Status of recovery of kidney function will be followed
.
# Anemia: Thought to be [**2-24**] hemorroidal bleed and also from
gastropathy seen on prior EGD. Colorectal surgery was consulted
previously for hemorrhoids but the family and pt did not want to
pursue surgery. Patient's hct has been stable at 25 in the past
but did drop to 18 at presentation. She received 2U PRBCs. On
[**8-10**] the patientunderwent successful coil embolization of a
distal jejunal branch of the
SMA with post-embolization angiograms demonstrating no further
extravasation
of contrast material.
.
Patient completed the course of Ceftriaxone for SBP, and based
on most recent diagnostic tap it is determined that the patient
is safe for transplant.
On [**2140-8-11**], an ABO incompatible liver was available for patient
and Deceased donor (brain dead) ABO INCOMPATIBLE (A TO O) liver
transplant (piggyback), portal vein to portal vein anastomosis,
common bile duct to common bile duct anastomosis, no T tube,
common hepatic artery to splenic artery, splenectomy was
performed by Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. During the surgery the patient
was maintained on CVVH. The patient received [**2129**] cc of
crystalloid, 6 units fresh frozen plasma, 6 units of packed
red cells, 3 units of platelets, [**2129**] cc of Cell [**Doctor Last Name **] and urine
output was 10 cc. Estimated blood loss was 5500 cc.
She was transferred to the SICU in stable condition.
The patient received induction immunosuppresion per the ABO
incomaptible pathway to include 1000 mg solumedrol, cellcept and
Thymoglobulin.
Post operatively the ABO incompatible pathway was continued with
steroid taper, Cellcept 1 gram [**Hospital1 **], Thymoglobulin was given for
5 total doses, and prograf was started on the evening of POD 1.
She received CVVH while in the unit and was then transitioned to
intermittent HD.
Daily Anti A titers were followed. Patient had received
plasmapheresis prior to the liver transplant and then on POD 4
and 5, the IgG titers were noted to be 1:8 and she received two
additional plasmepheresis sessions on those days.
She extubated on POD 2
The patient was having some difficulty with extubation, and
following physical exam, a chest CT was performed confirming a
large right sided pneumothorax and a chest tube was placed. This
remained in placed until POD 6 with full resolution of the
pneumothorax. The chest tube was d/c'd prior to her transfer to
the regular surgery floor.
The hemodialysis was continued throughout the hospital stay, her
urine output has been incidental and creatine has continued to
rise between HD treatments. She also continued to have
intermittent extra treatments for ultrafiltration. LE edema was
gone, however she was still having an oxygen requirement. Of
note the patient often goes in and out of AFib while on
hemodialysis. The patient has not been anticoagulated.
AST and ALT have returned to [**Location 213**], however the alk phos was
noted to be increasing into the second week post op. Bilirubin
was stable around 0.8. A liver biopsy was performed on [**8-25**]
showing no evidence of rejection and no Hepatitic C recurrence.
There was however bile duct proliferation noted and an ERCP was
performed on [**8-26**].
The ERCP showed that there was a size mismatch between the donor
bile duct and recipient. A sphincterotomy was performed and a
plastic stent was placed. This will need follow up in 6 weeks.
While ERCP being performed, the patient had an episode of
desaturation when being positioned for the ERCP. She was
intubated and following the procedure she was transferred to the
SICU and remained intubated overnight. The following day she was
able to be extubated. She still has an O2 requirement even at
rest and requires approximately 4 L at rest and 6 liters with
ambulation.
The patient has received all post splenectomy vaccinations.
Patient was evaluated by physical therapy was rehab was
recommended.
Medications on Admission:
1. citalopram 20 mg Tab: 0.5 Tablet PO DAILY
2. clotrimazole 10 mg Troche: 1 Troche QID
3. ergocalciferol (vitamin D2) 50,000 unit Cap: 1 Cap PO QWK(MO)
4. omeprazole 40 mg Cap: 1 Cap PO once a day.
5. cyanocobalamin (vitamin B-12) 500 mcg Tab: 1 Tab PO DAILY
6. folic acid 1 mg Tab: 1 Tab PO DAILY
7. rifaximin 550 mg Tab: 1 Tab PO BID
8. lidocaine 5 %(700 mg/patch) Patch: 1 Patch Daily prn pain
9. insulin glargine 100 unit/mL: 28 units SubQ at dinner time
10. insulin lispro 100 unit/mL: per insulin sliding scale SubQ
QID
11. lactulose 10 gram/15 mL: 30 ML PO TID
12. calcium carbonate 200 mg calcium (500 mg) Tab: 1 Tab, PO BID
13. pramoxine-mineral oil-zinc 1-12.5 % Ointment: 1 Appl Rectal
5X/DAY prnhemorrhoids.
15. ciprofloxacin 250 mg Tab: 1 Tab PO Q24H
Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
2. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain/fever: Maximum 6 tablets daily.
4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
6. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO 2X/WEEK
(WE,SA).
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
9. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day).
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection [**Hospital1 **] (2 times a day): Until fully ambulatory.
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO Q12 ().
12. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
13. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for Gastric Ulcer: Give at 10 AM, 2 PM and 10
PM. Must be given 2 hours separate from immunosuppressives.
14. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
15. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
16. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily):
Follow transplant clinic taper.
17. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation [**Hospital1 **] (2 times a day).
19. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
20. insulin glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
21. epoetin alfa 3,000 unit/mL Solution Sig: One (1) ml
Injection 3 x/week at hemodialysis: Adjust per anemia protocol.
22. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
23. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection q 6 hours: Follow QID finger stick blood
sugars.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Hepatitis C
Liver transplant (ABO incompatible)
Pneumothorax
Renal Failure currently on hemodialysis
Large gastroesophageal junction ulcer (seen on ERCP [**8-26**])
Prolapsed Bladder
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever,
chills, nausea, vomiting, diarrhea, constipation, increased
abdominal pain, yellowing of skin or eyes, inability to tolerate
food, fluids or medications, difficulties with the feeding tube
or tube dislodgement, increased edema of ankles, difficulties
with breathing, fluid overload, dialysis access issues.
Patient is to have labwork every Monday and Thursday with
results to the transplant clinic fax [**Telephone/Fax (1) 673**]. CBC, Chem 10,
AST, ALT, ALk Phos, T bili, Trough Prograf level
Please do not change any medications without first discussing
with the transplant clinic.
Please assure that sucralfate is given at least 2 (two) hours
separately from immunosuppression.
Continue hemodialysis via tunneled HD line qMonday, Wednesday
Friday
Continue Tube feeds via post pyloric feeding tube
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2140-9-7**]
9:40
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **], [**Location (un) 86**], MA
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2140-9-14**]
9:40
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **], [**Location (un) 86**], MA
.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2140-9-19**] 9:50
[**Hospital **] Medical Office Building, [**Last Name (NamePattern1) **], [**Location (un) 86**], MA
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2140-9-2**]
|
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icd9cm
|
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[
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"54.59",
"42.33"
] |
icd9pcs
|
[
[
[]
]
] |
12351, 12417
|
4022, 9235
|
319, 527
|
12664, 12664
|
3318, 3318
|
13747, 14673
|
2585, 2730
|
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|
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|
9261, 10030
|
12847, 13724
|
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|
2770, 3299
|
262, 281
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555, 1746
|
3334, 3689
|
12679, 12823
|
1768, 2183
|
2199, 2569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,603
| 127,451
|
7531
|
Discharge summary
|
report
|
Admission Date: [**2197-11-25**] Discharge Date: [**2197-11-28**]
Date of Birth: [**2128-5-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
Endoscopy
History of Present Illness:
69 year old who present with hematemesis and abdominal pain.
The patient initially woke up about this morning noticing blood
in his mouth. He said it was about a very small amount, less
than the bottom of a cup. Pt denies any vomiting, wretching or
melena. Because he was notified about his PCP 2 days prior that
he had a INR of 7.8 in the context of coumadin for atrial
fibriallation, he decided to come into the emergency room. In
the emergency room he started to experience sharp epigastric
abdominal pain that was gradually worsening. The pain was not
radiation and only improved with Dilaudid. He denies any similar
abdominal pain prior to this episode.
.
In the ED, the pt was found to have lateral STD and was given
Aspirin and Nitroglycerin initially without improvement. An NG
lavage found about 200cc of bright red blood in the stomach,
which subsequently cleared. He was given a GI cocktail,Protonix,
Morphine and Dilaudid for abdominal pain. A CT of the abdomen
did not show any poa[**Name (NI) 27529**] other then possible blood in his
stomach. Vit K was given for the reversal of his Coumadin. The
pt was hemodynamically stable throughout his hospital course.
.
ROS: He denies CP, lightheadedness, dizziness, mouthpain, easy
bleeding or easy bruising, dysuria, LLE. He reports chronic mild
SOB, which is uncahnged. He denies F/C/NS, weight loss. He also
denies changes in his diet or any intake of NSAIDS or large
amount of alcohol. Also, denies any liver problems in the past.
Past Medical History:
HTN
Smoking
Polycythemia [**1-19**] OSA?
OSA refractory to CPAP
hx iron deficiency anemia
CrI with bl CR 1.3-1.5 [**1-19**] HTN
CAD: last cath [**6-20**] documenting mild to mod diffuse CAD, but no
obstructing lesions, MI x 2; EF 50% most recently, 2+ MR, 2+ AR
Atrial fibrillation on coumadin
Medullary thyorid CA s/p thyroidectomy
Parathyroid adenoma s/p partial parathyroidectomy
TURP [**9-/2191**]
BPH
PUD s/p gastrectomy/Billroth II [**2172**]
[**Doctor First Name **] [**Doctor Last Name **] tear in [**2195**] p/w BRBPR
s/p CCY
ventral hernia
Raynaud's
hematuria with hx epidymitis
depression
Social History:
Lives in JP, divorced from wife [**Doctor First Name **], though she still is
involved w/ his care, Son [**Name (NI) 27524**] also suppportive, tobacco *40
pack year hx, stopped 1 month ago, rare EOTH, former engineer,
came to US from [**Country 532**] in'[**89**]
.
Family History:
No h/o premature CAD, no family hx of Medullary thyorid CA
Physical Exam:
Vitals: T96.1 BP 146/57 HR 56 R 20 94%4LNC
Gen: sleepy but awakens without difficulty, NAD
HEENT: NCAT, sclerae anicteric/noninjected, EOMI, P constricted
but ERRL, OP clear, no evidence of bleeding, uvula midline, dry
MM
Neck: JVP 8 cm, no LAD
CV: distant heart sounds, nl S1/S2, irregular 21/6 diastolic and
systolic non radiating murmur noted over precordium
Lungs: mild crackles in R base, no wheezes or rhonchi
Ab: soft, ND, NABS, no HSM by percussion, tenderness in
epigastrium, no rebound or guarding
Extrem: 2+ DP, no c/c/e
Skin: no rashes
Neuro: Oriented x3, moving all extremitites
Pertinent Results:
[**2197-11-25**] 09:14PM CK(CPK)-110
[**2197-11-25**] 09:14PM CK-MB-5 cTropnT-<0.01
[**2197-11-25**] 09:14PM HCT-44.8
[**2197-11-25**] 09:14PM PT-26.6* PTT-36.8* INR(PT)-2.7*
[**2197-11-25**] 02:04PM TYPE-[**Last Name (un) **] COMMENTS-GREEN TOP
[**2197-11-25**] 02:04PM HGB-16.6 calcHCT-50
[**2197-11-25**] 10:20AM GLUCOSE-95 UREA N-26* CREAT-1.3* SODIUM-139
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-14
[**2197-11-25**] 10:20AM estGFR-Using this
[**2197-11-25**] 10:20AM ALT(SGPT)-27 AST(SGOT)-25 CK(CPK)-122 ALK
PHOS-69 AMYLASE-73 TOT BILI-0.6
[**2197-11-25**] 10:20AM CK-MB-6 cTropnT-<0.01
[**2197-11-25**] 10:20AM WBC-6.4 RBC-5.31 HGB-16.4 HCT-47.7 MCV-90
MCH-30.9 MCHC-34.4 RDW-14.1
[**2197-11-25**] 10:20AM NEUTS-69.2 LYMPHS-22.3 MONOS-4.1 EOS-3.0
BASOS-1.4
[**2197-11-25**] 10:20AM PLT COUNT-163
[**2197-11-25**] 10:20AM PLT COUNT-163
[**2197-11-25**] 10:20AM PT-52.2* PTT-47.0* INR(PT)-6.2*
.
Brief Hospital Course:
69YO male with CAD, CM with EF 50%, CRI, hx BIllroth II for PUD,
polycythemia [**Doctor First Name **], Afib on coumadin who presents with UGIB in
the context of elevated INR with stable hematocrit and stable
vital signs. Brief hospital course by problem below:
.
GI bleed- EGD with multiple new and healed ulcers. Ulcers with
stigma of new bleeding. Pt was started on PPI [**Hospital1 **]. He was kept
NPO overnight. INR was reversed with 2U of FFP preprocedure and
1 additional unit post procedure. He was given Vit K 5mg 2x. Hct
was checked Q6h. pt dropped to as low as 42 and never required
blood transfusion. Hct has been stable for 8h on call out. Two
large bore ivs were maintained. H.pylori serology was sent and
empiric treatment was started. Given extend of ulceration and
history of PUD, NSAIDS use had to be suspected, however the
patient denies. Also, given hx of medullary thyroid cancer, and
prior hyperparathyroidism, possible MEN could be considered.
Medullary cancer would be associated with MEN II,
hyperparathyroidism with MEN I which presents which associated
Zollinger-[**Doctor Last Name 9480**] Syndrome. Gastrin levels were checked- given
gastrin level of 23, ZE unlikely. Pt had a stable Hct on
discharge and should follow up with Dr. [**Last Name (STitle) 3357**] on [**2197-12-5**].
.
Abdominal pain: likely etiology as above. No evidence of liver
disease or pancreatitis. No evidence of other intraabdominal
pathology on CT. No evidence of free air on CXR. Morphine iv prn
was given. Abdominal pain improved with treatment.
.
CV:new onset STD in V5, V6, concern for ischemia. Pt denies any
chest pain, suggesting against an acute coronary syndrome. Also,
hct > 40 therefore unlikely to be demand ischemia. SOB could be
CP-equivalent, however appears to be chronic. Aspirin was held
in the context of GIB. Antihypertensives in the context of GIB
were held initially, subsequently Carvedilol, Imdur, and
nifedipine were serially restarted. CE's trended-negative.
Statin started.
.
CHF: echo->EF 50% in [**2195**]. Antihypertensives in the context of
GIB were held initially, subsequently Carvedilol and Imdur were
restarted.
.
Afib: rate controlled with BB; held coumadin initially in the
context of GIB, restarted at low dose (2.5mg daily- to be
followed up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**]; holding BB initially,
subsequently restarted.
.
CRI- [**1-19**] long standing HTN. On baseline. Received dye load for
CT. IVF with sodium bicarbonate given for post-CT hydration.
Remained stable.
.
SOB: as above, might be ill-defined symptom of heart disease. No
evidence of fluid overload on CXR. Does not appear fluid
overloaded. Resolved to baseline at time of discharge.
.
Medications on Admission:
Calcitriol 0.5 [**Hospital1 **]
Fluoxetine 20 mg [**Hospital1 **]
Synthroid 150 mg qd
Coreg 3.125 mg [**Hospital1 **]
ASA 325 mg qd
Protonix 40 mg qd
Sucralfate 1 mg [**Hospital1 **]
Nfedipine 20 mg qd
Docusate 100 mg [**Hospital1 **]
Senna
Vitamin C [**Hospital1 **]
Calcium 600 mg tid
Ferrous gluconate 325 mg qd
Lipitor 80 mg qhs
Imdur 30 mg qhs
Doxazosin 2 mg
Coumadin 5d 5mg, 2d 2.5mg
Clonazepam 1 mg qhs
Uroxatral 10 mg qhs
Discharge Medications:
1. Carvedilol 12.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day).
Disp:*30 Tablet(s)* Refills:*2*
2. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 11 days.
Disp:*44 Capsule(s)* Refills:*0*
3. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours) for 11 days.
Disp:*44 Tablet(s)* Refills:*0*
4. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
8. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)) as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*0*
9. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
12. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO twice a
day.
Disp:*60 Capsule(s)* Refills:*2*
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day).
Disp:*120 Tablet, Chewable(s)* Refills:*2*
15. Nifedipine 90 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Erosive gastritis
Secondary Diagnoses:
1. Afib
2. CAD
3. Hypertension
4. Medullary thyroid cancer
Discharge Condition:
Stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
.
Please remember to make your follow-up appointments below
.
Return to the ED if you have any of the following:
*fever>101
*blood in your stool
*dark stool
*feeling dizzy or lightheaded
*vomiting blood
Followup Instructions:
Please remember to make the follow-up appointments below
.
You have an appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3357**] ([**Telephone/Fax (1) 4606**])
on [**2197-12-5**] at 9:30am. You will need to get your blood
checked on [**2197-11-30**] any time between 12pm-7pm. IT IS
VERY IMPORTANT TO MAKE THIS APPOINTMENT TO MAKE SURE YOUR BLOOD
THINNER IS WORKING PROPERLY. You will need to discuss with your
PCP about restarting medication for your prostate gland
including doxazosin and uroxatral.
.
These are your other appointments-
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2197-12-26**]
3:30
Provider: [**Name10 (NameIs) **] WEST,ROOM THREE GI ROOMS Date/Time:[**2198-2-9**] 1:30
Provider: [**Name10 (NameIs) **] PROCEDURES FELLOW Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2198-2-9**] 1:30
Completed by:[**2197-12-5**]
|
[
"403.90",
"427.31",
"585.9",
"535.41",
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"414.01"
] |
icd9cm
|
[
[
[]
]
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[
"44.43"
] |
icd9pcs
|
[
[
[]
]
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9562, 9568
|
4440, 7177
|
328, 340
|
9729, 9738
|
3475, 4417
|
10090, 11015
|
2787, 2847
|
7657, 9539
|
9589, 9589
|
7203, 7634
|
9762, 10067
|
2862, 3456
|
9647, 9708
|
277, 290
|
368, 1862
|
9608, 9626
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1884, 2487
|
2503, 2771
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,153
| 182,906
|
9215
|
Discharge summary
|
report
|
Admission Date: [**2127-7-16**] Discharge Date: [**2127-7-31**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
I had a colonoscopy for anemia, and I have a colon mass.
Major Surgical or Invasive Procedure:
s/p lap R colectomy [**7-16**] c/b anastomotic bleed s/p
exlap/revision ileocolonic anastomosis [**7-21**]
History of Present Illness:
Mr. [**Known lastname **] is a [**Age over 90 **] yo male who was noted to have iron deficiency
anemia by the NP[**MD Number(3) 31663**] [**Hospital3 **] "[**Location (un) 5481**]" in
[**Location (un) 2624**], MA where he resides with his wife. A work-up for his
anemia was started. He had a colonoscopy which showed a fairly
large lesion at the cecum. This was confirmed by CT scan. There
is a question of involved lymph nodes. There is no metastatic
disease. He was
extensively counseled as to his options. He decided to have
surgery, after several consultations. A Laparoscopic approach
was offered to the patient who
accepted. His surgery was scheduled on [**2127-7-16**] at [**Hospital1 18**] with Dr.
[**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **].
Past Medical History:
PMH:
- CAD, s/p CABG
- HTN
- ?CHF, normal echo in [**2122**], w/ EF > 60%
- COPD
- AAA (4 x 4.2 x 4.5cm by CT in [**2125**])
- basal cell carcinoma
- carotid stenosis
- spinal stenosis
- GERD, EGD ([**2122**]) demonstrated chronic gastritis
- Colonosocpy [**2123**] showed hemorrhoids, diverticula, has had
multiple polypectomies
- R ulnar, R leg neuropathy
.
PSH:
- CABG
- tonsillectomy
- right-sided hernia repair
- R knee arthroscopic surgery
- cholecystectomy
- prostatectomy
- R toe surgery
Social History:
The patient lives in an [**Hospital3 **] facility. He is married
and his wife lives on a skilled nursing facility 1 floor down
due to worsening dementia. At baseline, the patient can
ambulate, swim, self-dress, and feeds himself. The patient has 3
daughters. [**Name (NI) **] denies alcohol, drugs or recent cigarette
use. Last tobacco use was 50 years prior.
.
[**First Name8 (NamePattern2) 25415**] [**Last Name (NamePattern1) **] (daughter/[**Telephone/Fax (3) 31664**]). [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3501**]
(daughter/[**Telephone/Fax (5) 31665**]). Has three daughters who
are collectively his HCP, must have [**2-1**] agreement.
Family History:
No family history of anemia. Mother died of gastric cancer.
Physical Exam:
Vitals: BP-109/58, HR-100 RA 96% Lb-150lb
Cardiac: RRR, 2-3/6 holosyst M at base
Lungs: Rales, coarse rales at post bases, R>L, otherwise clear
Pertinent Results:
[**2127-7-31**] 05:00AM BLOOD WBC-12.3* RBC-2.99* Hgb-9.2* Hct-28.9*
MCV-97 MCH-30.7 MCHC-31.8 RDW-17.7* Plt Ct-765*
[**2127-7-17**] 07:20AM BLOOD WBC-13.4*# RBC-3.41*# Hgb-10.0*#
Hct-30.4* MCV-89# MCH-29.2 MCHC-32.8 RDW-20.9* Plt Ct-345
[**2127-7-16**] 06:26PM BLOOD Hct-30.0*
[**2127-7-26**] 03:19PM BLOOD Neuts-86* Bands-3 Lymphs-5* Monos-3 Eos-0
Baso-0 Atyps-0 Metas-2* Myelos-1*
[**2127-7-22**] 04:00PM BLOOD Neuts-66 Bands-20* Lymphs-8* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-1* NRBC-1*
[**2127-7-31**] 05:00AM BLOOD Plt Ct-765*
[**2127-7-25**] 02:45AM BLOOD PT-13.4* PTT-35.9* INR(PT)-1.2*
[**2127-7-21**] 05:59AM BLOOD PT-15.5* PTT-32.7 INR(PT)-1.4*
[**2127-7-17**] 07:20AM BLOOD Plt Ct-345
[**2127-7-22**] 04:00PM BLOOD Fibrino-304#
[**2127-7-21**] 11:10AM BLOOD Fibrino-252
[**2127-7-31**] 05:00AM BLOOD Glucose-112* UreaN-17 Creat-0.7 Na-139
K-3.7 Cl-103 HCO3-31 AnGap-9
[**2127-7-16**] 06:26PM BLOOD K-4.2
[**2127-7-22**] 07:27AM BLOOD CK(CPK)-156
[**2127-7-21**] 01:56PM BLOOD CK(CPK)-72
[**2127-7-22**] 07:27AM BLOOD CK-MB-6
[**2127-7-22**] 01:59AM BLOOD CK-MB-NotDone cTropnT-0.01
[**2127-7-31**] 05:00AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.9
[**2127-7-30**] 05:20AM BLOOD Albumin-1.9* Calcium-7.9* Phos-2.7 Mg-2.0
Iron-12*
[**2127-7-17**] 07:20AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.5
[**2127-7-30**] 05:20AM BLOOD calTIBC-138* Ferritn-340 TRF-106*
[**2127-7-29**] 07:45AM BLOOD Vanco-9.7*
[**2127-7-23**] 08:29PM BLOOD Glucose-90
[**2127-7-23**] 02:31AM BLOOD Lactate-1.9
[**2127-7-21**] 04:46PM BLOOD Glucose-131* Lactate-1.9 Na-135 K-3.9
[**2127-7-16**] 12:38PM BLOOD Glucose-112* Lactate-1.5 Na-133* K-4.2
Cl-100 calHCO3-28
[**2127-7-23**] 02:31AM BLOOD freeCa-1.18
[**2127-7-16**] 04:37PM BLOOD freeCa-1.08*
.
Pathology Examination
SPECIMEN SUBMITTED: RIGHT COLON.
[**2127-7-16**]
DIAGNOSIS:
Ileocolectomy
1. Adenocarcinoma of the ascending colon, see synoptic report.
2. Adenoma, sessile serrated adenoma and hyperplastic polyp of
the colon.
3. Focal chronic active colitis.
4. Ileal segment, within normal limits.
5. Appendix, with focal obliteration.
6. Small nodule of paraganglioma, about 6 mm. in diameter, in
the pericolic tissue (slides Q and X). Immunostains of the
nodule are positive for chromogranin, synaptophysin and S-100;
and negative for cytokeratin cocktail, with satisfactory
controls.
.
Brief Hospital Course:
Mr. [**Known lastname **] is a [**Age over 90 **] yo male who was noted to have iron deficiency
anemia by the NP[**MD Number(3) 31663**] [**Hospital3 **] "[**Location (un) 5481**]" in
[**Location (un) 2624**], MA where he resides with his wife. A work-up for his
anemia was started. He had a colonoscopy which showed a fairly
large lesion at the cecum. This was confirmed by CT scan. His
surgery was scheduled on [**2127-7-16**] at [**Hospital1 18**] with Dr. [**First Name8 (NamePattern2) 333**]
[**Last Name (NamePattern1) **].
Lap R colectomy/GI bleed: His surgical procedure on [**2127-7-16**] was
uncomplicated. He was transferred to PACU, and eventually
transferred to the floor ([**Wardname **]). On [**2127-7-21**] his BP dropped, and
HR increased. His HCT was collected indicating a signficant
drop. Management was attempted on the floor, but he was
eventually transferred to the ICU for treatment of his BP, and
decreased HCT. He was transfused with PRBC's. CT scan was
obtained revealing a anastomotic bleed. He was intubated in the
ICU, and extubated without residual Respiratory complications.
He developed mental status changes and confusion in the ICU
which gradually resolved. His mental status is back to baseline.
He was transferred back to [**Wardname **] once his Vitals and hematocrit
stabilized. His post-ICU course has been uneventful. He is both
surgically & hemodynamically stable, and is ready for REHAB. He
was evaluated per PT and OT. He will require extensive physical
rehab prior to returning to [**Location (un) **].
MRSA: Both his rectal and nasal swab came back positive on
[**2127-7-22**]. He remained afebrile. He has a PICC, proper placement
has been confirmed with xray on [**2127-7-31**], and is usable for
antibiotic treatment. His central line will be removed prior to
transfer to Rehab.
Cardiac: His BP and HR remained relatively stable throughout his
hospitalization besides his natural response to his unstable
hemodynamic status. He will be discharged to [**Hospital 100**] Rehab with
10days of Lasix and KDUR. Electrolytes should be checked in 2
days.
Abdominal incision/Skin breakdown: His midline abdominal
incision was opened distally due to increased seropurulent
drainage. The proximal portion is intact with staples. The
incision was evaluated per the wound RN. Please see enclosed
note for instructions. He should continue with a W-D dressing
[**Hospital1 **]. His scrotum has breakdown due to urine incontinence. Please
refer to wound RN recommendations.
Medications on Admission:
[**Last Name (un) 1724**]: ASA 81, Colace 100", Lipitor 20, Lisinopril 10, MVI, Nexium
Discharge Medications:
1. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q4H (every 4 hours) as needed.
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 2 weeks.
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
14. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-31**] Sprays Nasal
TID (3 times a day) as needed.
15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed. ML(s)
17. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 12H (Every 12 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Colon cancer
Anastomotic bleed
Coronary artery disease
Discharge Condition:
Good
Tolerating oral medications
Pain control well managed
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to amubulate several times per day.
* Increase your food and fluid intake. Eat several small meals
throughout the day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in [**2-1**] weeks. Please call
([**Telephone/Fax (1) 1483**] to make your appointment.
Completed by:[**2127-7-31**]
|
[
"428.0",
"788.30",
"153.6",
"530.81",
"608.86",
"496",
"V09.0",
"998.32",
"584.9",
"280.9",
"V45.81",
"041.11",
"998.59",
"E878.6",
"285.1",
"401.9",
"998.11",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.94",
"45.93",
"38.93",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
9276, 9342
|
5056, 7571
|
318, 427
|
9440, 9501
|
2696, 5033
|
10675, 10846
|
2455, 2516
|
7709, 9253
|
9363, 9419
|
7597, 7686
|
9525, 10652
|
2531, 2677
|
222, 280
|
455, 1234
|
1256, 1753
|
1769, 2439
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,495
| 195,747
|
8290
|
Discharge summary
|
report
|
Admission Date: [**2185-3-28**] Discharge Date: [**2185-4-1**]
Service: MEDICINE
Allergies:
Egg / Strawberry
Attending:[**Doctor Last Name 10493**]
Chief Complaint:
shortness of breath, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 83yo M with DM and CAD, in the [**Hospital Unit Name 153**] for 1 day for
respiratory distress due to pneumonia who is stable and
transferred to the floor. Pt lives in an [**Hospital3 **]
facility, 1d PTA noticed that he felt extremely fatigued and
"unlike himself". He reports a cough x 2 days, productive of
whitish sputum, along with wheezing and shortness of breath. He
felt hot but did not have fevers assessed by temperature, but
had chills. He has never felt like this before. He was sent from
his living facility to the [**Hospital1 18**] ED for further evaluation.
.
In the ED, initial vitals were: T 98.5, HR 92, BP 153/81, RR 16,
94% on room air. Later in ED stay, however, he was febrile (Tmax
101.4), tachycardic (HR 110-140), hypertensive (SBP 165-200),
and tachypneic (RR 22-36), with O2sats 94% on 4L nc. He received
1.6L NS, 1gm IV ceftriaxone, 5mg IV lopressor x 3, guaifenesin
w/ codeine, and 650mg po tylenol. He was sent to the [**Hospital Unit Name 153**] for
further monitoring given his labored breathing and abnormal
vital signs. CTA c/w atypical pneumonia. In the [**Hospital Unit Name 153**] his course
consisted of albuterol nebulizer, azithromycin and ceftriaxone
for pneumonia and vancomycin for ankle cellulitis.
.
On ROS, he denies chest/arm/jaw pain, palpitations, LE edema,
orthopnea, or PND. He does report some nausea and decreased po
intake x 1 day, but denies abdominal pain, vomiting, diarrhea,
or constipation. He notes that several individuals at his
[**Hospital3 **] facility had unspecified illnesses recently.
.
Pt was transferred to the floor, stable. He says he feels much
improved. He has no pain, breathing is not as difficult,
although he still has some wheezing and SOB on minimal exertion
such as sitting up in bed. The cough has improved but he is
still producing white sputum.
Past Medical History:
CAD: cath [**2182-8-1**] w/ 60% proximal LAD lesion, 80% ramus lesion,
and 90% mid circumflex lesion. The ramus and left circumflex
arteries were stented with hepacoat stents.
H/o MI [**2175**]
HTN
NIDDM
Dyslipidemia
Anxiety and depression
BPH s/p TURP [**12/2182**]
L inguinal hernia s/p repair [**10/2182**]
Glaucoma
Macular degeneration, near blindness in both eyes
Bl hip pain, likely [**1-7**] L4/5 foraminal disc herniation
Social History:
Patient lives at [**Location (un) **], an [**Hospital3 **] facility.
His wife of many years is deceased since [**2181**]. He has no
children. His closest family member is his sister-in-law,
[**Name (NI) 26196**] [**Name (NI) 29392**]. He does not use tobacco, EtOH, or other drugs,
although he did smoke a pipe x 25 years (quit in [**2157**]'s) He
used to work in the pharmacy at the [**Hospital **] Hospital.
Family History:
Non-contributory.
Physical Exam:
T 97.7 P 86 BP 140/60 RR 20 O2sat 96% 3Lnc Glu 96
Gen: [**Last Name (un) **] elderley male in NAD
HEENT: MM dry, tounge furrowed, sclerae anicteric. Pharynx w/o
exudates. Spider angioma on chin. Left pupil not reactive to
light, right 2mm, minimally reactive
Neck: Supple, no LAD. JVP 10cm
Lungs: wheezes diffusely on expiration and inspiration, coarse
rhonchi, most prominent on the R posterior-lateral lower lobe
Chest: RRR, nl S1/S2, no murmurs.
Abd: soft, nt, nd, nabs, no hsm.
Extrem: trace edema both feet. 2+ dorsal pedal pulses. L ankle
with mildly erythematous patch of dry, scaly, yellow/brown
flaky, non-swollen, non-tender, skin. No blistering or pus
drainage.
Neuro: AOx3. sensation to light touch intact and symmetric
throughout.
Pertinent Results:
[**2185-3-28**] 12:01PM BLOOD WBC-12.0*# RBC-4.79 Hgb-13.8* Hct-39.2*
MCV-82 MCH-28.7 MCHC-35.1* RDW-14.3 Plt Ct-264
[**2185-3-28**] 12:01PM BLOOD Neuts-83.2* Lymphs-11.1* Monos-5.4
Eos-0.2 Baso-0.1
[**2185-3-28**] 12:01PM BLOOD PT-13.1 PTT-27.8 INR(PT)-1.1
[**2185-3-28**] 12:01PM BLOOD Glucose-329* UreaN-15 Creat-0.8 Na-131*
K-4.0 Cl-92* HCO3-26 AnGap-17
[**2185-3-28**] 09:00PM BLOOD CK(CPK)-274*
[**2185-3-28**] 09:00PM BLOOD CK-MB-8
[**2185-3-28**] 09:00PM BLOOD cTropnT-<0.01
[**2185-3-29**] 05:22AM BLOOD CK-MB-12* MB Indx-3.0 cTropnT-0.02*
[**2185-3-29**] 01:47PM BLOOD CK-MB-8 cTropnT-0.01
[**2185-3-29**] 05:22AM BLOOD CK(CPK)-397*
[**2185-3-29**] 01:47PM BLOOD CK(CPK)-276*
[**2185-3-28**] 09:00PM BLOOD Calcium-9.0 Phos-3.1 Mg-1.8
[**2185-3-29**] 01:19AM BLOOD Type-ART pO2-72* pCO2-40 pH-7.44
calTCO2-28 Base XS-2 Comment-NASAL [**Last Name (un) 154**]
[**2185-3-28**] 12:14PM BLOOD Lactate-2.7*
[**2185-3-28**] 05:12PM BLOOD Lactate-1.43
[**2185-3-29**] 01:19AM BLOOD freeCa-1.09*
CTA ([**2185-3-28**])
1. No evidence of pulmonary embolism or aortic dissection.
2. Centrilobular opacities in the right lung most notable in the
superior segment of the right lower lobe and posterior segment
of the right upper lobe with underlying emphysema. Bilateral
peribronchial wall thickening. Differential diagnosis includes
atypical mycobacterium infection versus bronchopneumonia.
3. Hypodense lesion within segment IV of the liver is
incompletely characterized on this examination. Recommend
multiphase liver MRI for further evaluation.
4. Tubular soft tissue density in the region of the left adrenal
gland possibly representing adrenal hyperplasia.
5. Heterogeneous lesion within the left thyroid gland which may
be further evaluated with ultrasound.
6. Scattered mediastinal and hilar lymph nodes, the largest of
which measures 1.1 cm in short axis.
CXR [**2185-3-29**]
IMPRESSION: No evidence of acute pneumonia. No pleural effusions
or acute skeletal abnormalities are identified.
EKG: Sinus tachycardia@120BPM,L atrial abnormality, RBBB (new
relative to EKG [**2184-6-15**]) 1mm ST depressions V2-V3, frequent
PVC's.
Brief Hospital Course:
Assessment: 83yo M with DM and CAD, in the [**Hospital Unit Name 153**] 1 day for
respiratory distress due to pneumonia who was stable and
discharged from the floor.
Brief Hospital Course:
.
# Pneumonia: SOB, cough have improved, but are still present. He
has been afebrile since transfer from to the floor but his WBC
was still elevated until [**3-30**] when it was normal. Opacity on
chest CT c/w atypical pna. Also could represent viral
pneumonitis and aspiration. Speech and swallow team evaluated
and cleared for eating as pt has no apparent aspiration risk.
Sputum gram stain polymicrobial (2+GNR, 1+GPC, 1+GPR). CTA
negative for PE. Symptoms and imaging not c/w CHF. This is most
likely community aquired from his residence with multiple
elderly patients. Treated CAP with Azithromycin x 2 day course
(d1 [**3-29**]); CTX x 2d (d1 [**3-29**]). Transitioned to PO Levofloxacin
[**3-31**], will contiue Levo at rehab for 6 days. Blood cultures,
urinary legionella antigen are pending. CXR [**3-31**] showed
atelectasis. PT evaluated and have recomended physical therapy
in rehabilitation center.
.
# Wheezing: pt w/ 25y h/o pipe smoking, stopped in [**2157**]'s.
Evidence of COPD on CT. Nebs improve breathing according to pt.
Albuterol/atrovent nebs administered in hospital, patient
discharged on albuterol and atrovent inhalers for home use.
.
# Skin lesion: the dry, scaly, mildly erythematous yellow/brown
skin on L ankle is less likely to be cellulitis as it is not
hot, tender or swollen. However, due to his residence at a
facility with many other elderly people MRSA contact is possible
and should be considered. He received three days of IV
Vancomycin and is being discharged with 1% hydrocortisone cream.
.
# Hypertension: pt w/ h/o HTN on amlodipine, lopressor, and
lisinopril, furosamide at home, hypertensive in ED to SBP 200.
Stable on floor w/ home regimen meds, lisinopril was increased
from 20mg to 40mg QD on [**3-30**] due to systolic pressures >135 on
[**3-30**]. Metoprolol also increased to 150mg [**Hospital1 **] for control of HR,
BP tolerating well on discharge.
.
# Tachycardia: Tachy resolved on night of [**3-28**] w/ 500cc NS,
lopressor PM dose, 0.5 mg ativan. Could have been to volume
depletion and anxiety. No evidence of PE on CTAngio. On night of
[**3-29**] episode of tachy with PVC resolved with lopressor.
Additional episode of tachy on night of [**3-31**] prompted increase
of lopressor from 100mg to 150mg [**Hospital1 **] as above.
.
# H/o CAD: Other than SOB, no symptoms of ischemia. However, new
RBBB on EKG concerning: ddx rate-related conduction delay vs.
PE/R-heart strain (unlikely given neg CT) vs. ischemia. s/p
coated stent x 2 in [**2181**], and 60% non-stented LAD lesion [**2181**].
CK elevated (274, 397), but MB fraction <2.5% and minimally
elevated Tn (0.02) make ACS unlikely. [**Month (only) 116**] be small enzyme leak
related to tachycardia (demand ischemia. Negative cardiac
enzymes x3. Pt was continued on ASA, statin, ACE, Furosemide and
lopressor increased from 100mg [**Hospital1 **] to 150mg [**Hospital1 **] on [**4-1**] for HR
control as above. A repeat EKG ([**3-30**]) showed persistence of
RBBB, but with negative enzymes, did not mandate further
work-up.
.
# Frequent PVC's. Mg/K/Ca all normal. Pt was monitored on tele
and received home dose of lopressor 100bid (increased from 100mg
[**Hospital1 **] to 150mg [**Hospital1 **] on [**4-1**])
.
# Diabetes: NIDDM, on glyburide at home, currently blood sugars
are controlled. Received home dose of glyburide 2.5 [**Hospital1 **] and
humalog sliding scale prn.
.
# Glaucoma: latanaprost drops for both eyes as bimatoprost
initially not formulary. [**3-30**]- Patient started on Bimatoprost to
both eyes and Truopt to L eye as he was taking originally.
.
Medications on Admission:
Aspirin 325 mg PO DAILY
Amlodipine 10 mg PO DAILY
Lisinopril 20 mg PO DAILY
Metoprolol Tartrate 100 mg PO BID
Atorvastatin 10 mg PO qHS
Furosemide 20 mg PO DAILY
Glyburide 1.25 mg PO DAILY
Finasteride 5 mg PO qHS
Ranitidine 150mg po bid
Bimatoprost 0.03 % Drops One (1) Ophthalmic QHS
Tylenol, extra strength, 1000 mg PO tid
Neurontin 200mg po daily
Codeine 30mg po q6h prn pain
Lidoderm Patch
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Cortisone 1 % Cream Sig: One (1) Appl Topical QID (4 times a
day).
9. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic TID (3
times a day).
12. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Bimatoprost 0.03 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
14. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-7**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
15. Atrovent 0.02 % Solution Sig: [**12-7**] Inhalation every six (6)
hours as needed for shortness of breath or wheezing.
16. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
17. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 5 doses.
18. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Primary diagnosis: Pneumonia
Secondary diagnosis: coronary artery disease, hypertension,
Diabetes Mellitus Type II, Dyslipidemia, anxiety, depression,
Benign prostatic hyperplasia, glaucoma, macular degeneration
Discharge Condition:
Improved
Discharge Instructions:
You have been in the hospital because you had a cough and
shortness of breath. You had an episode of respiratory distress,
fever and high blood pressure and were stabilized in the
intensive care unit. In the hospital it was found that you had
pneumonia. You were given antibiotics for the pneumonia, and you
will continue to take antibiotics at home. It is possible that
the antibiotics can affect your diabetic medication. It is
important to check your sugar level everyday, and to go to the
ED or call your PCP if you have feelings of lightheadedness,
tremulosness or tingling.
Please go to the ED or call your PCP if you begin to have
fever>100.6, increased shortness of breath, chest pain or heart
racing.
Please see your PCP [**Last Name (NamePattern4) **].[**Last Name (STitle) 1007**] within one week.
Followup Instructions:
Due to some episodes of high blood pressure your lisinopril was
increaed from 20mg to 40mg every day. Please discuss this change
with your PCP. [**Name Initial (NameIs) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD
Phone:[**Telephone/Fax (1) 142**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**] MD, [**MD Number(3) 10495**]
Completed by:[**2185-4-1**]
|
[
"300.4",
"600.00",
"682.6",
"250.00",
"486",
"414.01",
"362.50",
"272.4",
"V45.82",
"785.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11653, 11788
|
6176, 9770
|
251, 257
|
12044, 12055
|
3825, 5964
|
12912, 13362
|
3025, 3045
|
10215, 11630
|
11809, 11809
|
9796, 10192
|
12079, 12889
|
3060, 3806
|
185, 213
|
285, 2122
|
11859, 12023
|
11828, 11838
|
2144, 2576
|
2592, 3009
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,625
| 190,763
|
30294
|
Discharge summary
|
report
|
Admission Date: [**2166-7-11**] Discharge Date: [**2166-7-18**]
Date of Birth: [**2103-6-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2166-7-14**] Five Vessel Coronary Artery Bypass Grafting utilizing
the left internal mammary artery to left anterior descending,
with saphenous vein grafts to diagonal, first obtuse marginal,
second obtuse marginal, and right coronary artery.
History of Present Illness:
This 63 year old white male, active smoker, and untreated
hyperlipidemia who presented to the [**Hospital1 **] emergency room on
the morning of admission with severe midsternal chest pain which
awoke him from sleep at 5:30 AM. An EKG revealed ST depressions
in leads I, aVL, and V2-V4. He was given sublingual
Nitroglycerin which immediately relieved his symptoms. His
troponin was 0.12 and he was started on IV heparin. He was
admitted to [**Hospital1 **] for cardiac catheterization which revealed
severe three vessel coronary artery disease including a
significant 50-60% left main lesion. He was stablized on medical
therapy and transferred to [**Hospital1 18**] for surgical revascularization.
Past Medical History:
Hypertension, Dyslipidemia, Recent Incision and Drainage of Skin
Abcess, Prior Left Eye Trauma in [**2132**]
Social History:
Occupation: Works as a home health aide
Lives with: wife
[**Name (NI) **]: caucasian
Tobacco: 1 ppd, smokes currently
ETOH: occasional, no history of abuse
Family History:
Denies premature coronary artery disease
Physical Exam:
Pulse:65 Resp:18 O2 sat: 95% RA
B/P Right: 106/56 Left:
Height: 5'9" Weight: 204 lbs
General: Middle aged male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [] EOMI [x] L eye blind
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft[x] non-distended[x] non-tender[x] + bowel
sounds[x]
Extremities: Warm[x], well-perfused[x], Edema: none,
Varicosities:None[x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: yes Left: no
Pertinent Results:
[**2166-7-11**] WBC-7.9 RBC-4.04* Hgb-11.9*# Hct-36.1*# Plt Ct-175
[**2166-7-11**] PT-11.0 PTT-33.5 INR(PT)-0.9
[**2166-7-11**] Glucose-156* UreaN-13 Creat-0.7 Na-140 K-3.7 Cl-107
HCO3-27
[**2166-7-11**] ALT-19 AST-65* LD(LDH)-254* CK(CPK)-493* AlkPhos-56
TotBili-0.3
[**2166-7-12**] CK(CPK)-334*
[**2166-7-12**] CK(CPK)-234*
[**2166-7-11**] CK-MB-55* MB Indx-11.2* cTropnT-1.49*
[**2166-7-12**] CK-MB-26* MB Indx-7.8*
[**2166-7-12**] CK-MB-22* MB Indx-9.4*
[**2166-7-11**] %HbA1c-6.5*
[**2166-7-11**] Albumin-3.8 Calcium-8.6 Phos-3.6 Mg-1.9
[**2166-7-18**] 07:30AM BLOOD WBC-8.0 RBC-3.60* Hgb-10.4* Hct-32.0*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.1 Plt Ct-216
[**2166-7-18**] 07:30AM BLOOD Plt Ct-216
[**2166-7-14**] 06:48PM BLOOD PT-12.7 PTT-29.1 INR(PT)-1.1
[**2166-7-18**] 07:30AM BLOOD Glucose-117* UreaN-13 Creat-0.7 Na-138
K-4.3 Cl-103 HCO3-26 AnGap-13
[**2166-7-12**] Echocardiogram:
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%). Right ventricular
chamber size and free wall motion are normal. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild to moderate
([**11-22**]+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
[**2166-7-13**] Chest CT Scan:
1. Ascending thoracic aorta slightly enlarged, maximal
transverse diameter
41mm. 2. Inhomogenous attenuation in both lungs and small
bilateral pleural effusions, may be consistent with mild fluid
overload. 3. Small volume mediastinal lymphadenopathy which is a
nonspecific finding, and may be related to chronic pulmonary
edema.
[**2166-7-14**] Carotid Ultrasound:
There is antegrade right vertebral artery flow. There is
antegrade left vertebral artery flow. Right ICA stenosis 60-69%.
Left ICA stenosis 40-59%.
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 72122**], [**Known firstname 20959**] [**Hospital1 18**] [**Numeric Identifier 72123**]
(Complete) Done [**2166-7-14**] at 3:24:29 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2103-6-4**]
Age (years): 63 M Hgt (in): 69
BP (mm Hg): 140/70 Wgt (lb): 200
HR (bpm): 75 BSA (m2): 2.07 m2
Indication: coronary artery bypass grafting
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2166-7-14**] at 15:24 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 #: 2009AW01-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.8 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% >= 55%
Aorta - Sinus Level: 3.3 cm <= 3.6 cm
Aorta - Ascending: 3.4 cm <= 3.4 cm
Findings
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending, transverse and descending thoracic
aorta with no atherosclerotic plaque.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild to moderate ([**11-22**]+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
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.
Conclusions
PRE-BYPASS: The left atrium is dilated. No spontaneous echo
contrast or thrombus is seen in the body of the left atrium/left
atrial appendage or the body of the right atrium/right atrial
appendage. Right ventricular chamber size and free wall motion
are normal. The ascending, transverse and descending thoracic
aorta are normal in diameter and free of atherosclerotic plaque.
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
([**11-22**]+) mitral regurgitation is seen. There is no pericardial
effusion.
Post-Bypass: Pt in sinus rhythm on phenylenpherine infusion.
Preserved biventricular function, perhaps slight improvement in
LV function. LVEF 50-55%. Aortic contours intact. Mitral
regurgitation remains mild to moderate. Remaining exam is
unchanged. All findings discussed with surgeons at time of the
exam.
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) **] [**2166-7-15**] 09:12
[**Known lastname 72122**],[**Known firstname 20959**] [**Medical Record Number 72124**] M 63 [**2103-6-4**]
Radiology Report CHEST (PA & LAT) Study Date of [**2166-7-17**] 3:41 PM
[**Hospital 93**] MEDICAL CONDITION: 63 year old man s/p CABG
Final Report
INDICATION: Status post bypass surgery. Evaluate for pleural
effusions.
FINDINGS: PA and lateral chest views were obtained with patient
in upright
position. Comparison is made with the PA and lateral
pre-operative chest
examination of [**2166-7-11**]. There is now status post
sternotomy and the presence of multiple surgical clips in the
anterior left mediastinum are compatible with the recent bypass
surgery. The heart shadow has increased, but the pulmonary
vasculature does not demonstrate an increased congestive
pattern. No progression of the previously described bilateral
basal plate atelectasis, but some pleural densities remain on
the left base continuing also along the left lateral chest wall
into the left axillary area, but the posterior pleural sinuses
are rather free on the lateral view.
No evidence of pneumothorax.
IMPRESSION: Satisfactory post-operative findings. Enlarged heart
silhouette most likely related to post-operative pericardial
thickening. No evidence of increased pulmonary vascular
congestion. Some left-sided pleural thickening remains, but no
evidence of any major atelectasis.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2166-7-17**] 5:55 PM
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the cardiac surgical service and
underwent extensive preoperative evaluation. Echocardiogram
showed normal left ventricular function with 1-2+ mitral
regurgitation. Echocardiogram also notable a slightly dilated
ascending aorta for which a CT scan was obtained. CT scan
measured ascending aorta with a maximum diameter of 4.1
centimeters. Prior to surgery, carotid ultrasound also revealed
mild to moderate carotid disease. Please see result section for
additional details. He otherwise remained pain free on medical
therapy and was eventually cleared for surgery.
On [**7-14**], Dr. [**Last Name (STitle) 914**] performed coronary artery bypass
grafting surgery. For surgical details, please refer to
operative note. Following the operation, he was brought to the
CVICU for invasive monitoring. Within 24 hours, he awoke
neurologically intact and was extubated without incident. His
CVICU course was otherwise uneventful and he transferred to the
dtep down unit on postoperative day one. Chest tubes and pacing
wires were removed without complication. He remained in a normal
sinus rhythm. He was seen in consultation by the physical
therapy service and activity was advanced. BBlockers and
diuretics were started and titrated to effect. By
post-operative day four he was ready for discharge to home with
visiting nurses.
Medications on Admission:
No medications at home
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*30 Capsule(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day for 2 weeks.
Disp:*28 Tablet Sustained Release(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary artery disease, s/p CABG
Hypertension
Dyslipidemia
Mild to Moderate Carotid Disease - Bilateral
Slightly Dilated Ascending Aorta - 4.1 centimeters
Discharge Condition:
Good
Discharge Instructions:
1)No driving for one month
2)No lifting more than 10 lbs for at least 10 weeks from the
date of surgery
3)Please shower daily. Wash surgical incisions with soap and
water only.
4)Do not apply lotions, creams or ointments to any surgical
incision.
5)Please call cardiac surgeon immediately if you experience
fever, excessive weight gain and/or signs of a wound
infection(erythema, drainage, etc...). Office number is
[**Telephone/Fax (1) 170**].
6)Call with any additional questions or concerns.
Followup Instructions:
Dr [**Last Name (STitle) **] for post-op wound check at [**Hospital3 1280**] in [**12-24**] weeks.
please call [**Telephone/Fax (1) 20259**] to schedule appointment
Dr. [**Last Name (STitle) 1295**], [**First Name3 (LF) 449**] (cardiologist) in [**12-24**] weeks, call for appt
Dr. [**Last Name (STitle) 5102**], [**First Name3 (LF) **] (PCP) in [**12-24**] weeks, call for appt
Completed by:[**2166-7-18**]
|
[
"414.01",
"272.4",
"458.29",
"433.30",
"401.9",
"433.10",
"424.0",
"410.71",
"441.2",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.14",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
11951, 12010
|
9562, 10931
|
330, 578
|
12210, 12217
|
2374, 8185
|
12761, 13171
|
1632, 1674
|
11004, 11928
|
8222, 9539
|
12031, 12189
|
10957, 10981
|
12241, 12738
|
1689, 2355
|
280, 292
|
606, 1310
|
1332, 1442
|
1458, 1616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,757
| 171,521
|
13234
|
Discharge summary
|
report
|
Admission Date: [**2119-12-18**] Discharge Date: [**2119-12-20**]
Date of Birth: [**2044-2-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2387**]
Chief Complaint:
transfer from NEBH for c. cath/PCI
Major Surgical or Invasive Procedure:
Cardiac Catheterization
History of Present Illness:
75 y/o M hx CABG X2 in [**2094**] and [**2102**] (LIMA->mid-LAD, SVG->LAD,
SVG to RCA), DM, HTN, hyperlipidemia, smoking who presented to
OSH earlier yesterday with unstable angina and s/p diagnostic
cath revealing 100% ostial LAD, serial 80%, 60%, and 70%
stenoses in LCX/marginals, 95% stenosis in distal RCA now
transferred here for RCA and SVG to RCA intervention in AM.
.
He had been in his USOGH until this AM (walks around [**Country **]
Pond [**2-13**] X /week, shovelled snow a few weeks ago without anginal
symptoms), when he developed sternal chest pressure after
drinking coffee at home. The symptoms lasted for 30 sec and
radiated to left shoulder. He took 1 SLNTG which resolved his
symptoms after 2 minutes. he told his wife, who then made him go
to hospital.
.
At NEBH, cardiac enzymes neg X 3. EKG with sinus bradycardia and
1st degree AVB, but no ST seg elev or depressions, mild TW
flattening in lateral leads. He was started on heparin gtt,
metformin held, and underwent cardiac cath, which revealed:
100% ostial LAD occlusion
Serial 80%, 60%, and 70% stenoses in LCX/marginals
Diffuse mild-mod in dominant RCA
95% stenosis in distal RCA involving posterior ventricular
branch
SVG->RCA with diffuse mod dz
.
Currently, upon transfer, he reports feeling well with no
further complaints of CP, SOB, N/V, palpitations, or any other
symptoms. He is complaining of slight pain in R groin at sheath
sight
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.
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.
Past Medical History:
Nephrolithiasis
CAD: CABG X 2
HTN
Hyperlipidemia
DM type 2
s/p coccyx cyst removal
s/p colonic polyp removal
Social History:
Pt lives with wife, who is very involved in care. He works as a
waiter.
Social history is significant for the absence of current tobacco
use; quit in [**2094**] but prior smoked 68pack years.
There is no history of alcohol abuse.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
VS: T , BP 144/65, HR 55, RR 12, O2 100% onRA
Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
CV: PMI located in 5th intercostal space, midclavicular line.
bradycardic, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits; sheath in place and dressing
C/D/I
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Femoral 2+ without bruit; 1+ DP
Left: 1+ DP
Brief Hospital Course:
The patient presented s/p cardiac catheterization from the NEBH
where he was found to have intervenable disease, with plans to
intervene here at the [**Hospital1 18**]. Upon arrival, he still had his
sheath in place, so he was started on a heparin drip; he was
hydrated in accordance with his creatinine clearance and
monitored on telemetry. At the cath lab a drug eluting cypher
stent was placed into his left circumflex artery. He was also
found to have 100% proximal occlusion in his LAD, which was not
intervened upon at this time. He will address this electively
at a later date.
Medications on Admission:
Lisinopril/HCTZ 10/12.5 [**Hospital1 **]
PLavix 75 daily
Toprol XL 100 daily
Verapamil SR 120 [**Hospital1 **]
Lipitor 40 daily
Tricor 48 daily
metformin 1000 [**Hospital1 **]
glyburide 5 [**Hospital1 **]
flomax 0.4 day
ASA 325 daily
eye vitamins
Discharge Medications:
1. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual every five minutes until chest pain has
resolved. You may do this up to three times. If your chest
pain is not resolved after three times, call 911 as needed for
chest pain.
Disp:*20 Tablet, Sublingual(s)* Refills:*2*
2. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
Qdaily ().
8. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Home
Discharge Diagnosis:
Myocardial infarction
Discharge Condition:
Stable
Discharge Instructions:
You were admitted for a cardiac catheterization, where a stent
was placed in one of your coronary arteries, specifically your
left circumflex artery. You also had a blockage in your Left
anterior descending artery, which we did not intervene on, you
should discuss the necessity of this with your cardiologist.
You did quite well after this procedure.
.
.
Please take all of your medications as indicated. Do not resume
your metformin until tomorrow.
.
.
Please follow up with Dr. [**Last Name (STitle) 14522**], you have an appointment
indicated below. At this appointment, you should discuss your
cardiac catheterization and whether or not to intervene upon
your second blocked artery.
.
.
Please return to the emergency department if you develop any
concerning symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) 14522**] on [**2120-1-4**] at 10:30AM
|
[
"250.00",
"V12.72",
"411.1",
"272.4",
"414.01",
"401.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"99.20",
"00.45",
"88.56",
"36.07",
"00.66"
] |
icd9pcs
|
[
[
[]
]
] |
5663, 5669
|
3623, 4214
|
352, 377
|
5735, 5744
|
6569, 6636
|
2753, 2835
|
4512, 5640
|
5690, 5714
|
4240, 4489
|
5768, 6546
|
2850, 3600
|
278, 314
|
405, 2356
|
2378, 2489
|
2505, 2737
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,076
| 144,627
|
5205
|
Discharge summary
|
report
|
Admission Date: [**2174-4-22**] Discharge Date: [**2174-5-6**]
Date of Birth: [**2119-6-30**] Sex: M
Service:
CHIEF COMPLAINT:
1. Nausea and vomiting.
HISTORY OF PRESENT ILLNESS: The patient is a 54 year-old
male with a past medical history significant for insulin
dependent diabetes mellitus with retinopathy, neuropathy, and
end stage renal disease, gastroparesis, coronary artery
disease, hypertension, status post left brain stroke in [**2158**]
with residual right arm and face weakness, recent right
lacunar hemorrhagic stroke presenting with a three day
history of nausea and vomiting.
The patient was unable to hold down any food or liquids by
mouth. The patient's family reports that three days ago, his
blood pressure was taken at home, showing a systolic blood
pressure of 200, and that he started vomiting soon after
that. The patient vomited once at dialysis with the same
associated rise in blood pressure. The family described the
vomitus as dark brown and greenish in small amounts.
The patient had been evaluated for gastroparesis symptoms
about two years ago. Dr. [**Last Name (STitle) 23**], his prior primary care
physician, [**Name10 (NameIs) **] in the process of arranging an upper GI series
for him, but his symptoms resolved and the study was not
done.
The patient denies fevers or chills. The patient is unsure
about when his last bowel movement was. The patient denied
chest pain, shortness of breath, diaphoresis, and as per the
family there are no acute mental status changes or focal
weakness. All of this history was obtained through the
patient's mother and father.
The patient's family also reports elevated finger stick blood
glucose levels at home in the 200 range.
PAST MEDICAL HISTORY:
1. Insulin dependent diabetes mellitus with retinopathy and
neuropathy.
2. End stage renal disease on hemodialysis every Tuesday,
Thursday and Saturday.
3. Hypertension.
4. Left brain stroke with residual right hemiparesis.
5. Coronary artery disease status post coronary artery
bypass graft two years ago, peripheral vascular disease.
6. Legal blindness.
7. Hypercholesterolemia.
MEDICATIONS:
1. Aspirin 81 milligrams po q day.
2. Atenolol 50 milligrams po q day.
3. Humulin.
4. PhosLo 67 milligrams q day.
5. Renagel 800 milligrams po q day.
6. Trental 400 milligrams po q day.
7. Nephrocaps 1 q day.
8. Pravachol 20 milligrams q day.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies drugs or alcohol use. The
patient lives with his wife in [**Name (NI) **].
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.5 F, blood
pressure 124/52, heart rate 16, respirations 18. In general
the patient was lying in bed, squirming around in no acute
distress. The patient appeared disheveled. Head and neck
exam - pupils are equal, round and reactive to light.
Sclerae were anicteric. Oropharynx clear. Mucous membranes
were dry. Cardiac exam - normal S1, S2, regular rate and
rhythm. No murmurs, rubs, or gallops. Lungs - there were
concentric bronchial breath sounds to the lower areas. There
are no wheezes, crackles, or rhonchi. There was good air
exchange. Extremities - no cyanosis, clubbing or edema.
Neurologic exam - unable to assess orientation secondary to
language barrier. The patient appeared alert. Cranial
nerves II through XII were intact except for right cranial
nerve VII (asymmetry of right face with smile). Strength was
[**6-12**] in the left upper extremity, [**5-13**] in the right upper
extremity. Full strength in lower extremities. There are
brisk bilateral lower extremity reflexes. Babinski was
positive bilaterally.
LABORATORY DATA: White blood cell count 11.8, hematocrit
41.4, platelet count 189,000, PT 12.7, PTT 31.4, INR 1.1,
sodium 141, potassium 4.9, BUN 35, creatinine 5.9, glucose
350.
KUB was done showing a nonspecific bowel pattern with no
evidence for obstruction.
Chest x-ray showing no pneumonia or CHF. There is a stable
widened mediastinum.
HOSPITAL COURSE: The initial impression was that the
patient's nausea and vomiting were secondary to
gastroparesis. The patient had been experiencing similar
symptoms about two years but no work up was done. The
patient was started on Reglan 10 milligrams IV qid and the
plan was to monitor for symptomatic improvement while
advancing his diet. However on hospital day three the patient
was noted to have asymmetric pupils on physical exam. The
patient became progressively more somnolent throughout the
day with poor blood pressure control ( blood pressure went as
high as in the low 200).
A head CT scan was done showing a left pontomedullary
hemorrhage. The patient was transferred to the Medical
Intensive Care Unit for blood pressure control with a
Labetalol drip. A repeat head CT scan was done the next day
which showed no interval change. A ct angiogram as well as
MRI/MRA of the head were done to evaluate for arteriovenous
malformation or aneurysm which was negative.
The patient's mental status gradually improved with improved
blood pressure control and the patient was transferred out of
the Intensive Care Unit and to the General Medical Floor. On
the floor adequate antihypertensive controlled with a
.................... regimen of Metoprolol 100 milligrams po
bid, Hydralazine 50 milligrams po qid and Vasotec 10
milligrams q day.
Hospital course was complicated by fever spikes to 102 F. In
light of a worsening pulmonary exam (dense rales in right
lung), and a questionable right sided infiltrate on chest
x-ray the patient was treated with Zosyn for a nosocomial
pneumonia to finish a two week course.
A swallow evaluation was done which showed silent aspiration
with nectar thick liquids in large boluses. Therefore the
Speech and Swallow Department suggested honey thick liquids
alternating with pureed solids in small amounts. The patient
appeared to be tolerating this diet well. A calorie count
was done on the day of discharge which showed that the
patient was only taking 12% of the required calories. It was
planned for the patient's caloric intake and nutritional
status to be re-evaluated once the patient was to be
transferred to rehabilitation.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient was discharged to [**Hospital3 7558**].
DISCHARGE MEDICATIONS:
1. Aspirin 81 milligrams po q day.
2. PhosLo 67 milligrams po q day.
3. Renagel 800 milligrams po q day.
4. Trental 400 milligrams po q day.
5. Nephrocaps 1 po q day.
6. Pravachol 20 milligrams po q day.
7. NPH 12 units subcutaneous [**Hospital1 **] with regular insulin
sliding scale on transfer to rehabilitation.
8. Metoprolol 100 milligrams po bid.
9. Hydralazine 50 milligrams po qid.
10. Vasotec 10 milligrams po q day.
11. Zosyn to finish a two week course.
[**Name6 (MD) 251**] [**Last Name (NamePattern4) 11865**], M.D. [**MD Number(1) 11866**]
Dictated By:[**Name8 (MD) 2692**]
MEDQUIST36
D: [**2174-5-17**] 15:20
T: [**2174-5-18**] 13:39
JOB#: [**Job Number 21292**]
|
[
"431",
"250.51",
"583.81",
"585",
"250.61",
"507.0",
"250.41",
"357.2",
"536.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6202, 6283
|
6306, 7031
|
4008, 6181
|
143, 169
|
198, 1730
|
2591, 3990
|
1752, 2444
|
2460, 2576
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
77,203
| 105,994
|
32494
|
Discharge summary
|
report
|
Admission Date: [**2139-11-5**] Discharge Date: [**2139-11-9**]
Date of Birth: [**2063-8-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
1. Cardiac Catheterization
2. Emergent vascular surgery with ligation of inferior
epigastric artery and evacuation of right groin/pelvic hematoma
History of Present Illness:
The patient is a 76-year-old female transferred from the [**First Name4 (NamePattern1) 3075**]
[**Last Name (NamePattern1) 3549**] Hospital ER on the evening of [**2139-11-4**] with chest pain
radiating to her right posterior shoulder area. Initial EKG had
some non-specific ST changes concerning for NSTEMI and EF per
ECHO (TTE) done at OSH noted to be 15%. Per outside hospital
records the patient had reported that her pain was relieved
after SL nitroglycerin tablets x 3 and Lopressor 5mg IV x 3. She
was also given a loading dose of Plavix 600mg in the ER and 75mg
the following morning and she was started on both Integrillin
and Heparin and was transferred directly to the cardiac
catheterization lab at [**Hospital1 18**] and found to not have any
obstructive coronary disease, LV-gram showing EF closer to 30%
but prominent apical ballooning consistent with Takotsubo's
Cardiomyopathy presentation. She began to have severe
hypotension during her cardiac catheterization and was started
on Dopamine then switched to Neosynephrine. She was noted to
have an expanding right groin. Of note, given reported
difficulty obtaining access initially thought was that she was
having a iatrogenic bleed.
.
In the operating room the patient was continued on
Neosynephrine, and had a right internal jugular central venous
line placed and failed attempt at a radial arterial line.
Intubation was uncomplicated. The patient was also given a total
of 3.5L of NS and 2 Units blood were given. Just prior to going
to the operating room with the vascular surgery team the patient
was also given IVFs and 2 Units of blood in cardiac
catheterization lab. Thus, she received in total, 4 Units of
blood before transfer up to CCU post-operatively. She was able
to be slowly weaned off of Neosynephrine and BP was 115/70 upon
presentation to the CCU. Per vascular team, the inferior
epigastric artery on the right was ligated and a hematoma was
evacuated, removing roughly 500cc of blood. Pressure dressing
was applied. Patient arrived to the CCU intubated and sedated
and a few continued bouts of intermittent low blood pressures.
Past Medical History:
1. CARDIAC RISK FACTORS: negative for Diabetes, no significant
dyslipidemia, but positive for age, hypertension, sedentary
lifestyle
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None / No priors
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Glaucoma
Osteoporosis
Cataracts
Social History:
The patient is married and lives in [**Location 1110**] with her husband. She
has one daughter who lives locally. In terms of recent stressors
the patient reports some anxiety regarding an upcoming Glaucoma
surgery and some additional stress and residual grief as she
learned that her brother died several months ago.
She denies any smoking history /tobacco use. She drinks
approximately 5 glasses of wine per week and denies any other
illicit drug use.
Family History:
No known family history of significant CAD, premature coronary
artery disease or sudden death.
Physical Exam:
On admission:
Vital Signs: 98.2F, BP 115/70 HR 70s, O2 100% on AC ventilation
550x14, PEEP of 5 and FiO2 of 100%. CVP 11
GENERAL: Intubated and sedated. responds to painful stimuli and
moving all 4 extremities.
HEENT: PERRLA bilaterally, sclera anicteric and EOMI, moist
mucosal membranes
CARDIAC: S1/S2 regular, no murmurs, rubs or gallops appreciated,
soft heart sounds noted, 2+ carotid upstrokes
LUNGS: No tracheal deviation, CTA bilaterally anteriorly and
laterally
ABDOMEN: Soft, nontender and nondistended. No HSM. Abdomnal
aorta not enlarged by palpation. No abdominal bruits.
EXTREMITIES: Right groin with thick pressure dressing, no
ecchymoses or tense areas noted
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: diminished 1+ radial pulses bilaterally, DP and PT
pulses are measured by doppler, PT pulses 1+ and palpable but
DPs difficult to palpate
Pertinent Results:
[**2139-11-5**] 07:24PM TYPE-MIX PO2-29* PCO2-40 PH-7.24* TOTAL
CO2-18* BASE XS--10
[**2139-11-5**] 07:24PM LACTATE-1.5
[**2139-11-5**] 07:24PM O2 SAT-52
[**2139-11-5**] 06:35PM GLUCOSE-178* UREA N-27* CREAT-0.7 SODIUM-139
POTASSIUM-4.4 CHLORIDE-118* TOTAL CO2-18* ANION GAP-7*
[**2139-11-5**] 06:35PM estGFR-Using this
[**2139-11-5**] 06:35PM CK(CPK)-189*
[**2139-11-5**] 06:35PM CK-MB-27* MB INDX-14.3* cTropnT-0.60*
[**2139-11-5**] 06:35PM CALCIUM-6.8* PHOSPHATE-3.1 MAGNESIUM-1.2*
[**2139-11-5**] 06:35PM WBC-15.1*# RBC-3.79*# HGB-11.2*# HCT-32.5*#
MCV-86# MCH-29.6 MCHC-34.5 RDW-14.9
[**2139-11-5**] 06:35PM NEUTS-90.7* LYMPHS-5.5* MONOS-3.6 EOS-0.1
BASOS-0.1
[**2139-11-5**] 06:35PM I-HOS-D
[**2139-11-5**] 06:35PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2139-11-5**] 06:35PM PLT SMR-LOW PLT COUNT-87*#
[**2139-11-5**] 06:35PM PT-15.7* PTT-47.5* INR(PT)-1.4*
[**2139-11-5**] 06:35PM FIBRINOGE-111*
[**2139-11-5**] 05:54PM TYPE-CENTRAL VE PO2-66* PCO2-48* PH-7.14*
TOTAL CO2-17* BASE XS--12
[**2139-11-5**] 05:20PM TYPE-ART PO2-341* PCO2-43 PH-7.14* TOTAL
CO2-15* BASE XS--14
[**2139-11-5**] 05:20PM HGB-11.2* calcHCT-34
[**2139-11-5**] 05:20PM GLUCOSE-309* LACTATE-4.0* NA+-133* K+-5.7*
CL--113*
[**2139-11-5**] 03:28PM TYPE-ART O2-100 PO2-434* PCO2-30* PH-7.38
TOTAL CO2-18* BASE XS--5 AADO2-267 REQ O2-50 INTUBATED-NOT
INTUBA
[**2139-11-5**] 03:28PM GLUCOSE-205* LACTATE-1.5 K+-4.4
[**2139-11-5**] 03:00PM WBC-7.2 RBC-2.17*# HGB-6.9*# HCT-20.3*#
MCV-94 MCH-32.1* MCHC-34.3 RDW-14.3
[**2139-11-5**] 02:49PM TYPE-ART O2 FLOW-2 PO2-94 PCO2-37 PH-7.32*
TOTAL CO2-20* BASE XS--6 COMMENTS-NASAL [**Last Name (un) 154**]
[**2139-11-5**] CARDIAC CATHETERIZATION RESULTS:
LMCA mild plaquing, LAD 20% origin, LCX patent, mid-RCA with
mild 25% diffuse plaquing. LV gram showing some MR, EF 30%,
bases intact, severe hypokinesis of anterolateral, apical and
inferior walls, bedside echo without pericardial effusion, no
LVOT gradient, depressed EF.
.
HEMODYNAMICS:
RA 4, RV 23/0
PCW mean 4
PA 15/4
Aorta 95/75, MAP 80
post angio:
PCW mean 7, PA 28/9
LV 134
Aorta 134/86
Cardiac index 1.32 pre angio, 1.30 post angio
Art sat 98%, SVC saturation 49%, PA sat 40%
.
[**2139-11-5**] ECHO: Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. The overall LV ejection
fraction appears moderately-to-severely depressed secondary to
extensive apical akinesis , and severe hypokinesis of the
anterior septum. 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. There is no pericardial effusion.
Overall impression is severe anteroseptal hypokinesis/akinesis,
LVEF = 30%.
.
[**2139-11-7**] REPEAT ECHO: The left atrium is normal in size. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. LV systolic function appears
moderately-to-severely depressed (ejection fraction 30 percent)
secondary to akinesis of the anterior septum and anterior free
wall; there is extensive apical akinesis with focal dyskinesi..
Right ventricular chamber size and free wall motion are normal.
The aortic arch is moderately dilated. There are focal
calcifications in the aortic arch. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild (1+)
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
There is an anterior space which most likely represents a fat
pad. Compared with the findings of the prior study (images
reviewed) of [**2139-11-5**], the findings are similar.
.
[**2139-11-5**] EKG: NSR, rate 60, normal axis and intervals, poor R
wave progression, no acute ST elevations or prominent
depressions.
.
[**2139-11-6**] EKG : Rate 80s, normal sinus rhythm, delayed R wave
transition. Q-T interval prolongation with QT/QTc = 430/472.
Significant resolution of the T wave abnormalities since
admission.
.
[**2139-11-6**] CXR: Right internal jugular catheter ends in the mid
SVC, mild bibasilar atelectasis, volume overload decreased, no
consolidations or effusions
.
[**2139-11-7**] EKG: Rate 90, Normal sinus rhythm, some
intraventricular conduction delay, poor R wave progression,
nonspecific inferolateral T wave flattening and low limb lead
voltages, Q-T interval appears shorter
.
[**2139-11-7**] LIPID PROFILE: Total Chol 83, Triglyc-147, HDL-26
CHOL/HD-3.2 LDLcalc-28
ADDITIONAL POST-ADMISSION LABS:
[**2139-11-6**] 05:22AM BLOOD CK-MB-28* MB Indx-14.4* cTropnT-0.41*
[**2139-11-5**] 06:35PM BLOOD CK-MB-27* MB Indx-14.3* cTropnT-0.60*
[**2139-11-5**] 06:35PM BLOOD CK(CPK)-189*
[**2139-11-6**] 05:22AM BLOOD CK(CPK)-194*
[**2139-11-7**] 03:49AM BLOOD ALT-9 AST-24 AlkPhos-29* TotBili-1.2
[**2139-11-8**] 01:19PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2139-11-9**] 06:25AM BLOOD WBC-8.0 RBC-3.44* Hgb-10.3* Hct-29.6*
MCV-86 MCH-30.0 MCHC-34.9 RDW-15.5 Plt Ct-133*, Glucose-98
UreaN-19 Creat-0.7 Na-143 K-4.1 Cl-114* HCO3-24 AnGap-9, Mg-2.0
Brief Hospital Course:
ASSESSMENT AND PLAN [**2139-11-6**] :
In summary, patient is a 76-year-old female with a past medical
history of hypertension and glaucoma who presented to her local
ED after several hours of chest "discomfort" and mid-sternal
chest pain with some radiation to her right shoulder which was
relieved after nitroglycerin and Lopressor at OSH. Initial EKG
had
some non-specific ST changes concerning for NSTEMI with possible
cardiogenic shock given EF per ECHO report at OSH noted to be
15%. Repeat ECHO and cardiac catheterization of [**Hospital1 18**] showed
findings consistent with Takotsubo's cardiomyopathy and very
scant evidence of coronary artery disease. Unfortunately the
patient's cardiac catheterization was complicated by a large
right groin hematoma and acute onset of hypotension. Inferior
epigastric artery required emergent ligation by the [**Hospital1 18**]
vascular surgery team and the patient also had about 500cc blood
evacuated from hematoma site.
.
CARDIAC PUMP FUNCTION /TAKOTSUBO CARDIOMYOPATHY: The patient's
heart had classic apical ballooning on ECHO and typical
presentation of Takotsubo's cardiomyopathy. Repeat ECHO [**2139-11-5**]
showing LVEF 30% (at OSH EF 15%). Per patient's spouse she had
been under stress lately regarding the death of a sibling and
her upcoming glaucoma surgery. Upon CCU arrival the patient's
blood pressure had been challenged in the setting of a recent
post-catheterization arterial bleed as noted below. However, she
had been resuscitated with over 5L IVFs and given 4 Units Blood
throughout the day leading up to CCU transfer and her BP had
stabilized to SBPs in the 90s range. An A-line was placed for
more accurate hemodynamic monitoring and the patient had been
weaned off of her pressors prior to CCU presentation. By
hospital day 2 the patient had SBPs in the low 100-110 range and
MAPs were consistently > 65 range. She had minimal crackles on
lung exam. She was given 10mg IV Lasix to optimize extubation on
CCU day 2 which she tolerated well. Fentanyl and Versed were
weaned down and RSBIs were in 50 range. She was successfully
extubated with no complications and by hospital day 3 she had
progressed to 95-99%on 2L NC and then she was weaned to room air
with no residual shortness of breath complaints. On [**2139-11-7**]
repeat ECHO was largely unchanged and EF still 30%. The team
ultimately decided not to maintain the patient on
anticoagulation for her apical enlargement/thrombus risk given
the recent setting of her acute hematoma and hemorrhage.
Moreover, the data on anticoagulation and thrombus/stroke
reduction rates in Takotsubo population is lacking and no clear
recommendations exist.
.
Additional cardiomyopathy etiologies were explored which
included a work-up sent off for TSH, lipid profile and iron
studies (hemochromatosis). Iron Saturation level was 63%,
however in setting of acute event iron studies were felt to be
unreliable. Given that Mrs. [**Known lastname 75808**] has no past medical history
of diabetes (HgAIC 5.5)and limited PMH in general
hemochromatosis is unlikely but she was encouraged to discuss
repeat iron studies at a later date with her PCP as an
outpatient. She was also found to have a borderline high TSH
which is also unreliable in acute setting and she will plan to
follow-up with her PCP on this issue.
.
Once the patient's blood pressure and hematocrits had stabilized
she was placed on additional 25mg daily Toprol XL and her home
dose of 5mg Lisinopril was restarted. She will plan for a repeat
ECHO in [**3-24**] weeks and a follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
.
CORONARIES: The patient had very minimal CAD on cardiac
catheterization with 20% LAD and mild 25% RCA plaques. ST
changes were very non-specific on EKGs and did not reveal
classic ACS presentation for STEMI or NSTEMI. The patient was
monitored telemetry in the CCU and she had no additional bout of
chest pain, shortness of breath, palpitations or lightheadedness
during her hospital stay. The patient's minimal bump in cardiac
enzymes (CK 180-190 range, Troponin peak of 0.60) was attributed
to mild ischemia/microvascular stress in setting oh her
Takotsubo cardiomyopathy. Aspirin therapy was initially held in
the setting of her recovery from an acute bleed but she was
advised to begin taking 81mg of Aspirin daily at time of
discharge. Lipid profile was likely inaccurate in acute illness
setting but showed no hyperlipidemia. She will plan to have a
repeat lipid panel as an outpatient.
.
RHYTHM: The patient was monitored on telemetry and daily EKGs
were performed during her CCU stay. She had slight QT
prolongation which resolved and her nonspecific ST changes also
improved during her hospital course. She was in normal sinus
rhythm at time of discharge.
.
RIGHT GROIN HEMATOMA /ARTERIAL BLEED: As a complication of her
cardiac catheterization the patient suffered a groin hematoma
after an accidental arterial bleed. The inferior epigastric
artery was emergently ligated and a hematoma (approximately
500cc)was evacuated by the vascular surgery team. She had an
initial Hct drop from 34 to 20 which stabilized after 4 Units of
blood and over 6 liters of IVF resuscitation. The patient's Hct
levels were checked q6hrs post-surgery and then twice daily as
her Hct stabilized. At time of discharge her Hct was 29.6 and
she had no residual right groin pain and minimal discomfort with
walking. PT cleared the patient to return home and she was
cautioned to avoid lifting heavy objects 9>10lbs) until her
incision site had healed completely in [**4-26**] weeks. She will plan
to follow up in 2 weeks at the vascular clinic to have her
staples removed.
.
THROMBOCYTOPENIA: Post-operatively the patient had some lasting
thombocytopenia with platelets in the 70-80s range at the nadir.
This was most likely consumption related given her large bleed
with abundant clotting. DIC workup was unrevealing and given the
timeline HIT was felt to be a less likely culprit. Mrs. [**Known lastname 75809**] platelets were trended and fortunately began to rise
into the 90s and she was at 133 platelets by time of discharge.
She had no additional bruising, petechiae, hypotension or
further complications.
.
LEUKOCYTOSIS: The patient had a spike to a white blood cell
count of 17.9 with neutrophilia but no left shift. on [**2139-11-6**]
which soon tapered down to within normal range over the next 48
hours. She had no febrile patterns, UA and urine cultures were
negative and her CXR had no consolidations. IV sites and
surgical staples were in tact,clean,non-erythematous and
without any signs of discharge. The brief leukocytosis was
likely related to stress response of bleeding.
.
HYPERTENSION: Initially, the patient's blood pressures were in
the hypotensive range and all blood pressure medications were
held. As she stabilized by hospital day [**3-24**] she was gradually
restarted on low dose Lisinopril and Toprol XL was added given
her low EF and cardiomyopathy.
.
GLAUCOMA : While an inpatient in the CCU the patient was
continued on her usual eye drops that she takes for her
Glaucoma. She will plan to follow-up as an outpatient with her
opthalmologist regarding the need to post-[**Last Name (un) 9495**] her scheduled
surgery a few weeks until she recovers from a recent acute bleed
and until she recuperates from her current cardiomyopathy.
.
PROPHYLAXIS / CODE STATUS : Anticoagulation was held in the
setting of a new acute bleed. Pneumoboots were used for DVT
prophylaxis and physical therapy was called by hospital day two
to help the patient ambulate better. She was given Protonix for
GI prophylaxis in the setting of her intubation and she was
given a bowel
regimen of Senna and Colace to maintain regularity. Mrs. [**Known lastname 75808**]
was maintained as a full code status for the entirety of her
hospital stay.
.
Upon discharge, she was set up for a repeat echo in a few weeks
and follow-up appointments with Dr. [**Last Name (STitle) **] and the vascular
surgery clinic. She was asked to please return to the emergency
room or call her new cardiologist or PCP as soon as possible if
she had any worsening shortness of breath, chest pain,
dizziness,lightheadedness or signs of bleeding, discharge or
erythema at her incision site in her right groin.
Medications on Admission:
Home Medications:
Dorzolamide-Timolol 2-0.5 % eye drops tid
Travatan 0.004 % eye drops qhs
Lisinopril 5mg daily
Occasional OTC Tylenol
.
Medications on Admission:
Heparin drip and Integrilin started [**11-4**] but discontinued in
setting of acute bleed on [**11-5**] (off both at CCU transfer time)
-plavix 600mg [**11-4**], 75mg [**11-5**]
-lopressor 25mg po .
-lipitor 40mg
-nitro paste 1 inch q 4 hours
-cosopt eye gtts
.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic TID (3 times a day).
5. TRAVATAN Z 0.004 % Drops Sig: One (1) gtt both eyes
Ophthalmic HS (at bedtime).
6. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Takotsubo Syndrome / Cardiomyopathy
Right groin bleed requiring surgical repair
Thrombocytopenia
Glaucoma
Discharge Condition:
Stable
Hct=29.6
Creat=0.7
K=4.1
BUN: 19
Discharge Instructions:
You had a cardiac catheterization and that showed a weakness in
your heart that is consistant with Takotsubo syndrome. This
syndrome is similar to a heart attack but your coronary arteries
do not show any major blockages. You have been continued on your
previous medicines except your Lisinopril was decreased to 5 mg
daily. Your new medicine is Toprol XL ( a beta blocker) that
helps your heart pump better. You will need to have an ECHO in 3
weeks that will evaluate the function of your heart. After your
catheterization, you had a large blood collection in your right
groin that required surgical repair. This is now stable but an
appt to take out the staples has been scheduled for you.
.
Your heart fucntion is somewhat weak, we expect this will
improve over the next few months. Please weigh yourself every
day and tell Dr. [**Last Name (STitle) **] if you develop a weight gain more than
3 pounds in 1 day or 6 pounds in 3 days. Please also call Dr.
[**Last Name (STitle) **] if you see that you have sweeling in your legs and feet
or if you have difficulty breathing.
Call Dr. [**Last Name (STitle) 172**] or Dr. [**Last Name (STitle) **] if you notice increased
swelling, pain or redness in your right groin. Also call for
chest pain, nausea, sweating or fevers.
Followup Instructions:
Cardiology:
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] ([**Telephone/Fax (1) 2037**] from Cardiology, [**12-2**]
at 1 p.m. in [**Hospital Ward Name 23**] 7th on the [**Hospital Ward Name 516**] at the [**Hospital3 **].
You have to come in on [**11-30**] at 3 p.m. for an
echocardiogram which is an ultrasound of your heart, this is
also on [**Hospital Ward Name 23**] [**Location (un) 436**].
.
Primary Care:
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 172**] Phone: [**Telephone/Fax (1) 133**] Date/time: Tuesday [**11-17**] at 3:00 pm.
.
[**Hospital **] Clinic: for staple removal Dr. [**Last Name (STitle) **] Phone: ([**Telephone/Fax (1) 1804**] Date/time: [**11-25**] at 12:00 pm. [**Hospital Unit Name **]
[**Hospital Unit Name **], [**Last Name (NamePattern1) 439**].
Completed by:[**2139-11-10**]
|
[
"428.0",
"428.41",
"429.83",
"287.4",
"401.9",
"998.12",
"733.00",
"458.29",
"998.2",
"785.51",
"E870.6",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"38.88",
"99.20",
"37.23",
"54.0",
"99.04",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
19220, 19226
|
9812, 18116
|
326, 473
|
19376, 19418
|
4444, 9164
|
20740, 21586
|
3432, 3528
|
18591, 19197
|
19247, 19355
|
18305, 18568
|
19442, 20717
|
3543, 3543
|
2794, 2879
|
18160, 18279
|
276, 288
|
501, 2619
|
9180, 9789
|
3558, 4425
|
2910, 2944
|
2641, 2774
|
2960, 3416
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,276
| 109,778
|
24731
|
Discharge summary
|
report
|
Admission Date: [**2197-10-21**] Discharge Date: [**2197-10-27**]
Date of Birth: [**2175-3-13**] Sex: F
Service: MEDICINE
Allergies:
Haldol
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Gamma hydroxybutyrate withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
22 y/o F w/a hx significant for severe [**First Name3 (LF) **] withdrawal [**Month (only) **]
[**2196**] requiring a MICU stay, as well as cocaine abuse, who
presented to the ED today c/o chest pain and wanting to detox
from [**Year (4 digits) **]. History obtained per notes as pt obtunded. She
stated that she didn't feel well yesterday and went to the
[**Location (un) 620**] ED, was told she has a heart murmur and was asked to
f/u. Today (day of admission) she consumed [**Location (un) **] once per hour
(last 3pm), had chest pain, and presented to the [**Hospital1 18**] ED.
In the ED, she was tachycardic in the low 100s but otherwise
hemodynamically stable. She had an initial set of cardiac
enzymes that was negative. Her urine tox was positive only for
cocaine. Serum tox negative. She received valium 5 mg IV x1
and was admitted to medicine for treatment of her likely
withdrawal.
On the floor, she became persistently more tachycardic to the
150s and her mental status became more disoriented. She
received valium 40 mg po and the MICU was called to evaluate
her.
Past Medical History:
1. [**Hospital1 **] withdrawal [**8-7**]: required large doses of valium (>400
mg/day) as well as precedex. Was never intubated.
2. Neuroleptic malignant syndrome: experienced during her
[**Hospital **] hospital course, reaction to haldol.
3. Infantile seizures requiring barbituate coma
Social History:
lives with her boyfriend who supports her financially and is
abusing [**Hospital **] and crack cocaine as well. Had been working in a
restaurant but not working currently. High school graduate by
chart report. Patient denies recent alcohol use (by records,
history of alcohol abuse); states she occasionally uses cocaine
IN, denies IV drug use or heroin use; smokes cigarettes. Denies
other drug use. Patient is a twin. Her mother has been in and
out of rehab. Uses [**Hospital **] twice daily chronically, Cocaine abuse,
Alcohol use 2 drinks/day
Family History:
Mother suffers from social anxiety and other types of anxiety
and takes Klonopin. Twin sister with hx of OD on [**Name (NI) **] x 3 in
past. Per patient, her sister (twin), mother and father have
all had psychiatric hospitalizations in past.
Physical Exam:
T: 96.8 BP: 140/68 P: 152 R: 18 O2 sat 100%RA
Gen: pt standing in room, shaky on feet. alert and oriented x3
after much prompting, forgets what has been said immediately
after it's said. thinks her friend is taking her somewhere,
wants to go smoke cigarettes. also hallucinating that her
boyfriend is talking to her.
HEENT: NC, AT. perrl, eomi. MM dry.
Neck: supple
Lungs: CTA bilaterally, no w/r/c
CV: tachycardic, regular, difficult to appreciate a murmur at
this rate but II/VI SEM noted at LUSB on prior exam today when
pt not as tachycardic
Abd: soft, nt/nd. +bs.
Ext: warm/dry. no edema. 2+ radial pulses bilaterally.
Neuro: A&Ox3 but confused and hallucinating as above. gait
unsteady.
- Physical exam on discharge -
VS: 96.7, 108/50, 80, 16, 98% RA
Gen: pt. alert and oriented * 3, conversant, able to remember
discharge instructions.
Neuro: no hallucinations. normal gait.
Pertinent Results:
[**2197-10-21**] 05:15PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2197-10-21**] 04:40PM GLUCOSE-91 UREA N-12 CREAT-0.9 SODIUM-146*
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-23 ANION GAP-21*
[**2197-10-21**] 04:40PM CK(CPK)-137
[**2197-10-21**] 04:40PM cTropnT-<0.01
[**2197-10-21**] 04:40PM CK-MB-2
[**2197-10-21**] 04:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2197-10-21**] 04:40PM WBC-13.3* RBC-4.61# HGB-15.1# HCT-42.1#
MCV-91 MCH-32.8* MCHC-35.9* RDW-12.5
[**2197-10-21**] 04:40PM PLT SMR-NORMAL PLT COUNT-340
CXR: normal
ECG (I and II unusable): rate 74, normal intervals, TWI in
III/avF/V2/V3, bisphasic T in V4
[**2197-10-25**] 06:10AM BLOOD WBC-8.4 RBC-3.66* Hgb-11.5* Hct-34.0*
MCV-93 MCH-31.6 MCHC-33.9 RDW-12.4 Plt Ct-287
[**2197-10-25**] 06:10AM BLOOD Plt Ct-287
[**2197-10-24**] 04:23AM BLOOD PT-12.6 PTT-27.7 INR(PT)-1.1
[**2197-10-25**] 06:10AM BLOOD Glucose-76 UreaN-11 Creat-0.7 Na-139
K-4.2 Cl-101 HCO3-29 AnGap-13
[**2197-10-22**] 06:13PM BLOOD CK-MB-1 cTropnT-<0.01
[**2197-10-22**] 02:48AM BLOOD CK-MB-2 cTropnT-<0.01
[**2197-10-21**] 04:40PM BLOOD cTropnT-<0.01
[**2197-10-25**] 06:10AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
[**2197-10-21**] 04:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
A/P: 21 y/o F w/hx of severe [**Month/Day/Year **] withdrawal who presents with
similar, as well as with chest pain in the setting of cocaine
use.
1. [**Month/Day/Year **] withdrawal: Half-life of [**Month/Day/Year **] is usually 30-40 minutes,
and withdrawal symptoms usually begin 1-6 hours after last dose
(her last dose at 3pm). This made her current presentation
consistent with [**Month/Day/Year **] withdrawal, given her tachycardia,
hypertension, and altered mental status. Treatment of this is
with high-dose benzos (which is what she required last time, at
doses of 400mg/day). She also did well last time with precedex,
which likely helped her to avoid intubation. There was no
indication for antipsychotics or anticonvulsants, and drugs like
haldol can actually precipitate seizures in this setting. She
was treated with high dose valium in the ICU and on transfer to
the floor was tapered down 5 mg tid of valium. She was
discharged with this dose. She was given 6 tablets of valium to
last until Monday when she has an appointment at the [**Hospital 191**] clinic
with Dr. [**Last Name (STitle) **] to establish a drug contract. She was also
given 2 tablets of Zyprexa to use at bedtime. On discharge her
mental status was normal; alert and oriented, able to remember
date/time of f/u appointments, able to understand importance of
calling rehab facilities. She was given list of phone numbers
and told to call Project Cope on Monday to arrange residential
rehab. This was discussed with psych, addiction consult
service, and medicine attending.
.
2. Chest pain: Concerning that she had chest pain and ECG
changes, in setting of cocaine use. She ruled out for MI. An
ECHO done on [**8-15**] showed normal LV systolic fxn, no significant
valvular disease.
.
3. Leukocytosis: WBC elevated, may have been due to stress
reaction from current situation, however pt also c/o difficulty
urinating so UA checked. CXR negative (possible she may have
aspirated as she reports vomiting earlier today), abd nontender.
Urine culture negative here. On d/c WBC normal.
.
4. Anion gap: Had anion gap of 17, for unclear reasons. Checked
urine for ketones which was negative. (?starvation ketoacidosis
if she's not taking po), checked venous lactate. [**Month (only) 116**] have had
other ingestion (ethylene glycol, methanol) but didn't have any
other symptoms consistent with those syndromes (vision problems,
renal failure). Salicylate negative, not uremic, not diabetic.
On d/c, AG closed to 9
.
5. FEN: Pt dehydrated (given sodium 146, likely poor po intake
while constantly intoxicated), so given IVF in ICU. On floor,
pt. transitioned to normal diet.
Medications on Admission:
Bactrim prn UTI symptoms
Discharge Medications:
1. Valium 5 mg Tablet Sig: One (1) Tablet PO three times a day
for 2 days.
Disp:*6 Tablet(s)* Refills:*0*
2. Zyprexa 5 mg Tablet Sig: One (1) Tablet PO at bedtime for 2
days.
Disp:*2 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
1. Gamma hydroxybutyrate withdrawal
2. Cocaine abuse
3. Delirium
Secondary
1. Heart murmur
Discharge Condition:
Good
Discharge Instructions:
You should take all your medications as directed. You should
keep all appointments with health care providers; especially the
appointment on Monday [**10-30**] at 12:10 PM with Dr. [**Last Name (STitle) **].
.
Take your valium as directed; DO NOT take it more frequently.
You should be in touch with Project Cope in [**Location (un) **] MA regarding
joining their residential program for addiction. You also can
contact [**Name (NI) 62363**] Mental Health or Club 24 in [**Location (un) 3786**], MA. Their
phone numbers are listed below. Do not use gamma-hydroxy
butyrate.
Followup Instructions:
You should join the residential program at Project Cope. You
should call them by Monday before your
appointment([**Telephone/Fax (1) 62366**]). You can also use Club 24 in [**Location (un) 3786**]
MA. They have a 24hour drop in service for substance abuse.
Their phone number is ([**Telephone/Fax (1) 62367**]). The phone number for
[**Telephone/Fax (1) 62363**] Mental Health is [**Telephone/Fax (1) 62368**]
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2197-10-30**] 12:10
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2197-11-9**] 10:30
|
[
"968.4",
"786.59",
"276.51",
"305.60",
"292.84",
"E855.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7850, 7856
|
4862, 7544
|
300, 307
|
7999, 8006
|
3500, 4839
|
8629, 9316
|
2321, 2567
|
7619, 7827
|
7877, 7978
|
7570, 7596
|
8030, 8606
|
2582, 3481
|
228, 262
|
335, 1423
|
1445, 1735
|
1751, 2305
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,439
| 170,348
|
22467
|
Discharge summary
|
report
|
Admission Date: [**2144-1-16**] Discharge Date: [**2144-2-20**]
Date of Birth: [**2098-3-27**] Sex: M
Service: MEDICINE
Allergies:
Bactrim / Levofloxacin
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
fevers
Major Surgical or Invasive Procedure:
Excisional biopsy of left cervical lymph node
Intubation
[**Last Name (NamePattern1) 16689**]
Bone marrow aspirate and biopsy
CVVH/Hemodialysis
PICC line placement
History of Present Illness:
The patient is a 45 yo man with h/o HIV, MRSA abscesses, and
anal fistula, who presents with fever and tachycardia. The
patient was reportedly in his normal state of health until
approximately 1 month ago, when he developed a cough and fever
and presented to his PCP. [**Name10 (NameIs) **] was treated for PNA with Levaquin
and was diagnosed with HIV. He presented to the hospital a few
days later, at which time he was admitted to from [**Date range (1) 58377**]
for fever, shortness of breath, and hypoxia. Given the high
concern for PCP PNA despite negative induced sputums, he was
started on Prednisone and Trimethoprim/Dapsone, the course of
which ended on [**2144-1-14**]. His LFTs also increased during this
admission to the [**2133**], so he had a liver Bx, which was
consistent with either drug effect or acute infection. He was
started empirically on acyclovir to treat possible HSV/VZV
hepatitis, which ended on [**2144-1-12**].
.
Since his discharge on [**12-30**], Mr. [**Name14 (STitle) **] states that he
continues to have daily fevers to 102, which typically resolve
with Tylenol. He finished his course of antibiotics, and his
PICC line was pulled without complication on [**1-13**]. He presented
to his PCP that day, at which time he was found to be anemic, so
he was transfused 2U of PRBCs. Of note, he does endorse a
non-productive cough at night with associated pain in his right
ribs. He also has had frequent pruritic rashes on his legs,
trunk and back of his hands since [**Month (only) 1096**]. This morning, he
woke up with a fever of 102 and then took Tylenol and went back
to bed. At 2 PM, his fever had increased to 104, so he called
his PCP, [**Name10 (NameIs) 1023**] recommended that he come to the ED for further
evaluation.
.
In the ED, the patient's initial VS were T 103, P 141, BP
100/72, R 16, O2 98% on RA. He had a CXR that was negative for
PNA and he was given IVFs. His VS at the time of admission were
P 109. BP 111/53, R 29, O2 100% on RA. On the floor, the patient
states that overall he was feeling run down but otherwise has no
new complaints. Patient continued to be febrile overnight,
complains of dry mouth and dry hacking cough which keeps him
awake. Otherwise he is without complaint, he just feels
extremely run down. He also really wants to know what the source
of "all this."
Past Medical History:
* Facial acne vs. folliculitis
* MRSA abscess on right buttocks ([**2139**])
* Anal fistula s/p fistulectomy ([**2137**])
* HIV/AIDS diagnosed on recent admission when he was treated
presumptively for PCP
Social History:
Occupation: teaches musical theatre at [**Location (un) 86**] Conservatory for
Music.
Tobacco: none
Alcohol: social use (none recently)
Illicit drugs: denies
Home: Lives with his husband (have been together for 18 years,
monogamous relationship) and his mother.
Family History:
Noncontributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 101, BP 102/64, P 101, R 22, O2 98% on RA
General: Pleasant man, alert, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, [**Last Name (un) **]/oropharynx
clear
Neck: Soft, supple, JVP not elevated, no LAD appreciated
Lungs: Poor inspiratory effort, decreased breath sounds
throughout. No wheezes/rales/rhonchi
CV: Tachycardic, 2/6 systolic murmur. Normal S1 + S2
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no hepatosplenomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Macular-reticular rash on dorsal aspect of hands
bilaterally and forehead.
DISCHARGE PHYSICAL EXAM:
VS: Tm/Tc 98.1/97.6, BP 115/75 (110-130)/(65-75), HR 85 (85-95),
RR 18, SaO2 100%RA
u/o 1.55L/24H
GEN: NAD
HEENT: sclerae anicteric, MMM
Cards: Normal S1 and S2. No murmurs.
Pulm: CTA throughout all fields bilaterally
Abd: protuberant but nondistended; no masses or tenderness
Extremities: warm, no peripheral edema
Pertinent Results:
ADMISSION LABS:
[**2144-1-16**] 04:05PM BLOOD WBC-7.8 RBC-2.75* Hgb-8.4*# Hct-25.3*
MCV-92# MCH-30.6 MCHC-33.3 RDW-21.0* Plt Ct-240
[**2144-1-16**] 04:05PM BLOOD Neuts-81* Bands-0 Lymphs-9* Monos-8 Eos-1
Baso-1 Atyps-0 Metas-0 Myelos-0
[**2144-1-16**] 04:05PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL Tear
Dr[**Last Name (STitle) 833**]
[**2144-1-16**] 04:05PM BLOOD Plt Smr-NORMAL Plt Ct-240
[**2144-1-18**] 07:35AM BLOOD PT-14.8* PTT-34.0 INR(PT)-1.3*
[**2144-1-16**] 04:05PM BLOOD Glucose-139* UreaN-38* Creat-1.4* Na-132*
K-4.9 Cl-105 HCO3-20* AnGap-12
[**2144-1-16**] 04:05PM BLOOD ALT-73* AST-20 LD(LDH)-143 AlkPhos-280*
TotBili-0.7
[**2144-1-17**] 07:10AM BLOOD Calcium-7.6* Phos-2.8# Mg-1.9 Iron-9*
[**2144-1-16**] 04:16PM BLOOD Glucose-133* Lactate-1.6 K-4.8
DISCHARGE LABS:
[**2144-2-20**] 06:00AM BLOOD WBC-3.9* RBC-2.96* Hgb-9.0* Hct-27.2*
MCV-92 MCH-30.5 MCHC-33.3 RDW-16.9* Plt Ct-110*
[**2144-2-16**] 06:00AM BLOOD PT-12.1 INR(PT)-1.0
[**2144-2-20**] 06:00AM BLOOD Glucose-83 UreaN-30* Creat-0.9 Na-140
K-3.6 Cl-108 HCO3-25 AnGap-11
[**2144-2-20**] 06:00AM BLOOD ALT-126* AST-58* AlkPhos-483*
TotBili-2.6*
[**2144-2-20**] 06:00AM BLOOD Calcium-8.5 Phos-2.9 Mg-1.7 UricAcd-3.4
CT ABD/PELVIS [**2144-1-17**]
1. Extensive hilar, mediastinal, axillary, and supraclavicular
lymphadenopathy, essentially unchanged from [**2143-12-27**],
exam. A large number of retroperitoneal, mesenteric, pelvic and
inguinal lymph nodes are present, many which are mildly enlarged
by CT criteria. Spleen is markedly enlarged.
These findings are consistent with patient's HIV positive
status; however,
given diffuse nature of lymphadenopathy, lymphoma should be
considered and
additional differential considerations and opportunistic
infections cannot be entirely excluded.
For further evaluation, axillary lymph nodes may be amenable to
FNA.
2. Marked gallbladder wall edema, compatible with HIV
cholangiopathy.
SUPRACLAVICULAR LYMPH NODE BIOPSY [**2144-1-18**]
-HIGH-GRADE B-CELL LYMPHOMA, BEST CLASSIFIED AS LARGE B-CELL
LYMPHOMA ARISING IN A BACKGROUND OF MULTICENTRIC CASTLEMAN'S
DISEASE (MCD), SEE NOTE.
CTA [**2144-1-20**]
1. No PE.
2. Bilateral small pleural effusions with associated
atelectasis, right
greater than left.
3. 5-mm right upper lobe pulmonary nodule for which a six-month
followup
chest CT is advised.
CXR [**2144-1-22**]
IMPRESSION: AP chest compared to [**2143-12-30**] through
[**1-20**]:
Elevation of the lung bases is probably due to component of
small pleural
effusions and basal atelectasis. On the left, there could be a
small region
of lower lobe consolidation, new since [**1-16**]. The heart is
normal size. The upper lungs are clear.
RUQ U/S [**2144-1-27**]
1. Partially collapsed gallbladder with wall thickening;
features do not
suggest acute cholecystitis. Again, the wall thickening is
likely secondary
to hypoalbuminemia, but may also represent CHF, underlying
hepatitis, or HIV cholangiopathy. No biliary dilatation is seen.
2. Splenomegaly.
3. Right pleural effusion.
SKIN PUNCH BIOPSY LEFT CHEST [**2144-2-9**]
Dermal vascular proliferation consistent with Kaposi's sarcoma
(see note).
Note: Immunohistochemical stains for D2-40 and HHV-8 are
positive within the lesion, consistent with the above diagnosis.
[**2144-1-31**] 2:28 pm IMMUNOLOGY
HIV-1 Viral Load/Ultrasensitive (Final [**2144-2-4**]): 341,000
copies/ml.
[**2144-2-17**] 4:14 pm IMMUNOLOGY
HIV-1 Viral Load/Ultrasensitive (Final [**2144-2-18**]): 321
copies/ml.
[**2144-2-18**] 9:08 am IMMUNOLOGY Source: Line-PICC.
HBV Viral Load (Final [**2144-2-20**]): HBV DNA not detected.
Brief Hospital Course:
Mr. [**Known lastname 58376**] is a 45y/o gentleman with recently diagnosed
HIV/AIDS, who presented with a one-month history of fevers, dry
cough and anemia. He developed multi-organ dysfnction
requiring ICU transfer, intubation, and temporary hemodialysis.
He was found to have HHV-8(+) Multicentric Castleman's disease
with diffuse large B cell lymphoma. He had a significant
improvement in his clinical status, and he was transferred to
the Oncology floor, where he was treated with one cycle of
chemotherapy. He was discharged home with close follow-up.
.
#. Multicentric Castleman's disease with Diffuse large B cell
lymphoma.
Bone marrow and lymph node biopsies confirmed that he has
plasmablastic lymphoma in the setting of HHV-8(+) Castleman's
Disease. His HIV(+) status predisposes him to having a more
acute course of Castleman's Disease; he presented with
multiorgan dysfunction, fevers, lymphadenopathy, weight loss,
fatigue, and anemia. He was treated with 1 cycle of modified
R-[**Hospital1 **] (steroids, Rituximab, Bortezomib, Vincristine,
Cyclophosphamide, and Doxorubicin):
[**2144-1-24**]: started Dexamethasone 20mg PO daily (decreased to 10mg
PO daily)
[**2144-1-31**]: Rituximab 710 mg IV (375 mg/m2)
[**2144-2-8**]: Rituximab 710 mg IV (375 mg/m2)
[**2144-2-10**]: Bortezomib 2.4mg IV (1.3 mg/m2)
[**2144-2-13**]: Cyclophosphamide 1340 mg IV (750 mg/m2), Doxorubicin 4
mg IV (2.5 mg/m2), Vincristine 0.4 mg IV (0.2 mg/m2), changed
from Dexamethasone to PredniSONE 100 mg PO
[**2144-2-14**]: Doxorubicin 4 mg IV (2.5 mg/m2), Vincristine 0.4 mg IV
(0.2 mg/m2), PredniSONE 100 mg PO
[**2144-2-15**]: no chemo
[**2144-2-16**]: no chemo
[**2144-2-17**]: Doxorubicin 8 mg IV (5 mg/m2), Vincristine 0.4 mg IV
(0.2 mg/m2), PredniSONE 100 mg PO
[**2144-2-18**]: Doxorubicin 8 mg IV (5 mg/m2), Vincristine 0.4 mg IV
(0.2 mg/m2), PredniSONE 100 mg PO
He tolerated the chemotherapy well without significant side
effects. He was on Allopurinol and TLS labs were monitored.
There are plans to treat with full-dose chemotherapy in the
future, including Etoposide, when his liver function improves
more. He will follow up with his Oncology team on the day after
discharge for monitoring, count check, transfusion, and Neupogen
teaching.
.
# HIV/AIDS: not on HAART as an outpatient, was started [**2144-2-11**]
while inpatient.
He had been treated presumptively for PCP the month prior; other
AIDS-defining illness is Kaposi's sarcoma. His HIV VL on
[**2144-12-23**] was 80,000 copies/ml, and on [**2144-1-31**] it was 341,000
copies/ml. When he was clinically stable on the floor, he was
started on Truvada/Raltegravir per ID recs (dual therapy for HBV
and HIV), on [**2144-2-11**]. HIV VL on [**2144-2-17**] was 321 copies/ml. He
was discharged on Truvada/Raltegravir as well as Dapsone for PCP
prophylaxis, and he will follow up with Dr. [**Last Name (STitle) 724**] (I.D.) within
one week after discharge for follow-up.
.
# Hepatitis B: prior infection without evidence of active or
latent infection. Hep B e Ab positive but e Ag negative. In
the setting of chemo, must take his past infection into account.
He was started on Truvada/Raltegravir on [**2144-2-11**] when he was
stable and on the floor. HBV VL from [**2-4**], [**2-11**], and [**2-18**]
undetectable. He will follow up with Dr. [**Last Name (STitle) 724**] (I.D.) within one
week after discharge for follow-up.
.
# HHV-8/Kaposi's sarcoma: HHV-8 is likely a factor that
contributes to his Multicentric Castleman's Disease. In
addition, he has skin lesions that were concerning for Kaposi's
sarcoma and biopsy by Dermatology has confirmed this diagnosis.
Treatment of Kaposi's will be similar to treatment of lymphoma;
at this point priority lies on lymphoma treatment. He had been
on Ganciclovir IV since [**2144-1-24**], but this was stopped prior to
discharge.
.
# Transaminitis/Hyperbilirubinemia: multifactorial, resolving.
On last admission he had transaminitis to the [**2133**]'s, which
resolved and AST/ALT were ~50. At the time, his liver
dysfunction had been attributed to Levofloxacin versus HSV/VZV
hepatitis, so he had been treated with empiric IV Acyclovir.
During this admission, Hepatology was consulted. CT scan showed
edematous gallbladder but ultrasound without gallstones. HIDA
scan inconclusive. Serology shows past but not current HBV
infection. Shock liver from systemic disease/SIRS was
considered. However, it is likely that his liver disease was
due to infiltration by his MCD/lymphoma. T. bili peaked at 20
during this admission and the patient had significant
jaundice/icterus, but as he improved it downtrended and was 2.5
at the time of discharge and he had no more icterus or jaundice.
His liver disease is improving, and when his T. bili is near
1.5 he will be a candidate for Etoposide therapy. He may have
an outpatient MRCP to assess the degree of infiltrative disease
in his liver.
.
# Thrombocytopenia: possibly from bone marrow infiltration as
well as chemotherapy.
His platelets decreased from the 330's down to 40-50 twice
during this admission: once in the ICU. The team considered
infection and drug effect from Meropenem; HIT Ab was negative
and there was no evidence of TTP or hemolysis. They concluded
that he likely had bone marrow infiltration from his underlying
disease. Then, again while stable and on the floor but this was
in the setting of receiving chemotherapy. He remained
clinically stable without signs of bleeding, and he did not
require any transfusions (goal plt>10). He will have follow-up
for count checks after discharge.
.
# Anemia: inflammation and chemotherapy.
He received a total of 15u pRBCs throughout his month-long
admission, mostly during his ICU stay. Guaiac negative. Bone
marrow biopsy did not show overt infiltration. Iron 9 and
ferritin 2553 suggests anemia of chronic inflammation, which is
consistent with his overall clinical picture. He was put on
marrow-suppressive therapy which could have caused further
anemia. He will have follow-up for count checks after
discharge.
.
#. Fevers: no infectious source, likely due to MCD/Lymphoma.
Patient had nighttime fevers for two weeks prior to admission,
despite treatment for PCP PNA, VZV/HSV hepatitis. Infectious
Disease team was following. On the medicine floor, he underwent
extensive infectious workup for opportunistic infection,
endocarditis (negative TTE), viral infection (brief course of
IVIG in the setting of suspicion for Parvo), fungal infection
(briefly on Fluconazole, which was stopped in the setting of
elevated T bili). Upon transfer to the ICU, he was broadly
covered with Vancomycin/Zosyn/Azithromycin/Meropenem. Blood,
urine, sputum, and respiratory viral cultures were all negative.
Negative AFB, C. diff, CMV. He was changed to
Vancomycin/Azithromycin/Meropenem/Micafungin in addition to
Primaquine/Clarithromycin/Methylprednisone for treatment of PCP.
[**Name10 (NameIs) **] had a negative BAL so PCP treatment was stopped and he was
on prophylaxis only. Also, started to treat him for HHV8 with
Gancyclovir (see above). At this time, his lymph node biopsy
returned.
BAL that was sent on [**1-23**] returned negative, thus PCP treatment
was dc'd and atovaquone for prophylaxis was started. Once it
became clear that the patient's fevers were not of an infectious
cause, all antimicrobials (except for Ganciclovir and
prophylactic Dapsone) were discontinued on [**2143-1-31**]. He remained
afebrile for the rest of his admission.
.
# Respiratory failure: resolved, likely from volume overload.
Due to tachypnea and increased work of breathing, patient was
intubated emergently upon arrival to the ICU on [**1-23**]. His
pressor requirement escalated quickly, requiring Neosynephrine,
Vasopressin, and Levophed for a short period. This was
initially concerning for sepsis in the setting of infectious
workup (see above). Bronch was performed which revealed
purulent secretions; BAL culture eventually returned negative.
CTA was negative for PE. Patient was found to had
small-moderate pleural effusions on CT chest and chest
radiographs suggestive of possible volume overload. He was
started on CVVH for a few days, which helped him to remain
euvolemic. Then he was switched to Lasix for a few days. His
ventilation requirements gradually improved and he was
successfully extubated on [**2144-1-31**]. He remained stable,
breathing comfortably on room air with occasional nebs as
needed, for the rest of his stay. He ambulated without dyspnea
and had no supplemental oxygen requirement.
.
# Leukocytosis: resolved (now leukopenic).
WBC peaked at 30 on [**2144-1-29**]. Steroids were started 5 days
earlier, but his WBC had been increasing prior to this as well.
Infectious workup had been negative (see above). His
leukocytosis was likely related to malignancy/acute illness.
His WBC was monitored and it trended down; in the setting of
chemo his WBC was 4 at the tie of discharge and will likely
decrease further after discharge. He will be started on
Neupogen as an outpatient and will follow-up for count checks
after discharge.
.
# Acute oliguric renal failure: resolved.
His baseline Cr is 0.9, but during this admission it peaked at
4.4 with oliguria. Nephrology was following. He had a CVVHD
requirement while in the ICU for less than 2 weeks. The insult
was likely secondary to a combination of contrast-induced
nephropathy, ATN, and possibly an element of tumor lysis
syndrome or Ig-related nephropathy as well (SPEP and UPEP were
not consistent with this, however). Once he was on the Oncology
floor, he had excellent urine output. Medications were renally
dosed (Truvada, Ganciclovir, Allopurinol). Over a few weeks his
Creatinine downtrended and at the time of discharge was 0.9.
Medications on Admission:
Nystatin 100,000 U/mL 10 mL PO qid prn for [**Date Range 11395**]
Tylenol prn
Prednisone taper (finished on [**1-14**])
Dapsone 100 mg PO daily (finished [**1-14**])
Trimethoprim 400 mg TID (finished [**1-14**])
Discharge Medications:
1. services
Skilled nursing services for PICC line care
2. prednisone 10 mg Tablet Sig: One (1) Tablet PO as directed
for 5 days: On [**2-21**] take 4 tabs at once, on [**2-22**] take 2 tabs at
once, on [**2-23**] take 2 tabs at once, on [**2-24**] take 1 tab, and on
[**2-25**] take 1 tab. Then stop.
Disp:*10 Tablet(s)* Refills:*0*
3. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1) Tablet
PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*0*
5. dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*0*
7. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for [**Month/Year (2) 11395**].
Disp:*600 ML(s)* Refills:*0*
8. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*21 Tablet, Rapid Dissolve(s)* Refills:*0*
9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
10. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-5**] sprays Nasal
four times a day as needed for nasal congestion.
Disp:*1 bottle* Refills:*0*
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for pain.
Disp:*60 Capsule(s)* Refills:*0*
12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
13. heparin, porcine (PF) 1,000 unit/mL Solution Sig: One (1)
flush Injection twice a day: PICC, heparin dependent: Flush with
50 units Heparin [**Hospital1 **] .
Disp:*1 month's supply* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Home Solutions Care Centrix
Discharge Diagnosis:
Diffuse large B cell lymphoma
Multicentric Castleman's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with continued fevers and you became extremely
ill with multi-organ dysfunction, requiring ICU transfer. You
were found to have Multicentric Castleman's Disease as well as
diffuse large B cell lymphoma. You were given treatment
including one round of chemotherapy, and you are much improved
now so you are being discharged with close follow-up.
.
You have been started on many new medications. You have been
given a list; please take these as directed.
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2144-2-21**] at 12:00 PM
With: [**First Name8 (NamePattern2) 8081**] [**Last Name (NamePattern1) 396**], BSN [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2144-2-21**] at 2:00 PM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
PRIMARY CARE
Name: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], PA
Specialty: Internal Medicine
When: Wednesday [**2-26**] at 11:30am
Location: [**Hospital1 **] HEALTH
Address: [**Location (un) **], [**Location (un) 86**], [**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 798**]
Department: HEME-ONC INFECTIOUS DISEASE
When: Wednesday [**2-26**] at 3:00pm
With: [**Last Name (LF) **], [**First Name3 (LF) **] [**Telephone/Fax (1) 31305**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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[
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[
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[
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29,067
| 119,987
|
32929
|
Discharge summary
|
report
|
Admission Date: [**2173-12-14**] Discharge Date: [**2173-12-17**]
Date of Birth: [**2110-5-22**] Sex: M
Service: MEDICINE
Allergies:
Norvasc / Clonidine / Cardura
Attending:[**First Name3 (LF) 4963**]
Chief Complaint:
Syncope followed by seizure activity
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 63 yo M with a h/o HTN who presents with syncope vs.
seizure. He was walking [**University/College 76621**] at approx 11:30 am on
[**2173-12-14**], on his way home from the office. He had a prodrome of
dizziness, lightheadedness,+ blurry vision, confusion, in his
words "I felt like I was going to pass out." He then syncopized,
bystanders commented that he had jerking movements in his upper
extremities. He woke up in handcuffs, being restrained by
paramedics and that was all he could remember. He denies bladder
or bowel incontinence during the event, but does admit to being
confused for a while after the event. He denies feeling nausea,
vomiting, chest pain, SOB or palpitations prior to event. He
denies any prior cardiac hx, did have cardiac cath for chest
pain at [**Doctor Last Name 1263**] hosptial 2 years ago. Pt fell landing on his
nose, causing a laceration of his nose.
.
On ROS, Pt denies any hx of MI, angina, DOE, orthopnea, recent
leg swelling, prior episodes of syncope, prior syncope, new
medications, fevers, chills, cough, any recent etoh or drug
ingestions. Pt does admit to having some heart burn, lasting 10
min, the am prior to his fall.
.
Pt was transported to the [**Hospital1 18**] ED by EMS. In the ED, the pt was
noted to be in afib with RVR. His VS T 98.3 HR 138 AFib, BP
186/103, RR 18, SaO2 100% on 4L N/C. He did report CP earlier
today and indigestion this morning for several minutes. His head
CT here shows a small right frontal hemorrhagic contusion. He
also has a minimally displaced small BL nasal bone fracture. He
received Diltiazem 10 mg IV x1 and Diltiazem 30 mg po x1,
Diltiazem 20mg IV and Diltiazem 40mg PO. He also received NTG SL
0.3 mg tablets, Tetanus shot, and Dilantin 1000 mg load. EKG
showed lateral ST depressions that resolved with rate control.
His C spine was cleared clinically. Cardiology will follow pt.
Plastics closed pts facial lac.
Past Medical History:
HTN
BPH
Substance abuse etoh, cocaine quit 18 years ago per pt
Anxiety
Social History:
Patient is divorced with one son. [**Name (NI) **] is Healthcare proxy and on
vacation in [**Name (NI) 76622**]. Pt does not want him called. Pt lives alone
at home. Pt is a construction supervisor for [**Company 2318**]. He denies any
substance abuse for the past 18 years, because of AA. Drug of
choice in the past was cocaine, but he was also an alcoholic.
Denies ever using IV drugs.
Family History:
Dad was an alcoholic died of MI at age 51, Mother died recently
pt unsure of diagnosis. No family hx of sz disorder
Physical Exam:
VS: Temp: 97.7 BP:167/85 HR: 95 RR:15 O2sat 97% 2L n/c
GEN: pleasant, comfortable, NAD
HEENT: PERRL, EOMI, anicteric, MMM, Patient noted to have large
nasal laceration, with 20 sutures.
NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no
carotid bruits,
RESP: CTA b/l with good air movement throughout
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: No edema, 2+dp, 2+pt bilat
SKIN: no rashes/no jaundice
NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No
sensory deficits to light touch appreciated. No pass-pointing on
finger to nose. 2+DTR's-patellar and biceps
RECTAL: not done
Pertinent Results:
EKG:
Axis 0 degrees, Afib Rate 130, 1mm ST depression on v3-v6.
Repeat ECG showed resolution of ST depression with rate of 101.
.
ADMISSION LABS
.
[**2173-12-14**] 01:55PM BLOOD WBC-10.7 RBC-4.56* Hgb-14.4 Hct-40.0
MCV-88 MCH-31.5 MCHC-35.9* RDW-13.4 Plt Ct-207
[**2173-12-14**] 01:55PM BLOOD Neuts-70.3* Lymphs-20.8 Monos-5.1 Eos-3.2
Baso-0.6
[**2173-12-14**] 01:55PM BLOOD PTT-23.1
[**2173-12-14**] 01:55PM BLOOD Plt Ct-207
[**2173-12-14**] 09:30PM BLOOD PT-12.5 PTT-23.5 INR(PT)-1.1
[**2173-12-14**] 09:30PM BLOOD Plt Ct-229
[**2173-12-14**] 01:55PM BLOOD Glucose-113* UreaN-17 Creat-1.2 Na-140
K-3.2* Cl-102 HCO3-24 AnGap-17
[**2173-12-14**] 01:55PM BLOOD CK(CPK)-117
[**2173-12-14**] 09:30PM BLOOD CK(CPK)-496*
[**2173-12-15**] 03:05AM BLOOD CK(CPK)-511*
[**2173-12-14**] 01:55PM BLOOD CK-MB-4
[**2173-12-14**] 01:55PM BLOOD cTropnT-<0.01
[**2173-12-14**] 09:30PM BLOOD CK-MB-12* MB Indx-2.4 cTropnT-<0.01
[**2173-12-15**] 03:05AM BLOOD CK-MB-9 cTropnT-<0.01
[**2173-12-14**] 01:55PM BLOOD Calcium-9.0 Phos-1.3* Mg-2.1
[**2173-12-14**] 10:47PM BLOOD %HbA1c-5.7
[**2173-12-14**] 09:30PM BLOOD Triglyc-122 HDL-32 CHOL/HD-4.6 LDLcalc-92
[**2173-12-14**] 09:30PM BLOOD TSH-1.7
[**2173-12-14**] 09:30PM BLOOD Phenyto-8.2*
[**2173-12-14**] 09:30PM BLOOD Ethanol-NEG Barbitr-NEG
[**2173-12-14**] 01:55PM BLOOD GreenHd-HOLD
Other Labs
.
[**2173-12-17**] 05:50AM BLOOD WBC-9.6 RBC-4.77 Hgb-14.9 Hct-43.1 MCV-90
MCH-31.3 MCHC-34.6 RDW-13.5 Plt Ct-224
[**2173-12-17**] 05:50AM BLOOD Glucose-94 UreaN-19 Creat-1.2 Na-142
K-4.4 Cl-103 HCO3-29 AnGap-14
[**2173-12-17**] 05:50AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.1
[**2173-12-14**] 10:47PM BLOOD %HbA1c-5.7
[**2173-12-14**] 09:30PM BLOOD Triglyc-122 HDL-32 CHOL/HD-4.6 LDLcalc-92
[**2173-12-14**] 09:30PM BLOOD TSH-1.7
[**2173-12-17**] 05:50AM BLOOD Phenyto-6.8*
[**2173-12-14**] 09:30PM BLOOD Ethanol-NEG Barbitr-NEG
.
IMAGING
CT sinus [**12-14**]
1. Minimally displaced fractures of the nasal bone bilaterally.
No additional evidence of fracture.
2. Maxillary, ethmoid and sphenoid sinus mucosal disease.
.
CT head wo contrast [**12-14**]
Small, focal area of mixed hypo- and hyperattenuation within the
right frontal lobe adjacent to the skull, most consistent with a
small hemorrhagic contusion. No significant mass effect.
Otherwise, no evidence of acute intracranial pathology.
.
CXR [**12-14**]
Question subtle focal opacity projecting at the lung apex. There
is a hypertensive cardiomediastinal configuration
.
CT HEAD W/O CONTRAST [**2173-12-15**] 10:08 AM
IMPRESSION: No significant change since the previous study or
evidence of progression of edema or worsening mass effect. No
hydrocephalus.
.
SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT [**2173-12-15**] 10:25 AM
IMPRESSION: No fracture or dislocation. Degenerative change
involving the acromioclavicular joint.
.
ECHO [**12-15**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Transmitral
Doppler and tissue velocity imaging are consistent with Grade I
(mild) LV diastolic dysfunction. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta is mildly dilated. The aortic arch is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. Trivial mitral
regurgitation is seen. The left ventricular inflow pattern
suggests impaired relaxation. There is mild pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion.
.
ECG Study Date of [**2173-12-15**] 7:41:32 AM
Sinus bradycardia. Within normal limits. Compared to tracing #3
there is
no significant change.
.
ECG Study Date of [**2173-12-14**] 7:33:30 PM
Sinus bradycardia. Otherwise, normal tracing. Compared to
tracing #2
atrial fibrillation is no longer present.
.
ECG Study Date of [**2173-12-14**] 2:47:28 PM
Atrial fibrillation with a ventricular response of 101. Compared
to tracing #1 there is improvement in the minor ST segment
depressions in the inferolateral leads and the rate is slower.
.
ECG Study Date of [**2173-12-14**] 1:41:50 PM
Atrial fibrillation with rapid ventricular response.
Inferolateral ST-T wave changes may be rate-related. No previous
tracing available for comparison.
.
EEG Study Date of [**2173-12-16**]
IMPRESSION: Normal EEG in the waking and drowsy states. There
were no
focal abnormalities or epileptiform features.
Brief Hospital Course:
Mr. [**Known lastname 4643**] is a 63 y/o male w/ prodrome, syncope, question of
possible seizure, tranferred to ED found to be hypertensive, in
afib w/ RVR, noted to have nasal laceration, small right frontal
lobe hemorragic contusion on CT head. Patient was evaluated in
ED by cardiology, neurosurgery, and plastic surgery. Given
Dilantin load, Diltiazem for rate control, w/ decision to hold
on aspirin and heparin until pt develops more notable cardiac
symptoms or progression of brain contusion ruled out.
.
#Syncope vs. Seizure: The DDx is wide but is likely syncope
secondary to Afib w/ RVR as pt was found to be in this rhythm in
ED. Pt may have had convulsive syncope. Unclear if pt did indeed
have seizure. Confusion would fit w/ post ictal state, pt did
not lose control of bladder or bowel. Cardiac arrthymia leading
to syncope, very possible given pt was found to be hypokalemic
and severely hypophosphotemic in ED, finding that would
predispose to arrythmia. These metabolic abnormalities by
themselves could have caused the syncope. Syncopal event may
have also been caused by sinus pause. Pt noted to have 4 sec
pause in ICU, but this may have been caused by large amount of
nodal blocking agents given in ED. Vasovagal or hypovolemia may
have also caused event, but not as likely given history, lack of
signs pointing to dehydration. Most likely, syncope was from
atrial fibrillation given he was found to be newly in afib. Per
neuro, seizure activity was likely post-syncopal seizure and
will not likely recur unless he experiences another syncopal
event. He was loaded on phenytoin and discharged with plan to
finish 7 total days of phenytoin followed by a taper. He will
by Mass. state law be unable to drive motor vehicles or operate
heavy machinery for at least months and corroborated this
understanding.
.
#.New onset Afib w/ RVR: Pt denies report of prior Afib, [**2169**].
He reverted to sinus rhythm with dilatiazem and atenolol. He
continued to be controlled with beta blockage and was discharged
on Toprol. Given he had no heart failure by ECHO and his [**Country **]
score is 1, he was not anticoagulated. TSH was normal.
.
#Head Trauma: Brain contusion on Head CT. Repeat CT showed no
change. He was started on aspirin.
.
# CAD: OSH records show stress [**Doctor First Name **] protocol [**2170**], 2mm st
depression at peak exercise resolving w/ recovery. Lipids were
checked showing LDL < 100. + family hx, +tob hx., +male. He was
begun on aspirin as above.
.
#ROMI: Pt unlikely to have MI, given history. Atypical
epigastric pain lasting for several minutes, occuring several
hours prior to syncope. CEs negative x three. EKG changes (ST
depression) resolved with control of RVR.
.
# Chronic Renal Insufficiency: Pt noted to have Cr of 1.2 on
admit, OSH labs from [**2169**] note Cr 1.1.
.
# HTN: Patient has a long standing of uncontrolled HTN. SBP
documented as in 180s in ED. OSH records show no RAS in [**2169**] on
angiogram. He was discharged on his home medications with the
exception of the Toprol as above.
.
# Nose laceration: sutured by plastic surgery. sutures are
absorbable. He was instructed to follow up at the post-surgical
plastics clinic on the Friday after discharge to evaluate
fracture after swelling improves. He was given bacitracin to
the suture line.
.
# L shoulder pain: [**12-18**] to trauma, full passive and active rom,
tylenol for pain, pt does not want opiates, avoid nsaids and
asa, given brain contusion. Shoulder xray showed no
fractures/dislocations but showed degenerative changes of the AC
joint.
.
# Code Status: Full
.
# Communication:
[**Name (NI) 2048**] Sister home [**Telephone/Fax (1) 76623**], cell [**Telephone/Fax (1) 76624**]
HCP is son, away on vacattion
Medications on Admission:
Lasix 20mg Daily
Avapro 300mg Daily
Atenolol 100mg Daily
[**Doctor First Name **] 180mg daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
Disp:*20 Tablet(s)* Refills:*0*
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
three times a day: until seen by Plastic surgery on [**2173-12-24**].
Disp:*1 tube* Refills:*0*
4. Toprol XL 200 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 4 days: Through [**2173-12-20**].
Disp:*10 Capsule(s)* Refills:*0*
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO twice a day for 1 days: Take for one day on [**2173-12-21**].
Disp:*2 Capsule(s)* Refills:*0*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: [**11-17**] Capsule PO
twice a day for 1 days: For only one day on [**2173-12-22**].
Disp:*1 Capsule(s)* Refills:*0*
8. Avapro 300 mg Tablet Sig: One (1) Tablet PO once a day.
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
atrial fibrillation, paroxysmal
Syncope
Post-syncopal convulsion
Discharge Condition:
Good, in NSR
Discharge Instructions:
You were seen at [**Hospital1 18**] after a fall with loss of consciousness.
You also had seizure activity. A head CT showed a brain
contusion, which was stable on repeat head CT. You were found
to be in a rhythm called atrial fibrillation, which reverted
back to a normal rhythm. You also had an ECHO cardiogram, which
showed essentially normal heart function, therefore, you will
not need a blood thinner. You should, however, use 325mg of
aspirin daily. Please do not take excedrin in addition to 325mg
tablets of aspirin since excedrin has aspirin in it.
.
You also had an EEG, which showed normal brain function.
Because you had a seizure, Massachusettes law prohibits you from
driving a vehicle for at least 6 months. You should also avoid
high places, ladders, roofs, or any place that you may be
seriously hurt if you had a seizure. We started you on a
medication for seizure prophylaxis called phenytoin. You will
complete a total of 7 days, then taper by 100mg per day as per
your prescriptions.
.
Please continue using bacitracin on your suture wound 2-3 times
per day. Your sutures are absorbable and will not need to be
removed. Please follow up in the Plastic and Reconstructive
Surgery Clinic as below.
.
Please call your primary care physician or return to the
emergency department if you experience shortness of breath,
light headedness, loss of consciousness, chest pain,
numbness/tingling/weakness in any part of your body, difficulty
speaking, facial droop, headache, fever greater than 101.5
degrees F, or any other symptoms that concern you.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 19961**], MD. Phone:[**Telephone/Fax (1) 33016**]
Date/Time:[**2173-12-28**] 5:00pm.
.
Please follow-up with the Plastic and Reconstructive Surgery
Clinic next Friday [**2173-12-24**]. We were unable to get you an
appointment at the clinic. Please call [**Telephone/Fax (1) 4652**] on Monday
to schedule the appointment for Friday.
|
[
"276.8",
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"403.90",
"802.1",
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"478.19",
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icd9cm
|
[
[
[]
]
] |
[
"21.81"
] |
icd9pcs
|
[
[
[]
]
] |
13312, 13318
|
8283, 12036
|
329, 335
|
13427, 13442
|
3594, 8260
|
15064, 15473
|
2791, 2908
|
12180, 13289
|
13339, 13406
|
12062, 12157
|
13466, 15041
|
2923, 3575
|
253, 291
|
363, 2276
|
2298, 2370
|
2386, 2775
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,081
| 116,846
|
4013
|
Discharge summary
|
report
|
Admission Date: [**2105-3-20**] Discharge Date: [**2105-3-25**]
Date of Birth: [**2026-6-26**] Sex: F
Service: MEDICINE
Allergies:
A.C.E Inhibitors
Attending:[**First Name3 (LF) 2234**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
NG tube placement
History of Present Illness:
78 yo female with h/o DM,HTN, PVD, who presented with two days
of feeling unwell. She was unable to urinate x2 days and has not
had a BM in the last day. Today she stood up and syncopized
after attempting to have BM and was unresponsive. EMS was called
and SBP was in the 90s with HR initially in the 60s and trending
down to the 50s. She was also c/o epigastric pain.
On arrival to the [**Hospital1 18**] ER, the pt immediately syncopized.
Her HR decreased to the 30s-40s and SBPs decreased to the
50s-70s. EKG demonstrated a junctional rhythm. She received 0.5
mg of atropine x 2, glucagon 5 mg x1 and IVFs wide open, for a
total of 6L NS. This resulted in improvement of HR and BPs.
Labs demonstrated an elevated lactate as high as 5.2 and
potssium of 8.2. She was treated with sodium bicarb, calcium
gluconate, insulin and D50 x2. She also received 30 mg PO
kayexalate. Repeat K was 6. Renal was called and UA appeared
c/w pre-renal etiology. Of note, when foley was placed
initially, only 100 cc of urine was drained. She later had a
total of 200-300 cc of UOP after 6L of NS.
Additionally, she was on a NRB during her time in the ER and
then her sats dropped to the 70s-80s. She was thought to be
volume overloaded,so started on bipap with improvement in sats.
She was also started on cefepime, flagyl and levofloxacin to
cover PNA and possible abdominal infection. Of note, she had a
non-contrast CT of the abdomen, which demonstrated possible
thrombosis of the SMA and heterogenous attenuation of the liver.
CT of the chest demonstrated possible b/l PNA. She was
evaluated by surgery who did not think there was any surgical
intervention indicated at the time. She was stable on bipap and
trasnferred to the MICU.
.
Upon speaking with pt in the MICU (grandson translating), she
has been feeling crampy abd pain for several days. Her biggest
complaint is that she tried to have a BM but was unable. Upon
questioning she stated she had worse lower back pain and some
substernal CP over the lsat week. CP is a substernal, pressure
that improved with exertion and was intermittent. She denied
diaphoresis, SOB, f/c.
.
Upon further discussion with the patient and family, it was
discovered the patient had been taking high dose NSAIDS for
several days prior to admission.
Past Medical History:
1. Non-insulin-dependent diabetes mellitus.
2. Hyperlipidemia.
3. Hypertension.
4. Gastroesophageal reflux disease.
5. Backpain-lumbar radiculopathy
6. Osteoporosis
7. PVD: s/p right leg angiogram
6. Admit in [**2099**], s/p syncopal event and fall, after which she
had backpain, constipation, abdominal distention and urinary
incontinence. Had spinal MRI with T1/T2 lesions c/w hemangioma
and T12 compression fx. Several disc bulges were noted but no
cord compression. Also had narcotic ileus.
Social History:
The patient denies alcohol or tobacco use. She lives in
[**Location 686**] with her family. She is [**Location 11543**]
and speaks Creole dialect.
Family History:
N/C
Physical Exam:
VS: T: 98.9 BP: 141/65 HR: 59 RR: 21 O2 sat: 94% on 6L NC
Gen: well appearing, pointing to her abdomen
HEENT: anicteric, dry MM
Neck: supple, obese
Pulmonary: exp wheezes b/l, moving air well
Cardio: bradycardic with regular rate
Abd: soft, very distended, NT, +BS
Ext: 1+ edema b/l
Neuro: pt mentating and moving all extremities
Pertinent Results:
Echo [**7-2**]: The left atrium is normal in size. 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 aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CT abd/chest w/out contrast (PRELIM READ): Limited study for
evaluation of bowel ischemia in the absence of IV contrast.
Heterogenous attenuation of the liver, with large geographic
areas of low attenuation, may reflect fatty change but in the
appropriate clinical setting, ischemia or inflammation are
alternative possibilities.
Focal hyperdense segment of SMA, occasionally associated with
acute thrombus. [**Month (only) 116**] be further evaluated with mesenteric vessel
doppler, considering patient's clinical status does not permit
contrast administration.
Bibasilar pulmonary consolidation, aspiration versus bilateral
pneumonia.
.
C. cath [**12-1**]:
1. Central aortic hypertension
2. Moderarate celiac artery lesion
3. Severe LTPT and PA lesion with one vessel run off to the L
foot via PA
4. successful atherectomy and PTA of the L TPT lesion
5. Successful PTA of the L PA lesion
.
EKG: narrow junctional rhythm with rate of 59, RBBB
Brief Hospital Course:
78 yo female with DM II, HTN, PVD, admitted to MICU ([**Date range (1) 17717**])
with ARF and resulting syncope in setting of high dose
ibuprofen.
.
# Acute Renal Failure: Admitted with a creatnine of 2.4 and
severe hyperkalemia. FENa 0.23% c/w pre-renal etiology. Also in
setting of high dose NSAID use, with likely resultant decrease
of renal blood flow. Resolved with IVF. She will have a renal
function check in 1 week. If her renal function is stable at
that time, she will resume her [**Last Name (un) **]. She received clear
instructions to avoid NSAIDs in the future.
.
# Syncope: Likely secondary to high junctional rhythm and
multiple metabolic derranagements on admission. With high
junctional rhythm at the time of syncope in ED, with
hyperkalemia to 8, treated with atropine, gluccagon, insulin,
bicarb and calcium. No further events on telemetry in the MICU.
BB and CCB initially held in the MICU, BB reintroduced and
tolerated well. CCB being held in the setting of bradycardia.
.
# Hypoxia: In the ED with desaturation to 70-80%, requiring
facemask. Treated initially with levofloxacin and flagyl until
[**3-22**]. Also diuresed with concern for volume overload. On room
air throughout the remainder of her hospitalizaiton. Suspect
that acute desaturation in ED is secondary to aspiration
pneumonitis (bilateral infiltrates seen on CT scan) in setting
of syncope and altered mental status. ECHO for w/u of syncope
revealed e/o RV hypokinesis. Subsequent CTA was negative for
PE.
.
# Hypertension: In MICU with SBP 170s. Reintroduced home regimen
of BB without complications. However, she was noted to have
junctional rhythm on admission (see below) and thus her
diltiazem was discontinued. Her [**Last Name (un) **] was held in the setting of
renal failure. Norvasc was started for BP control.
.
# Pulmonary Hypertension: Unclear etiology. No smoking history,
no evidence of PE on CTA. Clinical history not suggestive of
sleep apnea. She would benefit from a pulmonary follow up as
outpt for further w/u of her pulmonary hypertension.
.
# Abdominal Distension: With self-reported constipation, and
abdominal distension in the MICU. NGT placed and discontinued in
MICU. Abdominal exam remained benign. Treated initially with
levofloxacin and flagyl empirically ([**Date range (1) 17717**]); all antibiotics
discontinued since then. Her distension likely reflects ileus
versus constipation. She tolerated a regular diet on discharge.
.
# Transaminitis: AST/ALT 400s on admission, continued to trend
down. Suspect component of ischemic hepatopathy with junctional
rhythm and hypotension. But also with question of fatty liver on
CT scan. If her LFTs continue to be elevated, further w/u with
[**Name (NI) 5283**] son[**Name (NI) **] as an outpt is recommended.
.
# Question of SMA thrombosis: Question of SMA thrombosis on CTA
scan on admission. Clinical picture did not seem c/w acute
mesenteric artery thrombosis. She remained abdominal pain free
and without changes in her bowel habits. She was continued on
her outpt regimen of ASA, plavix, statin for her history of PVD.
Medications on Admission:
Amitriptyline 20 mg qhs
Atenolol 25 m daily
Atorvastatin 10 mg daily
Plavix 75 mg daily
Diltizaem 120 mg q12 hour
Gabapentin 300 mg [**Hospital1 **]
Glucophage 1000 mg [**Hospital1 **]
Vicodin 5-500 mg tab q 6-8 hrs prn
Ibuprofen 600 mg q6 hours prn
Insulin SS
Lantus 68 units sc daily
Lyrica 50 mg TID
Protonix 40 mg qod
Valsartan 160 mg daily
ASA 325 mg daily
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
3. Aspirin 325 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. Insulin Glargine Subcutaneous
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO tid ().
8. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed.
Disp:*30 Tablet(s)* Refills:*0*
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 17718**] Health Care
Discharge Diagnosis:
Primary
Acute renal failure
Hyperkalemia
Ileus
Transaminitis
Bradycardia, junctional rhythm
Secondary
Anemia
Hypertension
Type II Diabetes mellitus
Peripheral vascular disease
Hyperlipidemia
Vertigo
Discharge Condition:
good, tolerating POs, saturating on room air
Discharge Instructions:
You were admitted with kidney failure. You were found to have
elevated levels of potassium. You were treated with hydration
and your kidney function normalized. You also had a low heart
rate from an elevated potassium. All of these issues normalized
once your kidney function improved.
It is very important that you discontinue your pain medications
including ibuprofen, tylenol and other pain medications such as
vicodin with opioid properties (such as oxycodone, percocet,
etc). Your amitriptyline was also discontinued. Your lorsartan
was discontinued because of your recent contrast administration
with CT scan. This should be restarted by Dr. [**Last Name (STitle) **] as an
outpt. Your diltiazem was also discontinued. You were started
on a medication called norvasc. Please take all of your other
medications as directed.
Please return to the emergency room or see your PCP if you have
any of the following symptoms:
Chest pain, difficulty breathing, palpitations, loss of
consciousness or any other serious concerns.
Followup Instructions:
We have scheduled the following appointment for you with Dr.
[**Last Name (STitle) **]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]
Date/Time:[**2105-4-3**] 12:45
It is important that you have the following labs drawn at your
appointment with Dr. [**Last Name (STitle) **]:
Chem 7 and LFTs. You are being given a requisition to have
these labs drawn.
You should also schedule an appointment with pulmonary clinic in
the next 1-2 months. They can be reached at ([**Telephone/Fax (1) 513**].
Completed by:[**2105-4-9**]
|
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20,263
| 148,417
|
54198
|
Discharge summary
|
report
|
Admission Date: [**2197-10-18**] Discharge Date: [**2197-10-31**]
Date of Birth: [**2132-7-5**] Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Shortness of breath
Productive cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 65 year old female with PMH significant for multiple
drug resistant PNAs, asthma/COPD s/p multiple intubations on
2.5L of home O2, pulmonary hypertension, diastolic heart
failure, morbid obesity, OSA (not compliant with CPAP), aortic
stenosis with valve area of [**2-3**].2 cm2), atrial fibrillation off
Coumadin due to GI bleed, and HTN presenting with worsening
cough over the last 4 days, worsening shortness of breath, and
new greenish sputum production. Per patient, up until then, she
was doing very well and was about to be discharged home.
However, she then developed cough that became productive
yesterday and SOB worsened yesterday as well. No immediate sick
contact except a roommate's husband who has been coughing and
visiting frequently in the rehab. She mentioned that her
temperature was recorded at 99.7 and her baseline usually runs
around 96. She also says that she has had tremors that have
started yesterday as well. She noticed mild tremor at rest and
also jerky movements when she moves her arm.
She mentioned that her baseline home O2 was around 3L prior to
her last admission. She was discharged last time with around 3L
of O2, but at the rehab they adjusted it downward to 2L because
her CO2 was higher for concern of CO2 retention. However, since
then, she has been feeling a little more SOB then normal.
In the ED, initial vs were: T=99.4, HR=90, BP=124/62, RR=20,
POx= 98% on 4L. Per the ED her CXR showed new infiltrates
bilaterally and she was thought to have a PNA. She was given
nebs and started on Levofloxacin and cefepime. Prior to leavinig
the ED her vitals were T=98, HR=92, BP=99/54, RR=25, POx=97% 4L
(on 2.5L at home)
On the floor, the patient endorses that these are her usual
symptoms when she gets a PNA. What is new is her tremor (but
per patient, she had this one time in the past wher her blood
cell count was low). She also reports mild gas pains in her
abdomen and a headache. She did feel lightheaded at her rehab
when she got up to go to the bathroom.
Past Medical History:
- Hypertension
- Diastolic heart failure, LVEF > 55%, [**8-/2197**]
- Asthma (since childhood)/COPD s/p multiple intubation: 3L NC
(since [**2172**]) at baseline for Sat 91-95%, last PFT 6m- 1 yr ago
at the lab next to [**Hospital6 28728**] in [**Hospital1 3597**]
- Obstructive sleep apnea, not compliant with CPAP
- Moderate pulmonary HTN, PCWP > 18
- Atrial fibrillation on beta blocker, no anticoagulation due to
history of GI bleeding
- Aortic stenosis (valve area 1.0-1.2 cm^2)
- Gastroesophageal reflux disease
- Anemia (history of GI bleeding)
- Leukopenia, long standing, unclear etiology
(of note, trach was once suggested, but refused by patient)
(overnight oximetry "better than expected" when measured at
rehab)
Social History:
- used to live alone until last admission, then has been in [**Hospital 100054**] Rehab for pulmonary rehab
- sister (a nurse) and brother in law live upstairs
- has 3 children, 1 died @ 27 in [**4-/2197**] from asthma complication
- supportive daughter (a [**Name (NI) **]) and son
- quit smoking in [**2172**] (20 pack years)
- denies etoh
- denies illicit drug use
-
h/o asthma since child [**Doctor Last Name **]
on home oxygen 24hrs at 3L since [**2172**]
home oximeter and titrates O2 down to maintain sats 91-95%
no PFTs in many years
sleep study in [**2187**], recommended CPAP, but has not tolerated
trach suggested but pt refused
overnight oximetry "better than expected" when measured at rehab
Family History:
- Father (smoker) with lung ca, died at 62
- mother with cva at 53 and hypertension.
- There is a very strong family history of asthma and her 27
year old son recently passed away ([**4-/2197**]) suddenly from
complications of asthma.
Physical Exam:
Physical Exam on Admission:
Vitals: T: 97.6, BP: 131/75, P: 96, R: 20, O2: 91% 3L
General: Pleasant female, Alert and oriented times 3, able to
speak full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no neck stiffness, difficult to assess JVP given
body habitus
Lungs: Diffusely rhonchorous bilaterally
CV: Difficult to hear heart sounds, but irregularly irregular,
as they are masked by rhonchorous lung sounds.
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding
Neuro: A+Ox3, CN 2-12 intact, motor strength and sensory intact
bilaterally, mild asterixis noted, has a tremor with motion of
her extremity and also at rest, + clonus in the left foot but
may be the tremor as well
Ext: Severe chronic venous stasis changes bilaterally but worse
on the left, erythema and dry scaly skin bilaterally around
calves and ankles, left foot cooler than right. DP 1+
bilaterally
Physical Exam on Discharge: Vitals: T: 96.5 P 77-99 BP
110-123/55-77 RR 18 Sat >95%
I/O [**Telephone/Fax (1) 111066**]
HEENT: NC AT
CV: RRR
PULM: Bilateral coarse breathsounds
ABD: NT ND +BS
LIMBS: RLE dressing CDI
Pertinent Results:
[**Telephone/Fax (1) **]:
- CBC with differential: WBC-4.3 RBC-3.68* Hgb-10.0* Hct-31.4*
MCV-85 MCH-27.3 MCHC-32.0 RDW-15.6* Plt Ct-133* Neuts-76.2*
Lymphs-16.6* Monos-4.5 Eos-2.2 Baso-0.5
- Coags: PT-13.6* PTT-24.6 INR(PT)-1.2*
- CHEM 10 @ 5:40AM: Glucose-112* UreaN-31* Creat-1.2* Na-140
K-4.6 Cl-95* HCO3-40* Calcium-8.8 Phos-5.0* Mg-2.5
- CHEM 7 @ 8:02PM: Glucose-110* UreaN-32* Creat-1.2* Na-143
K-4.8 Cl-95* HCO3-42*
- Cardiac enzymes @ 8:02PM: cTropnT-0.02*
- Lactate-1.2
- UA: Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 Blood-NEG
Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-6.5 Leuks-NEG
[**2197-10-18**]
- blood cultures 2x- no growth
- urine culture- no growth
[**2197-10-19**]
- blood cultures 2x- no growth
- sputum cultures-
GRAM STAIN (Final [**2197-10-19**]):
>25 PMNs and <10 epithelial cells/100X field.
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final [**2197-10-21**]):
MODERATE GROWTH Commensal Respiratory Flora
[**2197-10-20**]
- Cardiac enzymes @ 6:25AM: CK-MB-3 cTropnT-0.02*
- proBNP- 3371*
- blood cultures 2x- no growth
- urine legionella antigen- negative
- sputum cultures- contaminated
[**2197-10-21**]
- LFT: ALT-7 AST-15 LD(LDH)-133 AlkPhos-72 TotBili-0.3
- sputum cultures-
GRAM STAIN (Final [**2197-10-21**]):
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final [**2197-10-23**]):
SPARSE GROWTH Commensal Respiratory Flora.
[**2197-10-24**]
- Cardiac enzymes @ 9:14PM: CK(CPK)-9* CK-MB-1 cTropnT-0.02*
[**2197-10-25**]
- Cardiac enzymes @ 6:00AM: CK(CPK)-10* CK-MB-1 cTropnT-<0.01
[**2197-10-27**]
- CBC with differential: WBC-2.3* RBC-3.52* Hgb-9.5* Hct-30.1*
MCV-86 MCH-26.9* MCHC-31.4 RDW-15.0 Plt Ct-120* Neuts-60.7
Lymphs-29.6 Monos-7.6 Eos-2.1 Baso-0.1
Images:
[**2197-10-18**]
- CXR (portable): Since the prior examination, there is
increased opacification overlying the left lower lobe, likely a
combination of now a moderate-sized left pleural effusion and
atelectasis, though infection is not excluded. There is
worsening right basilar likely atelectasis. There are increased
pulmonary interstitial markings compatible with interstitial
pulmonary edema. The cardiomediastinal contours are stable,
with stable cardiomegaly. There is tortuosity of the thoracic
aorta.
IMPRESSION: Interstitial pulmonary edema with moderate left and
small right pleural effusions and bibasilar opacification,
likely atelectasis, though pneumonia is not excluded.
[**2197-10-20**]
- CXR (portable): In comparison with the study of [**10-18**], there is
persistent enlargement of the cardiac silhouette with evidence
of elevation of pulmonary venous pressure. Bilateral pleural
effusions with compressive atelectasis. There is extensive
opacification in the retrocardiac region, suggesting substantial
volume loss in the left lower lobe.
[**2197-10-21**]
- PICC placement
- CXR (portable): Assess line. Left PICC does not cross the
midline and has a caudal course, left to the mediastinum, most
likely is in a tributary vein, please assess if It is not in an
arterial position. Comparison is made with prior study from
[**10-20**]. Cardiomegaly is stable. The right lower hemithorax
is not included in the film. There is no evident pneumothorax.
Large opacity in the left lower lobe is consistent with collapse
of the left lower lobe. Mild-to-moderate vascular
congestion, bilateral pleural effusions and right lower lobe
atelectasis are stable.
Brief Hospital Course:
(This is a 65 year old female with PMH significant for multiple
drug resistant PNAs, asthma/COPD s/p multiple intubations on
2.5L of home O2, pulmonary hypertension, diastolic heart
failure, morbid obesity, OSA (not compliant with CPAP), aortic
stenosis with valve area of [**2-3**].2 cm2), atrial fibrillation off
Coumadin due to GI bleed, and HTN presenting with worsening
cough over the last 4-5 days, worsening shortness of breath, and
new greenish sputum production consistent with PNA.)
.
This is a 65 yo F admitted for progressive SOB and productive
cough on [**2197-10-18**] and discharged on [**2197-10-31**]
.
# Dyspnea, multifactorial with the recent pneumonia, baseline
COPD, asthma, disastolic heart failure, and OSA. She initially
did well with medical therapy on the inpatient floor with
antibiotics, nebulizers, and asthma therapy. However, on
[**2197-10-20**], patient woke up with increased SOB, subjective
feeling of confusion, and sense of doom. Her O2 Sat was found
to be in the upper 90s on 4 L, which was subsequently dialed
down to 3L, and she was in the upper 80s-low 90s on 3L. ABG was
obtained showing severe CO2 retention (pCO2 130) that was
initially thought to be venous, but confirmed by repeat ABG.
Given patient's history of respiratory distress and requirement
of intubation, she was transferred to MICU ([**2197-10-20**]) for
hypercarbic respiratory failure .Antibiotics were broadened to
levofloxacin, vancomycin, and meropenem. The patient was
started on lasix drip with good response, diuresing ~24-25L of
fluid. She was able to transition from intermittent bipap when
awake, to nasal bipap just when sleeping. While in the MICU,
discussions regarding tracheostomy were had on multiple
occasions but the decision to proceed was defered to another
date due to remarkable improvement in clinical respiratory
status (although the patient and family understand that this
might be the eventual endpoint of her respiratory disease).
Upon transfer from MICU ([**2197-10-28**]), her O2 sats were maintained
in the low 90s to promote increased ventilation, and her ABG was
7.42/69/81/46. On the floor the patient completed her 10 day
course of antibiotics. She tolerated her nasal BIPAP well. She
was discharged home on 10mg of po Prednisone to complete her
taper over the next three days. She should be kept on night time
BIPAP to avoid nocturnal desaturations.
.
# Chronic diastolic CHF, EF >55% (7/[**2197**]). She appeared
dry-euvolemic initially on presentation, but did have
significant LE edema with skin changes consistent with chronic
venous stasis. Her initial weight in hospitalization was 147.87
kgs on [**2197-10-19**]. She received diuresis using lasix drip while
in the MICU, and was net negative 24-25L upon leaving the MICU.
Her weight on [**2197-10-29**] was 119 kg. No echocardiogram was done
during this admission; however it may be helpful to obtain
another one to assess LVEF with improved fluid status. Patient
is maintained at lasix 40mg [**Hospital1 **]. (Of note, patient reported
using torsemide 20 mg [**Hospital1 **] in the past which worked well for
her.) Her fluid status should be monitored closely by daily
weight or strict In's and Out's, and diuretic dosage and be
adjusted accordingly. She will need to have her electrolytes
checked daily for the next several days and repleted prn.
.
# Increased alkalosis. Patient as baseline alkalosis; however,
it went up to > 50 while in the MICU, [**3-7**] to extreme diuresis
the patient went through. She was started on diamox, which
decreased her bicarb, as well as her CO2. On the lfoor her
alkalosis has resolved no near baseline.
.
# Pneumonia. Initial clinical symptoms and signs were
consistent with recurrent pneumonia. She was treated empirically
initially with meropenem given her history of multi-drug
resistant bacterial infection in the past, then later added on
levofloxacin and vancomycin. However, her sputum culture
remained negative or contaminated throughout her stay. Tm was
~100. She completed a 10 day course of vancomycin, meropenem,
and levofloxacin on [**2197-10-29**].
.
# COPD/Asthma. Patient has poor lung function at baseline. Per
patient she had a PFT done in the beginning of this year but not
at the [**Hospital1 **]. She continued with alternative albuterol and
ipratropium in additional to Advair, fexofendine and Singulair.
The patient was started on a prednisone taper prior to transfer
to MICU and was continued on the floor. She should continue to
have a slow prednisone taper 10mg qd for three days following
discharge.
.
# Atrial fibrillation. Patient is rate controlled with
diltiazem and metoprolol. She was transitioned to short acting
diltiazem (360 mg XR) to 90 mg 4 times daily. She has not been
anticoagulated with coumadin given her history of GI bleeding.
.
# Pancytopenia. She was noted to have longstanding pancytopenia
of unclear origin. Cell counts are stable and in line with her
baseline. She is currently on Fe supplement.
.
# Obstructive sleep apnea. Patient had been quite resistant to
using CPAP for OSA. However, during this admission, she was
placed on BIPAP in the MICU, and initially had a tremendous
amount of difficulty due to nasal abrasion. With better fitting
masks, she was able to tolerate increasing amounts of time on
BIPAP.
.
# Deconditioning. Patient was evaluated by physical therapy who
recommended follow up and discharge to a rehabilitational
facility.
,
# Right shin blister. It developed while in the MICU. Patient
has been seen and assesed by wound care who reccomend daily
softsob sponge and kerlex wrap.
#. Code. She was confirmed a full code. Per patient, daughter,
[**Name (NI) 2808**] [**Name (NI) 50388**] [**Telephone/Fax (1) 111067**] is the HCP.
Medications on Admission:
- Furosemide 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): PLEASE ADJUST AS NEEDED. [**Month (only) 116**] need to decrease in next
several days.
- Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: 2
Inhalation DAILY (Daily).
- Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation [**Hospital1 **]
- Combivent 2 puffs [**Hospital1 **] (per patient)
- Combivent 2 puffs q4h prn SOB
- Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
- Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
- Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
- Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO TID (3 times a day).
- Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
- Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
- Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
- Ferrous Sulfate 325 mg One (1) Tablet PO DAILY (Daily).
- Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
- Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day)
as needed for constipation.
- Acetaminophen 325 mg Tablet 1-2 tabs Q6H (every 6 hours) as
needed for pain.
- Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: 10 ML
PO Q6H (every 6 hours) as needed for cough.
- Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
- Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
- KCl 20 mEq daily
- lidoderm patch 5% to right knee
- Flonase 2 sprays in each nostril, daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain, headache.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
4. Calcium Carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID (3 times a day).
5. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: Two (2)
Tablet PO DAILY (Daily).
6. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Liquid Sig: Ten
(10) ML PO Q6H (every 6 hours) as needed for cough.
7. Diltiazem HCl 360 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO at bedtime.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
11. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
1-2 puffs Inhalation once a day.
15. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal [**Hospital1 **] (2 times a day).
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation every
twelve (12) hours as needed for SOB.
17. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
18. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
19. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1122**] Center - [**Hospital1 3597**]
Discharge Diagnosis:
Primary diagnosis:
# Chronic obstructive pulmonary disease exacerbation
.
.
Secondary diagnoses:
# Obstructive sleep apnea
# Diastolic Heart Failure
# Pneumonia
# Acute Kidney Injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
worsening shortness of breath and productive cough. This is
thought to be a pneumonia. You completed a course of antibiotic
treatment and were started on steroids.
.
While you were admitted we made the following changes to your
medications:
We CHANGED your lasix (furosemide) to 40mg twice a day.
We started you on prednisone 10mg once a day. You should take
this medicine for the next 1 days.
.
You should also:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
The rehabilitation facility will draw blood in the next few days
to assess your electrolytes.
Followup Instructions:
Patient was recently restarted on twice daily lasix. Please draw
daily chem 7 for next three days to follow electrolyte levels.
.
Patient will need nightly BIPAP for her obstructive sleep apnea.
If she does not wear this she will desaturate to the 70's
overnight.
.
Patient will need daily weights. Please notify PCP if weight
changes by more than 3lbs.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"416.8",
"428.0",
"V85.4",
"709.8",
"459.81",
"284.1",
"276.3",
"278.01",
"493.22",
"327.23",
"486",
"424.1",
"428.33",
"V15.81",
"518.81",
"584.9",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
18632, 18709
|
8971, 14753
|
305, 312
|
18936, 18936
|
5296, 8948
|
19753, 20237
|
3859, 4095
|
16694, 18609
|
18730, 18730
|
14779, 16671
|
19087, 19730
|
4110, 4124
|
18827, 18915
|
5089, 5277
|
229, 267
|
340, 2369
|
18749, 18806
|
4138, 5061
|
18951, 19063
|
2391, 3118
|
3134, 3843
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,820
| 173,465
|
5827
|
Discharge summary
|
report
|
Admission Date: [**2171-8-31**] Discharge Date: [**2171-9-16**]
Service: MEDICINE
Allergies:
Indomethacin / Ace Inhibitors / Anti-Inflam/Antiarth Agents
Misc. Classf
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
[**Age over 90 **] yo M with a history of dCHF, severe CAD s/p CABG ([**2146**] and
[**2156**]) LIMA->LAD, SVG->LPLB (posterior left ventricular branch),
with numerous PCI's, most recently in [**2166**]. Last PCI [**2167-11-25**]
showed native 3VD, multiple SVG->LPL stenoses, patent LIMA->LAD,
a stent was placed to mid, prox, ostial
SVG (to LPL). He has been managed medically since then.
.
For the past 1-2 weeks, patient has had upper back pain which he
describes as either sharp or pressure. It has been on and off,
and he has a hard time describing what makes it better or worse.
This is quite different from his usual angina, which he hasn't
experienced since his last hospitalization in [**2171-1-27**]. He
saw his Cardiologist on [**8-28**]. This pain was thought to be
musculoskeletal. He denied any other symptoms of orthopnea, PND,
or LE edema, and lungs were clear at that time. [**8-30**] he called
his PCP complaining of SOB. He was instructed to take an
additional lasix.
.
On [**8-30**] patient noticed more dyspnea on exertion just walking
around his [**Last Name (un) **] and getting into bed. He felt like his legs
were heavy, and he was having trouble moving around. Denies any
CP, diaphoresis, nausea, or associated back pain. He called EMS
at that time. EMS administered full dose [**Last Name (un) **], SL nitro x2, and
40mg IV lasix.
.
At baseline, he does not have LE edema, orthopnea, or PND.
Denies fevers, chills, diarrhea, dysuria. Has had more of a
cough recently.
.
Per family, pharmacy accidentally filled imdur bottle with
carvedilol for the past month.
.
.
.
On review of systems, s/he denies any prior history of bleeding
at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. S/he denies exertional buttock or calf pain.
All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, palpitations, syncope or presyncope.
.
.
In the ED, vitals were HR 62 BP 120/47 RR 11 100% on Bipap
(FiO2 of 40%). He was started on a nitro gtt, given IV morphine
and 40mg IV lasix. EKG was unchanged from baseline. He is being
admitted to the CCU for non invasive ventilation, however Bipap
was weaned off on transfer from the ED.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-CAD s/p CABG ([**2146**], [**2156**]): LIMA->LAD, SVG->LPLB (posterior left
ventricular branch), Last PCI [**2167-11-25**]: native 3VD, multiple
SVG->LPL stenoses, patent LIMA->LAD, Stent to mid, prox, ostial
SVG (to LPL)
.
1. Coronary artery disease as noted above.
2. Moderately severe mitral regurgitation.
3. Mild-to-moderate aortic stenosis by echocardiography.
4. Chronic diastolic congestive heart failure with recent
exacerbation on
beta blocker and diuretic therapy. History of intolerance to
ACE
inhibitors and ARBs related to hyperkalemia.
5. Hyperlipidemia.
6. Hypertension.
7. History of ischemic bowel disease and subsequent urgent
right
hemicolectomy subsequent to his last coronary intervention.
8. Chronic anemia -requiring Epo.
- TIA
- GERD
- h/o UGI bleed (no NSAIDs aside from [**Month/Day/Year **])
- Glaucoma
- Carotid stenosis: 60-69% stenosis of the bilateral internal
carotid arteries.
- Myelodysplastic Syndrome s/p BMB in [**2167**], followed by Dr.
[**Last Name (STitle) 2539**]
- Chronic Renal Failure baseline Cr. 1.2-1.4
- Gout
Social History:
Lives with wife has some help that comes in several times a
week. Has 3 children, one son is a retired OB/GYN. Never smoked
cigarettes and rarely smoked cigars, none recently Denies
alcohol consumption. Patient was in the Navy. Retired
businessman.
Family History:
Had family hx of CAD
Physical Exam:
VS: T=96.9 BP=124/54 HR=71 RR=15 O2 sat= 100% on 6L nc
GENERAL: WDWN M in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of just above clavicle.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Harsh systolic murmur loudest at RUSB,
and 4/6 systolic murmur at apex. No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Bilateral crackles
halfway up the bases. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Warm, well perfused. 2+ LE edema bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
On admission:
[**2171-8-31**] 10:01PM TYPE-ART PO2-69* PCO2-78* PH-7.23* TOTAL
CO2-34* BASE XS-1
[**2171-8-31**] 04:58PM GLUCOSE-77 UREA N-80* CREAT-2.0* SODIUM-142
POTASSIUM-3.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
[**2171-8-31**] 10:07AM TYPE-ART PO2-120* PCO2-49* PH-7.38 TOTAL
CO2-30 BASE XS-3
[**2171-8-31**] 02:30AM NEUTS-70.5* LYMPHS-19.9 MONOS-7.2 EOS-2.0
BASOS-0.4
[**2171-8-31**] 02:30AM PT-12.5 PTT-22.4 INR(PT)-1.1
.
On discharge:
[**2171-9-16**] 05:20AM BLOOD WBC-8.7 RBC-3.40* Hgb-9.2* Hct-28.8*
MCV-85 MCH-27.1 MCHC-32.0 RDW-18.0* Plt Ct-248
[**2171-9-16**] 05:20AM BLOOD Glucose-67* UreaN-90* Creat-1.7* Na-136
K-3.9 Cl-100 HCO3-28 AnGap-12
[**2171-9-16**] 05:20AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.5
.
ECHO [**2171-9-2**]:
The left atrium is mildly dilated. No atrial septal [**Month/Day/Year 23115**] is
seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and mild
regioanl LV systolic dsyfunciton with infero-lateral
hypokinesis. The remaining segments are dynamic. There is no
ventricular septal [**Month/Day/Year 23115**]. Right ventricular chamber size is
normal with mild global free wall hypokinesis. 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. Moderate (2+) mitral
regurgitation is seen. 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 [**2171-2-22**],
the LVEF appears slightly better (infero-lateral near akinesis
was present on the prior study but not reported). Otherwise no
change.
.
CXR [**9-6**]:
Interval decrease in extent of perihilar alveolar opacities
consistent with improving edema. Small right pleural effusion
has also
decreased in the interval. Left retrocardiac opacity, presumably
representing
a combination of atelectasis and effusion, has not appreciably
changed.
.
EKG [**9-2**]:
Sinus rhythm. Left axis deviation. Non-specific intraventricular
conduction
delay. Tiny R waves in the inferior leads consistent with
possible inferior
infarction. Tiny R waves in the anterior leads consistent with
possible
prior anterior wall myocardial infarction. Compared to the
previous tracing no
significant change.
.
All micro date negative: Positive MRSA by nasal swab
Brief Hospital Course:
[**Age over 90 **] yo M with a history of dCHF, severe CAD s/p CABG who presents
with worsening dyspnea on exertion, associated with orthopnea,
and lower extremity edema. Patient treated for acute
exacerbation of CHF, primarily through diuresis.
.
# Acute on Chronic Diastolic congestive Heart Failure<br>
Echo from [**2171-1-27**] showed normal systolic function with
diastolic dysfunction. Pt was started on lasix gtt with poor
response, then required bumex gtt to diurese. Started on bumex
PO again after ARF resolving. On RA with good sats. Not
orthostatic over weekend, Bumex restarted and taking once daily.
Pt needs to be followed daily with weights and fluid assessment.
Will need to increase Bumex frequency and dose as pt recovers.
No ACE/[**Last Name (un) **] [**12-31**] hyperkalemia. will cont with Carvedilol [**Hospital1 **].
.
# RHYTHM: Currently in NSR with no significant VEA.
.
# CORONARIES: Patient has known severe CAD s/p CABG and
multiple PCIs. Denies CP, or usual anginal symptoms. EKG
unchanged from baseline. Continued on [**Hospital1 **], Clopidogrel,
Carvedilol, Atorvastatin.
.
# Acute on Chronic renal failure: Current Cr 1.7. Baseline 1.3.
Likely [**12-31**] poor forward flow in the setting of acute
exacerbation of diastolic heart failure. Pts creat also
increased to high of 3.1 after diuresed with Bumex IV. Resolved
slowly with cessation of diuretics and gentle hydration. Pt was
orthostatic and dizzy at this time, now resolved and ambulating
safely. Would recommend following up with PCP and labs for
complete resolution of renal failure, however he may have a new,
higher baseline at this time.
.
# Normocytic Anemia: Patient has known chronic anemia at
baseline thought [**12-31**] myelodysplasia. Followed by Heme as
outpatient, for Epo injections. Rectal exam showed no bleeding
here.
.
# Diabetes type 2: Poorly controlled FS here with high FS at
night and low in am. Lantus [**Month (only) **] to 12 units at HS today with
Humalog sliding scale. Can consider changing Lantus to the am if
BS still cont low at night. Pt should follow diabetic diet.
.
#Glaucoma: Stable. Continue outpatient eye drops
.
CODE: FULL -confirmed with patient
.
COMM: wife [**Name (NI) **] [**Telephone/Fax (1) 23120**]
Medications on Admission:
1. Allopurinol 300 mg po daily
2. Atorvastatin 40mg po daily
3. Brimonidine 0.15 % Drops One Drop Q8H
4. Brinzolamide 1 % Drops, one gtt [**Hospital1 **] ().
5. Clopidogrel 75 mg po daily
6. Latanoprost 0.005 % One Drop Ophthalmic HS
7. Nifedipine 30 mg SR po bid
8. Nitroglycerin 0.4 mg SL PRN CP
9. Aspirin 325 mg po daily
10. Docusate Sodium 100 mg po bid
11. Folic Acid 1 mg po daily
12. Isosorbide Mononitrate 90 mg Tablet Sustained Release 24 hr
po daily
13. Furosemide 80 mg po bid
14. Famotidine 20 mg po daily
16. Epoetin Alfa 20,000 unit/mL Solution Sig: 2ml Injection
once a week.
17. Carvedilol 50 mg po bid
18. Insulin Glargine
Discharge Medications:
1. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day.
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
4. Brinzolamide 1 % Drops, Suspension Sig: One (1) Ophthalmic
[**Hospital1 **] ().
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Latanoprost 0.005 % Drops Sig: One (1) Ophthalmic at
bedtime.
7. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO BID (2 times a day).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
13. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day.
14. Epogen 20,000 unit/2 mL Solution Sig: One (1) syringe
Injection once a week.
15. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily) as needed for constipation.
16. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as
needed for insomnia.
17. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Three (3) Tab Sust.Rel. Particle/Crystal PO once a day for
4 days.
20. Outpatient Lab Work
Please check chem-7, CBC on Wednesday [**2171-9-18**] and call results
to [**Provider Number 23121**]. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14)
units Subcutaneous at bedtime.
22. Bumetanide 1 mg Tablet Sig: One (1) Tablet PO once a day.
23. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
24. XIBROM 0.09 % Drops Sig: One (1) gtt Ophthalmic twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 5277**] - [**Location (un) 745**]
Discharge Diagnosis:
Acute on chronic exacerbation of diastolic congestive heart
failure
Mitral regurgitation
Coronary Artery disease
Acute Renal Failure
Discharge Condition:
Medically stable.
BUN 90, creat 1.7,
Discharge Instructions:
You presented to the hospital for chest pain and shortness of
breath, and were found to be in a heart failure exacerbation,
which means there was too much fluid in your heart and lungs.
You were given medications to remove the fluid with significant
improvement of your breathing, and with resolution of your chest
pain. Blood tests and EKGs did not show you had a heart attack.
An echocardiogram performed during your hospitalization
confirmed that your heart has an abnormal pumping function, and
abnormal heart valves. You will be discharged on medications to
help your heart pump blood and prevent excessive fluid
retention.
.
The following changes were made to your medications:
1. Discontinue lasix
2. Start Bumex which is another diuretic
3. Decrease Nifedipine XL to 30 mg twice daily
4. Decrease Imdur to 90 mg daily
-
.
If you develop any chest pain, shortness of breath, fevers, or
other concerning symptoms, please return to the hospital.
.
Because you have an weak heart, you should weigh yourself every
morning, call Dr. [**First Name (STitle) **] if weight goes up more than 3 lbs in 1
day or 6 pounds in 3 days. Adhere to 2 gm sodium diet
Fluid Restriction: You should drink less than 1.5L per day.
Followup Instructions:
Cardiology:
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2171-9-17**] 11:00
Hematology:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2171-10-18**] 11:00
Primary Care:
Please make an appt to see Dr. [**Last Name (STitle) 172**] when you get out of
rehabilitation
|
[
"428.0",
"414.01",
"365.9",
"584.9",
"285.29",
"403.90",
"250.00",
"428.33",
"272.4",
"V45.81",
"V45.82",
"424.1",
"585.9",
"238.75",
"V12.54",
"530.81",
"433.30",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12642, 12715
|
7629, 9877
|
300, 308
|
12891, 12930
|
5164, 5164
|
14196, 14661
|
4125, 4147
|
10569, 12619
|
12736, 12870
|
9903, 10546
|
12954, 14173
|
4162, 5145
|
2762, 3842
|
5621, 7606
|
241, 262
|
336, 2654
|
5179, 5606
|
2676, 2742
|
3858, 4109
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,807
| 173,742
|
9864+9865
|
Discharge summary
|
report+report
|
Admission Date: [**2145-8-23**] Discharge Date: [**2145-9-7**]
Date of Birth: [**2104-11-11**] Sex: F
Service: [**Company 191**] MEDICINE
HISTORY OF PRESENT ILLNESS: This is a patient well known to
me, she is a 40 year-old Caucasian female with a past medical
history significant for C3-C4 quadriplegia, recurrent
aspiration pneumonias with a history of MRSA positive sputum
with MRSA, chronic pain, anxiety/depression, adrenal
insufficiency, and multiple decubitus ulcers colonized by
Pseudomonas who now presents with recurrent aspiration
pneumonia and hypotension. The patient was recently
discharged from the [**Hospital1 69**] to
rehab on a total fourteen day course of Vancomycin for her
previous aspiration pneumonia. On [**8-22**] the patient was
found unresponsive with agonal respirations and hypoxia with
sats in the 80s after apparently eating popcorn. She was
suctioned by the Emergency Department at the time and corn
kernels were retrieved. On [**8-23**] she was intubated
without complications for a rigid bronchoscopy. Fragments of
popcorn were removed from the left lower lobe rhonchus and
copious white secretions were noted to be within the trachea
and lungs bilaterally.
PAST MEDICAL HISTORY: C3-C4 spinal cord injury after a motor
vehicle accident in [**2139**] with resulting quadriplegia with
some upper extremity use. Gastroesophageal reflux disease.
Depression. Chronic adrenal insufficiency. Recurrent
aspiration pneumonia with a history of MRSA positive sputum.
Chronic low back pain. History of left heel osteomyelitis.
Anxiety. Chronic anemia. Decubitus ulcers colonized by
Pseudomonas.
ALLERGIES: Penicillin and sulfa.
MEDICATIONS ON ADMISSION: Baclofen 5 mg t.i.d., Oxycodone 5
to 10 mg q 8 hours prn, Prednisone 5 mg q.d., Tylenol prn,
Tizanidine 4 mg t.i.d., heparin subQ b.i.d.,
Albuterol/Atrovent nebulizers prn, Colace 100 mg b.i.d.,
Clonazepam 1 mg b.i.d., Dulcolax prn, Zoloft 50 mg q.d.,
Protonix 40 mg q.d., Milk of Magnesia prn, Ambien prn,
vitamin C 500 mg b.i.d., zinc 220 mg b.i.d., iron 325 mg
q.d., Lactulose 30 cc t.i.d., Neurontin 400 mg t.i.d.,
Dilaudid 0.5 to 1 mg intravenous q 3 to 4 hours prn,
Oxycontin 30 mg b.i.d.
SOCIAL HISTORY: The patient apparently smokes five
cigarettes per day. She denies any alcohol or intravenous
drug use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.7. Blood
pressure 120/60. Pulse 54. Respirations 99% on AC 600 times
12 with a PEEP of 5 and 40% FIO2. In general, she was
intubated and sedated at the time and in no acute distress.
Her pupils are equal, round and reactive to light.
Extraocular movements intact. Oropharynx was clear post
intubation. There was no apparent JVD. Neck was supple
without any lymphadenopathy. Lungs were with coarse breath
sounds bilaterally, but with adequate air movement. There
was no wheezing or crackles appreciated. Cardiac examination
revealed a normal S1 and S2 with a brady rate. No murmurs,
rubs or gallops were appreciated. Abdomen was obese, soft
with good bowel sounds. It was noted that she had diffuse
tenderness to mild palpation after she was extubated. Her
extremities were 1+ pitting edema bilaterally. Her back
revealed a stage three sacral decubitus as well as a stage
three posterior thoracic decubitus ulcer. There was good
granulation tissue and no purulent discharge present.
LABORATORIES ON ADMISSION: White blood cell count 9.9 with a
differential of 84 neutrophils, 11 lymphocytes, 3 monocytes
and 3 eosinophils. Her hematocrit was 36, platelets 208,
sodium 150, potassium 3.3, BUN and creatinine of 16 and 0.9.
Urinalysis with moderate blood, moderate leukocyte esterase,
greater then 50 red blood cells, greater then 30 white blood
cells, many bacteria and positive nitrites. Chest x-ray was
stable bibasilar consolidations, revealing no change since
[**8-15**]. Electrocardiogram showing sinus brady in the
40s with normal axis, poor R wave progression and no ST
changes.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern4) 1198**]
MEDQUIST36
D: [**2145-9-7**] 07:53
T: [**2145-9-7**] 08:52
JOB#: [**Job Number 33136**]
Admission Date: [**2145-8-23**] Discharge Date: [**2145-9-7**]
Date of Birth: [**2104-11-11**] Sex: F
Service: [**Company 191**] MEDICINE
HOSPITAL COURSE: Pulmonary: The patient was extubated on
hospital day number two without complications. She was then
transferred to the medicine floor. Her sats remained
excellent on room air. Frequent chest physical therapy with
suctioning was continued. Incentive spirometry was
encouraged to keep the lungs well inflated.
Infectious disease: The patient was continued on intravenous
Vancomycin via her PICC line for her aspiration pneumonia .
She completed a fourteen day course during this admission.
On hospital day number eight the patient developed acute
mental status changes with significant hypothermia with a
temperature of 91.0. As a result intravenous Gentamycin was
started. Blood cultures were drawn, but continued to remain
negative. The patient's white count remained stable
throughout the course of her hospital stay. She was treated
with three days of Cipro for her initial urinary tract
infection while in the Intensive Care Unit. Subsequent urine
cultures came back with greater then 100,000 Klebsiella, but
this was thought to be a colonizer, so no further treatment
was indicated. A bone scan was obtained on hospital day
number eight and was consistent with osteomyelitis. The post
left hip/sacral area and the posterolateral aspect of the
left T8 rib, areas all underlying her stage three decubitus
ulcers. As a result plastic surgery, orthopedics and
infectious disease were all consulted. Since the patient
adamantly refused to undergo a diverting colostomy, it was
determined that there was no role for other surgical
debridement or further antibiotic treatment at this time.
Thus just supportive treatment was continued with b.i.d. wet
to dry dressings for the ulcers and frequent turning on her
air mattress.
Neurological: The Pain Service was consulted and the
patient's Neurontin and Oxycontin were both increased for
better pain control. She was continued on her regimen of
Trazodone, Clonazepam, Baclofen and prn Dilaudid. On
hospital day number eight she developed acute mental status
changes. Head CT at the time was negative for any acute
disease. Her electrocardiogram showed sinus brady with a
questionable new left bundle branch block, so cardiac enzymes
were drawn and came back negative times three. Arterial
blood gas was performed and was unremarkable. Chest x-ray
remained unchanged. The patient's electrolytes were all
stable at the time. Thus in the end it was determined that
her mental status changes were from a narcotic related
delirium. The patient's narcotics were held for three days
and the patient regained her baseline mental status.
Consequently her prn Dilaudid dose was significantly
decreased.
FEN/GI: The patient was given a regular diet with aspiration
precautions. The head of her bed was kept elevated at almost
90 degrees at all times. Her electrolytes were checked on a
regular basis and repleted as needed. She was continued on
her aggressive bowel regimen with Protonix prophylaxis. Her
phosphate continued orthopedics increase toward the later
part of her hospital stay, so she was started on around the
clock calcium carbonate.
Renal: The patient's creatinine slowly began to rise
throughout her hospital stay and was 1.6 on hospital day
number fourteen. Urine electrolytes were checked and her
FENA was calculated to be 2.9%. Although this was not
consistent with a prerenal state, she was given gentle
intravenous hydration with response. All nephrotoxic
medications were avoided. Her urine output continued to
remain excellent with approximately 3 liters per day. Her
mild renal insufficiency still remains of unclear etiology.
Endocrine: The patient was continued on her outpatient doses
of prednisone and Fluticasone for her adrenal insufficiency.
Her blood pressure continued to remain on the low side in the
90s to 100 throughout her hospital stay and her body
temperature also continued to remain on the lower side. This
hypothermia remained of unclear etiology. It was thought to
be possibly due to autonomic dysfunction versus persistent
low grade bacteremia, although all cultures continued to
remain negative.
Hematology: The patient was continued on her iron
supplements. Her hematocrit decreased slightly to 26 on
hospital day number twenty, but this was thought to be
dilutional. She remained guaiac negative. She was continued
on deep venous thrombosis prophylaxis with heparin subQ.
Orthopedics: The patient was moved out of bed to chair as
much as possible. Physical therapy was consulted and
followed the patient closely for frequent range of motion
exercises.
DISCHARGE DIAGNOSES:
1. Osteomyelitis of left hip/sacral area and posterior left
T8 rib per bone scan secondary to stage three decubitus
ulcers.
2. Recurrent aspiration pneumonia status post intubation
with MRSA positive sputum.
3. Persistent hypothermia of unclear etiology.
4. Mild renal insufficiency of unclear etiology.
5. Quadriplegia.
6. Hyperphosphatemia.
DISCHARGE MEDICATIONS: Lactulose 30 cc t.i.d., Neurontin 400
mg q.a.m., 400 mg eight hours later, 800 mg eight hours
later. Baclofen 20 mg q.i.d., vitamin C 500 mg b.i.d.,
heparin 5000 units subQ b.i.d., Colace 100 mg b.i.d.,
Clonazepam 1 mg b.i.d., Fluticasone 0.2 mg q.d., Prednisone 5
mg q.d., Ferrous sulfate 325 mg q.d., Zoloft 50 mg q.d., Zinc
220 mg q.d., Tizanidine 4 mg t.i.d., Protonix 40 mg q.d.,
Oxycontin 60 mg b.i.d., Trazodone 50 mg q.h.s., Tums 500 mg
t.i.d., Tylenol 325 to 650 mg q 4 to 6 hours prn, Dulcolax 10
mg p.r. q.d. prn, Phenergan 25 mg q 6 hours prn, Compazine 5
to 10 mg q 6 hours prn.
DISCHARGE STATUS: The patient was discharged in good
condition back to rehab. She is to remain on a 2 gram low
sodium diet with aspiration precautions at all times. The
head of her bed is to remain elevated at a near 90 degree
angle to prevent further aspiration. She is to continue with
chest physical therapy with frequent suctioning. She is to
remain on an air mattress with frequent turning. She is to
continue to have wet to dry b.i.d. dressing changes for her
decubitus ulcers.
[**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**]
Dictated By:[**Last Name (NamePattern4) 1198**]
MEDQUIST36
D: [**2145-9-7**] 09:04
T: [**2145-9-7**] 10:03
JOB#: [**Job Number 33137**]
|
[
"305.1",
"507.0",
"730.25",
"593.9",
"599.0",
"344.00",
"707.0",
"530.81",
"790.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
2350, 2389
|
9057, 9407
|
9431, 10762
|
1715, 2211
|
4449, 9036
|
188, 1220
|
3446, 4431
|
1243, 1688
|
2228, 2333
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,077
| 104,395
|
41300
|
Discharge summary
|
report
|
Admission Date: [**2113-7-17**] Discharge Date: [**2113-7-20**]
Date of Birth: [**2062-5-23**] Sex: M
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
Witnessed seizure
Major Surgical or Invasive Procedure:
[**2113-7-17**]: Intubation and mechanical ventilation.
History of Present Illness:
Mr. [**Known lastname 8360**] is a 51 year old gentleman with a history of
alcoholism, traumatic brain injury, frequent EtOH withdrawal
seizures, ? epilepsy who is presenting after he was witnessed to
be having a seizure outside the [**Hospital Ward Name 23**] Clinical Center earlier
today.
EMS was called and he was brought to the ED. Not felt to be
seizing when arrived in ED and no clear seizure events since. He
was intubated for airway protection and started on fentanyl and
midazolam. Slight eye deviation to right appreciated on initial
exam. A head CT was relatively unchanged from prior. He was
started him on CTX for a possible UTI. BPs fine, afebrile. Vent
Settings at time of transfer AC 550 x 14 PEEP 5. 2x PIVs for
access. On arrival to the MICU he was intubated and sedated.
Per report, the patient has a long history of alcoholism,
drinking up to 1 pint of vodka every day. He was seen in the ED
the day prior to admission ([**7-16**]) after being found intoxicated
on the ground. At that time he was found to have an blood
alcohol level of 383. Approximately three weeks prior to this
(on [**6-24**]) he was admitted to [**Hospital1 18**] for a seizure in the setting
of alcohol withdrawal. During that admission he was intubated
and extubated without complication. He expressed some interest
in going to detox however then eloped on [**6-28**] prior to any
arrangements being made. He did not have any prescriptions when
he eloped. An attempt was made to contact his sister to locate
him however she was not aware of his whereabouts.
Past Medical History:
1) EtOh abuse, hx of DTs with seizures, previously intubated
2) Essential tremor
3) Epilepsy
4) Incarceration in [**2108**] for 2 years
5) TBI after being hit in head with 2x4 and subsequent seizure
d/o
6) HL not on meds
7) HTN not on meds
Social History:
Patient is homeless, lives with friends and frequently at [**Name (NI) 89924**] Inn, begs on the street for money, has been drinking
"a quart" of vodka since he was 13. Smoked 1pp week for the last
3-4 years. Denies illicits. Has 2 daughters, is estranged from
family.
Family History:
Father died at age 44 from alcoholic complications; mother died
at age 65 from alcoholic complications.
Physical Exam:
ADMISSION PHYSICAL EXAM ([**2113-7-17**]):
Vitals: hr 82 bp 142/94 sat 100% on FiO2 40 550 x 14 PEEP 5
General: Somnolent/heavily sedated/unresponsive
HEENT: pupils constricted but equal and sluggishly reactive to
light, MMM, intubated
Lungs: intubated but clear anteriorly
CV: RR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present
Ext: Warm, well perfused, palpable distal pulses, thick
unclipped toenails, no clubbing, cyanosis or edema.
DISCHARGE PHYSICAL EXAM ([**2113-7-20**]):
PHYSICAL EXAM:
VS - Tm 99.1F, Tc 98.5, BP 100-120/57-75, HR 60-96, R 18, 95-98%
O2-sat % RA.
GENERAL - disheveled, NAD, uncomfortable, in C-collar
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength 5/5
throughout, sensation intact in all extremities. Gait deferred.
Pertinent Results:
ADMISSION LABS:
[**2113-7-17**] 07:48PM BLOOD WBC-3.6*# RBC-4.32* Hgb-13.2* Hct-41.7
MCV-97 MCH-30.5 MCHC-31.6 RDW-14.9 Plt Ct-225
[**2113-7-17**] 07:48PM BLOOD Neuts-76.1* Lymphs-15.4* Monos-6.3
Eos-1.1 Baso-1.2
[**2113-7-17**] 07:48PM BLOOD Glucose-90 UreaN-4* Creat-0.9 Na-143
K-3.8 Cl-104 HCO3-19* AnGap-24*
[**2113-7-18**] 04:44AM BLOOD Calcium-8.3* Phos-1.9* Mg-1.7
[**2113-7-17**] 07:59PM BLOOD Type-ART Rates-14/ Tidal V-550 PEEP-5
FiO2-100 pO2-457* pCO2-35 pH-7.37 calTCO2-21 Base XS--3
AADO2-220 REQ O2-45 -ASSIST/CON Intubat-INTUBATED
[**2113-7-17**] 07:45PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2113-7-17**] 07:45PM URINE Blood-SM Nitrite-POS Protein-30
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-SM
[**2113-7-17**] 07:45PM URINE RBC-6* WBC-51* Bacteri-MOD Yeast-NONE
Epi-0 TransE-<1 RenalEp-<1
DISCHARGE LABS:
[**2113-7-20**] 07:00AM BLOOD WBC-4.6 RBC-4.62 Hgb-14.7 Hct-44.4 MCV-96
MCH-31.8 MCHC-33.1 RDW-14.4 Plt Ct-201
[**2113-7-18**] 04:44AM BLOOD Neuts-80.5* Lymphs-12.1* Monos-5.9
Eos-1.1 Baso-0.3
[**2113-7-20**] 07:00AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-138 K-4.4
Cl-103 HCO3-24 AnGap-15
[**2113-7-20**] 07:00AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9
MICRO:
[**2113-7-17**] UCxr:
URINE CULTURE (Final [**2113-7-19**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
IMAGING:
[**2113-7-19**] C-spine MRI
IMPRESSION:
1. There is no evidence of cervical malalignment, the signal
intensity
throughout the cervical spinal cord is normal with no evidence
of focal or diffuse lesions.
2. Multilevel disc degenerative changes, more significant at
C4/C5, C5/C6 and C6/C7 levels.
[**2113-7-18**] CXR
IMPRESSION: Right lower lobe opacity consistent with pneumonia.
[**2113-7-17**] CT C-Spine w/o Contrast
No evidence of fracture or dislocation.
[**2113-7-17**] CT Head w/o Contrast
No evidence of acute process. Stable encephalomalacia in the
left frontal lobe.
[**2113-7-17**] CXR
Endotracheal tube tip projects approximately 5.5 cm above the
carina. Esophageal catheter tip projects over left upper
quadrant, likely within the stomach. Right costophrenic angle
incompletely imaged.
Brief Hospital Course:
51yo homeless gentleman with an extensive history of alcoholism
and TBI with seizure d/o who has had multiple ED visits and
admissions for ETOH toxicity/seizures who was admitted after a
generalized seizure likely [**12-29**] to alcohol withdrawal
# Alcohol Withdrawal/Abuse: Patient has an extensive history of
alcoholism with multiple admission for alcohol intoxication and
presumed withrawal seizures. Per patient, he drinks 1 quart of
vodka per day since he was a teenager. Patient was maintained on
a CIWA scale while inpatient and did not have significant
symptoms except diaphoresis, he did not receive any diazepam for
over 48 hours prior to discharge. He was treated with thiamine,
folate and multivitamins. He was seen by social work and
provided with detox information and housing resources. He was
evaluated by psych due to concern of capacity/insight/underlying
undiagnosed pychiatric disorder. He was assessed to have
capacity/insight but just makes poor decisions. He was offered a
stay at the [**Doctor Last Name **] House which he declined. Patient expresses
a wish to return to [**State 1727**] as soon as possible and was discharged
to a shelter with information on how to access outpatient
alcohol abstinence programs.
# Seizures: Patient's seizure prior to admission was most likely
due to ETOH withdrawal based on history. He also has a history
of TBI with resulting seizure disorder which likely contributes
as well. He has not taken his prescribed Keppra in 2 years.
Patient did not demonstrate seizure activity throughout
admission. He was restarted on Keppra and discharged with a
prescription.
# C-spine tenderness: Patient has baseline C-spine tenderness
after he was struck by a car in [**2-6**]. He displayed worsening
posterior midline neck pain after his witnessed seizure. He was
maintained in a C-collar throughout admission. C-spine CT and
MRI were negative for acute processes, only degenerative
changes. He was evaluated by neurosurgery who recommended a
C-collar for 4 weeks and follow-up with the spine clinic. We
provided him with the number for the Spine Clinic and he was
discharged with a [**Location (un) 2848**] J collar.
# UTI: Patient's UA was suggestive of a UTI with 51 WBCs,
moderate bacteria, nitrite positive, small leuk. Patient also
had a Foley catheter placed at admission. It was unclear if he
was symptomatic. Urcine culture grew out >100,000 Coag negative
Staph which was pan sensitive. He was treated for a complicated
UTI with IV ceftriaxone for 4 days and discharged on DS Bactrim
until Sunday [**7-23**] for a total of a 7day course.
# Code status: Patient was FULL CODE throughout admission.
# Transitional issues:
-Discharged in [**Location (un) 2848**] J collar with phone number for spine clinic
to follow-up in 4 weeks
-Discharged with prescription for Keppra and asked to make an
appointment with a PCP, [**Name10 (NameIs) **] was given the phone number for [**Company 191**] as
well as the [**Doctor Last Name **] House Primary Care Clinic.
-He was given information on local outpatient alcohol abuse
programs which he expressed some interest in attending
Medications on Admission:
1) Keppra 1000mg PO BID (not taking)
2) Thiamine 100mg PO daily (not taking)
3) Folate 1mg PO daily (not taking)
4) Multivitamin 1 tab PO daily (not taking)
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
2. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth Twice daily Disp
#*60 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*2
5. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please take last dose on Sunday [**7-23**].
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*6 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Seizure, likely secondary to alcohol withdrawal
Alcohol detoxification
Secondary diagnosis:
Acute on chronic cervical spine pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Hi Mr. [**Known lastname 8360**],
You were admitted to the hospital on [**2113-7-17**], because you
suffered a seizure from alcohol withdrawal. You were initially
in the intensive care unit and intubated for protection of your
airway. You were extubated the next day and transferred to the
medicine floor to manage your alcohol withdrawal symptoms. You
did not demonstrate any seizure activity and you did not display
any significant symptoms of withdrawal. You were placed in a
neck collar due to concern for neck injury. While you have
chronic neck pain and your CT and MRI scans were negative for
any damage to your spinal cord, you will need to keep the collar
on for the next 4 weeks. You will need to see a specialist in
the spine clinic at that time.
You were also seen by social work who provided with information
of alcohol abstinence programs and housing resources. You were
also restarted on Keppra to control your seizures. You should
continue this medication and it will be important to avoid
alcohol.
You also had a urinary tract infection which we treated with
antibiotics. Please take Bactrim twice daily until Sunday [**7-23**].
You have expressed wishes to return to [**State 1727**] as soon as
possible. We offered you a short stay at the [**Doctor Last Name **] House, but
you declined.
Followup Instructions:
You should see a PCP [**Name Initial (PRE) 176**] 3-5 days of discharge. The [**Hospital1 18**]
primary care practice phone number is [**Telephone/Fax (1) 2010**]. The [**Doctor Last Name **]
house phone number is [**Telephone/Fax (1) 89925**]. You may also see a PCP in
[**Name9 (PRE) 1727**] if you return there.
If you will stay in [**Location (un) 86**], please follow up with the [**Hospital1 18**]
Spine Clinic in 4 weeks in regards to your neck collar and
cervical spine pain, their phone number is [**Telephone/Fax (1) 8603**]. If you
return to [**State 1727**], please try to see a primary care physician for
management of your health.
|
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icd9cm
|
[
[
[]
]
] |
[
"96.07"
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icd9pcs
|
[
[
[]
]
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|
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287, 345
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3730, 3730
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1952, 2193
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2209, 2479
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,686
| 148,331
|
52902
|
Discharge summary
|
report
|
Admission Date: [**2185-12-5**] Discharge Date: [**2185-12-23**]
Service: MEDICINE
Allergies:
Quinolones / Penicillins / Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
CC: respiratory failure and hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 86-yo-man w/ CAD and HTN presented to [**Hospital3 **] Hospital
[**12-5**] with complaints of progressive weakness and fatigue. He
had an elective hemorrhoidectomy [**2185-11-26**] and has felt weak,
fatigued, and with decreased appetite since d/c from the
hospital. At the OSH, he denied any recent chest pain, dyspnea,
dysuria. He had some rectal bleeding after his surgery, which
has since resolved.
.
At [**Hospital3 **], he was afebrile and HD stable, w/ O2 sat 98% RA.
Labs were significant for HCT 21 (from 35 [**11-26**]), WBC 0.5 (from
4.1), plt 14 (from 107), creat 2.2 (from 2.8 [**11-26**]). He was
transfused 1unit PRBCs, but during transfusion spiked fever to
103F. Transfusion was stopped, rxn labs sent, and pt was given
fortaz (ceftaz) 2mg and clindamycin 600mg empirically in case of
infxn. Abd tenderness prompted abd CT w/ PO contrast only, which
demonstrated mild ascending colitis. After returning to ED, he
developed dyspnea [**2-16**] acute pulm edema. He was treated initially
w/ lasix 40mg IV, O2, and nitropaste, w/ no improvement after 20
minutes, prompting intubation. He was then given 2mg ativan,
50mcg fentanyl, and flown to [**Hospital1 18**] for further care.
.
At [**Hospital1 18**], initial vitals were T 102, HR 110, BP 96/41 on CMV
650x12/100/5, w/ ABG 7.32/27/138. Lactate was 8.3. His BP
started to trend down despite 2L NS, w/ nadir 70s/30s. RIJ was
placed, CVP was 14, levophed gtt was started, and the pt was
transfused 2units PRBCs and 1unit plt. Patient was then admitted
to the MICU for further management.
.
Past Medical History:
PMH:
1. CAD: MI at 55yo, s/p multiple PCAs, last 4 years ago
2. HTN
3. Hyperlipidemia
4. Hypothyroidism
5. CRI: baseline creat 2.0
6. Rheumatoid arthritis treated with weekly MTX
7. s/p R glass eye
8. s/p hemorrhoidectomy [**11-19**]
Social History:
SH: lives with his wife in [**Name (NI) 1474**]; retired truck
driver/backhoe operator; smoked but quit 35 years ago; no
alcohol or IVDU.
Family History:
FH:
CAD: mother had MI at 53
No h/o cancer, no leukemia or lymphoma
Physical Exam:
PE: T 96.8, HR 72, BP 143/66, O2 sat 96% RA
Gen: elderly man, hard of hearing, NAD
HEENT: anicteric, L pupil 4mm-->2mm w/ light, OP clear
JVP difficult to assess given RIJ
CV: distant heart sounds, reg s1/s2, no s3/s4/m/r
Pulm: CTAB, no wheezes or crackles anteriorly
Abd: obese, +BS, NT, distended, tympanic
GU: scrotal edema, foley in place
Ext: warm, 2+ DP B, anasarca
Neuro: moving all extremities
.
Pertinent Results:
[**2185-12-5**] 10:38PM TYPE-MIX TEMP-36.1 PH-7.23*
[**2185-12-5**] 10:38PM LACTATE-2.8* K+-3.8 TCO2-18*
[**2185-12-5**] 10:38PM O2 SAT-75
[**2185-12-5**] 10:28PM CK(CPK)-104
[**2185-12-5**] 10:28PM CK-MB-4 cTropnT-0.07*
[**2185-12-5**] 10:28PM CORTISOL-36.2*
[**2185-12-5**] 08:58PM LACTATE-3.4*
[**2185-12-5**] 06:45PM TYPE-MIX
[**2185-12-5**] 06:45PM LACTATE-5.6*
[**2185-12-5**] 06:40PM TYPE-ART PO2-138* PCO2-27* PH-7.32* TOTAL
CO2-15* BASE XS--10 INTUBATED-INTUBATED
[**2185-12-5**] 06:40PM O2 SAT-97
[**2185-12-5**] 05:50PM GLUCOSE-179* UREA N-31* CREAT-2.5* SODIUM-138
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-15* ANION GAP-20
[**2185-12-5**] 05:50PM LD(LDH)-253*
[**2185-12-5**] 05:50PM ALT(SGPT)-75* AST(SGOT)-55* CK(CPK)-93 ALK
PHOS-50 AMYLASE-55 TOT BILI-0.7
[**2185-12-5**] 05:50PM LIPASE-17
[**2185-12-5**] 05:50PM ALBUMIN-2.6* CALCIUM-6.6* PHOSPHATE-2.6*
MAGNESIUM-1.5*
[**2185-12-5**] 05:50PM HAPTOGLOB-216*
[**2185-12-5**] 05:50PM NEUTS-0* BANDS-0 LYMPHS-88* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0 NUC RBCS-20* OTHER-8*
[**2185-12-5**] 05:50PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-1+ BURR-1+ ACANTHOCY-1+
[**2185-12-5**] 05:50PM PLT COUNT-25*
[**2185-12-5**] 05:50PM PT-13.6* PTT-25.8 INR(PT)-1.3
[**2185-12-5**] 05:50PM CD33-DONE CD45-DONE CD13-DONE CD19-DONE
[**2185-12-5**] 05:50PM FIBRINOGE-384
[**2185-12-5**] 05:50PM CD34-DONE
[**2185-12-5**] 05:50PM IPT-DONE
[**2185-12-5**] 05:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020
[**2185-12-5**] 05:50PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.5
LEUK-NEG
[**2185-12-5**] 05:50PM URINE GRANULAR-[**3-19**]* HYALINE-0-2
[**2185-12-5**] 05:50PM URINE RBC-[**3-19**]* WBC-0-2 BACTERIA-MANY
YEAST-NONE EPI-0-2
[**12-9**] CXR:
some mild persistent pulmonary edema. No consolidations are
present. No pleural effusions are present.
.
Abd CT (Caritas [**Hospital3 **], [**2185-12-5**]):
1. ? mild colitis ascending colon
2. no obstruction, no free air, small bilateral pleural
effusions
.
Head CT (Caritas [**Hospital3 **], [**2185-12-5**]): normal per report
.
Brief Hospital Course:
Patient also thought to have SIRS based on leukopenia, fever and
tachycardia and was treated with broad spectrum abx x 7d.
Patient also found to be pancytopenic on presentation and was
treated with Leucovorin on the recommendation of Heme/onc. Acute
on chronic renal insufficiency resolved with IVF.
.
A/P: 86-yo-man w/ CAD, HTN, hypothyroidism transferred from OSH
w/ respiratory failure and hypotension likely [**2-16**] TRALI w/ SIRS,
now improved.
.
1. TRALI: The patient developed acute onset of pulm edema after
transfusion, arterial PO2<200 w/ FIO2 100%, and bilateral pulm
infiltrates on CXR. The patient required ventilatory support
initially but was successfully extubated [**12-9**] and was
transferred from the MICU to the floor with adequate O2sats on
RA.
.
2. SIRS: In the MICU the patient initially met criteria for
based on fever, low WBC, and tachycardia. There was no clear
source of infxn to dx sepsis. Urosepsis was thought to be the
most likely source given many bacteria on UA; a lack of WBCs on
UA may still be c/w UTI as his WBC was too low to mount immune
response. The patient was initially started on an amiodarone
drip to control his tachycardia. He was eventually transitioned
to metoprolol po. He was treated w/ broad spectrum abx including
ceftaz to cover Pseudomonas in setting of febrile neutropenia in
MICU and completed a 7 d course of Ceftazadime and Flagyl. The
patient's fever and tachycardia resolved.
.
3. Hypotension: On admission to the MICU, the patient was
hypotensive in the setting of SIRS, which resolved. His
hypotension may have also been related to hypovolemia given his
decreased PO intake prior to admission. His [**Last Name (un) 104**] stim revealed
inadequate adrenal response and he was treated with
fludrocortisone and hydrocortisone x7d in MICU. He was
transitioned to Prednisone and was tapered off it on the floor.
.
4. Pancytopenia/Subsequent leukocytosis: On admission the pt had
a WBC of 0.4, hct of 19.2, plt of 25. Per his outside records,
the pt pancytopenia developed over the 10 days prior to
admission, which was concerning for possibility of drug effect
(MTX for arthritis) vs infectious process (CT unrevealing for
source) vs malignancy w/ marrow infiltration, i.e. leukemia or
lymphoma. Per heme/onc's recs, the patient treated with
leucovorin in MICU ([**2105-12-7**]). Following treatment his counts
recovered (though he still remained somewheat anemic; hct in the
low to mid 30s). Eventually the pt developed a leukocytosis. His
wbc peaked on [**2185-12-14**] at 40.1. It trended down to 15.9 on the
day of discharge. Infection seemed unlikely as the pt was
afebrile and had just been treated with broad spectrum
antibiotics. By this point his lungs were clearing on exam and
he exhibited no signs of C diff. More likely on the differential
was marrow recovery following leukovorin rescue vs. stress
response to episode of TRALI vs. some other hematologic
abnormality. Heme/onc was consulted. They felt that early CML
may be a possibility. Out-pt follow-up was recommended and
arranged.
.
5. Anemia: The pt was initially anemic as above, but his hct
stabilized. His iron studies were consistent with anemia of
chronic disease. No transfusions were given as hct remained
stable.
.
6. hemorroids/GIB--On [**2185-12-15**], the pt experienced two large
[**Last Name (un) 12376**] movements with bright red blood and dark clots present.
His hct lowered but never below 30. He was evaluated by GI, who
were unable to examine the pt due to tenderness of his known
hemorroids. Surgery was consulted for potential examination
under anaesthesia, but the pt's GI bleeds stopped and he was
moving his bowells. His BMs continued to be OB positive, but
this was unsurprising given his known hemorrhoids. His hct has
been stable. Surgery will f/u with the pt as an out-pt for
possible examination and further w/u.
.
7. mental status changes: Later in the admission, the pt
exhibited some nocturnal delirium and depressed mood during the
daytime. Upon speaking with the pt's wife, she believed that his
depression were related to his hospitalization. Upon speaking
with the pt, he denied suicidal ideations but did appear to be
suffering from a reactive depression. He was started on an SSRI.
His mood has been improving and he has appeared more interactive
during the latter days of his hospitalization.
.
8. h/o CAD: The pt had no symptoms of ischemia recently and had
no EKG changes on admission. ASA was initially held for bleeding
concern, now restarted. Otherwise he was cotinued on lopressor,
statin, ASA, and an ACE-I.
.
9. Hypothyroidism: continue levothyroxine. TSH 17 ([**12-8**])-
increase levothyroxine to 100mcg (outpatient regimen).
.
10. CRI: The pt's baseline creatinine is 2.0 per OSH notes,
likely [**2-16**] HTN nephropathy. His creat was elevated on admission,
likely prerenal after decreased PO intake over past week. The
pt's cr returned to baseline shortly after admission and
remained stable.
.
11. Sacral decubiti: stage I and II. Wound care was consulted.
He was treated with daily miconazole powder to open areas, f/b
double guard cream.
12. FEN: He has been tolerating a ground regular cardiac
healthy/renal diet. His lytes were followed and repleted prn.
.
13. Ppx: pneumoboots, PPI, bowel regimen throughout admission
.
14. Communication: wife and daughter and PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17918**]: [**Street Address(2) 109066**]., [**Apartment Address(1) 109067**], [**Hospital1 1474**], [**Numeric Identifier 109068**]; phone [**Telephone/Fax (1) 17919**];
fax [**Telephone/Fax (1) 87528**]. Of note, pcp held [**Name Initial (PRE) **] discussion with the MICU
house officer on [**2185-12-7**]. During their coversation, Dr. [**Last Name (STitle) 17918**]
let her know that prior to pt's hemorrhoids and hemorrhoid
surgery and subsequent transfusion requirement, the patient
accidentally received Lomotil instead of Levoxyl due to a
medication error to do with the similar sound and appearance of
the drugs. A sequela of this was the pt's hemorrhoids, which led
to surgery and subsequent blood loss and transfusion. This in
turn led to TRALI, which led to transfer to [**Hospital1 18**] MICU. The
pharmacist on the MICU team, [**Doctor Last Name **], is ensured that this was
properly documented.
.
15. Full code: confirmed w/ wife
Medications on Admission:
Home Meds:
1. metoprolol 100mg [**Hospital1 **]
2. lisinopril 10mg daily
3. simvastatin 10mg daily
4. levothyroxine 100mcg daily
5. anzemet 12.5mg q 6 hours prn nausea
6. ibuprofen 600mg q 6 hours
7. dibucaine ointment to perirectal area daily
8. pramoxine + hydrocort ointment to perirectal area daily
9. methotrexate 2 tabs q Thursday
10. actanol: started months ago, stopped 1 week ago
.
Meds on Transfer to the [**Hospital1 18**] MICU:
Metoprolol 100 mg PO BID
Levothyroxine Sodium 50 mcg IV
Acetaminophen
Bisacodyl PRN
Docusate Sodium 100 mg PO BID
Pantoprazole 40 mg IV Q24H
Hydrocortisone Na Succ. 100 mg IV Q8H
Simvastatin 10 mg PO DAILY
Sliding Scale
Discharge Disposition:
Extended Care
Facility:
Baypointe - [**Hospital1 1474**]
Discharge Diagnosis:
Primary: Transfusion related lung injury, hemorroid associated
GI bleed
Secondary: CAD, HTN, hyperlipidemia, hypothyroidism, CRI, RA,
Discharge Condition:
stable, the patient's pulmonary status is stable. He is
hemodynamically stable.
Discharge Instructions:
Please contact the patient's PCP or send him to the ED if he
experiences:
--fever or chills
--bloody stools or black stools
--abdominal pain
--chest pain or shortness of breath
The patient should follow-up with his HEME/ONC, Surgery and PCP
appointments as below.
The patient should take all his medications as prescribed.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**]
Date/Time:[**2186-1-4**] 10:30
Provider: [**Name10 (NameIs) **],HEM/ONC HEMATOLOGY/ONCOLOGY-CC9
Date/Time:[**2186-1-4**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], MD Surgery [**Telephone/Fax (1) 109069**]
Date/Time:[**2185-12-27**] 9:30
PCP: [**Last Name (NamePattern4) **]. [**Known firstname 122**] [**Last Name (NamePattern1) 17918**]. [**2185-12-30**] at 2:45 pm. [**Telephone/Fax (1) 17919**]
|
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icd9cm
|
[
[
[]
]
] |
[
"96.71",
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icd9pcs
|
[
[
[]
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5062, 11424
|
296, 302
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12372, 12454
|
2833, 5039
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12828, 13398
|
2322, 2393
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11450, 12111
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12478, 12805
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2408, 2814
|
216, 258
|
331, 1893
|
1915, 2150
|
2166, 2306
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,565
| 181,361
|
37246+37247+58134
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2125-6-19**] Discharge Date: [**2125-6-21**]
Date of Birth: [**2062-7-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
acute renal failure
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis
History of Present Illness:
patient is a 62-year-old man with history of hepatitis C/EtOH
cirrhosis (MELD 30) who presents from liver clinic for
evaluation of elevated creatinine. Patient was in his usual
state of health after recent discharge one week prior. He had an
appointment in urology clinic with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] the day prior to
admission for asymptomatic bacteriuria. After that office visit,
he had labs drawn which showed a creatinine of 2.1 (up from
previous 0.9). Labs were also notable for bicarb of 15 with AG
13, white count of 13.4 (up from 8.6), with plts and hct at
baseline. Urine culture from that appointment is pending. Upon
reviewing the labs today with patient in liver clinic, Dr.
[**Last Name (STitle) 696**] admitted him directly for work-up of acute kidney
injury.
.
Of note, patient had been recently admitted [**Date range (1) 54167**] for
worsening abdominal distention, malaise, and guaiac positive
stools. He underwent diagnostic paracentesis that was negative
for SBP. [**Date range (1) **] showed no portal vein thrombosis. At time of
discharge he was restarted on spironolactone 50mg and Lasix
20mg, which he has been taking up until today. The guiaic
positive brown stool was thought to be secondary to portal
hypertensive gastropathy. His hematocrit remained stable.
.
REVIEW OF SYSTEMS: patient currently without pain or discomfort.
Denies confusion. Denies shortness of breath or respiratory
complaints. Denies diarrhea or urinary symptoms.
.
Past Medical History:
HCV and ETOH Cirrhosis: on tranplant list; denies any history of
SBP, encephalopathy or GI Bleed
s/p bilataral CEA for carotid stenosis
Social History:
Lives on [**Hospital3 **] with his wife [**Name (NI) **], works for ocean spray as
fork lift operator and has his own roofing company.
Tobacco: quit 8 years ago, prior smoked for 40 years
ETOH: none for past 21 years
IVDU: none currently
Family History:
N/C
Physical Exam:
Vitals: T 95.3, BP 118/63, HR 57, RR 18, sat 100%RA
General: well-appearing middle-aged man, no distress
HEENT: +scleral icterus
Neck: supple
Chest: RRR, normal s1/s2
Lungs: clear anterior fields
Abdomen: slightly distended, non-tender, no significant ascites
Extremities: no rashes, no edema, warm and well-perfused
Pertinent Results:
[**2125-6-18**] 11:35AM WBC-13.4*# RBC-3.40* HGB-11.9* HCT-36.5*
MCV-107* MCH-35.0* MCHC-32.6 RDW-18.0*
[**2125-6-18**] 11:35AM PLT COUNT-121*
[**2125-6-18**] 11:35AM UREA N-70* CREAT-2.1*# SODIUM-140
POTASSIUM-3.8 CHLORIDE-112* TOTAL CO2-15* ANION GAP-17
[**2125-6-18**] 11:35AM ALT(SGPT)-143* AST(SGOT)-219* ALK PHOS-300*
TOT BILI-22.8*
[**2125-6-18**] 11:35AM CALCIUM-8.6 PHOSPHATE-4.2 MAGNESIUM-2.6
[**2125-6-19**] Lactate:1.2
[**2125-6-21**] 06:41AM BLOOD WBC-5.1 RBC-4.09*# Hgb-11.2* Hct-34.0*
MCV-83# MCH-27.4# MCHC-33.0 RDW-15.6* Plt Ct-348#
[**2125-6-21**] 06:41AM BLOOD Glucose-104* UreaN-16 Creat-1.2 Na-140
K-4.1 Cl-102 HCO3-31 AnGap-11
[**2125-6-20**] 07:05AM BLOOD ALT-91* AST-142* LD(LDH)-188 AlkPhos-182*
TotBili-23.0*
Renal [**Month/Day/Year 950**]: The right kidney measures 10.6 cm and the left
kidney measures 10.9 cm. There is no evidence of stone or
hydronephrosis. A 10 x 9 x 7 mm simple cyst is present within
the upper pole of the left kidney.
Therapeutic paracentesis: Successful aspiration of 3.0 liters of
straw-colored fluid from the right lower quadrant. A portion of
this fluid was sent to the laboratory for Gram stain culture and
chemistries.
Brief Hospital Course:
ASSESSMENT/PLAN: a very nice 62-year-old man with HCV/EtOH
cirrhosis (MELD 30) who presents from clinic with acute kidney
injury after recently starting diuretics.
.
# Acute kidney injury: Most consistent with prerenal azotemia.
Other considerations for acute kidney injury in this man with
underlying cirrhosis were infectious sources, which were
evaluated with CXR, blood/urine cultures, and diagnostic
paracentesis, all of which were unrevealing. Renal [**Month/Day/Year 950**]
without evidence of obstructing stone or mass. Pt's creatinine
improved with fluids.
.
# Guaiac positive brown stool: Pt passed guaiac positive brown
stool. Had recent EGD on [**6-11**] with Grade I varices and portal
hypertensive gastropathy. Therefore not on nadolol. Also had
recent colonoscopy at OSH only notable for polyps. Pt was
hemodynamically stable.
# Cirrhosis: patient has end-stage liver disease. He is active
on the transplant list. This is complicated by abdominal ascites
and hepatic encephalopathy. He was continued on
rifaximin/lactulose. Spironolactone will be restarted day after
discharge. He had therapeutic tap with removal of 3 liters of
ascitic fluid. He recevied albumin 50 grams post tap.
.
# Hypertension: Blood pressure was low; his atenolol dose was
decreased by half. He may need to discontinue this medication if
blood pressures remain low.
# Anemia/thrombocytopenia: stable and at recent baseline.
Medications on Admission:
1. Lactulose 10 gram/15 mL Syrup Sig: Ten (10) ML PO TID.
2. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID.
4. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY.
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QID (4
times a day).
2. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Tablet(s)
3. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. Outpatient Lab Work
Please draw Chem -10 on Monday [**2125-6-25**] and fax results to
[**Telephone/Fax (1) 697**], Attention: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **]
5. Spironolactone 50 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Acute renal failure
Secondary:
Alcoholic cirrhosis
Hypertension
Anemia
thrombocytopenia
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 kidney injury. This was
secondary to being too dehydrated from the diuretic medication.
We gave you some fluid back and your kidney function improved.
We will restart the diuretics at a lower dose to remove fluid
from your abdomen but not affect your kidneys. This is a
delicate balance and may require further adjustment. Please
limit your fluid intake to no more than 2 liters a day.
During your hospitalization, 3 liters of fluid were removed from
your abdomen which reduced the swelling.
Changes to your medication include:
STOP FUROSEMIDE
START SPIRONOLACTONE (Aldactone) 50mg tomorrow ([**2125-6-22**]) and
take 1 tab daily
DECREASE ATENOLOL to 12.5mg daily from 25mg daily ([**12-30**] of your
prior dose as your blood pressure was lower)
Follow up with your regularly scheduled appointments.
Followup Instructions:
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2125-6-25**] 3:00
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 3688**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2125-7-3**] 11:00
Admission Date: [**2125-6-22**] Discharge Date: [**2125-7-1**]
Date of Birth: [**2062-7-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5608**]
Chief Complaint:
hematemesis
Major Surgical or Invasive Procedure:
EGD
Intubation
right IJ placement
History of Present Illness:
62 yo M with a history of ESLD (meld 30) [**1-30**] to hepatitis C and
etoh complicated by grade I varices without history of UGIB, and
lack of SBP or encephalopathy presents with one episode of
hematemesis. Patient was just discharged from [**Hospital1 18**] on the
afternoon of presentation on the Liver service for [**Last Name (un) **] that
resolved with fluids and reduction in diuretics. On his way
home, patient noted some vague abdominal discomfort. While
walking to his house from his car about 40 feet, patient
experienced presyncopal dizziness and dyspnea with exertion,
which resolved when he sat down in the house. He laid down to
take a nap and had 3 small volume dark stools without
hematochezia. Attempted to take in some pos, and felt worse so
he went to the bathroom and had an episode of hematemesis of
several hundred ccs with clots. He has never experienced
hematemesis before. He called his wife and EMS was dispatched to
the home, and patient was taken to [**Hospital3 **].
Additionally, patient reports nonproductive cough x 7 days, 20
lb weight loss over the last 2 weeks, occasional episodes of
subjective fevers, and abdominal bloating for several days. His
abdominal pain is mild and periumbilical in nature, without
radiation. He denies chest pain, PND, orthopnea, headaches,
neckache.
.
At the OSH, Hct was found to be 19 from a discharge hct of 34,
with an INR of 1.6. He was also found to be hypotensive to the
60s systolic. He received an 1L NS, ceftriaxone 1 g IV x1,
octretide 50 mcg bolus followed by a 50 mcg/hr drip, 2 U PRBC
and was transfered to [**Hospital1 18**].
.
In the [**Hospital1 18**] ED, he was initially hypotensive to the 70s
systolic, but improved with less than 500 cc of NS to systolics
above 100. Rectal exam was guaiac positive for gross blood, and
patient had approximately 400 cc BRBPR following exam. He
received Pantoprazole 80 mg x1, 2 U FFP, and 1 additional units
PRBC, with a total of 1 L NS. A third peripheral IV was placed.
Surgery, transplant surgery and hepatology were all consulted.
On transfer, VS were 104/44, 72, 12, 100%.
.
Of note, patient was just admitted [**6-19**] through [**6-21**] for [**Last Name (un) **]
with Cr to 2.4 which improved to 1.2 with gentle hydration.
Etiology was felt to be due to diuretic use, and lasix was
stopped, aldactone was reduced, and atenolol was reduced. He was
admitted [**6-14**] through [**6-15**] for abdominal distention with
negative paracentesis for SBP, and [**Month/Year (2) 950**] withoout portal
vein thrombosis. Patient also had guaiac positive stool on this
admission felt to be due to portal gastropathy. He was also
admitted [**6-8**] through [**6-11**] for worsening confusion and jaundice,
and eventually found to have decompendated liver disease [**1-30**] to
pan sensitive E coli UTI, so he completed a 7 day course of po
Cipro. During this stay, screening EGD on [**6-11**] demonstrate
portal gastropathy and grade I esophageal varicies.
.
In the ICU, patient reports abdominal pain is resolved and he is
without dizziness.
Past Medical History:
# HCV and ETOH Cirrhosis: on tranplant list; denies any history
of SBP, encephalopathy or GI Bleed; has history of grade I
varices
# s/p bilataral CEA for carotid stenosis
Social History:
Lives in [**Location 3320**] with his wife [**Name (NI) **], used to work for [**Name (NI) 83851**]
Spray as fork lift operator and has his own roofing company.
Tobacco: quit 8 years ago, prior smoked for 40 years
ETOH: none for past 21 years
IVDU: former IV cocaine user. none in past 20 years.
Family History:
No history of liver disease.
Physical Exam:
On admission
Vitals: T: 96.9 BP: 99/48 P: 78R: 18 O2: 100% 2L
General: Alert, oriented, no acute distress
HEENT: Sclera icteric, 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, n2/6 SEM, no rubs,
gallops
Abdomen: distended, + fluid wave, no hepatosplenomegaly, non
tender, + BS
Skin: + jaundice, + spider angion on chest
GU: foley with clear urine
Ext: No asterexis, 1+ pedal edema, warm, well perfused, 2+
pulses, no clubbing, cyanosis
Brief Hospital Course:
62 yo M with a history of ESLD (meld 30) [**1-30**] to hepatitis C and
etoh complicated by grade I varices without history of UGIB, and
lack of SBP or encephalopathy who was admitted with hematemesis
and BRBPR. Plan was made for transplant pending availability of
a cadaveric donor.
The patient developed septic shock and was unable to maintain
blood pressure on maxiumum doses of 3 pressors. He passed away
due to cardiac arrest with family at his bedside. Decision was
made for full autopsy with no restrictions.
Medications on Admission:
1. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO QID (4
times a day).
2. Atenolol 12.g mg daily
3. Rifaximin 200 mg po TID
4. Spironolactone 50 mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Name: [**Known lastname 13320**],[**Known firstname **] P Unit No: [**Numeric Identifier 13321**]
Admission Date: [**2125-6-22**] Discharge Date: [**2125-7-1**]
Date of Birth: [**2062-7-22**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 13322**]
Addendum:
Addendum to Hospital Course: Additional Details
62 yo M with ESLD from hepatitis C, grade I varices with no h/o
UGIB, a MELD of 30 on admission who presented with an episode of
hematemesis to the ED and admitted to the ICU. He was intubated
and required multiple blood transfusions and pressor support.
Bleeding thought to be [**1-30**] varices, but no bleeding from varices
seen on EGD. He was treated with broad spectrum antibiotics
given persistent hypotension. He was evaluated by transplant
surgery and eventually was extubated without difficulty.
He remained on the transplant list and plan was made for
transplant but donor liver was ultimately not available. He
became increasingly tachypneic and required several large volume
paracenteses to control respiratory symptoms - no evidence of
SBP on any of his ascitic fluid. He again developed hypotension
requiring blood pressure support with Levophed and had to be
removed from transplant list as was felt to be too clinically
unstable to undergo transplant. His antibiotics were broadened
to cover HAP and fungal infections - vancomycin, cefepime and
micafungin.
He developed hypoxic respiratory distress and required
intubation. His MAP's remained low even with maximum dose
Levophed and he required the addition of vasopressin and then
dopamine and was only able to maintain MAP's in the 40-50's
despite being on maximum doses of the 3 pressors. Given his
grave clinical status, family came in and was updated by the
hepatology attending on his poor prognosis. The decision was
made to make the patient DNR.
In the next 12 hours, in spite of maximal pressor support and
fluids, patient continued to have a severe metabolic acidosis
thought to be from profound septic shock likely from a pulmonary
source. However, the specific source was not established.
After coming to the patient's bedside and again meeting with the
hepatology attending, the patient's HCP (wife) and family chose
to make the patient comfort measures only. Pressor support was
discontinued and the patient passed away approximately 25
minutes.
Autopsy was offered and the patient's wife requested a full
autopsy with no restrictions.
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13323**] MD [**MD Number(2) 13324**]
Completed by:[**2125-7-7**]
|
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"572.8",
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"070.71",
"537.89",
"V49.83",
"789.59",
"305.63",
"571.2",
"507.0",
"995.92",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.04",
"38.93",
"96.07",
"99.05",
"99.07",
"96.71",
"54.91",
"42.33",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
15762, 15929
|
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|
7982, 8017
|
13093, 13102
|
2697, 3892
|
13158, 13570
|
11632, 11662
|
13001, 13010
|
13063, 13072
|
12814, 12978
|
13587, 15739
|
13126, 13135
|
11677, 12243
|
1746, 1905
|
7931, 7944
|
8045, 11104
|
6384, 6495
|
11127, 11302
|
11318, 11616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,977
| 156,182
|
46485+58920
|
Discharge summary
|
report+addendum
|
Admission Date: [**2188-8-25**] Discharge Date: [**2188-9-27**]
Date of Birth: [**2128-1-12**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish / amlodipine
Attending:[**First Name3 (LF) 16851**]
Chief Complaint:
Ischemic painful right heel
Major Surgical or Invasive Procedure:
1. A ultrasound guided [**First Name3 (LF) 1106**] access of the left common
femoral artery.
2. Angiography of the right lower extremity.
3. Catheter placement into the distal superficial femoral
artery, the contralateral superficial femoral artery,
and proximal popliteal artery.
4. Contralateral percutaneous angioplasty and stent
placement in the right distal superficial femoral
artery.
5. Right heel debridement.
6. Placement of tunneled right internal jugular hemodialysis
catheter.
7. Hemodialysis
History of Present Illness:
60F with PVD with femoral stents placed [**9-18**], CAD s/p CABG [**6-16**],
dCHF, T2DM, HTN, HCH, Hep C, asthma, nephrotic range proteinuria
and recent foot debridement was directly admitted from [**Month/Year (2) 1106**]
clinic with concern for ischemic RLE. Received right superficial
femoral stent placement and on the way to PACU became
unresponsive with HR 40s , pulseless, and apneic. Neither a O2
saturation nor a blood pressure tracing from the A-line was
unable to be registered. Immediate ACLS was initiated with CPR,
and epinephrine x2 and atropine x1 were given with ROSC after
5-10 minutes. She was reintubated, started on levophed, and
transferred to the ICU. Patient was unresponsive, raising
concern for anoxic encephalopathy. Head CT was negative for
intracranial bleeding, and she was initiated on therapeutic
hypothermia, sedated with versed/fentayl, paralyzed with
cisatracurium, and maintained CMV ventilation. TTE on [**8-27**]
showed a LVEF 50-55%, PCWP >18, less vigorous global ventricular
function, and mild-moderate aortic regurgitation. Overnight, she
was hemodynamically labile with episodes of hypotension (61/35
at 9PM) and hypertension as well as bradycardia (low 50s).
Vital signs normalized and she was extubated with altered mental
status, volume overload, and urine output of dark brown color.
She was transferred to medicine.
Past Medical History:
PAST MEDICAL HISTORY:
1. CAD: s/p MI [**2183**], cath with 3VD s/p CABGx3 (LIMA to LAD, SVG
to PDA and ramus); Cath [**2183-6-11**] Severe left main and a three
vessel coronary artery disease (LMCA 60%, LAD proximal 90%
lesion and 90% apical stenoses, LCx 80%, Ramus 80% ostial
lesion).
2. Diastolic CHF: TTE on [**8-27**] showed a LVEF 50-55%, PCWP >18,
mild symmetric left ventricular hypertrophy with normal cavity
size, mildly decreased global ventricular function,
mild-moderate aortic regurgitation, mild mitral regurgitation
3. Hypertension - Poorly controlled
4. Hyperlipidemia
5. DM2: A1c 8.6 ([**2188-8-25**]), on insulin
6. PVD: s/p PTCA and stents to bilateral SFAs in [**9-18**] for
chronic
claudication; also had angioplasty to RLE [**8-21**]
7. CKD (stage III/IV): thought to be due to diabetic
nephropathy, but never biopsied, baseline creatinine 2.9-3.1,
8. Hx. of Nephrotic Syndrome
9. HCV: Chronic viral hepatitis on biopsy ([**2183**])
10. Asthma
11. Hypothyroidism
12. Colon Cancer - Stage II s/p sigmoid colectomy, partial left
colectomy with end-to-end anastomosis, and TAH/BSO ([**9-17**])
13. Hx. of Axillary abscess ([**2178**])
14. Hx. of Sternal wound infection
15. ETOH and IVDU
16. Depression
PAST SURGICAL HISTORY
1. Right Heel ulcer debridement ([**2188-9-4**])
2. RSFA angioplasty + stent ([**2188-8-27**])
3. R [**Month/Day/Year 1793**] stent (Dr. [**Last Name (STitle) **], [**9-/2185**])
4. L [**Year (4 digits) 1793**] stent w peroneal angioplasty ([**8-/2185**])
5. Partial left colectomy with end-to-end anastomosis, Sigmoid
Colectomy, TAH-BSO ([**2184**])
6. CABG 3-Vessel (LIMA to LAD, SVG to PDA and ramus, [**2183-6-24**])
7. Myomectomy/L oophrectomy ([**2170**])
8. Cheloid Excision
Social History:
SOCIAL HISTORY: Smokes [**5-15**] cigarettes per day; 30-40 pack-year
history. History of alcohol & drug abuse (IV), sober for 20
years.
Family History:
Maternal GM died of MI at 56, mother died of MI age 52, sister
died of MI age 45. [**Month/Day (1) 2320**] and cancer runs in her family. No family
history of arrhythmia, cardiomyopathies, or sudden cardiac
death; otherwise non-contributory.
Physical Exam:
Admission Exam:
VS 97.3 BP 150/66 HR 76 RR 17 98% room air
GEN Oriented to self and [**Hospital1 18**], not date or day of week, not
able to converse on the phone, perseverating.
HEENT: MMM, sclera anicteric
PULM Good aeration, Bibasilar crackles, diffuse wheezes, no
ronchi.
CV Heart sounds distant, regular rate and rhythm
ABD Distended, soft, normoactive bowel sounds, no r/g
EXT Bilateral Lower extremetiy pitting edema, wound vac in place
right heel. Able to move all limbs spontaneously. Right foot is
warm, left lower leg foot cool, perfused.
Discharge Exam:
VS: 97.7; 133/85; 67; 18; 100RA
Gen: Oriented to self, [**Hospital1 18**], month, not date.
HEENT: PERRL, EOMI, MMM, OP clear.
Neck: No JVD, no LAD
Chest: lungs CTAB, good air movement, no wheezes, no accessory
muscle involvement. Tunneled IJ catheter on right, dressing with
clotted blood, no erythema.
CV: Heart sounds distant, RRR, Normal S1/S2, no MRG appreciated
Abd: Tender to palpation in LLQ, ~5cm bulge appreciated in LLQ
and L periumbilical. Normoactive bowel sounds, soft.
Ext: Nontender pitting edema throughout, distal pulses preserved
with doppler, warm, nonhealing ulcer right heel eroded to
calcaneus, black eschar distal left first toe.
Pertinent Results:
LABORATORY DATA:
CBC ([**2188-9-16**]): 9.3<8.2/26.4/186 MCV 99.0 RDW 17.3
BMP ([**2188-9-16**]): 136/5.1/99/23/118/5.4<151 Ca 7.8, Phos 6.5, Mg 2.7
Coags ([**2188-9-16**]): PT 11.7, INR 1.1, PTT 32.6
LFTs ([**2188-8-31**]): ALT 36, AST 62, Alk Phos 127, TBili 0.9, Lipase
28
HgbA1C ([**2188-8-25**]): 8.6%
Ammonia ([**2188-8-31**]): 14
STUDIES:
ECG ([**2188-8-27**], post-code): Sinus rhythm with left axis deviation.
Incomplete right bundle-branch block and diffuse non-specific ST
segment flattening throughout.
Head CT ([**2188-8-27**]): No evidence of hemorrhage, edema, or acute
[**Month/Day/Year 1106**]
territorial infarction.
EEG ([**2188-8-27**]): This is an abnormal continuous ICU monitoring
study because of continuous slowing of the background activity
with 5-7 Hz theta and occasional [**2-12**] Hz delta activity. There
are occasional brief periods of suppression in EEG activity
lasting 1-2 seconds. These are indicative of moderate to severe
encephalopathy of nonspecific etiology. In this patient, hypoxic
ischemic brain injury, hypothermia and use of sedative
medications are all potential causes of diffuse slowing.
ECHO ([**2188-8-27**]): TTE, Indication: Cardiac Arrest. [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 3841**]
dilated, elongated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Overall left ventricular
systolic function is low normal (LVEF 50-55%) secondary to mild
global hypokinesis. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Mild to moderate
([**2-11**]+) aortic regurgitation is seen. The mitral valve leaflets
are structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. There is moderate pulmonary
artery systolic hypertension, estimated 53mmHg. There is no
pericardial effusion. Compared with the
prior study dated [**2188-1-21**] (images reviewed), global left
ventricular systolic function appears less vigorous. The degree
of aortic regurgitation has progressed to mild-moderate. Other
findings are similar.
ABI ([**2188-9-15**]): On the right side, monophasic Doppler waveforms
were seen at the right femoral, popliteal, posterior tibial and
dorsalis pedis arteries. On the left side, monophasic Doppler
waveforms were seen at the left femoral, popliteal and dorsalis
pedis arteries. The right ABI was 0.963 and the left ABI was
0.28. However, artifactually high pressures seen in the distal
right lower extremity again interfere with this measurement.
Significant inflow arterial insufficiency with aortoiliac
disease bilaterally with likely artifactually elevated right
ankle/brachial index.
CXR ([**8-27**]): Mild pulmonary edema and more focal opacification in
the right upper lung where pneumonia or aspiration cannot be
excluded. The mild left pleural effusion and right
moderate-to-severe pleural effusion is unchanged. Moderate
cardiomegaly.
CXR ([**9-24**]):
1. Mild-to-moderate pulmonary edema is unchanged.
2. Left lower lobe consolidation is unchanged since a month,
mostly explained by atelectasis; however, a superimposed
infection cannot be excluded.
CTA Chest [**9-24**]:
1. There is no pulmonary embolism.
2. Sign of direct and indirect pulmonary artery hypertension.
3. Left upper lobe area of consolidation is most compatible
with pneumonia.
4. Sign of severe tracheobronchomalacia.
Pertient Labs:
[**2188-9-24**] 10:00PM BLOOD PT-12.3 PTT-29.1 INR(PT)-1.1
[**2188-9-16**] 06:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL
Macrocy-3+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Target-1+
Schisto-1+
[**2188-9-16**] 06:00AM BLOOD Fibrino-402*#
[**2188-8-31**] 02:55AM BLOOD ALT-36 AST-62* AlkPhos-127* TotBili-0.9
[**2188-9-19**] 06:58AM BLOOD calTIBC-259* Ferritn-219* TRF-199*
[**2188-9-15**] 06:55AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
[**2188-9-15**] 06:55AM BLOOD HCV Ab-POSITIVE*
[**2188-9-24**] 01:42PM BLOOD Type-ART pO2-49* pCO2-38 pH-7.45
calTCO2-27 Base XS-2
Discharge Labs:
Blood Cx [**2188-9-17**], [**2188-9-18**], [**2188-9-24**] Negative or pending
Urine Cx [**2188-9-11**], [**2188-9-17**], [**2188-9-21**] No growth
[**2188-9-27**] 06:35AM BLOOD WBC-10.2 RBC-3.20* Hgb-9.6* Hct-30.4*
MCV-95 MCH-30.0 MCHC-31.5 RDW-16.3* Plt Ct-208
[**2188-9-27**] 06:35AM BLOOD Glucose-97 UreaN-31* Creat-3.3* Na-134
K-3.7 Cl-98 HCO3-23 AnGap-17
[**2188-9-27**] 06:35AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.1
Brief Hospital Course:
Ms. [**Known lastname 449**] is a 60 year old female with PMH of poorly-controlled
HTN (home SBPs 190s), DM2 on insulin, diastolic CHF, CAD s/p MI
and 3-vessel CABG (LIMA-LAD, SVG-PDA, SVG-ramus in [**2183**]), PVD,
CKD now on HD (baseline Cr 2.9-3.1), and HCV who was admitted
originally on [**2188-8-25**] for evaluation of right lower extremity
ischemia and a non-healing right heel ulcer, received right
superficial femoral artery stent and developed PEA arrest in
PACU, reintubated, transferred to CCU with pressor support and
therapeutic hypothermia, extubated, and transferred to the
floor, course complicated by [**Last Name (un) **], now HD dependent.
# SURGERY, PEA ARREST, AND CONSEQUENCES:
On [**2188-8-27**], pt. underwent angiogram with distal superficial
femoral artery angioplasty and stenting with subsequent PEA
arrest (HR 40s, pulseless, and apneic) in the PACU likely [**3-13**]
apnea from sedation (versed and propofol) where she was down for
approximately 5-10 min. ACLS was initiated with CPR,
epinephrine x2, and atropine x1. She was reintubated and
transferred to the ICU on levo. Her post-arrest course has been
complicated by altered mental status likely [**3-13**] toxic metabolic
encephalopathy, hemodynamic lability with episodes of
hypotension with BPs as low as 60s/30s. She was transferred to
the floor on [**2188-9-8**] from the ICU. Since this time, her
creatinine continued to worsen. She did not respond to IV
diuresis with torsemide and metolazone. As such, she was
evaluated by nephrology and in the setting of increasing BUN and
volume overload, they recommended initiation of dialysis which
she has now been started on. She is now thought to have ESRD
that is HD-dependent (see below).
# ALTERED MENTAL STATUS:
Status post arrest, patient had asterixis, perseveration, poor
short term memory, and was oriented only to self and place.
Mental status waxed and waned, but overall improved late this
admission, establishing insight into her condition and able to
plan for the future. However, she is still not at her baseline,
per her son. Etiology for AMS is likely multi-factorial,
including hypoxic encephalopathy s/p arrest, uremic metabolic
encephalopaty, and labile serum glucose. Early after surgery she
had elevated white count suggesting infectious etiology for AMS
and her right internal jugular line was removed with subsequent
normalizing of WBC count. PNA was suspected on [**2188-9-17**] and
treated empirically for 7 days of Vancomycin and Cefipime, but
remained afebrile with normal white count and negative blood and
urine cultures taken before Abx admin. Had a
cognitive-linguistic evaluation on [**9-24**] that showed some
deficits with complex manipulation of information, including
short-term recall, executive functioning, and attention.
Recommended that she continue to receive cognitive-linguistic tx
with SLP/OT here and upon d/c.
# PVD with ischemic right foot: Admitted directly from clinic,
superficial right femoral stent was placed [**8-27**]. Patient
received Plavix x 1 month. Right heel ulcer was extensively
debrided by podiatry with failure to heal despite daily dressing
change with hydrogel and coverage with Augmentin x 14 days,
ultimately eroding to the calcaneus. Pain was covered with
oxycodone and acetaminophen. Waveform study [**9-15**] showed failure
of stent. The patient was made aware that amputation inevitable,
and cardiology performed a preop evaluation. Recommended
continuing beta-blocker and did not recommend stress test. BKA
will be scheduled as outpatient, not emergent. Will have office
visit with Dr. [**Last Name (STitle) 3407**] on [**10-3**].
# ESRD: History of nephrotic range proteinuria and baseline Cr
2.9-3.1 developed post-PEA ischemic ATN, given numerous muddy
brown casts in urine sediment. Patient developed volume overload
that did not respond to diuresis with metolazone and toresemide
with fluid restriction, and HD was initiated on [**2188-9-16**]. A
temporary line was placed initially due to epistaxis prior to
anesthesia, which the patient removed during agitation overnight
[**9-19**], tunneled catheter on the right placed [**2188-9-22**]. Now
HD-dependent. Scheduled as Tues/Thurs/Sat. Received bilateral
vein mapping. Transplant contact[**Name (NI) **] regarding graft/fistula
placement. They plan on doing this procedure after Ms. [**Known lastname 449**]
completes rehab. Continues to make urine.
# Bleeding diathesis: Developed repeated epistaxis and
hematomas/ecchymoses at superficial puncture sites. Likely due
to uremia. Transfused on unit during HD, but crit and INR
stable. No active liver, Hep C not active. Tolerated
self-removal of right IJ line without significant blood loss.
Desmopressin therapy initiated [**Date range (1) 98762**], converted to conjugate
estrogen [**Date range (1) 22898**]. Stopped SQH, stopped heparin dwell during
HD. Bleeding time remains prolonged, but stable.
# T2DM: Insulin requirement trended up after surgery and then
down during final week of admission with concomitant decreased
appetite. Please titrate insulin NPH and sliding scale at rehab.
# Heart failure: Patient saturated well throughout time on
floor, with small bilateral pleural effusions noted [**8-25**] and
unchanged [**9-25**]. Echo performed shortly after arrest showed
preserved EF of 50-55%. Triggered for lethargy and respiratory
distress [**9-25**] but maintained 99% saturation on room air, likely
mucus plugging from asthma.
# PNA: Seen on CXR [**9-17**]. Covered with vancomycin and cefepime for
a 7-day course, from [**9-18**] to [**9-24**]. On this, she remained
afebrile, with a stable white count and was satting well on room
air.
# Tracheobronchomalacia: Incidental finding on CTA for r/o PE.
Patient does not have positional stridor or wheezing related to
this finding. Plan to follow up with pulmonology as outpatient.
# CAD: PEA attributed to poor respiratory function, not an acute
coronary event. Serial troponins after PEA 0.2-0.3 in the
setting of ATN/CKI. CKMB not elevated.
Transitional Issues:
Code status: full code
Medication Changes we made are as follows:
We have made the following changes to your medications:
STARTED Metolazone 5mg daily
STARTED Quetiapine 12.5mg QHS
STARTED Calcium Carbonate 500mg TID
STARTED nephrocaps daily
STARTED Docusate Sodium 100mg [**Hospital1 **]
STARTED Polyethyleneglycol 17g daily PRN for constipation
STARTED Senna 1 Tab [**Hospital1 **]
STARTED Famotidine 20mg daily
STARTED Simvistatin 10mg daily
STARTED Oxycodone 2.5-5mg Q8hour PRN for pain
STARTED Neomycin-Polymyxin-Bacitracin with dressing changes
STARTED Nystatin Oral Suspension
STARTED Ipratropium Bromide Nebulizer Q6Hour PRN for shortness
of breath
CHANGED Insulin NPH to 8U AM and 0U PM (from 25AM 35PM), also
decreased sliding scale
CHANGED Torsemide from 100mg daily to 200mg daily
CHANGED Gabapentin 100mg daily from 800mg [**Hospital1 **]
STOPPED Lisinopril 40mg daily
STOPPED Oxycodone-Acetaminophen 5/325 Q6hr PRN for pain
Transplant surgery will followup regarding permanent HD access
placement.
Follow up with Dr. [**Last Name (STitle) **], Podiatry and Pulmonology (please call
([**Telephone/Fax (1) 513**] to help schedule in [**3-15**] weeks)
Medications on Admission:
1. ASA 81 mg po daily
2. Metoprolol Succinate 100 mg po daily
3. Hydralazine 50 mg po TID
4. Nitroglycerin 0.3 mg PRN
5. Lisinopril 40 mg po daily
6. Torsemide 100 mg daily
7. Metolazone 2.5 mg daily (mon-fri)
8. Gabapentin 800 mg po BID
9. Levothyroxine 175 mcg PO daily
10. ProAir 2 puffs Inh 4 times dialy PRN
11. Advair 500mcg-50mgc 1 puff inh [**Hospital1 **]
12. Humalog (Lispro) 10u w breakfast with SS & dinner w [**7-20**] U
13. NPH 35units qam, 28u qpm
14. Tylenol-Codeine 300mg-30mg PO Q8H PRN
15. Oxycodone-Tylenol 5-325 1-2 tabs Q6H PRN
15. Tylenol
16. Calcium Carbonate-Vitamin D3
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Famotidine 20 mg PO Q24H
3. Ipratropium Bromide Neb 1 NEB IH Q6H prn shortness of breath
4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q8H:PRN pain
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation
6. Quetiapine Fumarate 12.5 mg PO HS
7. Senna 1 TAB PO BID constipation
Hold for loose stool
8. Simvastatin 10 mg PO DAILY
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
10. Aspirin 81 mg PO DAILY
11. Calcium Carbonate 500 mg PO TIDAC
12. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
13. HydrALAzine 50 mg PO Q8H
14. Metolazone 5 mg PO DAILY
Please give 30 minutes before torsemide
15. Torsemide 200 mg PO DAILY
Please give 30 min after metolazone
16. Vitamin D 400 UNIT PO DAILY
17. Gabapentin 100 mg PO DAILY
18. Levothyroxine Sodium 175 mcg PO DAILY
19. NPH 8 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
20. Nitroglycerin SL 0.3 mg SL PRN CP
21. Nephrocaps 1 CAP PO DAILY
22. Heparin 5000 UNIT SC TID
23. Acetaminophen 1000 mg PO Q8H
24. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] - [**Location (un) 86**]
Discharge Diagnosis:
Ischemic right foot
Non-resolving heel ulcer
End-stage renal disease
Pulseless electrical arrest
Diabetes Mellitus II
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. [**Known lastname 449**],
It was a pleasure participating in your care at [**Hospital1 771**].
You were admitted to the [**Hospital3 **] to have a [**Hospital3 1106**] stenting
procedure to open up the blood vessels leading to your right
foot, so that it might heal better. After this surgery in the
recovery unit, your heart stopped briefly. You were revived
using cardiac life support techniques and you were temporarily
put on a cooling protocol to protect your organs.
Unfortunately, this damaged your kidneys to the point where they
needed the support of hemodialysis to clear the toxins from your
body. Your mental function has also been affected by these
toxins.
For your foot, podiatry and [**Hospital3 1106**] surgery determined that the
ulcer is not healing and that it has gone down to the [**Last Name (LF) 500**], [**First Name3 (LF) **]
it will require an amputation below the knee. This will be
discussed with Dr. [**Last Name (STitle) **] during your appointment with him next
week. You can schedule this surgery in coordination with his
clinic.
Your blood sugars have varied throughout your stay, and your
insulin requirement has been adjusted accordingly.
We have made the following changes to your medications:
STARTED Quetiapine 12.5mg QHS
STARTED Calcium Carbonate 500mg TID
STARTED Docusate Sodium 100mg [**Hospital1 **]
STARTED Famotidine 20mg daily
STARTED Senna 1 Tab [**Hospital1 **]
STARTED nephrocaps
STARTED Simvistatin 10mg daily
STARTED Polyethyleneglycol 17g daily PRN for constipation
STARTED Oxycodone 2.5-5mg Q8hour PRN for pain
STARTED Neomycin-Polymyxin-Bacitracin with dressing changes
STARTED Nystatin Oral Suspension
STARTED Ipratropium Bromide Nebulizer Q6Hour PRN for shortness
of breath
CHANGED Metolazone 5mg from 2.5mg daily
CHANGED Insulin NPH to 10U AM and 10U PM (from 28AM 35PM)
CHANGED Torsemide from 100mg daily to 200mg daily
CHANGED Gabapentin 100mg daily from 800mg [**Hospital1 **]
STOPPED Lisinopril 40mg daily
STOPPED Oxycodone-Acetaminophen 5/325 Q6hr PRN for pain
Followup Instructions:
Department: PODIATRY
When: WEDNESDAY [**2188-10-1**] at 1 PM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Street Address(1) **] SURGERY
When: [**Street Address(1) **] [**2188-10-3**] at 9:45 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Please call the Pulmonologist to set up an appointment in [**3-15**]
weeks to follow up on an abnormal finding on your CT scan called
tracheobronchomalacia
Pulmonary, Critical Care & Sleep Medicine Department:
Appointment Scheduling Location:
[**Hospital1 18**] Phone: ([**Telephone/Fax (1) 513**]
Name: [**Known lastname **],[**Known firstname **] J Unit No: [**Numeric Identifier 15791**]
Admission Date: [**2188-8-25**] Discharge Date: [**2188-9-27**]
Date of Birth: [**2128-1-12**] Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Shellfish / amlodipine
Attending:[**First Name3 (LF) 15534**]
Addendum:
ADDENDUM TO SECTION ON TRACHEOBRONCHOMALACIA:
- Question of whether severe tracheobronchomalacia could have
contributed to patient's PEA arrest after receiving anesthesia.
This was conveyed to the surgery team, and the patient will be
evaluated by pulmonary prior to any upcoming planned surgery.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2215**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15535**] MD [**MD Number(2) 15536**]
Completed by:[**2188-10-6**]
|
[
"E878.8",
"250.72",
"584.5",
"482.9",
"427.5",
"784.7",
"458.29",
"275.3",
"493.20",
"357.2",
"070.54",
"250.42",
"412",
"588.81",
"278.01",
"V45.81",
"682.7",
"305.1",
"428.33",
"585.6",
"349.82",
"244.9",
"275.2",
"272.4",
"403.11",
"428.0",
"V85.41",
"250.62",
"571.5",
"440.24"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.90",
"38.95",
"86.22",
"39.95",
"99.60",
"96.71",
"83.39",
"00.40",
"00.45",
"39.50"
] |
icd9pcs
|
[
[
[]
]
] |
23501, 23732
|
10351, 12093
|
346, 873
|
19533, 19533
|
5704, 9892
|
21772, 23478
|
4205, 4448
|
18224, 19277
|
19392, 19512
|
17605, 18201
|
19710, 20926
|
9908, 10328
|
4463, 5014
|
5030, 5685
|
16413, 16506
|
20955, 21749
|
279, 308
|
901, 2266
|
19548, 19686
|
2310, 4035
|
4067, 4189
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,893
| 113,708
|
7849
|
Discharge summary
|
report
|
Admission Date: [**2124-3-10**] Discharge Date: [**2124-4-5**]
Date of Birth: [**2048-1-2**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: This is a 74-year-old female,
recently diagnosed with a right femur osteosarcoma, status
post 1 cycle of neoadjuvant chemotherapy with adriamycin and
cisplatinum on [**2-28**], and a history of ulcerative colitis,
status post total colectomy and ileostomy in the past, who
presented to the Emergency Room with acute sharp abdominal
pain, nausea and vomiting.
PAST MEDICAL HISTORY:
1. Melanoma, right lower extremity, in [**2097**].
2. Hyperthyroidism.
3. Migraines.
4. Proctocolectomy.
5. Total abdominal hysterectomy.
6. Cholecystectomy.
7. Hemithyroidectomy.
8. Appendectomy.
9. Ulcerative colitis.
10.Hypertension.
MEDS AT HOME:
1. Aspirin 81.
2. OxyContin.
3. Norvasc.
4. Colace.
5. Compazine.
6. Cipro.
7. Propranolol.
8. Percocet.
9. Valium.
10.Ambien.
11.Imitrex.
12.Vioxx.
ALLERGIES: No known allergies.
SOCIAL HISTORY: Significant for 1-pack of cigarettes per
day. No alcohol.
EXAM ON ADMISSION: Temperature 97.6, heart rate 120-90,
blood pressure 132/54, respiratory rate 18, sats 95percent on
room air. In significant pain. Heart regular rate and
rhythm. Chest clear to auscultation bilaterally. Abdomen
tender on the right side with guarding. Stoma was
digitalized. There was no gross blood, and it was heme
positive. Extremities were warm.
LABS: White count 0.1, hematocrit 27.6, platelets 88.
Chemistries - sodium 132, potassium 3.6, chloride 101, bicarb
16, BUN 41, creatinine 1.7, glucose 131, lactate 1.7. UA was
negative for infection. EKG showed sinus tachycardia. Chest
x-ray showed COPD with no pneumonia or congestive heart
failure. CT of the abdomen was done and showed thickening
and stranding of the distal ileum with some fluid in the
abdomen. There was little progression of contrast into the
small bowel. The SMA and celiac were open.
HOSPITAL COURSE: Over the few hours after presenting to the
Emergency Room, her clinical picture worsened. She became
tachycardic and intermittently hypotensive. In view of these
symptoms and her very concerning CT scan, it was decided to
take her the operating room. On [**2124-3-10**], she
underwent an exploratory laparotomy. She was found to have
ischemia of the distal small bowel to the stomach from
previous adhesions and small bowel obstruction. The
adhesions were taken down, as well as the stoma. The distal
small bowel was resected, and a new ileostomy was
constructed. Her long postoperative course is summarized as
follows:
1. NEURO: Initially, her pain was controlled, and she was
sedated with a fentanyl drip. This was later weaned and
changed to prn morphine as needed, and prior to discharge
her pain was well-controlled on Roxicet prn, and very
small amounts of Ativan prn. On postoperative day 19, as
she was beginning to wake-up and drips were weaned off,
she was noted not to be moving her left side as well, and
had left side neglect with right-sided gaze. A CT was
done and showed recent infarctions in the middle cerebral
arterial territory and left occipital territory. Further
work-up for what seemed to be embolic strokes included an
echo which did not show any source of emboli. She was
seen by the neurology team and was started on aspirin.
1. CARDIOVASCULAR: Her immediate postop course was
significant for septic shock and need for vasopressors
which were gradually weaned as she stabilized. She
developed atrial fibrillation which was converted back to
sinus on an amiodarone drip. Prior to discharge, she was
on amiodarone through her G-tube. She has remained in
sinus and stable hemodynamically for many days.
1. RESPIRATORY: She had prolonged respiratory failure and
vent dependency. This required a tracheostomy which was
done on [**2124-3-30**]. Prior to discharge, she was
gradually weaning off the vent on a pressure support mode,
and had been on a trach mask for the last 48 hours prior
to transfer to rehab. She still required some suctioning
and chest physical therapy, but had been stable with good
saturations, and normal respiratory rate, and seemed very
comfortable on the trach mask.
1. GI: Initial postop nutrition was provided through TPN.
Once her new ileostomy began to function, she was started
on tube feeds, and on [**3-30**] a PEG was placed, and the
tube feeds were then given through this access. She has
been tolerating tube feeds at goal with 1 episode of
vomiting 2 days prior to discharge. After starting her on
Reglan, tube feeds were restarted, and she seemed to be
tolerating it well. She was receiving Prevacid for
prophylaxis.
1. GU: After her initial resuscitation around surgery, the
patient significantly volume overloaded. Once stabilized
hemodynamically, this required gentle diuresis. Her
creatinine was slightly elevated to peak of 1.4, but had
returned to [**Location 213**] prior to discharge. She was still 6 kg
up. Her last weight on [**4-5**] was 70 kg. Her baseline
was 64 kg. It was recommended still to continue gentle
diuresis as we had been doing, and she seemed to be
tolerating it well.
1. HEME: As noted on admission, the patient was
significantly neutropenic and just needed to be supported
by G-CSF. Blood counts, thereafter, improved. Her last
white count was 15.2 on [**4-5**]. Her hematocrits have
remained stable around 29/30 over the last few days.
Throughout her hospitalization, she did require
intermittent transfusions of blood and platelets, but none
in the period prior to discharge.
1. ID: Of note, her immediate postop course was significant
for sepsis and septic shock. She was broadly covered with
antibiotics, including vancomycin, Levaquin, Flagyl, and
fluconazole. Her OA positive culture was 1 out of 2
bottles of blood culture from the 22, the day of her
admission, which grew presumptive Clostridium septicum.
Once afebrile and her white counts were normal, this
regimen was stopped. On [**3-28**], she had a low-grade temp
and a slight elevation in her white count. At that point,
cultures were taken, and a central line that she had in
her IJ was removed. Her catheter, as well as 1 out of 4
bottles of blood grew Staph coag-negative, and her sputum
on that day grew Pseudomonas and MRSA. She was,
therefore, treated with Zosyn and vancomycin. She is now
7 days on these antibiotics, and the plan was to complete
a 10-day course for suspected possible bacteremia. She
has remained afebrile, hemodynamically stable, with a mild
and stable elevation of her white count over the last few
days.
1. MUSCULOSKELETAL: Because of her CVA, she was not moving
her left side, and her left side seemed to be slightly
more swollen. Work-up for that included an ultrasound
which was negative for DVT. She will probably need
occupational therapy to be involved in her care with a
question of splints for her left upper extremity. She was
seen by the oncology service, radiation oncology service
and the orthopedic service here for questions regarding
further treatment of her osteosarcoma. It was felt that
at this point treatment, the patient would not be a good
surgical candidate for an amputation, but would possibly
benefit, at least initially, from radiation treatment, but
even that should wait until the patient further recovers.
She will need to follow-up with the oncology service in
the future who will coordinate her care between radiation
oncology and possibly orthopedics later on. She was
discharged to rehab in stabile condition and with the
following recommendations.
DISCHARGE RECOMMENDATIONS:
1. Continue meds as listed in .
2. Continue PT, OT and respiratory rehabilitation.
3. Follow-up with oncology in 2 weeks.
4. Follow-up with surgery and scheduling on the same date
would be optimal.
DISCHARGE DIAGNOSES:
1. Small bowel obstruction.
2. Ischemic small bowel.
3. Exploratory laparotomy, status post small bowel resection
and ileostomy.
4. Sepsis.
5. Bacteremia.
6. Respiratory failure, status post tracheostomy.
7. Status post percutaneous endoscopic gastrostomy.
8. Osteosarcoma, right lower extremity.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **]
Dictated By:[**Last Name (NamePattern1) 28297**]
MEDQUIST36
D: [**2124-4-5**] 10:01:56
T: [**2124-4-5**] 11:17:09
Job#: [**Job Number 28298**]
|
[
"557.0",
"560.81",
"518.5",
"202.90",
"997.02",
"038.3",
"995.92",
"785.52",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.62",
"57.81",
"34.91",
"88.72",
"38.93",
"46.73",
"33.24",
"46.51",
"43.11",
"54.59",
"31.1",
"46.23",
"99.04",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8115, 8642
|
1987, 8094
|
181, 541
|
1095, 1969
|
563, 998
|
1015, 1080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,912
| 122,860
|
11780+56283
|
Discharge summary
|
report+addendum
|
Admission Date: [**2197-11-23**] Discharge Date: [**2197-11-29**]
Date of Birth: [**2138-7-16**] Sex: F
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: Ms. [**Known firstname 9198**] [**Known lastname **] is a
59-year-old female with a past medical history for a thyroid
cyst that was removed approximately 40 years ago, status post
dilatation and curettage for abnormal uterine bleeding, and
osteoarthritis of the right knee who noted increased
frequency of chest discomfort over the last several weeks.
This was not exertional in nature and was not precipitated by
any one activity.
Sh[**Last Name (STitle) 37242**]had a chronic history of osteoarthritis of the right
knee and was scheduled for right knee replacement surgery,
and during her preoperative workup she had a chest x-ray on
[**2197-10-10**] that was read as a possible dilated or
tortuous versus aneurysmal thoracic aorta. As a consequence
from this workup, and given her symptoms of chest discomfort
and pain, she was evaluated by chest computed tomography
which showed a thoracic aortic aneurysm measuring 5.5 cm
maximally at the root, 4 cm at the arch, and approximately
3 cm at the level of the diaphragm. Due to this, her knee
surgery was clearly and obviously postponed, and she was
referred to Dr. [**Last Name (Prefixes) **] for operative management of her
thoracic aortic aneurysm.
Preoperative cardiac catheterization showed a right-dominant
circulation and normal coronaries. No evidence of
significant stenoses, and an ejection fraction of 60%. This
catheterization was performed on [**2197-11-23**] on her
date of admission to the hospital. She had preoperative
laboratories significant for a hematocrit of 38, and a blood
urea nitrogen and creatinine of 14 and 0.6, and normal
coagulation profile.
PAST MEDICAL HISTORY: As stated.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She has no significant alcohol or tobacco
history.
RADIOLOGY/IMAGING: Electrocardiogram on admission just
showed borderline left ventricular hypertrophy, sinus rhythm
in the 60s. No ST segment changes.
HO[**Last Name (STitle) **] COURSE: On [**2197-11-24**], she went to the
operating room with Dr. [**Last Name (Prefixes) **] where she underwent a
Bentall procedure which was aortic root repair with hemograph
as well as an aortic valve replacement with a #21 St. [**Male First Name (un) 923**]
mechanical valve. This was done under general endotracheal
anesthesia with cardiopulmonary bypass. She tolerated the
procedure well, and her pericardium was subsequently left
open. She had a right radial arterial line, and the right
internal jugular Swan-Ganz catheter for hemodynamic
monitoring. Two ventricular and one atrial pacing wire were
present as well as two mediastinal and one left pleural tube.
Her mean arterial pressure coming off the bypass was 69 with
a central venous pressure of 23, pulmonary artery diastolic
pressure of 23, with a mean of 31. Her rate was 80 in normal
sinus. She was on Neo-Synephrine for pressure control,
aprotinin for anticoagulation given homograft, as well as
propofol for sedation.
She was transferred to the Cardiothoracic Surgical Intensive
Care Unit where she did well hemodynamically, and was
subsequently extubated on the night of surgery. She remained
in sinus rhythm in the 60s to 80s with blood pressures of
110s on Neo-Synephrine at 0.75 mcg/kg per minute. Her
aprotinin was weaned off, and she was given a bolus of 500 cc
of hespan times one. No blood products were utilized for
intermittent issues of hypotension during her efforts to wean
off of the Neo-Synephrine. On blood gas on nasal cannula was
7.43 for a pH, PCO2 of 44, and PO2 was 97. Base excess of 3.
She was subsequently found to have a hematocrit of 29.5
postoperatively, with a blood urea nitrogen and creatinine of
9 and 0.4. Her PT 14 and INR of 1.4 with a PTT of 37. On
examination postoperatively, she had a stable sternum with no
evidence of drainage. She had a 3/6 systolic murmur that was
diminished from her [**3-3**] or [**4-2**] murmur preoperatively with a
positive systolic click heard. Breath sounds were decreased
bilaterally. Her abdomen was soft with bowel sounds.
Extremities were warm and well perfused with no evidence of
edema. Neurologically, she was intact. She was on p.o. pain
medications.
Pulmonary wise, she was extubated. She was satting at 95% on
5 liters of nasal cannula. Chest tubes had stayed in until
later that day, on postoperative day one, due to high output.
Cardiovascular wise, she was weaned off her Neo-Synephrine.
She was subsequently placed on Lasix, Lopressor, aspirin, and
Coumadin, and she was off of her aprotinin at this time.
Electrolytes were repleted as tolerated. She was started on
a cardiac diet. Her Foley catheter was left in place, and
she was started on her diuresis. Her blood urea nitrogen and
creatinine were within normal limits at 9 and 0.4,
respectively.
Hematology/Infectious Disease wise, she did have a low-grade
temperatures postoperatively, but this was thought to be
secondary to atelectasis. She was given pulmonary toilet and
was subsequently transferred to the floor on postoperative
day one after her Neo-Synephrine was weaned off.
She did well while on the floor and had no issues. She was
hemodynamically stable. Her blood pressures were around
100/55 with heart rate in the 70s. Her sternum was stable,
and no evidence of drainage. Her murmur was not present, and
she was in a regular rate and rhythm. Her hematocrit was 29,
as stated.
By postoperative day three she was ambulating at a level III
with assistance. Her chest tubes had been removed, and the
chest x-ray just showed bilateral pleural effusions with
possible fluid in the left fissure. Questionable vascular
engorgement. There was some borderline clinical evidence of
congestive heart failure, and she was noted to be wheezing
audibly on auscultatory examination by postoperative day
three. She was subsequently given Lasix 20 mg intravenously
as well as given albuterol/Atrovent nebulizer treatments
q.6h. around the clock times 24 hours, which was then
subsequently changed to a meter-dosed inhaler p.r.n. q.6h.
These efforts resolved her cardiac and wheezing issues, and
she diuresed very well.
On [**2197-11-28**], she was now postoperative day four from
her Bentall and St. [**Male First Name (un) 923**] aortic valve, and was alert and
oriented times three. She had decreased wheezes and
continued her meter-dosed inhalers as needed with incentive
spirometry and other pulmonary toilet. Her Lopressor was
titrated to 50 mg p.o. b.i.d., and she remained
hemodynamically stable with pressures in the 130s at this
time with heart rates in the 70s, in sinus. Her Lasix was
increased to 40 mg p.o. b.i.d., and she was given K-Dur for
potassium repletion.
Renal wise, her blood urea nitrogen and creatinine were 18
and 0.6. Hematology/Infectious Disease wise, she remained
afebrile, and her hematocrit was 26 and stable. She was
maintained on Coumadin 5 mg p.o. q.d. with an INR of 1.7 on
this day.
DISCHARGE DISPOSITION: She was screened by rehabilitation
and was felt to be an appropriate candidate for
rehabilitation. The discharge plan will be to discharge to
rehabilitation on [**2197-11-29**].
MEDICATIONS ON DISCHARGE: (The patient's medications will
include)
1. [**Doctor Last Name 37243**] sulfate 325 mg p.o. t.i.d. (which she was on
preoperatively).
2. Colace 100 mg p.o. b.i.d.
3. Multivitamin p.o. q.d. (which she was also on
preoperatively).
4. Lopressor 50 mg p.o. b.i.d.
5. Lasix 20 mg p.o. b.i.d. times seven days.
6. K-Dur 20 mEq p.o. b.i.d. times seven days.
7. Protonix 40 mg p.o. q.d.
8. Aspirin 81 mg p.o. q.d.
9. Coumadin 5 mg p.o. q.h.s.
10. Combivent meter-dosed inhaler 2 puffs b.i.d.
11. Percocet 5/325 one to two tablets p.o. q.4-6h. p.r.n.
REHABILITATION INSTRUCTIONS: Treatments and frequency at the
rehabilitation facility will include a PT and INR check to be
done in 24 hours; and a Discharge Summary Addendum. This
shall be completed by Dr. [**Last Name (STitle) 37244**] [**Name (STitle) 37245**] (who is a new
intern on the Cardiothoracic Surgery Service as of [**2197-11-29**]). Dr. [**Last Name (STitle) 37245**] will document who the attending
physician will be that will be following the patient's PT and
INR as an outpatient. But regardless, the patient will
receive a PT and INR draw 24 hours from the time of
discharge. She was to receive wound checks, blood pressure
monitoring, and physical therapy including strengthening and
conditioning. She was instructed not to do any heavy lifting
times 30 days. No driving times 30 days. She may leave her
wound open and dry to air with showering allowed.
Anticipated goals are that the patient should return to her
preoperative level of function.
DI[**Last Name (STitle) 408**]E FOLLOWUP: She was to see Dr. [**Last Name (Prefixes) **] in four
weeks from the time of discharge. She should have a primary
care physician followup or [**Name Initial (PRE) **] cardiologist followup in two to
three weeks from the time of discharge.
DISCHARGE STATUS: To rehabilitation.
CONDITION AT DISCHARGE: She was stable, afebrile, and in
normal sinus rhythm.
DISCHARGE DIAGNOSES:
1. Thoracic aortic aneurysm.
2. Status post Bentall aortic replacement with homograft and
aortic valve replacement with a #21 St. [**Male First Name (un) 923**]; completed on
[**2197-11-24**].
3. Arthritis of the right knee.
4. Status post dilatation and curettage.
5. Thyroid cyst, status post removal 40 years ago.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 3204**]
MEDQUIST36
D: [**2197-11-28**] 20:05
T: [**2197-11-28**] 19:19
JOB#: [**Job Number 37246**]
Name: [**Known lastname 1193**], [**Known firstname 6666**] Unit No: [**Numeric Identifier 6667**]
Admission Date: [**2197-11-23**] Discharge Date: [**2197-11-30**]
Date of Birth: [**2138-7-16**] Sex: F
Service:
DISCHARGE SUMMARY ADDENDUM: At the time of discharge her INR
was 2.0. She will be sent to the rehab facility on Coumadin
5 milligrams po q day. She will have an INR check at the
rehab facility in 24 hours. The results of this will be sent
to her primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4319**], who was
spoken to. He will also follow the patient's INR after she is
discharged from the rehab facility.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Name8 (MD) 1561**]
MEDQUIST36
D: [**2197-11-30**] 10:37
T: [**2197-12-4**] 12:36
JOB#: [**Job Number 6668**]
|
[
"441.2",
"414.01",
"E878.4",
"E879.0",
"428.0",
"997.1",
"998.12",
"424.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"38.45",
"89.61",
"89.64",
"88.56",
"35.22",
"39.61",
"89.68",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
7143, 7323
|
9312, 10882
|
7350, 9221
|
9236, 9291
|
186, 1819
|
1843, 1893
|
1910, 7119
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,853
| 111,874
|
23002
|
Discharge summary
|
report
|
Admission Date: [**2174-11-29**] Discharge Date: [**2174-12-2**]
Date of Birth: [**2098-2-28**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
6yoM h/o DVT/PE, a fib, CRI, critical aortic stenosis was found
down by neighbors on the floor after a friend, who recently
became his HCP, called to check in and couldn't get ahold of
him. He was alert but somnolent. Recent hospitalization for
incarcerated ventral hernia and SBO, refused surgery. Seen by
palliative care and plans were made to make patient comfort
measures only, however paperwork not completed. Discharged home.
In the emergency department vitals on arrival HR 160 (a fib), BP
102/54, RR 32, O2sat 92%. Found to have large PNA and aspirated
in ED. Given Vanc/Zosyn/Flagyl. Intubated and had femoral line
placed (pt arrived in spinal immobilization). Given 6L IVF but
BP unresponsive to fluid. Started on levophed and with versed
for sedation.
Seen by surgery in ED who evaluated incisional hernia, which was
noted to be reduced but found to have a new left inguinal
hernia. CT with evidence of SBO. During last admission patient
refused surgical intervention, recommended keep OG tube in place
and will follow.
Pt intubated on arrival to MICU and unable to obtain further
history.
Past Medical History:
1. Ventral Hernia with SBO ([**11-4**])
2. DVT/PE ([**2170**])
3. A fib
4. Hyperlipidemia
5. CRI (baseline creatinine 1.4-1.8)
6. CHF
7. severe AS(0.6 from ECHO [**11-22**])
8. BPH
9. C diff colitis
Social History:
Veteran of the Korean retired due to back pain.
He lives alone. 60 pack-year tobacco history but quit 20 years
ago. Denies current ETOH use but up until [**2172**] had h/o ETOH
abuse.
Family History:
Unavailable
Physical Exam:
VITAL SIGNS:
T= 101.5 BP= 120/53 HR= 121 RR= 25 O2= 96%
PHYSICAL EXAM
GENERAL: Intubated, sedated
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA. MMM. Neck collared.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. Systolic
ejection murmur, no rubs or [**Last Name (un) 549**].
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. Soft hernia left of umbilicus
EXTREMITIES: Cool, 2+ dorsalis pedis pulses.
SKIN: No rashes/lesions, ecchymoses.
NEURO: Unable to assess
Pertinent Results:
LABS: (on admission)
7.3 > 43.5 < 185
N:66% Band:26% L:4% Atyps: 1%
140 | 96 | 38
-------------- < 102
3.8 | 24 | 2.2
Ca: 9.7 Mg: 1.8 P: 2.0
PT: 17.2 PTT: 26.9 INR: 1.5
ALT: 20 AST: 39 AP: 31 Tbili: 1.8 Lip: 22
Lactate 4.0 -> 2.1
CK: 105 CK-MB: 4 Trop: 0.09
ABG: 7.43 /37 / 174 / 25
UA: small bili, 500 protein, trace ketone, trace RBC
STUDIES:
CXR: Diffuse left lung opacities which are nonspecific, and
differential considerations include infection, infarction, or
hemorrhage.
CT head: no acute intracranial process.
CT C-spine: no fracture or traumatic malalignment. Degenerative
changes are noted with mild ventral thecal sac effacement at
C4/5. If concern exists for intrathecal abnormalities, these
would be best evaluated with MRI.
CT Chest/Abd/Pelvis: L renal cyst, large ventral hernia with
dilated loops proximally unchanged from previou
Brief Hospital Course:
76yoM with a history of CHF, atrial fibrillation on coumadin
found down by neighbor at home who presented with pneumonia and
sepsis to the medical ICU. He had a recent history of declining
aggressive care for a hernia, but gave verbal consent to
intubation in the emergency department.
On arrival he had a left-shifted leukocytosis and hypotension
thought to be due to pneumonia given the large inflitrate seen
on CXR. His urine did not have evidence of infection. He had a
recent history of incarcerated hernia without repair, but his CT
did not have evidence of abscess or perforation. He was started
on vancomycin, Zosyn and Flagyl on arrival and required Levophed
to maintain his blood pressures. Over the next 24 hours his
clinical situation deteriorated significantly. He had cool
mottled extremities and required significant pressor support to
maintain blood pressures. He had an elevated troponin and acute
on chronic renal failure. He was seen by surgery because of his
ventral and inguinal hernias. Neither appeared incarcerated and
the patient had recently expressed his desire not to be operated
upon.
The patient required increasing pressor support through hospital
day#2 and his health care proxy (HCP) [**Name (NI) **] [**Name (NI) 59353**] expressed
a desire to not escalate care. Pressors and mechanical
ventilation were maintained while the HCP [**Name (NI) 653**] family
members. WIth the family members it was decided to withdraw
care. The patient was extubated and his pain controlled with
fentanyl. He passed away peacefully.
Medications on Admission:
(per D/C plan [**11-25**])
Doxazosin 2mg PO HS
Metoprolol Tartrate 50mg PO BID
Lisinopril 5 mg PO DAILY
Simvastatin 10mg PO DAILY
Folic Acid 1 mg PO DAILY
Coumadin 2mg PO once a day: One tablet by mouth Monday-Saturday.
Two tablets by mouth on Sundays.
Discharge Medications:
n/a
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary diagnosis:
Severe Pneumonia complicated by sepsis
Secondary diagnoses:
Ventral and inguinal hernias
Cardiopulmonary arrest
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2174-12-11**]
|
[
"995.92",
"785.52",
"552.21",
"428.0",
"V12.51",
"518.81",
"585.9",
"272.4",
"486",
"584.9",
"785.51",
"600.00",
"038.42",
"424.1",
"427.31",
"562.10",
"790.5",
"560.81",
"550.90",
"428.32",
"576.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.27",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
5250, 5259
|
3357, 4919
|
333, 339
|
5434, 5443
|
2485, 2964
|
5495, 5666
|
1908, 1921
|
5222, 5227
|
5280, 5280
|
4945, 5199
|
5467, 5472
|
1936, 2466
|
5360, 5413
|
284, 295
|
367, 1469
|
2973, 3334
|
5299, 5339
|
1491, 1691
|
1707, 1892
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,073
| 177,559
|
20879
|
Discharge summary
|
report
|
Admission Date: [**2178-3-24**] Discharge Date: [**2178-4-4**]
Date of Birth: [**2095-5-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Bronchoscopy ([**2178-3-31**])
PICC line placement ([**2178-4-3**])
History of Present Illness:
82 yo M with h/o COPD, AS s/p AVR, afib, right nephrectomy for
RCC, colon ca s/p colectomy admitted with cough and shortness of
breath.
Patient had a recent admission [**2178-3-6**] - [**2178-3-17**] for community
acquired pneumonia right middle and lower lobe, pleural effusion
drained 800ccs (transudative) and melena (no scope due to
respiratory status, discharged on H. pylori treatment). CT torso
demonstrated right pre-bronchial and pretracheal mild adenopathy
with narrowing or part opacification of the right lower lobe
bronchus that could suggest mass. On [**2178-3-24**] patient followed up
at outpatient GI appointment found to have temp 100.2 with
persistent SOB and cough. CXR showed RLL consolidation and
smaller pleural effusion. Patient was given one dose of
Levofloxacin, but antibiotics held as infection felt less
likely. LENI demonstrated new thrombosis in branch of popliteal
vein. CTA [**2178-3-25**] done to r/o PE demonstrated RLL and RML
consolidation recurrence associated retrocrural and extrapleural
adenopathy suspicious for malignancy. Pulmonary consulted and
recommended bronch to evaluate airways and biopsy node (done
today). During admission patient also had a slowly drifting down
HCT - GI consulted and prep was attempted however not completed.
Patient developed abdominal pain from partially obstructed
ventral hernia whic was reproducible, followed by surgery and
improved on repeat imaging. Patient started spiking temperatures
[**3-28**] - work up involved blood cx, urine cx, c. diff, repeat CT
scan which only revealed RLL/RML opacities. ID consulted and
suspected post-obstructive pneumonia that may have been
partially treated and recommended bronch BAL.
Bronchoscopy [**2178-3-31**] demonstrated diffuse TBM, thickened mucosa
of RML and RLL, performed BAL and brushings RLL of superior
segment as well as EBUS TBNA (Transbronchial Needle Aspiration).
Patient was given versed and fentanyl. Around 10 pm night float
was called for acute respiratory distress. Patient 65% on 4 L
(following procedure on 4 L, baseline 2 L), BP 120/60, HR 105,
RR 34. He was given 40 mg laisx and CXR demonstrated white out
right lung concerning for atelactasis/mucus plugging. ABG on 4 L
7.32/58/53. Respiratory suctioned thick sputum. Patient
continued to be in respiratory distress and consequently
transferred to the MICU for care. Repeat CXR and ABG improved
7.31/56/70 (FiO2 70%).
Past Medical History:
1. Congestive heart failure
- Echo ([**9-26**]) with Mild symmetric LVH with normal cavity size
and global systolic function (LVEF>55%). Mild MR; Moderate TR
- Cath ([**1-28**]) with dilated left ventricle with significant
generalized hypokinesis and a global ejection fraction of 28%
(while the patient is in atrial flutter).
2. COPD- moderate to severe per Dr. [**First Name (STitle) **] (PCP)
3. Hypertension
4. s/p AVR for aortic stenosis
5. Atrial fibrillation, cardioversion ([**5-25**])
6. s/p splenic artery aneurysm resection/splenectomy ([**7-26**])
7. GERD
8. History of RCC s/p left nephrectomy ([**8-26**])
9. History of colon cancer status post colostomy ([**9-/2160**])
10. History of B12 deficiency
11. History of ITP
Social History:
Lives with his wife in [**Location (un) 538**]. He quite smoking in [**2172**].
30 etoh per week. Retired electrician. ID note at [**Hospital1 18**] from
[**2172**] documents he had been PPD negative and without TB risk
factors; he confirms he has not been exposed to anyone with TB
to his knowledge. No animal contacts. Was in the Navy many years
ago with travel to [**State 18559**] and [**State 8842**] but not to [**Female First Name (un) 8489**] or [**Country 480**]. No
prison exposure. Limited travel outside [**Location (un) 86**] in recent years.
Family History:
Noncontributory.
Physical Exam:
Vitals: 97.1, 104, 111/64, 20, 98/ 70% Face tent with 5L/NC
HEENT: Sclera anicteric, MM slightly dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: crackles in RML/RLL, diffuse wheezing
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: large hernia, positive bowel sounds, soft, very mild
diffuse tenderness, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema b/l R>L
Pertinent Results:
ADMISSION LABS
=======================================================
[**2178-3-24**] 05:30PM BLOOD WBC-7.8 RBC-3.03* Hgb-9.4* Hct-29.5*
MCV-97 MCH-31.1 MCHC-32.0 RDW-17.1* Plt Ct-254
[**2178-3-24**] 05:30PM BLOOD Neuts-66.7 Bands-0 Lymphs-22.7 Monos-9.8
Eos-0.7 Baso-0.1
[**2178-3-24**] 05:30PM BLOOD PT-15.2* PTT-38.5* INR(PT)-1.3*
[**2178-3-24**] 05:30PM BLOOD Glucose-101* UreaN-20 Creat-1.8* Na-136
K-4.7 Cl-102 HCO3-26 AnGap-13
[**2178-3-30**] 07:50AM BLOOD ALT-13 AST-28 LD(LDH)-214 AlkPhos-54
TotBili-0.5
[**2178-3-25**] 06:03AM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9 Iron-24*
[**2178-3-25**] 06:03AM BLOOD calTIBC-96* VitB12-331 Folate-13.8
Ferritn-458* TRF-74*
[**2178-3-31**] 10:36PM BLOOD Type-ART pO2-53* pCO2-58* pH-7.32*
calTCO2-31* Base XS-1 Intubat-NOT INTUBA
DISCHARGE LABS
=======================================================
[**2178-4-2**] 03:38AM BLOOD WBC-25.1*# RBC-2.90* Hgb-8.7* Hct-27.3*
MCV-94 MCH-30.0 MCHC-31.8 RDW-17.1* Plt Ct-192
[**2178-4-4**] 06:40AM BLOOD WBC-13.0* RBC-2.72* Hgb-8.5* Hct-27.2*
MCV-100* MCH-31.1 MCHC-31.1 RDW-17.3* Plt Ct-211
[**2178-4-2**] 06:16AM BLOOD Neuts-82.5* Lymphs-6.4* Monos-10.3
Eos-0.2 Baso-0.5
[**2178-4-4**] 06:40AM BLOOD PT-23.2* PTT-93.1* INR(PT)-2.2*
[**2178-4-4**] 06:40AM BLOOD Glucose-129* UreaN-17 Creat-1.4* Na-140
K-3.7 Cl-108 HCO3-26 AnGap-10
[**2178-4-4**] 06:40AM BLOOD Calcium-7.5* Phos-3.1 Mg-1.8
[**2178-4-1**] 07:50AM BLOOD CK-MB-NotDone cTropnT-0.13*
[**2178-4-1**] 05:52PM BLOOD CK-MB-NotDone cTropnT-0.08*
MICROBIOLOGY
=======================================================
[**2178-3-31**] 5:12 pm BRONCHOALVEOLAR LAVAGE RLL BAL.
GRAM STAIN (Final [**2178-3-31**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Preliminary):
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
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.
STAPH AUREUS COAG +. 10,000-100,000 ORGANISMS/ML..
SECOND MORHPHOLOGY.
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 +
| STAPH AUREUS COAG +
| |
CLINDAMYCIN----------- =>8 R =>8 R
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ <=0.5 S <=0.5 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN------------- =>4 R =>4 R
RIFAMPIN-------------- <=0.5 S <=0.5 S
TETRACYCLINE---------- 4 S 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S
VANCOMYCIN------------ <=0.5 S
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final [**2178-4-1**]):
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
REPORTS
=======================================================
UNILAT LOWER EXT VEINS RIGHT Study Date of [**2178-3-24**]
Nonocclusive thrombus in a branch of the right popliteal vein
only. No evidence of DVT in any other region of the left lower
extremity.
CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2178-3-25**]
1. RLL and RML consolidation, given recurrence in the same
region and
associated retrocrural and extrapleural adenopathy, is
suspicious for
malignancy, correlation with either FDG PET or tissue sampling
is recommended.
2. Unchanged lobulated left splenectomy bed soft tissues, could
represent
regenerated splenic tissue, however, local RCC recurrence is not
excluded.
3. Patchy LLL opacity, could be atelectasis, however, metastatis
is not
excluded and attention on followup is recommended.
4. Coronary and atherosclerotic aortic calcifications.
5. No evidence of pulmonary embolism or acute aortic syndrome.
Portable TTE (Complete) Done [**2178-3-26**]
The left atrium is markedly dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is mild
regional left ventricular systolic dysfunction with inferior
hypokinesis. No masses or thrombi are seen in the left
ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is moderately dilated. A bioprosthetic aortic valve
prosthesis is present. The aortic valve prosthesis appears well
seated, with normal leaflet/disc motion and transvalvular
gradients. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-4-24**],
regional LV systolic dysfunciton is now appreciated.
CT ABDOMEN / PELVIS W/O CONTRAST Study Date of [**2178-3-27**]
1. Partial colonic obstruction at the right anterior abdominal
wall hernia
with transverse colon herniated within. It appears that only the
anterior
wall of the transverse colon is in the hernia but there is
torquing of the
colon such that the large amount of fluid within the cecum,
ascending colon, and proximal transverse colon cannot cross
through the torqued transverse colon distal to the hernia. No
evidence of bowel compromise at this time.
2. Small amount of ascites. Unchanged appearance of splenules.
Left
nephrectomy with hypodense lesions in right kidney, as before
unchanged.
3. Abdominal aortic aneurysm up to 5.5 cm incompletely assessed
without
intravenous contrast.
4. Unusual soft tissue within the presacral space may represent
abnormal
lymph nodes, however, this is uncertain. Attention on followup
in three
months is recommended, preferably using MRI.
5. Urinary bladder containing contrast from CTA chest more than
two days ago suggests some renal insufficiency. Small urinary
bladder diverticulum.
CHEST (PORTABLE AP) Study Date of [**2178-4-3**]
In comparison with the study of [**4-2**], there is increased
opacification involving the right mid and lower lung zones. This
is consistent with increasing pleural effusion and underlying
compressive atelectasis. There is again enlargement of the
cardiac silhouette with evidence of pulmonary vascular
congestion. Postoperative widening of the mediastinum is again
seen.
BRONCHIAL BRUSHINGS Procedure Date of [**2178-3-31**]
NEGATIVE FOR MALIGNANT CELLS.
TBNA 11 R Procedure Date of [**2178-3-31**]
NEGATIVE FOR MALIGNANT CELLS.
Bronchial epithelial cells.
Brief Hospital Course:
82 yo M with h/o COPD, AS s/p AVR, afib, right nephrectomy for
RCC, colon ca s/p colectomy. Recent admission for PNA,
re-admission for shortness of breath and fevers. Transferred to
the MICU for hypoxia following bronchoscopy.
# Acute respiratory distress: Patient with shortness of breath
worse than baseline upon admission on [**2178-3-24**]. Then acutely
decompensated [**2178-3-31**] post-bronchoscopy. Based on chext x-ray
and recent bronchoscopy most likely mucus plugging worsened by
underlying effusion, atelactasis and possible post-obstructive
pneumonia. Patient has known DVT, but based on significant
findings on CXR and current anticoagulation unlikely PE. Patient
febrile on admission which could be related to recent
bronchoscopy, however due to rising leukocytosis, was broadly
covered. Patient never complained of chest pain to suggest ACS
and troponins were stably elevated. His acute worsening was
thought to be less likely congestive heart failure as CXR
findings unilateral and symptoms acute in onset. As below,
patient was continued on antibiotics. He was also positioned on
left side for improved oxygenation His respiratory status
improved with chest PT, [**Name (NI) 55569**] use, vibrating vest
therapy and Acapella therapy. He should continue all these
therapies as aggressive pulmonary toilet upon transfer in to the
MACU. BAL results as above. Started on Advair and Spiriva for
COPD component.
# Fevers with Leukocytosis: During admission, patient was noted
to have frequent febrile episodes. Initial evaluation included
persistant RLL/RML opacities. He also had numerous negative
blood cultures, urine culture and c. diff X 1. Most likely
etiology is post-obstructive pneumonia. His fevers resolved
with initiation of antibiotics post-broncoscopy on [**2178-3-31**]. He
was treated broadly for post-obstructive pneumonia with
Vancomycin, Cefepime and Flagyl. On [**4-4**] his BAL studies came
back as above with one S.Aureus with preliminary findings of
intermediate sensitivity to Vancomycin. Given this, he was
transitioned to Linezolid. On discharge, he is on day 4 of a
total 21 day course of antibiotics. If patient looks markedly
improved with decreased oxygen requirements and improved chest
x-ray, would consider decreasing course to 14 days. Given
Linezolid, patient will need weekly CBC checks. Additionally,
please call the [**Hospital1 18**] Microbiology department at ([**Telephone/Fax (1) 20850**]
on [**Telephone/Fax (1) 766**], [**2178-4-6**], to follow-up additional studies.
# Ventral Hernia: Patient with longstanding ventral hernia.
Some concern during admission that there be an element of
incarceration and CT scan [**2178-3-27**] demonstrated partial colonic
obstruction. Repeat CT scan [**2178-3-29**] with overall improvement.
Upon discharge, hernia easily reduced and without any abdominal
pain.
# Recent Gastroentestingal hemorrhage: HCT relatively stable
with mild intermittent drops. No melena during this admission.
Given that patient is a high colonoscopy perforation risk due to
colonic distension, GI did not perform any endoscopy. He was
continued on IV pantoprazole [**Hospital1 **]. He was transfused a total of
2U PRBC during this admission, the last one on [**2178-3-30**].
# DVT: Patient with Popliteal branch DVT as above. Initially
placed on a Heparing drip and then transitioned to Lovenox /
Warfarin. The day of discharge his INR was therapeutic at 2.2.
Would recommend daily INR checks for several days given newly on
Warfarin and newly therapeutic the day of discharge. Please
elevate the leg as able to decrease swelling and minimize pain.
# Chronic Diastolic CHF (EF>55%): With Echo results as above
concerning for new LV dysfunction. Lasix and beta blocker held
in the setting low blood pressure. Could consider restarting
and oral intake improves.
# COPD: Moderate to severe. Initially started on nebulizer
therapy PRN. Started on Advair and Spiriva while inpatient.
Patient should follow-up with Pulmonary as an outpatient for
continued management.
# Atrial Fibrillation: Rate controlled. Off coumadin temporarily
given recent GI bleeding. CHADS2 score is 3 and bioprosthetic
valve. Echo showed no evidence of thrombus. Restarted on
anticoagulation as above. Also continued on Digoxin. While
inpatient, Metoprolol was held for lower blood pressures in the
setting of poor po intake. Could consider restarting this as an
outpatient if need further rate control and blood pressure
tolerates it.
# GERD: Stable. Continued on Pantoprazole.
# Chronic Kidney Disease: Baseline approximately 1.6. Elevated
to 2.0 on [**3-30**] but resolved to 1.4 upon discharge. All
medications were renally dosed.
# Abdominal aortic anuerysm: Stable, per vascular surgery will
follow-up with Dr. [**Last Name (STitle) 1391**] as outpatient.
# Tachycardia: Initially attribued to atrial fibrillation with
holding of his beta blocker. Other considerations included
hypovolemia or secondary to infection (pneumonia). Given poor
oral intake, he was given maintenance fluid and heart rate
improved from 120s to low 100s. [**Month (only) 116**] need further IVF while in
MACU if oral intake poor.
# History of ITP: Platelets trended and stable during admission.
ACCESS: PICC placed [**2178-4-3**], please discontinue after
completion of antibiotic course. Line care per general
protocols.
Patient was a FULL CODE during his hospital stay.
Medications on Admission:
1. Digoxin 125 mcg PO daily
2. Atrovent 2puff daily
3. Albuterol 1puff q4 prn
4. Pantoprazole 40 mg daily
5. Recently held: Warfarin, Lasix, Metoprol
6. Recently completed: Flagyl and Amoxicillin x 14 days for H.
Pylori
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
7. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) Intravenous Q8H (every 8 hours) for 18 days.
8. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection
Q24H (every 24 hours) for 18 days.
9. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q12H (every 12 hours).
10. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 18 days.
11. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
One (1) neb Inhalation q4hrs PRN () as needed for SOB, wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary: Pneumonia
Secondary: atrial fibrillation, COPD, aortic stenosis
Discharge Condition:
Good, afebrile, vital signs stable, O2 sats 94% on face tent,
ambulates out of bed to chair with assistance, AOX3
Discharge Instructions:
You were admitted to [**Hospital1 **] Hospital on [**2178-3-24**]. You had initially presented to a GI appointment where you
were found to have a fever, and findings concerning for a
pneumonia. You were subsequently sent to the hospital where you
were evaluated with a procedure called a bronchoscopy. After
this procedure, you were admitted to the medical intensive care
unit after the levels of oxygen in your blood were noted to
drop. While in the ICU, you received a thorough evaluation and
multiple treatments for pneumonia. On [**2178-4-4**] your
condition had improved and you were discharged to the [**Hospital 100**]
Rehab MACU for continued physical therapy.
.
The following changes have been made to your outpatient
medication regimen:
-STARTED Cefepime 2g IV q24 hours. Last day of dosing will be
[**2178-4-21**]
-STARTED Linezolid 600 mg PO/NG, q12h. Last day of dosing will
be [**2178-4-21**].
- STARTED Metronidazole 500 mg IV q8h. Last day of dosing will
be [**2178-4-21**].
-STARTED Fluticasone Salmeterol 250/50, 1 Inh [**Hospital1 **]
-STARTED Tiotropium Bromide 1 cap Inh qD
-STARTED Senna, 1-2 tabs qD, PRN constipation
-STARTED Docusate 100 mg [**Hospital1 **] PRN, constipation
- STOPPED Lasix
- STOPPED Metoprolol
- STARTED Xoponex nebs, 1 neb q4h PRN wheezing or shortness of
breath
- STOPPED Albuterol nebs
- CONTINUE Digoxin 0.125 mg qD
- CONTINUE Pantoprozole 40 mg qD
- CONTINUE Coumadin 2.5 mg qD, until instructed to change the
dose by a physician
.
Please continue regular respiratory treatments with chest PT,
use of a cough assist device and acapella device.
.
It was a pleasure participating in your medical care.
Followup Instructions:
Please make an appointment to follow-up with Dr.[**Last Name (STitle) 575**] from
the Department of Pulmonology at [**Hospital1 18**]. Their office is closed
today so an appointment has not been made for you. Please call
their office at [**Telephone/Fax (1) 55570**] to [**Telephone/Fax (1) **] an appointment within
the next 1 month.
.
You should call your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an
appointment and discuss this hospitalization with them. Your
primary care doctor is listed as [**First Name4 (NamePattern1) 1022**] [**Last Name (NamePattern1) **]. Please call her
office at [**Telephone/Fax (1) 55571**] to [**Telephone/Fax (1) **] an appointment in the next
1-2 months.
.
You will need to have your INR checked daily to ensure that it
remains safely in a therapeutic range. Please have your INR
checked daily at [**Hospital 100**] Rehab and physicians can adjust your
Warfarin level appropriately.
.
Please have a CBC (blood counts) checked weekly to ensure that
your hematocrit is stable.
.
You have the following appointment scheduled with the
gastroenterology appointment.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2178-5-19**]
2:00
|
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"441.4",
"285.9",
"403.90",
"453.40",
"787.02",
"V10.52",
"552.21",
"V10.05",
"785.6",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"38.93",
"40.11"
] |
icd9pcs
|
[
[
[]
]
] |
18855, 18921
|
12037, 17492
|
334, 403
|
19038, 19154
|
4690, 6467
|
20853, 22120
|
4191, 4209
|
17763, 18832
|
18942, 19017
|
17518, 17740
|
19178, 20830
|
4224, 4671
|
8119, 12014
|
7904, 8085
|
6508, 7871
|
275, 296
|
431, 2845
|
2867, 3602
|
3618, 4175
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
357
| 117,876
|
29392
|
Discharge summary
|
report
|
Admission Date: [**2199-12-21**] Discharge Date: [**2200-1-18**]
Date of Birth: [**2135-3-22**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 17813**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
64 year old male with Hx of cirrhosis [**1-20**] NASH, DM, HTN, CHF
with EF 40%, CAD, seizure disorder, stage IV
decubitus ulcer p/w low grade fever and lethargy. Pt was found
to have a temp of 99.6 at nursing home on day of admission. the
family also thought that the pt was lethargic and may be w/ AMS.
he recd tylenol at NH and his temp came down to 98.6. He was
brought to the ER
.
In the ER VS 98.9 81 116/63 16 96/2L. he had a neg head CT. CXR
showed new LLL opacity. he recd 1 dose each of vanc and
cefepime.
.
ROS: ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
.
Past Medical History:
1. Seizure disorder with Hx of status epilepticus. Recent
admission for recurrent seizures & 2 prior admissions in [**2197**] &
[**2199-1-18**] for status requiring intubation. Has been on multiple
antiepileptic drugs.
2. NASH, cirrhosis, hepatocellular carcinoma, recently removed
from transplant list [**1-20**] chronic illness
3. Diabetes mellitus type II
4. Hypothyroidism
5. Hypertension
6. CHF with EF 40% on ECHO in [**7-/2198**]
7. Coronary artery disease status post cardiac catheterization
in [**2187**] w/o stenting
8. History of upper GI bleed s/p TIPS in [**2197**]
9. Stage IV sacral decubitus ulcer
Social History:
Remote tobacco history. No alcohol or illicit drug use.
Currently resides at [**Hospital 1820**] Nursing Home.
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION:
VS: 98.2 150/75 87 22 93/3l
GEN: NAD, awake, alert
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: b/l wheezes and rhonchi.
ABD: Soft, NT, ND, no HSM
EXT: No c/c/e
SKIN: maculopapular rash on back
Pertinent Results:
CXR: IMPRESSION: Study limited due to low inspiration. Bibasilar
likely
atelectasis although underlying aspiration or pneumonia cannot
be excluded. There may be a small left pleural effusion.
Head CT: IMPRESSION: No evidence of hemorrhage seen. Appearance
of the brain is unchanged from [**2199-6-18**]. Opacification of
visualized right maxillary sinus unchanged.
Abdominal U/S: GRAYSCALE IMAGING: The liver demonstrates a
heterogeneous echotexture without focal mass lesion detected on
this limited evaluation of the hepatic parenchyma. No intra- or
extra-hepatic biliary ductal dilatation with the common duct
measuring 3 mm. The gallbladder appears unremarkable, without
wall thickening or pericholecystic fluid/intraluminal stone.
There is splenomegaly with the spleen measuring 17.6 cm. No
intra-abdominal ascites. DOPPLER EXAMINATION: Color and pulsed
pulse-wave Doppler images were obtained. The main portal vein is
patent with normal hepatopetal flow with a velocity of 22
cm/sec. The TIPS shunt is patent with wall-to-wall flow.
Velocities of 27, 90 and 94 cm/sec. The splenic vein and SMV are
patent. IVC demonstrates patency with triphasic waveforms.
IMPRESSION: Normal TIPS evaluation with wall-to-wall flow. No
ascites identified.
L/SI Spine plain films and Pelvic plain films:
Brief Hospital Course:
# Respiratory failure: The patient developed respiratory
failure during seziure activity and recent HCAP. He was
intubated for airway protection and sent to the MICU. He was
able to be extubated days later without difficulty. The patient
was treated with lasix for diuresis. Sputum cultures were
positive for klebsiella, proteus, sensitive to meropenem, zosyn
and tobra however most likely contaminent not infection, and the
patient was not started on antibiotics as the patient had
received vanc/ceftriaxone/flagyl eariler in his hospital course.
He was evaluated by pulmonary who felt his tachypnea was likely
due to fluid overload. He was diuresed and his respiratory
status later stabilized. No further bronchoscopy was recommended
as it was unlikely that he laryngeal/tracheal stenosis given his
clinical improvement with diuresis.
.
#Seizure disorder: The patient has a known seizure disorder and
hx of NCSE. He again had continuous seizure activity documented
by continous EEG monitoring. His home regimen of keppra,
zonegran and topamax was increased and ativan, dilantin were
added to the regimen. He required dilantin loading on two
occassions. His seizures were eventually well controlled and the
ativan was weaned off without seizure recurrence under EEG
monitoring. His mental status started to improve signficantly
and at discharge, he was answering questions briskly, able to
state the place but did not know the date, and was eager to
leave the hospital.
.
# Cirrhosis: Secondary to NASH. During his hospital stay his
LFTs/bili and coags remained stable. He underwent an abdominal
U/S of liver w/ normal TIPS evaluation with wall-to-wall flow.
No ascites identified. He was continued on lactulose and
rifaxamin.
.
#. Stage IV sacral decub: No evidence of osteomyelitis per
X-ray. Wound care consulted and recommended daily packing.
.
#DM: The patient was temporarily taken off home lantus as had
episodes of hypoglycemia. He was restarted on his home dose of
lantus without problem.
.
#Hypothyroidism: continued home levothyroxine
.
# Hypernatremia: The patient became transiently hypernatremic
during his MICU course. Free water boluses were increased
through his tube feeds. The hypernatremia resolved.
.
# CAD: stress MIBI in [**3-25**] w/ Fixed, medium sized, severe
perfusion defect involving the PDA territory. Increased left
ventricular cavity size. Inferior hypokinesis with preserved
systolic function. No recent h/o chest pain. Most recent echo
with improved EF.
.
# Pancytopenia: Chronic issue, likely BM suppression or
secondary to seizure medications. Trended, remained stable.
.
#FEN: tube feeds, repleted electrolytes prn, free H20 boluses
through tube feeds.
#PPX: PPI, lactulose, pneumoboots (no heparin sq given low
platelets), aspiration precautions, contact [**Name (NI) 70584**]
#[**Name2 (NI) 7092**]: Full Code
#Communication: with wife [**Name (NI) **] ([**Telephone/Fax (1) 70585**]-home) and
[**Telephone/Fax (1) 70586**]-cell)
Medications on Admission:
-Topiramate 100 mg Tablet [**Hospital1 **]
-Metoprolol Tartrate 25 mg [**Hospital1 **]
-Levetiracetam 500 mg Tablet [**Hospital1 **]
-Zonisamide 500 mg Capsule qd
-Levothyroxine 400 mcg Tablet
-Lactulose 10 gram/15 mL prn
-Rifaximin 200 mg TID
-Lorazepam 0.5 mg HS
-Furosemide 40 mg qd
-Heparin 5,000 unit/mL tid
-Multivitamin qd
-Folic Acid 1 mg qd
-Lansoprazole 30 mg Tablet,qd
-Thiamine HCl 100 mg qd
-Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: One (1) 60 units
Subcutaneous twice a day: Give 60 units at breakfast, 60 units
at dinner.
-Ascorbic Acid 500 mg [**Hospital1 **]
-Ipratropium Bromide 0.02 % Solution q6h
-Albuterol Sulfate 2.5 mg /3 mL (0.083 %) qid
-Silver Sulfadiazine 1 % Cream
-Cephalexin 500 mg Capsule Q6H
-Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
-Nystatin 100,000 unit/mL three times a day.
-Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Ophthalmic PRN
-Aspirin 325 mg qd
-Lidocaine HCl 2 % Gel [**Hospital1 **]: One (1) Appl Mucous membrane PRN
-Oxycodone 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q4H (every 4 hours)
-Clotrimazole 1 % Cream [**Hospital1 **]: One (1) application Topical
twice a day as needed for facial rash for 3 weeks.
Discharge Medications:
1. Levothyroxine 100 mcg Tablet [**Hospital1 **]: Four (4) Tablet PO DAILY
(Daily).
2. Rifaximin 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID (3 times a
day).
3. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Tablet PO
DAILY (Daily).
4. Folic Acid 1 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
5. Thiamine HCl 100 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
7. Zinc Sulfate 220 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
8. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
9. Oxycodone 5 mg Tablet [**Hospital1 **]: 0.5 Tablet PO Q6H (every 6 hours)
as needed: before sacral ulcer dressing.
10. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO TID
(3 times a day).
11. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
12. Miconazole Nitrate 2 % Powder [**Last Name (STitle) **]: One (1) Appl Topical TID
(3 times a day) as needed for tinea cruris.
13. Levetiracetam 1,000 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2
times a day).
14. Keppra 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO twice a day.
15. Zonisamide 100 mg Capsule [**Last Name (STitle) **]: Six (6) Capsule PO DAILY
(Daily).
16. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) neb Inhalation Q4H (every 4 hours) as
needed for wheeze.
17. Ipratropium Bromide 0.02 % Solution [**Last Name (STitle) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheeze.
18. Erythromycin 5 mg/g Ointment [**Last Name (STitle) **]: One (1) application
Ophthalmic QID (4 times a day).
19. Lactulose 10 gram/15 mL Syrup [**Last Name (STitle) **]: Fifteen (15) ML PO TID (3
times a day): titrate to [**1-21**] BM per day.
20. Phenytoin 50 mg Tablet, Chewable [**Month/Day (3) **]: Four (4) Tablet,
Chewable PO DAILY (Daily): Give in AM.
21. Phenytoin 50 mg Tablet, Chewable [**Month/Day (3) **]: Six (6) Tablet,
Chewable PO DAILY (Daily): Give 8 pm.
22. Topiramate 100 mg Tablet [**Month/Day (3) **]: Three (3) Tablet PO BID (2
times a day).
23. Povidone-Iodine 10 % Solution [**Month/Day (3) **]: One (1) Appl Topical
DAILY (Daily): apply to PEG tube insertion site.
24. Insulin Glargine 100 unit/mL Cartridge [**Month/Day (3) **]: Thirty Eight
(38) Units Subcutaneous at bedtime.
25. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Month/Day (3) **]: 11-32
units Subcutaneous three times a day: Per sliding scale:
FS 71-100, 11 Units
FS 101-150, 17 Units
FS 151-200, 20 Units
FS 201-250, 24 Units
FS 251-300, 28 Units
FS 301-350, 32 Units.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Village
Discharge Diagnosis:
increased seizure frequency in the context of PNA
Secondary Dx:
NASH
DM
refractory seizures
recurrent hepatic encephalopathy
Discharge Condition:
stable; baseline MS difficulty with some memory and attention
deficits. Distal extremity contractures, and asteryxis.
Discharge Instructions:
You were admitted with worsening seizures and mental status in
the context of acquiring a pneumonia. You required temporary
intubation and were treated with antibiotics. Your seizures were
controlled with a combination of anti-epileptic medicines, which
you should continue. Please return to the ER if you experiece
any worsening of your seizure frequency, develop new types of
seizures, develop changes in mental status, weakness, changes in
sensation, vision, or language, and severe headaches, vertigo,
or anything else that concerns you seriously.
Followup Instructions:
Follow up with neurologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]; call ([**Telephone/Fax (1) 70587**] for appt
Completed by:[**2200-1-18**]
|
[
"244.9",
"428.0",
"511.9",
"V44.1",
"707.24",
"428.22",
"401.9",
"486",
"276.0",
"571.8",
"458.9",
"572.2",
"707.03",
"414.01",
"280.9",
"345.3",
"788.5",
"284.1",
"250.80",
"789.59",
"155.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"34.91",
"38.93",
"96.6",
"00.14",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10726, 10777
|
3637, 6632
|
340, 346
|
10946, 11065
|
2314, 2507
|
11665, 11838
|
1936, 1954
|
7904, 10703
|
10798, 10925
|
6658, 7881
|
11089, 11642
|
1969, 1969
|
1991, 2295
|
279, 302
|
375, 1153
|
2516, 3614
|
1175, 1790
|
1806, 1920
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,679
| 103,213
|
7205
|
Discharge summary
|
report
|
Admission Date: [**2131-12-26**] Discharge Date: [**2132-1-17**]
Date of Birth: [**2087-6-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
SOB and R arm swelling
Major Surgical or Invasive Procedure:
R AV fistula ligation
History of Present Illness:
Pt. is a 44 y/o with a hx of ESRD on HD (Tu, Th, Sat), Type II
DM, who p/w SOB x 2 day and R arm pain x 2 weeks. Pt. reports
she has had SOB with exertion since returning from HD on
Tuesday. Reports she has been getting a cold for the last week,
with rhinorrhea and cough productive of yellow sputum. Denies
HA, CP, fevers, reports chronic chills. Says she has had similar
episodes of SOB in the past "when I get fluid overloaded from
dialysis" but that she has been regular about HD so doesn't know
why she would be fluid overloaded now.
.
Pt. also reports getting a R AV fistula placed 1 month ago. She
reports her arm has been becoming painful and swollen for the
past 2 weeks. Says occasionally she'll get pain shooting from
elbow to R thumb, and sometimes her R hand goes numb if she
sleeps on her R, but otherwise denies weakness or numbness in R
hand.
.
In ED: A/A Nebs, ASA, Blood Cx x 2. Transplant surgery asked to
eval R arm fistula, Renal asked to eval for HD.
Past Medical History:
Type II DM, +retinopathy
ESRD on HD
HTN
Hx Pre-eclampsia
CHF- EF unknown, pt. reports "leaky valves"
Sleep Apnea -> CPAP, Home O2 PRN
CVA [**8-19**] with residual L arm and leg weakness
Social History:
No EtOH, hx tobacco quit 1 year ago, used to smoke 3 ppd x 33
years. Lives with cousin, [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 26707**], on
disability
Family History:
Adopted, unknown
Physical Exam:
VS: 96.8 116 167/93 18 99% on 2L
Gen: A+O, sitting on stretcher in NAD
HEENT: EOMI, PERRL
CV: tachycardic, regular rhythm, harsh 4/6 systolic murmer
Lungs: decreased BS at bases bilat, mild bibasilar crackles
Abd: obese, soft, NTND, +BS
Ext: fistula in R forearm, +thrill, R arm markedly swollen from
elbow to shoulder, TTP in this area. + radial pulse bilat
Pertinent Results:
CTA Chest [**2131-12-26**]: 1) No evidence of pulmonary embolism.
2) Congestive heart failure with mild bilateral pleural
effusions.
3) Nonspecific borderline mediastinal lymphadenopathy.
4) Tiny ill defined alveolar opacities in the anterior left
upper lobe
anteriorly, nonspecific; possibly infectious in nature; these
should be
reassessed to ensure resolution.
.
Right upper extremity venous ultrasound and Doppler examination,
[**2131-12-26**]:
Examination of the right internal jugular, right subclavian,
right axillary, paired brachial and basilic veins shows no
evidence of deep vein thrombosis. A very limited evaluation of
the fistula suggests that it is patent.
.
Fistulogram [**2131-12-28**]: Central subclavian occlusion. Limited
outflow of the AV fistula through multiple collaterals in the
arm, shoulder and thoracic wall. The AV anastomosis is patent.
Recommend MR venogram to determine central end of occlusion.
Based on MRI, decision to attempt further venous recanalization
under anesthesia could be considered.
.
MRI/MRA Chest [**2132-1-2**]: MRA of the thorax shows normal pulmonary
arteries bilaterally without central filling defects to suggest
pulmonary embolus. Pulmonary veins are patent and have a normal
appearance. The left ventricle wall appears mildly thickened
raising the question of left ventricular hypertrophy. Chamber
size is within normal limits for all four [**Doctor Last Name 1754**] of the heart.
The ascending and descending aorta have a normal appearance
without aneurysmal dilatation, ulcer, or large amount of
atherosclerosis. Bilateral common carotid arteries are widely
patent proximally and patent to their bifurcations. Bilateral
subclavian arteries are also widely patent giving rise to
respective vertebral arteries. The left vertebral artery appears
slightly dominant. No concerning lesions within the arteries.
.
There is marked narrowing of the right subclavian vein a few
centimeters
central to the right chest wall that extends over the entire
more central
portion of the right subclavian vein and right brachiocephalic
vein. The
caliber of the vessel at this level measures between 3 and 9 mm
with multiple areas of stenosis. PICC does extend through the
stenoses and into the superior vena cava. The right jugular vein
is completely thrombosed.
.
The left subclavian vein is markedly irregular with moderate
stenoses but
remains patent to the left brachiocephalic vein. Within the left
lateral
subclavian vein are some filling defects that could represent
chronic thrombus that are nonocclusive. The patient's
double-lumen dialysis catheter enters through the central left
subclavian vein and into the brachiocephalic vein and SVC. There
is minimal contrast around the dialysis catheter throughout its
course within the brachiocephalic vein and superior SVC, which
is narrowed superiorly, however there is slow flow around the
catheter. The left jugular vein is completely thrombosed.
.
Large number of venous collaterals shunting venous blood from
the neck and bilateral upper extremities around the bilateral
subclavian vein and
brachiocephalic vein stenoses. Collaterals are seen within
anterior chest
walls bilaterally, left much greater than right, within the
posterior thorax including the intercostal veins and within the
supraclavicular veins bilaterally. Early on after the injection,
contrast is seen to flow more through these collaterals than
through the bilateral subclavian veins, right brachiocephalic,
and proximal left brachiocephalic vein. The two largest central
collaterals are the azygos vein and the left superior
intercostal vein.
.
There are multiple bilateral enlarged axillary lymph nodes,
which are
nonspecific and were seen on the recent CT scan. Clinical
correlation to
explain this lymphadenopathy is recommended.
.
No definite abnormalities are seen within the upper abdomen on
limited
evaluation. Within the right latissimus dorsi muscle is a 8.6 x
3.6 x 4.0 cm lesion with predominantly fat within it, though
there is some central soft tissue with intermediate T1 and T2
signal. This is not definitely a simple lipoma and therefore
dedicated MRI is recommended to better characterize.
.
IMPRESSION:
1. Multifocal high-grade stenosis within the right subclavian
vein centrally and right brachiocephalic vein. These vessels are
patent though there is slow flow through them with large venous
collaterals.
.
2. Moderate stenoses within the left subclavian vein and minimal
flow through the left brachiocephalic vein about the patient's
dialysis catheter as well as in the superior SVC which is
slightly narrowed. These lumens are patent, however there is
decreased flow as evidenced by delayed filling and the extensive
collaterals.
.
3. Bilateral jugular vein occlusion inferiorly.
.
4. 8.6 cm fat-containing lesion within the right latissimus
dorsi does
contain soft tissue elements and therefore is not definitely a
simple lipoma. Dedicated MRI is recommended to better
characterize.
.
5. Right greater than left axillary lymphadenopathy is
non-specific and
clinical correlation is recommended
.
CTA Chest [**2132-1-6**]: 1. No evidence of pulmonary embolism.
2. Findings most consistent with congestive heart failure.
3. New bibasilar opacities, probably atelectases.
4. Prominent axillary lymph nodes.
Brief Hospital Course:
SOB: CTA showed findings c/w CHF. Pt. was aggressively
dialyzed with improvement in her SOB. After HD #3 she did not
require O2 during the day to maintain O2 sats. A TTE was
checked and showed and EF of 75% with moderate LV outflow
obstruction, [**12-17**]+ MR, and mild PA hypertension, and high outflow
CHF [**1-17**] her AV fistula was thought to contribute to SOB.
Pulmonary was consulted re: PA HTN contributing to SOB and
recommended PFTs, which showed a restrictive defect, as well as
a RA ABG, which showed a pH of 7.39, PO2 73, PCO2 46, HCO3 29.
She was continued on her CPAP at night. PA HTN was also thought
to contribute to her SOB. PE was considered on admission,
however CTA was negative for PE. It was considered again when
pt. was transferred to the MICU on [**1-5**] for hypotension and
hypoxia, especially given known UE thrombi, however repeat CTA
was negative for PE.
.
CHF: As mentioned above pt. was found to have high output CHF,
making her pro-load dependant. On [**1-5**] she became hypotensive
and hypoxic, and was transferred to the MICU for further
management. She briefly required pressors, but responded to
fluid resuscitation (3L NS), and briefly required BiPAP for
management of hypoxia, though she was quickly weaned to O2 by
NC. All blood cultures were negative, so this episode was
thought be be [**1-17**] decreased pre-load from decreased PO intake
and fluid removal at HD, and not sepsis. She was continued on
ASA QD throughout her hospitalization, as well as her BB (though
this was held during her episode of hypotension) She was
started on an ACE at the beginning of her hospitalization,
however this was stopped during her hypotensive episode and was
not restarted in order to maintain a higher basal BP. This was
later restarted at the time of discharge.
.
Arm Swelling: RUE dopplers were checked on admission and were
negative for DVT. Transplant evaluated pt in ED and reviewed
dopplers, and concluded that no intervention was necessary.
However given clinical concern for thrombosis, this was followed
up with an AV fistulogram which showed central subclavian
occlusion. Pt. was started on Heparin gtt. Transplant was
reconsulted and again recommended no intervention. Therefore
interventional radiology was consulted re: recanalization of R
subclavian vein. They recommended an MRI/MRV prior to
intervention, and this was obtained (see results above) and
showed bilateral thrombi and stenoses. While these studies were
being obtained pt. also developed LUE swelling, due to L sided
clots. On [**1-9**] recanalization of R subclavian clot was
attempted by IR, but was unsuccessful. Pt. was transferred to
the MICU for infusion of tPA overnight, and recanalization was
attempted again on [**1-10**], again unsuccessfully. Transplant was
contact[**Name (NI) **] again after these procedures, and on [**1-12**] they ligated
her R AV fistula.
.
ESRD: Renal was consulted, and pt. was continued on HD through
her L subclavian HD catheter. Her PhosLo was d/ced as her Phos
was WNL, and her Epogen at HD was continued. She was started on
Nephrocaps.
.
Type II DM: Actos was held given concern for fluid retention,
pt. was covered with RISS, with good blood glucose control over
admission.
.
Dispo: At the time of discharge the patient INR was to be drawn
at dialysis and followed up by Dr. [**First Name8 (NamePattern2) 26708**] [**Name (STitle) **]. The patient
would later be transitioned to the coumadin clinic at [**Hospital 6308**].
Medications on Admission:
Metoprolol 100 mg [**Hospital1 **]
Lansoprazole 30 mg [**Hospital1 **]
Pioglitazone 30 mg QD
Diltiazem Er 360 mg QD
Calcium Acetate 667 mg TID with meals
Reglan 10 mg TID
ASA 325 mg QD
Epogen with HD
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*0*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
PRN.
Disp:*qs inhaler* Refills:*2*
5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
6. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED): Will be given at dialysis.
8. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: One
(1) Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*5 Bottles* Refills:*2*
9. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
10. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-17**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*qs bottles* Refills:*0*
11. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*2*
12. trazadone Sig: 25mg at bedtime.
Disp:*30 pills* Refills:*2*
13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
14. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 7 days.
Disp:*30 Tablet(s)* Refills:*0*
15. Outpatient Lab Work
Patient needs INR level monitored on Tuesday, Thursday and
Saturday.
Please report value to Dr. [**First Name8 (NamePattern2) 26708**] [**Name (STitle) **] [**Numeric Identifier 26709**]
[**Hospital 191**] clinic
16. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
17. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis
Bilateral Upper Extremity Thrombus
.
Secondary Diagnosis
Type II DM, retinopathy
ESRD on HD
HTN
Pre-eclampsia
CHF: EF 75%
Sleep Apnea: CPAP
CVA [**8-19**] with L arma and leg weakness
Discharge Condition:
Good, vitals stable, patient ambulating and eating,
Discharge Instructions:
Seek medical services immediately if you should have any fevers,
chills, worsening upper extremity swelling or any other
worrisome sympmtom. Please take your medications as prescribed.
Please restrict your sodium intake to 2g per day.
.
Your INR will be checked at dialysis. They will report the
results to me. Do not take your Coumadin tonight. Take it on
Friday. I will contact you on Saturday as to whether or not you
need to take it.
.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-1-22**]
4:00
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-2-5**]
1:30
Completed by:[**2132-1-22**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
[]
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13314, 13371
|
7508, 11010
|
338, 362
|
13617, 13671
|
2187, 7485
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14166, 14468
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1775, 1793
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11260, 13291
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11036, 11237
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13695, 14143
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1808, 2168
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276, 300
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390, 1364
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1386, 1574
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1590, 1759
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,875
| 127,871
|
44420
|
Discharge summary
|
report
|
Admission Date: [**2118-10-5**] Discharge Date: [**2118-10-21**]
Date of Birth: [**2075-1-14**] Sex: F
Service: SURGERY
Allergies:
Prednisone / Purinethol
Attending:[**First Name3 (LF) 3376**]
Chief Complaint:
abdominal pain, distention, and decreased bowel movements
for the past 36 hours, preceding her recent procedure
Major Surgical or Invasive Procedure:
total abdominal colectomy with end ileostomy
History of Present Illness:
Patient is a 43-year-old female with a past medical history
of Crohn's Disease, with strictures and rectal cancer, with a
scheduled colectomy and ileostomy scheduled for [**2118-10-17**], and
IVC filter placement the day prior to presentation who presents
with abdominal pain, distention, and decreased bowel movements
for the past 36 hours, preceding her recent procedure. The
patient noted a decrease in bowel movements approximately one
and
a half days prior to presentation. Due to her Crohn's Disease,
the patient normally has [**10-23**] bowel movements a day which has
abruptly decreased to zero bowel movements; she denies flatus.
The patient notes that her abdomen appears more "distended" than
usual. The patient has also noticed crampy, episodic abdominal
pain radiating throughout the periumbilical area. She reports
mild nausea and notes one episode of emesis which occurred after
anesthesia for her IVC filter implantantation the day prior to
presentation. She reports decreased appetite and increased
eructation. She denies fever, chills, sweats, skin-color
changes
over the abdomen.
Past Medical History:
Crohn's Disease
Rectal Stricture
WPW Syndrome
Paroxysmal A Fib
Iron Deficiency Anemia
GERD
Osteopenia
Osteoarthritis
Scoliosis
Fibrocystic Breast disease
h/o DVT
h/o b/l PE (on coumadin chronically)
h/o Depression (?steroid related)
Social History:
Married, lives with husband and 3 kids. She works as a business
manager for a church and as a singer.
Tobacco: quit [**2105**]; 1 ppd x 10 years
EtOH: occasional.
Recreational Drugs: None
Family History:
Mother (living, 81) thyroid problems, rheumatoid arthritis
Father (deceased, 74) pulmonary hypertension
PGF: DM2
PAunt: Breast Cancer in her 30s
Brother: CAD/MI at 41
Physical Exam:
At Discharge:
Vitals: 99.3, 68, 100/66, 20, 99% on RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB
ABD: soft, ND, appropriately TTP
Incision: Midline OTA, CDI. RLQ JP drain dressing intact,
serosanguinous output.
Stoma beefy red, viable with liquid brown effluence
Extrem: 1+ pedal edema. no c/c
Pertinent Results:
[**2118-10-21**] 11:10AM BLOOD Hct-30.1*
[**2118-10-20**] 06:10PM BLOOD Hct-26.4*
[**2118-10-20**] 07:35AM BLOOD Hct-24.4*
[**2118-10-19**] 07:45AM BLOOD WBC-9.1 RBC-3.36* Hgb-8.9* Hct-28.9*
MCV-86 MCH-26.4* MCHC-30.7* RDW-17.9* Plt Ct-392
[**2118-10-16**] 05:35PM BLOOD PT-13.5* PTT-72.5* INR(PT)-1.2*
[**2118-10-18**] 08:30AM BLOOD Glucose-106* UreaN-6 Creat-0.7 Na-136
K-4.6 Cl-101 HCO3-30 AnGap-10
[**2118-10-16**] 05:35PM BLOOD Glucose-95 UreaN-8 Creat-0.7 Na-135 K-4.0
Cl-99 HCO3-24 AnGap-16
[**2118-10-18**] 08:30AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.9
[**2118-10-16**] 05:35PM BLOOD TotProt-6.9 Albumin-3.6 Globuln-3.3
Calcium-9.1 Phos-4.1 Mg-2.0 Iron-15*
[**2118-10-16**] 05:35PM BLOOD calTIBC-287 Ferritn-32 TRF-221
[**2118-10-16**] 05:35PM BLOOD Triglyc-161*
.
BILAT LOWER EXT VEINS Study Date of [**2118-10-6**] 10:40 AM
IMPRESSION: No evidence of deep vein thrombosis in either leg.
.
CT PELVIS W/CONTRAST Study Date of [**2118-10-9**] 1:25 PM
IMPRESSION:
1. Obliquely oriented IVC filter with tip projecting more
medially. A small linear thrombus is noted just superior to the
tip of the IVC filter. More contained thrombus is evident within
the filter itself.
2. Extensive thickening of the entire colon and rectum which may
be related to the patient's underlying inflammatory bowel
disease. However, other etiologies such as infection and
ischemia could also be considered.
3. Bilateral hypodensities within both kidneys, too small to
characterize,
likely represent simple cysts.
4. Bilateral ovarian cysts, likely physiologic.
.
[**2118-10-17**] Pathology Tissue: abdominal colon, RECTO [**2118-10-17**]
[**Last Name (LF) **],[**First Name3 (LF) **] Not Finalized
Brief Hospital Course:
Mrs. [**Known lastname **] was evaluated in ED. Both General Surgery and
Vascular surgery were consulted. She was admitted for further
evaluation.
.
[**Date range (1) 48685**]: She underwent Ultrasound of bilateral lower
extremities which was negative for DVT. Started on heparin gtt
to a goal PTT of 60-80. On [**10-5**] underwent Venogram, results:
Inferior venacavogram demonstrating large nonocclusive thrombus
below the IVC filter which itself is tilted approximately 45
degrees. Filter retrieval or repositioning not attempted due to
large thrombus. Plan Repeat CT venogram. Continue with heparin
gtt.
.
[**10-7**]: Heparin gtt held for scheduled surgery. Underwent Pelvic
Irradiation for Rectal Cancer as arranged pre-op. Underwent
scheduled surgery with Dr. [**Name (NI) 95227**] total
proctocolectomy and end-ileostomy. Tolerated procedure well.
Admitted to Stone 5 for routine post-op care.
.
[**10-8**]: Continued with IV fluid, Dilaudid PCA, Foley with adequate
output. JP with serosanguinous output.
.
[**10-9**]: Continued with plan from [**10-8**]. PCA dose increased. Started
on basal rate due to increased perineal pain. Underwent Repeat
CT venogram. Thrombus appeared slighlty smaller.
.
[**Date range (1) 73835**]: Diet advanced as bowel function resumed. Medications
converted to orals. Tolerating well. Foley removed. Urinating
adequate amounts. Ostomy RN continue to meet with patient during
recovery for ostomy teaching. Ambulating independently. Adequate
gas and effluence in ostomy. Vitals stable, Hct stable.
.
[**10-20**]: Received 2 units PRBC for Hct 24.4, increased to 26.4.
Tolerating a regular diet. Adequate pain control with oral
medication. Ambulating independently. Abdominal incision and
perineal area CDI. Ostomy beefy red, viable with liquid brown
effluence and gas.
.
[**10-21**]: Hct-30.1. Steroids discontinued for discharge. Discharged
home with visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] of ostomy, and JP drain.
Plan to follow-up with Dr. [**Last Name (STitle) **] from Vascular in 1 month with
repeat CT venogram on same day. Follow-up with Dr. [**Last Name (STitle) 1120**] in [**2-13**]
weeks.
Medications on Admission:
Balsalazide, lovenox(held), coumadin (held), MVI, Sotalol, MTX,
Protonix, probiotics
Discharge Medications:
1. Sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
2. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day:
Titrate dose according to INR.
Goal [**2-13**].
Disp:*60 Tablet(s)* Refills:*2*
3. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral Q 12H (Every
12 Hours) as needed for to rectal area.
Disp:*qs * Refills:*0*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours.
5. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
6. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 2 weeks: Do not
exceed 4000mg of acetaminophen in 24hrs.
Disp:*45 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Do not exceed 4000mg in 24 hrs
.
8. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice
a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] VNA
Discharge Diagnosis:
Primary:
IVC filter thrombus
rectal cancer
Crohns disease
.
Secondary:
Crohn's disease, rectal stricture, WPW, paroxysmal A fib,
anemia, GERD, osteopenia, H/O DVT, H/O pe, depression
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:
* 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.
*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:
-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.
.
Monitoring Ostomy output/Prevention of Dehydration:
-Keep well hydrated.
-Replace fluid loss from ostomy daily.
-Avoid only drinking plain water. Include Gatorade and/or other
vitamin drinks to replace fluid.
-Try to maintain ostomy output between 1000mL to 1500mL per day.
-If Ostomy output >1 liter, take 4mg of Imodium, repeat 2mg with
each episode of loose stool. Do not exceed 16mg/24 hours.
.
Rectal Discomfort:
-Sit on pillows, side to side as tolerated.
-Apply Lidocaine jelly to rectal area as needed for pain.
.
Followup Instructions:
1. Follow-up with Dr. [**Last Name (STitle) 1120**] ([**Telephone/Fax (1) 3378**] in [**2-13**] weeks.
2. Follow-up with PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Doctor Last Name **] [**Telephone/Fax (1) 3070**] in 1 week
and as needed. Please call PCP with INR values for Coumadin
dosing.
3. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] (Vascular)([**Telephone/Fax (1) 8343**]
in 1 month. You will have a CT Venogram to assess the blood clot
on the same day. Dr.[**Name (NI) 10618**] assistant will call you with the
appointment date & time.
.
Previous appointment:
1.Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2118-12-21**] 4:40
THIS SUMMARY NEITHER DICTATED NOR READ BY ME
Completed by:[**2118-10-25**]
|
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icd9cm
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icd9pcs
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|
1850, 2041
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,090
| 180,179
|
50252
|
Discharge summary
|
report
|
Admission Date: [**2164-10-18**] Discharge Date: [**2164-11-8**]
Date of Birth: [**2098-10-15**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Developed bronchitis and SOB about 2 weeks ago after jogging
outdoors. He has SOB when walking up stairs or with any
exertion.
Major Surgical or Invasive Procedure:
MV repair/ cabg x2
History of Present Illness:
65 yo male with DOE and a prior history of MI at age 39.Also had
a prior pacer. [**Name6 (MD) **] to MD [**First Name (Titles) **] [**Last Name (Titles) 2742**]. Was told recently he
had an abnormal EKG, so he was scheduled for cath. Stress echo
in [**2162**] showed dilated LV, and EF 15-25%
Past Medical History:
MI
CHF
pacer VVI DCCV for WCT
RF ablation for VTach
gout
HTN
hypothyroidism
TIA
recent bronchitis
PAF
Social History:
married and retired
Family History:
negative for CAD
Physical Exam:
6"0" 192 pounds
130/73 HR 77 RR 23 Sat 100% RA
skin unremarkable
NC, PERRLA, EOMI, trachea midline
RRR S1 S2, paced , 2/6 SEM no rub or gallop, no JVD
CTAB anteriorly
abd soft, NT, positive BS, no organomegaly appreciated
right carotid bruit, none appreciated on left
3+ bilat femoral pulses; 1+ bilat. DP/PT, no edema, no
varicosities
alert and oriented , [**3-22**] strengths MAE
Pertinent Results:
[**2164-11-1**] 07:30AM BLOOD WBC-11.6* RBC-4.81 Hgb-14.0 Hct-41.6
MCV-86 MCH-29.1 MCHC-33.7 RDW-14.4 Plt Ct-301
[**2164-11-1**] 07:30AM BLOOD PT-13.1 INR(PT)-1.2
[**2164-11-1**] 07:30AM BLOOD Plt Ct-301
[**2164-11-1**] 07:30AM BLOOD Glucose-97 UreaN-41* Creat-1.5* Na-137
K-4.0 Cl-101 HCO3-26 AnGap-14
[**2164-10-31**] 02:26AM BLOOD Calcium-8.6 Phos-4.0 Mg-2.0
[**2164-11-1**] 07:30AM BLOOD Mg-2.1
Cath [**10-8**]: LM 50%, LAD 80% , right dominant
[**2164-11-7**] 07:35AM BLOOD WBC-5.7 RBC-4.10* Hgb-12.6* Hct-35.3*
MCV-86 MCH-30.7 MCHC-35.6* RDW-15.0 Plt Ct-203
[**2164-11-8**] 06:30AM BLOOD PT-23.6* INR(PT)-4.0
[**2164-11-8**] 06:30AM BLOOD Glucose-82 UreaN-32* Creat-1.9* Na-140
K-3.8 Cl-104 HCO3-26 AnGap-14
[**2164-11-2**] CXR
Decreased left lower lobe atelectasis. Small left pleural
effusion.
[**2164-11-2**] ECHO
1. The left atrium is mildly dilated. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is an apical left
ventricular aneurysm. Overall left ventricular systolic function
is severely depressed. No masses or thrombi are seen in the left
ventricle.
3. Right ventricular chamber size is normal. Right ventricular
systolic
function is normal.
4. The aortic root is mildly dilated.
5. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
7. The estimated pulmonary artery systolic pressure is normal.
8. There is no pericardial effusion.
9. There is an echogenic density in the right ventricle
consistent with an
AICD lead.
[**2164-10-25**] XRay finger
There is cortical irregularity of the 4th and 5th proximal
phalanges which may represent healed fractures. Slight lucency
is seen along the cortical irregularity of the proximal fifth
phalanx which may represent residua of prior injury but an acute
hairline fracture cannot be excluded. Clinical correlation to
the patient's site of pain is recommended. Mineralization is
normal. Surrounding soft tissues are unremarkable.
[**2164-10-19**] EKG
Ventricular paced rhythm. Pacemaker rhythm. No further analysis.
Compared to the previous tracing no significant change.
Brief Hospital Course:
Mr. [**Known lastname 38315**] was admitted to the [**Hospital1 18**] on [**2164-10-19**] for elective
surgical management of his coronary artery and mitral valve
disease. He was take directly to the operating room where he
underwent coronary artery bypass grafting to two vessels and a
mitral valve repair with a 28mm annuloplasty band.
Postoperatively he was taken to the cardiac surgical intensive
care unit for monitoring. On postoperative day one, Mr. [**Known lastname 38315**] [**Last Name (Titles) **]e neurologically intact and was extubated. The
electrophysiology service was consulted for assistance with
changes to his pacemaker. Good lead function was noted. Mr.
[**Known lastname 38315**] developed respiratory distress and was reintubated.
Vancomycin and levofloxacin was started for presumed aspiration.
Lasix was given intravenously for pulmonary edema and natrecor
was started. He was transfused for postoperative anemia. He
underwent CVVH to assist with fluid management. On postoperative
day five, he was re-extubated successfully without complication.
The physical therapy service worked with him postoperatively to
improve his strength and mobility. Mr. [**Known lastname 38315**] complained of
right 5th digit pain and an x-ray was obtained. This revealed a
fracture and a splint was applied. His natrecor and milrinone
were slowly weaned. An ace inhibitor was started given his low
ejection fraction. On postoperative day 14, Mr. [**Known lastname 38315**] was
transferred to the step down unit for further recovery.
Amiodarone was started for paroxysmal atrial fibrillation.
Coumadin was resumed. He continued to be gently diuresed towards
his preoperative weight. His creatinine bumped and the renal
service was consulted. A foley was placed and he was transferred
back to the intensive care unit for 1 day. His ace inhibitor was
stopped as well as lasix. Acute renal failure was suspected in
the setting of an ace inhibitor, diuretics and dehydration. Over
the next few days, his creatinine stabilized and began to trend
back towards normal. His foley was removed and a flomax was
started for some frequency, hesitancy and urgency with good
relief. Mr. [**Known lastname 104792**] coumadin was held as his INR was elevated
to 4.2. Vitamin K was also given as he developed a nose bleed.
The Ear, nose and throat service was consulted who recommended
saline mist nasal sprays twice daily. His epistaxis subsequently
resolved. Mr. [**Known lastname 38315**] continued to make steady progress and was
discharged to rehabilitation on postoperative day twenty one.
His INR was 4.0 on discharge and his coumadin remains held. Dr.
[**Last Name (STitle) 1270**] will manage his coumadin after discharge from rehab
for a goal INR of 1.8-2.2. His room air saturations were 98% and
his discharge x-ray was only notable for a very small left
pleural effusion. Mr. [**Known lastname 38315**] will follow-up with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) 1270**] as an outpatient.
Medications on Admission:
synthroid 200 mcg daily
coumadin 5 mg as directed
lopressor 25 mg daily
ASA 325 mg daily
probenecid 500 mg/ colchicine 0.5 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. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
7. Cepacol 2 mg Lozenge Sig: One (1) Lozenge Mucous membrane
PRN (as needed).
8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
9. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
10. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime). Capsule, Sust.
Release 24HR(s)
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
12. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 6 days: Take 400mg daily until [**2164-11-14**]. Then take 200 mg
daily thereafter. .
13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
Start on [**2164-11-14**].
14. Synthroid 200 mcg Tablet Sig: One (1) Tablet PO once a day.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Probenecid 500 mg Tablet Sig: 0.5 Tablet PO BID (2 times a
day): 250mg twice daily.
17. Warfarin 1 mg Tablet Sig: As [**Name8 (MD) **] MD based on INR Tablet PO
DAILY (Daily): Dose for a goal INR of 2.0. Monitor Pt?INR daily.
18. Ocean Nasal Mist 0.65 % Aerosol, Spray Sig: Two (2) Sprays
Nasal three times a day: 2 sprays each nostril three times
daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
MV repair/ cabg x2 (LIMA to ramus, SVG to LAD, 28 mm CE
[**Doctor Last Name 405**] band)
elev. chol.
HTN
CRI
post op ARF-resolving
MI
pacer VVI
s/p RF ablation
gout
TIA
AF
DCCV for wide-complex tach.
Discharge Condition:
good
Discharge Instructions:
1) No lotions, creams or powders to any incision untile it [**Last Name (un) **]
healed
2) [**Month (only) 116**] shower over incision and pat dry
3) No driving for one month
4) No lifting greater than 10 pounds for 10 weeks
5) Coumadin for paroxysmal atrial fibrillation. Goal INR
1.8-2.2. Monitor PT/INR daily and dose coumadiin accordingly.
Coumadin held past two days for elevated INR. Likely dose will
be 2 or 2.5mg daily. Dr. [**Last Name (STitle) 1270**] will manage coumadin once
discharged from rehab.
6) Monitor vital signs.
7) Report any weight gain of 2 pounds in 24 hours or 5 pounds in
1 week. Monitor fluid status. Patient may need a diuretic in the
future given low EF preoperatively.
8) Monitor electrolytes and renal function.
9) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. Call ([**Telephone/Fax (1) 1504**] for
appointment
Follow up with Dr. [**Last Name (STitle) 1270**] in [**11-20**] weeks. Call [**0-0-**]
for appointment.
Follow-up with electrophysiology service/Pacemaker service as
instructed by them.
Follow-up with Dr. [**Last Name (STitle) 104793**] from Ear/Nose and Throat in [**12-23**] weeks
if needed for nose bleeds. ([**Telephone/Fax (1) 7767**]
Completed by:[**2164-11-8**]
|
[
"458.29",
"414.01",
"272.4",
"784.7",
"276.51",
"427.31",
"412",
"285.1",
"816.01",
"274.9",
"401.9",
"V53.31",
"998.11",
"997.5",
"424.0",
"427.41",
"600.00",
"584.9",
"428.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"36.15",
"89.45",
"88.72",
"00.13",
"96.04",
"99.62",
"36.11",
"39.95",
"39.61",
"35.33",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8713, 8783
|
3676, 6688
|
404, 425
|
9029, 9036
|
1372, 3653
|
9870, 10349
|
925, 943
|
6870, 8690
|
8804, 9008
|
6714, 6847
|
9060, 9847
|
958, 1353
|
238, 366
|
453, 747
|
769, 872
|
888, 909
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,426
| 166,144
|
54958
|
Discharge summary
|
report
|
Admission Date: [**2156-6-15**] Discharge Date: [**2156-6-19**]
Date of Birth: [**2086-3-2**] Sex: F
Service: MEDICINE
Allergies:
Dilantin
Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Chief Complaint: dyspnea
Reason for MICU transfer: central pulmonary obstruction
Major Surgical or Invasive Procedure:
Attempted bronchial stenting, bronchoscopy
Endotracheal intubation
History of Present Illness:
Ms. [**Known lastname 3825**] is a 70 yo F with significant smoking history who is
transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for evaluation and treatment of
presumed metastatic lung cancer with RML obstruction,
post-obstructive RML collapse, partial obstruction of lingular
lobe bronchus and BL pleural effusions.
.
She initially presented to her PCP [**Last Name (NamePattern4) **] [**6-7**] with several days of
cough and progressive shortness of breath, and 25 pound weight
loss over past several months. Chest x-ray and CT chest were
performed which revealed diffuse, extensive lung disease as
outlined above. She was scheduled for outpatient bronchoscopy,
but prior to appointment on [**6-11**] developed severe dyspnea and was
brought to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] emergency room. She was put on
Ventimask. Right thoracentesis was performed which yielded 15mL
serosanguinous fluid: WBC 7090, RBC 15,000 95% lymphs, glucose
189, LDH 257, tot prot 4.7. Bronchoscopy was also performed,
showing extrinsic compression of RML and possible submucosal
disease. No e/o endobronchial lesion or obstruction. Probably
external compression of lingular bronchus. Lavage, brushings,
and EBUS-guided biopsies were performed. Path report yielded
poorly-differentiated lung adenocarcinoma, probably bronchogenic
in origin. After her procedure, patient was monitored closely in
the ICU. Her oxygen requirements increased over the next several
days. She was also very anxious, requiring Xanax 1mg q6 hrs PRN
as well as morphine for sleep. It was felt that her fairly
precipitous decline was [**2-5**] occlusion of R MSB with subsequent
collapse/atalectasis. Based on admission CXR which showed new
density (infiltrate vs. effusion) at right lung base, she was
started on Zosyn for pneumonia despite no clinical s/s of
pneumonia.
.
On arrival to the MICU, vitals are: 99.3 106 120/46 23 78% 3L +
10L face tent. O2 sat quickly improved to 91% on face tent.
Patient complaining of shortness of breath, productive cough,
and anxiety.
Past Medical History:
-Extensive lung masses per above, likely poorly differentiated
bronchogenic adenocarcinoma
-Osteopenia
-Anxiety
-Panic disorder
-Lyme meningioencephalitis c/b seizures
-C. diff ([**2152**])
Social History:
She is married with two daughters and five grandchildren. She is
retired. Denies EtOH. Smokes cigarettes.
Family History:
noncontributory
Physical Exam:
On admission:
Vitals: 99.3 106 120/46 23 78% 3L + 10L face tent
General: thin F in mild respiratory distress, coughing, AAOx3,
talking in full sentences
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: sinus tachycardia, normal S1 + S2, no murmurs, rubs, gallops
Lungs: diffusely decreased breath sounds, moreso in BL posterior
middle and lower lung fields.
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: CN II-XII grossly intact
Pertinent Results:
On admission:
.
[**2156-6-15**] 10:30PM BLOOD WBC-11.1* RBC-3.23* Hgb-9.4* Hct-29.5*
MCV-91 MCH-29.0 MCHC-31.7 RDW-12.4 Plt Ct-427
[**2156-6-15**] 10:30PM BLOOD PT-17.5* PTT-32.6 INR(PT)-1.6*
[**2156-6-15**] 10:30PM BLOOD Glucose-57* UreaN-7 Creat-0.3* Na-144
K-2.0* Cl-121* HCO3-16* AnGap-9
[**2156-6-15**] 10:30PM BLOOD Albumin-1.5* Calcium-4.2* Phos-1.1*
Mg-1.0*
.
CT-A chest:
IMPRESSION:
1. No pulmonary embolism.
2. Short interval progression of metastatic central
lymphadenopathy, producing
more bronchial obstruction and middle lobe and left upper lobe
atelectasis/obstructive pneumonia.
3. New left lower lobe pneumonia and increasing moderate right
pleural
effusion since [**2156-6-8**].
4. Numerous lung metastases.
.
Brief Hospital Course:
Assessment and Plan: 70 yo F with significant smoking history
transferred from OSH for workup and treatment of extensive lung
masses with compression of RML bronchus and lingular bronchus
and post-obstructive collapse.
Active Issues:
# LUNG MASSES, BRONCHIAL COMPRESSION: Patient with extensive
burden of cancer on chest CT scan. Interventional Pulmonology
attempted to stent open the RML collapsed on HD#2 but were
unsuccessful - thoracentesis was performed. Pathology at OSH had
shown poorly differentiated adenocarcinoma - likely of lung
origin. Medical oncology and Radiation oncology were consulted
and explained to the family that given her burden of disease and
performance status, palliative treatment would offer little
benefit. Palliative care was consulted and after multiple
meetings with the patient and family, care was transitioned to
comfort measures and discharged to hospice.
.
# ANXIETY, PANIC DISORDER: Pt with history of anxiety and had
significant anxiety during hospitalization, which was
contributing to her dyspnea. Ativan and celexa were continued as
well as morphine for air hunger.
Inactive Issues
# SEIZURE DISORDER: Continued home Lamictal and Keppra.
.
# SMOKING HISTORY: Continued nicotine patch
Transitional Issues:
Patient will be cared for a hospice.
Medications on Admission:
HOME MEDS
ASA d/c on [**6-11**] + meds below
Medications on Transfer:
-Zosyn 3.375grams IV q6 hrs
-Lamictal 100mg PO BID
-Celexa 20mg PO daily
-Habitrol patch 14 grams daily
-Keppra 1500mg PO BID
-Albuterol nebs q4 hrs PRN
-Xanax 1mg PO q6 hrs PRN anxiety
-Colace 100mg PO daily
-Protonix 40mg PO daily
-Tylenol 650mg PO q4 hrs PRN
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain/fever
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
3. Albuterol Inhaler [**1-5**] PUFF IH Q4H:PRN wheeze
4. Chloraseptic Throat Spray 1 SPRY PO Q8H:PRN nausea
5. Citalopram 20 mg PO DAILY
6. Guaifenesin-CODEINE Phosphate 10 mL PO Q6H:PRN cough, sore
throat, PRN comfort
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 10 ml by mouth every
six (6) hours Disp #*1 Bottle Refills:*0
7. LaMOTrigine 100 mg PO BID
8. LeVETiracetam 1500 mg PO BID
9. Nicotine Patch 14 mg TD DAILY
10. Ondansetron 4-8 mg IV Q8H:PRN nausea
11. Lorazepam 1 mg PO Q4H:PRN anxiety
RX *lorazepam 2 mg/mL 1 mg(s) by mouth every four (4) hours Disp
#*1 Bottle Refills:*0
12. Morphine Sulfate (Oral Soln.) 5-10 mg PO Q4H:PRN pain,
shortness of breath, cough
RX *morphine 10 mg/5 mL 5-10 mg by mouth Q2H Disp #*1 Bottle
Refills:*0
13. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
The [**Hospital1 656**] Family Hospice House
Discharge Diagnosis:
Pulmonary adenomcarcinoma with bronchial compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. [**Known lastname 3825**],
You were transferred to [**Hospital1 69**] for
evaluation of your lung cancer. While in the medical intensive
care unit, several studies demonsrated considerable progression
of the disease. On discussion with your family and your doctors,
you decided to focus on maximizing your comfort. With your
family, you have decided to continue this care at Hospice House.
We have provided instructions for your new care team about the
medications you have been prescribed. Please do let them know if
any changes need to be made to your medicines to improve your
comfort.
Followup Instructions:
Transferred to hospice
|
[
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"V49.86",
"519.19",
"518.0",
"V66.7",
"511.81",
"300.01",
"V15.82",
"162.8",
"518.89",
"518.84"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"34.91",
"34.04",
"33.91"
] |
icd9pcs
|
[
[
[]
]
] |
6890, 6961
|
4315, 4535
|
351, 419
|
7058, 7058
|
3558, 3558
|
7818, 7844
|
2899, 2916
|
5989, 6867
|
6982, 7037
|
5631, 5677
|
7193, 7795
|
2931, 2931
|
5567, 5605
|
246, 313
|
4550, 5546
|
447, 2546
|
3572, 4292
|
7073, 7169
|
5702, 5966
|
2568, 2760
|
2776, 2883
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,374
| 140,569
|
45056
|
Discharge summary
|
report
|
Admission Date: [**2105-4-1**] Discharge Date: [**2105-4-4**]
Date of Birth: [**2042-6-25**] Sex: F
Service: MEDICINE
Allergies:
Mevacor / Bactrim / Dilantin / Naprosyn / Clindamycin / Percocet
/ Quinine / Levofloxacin / Penicillins / Vicodin
Attending:[**First Name3 (LF) 545**]
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HPI: The patient is a 62 year-old female with PMH significant
for CAD s/p DES to LAD, severe diastolic CHF, pulmonary HTN,
DM2, morbid obesity, and PVD with recent admissions for
exacerbations of her pulmonary disease who presents with 3-4
days increased dyspnea at rest and on exertion and fatigue. She
describes the feeling of SOB occurring gradually over this time
with associated fatigue and dry cough. She also reports
increased swelling in the legs and perhaps an 8 lb weight gain.
She has been adherent with her medications to include torsemide
which was recently switched back to lasix. However, she notes no
change in her chronic 02 requirement (3-4L NC), no change in
orthopnea, PND, and denies f/c, HA, chest pain, nausea,
sweating, abd pain, diarrhea or leg pain. No recent travel or
sick contacts. [**Name (NI) **] change in her diet.
.
In the ED, T 97.4, RR 20, 02 100% on 3L. CXR performed. Pt
became tachycardic to 120s and EKG demonstrated afib with RVR.
She was given Dilt 30mg IV with resolution of her tachycardia.
She was also given ASA 325mg, Solumedrol 125mg IV, and ativan
.
On arrival to the floor, she is fatigued but feels overall well.
Past Medical History:
Cardiac:
1. CAD s/p stent RCA in [**2100**], 2 Cypher stents to LAD in [**2102**];
NSTEMI in [**8-2**] -> cath then showed
2. PVD s/p bilateral fem-[**Doctor Last Name **] in 96
3. HTN
4. Afib noted on admission in [**9-2**] - reverted to sinus and seen
by cards who felt she did not need anticoagulation
5. Dyslipidemia
6. Syncope/Presyncopal episodes - This was evaluated as an
inpaitent in [**9-2**] and as an opt with a KOH. No etiology has been
found as of yet. One thought was that these episodes are her
falling asleep since she has a h/o of OSA. She has had no tele
changes in the past when she has had these episodes.
.
Pulm:
1. Severe Pulmonary HTN
2. Asthma or COPD (notes say both)
3. OSA- CPAP at home 14 cm of water and 4 liters of oxygen
4. Restrictive lung disease
.
Other:
1. Morbid obesity (BMI 54)
2. Type 2 DM on insulin - last A1C is 8.9 in [**10-3**]
3. CRI (baseline 1.7-2.0)
4. Crohn's disease - not currently treated, not active last 5
years
5. Depression
6. Gout
7. Hypothyroidism
8. GERD
9. Chronic Anemia
10. Restless Leg Syndrome
11. Back pain/leg pain from trochanteric bursitis and sciatica
.
PSHx:
S/P fem-popliteal bypass -'[**93**], '[**00**]
S/P Hernia repair
S/P cholecystectomy, appendectomy
S/P burn closure
Social History:
Lives at home with her sister. Quit smoking 2.5 years ago, rare
EtOH use, no illicit drug use.
Family History:
mother died of MI at 78, father died of MI at 61, sister has
HTN, brother s/p CABG, dm
Physical Exam:
Admit PE:
VS: T 96.7, BP 112/68, HR 102, RR 24, 95% 3L
Gen: awake and alert but sleepy, NAD
HEENT: EOMI, anicteric sclera, MMM, OP clear
Neck: supple, no LAD, JVP estimated at 8-10cm
Lung: Decent air movement without wheeze or crackles or rhonci
Heart: Difficult to appreciate heart sounds given habitus
Abd: Obese, soft NT/ND
Ext: Obese extremities bilat, symmetric, no pitting edema
Skin: warm, no rashes appreciated
Pertinent Results:
RADIOLOGY Final Report
BILAT LOWER EXT VEINS [**2105-4-1**] 6:28 PM
IMPRESSION: No evidence of DVT.
RADIOLOGY Final Report
CHEST (PA & LAT) [**2105-4-1**] 10:25 AM
IMPRESSION: PA and lateral chest compared to [**2-13**] and
[**4-1**]:
Overlying soft tissue probably lends some increasing
radiodensity to the right mid and lower lung but the area is
still suspicious for new consolidation, though unfortunately
motion artifact on the lateral film makes confirmation
impossible. If the patient can tolerate a repeat lateral, I
would obtain that as well as routine oblique views in hopes of
clarifying the status of the lower lobes. Pulmonary vascular
engorgement is longstanding even though heart size is only
mildly enlarged. There is no pleural effusion. No pneumothorax.
RADIOLOGY Final Report
CHEST (BOTH OBLIQUES ONLY) [**2105-4-1**] 6:03 PM
IMPRESSION:
Diffuse pulmonary opacification unchanged since [**Month (only) 404**], could
be due to hypersensitivity pneumonitis or other extensive
alveolitis.
No evidence of bacterial pneumonia.
Calcified right upper lobe granuloma.
ECHO [**2105-4-2**]
The left atrium is moderately dilated. The estimated right
atrial pressure is 0-10mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral regurgitation is seen. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2105-2-17**],
pulmonary artery pressure could not be determined in the current
study.
[**2105-4-4**] 06:10AM BLOOD WBC-4.9 RBC-3.89* Hgb-12.0 Hct-35.3*
MCV-91 MCH-31.0 MCHC-34.1 RDW-14.7 Plt Ct-228
[**2105-4-3**] 06:00AM BLOOD WBC-6.7 RBC-3.97* Hgb-12.3 Hct-36.2
MCV-91 MCH-31.0 MCHC-34.0 RDW-14.7 Plt Ct-256
[**2105-4-2**] 03:11AM BLOOD WBC-9.3 RBC-3.73* Hgb-11.4* Hct-33.8*
MCV-91 MCH-30.7 MCHC-33.8 RDW-14.2 Plt Ct-288
[**2105-4-1**] 09:00AM BLOOD WBC-8.9 RBC-4.31 Hgb-13.2 Hct-40.5 MCV-94
MCH-30.5 MCHC-32.5 RDW-14.2 Plt Ct-268
[**2105-4-1**] 12:30AM BLOOD WBC-7.2 RBC-4.50 Hgb-13.8 Hct-40.7 MCV-91
MCH-30.6 MCHC-33.8 RDW-14.8 Plt Ct-292
[**2105-4-1**] 12:30AM BLOOD Neuts-75.4* Lymphs-14.6* Monos-6.3
Eos-3.5 Baso-0.2
[**2105-4-4**] 06:10AM BLOOD Plt Ct-228
[**2105-4-4**] 06:10AM BLOOD PT-11.5 PTT-24.9 INR(PT)-1.0
[**2105-4-3**] 06:00AM BLOOD D-Dimer-513*
[**2105-4-4**] 06:10AM BLOOD Glucose-92 UreaN-74* Creat-1.7* Na-138
K-4.5 Cl-100 HCO3-31 AnGap-12
[**2105-4-3**] 06:00AM BLOOD Glucose-103 UreaN-83* Creat-1.9* Na-137
K-5.0 Cl-97 HCO3-33* AnGap-12
[**2105-4-2**] 03:11AM BLOOD Glucose-111* UreaN-85* Creat-2.2* Na-133
K-4.7 Cl-97 HCO3-27 AnGap-14
[**2105-4-1**] 09:00AM BLOOD Glucose-448* UreaN-73* Creat-2.1* Na-135
K-5.0 Cl-96 HCO3-25 AnGap-19
[**2105-4-1**] 12:30AM BLOOD Glucose-236* UreaN-70* Creat-2.0* Na-135
K-4.3 Cl-99 HCO3-22 AnGap-18
[**2105-4-1**] 03:35PM BLOOD CK(CPK)-224*
[**2105-4-1**] 12:30AM BLOOD CK(CPK)-353*
[**2105-4-1**] 03:35PM BLOOD CK-MB-5 cTropnT-0.02*
[**2105-4-1**] 12:30AM BLOOD cTropnT-0.02* proBNP-149
[**2105-4-4**] 06:10AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.7*
[**2105-4-3**] 06:00AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.6
[**2105-4-2**] 03:11AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.5
[**2105-4-1**] 09:00AM BLOOD Calcium-9.8 Phos-5.3* Mg-2.2
[**2105-3-31**] 04:30PM BLOOD %HbA1c-7.1*
Brief Hospital Course:
62 yo woman with CAD, diastolic CHF, pulm HTN, OSA who presents
with subacute dyspnea and elevated BS on admit.
.
PROBLEMS:
SHORTNESS OF BREATH
CAD, NATIVE VESSEL
HYPERTENSION, BENIGN
DIABETES TYPE II, UNCONTROLLED W/ COMPLICATIONS
APNEA, OBSTRUCTIVE SLEEP
HEART FAILURE, (B3) CHRONIC DIASTOLIC
ATRIAL FIBRILLATION
PULMONARY HYPERTENSION, SECONDARY
CHRONIC KIDNEY DISEASE, STAGE III (30-59)
ACUTE RENAL FAILURE
.
COURSE:
Pt. was initially admitted to the general medical floor.
Throughout HD1 she continued to have elevated blood sugars -
despite aggressive subcutaneous insulin administration. She was
transferred to the ICU the evening of HD1 because of a need for
an insulin drip. Also, during HD1 the patient was evaluated by
the [**Last Name (un) **] team, pulmonary consult, and cardiology consult
teams.
.
She spent the following two days in the ICU as she was
eventually transitioned back to her home dose of insulin - which
included Symlin - a medication she had brought in from home as
the [**Hospital1 18**] does not carry it. Moreover, during her time in the
ICU her Plavix was stopped - under direction of the cardiology
consult team - and she was started on Coumadin for her PAF. She
was continued on ASA during this hospitalization. She did well
the following two days she remained on the general medical
floor. Her blood sugars were well controlled. She was
evaluated by the physical therapy team and cleared for home with
the consideration of outpatient pulmonary rehab. Her blood
sugars were much better controlled on her home regimen. The
pulmonology team recommended that she stay on her current
regimen of breathing treatments - not needing to add back the
medications she'd stopped several months ago. However, under
their recommendations the patient underwent ultrasound
evaluation of her leg veins to eval for risk of pulmonary
embolism. These were negative. The patient was continued on
her coumadin for atrial fibrillation. She initially presented
with acute renal failure. There may have been some element of
volume depletion, so her ACE-i and Lasix were initially held.
Her volume status improved and the ACE inhibitor was restarted
as well as Torsemide, which has worked better for her in the
past. Her Cr remained at baseline. On the day of discharge the
patient was back to her baseline respiratory status, was feeling
quite well, and was set up for home physical therapy and VNA to
have her INR checked the following Monday. Her primary care
doctor was notified of these plans and need to f/u the INR. The
patient was discharged on HD 4 with instructions to follow-up
with her primary care doctor, cardiologist, [**Last Name (un) **]
endocrinologist, and pulmonologist.
Medications on Admission:
Baclofen 10 mg PO TID
Aspirin 81 mg PO DAILY
Levothyroxine 88 mcg PO DAILY
Lasix 160mg [**Hospital1 **]
Lisinopril 40 mg PO DAILY
Metoprolol Tartrate 37.5 [**Hospital1 **]
Clopidogrel 75 mg PO DAILY
Hexavitamin PO DAILY
Clobetasol 0.05 % Solution 1 Appl Topical [**Hospital1 **]
Omeprazole 20 mg PO once a day.
Paroxetine HCl 40 mg PO DAILY
NPH 40units qAM, 22 units qPM
Pramlintide (20) units three times a day before meals.
Albuterol 90 mcg [**1-28**] Inhalation every six (6) hours as needed
for shortness of breath or wheezing.
Humalog sliding scale
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
6. Paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
9. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO twice a day.
Disp:*120 Tablet(s)* Refills:*0*
10. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day for 3
days.
Disp:*3 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
parox. atrial fibrillation
acute renal failure
shortness of breath
Discharge Condition:
good
Discharge Instructions:
You were admitted and treated for you complaint of shortness of
breath. Several studies and labs were done while you were in
the hospital. You were seen by the pulmonology and cardiology
services as well. Some of your medications have changed. You
are now ready for discharge.
You will need to take all medications as instructed.
- While in the hospital two medications were stopped: the lasix
and plavix --> DO NOT TAKE THESE ANYMORE
- you have two new medications: coumadin and torsemide
- you should continue all of your other home medications:
including your insulin, inhalers, and vitamins
You will need to keep all follow-up appointments as indicated
below.
You will need to have your blood drawn on Monday to check your
INR - this will be done by VNA - you will need to talk to Dr.
[**Last Name (STitle) **] about how to adjust your doses based on this lab.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Call your primary care doctor or return to the ED if T>101.5,
chills, nausea, vomiting, chest pain, shortness of breath,
change in mental status, very elevated INR, or any other
concern.
Followup Instructions:
- You need to follow-up over the phone with Dr. [**Last Name (STitle) **] on Monday
[**2105-4-6**] -> this will be to adjust your coumadin dosing
- you need to follow-up with Dr. [**First Name (STitle) **] -> please call his
office first thing Monday to schedule an appointment. ([**Telephone/Fax (1) 16930**]
- You need to follow-up with Dr. [**Last Name (STitle) 7474**] / Dr. [**Last Name (STitle) **] -> please
call her office to schedule this appointment ([**Telephone/Fax (1) 513**]
.
**It is very important that you keep the following
appointments***
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 96307**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2105-4-6**] 11:15
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2105-4-17**] 3:20
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Date/Time:[**2105-4-28**] 12:00
|
[
"416.8",
"555.9",
"278.01",
"584.9",
"427.31",
"493.22",
"428.32",
"274.9",
"585.9",
"403.90",
"327.23",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11410, 11468
|
7179, 9901
|
391, 398
|
11579, 11586
|
3538, 7156
|
12795, 13781
|
2992, 3080
|
10506, 11387
|
11489, 11558
|
9927, 10483
|
11610, 12145
|
3095, 3516
|
12163, 12772
|
332, 353
|
426, 1593
|
1615, 2863
|
2879, 2976
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,024
| 162,455
|
50778
|
Discharge summary
|
report
|
Admission Date: [**2165-5-9**] Discharge Date: [**2165-5-16**]
Date of Birth: [**2092-6-26**] Sex: M
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
coffee ground emesis, fall Patient is a 72 -year-old male with
PMH of CAD s/p DES to LAD for 90% stenosis on [**9-10**] (on ASA,
plavix), HTN, HLID, and alcohol abuse who presented to OSH on
day prior to admission after falling at home. The fall was
mechanical, but in the setting of having consumed one bottle of
wine. He reportedly drinks 2 bottles of wine per day at home.
Patient went to [**Hospital3 **], where he was admitted with a
right femoral neck fracture. CT head and neck there showed no
hemmorhage or fracture. At [**Hospital1 **], patient had one episode of
coffee ground emesis which was positive for blood. GI was
consulted there and protonix was started. No further bleeding
occured and patient remained hemodynamically stable.
The patient wanted to have his hip surgery performed here at [**Hospital1 **]
and was transferred. He was to be transferred to the inpatient
medicine service tonight, however, en route with EMS he
developed nausea and vomiting of coffee ground emesis,
approximately 500 cc.
In the ED, initial VS were: 97.6 102 149/100 18 96% 4L
- NG tube placed with an additional 5-600 cc of coffee-ground
emesis. He later vomited around NGT with frank red blood. His
stools are guaiac + and brown.
-GI informed, and plan to scope tonight. He is type and crossed,
2 18g IV and 1 16g IV
-He is on a protonix gtt post bolus and was started on
octreotide as well.
-He is tachycardic presumably from withdrawing from alcohol and
bleed
-VS prior to transfer: HR 97, 20, 93% on 2L?, 155/98
On arrival to the MICU, patient's VS. T98.3, HR94, BP170/80,
RR16, O2sat:94%. He had another small episode of coffee ground
emesis about 100cc and the NG tube continues to suction with
black contents.
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty
EGD
History of Present Illness:
Patient is a 72 -year-old male with PMH of CAD s/p DES to LAD
for 90% stenosis on [**9-10**] (on ASA, plavix), HTN, HLID, and
alcohol abuse who presented to OSH on day prior to admission
after falling at home. The fall was mechanical, but in the
setting of having consumed one bottle of wine. He reportedly
drinks 2 bottles of wine per day at home. Patient went to [**Hospital1 **], where he was admitted with a right femoral neck
fracture. CT head and neck there showed no hemmorhage or
fracture. At [**Hospital1 **], patient had one episode of coffee ground
emesis which was positive for blood. GI was consulted there and
protonix was started. No further bleeding occured and patient
remained hemodynamically stable.
The patient wanted to have his hip surgery performed here at [**Hospital1 **]
and was transferred. He was to be transferred to the inpatient
medicine service tonight, however, en route with EMS he
developed nausea and vomiting of coffee ground emesis,
approximately 500 cc.
In the ED, initial VS were: 97.6 102 149/100 18 96% 4L
- NG tube placed with an additional 5-600 cc of coffee-ground
emesis. He later vomited around NGT with frank red blood. His
stools are guaiac + and brown.
-GI informed, and plan to scope tonight. He is type and crossed,
2 18g IV and 1 16g IV
-He is on a protonix gtt post bolus and was started on
octreotide as well.
-He is tachycardic presumably from withdrawing from alcohol and
bleed
-VS prior to transfer: HR 97, 20, 93% on 2L?, 155/98
On arrival to the MICU, patient's VS. T98.3, HR94, BP170/80,
RR16, O2sat:94%. He had another small episode of coffee ground
emesis about 100cc and the NG tube continues to suction with
black contents.
Past Medical History:
CAD s/p DES to LAD [**9-10**] for 90% occlusion
HTN
HLID
colon diverticulosis
Social History:
lives with wife, children. Drinks ~2 bottles of wine daily for
years, no tobacco, no drugs
Family History:
per OMR, No family history of premature coronary disease or
sudden death.
Physical Exam:
Admission exam
Vitals: T98.3, HR94, BP170/80, RR16, O2sat:94%
General: Alert, oriented, tremulous
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, [**3-5**] diastolic
murmur heard best at the left anterior axillary line in the 5th
itnercostal space
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley in place
Ext: Warm, well perfused, no clubbing, cyanosis or edema, brisk
capillary refill in the lower extremitied bilaterally
Neuro: CNII-XII grossly intact, sensation to light touch intact
in 2 dermatomes in the lower extremities bilatrally, moves toes
to command in both lower extremities
Discharge exam :
VS: 98.5 154/80 (135-172/68-90) 61 (61-84) 18 95RA
General: well appearing gentleman, NAD, laying comfortably in
bed, slow to respond to questions
HEENT: EOMI, sclera anicterus
CV: RRR S1 S2, no murmurs, rubs, gallops
lungs: CTA b/l, no rhonchi, crackles, wheezes
abdomen: soft, nontender, nondistended, +BS, no hepatomegaly
appreciated
extremities: no cyanosis, clubbing or edema, 2+ peripheral
pulses; R hip dressing, clean/dry/intact. slight tenderness to
palpation
Neuro: CN 2-12 grossly intact, normal muscle strength
throughout, except RLE which was not tested [**1-31**] pain; able to
wiggle toes b/l, normal sensation throughout, + tremor
Pertinent Results:
Admission labs
[**2165-5-9**] 07:30PM BLOOD WBC-14.5*# RBC-4.76 Hgb-13.8* Hct-42.0
MCV-88 MCH-29.0 MCHC-32.8 RDW-14.1 Plt Ct-198
[**2165-5-9**] 07:30PM BLOOD Neuts-84.3* Lymphs-9.6* Monos-5.5 Eos-0.4
Baso-0.2
[**2165-5-9**] 07:30PM BLOOD PT-12.6* PTT-25.4 INR(PT)-1.2*
[**2165-5-9**] 07:30PM BLOOD Glucose-148* UreaN-16 Creat-1.2 Na-142
K-4.2 Cl-100 HCO3-26 AnGap-20
[**2165-5-9**] 07:30PM BLOOD ALT-19 AST-25 CK(CPK)-187 AlkPhos-48
TotBili-1.9*
[**2165-5-9**] 07:30PM BLOOD Lipase-26
[**2165-5-9**] 07:30PM BLOOD CK-MB-2
[**2165-5-9**] 07:30PM BLOOD cTropnT-<0.01
[**2165-5-9**] 07:30PM BLOOD Albumin-4.3
[**2165-5-9**] 09:06PM BLOOD Hgb-14.3 calcHCT-43
H. pylori - negative
.
Urine
[**2165-5-9**] 08:25PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017
[**2165-5-9**] 08:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2165-5-9**] 08:25PM URINE RBC-5* WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2165-5-11**] 12:42AM URINE CastHy-3*
.
Micro
urine culture - no growth
blood cultures - no growth
Imaging
CXR: FINDINGS: Single portable view of the chest is compared to
previous exam from [**2161-12-8**]. The lungs are clear of
focal consolidation. Please note the left costophrenic angle is
excluded from the field of view. Cardiomediastinal silhouette
is within normal limits for technique. Osseous structures are
unremarkable. Colonic interposition over the liver seen in the
right upper quadrant.
IMPRESSION: No definite acute cardiopulmonary process.
.
ECHO
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. There is no aortic valve stenosis. No aortic
regurgitation is seen. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: No outflow tract obstruction or
clinically-significant valvular disease seen. Normal global
biventricular systolic function.
.
CXR [**5-10**]
Low lung volumes and supine positioning exaggerate heart size
and crowd the pulmonary vasculature but there is no pulmonary
edema or pneumonia, no pleural effusion or evidence of
pneumothorax. Severe gaseous distention of the gut would make
it difficult to detect pneumoperitoneum in this supine patient.
.
R knee Xray
TWO VIEWS RIGHT KNEE: There is no joint effusion. A frontal
view is not
provided. The oblique and lateral views demonstrate no definite
fracture.
There are moderate-sized patellofemoral osteophytes and
enthesophytes.
Vascular calcifications are noted.
IMPRESSION: Right subcapital hip fracture
.
R. hip Xray
TWO VIEWS RIGHT KNEE: There is no joint effusion. A frontal
view is not
provided. The oblique and lateral views demonstrate no definite
fracture.
There are moderate-sized patellofemoral osteophytes and
enthesophytes.
Vascular calcifications are noted.
IMPRESSION: Right subcapital hip fracture.
.
R. hip xray (intra-op)
FINDINGS: There has been placement of a right hemiarthroplasty
with a
cemented femoral component. There are no signs for
hardware-related
complications. Please refer to procedure note for additional
details.
.
CXR [**5-11**]
The heart is not enlarged. Heart size is at the upper limits of
normal. The aorta is calcified and minimally unfolded. No CHF,
focal infiltrate, or effusion is identified. No pneumothorax or
pneumomediastinum is detected.
Minimal pleural fluid or thickening at the right lung base is
unchanged
compared with [**2165-5-10**] at 1:35 a.m. Incidental note is made of
the right
hepatic colon flexure seen immediately beneath the right
hemidiaphragm,
unchanged.
.
Discharge labs:
[**2165-5-15**] 06:45AM BLOOD WBC-8.3 RBC-3.03* Hgb-8.9* Hct-27.4*
MCV-90 MCH-29.5 MCHC-32.6 RDW-14.4 Plt Ct-263
[**2165-5-15**] 06:45AM BLOOD Glucose-113* UreaN-18 Creat-1.0 Na-138
K-3.1* Cl-102 HCO3-27 AnGap-12
Brief Hospital Course:
Patient is a 72yo male with PMH of CAD s/p DES to LAD for 90%
stenosis on [**9-10**] (on ASA, plavix), HTN, HLD, and alcohol abuse
who presented to OSH on day prior to admission after falling at
home found to have R. hip fracture. He developed coffee ground
emesis during evaluation and was subsequently found to have
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear and is now s/p surgical repair.
#GI bleed: Patient found to have coffee ground emesis. Given
history of heavy alcohol use concern for alcoholic gastritis vs.
varices from potential cirrhosis. EGD from [**2158**] for odynophagia
showed no varices. GI was consulted. Upper endoscopy showed
severe esophagitis, blood in the stomach body, [**Doctor First Name 329**]-[**Doctor Last Name **]
tear s/p endoclip, severe duodenitis, and erosium in the antrum.
Patient was initially started on octreotide and protonix drips.
After endoscopy, octreotide was discontinued given no varices.
He was transitioned to IV PPI the following day. He was also
continued on sucralfate.
The patient's crits were trended and ultimately stabilized. He
had no further bleeding while on the floor. Mr. [**Known lastname **] will need
follow up outpatient endoscopy.
.
#Hip fracture: Patient found to have right femoral neck
fracture. He underwent right hip hemiarthroplasty. He was
started on lovenox 40 subQ daily and will need to continue this
for 2 weeks (END DATE [**2165-5-25**]). Patient was evaluated by PT
during admission. He will need outpatient follow up with
orthopedics.
.
#Alcohol Abuse: Patient has heavy alcohol use at home, up to 2
bottles of wine daily by report. He denies history of alcoholic
hallucinosis or withdrawal seizures. He was briefly on CIWA, but
scored only once. The patient was continued on multivitamin,
folate, and thiamine.
#CAD s/p DES: Patient had DES to LAD on [**9-10**]. Admission ECG
shows diffuse T-wave flattening. Cardiac enzymes negative times
one. The patient did not have any chest pain or palpitations
during this admission. He was continued on his Plavix and ASA.
The patient's ASA was reduced from full dose to 81 while in the
MICU; he was discharged on ASA 325. His metoprolol was
initially held, but once he was not longer actively bleeding,
his metoprolol was restarted. The patient was continued on his
statin.
# alcoholic hepatitis: The patient was noted to have elevated
Tbili, as well as a transaminitis. He was evaluated by liver
who thought that this could be early stages of alcoholic
hepatitis. The patient's LFTs were trending, and he was
encouraged to have adequate nutrition. Upon discharge, the
patient's LFTs were trending down.
#Murmur over mitral valve: Echo from [**2162**] showed no valvular
pathology, murmur clearly auscultated. Repeat TTE yesterday
showed no valvular pathology.
.
#Psych medications: The patient was continued on his patient is
on clonazepam and lexapro.
.
Transitional issues:
- The patient was full code on this admission.
- The patient will need follow up EGD in 8 weeks--> appt has
been made for [**7-12**] at 9AM.
- Please continue Lovenox until [**2165-5-25**].
Medications on Admission:
HOME MEDICATIONS: (not confirmed with patient but taken from
[**4-9**] clinic visit)
plavix 75mg PO daily
lexapro 10mg PO daily
benicar 20mg PO daily
crestor 40mg PO QHS
omega 3 fatty acids
Vit D 1000 unit cap
ASA 325mg PO daily
clonazepam 1.5mg PO QHS (0.5mg tabs)
metoprolol succinate 50mg PO daily
MEDICATIONS ON TRANSFER FROM OSH:
heparin 5000U SC Q12
losartan 50mg PO daily
clonazepam 1.5mg po qhs
simvastatin 40mg PO daily
plavix 75mg PO daily
Metoprolol succinate 25mg PO daily
pantoprazole 40mg IV BID
dilaudid 1mg IM Q4H prn
ondansetron 4mg IV Q6H prn
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
5. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
8. clonazepam 0.5 mg Tablet Sig: Three (3) Tablet PO at bedtime.
9. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a
day.
10. Omega 3 Oral
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
16. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) syringe
Subcutaneous once a day: End date: [**2165-5-25**].
Discharge Disposition:
Extended Care
Facility:
[**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**]
Discharge Diagnosis:
primary diagnosis:
right femoral neck fracture
[**Doctor First Name **]-[**Doctor Last Name **] tear
duodenitis, esophagitis
secondary diagnosis:
alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**]. You were transferred here because you needed a hip
surgery after falling. While in the emergency department, you
were noted to be vomiting blood and you underwent an emergent
endoscopy, where the stomach doctors put a [**Name5 (PTitle) **] down your
throat to look into your stomach and intestines; they found an
area that was bleeding, which they fixed.
Both your fall and the bleeding that you had were due to
drinking alcohol. It is VERY important that you STOP drinking
alcohol. Your liver functioning was also affected during this
hospitalization; it is now getting better, but you strongly urge
you to STOP drinking.
We made the following changes to your medications:
START Sucralfate 1 gram by mouth four times daily
START enoxaparin 40 mg injected subcutaneously daily (END DATE
[**2165-5-25**])
START thiamine 100 mg by mouth daily
START folic acid 1 mg by mouth daily
START multivitamin by mouth daily
START ranitidine 150 mg by mouth twice daily
Followup Instructions:
Please follow-up with your primary care doctor within 1 week of
leaving the rehab
Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2165-7-12**] at 10:00 AM [**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: FRIDAY [**2165-7-12**] at 10:00 AM
Completed by:[**2165-5-17**]
|
[
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icd9cm
|
[
[
[]
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[
"44.43",
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icd9pcs
|
[
[
[]
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14606, 14726
|
9702, 12631
|
1994, 2027
|
14931, 14931
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5589, 9448
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16215, 16722
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2055, 3750
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14766, 14873
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14946, 15083
|
3772, 3852
|
3868, 3961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,497
| 198,653
|
42723
|
Discharge summary
|
report
|
Admission Date: [**2181-1-16**] Discharge Date: [**2181-1-20**]
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Polytrauma following MVC
Major Surgical or Invasive Procedure:
1. Endotracheal intubation, [**2181-1-16**]
2. Exploratory laparotomy, [**2181-1-16**]
3. Bilateral chest tube placement, [**2181-1-16**]
History of Present Illness:
[**Age over 90 **]F unrestrained passenger in MVC that rear-ended truck in front
of them. Pt had entrapment of lower extremities, requiring
extrication. No airbag deployment. In field, patient attempted
to be intubated for GCS 4, however, only combitube able to be
placed. Oxygen saturation noted to be no greater than 80%
during transport. Pt transported as basic trauma to [**Hospital1 18**] ED
(called as STAT but paged out as basic).
Past Medical History:
-Alzheimers
-Remainder of history unknown
Social History:
Patient is reported to have one daughter, and both she and her
daughter receive 24hr care from the driver involved in the MVC.
Family friend, [**Name (NI) 501**], is a nurse and is acting as a support to
patient's daughter.
Family History:
Unknown
Physical Exam:
On admission:
HR 116, BP 80/49, RR Bagged, O2Sat 75%
GEN: GCS 4T
HEENT: Multiple facial lacerations including large laceration
over her left zygoma. Raccoon eyes. Pupils 4 mm & nonreactive.
+Rhinorrhea. Combitube in place.
Chest: Clear to auscultation
Cardiovascular: Tachycardic, regular.
Abdominal: Soft, nondistended. No palpable masses.
Pelvic: Pelvis stable.
Extr/Back: Left leg internally rotated, left wrist deformity.
Skin: Face laceration as described above. Multiple leg
lacerations.
Neuro: +gag. +corneal reflex. Minimal response to noxious
stimuli.
Pertinent Results:
LABS:
On admission:
WBC-8.6 RBC-3.31* Hgb-10.5* Hct-28.7* MCV-87 MCH-31.6 MCHC-36.5*
RDW-13.7 Plt Ct-242
PT-16.0* PTT-42.8* INR(PT)-1.5*
Fibrino-45*
Glucose-223* UreaN-19 Creat-0.6 Na-146* K-4.0 Cl-113* HCO3-19*
AnGap-18
Calcium-6.5* Phos-7.2* Mg-1.5*
CENTRAL VE pO2-31* pCO2-57* pH-7.18* calTCO2-22 Base XS--8
Lactate-5.1*
IMAGING:
[**1-16**] CT head
1. Left frontal subarachnoid hemorrhage, small right frontal
subarachnoid hemorrhage, intraventricular hemorrage, and small
medial left temporal hemorrhage, which may be parenchymal or
intraventricular.
2. Multiple facial fractures.
3. Large right intraorbital air and extensive facial soft tissue
air.
[**1-16**] X-Ray Chest: Left 4th and 6th rib fracture. Right 6-8th
rib fx.
[**1-16**] X-Ray Pelvis: No fracture
[**1-16**] X-Ray Left Wrist: Comminuted fracture of distal radius and
ulna.
[**1-16**] X-Ray Right Wrist: Comminuted fracture of distal radius
and ulna.
[**1-16**] X-Ray Left Femur/Tibia and Fibula: Subtrochanteric femur
fracture. Supracondular femur fracture. Tibial plateau and
fibular head fracture.
[**1-16**] X-Ray Right Femur/Tibia: Supracondular femur fracture.
Tibial plateau and fibular head fracture
Brief Hospital Course:
[**Age over 90 **]F transported to [**Hospital1 18**] ED as STAT trauma. On arrival pt's
combitube was changed over to an endotracheal tube, and a left
subclavian cordis was placed. Her oxygen saturation improved
after tube exchange. The pt was initially hypotensive but
responded to fluid boluses. Following completion of
primary/secondary surveys, she underwent radiographic imaging.
She proceeded to become hypotensive again, and was thus taken
emergently to the OR for exploratory laparotomy. No abdominal
injuries were identified intraop. Bilateral chest tubes were
placed for pneumothoraces and noted significant right-sided
hemothorax as well. Postoperatively, the patient was admitted
to the Trauma Surgical ICU under care of the ACS service with
the following injuries:
-Left cheek lac w/masseter injury
-Right frontal subgaleal hematoma
-Right maxillary sinus lateral wall fx
-Bilateral pterygoid plate fx
-Left zygomatic arch fx
-Left mandibular fx
-Left orbit lateral wall fx
-Left 4,6 rib fx
-Right [**6-28**] rib fx
-Bilateral comminuted distal radius/ulna fx
-Left subtrochanteric, supracondylar femur fx
-Left tibial plateau and fibular head fx
-Right supracondylar femur fx
-Left tibial plateau and fibular head fx
-Bilateral IVH
-Left frontal contusion
-Left parietal SAH
-Right pons SAH
-Bitemporal SAH
-Displaced C1 anterior arch fx
The patient remained on pressors postoperatively despite
aggressive resuscitation. She underwent splinting of all
extremity injuries, as well as having nasal packing and facial
laceration packing. She was not stable enough to undergo
further imaging studies. The patient's family was notified of
the devastating severity of the patient's injuries.
On HD 2 the patient was made DNR secondary to an extremely poor
prognosis related to unsurvivable injuries. Discussions
continued with patient's family, who was unable to come to the
hospital. Palliative care and Ethics consults were requested
for assistance with care goals for the patient.
On HD 3 the patient's daughter requested that the patient's
comfort be ensured. No excalation of care was made.
On HD 5 patient's daughter requested [**Name2 (NI) 60655**] [**Name (NI) 3225**] status. She
was terminally extubated and expired thereafter.
Medications on Admission:
Unknown
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Polytrauma with the following specific injuries:
-Left cheek lac w/masseter injury
-Right frontal subgaleal hematoma
-Right maxillary sinus lateral wall fx
-Bilateral pterygoid plate fx
-Left zygomatic arch fx
-Left mandibular fx
-Left orbit lateral wall fx
-Left 4,6 rib fx
-Right [**6-28**] rib fx
-Bilateral comminuted distal radius/ulna fx
-Left subtrochanteric, supracondylar femur fx
-Left tibial plateau and fibular head fx
-Right supracondylar femur fx
-Left tibial plateau and fibular head fx
-Bilateral IVH
-Left frontal contusion
-Left parietal SAH
-Right pons SAH
-Bitemporal SAH
-Displaced C1 anterior arch fx
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
|
[
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"802.5",
"813.44",
"276.2",
"861.21",
"801.25",
"348.1",
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icd9cm
|
[
[
[]
]
] |
[
"21.01",
"96.04",
"34.04",
"54.11",
"33.22",
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] |
icd9pcs
|
[
[
[]
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5366, 5375
|
3012, 5279
|
257, 397
|
6043, 6053
|
1802, 1808
|
6105, 6112
|
1192, 1201
|
5337, 5343
|
5396, 6022
|
5305, 5314
|
6077, 6082
|
1216, 1216
|
193, 219
|
425, 870
|
1823, 2989
|
892, 935
|
951, 1176
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
41,442
| 199,448
|
45037
|
Discharge summary
|
report
|
Admission Date: [**2189-5-14**] Discharge Date: [**2189-5-17**]
Date of Birth: [**2109-3-16**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Erythromycin Base / Percocet / Vicodin
Attending:[**First Name3 (LF) 509**]
Chief Complaint:
leg pains
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is an 80F with h/o CAD, bipolar disorder, and recent
admission for abdominal pain who presented to the ED with
complaints of bilateral legs pains x1 day. She describes these
as a "throbbing sharp pain" from her thighs to her feet in
bilateral LE, "14-13/10" in intensity and kept her up at night.
The symptoms were a little better this AM, but got worse by this
afternoon prompting her to come into the ER. She also notices
that she has been shaky the last day, and the leg aches seem to
worsen after this. On further history, she reports fatigue and
malaise over the last week, along with increased urinary
frequency and urgency, but without any dysuria or recorded
temperatures. She denies any back or abdominal discomfort. She
does mention 2-3 episodes of chest discomfort in the last few
weeks that feel similar to her prior angina (chest pressure with
SOB or lightheadedness, better after [**1-2**] nitroglycerins). She
apparently was scheduled for a stress test yesterday but didn't
go. She has had history of non-exertional chest discomfort in
the past, but was only getting this every few months in the
past.
.
In the ER, her vitals were 99.3 97 137/91 28 97% RA. Rectal temp
subsequently found to be 101.8. Found to be diaphoretic,
rigoring. Given vanc 1g, levoflox 750mg, flagyl after blood and
urine cultures drawn. BPs were stable initially, but dropped to
88/35. This followed getting 2mg morphine. Got 500cc boluses,
total about 1.5L total with BP responsive. She reported chest
discomfort and was given nitroglycerin, with BP dropp again
after getting nitroglycerin. Current vitals 84 100/40 14 99% on
room air. Has PIV x2.
.
On the floor, she denies any complaints.
.
Review of systems is negative for cough, diarrhea, bleeding.
Past Medical History:
* Coronary artery disease status post MI in [**2145**] and [**2146**].
Most recent dobutamine stress test in [**2185-4-1**] in Dr.[**Name (NI) 5765**]
office was normal per patient. Cardiac catheterization in [**2178**]
revealed single vessel disease in the right coronary artery with
a 50% lesion, but no intervention was performed at that time.
History of diastolic CHF, echocardiogram from [**2182**] shows an
EF of 67%.
* Bipolar disorder.
* Remote history of upper GI bleed from ulcer.
* History of PE and DVT following an appendectomy [**2140**]'s
* History of irritable bowel syndrome.
* GERD, and hiatal hernia s/p repair
* Hypothyroidism
Social History:
No alcohol and no cigarettes. Lives with husband. [**Name (NI) **] good
family support
Family History:
Her brother died from a MI in his late 30s.
Her father died from a MI in his 80s.
Her brother died from a MI in his late 80s.
Her mother died from a cerebral aneurysm.
Physical Exam:
Vitals 98 61 128/85 20 99% on RA
General Well appearing elderly woman in no distress
HEENT Sclera anicteric, conjunctiva pale, MMM
Neck No JVD
CV Regular S1 S2 II/VI SEM RUSB without significant radiation
Pulm Lungs clear bilaterally, no rales or wheezing
Back No CVA tenderness
Abd Soft +bowel sounds mild tenderness to suprapubic palpation
Extrem Warm no edema palpable pulses
Neuro Alert and interactive, no focal deficits
Pertinent Results:
Labs on admission:
[**2189-5-14**] 06:15PM BLOOD WBC-14.4*# RBC-3.80* Hgb-10.5* Hct-33.9*
MCV-89 MCH-27.8 MCHC-31.1 RDW-13.6 Plt Ct-734*#
[**2189-5-15**] 03:20AM BLOOD WBC-10.0 RBC-2.75*# Hgb-8.0* Hct-25.0*#
MCV-91 MCH-29.0 MCHC-32.0 RDW-13.5 Plt Ct-473*
[**2189-5-14**] 06:15PM BLOOD Neuts-90.3* Lymphs-7.1* Monos-2.3 Eos-0.2
Baso-0.1
[**2189-5-14**] 06:15PM BLOOD PT-12.8 PTT-30.5 INR(PT)-1.1
[**2189-5-14**] 06:15PM BLOOD Glucose-161* UreaN-25* Creat-1.2* Na-141
K-4.6 Cl-99 HCO3-29 AnGap-18
[**2189-5-15**] 03:20AM BLOOD Glucose-102 UreaN-15 Creat-0.8 Na-142
K-3.6 Cl-110* HCO3-27 AnGap-9
[**2189-5-14**] 06:15PM BLOOD ALT-13 CK(CPK)-122 AlkPhos-65 TotBili-0.2
[**2189-5-14**] 06:15PM BLOOD Lipase-73*
[**2189-5-14**] 06:15PM BLOOD cTropnT-<0.01
[**2189-5-15**] 03:20AM BLOOD CK-MB-5 cTropnT-<0.01
[**2189-5-14**] 06:15PM BLOOD Albumin-4.6 Calcium-10.6* Phos-3.3
Mg-2.8*
[**2189-5-15**] 03:20AM BLOOD Calcium-8.4 Phos-2.5* Mg-2.4
[**2189-5-14**] 06:15PM BLOOD Lithium-0.9
[**2189-5-14**] 08:36PM BLOOD Lactate-1.4
.
Labs on discharge:
[**2189-5-17**] 07:40AM BLOOD WBC-8.3 RBC-3.09* Hgb-8.9* Hct-28.1*
MCV-91 MCH-28.8 MCHC-31.7 RDW-14.2 Plt Ct-496*
[**2189-5-17**] 07:40AM BLOOD Glucose-115* UreaN-6 Creat-0.7 Na-141
K-3.5 Cl-105 HCO3-26 AnGap-14
[**2189-5-17**] 07:40AM BLOOD Calcium-8.6 Phos-4.0 Mg-1.8
[**2189-5-17**] 07:40AM BLOOD WBC-8.3 RBC-3.09* Hgb-8.9* Hct-28.1*
MCV-91 MCH-28.8 MCHC-31.7 RDW-14.2 Plt Ct-496*
[**2189-5-17**] 07:40AM BLOOD Glucose-115* UreaN-6 Creat-0.7 Na-141
K-3.5 Cl-105 HCO3-26 AnGap-14
.
Imaging:
[**5-14**] CXR: The lungs are well expanded and clear. The mediastinum
is
unremarkable. The cardiac silhouette is within normal limits for
size. No
effusion or pneumothorax is noted. The visualized osseous
structures are
unremarkable. IMPRESSION: No acute pulmonary process.
.
Microbiology:
URINE CULTURE (Final [**2189-5-16**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN---------- 32 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
.
Blood culture: No growth.
Brief Hospital Course:
Ms. [**Known lastname **] 80 female with remote h/o CAD, h/o DVT/PE who p/w
bilateral leg pains. Found to have UTI. Hospital course
according to problem list.
.
* Complicated urinary tract infection: Urine culture grew E.
Coli. Patient received IV Ceftriaxone during hospitilization and
was discharged on Nitrofurantin for 10 days total based on
sensitivities (see results section). Blood cultures no growth at
time of discharge.
.
* Leg pains: TSH, CK within normal limits. Bilateral LENI
negative for DVT (final report pending at time of discharge).
Felt to be myalgias related to rigors from complicated urinary
tract infection. Resolved at time of discharge.
.
# Anemia: HCT at baseline 25-29. Normocytic, most likely anemia
of chronic disease. However, patient does have history of PUD
and gastritis. Required no blood products during hospital stay.
Treated PUD and gastritis with pantoprazole 40 mg [**Hospital1 **].
.
# Hypotension: In ED BP decreased to 88/35 following
adminstration of morphine and nitroglycerin. However, based on
positive urine culture there was concern of urosepsis and
patient was admitted to MICU. SBP responded to IVF and required
no prsesor support. Patient was transferred to the medical floor
following observation overnight. BP stable throughout rest of
admission. Lasix and Diltiazem were held on admission, but
re-started prior to discharge. No blood culture growth at time
of discharge.
.
# CAD: Her history of increased frequency of chest discomfort
raises the question of unstable angina. No new EKG changes,
cardiac enzymes q 8hr negative - ruled out for ACS. Continued
ASA and Statin.
- Patient did not attend outpatient stress test - needs to be
rescheduled
- Consider starting B-blocker with primary care doctor
.
# Acute on chronic renal failure: Resolved with IVF.
.
# PUD: Continued PPI
# Bipolar: Continued home lithium
* Hypothyroid: Continued home levothyroxine
# FEN regular cardiac
# Full Code throughout admission.
Medications on Admission:
Atorvastatin 40mg daily
Buspar 15mg [**Hospital1 **]
Diltiazem 30mg TID
Levothyroxine 88mg daily
Lithium 300mg daily
Lasix 40mg daily
Reglan 15mg TID
Sucralfate 1g QID -- no longer taking
ASA 81mg daily
Folate 1mg daily -- not taking at home
Fexofenadine 60mg daily
Omeprazole 40mg [**Hospital1 **]
Fluticasone nasal spral
Fioricet 1-2 tabs q6h
Colace, senna, dulcolax, compazine, simethicone, miralax
Discharge Medications:
1. Nitrofurantoin Macrocrystal 100 mg Capsule Sig: One (1)
Capsule PO twice a day for 7 days: For 10 days total. .
Disp:*14 Capsule(s)* Refills:*0*
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a
day).
4. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO
QDAILY ().
6. Metoclopramide 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO once a day.
12. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Urinary tract infection (complicated)
Hypotension
Discharge Condition:
Good, ambulating.
Discharge Instructions:
You presented to the ED for leg pains. You were found to have a
urinary tract infection and low blood pressure. You were briefly
observed in the ICU for low blood pressure and transferred to
the general medicine floor when stable. You are being discharged
on antibiotics to treat the urinary tract infection. The leg
pains were related to muscle strain from high fevers. You had
ultrasounds of both legs that showed no blood clots.
.
Medications:
NEW Nitrofurantin (antibiotic) for 7 more days.
Otherwise we made no changes to your medications.
.
Call your primary care doctor, [**Doctor Last Name **],[**Doctor First Name **] H. [**Telephone/Fax (1) 4615**],
and schedule an appointment in [**1-2**] weeks for follow-up.
.
Call your doctor if you experience fever, chills, nausea,
vomiting, shortness of breath or any other concerning symptoms.
Followup Instructions:
Call your primary care doctor, [**Doctor Last Name **],[**Doctor First Name **] H. [**Telephone/Fax (1) 4615**],
and schedule an appointment in [**1-2**] weeks for follow-up.
.
You have the following scheduled appointments:
Provider: [**First Name8 (NamePattern2) 870**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2189-6-2**] 9:15
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] (ST-3) GI ROOMS Date/Time:[**2189-6-2**] 9:15
Completed by:[**2189-5-18**]
|
[
"414.01",
"796.3",
"285.29",
"585.9",
"041.4",
"599.0",
"E935.2",
"584.9",
"533.90",
"V12.51",
"729.5",
"412",
"296.80",
"E942.4",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9869, 9926
|
6239, 8210
|
332, 338
|
10020, 10040
|
3563, 3568
|
10934, 11446
|
2932, 3102
|
8662, 9846
|
9947, 9999
|
8236, 8639
|
10064, 10911
|
3117, 3544
|
283, 294
|
4602, 6216
|
366, 2139
|
3582, 4583
|
2161, 2811
|
2827, 2916
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,086
| 123,250
|
13765
|
Discharge summary
|
report
|
Admission Date: [**2183-2-14**] Discharge Date: [**2183-2-21**]
Service: MEDICINE
Allergies:
Lipitor / Lovastatin / Niaspan
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
Chest pain, shortness of breath, hypotension
Major Surgical or Invasive Procedure:
Cardiac catheterization
PA catheter placement
History of Present Illness:
Patient is a 84 yo man with h/o of DM, HTN, hyperlipidemia, s/p
pacer for 3rd degree heart block, non-ischemic cardiomyopathy
with EF of 50% who called his cardiologist this AM with CP and
SOB and was found to be hypotensive and in renal failure. Of
note, patient underwent underwent a colonscopy the day PTA with
polypectomy x 2 at [**Hospital1 **] [**Location (un) 620**]. Per reports for OSH he was
hypotensive with SBPs in the 70 prior to colonoscopy yesterday
and therefore it was done without sedation. Per patient, his
SBP remained low after the procedure, but he was sent home. At
2 am he awoke with CP described as a dull ache located over his
left shoulder and to his back associated with SOB. Nothing made
the pain better, but putting a 3rd pillow under his head
improved his SOB. He was seen in his cardiologist's office today
where he was found to have SBP in the 70s, with JVD and crackles
on exam and was sent to the ED to evaluate for possible
cardiogenic shock. By that time his CP and SOB had improved. In
the ED at [**Hospital1 **] [**Location (un) 620**] he was found to be hypotensive with SBPs
70s-80s and in renal failure with creatinine of 3.7 from a
baseline of 1.3, with crackles on exam, BNP 2422 and mild
pulmonday edema on CXR. He was seen by cardiology and echo done
which revealed EF 20%. He was given 1.4 liters NS, was started
on peripheral levophed, and a triple lumen right femoral line
was placed. CE's revealed CK 27 and trop 0.016 in the setting of
a creatinine of 3.5. Per report CXR revealed mild pulmonary
edema. He was transferred to [**Hospital1 **] for further management.
On arrival, SBP 90s/50s on levophed, O2 sats 96 % on 2 L, HR
60. He reports that he breathing feels better. Denies CP,
palpitations, abdominal pain, dizziness, lightheadedness.
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. He has occasional BRB on the toilet paper. 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,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope. He has stable 2 pillow orthopnea. He does note
that over the past 2 months he has been more SOB when walking up
stairs when he does the laundry. Denies associated CP. He
reports that he goes to the [**Company 3596**] 3 times per weeks and lifts
weights and does some exercises, which he has continued to do.
Past Medical History:
1. Diabetes for the past 5 years.
2. Hypertension.
3. Hyperlipidemia.
4. He has a pacemaker inserted [**2172**] 3rd degree heart block
[**Company 1543**] model number DR 7088.
5. CKD with baseline creatinine 1.3
6. CCY [**2117**]
7. Appendectomy [**2117**]
8. shoulder surgery
9. Cataract surgery
[**84**]. BPH
11. GERD
Social History:
Social history is significant for the absence of current tobacco
use quite in [**2152**]. drinks 2-3 glases of wine per night. No h/o
DTS or ETOH withdrawal. Last drink 2 nights ago. He is married.
Family History:
Mother died at the age of 96 of "old age." Father had heart
problems in his 80s. He has 2 sisters, who are alive and well.
He has 7 children, who are alive and well.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 97.9, BP 89/42, HR 61 , RR 18 , O2 % 95 % on 1.5 L
Gen: Elderly male in NAD. Oriented x3. Mood, affect appropriate.
Lying flat in bed breathing comfortabley.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
Neck: on JVD could be appreciates, no carotid bruits.
CV: Distant heart sounds, RR, normal S1, S2. No S4, no S3.
could not appreciate any murmurs
Chest: Resp were unlabored, no accessory muscle use. Crackles at
the bases bilaterally with diffuse wheezes but good air movement
Abd: Obese, soft, minimally distended, No HSM or tenderness. No
abdominial bruits.
Ext: No c/c/e. No femoral bruits, right femoral line in place.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
ADMISSION LABS:
[**2183-2-14**] 06:04PM BLOOD WBC-10.1 RBC-3.41* Hgb-10.8* Hct-31.4*
MCV-92 MCH-31.6 MCHC-34.3 RDW-13.1 Plt Ct-188
[**2183-2-14**] 06:04PM BLOOD PT-13.3 PTT-27.1 INR(PT)-1.1
[**2183-2-14**] 06:04PM BLOOD Plt Ct-188
[**2183-2-14**] 06:04PM BLOOD Glucose-67* UreaN-56* Creat-3.6*# Na-136
K-4.4 Cl-104 HCO3-19* AnGap-17
[**2183-2-14**] 06:04PM BLOOD Calcium-8.6 Phos-5.7* Mg-1.7
[**2183-2-15**] 04:24AM BLOOD Type-ART pO2-77* pCO2-34* pH-7.36
calTCO2-20* Base XS--5
CARDIAC ENZYMES:
[**2183-2-14**] 06:04PM BLOOD CK(CPK)-72
[**2183-2-15**] 03:49AM BLOOD CK(CPK)-74
[**2183-2-14**] 06:04PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2183-2-15**] 03:49AM BLOOD CK-MB-NotDone cTropnT-0.02*
ADMISSION EKG: AV paced rhythm, rate 63, with no significant
change compared with prior.
2D-ECHOCARDIOGRAM performed on [**2183-2-14**]: The left atrium is
mildly dilated. The estimated right atrial pressure is
10-15mmHg. Left ventricular wall thicknesses are normal. The
left ventricular cavity is moderately dilated. There is severe
global left ventricular hypokinesis (LVEF = 20 %). The right
ventricular cavity is moderately dilated with moderate global
hypokinesis and apical akinesis. 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. Moderate (2+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is mild pulmonary artery systolic hypertension.
Cardiac catheterization ([**2183-2-20**]): 1. Coronary angiography in
this right-dominant system revealed minimal coronary artery
disease.
--the LMCA had no angiographically apparent disease.
--the LAD had mild diffuse disease.
--the LCX had a 40% stenosis in its mid-portion.
--the RCA had no angiographically apparent disease.
2. Resting hemodynamics revealed normal right- and left-sided
filling pressures, with RVEDP 8 mmHg and LVEDP 16 mmHg.
Borderline pulmonary arterial systolic pressures with PASP 26
mmHg. Normal systemic arterial
systolic pressures with SBP 113 mmHg. The cardiac output was
depressed
with CI 2 L/min/m2. 3. There was no gradient across the aortic
valve upon pullback of the angled pigtail catheter from LV to
ascending aorta. FINAL DIAGNOSIS: 1. Nonischemic
cardiomyopathy. EF 20%
Brief Hospital Course:
Mr. [**Known lastname 41407**] presented with shortness of breath, chest pain and
acute on chronic renal failure. His exam, laboratory values
(including elevated BNP) and CXR were consistent with overt
volume overload. He was relatively hypotensive with signs of
end-organ underperfusion as evidenced by acute on chronic renal
failure. He had no ischemic EKG changes and negative cardiac
enzymes. TTE revealed newly depressed EF to 20%. The patient
required levophed for vasopressor support in the setting of
hypotension and poor perfusion. He was admitted to the CCU where
he had a PA catheter placed and underwent successful diuresis.
With symptomatic improvement, successful removal of pressor
support and return of renal function toward CKD baseline, the
patient underwent cardiac catheterization with appropriate
contrast nephropathy prophylaxis. Cath revealed no significant
CAD. His cardiac regimen was targeted to therapy of non-ischemic
cardiomyopathy with severely depressed EF: He was initiated on
furosemide 20mg once daily, carvedilol 3.125mg twice daily,
aspirin 81mg once daily and digoxin 0.125mg once every other
day. His ACEi dose was reduced to lisinopril 2.5mg once daily
(down from 5mg once daily prior to admission) due to relative
hypotension. Upon discharge, his home spironolactone, doxazosin
and finasteride were held and he was instructed to discuss
restarting these medications with his outpatient cardiologist,
Dr. [**Last Name (STitle) 121**]. His home bisoprolol was discontinued. The inciting
etiology for his decompensation is not known though appears
temporally related to his recent colonoscopy prep. The patient
will follow-up with Dr. [**Last Name (STitle) 121**] - his outpatient cardiologist -
within 1 week (and the plan was discussed over the phone with
Dr. [**Last Name (STitle) 121**]. He will also undergo repeat echo in approximately 2
months time with follow-up with Dr. [**Last Name (STitle) **] of EP. If his EF is
persistently depressed at that time he may benefit from upgrade
of his pacer to BiV ICD. At the time of discharge the patient's
symptoms were markedly improved with near complete return to
pre-admission baseline.
Medications on Admission:
Spironolactone 25 mg every evening
lisinopril 5 mg every evening
bisoprolol fumirate 7.5 mg every evening
pravastatin 40 mg every evening
gemfibrozil 600 mg PO BID
doxazosin 4 mg every evening
levothyroxine 50 mcg every morning
glipizide 2.5 mg each morning
Prilosec 20 mg every morning
fenesteride 5 mg every morning
calcium D super complex and A-Z vitamins
Discharge Medications:
1. Pantoprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
2. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. CALCIUM 500+D 500 (1,250)-200 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day: Three
month supply.
Disp:*90 Tablet(s)* Refills:*4*
9. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Three month supply.
Disp:*180 Tablet(s)* Refills:*4*
11. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): Three month supply.
Disp:*90 Tablet(s)* Refills:*4*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
14. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day): Three month supply.
Disp:*45 Tablet(s)* Refills:*4*
15. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO every other
day.
Disp:*15 Tablet(s)* Refills:*2*
16. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary:
Non-ischemic cardiomyopathy
Acute on Chronic renal failure
Secondary:
Diabetes Mellitus II
Hypertension
Hypercholesterolemia
Chronic Kidney disease
Benign Prostatic Hypertrophy
GERD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with chest pain, shortness of breath and
kidney failure. The cause of this is newly decreased cardiac
function with fluid overload. You were treated with fluid
removal and medical therapy intended to improve your cardiac
function. The cause of this [**Last Name **] problem is currently unknown,
however, it is not due to coronary artery disease.
Please call Dr.[**Name (NI) 41408**] office within the next week for
follow-up. In addition you must have a repeat echocardiogram on
[**2183-4-25**] to evaluate for interval change in your cardiac
function. After this echocardiogram you must follow-up with Dr.
[**Last Name (STitle) **] (an electrical heart specialist) for consideration of a
change in your pacemaker type.
Take all medications as prescribed. New medications include
furosemide 20mg once daily, carvedilol 3.125mg twice daily,
aspirin 81mg once daily and digoxin 0.125mg once every other
day. Please reduce your dose of lisinopril at home to 2.5mg once
daily (down from 5mg once daily prior to admission). Discontinue
your home spironolactone (also called aldactone) and bisoprolol.
Please do not take your home doxazosin and finasteride
(medications for enlarged prostate which can cause low blood
pressure) until you are seen by Dr. [**Last Name (STitle) 121**] and discuss restarting
these medications with him.
Weigh yourself daily and call your doctor for any increase in
weight greater than 3lbs. Adhere to a low salt diet less than 2g
salt daily.
Call your doctor or return to the hospital for any new or
worsening chest pain, shortness of breath, difficulty breathing
when lying flat in bed, nausea, vomiting or any other concerning
symptom.
Followup Instructions:
Call Dr.[**Name (NI) 41408**] office ([**Telephone/Fax (1) **]) to follow-up within the
next week.
Echocardiogram [**Last Name (LF) 2974**], [**2183-4-25**] 8:00AM in [**Location (un) 436**] of the
[**Last Name (un) 469**] building.
Dr. [**Last Name (STitle) **] [**Name (STitle) 2974**] [**2183-4-25**] 11:20AM in [**Location (un) 436**] of the
[**Last Name (un) 469**] building.
|
[
"V45.01",
"530.81",
"428.0",
"785.51",
"428.23",
"600.00",
"584.9",
"585.9",
"272.0",
"425.4",
"426.0",
"403.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.52",
"37.23",
"89.64",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11224, 11273
|
7068, 9245
|
283, 331
|
11509, 11518
|
4713, 4713
|
13252, 13638
|
3586, 3754
|
9654, 11201
|
11294, 11488
|
9271, 9631
|
7004, 7045
|
11542, 13229
|
3769, 3779
|
3801, 4694
|
5210, 6987
|
198, 245
|
359, 3006
|
4729, 5193
|
3028, 3353
|
3369, 3570
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,180
| 178,202
|
10390
|
Discharge summary
|
report
|
Admission Date: [**2118-7-23**] Discharge Date: [**2118-7-25**]
Date of Birth: [**2065-4-5**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization s/p [**First Name3 (LF) **] to LAD
History of Present Illness:
53M with HIV (Dx [**2105**], CD4 520, VL ND, on Atripla), HCV (14.M
VL, [**3-25**]), +40 pack year smoking hx, no known CAD that presents
with 3 hrs of chest pain. The pt reports that he awoke this
morning with emesis at followed by chest pain. Initially was
intermittent, then constant for >1hr, radiating to his back. The
pt denies prior episodes of chest pain and is able to walk up
two flights of stairs without difficulty. as well. Associated
with vomiting, diaphoresis, no shortness of breath. Has not had
these symptoms before. CP x 3 and +SOB. no parasthesias. BP
153/119 on left.
.
On arrival to the ED 95.1 80 NSR 153/119 (LUE) 168/140 (RUE) 16
100% RA. ECG with STEs V1-V4. WBC of 18K. He received ASA,
Plavix 600mg, Metoprolol 5mg IV, Heparin gtt. He was
subsequently transferred to the cath lab.
.
While in the cath lab, the pt noted to have mid LAD total
occulusion. The pt underwent balloon angioplasty followed by
[**Month/Year (2) **]. He had AIVR following reperfusion. He received two boluses
of Eptifibatide and then continued on Eptifibatide gtt. Pt
subsequently transferred to the CCU.
.
On arrival to the CCU the pt denies chest pain, SOB, nausea,
vomitting or leg pain.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. He denies recent fevers, chills or rigors.
He denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, -Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: None
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
# HIV CD4 520, VL ND, on Atripla
# HCV 14.M VL, [**3-25**]
# GERD
# s/p Tonsillectomy
Social History:
MSM. Lives with partner. Computer Analyst. Vice President.
-Tobacco history: +
-ETOH: Not significant
-Illicit drugs: None
Family History:
Mom died at age 53 from CVA, Dad died at 74 CAD.
Physical Exam:
ON admission:
VS: Afebrile 80NSR 132/83 16 100% 2L
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 5cm.
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: Clear anteriorly. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: R groin with small non-tender hematoma 1cm. No
appreciable bruit. No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
On discharge:
Tm 99.6 BP 107-115/69-86 77-87 16 100% on RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP not elevated
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: Clear anteriorly. No chest wall deformities, scoliosis or
kyphosis. Resp were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: R groin with large, stable hematoma. No appreciable
bruit. No c/c/e. No femoral bruits. R pedal pulses 2+
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ON admission:
.
[**2118-7-23**] 11:00AM BLOOD WBC-18.9*# RBC-4.86 Hgb-15.5 Hct-45.9
MCV-94 MCH-32.0 MCHC-33.9 RDW-14.6 Plt Ct-366
[**2118-7-23**] 11:00AM BLOOD Neuts-82.1* Lymphs-14.8* Monos-1.9*
Eos-0.4 Baso-0.8
[**2118-7-23**] 11:00AM BLOOD PT-11.9 PTT-22.6 INR(PT)-1.0
[**2118-7-23**] 11:00AM BLOOD Glucose-158* UreaN-12 Creat-1.1 Na-140
K-4.2 Cl-103 HCO3-21* AnGap-20
[**2118-7-23**] 11:00AM BLOOD cTropnT-<0.01
.
On discharge:
[**2118-7-25**] 06:35AM BLOOD Hct-39.6*
[**2118-7-25**] 06:35AM BLOOD Glucose-97 UreaN-14 Creat-0.8 Na-143
K-4.2 Cl-107 HCO3-28 AnGap-12
[**2118-7-25**] 06:35AM BLOOD cTropnT-1.20*
[**2118-7-25**] 06:35AM BLOOD Calcium-8.8 Phos-2.6* Mg-2.1 Cholest-137
[**2118-7-25**] 06:35AM BLOOD Triglyc-163* HDL-36 CHOL/HD-3.8
LDLcalc-68
.
[**2118-7-23**] Cardiac cath:
COMMENTS:
1. Selective coronary angiography in this right dominant system
demonstrated single vessel disease. The LMCA was normal. The
LAD had a
mid vessel occlusion, but was otherwise normal. The LCx and RCA
were
normal.
2. Limited resting hemodynamics demonstrated mild systemic
hypertension
with central aortic pressure 146/89 with a mean of 102 mmHg.
.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild systemic hypertension.
.
[**7-25**] ECHO:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Overall left ventricular
systolic function is moderately depressed (LVEF= 35%) with mild
global hypokinesis and akinesis of the mid to distal
septum/anterior wall and apex. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. 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
Brief Hospital Course:
ASSESSMENT AND PLAN:
53M with HIV, HCV p/w with chest pain, found to have mid-LAD
occulusion now s/p [**Month/Year (2) **].
# Mid-LAD STEMI: Patient with no known cardiac history but w/
risk factors - 40 pack-year tobacco, HIV on HAART and family hx.
Presented with 10/10 chest pressure and EKG concern for anterior
STE. Cath revealed LAD occlusion and [**Month/Year (2) **] was placed. ASA 325 mg,
plavix (loaded w/ 600 mg) 75 mg qday, atorvastatin 80 mg qday
were started. Beta-blocker was given in the ED but was not
started immediately out of concern for groin hematoma.
Eptifibatide gtt was started and continued for 18 hours
post-cath. He was subsequently started on Toprol XL 50 mg qday.
He remained symptom free during the rest of his hospital stay.
.
# Apical akinesis: [**7-25**] TTE demonstrated mild global hypokinesis
and akinesis of the mid to distal septum/anterior wall and apex,
so patient was started on Warfarin 5mg daily with Lovenox (80mg
[**Hospital1 **]) bridge. He will follow-up at [**Hospital1 778**] on [**7-27**] for an INR and
further management of his warfarin will be done by his PCP. [**Name10 (NameIs) **]
should follow up in one month for repeat ECHO to assess for
resolution or improvement of akinesis.
# Right Groin Hematoma: Enlarged acutely after cath while on
integrillin gtt. Pressure was held with stabilization of
hematoma. Good distal pulses. No appreciable bruit. Hematocrit
remained stable.
# PUMP: No known CMP. Pt appears clinically euvolemic. Received
B-Blocker while in ED and was started on Toprol XL 50mg daily.
TTE showed Overall left ventricular systolic function is
moderately depressed (LVEF= 35%) with mild global hypokinesis
and akinesis of the mid to distal septum/anterior wall and apex.
Management as above.
# RHYTHM: Pt currently in NSR. AVIR following reperfusion.
Monitored on tele thereafter.
# HIV: Last CD4 520, VL ND. Continued Atripla
(Emtricitabine/Tenofovir/Efavirenz)
# HCV: (14.M VL, [**3-25**]). Followed by hepatology as outpatient.
Last bx with focal mild portal and minimal lobular mononuclear
inflammation (grade 1). Patient was encouraged to follow-up with
his outpatient hepatologist.
FOLLOW UP
1. AKINETIC LV - on coumadin and lovenox. Instructions given to
patient and [**Hospital1 778**] to check INR on Wednesday [**7-27**]. Patient
instructed to have follow up TTE in one month; follow up with
cardiology planned.
2. STEMI s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] - [**Last Name (Prefixes) **] instructed to never stop aspirin.
Medications on Admission:
Atripla 1 tab daily
Omeprazole 20mg Daily
Discharge Medications:
1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*11*
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
4. Toprol XL 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*11*
5. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO qday ().
6. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
7. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) Syringe
Subcutaneous twice a day.
Disp:*10 Syringe* Refills:*0*
8. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day.
Disp:*150 Tablet(s)* Refills:*2*
9. Outpatient Lab Work
Please check INR on Wednesday [**2118-7-27**].
.
Please fax results to Dr. [**Last Name (STitle) 7991**] at [**Telephone/Fax (1) 34420**].
.
Goal INR [**3-17**]
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
STEMI s/p [**Month/Day (3) **] to LAD
.
Secondary:
HIV on HAART
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for chest pain and you were
found to have had a heart attack. You had a blockage in one of
your main coronary arterties - the left anterior descending
artery. A drug-eluting stent was placed. We started many new
medications that are important to help prevent further heart
attacks and to keep the stent patent. Please stop smoking as it
will greatly improve your heart health.
.
We made the following changes to your medications:
We STARTED Aspirin 325 mg per day
WE STARTED Atorvastatin 80 mg per day
We STARTED Clopidogrel (Plavix) 75 mg per day to keep your stent
open
We STARTED Lisinopril 2.5 mg per day
We STARTED Toprol XL 50 mg per day
.
You have also been started on a medication called Warfarin (or
coumadin) which is a blood thinner. You should get your blood
checked on Wednesday [**7-27**] at [**Hospital1 778**] to assess if your coumadin
level (INR) is therapeutic. Until your INR is therapeutic you
should take the medication Lovenox. This can be discontinued
once your INR is >2.
.
You should follow-up with your cardiologist and arrange a repeat
ECHO in 1mo to assess if you need to continue on warfarin at
that time.
.
You should never stop taking Aspirin.
.
Your follow-up information is listed below.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name3 (LF) 8002**]
Location: [**Location (un) **] ASSOCIATES OF [**Hospital1 **] HEALTH
Address: [**Location (un) 34421**], 2ND FL, [**Location (un) **],[**Numeric Identifier 2900**]
Phone: [**Telephone/Fax (1) 5723**]
When: Tuesday, [**8-2**], 10AM
Department: CARDIAC SERVICES
When: THURSDAY [**2118-8-4**] at 9:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: LIVER CENTER
When: THURSDAY [**2118-10-6**] at 8:30 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Completed by:[**2118-7-25**]
|
[
"530.81",
"410.01",
"070.70",
"414.01",
"401.9",
"V08",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"88.56",
"00.40",
"00.45",
"00.66",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
10400, 10406
|
6530, 9075
|
313, 373
|
10535, 10535
|
4425, 4425
|
12011, 12902
|
2582, 2632
|
9167, 10377
|
10427, 10514
|
9101, 9144
|
5591, 6507
|
10686, 11166
|
2647, 2647
|
2235, 2308
|
4857, 5574
|
11195, 11988
|
263, 275
|
401, 2127
|
4439, 4843
|
10550, 10662
|
2339, 2426
|
2149, 2215
|
2442, 2566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,912
| 164,021
|
53036
|
Discharge summary
|
report
|
Admission Date: [**2117-6-20**] Discharge Date: [**2117-6-25**]
Date of Birth: [**2040-4-5**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5129**]
Chief Complaint:
unresponsiveness and PE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
77yo F w/hx of dementia, bipolar, anxiety, R hip fx [**2-27**] with
post-op PE and infected hematoma, s/p IVC filter, recurrent UTI
[**2-27**], advanced dementia who comes in from NH after being found
unresponsive. She was reportedly unresponsive for 5-10m and
hypoxic at 88%. Put on NRB and was 94% so was brought in.
Reportedly awoke to her baseline AAOx1 after 5m.
.
Of note: she had right ORIF [**2-27**] c/b postop PE (right lower
lobe) then hematoma. Anticoag stopped and IVC filter placed. She
also developed infection and pseudoanyeursm both treated.
.
In ED, 89% on RA then up to 96% on 2L. BP stable. HR 60-70. EKG
showed NSR, LAD, Q aVF, TWI III, TWF V3-V6 (no change). CTA
chest showed acute thrombus at bifurcation of right PA extending
into right middle lobe artery. No thrombus in left side. She was
started on heparin gtt without bolus. CE: CK flat but Trop 0.05.
Seen by vascular service who recommended bilat ultrasounds which
showed bilat lower ex DVTs. Hct at 36. Repeat HCT stable.
.
Currently, she feels well but difficult to assess related to
dementia. She denies pain anywhere. Denies CP or SOB. No leg
pain. Wants to be left alone to rest. ROS neg for fevers,
chills, or other systemic sx.
.
Past Medical History:
- R hip ORIF [**2117-3-8**] with course complicated by:
--- post-op PE (with bleeding complications requiring up to 14u
postop. Led to decision to stop anticoag and place IVC filter
([**2-27**] by Dr. [**Last Name (STitle) 1391**]
--- Morganella hip infection s/p IV abx (now on levaquin 500
daily)
--- pseudoaneurysm s/p correction [**5-6**]
- Bipolar
- Depression and anxiety
- HTN
- Pedal Edema
- Alzheimer's dementia with delusions and delirium, baseline MS
per nursing home records is oriented to self only
- Hyperlipidemia
- h/o CVA [**2097**]
Social History:
Lives in [**Hospital 745**] [**Hospital **] Nursing home.
Son [**Name (NI) **].
Family History:
Noncontributory
Physical Exam:
Admission Exam:
==============
VS: 128/83 62 95% 2L RR12
Gen: frail, NAD, RR normal, no accessory muscles
HEENT: mm dry. JVP 7cm
Lungs: CTAB w no rales or wheeze
Heart: RRR iii/vi harsh early systolic murmur LUSB
Abd: BS+ mildly tender diffusely, no rebound or guarding
Ext: no rashes. 1+ pulses in feet bilat. 2+ edema bilat without
assymetry or pain. right hip does not feel particularly tense
Neuro: AAO to name but not otherwise. Can follow simple
commands.
- PERRLA, tongue midline. face symmetric
- toes down. FROM bilat upper/lower
Pertinent Results:
Admission labs:
==============
[**2117-6-20**] 11:30AM BLOOD WBC-5.1 RBC-4.08* Hgb-11.3* Hct-36.2
MCV-89 MCH-27.6 MCHC-31.2 RDW-14.6 Plt Ct-304
[**2117-6-20**] 11:30AM BLOOD Neuts-61.2 Lymphs-30.6 Monos-6.3 Eos-1.5
Baso-0.4
[**2117-6-20**] 11:30AM BLOOD PT-14.4* PTT-26.4 INR(PT)-1.2*
[**2117-6-20**] 11:30AM BLOOD Glucose-129* UreaN-13 Creat-0.5 Na-141
K-5.1 Cl-106 HCO3-28 AnGap-12
[**2117-6-20**] 11:30AM BLOOD CK(CPK)-103
[**2117-6-20**] 11:30AM BLOOD CK-MB-4
[**2117-6-20**] 11:30AM BLOOD cTropnT-0.05*
[**2117-6-20**] 08:00PM BLOOD cTropnT-0.07*
[**2117-6-21**] 01:52AM BLOOD CK-MB-4 cTropnT-0.06*
[**2117-6-21**] 01:52AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.9
[**2117-6-20**] 10:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015
[**2117-6-20**] 10:25AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2117-6-20**] BLOOD CULTURE Blood Culture, Routine - pending
[**2117-6-20**] URINE URINE CULTURE - no growth
Imaging:
========
[**6-20**] LE Duplex
1. Partially occlusive thrombus in the right superficial femoral
vein extending to the right popliteal vein.
2. Partially occlusive thrombus in the left common femoral vein,
which does not extend distally.
3. Thrombosed pseudoaneurysm in the left groin.
[**2117-6-20**] UE Duplex: No evidence of upper extremity DVT,
bilaterally
[**2117-6-21**] ECHO:
Left ventricular systolic function is hyperdynamic (EF>75%).
Right ventricular chamber size is normal. with normal free wall
contractility. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension.
IMPRESSION: Sub-optimal image quality. Right ventricular size
and systolic function is probably normal. Left ventricular
function is hyperdynamic. Mild mitral and tricuspid
regurgitation.
Compared with the prior study (images reviewed) of [**2117-3-12**],
the estimated pulmonary artery systolic pressure is lower on the
current study (however the TR jet velocity may be underestimated
on the current study).
[**2117-6-20**] CTA:
1. Acute pulmonary embolism in the right pulmonary artery at its
bifurcation, extending into the right middle lobe branches. More
chronic-appearing thrombus present in the right lower lobe
branches.
2. Compression deformity of T10 vertebral body, appears
unchanged, but not
completely visualized on the [**2117-3-11**] study.
3. No acute aortic abnormality. Stable atherosclerotic
calcification.
[**2117-6-20**] CT Head: No acute intracranial abnormalities.
[**2117-6-20**] CXR: Patient is quite kyphotic. There are low lung
volumes. There is plate-like atelectasis at the left lung base.
Lungs are otherwise grossly clear. Heart and mediastinum are
within normal limits. The bones are quite osteopenic.
Brief Hospital Course:
77 yo woman w hx of R hip ORIF [**2-27**] c/b post-op PE c/b hip
hematoma and hip infection. Patient had IVC filter placed and is
not on anticoagulation. Found unresponsive in NH and hypoxic
which improved now with only 2L. CTA shows large prox right pulm
artery PE. EKG without noticable strain. Mild trop leak.
.
# PE
No comment on RH strain seen on CT. Still given proximitiy,
likely this could be considered submassive. She is HD stable at
this point and has good resp status. Pt was anticoagulated with
IV heparin and also started on low dose coumadin (2.5-3mg/d).
Her INR today is 1.9. She was switched to lovenox on the day of
discharge and should overlap heparin with coumadin for at least
3 days more. Because this is recurrent PE despite IVC filter she
is a candidate for life-long anticoagulation. Goal INR should be
2 - 2.5
.
# Hx hematoma - H&H was monitored daily and was stable. There
was no clinical evidence of bleeding.
.
# dementia/psych:
Mental status improved over 24-48 hrs and returned to her
baseline. continue psych meds.
.
# ID:
Pt remained on the fluoroquinolone for her prior hip infection.
She developed low grade fever (<100.5) on [**6-24**] and ha d a chest
x-ray (negative except for improving atelectasis) and UA
(negative). No evidence of infection identified, and she
defervesced spontaneously, so likely secondary to atelectasis.
.
.
# Hypertension:
Initially Metoprolol was held given history of bleed and PE.
This was restarted [**6-22**] after heparin was therapeutic for >24
hours and she had no bleeding.
# FEN/GI - tolerating regular diet, puree solids, thin liquids
Medications on Admission:
Buproprion 75 [**Hospital1 **]
Citalopram 30 daily
Fentanyl patch 25
Metoprolol 12.5 [**Hospital1 **]
Olanzapine 5 [**Hospital1 **] prn
Famvir 500mg daily ???
levaquin 500 daily
asa 325
Oxycodone 2.5 prn
tylenol prn
Pantoprazole 40 daily
bisacodyl 10 qhs prn
Calcium/Vitamin D
Colace
MVI
Senna
Discharge Medications:
1. Aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet [**Hospital1 **]: 1.5 Tablets PO DAILY (Daily).
3. Fentanyl 25 mcg/hr Patch 72 hr [**Hospital1 **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Olanzapine 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for agitation.
5. Levofloxacin 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q24H (every
24 hours).
6. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1)
Tablet, Chewable PO TID (3 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
10. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
11. Multivitamin Tablet [**Hospital1 **]: One (1) Cap PO DAILY (Daily).
12. Bupropion 75 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day).
13. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day).
14. Miconazole Nitrate 2 % Cream [**Hospital1 **]: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
15. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO TID (3
times a day).
16. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. Senna 8.6 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY (Daily).
18. Warfarin 1 mg Tablet [**Last Name (STitle) **]: Three (3) Tablet PO Once Daily at
4 PM as needed for Pulmonary embolism: Goal INR = 2-2.5.
19. Enoxaparin 80 mg/0.8 mL Syringe [**Last Name (STitle) **]: One (1) 70 Subcutaneous
Q12H (every 12 hours) for 3 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 745**] Health Care Center
Discharge Diagnosis:
Pulmonary embolism
Alzheimer's dementia with delusions and delirium, baseline
mental status is oriented to self only
S/P R hip ORIF [**2117-3-8**] following hip fracture
Morganella hip infection post ORIF - on long-term Abx
Bipolar D/O
HTN
Depression and anxiety
Hyperlipidemia
S/P CVA [**2097**]
Chronic anemia
Discharge Condition:
Good
Discharge Instructions:
Continue Lovenox at treatment doses for Pulmonary embolism for 3
more days in addition to coumadin.
Goal INR = 2.0-2.5.
Patient will likely require life-long anticoagulation given
recurrent pulmonary embolism despite IVC filter.
Watch clinically for evidence of bleeding and monitor H & H
given history of significant bleeding after hip surgery.
Followup Instructions:
Follow up with physician in Nursing [**Name9 (PRE) **] in 1 week
|
[
"272.4",
"415.19",
"285.29",
"296.80",
"453.40",
"401.9",
"331.0",
"294.11",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9793, 9857
|
5870, 7482
|
296, 302
|
10212, 10219
|
2831, 2831
|
10616, 10684
|
2239, 2256
|
7827, 9770
|
9878, 10191
|
7508, 7804
|
10243, 10593
|
2271, 2812
|
233, 258
|
330, 1549
|
5560, 5847
|
2847, 5551
|
1571, 2124
|
2140, 2223
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,182
| 192,079
|
13242
|
Discharge summary
|
report
|
Admission Date: [**2125-11-29**] Discharge Date: [**2125-12-3**]
Date of Birth: Sex:
Service: C-MED
CHIEF COMPLAINT: Chest pain.
HISTORY OF PRESENT ILLNESS: Patient is a 74 year-old female
with history of coronary artery disease, peripheral vascular
disease, aortic patch and insulin dependent diabetes mellitus
who has had a coronary artery bypass graft with multiple
catheterizations as well as recent increase in her anginal
symptoms. She developed chest pain radiating to her back and
arms since 8 P.M. the night before admission. She also
complained of shortness of breath which was worsening and
cough but no wheezing noted as well as nausea, vomiting and
abdominal pain. Patient was seen at [**Hospital3 36606**] Hospital
where she received nitroglycerin and the pain improved. She
was transferred to [**Hospital1 69**] with
only tightness as her complaint. She is currently pain-free
on admission and hasn't received any new medications.
PAST MEDICAL HISTORY: Is significant for 1) insulin
dependent diabetes mellitus time 40 years, 2) coronary artery
disease with coronary artery bypass graft times two [**Numeric Identifier 40358**],
history of angioplasty at [**Hospital6 2910**]. 3)
Arteriovenous malformation in the bowel. 4) Peptic ulcer
disease with history of gastrointestinal bleeding. 5) total
abdominal hysterectomy. 6) Possible aortic valve
replacement. 7) Aortic patch. 8) Colostomy which has since
been reversed.
MEDICATIONS ON ADMISSION: 1) Protonix 40 mg p.o. q day, 2)
insulin NPH, 3) folic acid, 4) iron supplementation, 5)
Lipitor 80 mg p.o. q.h.s., 6) Imdur 120 mg p.o. q. day, 7)
nitroglycerin p.r.n., 8) metoprolol 25 mg p.o. q.h.s., 9)
Lasix 20 mg p.o. b..d., 10) Premarin 0.625 mg p.o. q. day,
11) vitamin B12 q month, 12) Zestril 10 mg p.o. q day, 13)
Epogen.
ALLERGIES: 1) Beef insulin, 2) sulfa, 3) cefoxitin, 4)
penicillin, 5) codeine, 6) Clindamycin, 7) Cardizem, 8)
shellfish.
FAMILY HISTORY: Father and mother both with coronary artery
disease. All have hypertension and diabetes.
SOCIAL HISTORY: No alcohol or drug use or tobacco use.
PHYSICAL EXAMINATION: On admission - a well developed and
obese female in mild respiratory distress. Vital signs:
Temperature 97.9,blood pressure 145/37, pulse 60, O2
saturation 98% on 2 liters. Head, eyes, ears, nose and
throat: pupils equal, round and reactive to light and
accomodation, extraocular movements intact. Oropharynx
clear. Neck supple, unable to assess jugular venous
distention. Lungs bilateral dependent rales, no wheezing.
Cardiovascular examination - regular rate and rhythm, S1, S2,
no distant heart sounds. Abdomen soft, nontender,
nondistended, normal active bowel sounds. Extremities: warm,
no edema. Pulse: right with radial 2+, dorsalis pedis 2+,
radial on the left is dopplerable, dorsalis pedis is 1+.
LABORATORY DATA: On admission white blood cell count 7.1,
hematocrit 31.1, sodium 141, potassium 4.3, chloride 104,
bicarbonate 26, BUN 26, creatinine 1.1, glucose 179. CK 72
at the outside hospital, troponin of 0.9. Electrocardiogram
with sinus rhythm at 74, left bundle branch block, normal
axis, ST elevations in V2 to V3 with depressions in V4 and
V5. No significant change from outside hospital. Chest
x-ray with mild congestive heart failure, no pneumonia.
IMPRESSION: Patient is a 74 year-old female with cardiac
history and diabetes mellitus who presents with worsening
angina and acute chest pain radiating to the back and arms
and neck which has now resolved.
HOPSITAL COURSE: 1) Cardiovascular. Chest pain was felt to
be consistent with acute coronary syndrome versus aortic
dissection especially with the history of aortic patch.
Patient was cycled with serial enzymes and did rule in for
myocardial infarction by enzymes, was continued on her
statin, Nitropaste and Imdur, on metoprolol and Zestril and
increased dose of Lasix for mild degree of failure. On
[**2125-11-29**] patient developed 10 out of 10 chest pain
radiating to the neck with severe shortness of breath.
Vitals were 89 percent on 2 liters of O2. She was then given
a nonrebreather, Lopressor 5 mg intravenous times two, 4 mg
of morphine, 2 mg of Ativan. Her vitals were then 100
percent on nonrebreather with stable blood pressure and
pulse. Laboratories showed troponin of 3.2, arterial blood
gases showing a gas of pO2 161, CO2 of 53. Chest x-ray
showed bilateral pulmonary edema. Patient was transferred to
the Cardiac Care Unit for further management. She was
continued on heparin, nitro drip as well as all of her home
medications and no further episodes of chest pain. Patient
underwent catheterization on [**2125-11-30**] which had a PTCA
and stent of the SVG to LAD and anastomosis distal to graft
touchdown. SVG to RCA showed no evidence of stenosis. There
was a tight ostial and proximal left circumflex which was not
stented secondary to dye load that was given and patient was
transferred back to the Cardiac Care Unit for monitoring
until further catheterization on [**Last Name (LF) 766**], [**2125-12-3**].
Over the weekend she had no significant events and underwent
cardiac catheterization on [**2125-12-3**]. Cardiac
catheterization on [**2125-12-3**] with an attempt to
intervene on the left circumflex. However, due to difficulty
passing wire through the left circumflex artery lesion there
was no intervention that was done. Post procedure patient
was doing well. However, after the sheath was pulled she
began to develop a large groin hematoma around noon on
[**2125-12-3**]. Patient had a significant groin hematoma
which began to expand, was given blood as well as several
liters of intravenous fluid. The interventional fellow was
present and attempted to put pressure on the femoral artery.
However, the hematoma was large and the patient's body
habitus prevented adequate hemostasis. Patient was
transferred up to the Cardiac Care Unit for evaluation and
treatment. Arterial line was placed for further monitoring
of her blood pressure and patient was noted to be severely
hypotensive. Blood pressure readings were difficult to
correlate with cuff measurements as patient's cuff
measurements were fluctuating wildly from 60 systolic to 120
systolic. Arterial line measurements were the ones that were
used for evaluation and treatment. Patient was started on
Dopamine as well as Levophed for increasing her systolic
pressure. However, she was failing to respond to both of
these. Over 4 liters of intravenous saline were given to her
with little improvement in systolic blood pressure. Patient
was taken to the cardiac catheterization laboratory which was
performed as an emergent catheterization by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
with fellow [**First Name8 (NamePattern2) **] [**Hospital1 46**] present. Left sided cardiac
catheterization showed occlusion 100 percent of the left main
coronary artery, SVG to the LAD was 100 percent occluded, SVG
to the RCA was not injected due to cardiac arrest.
Immediately upon establishing arterial accessed patient began
to develop refractory ventricular tachycardia and pulseless
electrical activity. Attempt was made to PTCA the occluded
SVG to LAD but while preparing equipment patient became
asystolic. Cardiopulmonary resuscitation was initiated and
patient coded for about 25 minutes. Despite multiple doses
of intravenous epinephrine, atropine, calcium chloride,
bicarbonate patient remained in PA for more than 20 minutes
with no return of any visible cardiac activity by
fluoroscopy. Code was called at 6:55 P.M.
DISCHARGE DIAGNOSIS:
Acute myocardial infarction.
CONDITION ON DISCHARGE: Expired.
[**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**]
Dictated By:[**Name8 (MD) 4630**]
MEDQUIST36
D: [**2126-2-11**] 10:59
T: [**2126-2-11**] 13:38
JOB#: [**Job Number 40359**]
|
[
"250.00",
"414.00",
"V45.82",
"428.0",
"410.91",
"V43.3",
"412",
"785.51",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"96.71",
"96.04",
"37.22",
"88.53",
"88.56",
"36.06",
"36.01"
] |
icd9pcs
|
[
[
[]
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] |
1984, 2075
|
7640, 7670
|
1510, 1967
|
2155, 7619
|
149, 162
|
191, 986
|
1009, 1483
|
2092, 2132
|
7695, 7933
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,425
| 150,284
|
9512
|
Discharge summary
|
report
|
Admission Date: [**2125-1-22**] Discharge Date: [**2125-3-6**]
Date of Birth: [**2068-10-25**] Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / clarithromycin / Penicillins / Macrolide
Antibiotics / Dilantin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
lower extremity weakness
Major Surgical or Invasive Procedure:
[**2125-1-22**]: cervical spine traction / [**Location (un) **] [**Doctor Last Name **] tongs
[**2125-1-26**]: C5/6/7 corpectomies and C4-T1 anterior fusion
[**2125-1-31**]: C3-T3 Posterior Fusion
[**2125-2-8**]: Tracheostomy
[**2125-2-26**] PEG
History of Present Illness:
56 yo F with cervical myelopathy s/p extensive posterior
decompressive laminectomy C3-C7, foraminotomy 3 years prior with
progressive leg weakness and increased falls over several
months. She had recent admission for similar complaints in
[**Month (only) **] and underwent cervical MRI but left AMA for financial
reasons. Since that time, her condition has worsened. At home,
she has minimal
ability to ambulate and has been using wheelchair at home
intermittently since [**Month (only) **] of last year. She continues to
have moderate-severe neck pain as well requiring opioids.
She was readmitted to [**Hospital1 **] on [**2125-1-16**] at which time her
neurodiagnostics were reevaluated. On further review, there was
question of a fibrous scarring band at C5-C6 that might be
acting as a compression anchor on the cord. NSurg also felt that
she had pathologically brisk reflexes and upgoing toes b/l and
recommended repeat MRI cervical spine w/ contrast (report not
available). Neurology and Nsurg noted edema around cord at
C6-C7. Recommended IV steroids and continued neck brace as well
as transfer to [**Hospital1 18**].
Pt wears soft C-collar at all times and requires significant
pain medication (percocet, flexeril, vistaril). She is noted to
be a 1-assist to commode with unsteady gait.
Past Medical History:
HL
Arthritis, + [**Doctor First Name **], treated with hydroxychloroquine
Asthma
IBS
Endometriosis
Chronic hip/back pain, treated with oxycodone
Social History:
She lives at home with her husband on [**Hospital3 **]; smokes [**12-11**] pk
daily, minimal alcohol
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.3 HR 64 RR: 16 BP: 125/65 SaO2: 99%RA
General: Awake, cooperative, NAD.
HEENT: no scleral icterus noted, [**Month/Day (2) 5674**], no lesions noted in
oropharynx, soft collar in place with some neck tenderness on
palpation
Neck: In soft collar, no carotid bruits appreciated. nuchal
rigidity not assessed
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] 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 low volume and slightly
horse but not dysarthric. Able to follow both midline and
appendicular commands. Pt. was able to register 3 objects and
recall [**2-10**] 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 4 to 2mm and brisk. VFF to confrontation. Funduscopic
exam defered.
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: Decreased bulk in upper extremity, increased tone in
lower extremity. Pseudoathetosis in upper extremity 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**] EDB
L 5 5 4- 5 5 4 4- 5 5 4 4+ 5 5 5
R 5 5 4- 5 5 4 3 4+ 5 4 4 5 4 5
-Sensory: decreased light touch, pinprick, cold sensation,
vibratory sense, proprioception in hands bilaterally. No
extinction to DSS. Significant Lower extremity sensory loss to
light touch, pinprick, vibration, cold,
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 3 3 3 3 3 (with clonus)
R 3 3 3 3 3 (with clonus)
Plantar response was ext bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF b/l, HKS could not be performed [**1-11**]
weakness.
-Gait: defered
PHYSICAL EXAM UPON DISCHARGE:
98 tc, 114/70 (110-121/69-73), 78, 20, 100% ON RA, FSG 123 (FSG
ON [**3-5**]: 139, 156, 103, 123)
I/O: 1.5/inc 620+
GENERAL: Alert, interactive, appropriate, no acute distress.
HEENT: [**Last Name (LF) 5674**], [**First Name3 (LF) 13775**], intact EOM, conversing
NECK: Brace in place, posterior incision well healed
CV: RRR, normal S1/S2, no m/g/r.
PULM: scat rhonchi anteriorly, able to clear with cough,
otherwise CTA, no wheezes/rales.
ABD: +BS, soft, non-distended, very mild left quadrant
tenderness over PEG tube site, site looks c/d/i, + BS. Small
ecchymotic area on LLQ r/t heparin injection.
Skin: small healing ulcer on her submadibular area, and small
scab on occipital area above the brace
NEURO: Conversing this AM, A+OX 3, EOMI, face symmetric, tongue
midline. Able to wiggle all finges and toes, lift legs from bed.
She OOB to chair with min assist
Pertinent Results:
[**1-23**] C-spine Xray: HISTORY: Spondylolisthesis in traction.
7 AP and lateral radiographs of the cervical spine show little
change in the appearances including the grade 3 anterolisthesis
with deformed C6 body on C7 since exam [**2125-1-19**].
[**1-24**] C-spine Xray:
This is the second of four similar radiographs of the cervical
spine obtained over 14-hour interval. The grade 2
anterolisthesis of C6 on C7 and grade [**12-11**] anterolisthesis of C4
on C5 are little changed allowing for differences in rotation.
[**1-24**] C-spine Xray: The patient is status post posterior fusion
spanning C3-C6. There is again seen grade II anterolisthesis of
C4 over C5 which measures 9 mm and is stable. There is also
anterolisthesis of C6 over C7, which measures 11 mm and is also
relatively stable. Degenerative changes with loss of
intervertebral disc height at multiple levels is seen. There is
sclerosis of the C7 vertebral body. Overall, there has been no
appreciable change.
[**1-24**] C-spine Xray:
Single side lateral film of the cervical spine shows posterior
fusion hardware extending from C3 through C6. There is osseous
anterior fusion of C2 and C3 as well as C5 and C6. There is a
grade 2 anterolisthesis of C4 on C5 and C6 on C7 with appearance
unchanged from similar bedside exam 23 minutes earlier.
[**1-25**] portable chest Xray: No significant changes since prior
study. Lungs are well expanded and clear bilaterally. There is
no pleural effusion, masses or lesions. There is no
pneumothorax. The cardiomediatinal silhouette is within normal
limits and stable. Pleural surfaces and osseous structures are
unremarkable.
[**1-26**] CT cervical Spine: IMPRESSION:
Limited study due to streak artifact from hardware demonstrates
new
anterior cervical discectomy and fusion from C4 to T1. Expected
postoperative changes.
[**1-29**] Chest Xray: As compared to the previous radiograph, there
has been a cervical fusion. There is no evidence of pneumonia or
other pathologic changes in the lungs. Unchanged mild symetrical
apical thickening. Normal size of the cardiac silhouette. No
pleural effusions, no pneumothorax.
[**1-30**] Lower extremity doppler US: no evidence of DVT
[**1-31**] CT C-spine-
1. C4-T1 anterior and C3-T3 posterior fusion. Increasing
fluid/air
collections throughout the prevertebral, intraspinal, and
perivertebral spaces and superior mediastinum could represent
post-surgical changes, but it is difficult to exclude
superimposed infection. If clinically indicated,
contrast-enhanced study of the neck and chest could be ordered
to assess for possible abscess, fistula, and/or mediastinitis.
This was paged to nurse [**First Name8 (NamePattern2) 3639**] [**First Name4 (NamePattern1) 951**] [**Last Name (NamePattern1) **] on [**2125-2-1**]
at 12:50 a.m.
2. Moderate retropharyngeal edema. Limited evaluation of
supraglottic
structures due to retained secretions
[**2-1**] CXR-
: As compared to the previous radiograph, the patient has
received a
left-sided PICC line. The course of the line is unremarkable,
the tip of the line projects over the mid SVC. There is no
evidence of complications,
notably no pneumothorax.
[**2125-2-6**] CXR
FINDINGS: Compared to the previous radiograph, there is no
relevant change. The tip of the endotracheal tube projects 2.7
cm above the carina. The course of the left-sided PICC line is
constant. No acute lung changes. Normal size of the cardiac
silhouette. Vertebral stabilization devices in unchanged
position.
[**1-/2042**] CXR: FINDINGS: In comparison with study of [**2-6**], the tip of
the endotracheal tube measures about 5 cm above the carina.
Nasogastric tube extends well into the stomach. No acute
cardiopulmonary disease.
[**1-/2042**] EEG:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of a slow and disorganized background. There is diffuse slowing
of
background for a few hours which could be indicative of
medication
effect. However, the background activity appears again after
that
portion of the recording. These findings are indicative of a
mild
diffuse encephalopathy which is etiologically non-specific.
There were
no focal asymmetries or epileptiform features. Compared to the
prior
day's recording, there is slight improvement and more
organization of
the background activity.
[**2125-2-10**] CXR A tracheostomy is in place. At the periphery of these
films, cervical fixation hardware is noted. The apices are
obscured by overlying mask. Allowing for this, the lungs appear
hyperinflated. Heart size is at the upper limits of normal.
There is upper zone redistribution, without overt CHF. There is
minimal hazy density in the left lung, which most likely
represents mild atelectasis. No frank consolidation or gross
effusion. Left subclavian PICC line tip overlies mid/lower SVC.
Allowing for artifact due to the oxygen mask, no pneumothorax is
detected.
[**2125-2-11**] LENIES
FINDINGS: Grayscale and color Doppler son[**Name (NI) 1417**] with spectral
analysis of the bilateral common femoral veins, superficial
femoral and popliteal veins was performed. There is normal
compressibility, flow and augmentation. There is normal flow and
compressibility in the left peroneal and posterior tibial veins.
The right calf veins were not visualized.
IMPRESSION: No bilateral lower extremity DVT. Right calf veins
not
visualized.
[**2125-2-12**]: CT C-spine/neck
IMPRESSION:
Preliminary Report1. 2.5 x 2.1 x 6.2 cm fluid collection at the
surgical access site at the posterior cervical spine extending
from C2 to T1 might be postsurgical, however, superimposed
infection cannot be excluded.
2. Interval decrease of the previously seen prevertebral and
superior
mediastinal fluid collections. 3. 2.4-cm
supraglottic/pre-epiglottic soft tissue mass. DDx includes
ectopic thyroid, atypical thyroglossal duct cyst or supraglottic
carcinoma.
[**2125-2-21**]:
FINDINGS: The liver shows no focal or textual abnormalities.
The portal vein is patent showing hepatopetal flow.
Multiple small gallbladder stones are seen.
No thickening or edema is seen in the gallbladder wall.
There is no intra- or extra-hepatic biliary duct dilatation. The
CBD measures 0.3 cm.
The right kidney measures 10.2 cm and is normal without
hydronephrosis or
stones. The left kidney measures 8.8 cm and is normal without
hydronephrosis or stones.
Atherosclerotic disease of the aorta.
IMPRESSION: Cholelithiasis without signs of cholecystitis.
[**2125-2-21**]:
MRI of head-
IMPRESSION:
1. Hyperintense signal on diffusion weighted and FLAIR images in
right medial frontal and parietal lobe without corresponding low
signal on ADC images. This likely represents seizure related
change.
2.FLAIR hyperintensity in left posterior temporal lobe sulci,
which is
unchanged since the prior study. This likely represents a
cortical vein
3. Focal and confluent T2/FLAIR hyperintensities in bilateral
periventricular and subcortical white matter of bilateral
cerebral hemispheres and pons. The differential for this finding
includes demyelination, changes of chronic small vessel ischemic
disease or changes of vasculitis.
4. No abnormal leptomeningeal or parenchymal enhancement.
[**2125-2-21**] MRI of c-spine:
1. Post-operative changes in the form of anterior fusion from C4
to T1
vertebrae and posterior fusion at T2-T3 level. Although it is
difficult to
compare across imaging modalities, and the MR images are
obscured by artifact
from the fusion hardware, anterolisthesis of C3 over the fused
vertebrae
appears more severe than the prior CT. Repeat CT is advised if
clinically
indicated.
2. Peripherally enhancing collection in posterior paraspinal
soft tissues
from C2 to C5 level which likely represents post-operative fluid
collection. This has decreased in size since the prior study.
3. Hyperintense signal in the spinal cord at C6-C7 level, which
likely
represents edema from prior compression.
4. No abnormal leptomeningeal or intramedullary enhancement.
5. Supraglottic mass which is better evaluated on the prior CT
images.
[**2125-2-25**] EEG:
FINDINGS:
CONTINUOUS EEG RECORDING: Began at 7:01 on the morning of [**2-25**] and
continued through 19:53 that evening. It showed normal posterior
[**8-20**]
Hz alpha frequency activity posteriorly wakefulness, as well as
some
drowsiness and sleep.
SPIKE DETECTION PROGRAMS: Showed no clearly epileptiform
features.
SEIZURE DETECTION PROGRAMS: Captured no electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: The patient progress from wakefulness to sleep at
different
times with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The
background appeared remain normal, in wakefulness and sleep.
There were
no electrographic seizures
[**2125-2-25**] EKG:
Normal sinus rhythm. Small inferior Q waves consistent with
possible inferior myocardial infarction. No significant change
from tracing of [**2125-2-19**].
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
101 132 76 346/417 68 51 75
[**2125-2-25**]
FINDINGS: Bilateral intracranial internal carotid arteries,
vertebral
arteries, basilar artery and their major branches are patent
with no evidence of stenosis, occlusion or vascular
malformation. There are tiny outpouchings arising from the
medial aspect of the right cavernous ICA, which are less than 2
mm in size. These may represent infundibula of tiny branch
vessels or small aneurysms. Evaluation of the brain parenchyma
was limited on these angiographic images.
IMPRESSION:
Tiny outpouchings from the medial aspect of right cavernous ICA
may represent small aneurysms or infundibula of branch vessels.
Otherwise, unremarkable MRA of the brain.
[**2125-2-28**] ECHO:
Conclusions
Regional left ventricular wall motion 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 number of aortic valve leaflets
cannot be determined. There is no aortic valve stenosis. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Based on limited apical views only (no parasternal
imaging available), left ventricular regional and global
systolic function are normal. Mild aortic regurgitation.
[**2125-3-1**] EKG:
Sinus rhythm. There are Q waves in the inferior leads consistent
with
possible myocardial infarction. There are Q waves in the
anterolateral leads consistent with possible myocardial
infarction. Compared to the previous tracing of [**2125-2-26**] there is
no significant change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 150 68 [**Telephone/Fax (2) 32346**] 86
[**2125-3-1**] VIDEO SWALLOW:
FINDINGS: Barium passes freely through the oropharynx and
esophagus without evidence of obstruction. There is profound
gross aspiration with ice, nectar-thick and pudding
consistencies. The patient is status post anterior and posterior
cervical spinal fusion with pre-epiglottic and prevertebral
fluid collections seen on CT of [**2125-2-12**]. There is apparent holdup
of barium at the upper esophageal sphincter, which may be
related in part to narrowing of the esophagus due to swelling
and fluid collections in the neck.
IMPRESSION: Profound gross aspiration with ice, nectar thick and
pudding
consistencies. Holdup of barium at the UES may be related to
prevertebral
fluid collections seen on CT of [**2125-2-12**].
[**2125-3-4**] EKG:
Normal sinus rhythm. Possible prior inferior myocardial
infarction. Compared
to the previous tracing of [**2125-3-1**] no diagnostic interval
change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 140 78 390/432 65 29 85
ADMISSION LABS:
================
[**2125-1-23**] 05:45AM BLOOD WBC-11.4* RBC-3.80* Hgb-10.4* Hct-31.6*
MCV-83 MCH-27.4 MCHC-32.9 RDW-15.0 Plt Ct-330
[**2125-1-31**] 04:45AM BLOOD Neuts-89.3* Lymphs-6.5* Monos-2.7 Eos-1.3
Baso-0.2
[**2125-1-23**] 05:45AM BLOOD PT-10.1 PTT-26.5 INR(PT)-0.9
[**2125-1-23**] 05:45AM BLOOD Glucose-82 UreaN-18 Creat-0.6 Na-142
K-3.5 Cl-105 HCO3-30 AnGap-11
[**2125-2-1**] 04:58AM BLOOD ALT-44* AST-46* LD(LDH)-231 AlkPhos-289*
TotBili-0.9
[**2125-1-23**] 05:45AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
[**2125-2-13**] 06:27AM BLOOD Hapto-371*
[**2125-2-27**] 05:30AM BLOOD Triglyc-114 HDL-48 CHOL/HD-4.5
LDLcalc-146*
RHEUM LABS:
=============
[**2125-2-25**] 11:25AM BLOOD ANCA-NEGATIVE B
[**2125-2-24**] 08:03PM BLOOD [**Doctor First Name **]-NEGATIVE dsDNA-NEGATIVE
[**2125-2-24**] 08:03PM BLOOD C3-172 C4-30
[**2125-2-24**] 08:03PM BLOOD ACA IgG-1.2 ACA IgM-16.2*
SM ANTIBODY
Test Result Reference
Range/Units
SM ANTIBODY <1.0 NEG <1.0 NEG AI
RO & [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **] Result Reference
Range/Units
SJOGREN'S ANTIBODY (SS-A) <1.0 NEG <1.0 NEG AI
SJOGREN'S ANTIBODY (SS-B) <1.0 NEG <1.0 NEG AI
METHYLMALONIC ACID
Test Result Reference
Range/Units
METHYLMALONIC ACID 66 L 87-318 nmol/L
CARDIAC LABS:
==============
[**2125-2-27**] 05:30AM BLOOD %HbA1c-4.9 eAG-94
[**2125-2-27**] 05:30AM BLOOD Triglyc-114 HDL-48 CHOL/HD-4.5
LDLcalc-146*
[**2125-2-25**] 09:53AM BLOOD CK-MB-12* MB Indx-18.8* cTropnT-<0.01
[**2125-2-26**] 02:46AM BLOOD CK-MB-12* MB Indx-20.3* cTropnT-<0.01
[**2125-2-26**] 11:00AM BLOOD CK-MB-13* MB Indx-19.7*
[**2125-2-27**] 05:30AM BLOOD CK-MB-13* cTropnT-0.01
[**2125-2-28**] 04:55AM BLOOD CK-MB-11* MB Indx-20.0* cTropnT-<0.01
HEME LABS:
===========
[**2125-2-13**] 06:27AM BLOOD Ret Aut-2.4
[**2125-2-19**] 12:10PM BLOOD Ret Aut-4.2*
[**2125-1-31**] 07:05PM BLOOD Fibrino-779*
[**2125-1-31**] 08:30PM BLOOD Fibrino-752*
[**2125-2-12**] 09:30AM BLOOD Fibrino-470*#
[**2125-2-13**] 06:27AM BLOOD Hapto-371*
[**2125-2-14**] 04:59AM BLOOD VitB12-749
[**2125-2-17**] 04:55AM BLOOD calTIBC-264 Ferritn-236* TRF-203
[**2125-2-19**] 05:54AM BLOOD Hapto-353*
DISCHARGE LABS:
================
LYTES FROM THIS PM STILL PND
[**2125-3-4**] 07:05AM BLOOD Calcium-9.3 Phos-4.7*# Mg-1.7
[**2125-2-28**] 04:55AM BLOOD ALT-54* AST-37 CK(CPK)-55 AlkPhos-275*
TotBili-0.2
[**2125-3-5**] 05:15AM BLOOD Glucose-102* UreaN-17 Creat-0.4 Na-141
K-3.2* Cl-102 HCO3-29 AnGap-13
[**2125-3-5**] 05:15AM BLOOD WBC-10.1 RBC-3.11* Hgb-9.1* Hct-29.5*
MCV-95 MCH-29.3 MCHC-30.8* RDW-15.3 Plt Ct-563*
URINE:
[**2125-2-25**] 10:55AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.013
[**2125-2-25**] 10:55AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM
[**2125-2-25**] 10:55AM URINE RBC-1 WBC-18* Bacteri-FEW Yeast-NONE
Epi-1
CEREBRAL FLUID:
[**2125-2-13**] 02:31PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
Lymphs-40 Monos-60
[**2125-2-13**] 02:31PM CEREBROSPINAL FLUID (CSF) TotProt-15 Glucose-86
[**2125-2-13**] 02:31PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
MICROBIOLOGY:
[**2125-3-4**] 12:06 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT [**2125-3-6**]**
FECAL CULTURE (Final [**2125-3-5**]): NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final [**2125-3-6**]): NO CAMPYLOBACTER
FOUND.
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2125-3-5**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2125-2-21**] 9:44 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT [**2125-2-21**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2125-2-21**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2125-2-19**] 3:02 am URINE Source: Catheter.
**FINAL REPORT [**2125-2-20**]**
URINE CULTURE (Final [**2125-2-20**]): NO GROWTH.
[**2125-2-19**] 12:42 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2125-2-25**]**
Blood Culture, Routine (Final [**2125-2-25**]): NO GROWTH.
[**2125-2-18**] 11:34 pm BLOOD CULTURE Source: Line-R PICC.
**FINAL REPORT [**2125-2-25**]**
Blood Culture, Routine (Final [**2125-2-25**]): NO GROWTH.
[**2125-2-18**] 3:28 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-2-18**]**
GRAM STAIN (Final [**2125-2-18**]):
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
[**2125-2-13**] 2:31 pm CSF;SPINAL FLUID Source: LP #3.
GRAM STAIN (Final [**2125-2-13**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2125-2-16**]): NO GROWTH.
FUNGAL CULTURE (Final [**2125-3-5**]): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
The sensitivity of an AFB smear on CSF is very low..
If present, AFB may take 3-8 weeks to grow..
NO MYCOBACTERIA ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
[**2125-2-8**] 9:02 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2125-2-10**]**
GRAM STAIN (Final [**2125-2-8**]):
[**10-4**] PMNs and <10 epithelial cells/100X field.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST WITH
PSEUDOHYPHAE.
RESPIRATORY CULTURE (Final [**2125-2-10**]):
Commensal Respiratory Flora Absent.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
YEAST. RARE GROWTH. OF TWO COLONIAL MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
Brief Hospital Course:
On [**2125-1-22**] Ms [**Known lastname **] was transferred from OSH to [**Hospital1 18**] for
neurosurgical management. Her imaging studies were uploads and
revealled C7 to T1 listhesis.
Patient was admitted to the intensive care unit and placed in
cervical traction. After reducing adequately, she was taken to
the Operating room on [**2125-1-26**] and underwent a C5/6/7
Corpectomies and C4-T1 Fusion. This was without complication.
She was extubated, removed from traction and transferred back to
the ICU. Post operative CT revealed good fusion. A SOMI brace
was ordered and she was liberalized to HOB at 45 degrees.
The patient was febrile to 102.6 on [**1-30**] with a leukocytosis of
17.7. Blood and urine cultures were sent. CXR did not show a
definite infiltrate however the patient did have a productive
cough. In the setting of elevated WBC, fever and cough she was
started on Levofloxacin for PNA. Sputum culture was requested.
Lower extremity dopplers were negative for DVT.
A speech and swallow eval was ordered given patient's swallowing
difficulties and was performed on [**1-30**]. Unfortunately the
patient failed the study and so she was placed on strict NPO
diet.
On [**1-31**] she was taken back to the OR and underwent a C3-T3
fusion. During positioning she was noted to have a sacral
decubitis so a wound care consult was called. INR was 1.5 and
HCT was 22 so she was transfused with PRBC's and FFP. Post
operatively she was not extubated due to laryngeal edema
(difficult intubation) therefore ENT was consulted for
evaluation. They recommended steroids, PPI and to keep her
intubated. She was continued on vanc/gent for prophylaxsis. On
[**2-1**] her exam was grossly stable but difficult to examine due to
being intubated. CT C-spine revealed moderate retropharyngeal
edema but no hardware malfunction or misalignment. On [**2-2**] she
remained stable, extubation was discussed but she was not doing
well on CPAP trial and also did not have a cuff leak.
On [**2-3**], patient self extubated. She was breathing well on face
mask. Strength was full post operatively and her pain was being
treated with morphine.
On [**2-4**], the decadron was being weaned due to delirium and she
required the addition of olanzapine. She was febrile to 101 on
[**2-5**] and she was pancultured. On this day she was reintubated
for hypoxia. She required high sedation to prevent self
extubation.
On [**2-6**] the patient was being prepped for the OR with ENT but
was noticed in the afternoon to be unresponsive with eyes
deviated laterally and out, with flickering of the eye lids. She
was given dilantin and ativan and a stat Head CT was performed
which was questionable for a right temporal hypodensity. Per
neurorad recommendation an MRI was performed. This was negative
for stroke or lesion therefore an EEG was ordered to rule out
seizure activity. EEG was negative therefore it was discontinued
along with the dilatin.
On [**1-/2042**] the patient was very lethargic so her sedation was held
(> 1 hr) for examination. During this time she self-extubated.
O2 sats were stable but she was noted to be aspirating therefore
she was reintubated and subsequently trached.
On [**2-8**] she was neurologically stable and vent was weaned to a
trach collar. Her staples were d/c'd.
On [**2-10**] patient was transferred to the floor. However, she spiked
another low grade temp of 100.8 and was recultured and had an
additional chest x-ray. Fever work-up was negative, except for
positive pan-sensitive pseudomonas on sputum culture.
On [**2-11**] Infectious disease consult was called due to patient's
leukocytosis and continued fevers. They recommended switching
her antibiotics to Cefepime, obtaining a mini-bal, a clostridium
difficile culture, and possible IR guided LP. These studies were
found to be negative.
On [**2-12**] Her INR was found to be trending upwards. Hematology was
consulted for their input and recommended Vit. K+. Her PEG was
delayed because on her fever and wbc. Nutrition recommendations
for TPN was initiated. ENT was also re-contact[**Name (NI) **] for possibility
of scoping this pt for eval of possible para-vocal mass that was
initially seen on intubation for ACDF. Due to concern
surrounding her waxing/wanning mental status
On [**2-13**] Her INR returned to [**Location 213**], her TPN was initiated as per
nutrition. ENT did a fiberoptic evaluation and they found poor
management of secretions, but no mass and they signed off. She
had her LP in INR on this day. Neuromedicine saw her and fel;t
that she was in a oculogyrate crisis. Benadryl was given without
good effect. She was transfered to medicine due to the
complexity of her problems.
Her medical floor course can be summarized as follows:
======================================================
INACTIVE TISSUES:
=================
#. FEVERS/LEUKOCYTOSIS: She was inherited on vanco/cefepime
broad spectrum antibiotics without clear source of infection- a
pan sensitive psuedomonas was found in the sputum but no
radiographic evidence of pneumonia was ever apparent. On [**2125-2-14**],
her antibiotics were discontinued due to the lack of fevers and
a downtrending WBC. A small fluid collection seen on CT along
the posterior cervical surgical incision site was sampled via
IR/ultrasonography, with a bland fluid not suggestive of
infection. Urine, blood cultures were negative, as were C dif.
On [**2-19**], she spiked to 102, she was then restarted on vanco and
cefepime. She had pan culture which at the time was all
negative. Her only + culture was from sputum the day before with
pan-sensitive pseudomonas, although there was no radiologic
evidence of infection (pneumonia) this was thought to be causing
elevation in WBC- so she was treated with cefepime for a total
of 10 days last day was on [**2-26**] and she has been afebrile since
then.
#. DELIRIUM/ENCEPHALOPATHY: she showed a waxing and [**Doctor Last Name 688**] level
of responsiveness. EEG had previously shown only diffuse
slowing of encephalopathy, which could have been from her
surgical interventions, steroids, zyprexa, infection. There was
concern for seizure activity due to contraction of the arms and
eye deviation, so an extended EEG was conducted without definite
evidence of seizures. Deliriogenic meds avoided. She was then
treated for seizures with Keppra and then Dilantin was added
since she continue to have seizure activity. Within hours of her
dilantin infusion, she developed a severe rash. So this was
stopped and she was continued on keppra and started on
Lacosamide. She was doing well and then had her last episode of
confusion last week in the setting of receiving trazadone for
sleep and pain meds. Her sedating meds were held and pt has been
doing much better. Now A+O x 3. She was restarted on oxycodone
for pain and I would consider restarting Ambien once pt is
stable on her new location. There were multiple head images
which did not show anatomical cause of her confusion or seizures
#. OCULOGYRIC CRISIS: she had a dystonic reaction from zyprexa
with an unclosable mouth and eye deviation. This lysed with IV
benadryl on [**2-13**]. She had similar symptoms on [**2-16**] which again
responded to IV benadryl. Anti-psychotics were avoided.
ACTIVE ISSUES:
===============
# Seizures: Has been having unusual EEG activity and three
confirmed seizures since [**2-18**], most recently on [**2-24**]. She was
loaded on Keppra on [**2-20**]. Loaded with dilantin on [**2-21**] but
experienced a drug rash. She then had recurrence of witnessed sz
over the weekend on 03/25th that lasted 3 min with lip smacking,
arm movement and blinking. No other event since then. Spoke to
neurology who recommended increasing dose of Lacosamide from
200-> 300 mg on [**3-4**]. We still uncertain what is causing the sz
activity, multiple head images did not show anatomical causes.
Possible encephalalitis r/t medications. However, pt has
remained stable. Neuro is okay with us restarting pt on
neurontin for neuropathic pain, so this was done on [**3-5**] and
dose was increased to [**Hospital1 **].
- Continue PO Keppra 1500mg [**Hospital1 **] and Lacosamide 300mg [**Hospital1 **]
- Started on neurontin 300mg [**Hospital1 **] on [**3-5**] for neuropathic pain
which can increase to [**Hospital1 **] today if tolerating well and may
increase to TID
- Neurology will be calling your facility to schedule a
follow-up appointment within 2 weeks.
# s/p Tracheostomy: Patient was complaining of sore throat and
discomfort. No change in oxygen saturations. Dr. [**Last Name (STitle) **],
general surgeon, did not feel she was amenable to a trach
revision to a smaller trach. Recommended ENT evaluation for
increased secretions, failed speech and swallow, apparent
difficulty with the trach. ENT saw pt on [**3-4**] and scoped pt at
bedside and findings are consistent with weakened muscles and
aspiration, so no intervention at this time, except for cont
with trach care, humidified oxygen and speech therapy. She also
had video swallow on [**3-4**] that showed aspiration. So for now pt
should cont to be NPO.
- Continue supplemental oxygen via trach mask
- Trach care
- Cont to work with speech therapy
- Pt able to clear secreations and to use passmier valve
.
# s/p cervical fusion/Anterolisthesis: she was taken to the
operating room on [**2125-1-26**] and underwent a C5/6/7 Corpectomies
and C4-T1 Fusion. This was without complication, but as noted
above she had multiple complications. Anterolisthesis (anterior
dislocation of her spinous process) was found to have worsened
on the most recent MRI c-spine. SOMI cervical brace was placed
per Neurosurgery and should be on at all times. The brace was
just adjusted yesterday and is fitting more comfortable by
patient. She has small pressure ulcer on her chin that is
healing and on the back of her head that is also healing.
Neurosurgery will be following the patient and she has
appointment on [**4-3**]. She will have a repeat CT scan at
that time.
- Per neurosurgery: Patient must be lying flat if she is in an
aspen collar, otherwise she must be put in a full neck brace at
all times (would prefer not changing from SOMI brace to Collar
since concern for dislocation).
# Pain: pt with pain at her surgical site and due to position
related to brace. She has also chronic neuropathic pain and has
been on neurontin and multiple meds prior to her admission. She
asked to have neurotin restarted. Neuro was okay in adding this
medication.
- Cont on tylenol 650mg Q 6 hours as needed
- Restarted on oxycodone 5mg Q 6 hours as needed
- Restarted on neurotin 300mg once daily, will increase to [**Hospital1 **]
tomorrow if tolerates and to TID on the following day
.
# CP/SOB: Patient had previously reported having new, sudden
onset chest pain that was sharp and substernal [**2-25**]. Normal EKG,
CXR and Trop. CKMB was initially 18.8 and has been trended down
to 11. Given downward trend and current clinical status there is
no concern for ACS. Demand ischemia was considered but cardiac
echo performed on [**3-1**] showed that the left ventricular regional
and global systolic functions are normal w/ only mild aortic
regurgitation. CKMB may be originating from brain tissue.
-Continue lipitor, low dose aspirin, and metoprolol
.
# Brain imaging findings: There were initial concerns about
vasculitis since MRI of brain on [**2-21**] that showed focal and
confluent T2/FLAIR hyperintensities in bilateral periventricular
and subcortical white matter of bilateral cerebral hemispheres
and pons. The differential for this finding includes
demyelination, changes of chronic small vessel ischemic disease
or changes of vasculitis. So, rheumatology was consulted for
evaluation of vasculitis, especially given her hx of + [**Doctor First Name **]. She
also had a MRA brain on [**2-25**] was not c/w vasculitis. Rheum panel
was sent w/ only abnormality being anticardiolipin antibody IgM
elevated to 16.2, which may occur with vasculitis, SLE or ACA
syndrome. However rheumo does not think that pt's findings are
consistent with vasculitis.
.
# Drug rash: Due to dilantin given timing of rash with dilantin
administration. Allergy list updated
- Hold dilantin
.
# Blurry vision: Pt c/o "foggy vision at times" which has been
happening since surgery. She with normal visual acuity. She was
also evaluted by neuro and had multiple head images which did
not show an anatomical abnormality. This does not appear to be
an acute issue. The other potentially cause could be optic
neuritis due to MS. MS has not been r/o yet as the MRI findings
are some what suggestive.
- she will be followed by neuro
.
# SKIN: pt with a small healing ulcer on submandibular are and
scab on posterior occipital area. She also had a very small
sacral decubitus ulcer that has healed. No signs of infection.
Cont with positioning and skin care.
.
.
# FEN: replete electrolytes, NPO on TPN, Q4H oral care
# Prophylaxis: Subcutaneous heparin ([**Month (only) **] BE D/C WITH INCREASE
MOBILITY), ppi, bowel regimen
# Access: peripherals
# code: Full code (from chart)
# Communication: Patient and her husband
# Disposition: [**Hospital1 **] at [**Hospital3 **]
TRANSITION OF CARE:
===================
# She will need to follow-up with Neurology who will be calling
to schedule appointment with 2 weeks. If you do not hear from
then by [**3-15**], please call the neurology office to schedule
f/u appointment at [**Telephone/Fax (1) 8302**]
# Continue to monitor for seizures, pt may continue to have occ
seizures (usually associated with blank starring with blinking
of the eyes, and arm movement. This has only lasted a few
minutes at the time. During her last episode on [**3-4**] she had an
episode of hypoxia and had to have supplement 02 via AMBU bag
for a short period of time and this quickly improved with
supportive care. If continues to have episodes of seizures
please call the neurologist on call and may ask for advice
([**Telephone/Fax (1) 2756**]).
# She will be following up with neurosurgery on [**4-3**] with
repeat CT-cervical spine. If there is any concern with her brace
please call NEOPS [**Telephone/Fax (1) 32347**] (company that made the brace). If
any other concerns may also call [**Telephone/Fax (1) 2756**] and ask to speak
to neurosurgeon on call.
Please feel free to contact us with any additional questions in
regards her care: [**First Name8 (NamePattern2) 32348**] [**Last Name (NamePattern1) 17157**]- PGY 3 or Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 2756**]
Medications on Admission:
Ambien 10mg at night
Percocet q6h prn
Zetia 10mg daily
Alprazolam 1mg TID prn anxiety
Vistaril 50mg Q6h prn
Gabapentin 300mg TID
Paxil 40mg daily
Estrogen 1.25mg daily
Hydroxychloroquine 40mg daily
Amitryptyline 100mg at night
Albuterol prn
Advair prn
Discharge Medications:
1. paroxetine HCl 10 mg/5 mL Suspension [**Telephone/Fax (1) **]: Forty (40) mg PO
DAILY (Daily).
2. senna 8.8 mg/5 mL Syrup [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
3. glucagon (human recombinant) 1 mg Recon Soln [**Telephone/Fax (1) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
4. docusate sodium 50 mg/5 mL Liquid [**Telephone/Fax (1) **]: One (1) PO BID (2
times a day).
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Telephone/Fax (1) **]: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. ipratropium bromide 0.02 % Solution [**Telephone/Fax (1) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
7. insulin regular human 100 unit/mL Solution [**Telephone/Fax (1) **]: One (1)
injection Injection ASDIR (AS DIRECTED).
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Telephone/Fax (1) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
9. chlorhexidine gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
10. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical
QID (4 times a day) as needed for itching.
11. atorvastatin 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
12. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO BID (2
times a day): Please hold for SBP<100 and HR<60.
13. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
14. oxycodone 5 mg/5 mL Solution [**Hospital1 **]: Five (5) Mg PO Q6H (every
6 hours) as needed for pain : Please hold for sedation and
RR<12.
15. levetiracetam 100 mg/mL Solution [**Hospital1 **]: 1500 (1500) mg PO BID
(2 times a day).
16. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
17. lacosamide 10 mg/mL Solution [**Last Name (STitle) **]: Three Hundred (300) Mg PO
BID (2 times a day).
18. oxycodone 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every 6
hours) as needed for pain: Please hold for sedation and RR<12.
19. acetaminophen 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
20. gabapentin 300 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO twice a
day: Just started on [**3-5**] as [**Last Name (LF) **], [**First Name3 (LF) **] increase dose today to
[**Hospital1 **]. [**Month (only) 116**] increse dose to TID as tolerated .
21. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month (only) **]: Four (4)
Injection Q6H (every 6 hours) as needed for nausea.
22. diphenhydramine HCl 50 mg/mL Solution [**Month (only) **]: Twenty Five (25)
mL Injection Q6H (every 6 hours) as needed for itching: Please
hold for sedation .
23. heparin (porcine) 5,000 unit/mL Solution [**Month (only) **]: One (1)
Injection Injection TID (3 times a day): ***Okay to d/c if
patient has increse mobility.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Cape & Islands
Discharge Diagnosis:
cervical myelopathy
dysphagia
failure to thrive
fever of unknonw origin
leukocytosis
VAP PNA
supraglottic edema
C6-C7 listhesis
hypomobile Right vocal Cord
delirium
hypoxia to 60's
coagulopathy
malnutrition
cachexia
Vitamin K deficiency
Oculogyrate crisis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mrs. [**Known lastname **],
It was a pleasure taking care of you.
You were admitted to [**Hospital1 18**] for cervical fusion on [**2125-1-22**].
Unfortunately, you had a very complicated post-operative course
which included infection, respiratory failure requiring a
tracheostomy. You also had seizures of uncertain etiology that
have now been treated with anti-seizure medication. You also had
a peg-tube placed for You have been afebrile for at least 2
weeks now, you are also tolerating the tracheal tube well and
your sezures have become less frequent.
You have shown great improvement and you will need to follow-up
with the neurosurgeon and with the neurologist as noted below.
Once you leave the rehab facility you will also need to have
follow-up with your primary care doctor.
This are the instructions given by neurosurgery:
?????? Do not smoke.
?????? No tub baths or pool swimming for two weeks from your date of
surgery.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? you are required to wear the SOMI cervical brace at all times
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort. This medication is as
needed for pain, you do not need to take it if you have no pain.
?????? Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc until cleared by Dr.
[**Last Name (STitle) 739**]
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
You had one episode of chest pain and your cardiac enzymes where
mildly elevated, so you were started on medications for your
heart which include metoprolol, Atorvastatin and on aspirin.
You were just restarted on medication for your neuropathic pain:
neurotin 300mg once daily on [**3-5**], this will be able to be
increased to twice daily today and to three times daily as you
tolerate.
You were given medication for your seizures. You had a very bad
allergic reaction to DILANTIN and you should not received this
medication again. You are currently on LeVETiracetam Oral
Solution 1500 mg twice daily and on Lacosamide 300 mg twice
daily.
We have not been giving you sleeping aid (Trazadone) since you
had episodes of delerium (confusion) while taking this
medication. Once you are stable in your new location, you should
discuss when would be okay to start on ambien.
Followup Instructions:
Follow Up Instructions/Appointments
You will have an appointment with Dr. [**Last Name (STitle) **], neurosurgeon, in 4
weeks, on [**Month (only) 547**]
Please call ([**Telephone/Fax (1) 8619**]
You will need cat scan of c-spine prior to your appointment. So
you should arrive at
The neurologist will call your facility with a follow-up
appointment at [**Telephone/Fax (1) 8302**]
|
[
"348.30",
"E939.3",
"507.0",
"263.0",
"721.1",
"707.03",
"738.4",
"493.90",
"305.1",
"478.6",
"272.4",
"707.09",
"V49.87",
"E936.1",
"286.7",
"378.87",
"345.90",
"733.13",
"356.9",
"795.79",
"518.81",
"997.31",
"V85.1",
"693.0",
"E879.8",
"530.81",
"737.12",
"707.22",
"564.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.42",
"81.02",
"96.6",
"03.31",
"02.94",
"31.1",
"84.51",
"77.79",
"84.52",
"81.63",
"93.41",
"96.72",
"33.22",
"43.11",
"80.51",
"81.33",
"03.53"
] |
icd9pcs
|
[
[
[]
]
] |
42510, 42568
|
24555, 31821
|
363, 612
|
42868, 42868
|
5917, 17831
|
45527, 45912
|
2242, 2246
|
39450, 42487
|
42589, 42847
|
39173, 39427
|
43019, 45504
|
20196, 23176
|
3559, 4995
|
2287, 2894
|
23215, 24532
|
299, 325
|
31836, 39147
|
5025, 5898
|
640, 1939
|
17847, 20180
|
42883, 42995
|
1961, 2107
|
2123, 2226
|
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