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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
76,803
| 151,844
|
38102
|
Discharge summary
|
report
|
Admission Date: [**2165-1-8**] Discharge Date: [**2165-1-14**]
Date of Birth: [**2093-7-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
hypotension following right total hip arthroplasty
Major Surgical or Invasive Procedure:
right total hip arthroplasty
History of Present Illness:
Ms. [**Known lastname 15568**] is a 71-year-old female
previously seen by Dr. [**Last Name (STitle) 5322**] who presents to Dr. [**Last Name (STitle) **] for a
right total hip replacement. She reports that she had a motor
vehicle accident on [**2163-8-4**] when she was a pedestrian hit by a
car at a low speed and suffered from an intertrochanteric
fracture, which was fixed with a DHS by Dr. [**First Name (STitle) 85032**] [**Doctor Last Name 85033**].
The patient said that she initially had some relief from the
operation; however, has had progressively increasing right hip
pain ever since. The patient, prior to her injury, was an
independent ambulator walking over three miles a day and now she
is wheelchair-bound in the community and walks with a cane at
home. She does not ascend stairs. The patient states that she
has [**11-12**] pain with any type of ambulation. The patient has
tried numerous narcotic medications, which have not provided her
with any relief.
Past Medical History:
Hypertension
High cholesterol
COPD
Depression
Osteoporosis
Colon cancer
Sensorineural hearing loss
Macular degeneration
Right intertrochanteric hip fracture [**3-7**] MVA s/p hardware
implantation c/b degenerative joint disease - now s/p old
hardware removal with TKR
Social History:
- Tobacco: 1 ppd for "a long time"
- Alcohol: denies
- Illicits: denies
Family History:
Noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 85, 124/88, 12, 96% 2L
Pulsus: 4-6 mmHg
General: AAOx3, in mild discomfort
HEENT: PERRLA, EOMI, dry mucus membranes, no JVD
CV: S1S2, RRR, no m/r/g
Chest: decreased breath sounds throughout, although decent air
movement, slight end expiratory wheeze diffusely, no rales or
rhonchi
Abd: soft, ND, NT, decreased bowel sounds
Right LE: warm, good capillary refill, surgical site c/d/i,
painful to palpation at this time, dopplerable PT pulse, thready
but dopplerable DP
Left LE: warm, good capillary refill, 1+ palpable PT/DP pulses
Pertinent Results:
Admission labs:
WBC-14.0* RBC-3.85*# HGB-12.4# HCT-36.0# MCV-93 MCH-32.2*
MCHC-34.4 RDW-13.2
ABG (in PACU) 7.25/64/71
K 2.9
.
Micro:
MRSA screen pending
.
Images:
TTE ([**2165-1-9**])- The left ventricular cavity is unusually small.
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. There is a small pericardial effusion.
The effusion appears circumferential. There are no
echocardiographic signs of tamponade. Compared with the prior
study (images reviewed) of [**2163-8-5**], the pericardial effusion is
smaller. The other comparable findings are similar.
Hip film ([**2165-1-8**])- Skin staples are present laterally.
Subcutaneous edema and emphysema, post-surgical. Status post
right total hip arthroplasty. The hardware appears intact on
this single view. No definite fracture or dislocation. Unchanged
degenerative changes of the pubic symphysis. Unchanged left hip
joint. IMPRESSION: Expected postoperative appearance status post
right total hip arthroplasty.
Brief Hospital Course:
71 F with h/o HTN, HL, COPD, pericardial effusion, OA, right
intertrochanteric hip fracture [**3-7**] MVA s/p hardware implantation
c/b degenerative joint disease, presents for elective right
total hip arthroplasty c/b post-op hypotension and admitted to
the ICU.
ICU COURSE:
#. Hypotension - transiently hypotensive post-op while in the
PACU, likely [**3-7**] hypovolemia as BP improved with 4L of IV
fluids. Blood loss during surgical procedure reported to be
200cc, received 2 units of pRBC in the PACU. Also happened in
setting of receiving 1 mg of dilaudid IV, question whether this
may be medications related. Patient has also been using her
right hand quite frequently, which is where her arterial line is
placed, possibly transient hypotension in PACU was due to
position or kinking of A-line. Given past hsitory of
pericardial effusion, concern was high for cardiac tamponade.
TTE showed small pericardial effusion (consistent with prior)
without tamponade physiology, pulsus of [**5-9**] mmHg. BP improved
to 120-130??????s prior to transfer to ICU and remained stable
overnight. Patient did not require further fluid boluses or
pressors. Home antihypertensives were held.
#. Hypokalemia - found to have K of 2.9 which was repleted
overnight.
#. s/p THR- Patient's pain was controlled overnight on admission
with dilaudid pump. On HD1 when she was taking orals, she was
restarted on home methadone. Dilaudid pump was titrated up as
pain was suboptimally controlled. Drain was pulled by
orthopedics on HD1.
#. Hypertension- held lisinopril in setting of hypotension on
admission to ICU.
#. High cholesterol- continued home statin
#. COPD- stable on arrival. Oxygen was weaned.
#. Depression- continued home mirtazapine and sertraline
#. Osteoporosis- continued home calcium, vitamin D
The patient was transferred to the floor on POD#1. The surgical
dressing was changed on POD#2 and the surgical incision was
found to be clean and intact without erythema or abnormal
drainage. The patient was seen daily by physical therapy. Labs
were checked throughout the hospital course and repleted
accordingly. At the time of discharge the patient was tolerating
a regular diet and feeling well. The patient was afebrile with
stable vital signs. The patient's hematocrit was acceptable and
pain was adequately controlled on an oral regimen. The operative
extremity was neurovascularly intact and the wound was benign.
The patient's weight-bearing status is partial weight bearing
(50%) on the operative extremity with STRICT posterior
precautions.
Ms. [**Known lastname 15568**] is discharged to rehab in stable condition.
Medications on Admission:
Sertraline 100 mg PO daily
Famotidine 20 mg PO daily
Atorvastatin (LIPITOR) 40 mg PO daily
Gabapentin 300 mg PO daily
Methadone 5 mg PO q8hours prn pain
Mirtazapine 7.5 mg PO qHS
Tramadol 50 mg PO q8 hours
Senna prn
Lisinopril 5 mg PO daily
Miralax prn
Ipratropium nebs twice daily prn
Benzonatate (TESSALON PERLE) 100 mg PO q6H prn cough
Bisacodyl 5 mg PO prn
Tylenol prn
Colace prn
Calcium carbonate 1000mg PO daily
Cholecalciferol, Vitamin D3, 1000 unit daily
Fosamax 70mg weekly
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40mg
Subcutaneous DAILY (Daily) for 3 weeks: Take for 3 weeks
post-operatively to prevent DVTs.
Disp:*21 40mg* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO twice a day for
3 weeks: After you complete your 3 weeks of lovenox, please take
3 weeks of aspirin 325mg twice a day to prevent DVTs.
Disp:*42 Tablet(s)* Refills:*0*
5. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
6. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for shortness of breath, wheezing.
9. rosuvastatin 5 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
11. sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
13. methadone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
14. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: Do not drive or operate heavy
machiner while on narcotics. .
Disp:*80 Tablet(s)* Refills:*0*
15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO DAILY (Daily): hold for loose stools.
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation.
Discharge Disposition:
Extended Care
Facility:
Life Care Center at [**Location (un) 2199**]
Discharge Diagnosis:
R hip OA s/p R IT fx
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:
1. Please return to the emergency department or notify your
physician if you experience any of the following: severe pain
not relieved by medication, increased swelling, decreased
sensation, difficulty with movement, fevers greater than 101.5,
shaking chills, increasing redness or drainage from the incision
site, chest pain, shortness of breath or any other concerns.
2. Please follow up with your primary physician regarding this
admission and any new medications and refills.
3. Resume your home medications unless otherwise instructed.
4. You have been given medications for pain control. Please do
not drive, operate heavy machinery, or drink alcohol while
taking these medications. As your pain decreases, take fewer
tablets and increase the time between doses. This medication can
cause constipation, so you should drink plenty of water daily
and take a stool softener (such as colace) as needed to prevent
this side effect. Call your surgeons office 3 days before you
are out of medication so that it can be refilled. These
medications cannot be called into your pharmacy and must be
picked up in the clinic or mailed to your house. Please allow
an extra 2 days if you would like your medication mailed to your
home.
5. You may not drive a car until cleared to do so by your
surgeon.
6. Please keep your wounds clean. You may shower starting five
(5) days after surgery, but no tub baths or swimming for at
least four (4) weeks. No dressing is needed if wound continues
to be non-draining. Any stitches or staples that need to be
removed will be taken out by the visiting nurse (VNA) or rehab
facility two
weeks after your surgery.
7. Please call your surgeon's office to schedule or confirm your
follow-up appointment in four (4) weeks.
8. Please DO NOT take any non-steroidal anti-inflammatory
medications (NSAIDs such as celebrex, ibuprofen, advil, aleve,
motrin, etc).
9. ANTICOAGULATION: Please continue your lovenox for three (3)
weeks to help prevent deep vein thrombosis (blood clots). After
completing the lovenox, please take Aspirin 325mg TWICE daily
for three weeks. [**Male First Name (un) **] STOCKINGS x 6 WEEKS.
10. WOUND CARE: Please keep your incision clean and dry. It is
okay to shower five days after surgery but no tub baths,
swimming, or submerging your incision until after your four (4)
week checkup. Please place a dry sterile dressing on the wound
each day if there is drainage, otherwise leave it open to air.
Check wound regularly for signs of infection such as redness or
thick yellow drainage. Staples will be removed by the visiting
nurse or rehab facility in two (2) weeks.
11. VNA (once at home): Home PT/OT, dressing changes as
instructed, wound checks, and staple removal at two weeks after
surgery.
12. ACTIVITY: Partial weight bearing 50% RLE, strict posterior
precautions
Physical Therapy:
Partial weight bearing 50% RLE, strict posterior precautions
Treatments Frequency:
WOUND CARE: Please keep your incision clean and dry. It is okay
to shower five days after surgery but no tub baths, swimming, or
submerging your incision until after your four (4) week checkup.
Please place a dry sterile dressing on the wound each day if
there is drainage, otherwise leave it open to air. Check wound
regularly for signs of infection such as redness or thick yellow
drainage. Staples will be removed by the visiting nurse or rehab
facility in two (2) weeks.
VNA (once at home): Home PT/OT, dressing changes as instructed,
wound checks, and staple removal at two weeks after surgery.
Followup Instructions:
[**2165-2-8**] 11:00a [**Last Name (LF) 3260**],[**First Name3 (LF) 177**] C.
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
[**Hospital **] CLINIC (SB)
Please follow-up with your PCP regarding your hospitalization.
Completed by:[**2165-1-14**]
|
[
"V10.05",
"276.52",
"401.9",
"799.02",
"458.29",
"423.9",
"733.00",
"716.15",
"311",
"564.00",
"276.8",
"305.1",
"496",
"272.0",
"280.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.51",
"78.65"
] |
icd9pcs
|
[
[
[]
]
] |
8795, 8866
|
3745, 6390
|
356, 386
|
8931, 8931
|
2411, 2411
|
12679, 12951
|
1795, 1812
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|
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|
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|
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|
266, 318
|
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|
414, 1397
|
2427, 3722
|
8946, 9090
|
1419, 1689
|
1705, 1779
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,724
| 170,729
|
49229
|
Discharge summary
|
report
|
Admission Date: [**2200-7-1**] Discharge Date: [**2200-7-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
SOB, bilateral chest pain
Major Surgical or Invasive Procedure:
1.) Pericardiocentesis
2.) Flexible bronchoscopy, right video-assisted thorascopic
surgery pericardial window and pleural biopsy.
History of Present Illness:
Patient is an 83 year old male with multiple medical problems,
including [**Name2 (NI) **] cirrhosis,s/p encephalopathy, DM2, HTN, portal
vein thrombosis, s/p stent LAD [**2196**], and multiple hospital
admissions for chest and abdominal pain. Patient states that
over the last 3 weeks he has had increasing bilateral sharp
chest pain, over the nipple areas. Patient denies palpitations,
jaw pain, arm pain, nausea,but reports some diaphoresis.
Patient also c/o SOB worsening over the last 3 weeks. Patient
describes PND and states he is not on home O2. Patient also c/o
midline sharp abdominal pain. Patient has a history of multiple
paracentesis. Patient also c/o diffuse back pain and R.sided
neck pain. He states that he has had all this pain before and
it is due to his "water". Patient cannot describe any measures
that make his pain better or worse. He denies headache,
dizziness, numbness, nausea, vomiting, diarrhea, or difficulty
with urination.
Past Medical History:
1. Non-alcoholic steatohepatitis with associated cirrhosis. Two
discrete liver lesions in segment 2 and segment 8, initial core
biopsy concerning for HCC, both s/p radiofrequency ablation in
[**2196**]. Recently found to have 3 new liver lesions concerning for
HCC. Known grade II varices (7/[**2198**]).
2. Non-obstructive cholelithiasis
3. BPH
4. DM2 ?????? diet controlled
5. HTN
6. Receovered hepatitis A infection per serologies
7. Benign polyps in the colon/GERD
8. Recent admit for incidental portal vein thrombosis. No
anticoag due to bleeding risk.
9. CAD s/p stenting of the LAD ([**2196**])
medications:
levothyroxine 88mcg po dialy
MVI
zolpidem 10mg qhs
lactulose 30mg tid
trazadone 50mg po hs
paroxetine 10mg 2 po QD
asa 325mg po qd
spironolactone 50mg po qday
prilosec 40mg po qday
nadolol 20mg po qday
welchol 625mg po daily
imdur 30mg po qday
doxazosin 2mg po qday
plavix 75mg po qday
Social History:
Retired Russian army general. 3ppd smoker, but quit 30 years
ago. [**12-24**] glasses of liquor/day, quit 30 years ago. Lives with
his wife of 60 years.
Family History:
Mother with gastric cancer, CAD. Son with brain tumor.
Physical Exam:
Gen: NAD, lying in bed, cooperative
Vitals: T.97 BP R.arm 110/58 L.arm 100/50 P64, RR 24 Sat
97% 2L, pulsus <10
Heent:PERRLA, EOMI, no oropharyngeal lesions/exudates
neck:no LAD, no JVD
Chest:B/L air entry decreased breath sounds at bases, no w/r
heart:S1S2 RRR, 2/6 systolic murmur loudest in aortic area, no
R/G
abd: ascites, +bs, diffusely tender to deep palp, no pulsatile
masses, no bruits
ext:no C/C/E 2+ pulses B/L
neuro:AAOx3, CN2-12 intact, motor [**4-26**] UE LE B/L, no gross
sensory deficits.
Pertinent Results:
LABORATORY DATA:
[**2200-7-2**]
AFP: <1.0
.
[**2200-7-2**] (Admission)
Na: 137; K 4.8; Cl 103; HCO3 27; BUN 16; Creat 1.0; Gluc 118
AST 24; ALT 24; AP 134; TBili 1.6; LDH 151
WBC 9.4; Hbg 11.9; HCT 36.5; Plt 194
PT 14.9; PTT 41.2; INR 1.3
.
PERICARDIAL FLUID ([**7-2**])
TotProt: 4.9
Glucose: 89
LD(LDH): 320
Amylase: 28
Albumin: 2.8
WBC: 1420
RBC: [**Numeric Identifier 103208**]
Polys: Pnd
Lymphs: Pnd
Monos: Pnd
.
PERICARDIAL FLUID GRAM STAIN ([**7-2**])
1+ PMNs
Fluid cx prelim: no growth
Anaerobic cx prelim: no growth
.
PERICARDIAL FLUID CYTOLOGY ([**7-2**]) : no malignant cells;
mesothelial cells and many PMNs
.
Pericardial drain swab ([**7-2**])
Final cx: no growth
acid fast smears - no AFB (cx pending)
Fungal cx prelim: no growth
.
PERICARDIAL FLUID GRAM STAIN ([**7-3**])
2+ PMNs, 1+ gram negative rods
Fluid cx: pending
Anaerobic cx: pending
.
PERICARDIAL TISSUE ([**7-3**])
1+ PMNs, no organisms identified
Culture pending
Prelim fungal cx: negative
.
Blood culture ([**7-4**]) - pending
.
STUDIES:
.
CHEST, TWO VIEWS ([**2200-7-2**]): bilateral small pleural effusions,
enlarged cardiac silhouette
.
ECHO ([**7-2**]):
LV systolic function is normal (LVEF>55%). Small to moderate
sized pericardial effusion. [**Last Name (un) **] RA diastolic collapse, no RV
collapse. Accentuated respiratory variation in mitral/tricuspid
valve inflows.
.
ECHO ([**7-3**])
LV size and cavity normal. RV mildly dilated. There is a
trivial/physiologic pericardial effusion. No sign of tamponade
ECHO [**7-10**] trivial pericardial effusion.
.
Flexible Bronchoscopy: No anatomic abnormalities. No blood,
plugging, purulence, or endobronchial tumor encountered. There
was some minimal thin secretions in the right lower lobe basilar
segments.
CT head [**7-10**]: negative
.
CXR [**7-11**]:
The cardiomediastinal silhouette is unchanged including mild
cardiomegaly and tortuous and calcified aorta. The left lung is
clear. The right lung
demonstrate unchanged linear areas of atelectasis especially in
the right
lower lobe. Small right pleural effusion is again noted,
unchanged. No
pneumothorax is present. IMPRESSION: No evidence for acute
changes.
.
EKG's remained unchanged.
Brief Hospital Course:
Mr. [**Known lastname 103207**] is an 83 y/o M with known CAD, HTN, cirrhosis,
portal vein thrombosis, h/o HCC, h/o hepatic encephalopathy
admitted with chest pain and found to have a worsening
pericardial effusion/cardiac tamponade compared to ECHO [**2200-6-18**],
now s/p R heart cath and pericardocentesis [**7-2**], and R. VATS,
pericardial window [**7-3**].
.
# Pericardial effusion/ pre-tamponade: Pt admitted on [**7-2**] with
chest pain and significant worsening of pericardial effusion on
echocardiogram indicating tamponade. The etiology of the
patient's effusion is unclear. [**Name2 (NI) **] has a prior known malignancy
(HCC) with recent new liver lesions on CT of the abdomen;
however, AFP < 1, and pericardial fluid cytology was negative
for malignant cells. Patient underwent pericardiocentesis on
[**7-2**] with drainage of approximately 300cc serosanguinous fluid.
On [**7-3**] he underwent a right VATs procedure with pericardial
window and chest tube placement. Due to a gram stain result on
[**7-3**] which showed gram positive rods in the pericardial fluid,
he was treated with one dose of Ceftriaxone. However it was felt
that this finding was most likely a result of contamination
because no other fluid or culture specimens showed bacteria, pt.
was afebrile without a white count. Antibiotics were held
pending culture results. Flexible bronchoscopy and thoracotomy
showed no evidence of malignancy.
Patient's cultures were all negative. Serial CXR's showed R.
lower pleural effusion and R.lower lobe atelectasis. Pain was
given morphine for pain control. His last echo on [**7-10**] showed a
trivial pericardial effusion. He remained without symptoms of
tamponade for the remainder of this admission.
#SOB-Thought to be due to pain s/p procedures, possible ascites
.
#melena/BRBPR: Patient experienced melena on [**7-9**], BRBPR [**7-10**],
HCT drop on [**7-8**], transfused. Serial HCT's followed. Hepatology
was closely following patient during this time and recommended
IV PPI, octreotide IV. Patient was temporarily transferred to
the unit.
Brief MICU course: Patient transferred to MICU team on [**2200-7-10**]
due to the development of altered mental status after
pericardial window and the development of a slow GI bleed. He
was evaluated by the GI service and Hct was monitored and found
to be consistant with a slow bleed. Patient had non-contrast
head CT which found no acute changes. Cardiac echo found a very
small pericardial effusion without signs of tamponade. Mr
[**Known lastname 103207**] had spontaneous resoution of mental status changes and
per liver team recommendation had a meeting with palliative care
regarding long term treatment options and goals of care. He was
transfered back to the floor on the same day. While back on [**Hospital Ward Name 121**]
2, patient HCT's remained stable, he had occasional guiac +
stools with no gross blood.
# Hypertension: Well controlled during hospitalization with SBP
ranging in 110-120s. Holding all antihypertensives s/p
procedures. Restarted on nadolol for varices.
.
# Coronary artery disease: Chest pain on admission does not
appear to be due to ACS (enzymes negative). On aspirin as per
outpatient. Plavix held for VATS/ pericardial window procedure.
Asa and plavix were dc'd in light of recent bleeding. Chest pain
during admission was related to the chest tube placement and
surgical intervention. It did not have qualities of angina and
work up was negative.
.
# Alcoholic vs [**Hospital Ward Name **] cirrhosis: Has been complicated by
encephalopathy in the past. Pt. managed at home with lactulose.
Patient developed altered mental status-delerium in hospital.
His lactulose was increased during this time. Possibilities
included narcotic pain medication, hepatic encephalopathy,
"hospital delirium", sleeping medication. However, patient's
altered mental status returned to During this admission
antihypertensives(nadolol, spironolactone) were held due to
hypotension. Nadolol and lasix were restarted and pt will be
discharged on them. However, day of admission K was 5.
Spironolactone will be held for now and restarted as an
outpatient with following of his electrolytes.
Additionally, patient has a h/o HCC. Recent imaging suggests
reoccurance of the disease. He has chronic "liver pain". He
will be following up with Dr. [**Last Name (STitle) **] to adjust and monitor his
nadolol, lactulose, lasix, and spironolactone and treatment of
HCC. Patient will also be discharged on cipro 500mg [**Hospital1 **] and
finish on [**2200-7-19**]. He did not have enough ascites for
diagnostic and therapeutic tap this admission.
.
# DM2: Diet controlled. Finger sticks were performed.
# Hypothyroidism: Patient was continued on home dose
levothyroxine.
.
# Insomnia: Ambien per home regimen with trazadone prn (home
regimen). Ambien eventually dc/d due to mental status changes
and trazadone given.
.
# Depression: Home paroxetine.
.
# FEN: Patient was placed on a low sodium/cardiac diet. He was
prophylaxed on PPI and given a bowel regiment. He was on SC
heparin; however this had to be stopped secondary to bleeding.
Medications on Admission:
levothyroxine 88 mcg po daily
MVI
zolpidem 10mg qhs
lactulose 30mg tid
trazadone 50mg po hs
paroxetine 10mg 2 po QD
asa 325mg po qd
spironolactone 50mg po qday
prilosec 40mg po qday
nadolol 20mg po qday
welchol 625mg po daily
imdur 30mg po qday
doxazosin 2mg po qday
plavix 75mg po qday
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
6. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
every four (4) hours as needed.
Disp:*qs * Refills:*0*
8. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 9 doses: you will finish your antibiotic at
the end of the day on [**2200-7-19**].
Disp:*9 Tablet(s)* Refills:*0*
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Family Care Extended VNA
Discharge Diagnosis:
1.) Pericardial effusion, early cardiac tamponade
2.) Alcohol-related cirrhosis
3.) Hypertension
4.) Hypothyroidism
5.) Gastrointestinal bleeding
Discharge Condition:
good, vitals stable, afebrile
Discharge Instructions:
You were in the hospital because of a pericardial effusion, or a
collection of fluid around your heart. This fluid was initally
drained with a needle and small drain put in place. Then you
underwent a surgery that allowed for a more permanent opening in
your pericardiac sac (or sac of tissue that encloses the heart).
Then, you developed bleeding from your gastrointestinal tract.
Please continue to take all medications as prescribed and
continue to keep all health care appointments as scheduled.
If you have worsening shortness of breath or chest pain, fevers,
notice blood in your stool or darkening of the stool, or your
condition worsens in any way, seek immediate medical attention
by calling your doctor's office or going to the emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2200-8-7**] 10:30. Please confirm with Dr. [**Last Name (STitle) **] when
he would like to restart your spironolactone as your potassium
today is 5.0
Dr. [**MD Number(4) 103209**]- [**Name10 (NameIs) 766**] [**7-21**] at 8:45am. [**Telephone/Fax (1) 4606**] to have
BMP/electrolytes checked.
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**]
Date/Time:[**2200-8-15**] 8:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2200-8-28**] 12:15
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2200-8-7**] 10:30
|
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"V12.72",
"V15.82",
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icd9cm
|
[
[
[]
]
] |
[
"99.04",
"34.04",
"34.24",
"37.21",
"33.22",
"37.12",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
12056, 12111
|
5334, 10461
|
286, 418
|
12301, 12333
|
3129, 5311
|
13138, 13974
|
2526, 2582
|
10799, 12033
|
12132, 12280
|
10487, 10776
|
12357, 13115
|
2597, 3110
|
221, 248
|
446, 1410
|
1432, 2338
|
2354, 2510
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,411
| 188,819
|
19546
|
Discharge summary
|
report
|
Admission Date: [**2182-1-22**] Discharge Date: [**2182-2-4**]
Service: CARDIOTHORACIC
CHIEF COMPLAINT: Ms. [**Known lastname 53015**] is an 82-year-old patient of Dr.
[**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3321**] referred for outpatient
cardiac cath after a positive exercise tolerance test with
exertional symptoms.
HISTORY OF PRESENT ILLNESS: An 82-year-old woman, with new
onset exertional chest pain since [**Holiday 1451**], notices
angina after climbing one flight of stairs or rushing around.
Chest pain is easily resolved with rest. Uses no
Nitroglycerin. During dobutamine stress echo, the patient
experienced chest heaviness, and the EKG was uninterpretable
due to left bundle branch block. Echo imaging at rest showed
normal LV systolic function, no AI, and mild MR. [**Name13 (STitle) **]
dobutamine showed inferoseptal and inferoposterior
hypokinesis. The patient had carotid ultrasounds done on
[**12-14**] which showed significant plaque formation in the
common carotid arteries, carotid bulb, and the origin of the
internal carotid arteries bilaterally. Right ICA showed a
60-69% stenosis. The origin of the left ICA showed a 40-50%
stenosis.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Hyperlipidemia.
3. Left bundle branch block.
4. Glaucoma.
5. Hypercholesterolemia.
6. Hernia repairs.
7. Appendectomy.
8. Bilateral cataract surgery.
9. Hysterectomy.
10.Bursitis.
ALLERGIES: The patient states no known drug allergies.
MEDS:
1. Moexipril 22.5 qd.
2. Alphagan 0.15% 1 drop to the OS [**Hospital1 **].
3. Cosopt 0.1% 1 drop OU [**Hospital1 **].
4. Lipitor 10 mg q hs.
5. Tenex 1 mg q hs.
6. Trazodone 50 mg q hs.
7. Aspirin 81 mg q hs.
8. Citracal.
9. Multivitamin with calcium.
10.Motrin prn.
11.Nitroglycerin prn.
LAB DATA PRIOR TO ADMISSION: White count 7.2, hematocrit
38.1, platelets 378, sodium 140, potassium 4.8, chloride 102,
CO2 30, BUN 15, creatinine 0.8, INR 1.1.
HOSPITAL COURSE: The patient was admitted to the cardiac
catheterization laboratory where she underwent cardiac
catheterization. Please see report for full details. In
summary, the patient had a cath which showed 80-90% left
main, mild diffuse disease of the LAD, 90% circumflex, 60%
ostial RCA, and an EF of 55%. Following cardiac
catheterization, cardiac surgery was consulted. The patient
was seen and accepted for coronary artery bypass grafting.
On [**1-23**], the patient was brought to the operating
room. Please see the OR report for full details. In
summary, the patient had a CABG x 4 with a LIMA to the RI, a
saphenous vein graft to the LAD, and a saphenous vein graft
to OM2 and PLB sequentially. The patient's bypass time was
82 minutes. Her crossclamp time was 65 minutes. She
tolerated the operation well and was transferred from the
operating room to the Cardiothoracic Intensive Care Unit.
The patient did well in the immediate postoperative period.
Her anesthesia was reversed. She was weaned from the
ventilator and successfully extubated. She remained
hemodynamically stable throughout the evening of her
operative date, requiring Levophed drip to support her blood
pressure. On postoperative day #1, the patient remained
hemodynamically stable. She was noted to be in a first
degree heart block and continued to need Levophed infusion to
maintain adequate blood pressure. During the course of
postoperative day #1, the Levophed infusion was transitioned
to a Neo-Synephrine infusion to maintain her blood pressure.
Also, EP service was consulted because along with the first
degree heart block, the patient had periods of bradycardia.
On postoperative day #2, the patient was weaned from her
Neo-Synephrine drip and begun on diuretics. Also, her chest
tubes were discontinued. The patient continued to be
followed by the electrophysiology service, as she continued
to have periods of bradycardia. By postoperative day #4, the
patient was in a predominantly sinus rhythm with a heart rate
in the 80s. She did have multiple PACs with one short burst
of atrial fibrillation and was, therefore, trialed on a low
dose beta blocker. Following the beta blocker, she again
became bradycardic and that was discontinued. Therefore, the
patient remained in the Cardiothoracic Intensive Care Unit
until postoperative day #6. At that time, she was
hemodynamically stable, had been adequately diuresed, had
begun on low dose oral beta blockade which was tolerated
well, and she was then transferred to the floor for continued
postoperative care and cardiac rehabilitation.
Once on the floor, the patient had an uneventful course with
the exception that she did have a period of postoperative
atrial fibrillation which responded to increased beta
blockade. Following increased beta blockade, the patient
converted to a sinus rhythm and stayed in a sinus rhythm
throughout the rest of her hospitalization. The patient was,
however, begun on heparin and insulin at that time. With the
assistance of the nursing staff and physical therapy, the
patient's activity level was increased to level [**2-7**], meaning
that she could walk 200-300' on a flat surface. She never
attained a level 5 and was, therefore, screened for
rehabilitation. On postoperative day #12, it was felt that
the patient was stable and ready to be discharged to
rehabilitation.
VITAL SIGNS AT DISCHARGE: Temperature 97.8, heart rate 73,
sinus rhythm, blood pressure 129/57, respiratory rate 20, O2
sat 96% on room air, weight preoperatively 55.3 kg, at
discharge 59.3 kg.
LAB DATA: White count 8.3, hematocrit 29.5, platelets 400,
sodium 140, potassium 4.4, chloride 105, CO2 29, BUN 13,
creatinine 0.6, glucose 104, PT 14.3, PTT 72.4, INR 1.4.
PHYSICAL EXAM: Alert and oriented x 3. Moves all
extremities. Follows commands. Respiratory decreased in the
left base, otherwise clear to auscultation. Cardiac -
regular rate and rhythm, S1, S2, no murmurs. Sternum stable.
Incision with Steri-Strips, open to air, clean and dry.
Abdomen soft, nontender, nondistended, normoactive bowel
sounds. Extremities warm and well-perfused with 1-2+ pedal
edema. Right saphenous vein graft site with Steri-Strips,
open to air, clean and dry.
DISCHARGE MEDICATIONS:
1. Lasix 20 mg [**Hospital1 **] x 7 days, then qd x 7 days.
2. Potassium chloride 20 mEq [**Hospital1 **] x 7 days, then qd x 7 days.
3. Colace 100 mg [**Hospital1 **].
4. Zantac 150 mg qd.
5. Atorvastatin 10 mg qd.
6. Metoprolol 50 mg [**Hospital1 **].
7. Cosopt 0.1% 1 drop OU [**Hospital1 **].
8. Alphagan 0.15% 1 drop OS [**Hospital1 **].
9. Warfarin to maintain a target INR of 2.0, 4 mg on [**2-4**].
The past 3 nights, [**2106-2-1**] and 29, the patient had
received 3 mg on each of those night.
10.Percocet 5/325, 1-2 tabs q 4 h prn.
CONDITION AT DISCHARGE: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery bypass
grafting with left internal mammary artery to the ramus
intermedius, with saphenous vein graft to left anterior
descending, and saphenous vein graft to second obtuse
marginal, and posterolateral branch sequentially.
2. Hypertension.
3. Hypercholesterolemia.
4. Postoperative atrial fibrillation.
5. Glaucoma.
6. Sciatica.
7. Status post hernia repairs.
8. Status post appendectomy.
9. Status post bilateral cataract surgery.
10.Status post hysterectomy.
FOLLOW-UP: With Dr. [**Last Name (STitle) **], her primary care provider, [**Last Name (NamePattern4) **] [**2-7**]
weeks. Follow-up with Dr. [**Last Name (STitle) 3321**] as directed by Dr.
[**Last Name (STitle) **]. Follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Name8 (MD) 415**]
MEDQUIST36
D: [**2182-2-4**] 11:48
T: [**2182-2-4**] 11:51
JOB#: [**Job Number 53016**]
|
[
"272.4",
"414.01",
"413.9",
"401.9",
"427.31",
"E878.2",
"426.0",
"997.1",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"39.61",
"88.53",
"36.13",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
6884, 7969
|
6288, 6841
|
2037, 5415
|
5790, 6265
|
6856, 6863
|
117, 430
|
459, 1281
|
1303, 2019
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,641
| 183,695
|
3498
|
Discharge summary
|
report
|
Admission Date: [**2154-1-30**] Discharge Date: [**2154-2-7**]
Date of Birth: [**2079-10-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname 16063**] is a 74-year-old man with a history of lung
cancer s/p LUL lobectomy and radiation, bladder cancer with
radical cystectomy, history of CHF (no documentation by
echocardiography), and small bowel obstruction, who is
presenting with two weeks of fever and cough. For approximately
two weeks, the patient has been experiencing cough, fevers, and
shortness of breath upon exertion. The patient's cough has only
occasionally been productive of sputum. His son and
daughter-in-law have also been sick lately with a cold-like
illness. The patient has not received an influenza or
pneumococcal vaccine this year. He has recently been
immunosuppressed on prednisone and azathiporine for ulcerative
colitis. He reportedly also has CHF, but does not have
cardiology notes in our system, and has never been hospitalized
for his heart failure and does not take diuretics. The patient
has further not experienced any swelling in his lower legs over
the past two weeks. The patient denies any changes to his GI
symptoms over the past two weeks. His primary nephrologist saw
him today and noted that he was dyspneic with a saturation of
87% on room air and sent him to the Emergency Department for
further evaluation.
In the ED, the patient's initial vital signs were 100.9 118
133/66 36 95%. A chest X-ray showed a new opacity at the right
lung base, so the patient was started on ceftriaxone and
azithromycin. He also received acetaminophen for fever. The
patient also had his systolic blood pressure drop to the high
80s, for which he was given 500cc bolus of NS. On transfer, his
vitals were manual BP 100/70 HR 76 reg temp down to 98.9po after
Tylenol and 02 sat 95% 2.5L NP
On the floor, the patient was dyspneic after getting up to use
the bathroom. The interview was primarily performed via the
patient's son. The patient was capable of answering short
questions without being short of breath. The patient also
complained of being cold.
Past Medical History:
1. ulcerative proctitis with evidence of ulcerative colitis
[**3-/2151**] - pt currently on Azathioprine started [**12/2153**]
2. bladder cancer diagnosed in [**2139**]
3. s/p radical cystectomy & neobladder operation in [**2139**].
4. non-small cell lung cancer s/p neoadjuvant chemo, surgery &
x-ray therapy.
5. s/p Left thoracotomy, LUL lobectomy, left chest wall
resection, ribs one through four. [**2143**] ([**Doctor Last Name 175**])
6. SBO [**2143**] ([**Doctor Last Name **])
7. Severe pneumonia [**1-/2154**] complicated by AFib/RVR and MICU
admission for hypoTN due to RVR, hypoxia
8. AFib: noted during [**1-/2154**], per son possibly could have been
longstanding before that. CHADS2 of 1, per discussion with son,
only giving ASA 325
Social History:
He was born in Leningrad moved to the United States in
[**2137**], a former welder. He is married. He smoked one pack a day
but quit 12 years ago after his bladder diagnosis. He is
married, has one son. [**Name (NI) **] denies alcohol.
Family History:
One sister with osteoporosis and diabetes. No known kidney
problems in the family. His son has AFib necessitating ablations
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS - Temp 97.5F, BP 129/76, HR 94, R 22, O2-sat 93% 4L
GENERAL - No acute distress, dyspneic on minimal exertion but
able to hold conversation
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, oropharynx
clear
NECK - supple, no JVD
LUNGS - Wheezes, especially at bases, with occasional rhonchi,
no crackles, moderate air movement, resp unlabored
HEART - S1-S2, no murmurs auscultated
ABDOMEN - NABS, soft, non-tender, no rebound/guarding
EXTREMITIES - WWP, no lower extremity edema, 2+ peripheral
pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs III-XII grossly intact, muscle
strength 5/5 throughout, sensation grossly intact throughout
Pertinent Results:
Labs on Admission:
[**2154-1-30**] 04:30PM BLOOD WBC-14.8* RBC-3.87* Hgb-9.7* Hct-31.2*
MCV-81* MCH-25.0* MCHC-31.0 RDW-20.1* Plt Ct-635*#
[**2154-1-30**] 04:30PM BLOOD Neuts-88.6* Lymphs-8.7* Monos-2.5 Eos-0
Baso-0.2
[**2154-1-30**] 04:30PM BLOOD Glucose-114* UreaN-21* Creat-1.3* Na-136
K-4.3 Cl-97 HCO3-26 AnGap-17
[**2154-1-30**] 04:30PM BLOOD proBNP-1229*
[**2154-1-30**] 04:30PM BLOOD cTropnT-<0.01
[**2154-1-31**] 07:25AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.9
Iron Studies:
[**2154-1-30**] 04:30PM BLOOD calTIBC-278 Ferritn-80 TRF-214
Lactate:
[**2154-1-30**] 04:39PM BLOOD Lactate-1.7
[**2154-1-30**] 08:41PM BLOOD Lactate-1.1
[**2154-1-31**] 04:00PM BLOOD Lactate-1.3
Micro:
Blood Culture [**1-30**]:
Urine Cutlure [**1-31**]:
Respiratory Culture [**1-31**]:
Imaging:
CXR [**1-30**]:
IMPRESSION:
Bibasilar opacities are new since [**2153-6-6**] exam, possibly
atelectasis,
aspiration, or infection in appropriate clinical setting.
.
[**2-1**] echo IMPRESSION: Normal left ventricular cavity size with
preserved regional and excellent global systolic function. Mild
right ventricular dilitation with preserved free wall motion.
Moderate pulmonary artery systolic hypertension. Dilated aorta.
.
Labs on discharge:
Brief Hospital Course:
74yo Russian speaking M with h/o ?CHF (normal stress test [**2151**],
normal EF), lung cancer s/p LUL lobectomy and radiation, bladder
cancer s/p radical cystectomy, UC on Prednisone/Azathioprine
presented 1 wk ago with productive cough of green sputum,
fevers, and dyspnea on exertion for [**3-15**] wks, found to have PNA.
On arrival pt triggered for AFib/RVR to 140-150's given
Metoprolol IV x3 leading to hypoTN, given IVF's and became
hypoxic. Sent to MICU where RVR controlled with Diltiazem and
converted to NSR. Called out and was continued on treatment for
PNA, AFib and continued to improve.
.
1. Community acquired-pneumonia: Complicated by chronic
immunosuppression on Prednisone and Azathiprine. Presented with
productive cough and fever of 10 day duration, and likely
opacity at right lower lung base. The patient's son reports no
history of aspiration or choking. Treated initially for CAP with
Ceftriaxone and Azithromycin; however given decompensation and
MICU admission, pt was broadened with Vancomycin. Completed 6d
course of Azithromycin, 7d course of Vancomyin, and 14 of
Ceftriaxone transitioned to Cefpodoxime to complete as an
outpatient.
.
2. AFib with RVR: On morning of arrival, pt with RVR to
140-150's with symptoms, and appeared unwell. Given nodal agents
that dropped his blood pressure, so given IVF's to maintain
pressure but then had some element of flash edema with hypoxia,
so sent to MICU where Diltiazem was initiated and converted him
to NSR. Called out, he was continued on Diltiazem, uptitrated,
and eventually converted to long acting. Pt still noted to have
paroxysms of AFib on the floor, symptomatic if very rapid to
>140, but tolerable if lower; lower rates were tolerated, and
overall AFib was controlled. Per discussion with son, and with
[**Name (NI) 16064**] of only 1, pt was only treated with ASA 325. On
discharge, home Atenolol was stopped in favor of Diltiazem, and
of note pt without known h/o low EF or infarct; had normal mibi
scan in [**2151**].
.
3. Hypoxia: Initially with 4-5L O2 requirement that worsened
prompting MICU transfer but by call out, this was eventually
able to be weaned down to RA successfully. Likely due to V/Q
mismatch from PNA and low reserve given s/p LUL lobectomy.
.
4. Ulcerative colitis/proctitis: Was on home mesalamine,
Prednisone, Azathioprine before admission and per discussion
with pt's GI Dr. [**First Name (STitle) 679**], these were all continued; Prednisone was
given 30 mg x3d, 20mg x3d, then 10 mg every other day per Dr.
[**First Name (STitle) 679**] continued until he sees Dr. [**First Name (STitle) 679**] in follow up.
.
5. CHF: CHF listed on patient's problem list, but no evidence
based on TTE or Mibi. The patient is not on home diuretics,
though he evidently has some level of dyspnea on exertion at
baseline. Atenolol was stopped and switched to Diltiazem as
above.
.
TRANSITIONAL ISSUES:
-patient's atenolol was changed to diltiazem
-patient's prednisone was tapered per his outpatinet GI's recs
-patient was started on asa 325 for stroke prevention
Medications on Admission:
1. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
hold for systolic blood pressure <110, hr <60.
2. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
6. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
7. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO QID
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
9. Pentasa 250 mg 4 pills three times daily.
10. mesalamine 1,000 mg Suppository Sig: 1000 (1000) mg Rectal
twice a day.
11. Prednisone 40 mg
12. Azathioprine 100 mg
Discharge Medications:
1. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. gabapentin 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. sodium bicarbonate 650 mg Tablet Sig: One (1) Tablet PO QID
(4 times a day).
7. mesalamine 250 mg Capsule, Extended Release Sig: Four (4)
Capsule, Extended Release PO TID (3 times a day).
8. mesalamine 1,000 mg Suppository Sig: One (1) Rectal twice a
day: Continue taking this if you were taking it before
admission.
9. prednisone 10 mg Tablet Sig: One (1) Tablet PO every other
day for 10 days.
Disp:*5 Tablet(s)* Refills:*0*
10. azathioprine 50 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. diltiazem HCl 180 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
Disp:*30 Capsule, Extended Release(s)* Refills:*2*
12. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours) for 2 days.
Disp:*8 Tablet(s)* Refills:*0*
13. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler
Sig: Two (2) Puff Inhalation QID (4 times a day) for 10 days.
Disp:*1 inhaler* Refills:*0*
14. codeine-guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO
Q6H (every 6 hours) as needed for cough for 5 days.
Disp:*100 ML(s)* Refills:*0*
15. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Severe community acquired pneumonia
Atrial fibrillation with rapid ventricular response
Hypoxia
Hypotension
Ulcerative colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr [**Known lastname 16063**],
It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted
with a severe pneumonia and were treated with antibiotics.
Because you were fairly sick, you developed atrial fibrillation
with a rapid heart rate. This was complicated by low blood
pressure and hypoxia and you were briefly in the ICU. These
improved however on a medicine called Diltiazem, and you
continued to recover out of the ICU. Your oxygen levels slowly
improved to normal and your infection was treated.
The following changes were made to your medication regimen:
1. START 200 mg Cefpodoxime every 12 hours for 2 more days.
2. START Diltiazem 180 mg extended release daily. This is to
control your heart rate with the AFib
3. STOP Atenolol 25 mg daily
4. INCREASE Aspirin to 325 mg daily
5. Your medication list stated you were taking 40 mg Prednisone
daily, but this was not correct; you are being discharged on 10
mg Prednisone everyother day for 10 days.
6. START Ipratropium 2 puffs four times a day for 10 days to
control you cough
7. START Guaifenesin-Codine 5 mL every 6 hours as needed for
cough
8. START Aspirin 325 mg daily
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2154-8-28**] at 9:00 AM
With: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**Telephone/Fax (1) 164**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Last Name (LF) **],[**First Name3 (LF) **] L.
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State 4607**], [**Location (un) **],[**Numeric Identifier 588**]
Phone: [**Telephone/Fax (1) 4606**]
Appointment: Friday [**2154-2-21**] 12:15pm
Name: [**Last Name (LF) 679**], [**Name8 (MD) 1158**] MD
Department: Gastroenterology
Address: [**Doctor First Name **],STE 8A, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 682**]
Appointment: Thursday [**2154-2-28**] 10:30am
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,274
| 191,719
|
49226
|
Discharge summary
|
report
|
Admission Date: [**2160-4-15**] Discharge Date: [**2160-4-21**]
Date of Birth: [**2096-10-21**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
Esophagogastroduodenoscopy
History of Present Illness:
Mr. [**Known lastname 1024**] is a 63-year-old male with past medical history
significant for erosive gastritis ( EGD [**9-/2158**]), aortic
stenosis with 3 x [**Year (4 digits) 1291**] ( last mechanical valve placed in [**2157**])on
home coumadin, depression, HTN, and hyperlipidemia who presented
to [**Hospital1 18**] [**Location (un) 620**] with complaints of melanotic stools x 2 days.
He states he had a total of [**8-5**] total marroon colored stools
over past 48 hours, and his last bowel movement was early this
morning around 8 am. He is a limited historian but he feels that
he "might" have also had some blood in 1 episode of vomitus last
night. At OSH he had a negative NG lavage and positive stool
guiaic. At OSH emergency room he was tachycardic per reports
with HCT of 28 (baseline 30) and INR was elevated to 7. He was
given 1 Unit PRBCs and 2 Units FFP and placed on IV Protonix at
OSH before transfer here. He was also given 1mg Ativan IV for
anxious demeanor and concern for ETOH withdrawal. Also had CT
head at OSH after some mild confusion noted but imaging was
negative.
In ED here initial vitals were: T 98.8F, HR 93, BP 138/74, RR
16, O2 sat 97% RA. Repeat NG lavage here in ED was again
negative and he had positive stool guiaic. Patient was given
10mg Valium, 10mg IV Vitamin K, and IV protonix continued. HCT
s/p 1 Unit PRBCs here was down to 25.1. INR was 2.7, PT 28, PTT
43.9. GI service consulted and plan was to trend HCTs overnight,
continue PRBCs as needed and tentative plan was for morning EGD
in ICU.
On arrival to the ICU he appeared to be in no distress but
seemed slightly anxious with stuttering voice and tremulous. He
was also confused regarding details of his history. Vitals on
arrival to ICU were T: 97.5F, BP: 165/81, P: 91, RR:18, and O2
saturation 98 % on 2L NC.
Past Medical History:
-erosive gastritis ( EGD [**9-/2158**])
-aortic stenosis with 3 x [**Year (4 digits) 1291**] ( last mechanical valve placed in
[**2157**], INR goal is 2.5-3.5)on home coumadin for [**Year (4 digits) 1291**]
-depression
-hypertension
-hyperlipidemia,
-h/o polio
-alcoholism
-benign essential tremor
-abdominal lymphadenopathy
-s/p traumatic splenectomy
-s/p Hernia repair
-AVN of bilateral hips
Social History:
Lives alone in house in [**Location (un) 17927**] but his daughter and son
check in on him daily. He states he smokes occasional cigar and
drinks anywhere from 4 to 12 beers a day, sometimes "more".
Denies any illicit drug use. He is divorced. Retired police
officer.
Family History:
Parents died young. Mother history of depression and essential
tremor. GM with open heart surgery (unclear indication)
Physical Exam:
MICU Admission Exam
Vitals: T: 97.5F, BP: 165/81, P: 91, RR:18, O2: 98 % on 2L NC
General: oriented x 1, answers "[**2129**]" to year, no acute
distress, stuttering speech, pallid complexion
HEENT: Sclera anicteric, MMM, oropharynx clear, small maroon
area of dried blood on side of lip, NGT in place
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales, or
rhonchi
CVS: Regular rate, loud systolic mechanical murmur over LUSB. No
rubs or gallops.
Abdomen: Soft, non-tender, non-distended, normoactive bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
Neuro: tremors over bilateral upper extremities, no asterixis,
CNs [**2-8**] in tact, light toush sensation in tact throughout, gait
assessment deferred
GU: foley in place, draining yellow fluid
Skin: no telangiectasias, pale skin, no jaundice
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2160-4-15**] 11:30PM WBC-7.4 RBC-2.79* HGB-8.3* HCT-25.1* MCV-90#
MCH-29.8 MCHC-33.1 RDW-20.0*
[**2160-4-15**] 11:30PM PLT SMR-NORMAL PLT COUNT-169
[**2160-4-15**] 11:30PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ TARGET-2+
SCHISTOCY-2+ HOW-JOL-1+
[**2160-4-15**] 11:30PM NEUTS-46* BANDS-3 LYMPHS-39 MONOS-11 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2160-4-15**] 11:30PM GLUCOSE-98 UREA N-8 CREAT-0.6 SODIUM-144
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-28 ANION GAP-14
[**2160-4-15**] 11:30PM ALT(SGPT)-22 AST(SGOT)-46* ALK PHOS-62 TOT
BILI-1.4
EGD [**2160-4-16**]
Esophagus:
Excavated Lesions Non-bleeding ulcerations noted at the GE
junction with severe esophagitis. Likely source of bleeding in
the setting of supratherapeutic INR.
Stomach:
Mucosa: Patchy erythema in antrum of stomach consistent with
gastritis.
Duodenum: Normal duodenum.
Impression: Esophageal ulcer
Abnormal mucosa in the stomach
Otherwise normal EGD to second part of the duodenum
[**2160-4-21**] 06:37AM BLOOD WBC-10.6 RBC-3.64* Hgb-10.8* Hct-35.0*
MCV-96 MCH-29.6 MCHC-30.8* RDW-20.0* Plt Ct-212
[**2160-4-21**] 06:37AM BLOOD PT-14.1* PTT-95.6* INR(PT)-1.2*
[**2160-4-21**] 06:37AM BLOOD Glucose-95 UreaN-8 Creat-0.7 Na-141 K-4.1
Cl-103 HCO3-30 AnGap-12
[**2160-4-21**] 06:37AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.3
[**2160-4-16**] 03:48AM BLOOD VitB12-354
[**2160-4-16**] 03:48AM BLOOD TSH-2.0
[**2160-4-18**] 06:55PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2160-4-17**] 10:31AM URINE Color-Amber Appear-Cloudy Sp [**Last Name (un) **]-1.012
[**2160-4-18**] 06:55PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln->12 pH-8.0 Leuks-MOD
[**2160-4-17**] 10:31AM URINE Blood-LG Nitrite-POS Protein-150
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-12* pH-7.0 Leuks-MOD
[**2160-4-18**] 06:55PM URINE RBC-71* WBC-104* Bacteri-FEW Yeast-NONE
Epi-1
[**2160-4-17**] 10:31AM URINE RBC->50 WBC-21-50* Bacteri-FEW Yeast-NONE
Epi-<1
[**2160-4-17**] 10:31 am URINE Source: Catheter.
**FINAL REPORT [**2160-4-19**]**
URINE CULTURE (Final [**2160-4-19**]):
STAPH AUREUS COAG +. >100,000 ORGANISMS/ML..
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- 32 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
[**2160-4-19**] 3:50 pm SEROLOGY/BLOOD
**FINAL REPORT [**2160-4-21**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2160-4-21**]):
NEGATIVE BY EIA.
(Reference Range-Negative).
Time Taken Not Noted Log-In Date/Time: [**2160-4-16**] 11:34 am
SEROLOGY/BLOOD CHEM# [**Serial Number 103203**]D.
**FINAL REPORT [**2160-4-17**]**
RAPID PLASMA REAGIN TEST (Final [**2160-4-17**]):
NONREACTIVE.
Reference Range: Non-Reactive.
Brief Hospital Course:
#. GI Bleed: With report of melena, upper source of bleeding was
suspected and patient treated with PPI, FFP, vitamin K for
supratherapeutic INR and was admitted to the ICU. Patient
transfused 1unit of PRBCs, plus additional 2 units PRBCs at
[**Hospital1 18**]. He was tachycardic on presentation to the ER, thought due
to anxiety and possible alcohol withdrawal, treated with
benzodiazepines. BP remained stable. EGD showed esophageal
erosions and esophagitis. Sucralafate was added at GI
recommendations to be continued while inpatient, but can be
discontinued at the time of discharge. Given mechanical valve,
IV heparin was started following endoscopy. His hematocrit
subsequently remained stable.
#. S/p mechanical [**Hospital1 1291**]: Patient's INR was elevated at
presentation. He denies taking excess doses of warfarin, though
acknowledged he does not know his medications - he has
assistance from family. He has reportedly refused visiting nurse
services in the past and there is some concern that his
medication assistance is not adequate. He was given vitamin K
in the ER given ongoing bleeding and then transitioned to
heparin drip following EGD. His Coumadin was eventually
restarted for an INR goal of 2.5-3.5. The heparin drip can be
stopped when INR is therapeutic.
#. Alcohol withdrawal: Patient drinks a substantial amount of
beer at home and was placed on a CIWA scale for alcohol
withdrawal. He received some valium per the CIWA scale but
otherwise had uncomplicated withdrawal. It was recommended that
he follow-up with psychiatry as an outpatient.
#. Confusion: Patient had head CT at OSH that per report showed
no evidence of bleeding. Neurologic exam here was nonfocal. He
has been followed by cognitive neurology and felt to have "mild
diffuse executive impairments most compatible with
hypoxic or microembolic injury during surgery." His mental
status remained stable.
#. UTI: Patient noted to have an MRSA UTI. He was started on
Bactrim which should be continued until [**2160-4-27**].
Medications on Admission:
ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider) - 20 mg
Tablet - 1 Tablet(s) by mouth once a day
FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth once a day
PROPRANOLOL - (Prescribed by Other Provider) - 10 mg Tablet - 1
Tablet(s) by mouth twice a day
PROTONIX 40mg [**Hospital1 **]
WARFARIN - (Prescribed by Other Provider) - 4 mg Tablet - 1
(One) Tablet(s) by mouth once a day
FERROUS SULFATE [FERROUSUL] - (Prescribed by Other Provider) -
325 mg (65 mg Elemental Iron) Tablet - 1 (One) Tablet(s) by
mouth
once a day
MULTIVITAMIN - (Prescribed by Other Provider) - Capsule - 1
Capsule(s) by mouth daily
Discharge Medications:
1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4
PM.
7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
8. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Heparin (Porcine) in D5W 25,000 unit/500 mL Parenteral
Solution Sig: One (1) unit Intravenous continuous: Please dose
according to provided heparin sliding scale until INR is
therapeutic. .
11. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 6 days.
Disp:*12 Tablet(s)* Refills:*0*
12. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis:
Upper GI bleed due to severe esophagitis and gastritis
Secondary Diagnosis:
Alcohol withdrawal
Discharge Condition:
Mental Status: Confused - always.
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 bleeding from your
gastrointestinal tract. Your Coumadin level (INR) was high on
admission and it was felt this may have contributed to your
bleeding. You underwent an EGD which showed that you have
inflammation in your esophagus and stomach that likely was the
source of your bleeding. Your blood count remained stable since
this study.
Your Coumadin was temporarily stopped on admission and you were
given heparin to thin your blood while your Coumadin level (INR)
increased again. You will need to continue this medication until
your INR is therapeutic.
You were also given a medication called Valium used in alcohol
withdrawal.
Changes to your medications:
Added thiamine
Added Bactrim for a urinary tract infection, you will need to
finish a 7 day course of this medication. Last day is [**2160-4-27**].
CONTINUE Heparin IV drip until INR is therapeutic
INCREASED protonix to twice daily dosing
Followup Instructions:
You have the following appointments scheduled:
Name: [**Last Name (LF) **],[**First Name3 (LF) **] F.
Appointment: [**Last Name (LF) 766**], [**4-28**], 1:45pm
Location: FAMILY PHYSICIANS OF [**Location (un) **]
Address: [**State 21595**], [**Location (un) **],[**Numeric Identifier 9310**]
Phone: [**Telephone/Fax (1) 17753**]
Name: [**Last Name (LF) **], [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Appointment: [**Last Name (LF) 766**], [**5-5**], 1:15pm
Address: [**Location (un) 10877**]
Phone: [**Telephone/Fax (1) 3632**]
A psychiatry follow up has been recommended for you. To see a
psychiatrist at [**Hospital1 18**], please call Dr. [**Last Name (STitle) 30940**] at [**Telephone/Fax (1) 103204**].
If you prefer to see a psychiatrist closer to home, please
contact your PCP for [**Name Initial (PRE) **] recommendation.
If you are interested in seeking treatment for alcohism, please
contact the following:
1. SSTAR, Intensive Outpt Treatment Program
Contact: [**Name (NI) 13788**] [**Name (NI) **] [**Telephone/Fax (1) 103205**]
2. [**Location (un) 22870**] Addiction Treatment Center, Structured OutPt
Addiction Program and Outpt Mental Health and Substance Abuse
Services ([**Telephone/Fax (1) 103206**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"535.51",
"041.11",
"733.42",
"288.60",
"311",
"305.1",
"V45.79",
"V43.3",
"530.19",
"599.0",
"294.8",
"285.1",
"V12.02",
"333.1",
"272.4",
"303.91",
"401.9",
"291.81",
"303.90",
"530.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
11388, 11454
|
7421, 9452
|
324, 352
|
11613, 11613
|
4011, 7398
|
12766, 14163
|
2916, 3037
|
10262, 11365
|
11475, 11475
|
9478, 10239
|
11795, 12474
|
3052, 3992
|
12503, 12743
|
276, 286
|
380, 2197
|
11571, 11592
|
11494, 11550
|
11628, 11771
|
2219, 2614
|
2630, 2900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
954
| 176,383
|
27216
|
Discharge summary
|
report
|
Admission Date: [**2147-4-26**] Discharge Date: [**2147-5-25**]
Date of Birth: [**2076-6-19**] Sex: M
Service: MEDICINE
Allergies:
Aleve
Attending:[**First Name3 (LF) 4219**]
Chief Complaint:
hip fracture
Major Surgical or Invasive Procedure:
R hip ORIF [**2147-4-27**]
Cental line (R IJ, R subclavian dialyisis line)
R PICC line placed [**2147-5-12**]
History of Present Illness:
70yo man with ESRD not yet on HD, DM, PVD who initially
presented s/p fall while getting out of bed in setting of
hypoglycemia and poor appetite. He landed on his R hip and
sustained a displaced femoral neck fracture. He was found by his
son on the floor next to his bed, who called EMS. On arrival to
an OSH he was found to have FS 36 and the above fracture and he
was sent to [**Hospital1 18**] for further management. He was recently
treated at an outside hospital from [**Date range (1) 61322**] for a R great toe
cellulitis and was discharged to home on IV antibiotics
(imipenem and zyvox). He was found to have a necrotic R great
toe on arrival. He was medically cleared for the OR and had a
hemiarthroplasty of the R hip, immediate post op period was
complicated by DKA and the patient was sent to the micu, where
he was kept on an insulin drip for one day. Since then he has
had very volatile FS, running between very elevated and quite
low. [**Last Name (un) **] has been following and with their recs the pt's FS
have been stable off D5 for the last 24 hours.
.
[**Hospital 1094**] hospital course has also been complicated by hospital
acquired LLL pneumonia for which he is being treated with
vanco/zosyn, MS changes believed to be due to
narcotics/psychotropic meds, development of a coccygeal
decubitus pressure ulcer, and elevated INR in setting of
coumadin use s/p femoral fracture (avoiding lovenox given CRI).
He has been followed by renal, ID, [**Last Name (un) **], [**Last Name (un) 1106**] surgery and
orthopedic surgery throughout his stay.
.
ROS: pt reports mild pain in his r hip and r toe. no cp, no sob,
no other complaints. eating well.
Past Medical History:
CRI
DM
PVD with R great toe cellulitis/necrosis
HTN
Social History:
lives with son and daughter-in-law, usually I in ADLs; 100+ py
tobacco hx, quit [**2129**] ([**4-12**] ppd x 40y); no etoh or other drugs
Family History:
NC
Physical Exam:
99.1, 155/52, 63, 13, 98% RA, FS 74-123
Gen: confused man, NAD, oriented x 3 with much effort, answers
questions but very circuitously
HEENT: PERRL, OP not injected, MMM, CM II-XII intact
Neck: no JVD, no LAD
Pulm: decreased BS and inspiratory rhonchi at bilateral bases
anteriorly
Cor: rrr, s1s2, no r/g/m
Abd: soft, NT, ND, +bs, no hsm
Ext: R great toe black and necrotic, R hip wound c/d/i, staples
in place, nontender, nonerythematous, trace edema bilaterally,
small 2x2cm coccygeal decub stage II, bilateral PT and DP not
palpable
GU: yellow urine in foley, scrotum erythematous with fungal skin
infection around scrotal skin and inguinal folds
Pertinent Results:
Labs:
141 110 56 83 AGap=13
4.6 18 4.7
.
Ca: 7.4 Mg: 2.1 P: 4.8
Other Blood Chemistry:
Vanco: 21.2 (last dose on [**5-3**])
.
....7.6 87
15.3>---<191
...**23.5**
.
PT: 26.6 *PTT: 112.3* INR: 2.7
.
ColorYellow AppearClear SpecGr1.012 pH 5.0 UrobilNeg BiliNeg
LeukNeg BldLg NitrNeg Prot100 Glu100 KetNeg
.
Mg: 2.1
Acetone:Negative
Comments: Detects Acetone + Acetoacetate Not Beta-Hydroxy
Butyrate
_
_
_
_
_
_
_
_
_
________________________________________________________________
FEMUR (AP & LAT) RIGHT [**2147-4-26**] 1:17 AM
PELVIS (AP ONLY); HIP UNILAT MIN 2 VIEWS RIGHT
AP PELVIS AND AP AND LATERAL VIEWS OF THE RIGHT FEMUR. There is
a right subcapital/transcervical femoral fracture with superior
displacement of the distal fracture with limb shortening. There
is varus angulation of the fragments. The femoral head
articulates with the acetabulum appropriately. The left femoral
neck appears intact. No fractures are detected involving the
right femur or knee. The soft tissues are unremarkable.
IMPRESSION:
1. Right femoral subcapital/transcervical fracture with
impaction and varus angulation of the distal fragment.
2. Extensive [**Month/Day/Year 1106**] calcifications.
_
_
_
_
_
_
_
_
_
________________________________________________________________
CHEST (PRE-OP AP ONLY) [**2147-4-26**] 1:23 AM
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Lungs clear. Heart size top normal, exaggerated by low lung
volumes and supine positioning. No pleural effusion or evidence
of central adenopathy. No pneumothorax. Tip of a right-sided
central venous catheter projects over the junction of the
brachiocephalic veins.
_
_
_
_
_
_
_
_
_
________________________________________________________________
CT HEAD W/O CONTRAST [**2147-4-30**] 11:35 AM
NON-CONTRAST HEAD CT: No priors for comparison. No
hydrocephalus, shift of normally midline structures, hemorrhage,
or infarct is identified. Calcified internal carotid arteries
are noted. No fracture. Retention cyst vs polyp in left
maxillary sinus; other imaged sinuses are clear. There is
cavernous carotid artery calcification.
_
_
_
_
_
_
_
_
________________________________________________________________
CHEST (PA & LAT)
AP AND LATERAL CHEST RADIOGRAPHS:
Dating back to [**2147-4-26**], there has been interval
development of left lower lobe consolidation obscuring the left
hemidiaphragm consistent with pneumonia. Cardiac, mediastinal,
and hilar contours are stable. Right internal jugular catheter
tip is seen within the mid SVC. No evidence of pneumothorax or
pleural effusions. Osseous and soft tissue structures are
unremarkable.
_
_
_
_
_
_
_
_
_
________________________________________________________________
RADIOLOGY Final Report
AORTA AND BRANCHES
AORTA AND BRANCHES U/S [**2147-5-8**] 1:15 PM
The abdominal aorta is normal in caliber measuring 2.3 cm in
maximal diameter and showing no focal aneurysmal dilatation.
There is some elevated atherosclerotic plaque in the distal
abdominal aorta and at the iliac bifurcation. These plaques do
not compromise flow, however. The possibility of the plaques
being a source for peripheral emboli cannot be assessed by this
technique. Iliac arteries are normal in caliber bilaterally.
_
_
_
_
_
_
_
_
_
________________________________________________________________
Cardiology Report ECHO Study Date of [**2147-5-10**]
MEASUREMENTS:
Left Ventricle - Ejection Fraction: 60% (nl >=55%)
INTERPRETATION:
Findings:
LEFT ATRIUM: No spontaneous echo contrast or thrombus in the
LA/LAA or the RA/RAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No
ASD or PFO by 2D, color Doppler or saline contrast with
maneuvers.
LEFT VENTRICLE: Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV systolic function.
AORTA: No atheroma in aortic arch. Simple atheroma in descending
aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No
masses or
vegetations on aortic valve. No AR.
MITRAL VALVE: Normal mitral valve leaflets. No mass or
vegetation on mitral valve. Physiologic MR (within normal
limits).
TRICUSPID VALVE: Normal tricuspid valve leaflets. No mass or
vegetation on tricuspid valve. Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
No
vegetation/mass on pulmonic valve.
Conclusions:
1. No spontaneous echo contrast or thrombus is seen in the body
of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial
appendage. No atrial septal defect or patent foramen ovale is
seen by 2D,
color Doppler or saline contrast with maneuvers.
2.Overall left ventricular systolic function is probably normal
(LVEF>55%),
however, the probe was not passed beyond the GE junction and
transgastric
views were not obtained.
3.Right ventricular systolic function is normal.
4.There are simple atheroma in the descending thoracic aorta.
5.The aortic valve leaflets (3) are mildly thickened. No masses
or vegetations
are seen on the aortic valve. No aortic regurgitation is seen.
6.The mitral valve leaflets are structurally normal. No mass or
vegetation is
seen on the mitral valve. Physiologic mitral regurgitation is
seen (within
normal limits).
7. No vegetation/mass is seen on the pulmonic valve.
_
_
_
_
_
_
_
_
_
_
________________________________________________________________
VIDEO OROPHARYNGEAL SWALLOW [**2147-5-16**] 2:49 PM
OROPHARYNGEAL VIDEO FLUOROSCOPIC STUDY:
Oropharyngeal video fluoroscopic swallowing evaluation was
performed with speech and swallow therapist, and demonstrates
mild oral and pharyngeal dysphasia, mild swallowing delay. Mild
silent aspiration was noted. No significant improvement in mild
aspiration. For further details please refer to speech and
swallow report.
_
_
_
_
_
_
_
_
_
________________________________________________________________
FOOT AP,LAT & OBL BILAT [**2147-5-17**] 3:26 PM
BILATERAL FEET, SIX VIEWS: No cortical destruction or
irregularity is identified to indicate osteomyelitis. The
mineralization is normal. There are diffuse [**Year/Month/Day 1106**]
calcifications. The joint spaces are preserved. There is a
posterior and plantar calcaneal spur on the left.
IMPRESSION: No radiographic evidence of osteomyelitis.
Brief Hospital Course:
# R great toe and left [**2-10**] toe necrosis: Likely embolic. TEE,
aorta MRA and lower extremity angiogram did not show any source
of emboli. Pt was on anticoagulation for right hip
orif..completed several weeks of heparin gtt..and currently on
aspirin for prophylaxis. Also started on statin for possiblity
of cholesterol emboli. Xray do not show sign of osteomylelitis.
No signs of active infection. Followed by vasuclar surgery
while in house who plan for amputation after discharge at outpt
follow up.
.
# R femoral neck fracture s/p hemiarthroplasty- Repaired on [**4-27**]
- Pt to f/u with Dr. [**Last Name (STitle) 1005**] in ortho clinic 1-2w after
discharge [**Telephone/Fax (1) 1228**].
- WBAT for pt.
- staples removed [**2147-5-11**]
.
# DM/DKA: Initially developed DKA in setting of orthopedic
surgery around [**2147-4-27**]. Treated with insulin drip in the ICU.
Sent to floor with closed gap. Developed DKA again on [**2147-5-1**] in
setting of fever and hospital aquired PNA/ Again treated in teh
ICU with insulin drip. Transferred back to floor on [**5-7**].
GLucose has been stable and lantus dose titrated up as diet
increased. Has been difficult to follow GAP with renal acidosis.
Have been following urine ketones which are negative at the time
of discharge.
.
# CRI: pt with ESRD but not yet on HD. renal following during
hospitalization and pt requiring frequent adjustments to
phosphate binders, lytes, etc. Never required HD despite dye
load from angiogram. Renal care will needs to be continued,
unclear when pt will need hemodialysis.
.
# LLL pneumonia: likely hospital acquired, Treated with 14d
course of zosyn and vanco for broad coverage. afebrile. cultures
negative.
.
# MS change: Confused in the settin gof high INR (up to 13).
Head ct negative. Likely delerium secondray to illness and
medication (narcotics and benzodiazepines). Mental status is now
back to baseline.
.
#Hypotension/Hypoxia/Bradycardia - On[**2147-5-11**], pt was found
unresponsive at 9am. The previous night he had been getting
hydration for renal ppx prior to dye load. Initial assement - RR
5, BP 50/pal, sinus brady at 34. Given 200 mg IV lasix push, 1
amp atropine, and narcan. Pt responed with increased HR and RR.
CT scan done showed no bleed. Likely volume overload, leading to
hypoxia and and bradycardia. Resolved quickly and never
recurred.
# HTN: fairly well controlled at present. continue BB, norvasc,
hydralazine. titrate as tolerated.
.
# diarrhea; c diff negative x 3. continue to follow for
frequency.
.
# coccygeal decubitus ulcer and penile ulcer- continue wound
care as previously. turn q2 hours as tolerated. coccygeal swab +
for pseudomonas which was more likely a colonization rather than
infection. coccygeal ulcer had an overlying fungal infection
that improved with local care.
.
# penile necrosis - secondary to foley trauma from pt pulling on
it in setting of altered mental status. Seen by urology who
recommend leaving foley in place, securing it tightly to leg,
and local wound care with bacitracin and silvadeine.
# access: PICC placed [**2147-5-12**].
.
#Aspiration risk - pt failed speech and swallow eval. recommend
thin liquids and observation.
Medications on Admission:
ASA
lantus 35, HISS
Iron sulfate qday
mag oxide 400mg po qday
sodium bicarb 650po [**Hospital1 **]
norvasc 10 qday
toprol 25 po qday
allopurinol 100 po qday
was on 6wk course of imipenem 250mg [**Hospital1 **], zyvox 600mg [**Hospital1 **]
Discharge Medications:
1. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
2. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
QID (4 times a day): apply to penis.
4. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical QID
(4 times a day): apply to penis.
10. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO QID
(4 times a day).
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) ml
Injection QMOWEFR (Monday -Wednesday-Friday).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
16. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
17. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
18. Insulin Glargine 100 unit/mL Cartridge Sig: Seven (7) units
Subcutaneous once a day.
19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
21. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
23. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
24. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
25. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
26. Calcitriol 0.5 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
hip fracture
renal failure
peripheral [**Location (un) 1106**] disease
diabetic ketoacidosis
pneumonia
Discharge Condition:
Stable
Discharge Instructions:
Please follow up as directed.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2147-6-13**] 11:15
.
Please see the Urology department at the first available
appointment on [**2147-6-7**] 3pm with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10426**]
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2147-6-6**] 3:00
.
Provider: [**Name10 (NameIs) 5865**] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2147-6-6**] 2:40
.
Please make a follow up appointment with your renal (kidney)
doctor.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 4231**]
Completed by:[**2147-5-25**]
|
[
"682.6",
"250.12",
"707.03",
"996.76",
"E935.8",
"444.22",
"440.24",
"486",
"585.4",
"820.09",
"110.3",
"E884.4",
"681.10",
"403.91",
"287.5",
"605",
"292.81",
"584.9",
"607.82",
"286.9",
"250.82",
"787.91",
"997.2",
"V58.67",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"38.93",
"81.52",
"00.14",
"99.07",
"88.42",
"88.48",
"00.75",
"38.95",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
15015, 15117
|
9270, 12464
|
279, 391
|
15264, 15273
|
3023, 4818
|
15351, 16149
|
2332, 2336
|
12755, 14992
|
15138, 15243
|
12490, 12732
|
15297, 15328
|
2352, 3004
|
227, 241
|
419, 2085
|
4827, 9247
|
2107, 2161
|
2177, 2316
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,512
| 108,709
|
6178
|
Discharge summary
|
report
|
Admission Date: [**2127-1-3**] Discharge Date: [**2127-1-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Here for Carotid Stent Placement
Major Surgical or Invasive Procedure:
Carotid Stent Placement
History of Present Illness:
84 F w/ CAD s/p CABG '[**10**], PCI '[**19**] and '[**23**], s/p MI, afib, AS,
Parkinson's disease, hyperlipidemia who is admitted to the CCU
s/p Left carotid stent. Patient was referred from OSH after
presenting to OSH with acute slurred speech and leg weakness in
[**10-21**]. The patient describes only the speech, but says they told
her she also had the weakness. No numbness, tingling, dizziness,
visual changes, other symptoms. She was admitted to OSH. During
her w/u there, an MRI demonstrated a tiny acute infarct in the
Left parietal cortex. Her L ICA had a 70-90% stenosis (R ICA was
10-20%). She was referred for carotid stent to DR. [**First Name (STitle) **]. She
notes she has not had any recurrent symptoms since [**Month (only) **].
She notes she has been weaker lately and fell last week -- the
fall occurred when she sat on blankets piled on a chair and
slipped off. No LOC, no trauma.
.
Patient had cath today with L ICA 80% ulcerated lesion which was
stented.
.
Past Medical History:
PMH:
1. hyperlipidemia
2. HTN
3. CAD s/p MI, s/p CABG [**2110**] LIMA - LAD, SVG-OM, SVGT-D,
SVG-PDA, s/p PCI in [**2113**] to SVG-PDA, PCI [**6-/2119**] (NQWMI) to
SVG-PDA, and PCI [**8-17**] to LMCA
4. ventral hernia
5. TAH/BSO
6. s/p L TKR
7. s/p R ankle sx
8. hard of hearing
9. depression
10. Prakinsons disease x 10 years
11. atrial fibrillation, not anticoagulated
12. falls
13. severe AS
Social History:
SHx: No tobacco, no etoh. Lives at home with her husband, who is
frail. Has niece who is involved and also has a helper twice a
week. Husband is verbally abusive, but not physically abusive.
.
FHx: NC
Family History:
NC
Physical Exam:
PE on discharge
VS T 97.2 HR (50s-60s) RR 18 99% RA weight 120 BP:
110-130/50s-60s
GEN: thin, elderly, NAD, lying flat
HEENT: PERRL, EOMI, o/p clear
NECK: supple
CV: +S1S2, [**5-22**] sys ejection mur - RUSB radiates to R carotid
LUNG: CTA anteriorly and at bases
ABD: soft, nt, bs+, [**Doctor First Name **] scars
EXT: no edema, DP 2+, PT dopplerable, no bruit
.
Pertinent Results:
Labs: hct 31 (from 41 [**12-23**]) baseline is low 30s
Cr 1.0
K 3.7
.
EKG: NSR 69 bpm, nl axis, LVH, q III, .5 mm depressions in V5-V6
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2127-1-7**] 06:25AM 6.2 3.19* 10.4* 30.6* 96 32.6* 34.0 13.3
69*
[**2127-1-6**] 06:30AM 6.7 3.37* 11.2* 32.3* 96 33.3* 34.8 13.2
75*
[**2127-1-5**] 06:36AM 4.8 3.24* 10.7* 32.3* 100* 33.0* 33.1
13.0 71*
[**2127-1-4**] 07:00AM 4.7 3.42* 11.3* 33.8* 99* 33.2* 33.6 13.0
91
[**2127-1-3**] 03:00PM 4.9 3.31* 10.9* 30.8* 93 33.0* 35.6 13.1
92*
.
SMA7 Glu BUN Cr Na K Cl HCO3 AnGap
[**2127-1-7**] 06:25AM 82 22* 0.9 143 4.3 109* 271 11
[**2127-1-6**] 06:30AM 89 23* 1.0 143 4.3 110* 261 11
[**2127-1-5**] 06:36AM 86 13 0.9 143 4.0 107 291 11
[**2127-1-4**] 07:00AM 75 12 1.0 141 3.7 101 321 12
.
HEMATOLOGIC B12 Folate
[**2127-1-3**] 03:00PM 432 7.9
Chol TG HDL CHOL/HD LDLcalc
[**2127-1-4**] 07:00AM 222* 103 77 2.9 124
.
Catheterization report: This is an 84 yo woman with CAD and PVD
who had a recent stroke and was found to have a 70% stenosis of
the left ICA on MRA. She is now referred for carotid angiography
with potential PTA.
COMMENTS:
1. Access was obtained via the right CFA in a retrograde
fashion.
2. Resting hemodynamics showed central aortic hypertension.
3. Thoracic aorta: Type II arch with moderate diffuse
calcifications.
4. The left vertebral artery was normal and filled the basilar
and
cerebellar arteries without lesions.
5. The right vertebral artery was small and not imaged.
6. The right CCA was normal. The ICA had no significant lesions
and
filled the ipsilateral ACA and MCA without cross-filling.
7. The left CCA was normal. The ICA had an eccentric/ulcerated
80%
lesion and filled the ipsilateral ACA and MCA.
8. Successful stenting of the left ICA with a 6-8 mm AccuLink
stent,
post-dilated to 4.5 mm.
9. The right femoral arteriotomy site was closed with a 6
French
Angioseal.
FINAL DIAGNOSIS:
1. Successful stenting of the left ICA.
Brief Hospital Course:
Course:
1.Neuro: The patient was admitted to step-down s/p carotid
revascularization. ASA, Plavix were initiated with plan for Neo
prn. The pt was not on a statin, so FLP was obtained showing low
lipids. Patient underwent successful catheterization of the L
ICA on [**2127-1-3**].
.
Hypotension: Pt was hypotensive throughout post cath day 1 -
generally in 100's with HR in 50's. Periodically dipping to SBP
70's to 80's temporarily. Boluses of 500cc NS x 2 given with
some response. Pt was tx'd to CCU for possible NeoSynephrine.
Following day started on neosynephrine gtt (low dose). weaned
off overnight, however at night SBP~88-90 with MAP near 60,
given 250 cc bolus with good response.
.
Cardiac:
Ischemia: No acute evidence of ischemia. Cont'd. ASA. Not on
bbl, ace, or statin as she could not tolerate asa for GI reasons
and had not had HTN. Held on BB and ACE given low BP at this
hospitalization. Given severity of CAD and hx of LMCA PCI in '[**23**]
the goal was to avoid further Neosynephrine.
.
Pump: Unknown EF, but thought to be low given multiple ischemic
events and CABG. Euvolemic. Daily lasix was held given low spbs.
.
Rhythm: Sinus on tele at this hospitalization, though there is a
known h/o Afib. NO anticoagulation -- thought to be b/c of
falls. Cont'd. ASA. Tele.
.
Valve: H/o AS, severe per note. Preload dependent - this may
have played into her low BP post-procedure. She had a stable
loud SEM over her RUSB.
.
Parkinson's Disease: Cont'd. sinemet/requip and the patient did
quite well. Masked facies were prominent and there were
occasional choreoathetoid movements, however she had very little
tremor and only mild bradykinesia during this hospitalization.
She was able to ambulate with the assistance of a walker.
.
Depression: Celexa/remeron were continued.
.
Groin hematoma: The pt developed a small groin hematoma after
her procedure that was marked and was not found to be expanding.
THe fellow examined her hematoma and she was followed
clinically. HCT dropped from 41-30 from [**12-23**] - [**1-3**], though the
[**Location (un) 1131**] from [**12-23**] was likely spurious as her baseline was
generally in the low 30's.
.
PPX: SQ hep tid, zantac were initiated and continued throughout
the hospitalization.
.
Full code
.
Social: Before discharge, patient informed RN that she felt
verbally abused by her husband at home and that they no longer
communicate very much. She denied any physical harm. Niece is
involved in her care and well being.
.
PAtient was AAOx3, communicative and ambulatory and taking PO on
discharge.
Discussed discharge with Dr. [**First Name (STitle) **] who agrees with the plan. He
requests that he be called regarding her blood pressures and to
be informed regarding any significant events that come up. His #
is [**Telephone/Fax (1) 920**].
Medications on Admission:
Meds at home: Lasix 80 qd, ditropan 10 tid, imdur 60 qd, mvi,
cal/D, sinemet 25/100 qid and sinemet CR 25/100 qhs, remeron 15
qd, zantac 150 qd, feso4 325, kdur 20 qd, plavix 75, asa 325
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO
QID (4 times a day).
4. Carbidopa-Levodopa 25-100 mg Tablet Sustained Release Sig:
One (1) Tablet PO HS (at bedtime).
5. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO QAM
(once a day (in the morning)).
6. Ropinirole 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
13. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Life Care Center of [**Location 15289**]
Discharge Diagnosis:
Carotid Artery Stenosis (Left)
Discharge Condition:
AAOx3
Communicating appropriately
No chest pain, or shortness of breath.
Ambulatory w/ aid of walker
Discharge Instructions:
Please keep blood pressure between 120-160. Please increase her
beta blocker for tighter blood pressure control (keep HR>50).
Would avoid vasodilators such as imdur and norvasc.
.
Please call Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 920**] with daily blood
pressure readings.
.
Please call your primary care physician or Dr. [**First Name (STitle) **] in the
event that you experience any chest pain, shortness of breath,
any new changes in vision or new weakness. Also, if there are
any other concerning symptoms, please call or go to the
emergency room.
Followup Instructions:
You have the following premade appointments.
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-3-11**]
11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. Phone:[**Telephone/Fax (1) 920**]
Date/Time:[**2127-3-11**] 2:00
.
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2127-7-29**]
1:30
Completed by:[**2127-1-7**]
|
[
"V45.81",
"433.10",
"401.9",
"332.0",
"438.84",
"272.4",
"424.1",
"998.12",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.61",
"00.63",
"00.45",
"00.40",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
8723, 8790
|
4501, 7312
|
293, 318
|
8865, 8968
|
2393, 4418
|
9629, 10069
|
1986, 1990
|
7549, 8700
|
8811, 8844
|
7338, 7526
|
4435, 4478
|
8992, 9606
|
2005, 2374
|
221, 255
|
346, 1330
|
1352, 1750
|
1766, 1970
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,198
| 135,189
|
49622+49623+49624+49693
|
Discharge summary
|
report+report+report+report
|
Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-10**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
white male with multiple medical problems who had been in his
usual state of health except for a recent cough, when he
awoke this morning feeling very weak with no strength in his
legs. He awoke and went to the bathroom where he was
attempting to urinate and collapsed because of weakness,
striking his head. The patient never lost consciousness and
remembers collapsing because of weakness in his legs. He
denies palpitations or chest pain. His wife witnessed the
incident and notes that he was very weak but completely alert
and oriented. The only abnormality was him having a change
in his voice.
Upon arrival, EMS noted a blood sugar of 50 and the patient
was noted to be greatly improved after administration of one
amp of D50. Since arrival in the Emergency Department, the
patient complains of intermittent light chest heaviness that
is intermittent. Regarding his blood sugar, the patient has
had only one previous episode of hypoglycemia to his
knowledge. The patient notes having a lighter than normal
dinner last evening.
REVIEW OF SYSTEMS: He has had a recent cough. Chest x-ray
negative. No fever or chills. No bright red blood per
rectum. No melena.
PAST MEDICAL HISTORY:
1. Diabetes mellitus.
2. End-stage renal disease treated medically with a baseline
of creatinine of 4.0 to 5.0.
3. Hyperphosphatemia, did not tolerate TUMS.
4. Coronary artery disease, status post coronary artery
bypass graft sixteen years ago and now with chronic
intermittent angina.
5. Hypertension poorly controlled.
6. Status post cerebrovascular accident, right lacunar in
[**2175**].
7. Hydrocephalus.
8. Chronic gait instability with urinary incontinence.
9. Echocardiogram [**2181-2-2**], showed left atrial dilatation,
left ventricular hypertrophy with preserved function,
questionable aortic stenosis.
10. Hypercholesterolemia.
11. Colonic polyps.
12. Status post partial colectomy in [**2141**].
MEDICATIONS ON ADMISSION:
1. Glyburide 5 mg p.o. q.d.
2. Glucophage 1000 mg p.o. b.i.d.
3. Hydrochlorothiazide 25 mg p.o. q.d.
4. Aspirin 325 mg p.o. q.d.
5. Procardia XL 90 mg p.o. b.i.d.
6. Zestril 40 mg p.o. morning and 20 mg evening.
[**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2181-2-11**] 12:57
T: [**2181-2-11**] 13:18
JOB#: [**Job Number 103767**]
Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-10**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
gentleman with multiple medical problems who had been was in
his usual state of health except for a cough, when he awoke
on the morning of admission feeling weak, with no strength in
his legs. Upon going to the bathroom, attempting to urinate,
he collapsed to the floor and was unable to rise due to
weakness. His wife was by his side and witnessed this event,
and states that the patient never lost consciousness, never
had any seizure-like activity or bowel or bladder
incontinence. Aside from being weak, his only change was a
heavy voice.
Upon arrival, emergency medical technicians noted the
patient's blood sugar of 50. After placing an intravenous
line and administering one ampule of D50, the patient became
much more alert and was then transported to the Emergency
Room for further evaluation.
PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus for at
least five years. 2. End-stage renal disease, treated
medically, with a baseline creatinine of 4 to 5, has
progressively increased over the last three years. 3.
Coronary artery disease, status post coronary artery bypass
grafting 15 years ago, now with chronic intermittent
exertional angina. 4. Hypertension. 5. Status post
cerebrovascular accident with a right lacune in [**2175**]. 6.
Hydrocephalus, initially presented with chronic gait
instability and urinary incontinence. 7.
Hypercholesterolemia. 8. Colonic polyps, status post
partial colectomy in [**2141**]. 9. Echocardiogram in [**2181-1-6**] showed a left atrium that was dilated, left ventricle
with preserved function, some mitral annular calcification
and trivial mitral regurgitation.
SOCIAL HISTORY: The patient is a retired AP news reporter
who covered the [**State **] beats. He lives with his wife in
their home in [**Name (NI) 745**], [**State 350**]. The patient denies the
use of tobacco or alcohol.
HOSPITAL COURSE: 1. Renal: The patient appeared to have a
clinical course consistent with end-stage renal disease
secondary to poorly controlled hypertension and diabetes
mellitus. An emergent ultrasound was performed on initial
presentation and ruled out any evidence of hydronephrosis and
showed mildly shrunken kidneys bilaterally with an
echogenicity consistent with medical renal disease.
Initially, the patient had a metabolic acidosis with a
bicarbonate level of 10 that was treated appropriately with
bicarbonate supplementation. He was hyperphosphatemic, which
was treated with phosphorous binders. The patient initially
did not require hemodialysis, however, after receiving large
amounts of volume for treatment of his anemia, the patient
went into congestive heart failure and was not responsive to
Lasix.
At that time, an emergent right Quinton femoral catheter was
placed and the patient was given hemofiltration with good
effect and resolution of his volume overload. After
traumatic self removal of his right femoral Quinton, the
patient was taken to the Operating Room and had a permanent
right subclavian venous access catheter placed. Definitive
placement of an arteriovenous fistula will be necessary but
has been deferred at this time.
The patient subsequently needed hemodialysis on a three day
per week schedule, and will continue to receive dialysis at
rehabilitation and at the local center in [**University/College **] after the
patient returns home. Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] will follow the
patient in dialysis and act as his primary nephrologist. An
appointment with him can be scheduled prior to discharge from
the rehabilitation facility, through his office, which is
[**Telephone/Fax (1) 3637**].
2. Diabetes mellitus: The patient was hypoglycemic at the
time of presentation, which was thought to be secondary to
decreased renal clearance of his oral hypoglycemic
medications. They were subsequently discontinued and the
patient was managed on a regular insulin sliding scale per
standard routine. Longer standing insulin was not initiated
due to wide fluctuations in his insulin requirement, thought
to be secondary to his metabolic flux from dialysis and
changes associated with reinstitution of his diet, which was
quite poor during the initial portion of his hospitalization.
3. Cardiac: On the first evening of the patient's
hospitalization, he was being ruled out for an acute coronary
syndrome with cardiac enzymes because of his complaint of
current chest heaviness, even while at rest. Initial cardiac
enzymes were negative, however, he subsequently began to rule
in, with positive troponin and CK but a negative MB index.
The patient was subsequently heparinized, however, this was
during his transfusion, which was not bumping appropriately
and it was discovered that the patient had developed a large
left retroperitoneal iliopsoas bleed while on heparin.
The patient was transferred to the Medical Intensive Care
Unit, heparin was discontinued, DDAVP and
.................... were given to improve his uremic
platelet function and he continued to be transfused for a
hematocrit of over 30.
Subsequent cardiac enzymes trended downward and the patient
had no ST segment elevations. He was managed medically with
increased doses of beta blockers and nitrates, and did not
have any recurrent episodes of chest pain. The patient
should have a stress test in approximately two months' time,
which can be coordinated with his primary care physician.
4. Urology: The patient had intermittent episodes of
hematuria during his stay, which were most likely related to
the traumatic Foley catheter placement. He did require
numerous episodes of bladder irrigations with a three-way
Foley, with subsequent resolution of his difficulty. He did
continue to have occasional episodes of urinary incontinence,
as he has had for many years, which was thought to be due to
his normal pressure hydrocephalus.
5. Neurology: The patient was followed by his primary
neurologist, Dr. [**First Name8 (NamePattern2) 1692**] [**Last Name (NamePattern1) 1693**], while in house and did not
have any active neurologic issues.
6. Anemia: The patient presented initially with a
hematocrit of 21, which was thought to be due to medical
renal disease. He has received iron and erythropoietin
supplementation with his hemodialysis, and will continue to
receive it as such. The patient should be maintained with a
hematocrit of greater than 30 because of his coronary artery
disease.
7. Nutrition: The patient had very poor nutrition during
the initial portion of his hospital stay and was slow to
recover in his diet. He should continue to be on a phosphate
restricted diet and should receive a diet of 1,780
kilocalories with 74 grams of protein per day.
8. Left leg pain: The patient had moderate to severe
episodes of left leg pain, thought to be related to his
retroperitoneal bleed on that side. Plain films of the hip
joint were negative for fracture.
9. Infectious disease: The patient had a Enterococcal
urinary tract infection which was treated successfully with
ampicillin.
DISCHARGE STATUS: To [**Hospital1 **] Rehabilitation.
CONDITION AT DISCHARGE: Stable.
DISCHARGE MEDICATIONS:
Protonix 40 mg p.o.q.d.
Lipitor 20 mg p.o.q.d.
Diovan 80 mg p.o.q.d.
Ampicillin 1 gm i.v.q.d. on [**2-10**] and 6, [**2181**].
Epogen 3,000 units i.v.t.i.w. at hemodialysis.
Zemplar 2 mcg i.v.t.i.w. at hemodialysis.
Isordil 15 mg p.o.t.i.d.
Lopressor 75 mg p.o.b.i.d.
Erythromycin ointment topically o.u.b.i.d.
Regular insulin sliding scale.
Phos-Lo three tablets p.o.t.i.d.q.a.c.
Tylenol 650 mg p.o.q.6h.p.r.n.
Aspirin 81 mg p.o.q.d.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 7115**]
MEDQUIST36
D: [**2181-2-9**] 07:37
T: [**2181-2-9**] 20:05
JOB#: [**Job Number **]
cc:[**Last Name (NamePattern4) 103768**] Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-10**]
Service: Medicine
HOSPITAL COURSE:
1. End Stage Renal Disease - The patient upon admission had
evidence of longstanding medical renal disease with a
progressive decline in his renal function over the last three
years. His renal disease was complicated by metabolic
acidosis with a bicarb of 10 on admission and anemia with a
hematocrit of 21 on admission and hyperphosphatemia. However
the patient was able to make urine and balance his fluids at
the time of admission.
He initially did not require dialysis and was treated
medically with bicarbonates, transfusion and oral
administration for his acidosis as well as the use of
phosphate finders for his hyperphosphatemia. However after
aggressive treatment with IV fluids and blood cell
transfusions the patient became volume overloaded and was
minimally responsive to Lasix administration. At that time
Quinton catheter was placed and emergency infiltration with
fluid removal was instituted with good affect. The patient
subsequently required hemodialysis to maintain adequate
electrolytes and fluid balances. He was transfused by a right
subclavian venous access catheter that was placed [**2181-2-5**].
Plans were initially made for a placement of AV fistula for
long term access. However this has been deferred until a
later date when the patient's other numerous issues are
resolved.
The patient will continue to receive phosphate finders for
his hyperphosphatemia and will follow up with primary
nephrologist, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]. He will receive dialysis at
a local facility while at rehab and eventually will receive
his outpatient dialysis at [**Location (un) 4265**] [**Location (un) 3678**]. An appointment
should be made for Mr. [**Name14 (STitle) 103769**] to see Dr. [**First Name (STitle) 805**] around
the time of his transfer home. Dr. [**Last Name (STitle) 18991**] office phone
number is [**Telephone/Fax (1) 3637**].
2. Diabetes - The patient was hypoglycemic at the time of
admission presumably due to decreased renal metabolism of his
oral hypoglycemics. He was taken off of these medications
and managed on regular insulin sliding scale during the rest
of his hospitalization. We were unable to initiate standing
insulin dosing regimen due to the patient's wide fluctuations
most likely from metabolic abnormalities related to his
dialysis. The patient should be initiated on the standing
insulin regimen as soon as his sugars are more regular.
3. Anemia - The patient was hospitalized with a hematocrit
of 21. He was guaiac negative from below and presumably this
was all due to his medical renal disease. Iron studies were
checked and he had adequate iron stores so the patient was
initiated on regimen of 3000 units subcutaneous
Erythropoietin with each dialysis and iron supplementation
with dialysis. At the time of discharge the patient's
hematocrit was stable and rising slowly in the low to mid
30s.
4. Coronary artery disease - On the day of admission the
patient was noted having intermittent chest heaviness. He had
his cardiac enzymes monitored and began to rule in for non-ST
segment MI, with elevated CK but flat MB and Troponin as high
as 7. He was Heparinized initially but this appeared to have
caused abnormal bleeding with the development of a large,
left sided ileus and left retroperitoneal bleed. Heparin was
stopped. DDAVP and Esterase were given and the patient's
bleeding apparently stopped. He was transfused aggressively
to try to bring his hematocrit over 30 as we believe this
ischemia to be demand induced.
The patient did not have any recurrent episodes of chest
heaviness and his cardiac enzymes trended down subsequently.
Given the fact the patient has already had bypass surgery
and because of his renal issues we were not inclined to take
the patient for cardiac catheterization and opted to treat
him as aggressively as we could medically with initiation and
upward titration of oral nitrites and increased doses of beta
blockers. The patient returned to aspirin therapy just prior
to his discharge once his anemia was resolved. At the time
of discharge it was decided that the patient may benefit from
a stress test in approximately two months time.
5. Urinary tract infection - The patient was found to have
an enterococcal UTI that was pan sensitive to antibiotics and
was treated with a five day course of Ampicillin.
6. Hematuria - The patient had recurrent episodes of
hematuria throughout his hospital stay most likely secondary
to Foley trauma. The patient did intermittently pass clots
and had bladder irrigation with a three way Foley. Prior to
discharge the patient had been on bladder irrigation for 48
hours for hematuria subsequent discontinuation of the Foley
and the patient had brief episode of a few, scant clots in
his urine but no further episodes.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 7115**]
MEDQUIST36
D: [**2181-2-12**] 10:45
T: [**2181-2-12**] 11:22
JOB#: [**Job Number 56518**]
cc:[**Female First Name (un) 103770**] Admission Date: [**2181-1-27**] Discharge Date: [**2181-2-10**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 83 year old
white male with multiple medical problems, who had been in
his usual state of health except for a recent cough, when he
awoke this morning feeling very weak with no strength in his
legs. He awoke and went to his bathroom where he was
attempting to urinate and collapsed secondary to weakness,
striking his head. The patient denies ever losing
consciousness, but he remembers collapsing because of his
weakness in his legs. He denies any palpitations or chest
pain.
His wife witnessed the incident and notes that he was very
weak but completely alert and oriented, the only abnormality
being a deeper voice. Upon arrival, EMS noted a blood sugar
of 50 and the patient was noted to be greatly improved with
administration of one amp of D50.
Since coming to the Emergency Department, the patient has
been complaining of intermittent and light chest heaviness
that he gets intermittently. Regarding his blood sugar, the
patient reports having had only one previous episode of
hypoglycemia to his knowledge. The patient is noted as
having a lighter than normal dinner last evening.
REVIEW OF SYSTEMS: He has had a recent cough but no chest
x-ray as an outpatient. No fever or chills, no bright red
blood per rectum.
[**First Name11 (Name Pattern1) 312**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 313**], M.D. [**MD Number(1) 314**]
Dictated By:[**Name8 (MD) 4523**]
MEDQUIST36
D: [**2181-2-11**] 11:41
T: [**2181-2-11**] 12:12
JOB#: [**Job Number 35003**]
|
[
"276.2",
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"413.9",
"428.0",
"998.12",
"250.40",
"410.71",
"585"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
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] |
9878, 10741
|
2088, 2666
|
10759, 15999
|
9846, 9855
|
17163, 17577
|
16028, 17143
|
3557, 4357
|
4374, 4583
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,752
| 128,392
|
49740
|
Discharge summary
|
report
|
Admission Date: [**2149-12-10**] Discharge Date: [**2149-12-13**]
Service: MICU-TULLI
HISTORY OF PRESENT ILLNESS: This is an 88 year old gentleman
with a history of ETOH requiring chronic Foley catheter, also
with insulin dependent diabetes mellitus, congestive heart
failure with an ejection fraction of 20%, coronary artery
disease, who presents with complaints of pain in his penis
after a Foley catheter was changed and performed in the
Emergency Department today. He had a difficult Foley
catheter placement on the day prior to admission and pain
around the Foley catheter placement necessitating return to
the Emergency Department for pain management and Foley
catheter bleeding. Since arrival to the Emergency
Department, the patient was complaining of nausea, had
vomiting times one. A KUB and a chest x-ray were performed
to rule out bowel perforation, read as normal with no
perforations.
The patient became progressively hypotensive to the 80s over
40s and required 1200 cc of normal saline intravenous fluid
bolus to which his blood pressure responded. The Medical
Intensive Care Unit was then called to evaluate for sepsis
protocol and the blood pressure was 116/60. On evaluation,
temperature was 97.0 F.; white blood cell count was 18.7,
lactate was 3.1.
Medicines given in the Emergency Department were morphine
sulfate 2 mg intravenously times one and Rocephin one gram
intravenously times one.
PAST MEDICAL HISTORY:
1. Congestive heart failure with ejection fraction of 20 to
25% in [**2148-7-22**].
2. Insulin dependent diabetes mellitus.
3. Coronary artery disease status post myocardial infarction
times three with coronary artery bypass graft in [**2132**].
4. Atrial fibrillation.
5. Hypertension.
6. Esophageal dysmotility.
7. Chronic obstructive pulmonary disease.
8. Methicillin resistant Staphylococcus aureus.
9. Peripheral vascular disease.
10. Benign prostatic hypertrophy status post transurethral
resection of the prostate.
11. Hypothyroid.
12. Hypercholesterolemia.
13. Tachy/brady syndrome, status post pacer.
14. Bilateral inguinal hernias.
MEDICATIONS ON ADMISSION:
1. Aldactone.
2. Toprol XL
3. Multivitamin.
4. Metamucil.
5. Colace.
6. Iron.
7. Lasix.
8. Zantac.
9. Flonase.
10. Coumadin.
11. Levofloxacin.
12. Amiodarone.
13. Aspirin.
14. Cozaar.
15. Digoxin.
16. Levoxyl.
17. Insulin 70/30.
18. Senna.
ALLERGIES: Include clindamycin which causes elevated liver
function tests. Percocet causes confusion.
SOCIAL HISTORY: He lived at the [**Hospital **] nursing home.
PHYSICAL EXAMINATION: On admission was temperature 97.0 F.;
blood pressure 100/55 to 116/60; pulse 81 to 72; respiratory
rate 18 to 14; O2 is 95 to 97% on room air. In general, he
was chronically ill appearing male in no acute distress.
HEENT: Sclerae were anicteric. Pupils with right surgical
reactive, left mildly reactive. Mucous membranes were moist.
Neck was supple. Chest was with decreased air movement but
no wheezes, rales or rhonchi. Cardiovascular was regular
rate and rhythm, S1, S2, positive S3 and S4. Abdomen was
soft, nontender, nondistended with positive bowel sounds.
Extremities with positive left lower extremity with ulcer; no
erythema. Chronic venous stasis changes. Rectal examination
was heme negative. Stool was moderately firm at the vault.
Neurologic examination was awake, alert and oriented times
three.
LABORATORY: Labs on admission were notable for a white blood
cell count of 22,000, which was 89% neutrophils, hematocrit
of 39.2, platelets of 448, INR of 3.3, bicarbonate of 21, BUN
and creatinine of 75 and 2.2.
Urinalysis which was notable for large blood, 100 protein,
moderate leukocyte esterase, greater than 50 red blood cells.
Chest x-ray with no acute changes.
KUB with a large amount of stool.
HOSPITAL COURSE: This is an 88 year old gentleman with a
complicated medical history including benign prostatic
hypertrophy, coronary artery disease, congestive heart
failure, insulin dependent diabetes mellitus, who presents
after a traumatic Foley catheter placement with severe pain,
now with leukocytosis and hypotension, and hematuria.
1. HYPOTENSION: Although the patient was worked up
including the sepsis protocol, it was likely secondary to
intravenous narcotics. The patient responded after a fluid
bolus and otherwise blood pressure remained stable throughout
the course of his stay. The patient's blood pressure
medicines were initially held secondary to hypotension but
then restarted as his blood pressure remained stable.
2. BENIGN PROSTATIC HYPERTROPHY STATUS POST TRANSURETHRAL
RESECTION OF THE PROSTATE AND WITH NOW HEMATURIA: The
patient had a traumatic Foley catheter placement on the [**8-8**] and in the Emergency Room had a clean bladder
irrigation which showed evidence of clots in his bladder, but
responded to irrigation. Eventually, the Foley catheter was
reinserted. On the 19th the patient was continued to
irrigate, responded and continued to have minimal amounts of
blood in his urine but had decreased pain and was otherwise
stable. Urology was following the patient and the patient's
hematocrit and hematuria remained stable throughout the
course of his stay.
3. LEUKOCYTOSIS: Unsure of the source; initially at 22,000
on admission with 89% neutrophils. Unsure of source of
infection. Urinalysis did have evidence of leukocyte
esterase although had been on antibiotics, so patient had
urine culture sent which was consistent with mixed bacterial
flora consistent with fecal contamination. The patient was
started on ceftazidime 2 grams q. day and is to complete a
seven day course. The patient's antibiotics were started on
the 19th and at the time of discharge will be day four of day
seven to complete a seven day course. No different access
was needed as the patient continued to receive his
antibiotics through peripheral access at the nursing home.
Otherwise, the patient remained afebrile throughout the
course of his stay and his white blood cell count continued
to decline on treatment and on day prior to discharge had a
white blood cell count of 12.5.
4. CONGESTIVE HEART FAILURE: The patient with an ejection
fraction of 25 to 30% in [**Month (only) 205**] but no evidence of fluid
overload. On this hospitalization, his initial
anti-hypertensives and diuretics were held secondary to
hypotension. When hypotension stabilized, the patient
tolerated his cardiac regimen without difficulty.
5. ATRIAL FIBRILLATION: The patient remained in regular
rhythm throughout the course of his stay and otherwise was
stable. The patient was continued on his digoxin and
amiodarone and then restarted on his Toprol and beta blocker
and otherwise was stable in terms of an atrial fibrillation
standpoint.
6. CHRONIC RENAL FAILURE: For the patient's chronic renal
failure, the patient's baseline creatinine was from 2.4 to
2.5 and was at baseline and remained at baseline through the
course of his stay. His medicines were continued to be
renally dosed.
7. INSULIN DEPENDENT DIABETES MELLITUS: For the patient's
insulin dependent diabetes mellitus, the patient had finger
stick and was on an American Diabetic Association diet and
maintained on a 70/30 regimen with sliding scale in between.
The patient's blood sugars remained stable, however, did drop
slightly while he was NPO; however, the patient's
fingerstick and blood sugars remained stable throughout the
course of his stay and will continue on his same outpatient
regimen.
8. NAUSEA AND VOMITING; Unsure of source; ruled out for
obstruction with a KUB. The patient's nausea and vomiting
improved after a large bowel movement and constipation
resolved. [**Month (only) 116**] have been complication from pain; otherwise
the patient will follow-up with the Gastroenterologist for a
sigmoidoscopy as an outpatient. The patient has the
appointment already scheduled.
9. HYPOTHYROIDISM: Remains stable on his home regimen of
Levoxyl 100 mg q. day.
10. CORONARY ARTERY DISEASE: The patient's coronary artery
disease remains stable on aspirin and beta blocker and
otherwise no issues during the course of this admission.
11. CHRONIC OBSTRUCTIVE PULMONARY DISEASE HISTORY: The
patient was saturating comfortably on room air and was stable
at this time.
CODE STATUS: The patient was confirmed to be a "DO NOT
RESUSCITATE" "DO NOT INTUBATE".
DISCHARGE STATUS: Discharged to the nursing home.
CONDITION AT DISCHARGE: Good.
DISCHARGE INSTRUCTIONS:
1. The patient is bedridden secondary to peripheral vascular
disease and lower extremity changes.
2. Not on oxygen and communicating without difficulty with
pain well controlled.
DISCHARGE DIAGNOSES:
1. Traumatic Foley catheter placement with secondary
hematuria with benign prostatic hypertrophy.
2. Hypotension secondary to narcotics.
3. Nausea and vomiting.
4. Constipation.
5. Coronary artery disease.
6. Congestive heart failure.
7. Atrial fibrillation.
8. Diabetes mellitus.
9. Chronic renal failure.
DISCHARGE MEDICATIONS:
1. Ceftazidime 2 grams intravenously q. 24 hours to be
continued until [**12-16**].
2. Cozaar 25 mg p.o. q. day.
3. Digoxin 0.0625 mg p.o. q.o.d.
4. Spironolactone 12.5 mg p.o. q. day.
5. Toprol XL 12.5 mg p.o. q. day.
6. Multivitamin one p.o. q. day.
7. Metamucil one tablespoon in eight ounces p.o. q. day.
8. Colace 100 mg p.o. twice a day.
9. Ferrous sulfate 325 mg p.o. twice a day.
10. Lasix 20 mg p.o. twice a day.
11. Ranitidine 150 mg p.o. twice a day.
12. Flonase one spray each nostril twice a day.
13. Coumadin 1.5 mg p.o. q. day.
14. Acetaminophen 325 to 650 p.o. q. four to six p.r.n.
15. Tylenol #3, two tablets p.o. q. four hours p.r.n. pain.
16. Amiodarone 200 mg p.o. q. day.
17. Aspirin 325 mg p.o. q. day.
18. Levoxyl 100 micrograms p.o. q. day.
19. Insulin 70/30, 12 units q. a.m. and q. 7 p.m.
20. Senna, one tablet p.o. q. h.s.
21. Nitroglycerin 0.5 mg tablets p.r.n.
22. Bisacodyl 10 mg suppository p.r. q. day p.r.n.
23. Fleet enema p.r. q. day p.r.n.
24. Milk of Magnesia 30 ml p.o. q. day p.r.n.
FOLLOW-UP INSTRUCTIONS:
1. The patient is to follow-up with his primary care
physician in seven to ten days.
2. The patient is to follow-up with GI for a flexible
sigmoidoscopy as directed.
[**First Name11 (Name Pattern1) 2114**] [**Last Name (NamePattern4) 5231**], M.D. [**MD Number(1) 5232**]
Dictated By:[**Name8 (MD) 264**]
MEDQUIST36
D: [**2149-12-12**] 15:13
T: [**2149-12-12**] 16:02
JOB#: [**Job Number 103992**]
|
[
"E935.8",
"428.0",
"244.9",
"458.29",
"427.31",
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"250.00",
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] |
icd9cm
|
[
[
[]
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|
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8692, 9009
|
9032, 10065
|
2133, 2489
|
3824, 8442
|
8489, 8671
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2576, 3806
|
8458, 8465
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127, 1433
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10089, 10528
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1455, 2107
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2506, 2553
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,924
| 185,818
|
37646
|
Discharge summary
|
report
|
Admission Date: [**2109-8-29**] Discharge Date: [**2109-9-4**]
Date of Birth: [**2033-8-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Fatigue
Major Surgical or Invasive Procedure:
[**2109-8-30**] -
1. Mitral valve repair, radical mitral valve repair with
posterior leaflet (P2) triangular leaflet resection and
ring annuloplasty using an [**Doctor Last Name **] 32-mm physio II ring.
2. Coronary artery bypass grafting x1, left internal
mammary artery to left anterior descending coronary
artery.
3. Full left and right-sided Maze procedure with resection
of left atrial appendage using combination of [**Company 1543**]
Gemini X Bipolar RF System and the CryoCath System.
4. Left atrial reduction procedure.
[**2109-8-28**] - Cardiac Catheterization
History of Present Illness:
75 year old gentleman with known mitral valve regurgitation and
prolpase which has been followed by echocardiogram. This was
first discovered in [**2108**] when he established primary care with
Dr. [**Last Name (STitle) **] [**Last Name (STitle) **]. He previously had not been to a physician in many
years however notes a 26 year history of being told he had a
heart murmur. His history is complicated by an episode last year
of delerium and dementia which was possibly caused by acute
alcohol toxicity and or acute renal failure. He is left with a
bilateral frontal lobe dysfunction which leave him with
cognitive and psychomotor dysfunction but his laguage function,
visuospacial and memory are intact. Given the severity of his
disease, he has been referred for surgical evaluation.
Past Medical History:
Mitral regurgitation
Mitral valve prolapse
Paroxysmal Atrial fibrillation
Hypertension
Vitamin B12 deficiency
Dementia
Alcohol abuse
Social History:
Lives with: Wife
Occupation: Retired Police Officer
Tobacco: 1ppd for 15 years quit 40 years ago
ETOH: ?Past ETOH abuse. None in 1 year
Family History:
Noncontributory
Physical Exam:
Pulse: 65 Resp: 16 O2 sat: 100%
B/P Right: 154/95 Left: 154/99
Height: 70 Weight: 195
General: WDWN
Skin: Warm [X] Dry [X] intact [X]
HEENT: NCAT [X] PERRLA [X] EOMI [X]Sclera anicteric, OP [**Last Name (un) 17066**].
Teeth in good repair.
Neck: Supple [X] Full ROM [X] JVD[X]
Chest: Lungs clear bilaterally [X]
Heart: RRR, IV/VI blowing systolic murmur
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+ [X]
Extremities: Warm [X], well-perfused [X] No Edema
Varicosities: None [X]
Neuro: Slowing in regards to his reponse to questions noted. Did
repeat questions. A+Ox3. Strength equal [**6-12**] bilaterally. Gait
steady. No focal deficits.
Pulses:
Femoral Right:2 Left:2
DP Right:2 Left:2
PT [**Name (NI) 167**]:2 Left:2
Radial Right:2 Left:2
Carotid Bruit- Right: Transmitted vs bruit Left: None
Pertinent Results:
[**2109-8-30**] ECHO
PREBYPASS
The left atrium is massive. No atrial septal defect is seen by
2D or color Doppler. The left ventricle is not well seen.
Overall left ventricular systolic function however appears
normal (LVEF>55%). [Intrinsic left ventricular systolic function
is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. The mitral valve leaflets are mildly thickened. There
is partial posterior mitral leaflet flail. An eccentric,
anteriorly directed jet of Severe (4+) mitral regurgitation is
seen.
POSTBYPASS
The LV remains difficult to visualize. LV systolic function
appears at least mildly impaired. The ventricular septum appears
dyskinetic and the inferior wall appears hypokinetic. There is a
ring prostheis in the mitral position. The MV leaflets coapt and
no MR [**First Name (Titles) **] [**Last Name (Titles) 48613**]. The LAA is no longer [**Last Name (Titles) 48613**]. RV
systolic function remains normal.
[**2109-8-29**] - Cardiac Catheterization
1. Coronary angiography in this right dominant system
demonstrated
single vessel disease. The LMCA in some views appeared to have a
50%
ostial lesion however with repositioning of the catheter there
was no
stenosis present and there was no catheter dampening observed.
The LAD
had 30% proximal stenosis and 50-60% mid vessel stenosis. The
LCx and
RCA had minimal disease.
2. Limited resting hemodynamics revealed mild systemic arterial
systolic
hypertension with SBP 140 mmHg.
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. Mild systemic arterial systolic hypertension.
[**2109-8-29**] - Carotid Ultrasound
Impression: Right ICA stenosis <40%. Left ICA stenosis <40%.
Coumadin at hospital - received 2mg coumadin - INR 1.3 [**9-1**], 5mg
coumadin - INR 1.2 [**9-2**], coumadin 2mg - INR 1.3 [**9-3**] - coumadin
2 mg - INR 1.8 [**9-4**]
Brief Hospital Course:
Presented for cardiac catheterization and admitted post
procedure for preoperative workup. On [**2109-8-30**] he was taken to
the operating room and underwent mitral valve repair, a MAZE
procedure and coronary artery bypass graft surgery. Please see
operative note for further details. Postoperatively he was taken
to the intensive care unit for monitoring. He required
Epinephrine, fluids, and neosynephrine for hemodynamic
management, continued on amiodarone drip for MAZE procedure. He
remained intubated due to hypoxia requiring increased PEEP. On
postoperative day and fluids vasn postoperative day one, he was
weaned off the neosynephrine and epinephrine and hemodynamically
remained stable. The amiodarone was stopped due to slow
junctional rhythm at rate of 50. He remained on propofol while
intubated and postoperative day two he was weaned and extubated
from the ventilator. He was started on betablockers when he was
in atrial fibrillation with ventricular rate 70-80, and started
on ace inhibitor for blood pressure management. The physical
therapy service was consulted for assistance with his
postoperative strength and mobility. On postoperative day three
he was transferred to the step down unit for further recovery.
He continued to progress, EP was consulted for rhythm management
with plan for betablockers at this time and potential
cardioversion and amiodarone in one month. His epicardial wires
were cut due to low platelet count and he was restarted on
coumadin for his atrial fibrillation. He was ready for
discharge to rehab on post operative day five to the [**Location (un) 582**] in
[**Location (un) 620**].
Coumadin at hospital - received 2mg coumadin - INR 1.3 [**9-1**], 5mg
coumadin - INR 1.2 [**9-2**], coumadin 2mg - INR 1.3 [**9-3**] - coumadin
2 mg - INR 1.8 [**9-4**]
Plan from EP for treatment of atrial fibrillation from OMR note
[**9-3**]
76 yo male with history of CAD, atrial fibrillation, and MVP/MR
s/p MV repair/CABGx1(LIMA->LAD)/MAZE/LAA resection on [**2109-8-30**].
Patient had successful repair of mitrial valve and persistent
atrial fibrillation with adequate ventricular response. At this
point the patient is asymptomatic, rate controlled with
Metoprolol and anti-coagulated with Warfarin (INR
subtherapeutic). Goal will be to revert to sinus rhythm,
however
we do not want to cardiovert this patient in the post-op period
without adequate anti-coagulation
--continue anti-coagulation with Warfarin
--after 4 weeks will initiate Amiodarone 400mg PO daily
--plan for DC Cardioversion in 5 weeks - we will arrange this
procedure
--follow up with surgery/primary cardiologist as scheduled
Medications on Admission:
Atenolol 100 mg daily
Coumadin 2mg daily (LD [**2109-8-23**])
Aricept 10mg daily
Folate 1mg daily
Lorazepam PRN
Vitamin B12
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Aricept 10 mg Tablet Sig: One (1) Tablet PO once a day.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours).
7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day:
please check PT/INR mon and wed and fri - and adjust dose based
on INR with goal INR 2.0-2.5 for Afib .
9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. coumadin and INR
Coumadin at hospital - received 2mg coumadin - INR 1.3 [**9-1**], 5mg
coumadin - INR 1.2 [**9-2**], coumadin 2mg - INR 1.3 [**9-3**] - coumadin
2 mg - INR 1.8 [**9-4**]
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 2 weeks.
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
2 weeks.
13. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-9**]
Drops Ophthalmic PRN (as needed) as needed for dry eyes.
14. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day): 75 mg twice a day .
16. Labs
Please check PT/INR monday, wednesday and friday for minimum of
2 weeks
Please check Cr and potassium and magnesium weekly while at
rehab
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 582**] at [**Location (un) 620**]
Discharge Diagnosis:
Mitral regurgitation s/p MV repair
Mitral valve prolapse
Paroxysmal atrial fibrillation s/p MAZE
Coronary Artery Disease s/p CABG
Hypertension
Vitamin B12 deficiency
Dementia
Discharge Condition:
Alert and oriented x2, nonfocal
Ambulating with assistance
Incisional pain managed with tylenol ATC
Incisions:
Sternal - healing well, no erythema or drainage with steri
strips
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) 914**] on Tuesday [**10-1**] at1:30PM
([**Telephone/Fax (1) 170**])
Cardiologist: Dr [**Last Name (STitle) **] [**9-24**] at 10:30 am
Please call to schedule appointments with your:
Primary Care: Dr. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 66650**] ([**Telephone/Fax (1) 19980**]) in [**2-9**]
weeks
Labs: PT/INR for Coumadin
Indication: Atrial Fibrillation
Goal INR 2.0-2.5
First draw day after discharge friday [**9-6**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease as directed by PCP
Please contact coumadin clinic at [**Hospital1 18**] [**Name (NI) 620**] for management
of coumadin after discharge from rehab
Coumadin at hospital - received 2mg coumadin - INR 1.3 [**9-1**], 5mg
coumadin - INR 1.2 [**9-2**], coumadin 2mg - INR 1.3 [**9-3**] - coumadin
2 mg - INR 1.8 [**9-4**]
**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:[**2109-9-4**]
|
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"424.0",
"V58.61",
"294.8",
"266.2",
"285.1",
"518.0",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"88.56",
"88.53",
"36.15",
"39.61",
"37.33",
"96.71",
"37.36",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
9439, 9516
|
4982, 7636
|
327, 923
|
9735, 9914
|
2996, 4583
|
10668, 11819
|
2067, 2084
|
7812, 9416
|
9537, 9714
|
7662, 7789
|
4600, 4959
|
9938, 10645
|
2099, 2977
|
280, 289
|
951, 1740
|
1762, 1897
|
1913, 2051
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,226
| 146,348
|
30654
|
Discharge summary
|
report
|
Admission Date: [**2104-6-24**] Discharge Date: [**2104-7-2**]
Date of Birth: [**2029-3-29**] Sex: F
Service: SURGERY
Allergies:
Oxycodone / Percocet / Hydrochlorothiazide
Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
CT scan concerning for splenic rupture
Major Surgical or Invasive Procedure:
[**2104-6-24**] Splenectomy
History of Present Illness:
75yF with h/o AVR, ascending aortic dissection with aortic
conduit on coumadin, and Chronic Renal failure presented
initially to [**Hospital3 **] with lower GI bleed. Her Hct at
admission was 18. She was transfused 4 units of PRBC. Coumadin
was held, she underwent c-scope. Post c-scope she was
hypotensive and requiring dopamine. CT scan of abdomen
demonstrated free fluid and and a AAA. This was initially
believed to be a ruptured AAA, even thought non-con CT.
Vascular
was initially consulted. Re-eval of CT scan was concerning for
splenic rupture. Pt was transfered here for further management
Past Medical History:
1. Anemia
2. Chronic renal insufficiency, s/p R renal artery stent
3. s/p Aortic root repair for dissection, 1-vessel CABG, and AVR
4. Hypertension
5. Perioperative atrial fibrillation
6. history of gastrointestinal bleeding
7. history of transient ischemic attack in [**3-20**] with aphasia
that improved without treatment
Social History:
SH: lives at home, exsmoker 25 pack year history
Family History:
mother-died at 63, HTN, MI, CHF, CVA, DM
father- on "digitalis"
Physical Exam:
On Admission:
VS: HR 90s BP 105/60 RR 18 962 L
PE:
Gen: mild distress, confused
CV: RRR
Pulm: CTA b/l
Abd: distended, diffusely tender
Ext: no edema
Pertinent Results:
[**2104-6-24**] 05:09PM BLOOD WBC-15.0*# RBC-2.88* Hgb-8.5* Hct-24.3*
MCV-84# MCH-29.4 MCHC-34.9# RDW-17.1* Plt Ct-162
[**2104-6-25**] 01:52AM BLOOD WBC-12.5* RBC-3.73*# Hgb-11.3*#
Hct-31.1*# MCV-83 MCH-30.3 MCHC-36.4* RDW-17.4* Plt Ct-147*
[**2104-6-25**] 01:37PM BLOOD Hct-30.2*
[**2104-6-24**] 04:00PM BLOOD PT-17.8* PTT-23.4 INR(PT)-1.6*
[**2104-6-25**] 01:52AM BLOOD PT-14.8* PTT-20.7* INR(PT)-1.3*
[**2104-6-24**] 05:09PM BLOOD Glucose-215* UreaN-16 Creat-1.1 Na-140
K-4.7 Cl-112* HCO3-17* AnGap-16
[**2104-6-25**] 01:52AM BLOOD Glucose-112* UreaN-18 Creat-1.2* Na-139
K-4.2 Cl-111* HCO3-21* AnGap-11
[**2104-6-24**] 05:09PM BLOOD Calcium-8.9 Phos-5.1* Mg-2.0
[**2104-6-24**] 04:09PM BLOOD Glucose-210* Lactate-3.0* Na-138 K-4.2
Cl-114*
[**2104-6-24**] 04:29PM BLOOD Glucose-204* Lactate-2.2* Na-137 K-4.0
Cl-113*
[**2104-6-24**] 05:15PM BLOOD Glucose-195* Lactate-1.6
[**2104-6-24**] 04:09PM BLOOD freeCa-0.87*
[**2104-6-24**] 04:29PM BLOOD freeCa-1.30
[**2104-6-24**] 05:15PM BLOOD freeCa-1.22
[**2104-6-25**] 03:12AM BLOOD freeCa-1.13
Brief Hospital Course:
Patient admitted aggressively resuscitated and went for urgent
exploratory laparotomy and splenectomy [**2104-6-24**]. She received a
total of 7 PRBC, 2 FFP on the first hospital day. The patient
tolerated the procedure well and was extubated on POD 1. NG
tube on low continuous suction and Foley to gravity left in
place. She also received her post splenectomy vaccinations on
POD 1. On POD 2 the patient was started on a heparin drip to
anticoagulation for her artificial valve. She was given IV
Lasix 20 [**Hospital1 **] and diuresed appropriately.
Hcts were cycled and remained stable in the trauma ICU. She was
transferred to the surgical floor on HD 3 POD 2 and was
continued on the heparin gtt. She was noted with another drop in
her hematocrit down to 22 and was transfused with 1 unit of
packed cells; her HCT on day before discharge was 24. She is on
Epogen at home and will be following up with her primary
providers for resuming this. She has remained hemodynamically
stable since her last transfusion. As for her anticoagulation
Cardiology was consulted to determine if she needed to be within
therapeutic range prior to discharge and it was determined that
she would need to be therapeutic. She is being discharged home
on 3 mg of Coumadin; her usual home dose is 5mg per patient
report. Because her INR is 3.4 on day of discharge it was
decided to cut her dose in half from the 6 mg she received just
the evening before. She will have her INR drawn tomorrow and the
results will be sent to Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
She is being discharged to home with services and instructions
for follow up.
Medications on Admission:
lopressor 25'', calcitriol, EPO, lasix 20', gabapentin 100'',
lisinopril 40', simvastatin 10', tramadol 50''' prn, warfarin
7.5, coenzyme 100''
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Coumadin 1 mg Tablet Sig: Three (3) Tablet PO evening of
[**2104-7-2**] for 1 days.
10. Coumadin 1 mg Tablet Sig: * Tablet PO Every evening: *As
directed based on INR goal of 2.5-3.5.
Disp:*90 Tablet(s)* Refills:*2*
11. Outpatient [**Name (NI) **] Work
PT/INR 2-3x/wek and prn
Goal INR 2.5-3.5
Results called to [**Last Name (LF) **], [**First Name3 (LF) **] Z. MD, PHD
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**Street Address(2) 10534**], [**Location (un) **],[**Numeric Identifier 10535**]
Phone: [**Telephone/Fax (1) 9347**]
Fax: [**Telephone/Fax (1) 12540**]
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 932**] Area VNA
Discharge Diagnosis:
Splenic rupture
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 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 [**4-21**] lbs until you follow-up with your
[**Month/Year (2) 5059**], who will instruct you further regarding activity
restrictions.
Avoid being around anyone who has a cold/flu; because of your
spleen being removed you are more susceptible to catching a
cold/flu. You were given vaccines that will provide some
protection against pneumonia, hepatits and meningiococcal
infections.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your [**Month/Year (2) 5059**] 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:
Follow up in [**12-15**] weeks in [**Hospital 2536**] clinic; call [**Telephone/Fax (1) 600**] for an
appointment.
The following appointments were made for you before your
hospitalization:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2104-7-23**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20031**], MD Phone:[**Telephone/Fax (1) 3736**]
Date/Time:[**2104-8-6**] 10:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2104-10-15**] 10:00
Completed by:[**2104-7-2**]
|
[
"285.1",
"V05.3",
"568.81",
"V05.8",
"V03.82",
"V45.81",
"V58.61",
"403.90",
"V12.54",
"V43.3",
"585.9",
"289.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.5"
] |
icd9pcs
|
[
[
[]
]
] |
5874, 5937
|
2757, 4412
|
340, 369
|
5996, 5996
|
1689, 2734
|
7569, 8238
|
1437, 1502
|
4606, 5851
|
5958, 5975
|
4438, 4583
|
6178, 7041
|
7056, 7546
|
1517, 1517
|
262, 302
|
397, 1006
|
1531, 1670
|
6011, 6154
|
1028, 1354
|
1370, 1421
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,453
| 134,546
|
32318
|
Discharge summary
|
report
|
Admission Date: [**2131-8-5**] Discharge Date: [**2131-8-8**]
Date of Birth: [**2089-3-19**] Sex: M
Service: MEDICINE
Allergies:
Morphine / Codeine / Ciprofloxacin
Attending:[**First Name3 (LF) 1377**]
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
Upper Endoscopy
History of Present Illness:
42 year old homeless man with a PMH significant for EtOH
cirrhosis complicated by multiple episodes of esophageal varices
bleed(grade I varices) with banding, chronic pancreatitis, and
EtOH withdrawl admitted to the MICU for coffee ground vomiting
and abdominal pain. Patient was admitted twice within the last
month with similar symptoms of coffee ground emesis and
abdominal pain after heavy drinking. He had an upper endoscopy
on [**2131-7-25**] which showed 1 cord of grade 1 varices, erosive
esophagitis, and portal hypertensive gastropathy with no
evidence of variceal bleeding. He was started on Nadolol upon
discharge. He also was found to have a trace ascites on US. At
this admission patient reports drinking 1 quart of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**]
daily, and had binge drinking 2 days prior to admission followed
by non-bloody vomiting. He than developed coffee ground vomit
and presented to ER. His chronic abd pain also increased
yesterday. He denies black stools, red blood in his vomiting,
BRBPR, dizziness or syncope.and 3 episodes of hematemesis since
2 days prior to admission. He also reports associated [**8-30**]
abdominal pain (baseline [**2-27**]) described as intermitent sharp
located in the epigastrum radiating to his back which was worse
than his chronic abdominal pain. He noted to have dark stools in
the last "few" days, but denies having any melena. He also
denies having any shortness of breath, dizziness,
lightheadedness, fever, or chills.
.
In the [**Hospital1 18**] ED, VS 95.5 97/62 72 18 95%RA. The patient was
guaiac negative in the ED, and received a protonix, dilaudid,
zofran, ativan, and ciprofloxacin, for which he developed hives
and received diphenhydramine. He was admitted to the MICU for
further management.
.
In the MICU patient had NGL which was negative for blood and
bile. He had an [**Hospital1 **] today which showed no varices, grade 2
esophagitis in the gastroesophageal junction and mild gastritis.
He had no other episodes of vomiting. His Hct has been stable at
lower 30s, and VSS. He was started on PPI IV and placed on
ceftriaxone as prophylaxis given his prior reaction to cipro. He
had no other episodes of vomiting or melena since admission.
Currently, he appears to be in NAD laying comfortable on his
bed. He states to continue to have epigastric abdominal
radiating to his back which is at the same location as his
chronic pancreatitis pain, but with worse intensity now [**7-30**] and
at home is pain level is usually [**2-27**]. His VSS: Temp 97.7, Pulse
63, BP 107/70, RR 11, O2 Sat 94% on RA.
.
ROS: As above, otherwise negative.
Past Medical History:
Alcoholic cirrhosis with [**Month/Year (2) **] on [**7-29**] with Grade 1 varices.
-Variceal bleeds, 6 episodes from [**2128**] to [**11-27**] s/p multiple
bandings. Bleed in [**11-27**] was grade II on [**Date Range **], s/p banding.
-Chronic pleural effisions
-Chronic pancreatitis
-Alcohol dependence: heavy drinking started at age 30-35. Has
been to detox and dual diagnosis clinics in the past. Has had
periods of sobriety. H/o delirium with past withdrawal; no h/o
seizures.
-Bipolar disorder and anxiety disorder NOS, well controlled on
citalopram, quetiapine, and ativan. Has psychiatrist in the
community.
-S/p cholecystectomy on [**5-29**]
-S/p right ACL replacement and meniscectomy in [**2126**]
Social History:
Currently homeless, occupation: previously employed as an
electrician. Divorced. Has daughter in [**Name (NI) 614**] and son in
[**Name (NI) 3320**]. 12 year history of drinking 1-1.75 liters of vodka
daily. Denies tobacco or other illicits.
His mother, [**Name (NI) 1439**] [**Name (NI) 53917**], is his healthcare proxy
Family History:
History of alcoholism. Paternal grandfather died of prostate
cancer. Maternal grandmother died of MI; no other family h/o
CVD. Father alive, with h/o kidney cancer. Mother and children
healthy.
Physical Exam:
VS: Temp 97.7, Pulse 63, BP 107/70, RR 11, O2 Sat 94% on RA.
Gen: Age appropriate male in NAD
HEENT: sclerae anicteric. MM dry, OP clear without lesions,
exudate, or erythema
CV: RRR, normal S1 and S2, no m/r/g
Pulm: CTAB, no C/R/W
Abd: Soft, ND, tender to palp on epigastric area, +bs, . No
rebound or guarding.
Ext: No c/c/e. 2+ dp/pt bilaterally.
Neuro: AOx3, no asterixis.
Pertinent Results:
[**Name (NI) **] on [**2131-8-6**]: Impression: No varices
Grade 2 esophagitis in the gastroesophageal junction
Congestion in the whole stomach compatible with mild gastritis
Pancreatic rest about 1.2 cm found in antrum of stomach
Otherwise normal [**Date Range **] to second part of the duodenum
cxay on [**2131-8-4**]: This film is very limited due to technique.
There is a linear density projecting over the expected location
of the esophagus with distal tip in the fundus of the stomach
with a single loop. Would recommend repeat films for definite
confirmation. There is atelectasis at the left lower lobe. There
are no signs for overt pulmonary edema or pleural effusions. No
pneumothoraces are seen.
-----------------
ADMISSION LABS:
-----------------
[**2131-8-4**] 10:20PM
WBC-4.7# RBC-4.69 Hgb-11.8* Hct-36.9* MCV-79* MCH-25.1*
MCHC-31.9 RDW-15.5 Plt Ct-211 Neuts-53.1 Lymphs-41.1 Monos-2.0
Eos-3.2 Baso-0.6
PT-16.2* PTT-30.8 INR(PT)-1.4*
Glucose-123* UreaN-8 Creat-0.8 Na-145 K-5.0 Cl-107 HCO3-26
AnGap-17
ALT-15 AST-58* AlkPhos-205* TotBili-0.5
Lipase-17
ASA-NEG Ethanol-252* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
[**2131-8-4**] 10:25PM BLOOD Hgb-13.0* calcHCT-39
[**2131-8-5**] 03:45AM BLOOD Albumin-3.7 Calcium-7.8* Phos-3.5 Mg-1.7
[**2131-8-5**] 10:04AM BLOOD Type-[**Last Name (un) **] pH-7.34*
------------------
DISCHARGE LABS:
------------------
[**2131-8-7**] 05:10AM BLOOD WBC-1.8* RBC-4.06* Hgb-9.9* Hct-31.5*
MCV-78* MCH-24.5* MCHC-31.5 RDW-16.1* Plt Ct-161
[**2131-8-7**] 05:10AM BLOOD Neuts-44.6* Lymphs-44.7* Monos-5.4
Eos-4.9* Baso-0.3
[**2131-8-7**] 05:10AM BLOOD PT-15.4* PTT-31.6 INR(PT)-1.3*
[**2131-8-7**] 05:10AM BLOOD Glucose-95 UreaN-6 Creat-0.7 Na-143 K-3.7
Cl-104 HCO3-32 AnGap-11
[**2131-8-7**] 05:10AM BLOOD ALT-11 AST-36 AlkPhos-187*
[**2131-8-7**] 05:10AM BLOOD Lipase-9
[**2131-8-7**] 05:10AM BLOOD Calcium-8.8 Phos-4.2 Mg-1.9
Brief Hospital Course:
42 year old homeless man with a PMH significant for EtOH
cirrhosis complicated by multiple episodes of esophageal varices
bleed(grade I varices) with banding, chronic pancreatitis, and
EtOH withdraw admitted to the MICU for coffee ground vomiting
and abdominal pain and now transferred to [**Doctor Last Name 3271**] [**Doctor Last Name 679**] team.
.
# Hematemesis: Patient was admitted twice within the last month
with similar symptoms of coffee ground emesis and abdominal pain
after heavy drinking. He had an upper endoscopy on [**2131-7-25**] which
showed 1 cord of grade 1 varices, erosive esophagitis, and
portal hypertensive gastropathy with no evidence of variceal
bleeding. He was started on Nadolol upon discharge. He also was
found to have a trace ascites on US. At this admission patient
reports drinking 1 quart of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5261**] daily, and had binge
drinking 2 days prior to admission followed by non-bloody
vomiting. He than developed coffee ground vomit and presented to
ER. In the differential there is [**Doctor First Name 329**] [**Doctor Last Name **],erosive
esophagitis and gastritis. Patient is currently hemodynamically
stable without further hematemesis. [**Doctor Last Name **] didn't show no varices
and no active bleeding. He had an initial hematocrit drop from
36->30, now stable at 31.5. He is tolerating regular diet well
prior to discharge. Continue on PPI. He was also encouraged to
stop drinking. We discuss the risks associated if he continues
to drink with GI bleed, pancreatitis and death. Patient
verbalized understanding. He spoke to the social worker and told
us that he was planning to attend AA meetings.
.
# Liver disease: Patient is an active drinker with multiple
hospitalizations for variceal bleeds with banding. His LFTs are
WNL, except for AP sl elevated at 187 (but lower than prior
admissions). He has missed follow-up appointments w/liver
center. The patient received ciprofloxacin in the ED but
developed hives and this was discontinued. As noted above we
discussed the importance of him stop drinking and to follow-up
with Liver clinic.
- Ceftriaxone for upper GI bleed ppx- D/c this AM
- Continue lactulose
- Placed back on home dose of nadolol given his prior esophageal
varices history
.
# EtOH: Patient does not have a history of DTs or withdrawl
seizures. He was place on CIWA protocol with valium for scores
>10. He did well and did not needed any valium. He was given
thiamine and folate. Social worked discuss sobriety option and
how patient could afford to get housing, this would help him
stay out of the shelter and away from the enviromental triggers.
He was given information on possible housing places that he
could afford. Continue to talk about the importance of him
quitting drinking and outpatient programs. Uncertain if he could
qualify for inpatient or if he would be willing to participate
in shuch programs.
.
# Anemia: Hct currently at baseline (30-34), and stable. As
noted above decrease from 36->30 at admission. Recent work-up
demonstrated Fe/TIBC of 8% with ferritin of 23, normal folate
and B12 levels.
.
# Chronic leukopenia: patient with low WBC count since [**2128**],
this however is the lowest level when compared to previous
admission. He does have large spleen as per imaging, however
plalets are within normal limits and he only has very mild
anemia.
-Heme/onc consult as outpatient to evaluate for causes of
leukopenia
-Currently asymptomatic
.
.
#Chronic pancreatitis: Patient with complain of chronic
abdominal pain related to chronic pancreatitis. LFTs and lipase
WNL, Alk Phos continue to be elevated, but trending down when
compared to previous admssion. Pt initially had dilaudid for
pain which was d/c. He was restarted on home pain meds:
oxycodone 5 mg po Q6-8HRs PRN. Continue home Pancreatic enzymes.
Post discharge patient left the in patient unit to go home and
immidiately walked to the emergency room c/o abdominal pain and
requesting IV pain meds.
.
# Psych: History of bipolar disorder and anxiety. Continue
citalopram and seroquel
As noted above, patient walked to the emergency room as soon as
he was discharge from the inpatient unit asking for pain meds.
Drug seeking behavior. He was then discharged from the ED. He
has a follow-up appointment with his psychiatrist on [**8-29**]. He
was encouraged to go to his appointment
.
FEN: regular diet tolerating well
.
Code: Full (confirmed)
.
Communication: [**Known lastname **],[**Name (NI) **] (mother) [**Telephone/Fax (1) 75519**],
[**Telephone/Fax (1) 75524**]
Medications on Admission:
HOME MEDS:
Sucralfate 1 gram po qid
Quetiapine SR 400 mg daily
Citalopram 40 mg daily
Lactulose 10 grams po tid
Thiamine 100 mg daily
Folate 1 mg daily
Oxycodone 5 mg po Q6-8H prn for pain
Trazodone 100 mg po qhs prn
Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) po tid with meals
MVI
Ativan 0.5 mg 1-2 tablets Q8H prn for anxiety
Nadolol 10 mg daily
FeSO4 325 mg po bid
.
TRANSFER MEDS:
CeftriaXONE 1 gm IV Q24H started on [**8-5**] @ 0349
Midazolam 1-3.5 mg IV ONCE [**8-6**] @ 1013
Citalopram Hydrobromide 40 mg PO DAILY
Multivitamins 10 mL IV Q24H
Diazepam 5-10 mg PO Q4H:PRN for CIWA>10
Pantoprazole 40 mg IV Q12H
Quetiapine extended-release 400 mg PO DAILY
FoLIC Acid 1 mg IV Q24H
HYDROmorphone (Dilaudid) 1 mg IV Q4H:PRN Pain
Thiamine 100 mg IV DAILY
Lactulose 15 mL PO TID Titrate to 3 BM/day
Discharge Medications:
1. Quetiapine 200 mg Tablet Sustained Release 24 hr Sig: Two (2)
Tablet Sustained Release 24 hr PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO TID (3
times a day).
4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
8. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
9. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Nadolol 20 mg Tablet Sig: [**12-22**] Tablet PO DAILY (Daily).
12. Maalox 200-200-20 mg/5 mL Suspension Sig: Ten (10) ml PO
three times a day as needed for heartburn.
Disp:*1 bottle* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Upper GI bleed
.
Secondary:
ETOH Dependance
Bipolar Disorder
Cirrhosis
Chronic Pancreatitis
Discharge Condition:
Stable, tolerating regular diet and pain controlled on oral
medications
Discharge Instructions:
You were admitted with upper GI bleed but you have not required
any blood transfusions and your red blood cell counts have
remained stable in house. You were evaluated by the
gastroenterologist who performed an [**Month/Day (2) **] which revealed mild
gastritis but no evidence of varices.
.
We have made no changes to your medications, except for:
- Start Maalox
.
If you develop any chest pain, shortness of breath, significant
bleeding, fevers or any other general worsening of condition
that is concerning to you, please call your PCP or come directly
to the ED.
Followup Instructions:
We recommend that you are seen by the Hematology/Oncologist for
your persistently low white blood cell counts. You have an
appointment scheduled with them on [**2131-9-19**] 03:00p with Dr.
[**Last Name (STitle) **]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC. Phone:[**Telephone/Fax (1) 22**]
.
You can see Dr. [**Last Name (STitle) 75523**] at any time between 8:30am and 1pm on
Friday, [**8-10**] at her walk in clinic. Please call her office
at [**Telephone/Fax (1) 5128**] if you have any questions.
Appointment with Dr. [**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] on [**2131-9-3**] at 9:30A M
LM [**Hospital Unit Name **], [**Location (un) **] LIVER CENTER (SB)
Phone: [**Telephone/Fax (1) 75525**]
Please make sure to follow-up with your psychiatrist-
appointment scheduled for [**2131-8-29**]
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1379**]
|
[
"296.80",
"577.1",
"285.9",
"530.82",
"303.91",
"288.50",
"530.19",
"535.41",
"571.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.07",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
13261, 13267
|
6609, 11193
|
305, 323
|
13412, 13486
|
4691, 5419
|
14102, 15092
|
4084, 4279
|
12079, 13238
|
13288, 13391
|
11219, 12056
|
13510, 14079
|
6060, 6586
|
4294, 4672
|
254, 267
|
351, 2996
|
5435, 6044
|
3018, 3728
|
3745, 4068
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,781
| 169,273
|
36634
|
Discharge summary
|
report
|
Admission Date: [**2195-8-28**] Discharge Date: [**2195-9-5**]
Date of Birth: [**2151-7-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Old myocardial infarction by echo and low ejection fraction. No
symptoms.
Major Surgical or Invasive Procedure:
[**2195-9-1**] - 1. Coronary artery bypass grafting
x3(LIMA-LAD,SVG-lPDA,SVG-rPDA)& Patent foramen ovale closure.
left heart catheterization, coronary angiography
History of Present Illness:
This 44 year old white male with a history of hypertension,
hyperlipidemia and recent stroke was referred for cardiac
catheterization due to low EF of 20-30%. The patient was
admitted to [**Hospital1 2025**] in [**4-28**] with left CVA where they discovered an
old anterior wall MI with a low EF. The etiology of his stroke
was undetermined and he was discharged wearing a defibrillator
harness with plans for ICD in future. He has no cardiac
symptoms, but reports occasional parasthesias in arms and legs.
Past Medical History:
hypertension
Hyperlipidemia
h/o Anterior wall MI
Left Cerebellar CVA [**4-28**] without residual deficits
s/p orchiplexy age 4
Social History:
Last Dental Exam: 2 years ago
Lives with:wife and 4 kids
Occupation:Full time welder, has not worked since CVA [**4-28**] and
wears a defibrillator harness
Tobacco:quit [**4-/2195**], 70 pack year history
ETOH:denies
Illicit drug use: denies
Family History:
Grandfather died of MI in his 50s
Physical Exam:
Admission:
Pulse:71 Resp:16 O2 sat: 99%RA
B/P Right:116/74 Left: 113/66
Height: 6'3" Weight:250 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: no
Dishcarge
T: 97.8 HR: 79 SR BP: 124/70 Sats: 95% RA
General: walking in halls no apparent distress
HEENT: normocephalic, mucus membranes moist
Neck: supple, no lyphadenopathy
Card: RRR normal S1,S2 no murmur/gallop or rub
Resp: diminished breath sounds otherwise clear
GI: bowel sounds positive, abdomen soft non-tender/non-distended
Extr: warm 1+ edema bilateral
Incision: sternal incision clean, no erythema, no click
Neuro: non-focal
Pertinent Results:
[**2195-8-31**] ECHO
PREBYPASS
The interatrial septum is aneurysmal. A patent foramen ovale is
present with right to left flow demonstarted with agitated
saline comtrast and Valsalva/release.. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe regional left ventricular
systolic dysfunction with akinesis of the apex distal anterior,
inferior, lateral and septal walls and mid anterior,
anteroseptal and inferoseptal walls. The remaining wall are
hypokinetic. Overall left ventricular systolic function is
severely depressed (LVEF= <20 %). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Physiologic mitral regurgitation is seen
(within normal limits).
POSTBYPASS
There is improvement of the inferolateral and anterolateral
walls.(LVEF 20-25%) Akinetic areas remain unchanged. RV systolic
function remains unchanged. No color flow Doppler is visualized
through the interatrial septum. No agitated saline contrast is
visualized across the septum and rest or with Valsalva/release.
MR remains trace.
[**2195-8-31**] Carotid U/S
No hemodynamically significant stenosis.
[**2195-8-28**] Cardiac Catheterization
1. Coronary angiography in this co-dominant system demonstrated
three
vessel disease. The LMCA was long with mild luminal
irregularities. The
proximal LAD had focal calcification and was totally occluded
after a
high 1st diagonal branch and 1st septal branch. The mid-distal
LAD
filled vial left-to-left collaterals. The 1st diagonal branch
had mild
luminal irregularities. The LCx had proximal-mid vessel tapering
that
culminated in a 60% stenosis before OM2. The OM2 had mild origin
stenosis. There were distal collaterals from the LCx to the
RPL/RPDA
system. The RCA had diffuse disease with a 70% proximal
stenosis, a 50%
mid stenosis, and a 80% distal stenosis with subsequent total
occlusion.
There was minimal filling iof the distal RCA, RPDA, and RPL.
2. Resting hemodynamics revealed mildly elevated right and left
sided
filling pressures with RVEDP of 14 mmHg and LVEDP of 18 mmHg.
The
pulmonary arterial systolic pressure was normal at 27 mmHg. The
cardiac
index was preserved at 2.8 L/min/m2. There was normal systemic
arterial
pressure with SBP of 101 mmHg and DBP of 61 mmHg.
3. There was no evidence of significant right-to-left or
left-to-right
shunting based on oxygen saturation.
CXR: [**2195-9-4**] FINDINGS: In comparison with study of [**9-2**], the
right IJ sheath has been removed. There is a persistent, though
apparent decreasing opacification at the left base, consistent
with effusion and atelectasis. Mild atelectatic changes are seen
at the right base medially.
[**2195-9-4**] WBC-9.8 RBC-3.61* Hgb-10.4* Hct-30.6* Plt Ct-181
[**2195-9-4**] Glucose-121* UreaN-15 Creat-0.9 Na-136 K-4.5 Cl-97
HCO3-29 Mg-2.1
Brief Hospital Course:
Mr. [**Known lastname 82897**] was admitted to the [**Hospital1 18**] on [**2195-8-28**]. He underwent a
cardiac catheterization which revealed severe three vessel.
Given the severity of his disease, the cardiac surgical service
was consulted for surgical revascularization. He was worked-up
in the usual preoperative manner including a carotid duplex
ultrasound which showed no hemodynamically significant disease.
On [**2195-9-1**] Mr. [**Known lastname 82897**] was taken to the operating room where he
underwent coronary artery bypass grafting to three vessels and
closure of a patent foramen ovale. Please see operative note for
details.
Postoperatively he was taken to the intensive care unit for
monitoring. Within 24 hours, he awoke neurologically intact and
was extubated. On [**2195-9-2**], Mr. [**Known lastname 82897**] was transferred to the
step down unit for further recovery. He was gently diuresed
towards his preoperative weight. His electrolytes were repleted
as needed. The chest-tube and pacing wires were removed per
protocol. He was followed by serial chest films which revealed
small left lower lobe effusion with atelectasis. The foley was
removed and he voided without difficulty. The physical therapy
service was consulted for assistance with his postoperative
strength and mobility. He was started on coreg 3.125 which he
tolerated. His home meds were restarted. His pain was well
controlled with Dilaudid and motrin. He tolerated a regular
diet. He made steady progress and was discharged to home on
[**2195-9-5**]. He will follow-up as an outpatient.
Medications on Admission:
Warfarin 7', Simvastatin 40', Carvedilol 6.25mg 1.5mg tab/am and
1.5 tab/pm, Lisinopril 5', ASA 81', Citalopram 20'
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. 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).
Disp:*30 Tablet(s)* Refills:*2*
5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Motrin 600 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: take with food and water.
Disp:*90 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day: take with lasix.
Disp:*30 Tablet Sustained Release(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass grafts
hypertension
Hyperlipidemia
h/o Anterior wall mycardial infarction
s/p Left Cerebellar CVA [**4-28**] without residual deficits
s/p orchiplexy
Discharge Condition:
Good.
Discharge Instructions:
Weigh yourself daily, call if weight goes up more than 2 pounds
[**Last Name (un) 5490**] or 5 pounds a week.
Take medications as directed on discharge instructions.
Do not drive for 4 weeks and while taking narcotics.
Do not lift more than 10 lbs. for 10 weeks.
Shower daily, let water flow over wounds, pat dry with a towel.
Do not use lotions, creams, or powders on wounds.
Call our office for sternal drainage or temperature greater
than100.5.
Followup Instructions:
Dr. [**First Name11 (Name Pattern1) 1158**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1159**] in [**11-21**] weeks ([**Telephone/Fax (1) 20587**]) .
Dr. [**First Name (STitle) **] [**Name (STitle) 1911**] in [**12-23**] weeks ([**Telephone/Fax (1) 62**]).
Dr. [**Last Name (STitle) **] for 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks.
please call for appointments
Completed by:[**2195-9-5**]
|
[
"311",
"V12.54",
"428.0",
"412",
"745.5",
"414.01",
"401.9",
"427.2",
"272.4",
"425.4",
"428.22",
"V15.82",
"V45.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"39.61",
"36.15",
"88.56",
"35.71",
"36.12",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
8469, 8537
|
5698, 7288
|
394, 560
|
8782, 8790
|
2674, 5675
|
9286, 9745
|
1527, 1562
|
7454, 8446
|
8558, 8761
|
7314, 7431
|
8814, 9263
|
1577, 2655
|
281, 356
|
588, 1100
|
1122, 1251
|
1267, 1511
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,105
| 110,948
|
18987+18988+57005
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2155-9-4**] Discharge Date:
Date of Birth: [**2107-11-15**] Sex: M
Service: Medicine
HISTORY OF PRESENT ILLNESS: This is a 47-year-old morbidly obese
Caucasian male with multiple medical problems who was recently
discharged from [**Hospital6 256**] on [**2155-9-1**] after a 50 day hospital stay in the Medical Intensive
Care Unit for endocarditis with enterococcus, pan resistant
Klebsiella and coagulation negative Staph bacteremia. He was on
multiple antibiotic regimens and is transferred back to [**Hospital6 1760**] from his rehabilitation facility.
The patient was in the Medical Intensive Care Unit for 50 days
and treated with multiple antibiotic regimens for endocarditis
with multiple resistant bacteria and was also noted to have a
somewhat altered mental status, as well as right upper extremity
paresis while in the Medical Intensive Care Unit. He was
discharged to [**Hospital3 **] Facility and was brought
back to the Emergency Department today for a question of altered
mental status and right upper extremity paresis.
The patient, his mother, and his wife state that nothing has
changed since his discharge from the Medical Intensive Care Unit
and in fact the patient has been doing significantly better since
he was discharged from [**Hospital6 256**]. His
right upper extremity paresis has been ongoing for the last two
weeks as is his lower extremity weakness. Per the patient's
wife, there is no noted change in the patient's mental status.
The intern from the Medical Intensive Care Unit was contact[**Name (NI) **] and
came down to the Emergency Department who confirmed that the
patient's mental status appeared much improved compared with the
time of his discharge.
The patient denies fevers, chills, night sweats, nausea,
vomiting, diarrhea, melena, bright red blood per rectum,
abdominal pain, headaches, visual changes. He reports chronic
back pain since being stationary in his bed.
PAST MEDICAL HISTORY:
1. Morbid obesity.
2. Diabetes mellitus type 2.
3. Prostate cancer, status post radical prostatectomy with
perineal approach in [**2154-11-24**] complicated by multiple
wound infections. Prostate cancer was [**Doctor Last Name **] 6 adenocarcinoma.
4. Hypercholesterolemia.
5. Hypertension.
6. Depression/anxiety.
7. Endocarditis - aortic valve vegetation, enterococcus, pan
resistant Klebsiella bacteremia and coagulation negative Staph
bacteremia.
8. Baseline confusion.
9. Right hand/upper extremity paresis.
10. Echocardiogram done on [**2155-8-4**] significant for left
ventricular ejection fraction over 55% with 3+ aortic
regurgitation and 2+ mitral regurgitation.
11. Catheterization on [**2155-7-23**] negative for CAD.
MEDICATIONS:
1. Metoprolol 50 mg b.i.d.
2. Imipenem 500 intravenous q. 8.
3. Epogen 15,000 subcutaneously three times a week.
4. Ciprofloxacin intravenously 400 mg q. 12 hours.
5. Aspirin 81 mg q.d.
6. Klonopin 1 mg nasogastric tube t.i.d.
7. Zoloft 50 mg q.d.
8. Heparin 5,000 subcutaneously.
9. Atrovent/albuterol inhalers.
10. Capoten 50 mg t.i.d.
11. Zantac 150 b.i.d.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Vital signs: Temperature 96.9. Blood
pressure 111/54. Heart rate 100. Respiratory rate 20.
Oxygen saturation 100% on room air. General: Morbidly obese
male, uncomfortable, appears in distress, noncompliant with
interview. Head, eyes, ears, nose and throat: Pupils equal,
round and reactive to light. Extraocular movements intact.
Moist mucous membranes. Oropharynx clear. Neck: Supple,
full range of motion, no evidence of jugular venous
distention, trachea was in place and appears clean, dry and
intact. Lungs: Distant breath sounds but clear to
auscultation bilaterally. Cardiovascular: Distant heart
sounds, but regular rate and rhythm, normal S1, S2, systolic
murmur appreciated. Abdomen: Obese, G tube site clean, dry
and intact, normal active bowel sounds, soft, nontender,
nondistended. Extremities: Nonpitting edema at the
bilateral lower extremities and edema of the right upper
extremity, no clubbing or cyanosis. Neurological: Alert and
oriented times three, cranial nerves II through XII are
grossly intact, bilateral lower extremities 4/5 strength,
right upper extremity moves fingers, sensation is intact.
LABORATORIES: White blood cell count 14.3, hematocrit 27.0,
platelet count 410,000. Sodium 138, potassium 3.7, chloride
101, bicarbonate 25, BUN 18, creatinine 0.6, glucose 104.
Urinalysis positive nitrates, trace leukocytes. Head CT: No
bleed, no mass effect.
HOSPITAL COURSE:
1. Infectious Disease: The patient was admitted with a history
of endocarditis with bacteremia secondary to multiple strains of
various bacteria with varying resistant patterns. Blood cultures
drawn on the day of the patient's admission were positive for [**3-28**]
blood culture bottles with coagulation negative Staph, all
sensitive to vancomycin, rifampin and tetracycline. The patient
was immediately placed on vancomycin 1 gram intravenously q. 12
hours. Vancomycin levels were drawn and noted to be within the
normal range. The patient had a PICC line from his stay in the
Medical Intensive Care Unit that was discontinued. The tip was
sent for culture and came back with coagulation negative Staph
also resistant to methicillin, sensitive to tetracycline and
vancomycin. The patient was continued on vancomycin for line
infection and recurrent bacteremia. He was continued on
ampicillin for suppressive therapy given his endocarditis and
recurrent bacteremia. The patient remained febrile throughout
his hospitalization and denied any symptoms localizing any
further infection. The infectious disease team assisted in
comanagement of his infection during the hospitalization.
2. Endocarditis: The Cardiothoracic Surgery Team was re-
consulted once the patient was re-admitted to the hospital. Dr.
[**Last Name (STitle) 1537**] and his team saw the patient and agreed to take him to the
Operating Room on [**Last Name (LF) 766**], [**9-15**] for a valve replacement
therapy. A Surgery Consult, chest x-ray, and a urinalysis were
done for preop. The patient was continued on vancomycin and
ampicillin for endocarditis.
3. Neurology: The patient was admitted with a questionable
history of altered mental status but was noted to be alert and
oriented times three throughout his hospitalization. The
Neurology Consult Team was involved in the patient's care for his
right upper extremity paresis and lower extremity weakness.
Mononeuritis multiplex was the prevailing theory in terms of the
etiology for the patient's multifocal deficits. Given that the
treatment for this syndrome is high dose steroids, and the
patient was not a candidate for steroids given his bacteremia,
sacral ulcers and his preoperative status, it was decided not to
place him on steroids upon admission. The Neurology Team also
expressed a concern of abscesses in the patient's spinal cord or
brain and recommended an MRI. Given that the patient's weight
exceeded the limit for the MRI, this was not an option. The
neuroradiologist was contact[**Name (NI) **] and felt that a CT scan was
significantly inferior for detecting abscesses in the spine and
brain and therefore further work-up of the patient's mononeuritis
multiplex was postponed and he was continued on treatment for his
bacteremia.
4. Endocrine: The patient was admitted with a history of
diabetes mellitus type 2 and was maintained on glargine 60 units
q.h.s. with an insulin sliding scale. He had well-controlled
blood sugars throughout his hospitalization.
5. Cardiovascular: The patient was admitted with a history of
hypertension, hypercholesterolemia and diabetes mellitus type 2.
He was maintained on his aspirin, beta-blocker and ACE inhibitors
throughout his hospitalization and was known to be
hemodynamically stable. He denied any chest pain, shortness of
breath, or palpitations throughout his hospitalization. See
above for details of his endocarditis.
6. Pulmonary: The patient demonstrated adequate oxygen
saturations throughout his hospitalization (on trach mask) and
was maintained on his albuterol and ipratropium MDI.
7. Fluid, electrolytes and nutrition: The patient was admitted
with a G tube and on tube feeds. A Nutrition Consult was
obtained and the patient was maintained on hypocaloric high
protein tube feeds throughout his hospitalization, in order to
promote weight loss while maintaining nutritional status. A
weight taken demonstrated that the patient lost approximately 90
pounds since his stay in the Medical Intensive Care Unit. A
speech and swallow study was obtained to evaluate the patient's
swallow for evidence of aspiration. The patient's diet was
advanced and he was able to take solids, but also continued tube
feeds in order to maintain adequate nutrition. He was maintained
on his hypocaloric tube feeds throughout his hospitalization.
8. Decubitus ulcer: The patient was noted to have two Stage 1
and one Stage 2 sacral decubitus ulcers. A wound care nurse
followed the patient throughout his hospitalization. The
patient's ulcers were managed with b.i.d. Tegaderm dressing
changes.
An addendum will be added to address the patient's
continued medical care after [**2155-9-13**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**First Name3 (LF) 13272**]
MEDQUIST36
D: [**2155-9-13**] 02:25
T: [**2155-9-13**] 17:37
JOB#: [**Job Number 51883**]
Admission Date: [**2155-9-4**] Discharge Date: [**2155-10-2**]
Date of Birth: [**2107-11-15**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This 47 year old morbidly obese
white male with multiple medical problems was recently
discharged from [**Hospital6 256**] on
[**2155-9-1**] after a 50 day hospital course for
endocarditis with panresistant Klebsiella and coagulase
negative Staphylococcus bacteremia on multiple antibiotic
regimens. He was transferred to rehabilitation and was not
happy with the rehabilitation and returned and was
readmitted.
PAST MEDICAL HISTORY: His past medical history is
significant for a history of morbid obesity, a history of
adult onset diabetes, history of prostate carcinoma, status
post radical prostatectomy with perineal approach in
[**2154-11-24**]. He had a [**Doctor Last Name 51884**] 6 adenocarcinoma. This
was complicated by multiple wound infections and he currently
has a large decubitus, history of hypercholesterolemia,
history of hypertension, history of depression and anxiety,
history of endocarditis with an aortic valve vegetation,
panresistant Klebsiella bacteremia and coagulase negative
Staphylococcus bacteremia, history of baseline confusion,
history of right hand decrease movement. He had an
echocardiogram on [**2155-8-4**] which revealed an ejection
fraction of greater than 55%, 3+ aortic regurgitation and 2+
mitral regurgitation and cardiac catheterization on [**2155-7-23**] revealed clean coronaries.
MEDICATIONS ON ADMISSION: Metoprolol 50 mg p.o. b.i.d.,
Imipenem 500 mg intravenously q. 8 hours, Epogen 15,000 units
subcutaneously q. [**Year (4 digits) 766**], Wednesday and Friday, Ciprofloxacin
400 mg intravenously q. 12 hours, Aspirin 81 mg p.o. q. day,
Klonopin 1 mg p.o. t.i.d., Zoloft 50 mg p.o. q. day, Heparin
5000 units subcutaneously b.i.d., Atrovent/Albuterol inhaler,
Captopril 50 mg p.o. t.i.d., Zantac 150 mg p.o. b.i.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: He is married, he smokes three packs a day
for ten years and quit five years ago. He does not drink
alcohol.
FAMILY HISTORY: Unremarkable.
REVIEW OF SYSTEMS: Significant for hematochezia found to be
from antibiotics for wound infection after prostate surgery,
chest pain and palpitations.
PHYSICAL EXAMINATION: On physical examination his
temperature maximum is 96.9, blood pressure 111/54, heartrate
100, respirations 20, oxygen saturation 100%. General: He
is a morbidly obese white male, uncomfortable, appears in
distress, noncompliant. Head, eyes, ears, nose and throat
examination, normocephalic, atraumatic, extraocular movements
intact, oropharynx benign. Neck: Supple, full range of
motion, no thyromegaly or lymphadenopathy. No jugulovenous
distension. Carotids 2+ and equal bilaterally without
bruits. Lungs were clear to auscultation and percussion.
Cardiovascular examination: Distant heartsounds. Regular
rate and rhythm. Normal S1 and S2 with no rubs, murmurs or
gallops. Abdomen was obese. Gastrostomy tube in place.
Normal bowel sounds, soft, nontender with no masses or
hepatosplenomegaly. Extremities: Nonpitting edema in
bilateral lower extremities and right upper extremity edema.
Neurological examination: He was alert and oriented times
three. Cranial nerves were intact. Bilateral lower
extremities had 4/5 strength. Right upper extremity, moved
fingers and sensation intact.
LABORATORY DATA: Laboratory data on admission revealed
hematocrit 27, white count 14,300, platelets 410,000, sodium
138, potassium 3.7, chloride 101, carbon dioxide 25, BUN 18,
creatinine 0.6, blood sugar 104. He had a head computerized
tomography scan which was negative.
HOSPITAL COURSE: He was admitted to the medical floor and
was continued on his antibiotics. He also had a large
decubitus which was being treated with Duoderm. He continued
to have positive blood cultures and he also had a trach in
place and was using Passy-Muir valve. Dr. [**Last Name (STitle) 1537**] was
reconsulted, he had seen him previously and he was evaluated
by Neurology who felt that they had limited treatment options
at this time and felt that he needed his valve fixed prior to
further workup. On [**9-15**], the patient underwent a
mitral valve replacement with a #27 Porcine mitral valve
replacement and a #23 pericardial mitral valve replacement.
He also had his tracheostomy removed at that time and was
nasotracheally intubated. He was transferred to the Cardiac
Surgery Recovery Unit on insulin, Levophed, Milrinone and
Propofol. He had a stable postoperative night. He had a
bronchoscopy for thick secretions on postoperative day #1.
He was continued on Vancomycin and Ampicillin and
Levofloxacin. He was eventually slowly weaned off of his
Milrinone. He had his chest tube discontinued on
postoperative day #2. He was eventually weaned off of his
Levophed as well and he was followed by Infectious Disease
who recommended discontinuing his Ampicillin on day #3. The
pathology of his valve revealed dead bacteria, it did not
grow anything and it was from his prior Enterobacter
endocarditis. He was restarted on his tube feeds. He was
heparinized to prevent deep vein thromboses. He was then
started on Zosyn on postoperative day #5. He did grow out
Klebsiella from his sputum and he had coagulase negative
Staphylococcus on the line tip. He was unable to wean from
the ventilator and on postoperative day #8 he went back to be
retrached, tolerated the procedure well and continued to
slowly improve. He was weaned off of the Milrinone on
postoperative day #12 and he was aggressively diuresed
throughout this time. He did go into atrial fibrillation at
that point. His Lopressor was increased and he was started
on Amiodarone and he converted to sinus rhythm. He was
weaned off of the ventilator on postoperative day #13 and he
had a swallowing evaluation on postoperative day #16 and
passed with thin liquids, food and could tolerate everything.
He was continued on his tube feeds but started eating. On
postoperative day #16 he was noted to have his right shoulder
dislocated, this had been going on for a few days according
to the patient. He had shoulder films and was evaluated by
Orthopedics and they are repeating the films and will decide
on the treatment for that tomorrow. They will try to reduce
it, if it truly is dislocated and then he will probably need
a sling after that. On postoperative day #17 he was
discharged to rehabilitation in stable condition.
His laboratory data on discharge revealed white count 15,100,
hematocrit 37.7, platelets 429. Sodium 141, potassium 4,
chloride 95, carbon dioxide 32, BUN 43, creatinine 0.9, and
blood sugar 169.
MEDICATIONS ON DISCHARGE:
Percocet 1 to 2 p.o. q. 4-6 hours prn pain
Zantac 15 mg p.o. b.i.d.
Colace 100 mg p.o. b.i.d.
Clonazepam 1 mg p.o. t.i.d.
Sertraline 50 mg p.o. q. day
Ascorbic acid 50 mg p.o. b.i.d.
Zinc Sulfate 220 mg p.o. q. day
Multivitamins one p.o. q. day
Lopressor 50 mg p.o. b.i.d.
Amiodarone 400 mg b.i.d. for seven days and then decrease to
400 mg p.o. q. day for seven days and then decreased to 200
mg p.o. q. day
Mycostatin powder prn
Nystatin 5 cc p.o. q.i.d.
Albuterol inhaler 1-2 puffs q. 6 hours prn
Lasix 40 mg intravenously b.i.d.
Zosyn 4.5 mg intravenously q. 8 hours times 26 days
Heparin 5000 units subcutaneously b.i.d.
Potassium 40 mEq p.o. b.i.d.
Regular insulin sliding scale
FOLLOW UP: He will be followed by Dr. [**Last Name (STitle) **] in one week
following discharge from rehabilitation and by Dr. [**Last Name (STitle) 1537**] in
four weeks. He should have his staples discontinued in two
weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 11726**]
MEDQUIST36
D: [**2155-10-1**] 17:51
T: [**2155-10-1**] 18:44
JOB#: [**Job Number 51885**]
Name: [**Known lastname 4996**], [**Known firstname 77**] Unit No: [**Numeric Identifier 9645**]
Admission Date: [**2155-9-4**] Discharge Date: [**2155-10-6**]
Date of Birth: [**2107-11-15**] Sex: M
Service: Cardiac Surgery
Patient was originally scheduled to be discharged to rehab on
[**10-2**], however, the patient began complaining of right
shoulder pain. Shoulder films were obtained and there was a
question whether or not patient had dislocation of the
shoulder. Orthopedics consult was obtained. The Orthopedic
team was unable to determine the status of the patient's
shoulder on the previous films.
Patient underwent a CT scan of his shoulder, which showed
that it was not dislocated. A small glenohumeral effusion,
no fracture consistent with calcific tendinitis and early
frozen shoulder in the setting of right upper extremity
paresis. There was no intervention recommended by them at
that time.
Also on the evening of [**10-2**], the patient went into
rapid atrial fibrillation. Required IV Lopressor with the
administration of the IV Lopressor. The patient continued to
have a rapid ventricular response and required cardioversion
for his atrial fibrillation. The patient was cardioverted
into sinus rhythm with 100 joules x1. Patient tolerated this
procedure well.
On the morning of [**10-3**], the patient was still mildly
hypotensive with the patient's BUN and creatinine ratio being
greater than 40:1, and patient being 10 kg below his
preoperative weight. It was determined the patient was on
intravascularly dry. Patient was given couple of IV fluid
boluses with good response in his blood pressure. Patient
was also noted to have a low grade temperature. On [**10-4**], the patient was pancultured. Was found to have greater
than 100,000 colonies of yeast in his urine. Was started on
fluconazole. Sputum cultures showed pseudomonas. The
pseudomonas in his sputum was sensitive to everything except
meropenem.
The patient continued on his Zosyn and ciprofloxacin was
started. Patient continued on a Heparin drip. Patient was
started on Coumadin for anticoagulation for atrial
fibrillation, and the patient has remained hemodynamically
since.
CONDITION ON DISCHARGE: T max 98.7. Heart rate 88 in sinus
rhythm. Blood pressure 96/49. Respiratory rate 16. Oxygen
saturation 98% on a 40% trache collar with a Passy-Muir valve
in place. Patient is awake, alert, and oriented times three.
Heart: Regular, rate, and rhythm without rub or murmur.
Lungs are coarse bilaterally. Sputum is minimal to moderate
amount of yellow thick, which the patient is coughing and
clearing on his own. Abdomen is obese, positive bowel
sounds, nontender. Patient is tolerating a regular diet.
Patient is having tube feeds cycled from 6 p.m. to 6 a.m. as
patient is not taking his full calorie requirement and p.o.
Laboratory data for [**10-6**]: White blood cell count 11,
hematocrit 35, platelet count 303. Sodium 133, potassium
3.6, chloride 90, bicarb 32, BUN 34, creatinine 0.9, blood
sugar 175.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 1-2 tablets p.o. q.4-6h. prn.
2. Zantac 150 mg p.o. b.i.d.
3. Colace 100 mg p.o. b.i.d.
4. Clonazepam 1 mg p.o. t.i.d.
5. Sertraline 50 mg p.o. q.d.
6. Vitamin C 500 mg p.o. b.i.d.
7. Zinc sulfate 220 mg p.o. q.d.
8. Multivitamin one p.o. q.d.
9. Lopressor 50 mg p.o. b.i.d.
10. Amiodarone 400 mg p.o. b.i.d. x7 days, then 400 mg p.o.
q.d. x7 days, then 200 mg p.o. q.d.
11. Miconazole nitrate powder one application b.i.d. to
effected areas.
12. Nystatin swish and swallow 5 cc p.o. q.i.d.
13. Albuterol MDI 1-2 puffs q.6h. prn.
14. Lasix 40 mg p.o. b.i.d.
15. Zosyn 4.5 grams IV q.8h. x26 days.
16. Potassium chloride 20 mEq p.o. b.i.d.
17. Fluconazole 400 mg p.o. q.d. x10 days.
18. Heparin infusion at 1800 units which will continue until
the patient's INR is greater than 2. PTT should be
maintained between 50-60.
19. Coumadin: Patient should receive 5 mg on [**10-6**]. INR
should be checked on [**10-7**] and Coumadin to be titrated for an
INR of 2.0.
20. Regular insulin-sliding scale: Blood sugar 120-150 give
3 units subQ, blood sugar at 150-200 give 6 units subQ, blood
sugar 201-250 give 9 units subQ, blood sugar 251-300 give 12
units, blood sugar 301-350 give 15 units subQ, blood sugar
greater than 50 give 20 units.
21. Guaifenesin syrup 100 mg in 5 cc, 5-10 cc p.o. q.6h. prn.
22. Ciprofloxacin 400 mg IV b.i.d. x10 days.
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**]
Dictated By:[**Last Name (NamePattern1) 5788**]
MEDQUIST36
D: [**2155-10-6**] 08:59
T: [**2155-10-6**] 09:01
JOB#: [**Job Number 9646**]
|
[
"707.0",
"421.0",
"278.01",
"790.7",
"996.62",
"354.5",
"482.1",
"427.31",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"81.91",
"38.93",
"33.23",
"99.61",
"35.23",
"35.21",
"97.37",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
11666, 11681
|
20579, 22220
|
16283, 16969
|
11070, 11521
|
13259, 16257
|
16981, 19710
|
11856, 13241
|
11701, 11833
|
9706, 10120
|
4549, 4576
|
10143, 11043
|
11538, 11649
|
19735, 20556
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,360
| 112,380
|
53306+53307
|
Discharge summary
|
report+report
|
Admission Date: [**2103-9-15**] Discharge Date:
Service:
HISTORY OF PRESENT ILLNESS: This is an 81-year-old woman
with a past medical history of dermatomyositis on chronic
steroids, and hypertension, who was transferred from [**Hospital6 3622**] on [**2103-9-15**], after presenting with
chest pain radiating to the left arm, shortness of breath,
diaphoresis, and malaise. She then demonstrated a non-Q wave
myocardial infarction with CPK greater than 1100, and
troponin-T of .82. She underwent echocardiogram and
catheterization, which showed three vessel disease with 50 to
80% stenosis in the left anterior descending, and 95%
stenosis in the D1, 50% stenosis of the circ, 80% stenosis of
the obtuse marginal I, 90% stenosis of the obtuse marginal
II, an ejection fraction of 65%, and 4+ mitral regurgitation.
She additionally had been found to be in atrial flutter at
the outside hospital, and was started on a Diltiazem drip as
well as heparin.
On [**9-15**], she was transferred to [**Hospital1 190**] for further management, and was admitted to
Cardiothoracic Surgery service.
PAST MEDICAL HISTORY: Significant for dermatomyositis, on
chronic prednisone, hypertension, gastroesophageal reflux
disease, macular degeneration, status post colectomy, status
post cholecystectomy, status post right total hip
replacement, and depression.
MEDICATIONS: Medications on transfer included Diltiazem
drip, heparin drip, Digoxin .25 once daily, aspirin 325 once
daily, Losartan 25 once daily, atenolol 25 twice a day, and
prednisone 5 mg once daily.
ALLERGIES: She was admitted with no known drug allergies,
but subsequently developed a poor tolerance for morphine,
which caused confusion and hallucinations.
PHYSICAL EXAMINATION: On admission, blood pressure was
145/65, heart rate 145, respiratory rate 20, oxygen
saturation 99%, temperature 97.7, weight 59.4 kg. Her lungs
had minimal crackles bilaterally. The heart was tachycardic
and regular. The abdomen was soft, nontender, nondistended.
The extremities had minimal edema.
LABORATORY DATA: On admission, white count 9.8, hematocrit
37.0, platelets 242. PT 13.3, PTT 93. Sodium 138, potassium
4.0, chloride 96, bicarbonate 27, BUN 15, creatinine 0.4,
glucose 120. Calcium 1.05, magnesium 1.9.
HOSPITAL COURSE: The patient underwent a three vessel
coronary artery bypass graft on [**9-17**], including a left
internal mammary artery to the left anterior descending,
saphenous vein graft to the obtuse marginal, and saphenous
vein graft to the D1. Additionally, she continued to have
atrial flutter, for which she was started on Lopressor and
amiodarone, and her heparin drip was continued. A TSH was
checked and was within normal limits. She additionally had a
urinary tract infection, for which she was treated with Cipro
for three days.
Postoperatively, she was extubated on [**9-18**], however, she
required reintubation on [**9-20**] secondary to pulmonary
secretions and respiratory distress. She was started on
levofloxacin and Flagyl for presumed aspiration. On [**9-21**], she underwent a repeat catheterization, which showed her
grafts to be patent, her mitral regurgitation to be decreased
to 1 to 2+, and an ejection fraction of 50%. She was again
extubated on [**9-22**], and underwent a swallowing study on
[**9-25**], which was positive for aspiration. Subsequently
the patient was started on tube feeds.
The patient was noted to have bloody stools on [**9-26**],
and her heparin was discontinued. On [**9-28**], she again
required reintubation for respiratory failure, and she
underwent a bronchoscopy which showed aspirated barium from
her swallowing study in her right bronchial system.
Additionally, Infectious Disease consultation was requested,
and the patient was changed from levofloxacin to Zosyn 4.5 mg
every eight hours in addition to Flagyl, for worsening
pneumonia.
On [**9-29**], she continued to have bloody bowel movements,
and she was lavaged, which was clear. She was transfused
packed cells, and a Gastroenterology consultation was
requested. The patient subsequently had an
esophagogastroduodenoscopy and percutaneous endoscopic
gastrostomy tube placement on the 11th.
Esophagogastroduodenoscopy revealed gastritis.
On [**9-29**] as well, the patient had a blood culture
return positive for coag negative staph. Vancomycin had been
added to the patient's regimen of Zosyn and Flagyl starting
on [**9-29**], and was continued for a ten day total.
On [**9-30**], a Rheumatology consultation was obtained,
which concluded that the patient was not having a flare of
her dermatomyositis, and she was switched to Solu-Medrol 8 mg
intravenously twice a day.
On [**10-1**], the patient had a tracheostomy performed,
and a repeat bronchoscopy to check tracheostomy placement and
suction secretions. On [**10-1**], the patient's Flagyl
was discontinued, given low suspicion for anaerobic
infection.
On [**10-3**], the patient had had recurrent atrial
flutter, and she underwent DC cardioversion, which was
successful. She was continued on her Lopressor and
amiodarone. After receiving approximately two weeks of 400
mg by mouth twice a day, the patient was decreased to 400 mg
by mouth once daily, which was ultimately reduced to 200 mg
once daily after approximately ten days due to bradycardia.
On [**10-5**], the patient was noted to have again a rising
white blood cell count. Chest CT and thoracentesis were
recommended. Her anticoagulation was held prior to this
procedure. She underwent a thoracentesis on the 16th, where
300 cc of serous fluid was removed. Prior to the
thoracentesis, she had a chest CT which showed multilobar
pneumonia, large effusions, consolidation in multiple lobes,
bilateral lower lobe collapse. A CT had been performed prior
to her thoracentesis.
On [**10-8**], the patient underwent a repeat bronchoscopy,
where a small amount of barium was noted to be present.
Additionally, the patient was noted to have vesicles
throughout the right main stem bronchus area, which was felt
to be possibly a chemical irritation vs. possible infectious
etiology. Specimens were sent to the Laboratory, which
showed cultures all negative at the time of this dictation,
and pathology of the biopsy taken during the bronchoscopy
showed squamous metaplasia and acute inflammation. The
patient was continued on her Zosyn.
On [**10-9**], the patient's vancomycin was discontinued
after a ten day course. Additionally, she was noted to have
bloody pulmonary secretions. Because of this and her recent
history of gastritis with bloody stools, and the fact that
she was now in normal sinus rhythm, the patient's
anticoagulation was held. On [**10-9**], the patient was
transferred from the general floor back to the Intensive Care
Unit, as her pulmonary secretions required more frequent
suctioning.
In the Intensive Care Unit, she received aggressive pulmonary
toilet. Cultures were followed, which were all negative at
the time of this dictation. The patient's white count was
decreasing, and she remained afebrile. A chest x-ray on
[**10-11**] raised a question of a possible area of aerated
lung vs. cavity, and the patient underwent repeat CT scan on
[**10-12**], which revealed no abscess, but pockets of
aerated lung.
The patient's pulmonary secretions decreased considerably
over the next several days, and rehabilitation planning was
arranged. The patient remained in normal sinus rhythm and,
as noted above, her amiodarone was decreased to 200 mg by
mouth once daily secondary to bradycardia. She was continued
on her lasix and afterload reducing agents as well as the
rest of her antihypertensive medications. She was continued
on Zosyn for her pneumonia, with the last day, per Infectious
Disease consult service, to be [**10-13**]. Additionally,
her Solu-Medrol was continued for her dermatomyositis.
During her time in the Intensive Care Unit, the patient also
requested that her code status be changed to Do Not
Resuscitate/Do Not Intubate. This was discussed with both
the patient and her daughter, and they both agree.
Currently rehabilitation screening is taking place. The
patient has been maintained on trach mask and FIO2 of 0.4,
with very acceptable saturations, and significant improvement
in her pulmonary secretions. She will need follow up after
discharge with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **],
here in [**Location (un) 86**], as well as with Dr. [**Last Name (STitle) **], her
cardiothoracic surgeon.
DISCHARGE MEDICATIONS: Prozac 10 mg once daily, Ambien 10
mg daily at bedtime, Solu-Medrol 8 mg intravenously every 12
hours, Norvasc 5 mg once daily, Zosyn 4.5 grams intravenously
every eight hours through [**2103-10-13**], ProMod with fiber tube
feeds, Lopressor 25 mg twice a day, Colace 100 mg twice a
day, Hydralazine 5 mg four times a day, Lisinopril 80 mg once
daily, Prevacid 30 mg once daily, amiodarone 200 mg once
daily, lasix 20 mg once daily.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Name8 (MD) 29900**]
MEDQUIST36
D: [**2103-10-12**] 20:35
T: [**2103-10-13**] 00:45
JOB#: [**Job Number 6368**]
Admission Date: [**2103-9-15**] Discharge Date: [**2103-10-17**]
Service: [**Company 191**]
HISTORY OF PRESENT ILLNESS: THis is an 81 year-old woman
with a past medical history of dermatomyositis on chronic
steroids and hypertension who was transferred from [**Hospital6 3622**] on [**2103-9-15**] after presenting with chest
pain radiating to the left arm, shortness of breath,
myocardial infarction with CPK greater then 11,000 and
troponin T of .82. She underwent electrocardiogram and
catheterization, which showed three vessel disease 50 to 80%
stenosis in the left anterior descending and 95% stenosis in
the D1, 50% stenosis at the circumflex, 80% stenosis of the
obtuse marginal one, 90% stenosis of the obtuse marginal two
and an ejection fraction of 65% and 4+ mitral regurgitation.
the outside hospital and was started on a Diltiazem drip as
well as heparin.
On [**9-15**] she was transferred to [**Hospital1 190**] for further management and was admitted to the
Cardiothoracic Surgery Service.
PAST MEDICAL HISTORY: Significant for dermatomyositis on
chronic Prednisone, hypertension, gastroesophageal reflux
disease, macular degeneration, status post colectomy, status
post cholecystectomy, status post right total hip replacement
and depression.
MEDICATIONS ON TRANSFER: Diltiazem drip, heparin drip,
Digoxin .25 once a day, aspirin 325 mg once a day, Losartan
25 mg once a day, Atenolol 25 mg twice a day and Prednisone 5
mg once a day.
SOCIAL HISTORY: Prior to her coronary artery bypass graft
the patient lived in [**Location **] with her two sons. She has
smoked for many years approximately two cigarettes per day
recently. She has known DNR/DNI.
PHYSICAL EXAMINATION: On admission blood pressure was
145/65. Heart 145. Respiratory rate 20. Oxygen saturation
99%. Temperature 97.7. Weight 69.4 kilograms. Her lungs
had minimal crackles bilaterally. Her heart was tachycardic
and regular. The abdomen was soft, nontender, nondistended.
Extremities had minimal edema.
LABORATORY DATA ON ADMISSION: White count 9.8, hematocrit
37.0, platelets 242, PT 13.3, PTT 93. Sodium 138, potassium
4.0, chloride 96, bicarb 27, BUN 15, creatinine 0.4, glucose
120, calcium 10.5, magnesium 1.9.
HOSPITAL COURSE: The patient underwent a three vessel
coronary artery bypass graft on [**9-17**] including a left
internal mammary coronary artery to the left anterior
descending coronary artery, saphenous vein graft to the
obtuse marginal, and saphenous vein graft to the D1.
Additionally she continued to have atrial flutter, for which
she was started on Lopressor and Amiodarone and her heparin
drip was discontinued. TSH was checked and was within normal
limits. She additionally had a urinary tract infection for
which she was treated with Cipro for three days.
Postoperatively, she was extubated on [**9-18**], however, she
required reintubation on [**9-20**] secondary to pulmonary
secretions and respiratory distress. She was started on
Levofloxacin and Flagyl for presumed aspiration. On [**9-21**] she underwent a repeat catheterization, which showed her
grafts to be patent, her mitral regurg to be decreased to 1
to 2+ and an ejection fraction of 50%. She was again
extubated on [**9-22**] and underwent a swallowing study on
[**9-25**], which was positive for aspiration. Subsequently
the patient was started on tube feeds.
The patient was noted to have bloody stools on [**9-26**] and her
heparin was discontinued. On [**9-28**] she again required
reintubated for respiratory failure and underwent a
bronchoscopy, which showed aspirated barium from her
swallowing study in her right bronchial system.
Additionally, ID consultation was requested and the patient
was changed from Levo to Zosyn 4.5 mg every eight hours in
addition to Flagyl for worsening pneumonia.
On [**9-29**] she continued to have bloody bowel movements and she
was lavaged, which was clear. She was transfused packed
cells and a GI consultation was requested. The patient
subsequently had an EGD and PEG tube placed on [**10-2**]. The
esophagogastroduodenoscopy revealed gastritis.
On [**9-29**] as well the patient had a blood culture return
positive for coag negative staph. Vancomycin had been added
to the patient's regimen of Zosyn and Flagyl starting on [**9-29**]
and was continued for a ten day course.
On [**9-30**] a rheumatology consultation was obtained, which
concluded that the patient was not having a flare of her
dermatomyositis and she was switched to Solu-Medrol 8 mg IV
b.i.d.
On [**10-1**] the patient had a trach performed and a repeat
bronchoscopy to check trach placement and to suction
secretions. On [**10-1**] the patient's Flagyl was discontinued
given low suspicions for her leg infections.
On [**10-3**] the patient had a recurrent atrial flutter, and she
underwent DC cardioversion, which was successful. She was
continued on her Lopressor and Amiodarone. After receiving
approximately two weeks of 400 mg by mouth the dose was
decreased to 400 once a day and then to 200 mg once a day
after approximately ten days secondary to bradycardia.
On [**10-5**] the patient was noted to have again a rising white
blood cell count. Chest CT and thoracentesis was
recommended. Her anticoagulation was held prior to this
procedure. She underwent a thoracentesis on the 16th where
300 cc of serous fluid was removed. Prior to the
thoracentesis she had a chest CT, which showed multi lobar
pneumonia, large effusions, consolidation of multiple lobes,
bilateral lower lobe collapse. A CT had been performed prior
to her thoracentesis. On [**10-8**] the patient underwent a repeat
bronchoscopy where a small amount of barium was noted to be
present. Additionally the patient was noted to have
vesicles throughout the right bronchus area, which was felt
to be a chemical irritation verses possible infectious
etiology. Specimens were sent, which were all negative.
Biopsy taken showed squamous metaplasia and inflammation.
On [**10-9**] the patient's Vancomycin was discontinued after a ten
course. She was also noted to have bloody pulmonary
secretions and her heparin was discontinued as she was now in
normal sinus rhythm. The patient was in the ICU as she
required aggressive pulmonary toilet. Cultures followed,
which were all negative. The white blood cell had decreased
and she remained afebrile. A chest x-ray on [**10-11**] suggested a
possible cavitary lesion, which was not seen on follow up CT
scan.
The patient's pulmonary secretions decreased considerably and
rehab planning was initiated. The patient remained in normal
sinus rhythm on Amiodarone 200 mg q.d. She was continued on
Lasix and after loading reducing agents. Zosyn was
discontinued on [**10-13**]. Solu-Medrol was continued for her
dermatomyositis. The patient was also maintained on a trach
mask with an FIO2 of 40% with SaO2 97%. The patient was made
DNR/DNI and this was discussed with the patient's daughter as
well. On [**10-14**] the patient was transferred from the Intensive
Care Unit to a regular medical floor. At the time of transfer to
the [**Company 191**] team the patient stated she was feeling better. She was
able to answer yes no questions and mouth the answers to other
questions as well. She stated she was still trying to cough and
needed suctioning, but less then before.
The patient remained hemodynamically stable while on the
medical floor. She was noted to have a relatively high blood
pressure ranging approximately 160 to 180 over 80 to 90.
Therefore her medications were altered to obtain optimal
blood pressure control. At the time of discharge the patient
was stilled continued on Norvasc, Hydralazine, Lisinopril and
Lopressor. Her current dose of Amiodarone was continued and
the patient remained in normal sinus rhythm. In addition,
the surgical wounds from her coronary artery bypass graft
surgery continued to heal appropriately and did not cause any
further problems.
The patient continued to require aggressive pulmonary toilet
while on the medical floor. She was also maintained on an
FIO2 of 40% via a mask over her trach, we will try to
maintain saturations of 100%. Nebulizers, suctioning and
inhalers were continued to maintain good pulmonary toilet.
The patient will require significant pulmonary rehabilitation
once discharged from the hospital, however, her pulmonary
status is currently stable at this time.
The patient had been maintained on tube feeds while in the
Medical Intensive Care Unit via a PEG tube placement. She
was at goal tube feeds of 60 cc per hour continuous feeding
of Promote with fiber. Prevacid was continued to treat
gastritis and Colace was continued to prevent constipation.
The patient had no further gastrointestinal problems over the
course of the hospital stay.
At the time of transfer to the medical floor all antibiotics
had been discontinued. The patient remained afebrile with a
normal white blood cell count over the remainder of the
course of her hospital stay. All blood cultures were
negative at the time of discharge.
The patient has a history of dermatomyositis, which was
stable over the course of the hospital stay. She was
continued on her current dose of Solu-Medrol without change.
Discussions were had between the patient, the social worker,
and the family regarding the patient's wishes and goals for
rehabilitation. She did admit of some feelings of depression
every now and then. Her current dose of Prozac was continued
as it was.
MEDICATIONS ON DISCHARGE: Prozac 10 mg per PEG tube q.d.,
Ambien 10 mg per PEG tube q.h.s., Solu-Medrol 8 mg IV q 12
hours, Norvasc 5 mg per PEG tube q.d. hold for systolic less
then 100. Promote with fiber 60 cc per hour per PEG tube.
Check residual q 8 hours, hold for residual greater then 150
cc per hour. Lopressor 100 mg per PEG tube b.i.d., hold for
systolic less then 100, heart rate less then 50. Colace 100
mg per PEG tube b.i.d., Hydralazine 5 mg per PEG tube q.i.d.,
hold for systolic less then 100. Lisinopril 80 mg per PEG
tube q.d., hold for systolic less then 100. Prevacid 30 mg
per PEG tube q.d., Amiodarone 200 mg per PEG tube q.d., Lasix
20 mg per PEG tube q.d., aspirin 81 mg per PEG tube q.d.,
Tylenol 650 mg per PEG tube q 6 hours prn, Dulcolax 10 mg per
PEG tube or per rectum q.d. prn constipation.
Desitin/Xylocaine jelly to the buttock area prn.
DISCHARGE STATUS: The patient was discharged to
rehabilitation in stable, but guarded condition.
DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft and myocardial infarction.
2. Mitral regurgitation.
3. Atrial flutter.
4. Aspiration pneumonia.
5. Hypertension.
6. Gastroesophageal reflux disease.
7. Dermatomyositis.
8. Colectomy.
9. Macular degeneration.
10. Depression.
11. Cholecystectomy.
12. Gastritis.
The patient is to follow up with her primary care physician
[**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 26790**] as well as her cardiac
surgeon Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 170**].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Name8 (MD) 8860**]
MEDQUIST36
D: [**2103-10-17**] 08:25
T: [**2103-10-17**] 08:32
JOB#: [**Job Number **]
|
[
"710.3",
"507.0",
"427.32",
"518.81",
"410.71",
"997.1",
"424.0",
"428.0",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"88.53",
"39.61",
"43.11",
"39.63",
"36.15",
"37.23",
"31.29",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
8620, 9425
|
18853, 20671
|
11574, 18826
|
11034, 11356
|
9454, 10343
|
11371, 11556
|
10625, 10793
|
10366, 10599
|
10810, 11011
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,860
| 141,888
|
31050
|
Discharge summary
|
report
|
Admission Date: [**2141-9-12**] Discharge Date: [**2141-9-15**]
Date of Birth: [**2058-12-27**] Sex: M
Service: UROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6736**]
Chief Complaint:
urinary retention
Major Surgical or Invasive Procedure:
TURP-trans urethral resection prostate
History of Present Illness:
HPI: Mr. [**Known lastname 73330**] is an 82 y/o man with PMH of
hypertension and BPH admitted for TURP on [**9-12**] now presenting to
the [**Hospital Unit Name 153**] for tachycardia. The patient was admitted on [**9-12**]
following elective TURP; the patient tolerated the procedure
without complication. He was set for discharge earlier today but
failed his voiding trial. At about 1600, he had a straight
catheterization after bladder scan showed 350 cc in his bladder.
At about 1700, the patient was found to be febrile to 102.6 with
heartrate in the 180s on routine vitals check; his blood
pressure at the time was 110/74. He denied any symptoms at that
time and had not been exerting himself. EKG demonstrated ?
atrial flutter at 180.
.
Labs were drawn and the patient was given lopressor 5 mg IV X 2
without success. Cardiology was consulted who felt that the
patient should received IV adenosine for supraventricular
tachycardia. However, prior to giving adenosine, cardiology was
called elsewhere and the patient could not receive adenosine on
the floor without cardiology at the bedside. Therefore, the
patient was transferred to the [**Hospital Unit Name 153**] for further care. Throughout
this time, the patient's blood pressure remained stable in the
110-140s and he was asymptomatic. For his fever, cultures were
sent and he was given a dose of vancomycin as his prior urine
culture (from [**9-4**]) has MRSE. Foley catheter was placed per
urology before transfer.
.
On arrival to the [**Hospital Unit Name 153**], the patient denies any chest pain,
palpitations, dizziness/lightheadedness, or difficulty
breathing. Initial heartrate remained in the 160s and blood
pressure transiently dropped to the 90s systolic. He received a
500 cc normal saline bolus at that time.
.
Past Medical History:
PMH:
Hypertension
BPH s/p TURP on [**9-12**]
Chronic renal insufficiency, recent creatinine 1.7
Anemia (baseline Hct 30-32)
h/o varicose vein stripping
.
Social History:
.
SH: Lives with his daughter who is a pediatrics resident at
[**Hospital1 **]. Prior smoker but quit in [**2096**]. Has one alcoholic
beverage rarely.
Family History:
FH: Stroke in patient's father.
Physical Exam:
PE: T: 102 BP: 147/63 HR: 164 RR: 19 O2 95% RA
Gen: Pleasant, well appearing gentleman who appears younger than
stated age
HEENT: No conjunctival pallor. No icterus. Mucous membranes
moist. OP clear.
NECK: Supple, JVD < 10 cm. No thyromegaly.
CV: regular tachycardic rhythm, no murmur appreciated
LUNGS: crackles at left base, otherwise clear
ABD: soft, nontender, hypoactive bowel sounds
EXT: warm & well perfused throughout, DP pulses 2+ bilaterally
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. Appropriate. Speaking clearly and in full
sentences, face symmetric, moving all extremities without
difficulty.
PSYCH: Listens and responds to questions appropriately, pleasant
.
Pertinent Results:
LABS:
WBC 11.9, Hct 30.3, Plt 236
sodium 136, K 3.4, Cl 99, HCO3 27, BUN 29, creatinine 2.5
glucose 142
CK 77 CKMB 3 trop < 0.01
Ca 8.5, mg 1.5, Phos 2.7
INR 1.3
.
UA: 121 RBCs, 6 WBCs, occasional bacteria, no epis, 30 protein
.
ABG: 7.49 / 37 / 136 (on O2 via nasal cannula)
.
Urine culture ([**9-4**]): MRSE
urine culture ([**9-13**]): pending
blood culture ([**9-13**]): pending
.
STUDIES:
EKG (baseline): sinus brady with PR prolongation, normal axis
EKG ([**9-13**], 1700): regular tachycardia with normal axis, ? p
waves at rate of 300 and ventricular rate (narrow QRS) at 180
EKG ([**9-13**], 2100):
.
CXR ([**9-13**]): faint LLL infiltrate (? atelectasis versus
pneumonia)
.
Brief Hospital Course:
A/P: This is an 82 y/o M with PMH of hypertension and BPH status
post TURP on [**9-12**] who presents to the [**Hospital Unit Name 153**] with tachycardia up
to 180s in setting of fever to
.
# Supraventricular tachycardia: Unclear trigger but did occur in
the setting of the fever and following straight catheterization.
Patient largely asymptomatic and returned to sinus rhyhtm
following 6 mg IV adenosine X 1. Does have PACs on
post-adenosine EKG. Could have a primary pulmonary event with
right heart strain though ABG on room air demonstrates at PO2 of
88. PE could present with fever and tachycardia, but patient is
not tachypneic and has only been in the hospital ~ 36 hours.
- continue monitoring on telemetry
- 2nd set of enzymes with AM labs
- consider echocardiogram in the morning
- cardiology consulted by urology, will touch base with consult
team in the morning for further recommendations
- replete electrolytes as necessary
.
# Fever: Likely related to recent instrumentation given
occurrence just after straight catheterization. He does have
MRSE in his urine from [**9-4**] and unclear which antibiotic he was
treated with prior to admission. Notes indicate Keflex ([**9-4**])
and prior to this, cipro is listed in his medication list in
OMR. Also has ? of infiltrate seen on CXR though absence of
oxygen requirement and respiratory symptoms.
- add on diff to earlier CBC
- vancomycin to cover MRSE
- given recent instrumentation of the GU tract and ? of
complicated UTI, will also given zosyn
- zosyn and vancomycin would also cover potential lung sources
of fever
- blood & urine cultures pending
.
# Hypertension: Will hold usual HCTZ given relative hypotension
in this setting.
.
# BPH: s/p TURP yesterday and was doing quite well until his
fever spike earlier tonight. Urology to continue following and
for now the patient has a foley catheter in place.
- continue tamsulosin per urology
.
# FEN: Regular, low salt diet. Replete lytes prn.
.
# PPx: Pneumoboots. bowel regimen prn. No need for PPI if
eating.
.
# CODE: Full.
.
# COMM: With patient and his daughter.
.
# DISP: ICU overnight for close monitoring.
Addendum (Urology)
In Brief, patient admitted for TURP. POD 1 developed urinary
retention after catheter removal. Pt was straight catheterized
and within an hour developed a fever of 102.2 and tachycardia in
the 200s. EKG showed SVT. Cards was consulted and recommended
adenosine. Due to hospital policy and an emergency that
Cardiology had to attend to, it was safest to transfer the
patient to the ICU in order to administer the adensoine. The
adenosine did break the rhythm and his rate was now 80. Patient
was stable and transferred back to the floor the next day. he
also received Vancomycin and a dose of Zosyn at this time, with
the presumption that this event was triggered by a transiet
bacteremia. His foley was removed POD 3 and a voiding trial was
performed. He did void and was stable to send home. He would
need to continue on 14 days of tetracycline for his bacteruria.
Medications on Admission:
.
MEDS:
HCTZ 12.5 mg daily
avodart 0.5 mg daily
flomax 0.4 mg daily
Discharge Medications:
1. 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*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
while taking narcotics.
Disp:*30 Capsule(s)* Refills:*0*
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
4. Tetracycline 500mg PO bid x 14days
Discharge Disposition:
Home
Discharge Diagnosis:
BPH and bilateral hydronephrosis
Discharge Condition:
stable
Discharge Instructions:
Call Urology office or go to your local Emergency Room if
1) Temp greater than 101
2) Nauseau and Vomitting for greater than 24 hours
3) Worsening Pain not relieved by Medications
4) Inability to Urinate
You may resume your home Medications
You may shower
Followup Instructions:
Call [**Hospital 159**] Clinic at [**Telephone/Fax (1) 164**] for follow up appointment
with Dr. [**Last Name (STitle) 3748**] or Dr. [**Last Name (STitle) **]
|
[
"788.20",
"600.01",
"427.42",
"591",
"596.0",
"285.21",
"403.90",
"997.5",
"599.0",
"585.9",
"996.64",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"57.94",
"60.29"
] |
icd9pcs
|
[
[
[]
]
] |
7651, 7657
|
4016, 7047
|
333, 374
|
7734, 7743
|
3308, 3993
|
8048, 8210
|
2556, 2590
|
7165, 7628
|
7678, 7713
|
7073, 7142
|
7767, 8025
|
2605, 3289
|
276, 295
|
402, 2193
|
2215, 2371
|
2387, 2540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,059
| 122,098
|
28528
|
Discharge summary
|
report
|
Admission Date: [**2150-8-22**] Discharge Date: [**2150-8-29**]
Date of Birth: [**2081-1-3**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 297**]
Chief Complaint:
BRBPR.
Major Surgical or Invasive Procedure:
EGD, s/p banding x6.
History of Present Illness:
69 year old male with hepatitis C cirrhosis, esophageal varices,
ascites, portal hypertension and recent admission for
hematemesis/BRBPR. He presents with two episodes of BRBPR. He is
status post variceal banding approximately 10 days ago. Today at
1:30 pm he noted two episodes of BRBPR and melena at the
commode. Did not feel dizzy or lith No nausea, vomiting, or
diarrhea. Pt also notes his abdominal girth has been increasing.
No fevers, chills or sweats. On presentation to the [**Name (NI) **], pt was
hemodynamically stable with pulse in 80's, SBP in 130's. Hct at
25 (baseline 28). Pt given two units of blood. While in [**Name (NI) **] pt
had another BRBPR and felt lightheaded at that time. Vital signs
remained unchanged. Pt subsequently admitted to MICU.
Past Medical History:
Hepatitis C - followed by Dr. [**First Name (STitle) 26390**] at [**University/College **] Pilgram;
contracted hepatitis C through blood transfusion
- hx of ascites treated with diuretics
PUD with bleed requiring transfusion in [**2125**]
Esophageal varices
HTN
Anemia
s/p prostate biopsy with + prostate CA, [**Doctor Last Name **] 4+3
Social History:
Married, retired from [**Company 22957**], tobacco: smoked "off and on" [**1-9**]
cigs per day x 46 years, quit 5 years ago; alcohol: quit 40
years ago, drank socially, no drugs
Family History:
Mom with Breast CA
Physical Exam:
VS: Temp: BP: 120-130/58 HR: 73 RR: 11 O2sat: 100% on RA
GEN: NAD, AOX3
Eyes: PERRL, anicteric, EOMI,
Mouth: MM dry , OP clear, no blood seen.
Neck: supple, no JVD, no blood
RESP: CTA b/l, no m/r/g
CV: regular, nl s1, s2, no m/r/g
ABD: soft but distended, BS hypoactive, no HSM, tympanic
EXT: no edema, +2 DP pulses
Brief Hospital Course:
A/P: 69 M with hep C cirrhosis, esophageal varices, portal HTN,
underwent upper endoscopy with bandings x6 on admission; pt had
to be intubated during this for airway protection. New portal
vein thrombosis on U/S confirmed on MRI. Presented with acute
renal failure concerning for hepatorenal syndrome. Despite
agressive therapy for his respiratory failure, and acute renal
failure and shock, clinical improvement was not made. As there
was no hope of liver recovery or transplant, goals of care
changed to comfort measures only after patient's family informed
he was not a candidate for liver transplant with portal vein
thrombosis and pressor requirement. Pt. passed away comfortably
in the AM of [**8-29**], 2d after comfort measures initiated
Medications on Admission:
Spironolactone
Lisinopril
Propranolol
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
HCV cirrhosis (MELD 28)
Recurrent EV bleed
ARF
PV thrombosis from confluence to RPV
Sepsis - source unclear, ascites clean
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"785.52",
"995.92",
"456.20",
"280.0",
"584.9",
"585.9",
"518.81",
"789.5",
"571.5",
"452",
"572.3",
"070.70",
"038.9",
"572.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"38.91",
"96.72",
"45.13",
"38.95",
"54.91",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2954, 2963
|
2086, 2837
|
320, 342
|
3130, 3139
|
3192, 3199
|
1710, 1730
|
2925, 2931
|
2984, 3109
|
2863, 2902
|
3163, 3169
|
1745, 2063
|
274, 282
|
370, 1138
|
1160, 1499
|
1515, 1694
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,322
| 152,910
|
11326
|
Discharge summary
|
report
|
Admission Date: [**2135-3-7**] Discharge Date: [**2135-3-23**]
Date of Birth: [**2074-2-6**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
dysphagia and weight loss
Major Surgical or Invasive Procedure:
Total gastrectomy
distal esophagectomy
esophagojejunostomy
tube jejunostomy
History of Present Illness:
This is a 60-year-old [**Location 7972**] gentleman who reports a
one-month history of dysphagia and weight loss. He was
initially evaluated by your nurse practitioner, [**First Name8 (NamePattern2) 1743**] [**Last Name (NamePattern1) **],
in clinic on [**1-28**]. At that time, he was reporting that both
food and liquids were getting hung up in his throat and he was
also complaining of some dyspepsia. He noticed a fairly
significant weight loss with his pant size going down two belt
buckles. She referred him for a barium upper GI swallow which
showed a long segment of irregular narrowing in the distal
esophagus with malignant features. A follow-up upper endoscopy
was performed by Dr. [**First Name4 (NamePattern1) 3613**] [**Last Name (NamePattern1) **] on [**2-21**] and this showed
an infiltrative, villous circumferential 4-cm mass of malignant
appearance at the cardia and fundus of the stomach. There was
evidence of a partial obstruction. Biopsies were performed and
show a poorly differentiated adenocarcinoma with signet ring
cells. He has been referred to me for further management.
Mr. [**Known lastname 15655**] reports that he is currently unable to eat meat or
bread and is largely eating only soups. He admits to a
decreased
appetite as well as an at least 20-pound weight loss over the
last month. He vomits on an almost daily basis without blood in
the vomit. He is passing normal formed bowel movements. He
denies any abdominal pain per se, but does have some dyspepsia,
especially when food seems to get stuck in his chest.
Past Medical History:
1. Dyspepsia, status post previous upper endoscopy in [**Country **]
back in [**2127**], which reportedly showed no abnormality. In
addition, he underwent an upper GI study in [**8-/2129**] here at
[**Hospital1 18**]
to evaluate dyspepsia. There was noted to be extensive scarring
of the first part of his duodenum with a small ulcer crater at
that site.
2. Tuberculosis, status post a year of treatment at [**Hospital6 11241**]. He has had a previous CT scan of the chest in
[**7-/2132**] that showed multiple conglomerated ill-defined
parenchymal opacities in the superior segment of the left lower
lobe as well as in the superior segment of the right lower lobe.
There was also left hilar lymphadenopathy up to 3 cm in size,
which were all suggestive of tuberculosis.
Social History:
The patient is married and has four children who
all live here in the [**Location (un) 86**] area. He has lived in [**Location 86**] for
the
past five years. He has formerly worked in the maintenance and
cleaning industry but is currently not working. He has a
40-year
history of smoking approximately two to three packs per week.
He
currently is not smoking. He has no history of heavy alcohol
use
and only occasionally drinks alcohol on the weekends.
Family History:
remarkable for possible gastric cancer in a
maternal uncle. There was otherwise no family history of
cancers.
Physical Exam:
blood pressure 116/75, pulse 63.
General: pleasant gentleman who shows evidence of recent weight
loss.
HEENT: Sclerae are anicteric. Neck and supraclavicular
fossae are supple without lymphadenopathy.
Lungs: clear to auscultation bilaterally.
Heart: regular rate and rhythm.
Abdomen: is scaphoid with evidence of weight loss. It is soft
and
nontender without palpable mass. There is no
hepatosplenomegaly.
Groins show no lymphadenopathy.
Extremities: no edema.
Pertinent Results:
CHEST (PORTABLE AP) [**2135-3-7**] 7:18 PM
IMPRESSION:
1. Small right apical pneumothorax.
2. Stable appearance of cardiomediastinal silhouette.
.
CHEST (PORTABLE AP) [**2135-3-8**] 4:48 AM
IMPRESSION: AP chest compared to [**3-7**]:
Left basal tube tip projects over the mediastinum, upper tube
ends in the apex. No appreciable left pneumothorax or pleural
effusion. Mediastinal drain appears to enter from the right
supraclavicular region. Left cervical drain projects over region
of persistent small subcutaneous emphysema. Mild edema has
developed at the left lung base and lung volumes are slightly
smaller today than yesterday, but otherwise clear. Heart size
normal. Endoluminal drainage tube traverses the neoesophagus to
the left upper quadrant.
.
CHEST (PA & LAT) [**2135-3-14**] 5:56 AM
REASON FOR THIS EXAMINATION:
temp 101.9; coarse left lung, sputum production. concern for
consolidation.
IMPRESSION: Development of focal density at the left base,
suspicious for pneumonia.
.
CT CHEST W/O CONTRAST [**2135-3-15**] 1:33 PM
IMPRESSION:
1. A loculated left pleural effusion, small. Questionable cavity
within the adjacent lung.
2. Denser than expected material within the left chest tube
which may represent _____ anastomosis in the absence of
high-density material in any other location.
3. Right lower and right middle lobe atelectasis due to mucus
impaction of the bronchi.
4. Stable left lower and right lower lobe nodules.
.
CT ABDOMEN W/CONTRAST [**2135-3-15**] 12:51 PM
IMPRESSION:
1. Mildly dilated loops of small bowel proximal to
jejunal-jejunal anastomotic site, with decompressed small bowel
distal to this site. However, contrast passes freely through
this site, and no definite stricture or narrowing is seen. These
findings may suggest mild edema at the anastomotic site slightly
limiting flow.
2. Left chest tube in place, with two residual foci of loculated
pleural fluid. Adjacent left lower lobe atelectasis. The lumen
of the chest tube appears dense although there is no evidence of
oral contrast extravasation. If clinically indicated, the fluid
draining through this chest tube could be expose to x- ray to
rule out leak.
3. Right lower lobe atelectasis or consolidation, and adjacent
area of ground-glass opacity suggestive of active or ongoing
infection.
4. Layering high-density material within the gallbladder, not
seen on prior exam, may represent layering sludge versus
concentrated bile
5. Small amount of ascites and free fluid throughout the abdomen
and tracking into the left paracolic gutter.
.
[**2135-3-22**] 04:54AM BLOOD WBC-8.5 RBC-2.92* Hgb-9.1* Hct-27.1*
MCV-93 MCH-31.1 MCHC-33.5 RDW-15.5 Plt Ct-819*
[**2135-3-22**] 04:54AM BLOOD Glucose-133* UreaN-20 Creat-0.9 Na-135
K-4.4 Cl-103 HCO3-22 AnGap-14
[**2135-3-17**] 05:03AM BLOOD ALT-19 AST-21 AlkPhos-75 Amylase-33
TotBili-2.4* DirBili-1.7* IndBili-0.7
[**2135-3-22**] 04:54AM BLOOD Calcium-8.4 Phos-3.5 Mg-2.3
[**2135-3-17**] 05:03AM BLOOD Lipase-35
.
UGI SGL CONTRAST W/ KUB [**2135-3-21**] 10:41 AM
IMPRESSION: No evidence of anastomotic leak at
esophagojejunostomy. Contrast passes freely through the jejunum,
without evidence of obstruction.
.
Brief Hospital Course:
He went to the OR on [**2135-3-7**] for a Distal esophagectomy,
esophagogastroduodenoscopy,
total gastrectomy, tube jejunostomy.
He recovered in the TSICU for 1 night. He was extubated in the
OR and off pressors.
.
Resp: He had Chest Tube x 2 on the left side. The Chest tubes
were managed by the Thoracic service. The CT were placed to H2O
seal on POD 2 and a CXR showed No pneumothorax.
POD 3, The CT was removed and the other [**Doctor Last Name **] drain place to
bulb suction. A post-pull CXR revealed Small-to-moderate left
pneumothorax following left chest tube removal. Improving
bibasilar atelectasis.
A CT Chest on [**3-16**] showed: 1. A loculated left pleural effusion,
small. Questionable cavity within the adjacent lung. 2. Denser
than expected material within the left chest tube which may
represent _____ anastomosis in the absence of high-density
material in any other location. 3. Right lower and right middle
lobe atelectasis due to mucus impaction of the bronchi.
The [**Doctor Last Name 406**] drain was D/C'd on POD 13. His respiratory status was
improved and he was no longer requiring O2 nasal cannula.
.
Abd/GI: He was NPO, with IVF and a NGT. He had a J-tube in
place. He was started on trophic tubefeedings on POD 2 @
10cc/hr. The tubefeedings were increased slowly as we awaited
return of bowel function. He continued to have an ileus and slow
return of function. The tube feedings were then held due to
increased distention. The NGT remained in place and he continued
to be NPO.
A CT was done on [**2135-3-15**] and showed Mildly dilated loops of
small bowel proximal to jejunal-jejunal anastomotic site, with
decompressed small bowel distal to this site. However, contrast
passes freely through this site, and no definite stricture or
narrowing is seen. These findings may suggest mild edema at the
anastomotic site slightly limiting flow. Left chest tube in
place, with two residual foci of loculated pleural fluid.
Adjacent left lower lobe atelectasis. The lumen of the chest
tube appears dense although there is no evidence of oral
contrast extravasation. If clinically indicated, the fluid
draining through this chest tube could be expose to x- ray to
rule out leak. Small amount of ascites and free fluid throughout
the abdomen and tracking into the left paracolic gutter.
On POD 9, he was started back on trophic TF 1/2 strength at
10cc/hr. He received a PICC and TPN.
He was very slow for his bowels to open up and he received
several enemas with good success. On POD 11, his abdomen was
still distended and hypoactive bowel sound. The NGT remained in
place.
The NGT was D/C'd on POD 14. His abdomen was now soft, and
non-distended and he reported +flatus. His staples were D/C'd on
POD 15.
A SBFT was performed and showed no evidence of anastomotic leak
at esophagojejunostomy. Contrast passes freely through the
jejunum, without evidence of obstruction.
.
He was started on sips and his diet was slowly advanced over the
next few days. His tubefeedings were increased to 3/4 strength
at 120cc/hr and his TPN was weaned to off. He was advanced to
clears, then fulls. He was discharged with Full strength TF.
.
Pain: He had an epidural for pain control. The epidural was
d/c'd on POD 2 and he continued with a PCA. He was then switched
to PO meds and was not complaining of pain.
.
Post-op Hypovolemia: He had low urine output on POD 1 and 2, and
received several IV fluid boluses. He responded well to the
fluid.
Medications on Admission:
None
Discharge Medications:
1. Tube Feeding
Tubefeeding: Replete w/fiber Full strength;
Starting rate:120 ml/hr; Cycle over 18 hours.
Flush w/ 30 ml water q8h.
Can increased rate to 150ml/hr over 14 hours if tolerated.
2. Oxycodone 5 mg/5 mL Solution Sig: [**11-30**] PO Q4H (every 4 hours)
as needed for Pain for 3 weeks.
Disp:*300 ml* Refills:*0*
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day) as needed for constipation.
Disp:*60 * Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Atria
Discharge Diagnosis:
GE Junction Cancer
Post-op Ileus
Loculated L pleural effusion
Discharge Condition:
Good.
Tolerating Tubefeedings
tolerating full liquid diet.
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 with Tube feedings at home. Replete w/fiber at Full
strength at 120cc/hr, cycle over 18 hours. Can increase to
150cc/hr over 14 hours if tolerating.
.
Full liquid diet.
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 1927**]
Date/Time:[**2135-3-29**] 1:15
Please follow-up with Thoracics in 2 weeks on [**2135-4-7**] at
9:00am. Call ([**Telephone/Fax (1) 1504**] with questions.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7978**], MD Phone:[**Telephone/Fax (1) 7976**]. Call to schedule
Provider: [**Name10 (NameIs) **] FELLOW ([**Doctor Last Name 12049**]) Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2135-4-27**] 1:00
Completed by:[**2135-3-23**]
|
[
"560.1",
"511.9",
"151.8",
"197.6",
"276.52",
"997.4",
"196.6",
"196.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.99",
"96.6",
"46.39",
"99.15",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
11082, 11118
|
7098, 10554
|
338, 416
|
11224, 11285
|
3915, 4716
|
12508, 13146
|
3302, 3415
|
10609, 11059
|
11139, 11203
|
10580, 10586
|
11309, 12485
|
3430, 3896
|
273, 300
|
4745, 7075
|
444, 2010
|
2032, 2811
|
2827, 3286
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,245
| 147,018
|
40957
|
Discharge summary
|
report
|
Admission Date: [**2151-4-17**] Discharge Date: [**2151-4-24**]
Date of Birth: [**2125-1-2**] Sex: M
Service: SURGERY
Allergies:
Soma / Flexeril / Metaxalone
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
bile leak
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a 26-year old Male with myotonic dystrophy who underwent
a laparoscopic cholecystectomy at [**Hospital3 **] on [**2151-4-13**]
(Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3912**]). This was presumed to be for
biliary colic. He was discharged home and began to have
worsening abdominal pain over the next 3-days. On POD#3 he also
began to have dyspnea so he presented to [**Hospital6 302**] for
evaluation. His LFTs were noted to be elevated. A HIDA scan was
performed and revealed a bile leak. A CT scan was performed as
well and this revealed bilateral atelectasis and free fluid in
the gallbladder fossa and in the right paracolic gutter. An ERCP
was attempted and they were unable to cannulate the CBD; they
did however stent his pancreatic duct. He was then transferred
to [**Hospital1 18**] for a repeat ERCP. Upon evaluation, Dr. [**Last Name (STitle) 11326**] felt
the patient was not fit for an ERCP. Surgery was then consulted.
The patient's only complaint was abdominal pain that was diffuse
in nature. Records stated that he did have a temperature of 101F
at home, but he was afebrile on admission.
Past Medical History:
PMH: myotonic dystrophy (states this makes him weak), ADD
PSH: laparoscopic cholecystectomy with umbilical hernia repair
[**2151-4-13**] at [**Hospital3 **], ERCP with PD stent/unable to
cannulate CBD at [**Hospital6 302**] in [**Location (un) 5503**] [**2151-4-16**]
Social History:
Live at home with his parents. Denies alcohol or tobacco use.
Family History:
Sister with myotonic dystrophy, who is s/p tracheostomy
Physical Exam:
PE: 99.8, 118, 134/90, 22, 93% on 2L
Gen: somnolent but arousable, alert, answers questions
appropriately
HEENT: NC/AT, PERLA, anicteric, mucus membranes dry
Neck: supple, no lymphadenopathy
Chest: tachycardic, no murmur, lungs clear with decreased breath
sounds at the bases
Abd: distended, tender diffusely with maximal tenderness in the
epigastrium, no rebound, healing laparoscopic incisions
Rectal: no gross blood, normal tone
Ext: warm, well perfused
Pertinent Results:
[**2151-4-17**] 01:26PM BLOOD WBC-11.0 RBC-4.33* Hgb-14.0 Hct-41.9
MCV-97 MCH-32.3* MCHC-33.4 RDW-14.9 Plt Ct-159
[**2151-4-17**] 01:26PM BLOOD PT-31.7* PTT-45.4* INR(PT)-3.1*
[**2151-4-17**] 01:26PM BLOOD Glucose-77 UreaN-7 Creat-0.4* Na-140
K-4.3 Cl-103 HCO3-26 AnGap-15
[**2151-4-17**] 01:26PM BLOOD ALT-86* AST-61* AlkPhos-107 Amylase-1145*
TotBili-2.0*
[**2151-4-17**] 01:26PM BLOOD Lipase-1883*
[**2151-4-17**] 01:26PM BLOOD Albumin-3.2* Calcium-8.8 Phos-2.1* Mg-1.9
Iron-22*
[**2151-4-17**] CT ABD & PELVIS WITH CONTRAST: Free fluid within the
right upper quadrant tracking in the bilateral paracolic gutters
and into the pelvis. While the fluid measures simple fluid
density, bile leak is not excluded. If this is of clinical
concern, HIDA scan may be obtained. Normally enhancing pancreas
with pancreatic stent. No large peripancreatic fluid collection.
Minimal fat stranding of the omentum could be related to history
of pancreatitis. Status post cholecystectomy, no fluid
collection in the gallbladder fossa Small, right greater than
left, pleural effusions. Subtotal bilateral lower lobe and
subsegmental right middle lobe atelectasis.
[**2151-4-18**] GALLBLADDER SCAN: Serial images over the abdomen show
uptake of tracer into the hepatic parenchyma. The patient is
status post cholecystectomy. No extraluminal tracer noted to
suggest bile leak.
Brief Hospital Course:
26M with bile leak seen on HIDA scan s/p lap chole from [**Hospital **]
transferred from OSH after ERCP stenting of his pancreatic duct
(unable to cannulate the CBD at [**Hospital6 302**]), presenting
with evidence of acute pancreatitis. A decision was made to
delay the repeat ERCP here in favor of adequately resuscitating
the patient. On [**4-17**], patient was admitted to TICU. A CT showed
free fluid within the right upper quadrant tracking in the
bilateral paracolic gutters and into the pelvis, but likely
simple fluid density. He was intubated overnight for worsening
respiratory distress, felt to be an ARDS picture. On [**4-18**] a HIDA
was repeated and was negative for leak. (OSH HIDA had shown a
bile leak at the R inferior hepatic lobe). He was febrile to
103, and tachycardic, but had a normal WBC. His Lipase decreased
from 1800 initially to 1600 and then 247. During [**4-18**] and [**4-19**]
multiple attempts to wean the vent were unsuccessful as pt would
become hypercarbic and hypoxic with lower settings, kept on
pressure support [**6-28**]. On [**4-20**] was able to be weaned to minimal
settings [**3-25**], tolerating that well. His lipase was down to 72
with improved abdominal tenderness. On [**4-20**] in the evening, the
patient was tolerating pressure support [**3-25**] and was weaned to
face mask for supplemental oxygen support, and he did well. On
[**4-21**], he was more alert, but still had some mental status
clouding, was tolerating only facemask supplemental oxygen, and
was out of bed to chair. At this point he was transfered from
the ICU to the floor without issue. Over the next few days
([**Date range (1) 5975**]) he tolerated a regular diet, was hep-locked and was
ambulating and out of bed with physical therapy. He had no
abdominal complaints and his laboratory studies were reassuring.
He was on room air and requiring no supplemental oxygen upon
discharge. He will be discharged home with VNA services and will
seek outpatient physical therapy services.
Medications on Admission:
adderall
Discharge Medications:
1. amphetamine-dextroamphetamine 5 mg Capsule, Ext Release 24 hr
Sig: Two (2) Capsule, Ext Release 24 hr PO daily ().
Discharge Disposition:
Home With Service
Facility:
[**Hospital 6136**] Homecare
Discharge Diagnosis:
pancreatitis, bile leak, acute respiratory distress syndrome
(ARDS)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to Dr.[**Name (NI) 2829**] surgical service for
evaluation and management of your pancreatitis, respiratory
issues. You are now being discharged home. Please follow these
instructions to aid in your recovery:
Please call your doctor or go to the emergency department if:
* You experience new chest pain, pressure, squeezing or
tightness.
* You develop new or worsening cough, shortness of breath, or
wheezing.
* You are vomiting and cannot keep down fluids, or your
medications.
* If you are getting dehydrated due to continued vomiting,
diarrhea, or other reasons. Signs of dehydration include: dry
mouth, rapid heartbeat, or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit, or have a
bowel movement.
* You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
* Your pain is not improving within 12 hours or is not under
control within 24 hours.
* Your pain worsens or changes location.
* You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
* You develop any other concerning symptoms.
General 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 operate 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 10 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.
* You are being discharged with a home visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **]
in your care.
Followup Instructions:
You should schedule follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] by calling
[**Telephone/Fax (1) 2998**] in her [**Location (un) 620**] Surgical Office; please call Monday
[**2151-4-26**] to schedule this appointment.
Please follow-up with your primary care physician [**Last Name (NamePattern4) **] [**11-22**] weeks.
|
[
"359.21",
"518.0",
"518.5",
"577.0",
"E878.6",
"997.4",
"314.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6031, 6090
|
3822, 5829
|
296, 323
|
6202, 6202
|
2431, 3799
|
8433, 8796
|
1882, 1939
|
5888, 6008
|
6111, 6181
|
5855, 5865
|
6353, 7493
|
1954, 2412
|
7526, 8410
|
247, 258
|
351, 1494
|
6217, 6329
|
1516, 1787
|
1803, 1866
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,694
| 157,203
|
47066
|
Discharge summary
|
report
|
Admission Date: [**2187-4-5**] Discharge Date: [**2187-4-10**]
Service: MED
HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman
resident of [**Hospital3 **] with
multiple medical problems presents with shortness of breath
and pleuritic chest pain as well as right upper quadrant
pain. The patient reports she has had a persistent cough
productive of yellow sputum for weeks. Over the last few
days reports increasing shortness of breath and a development
of right flank pain which is exacerbated by movement and
reproduced by soft palpation. Flank pain is right sided
abdomen and chest. Denies fever, chills, denies any left
sided pain. Per [**Hospital3 **] the patient has a
history of coughing associated with ingestion of solids and
liquid food.
PAST MEDICAL HISTORY: Gastroesophageal reflux disease
Hypertension.
Degenerative joint disease and severe osteoarthritis.
Colon cancer, status post colectomy in [**2184**].
Breast cancer and/or DCIS, unclear.
History of transient ischemic attacks.
Chronic obstructive pulmonary disease/asthma.
History of meningoma right cavernous sinus.
Peripheral edema.
History of C. Diff colitis.
Status post right rotator cuff tear.
ALLERGIES: Penicillin and sulfa. .
MEDICATIONS:
1. Cetrizine 5 q day.
2. Multivitamin.
3. Celexa 15 mg q day.
4. Premarin cream.
5. Fentanyl patch 25 mcg per hour q 72 hours.
6. Ferrous Gluconate q day.
7. Lasix 40 mg q day.
8. Glucosamine.
9. Lopressor 12.5 mg q h.s.
10. Meclizine 12.5 mg twice a day.
11. Ditropan XL 10 mg q PM.
12. Sorbitol
13. Prevacid 15 mg q h.s.
14. Combivent
15. Roxanol 8 mg q 3 hours p.r.n.
16. Percocet p.r.n.
17. Ativan 1 mg q AM and 0.5 mg p.r.n.
18. Zyprexa 2.5 mg
19. Vagisil.
20. Patanol.
21 MetroGel.
SOCIAL HISTORY: Remote tobacco and no alcohol. Lives at
[**Hospital3 **].
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: On admission temperature was 100.5,
blood pressure 114/102, heart rate 98, respiratory rate 28,
sating 99% on four liters nasal cannula. In general she was
awake and alert times 2.5 and mild respiratory distress.
Head, eyes, ears, nose and throat: Lip smacking was noted.
Oropharynx was clear with dry mucous membranes. Lungs:
Decreased breath sounds on the right. No crackles. Also had
bronchial breath sounds on the right. Cardiovascular
examination was normal. Abdominal examination had a
reducible, nontender, ventral hernia. Belly was soft with
normal bowel sounds, mild tenderness to palpation on the
right side without guarding. Extremities: Edema of
bilateral lower extremities.
LABORATORY FINDINGS: White count 19 with 95% neutrophils, 0
bands, 3 lymphocyte. Hematocrit 38.4, platelet count 264.
Chem 7 with creatinine of 1.4. Prothrombin time of 15, PTT
of 31.6, INR 1.5. Lactate on admission was 2.8. Urinalysis
showed moderate leukocyte esterase, positive nitrates, 21 to
50 white blood cells and moderate bacteria. CT of the chest
and abdomen showed no pulmonary embolus, right lung
consolidation, no hepatobiliary pathology except gallstones,
multiple bilateral simple renal cysts. Stable right adrenal
mass and a ventral hernia. KUB was unremarkable.
Electrocardiogram was normal sinus rhythm at 89, normal axis
and intervals and no changes from [**2181**].
ASSESSMENT: This is a [**Age over 90 **]-year-old woman with multiple
medical problems who presents with shortness of breath and
hypoxia and right sided flank and abdominal pain in mild
respiratory distress. Imaging with a right lung
consolidation. Additionally urinalysis also indicates
possible urinary tract infection with concern for
pyelonephritis as a possible additional cause of her right
flank pain.
HOSPITAL COURSE: Pulmonary issues including right lower lobe
consolidation, respiratory failure, new endobronchial lesion.
On admission imaging showed right lower lobe consolidation
concerning for possible aspiration pneumonia verses a post
obstructive process. The patient was initially admitted to
the General Medicine Service and she was started on broad
spectrum antibiotics of Vancomycin, Levofloxacin and Flagyl.
Given the concern for possible post obstructive pneumonia the
Pulmonary service was consulted, they performed a flexible
bronchoscopy on [**2187-4-6**] notable for a polypoid lesion
obstructing the right lower lobe. Brushings were done and
sent for cytology but no biopsy was done at that time given
the patient's elevated INR. Over the first several days of
her hospital course the patient's O2 requirement continued to
increase and she remained extremely tachypneic in the 20 to
30's. She was tried on CPAP but did not tolerate it. Then
on [**2187-4-7**] she developed increasing respiratory distress
complicated by atrial fibrillation with rapid ventricular
response. Further complicated by hypotension. The night
intern and resident were called to see the patient at which
point her vital signs included a heart rate in the 140's,
blood pressure 82/palp, respiratory rate 28, sating 91% on
six liters which improved to 99% on non-rebreather. Her
arterial blood gas was consistent with acute respiratory
acidosis and given her hypoxia and progressive hypercarbic
respiratory failure secondary to fatigue the patient was
electively intubated and transferred to the Intensive care
unit.
While in the Intensive care unit sputum cultures became
positive for Methicillin resistant Staphylococcus aureus and
the patient is being continued on a 14 day course of
Vancomycin. Additionally she was continued on the
Levofloxacin and Flagyl for possible gram negative rods and
anaerobes as a result of her post obstructive pneumonia
although sputum gram stain and cultures have only been
positive for gram positive cocci. She will be given a 7 day
course of these antibiotics as well. After intubation the
patient did well, and self-extubated on the night of the
24th. After extubation the patient clearly stated she did
not wish to be re-intubated and did not wish to be
resuscitated in the event of cardiac arrest. Therefore, she
was continued on supplemental O2 and has continued to sat
well on 5 liters nasal cannula with stable ventilatory status
at this point although she is still tachypneic.
The cytology brushings of her bronchoscopy were negative for
malignant cells on preliminary report. The patient does not
wish to have any further workup at this time of this
endobronchial lesion and is not interested in pursuing a
diagnosis.
Arrhythmia. The night of intubation the patient had an
episode of atrial fibrillation with rapid ventricular
response complicated by hypotension that responded well to 5
mg of Metoprolol intravenous. She had no further episodes of
atrial fibrillation. However, while in the Intensive care
unit she did have one episode of supraventricular tachycardia
which also responded well to Metoprolol. She has been
restarted on p.o. Metoprolol to both control her heart rate
as well as to control her blood pressure.
Anemia. The patient was noted to have hematocrit in the low
30's iron studies were consistent with anemia of chronic
disease and the patient did not require transfusions while
she was in house.
Elevated INR. The patient came in with an INR of 1.5 most
likely secondary to nutritional deficit in combination with
the Levofloxacin. She was given Vitamin K and had no
evidence of bleeding while in house.
Hypertension. On admission to the Intensive care unit the
patient had trouble with hypotension and her blood pressure
medicines were held. She has since been restarted on
Metoprolol with good effect.
The patient's other medical problems namely her
osteoarthritis and anxiety were stable while she was in the
hospital and she was continued on her Fentanyl patch and
Percocet as well as Ativan.
Code status and Communication: Initially the night the
patient was intubated she was extremely uncomfortable in her
breathing and did agree to the intubation. Discussions with
her family indicated that they felt that she would want to be
resuscitated in the event of cardiac arrest. However, after
the patient self-extubated on the night of the 24th she very
clearly stated that she did not wish to be re-intubated nor
to be resuscitated and was interested in only "living out her
life until she dies." Therefore, her Code status was changed
to DNR/DNI.
CONDITION ON DISCHARGE: Improved. Now sating well on 5
liters.
DISCHARGE DIAGNOSIS: Methicillin resistant Staphylococcus
aureus pneumonia
Endobronchial lesion right lung
Hypercarbic and hypoxic respiratory failure, resolved.
Hypotension resolved.
Atrial fibrillation resolved.
Anemia of chronic disease.
Coagulopathy.
Osteoarthritis.
Hypertension.
Anxiety.
DISCHARGE MEDICATIONS:
1. Heparin subcutaneously.
2. Combivent one to two puffs q 6 hours.
3. Protonix 40 mg q day.
4. Tylenol p.r.n.
5. Metoprolol 25 mg p.o. twice a day.
6. Fentanyl patch 25 mcg per hour q 72 hours.
7. Percocet one to two tabs q 4 to 6 hours p.r.n.
8. Lorazepam .5 mg p.o. q 4 to 6 hours p.r.n.
9. Senna p.r.n.
10. Colace p.r.n.
11. Vancomycin 1 gram q 24 hours for eight days.
FOLLOW UP: The patient is to follow-up with the doctors [**First Name (Titles) **]
[**Hospital3 **] as needed. Additionally she has a
previously scheduled appointment with her rheumatologist Dr.
[**Last Name (STitle) 99785**] [**Name (STitle) 28416**] on [**2187-4-27**] at 12:00.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **], [**MD Number(1) 4546**]
Dictated By:[**Last Name (NamePattern1) 49323**]
MEDQUIST36
D: [**2187-4-10**] 12:44:11
T: [**2187-4-10**] 13:43:53
Job#: [**Job Number 99786**]
|
[
"530.81",
"285.9",
"518.89",
"V09.0",
"715.90",
"401.9",
"518.81",
"427.31",
"482.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04",
"38.93",
"33.24",
"96.6",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1911, 1929
|
8796, 9182
|
8490, 8773
|
3775, 8402
|
9194, 9761
|
1952, 3757
|
117, 788
|
811, 1817
|
1834, 1894
|
8427, 8468
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,653
| 158,278
|
53808
|
Discharge summary
|
report
|
Admission Date: [**2133-7-15**] Discharge Date: [**2133-8-4**]
Date of Birth: [**2070-4-12**] Sex: F
Service: SURGERY
Allergies:
Sulfa(Sulfonamide Antibiotics) / Augmentin / bees
Attending:[**First Name3 (LF) 19859**]
Chief Complaint:
hiatal hernia
Major Surgical or Invasive Procedure:
[**2133-7-15**] Laporoscopic hiatal hernia repair with Nissen
fundoplication
[**2133-7-19**] Exploratory laparotomy, washout, oversewn staple line,
Dor fundo
History of Present Illness:
The patient was evaluated in clinic for a large hiatal hernia as
well as gastroesophageal reflux disease. She underwent a barium
swallow which demonstrated a sliding type hiatal hernia with a
large part of her proximal stomach within the chest. She also
has had a longstanding history of gastroesophageal reflux
disease. In addition, underwent endoscopy which ruled out
Barrett's esophagitis as well as manometry which revealed a
normal manometry.
Past Medical History:
HTN, Asthma, Cervical myelophathy, glucose intolerance, Spinal
stenosis, Obesity, GERD, Hiatal hernia, osteoarthritis,
sinusitis, arthralgia, vitreous floater, IBS, Lyme disease
Social History:
Lives at home with husband
Physical Exam:
(Just prior to admission)
Blood pressure 128/70, pulse 76, resp. rate 16, weight 218 lb
(98.884 kg), last menstrual period [**2107-9-26**].
HEENT: PERRL, EOMI
no sinus tenderness
no scleral injection, conjunctiva not inflamed
TM's and canals mostly bbut not entirely blocked with
cerumen bilaterally
mouth mucosa moist, without lesion
post pharynx not injected
no palpable neck or supraclavicular nodes
no JVD, carotids symmetric
Chest: chest clear to auscultation
Cardiac:heart rate and rhythm regular, nl S1S2, no murmurs
Abd: Normal active bowel sounds
abdomen soft, non tender, not distended,
no palpable masses, no hepatomegaly
Extr: distal pulses are 2+ bilat
no edema present
Neuro: motor 5/5 strength bilat in distal upper and lower
extremities,
prox hips [**4-9**] bilaterally
sensory grossly nl to light Touch distally
DTR 2+ patella bilaterally
Pertinent Results:
Complete Blood Counts w/ Differentials:
[**2133-7-18**] 10:17PM BLOOD Neuts-75* Bands-12* Lymphs-6* Monos-1*
Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-4* NRBC-1*
[**2133-7-22**] 11:36AM BLOOD WBC-21.4* RBC-3.90* Hgb-11.5* Hct-35.5*
MCV-91 MCH-29.5 MCHC-32.4 RDW-14.1 Plt Ct-162
[**2133-7-22**] 11:36AM BLOOD Plt Ct-162
[**2133-7-22**] 11:36AM BLOOD Glucose-93 UreaN-57* Creat-2.0* Na-144
K-4.0 Cl-110* HCO3-22 AnGap-16
[**2133-7-22**] 11:36AM BLOOD Calcium-8.0* Phos-5.6* Mg-3.2*
[**2133-7-22**] 06:08PM BLOOD Type-ART Temp-37.2 pO2-108* pCO2-28*
pH-7.47* calTCO2-21 Base XS--1 Intubat-NOT INTUBA
[**2133-7-22**] 02:13PM BLOOD Lactate-1.2
[**2133-7-22**] 02:13PM BLOOD O2 Sat-74
[**2133-7-23**] 01:53AM BLOOD WBC-19.8* RBC-4.05* Hgb-12.2 Hct-36.6
MCV-90 MCH-30.1 MCHC-33.3 RDW-14.2 Plt Ct-145*
[**2133-7-24**] 02:10AM BLOOD WBC-15.1* RBC-3.68* Hgb-10.7* Hct-33.0*
MCV-90 MCH-29.1 MCHC-32.4 RDW-14.0 Plt Ct-176
[**2133-7-25**] 01:53AM BLOOD WBC-21.5* RBC-3.70* Hgb-10.9* Hct-34.3*
MCV-93 MCH-29.4 MCHC-31.7 RDW-14.2 Plt Ct-222
[**2133-7-26**] 01:38AM BLOOD WBC-24.4* RBC-3.57* Hgb-10.8* Hct-33.1*
MCV-93 MCH-30.3 MCHC-32.6 RDW-14.2 Plt Ct-318
[**2133-7-26**] 02:41PM BLOOD WBC-23.4* RBC-3.58* Hgb-11.0* Hct-33.1*
MCV-93 MCH-30.6 MCHC-33.1 RDW-14.4 Plt Ct-393
[**2133-7-27**] 01:25AM BLOOD WBC-20.6* RBC-3.42* Hgb-10.1* Hct-31.1*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.3 Plt Ct-430
[**2133-7-28**] 01:54AM BLOOD WBC-16.3* RBC-3.23* Hgb-9.6* Hct-29.9*
MCV-93 MCH-29.8 MCHC-32.1 RDW-13.9 Plt Ct-673*#
[**2133-7-29**] 03:50AM BLOOD WBC-14.8* RBC-3.08* Hgb-9.1* Hct-28.3*
MCV-92 MCH-29.4 MCHC-32.0 RDW-14.3 Plt Ct-771*
[**2133-7-29**] 05:10AM BLOOD WBC-16.0* RBC-3.17* Hgb-9.3* Hct-28.7*
MCV-91 MCH-29.3 MCHC-32.2 RDW-14.1 Plt Ct-887*
[**2133-7-30**] 02:11AM BLOOD WBC-12.3* RBC-2.99* Hgb-8.8* Hct-27.7*
MCV-92 MCH-29.6 MCHC-32.0 RDW-14.3 Plt Ct-830*
[**2133-7-31**] 07:15AM BLOOD WBC-11.6* RBC-2.93* Hgb-8.5* Hct-26.9*
MCV-92 MCH-29.0 MCHC-31.5 RDW-14.5 Plt Ct-886*
[**2133-8-1**] 07:40AM BLOOD WBC-13.6* RBC-3.26* Hgb-9.4* Hct-30.1*
MCV-93 MCH-28.7 MCHC-31.0 RDW-14.2 Plt Ct-920*
[**2133-8-2**] 07:45AM BLOOD WBC-16.6* RBC-3.24* Hgb-9.4* Hct-29.6*
MCV-92 MCH-29.1 MCHC-31.8 RDW-14.4 Plt Ct-933*
[**2133-8-3**] 08:45AM BLOOD WBC-13.9* RBC-3.17* Hgb-9.0* Hct-29.0*
MCV-91 MCH-28.5 MCHC-31.2 RDW-14.2 Plt Ct-926*
Basic Metabolic Profiles:
[**2133-7-18**] 07:40AM BLOOD Glucose-122* UreaN-43* Creat-3.7* Na-134
K-5.0 Cl-96 HCO3-18* AnGap-25*
[**2133-7-18**] 05:20PM BLOOD Glucose-106* UreaN-48* Creat-4.3* Na-133
K-4.9 Cl-98 HCO3-18* AnGap-22
[**2133-7-18**] 10:17PM BLOOD Glucose-111* UreaN-53* Creat-4.6* Na-133
K-4.9 Cl-97 HCO3-16* AnGap-25*
[**2133-7-19**] 01:21AM BLOOD Glucose-123* UreaN-50* Creat-4.4* Na-134
K-4.7 Cl-102 HCO3-18* AnGap-19
[**2133-7-19**] 07:38AM BLOOD Glucose-98 UreaN-54* Creat-3.5* Na-136
K-4.7 Cl-107 HCO3-19* AnGap-15
[**2133-7-19**] 05:50PM BLOOD Glucose-84 UreaN-54* Creat-3.3* Na-137
K-4.6 Cl-106 HCO3-17* AnGap-19
[**2133-7-20**] 02:03AM BLOOD Glucose-100 UreaN-59* Creat-3.1* Na-132*
K-4.5 Cl-103 HCO3-17* AnGap-17
[**2133-7-20**] 07:46AM BLOOD Glucose-111* UreaN-63* Creat-2.9* Na-136
K-4.4 Cl-107 HCO3-18* AnGap-15
[**2133-7-20**] 02:44PM BLOOD Glucose-94 UreaN-58* Creat-2.6* Na-136
K-4.1 Cl-106 HCO3-20* AnGap-14
[**2133-7-21**] 02:11AM BLOOD Glucose-96 UreaN-59* Creat-2.3* Na-139
K-3.7 Cl-108 HCO3-20* AnGap-15
[**2133-7-21**] 08:33AM BLOOD Glucose-106* UreaN-63* Creat-2.2* Na-140
K-3.6 Cl-108 HCO3-21* AnGap-15
[**2133-7-21**] 02:50PM BLOOD Glucose-97 UreaN-57* Creat-2.1* Na-142
K-3.8 Cl-109* HCO3-21* AnGap-16
[**2133-7-21**] 09:47PM BLOOD Glucose-100 UreaN-57* Creat-2.0* Na-142
K-3.7 Cl-110* HCO3-20* AnGap-16
[**2133-7-22**] 02:21AM BLOOD Glucose-106* UreaN-57* Creat-1.9* Na-141
K-3.6 Cl-110* HCO3-21* AnGap-14
[**2133-7-22**] 11:36AM BLOOD Glucose-93 UreaN-57* Creat-2.0* Na-144
K-4.0 Cl-110* HCO3-22 AnGap-16
[**2133-7-23**] 01:53AM BLOOD Glucose-108* UreaN-59* Creat-1.9* Na-149*
K-3.5 Cl-114* HCO3-20* AnGap-19
[**2133-7-23**] 04:37PM BLOOD Glucose-144* UreaN-59* Creat-1.6* Na-141
K-3.8 Cl-110* HCO3-20* AnGap-15
[**2133-7-24**] 02:10AM BLOOD Glucose-137* UreaN-58* Creat-1.5* Na-144
K-3.8 Cl-112* HCO3-23 AnGap-13
[**2133-7-25**] 01:53AM BLOOD Glucose-145* UreaN-49* Creat-1.3* Na-148*
K-4.1 Cl-113* HCO3-26 AnGap-13
[**2133-7-26**] 01:38AM BLOOD Glucose-139* UreaN-45* Creat-1.2* Na-145
K-3.2* Cl-110* HCO3-25 AnGap-13
[**2133-7-26**] 02:41PM BLOOD Glucose-122* UreaN-43* Creat-1.2* Na-145
K-3.9 Cl-109* HCO3-26 AnGap-14
[**2133-7-26**] 02:41PM BLOOD Glucose-122* UreaN-43* Creat-1.2* Na-145
K-3.9 Cl-109* HCO3-26 AnGap-14
[**2133-7-27**] 01:25AM BLOOD Glucose-99 UreaN-43* Creat-1.2* Na-144
K-3.6 Cl-109* HCO3-25 AnGap-14
[**2133-7-28**] 01:54AM BLOOD Glucose-99 UreaN-43* Creat-1.3* Na-147*
K-3.7 Cl-109* HCO3-26 AnGap-16
[**2133-7-29**] 03:50AM BLOOD Glucose-116* UreaN-34* Creat-1.2* Na-146*
K-3.7 Cl-112* HCO3-23 AnGap-15
[**2133-7-29**] 05:10AM BLOOD Glucose-99 UreaN-33* Creat-1.2* Na-148*
K-4.3 Cl-114* HCO3-24 AnGap-14
[**2133-7-29**] 09:52PM BLOOD Glucose-102* UreaN-26* Creat-1.2* Na-149*
K-3.8 Cl-115* HCO3-25 AnGap-13
[**2133-7-30**] 02:11AM BLOOD Glucose-81 UreaN-26* Creat-1.2* Na-148*
K-4.1 Cl-115* HCO3-24 AnGap-13
[**2133-7-31**] 07:15AM BLOOD Glucose-103* UreaN-24* Creat-1.2* Na-147*
K-3.8 Cl-115* HCO3-24 AnGap-12
[**2133-8-1**] 07:40AM BLOOD Glucose-116* UreaN-19 Creat-1.2* Na-139
K-4.0 Cl-106 HCO3-22 AnGap-15
[**2133-8-3**] 08:45AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-135
K-3.6 Cl-106 HCO3-23 AnGap-10
Liver Function Tests:
[**2133-7-18**] 10:17PM BLOOD ALT-32 AST-49* CK(CPK)-1230* AlkPhos-60
TotBili-0.5
[**2133-7-23**] 01:53AM BLOOD ALT-41* AST-54* AlkPhos-75 TotBili-1.0
[**2133-7-25**] 10:25PM BLOOD ALT-21 AST-23 AlkPhos-58 TotBili-0.8
[**2133-7-29**] 05:10AM BLOOD CK(CPK)-76
[**2133-8-2**] 06:40PM BLOOD ALT-23 AST-26 AlkPhos-73 TotBili-0.4
Arterial Blood Gases:
[**2133-7-18**] 08:02PM BLOOD Type-ART Temp-37.0 Rates-/28 FiO2-92 O2
Flow-3 pO2-73* pCO2-31* pH-7.35 calTCO2-18* Base XS--7 AADO2-557
REQ O2-91 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
[**2133-7-18**] 10:25PM BLOOD Type-[**Last Name (un) **] pO2-65* pCO2-33* pH-7.34*
calTCO2-19* Base XS--6
[**2133-7-19**] 01:33AM BLOOD Type-ART pO2-166* pCO2-41 pH-7.26*
calTCO2-19* Base XS--8
[**2133-7-19**] 08:38AM BLOOD Type-ART pO2-80* pCO2-60* pH-7.14*
calTCO2-22 Base XS--9
[**2133-7-19**] 09:29AM BLOOD Type-ART Temp-34.5 pO2-76* pCO2-39
pH-7.26* calTCO2-18* Base XS--8 Intubat-INTUBATED
[**2133-7-19**] 12:13PM BLOOD Type-ART pO2-139* pCO2-38 pH-7.29*
calTCO2-19* Base XS--7
[**2133-7-19**] 02:51PM BLOOD Type-ART pO2-81* pCO2-33* pH-7.35
calTCO2-19* Base XS--6
[**2133-7-19**] 05:53PM BLOOD Type-ART pO2-77* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7
[**2133-7-19**] 08:19PM BLOOD Type-ART pO2-80* pCO2-33* pH-7.34*
calTCO2-19* Base XS--6
[**2133-7-19**] 09:03PM BLOOD Type-MIX
[**2133-7-20**] 02:14AM BLOOD Type-ART pO2-100 pCO2-32* pH-7.35
calTCO2-18* Base XS--6
[**2133-7-20**] 03:16AM BLOOD Type-MIX
[**2133-7-20**] 08:02AM BLOOD Type-ART pO2-98 pCO2-33* pH-7.36
calTCO2-19* Base XS--5
[**2133-7-20**] 03:05PM BLOOD Type-ART Temp-36.8 pO2-89 pCO2-33*
pH-7.37 calTCO2-20* Base XS--4 Intubat-INTUBATED
[**2133-7-20**] 03:13PM BLOOD Type-MIX
[**2133-7-20**] 06:10PM BLOOD Type-ART Temp-36.7 pO2-74* pCO2-32*
pH-7.37 calTCO2-19* Base XS--5 -ASSIST/CON Intubat-INTUBATED
[**2133-7-21**] 02:20AM BLOOD Type-ART pO2-106* pCO2-32* pH-7.41
calTCO2-21 Base XS--2
[**2133-7-21**] 02:34PM BLOOD Type-[**Last Name (un) **]
[**2133-7-21**] 02:54PM BLOOD Type-ART Temp-36.9 pO2-113* pCO2-35
pH-7.40 calTCO2-22 Base XS--1 -ASSIST/CON Intubat-INTUBATED
[**2133-7-21**] 05:17PM BLOOD Type-ART Temp-36.7 pO2-119* pCO2-35
pH-7.40 calTCO2-22 Base XS--1
[**2133-7-22**] 05:49AM BLOOD Type-ART pO2-85 pCO2-41 pH-7.37
calTCO2-25 Base XS--1
[**2133-7-22**] 11:54AM BLOOD Type-ART Temp-37.4 pO2-88 pCO2-36 pH-7.41
calTCO2-24 Base XS-0 -ASSIST/CON Intubat-INTUBATED
[**2133-7-22**] 02:13PM BLOOD Type-CENTRAL VE
[**2133-7-22**] 03:36PM BLOOD Type-ART Temp-37.2 pO2-85 pCO2-35 pH-7.41
calTCO2-23 Base XS--1 Intubat-NOT INTUBA
[**2133-7-22**] 06:08PM BLOOD Type-ART Temp-37.2 pO2-108* pCO2-28*
pH-7.47* calTCO2-21 Base XS--1 Intubat-NOT INTUBA
[**2133-7-23**] 02:12AM BLOOD Type-ART pO2-87 pCO2-27* pH-7.51*
calTCO2-22 Base XS-0
[**2133-7-23**] 04:03AM BLOOD Type-ART pO2-97 pCO2-27* pH-7.49*
calTCO2-21 Base XS-0
[**2133-7-23**] 07:16AM BLOOD Type-ART pO2-122* pCO2-30* pH-7.49*
calTCO2-23 Base XS-1
[**2133-7-23**] 05:57PM BLOOD Type-ART pO2-116* pCO2-26* pH-7.54*
calTCO2-23 Base XS-1
[**2133-7-24**] 02:16AM BLOOD Type-ART pO2-162* pCO2-30* pH-7.51*
calTCO2-25 Base XS-2
[**2133-7-26**] 02:40PM BLOOD Type-MIX pO2-33* pCO2-37 pH-7.47*
calTCO2-28 Base XS-3
[**2133-7-29**] 05:45AM BLOOD Type-ART pO2-81* pCO2-26* pH-7.58*
calTCO2-25 Base XS-3
Lactate Levels:
[**2133-7-18**] 08:02PM BLOOD Lactate-4.0*
[**2133-7-18**] 10:25PM BLOOD Glucose-103 Lactate-4.4*
[**2133-7-19**] 01:33AM BLOOD Lactate-3.5*
[**2133-7-19**] 08:38AM BLOOD Lactate-2.5*
[**2133-7-19**] 12:13PM BLOOD Lactate-3.2*
[**2133-7-19**] 02:51PM BLOOD Lactate-2.6*
[**2133-7-19**] 05:53PM BLOOD Lactate-2.5*
[**2133-7-19**] 09:03PM BLOOD Lactate-2.3*
[**2133-7-20**] 02:14AM BLOOD Glucose-97 Lactate-1.9
[**2133-7-20**] 03:05PM BLOOD Lactate-1.3
[**2133-7-21**] 02:20AM BLOOD Glucose-93 Lactate-1.1
[**2133-7-21**] 02:54PM BLOOD Lactate-0.9
[**2133-7-22**] 05:49AM BLOOD Lactate-0.6
[**2133-7-29**] 05:45AM BLOOD Lactate-1.4
Miscellaneous Labs:
[**2133-7-31**] 07:15AM BLOOD VitB12-1445*
[**2133-7-23**] 01:53AM BLOOD Triglyc-398*
[**2133-7-31**] 07:15AM BLOOD TSH-6.5*
[**2133-8-1**] 07:40AM BLOOD T3-68* Free T4-0.84*
[**2133-7-24**] 06:13AM BLOOD Vanco-11.5
[**2133-7-21**] 08:33AM BLOOD Vanco-7.9*
Microbiology:
[**2133-7-29**] ABSCESS GRAM STAIN-FINAL; WOUND
CULTURE-FINAL {BETA STREPTOCOCCI, NOT GROUP A}; ANAEROBIC
CULTURE-FINAL INPATIENT
[**2133-7-29**] ABSCESS GRAM STAIN-FINAL; WOUND
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL INPATIENT
[**2133-7-29**] FLUID,OTHER GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {BETA STREPTOCOCCI, NOT GROUP A}; ANAEROBIC
CULTURE-FINAL
[**2133-7-25**] 04:00PM ASCITES WBC-600* RBC-1000* Polys-100* Lymphs-0
Monos-0
[**2133-7-27**] STOOL C. difficile DNA amplification
assay-FINAL
[**2133-7-26**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {ENTEROBACTER CLOACAE COMPLEX} INPATIENT
[**2133-7-26**] URINE URINE CULTURE-FINAL INPATIENT
[**2133-7-25**] ABSCESS GRAM STAIN-FINAL; FLUID
CULTURE-FINAL {LACTOBACILLUS SPECIES, ENTEROCOCCUS SP.};
ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY INPATIENT
[**2133-7-19**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL; FUNGAL CULTURE-FINAL
{[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION} INPATIENT
* blood cultures were negative
Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment. On [**2133-7-15**], the patient underwent a
laparoscopic hiatal hernia repair with Nissen fundoplication.
Please refer to the operative note for details. She was
transferred to the floor NPO/IVF/NGT/ and a foley. On
post-operative day 1 a swallow study was done which was normal
and the patient was started on clears. The foley was removed and
the patient failed to void afterwards. She responded
appropriately with a 500 cc bolus. On postoperative day 2 the
patient was passing flatus and was tolerating a soft diet. Her
abdomen appeared distended and she was started on stool
softeners. Patient was doing well and ambulating. She was
desaturating to low 89 on room air with walking. On
postoperative day 4 the patient was making minimal urine output
with only 260 cc over 24 hours. 3 separate separate were
inserted and the patient failed to produce any urinary output.
Creatinine was elevated at 4.3. Toward the evening the patient
appeared lethargic and her respiratory rate was in the 40's. The
patient was immediately transferred to trauma ICU. An
abdominal/pelvic CT scan showed leakage from stomach . The
patient was intubated in the TSICU and taken back for an
emergent laparoscopy, washout, repair of gastric perforation on
ant wall, [**Last Name (un) **] fundoplication. The patient was transferred to
the TSICU afterwards. Her hospital course is as follows:
[**2133-7-19**] The patient arrived to the TSICU post operation. She was
intubated on fentanyl, propofol for sedation. For cardiovascular
the patient was started on a vasopressin and norepinephrine drip
with 150 cc of IV fluids/hour. She had an NGT tube inserted and
two abdominal JP drains. UOP was 20-30 cc/hour even with 2 L of
fluid boluses. The patient was tolerating CPAP.Lactate levels
were improved at 2-3.
[**2133-7-20**] Patient was taken off of vasopressin and norepinephrine
and BP remained stable. She continued sedation with propofol
and fentanyl she was tolerating CPAP [**2072-10-7**]. Patient's lactate
was improved at 2. UOP was improved and creatinine was 2.9.
Patient was afebrile with wbc count of 16.4. Chest xray showed
new volume overload with bilateral moderate pleural effusion and
the left retrocardiac atelectasis. Patient was given 20 mg
lasix.
[**2133-7-21**] Patient continued to be weaned off of propofol and
fentanyl. She was tolerating CPAP. Patient continued to be
afebrile with wbc count ranging from 19 to 21. Chest xray
appeared stable with continuing volume overload the patient
continued to receive lasix.
[**2133-7-22**] Patient was weaned off of fentanyl and propofol. She was
receiving intermittent Dilaudid. She was extubated and placed on
FiO2 40% with an appropriate post-extubation ABG with Ph
7.41/35/85/23. She was nonresponsive to commands. She was
afebrile with a wbc count of 21.4. Patient was not receiving IV
fluids, was continued on lasix 20 mg IV BID and was producing
urine at a rate of 100 cc/hour.
[**2133-7-23**] CT head, torso unremarkable. She was continued on TPN
and antibiotics. WBC 19.8 from 21.4. She had persistent
agitation, for which she was started on dexmedetomidine. She
was also hypertensive to systolic pressures of 200, for which
she was on a beta-blocker drip.
[**2133-7-24**] Neurology was consulted for her persistent altered
mental status. A post-pyloric Dobbhoff tube was placed in hopes
of commencing enteral feeds.
[**2133-7-25**]: Overnight Ms. [**Known lastname 110419**] required propofol sedation to
prevent self extubation. Although afebrile, her which blood
cell count began to rise (21.5<-15.1).
[**2133-7-26**] Due to recent WBC spike, her right subclavian line was
discontinued, and the tip was cultured. A chest xray revealed a
right lower lobe infiltrate. Sputum cultures grew out 3+ gram
negative rods. To cover pseudomonas, ciprofloxacin was started.
Of note her NGT output increased to about 500 over 24 hours, so
her tube feeds were held overnight. Regarding her altered
mental status, neuro recommended a 24-hour EEG to rule out
epileptiform activity. The EEG was negative.
[**2133-7-27**] Today her mental status was much better. Tube feeds
were restarted at 1/2 goal rate in the morning (20cch) and
ultimately advanced to goal rate (45 cch) later that afternoon.
Her [**Location (un) 1661**]-[**Location (un) 1662**] drains were both withdrawn ~5 cm, and JP#1 put
out an additional 50cc of fluid. From a respiratory standpoint,
she was extubated and weaned to 3L NC. A morning chest xray
showed no interval change in the appearance of her lungs versus
[**7-26**]. There was persistent bilateral atelectasis, low lung
volumes, and a possible left-sided pleural effusion. From an ID
perspective, her WBC count was on a downward trend:
20.6<-23.4<-24.4. We therefore discontinued her vancomycin and
fluconazole. At the end of the day, it was felt her great
improvement possibly meant she could be transferred to the floor
on [**2133-7-28**]. Occupational therapy saw her and felt she should
go to rehab.
[**2133-7-28**]: transferred to floor, sputum Cx Enterobacter cloacae,
so we ordered a chest xray to r/o pneumonia. The chest xray
showed mild bilateral atelectasis, low lung volumes, and a small
left-sided pleural effusion. We put her albuterol nebulizer
treatments on standing. We performed a nasogastric tube clamp
trial, which was successful.
[**2133-7-29**]: From a respiratory standpoint, Mrs. [**Known lastname 110419**] developed
acute onset tachypnea and tachycardia this morning for which she
was triggered and transferred to the TI CU. Etiologies include
PE vs. expanding loculated fluid collection in RUQ vs.
Enterobacter cloacae pneumonia. ABG this morning: 7.58/26/81.
CTA chest: negative for pulmonary embolism. She was continued
on her ciprofloxacin for a positive sputum culture for
ciprofloxacin-sensitive Enterobacter cloacae. She continued her
albuterol nebulizer therapy every four hours.
From a gastrointestinal standpoint, she underwent ultrasound
guided drainage of her fluid collections in her RUQ and RLQ. The
RUQ drain put out 300cc maroon fluid and the RLQ put out 30cc
maroon fluid. The LLQ drain, placed on [**2133-7-25**], put out 40.
On the CT scan of the abdomen, it was felt there was not much
fluid to drain anymore, and a plan was made tentatively to
discontinue the drain in the morning if it drained <10 cc.
During the procedure, it was noted that the patient's right
sided trocar site began leaking yellow fluid, a new finding.
She was, however, on multiple antibiotics and did not require
additional intervention. A new Dobbhoff tube was placed, and
tube feeds restarted. Her rectal tube put out 100 cc loose
stool.
[**2133-7-30**]: We consulted psychiatry out for recommendations for
her delirium. They recommended we test TSH, B12, RPR. For
sedation, we changed (based on recommendations by psychiatry)
quetiapine to 50qAM, 100qHS standing, and 25 mg qTID PRN. We
started serial EKGs for QTc during wake to monitor for
quetiapine toxicity. Her baseline QTc was in the low 400s.
Antibiotics were discontinued as she had been remaining afebrile
with a downward trending WBC count.
[**2133-7-31**] - [**2133-8-4**]: Over the next days, Mrs.[**Known lastname 110420**] mental
status improved dramatically. She was AAOx3 at several
intervals throughout the day and night. She had some episodes
of post-prandial emesis that were nonbloody and well controlled
on ondansetron. Overall, she was tolerating her diet. A CT
scan of the abdomen and pelvis on [**8-2**] showed a smaller right
perihepatic fluid collection, a smaller pelvic collection, a
left lower quadrant collection remaining collapsed with drain in
place, and no new collections. She was discharged to rehab on
[**2133-8-4**] in stable condition. Upon discharge, Mrs.[**Last Name (un) 110420**]
body mass was 101.5 kg, increased from admission (98.88 kg).
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Atrius.
1. Atenolol 25 mg PO DAILY
2. esomeprazole magnesium *NF* 40 mg Oral twice daily GERD
3. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
4. Albuterol Inhaler [**1-5**] PUFF IH Q4H:PRN dyspnea
5. Venlafaxine 75 mg PO UNDEFINED
6. Venlafaxine 37.5 mg PO UNDEFINED
7. Chlorpheniramine Maleate 4 mg PO UNDEFINED
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
3. Atenolol 25 mg PO DAILY
4. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 6 hours Disp
#*48 Tablet Refills:*0
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 5 mg 2 tablets by mouth four times a day
(QIDACHS) Disp #*40 Tablet Refills:*0
7. Nystatin Oral Suspension 5 mL PO QID:PRN esophageal thrush
swish and swallow
RX *nystatin 100,000 unit/mL 5 mL(s) by mouth four times daily
Disp #*140 Milliliter Refills:*0
8. Murine Ear Wax Removal System *NF* (carbamide peroxide) 6.5 %
AU [**Hospital1 **] ear wax Reason for Ordering: Wish to maintain
preadmission medication while hospitalized, as there is no
acceptable substitute drug product available on formulary.
5-10 drops and leave for 15mins and for 4days
9. Fluticasone Propionate 110mcg 1 PUFF IH [**Hospital1 **]
10. Chlorpheniramine Maleate 4 mg PO UNDEFINED
11. Esomeprazole Magnesium *NF* 40 mg ORAL TWICE DAILY GERD
12. Venlafaxine 75 mg PO UNDEFINED
13. Venlafaxine 37.5 mg PO UNDEFINED
14. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Hiatal Hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to West 3 Surgery for a hiatal hernia repair
with nissen fundoplication for acid reflux. Your recovery was
complicated by a intrabdominal leak that was discovered on post
operative day 4. On [**2133-7-19**] you underwent an emergent
Exploratory laparotomy, washout, oversewn staple line, Dor
fundo. You were transferred to the TSICU after your operation
for management. When you were more hemodynamically stable you
were transferrred to the floor and did well. You are now ready
for discharge.
General 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 [**5-14**] 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.
You are to eat a soft mechanical diet at home. Do not consume
any carbonated beverages.
Continue taking your home dose of nexium as prescribed.
Followup Instructions:
You have an appointment on [**2133-8-13**] at 0300 PM as follows:
Location: [**Hospital Ward Name 23**] - [**Location (un) **] outpatient clinic
Phone:[**0-0-**]
Provider: [**Name10 (NameIs) 1532**] [**Name11 (NameIs) 1533**], MD
You have an appointment with Dr. [**Last Name (STitle) **] on [**2133-8-13**] at 0845 AM at
the following location:
[**Hospital1 **]
[**Street Address(2) 34126**]
[**Location 1268**], [**Numeric Identifier 26374**]
Phone: [**Telephone/Fax (1) 88393**]
Fax: [**Telephone/Fax (1) 110421**]
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icd9cm
|
[
[
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[
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icd9pcs
|
[
[
[]
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] |
22677, 22813
|
13011, 20984
|
323, 483
|
22871, 22871
|
2227, 12988
|
24625, 25147
|
21474, 22654
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|
24161, 24602
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23567, 24146
|
270, 285
|
511, 964
|
22886, 22998
|
986, 1165
|
1181, 1209
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,670
| 103,469
|
23169
|
Discharge summary
|
report
|
Admission Date: [**2191-11-30**] Discharge Date: [**2191-12-4**]
Date of Birth: [**2135-8-26**] Sex: F
Service: [**Last Name (un) **]
CHIEF COMPLAINT: Fulminant hepatic failure.
HISTORY OF PRESENT ILLNESS: The patient is a 56-year old
female of Indian origin with no known prior history of liver
disease and a past medical history significant for rheumatoid
arthritis and hypercholesterolemia who had been on Arava and
Lipitor who was transferred from [**Hospital 59596**] to [**Hospital1 1444**] for acute hepatic failure.
The patient has a history of rheumatoid arthritis and has
been on Arava on 10 mg once daily with an increasing dose of
20 mg once daily since [**2191-6-16**]. The patient was also on
Lipitor 20 mg by mouth once daily which was also increased to
40 mg by mouth once daily at the time of [**Month (only) **] of [**2191-6-16**]. The patient traveled to [**Country 11150**] during the Summer and
while there developed some fatigue, anorexia, nausea, and
dark urine. The patient was worked up as an outpatient in
the United States. Subsequently, the patient developed a
fever, nausea, vomiting, abdominal pain, and diarrhea, and
jaundice. The patient was found to have elevated liver
function tests and was noted to have mild ascites on
ultrasound on [**2191-11-23**].
The patient was admitted to [**Hospital3 8544**] on [**2191-11-25**] and was found to have an elevated INR to 4 and an
elevated bilirubin. She underwent a paracentesis at [**Hospital3 52139**] which demonstrated 4500 white cells per cc. The
patient was started on third-generation cephalosporin for
concern of spontaneous bacterial peritonitis. The patient's
mental status worsened over the next 24 hours with elevations
in INR and bilirubin, and the patient was transferred to [**Hospital1 1444**].
PAST MEDICAL HISTORY: Rheumatoid arthritis,
hypercholesterolemia, hypertension, and hypothyroidism.
HOME MEDICATIONS: Arava 20 mg by mouth once daily and
Lipitor 50 mg by mouth once daily (both of which were stopped
on [**2191-11-4**]), Tylenol as needed for pain relief
(which was stopped on [**11-18**]), and Levoxyl.
ADDITIONAL MEDICATIONS ON TRANSFER: Zofran, Protonix,
Demerol, Aldactone, Lasix, vitamin K, cholestyramine, and
Cefotetan.
ALLERGIES: SULFA.
SOCIAL HISTORY: No alcohol use. No tobacco use.
FAMILY HISTORY: No known history of liver disease.
PHYSICAL EXAMINATION ON ADMISSION: The temperature was 96.6,
the heart rate was 110 and regular, sinus tachycardia, the
blood pressure was 147/69, the respiratory rate was 19, and
100 percent on nonrebreather. Obtunded. On mental status,
responding only to painful stimuli. Markedly jaundiced with
icteric sclerae. The pupils were equally round and reactive
to light. The neck was supple. Cardiovascular examination
revealed a regular rhythm, sinus tachycardia. No murmurs.
The lungs were clear to auscultation bilaterally. The
abdomen was mildly distended, soft, and nontender. The right
flank with ecchymosis noted.
PERTINENT LABORATORY DATA ON ADMISSION: On admission to [**Hospital1 1444**] the white count was 9.3, the
hematocrit was 34.4, and the platelets were 104. Chemistries
revealed the sodium was 134, potassium was 3.7, chloride was
106, bicarbonate was 21, blood urea nitrogen was 13,
creatinine was 0.8, and glucose was 125. AST was 541, ALT
was 469, alkaline phosphatase was 162, total bilirubin was
23.9, albumin was 2.4, and amylase was 174. Coagulations
revealed PT was 34.8, PTT was 138.5, and INR was 7.6.
RADIOLOGY STUDIES: A CT of the abdomen and pelvis done at
[**Hospital3 8544**] on [**2191-11-28**] with the report from
Study Hospital of small nodule in the liver, normal size
spleen, moderate ascites, bilateral pleural effusion, and
positive gallstones.
BRIEF HOSPITAL COURSE: The patient was admitted to the
Surgical Intensive Care Unit late in the evening of [**2191-11-30**]. The patient was given 4 units of fresh frozen
plasma given her severe coagulopathy. Because of continued
deteriorated mental status, the patient was intubated.
Early in the morning of [**2191-12-1**] the patient's
mental status changes were deemed to be due to hepatic
encephalopathy and received a head CT STAT after intubation
which was within normal limits without any masses or
bleeding. The patient was found to be tachycardic, and
reexamination was found to have a systolic ejection murmur.
A cardiac echocardiogram was done which revealed a left-to-
right shunt consistent with an atrial septal defect or patent
foramen ovale. The patient also had increased pulmonary
artery pressures. The patient also underwent an ultrasound
of the abdomen which showed a very small nodule in the liver
and some ascites. A CT of the abdomen also done at the same
time showed generalized anasarca with edematous small bowel,
again a small nodule in the liver about the size of a spleen.
The patient's liver function tests and bilirubin continued to
rise with the total bilirubin peaking at 31.7. This was
fulminant hepatic failure. The patient's renal system
continued to be poor. The patient did not make much urine on
arrival, and her creatinine - while it was normal - did not
explain her cause of oliguria. Because the patient was
oliguric, the patient became volume overloaded given the
medication that was necessary to sustain her life.
Eventually, the patient was started on continuous venovenous
hemofiltration. Because the patient had severe coagulopathy,
the patient was put on a fresh frozen plasma drip and
received packed red blood cells as needed to keep her
hematocrit from falling. The patient also received platelets
as needed to keep her platelets above 100.
The patient's respirations were difficult to maintain. A
chest x-ray revealed possible right-sided consolidative
processes, and it there was concern that the patient might
have had an aspiration event. The patient underwent a
bronchoscopy which did not show any pockets of thickened
sputum or purulence within the bronchial system.
The patient was maintained on ceftriaxone prophylaxis as well
as on Levaquin. Despite all our best efforts, the patient
went into multisystem failure with pulmonary hypertension
with left-to-right shunting, respiratory failure with
possible aspiration pneumonia, fulminant liver failure, and
acute renal failure. The multisystem failure became
overwhelming, and the patient's life could not be sustained
despite our best efforts.
The patient was comfort measures only [**2191-12-3**] - on
the fourth day of her Intensive Care Unit stay at the [**Hospital1 1444**] - after conferring with the
family who understood the patient's grave prognosis. The
patient's supports were turned off. The patient was placed
on a morphine drip, and the patient expired without
discomfort in the early morning of [**2191-12-4**].
DISCHARGE STATUS: Expired.
DISCHARGE DIAGNOSES:
1. Acute fulminant hepatic failure; likely due to medication
toxicity from Arava and Lipitor.
2. Multisystem organ failure with cardiovascular failure,
respiratory failure, hepatic failure, and renal failure.
DATE OF DEATH: [**2191-12-4**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 3432**]
Dictated By:[**Last Name (NamePattern1) 12164**]
MEDQUIST36
D: [**2191-12-26**] 16:41:10
T: [**2191-12-26**] 17:28:10
Job#: [**Job Number 59597**]
|
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icd9cm
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[
[
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[
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icd9pcs
|
[
[
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3821, 6888
|
2360, 2417
|
6909, 7430
|
1944, 2158
|
173, 201
|
230, 1823
|
3066, 3797
|
2184, 2292
|
1846, 1925
|
2309, 2343
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,226
| 116,465
|
44442
|
Discharge summary
|
report
|
Admission Date: [**2193-4-29**] Discharge Date: [**2193-6-1**]
Date of Birth: [**2140-6-2**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Epigastric abdominal pain
Major Surgical or Invasive Procedure:
[**2193-5-21**]: Exploratory laparotomy, lysis of adhesions, serosal
repair x5
History of Present Illness:
52M w/HIV last CD4 258 VL undetectable [**3-21**] presents to the ED
c/o epigastric pain. 3 days PTA, the patient experienced severe
epigastric pain with nausea. This pain was not related to food
intake. In fact, his appetite was very poor. He reported no
f/c during those 3 days. Presenting to the ED, his WBC was 16.5
(4.3 previous note before presentation), a BUN of 69 and a
creatinine of 3.0 (baseline 1.2). His amylase and lipase were
significantly elevated to 1204 and 1272. A Lactate level was
3.4.
A CTA/Pancreas was obtained and revealed extensive, severe acute
pancreatitis, with internal pancreatic hypoattenuation that may
represent edema versus necrosis.
Past Medical History:
HIV: diagnosed [**2179**]; c/b PCP, [**Name10 (NameIs) 95264**] zoster; treatment
experienced, good virologic suppression currently
HBV, cleared
HTN, on atenolol and lisinopril
Hyperlipidemia, on fenofibrate
schizophrenia & depression, on Buspar, Loxapine, tranylcypromine
Social History:
paitent was b/r in [**Location (un) 7658**] MA, went to boarding school then
college and some grad work in [**Country 2784**] in art history, stopped
when he "fell on (his) face." He did not want to further expaine
that statment. He has a partner [**Name (NI) **] x 20 years. close relation
with his father. [**Name (NI) **] is on SS for HIV and psych issues. He also
is
an artist.
Denies ETOH/recreational drugs/smoking.
Family History:
No h/o anal, colon, cervical or head/neck ca. Brother with
brain tumor, father with prostate ca, mother with breast ca.
Physical Exam:
On Discharge:
VS: AFVSS
Gen: NAD, A+OX3, supine on bed
CV: RRR, normal S1/S2
Resp: CTAB, no wheezes/crackles/rhonchi
Abd: Slightly distended however soft, NT, +BS, incisional site
is C/D/I, staples intact
Ext: No edema, 2+ radial and pedal pulses
Pertinent Results:
Admit WBC: 16.5
Discharge WBC: 10.4
Admit Amylase: 1204
Admit Lipase: 1272
Discharge Amylase: 55
Discharge Lipase: 76
Admit H/H: 17.3/48.2
Discharge H/H: 9.2/28.6
All urine and blood cultures were negative throughout hospital
course.
C-Diff was negative X 3
CTA (Admit): Extensive, severe acute pancreatitis, with internal
pancreatic hypoattenuation that may represent edema versus
necrosis
CTA ([**5-3**]): Continued pancreatitis without evidence of clearing,
there is now an ileus seen on CT
CTA ([**5-13**]): Interval increase in peripancreatic inflammatory
changes, multiloculated fluid collection extending into the left
pericolic gutter and along the descending colon. SBO seen on CT.
CTA ([**5-29**]): 1. Interval increase in peripancreatic inflammatory
changes and interval unification of some of the multiloculated
fluid collection in the left pericolic gutter and in the lesser
sac. New areas of fluid collection are noted in the anterior
abdominal wall. Percutaneous drainage is not feasible given the
multiple internal septations.
2. No evidence of pancreatic necrosis or venous thrombosis or
pseudoaneurysm.
Brief Hospital Course:
After presenting to the ED, the patient was directly admitted to
the SICU for monitoring. During his short stay in the SICU, his
BPs were stable in the 120-150's, HRs were in the 80-90's (NSR),
and his sats were in the high 90's on 2 L NC. He did not
require intubation nor did he require pressors in the SICU.
After being transferred to the floor, the patient did well. He
was tolerating clears well, did not c/o N/V, and his WBC trended
downwards. His pain was well controlled at first by a PCA then
transitioned to PO pain meds. He did not c/o significant
pain/breakthrough pain.
Psychiatry was consulted given his h/o schizophrenia. ID was
consulted given his h/o HIV. Given these recommendations, the
patient was started on his PO anti-psychotic /depression
medications but did not start on his HIV regimen in fear of
resistance (PO status may change at any minute).
Halfway through his hospital course, the patient suddenly became
distended and had episodes of emesis. He was made NPO and a NGT
was inserted. He stopped passing flatus and required daily
suppositories. Despite being NPO with a NGT, the patient
remained distended. In addition he began to c/o more pain,
located in the epigastric region. He began to spike fevers. His
WBC started to rise. He was continued on IV Abx for empiric
treatment and cultures from his urine and blood were obtained.
Repeat CTAs were performed, showing evidence of non-resolving
and worsening pancreatitis. In addition, the CTA suggested
ileus.
In light of his nutritional status, a PICC was placed and TPN
was started. He remained NPO. Despite numerous attempts in
D/Cing the NGT, the patient became more nauseated and distended.
After failing conservative management for approximately a week,
a repeat CTA was obtained which showed pancreatitis and a SBO.
The patient was then taken to the OR and explored on [**5-21**]. LOA
was performed.
Post-operatively the patient did well. He became less distended
and could tolerate not having a NGT. He was passing flatus had
numerous BM. C-diffs were negative X 3. His abdomen became
much less distended and softer. His diet was advanced.
On the day of discharge, he was cleared by psychiatry and ID.
He was to restart all his home medications. He was afebrile X 24
hours with a normal WBC. He was tolerating a diet and had less
frequent BM. His abdomen was slightly distended but soft. His
Amylase and Lipase levels are WNL.
Medications on Admission:
1) Atenolol 50 mg Tablet one and a half Tablet(s) by mouth once
a day
2) BUSPAR 5MG Tablet 2 BY MOUTH EVERY DAY
3) Darunavir 300 mg Tablet 2 Tablet(s) by mouth twice a day take
with Norvir
4) Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg Tablet 1
Tablet(s) by mouth daily
5) Etravirine [Intelence] 100 mg Tablet 2 Tablet(s) by mouth
twice daily with some food
6) Fenofibrate Micronized 67 mg Capsule 1 Capsule(s) by mouth
once a day take this medication with food/meal
7) Lisinopril 10 mg Tablet 1 Tablet(s) by mouth once a day
8) LOXAPINE 80 MG Capsule ONE BY MOUTH EVERY DAY
9) Ritonavir [Norvir] 100 mg Capsule 1 Capsule(s) by mouth twice
daily take with Darunavir
10) TRANYLCYPROMINE 10 MG TABLET 2 BY MOUTH EVERY DAY
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain for 2 weeks.
Disp:*40 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Tranylcypromine 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily). Tablet(s)
6. Loxapine Succinate 10 mg Capsule Sig: Eight (8) Capsule PO
DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis, Small-bowel obstruction
Discharge Condition:
stable
Discharge Instructions:
Please call or come to the Emergency Department if you
experience temperature >101.5, chills, persistent nausea or
vomiting, abdominal distension, shortness of breath or
difficulty breathing, chest pain, redness / tenderness /
purulent drainage from your incision, or any other symptoms of
acute concern.
Diet: low-fat
New Medications: Dilaudid (pain medication). No driving while
taking.
Activity: as tolerated. No heavy lifting or strenuous activity.
No swimming or tub bathing until told otherwise. [**Month (only) 116**] shower.
Followup Instructions:
Please call Dr[**Name (NI) 11471**] office ([**Telephone/Fax (1) 2998**]) to schedule
appointment in [**11-14**] week.
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-6-12**] 2:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2193-7-17**]
9:30
[**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], M.D. Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2193-9-4**] 11:30
Completed by:[**2193-6-3**]
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,472
| 197,051
|
8793
|
Discharge summary
|
report
|
Admission Date: [**2124-8-29**] Discharge Date: [**2124-9-20**]
Date of Birth: [**2066-4-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3913**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Intubation during ICU course to protect your airway.
[**2124-8-31**] PICC Placement
[**2124-9-1**] - PICC line exchange for a new 5-French double lumen
PICC line. Final internal length is 50 cm, with the tip
positioned in the SVC.
PICC removed at discharge.
History of Present Illness:
This is a 58 year old male with CML s/p allo stem cell
transplant [**9-/2121**] c/b chronic GVHD of liver/lung/gut, O2
dependent bronchiolitis obliterans and bronchiectasis,
presenting with hypoxia. Of note, he has had multiple recent
admissions for pneumonias, as noted in PMHx below. He was seen
by Dr. [**Last Name (STitle) **] (onc) on [**8-24**] and noted to be having increased
dyspnea. He was discharged home from a rehab facility the day
prior to admission, and was noted by his wife to be weak and
tired with a poor appetite. The next am, he took off his
baseline oxygen to go to the bathroom and had 5 episodes of
diarrhea, which he had been having at the rehab facility as
well. He felt very short of breath coming back from bathroom;
brother-in-law reports he was ashen-looking and shaking, and
sounded congested. Visiting nurse [**First Name (Titles) 13431**] [**Last Name (Titles) 30712**] to 78% on
2.5L; after nebs, he was saturating at 82%. After calling Dr. [**Name (NI) 30713**] office, the nurse practitioner advised patient to be
evaluated in ED.
.
In the ED, O2 sat improved with NC, but he then became more
hypoxic and somnolent with CO2 retention, resulting in
intubation. CXR showed LLL infiltrate and labs reveaked WBC of
8.7 with 33% bandemia. He was given vanc, pip-tazo, and cipro
and 3L IVF. His SBP remained 80s-90s (baseline reportedly 100),
so a CVC was placed and norepinephrine was started. Labs also
showed troponin elevation with normal CK and EKG. BMT service
was made aware and requested stress dose steroids; 60mg
methylprednisolone was given in the ED. Vitals prior to transfer
were: afebrile 95/65 90 15-20 93-94% on 60% FiO2.
.
On the floor, the patient is intubated but alert and able to
follow commands. He denies any complaints, including pain or
trouble breathing. Full ROS is limited by his intubated status.
Past Medical History:
ONCOLOGIC HISTORY: He is approximately 2.5 years status post
allo SCT from an unrelated donor for CML. His last bone marrow
biopsy was done in [**1-/2122**] and was consistent with remission
from CML. PCR has been negative for BCR-ABL.
.
In terms of chronic GVHD, he has had chronic abdominal
discomfort since transplant that is thought to be associated
with GVHD. He last underwent enteroscopy in [**8-/2122**], which
showed abnormal mucosa in the jejunum, normal mucosa in the
duodenum, and erythema in the whole stomach compatible with
gastritis. These areas were biopsied showing chronic
inflammation in the antral mucosa and focal active enteritis in
the duodenum and jejunum. In [**11/2122**], his GVHD progressed with
skin rash and liver function abnormalities. His skin rash
resolved on increased immunosuppression and he is now left with
some hyperpigmentation and telangiectasia over areas of his face
and back. His liver function tests have been intermittently
elevated and his immunosuppression has been titrated along with
this. He was on photophoresis for approximately one year for
GVHD management. He also has had persistent bilateral lower
extremity edema that has limited his ambulation but it is
unclear as to whether this is a GVHD manifestation or not. He
has undergone his 3rd cycle of Rituxan for GVHD.
.
In terms of other post-transplant complications, he has had a
total of four compression fractures since the beginning of [**2122**]
at T8, T9, T11, L1, and L3. This has caused chronic pain. He was
offered vertebroplasty by Dr. [**Last Name (STitle) 1352**], who follows him for this
condition, however, this was never done. He was seen by
endocrine and received a dose of 5 mg of Reclast in 5/[**2122**]. He
has been on chronic pain medication for the back pain, as well
as the abdominal discomfort. He was on anticoagulation for a PE
diagnosed in [**3-/2123**] and this was stopped in [**9-/2123**] as he had
received 6 months of anticoagulation and was also at risk for
falls. He was again noted for PE at the end of [**10/2123**] and a DVT
in [**12/2123**] and is currently anticoagulated with lovenox.
.
PMH:
# CML s/p allogeneic stem cell transplant [**2121**] c/b GVHD
# chronic GVH on immunosuppressants
# Chronic RUQ pain since [**2113**]
- work up unrevealing
- on narcotics
# h/o pseudomonas and stenotrophomonas in sputum
# GERD w/ Barrett's esophagus
# Hypertension
# h/o pulmonary embolism in [**3-24**] on Lovenox
# four compression fractures since the beginning of [**2122**]
at T8, T9, T11, L1, and L3
# course of linezolid for VRE bacteremia which he contracted
during a hospitalization for cellulitis
Social History:
On disability, was a manufacturing manager. Quit tobacco 12 yrs
ago. Smoked 1 ppd x 10 yrs. No etoh or drug use. Previous mj
use. He states that about one year ago he was able to ambulate
independently, but prior to his recent hospitalizations, had
been using a walker. It has been some time since he was
ambulating. He has never been married and has no children but
has a very strong support system. He has a group of 5 male
friends who he has known since childhood who are a huge source
of support (they have done multiple fundraisers in his honor
since his diagnosis of CML, for example). He also has many
local siblings who are very involved in his life and care. For
the past several years, he has lived on and off with his sister
and HCP, [**Name (NI) 717**] [**Name (NI) 23227**] and her husband at their home in [**Name (NI) 5289**].
He owns a condominium in [**Hospital1 189**], MA where he lived independently
up until one year ago; this is now rented out while he resides
with his sister when not in the hospital or rehab.
Family History:
Father with diabetes mellitus, BPH, alive at 85yrs
Mother with h/o breast cancer; d. TIAs and CVD at 75yrs
Sister with h/o breast cancer in her 50s, atrial fibrillation
Two brothers with h/o melanoma
Physical Exam:
Physical exam on admission to ICU [**2124-8-29**]:
Vitals: T: 96.6 BP: 107/61 P: 54 R: 18 O2: 96 on FiO2 50%
General: responsive to verbal commands, no acute distress
HEENT: intubated, pupils equal, slightly reactive
Neck: RIJ in place
Lungs: Coarse BS bilat with diminished sounds at L base
CV: soft heart sounds, RRR no m/r/g.
Abdomen: soft, diffuse inconsistent tenderness without
rebound/guarding, non-distended, bowel sounds present, no
organomegaly
Ext: ecchymotic, 3+ LE pitting edema. Warm with 2+ pulses.
Skin: very thin and delicate; dark ecchymoses right shoulder and
upper chest
.
Physical exam on transfer from ICU to floor [**2124-9-1**]:
VS: T:98.0, BP:132/76, HR:86, RR:18, O2 sat:97% on 3L NC
Gen: chronically ill-appearing male laying in bed in NAD.
HEENT: NCAT, anicteric, PERRLA, EOMI, OP clear, no thrush, MM
dry.
Neck: supple, no LAD.
Cardiac: RRR no m/r/g.
Lungs: very coarse rhonchi/crackles diffusely right > left, no
wheezing.
Abdomen: NABS, distended, non-tender, no rebound or guarding.
Extremities: 2+ pitting edema to knees b/l, right foot is warm.
Pulses difficult to palpate secondary to edema but feet are warm
and well perfused.
Back: kyphotic and wears a clamshell device for compression
fracture when standing.
Skin: markedly ecchymotic with several areas with small
excoriations/skin breaks. Skin is very fragile, likely secondary
to effects of prednisone and edema.
Neuro: CN 2-12 grossly intact. 2/5 strength in the flexors and
extensors of the bil LEs. 4/5 strength in the flexors and
extensors of the bil UEs. The dorsum of the L foot is slightly
erythematous and warm to the touch, but not particularly tender
to palpation.
.
Physical exam at discharge [**2124-9-20**]:
VS: T 97.3 BP 128/70 HR 59 SaO2 96% 2L NC Wt: 152.2 lbs
Gen: pleasant, chronically ill-appearing male laying in bed in
NAD.
HEENT: NCAT, anicteric, PERRLA, EOMI, OP clear, no thrush, MMM.
Neck: supple, no LAD.
Cardiac: Soft heart sounds. RRR no m/r/g.
Lungs: Diffuse coarse rhonchi bilaterally, no wheezing.
Abdomen: NABS, distended, diffusely tender without rebound or
guarding.
Extremities: 2+ pitting edema to knees b/l. Pulses difficult to
palpate secondary to edema but feet are warm and well perfused.
Back: kyphotic and wears a TLSO for compression fractures when
standing.
Skin: markedly ecchymotic with several areas with small
excoriations/skin breaks. Skin is very fragile, likely secondary
to effects of prednisone and edema. Large blood blister on
mid-back, dressing is c/d/i.
Neuro: CN 2-12 grossly intact. 2/5 strength in the flexors and
extensors of the bil LEs. 4/5 strength in the flexors and
extensors of the b/l UEs. Ambulatory with TLSO device and
walker.
Pertinent Results:
Labs on admission [**2124-8-29**]:
WBC-8.7 RBC-3.35* HGB-10.6* HCT-34.4* MCV-103* MCH-31.7
MCHC-30.9* RDW-17.7*
NEUTS-59 BANDS-33* LYMPHS-2* MONOS-5 EOS-0 BASOS-0 ATYPS-0
METAS-1* MYELOS-0
Glucose-124* UreaN-24* Creat-1.1 Na-145 K-4.8 Cl-100 HCO3-37*
AnGap-13
ALT-103* AST-122* LD(LDH)-334* AlkPhos-682* TotBili-0.4
Albumin-3.6
Calcium-9.5 Phos-2.5*# Mg-2.0
.
Labs on discharge [**2124-9-20**]:
WBC-8.2 RBC-2.64* Hgb-8.5* Hct-25.8* MCV-98 MCH-32.3* MCHC-33.0
RDW-16.8* Plt Ct-134*
Glucose-113* UreaN-17 Creat-0.6 Na-139 K-4.2 Cl-101 HCO3-33*
AnGap-9
ALT-37 AST-49* LD(LDH)-418* AlkPhos-424* TotBili-0.3
Calcium-8.4 Phos-2.7 Mg-1.8
.
[**2124-9-16**] VitB12-628 Folate-9.3
.
Cardiac enzymes:
[**2124-8-29**] 01:00PM BLOOD cTropnT-0.66*
[**2124-8-29**] 08:51PM BLOOD CK-MB-8 cTropnT-0.26*
[**2124-8-30**] 04:04AM BLOOD CK-MB-7 cTropnT-0.19*
.
IMAGING:
CT Chest ([**2124-8-30**]): IMPRESSION:
1. New left lower lobe opacification, which could be secondary
to infectious pneumonia and/or atelectasis.
2. Resolution of right upper lobe consolidation.
3. Stable bilateral cylindrical bronchiectasis and centrilobular
emphysema.
4. Stable extent of multiple vertebral compression fractures,
sternal
fracture, and rib fractures
CT chest ([**9-8**]): IMPRESSION:
1. Progression of a left lower lobe consolidation as well as a
right lower
lobe consolidation. These findings, in conjunction with history
of fever and the presence of small bilateral pleural effusions
suggests an infectious etiology.
2. Minimal bilateral upper lobe posterior opacities, possibly
also infectious, though in the setting of visible secretions
within the trachea and main stem bronchi, this distribution may
also represent foci of aspiration.
3. Unchanged bilateral bronchiectasis and centrilobular
emphysema.
4. Redemonstration of numerous compression fractures, sternal
fracture, and rib fractures.
.
CT Chest ([**2124-9-17**]):
1. Dependent bilateral prominently basilar airspace opacities,
associated
pleural effusions, moderate on the left and small on the right,
not significantly changed from the prior study and most likely
representing atelectasis. Infection is thought to be less
likely.
2. Layering mucus vs debris noted within the distal trachea and
bilateral main stem bronchi.
3. Stable centrilobular emphysema and basilar bronchiectasis.
.
MICRO:
[**2124-8-29**] BCx: no growth
[**2124-8-29**] UCx: skin contamination
[**2124-8-29**] MRSA negative
[**2124-8-29**] Endotracheal sputum: contaminated with oropharyngeal
flora
[**2124-9-6**], [**2124-9-8**], [**2124-9-12**] Induced sputums: PCP negative,
contaminated with oropharyngeal flora
[**2124-9-3**] C diff negative
[**2124-9-4**] Catheter tip no growth
[**2124-9-12**] Respiratory antigen screen and culture: negative
[**2124-8-30**] and [**2124-9-13**]: galactomannan negative
[**2124-8-30**]: B-glucan negative
[**2124-9-12**]: B-glucan positive (101 pg/ml)
[**2124-9-12**] Mycoplasma antibodies: negative
Brief Hospital Course:
58 year old male w past medical history of CML s/p BMT in [**2121**]
on chronic immunosuppression, with recent hospitalizations for
his bronchiolitis obliterans and for resistant pseudomonal
infections, presenting with respiratory distress and
hypotension.
.
# Hypoxic Respiratory Failure: Given his immune compromised
state and history of multi-drug resistant organisms, the concern
was for a new pneumonia. After a period of observation in the
ER, it appeared that he was tiring and he was intubated for
increased work of breathing. He had a bronchoscopy that did not
show many secretions or mucus plugging. His chest x-ray
appeared clear, CT scan the next day showed a new LLL opacity,
and he was treated empirically with Zosyn and linezolid. On
hospital day #2 ([**2124-8-30**]), his respiratory status had improved
significantly and he was able to be extubated without
difficulty. Mr. [**Known lastname 976**] was transferred to the BMT service
after having a PICC placed. He continued IV Zosyn and PO
linezolid. He was also started on prophylactic Azithromycin (see
below) for its antimicrobial and antiinflammatory effects in
bronchiolitis obliterans patients.
.
# Hypotension: Mr. [**Known lastname 976**] was hypotensive on admission,
initially did not respond to fluids, thought to be due sepsis
given his elevated lactate and bandemia. He was intially on
levophed but with IV fluid boluses he was able to weaned off
levophed. After his blood pressure normalized, and with
antibiotic treatment his lactate also normalized. During his
stay on the BMT floor, his blood pressure was noted to be normal
to slightly elevated.
.
# CML s/p BMT, Chronic GVHD, immunosuppression: patient with
chronic abdominal pain, and GVHD of his lungs, liver and GI
tract. He is chronically on steroids, so while intubated he
received stress dose steroids. Mr. [**Known lastname 976**] was also put on a 40
mg taper of oral prednisone while on the BMT service. His
respiratory status began to decline with taper when prednisone
was 10mg daily so it was increased to 15mg [**Hospital1 **] and tapered to
10mg [**Hospital1 **]. His MMF was tapered to 500mg qAM/250mg qPM. He was
continued on his bactrim, voriconazole, and acyclovir for
prophylaxis.
.
# LLL Pneumonia/Respiratory status: Pt was treated with Zosyn
and linezolid as above. Good sputum samples were unable to be
obtained despite multiple attempts. On [**2124-9-11**], Mr. [**Known lastname **]
respiratory status began to decline with his steroid taper. His
zosyn and azithromycin were stopped and he was given a 7 day
course of cefepime and cipro (ended [**2124-9-18**]). His Linezolid was
stopped on [**2124-9-14**] (completed 17 day course). Per pulmonology
recommendations, due to his pleural effusions, he was diuresed
with improvement in his breathing. CT Chest [**2124-9-17**] demonstrated
continued bibasilar atelectasis and pleural effusions but it was
felt that infection was less likely at this time. He also had
secretions in the trachea and bronchi, which he continued to
have difficulty clearing although the acapella device, regular
use of incentive spirometry, and cough assist machine greatly
helped. Pulmonology recommended continuing tobramycin 4 weeks
on/4 weeks off (prior course ended [**2124-8-28**], RESTART [**2124-9-28**]).
He was started on azithromycin 500mg x6 days ([**Date range (1) 30714**]),
250mg x6 days ([**Date range (1) 30715**]), then 250mg every other day
(start [**2124-9-29**]). ID recommended monthly IVIG and he received
35g IVIG on [**2124-9-17**], premedicated with tylenol and
diphenhydramine. He still tended to desaturate to mid 80%s with
ambulation and required oxygen 2-3L/min at all times.
.
# Troponin Leak: Patient noted to have elevated troponin in the
ER, with normal CK and CK-MB's, troponin trended down and the
CK/CK-MB remained in the normal range. His EKG did not show any
ischemic changes, and the elevated troponins were thought to be
due to demand ischemia in the setting of his initial
hypotension. He had no further sequelae of this during his stay
on 7 [**Hospital Ward Name 1826**].
.
# Diarrhea: Patient had multiple episodes of diarrhea prior to
admission, has chronic diarrhea due to GVHD. ID felt that it
could be related to cytokine production in the setting of a new
pneumonia. On admission to the hospital his diarrhea resolved.
His diarrhea at the time of discharge was at his baseline of
approximately 400cc/day.
.
# Hx of PE, DVT: Has hx of multiple PEs in [**2122**] and DVT in early
[**2123**], is on chronic anticoagulation, was continued on his home
dose of lovenox 40mg [**Hospital1 **].
.
# Multiple Vertebral Fractures: patient on narcotics at home,
methadone initially held while intubated and on a fentanyl drip,
on extubation his home pain regimen was restarted. He did well
on his home pain regimen. Physical therapy worked with him daily
to get him ambulating and to increase his strength and mobility.
He continued use of his TLSO brace when ambulating.
.
# GERD: patient maintained on a PPI, due to history of GERD and
chronic steroid use.
Mr. [**Known lastname 976**] was deemed medically stable and fit for discharge to
a rehabilitation facility ([**Hospital 30716**] Healthcare Facility
[**Telephone/Fax (1) 30717**]) on [**2124-9-20**]. He will have outpatient follow-up with
the hematology/oncology clinic and with pulmonary within several
weeks of his discharge.
Medications on Admission:
Iron sulfate 325mg [**Hospital1 **]
Prednisone 15mg daily
Pregabalin 150mg QID
Budesonide 3mg PO Q8H
Mycophenolate mofetil 500mg [**Hospital1 **]
Acyclovir 400mg [**Hospital1 **]
Methadone 15mg [**Hospital1 **] and 20mg QHS
Morphine IR 60mg PO Q4H PRN pain
Vit D3 800 units daily
Lidoderm 5% patch, 1 to L back and 1 to R back, daily
Voriconazole 200mg [**Hospital1 **]
Enoxaparin 40mg [**Hospital1 **]
TMP-SMX SS 1 tab daily
Fentanyl patch 200mcg Q72H
Metoprolol 75mg TID
Polyethylene glycol 17g daily
Tobramycin 300mg neb [**Hospital1 **] (ending [**8-28**])
Calcium carbonate 1000mg TID
Pantoprazole 40mg daily
MVI with minerals daily
Pancrease EC 2 tab TID
Lorazepam 0.5-1mg Q4H PRN anxiety
Albuterol/ipratropium nebs Q4H PRN
Discharge Medications:
1. Pregabalin 150 mg Capsule Sig: One (1) Capsule PO four times
a day.
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO once as
needed for pre-IVIG.
3. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
QAM (once a day (in the morning)).
4. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
QPM (once a day (in the evening)).
5. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Two (2) Adhesive Patch, Medicated Topical DAILY (Daily): one to
right back, one to left back; place for 12 hours on each day,
and remove for 12 hours .
7. Voriconazole 200 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
8. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg
Subcutaneous Q12H (every 12 hours).
9. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
10. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily): Hold for loose stools.
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
12. Combivent 18-103 mcg/Actuation Aerosol Sig: One (1) puff
Inhalation every 4-6 hours as needed for shortness of breath or
wheezing.
13. Methadone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day): Pt should not drive or lift heavy objects when taking
this medication.
14. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)): Pt should not drive or lift heavy objects
when taking this medication.
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
16. Pancrease MT 10 30,000-10,000- 30,000 unit Capsule, Delayed
Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO TID
(3 times a day) with meals.
17. Multi-Vitamin W/Minerals Capsule Sig: One (1) Capsule PO
once a day.
18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
19. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO Q 8H (Every 8 Hours).
20. Morphine 30 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain: Hold for sedation or RR<12. Pt should
not drive or lift heavy objects when taking this medication.
21. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
22. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
23. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
24. Fentanyl 100 mcg/hr Patch 72 hr Sig: Two (2) Patch 72 hr
Transdermal Q72H (every 72 hours): Pt should not drive or lift
heavy objects when taking this medication. .
25. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for anxiety: Hold for sedation or RR<12.
26. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: Five
(5) mL Inhalation twice a day for 4 weeks: Day 1 = [**2124-9-28**].
5 mL(s) inhaled by nebulizer twice daily for 4 weeks, then hold
for 4 weeks.
27. Gammagard S/D 10 gram Recon Soln Sig: as directed as
directed Intravenous once a month: 0.5g/kg (dose on [**2124-9-17**] was
35g) each month. Pre-medicate with acetaminophen 650mg PO and
Diphenhydramine 12.5mg IV x1 dose. Last dose was [**2124-9-17**].
28. Azithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q24H
(every 24 hours) for 2 days: [**2124-9-21**] and [**2124-9-22**].
29. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days: [**Date range (3) 30715**].
30. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY: Start [**2124-9-29**].
31. Oxygen
Oxygen 2-3 liters/min by nasal cannula at all times. [**Month (only) 116**] need
3L/min with ambulation.
32. Cough Assist
Please dispense one (1) Mechanical Insufflator-Exsufflator for
Cough Assist.
Use: AT LEAST twice daily use of cough assist machine.
Cough machine settings: Inspiratory pressure 26, Expiratory
pressure 32, Pause dial at 2, AUTO Mode, Pressures depend on
seal of mask which is a small
33. Benadryl 50 mg/mL Solution Sig: 12.5 mg Injection once a
month: Pre-medicate prior to IVIG administration each month.
34. Respiratory therapy
[**Hospital1 **] use of acapella PEP device (at bedside); hourly use of
incentive spirometer (at bedside); at least twice daily use of
cough induction machine for [**2-20**] cycles (prescription given).
Cough machine settings:
Inspiratory pressure 26,
Expiratory pressure 32,
Pause dial at 2,
AUTO Mode,
Pressures depend on seal of mask which is a small.
35. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO
twice a day: Hold for SBP<100 or HR<55.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 15644**] Long Term Health - [**Location (un) 47**]
Discharge Diagnosis:
Pneumonia
Bronchiolitis obliterans
Chronic graft versus host disease
Discharge Condition:
Stable, afebrile, ambulatory with walker and TLSO brace, SaO2
92-96% 2-3L NC at rest, ambulatory SaO2 85-92% 2-3L NC. Pt tends
to desaturate with movement and ambulation. [**Month (only) 116**] require 2-3L
oxygen depending on his activity level and how recently he has
used cough machine and incentive spirometry.
Discharge Instructions:
Mr. [**Known lastname 976**], you were admitted to the hospital because of
respiratory distress. A chest CT showed that you had a new
pneumonia. You were treated with antibiotics and adjustments
were made to your immunosuppressive medications in consultation
with the pulmonary and infectious disease specialists and your
respiratory status improved.
You were deemed medically stable and fit for discharge to a
rehabilitation facility ([**Hospital 30716**] Healthcare Center [**Telephone/Fax (1) 30717**])
on [**2124-9-20**].
The following changes were made to your medications:
1. START Azithromycin 500mg daily for 6 days ([**Date range (1) 30714**]);
250mg daily for 6 days ([**Date range (3) 30715**]), then 250mg daily
every other day (starting 11/1/309).
2. CONTINUE Tobramycin inhaled antibiotic (start 4 week course
again on [**2124-9-28**], then 4 weeks off)
3. INCREASE to Prednisone 10mg twice a day - Dr [**Last Name (STitle) 2168**] and Dr
[**Last Name (STitle) **] will tell you how to titrate this medication
4. DECREASE to Cellcept [**Pager number **] mg in morning, 250mg in evening
5. IVIG 0.5g/kg q month (last dose 35g given [**2124-9-17**]) -
premedicate with acetaminophen 650mg x1 dose and diphenhydramine
12.5mg IV x1 dose.
6. DECREASE your metoprolol to 50mg twice daily
7. STOP iron sulfate 325mg twice daily
.
OUTPATIENT TREATMENTS
Respiratory therapy: [**Hospital1 **] use of acapella PEP device; hourly use
of incentive spirometer; at least twice daily use of cough
induction machine for [**2-20**] cycles.
Cough machine settings:
Inspiratory pressure 26,
Experiatory pressure 32,
Pause dial at 2,
AUTO Mode,
Pressures depend on seal of mask, which is a small.
No Chest PT as pt has multiple spinal fractures.
Oxygen 2-3 L/minute by nasal cannula at all times. [**Month (only) 116**] need
3L/min with ambulation.
Mr. [**Known lastname 976**] will also need daily treatment with inhaled
tobramycin starting [**2124-9-28**] (4 weeks on and 4 weeks off) with
follow-up as outpatient with pulmonary (followed by Dr. [**Last Name (STitle) 2168**]
at [**Hospital1 18**]).
Wound Care:
Site: Left posterior leg
Description: full thickness traumatic wound approx. 2.3 x 0.7 cm
with epidermal skin flap covering approx 50% of the wound. The
wound edges are irregular. There is a small amount of serosang
drainage with odor. The periwound tissue is intact with fragile
tissue.
Care: Apply a thin layer of DuoDerm Gel, Adaptic, dry gauze, ABD
Avoid tape to skin - use tubular netting, Kerlix or conform
dressings to extremities Change daily.
Wound Care:
Site: Left shoulder:
Description: approx 4 x 4 cm dry ulcer with irregular wound
Care: Cleanse all open site with commercial wound cleanser or
normal saline. Pat the tissue. Apply Mepilex border dressing 4 x
4" and change every 3 days or prn
Wound Care:
Site: left forearm
Description: full thickness ulcer approx 1.5 x 1.2 cm with
epidermal flap partially in place, wound edges were irregular.
There was a small amount of serosang drainage with no s/s of
infection.
Care: Apply a thin layer of DuoDerm Gel, Adaptic, dry gauze, ABD
Avoid tape to skin - use tubular netting, Kerlix or conform
dressings to extremities Change daily.
Blood blister x2 on back:
Please place large soft bandage (mepilex) over blister on back.
Change dressing every 3 days. Please place padding (e.g. ABD pad
or towel) between pt's back and TLSO brace when using brace to
prevent worsening of or recurrence of blister. Please do not
apply tape to skin as this causes blistering.
Please seek immediate medical attention if you develop fever
>100.4F, chills, shortness of breath, inability to tolerate food
or water, pain with urination, blood in the stool, black stool,
abdominal pain, chest pain, or any new concerning symptom.
You have follow-up appointments as outlined below.
It was a pleasure caring for you during this hospital stay.
Followup Instructions:
The following appointments have been scheduled for you:
Dr. [**Last Name (STitle) **] (Hem/Onc)
Phone: [**Telephone/Fax (1) 3237**]
Monday, [**2124-9-25**] at 2pm (Please come at 1:15pm to check
your labs)
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2164**], MD (Endocrinology)
Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2124-9-28**] at 9:00
PROVIDER: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 2168**] (Pulmonary)
Thursday, [**11-2**] at 2:30pm
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB
Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2124-11-2**] 2:40pm
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2124-11-2**] at 3:00pm
You are on the cancellation list. If there is an earlier
appointment available, you will be contact[**Name (NI) **].
|
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47,733
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21692
|
Discharge summary
|
report
|
Admission Date: [**2151-3-7**] Discharge Date: [**2151-3-28**]
Date of Birth: [**2111-7-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
VF arrest
Major Surgical or Invasive Procedure:
Endotracheal intubation (now extubated)
Central venous line placement (now removed)
Femoral line placement (now removed)
Electrophysiology study with cardiac catheterization
History of Present Illness:
39M w/ pmh significant for ebstein's anomaly s/p tricuspid valve
reconstruction, right and left sided systolic congestive heart
failure, presenting with palpitations which awoke him from
sleep. The patient presented to the ED where he appeared pale
and was found to be in VT to the 230's. He began to experience
chest pain and was given amiodarone 150mg IV X1, followed by
amiodarone gtt. He became diaphoretic and was therefore given
etomidate and shocked with 200J. His rhythm then became fine
V-fib, he became unresponsive and apneic. CPR was initiated,
epinephrine given X1, CPR continued, shocked again at 360J,
returned to V-Tach @ 240, Intubated, returned to sinus rhyhthm,
aspirated vomitus. had right bronchus intubation and ETT was
pulled back in ED. Blood pressures dropped to 48/43, started on
levophed, pressure increased to 124/77.
.
On presentation to the CCU, the patient is intubated with
mottled skin, on levophed, neosynephrine and vasopressin, with
HR 85 and BP 125/77.
Past Medical History:
1. Ebstein anomaly, s/p tricuspid valve reconstruction
- moderate to severe tricuspid regurgitation
- right heart failure, RVEF 25% in [**6-17**]
2. ASD, s/p primary closure [**3-/2136**]
3. Left heart failure with evidence of noncompaction of LV, with
LVEF 28% in [**6-17**]
4. Hyperlipidemia
5. Hypertension
6. Obstructive sleep apnea
7. Obesity
8. DVT
9. Superficial phlebitis
10. endocarditis w/ septic emboli to brain prior to Cardiac
surgery.
Social History:
Remote tobacco use, quit 5-6 years ago. Still smokes an
occasional cigar. No history of alcohol abuse but has occasional
drink. No illicit drugs. Patient works as the [**Hospital1 18**] fax machine
repairman. He is married with 1 biologic child, aged 9 months, 2
older children from his wife's prior marriage
Family History:
There is no family history of premature coronary artery disease
or sudden death. Father's family history is unknown, mother is
alive in her 60's
Physical Exam:
Date and time of exam: [**2151-3-7**]
General appearance: sedated, intubated, obese
Vital signs: per R.N.
Height: 72 Inch, 183 cm BP right arm: 95 / 67 mmHg
Weight: 100 kg T current: 99.6 Cm HR: 99 bpm RR: 32 insp/minO2
sat: 93 % on Supplemental oxygen: 100%
Eyes: (Conjunctiva and lids: WNL)
Ears, Nose, Mouth and Throat: (Oral mucosa: WNL), (Teeth, gums
and palette: WNL)
Neck: (Jugular veins: Not visible), (Thyroid: WNL)
Back / Musculoskeletal: (Chest wall structure: WNL)
Respiratory: (Auscultation: diminished on left, rhonchi
bilaterally.)
Cardiac: (Rhythm: Regular), (Palpation / PMI: WNL),
(Auscultation: S1: WNL, S3: Absent, S4: Absent)
Abdominal / Gastrointestinal: (Bowel sounds: WNL), (Bruits: No),
(Pulsatile mass: No), (Hepatosplenomegaly: No)
Genitourinary: (WNL)
Femoral Artery: (Right femoral artery: No bruit), (Left femoral
artery: No bruit)
Extremities / Musculoskeletal: (Digits and nails: WNL), (Gait
and station: WNL), (Muscle strength and tone: WNL), (Dorsalis
pedis artery: Right: 1+, Left: 1+), (Posterior tibial artery:
Right: 1+, Left: 1+), (Edema: Right: 0, Left: 0)
Skin: (mottled abdomen, cyanotic extreemities.)
Pertinent Results:
admission labs-
[**2151-3-7**] 05:30AM BLOOD WBC-9.4 RBC-4.83 Hgb-14.9 Hct-44.4 MCV-92
MCH-30.8 MCHC-33.5 RDW-14.0 Plt Ct-306
[**2151-3-7**] 05:30AM BLOOD Neuts-57.6 Lymphs-35.6 Monos-4.5 Eos-1.9
Baso-0.4
[**2151-3-7**] 05:30AM BLOOD PT-16.7* PTT-30.4 INR(PT)-1.5*
[**2151-3-8**] 02:59PM BLOOD Fibrino-546*
[**2151-3-8**] 02:59PM BLOOD FDP-80-160*
[**2151-3-7**] 05:30AM BLOOD Glucose-185* UreaN-16 Creat-1.0 Na-133
K-6.3* Cl-97 HCO3-26 AnGap-16
[**2151-3-7**] 05:30AM BLOOD CK(CPK)-267*
[**2151-3-7**] 02:56PM BLOOD CK(CPK)-262*
[**2151-3-7**] 08:29PM BLOOD CK(CPK)-740*
[**2151-3-8**] 03:01AM BLOOD ALT-400* AST-448* LD(LDH)-586* AlkPhos-68
TotBili-1.2
[**2151-3-11**] 04:12AM BLOOD Lipase-200*
[**2151-3-7**] 05:30AM BLOOD CK-MB-6
[**2151-3-7**] 05:30AM BLOOD cTropnT-<0.01
[**2151-3-7**] 02:56PM BLOOD CK-MB-7 cTropnT-0.36*
[**2151-3-7**] 08:29PM BLOOD CK-MB-9 cTropnT-0.30*
[**2151-3-7**] 05:30AM BLOOD Calcium-8.6 Phos-4.6* Mg-2.1
[**2151-3-8**] 08:21PM BLOOD Vanco-6.6*
[**2151-3-7**] 06:19AM BLOOD Type-ART pO2-71* pCO2-51* pH-7.24*
calTCO2-23 Base XS--5 Intubat-INTUBATED
[**2151-3-7**] 05:35AM BLOOD Glucose-165* Na-135 K-9.6* Cl-94*
calHCO3-25
[**2151-3-7**] 06:19AM BLOOD Hgb-14.6 calcHCT-44 O2 Sat-90 COHgb-2
MetHgb-0.2
[**2151-3-7**] 06:19AM BLOOD freeCa-1.07*
Select labs-
[**2151-3-12**] 04:36AM BLOOD WBC-18.9*# RBC-4.13* Hgb-12.6* Hct-37.2*
MCV-90 MCH-30.5 MCHC-33.8 RDW-14.7 Plt Ct-307
[**2151-3-8**] 02:59PM BLOOD PT-24.6* PTT-39.6* INR(PT)-2.5*
[**2151-3-9**] 03:33AM BLOOD Glucose-170* UreaN-48* Creat-3.2* Na-129*
K-4.4 Cl-96 HCO3-23 AnGap-14
[**2151-3-9**] 03:33AM BLOOD ALT-1211* AST-1132* CK(CPK)-4046*
AlkPhos-53 TotBili-1.8*
[**2151-3-10**] 05:00AM BLOOD ALT-1286* AST-864* LD(LDH)-677*
AlkPhos-54 TotBili-1.7*
[**2151-3-11**] 04:12AM BLOOD Lipase-200*
Reports-
head CT with and without contrast [**2151-3-7**]
IMPRESSION:
1. No acute intracranial pathology.
2. Encephalomalacia of the right occipital pole with associated
ex vacuo
dilatation of the right lateral ventricular occipital [**Doctor Last Name 534**]
suggestive of prior cerebral injury.
================================
Chest CTA [**2151-3-7**]
IMPRESSION:
1. Small left pneumothorax, likely related to acute left rib
fractures. Other rib deformities are bilateral.
2. Bibasilar and peribronchial opacities, could be due to
massive aspiration, associated with atelectasis.
3. Severe cardiomegaly with marked enlargement of right atrium
and right
ventricle in this patient with known Ebstein malformation and
prior sternotomy for tricuspid plasty.
4. Mediastinal lipomatosis.
5. Venous shunt between the right and the middle hepatic veins,
could be due to old Budd-Chiari disease. Tiny filling defect in
the abnormal connection could be branching vessels or thrombus,
likely old.
.
================================
[**2151-3-7**] CT chest
IMPRESSION:
1. No residual pneumothorax in the upper two-thirds of the
chest. One
residual air bubble in the mediastinum. No chest tube was
installed.
2. No other change since earlier today.
================================
CT chest [**2151-3-13**]- IMPRESSION:
1. No evidence of intra-abdominal fluid collection.
2. Basal pulmonary consolidation with small pleural effusions.
3. Mediastinal lipomatosis.
4. Right adrenal myelolipoma.
5. Evidence of previous right hip AVN.
.
Echo with bubble study
No spontaneous echo contrast or thrombus is seen in the left
atrium/left atrial appendage or the right atrium/right atrial
appendage. The left and atrial and right appendage emptying
velocities are depressed (<0.2m/s). The intra-atrial septum is
thickened consistent with prior ASD closure surgery. No residual
atrial septal defect is seen by 2D or color Doppler. Left
ventricular wall thickness and cavity size are grossly normal.
The apex is heavily trabeculated. Systolic function could not be
adequately assessed. Th e systolic function appears depressed.
The right ventricular cavity is dilated with marked free wall
hypokinesis. There are simple atheroma in the descending
thoracic aorta to 45cm from the incisors. The descending aorta
is relatively small, but no coarctation or dissection is seen.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. The tricuspid annular ring is identified and appears well
seated. Mild to moderate tricuspid regurgitation is seen. There
is no pericardial effusion.
IMPRESSION: No atrial septal defect by 2D or color Doppler. Well
seated tricuspid annular ring with mild-moderate tricuspid
regurgitation. Severe right ventricular cavity enlargement with
depressed biventricular systolic function.
.
Cardiac MRI:Impression:
1. Normal left ventricular cavity size with globally depressed
systolic function. The LVEF was severely decreased at 28%. No MR
evidence of prior myocardial scarring/infarction although images
technically suboptimal. Prominent non-compacted left ventricular
myocardium that meet CMR criteria for non-compaction.
2. Abnormal and apically displaced tricuspid valve consistent
with Ebstein's anomaly. A tricuspid annulplasty ring was
present. Moderately depressed systolic function of the
functional right ventricle with RVEF at 25%. Abnormal septal
motion consistent with right ventricular pressure / volume
overload. Markedly dilated inferior vena cava and hepatic veins
consistent with elevated
right atrial pressure.
3. Mild aortic regurgitation. Moderate-to-severe tricuspid
regurgitation through tricuspid leaflets of functional right
ventricle. Severe tricuspid regurgitation through tricuspid
annulus of structural right ventricle. 4. The indexed diameters
of the ascending and descending thoracic aorta were
normal. The main pulmonary artery diameter index was normal.
5. Biatrial enlargement.
.
Chest x-ray [**2151-3-17**] - IMPRESSION: 1. Stable appearance of the
mediastinum and cardiac silhouette. 2. Status post extubation.
No evidence of atelectasis.
.
EKG [**2151-3-26**]- Sinus rhythm. The P-R interval is prolonged. Left
axis deviation. Right bundle-branch block with left anterior
fascicular block. There are Q waves in the inferior leads
consistent with prior infarction. There is an abnormal
precordial transition consistent with possible prior anterior
myocardial infarction. Low voltage in the precordial leads.
Compared to the previous tracing the P-R interval is longer.
Brief Hospital Course:
39M w/ pmh of ebstein's anomaly, s/p tricuspid valve
reconstruction, right and left sided systolic congestive heart
failure, presenting with unstable ventricular tachycardia, s/p
resuscitation with return to sinus tachycardia, s/p intubation
and extubation.
.
# Ventricular Tachycardia: Likely result of natural history of
ebstein anomaly. Patient underwent CPR and intubation with
return to normal sinus rhythm. Suppressed ectopy with
Amiodarone. Also started metoprolol for rate-control. Amiodarone
increased to 200mg TID. Had cardiac MRI with final read as
above. Patient then underwent EP study where they were unable to
induce ventricular fibrillation so unable to ablate. EP was
unable to place an ICD during this admission given recent
procedure and significant abnormal heart anatomy. Patient to
follow up with Dr. [**Last Name (STitle) **] in [**2-12**] weeks to discuss possible
ICD placement in the future. In addition, patient to have
monitor set up at home as per Dr. [**Last Name (STitle) **].
.
#Respiratory Failure - Now resolved. Initially primarily
hypoxemic, with unclear etiology. Differential includes ARDS,
PNA/sepsis, shunt, and volume overload. Improvement with nitric
oxide suggested some shunt physiology, although intracardiac
shunt was not evident on TEE. Respiratory failure improved with
diuresis. Decreased Fi02 and PEEP and nitric oxide weaned off
with improved compliance. Methemaglobin negative. Multifactorial
secondary to CHF, OSA, and restrictive ventilation due to
habitus. Required mechanical ventilation from admission
(intubated during V Fib arrrest in ED), and extubated on
[**2151-3-16**], without difficulty. Since, patient has been satting
well on room air using CPAP at night.
.
#Hypotension (resolved): Initially secondary to VT, in addition
probably contribution from sedatives, positive pressure
ventilation especially in the setting of marked RV dysfunction.
[**Month (only) 116**] also be intravscularly volume depleted, but total body
overloaded. Sepsis less likely at this point, given broad
spectrum antibiotic coverage, negative culture data, although
stil febrile. Patient initially on 3-pressors which were weaned
off. In terms of sepsis work-up all culture data negative,
although patient was treated empirically for VAP. Initially
held all blood pressure medications including beta blocker and
ACE inhibitor which were restarted slowly after hypotension had
resolved.
.
# Fevers: Leukocytosis/fever/right lobe infiltrate- Patient felt
to have likely aspiration PNA with witnessed emesis during
intubation. Cultures were all negative. Femoral line was
removed and sent for culture. Given negative culture data,
patient was treated for VAP and then there was concern that
possible drug fever given persistant fever and no positive
culture data. Fevers improved after patient was extubated and
did not recur.
.
# Chronic Systolic Congestive Heart Failure: Has right sided
heart failure only, s/p tricuspid reconstruction and ASD repair.
Patint on low dose metoprolol and lisinopril as above, cont
aspirin 325. Initially held statin in the setting of worsening
liver abnormalities but restarted as LFTs improved. Continued
patient's outpatient lasix dose of 40 mg Po daily once blood
pressures had improved.
.
# Pain: has left sided chest wall pain [**3-15**] fractured ribs from
resuscitation. Patient was treated with Lidocaine patch daily
as well as standing Tylenol. Patient was discharged on tylenol
PRN.
.
#Gout: Patient as outpatient on colchicine and allopurinol
although patient not taking allopurinol at home. Initially
concern that fever may be secondary to gout. Patient was tapped
and tap revealed WBC, Joint Fluid 300* #/uL 0 - 150
RBC, Joint Fluid [**Numeric Identifier 1871**]* #/uL 0 - 0 Polys 80* % 0 - 25
Lymphocytes 4 % 0 - 75
Monocytes 0 % 0 - 70 Macrophage 16 % 0 - 70 FEW SIDEROTIC
GRANULES PRESENT
Joint Crystals, Number NO[**Serial Number **]. Patient states that he is having
pain in his right knee which he thinks is from his gout. Given
improvement in renal function and patient's request restarted
colchicine at outpatient dose.
.
# Anemia - patient with Cr 31 currently previous baseline 41.
Patient has not had anemia labs checked. Added on anemia labs to
discharge labs. Patient will require active type and screen
prior to additional procedures
.
FEN: regular cardiac diet, replete lytes PRN
.
ACCESS: PIV
.
PROPHYLAXIS: hep sc, colace, senna, PPI daily
CODE: Full Colde
Medications on Admission:
ALBUTEROL - 90 mcg Aerosol - ii puffs ih qid prn
ALLOPURINOL - 300 mg Tablet - 2 Tablet(s) by mouth daily
ATORVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day
COLCHICINE - 0.6 mg Tablet - One Tablet(s) by mouth once a day
DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth daily
FLUTICASONE [FLOVENT HFA] - 220 mcg Aerosol - 2 puffs nasally
twice a day x two weeks
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day
LISINOPRIL - 10 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE [TOPROL XL] - 25 mg Tablet Sustained
Release
24 hr - 1 Tablet(s) by mouth once a day
Discharge Medications:
1. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice
a day.
Disp:*60 Tablet(s)* Refills:*2*
7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
four times a day as needed for shortness of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Ventricular fibrillation arrest
.
Secondary:
Ebstein's anomaly
Chronic left heart failure
Hyperlipidemia
Hypertension
Obstructive sleep apnea
Gout
Discharge Condition:
Good, hemodynamically stable, afebrile
Discharge Instructions:
You were admitted after cardiac arrest. The arrest was most
likely caused by underlying rhythm abnormalities related to your
Ebstein's Anomaly. You were intubated for airway protection, and
finally extubated after your respiratory status improved. You
had fevers that resolved after extubation. As you improved
significantly, you were transferred to the floor from the ICU.
You were evaluated by an electrophysiology study, but no
ablatable source could be identified in your heart. You need to
follow-up in 2 weeks with Dr. [**Last Name (STitle) **] for further evaluation
and possible ICD placement. Please also follow-up as strongly
advised below. Dr. [**Last Name (STitle) **] is arranging for you to have an
outpatient cardionet or loop recorder at home after discharge.
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500ml
.
The following changes were made to your medications:
- We are stopping your digoxin as your have not been on it in
the hospital
-STOP Allopurinol for now, re-discuss with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] Lisinopril to 2.5mg PO daily
-CHANGE Metoprolol to 25 mg PO BID
-START Amiodarone 200mg PO 3 times daily
-START Aspirin 325mg PO daily
.
If you experience any chest pain, shortness of breath,
palpitations, weakness, nausea, vomiting, dizziness,
lightheadedness, or have any other concerns please [**Name6 (MD) 138**] your MD
or return to the ED.
Followup Instructions:
Please call to set up a follow-up appointment within 2 weeks
with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 2037**] for further evaluation for ICD
and monitoring of your cardiac status.
.
Please follow-up with the Adult Congenital Heart Clinic within 1
month for further monitoring of your Ebstein's anomaly.
.
Please call the rheumatology department ([**Telephone/Fax (1) 1668**] for a
follow up appointment with Dr. [**Last Name (STitle) **] to discuss when and if to
restart allopurinol treatment for gout.
.
Please follow-up with Sleep Medicine ([**Telephone/Fax (1) 9525**] to schedule
a repeat outpatient sleep study.
.
Please call the [**Hospital **] Clinic ([**Telephone/Fax (1) 7026**] as outpatient to
discuss weight loss in the case of further possible heart
surgery. We would reccomend you follow up within 1-2 weeks.
Completed by:[**2151-3-28**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.04",
"81.91",
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"96.72",
"99.62",
"37.27",
"88.72",
"38.91",
"38.93",
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] |
icd9pcs
|
[
[
[]
]
] |
16052, 16058
|
10178, 14657
|
323, 499
|
16257, 16297
|
3665, 10155
|
17819, 18689
|
2335, 2482
|
15305, 16029
|
16079, 16236
|
14683, 15282
|
16321, 17796
|
2497, 3646
|
274, 285
|
527, 1519
|
1541, 1993
|
2009, 2319
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,479
| 186,583
|
48347+59086+59089
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2109-7-19**] Discharge Date: [**2109-7-31**]
Date of Birth: [**2054-1-15**] Sex: F
Service:
HISTORY OF THE PRESENT ILLNESS: The patient is a 55-year-old
female with a known history of coronary artery disease, CHF,
who presented in pulmonary edema. Per verbal report, the
patient had become very anxious during a thunderstorm,
hyperventilating, and had progressive dyspnea on exertion
without chest pain. Upon arrival, EMTs found the patient
confused, hypoxic, and severely hypertensive. The patient
was intubated.
ALLERGIES: The patient has no known drug allergies.
MEDICATIONS AT HOME:
1. Imdur 30 mg PO q.d.
2. Toprol XL 75 mg q.d.
3. Lasix 40 mg p.o.q.d.
4. Norvasc unknown dose.
5. Zocor.
6. Aspirin.
PAST MEDICAL HISTORY: History revealed coronary artery
disease with a non-Q-wave MI in [**2109-1-22**] and [**2108-9-22**]. Known chronic .......... and has had multiple PCIs
including brachytherapy to that lesion. Pulmonary
hypertension. On previous catheterizations the patient has
been noted to have severely PA pressures as high as 90/45.
She has had negative lower extremity Dopplers for DVT in the
past as well as CT angiograms felt to demonstrate evidence of
pulmonary embolism. Diabetes mellitus type 2. Severe,
poorly controlled hypertension. Hypercholesterolemia.
Congestive heart failure with decreased ejection fraction
most recently in [**2108-9-22**] showing an EF of 35% to 40%
with diffuse hypokinesis inferior and apical akinesis.
Hypothyroidism status post thyroidectomy for multinodular
goiter. GERD. Anxiety disorder.
ALLERGIES: The patient is allergic to PENICILLIN, WHICH
CAUSES EDEMA; ACE WHICH CAUSES A COUGH, AS WELL AS ARBs,
which are thought to cause cough and may partially have given
her laryngeal edema in the past.
SOCIAL HISTORY: The patient is a distant tobacco user, quit
20 years ago. She has six children, lives in [**Location 686**].
She denies drug or alcohol use.
FAMILY HISTORY: History revealed that the patient is widely
positive for diabetes mellitus and coronary artery disease.
PHYSICAL EXAMINATION: Examination on admission revealed the
following: Blood pressure 180/100, heart rate 100,
respiratory rate 24, oxygen saturation initially was 50%,
subsequently, the patient was intubated. GENERAL: The
patient is a morbidly obese African-American female with a
large amount of redundant soft tissue of the neck. Pupils
equal, round, and reactive to light. Sclerae were anicteric.
JVP was not appreciated due to soft tissue. She had very
distant heart sounds, S1 and S2 barely being audible. Post
intubation, the lungs were clear to auscultation anteriorly
with diffuse rhonchi posteriorly and laterally. ABDOMEN:
Obese, nontender, nondistended with hypoactive bowel sounds.
EXTREMITIES: The patient had 2+ pitting edema, distal pulses
were intact.
LABORATORY DATA: Admitting labs revealed the following: BUN
and creatinine 20 and 1.7. Hematocrit 42.7. Coagulations
normal.
HOSPITAL COURSE: (by issue)
RESPIRATORY FAILURE: Etiology was thought to be
multifactorial with LV failure and subsequently pulmonary
edema as well as the severe pulmonary artery hypertension.
The patient was treated aggressively with antihypertensive
regimen, as well as diuresis, appropriate amounts of sedation
as the patient was highly anxious with minimal stimulation
with increase in her pulmonary artery pressures to systolic
measurements of 100 mmHg. Eventually, with the discharge
antihypertensive regimen, the patient had stable pulmonary
artery pressures of 40s/20s. A transesophageal
echocardiogram was performed early in the hospital stay to
rule out shunting, but there was no evidence of any
intracardiac shunting to explain the pulmonary hypertension.
Lower extremity Dopplers were done. The patient did not have
any DVTs to suggest chronic pulmonary embolisms. Etiology of
her chronic pulmonary hypertension was most likely secondary
to hypertension of obesity and obstructive sleep apnea, but
seemed to be adequately treated with aggressive
antihypertensive regimen.
LARYNGEAL EDEMA: The patient failed her initial extubation
because of laryngeal edema with severe stridor that was
refractory to inhaled racemic epinephrine. The patient was
re-intubated and treated with aggressive doses of IV steroids
and eventually transitioned to PO Prednisone, of which she
will taper off.
Subsequent re-attempts at extubation were successful without
any evidence of recurrence, laryngeal edema. Etiology was
thought to be mechanical irritation.
RENAL: The patient had stable BUN and creatinines throughout
the hospital stay.
INFECTIOUS DISEASE: The patient had spiked fevers and
elevated white counts earlier in the hospitalization course
with right lower lobe infiltrate. The patient was thought to
be in aspiration pneumonia secondary to her emergence
intubation. She was treated with a ten-day course of
Levofloxacin and Flagyl and improved clinically.
ENDOCRINE: The patient was kept on her home regimen of
diabetes treatment and had fairly well controlled blood
glucose, except for when she was on high doses of steroids
during which time she briefly required an insulin drip.
HYPOTHYROIDISM: The patient was stable on a dose of
Levothyroxine and had a normal TSH.
ELEVATED CREATININE: During the stay in the Intensive Care
Unit while on mechanical ventilation, the patient had periods
of elevation creatinine kinase to the level of 6000 with
negative MB fraction. This was thought to be a myositis or
rhabdomyolysis and secondary to prolonged immobilization.
This improved spontaneously over the course of her stay.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: The patient is discharged to [**Hospital 3058**]
rehabilitation.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o.q.d.
2. Levothyroxine 50 mcg p.o.q.d.
3. Albuterol inhaler one to two puffs q.6h.p.r.n.
4. Zantac 150 mg p.o.b.i.d.
5. Colace 100 mg p.o.b.i.d.
6. Ativan 1 mg PO q.6h.p.r.n. agitation.
7. Furosemide 40 mg p.o.b.i.d.
8. Amlodipine 20 mg PO b.i.d.
9. Metoprolol 50 mg PO b.i.d.
10. Prednisone 30 mg p.o.q.d. with taper over two weeks.
11. Regular insulin sliding scale; NPH insulin 30 units
subcutaneously in the morning and 30 units subcutaneously in
the evening.
DISCHARGE DIAGNOSES:
1. Coronary artery disease.
2. Congestive heart failure.
3. Pulmonary hypertension.
4. Anxiety disorder.
5. Diabetes mellitus.
6. Hypothyroidism.
7. Chronic anxiety.
DISCHARGE FOLLOWUP: The patient will followup with the
primary cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to two
months after discharge from rehabilitation and with the
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within one month of
discharge from chronic rehabilitation.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-661
Dictated By:[**Name8 (MD) 7115**]
MEDQUIST36
D: [**2109-7-31**] 11:57
T: [**2109-7-31**] 13:04
JOB#: [**Job Number 101836**]
Name: [**Known lastname 10897**], [**Known firstname 153**] Unit No: [**Numeric Identifier 16416**]
Admission Date: [**2109-7-19**] Discharge Date: [**2109-8-2**]
Date of Birth: [**2054-1-15**] Sex: F
Service:
ADDENDUM: The patient was complaining of throat pain after
extubation. Pain persisted. She had no evidence of
infection, no fever, no lymphadenopathy and no exudate seen
on examination. The patient was evaluated by ENT. ENT feels
sore throat is related to trauma from the extubation but
wants to see patient in two weeks. The patient is instructed
to make an appointment by calling [**Telephone/Fax (1) 16417**] and she will
be seen in [**Hospital **] Clinic at [**Hospital1 536**]
in about two weeks.
The patient also was complaining of some dysuria. Foley
catheter was pulled and a urinalysis was sent which was
negative for nitrites, leukocyte esterase and bacteria. The
patient subsequently stopped complaining of any dysuria. She
remained afebrile and had a low white blood count.
The patient was also started on Paxil 10 mg po q d for which
she will be discharged on. This is for her anxiety. The
patient may have some component of generalized anxiety
disorder. The patient agreed to a trial of Paxil. She is
also being discharged on Darvocet one tablet po q 6 hours prn
for pain and also sublingual Nitroglycerin q 5 minutes for
angina prn.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1095**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2109-8-2**] 10:37
T: [**2109-8-2**] 10:50
JOB#: [**Job Number 16418**] & [**Numeric Identifier 16419**]
Name: [**Known lastname 10897**], [**Known firstname 153**] Unit No: [**Numeric Identifier 16416**]
Admission Date: [**2109-8-2**] Discharge Date: [**2109-8-6**]
Date of Birth: Sex:
Service:
The patient remained hospitalized for observation from [**8-2**]
to [**8-5**]. She still was complaining of leg pain and sore
throat, however, all tests including lower extremity
ultrasound were negative for deep venous thrombosis.
The patient was discharged on [**2109-8-5**]. Her prednisone taper
had been tapered down to 10 mg q day. She will be weaned off
prednisone gradually in the next week.
DISCHARGE MEDICATIONS:
1. Lopressor 50 mg [**Hospital1 **].
2. Norvasc 20 mg [**Hospital1 **].
3. Lasix 40 mg [**Hospital1 **].
4. Paxil 10 mg q day.
5. Levothyroxine 50 mcg q day.
6. Aspirin.
7. SubQ Heparin.
8. Zantac.
9. Darvocet.
FOLLOW-UP INSTRUCTIONS: The patient is scheduled to followup
at [**Last Name (un) 616**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16437**] for better monitoring of her
diabetes.
CONDITION ON DISCHARGE: Good. The patient was discharged to
home.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-661
Dictated By:[**Last Name (STitle) 16438**]
MEDQUIST36
D: [**2109-9-25**] 11:40
T: [**2109-12-26**] 04:15
JOB#: [**Job Number **]
|
[
"780.57",
"402.91",
"300.00",
"507.0",
"518.82",
"728.89",
"278.01",
"250.00",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"96.6",
"88.72",
"96.04",
"96.71",
"38.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
5684, 5778
|
1992, 2097
|
6332, 6506
|
9534, 9746
|
3025, 5662
|
633, 758
|
2120, 3007
|
6527, 9511
|
9771, 9952
|
781, 1815
|
1832, 1975
|
9977, 10242
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,921
| 110,695
|
36822
|
Discharge summary
|
report
|
Admission Date: [**2161-5-23**] Discharge Date: [**2161-6-12**]
Date of Birth: [**2078-10-31**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
1. Central venous line placement and removal
2. PICC line placement ([**2161-5-29**])
3. Craniotomy ([**2161-6-5**])
4. Intubation ([**2161-6-7**])
History of Present Illness:
82yo female with a PMH notable for anxiety and depression, HTN,
bilateral PE s/p IVC filter on coumadin, aortic stenosis (valve
area 0.8), CAD s/p BMS to LAD on [**2161-2-3**] presenting to an
outside s/p fall witnessed by her daughter. On CT from the
outside hospital, there was an acute on chronic subdural
hematoma. She was transferred to [**Hospital1 18**] for evaluation. She was
anticoagulated on Coumadin for a PE in the past and her
INR=2.97. The INR was reversed at the outside hospital. While in
the ER, she had a hypoxic episode and required intubation and
subsequently was admitted to the ICU.
Past Medical History:
1. CAD s/p stent placement, bare metal stent [**1-/2161**]
2. [**Location (un) 260**] filter
3. PE
4. MI
5. HTN
6. GERD
7. anemia
8. Anxiety
9. Aortic stenosis
Social History:
Patient walks with a cane. Lives with her daughter. [**Name (NI) **] drinking
or smoking history.
Family History:
Non-contributory
Physical Exam:
GCS 14. Limited due to pt cooperation
O: T:96.3 BP:168 /73 HR:81 R 20 O2Sats 93%
Gen: WD/WN, comfortable, NAD.
HEENT: Nasal fx with multiple facial lacerations. Pupils:4mm to
3mm EOMs: Full
Neck: Supple. No JVD
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Anxious & agitation is escalating. Alert,
cooperative with select portions of exam. Affect initially
normal. Through course of exam she has become extremely
agitated. She does not keep medical monitors or oxygen on and is
hypoxic with low Oxygent sat of 80%-82% on room air.
Orientation: Oriented to person,and place. Not to day,month or
year.
Language: Speech short. Requiring frequent reminders regarding
monitoring equipment.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 4mm to
3mm bilaterally. Visual fields are full as pt follows examiner
around bed.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing decreased to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Pt would not comply.
XII: Tongue midline without fasciculations.
Motor: Pt does not cooperate fully with exam. Normal bulk and
tone bilaterally. No abnormal movements,tremors. Strength full
power [**3-31**] throughout. Moves all extremities symmetrically
without
difficulty
Sensation: Intact to light touch, pain bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 2 2
Left 2 2 2 2 2
Toes downgoing bilaterally
Coordination: pt not cooperative with coordination exam.
Pertinent Results:
Labs on admission ([**2161-5-22**])
GLUCOSE-133* UREA N-25* CREAT-1.1 SODIUM-138 POTASSIUM-3.2*
CHLORIDE-99 TOTAL CO2-27 ANION GAP-15
WBC-13.4* RBC-3.13* HGB-9.2* HCT-27.2* MCV-87 MCH-29.3 MCHC-33.7
RDW-16.1* Plat count: 344 NEUTS-72.4* LYMPHS-21.1 MONOS-4.3
EOS-1.7 BASOS-0.4
PT-23.3* PTT-27.6 INR(PT)-2.2*
Labs on discharge ([**2161-6-11**])
WBC-12.6* RBC-2.72* Hgb-7.8* Hct-24.6* MCV-90 MCH-28.6 MCHC-31.7
RDW-15.7* Plt Ct-479*
PT-14.3* PTT-24.1 INR(PT)-1.2*
Glucose-132* UreaN-27* Creat-1.0 Na-140 K-4.1 Cl-102 HCO3-26
ALT-160* AST-159* LD(LDH)-301* AlkPhos-170* TotBili-0.3
Albumin-3.5 Calcium-9.2 Phos-3.5 Mg-1.4*
[**2161-6-10**] calTIBC-308 VitB12-727 Folate-7.2 Ferritn-299* TRF-237
[**2161-6-7**] TSH-0.84
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2161-6-10**]):
Feces negative for C.difficile toxin A & B by EIA.
URINE CULTURE (Final [**2161-5-26**]):
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL
MORPHOLOGIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST ([**2161-5-23**]):
Minimally displaced comminuted nasal bone fracture. No other
evidence of acute fracture.
NON-CONTRAST CT HEAD ([**2161-5-23**]): There is a large subdural
hematoma covering the entire right convexity, which measures up
to 2 cm from the inner table, which causes 6 mm shift of
normally midline structures, unchanged since [**2161-5-23**]. There is
mild compression of the right lateral ventricle without evidence
of subfalcine or uncal herniation. The bony calvarium is intact.
The paranasal sinuses and mastoid air cells are clear.
Non-contrast CT of the head ([**2161-6-3**]):
1. Increased leftward shift of midline structures, with
increased subfalcine and stable transtentorial herniation. There
is increased effacement of the frontal [**Doctor Last Name 534**] of the right lateral
ventricle.
2. Stable appearance to right convexity subdural hematoma
without evidence for new foci of hemorrhage.
Non-contrast CT of the head ([**2161-6-5**]): Status post evacuation
of right frontal subdural hematoma with improvement in mass
effect with reduction in subfalcine herniation with an
improvement in leftward midline shift, now 9 mm. No evidence of
acute hemorrhage.
Non-contrast CT head ([**2161-6-8**]): Status post right craniotomy
for evacuation of right frontal subdural hematoma, now with
improvement of midline shift, now only 4 mm in leftward
direction. There is no evidence of an acute hemorrhage.
CHEST (PORTABLE AP) ([**2161-5-22**]): Vascular engorgement without
overt CHF.
Echocardiogram ([**2161-5-25**]): Severe/critical aortic stenosis(valve
area 0.6cm2). At least moderate mitral regurgitation. Pulmonary
artery systolic hypertension. Mild symmetric left ventricular
hypertrophy with preserved global and regional biventricular
systolic function.
CXR 2V ([**2161-6-8**]): Interval improvement in bibasilar atelectasis
or consolidation, and pleural fluid.
RUQ ultrasound ([**2161-6-9**]):
1. Normal Doppler study.
2. Small right pleural effusion.
3. Mild calcifications of the abdominal aorta, without
aneurysmal dilatation.
4. Calcified granuloma within the liver.
Brief Hospital Course:
82 year-old female with history of pulmonary embolism and atrial
fibrillation on coumadin admitted [**2161-5-23**] following fall. On
admission, she was found to have a subdural hematoma which was
evacuated. Hospital course was complicated by respiratory
distress requiring intubation, ventilator associated pneumonia,
and UTI. Brief hospital summary is as follows.
1. Sub-dural hematoma: Pt was admitted through the emergency
department after being brought in s/p fall. She was intubated in
the ED for respiratory distress and increasing agitation. Head
CT revealed acute on chronic SDH on the right. She had been on
aspirin, plavix and coumadin and her anticoagulation was
reversed and her labs were followed closely. She was admitted to
the trauma ICU and after being cleared from a trauma
standpoint, she was admitted to neurosurgery. Extubation was
considered on hospital day #2 however she went into pulmonary
edema and the extubation was not attempted. Her management
continued to be primarily medical. Extubation was again
considered [**5-26**] but CXR showed fluid and she remained intubated.
Her neurologic exam improved on this day - her eyes were open,
she attended examiner and followed commands with motors
appearing full. Extubation again considered on [**5-27**] and was
successful.
On [**5-28**] she was neurologically intact. She was transferred
to the medicine service. She continued to complain of a dull,
persistent headache. A head CT on [**2161-5-31**] showed progression of
SDH further from the previous CT scan. Neurosurgery evaluated
the patient and decided that surgery was indicated. Over the
next couple of days, the patient steadily became more lethargic
and often lost her concentration. Her mental status would
fluctuate. Another CT scan on [**2161-6-3**] showed increased midline
shift of the brain. During a meeting with the neurosurgeons,
cardiologist, and primary medicine team, the risks and benefits
of surgery were explained to the family and the family decided
to pursue a craniotomy. The patient tolerated the procedure well
and was monitored for 24 hours in the PACU before being
transferred to the neurosurgical floor. She was transferred back
the medical service. She was noted to have continued delirium
which is much improved on discharge. She will need follow-up
with neurosurgery in one month. She will also need a repeat head
CT in one month. If patient has any evidence of neurological
decline, her neurosurgeon should be [**Date Range 653**] immediately.
Patient will need to have sutures removed from craniotomy site
on [**2161-6-15**].
Neurological deficits on discharge: Minor parathesia in
left hand, non-dermatomal distribution. Sluggish pupil in right
eye (secondary to macular degeneration). Occasional involuntary
movement of left fingers (likely residual deficits of SDH).
Re: SDH evacuation, patient underwent cranitomy with bone
flap. Presently the bone flap moves in a pulsatile manner; this
will continue to do so until fusion.
2. Ventilator-associated pneumonia: While in the ICU, the
patient developed hospital acquired pneumonia. She was started
on a 10 day course of Vancomycin and Ceftazidime to cover
ventilator and hospital acquired pneumonia. A sputum culture was
not diagnostic. In the ICU, she had a central line which was
later discontinued on the floor after placement of a PICC line.
In addition, the patient received chest PT. The cough persisted,
but she remained afebrile. The 10 day course of antibiotics was
finished in the hospital. Patient is afebrile and without
productive cough on discharge.
3. Anticoagulation: Due to the SDH, the patient was stopped on
her Coumadin therapy. In addition, her Plavix for her bare metal
stent placed on [**2161-2-4**] was discontinued - Plavix is no longer
indicated. Cardiology recommended that she no longer needed
Plavix. After her craniotomy, neurosurgery recommended that the
patient should continue her daily aspirin.
4. Episode of rapid A. fib vs. A. flutter: Prior to extubation
in the ICU, the patient did have an episode of rapid a-fib which
she was given Diltiazem/Lopressor and converted back to sinus
rhythm. Following craniotomy, patient again had episode of
atrial fibrillation with RVR. With the guidance of cardiology,
patient was amiodarone-loaded. Patient was subsequently noted to
have a transaminitis (see above). On discharge, transaminitis is
improved. Patient should have repeat LFTs within 3-4 days of
discharge. If rising, patient's PCP should be [**Name (NI) 653**]. We are
currently hold statin as well; may be started once transaminitis
resolves.
5. UTI: The patient developed a complicated UTI. A culture
revealed E. coli which was sensitive to ceftazidime. The UTI
resolved after antibiotic treatment.
6. Hypertension: Given that the patient has severe aortic
stenosis and therefore preload dependent, the patient was
discontinued on Isordil. With this exception, the patient was
continued on lisinopril (increased) and metoprolol with adequate
BP control.
7. Asymptomatic aortic stenosis: The patient has severe aortic
stenosis with a valve area of 0.6 cm2, but does not have any
symptoms related to AS. Continuing Lasix per home regimen.
8. Hypokalemia: Continuing potassium supplement.
9. Diarrhea, now resolved: C. diff negative x2.
10. Seizure. Partial complex with secondary generalization, six
days post-craniotomy. Likely contributors were some mild trauma
to the brain upon falling, with the development of the subdural
hematoma and the subsequent craniotomy. Seizure prophylaxis was
not indicated initially, but has now been started after the
seizure on [**2161-6-11**]. The [**Doctor Last Name 360**] used is Keppra 500 mg [**Hospital1 **].
Medications on Admission:
Zocor 80mg QD,
KCL 20Meq QD,
Coumadin 4mg [**Last Name (LF) 244**],
[**First Name3 (LF) **] 325mg QD,
Plavix 75mg QD,
Iron 325mg QD,
Monopril 10mg QD,
Isordil 10mg [**Hospital1 **],
Ativan 0.5mg TID,
Metoprolol 50mg Q8Hr,
Zoloft 75mg QD,
Mg Sulfate
Discharge Medications:
[**2161-6-13**]
Please draw liver function tests, electrolytes (chem-10) to
assess for resolving transaminitis and stability of
electrolytes.
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID:PRN as
needed for anxiety.
2. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two
(2) Tablet Sustained Release PO once a day.
3. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One
(1) Tablet PO once a day.
4. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for Possible fungal infection in
mouth.
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*2*
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 34004**] Nursing & Rehabilitation Center - [**Location (un) 14663**]
Discharge Diagnosis:
Primary diagnoses:
-Subdural hematoma, right-sided after fall that also resulted in
nasal fracture.
Secondary diagnoses:
UTI, now resolved
Atrial fibrilation with rapid ventricular rate
Pulmonary edema, now resolved
Pneumonia - ventilator associated, now resolved
Transaminitis, secondary to amiodarone; improved
Brief diarrhea, now resolved
Seizure, secondary to fall/sdh/craniotomy
Discharge Condition:
There are some minor neurological deficits at present: There is
some parathesia of the left hand, likely of cortical origin and
secondary to the subdural hematoma. The right pupil is
sluggish, but this is likely due to a relative sensory afferent
defect caused by macular degeneration. There was one seizure
while an inpatient (partial complex with secondary
generalization) which ended spontaneously with some post-ictal
confusion, amnesia, partial paralysis, hypertension, all of
which resolved over the ensuing minutes to hours. Seizure
prophylaxis is now in place.
The bone flap is slightly pulsatile. This is because the
subdural was evacuated with a bone flap craniotomy. The wound
is healing well.
Mrs. [**Known lastname 39602**] is capable of taking a full diet, but has had
reduced intake of food and water. This originates in her desire
to not urinate or get up to toilet too often. It would be great
if her diet could be progressed further while in rehabilitation.
She is able to walk and toilet with assistance.
Discharge Instructions:
You came to the hospital after hitting your head on the ground.
You were found to have a bleed inside of your head. Your blood
thinner, Coumadin, was stopped. You required a breathing tube
while in the ER and were sent to the ICU. In the ICU, you became
more stable. You no longer needed a tube. You were found to have
a urinary tract infection and pneumonia, so you needed
antibiotics. You finished your antibiotics while in the
hospital. You underwent a craniotomy on [**2161-6-5**] for the
bleeding around your brain and currently are doing well. While
recovering you developed an abnormal heart rhythm which was
treated. This was treated with amiodarone with which you
reacted with some liver inflammation. This drug was stopped and
your liver function is improving. There was also one day of
diarrhea which has now resolved. On the day of intended
discharge, you had a seizure. This seizure is sometimes a
consequence of subdural hematoma (the bleed that you had) as
well as craniotomy. You have been started on an anti-seizure
medication (Keppra). We have monitored you recovery and now see
that you are well enough for rehabilitation.
Your medication regimen has changed. Please see attached
medication list.
Please follow-up with your providers: Neurosurgery, cardiology
and your PCP, [**Name10 (NameIs) 3**] directed below.
If you develop weakness of an arm or leg, worsening abnormal
sensation in the left hand, involuntary movements, particularly
of the left hand or arm, seizure, difficulty with speech, fever,
inflammation of the wound site, headache, confusion, or any
other concerning symptom, please return to hosptial.
Followup Instructions:
SUTURES NEED TO BE REMOVED ON THE [**6-15**].
Neurosurgery:
After leaving the hospital, please call the office of Dr.
[**Last Name (STitle) **], your neurosurgeon, to schedule an appointment. They
will arrange for a follow-up CT scan of your head that will
occur prior to the appointment. His rooms can be [**Last Name (STitle) 653**] at
([**Telephone/Fax (1) 26566**]. Ideally, this appointment would be one month
after discharge from the hospital. Until this time, please
continue to take your anti-seizure medication.
.
Cardiologist:
Please follow-up with your cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8573**].
We will give you a letter describing your care here that will be
helpful in his ongoing management of your arryhthmia and
medications. Again, please make this appointment when you are
discharged, so that you will not have to wait too long. It would
be good if you could make this appointment for one to two weeks
after discharge from rehabilitation.
.
PCP:
[**Name10 (NameIs) 357**] make an appointment to see your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 32683**].
Please give him a copy of your discharge summary, so that he can
manage your global care. This appointment can be made for a date
one to two weeks after your discharge from rehabilitation.
|
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21,220
| 168,219
|
47448
|
Discharge summary
|
report
|
Admission Date: [**2174-10-9**] Discharge Date: [**2174-10-19**]
Date of Birth: [**2112-4-1**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
Central venous line placement
History of Present Illness:
Ms. [**Known lastname 46**] is a 63 yo female with Type 2 DM, polysubstance
abuse, hypertension, admitted with hypoglyemia. Patient was
noted to have a FS of 28 at 2AM so called EMS and was taken to
the emergency department.
Upon arrival to the ED, her HR was 111, BP 154/99, RR 20, 100%
on RA, T 97.1. She denies change in her diety intake or change
in her insulin regimen. In the ED, she had biphasic T waves
inversions in V3 and V4 with ST depressions in V3-V6. In the ED,
her FS was 47, 53, 186 and 134. She was tachycardic and
hypertesnive during her stay in the ED but was not treated for
this. She developed chest pain and shortness of breath prior to
transport up from the emergency department which responded to
NGL x 3 and ativan.
Upon arrival to the floor, patient reported shortness of breath,
but no chest pain. No nausea, vomiting. No diarrhea,
constipation. Patient reported fevers at home and reported
productive cough over the past few days of green sputum. She
denies headaches. She denies sick contacts or recent antibiotic
use. Patient denies cocaine use for the past 2 weeks and denies
alcohol use today.
Past Medical History:
Type 2 Diabetes
HCV
H/o Subtance abuse (alcohol, cocaine)
Chronic renal insufficiency
Hypertension
Thrombocytopenia
Chronic pancreatitis
Depression
Social History:
Patient has a history of polysubstance abuse (alcohol, cocaine).
This includes a heavy alcohol history though she does not
currently drink. She also admits to 40 years of cocaine use,
inhaling as frequently as every other day at one point. She has
a 10 pack year smoking history ([**1-26**] PPD for 20 years), but quit
20 years ago.
Family History:
Hypertension. No history of premature CAD. Father with lung
cancer who died in his early 60s, mother with sarcoid who died
in her early 50s.
Physical Exam:
VS: HR 101, T 100.2, BP 165/105, RR 40, 100% on NRB
Gen: tachypneic, labored breathing, sleepy but arousable
HEENT: EOMI, o/p clear, NC, AT, PERRLA
CV: tachycardic, no m/r/g
Pulm: Crackles diffusely, no wheezing
Abd: soft, NT, ND, bowel sounds present
Ext: no peripheral edema
Neuro: A&Ox3, motor and sensation grossly intact.
Pertinent Results:
[**2174-10-9**] 01:30PM BLOOD WBC-7.8 RBC-3.44* Hgb-11.4* Hct-33.0*
MCV-96 MCH-33.1* MCHC-34.4 RDW-15.9* Plt Ct-226#
[**2174-10-9**] 01:30PM BLOOD Neuts-84.9* Lymphs-12.7* Monos-1.1*
Eos-0.4 Baso-1.0
[**2174-10-9**] 01:30PM BLOOD PT-14.1* PTT-26.8 INR(PT)-1.2*
[**2174-10-9**] 01:30PM BLOOD Plt Ct-226#
[**2174-10-9**] 01:30PM BLOOD Glucose-54* UreaN-20 Creat-1.7* Na-138
K-3.9 Cl-99 HCO3-24 AnGap-19
[**2174-10-10**] 01:53AM BLOOD ALT-65* AST-129* LD(LDH)-269* CK(CPK)-69
AlkPhos-203* TotBili-1.0
[**2174-10-14**] 03:25AM BLOOD Lipase-10
[**2174-10-16**] 08:00AM BLOOD proBNP-[**Numeric Identifier **]*
[**2174-10-9**] 01:30PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2174-10-9**] 01:30PM BLOOD Calcium-9.5 Phos-2.8 Mg-1.3*
[**2174-10-13**] 09:00AM BLOOD calTIBC-111* VitB12-472 Folate-18.1
Hapto-104 Ferritn-615* TRF-85*
[**2174-10-13**] 09:00AM BLOOD Triglyc-63 HDL-32 CHOL/HD-3.6 LDLcalc-71
MICRO:
[**2174-10-9**]- blood culture x 2 - NGTD
[**10-9**] - Urine culture x 2 - NGTD
Relevant Imaging:
EKG. Sius tachycardia at 131 bpm. Normal PR interval, Normal qrs
interval, normal qtc. Normal Axis. no LVH. TWI in R, L, V1. ST
depressions in V4. unchanged from prior EKG dated [**2174-7-28**].
CXR ([**2174-10-9**]): Early left lower lobe bronchopneumonia.
CXR ([**2174-10-14**]): Interstitial infiltrative abnormality, most
pronounced in the lower lungs accompanied by probable small
right pleural effusion has worsened since [**10-11**], probably
pulmonary edema. Heart size top normal. No pneumothorax.
CXR ([**2174-10-16**]): Persistent bilateral interstitial pulmonary
infiltrates
consistent with edema. Blunting of the right costophrenic sulcus
likely
representing a small effusion. No definite change.
CT CHEST W/O CONTRAST ([**2174-10-17**]):
1. Moderate bilateral pleural effusion with adjacent bibasilar
opacities,
which could be related to pneumonia, aspiration, or atelectasis.
2. Diffuse smooth septal thickening with ground glass opacity
mostly in upper lobes, suggestive of pulmonary edema, which
could be due to volume
overload, CHF, or non-cardiogenic, drug-induced edema. In an
appropriate
clinical setting, cocaine- induced hemorrhage could also be
possible.
3. Mild centrilobular emphysema.
4. Top normal mediastinal lymph nodes could be reactive or
edematous.
5. Anemia.
6. Severe fatty liver. Atrophic partly calcified pancreas is
probably due to chronic pancreatitis.
ECHOCARDIOGRAM ([**2174-10-17**]): The left atrium is mildly dilated.
Left ventricular wall thicknesses and cavity size are normal.
There is mild regional left ventricular systolic dysfunction
with mild hypokinesis of the basal inferior and inferolateral
walls. The remaining segments contract normally (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. There is no mitral valve prolapse. Mild to moderate
([**1-26**]+) mitral regurgitation is seen. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
Ms. [**Known lastname 46**] is a 62 yo female with history of polysubstance
abuse, DM2, admitted with hypoglycemia and NSTEMI in the setting
of cocaine abuse.
1) Respiratory Distress: The patient was in mild respiratory
distress upon arrival to the emergency room on [**2174-10-9**]. At
that time, CXR showed a new left lower lobe opacity that was
consistent with early bronchopneumonia. In light of this
respiratory distress, CXR finding, and fever of unknown source
the patient was started on empiric antibiotics for community
acquired pneumonia. Upon transfer to the MICU, the patient
developed increased respiratory distress requiring oxygen
supplementation. This was felt to be a result of aggressive IV
fluid resuscitation in the ED. CXR at that time showed
resolution of the LLL opacity and some increased interstitial
markings felt to be pulmonary edema. The patient was diuresed
on lasix as needed and responded appropriately with resolution
of her respiratory distress. Her oxygen requirement decreased
from NRB to 2L NC. After transfer to the hospital floor, the
patient was weaned to RA with good O2 saturation. However, on
[**10-14**], the patient was found to again have an O2 requirement of
4L NC at baseline and 5L NC when the patient was ambulating.
She was febrile and complained of having a dry cough.
Differential at this time included pulmonary edema, pneumonia,
or pulmonary complications in the context of her chronic cocaine
abuse. CXR showed a new RLL opacity c/w pneumonia and pulmonary
edema. At this time, the patient was started on
ceftriaxone/azithromycin for treatment of community acquired
pneumonia. Her coverage was broadened to Vancomycin, Zosyn, and
Azithromycin since she continued to spike temperature. The
pulmonary service was consulted at this time. Per their
recommendations, a CT Chest was performed to better evaluate her
pulmonary status. CT scan demonstrated bilateral pleural
effusions which was consistent with pulmonary edema and some
haziness in the RLL suggestive of a pneumonia. These findings
were felt not be related to her chronic cocaine abuse. She was
agressively diuresed with IV lasic and her respiratory distress
improved. Her antibiotic regimen was changed to Levaquin x 5
days and her fever eventually defervesced. She was discharged on
a low dose of PO Lasix. The patient will also need a follow-up
CAT scan in approximately 6-8 weeks.
2) Diabetes: Upon arrival to the ED, the patient was noted to
be hypoglycemic in the setting of cocaine use, poor PO intake
and glargine use. The patient was monitored in the ICU with
q1hour fingersticks. Her fingersticks were initially as low as
the 20s and the patient was asymptomatic. The patient was
started on a D5W drip and her sliding scale/glargine was
stopped. Fingersticks were very labile during this period
ranging from 20-300. At this point, the D5W drip was turned off
and the patient's glargine was resumed. The [**Last Name (un) **] service was
consulted to optimize the patient's insulin regimen. While on
the medicine floor, the patient continued to have hypoglycemia
into the 60-80s especially at night without any symptoms. Her
glargine changed from a nightime dose to an after breakfast dose
and her sliding scale was tightened in order to better control
her sugars. On discharge, the patient was placed on 6 units of
glargine after breakfast and her insulin sliding scale. Her
glucose levels during this time ranged from 80-160. The patient
also underwent diabetic teaching regarding diet and compliance
with insulin regimen. She will follow up with her [**Last Name (un) **]
physician for further optimization of her insulin regimen [**1-26**]
weeks after discharge.
3) NSTEMI: The patient was noted to have lateral ST depressions
in leads V3-V6 upon arrival to the ED. She developed chest pain
and SOB both of which resolved on nitroglycerin x 3 and ativan.
At this time, the patient was placed on a heparin drip. In the
MICU, the patient's troponin came back elevated. This was felt
to be an NSTEMI in the setting of cocaine use. Cardiology was
consulted and recommended medical management with Aspirin and
Verapamil for blood pressure control.
B-blocker was held in the context of recent cocaine abuse. Upon
arrival to the medicine floor, she began to complain of
difficulty breathing on [**10-14**] and developed a new O2 requirement.
In the context of this new O2 requirement, suspicion for
pulmonary edema, and recent NSTEMI, the patient underwent an
echocardiogram which showed good cardiac function (EF = 55%)
with prominent and more severe mitral regurgitation (from
previous study on [**2174-9-7**])and inferior and anteroinferal
systolic wall motion. At this time, the patient was started on
additional afterload reduction medications,
hydralazine/isosorbide dinitrate.
4) Hypertension: The patient's Nifedipine was held due to
concern for tachycardia in the setting of an NSTEMI. The
patient was instead started and uptitrated on verapamil with
excellent control of her blood pressures. Hydralazine and
isosorbide dinitrate were added for afterload reduction as
discussed above.
5) Pancreatic exocrine insufficiency: The patient was stable and
continued on her pancrease enzymes.
Medications on Admission:
Pancrease TID
Insulin Aspart sliding scale
Insulin glargine 16 units qhs
Nifedipine 60 mg daily
Zoloft 25 mg daily
Aspirin 81
Calcium + Vitamin D
Discharge Medications:
1. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*90 Cap(s)* Refills:*2*
2. Verapamil 120 mg Tablet Sig: Three (3) Tablet PO Q24H (every
24 hours).
Disp:*90 Tablet(s)* Refills:*2*
3. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*120 Tablet(s)* Refills:*2*
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
5. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 tablets* Refills:*2*
6. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
7. Calcium Carbonate 500 mg (1,250 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO TID W/ Meals (3 times a day with meals).
8. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
9. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO q48h for 2
doses: Please take 1 tablet on [**10-20**] and [**10-22**]. .
Disp:*2 Tablet(s)* Refills:*0*
10. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
Disp:*1 inhalers* Refills:*2*
11. Sertraline 25 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
12. Lantus 100 unit/mL Solution Sig: Six (6) units Subcutaneous
after breakfast.
13. Insulin sliding scale
Your insulin sliding scale has been modified. A copy of this is
attached to your discharge instructions.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
Diabetes Mellitus Type II, uncontrolled with complications
Myocardial Infarction, non-ST elevation
Pulmonary Edema
Community Acquired Pneumonia
Secondary Diagnoses:
Hypertension
Chronic Kidney Disease stage III
Substance Abuse
Chronic Pancreatitis
Discharge Condition:
Stable.
Discharge Instructions:
1) You were admitted to the hospital with low blood sugars. You
were seen by a diabetes specialist from the [**Hospital **] clinic to
optimize your insulin at home. You were placed on Lantus
(Glargine) insulin 6 units after breakfast daily and on an
insulin sliding scale as documented in the discharge
instructions below.
2) You were also evaluated for a heart attack. Your heart was
evaluated by an ultrasound and you were found to have good
cardiac function. Your blood pressure medications were
adjusted. We stopped your Nifedipine and placed you on
Verapamil (360 mg once a day), Hydralazine (10 mg every 6
hours), and Isosorbide Dinitrate (30 mg once a day).
3) You were also evaluated for shortness of breath. This was
evaluated with a chest x-ray and a chest CT scan which showed
that you may have a pneumonia as well as pulmonary edema (fluid
in your lungs). To treat your pneumonia, you will take 1 dose
of Levofloxacin on [**10-20**] and 1 additional dose of Levofloxacin on
[**10-22**] for a total of 2 doses. Additionally, you are being
started on Lasix 20 mg by mouth daily.
4) You were additionally started on a) Albuterol inhaler for
wheezing/shortness of breath and b)We also increased your
aspirin from 81 mg daily to 325 mg daily and modified your
insulin dosing as noted in the discharge instructions. A copy of
the insulin sliding scale is attached to the discharge
instructions.
5)Please take all medications as listed in the discharge
instructions. You have been started on the following new
medications:
- Hydralazine
- Isosorbide
- Lasix
- Levofloxacin to treat your pneumonia (as above)
- Your dose of Verapamil was increased
- Your dose of Aspirin was increased
- Your dose of Lantus has been modified and the insulin sliding
scale has been modified.
6)Please attend all appointments as listed below. You are
scheduled to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Hospital6 733**] for
follow-up next week on [**2174-10-26**] at 3:15pm. Please attend all
other appointments as listed below.
7)You will also need a repeat CAT scan of your chest to see if
the fluid has resolved. You will be scheduled for this by your
primary care physician.
8) Please call your doctor or return to the emergency room if
you develop chest pain, worsening shortness of breath, weight
increase > 3 lbs, fevers and chills, nausea and vomiting, loss
of conciousness, or any other concerns.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2174-10-26**] 3:15
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2174-11-1**] 11:15
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14290**], OD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2174-12-12**]
9:30
Please call your [**Last Name (un) **] physician to schedule [**Name Initial (PRE) **] follow-up
appointment in the next 1-2 weeks.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12905, 12962
|
5763, 11020
|
283, 315
|
13274, 13284
|
2515, 3495
|
15779, 16475
|
2010, 2152
|
11217, 12882
|
12983, 13147
|
11046, 11194
|
13308, 15756
|
2167, 2496
|
13168, 13253
|
231, 245
|
3513, 5740
|
343, 1470
|
1492, 1642
|
1658, 1994
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
195
| 118,936
|
21734+21735
|
Discharge summary
|
report+report
|
Admission Date: [**2167-11-29**] Discharge Date: [**2167-12-23**]
Date of Birth: [**2093-7-30**] Sex: F
Service: CSU
HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname 57118**] is a 74-year-old
woman, with a several month history of shortness of breath
leading to an echo which showed aortic stenosis as well as
mitral regurgitation and tricuspid regurgitation. A cardiac
cath done in [**2167-8-12**] showed minimal coronary artery
disease. She had been admitted twice to the cardiothoracic
service before, but was sent home for a yeast infection under
her breast and an infection of the left forearm. She
presented again on the day of admission, one day prior to her
surgery for physical evaluation.
PAST MEDICAL HISTORY: Significant for rheumatic heart
disease, obesity, aortic stenosis, mitral regurgitation,
osteoarthritis, cataracts, atrial fibrillation, congestive
heart failure, neuropathy, and rheumatoid arthritis.
PAST SURGICAL HISTORY: Significant for tonsillectomy and
hernia repair.
She has no known drug allergies.
MEDS AT HOME: Lasix 40 every day, diltiazem 30 q.i.d.,
potassium chloride 40 every day, Coumadin 4 every day, and
Protonix 40 every day.
SOCIAL HISTORY: Lives in [**Hospital1 10478**] with her son, still
lives independently, remote tobacco history and rare alcohol
use.
FAMILY HISTORY: No significant history of CAD.
PHYSICAL EXAM: Weight 103.9 kg, temperature 95.6, heart rate
64 sinus rhythm, blood pressure 135/56, respiratory rate 18,
O2 sat 97 percent on room air. In general no acute distress.
Neurological alert and oriented x3, nonfocal exam. Cardiac
showed regular rate and rhythm. Respiratory was clear to
auscultation bilaterally. Abdomen was soft, nontender,
nondistended with no hepatosplenomegaly. Extremities warm
and well perfused with bilateral lower extremity edema.
LABORATORY DATA: PT 17.1, INR 1.9, sodium 142, potassium
4.1, chloride 106, CO2 27, BUN 26, creatinine 1.0, glucose
123, white count 9.2, hematocrit 39.2, platelets 301,000.
Chest x-ray showed mild cardiomegaly with no CHF,
consolidations or effusions.
The patient was begun on a heparin infusion. She was typed
and screened and was prepared for the Operating Room. Due to
her elevated INR the patient received subcutaneous vitamin K.
On [**12-1**] the patient was brought to the Operating Room.
Please see the OR report for full details. In summary she
underwent an AVR, MVR and modified Mays. AVR was with a
number 23 [**Last Name (un) 3843**] [**Doctor Last Name **] valve. The MVR was a number 25
[**Last Name (un) 3843**] [**Doctor Last Name **] valve. Her bypass time was 196 minutes
with a crossclamp time of 165 minutes. She tolerated the
operation well and was transferred from the Operating Room to
the Cardiothoracic Intensive Care Unit.
At the time of transfer the patient was in sinus rhythm at 92
beats per minute, with a mean arterial pressure of 85 and a
CVP of 18. She had epinephrine at 0.01 mcg per kilogram per
minute, propofol at 40 mcg per kilogram per minute, and
Nipride at 0.2 mcg per kilogram per minute. The patient did
well in the immediate postoperative period. Propofol was
discontinued. Her anesthesia was reversed, however, she was
slow to fully awaken from her anesthesia and she remained
intubated throughout the day of her surgery.
On postoperative day one the patient remained hemodynamically
stable, requiring a Nipride infusion to maintain blood
pressure control. She was weaned from the ventilator and
successfully extubated. By the end of the day the patient
was begun on oral agents. Her Nipride infusion was
discontinued.
On postoperative day two she remained hemodynamically stable.
She was begun on beta blockade as well as diuresis. Her
Coumadin was restarted. Swan Ganz catheter was removed as
were her chest tubes, however, the patient went back into
atrial fibrillation and it was, therefore, decided to keep
her in the Intensive Care Unit for closer hemodynamic
monitoring.
On postoperative day three the patient continued to do well.
The electrophysiology service was consulted regarding her
atrial fibrillation following Mays. She was begun on an
amiodarone infusion and again she remained in the Intensive
Care Unit. She remained hemodynamically stable on
postoperative day four.
Finally on postoperative day five the patient's temporary
pacing wires were removed and she was transferred to the
floor for continuing postoperative care and cardiac
rehabilitation. Once on the floor the patient was slowly
progressing in her activity level. Screening was begun for
potential transfer to rehabilitation.
On postoperative day seven the patient began to complain of
increasing nausea as well as diarrhea. Stools were sent at
that time for C. diff and she was begun on empiric Flagyl.
The following morning the patient had a white count of
34,000. She was pan cultured and had abdominal films done at
that time. General surgery was consulted. The General
surgery service felt the patient had a toxic megacolon. She
was brought to the Operating Room where she underwent a
partial colectomy with ileostomy and as well as a
cholecystectomy, following which the patient was transferred
back to the Cardiothoracic Intensive Care Unit.
Throughout the remainder of the [**Hospital 228**] hospital course she
was followed by both the hepatobiliary pancreatic surgery
service as well as the cardiothoracic surgical service. She
spent four days in the Intensive Care Unit following her
abdominal surgery, and was then transferred to the floor for
continuing postoperative care.
Over the next week the patient was gradually transitioned
from TPN to a P.O. diet. Activity level was increased with
the assistance of the nursing staff as well as physical
therapy staff. Her antibiotic coverage was tailored and on
postoperative day 20 from her cardiac surgery, 11 from her
abdominal surgery, it was decided the patient was stable and
ready to be discharged to rehabilitation.
At the time of this dictation the patient's physical exam is
as follows: Temperature 97.3, heart rate 66 atrial
fibrillation, blood pressure 136/74, respiratory rate 20, O2
saturation 97 percent on room.
Laboratory data on [**12-22**] showed PT 23.7, INR 3.5.
MEDICATIONS ON DISCHARGE:
1. Amiodarone 200 mg b.i.d.
2. Flagyl 500 mg t.i.d.
3. Regular insulin sliding scale.
4. Naprosyn 500 mg b.i.d. p.r.n.
5. Percocet 5/325 one to two tablets q. six hours p.r.n.
6. Prilosec 40 mg every day.
7. Warfarin to maintain a target INR 2 to 2.5.
Physical exam shows in general she is in no acute distress.
Neurologically alert, oriented x3. Moves all extremities.
Follows commands. Nonfocal exam. Pulmonary is clear to
auscultation bilaterally. Cardiac shows irregular rate and
rhythm. Sternum is stable. Incision has Steri-Strips
without erythema or drainage. Abdomen is soft, nontender,
with positive bowel sounds and ileostomy site with dark fluid
drainage. Abdominal incision with staples and minimal
erythema at the staple line. No drainage. Extremities are
warm with trace edema.
Patient is to be discharged to rehabilitation.
CONDITION AT TIME OF DISCHARGE: Good.
DISCHARGE DIAGNOSES.:
1. Status post aortic valve replacement with number 23
[**Last Name (un) 3843**] [**Doctor Last Name **] tissue valve.
2. Status post mitral valve replacement with number 25
[**Last Name (un) 3843**] [**Doctor Last Name **] tissue valve.
3. Status post modified Mays.
4. Clostridium difficile colitis requiring partial colectomy
with ileostomy as well as a cholecystectomy.
5. Rheumatic heart disease.
6. Obesity.
7. Osteoarthritis.
8. Cataracts.
9. Atrial fibrillation.
10. Congestive heart failure.
11. Neuropathy.
Th[**Last Name (STitle) 1050**] is to have follow-up with Dr. [**First Name (STitle) **] in his
office in two weeks. The patient is to call the office to
schedule an appointment and follow-up with Dr. [**Last Name (Prefixes) **] in
four to six weeks. Patient is also to call his office to
schedule the appointment.
DISCHARGE MEDICATIONS:
1. Ketoconazole powder topically under the breast as needed.
2. Amiodarone 200 mg b.i.d. times one week then 200 mg every
day times two months.
3. Percocet 5/325 one to two tablets q. four to six hours
p.r.n.
4. Prilosec 40 mg every day.
5. Naprosyn 500 mg q.12 hours p.r.n.
6. Flagyl 500 mg t.i.d. times two days. The patient's Flagyl
is to be discontinued on [**12-25**].
7. Warfarin to maintain a target INR 2 to 2.5.
The patient had been on 4 mg Coumadin every day prior to
admission. She has received 1 mg on the day prior to
discharge, 5 mg two days prior to discharge, and 7.5 mg for
the three days prior to that.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2167-12-22**] 18:19:22
T: [**2167-12-23**] 10:28:50
Job#: [**Job Number 57119**]
Admission Date: [**2167-11-29**] Discharge Date: [**2167-12-23**]
Date of Birth: [**2093-7-30**] Sex: F
Service: CSU
DICTATION ENDED
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**]
Dictated By:[**Last Name (NamePattern4) 1718**]
MEDQUIST36
D: [**2167-12-22**] 17:34:24
T: [**2167-12-23**] 10:49:39
Job#: [**Job Number 57120**]
|
[
"278.00",
"995.92",
"557.0",
"427.31",
"038.3",
"V58.61",
"368.8",
"714.0",
"575.0",
"356.9",
"398.91",
"008.45",
"396.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.33",
"99.62",
"00.17",
"99.07",
"35.23",
"99.15",
"46.21",
"88.72",
"51.22",
"39.61",
"35.21",
"99.04",
"45.8"
] |
icd9pcs
|
[
[
[]
]
] |
1352, 1384
|
8089, 9395
|
6297, 8066
|
976, 1200
|
1400, 6271
|
167, 727
|
750, 952
|
1217, 1335
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,378
| 123,905
|
27370
|
Discharge summary
|
report
|
Admission Date: [**2122-5-22**] Discharge Date: [**2122-6-5**]
Date of Birth: [**2102-11-10**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
motorcycle collision into trees
Major Surgical or Invasive Procedure:
1. Multiple intubations (due to failed extubations)
2. Tracheostomy
3. Intramedullary rod fixation of left subtrochanteric femur
fracture
4. R thorocostomy
History of Present Illness:
19 y/o male s/p motorcycle vs tree without a helmet. Pt was
found prone in the [**Doctor Last Name 6641**], seen at [**First Name8 (NamePattern2) **] [**Doctor Last Name 11042**], found to have
pulmonary contusions, kidney and liver lacerations and a left
femur fx and was transferred to [**Hospital1 18**].
Past Medical History:
None.
Social History:
Rides motorcycle. +EtOH. Due to serve in [**Country 2451**] in [**Month (only) 205**] (prior to
this accident). Lives in [**Location **].
Family History:
NC.
Physical Exam:
101.4 110 118/62 24 99%NRB
NAD
Abrasion L forehead, PERRLA, No oral trauma, TMs clear
c-collar. trachea midline.
CTAb
Tachy RR
S, NT, ND, good tone and no blood on rectal
no TLS stepoffs
L hip tender
MAE
GCS 14
Pertinent Results:
[**2122-5-22**] 06:41AM URINE RBC->50 WBC-[**3-1**] BACTERIA-MOD YEAST-NONE
EPI-0-2
[**2122-5-22**] 06:41AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2122-5-22**] 06:41AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]->1.035
[**2122-5-22**] 06:41AM PTT-ERROR
[**2122-5-22**] 06:41AM PLT COUNT-192
[**2122-5-22**] 06:41AM WBC-19.0* RBC-4.21* HGB-12.8* HCT-36.0*
MCV-86 MCH-30.5 MCHC-35.6* RDW-12.9
[**2122-5-22**] 06:41AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2122-5-22**] 06:41AM URINE HOURS-RANDOM
[**2122-5-22**] 06:41AM ASA-NEG ETHANOL-81* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2122-5-22**] 06:41AM AMYLASE-43
[**2122-5-22**] 06:41AM UREA N-13 CREAT-0.9
[**2122-5-22**] 06:45AM HGB-12.8* calcHCT-38 O2 SAT-98
[**2122-5-22**] 06:45AM GLUCOSE-128* LACTATE-2.7* NA+-132* K+-6.7*
CL--104
[**2122-5-22**] 06:45AM PO2-204* PCO2-51* PH-7.22* TOTAL CO2-22 BASE
XS--7
[**2122-5-22**] 08:24AM FIBRINOGE-116*
[**2122-5-22**] 07:03AM K+-4.3
[**2122-5-22**] 08:24AM PT-14.2* PTT-26.3 INR(PT)-1.3*
[**2122-5-22**] 08:24AM PLT COUNT-171
[**2122-5-22**] 08:24AM WBC-16.1* RBC-3.84* HGB-11.3* HCT-32.9*
MCV-86 MCH-29.5 MCHC-34.4 RDW-13.0
[**2122-5-22**] 08:24AM ALBUMIN-3.2* CALCIUM-7.4* PHOSPHATE-3.1
MAGNESIUM-1.5
[**2122-5-22**] 08:24AM LIPASE-113*
[**2122-5-22**] 08:24AM ALT(SGPT)-756* AST(SGOT)-746* LD(LDH)-987*
ALK PHOS-87 AMYLASE-48 TOT BILI-1.0
[**2122-5-22**] 08:24AM GLUCOSE-125* UREA N-11 CREAT-0.9 SODIUM-133
POTASSIUM-5.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-14
[**2122-5-22**] 08:26AM freeCa-1.13
[**2122-5-22**] 08:26AM GLUCOSE-128* LACTATE-3.5* K+-5.0
[**2122-5-22**] 08:26AM TYPE-ART TEMP-36.9 PO2-240* PCO2-55* PH-7.26*
TOTAL CO2-26 BASE XS--2
[**2122-5-22**] 09:20AM GLUCOSE-125* LACTATE-2.8*
[**2122-5-22**] 09:20AM TYPE-ART TEMP-36.7 PO2-168* PCO2-48* PH-7.29*
TOTAL CO2-24 BASE XS--3
[**2122-5-22**] 10:00AM HCT-33.4*
[**2122-5-22**] 10:09AM LACTATE-2.4*
[**2122-5-22**] 10:09AM TYPE-ART TEMP-36.9 PEEP-10 PO2-181* PCO2-45
PH-7.33* TOTAL CO2-25 BASE XS--2 INTUBATED-INTUBATED
[**2122-5-22**] 01:42PM HCT-29.0*
[**2122-5-22**] 02:00PM GLUCOSE-117* LACTATE-1.4
[**2122-5-22**] 02:00PM TYPE-ART TEMP-36.6 PO2-169* PCO2-42 PH-7.42
TOTAL CO2-28 BASE XS-3
[**2122-5-22**] 06:21PM HCT-27.5*
[**2122-5-22**] 06:32PM freeCa-1.18
[**2122-5-22**] 06:32PM GLUCOSE-103 LACTATE-1.9
[**2122-5-22**] 06:32PM TYPE-ART TEMP-37.2 RATES-22/ TIDAL VOL-500
PEEP-10 O2-50 PO2-183* PCO2-42 PH-7.45 TOTAL CO2-30 BASE XS-5
-ASSIST/CON INTUBATED-INTUBATED
[**2122-5-22**] 10:10PM HCT-28.8*
[**2122-6-2**] 06:55AM
COMPLETE BLOOD COUNT
White Blood Cells 14.6* K/uL 4.0 - 11.0
PERFORMED AT WEST STAT LAB
Red Blood Cells 3.02* m/uL 4.6 - 6.2
PERFORMED AT WEST STAT LAB
Hemoglobin 8.6* g/dL 14.0 - 18.0
PERFORMED AT WEST STAT LAB
Hematocrit 25.9* % 40 - 52
PERFORMED AT WEST STAT LAB
MCV 86 fL 82 - 98
PERFORMED AT WEST STAT LAB
MCH 28.4 pg 27 - 32
PERFORMED AT WEST STAT LAB
MCHC 33.1 % 31 - 35
PERFORMED AT WEST STAT LAB
RDW 14.1 % 10.5 - 15.5
BASIC COAGULATION (PT, PTT, PLT, INR)
Platelet Count 711* K/uL 150 - 440
PERFORMED AT WEST STAT LAB
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2122-5-30**] 9:15 AM
CHEST (PORTABLE AP)
Reason: NGT placement
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p MCC w/ new NGT placed.
REASON FOR THIS EXAMINATION:
NGT placement
CHEST SINGLE VIEW ON [**5-30**].
HISTORY: NG tube placement.
REFERENCE EXAM: [**5-29**].
FINDINGS: This film is completely distorted by motion and is
insufficient for diagnosis. This study is being read [**5-31**] at
7:30 a.m. Although, motion distorts the film, the NG tube is
visualized but is not the expected location of the esophagus,
rather it may be in the left main stem bronchus. Technologist
had returned to the floor to repeat the film, but the physician
caring for the patient stated that a repeat film was not
desired. The finding of the NG tube location was called to the
floor at the time of interpreting this chest x-ray, by which
time the tube had been removed.
DR. [**First Name (STitle) **] [**Doctor Last Name **]
Approved: SUN [**2122-5-31**] 8:53 AM
-----------
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2122-5-28**] 5:07 PM
CT CHEST W/CONTRAST; CT 100CC NON IONIC CONTRAST
Reason: upper airway obstruction? cause for stridor?
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p MVC w/ failed extubation and stridor. Now
reintubated.
REASON FOR THIS EXAMINATION:
upper airway obstruction? cause for stridor?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: Status post MVC with failed extubation. Please
evaluate for cause of stridor.
COMPARISON: CT chest from [**2122-5-22**].
TECHNIQUE: Contrast-enhanced axial CT imaging of the chest with
multiplanar reformats was reviewed.
CT CHEST WITH CONTRAST: There is marked bibasilar dependent
atelectasis with small bilateral effusions. There is a lobulated
soft tissue density mass measuring 3.5 cm in the right lower
lobe in the region of large contusion from [**5-22**] that likely
represents coalescing hemorrhage. Multiple small other
ill-defined and nodular densities are present throughout the
lungs (right greater than left that also probably represent
pulmonary contusion). However, a small developing infection in
the right upper lobe cannot be excluded. Small apical
pneumothorax has resolved. Subcutaneous gas within the right
soft tissues is present secondary to chest tube. Right
subclavian line is seen terminating in the cavoatrial junction.
An NG tube is present in the stomach. ET tube terminates 4 cm
above the carina, unchanged in position. The heart and great
vessels of the mediastinum are unchanged. There are multiple rib
fractures identified, including posterior right rib fractures of
the ninth, eighth ribs at the spinous articulation. The eighth
rib may also be fractured more at a separate location along the
posterior aspect. The bronchi are patent to the subsegmental
level, secretions identified within the trachea at the [**Female First Name (un) 5309**].
The Hypodensity within the visualized portions of the liver dome
is the sequela of hepatic lacerations. Fat stranding about the
right kidney is unchanged. Upper pole of the right kidney
demonstrates heterogeneous enhancement that is not fully
evaluated on this study, but was seen at the time of the trauma.
The left kidney enhances and excretes normally. Visualized
portions of the spleen is normal. Again seen is a right adrenal
lesion, likely hematoma.
IMPRESSION:
1. Bibasilar consolidations with airbronchograms indicate
atelectasis and/or infection.
2. Coalescing 3.5 cm right lower lobe pulmonary
contusion/hemorrhage. Multiple other ill- defined opacities in
the lungs may be contusion or developing infection.
3. Multiple rib fractures.
4. Sequela of traumatic injury in the visualized abdomen as
described above.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 4343**]
Approved: SUN [**2122-5-31**] 4:23 PM
--------------
RADIOLOGY Final Report
CT NECK W/CONTRAST (EG:PAROTIDS) [**2122-5-28**] 5:08 PM
CT NECK W/CONTRAST (EG:PAROTID; CT 100CC NON IONIC CONTRAST
Reason: EVAL FOR STRIDOR, FAILED EXTUBATION.
Contrast: OPTIRAY
INDICATION: Eval for stridor or failed extubation.
COMPARISON: CT C-spine [**2122-5-22**].
TECHNIQUE: Contrast enhanced CT axial imaging of the neck was
reviewed.
FINDINGS: There is lobulated mucosal thickening of the maxillary
sinuses and partial fluid air opacification of the ethmoid air
cells. Bilateral medial maxillary defects suggest previous sinus
surgery. Soft tissue density above the endotracheal tube balloon
suggests soft tissue swelling or combination of secretions. The
ET tube is unchanged in position. An NG tube is present in the
esophagus. Below the vocal cords, the trachea is patent. Just
above the level of the carina is layering soft tissue density
that opacifies up to a third of the trachea at its greatest
dimension. This is incompletely evaluated on this neck CT. The
visualized portions of the lung apices contain multiple small
ill-defined opacities that may be small contusions versus small
developing infection given this patient's clinical history.
Small amount of atelectasis is identified within the dependent
portion of the right lung apex. Right subclavian central line is
seen within the SVC. The osseous structures are unremarkable.
There is near complete opacification of both mastoid air cells,
likely from fluid that was not present on [**2122-5-22**].
IMPRESSION: Mucosal fluid opacification of multiple sinuses with
soft tissue swelling/secretions within the pharynx. Secretions
within the trachea at the level of the carina that are
incompletely evaluated. Patchy consolidations in the lung apices
that may be contusion versus infection.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 16277**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: FRI [**2122-5-29**] 9:43 AM
--------------------
RADIOLOGY Final Report
CHEST PORT. LINE PLACEMENT [**2122-5-26**] 5:46 PM
CHEST PORT. LINE PLACEMENT
Reason: check CVL, f/u hemothorax
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p MCC now intubated w R ptx, effusion, pulm
contusion
REASON FOR THIS EXAMINATION:
check CVL, f/u hemothorax
INDICATION: 19-year-old man status post motor vehicle collision,
now intubated with right pneumothorax, effusion, and pulmonary
contusion, assess for central venous line.
COMPARISON: Chest x-ray from eight hours earlier.
SINGLE PORTABLE AP SUPINE CHEST RADIOGRAPH: An endotracheal tube
is seen at 4.8 cm above the carina. A nasogastric tube tip is at
the gastroesophageal junction and needs to be advanced. Again
seen is a right-sided chest tube with its tip in the lung apex.
Again seen is a right central venous line with its tip in the
superior vena cava. No pneumothorax is identified. There has
been obscuration of the left hemidiaphragm suggesting
atelectasis. Again seen is right basilar opacity consistent with
known contusion in this region, slightly improved. The cardiac
and mediastinal contours are stable as compared to the prior
study. The pulmonary vasculature is not as prominent as on the
prior study.
IMPRESSION:
1. Nasogastric tube with its tip at the gastroesophageal
junction. Please advance for appropriate positioning.
2. Slightly decreased opacity in the right lower lung consistent
with contusion, atelectasis or aspiration.
4. Less prominent pulmonary vasculature as compared to the prior
study.
Findings paged to Dr. [**First Name (STitle) 67050**] at 6:20 p.m. on [**2122-5-26**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name (STitle) 7204**] [**Name (STitle) 7205**]
Approved: TUE [**2122-5-26**] 10:19 PM
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2122-5-23**] 12:57 PM
CHEST (PORTABLE AP)
Reason: ? ett location? ptx ? effusions
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p MCC now intubated s/p OR
REASON FOR THIS EXAMINATION:
? ett location? ptx ? effusions
HISTORY: Motorcycle collision. Intubated. Question pneumothorax
or effusions.
IMPRESSION: AP chest compared to 3:41 p.m. on [**5-22**]:
Moderate right pneumothorax has grown since documented on the
chest CT [**5-22**] at 7:01 a.m., and in comparison to chest film
3:41 p.m. on [**5-22**]. ET tube, right subclavian line are in
standard placements. Nasogastric tube would need to be advanced
at least 8 cm to move all the side ports into the stomach.
Cardiomediastinal silhouette is unremarkable, stable and
midline. Extent of hemorrhage in the right lower lung has
decreased. A smaller amount of hemorrhage in the perihilar left
lower lung is stable.
Dr. [**Last Name (STitle) 46162**] was paged to report these findings at the time of
dictation.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**]
Approved: SUN [**2122-5-24**] 10:40 AM
--------------------
RADIOLOGY Final Report
TRAUMA #2 (AP CXR & PELVIS PORT) [**2122-5-22**] 6:42 AM
TRAUMA #2 (AP CXR & PELVIS POR
Reason: S/P MVA TRANSFER, LT HIP FX
[**Hospital 93**] MEDICAL CONDITION:
19 year old man with
REASON FOR THIS EXAMINATION:
trauma
INDICATION: 19-year-old male with trauma.
AP CHEST AND AP PELVIS: The heart size is probably normal given
the AP technique. There is diffuse air space opacity of the
right lung consistent with pulmonary contusion. There is hazy
opacity of the left lung, probably representing less severe
contusion. No fractures are identified in the chest cage. No
definite pneumothorax is found. There is no free air under the
diaphragm.
There is a complete subtrochanteric left femoral fracture. No
other fractures are identified in the pelvis. The regional soft
tissues are unremarkable. There is contrast in the bladder from
prior CT scan.
IMPRESSION:
1. Massive right pulmonary contusion and less severe left
contusion.
2. Complete subtrochanteric left femoral fracture.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) 3347**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 5034**]
Approved: FRI [**2122-5-22**] 5:04 PM
----------------
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2122-5-22**] 6:47 AM
CT HEAD W/O CONTRAST
Reason: eval: bleed
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p Motorcycle [**Last Name (un) **]
REASON FOR THIS EXAMINATION:
eval: bleed
CONTRAINDICATIONS for IV CONTRAST: None.
19-year-old male motorcycle accident.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence of hemorrhage, shift of normally
midline structures, hydrocephalus, or major vascular territorial
infarction. The ventricles and sulci are symmetric. There is
preservation of the normal [**Doctor Last Name 352**]/white matter differentiation.
The paranasal sinuses are pneumatized and the orbits are
unremarkable. There is no evidence of fracture.
IMPRESSION: No evidence of hemorrhage or fracture.
ER dashboard wet read 7:10 a.m. on [**2122-5-22**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: FRI [**2122-5-22**] 10:19 AM
------------------
RADIOLOGY Final Report
CT C-SPINE W/O CONTRAST [**2122-5-22**] 6:48 AM
CT C-SPINE W/O CONTRAST
Reason: eval: fx
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p Motorcycle [**Last Name (un) **]
REASON FOR THIS EXAMINATION:
eval: fx
CONTRAINDICATIONS for IV CONTRAST: None.
19-year-old male in motorcycle accident.
TECHNIQUE: Non-contrast CT of the cervical spine.
FINDINGS: The cervical spine through T2 are well visualized.
There is no evidence of fracture or malalignment of the cervical
spine. The vertebral body heights and disc spaces are preserved.
The prevertebral soft tissues are unremarkable and the airway is
patent. There is no encroachment upon the spinal canal.
IMPRESSION: No fracture or malalignment of the cervical spine.
ER dashboard wet read at 7:25 a.m. [**2122-5-22**] and it was
discussed with Dr. [**Last Name (STitle) 33863**].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 7415**]
Approved: FRI [**2122-5-22**] 9:13 AM
-------------
RADIOLOGY Final Report
CT CHEST W/CONTRAST [**2122-5-22**] 6:48 AM
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: eval: intra-torso path
Field of view: 36 Contrast: OPTIRAY
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p Motorcycle [**Last Name (un) **]
REASON FOR THIS EXAMINATION:
eval: intra-torso path
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 19-year-old male in motorcycle accident.
TECHNIQUE: MDCT continuously acquired axial images of the chest,
abdomen, and pelvis were obtained after 130 mL of Optiray IV
contrast. Coronal and sagittal reconstructions were performed.
CT OF THE CHEST WITH IV CONTRAST: There is extensive airspace
opacity of the right lung consistent with contusion. Within the
area of contused right lung. There are multiple small
pneumatoceles. Also noted is a small anterior right
pneumothorax. A moderate portion of the left posterior lung is
also contused. The heart and great vessels of the chest opacify
well, and there is no evidence of vascular injury.
CT OF THE ABDOMEN WITH IV CONTRAST: At least four peripheral
superficial hepatic lacerations are identified, the largest of
these are of the liver dome and posterior right hepatic lobe.
There is a small subcapsular tear associated with the posterior
right hepatic laceration with a small amount of associated blood
layering around the inferior liver margin. The gallbladder is
intact. There is lack of perfusion to the posterior right kidney
as well as a small right perirenal hematoma, which is concerning
for vascular pedicle injury. There is an adjacent right adrenal
hematoma as well. The left adrenal gland and kidney as well as
spleen, pancreas, stomach, duodenum, and intra-abdominal loops
of bowel are unremarkable. There is no free intra- abdominal air
or fluid. There is no extravasation of contrast outside of the
vasculature or bowel. The abdominal vasculature is intact.
CT OF THE PELVIS WITH IV CONTRAST: The ureters are intact and
the bladder is filled with intravenous contrast with a Foley
catheter present. The rectum, prostate, seminal vesicles, and
pelvic loops of bowel are unremarkable. There is no free pelvic
fluid.
BONE WINDOWS: There is a complete subtrochanteric left femoral
fracture. There is mild prominence of the adjacent musculature,
but no discrete hematoma. No other fractures of the torso are
identified. No suspicious lytic or sclerotic osseous lesions are
found.
IMPRESSION:
1. Massive right pulmonary contusion with multiple small
pneumatoceles. Moderate left pulmonary contusion.
2. Small anterior right pneumothorax.
3. At least four peripheral superficial hepatic lacerations
involving more than three hepatic segments consistent with a
grade IV liver injury.
4. Lack of perfusion to the posterior right kidney with a small
perirenal hematoma concerning for vascular pedicle injury.
5. Adrenal hematoma.
6. Complete subtrochanteric fracture of the left femur.
An ER dashboard wet read was placed at time 7:40 a.m. [**2122-5-22**] and this was discussed with the trauma surgeons caring for
the patient.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**]
Approved: FRI [**2122-5-22**] 1:40 PM
----------------
RADIOLOGY Final Report
FEMUR (AP & LAT) LEFT [**2122-5-22**] 11:54 AM
HIP UNILAT MIN 2 VIEWS LEFT; FEMUR (AP & LAT) LEFT
Reason: eval: fx
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p MCC now intubated
REASON FOR THIS EXAMINATION:
eval: fx
INDICATION: 19-year-old status post MVC, reassess fracture.
AP PELVIS, TWO VIEWS RIGHT HIP: Again demonstrated is the
severely displaced and angulated subtrochanteric fracture in the
left hip. The appearance is not significantly changed from the
prior study.
THREE VIEWS, LEFT FEMUR: No acute fracture.
THREE VIEWS, LEFT TIBIA/FIBULA: No acute fracture or
dislocation. No radiopaque foreign bodies.
THREE VIEWS, LEFT ANKLE: No acute fracture or dislocation. The
ankle mortise is intact.
TWO VIEWS, LEFT KNEE: No acute fracture or dislocation. No joint
effusion. Joint space is preserved.
IMPRESSION: Displaced left subtrochanteric fracture, unchanged.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6892**]
Approved: [**Doctor First Name **] [**2122-6-4**] 6:21 PM
------------------
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2122-5-22**] 8:43 AM
CHEST (PORTABLE AP)
Reason: eval: tube
[**Hospital 93**] MEDICAL CONDITION:
19 year old man s/p MCC now intubated
REASON FOR THIS EXAMINATION:
eval: tube
INDICATION: Status post MCC, intubated.
Comparison is made to the chest CT performed earlier on the same
day.
SUPINE AP CHEST: There has been placement of an endotracheal
tube, which terminates at the level of thoracic inlet. A NG tube
is present, which terminates in the body of the stomach. The
heart and mediastinal contours are within limits. There is
diffuse increased opacity throughout the right hemithorax
consistent with the areas of consolidation/injury on the
concurrent CT scan. The tiny right-sided pneumothorax and right
posterior rib fractures on the CT scan are not as evident on
this study. Less pronounced areas of patchy airspace opacity are
also demonstrated at the left base.
IMPRESSION:
1. Endotracheal tube terminates at the thoracic inlet
2. Large area of consolidation/contusion in the right lung.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1508**]Approved: FRI [**2122-5-22**] 2:07 PM
Brief Hospital Course:
19 y/o male who was scheduled to go to [**Country 2451**] in [**Month (only) 205**] who was in
a motorcycle vs tree
without a helmet. Pt was found prone in the [**Doctor Last Name 6641**], seen at St.
[**Doctor Last Name 11042**], found to have pulmonary contusions, kidney and liver
lacerations and a left femur fx, and was tx'd to [**Hospital1 18**].
.
On arrival to [**Hospital1 18**], pt was awake but combative. CT panscanning
was performed to better characterize injuries (see results) and
confirmed pt had pulmonary contusions, kidney and liver
lacerations, and a left femur fx.
.
Pt was admitted to the Trauma/Surgical ICU where he was soon
intubated due to pulmonary concerns. Over the first week his
vent settings were weaned slowly, but patient failed extubation
twice and was noted to have some abnormal laryngeal swelling on
ENT evaluation (which may have contributed to failed extubations
and failure to wean from vent). Therefore, pt was trach'd.
Afterward, he weaned from the vent that same day. Pt was then
transferred to the floor.
.
During his ICU stay, pt underwent ORIF of his left hip fx ([**5-23**];
HD#2). There were no orthopedics post-op complications.
.
A PEG tube was not placed. Patient was tube fed in ICU,
self-d/c'd NGT on floor, and patient eventually passed a swallow
evaluation on HD#14. Speech therapy recommendations include:
.
1. Pt can be advanced to a PO diet of thin liquids and regular
consistency solids.
.
2. The TRACHEAL CUFF MUST BE DEFLATED for all PO intake. Please
reinflate the cuff after meals until his secretions improve
further.
.
3. Pt must tuck his chin to his chest for all sips of thin
liquid
and for mixed consistencies (i.e. cereal with milk, chicken
noodle soup that have liquids and solids).
.
4. Please give liquids by straw.
.
5. Provide supervision as needed to follow the above strategies.
It is unclear if the pt will be able to independently follow the
above strategies.
.
6. Please crush medications and give with purees.
.
7. Speech-language therapy in rehab given pt's cognitive
deficits.
.
Regarding his tracheostomy, pt has failed 2 Passey-Muir
evaluations due to excess secretions and laryn/pharyngeal
swelling that required trach placement. We recommend that his
trach remain as is for one more week, then may be downsized as
needed and tolerated. PMV may be better tolerated with smaller
trach.
Medications on Admission:
None.
Discharge Medications:
1. Benzoyl Peroxide 10 % Gel Sig: One (1) Appl Topical DAILY
(Daily).
2. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q4-6H (every 4 to 6 hours) as needed for fever.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Hold for loose stools.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4
hours) as needed for agitation.
7. Morphine 10 mg/mL Solution Sig: 1-5 mg Intravenous every six
(6) hours as needed for pain.
8. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain: keep total acetaminophen below 4g/day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
1. Massive right pulmonary contusion with multiple small
pneumatoceles.
2. Moderate left pulmonary contusion.
3. Small anterior right pneumothorax.
4. Superficial hepatic lacerations involving more than three
hepatic segments consistent with a grade IV liver injury.
5. Perirenal hematoma
6. Adrenal hematoma.
7. Complete subtrochanteric fracture of the left femur
8. Closed head injury
Discharge Condition:
Good. Trached. Tolerating POs (passed beside and video swallow
studies). Ambulating.
Discharge Instructions:
Please take all medications as prescribed. Please schedule and
attend all followup appointments. Please seek medical attention
for any fever, nausea, vomiting, worsening pain, shortness of
breath, or with any other concerns.
Followup Instructions:
Please followup with your regular doctor within 24hours of
discharge from rehab.
Please followup with the Trauma service in 1.5 weeks (Tuesday,
[**6-16**]). You should call ([**Telephone/Fax (1) 376**] soon to schedule this
appointment.
Please followup with the Orthopedics service in two weeks (Dr.
[**First Name (STitle) **]. You should call ([**Telephone/Fax (1) 2007**] to schedule this
appointment.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"285.9",
"866.01",
"V46.11",
"807.09",
"518.89",
"E823.2",
"300.00",
"820.22",
"850.5",
"861.21",
"518.0",
"864.04",
"785.0",
"041.11",
"305.00",
"V15.82",
"868.01",
"860.0",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"31.1",
"34.04",
"96.6",
"93.96",
"96.04",
"96.72",
"79.35",
"33.23",
"96.07",
"38.93",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
26685, 26732
|
23402, 25777
|
346, 504
|
27163, 27250
|
1302, 4674
|
27523, 28060
|
1042, 1047
|
25833, 26662
|
22223, 22261
|
26753, 27142
|
25803, 25810
|
27274, 27500
|
1062, 1283
|
275, 308
|
22290, 23379
|
532, 842
|
864, 871
|
887, 1026
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,784
| 105,464
|
17386+56848
|
Discharge summary
|
report+addendum
|
Admission Date: [**2118-11-22**] Discharge Date: [**2118-12-9**]
Date of Birth: [**2052-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ceftriaxone / Crestor / Bee
Pollens
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
prothetic mitral regurgitation, rapid atrial fibrillation
Major Surgical or Invasive Procedure:
[**2118-11-25**] Redo mitral valve replacement(33mm On-X), coronary
artery bypass graft x 1 (LIMA-LAD), esophagogastroscopy
Implantation of permanent transvenous pacemaker/defibrillator
[**2118-12-5**]
Redosternotomy, removal Right pleural chest tube [**2118-12-2**]
History of Present Illness:
This 65 year old white male underwent tissue mitral valve
replacement here in [**2112**] for endocarditis after a bout with a
septic prosthetic knee. This was done via a right thoracotomy.
He did well until recently when heart failure symptoms
developed. He was found to have significant mitral
regurgitation with left ventricular dysfunction. He was
scheduled for rooperation and was admitted now with rapid atrial
fibrillation and acute heart failure.
Past Medical History:
Coronary Artery Disease
History of Streptococcal Endocarditis [**2112**]
chronic Atrial Fibrillation
s/p Ablation
Hypertension
Pulmonary Hypertension
Rheumatoid Arthritis
s/p Minimally Invasive mitral valve replacement
s/p Left total knee replacement
s/p Redo Left total knee replacement
s/p right rotator cuff repair
s/p cervical mediastinoscopy/bronchoscopy [**11-14**]
Schatzki Ring
Social History:
Occupation: dentist
Last Dental Exam:
Lives with wife
[**Name (NI) **]:Caucasian
Tobacco:[**1-7**] mini-cigars per yr.
ETOH:1 beer/night
Family History:
noncontributory
Physical Exam:
Admission:
Pulse:110s Resp: O2 sat: 100%
B/P Right: 89/63 Left:
Height: 71" Weight:88.6kg
General:fatigued easily
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Heart: irregularly irregular, SEM III/VI
Lungs: bibasilar crackles
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None []
Neuro: Grossly intact
Pulses:
Femoral Right: 2 Left:2
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: 2 Left:2
Radial Right: 2 Left:2
Carotid Bruit Right:n Left:n
Pertinent Results:
[**2118-12-5**] Echocardiogram
Suboptimal image quality. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. There is
severe global left ventricular hypokinesis (LVEF = 20%) with
inferior/infero-lateral akinesis. No masses or thrombi are seen
in the left ventricle. The right ventricular cavity is dilated
with depressed free wall contractility. There is no aortic valve
stenosis. A bileaflet mechanical mitral valve prosthesis is
present. The transmitral gradient is normal for this prosthesis.
Mitral regurgitation is present (probably mild?) but cannot be
quantified. [Due to acoustic shadowing, the severity of mitral
regurgitation may be significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
[**2118-12-8**] 05:02AM BLOOD WBC-12.2* RBC-3.29* Hgb-9.7* Hct-29.1*
MCV-88 MCH-29.6 MCHC-33.5 RDW-14.7 Plt Ct-497*
[**2118-12-8**] 05:02AM BLOOD PT-27.2* INR(PT)-2.7*
[**2118-12-7**] 11:09PM BLOOD PT-27.2* PTT-61.8* INR(PT)-2.7*
[**2118-12-7**] 03:49PM BLOOD PT-24.0* PTT-50.7* INR(PT)-2.3*
[**2118-12-7**] 06:17AM BLOOD PT-23.1* PTT-44.1* INR(PT)-2.2*
[**2118-12-6**] 11:24PM BLOOD PT-23.7* PTT-48.0* INR(PT)-2.2*
[**2118-12-6**] 03:13PM BLOOD PT-21.0* PTT-37.7* INR(PT)-1.9*
[**2118-12-8**] 05:02AM BLOOD UreaN-20 Creat-0.8 K-4.6
[**2118-12-7**] 06:17AM BLOOD Glucose-100 UreaN-17 Creat-0.7 Na-138
K-4.0 Cl-103 HCO3-28 AnGap-11
[**2118-12-9**] 08:19AM BLOOD PT-30.6* INR(PT)-3.1*
Brief Hospital Course:
Following admission he was stabilized, diuresed and his heart
failure cleared. His creatinine rose to 1.6 and stabilized. On
[**11-25**] he was taken to the Operating Room where redo mitral valve
replacement was accomplished via a median sternotomy. See
operative note for details. He weaned from bypass on Milrinone,
Levophed and Propofol in stable condition. His coagulopathy was
corrected and he was extubated the following morning. The
Milrinone was turned off and Lisinopril begun. The Levophed was
also weaned off and his hemodynamics were good with PA pressures
in the low 50s and a cardiac index of greater than 2.5.
He remained well and invasive lines were removed, diuresis were
begun and he was mobilized. Slow ventricular response to atrial
fibrillation led to ventricular pacing. Anticoagulation was
started for the mechanical valve and fibrillation on POD 1 and
intravenous Heparin on POD 2.
Mr. [**Known lastname **] right pleural chest tube was unable to be removed
and the patient was taken to the Operating Room on [**12-2**] for
removal of trapped chest tube and exploration of inferior pole
of sternotomy incision. The inferior pole of the incision was
opened and it was discovered that the tube had been caught on
the Vicryl midline fascial closure suture. That suture was cut,
and the tube was pulled back from under the drapes. The wound
was irrigated with copious amounts of antibiotic irrigation. A
small fluid collection at the inferior aspect of the wound
substernally was noted and the patient was started on
ciprofloxacin and vancomycin for a 7 day course empirically.
There were no positive cultures.
Electrophysiology was consulted due to conduction issues
perieoperatively. Due to prolonged AV conduction, dilated
cardiomyopathy and prolonged QRS, it was determined that he
needed an ICD placed. Coumadin was held and Heparin drip was
started. On [**2118-12-5**] the INR was 1.8 and he was taken to the EP
lab for ICD implantation. Lopreesor was titrated up for rate
control after ICD implantation. Heparin and Coumadin were
resumed post procedure.
He progressed well and Heparin was discontinued once the INR
rose above 2.0. His antibiotics were continued for a seven day
course. Arrangements for Coumadin follow up at the [**Hospital **]
[**Hospital 197**] clinic were made, as this was his routine before this
surgery. He was ambulatory, wounds were clean and healing well.
Discharge medications and restrictions were discussed with him
prior to leaving the hospital. He was neurologically intact. He
was discharged on 5mgm of Coumadin 12/4,5 and 6 to have an INR
checked on [**12-12**].
Medications on Admission:
Lipitor 40 mg(1), Aspirin 81 (1), Plaquenil 200 (1),
Leflunomide 20 (1), lisinopril 5 mg daily, Clindamycin prn
dental
proc., lasix 20 mg daily, KCl 20 mEq daily
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Vicodin ES 7.5-750 mg Tablet Sig: 1-2 Tablets PO every [**4-11**]
hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
daily as directed. INR [**2-8**] goal.
Disp:*100 Tablet(s)* Refills:*2*
13. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
Bioprosthetic mitral regurgitation
s/p mitral valve replacement
s/p redo mitral valve replacement
s/p Coronary Artery Disease s/p coronary artery bypass graft x 1
chronic atrial fibrillation
s/p Ablation
Streptococcal Endocarditis [**2112**]
hypertension
gastroesophageal reflux disease
hyperlipidemia
rheumatoid arthritis
Schatzki Ring
s/p Left total knee replacement
s/p Redo Left total knee replacement
s/p Esophogeal Dilatation
s/p right rotator cuff repair
s/p mediastinoscopy/bronchoscopy [**11-14**]
Discharge Condition:
good
Discharge Instructions:
shower daily, no baths or swimming
no lotions, creams or powders to incisions
no driving for 4 weeks and off all narcotics
no lifting more than 10 pounds for 10 weeks
report any redness of, or drainage from incisions
report any fever greater than 100.5
report any weight gain greater than 2 pounds a day or 5 pounds a
week
take all medications as directed
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**])
[**Hospital Ward Name 121**] 6 wound clinic in 2 weeks
Dr. [**First Name (STitle) **] [**Name (STitle) 48633**] in 2 weeks ([**Telephone/Fax (1) 35142**])
Please call for appointments
Coumadin management by [**Hospital1 **] Heart Center [**Hospital 197**] Clinic
Completed by:[**2118-12-9**] Name: [**Known lastname 8981**],[**Known firstname **] Unit No: [**Numeric Identifier 8982**]
Admission Date: [**2118-11-22**] Discharge Date: [**2118-12-9**]
Date of Birth: [**2052-12-3**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Sulfa (Sulfonamides) / Ceftriaxone / Crestor / Bee
Pollens
Attending:[**First Name3 (LF) 741**]
Addendum:
The patient's creatinine rose to 1.6 after surgery while in the
ICU from a base line of 0.9.
Observation and management of diuretics resulted in a fall of
this number to near baseline at discharge.
Chief Complaint:
see summary
Major Surgical or Invasive Procedure:
[**2118-11-25**] Redo mitral valve replacement(33mm On-X), coronary
artery bypass graft x 1 (LIMA-LAD), esophagogastroscopy
Implantation of permanent transvenous pacemaker/defibrillator
[**2118-12-5**]
Redosternotomy, removal Right pleural chest tube [**2118-12-2**]
History of Present Illness:
see summary
Past Medical History:
Coronary Artery Disease
History of Streptococcal Endocarditis [**2112**]
chronic Atrial Fibrillation
s/p Ablation
Hypertension
Pulmonary Hypertension
Rheumatoid Arthritis
s/p Minimally Invasive mitral valve replacement
s/p Left total knee replacement
s/p Redo Left total knee replacement
s/p right rotator cuff repair
s/p cervical mediastinoscopy/bronchoscopy [**11-14**]
Schatzki Ring
Social History:
Occupation: dentist
Last Dental Exam:
Lives with wife
[**Name (NI) **]:Caucasian
Tobacco:[**1-7**] mini-cigars per yr.
ETOH:1 beer/night
Family History:
noncontributory
Physical Exam:
see summary
Pertinent Results:
see summary
Brief Hospital Course:
see summary
Medications on Admission:
see summary
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
Disp:*30 Tablet(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain/fever.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Leflunomide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Vicodin ES 7.5-750 mg Tablet Sig: 1-2 Tablets PO every [**4-11**]
hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
8. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily).
Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once):
daily as directed. INR [**2-8**] goal.
Disp:*100 Tablet(s)* Refills:*2*
13. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
tba
Discharge Diagnosis:
s/p Bioprosthetic mitral regurgitation
s/p redo mitral valve replacement
s/p Coronary Artery Disease s/p coronary artery bypass graft x 1
chronic atrial fibrillation
s/p Ablation
Streptococcal Endocarditis [**2112**]
hypertension
gastroesophageal reflux disease
hyperlipidemia
rheumatoid arthritis
Schatzki Ring
s/p Left total knee replacement
s/p Redo Left total knee replacement
s/p Esophogeal Dilatation
s/p right rotator cuff repair
s/p mediastinoscopy/bronchoscopy [**11-14**]
Discharge Condition:
Good
Discharge Instructions:
Shower daily including washing incisions gently with mild soap,
no baths or swimming, and look at your incisions
NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month until follow up with surgeon and taking
narcotics
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1477**])
[**Hospital Ward Name **] 6 wound clinic in 2 weeks
Dr. [**First Name (STitle) 8983**] [**Name (STitle) 8984**] in 2 weeks ([**Telephone/Fax (1) 8985**])
EP device clinic in 1 week after discharge [**Telephone/Fax (1) 337**]
Dr [**Last Name (STitle) 86**] in 2 weeks [**Telephone/Fax (1) 8986**]
[**Hospital6 2271**] [**Hospital 8325**] Clinic as directed by
cardiology
Please call for appointments
[**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**]
Completed by:[**2118-12-23**]
|
[
"427.31",
"996.02",
"285.9",
"V43.65",
"997.5",
"530.3",
"427.32",
"401.9",
"426.4",
"428.21",
"305.1",
"276.2",
"428.0",
"416.8",
"414.01",
"714.0",
"424.0",
"E878.1",
"518.89",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"36.15",
"45.13",
"34.03",
"37.94",
"39.61",
"35.24"
] |
icd9pcs
|
[
[
[]
]
] |
12953, 12987
|
11373, 11386
|
10379, 10650
|
13513, 13520
|
11337, 11350
|
14054, 14651
|
11273, 11290
|
11448, 12930
|
13008, 13492
|
11412, 11425
|
13544, 14031
|
11305, 11318
|
10328, 10341
|
10678, 10691
|
10713, 11102
|
11118, 11257
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,329
| 163,661
|
44362
|
Discharge summary
|
report
|
Admission Date: [**2185-10-31**] Discharge Date: [**2185-11-6**]
Date of Birth: [**2122-3-3**] Sex: F
Service: [**Last Name (un) **]
HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname **] is a 63-year-old
woman who is status post a gastric bypass in the past who has
developed a ventral hernia and a gastrogastric remnant
fistula. She presented for elective repair of the fistula and
ventral hernia on [**2185-10-31**].
PAST MEDICAL HISTORY: Significant for obstructive sleep
apnea, lower back pain, morbid obesity, asthma, hypertension,
spastic bladder and depression.
PAST SURGICAL HISTORY: Significant for a cholecystectomy in
the [**2160**], gastric bypass in [**2179**] and an internal hernia in
[**2183**].
MEDICATIONS ON ADMISSION: Include hydrocodone, Diovan,
Ambien, Lexapro, [**Doctor First Name **], Arimidex, potassium, Flonase and an
inhaler for asthma.
PHYSICAL EXAMINATION ON PREOPERATIVE ASSESSMENT: Showed her
lungs to be clear to auscultation. Heart was regular. She was
without edema.
PERTINENT PROCEDURES PERFORMED: Revision of Roux-en-Y
gastric bypass and ventral hernia repair with mesh on
[**2185-10-31**].
SUMMARY OF HOSPITAL COURSE: The patient was taken to the
operating room for an elective revision of her gastric
bypass, including a completion gastrectomy as well as repair
of her ventral hernia with mesh. Postoperatively, she was
transferred to the PACU where she did well. However, on
postoperative day #2 she was noted to have an increasing
fluid requirement to maintain her urine output at 30 cc or
better per hour. After approximately 5 liters of volume
resuscitation on the floor she was transferred to the ICU for
closer hemodynamic monitoring. While in the intensive care
unit she received further IV fluid resuscitation, and after a
single day in the ICU she was found to be ready to be
transferred back to the floor. Her nasogastric tube was
removed on postoperative day #4, and she was started on a
stage #1 diet which she tolerated without difficulty.
DISCHARGE STATUS: Her diet was advanced through gastric
bypass stage #3, and she was discharged to home on [**2185-11-6**] in good condition.
DISCHARGE DIAGNOSES: Morbid obesity, ventral hernia and
gastrogastric fistula.
DISCHARGE MEDICATIONS: Metoprolol 50 mg p.o. b.i.d., Pepcid
20 mg p.o. b.i.d., Percocet elixir and Colace.
FOLLOW-UP PLANS: The patient was to follow up with Dr. [**Last Name (STitle) **]
in his office as well as with her primary care doctor, Dr.
[**First Name8 (NamePattern2) 2048**] [**Last Name (NamePattern1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 37606**]
Dictated By:[**Last Name (NamePattern4) 95120**]
MEDQUIST36
D: [**2186-1-20**] 13:38:18
T: [**2186-1-21**] 11:38:47
Job#: [**Job Number 95121**]
|
[
"568.0",
"V10.3",
"724.2",
"311",
"278.01",
"997.4",
"780.57",
"715.90",
"596.8",
"553.21",
"719.46",
"276.5",
"493.90",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"93.90",
"53.61",
"43.89"
] |
icd9pcs
|
[
[
[]
]
] |
2194, 2253
|
2277, 2362
|
766, 1162
|
618, 739
|
1191, 2172
|
2380, 2844
|
183, 442
|
465, 594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,476
| 152,255
|
54293
|
Discharge summary
|
report
|
Admission Date: [**2200-9-17**] Discharge Date: [**2200-10-20**]
Date of Birth: [**2158-4-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Morphine
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
positive blood cultures
Major Surgical or Invasive Procedure:
placement of temporary pacing wire [**2200-9-23**]
chest tube placement
dental extractions [**2200-10-2**]
cardiac cath [**2200-10-1**]
[**2200-10-6**] - AVR/debridement of LVOT abscess/ Pacemaker placement
(27 mm CE Magna pericardial valve, [**Company 1543**] Enpulse DR [**Last Name (STitle) 10550**]
E2DR31)
History of Present Illness:
42 yo M with h/o HTN, MVP presented with positive blood cultures
and 6 week h/o fever thought to be endocarditis. He was in USOH
until 6PM on [**8-11**] when he was overcome with the feeling of
a fever. Since then, he has had daily fevers and nightly sweats.
He has been soaking though [**6-5**] shirts a night. He saw his PCP
and was worked up for West [**Doctor First Name **] and Lyme which reportedly was
negative. In the last few weeks, the fevers, fatigue, and
lethargy have been increasing in frequency and severity. He has
been unable to keep up with his 2 and 4 year olds as he has
before. he has had DOE which resolves with rest. He went to see
his PCP [**Name9 (PRE) 766**] who drew blood cultures on Tuesday. These came
back positive today and he wa sent to the ED.
.
He had a routine dental cleaning on [**7-17**] before which he took
his regular amox. pills were 1 year old. He has had no surgeries
and has no hardware. He has only traveled to [**Location (un) **]. he had
morning HAs in [**Month (only) 205**] and early [**Month (only) 216**] which has since decreased
in frequency. He has had had migratory arthralgias, no joint
swelling. + myalgias. no rashes. + 15 lb weight loss. No sick
contacts. no exposure to gyms, health care facilities. No family
member with MRSA. has had mild diarrhea for the last 1 week.
Stools are "forest green" in color. he has been drinking 3
Gatorades per day and 3 bottles of water. No visual changes,
focal pain, difficulty walking, chest pains, n/v. no melana,
BRPRPR.
.
In the ED, had temp to 101. Recieved 2 L NS, vamcomycin and
gent.
has a PR 0.3 (not 0.7 as noted on EKG) therefore admitted on
[**2200-9-17**] for abx therapy. Dr. [**Last Name (STitle) 1290**] consulted for surgery
evaluation. Pre-op events in the 2 weeks prior to surgery
included completion of TEE, heart block with insertion of temp
transvenous pacer (removed at surgery), ID consult for treatment
of strep viridans endocarditis, EP consult, chest tube for right
pneumothorax, mid-line placement.
Past Medical History:
1. ? h/o mitral valve prolapse - not seen on current or [**2199**]
echo
2. AR 2+ on echo [**5-30**], seen in [**2191**]
3. bicuspid aortic valve
4. HTN
Social History:
works in the gourmet and smoked meat industry. drinks occ beer
on weekends. no tobacco. married with 2 kids
Family History:
adopted
Physical Exam:
Vitals: T: 98.2 P:94 R:61 BP:118/48 SaO2:99 RA
General: thin male, alert and in NAD.
HEENT: PERRL/ EOMI, sclera anicteric. MMM, OP clear, no
conjunctival hemorrhages (per [**Hospital Ward Name 121**] 6 resident).
Neck: supple, no JVD or carotid bruits appreciated, 2+ carotid
pulses b/t
Pulmonary: Lungs CTAB
Cardiac: RRR, sharp S1, normal S2, soft non-radiating II/VI
diastolic murmur heard at the lower left sternal border when
sitting forward.
Abdomen: soft, NT/ND, + BS, no masses or organomegaly noted.
Extremities: No edema, 2+ radial, DP and PT pulses b/l.
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no splinter hemorrhages noted; no [**Last Name (un) 1003**] lesions or
Osler's nodes
Neurologic: Alert, oriented x 3. Able to relate history without
difficulty. CN II-XII grossly intact.
Pertinent Results:
[**2200-10-20**] 06:00AM BLOOD WBC-14.1*# RBC-3.22* Hgb-9.7* Hct-27.0*
MCV-84 MCH-30.1 MCHC-35.9* RDW-14.3 Plt Ct-559*
[**2200-10-18**] 05:25AM BLOOD WBC-8.0 RBC-2.87* Hgb-8.3* Hct-24.8*
MCV-86 MCH-29.0 MCHC-33.6 RDW-14.4 Plt Ct-480*
[**2200-10-20**] 06:00AM BLOOD Plt Ct-559*
[**2200-10-20**] 06:00AM BLOOD PT-13.5* PTT-28.5 INR(PT)-1.2*
[**2200-10-18**] 05:25AM BLOOD Plt Ct-480*
[**2200-10-20**] 06:00AM BLOOD Glucose-138* UreaN-11 Creat-0.6 Na-136
K-3.9 Cl-98 HCO3-27 AnGap-15
[**2200-10-18**] 05:25AM BLOOD Glucose-114* UreaN-17 Creat-0.8 Na-137
K-4.1 Cl-100 HCO3-29 AnGap-12
Brief Hospital Course:
# AV Block: recent complete heart block most likely from
paravalvular abscess. S/p screw-in pacer placement on [**2200-9-23**].
Currently in 1st degree AVB. Per EP, given PR of 330 ms and
recent CHB, patient would still be at risk; hence, in-house
observation.
- cont daily EKGs
- monitor on tele
- transfer to floor for continued observation till AVR surgergy
.
# Aortic abscess/Strep viridans bacteremia: aortic abscess not
seen on initial read of echo, but has probable 0.8 cm abscess on
review. Subacute bacterial endocarditis suspected. 2 major and 2
minor criteria by [**Location (un) **] classification - (+blood cx, endocardial
involvement, predisposing heart condition, fever). ESR 61, CRP
79. Followed by cardiac [**Doctor First Name **] and ID. AVR either next week or
after 4-to-6-week course of abx. CT abdomen without evidence of
emboli or abscess.
Blood cx from [**9-18**] to [**9-23**] show no growth to date. Stable exam
with 2/4 diastolic murmur at LLSB.
- cont ceftriaxone (day 6) x 4-6 weeks (day 8 of total abx)
- once surgery date is more definite, will consider either PICC
or midline IV access for abx.
- serial cardiac exams to look for signs of LV dysfunction
.
# PTX: secondary to temporary pacer placement, now s/p screw-in
pacer. Chest tube in on [**9-21**], pulled on [**9-24**]. Latest CXR shows
stable small R apical PTX.
.
# Elevated LFTs: newly elevated AST and ALT, normal alk phos and
bili: hepatocellular injury pattern, most likely due to
ceftriaxone; ?liver ischemia.
- cont to monitor LFTs
- limit tylenol to 2g QD
- stopped ceftriaxone; switched to penicilin [**2200-9-25**]
- resolving
.
# Tachycardia: likely [**2-27**] ectopic supraventricular focus getting
triggered by edema/inflammation from endocarditis. Now with reg
rate.
- cont to monitor on tele.
- HR better control
.
# AI: noted first in [**2191**]. has murmur, echo evidence, wide pulse
pressure.
- monitor for acute worsening (hypotension + pulmonary edema)
.
# HTN: Stable BPs.
- continue lisinopril 10 mg qd.
.
# Anemia: Low Fe, low TIBC, Fe/TIBC <18%. Elevated ferritin
consistent with anemia of inflammation. Cont to monitor
.
# FEN: Cardiac diet. Mild hyponatremia. Probable hypovolemic.
Will cont to monitor and consider urine lytes to further assess.
.
# ACCESS: peripherals
.
# COMM: with pt and wife, [**Name (NI) 402**]
.
# PPX: heparin SC, bowel regimen
.
# CODE: Full
Completed 17 days of IV antibiotic therapy with pre-operative
events outlined in history above. Dental clearance obtained also
after teeth extraction. Cardiac cath [**10-1**] showed normal
coronaries. Underwent AVR/ LVOT abscess debridement/removal of
temp. pacer wire, placement of permanent pacer on [**2200-10-6**].
Transferred to the CSRU in stable condition on titrated
phenylephrine and propofol drips.Extubated that evening and
transferred to the floor on POD #1 to begin increasing his
activity level. PICC line placed on POD #2 and chest tubes
removed in stages on POD #2, 3, 4 due to a persistent small
pneumothorax. Pacing wires removed without incident on POD #2.
On [**10-10**] he was found to have pleuritic right chest and a rise in
WBC to 19. He had a CT chest and he was found to have a large
right loculated pleural effusion for which he was seen in
consultation by thoracic surgery. He underwent a VATS/decort on
[**2200-10-16**]. His chest tubes were discontinued on [**10-18**] and [**10-19**]. He
was ready for discharge home on [**2200-10-20**].
Medications on Admission:
lisinopril 10 mg QD
MVI
amoxicillin prior to dental procedures
advil prn
tylenol prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous DAILY (Daily) as needed for 4 weeks: 10 ml NS
followed by 2 ml of 100 units/ml heparin ( 200 units heparin)
each lumen daily and PRN.
Disp:*QS ML(s)* Refills:*0*
7. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback
Sig: Three (3) million units Intravenous Q4H (every 4 hours)
for 4 weeks.
Disp:*504 million units* Refills:*0*
8. Outpatient Lab Work
CBC with Diff, SMA 7, LFT twice weekly
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (Infectious disease) Fax: [**Telephone/Fax (1) 1419**]
9. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
s/p AVR/debridement LVOT abscess/ pacer placement [**10-6**]
dental extractions [**10-2**]
endocarditis
HTN
? MV prolapse
PICC placement [**10-8**]
right pneumothorax
Discharge Condition:
good
Discharge Instructions:
no lifting greater than 10 pounds for 10 weeks
no driving for one month
no lotions, creams,or powders on any incision
may shower over incision and pat dry
call for fever greater than 100, redness or drainage
Followup Instructions:
see Dr. [**Last Name (STitle) 410**] in [**1-27**] weeks
See Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] in [**2-28**] weeks
See Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2200-10-21**]
|
[
"794.8",
"E930.5",
"511.9",
"401.9",
"746.4",
"521.00",
"423.9",
"512.1",
"041.19",
"790.7",
"426.0",
"421.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"37.83",
"39.61",
"37.22",
"35.39",
"23.19",
"88.72",
"34.51",
"99.05",
"99.06",
"99.07",
"88.56",
"37.72",
"34.04",
"99.04",
"37.78",
"35.21"
] |
icd9pcs
|
[
[
[]
]
] |
9449, 9500
|
4491, 7950
|
300, 614
|
9711, 9718
|
3886, 4468
|
9974, 10219
|
2987, 2997
|
8086, 9426
|
9521, 9690
|
7976, 8063
|
9742, 9951
|
3012, 3867
|
237, 262
|
642, 2669
|
2691, 2845
|
2861, 2971
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,002
| 106,384
|
25039
|
Discharge summary
|
report
|
Admission Date: [**2151-1-25**] Discharge Date: [**2151-1-27**]
Date of Birth: [**2077-10-24**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
chest pain, hypotension
Major Surgical or Invasive Procedure:
Stress MIBI test
History of Present Illness:
73 year old patient of Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] with a history of
rheumatic heart disease with moderate MR [**First Name (Titles) **] [**Last Name (Titles) **], PAF (on
coumadin), hypertension who has a history of vague chest pain.
She was admitted to [**Location (un) **] back in [**Month (only) 359**] and ruled out.
Stress on [**2150-11-9**] exercised for 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol
to a heart rate of 98. She experienced no chest pain and had no
significant ST-T wave changes. Nuclear images did show a
posterolateral reversible defect in addition to a small anterior
apical defect. She was seen last week by Dr. [**Last Name (STitle) 11493**] in the office
for evaluation of near syncope and given an event monitor. Today
she went to the [**Location (un) **] ER due to increasing chest pain over the
past week with associated weakness. No significant findings on
event monitor per [**Doctor Last Name 11493**]. Per patient, she has had symptoms of
left shoulder pain radiating down her left arm and up left jaw
for many years and all previous work-up has been negative.
However, in past month, she has developed a new type of chest
discomfort over entire chest and associated with nausea and
feeling fatigued and lightheaded. No palps, no SOB, no LOC, no
association with any activity. She has 4 episodes a day lasting
about 5 minutes. Nothing make it better or worse and they occur
irregardless of activity.
.
Upon arrival to [**Location (un) **] ER, INR 3.3. EKG without acute findings
of ischemia. She received SLNTG X3 with no effect. Nitro gtt
started and CP free after 30 min. Then, 45 min later developed
hypotension to 84/36, pt asymptomatic -> nitro gtt stopped, 500
of NS, then 1L NS bolus. SBP in mid80's and she was transferred
to [**Hospital1 18**].
.
On route to [**Hospital1 18**], SBP dropped again->500 cc NS given. SBP
dropped to 47/26 -> started dopamine 20 mcg in ambulance. BP
rose to 110-130s within 5 minutes. NO chest pain, palps, SOB
during this, but did feel more fatigued.
.
In CCU, afebrile, 111/64, 62, 100%2LNC. She reports feeling
fatigued, but no other symptoms of CP, palp, SOB, LHD,
dizzyness. At baseline, she can climb 2 flights of stairs and
now feels slightly more fatigued than usual.
.
ROS remarkable for intermittent right eye loss of vision "like
blind pulled down" for past month, occasional tingling and
numbess of right face for at least 6 years (prior to stroke).
+PND, sleeps with 2 pillows, no LE swelling, no pleuritic CP,
recent illnesses, bladder/bowel changes.
Past Medical History:
- HTN
- hyperlipidemia
- PAF: on coumadin, started propafenone 2 years ago which has
kept her in sinus
- Hx of rheumatic fever: MR/MS [**Name13 (STitle) **] per Dr. [**Last Name (STitle) 11493**] note, no
significant valvular disease
- GERD
- Stroke: 6 years ago with recovery of right hand function
- thyroidectomy due to goiter
- colon cancer s/p surgery and chemotherapy
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse.
Family History:
There is family history of premature coronary artery disease or
sudden death in brother who died of MI age 51.
Father: stroke, lung ca, HTN, MI
Physical Exam:
VS 96.0 104/56 62 17 99% 2LNC
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 of 8 cm; no carotid bruits
CV: RR, normal S1, S2. I/VI systolic murmur at apex. No thrills,
lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness.
Ext: trace pitting edema; faint DP pulses bilaterally
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
EKG demonstrated sinus rhythm, 60bpm, nl axis, PR 200 msec, no
ST or TW changes compared to earlier in day. PR from OSH EKG
TELEMETRY demonstrated: normal rhythm,
2D-ECHOCARDIOGRAM: Per patient, she had an echo 1 week prior
which was reportedly normal
ETT: Per Dr. [**Last Name (STitle) 11493**] notes: [**2150-11-9**]. 4 minutes on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
protocol to a heart rate of 98. She experienced no chest pain
and had no significant ST-T wave changes. Nuclear images did
show a posterolateral reversible defect in addition to a small
anterior apical defect.
CXR: In comparison with the study of [**1-25**], the patient has
taken a
better inspiration. The cardiac silhouette is within normal
limits with mild prominence of the ascending aorta that would
reflect aortic stenosis or hypertension.
Pertinent labs on discharge:
[**2151-1-27**] WBC-3.9* RBC-3.93* Hgb-12.1 Hct-36.0 MCV-92 MCH-30.8
MCHC-33.6 RDW-13.7 Plt Ct-149*
[**2151-1-27**] PT-16.9* PTT-31.5 INR(PT)-1.5*
[**2151-1-26**] PT-32.5* PTT-38.3* INR(PT)-3.4*
[**2151-1-25**] PT-31.8* PTT-37.7* INR(PT)-3.3* ->given 5mg PO vit K
[**2151-1-26**] TSH-2.9 Free T4-1.3
[**2151-1-26**] %HbA1c-6.1*
[**2151-1-26**] Triglyc-107 HDL-40 CHOL/HD-3.3 LDLcalc-70
Brief Hospital Course:
Patient is a 73 y/o F hx PAF on coumadin, HTN, bradycardia and
first degree AVB now presents with chest pressure and
lightheadedness
CAD: Patient has no known diagnosis of CAD, and cardiac cath
from [**2148**] from [**Hospital3 2568**] had clean coronary arteries. She ruled
out for an MI here and had a stress stress P - MIBI which
revealed no perfusion defects and an LVEF of 65%. Recent stress
test per OSH cardiologist notes echo done last week per Dr.
[**Last Name (STitle) 11493**] no valve abnormalites. Prior report of MS/MR incorrect.
She has been having these symptoms for the past month and her
cardiologist felt that there may be a component of near syncope
[**3-13**] bradycardia as opposed to CAD. However, her symptoms were
relieved with nitro. NO EKG changes. [**Hospital3 **] cath report from
[**2148**] show clean coronary arteries. Given negative stress,
recent cath that was negative, reportedly normal echo a decision
was made not to cath the patient. Beta blocker, aspirin, statin
were continued. Her coumadin was held as an inpatient as she
was supratherapeutic, this drifted down to INR 1.5 upon
discharge, she was discharged with a lovenox bridge. A1C 6.1%.
LDL 70, HDL 40, Total 131, Trig 107.
Chest Pain: 2 weeks at most 30 min at a time, no assoc w/
exerction, not reproduced w/ palpation dull in nature, several
times per day. Supratherapeutic on couadmin and not pleurtic
making PE less likely, no tenderness on exam so costochondritis
is less likely, cannot rule out coronary vasospasm. Patient
should also have a workup for GERD as an outpatient.
Rhythm: Hx of paroxsysmal afib, continue anticoagulation and
propafenone. INR 1.4 on discharge, discharged with lovenox
bridge with close follow up with her primary cardiologist.
Hypotension: patient was hypotensive in the setting of nitro
gtt, transiently on a dopamine drip for a SBP in the 40s
although the patient was mentating at the time and there is a
question as to whether the pressure was actually as low as
recorded. Hypotension did not return and the patient was
normotensive with the addition of her home antihypertensive
regimen.
Loss of vision/curtain like loss of vision in R eye on waking
for the past month. temporal arteritis given ESR of 7 and
normal physical exam. Normal carotids on exam, possibly TIA,
the patient should have carotid ultrasounds as an outpatient at
an early date if she has not already had them. She is on
aspirin and anticoagulated.
Medications on Admission:
propafenone 150 mg b.i.d.
aspirin 325 mg
Cozaar 50 mg
Levoxyl 112 mcg daily
Prilosec 20 mg
Zocor 20 mg
metoprolol 50 mg b.i.d.
Coumadin 3 mg daily
Discharge Medications:
1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Propafenone 150 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once
Daily at 16).
9. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous [**Hospital1 **] (2 times a day): Continue taking lovenox
injections until INR is between [**3-14**] on coumadin as directed by
your primary care physician.
[**Name Initial (NameIs) **]:*14 syringes* Refills:*1*
10. Outpatient Lab Work
Please check PT/INR on [**2151-1-29**] at Dr.[**Name (NI) 62094**] Office and
every week thereafter. Please follow up results with him to
decide on coumadin dosing and how long to continue with the
lovenox injections
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Atypical chest pain
Secondary diagnoses:
Paroxysmal atrial fibrillation on coumadin
Hypertension
Hyperlipidemia
History of rheumatic fever
Discharge Condition:
Good, chest pain free, ambulating
Discharge Instructions:
You were admitted for workup of chest pain, lightheadness. You
had a full workup of your heart which was negative for any
problems with your heart as the reason for your symptoms. This
was including a stress test that was negative for any
significant cardiac abnormalities.
While you were here, your coumadin level (INR) was found to be
low. We have started you on a medication, Lovenox, to be
injected twice daily. This should be continued until your INR
becomes therapeutic at a level of [**3-14**]. You should follow up with
your primary care doctor this week for regular checks of your
INR to determine when you can stop this medication. Your first
lab check for this will be in 2 days from discharge on [**2151-1-29**]
where you should get your INR checked before your annual
physical exam with Dr. [**Last Name (STitle) 27542**].
Please take all your medications as prescribed and keep all
follow up appointments. We made no changes to your medications
except the addition of the lovenox injections twice a day until
your INR is within the 2-3 range on your coumadin and Dr.
[**Last Name (STitle) 27542**] gives the okay for you to stop the lovenox
injections.
If you develop chest pain, increased shortness of breath, severe
weakness or any other symptom that concerns you, please call
your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room as soon as
possible.
Followup Instructions:
Please keep the following appointment:
Provider [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 16827**] Date/Time:[**2151-2-15**] 9:40
It is very important that you follow up with your primary care
doctor, Dr. [**Last Name (STitle) 27542**], this week to check your coumadin level
(INR). Please keep your follow up appointment on [**2151-1-29**] with
Dr. [**Last Name (STitle) 27542**]. At this visit, and weekly afterwards, he will
need to follow up on your INR level to decide how long you
should continue on the lovenox injections.
|
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] |
icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
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9498, 9566
|
5683, 8154
|
340, 359
|
9750, 9786
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4396, 5254
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3717, 4377
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9629, 9729
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277, 302
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5273, 5660
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387, 3017
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3039, 3415
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3431, 3540
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,543
| 170,214
|
36253
|
Discharge summary
|
report
|
Admission Date: [**2199-3-31**] Discharge Date: [**2199-4-6**]
Date of Birth: [**2117-2-19**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
trauma s/p fall from [**7-1**] ft.
Major Surgical or Invasive Procedure:
Cephalomedullary fixation with trochanteric fixation nail, 11 mm
x 130 degrees x 400 mm for Right subtrochanteric femur fracture.
History of Present Illness:
Mr [**Known lastname 82190**] is an 81M who was trimming branches on [**2199-3-31**]
while standing on a ladder. He fell [**7-1**] feet and landed on his
right side / back. He immediately felt pain in his lower back.
He fully remembered all events and denied experiencing any loss
of consciousness or head trauma.
Past Medical History:
COPD, CAD, s/p CCY, s/p CABG
Social History:
Pt is a retired engineer who lives independently with his wife.
Family History:
NC
Physical Exam:
VS: Temp 96F, HR 96, BP 124/69, RR 20, POx 92%RA
GEN: pale, NAD
NEURO: GCS 15, no focal deficits, sensation intact in all 4
extremities
HEENT: WNL
CV: WNL
RESP: WNL
ABD: WNL
SPINE: R low back TTP
MSK: 5/5 strength b/l, L ankle edema
Pertinent Results:
[**2199-3-31**] 01:37PM BLOOD WBC-21.9* RBC-3.78* Hgb-12.4* Hct-35.8*
MCV-95 MCH-32.7* MCHC-34.5 RDW-12.4 Plt Ct-90*
[**2199-3-31**] 01:37PM BLOOD Neuts-94.2* Lymphs-2.9* Monos-2.6 Eos-0.2
Baso-0.1
[**2199-4-5**] 02:09AM BLOOD WBC-11.0 RBC-2.92* Hgb-9.2* Hct-27.3*
MCV-94 MCH-31.7 MCHC-33.9 RDW-14.9 Plt Ct-82*
[**2199-3-31**] 01:37PM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1
[**2199-3-31**] 01:37PM BLOOD UreaN-15 Creat-0.7
[**2199-4-5**] 02:09AM BLOOD Glucose-120* UreaN-19 Creat-0.6 Na-139
K-4.1 Cl-110* HCO3-23 AnGap-10
[**2199-3-31**] 01:37PM BLOOD CK(CPK)-559*
[**2199-3-31**] 01:37PM BLOOD cTropnT-<0.01
[**2199-4-1**] 02:22AM BLOOD CK(CPK)-561*
[**2199-4-1**] 02:22AM BLOOD CK-MB-6 cTropnT-<0.01
[**2199-4-5**] 02:09AM BLOOD Calcium-7.9* Phos-2.3* Mg-2.4
[**2199-4-1**] 10:30AM BLOOD Type-ART pO2-109* pCO2-43 pH-7.39
calTCO2-27 Base XS-0
[**2199-3-31**] 02:19PM BLOOD Lactate-3.1*
[**2199-4-2**] 02:23AM BLOOD Lactate-1.5
CT head (OSH): neg
CT c-spine (OSH): neg
CT LE: Extensively comminuted calcaneal fracture with extension
to articular surfaces with talus and cuboid.
CT torso: L3 and L4 communited fractures involving the superior
end plate with a retropulsed ossific fragment from
posterosuperior L3 and moderate central canal stenosis.
Communited minimally displaced right proximal femoral fracture.
R inf renal macrolobulated cyst with peripheral calcified mural
nodularity.
Brief Hospital Course:
Mr [**Known lastname 82190**] was transfered from [**Hospital3 **] Hospital with the above
mentioned complaint. He was admitted to the TSICU for close
monitoring and in preparation for surgery.
On [**4-1**] he went to the OR with orthopedic surgery and tolerated
the procedure well. He was kept in the ICU postoperatively
where he was persistently tachycardic. This was controlled with
an increased dose of lopressor. A TLSO brace was ordered from
NEOPS for stabilization of his lumbar spine fracture.
On [**4-2**] he was transfused in total 3U PRBCs for a 4pt HCT drop
and his HCTs were followed. He began to take some nutrition by
mouth. Pain was controlled with IV dilaudid. He began to be
intermittently disoriented and delirious. There were no focal
neuro deficits.
On [**4-3**] he received his TLSO brace and began to work with PT.
He was seen by Geriatrics for his delirium and in addition they
mentioned the benefit of beginning Fosamax therapy for
osteoporosis.
On [**4-5**] he was transfered to the floor where he continued to be
intermittently disoriented and did in fact have some visual
hallucinations which were noted by Geriatrics. He had a number
of small bowel movements.
On [**4-6**] he is being discharged to rehab with a TLSO brace and on
lovenox 30mg SC bid for prophylaxis. He is instructed to
follow-up with Neurosurgery, Orthopedic Surgery and with his
PCP.
Medications on Admission:
ASA, Combivent, Albuterol, Simvastatin 40', omeprazole 20',
metoprolol 25mg [**Hospital1 **]
Discharge Medications:
1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Nebulizer Inhalation Q6H (every 6
hours) as needed for SOB, wheeze, cough.
2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Nebulizer
Inhalation Q6H (every 6 hours) as needed for SOB, wheeze, cough.
3. Haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for agitation.
4. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours): Please continue until your
follow up with Dr. [**Last Name (STitle) 1005**], who will evaluate the need for
continuing the medication.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
9. Oxycodone 5 mg/5 mL Solution Sig: 2.5 mg PO Q4H (every 4
hours) as needed for pain.
10. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily).
12. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-23**]
Puffs Inhalation Q6H (every 6 hours).
14. Mom[**Name (NI) 6474**] 110 mcg (30 doses) Aerosol Powdr Breath Activated
Sig: One (1) puff Inhalation 1 puff [**Hospital1 **] ().
15. Niacin 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
17. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]
Discharge Diagnosis:
Primary Diagnosis: s/p fall from ladder [**7-1**] feet.
Injuries:
-L3-L4 comminuted compression fx, with retropulsion into spinal
canal
-R comminuted min. displaced proximal femur fx.
-L calcaneal fx.
Secondary Diagnoses: COPD, CAD, HLD, intermittent delirium
primarily nocturnal
Discharge Condition:
Stable
Tolerating regular diet with intermittent difficulty swallowing
when disoriented at night
Voiding appropriately
Discharge Instructions:
You must wear your TLSO brace at ALL times while out of bed. If
you are unable to lie flat in bed, or are too agitated to be out
of your brace safely in bed then you must keep it on at all
times until your follow up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Followup Instructions:
Please call ([**Telephone/Fax (1) 88**] to make an appointment with Dr. [**First Name (STitle) **]
from Neurosurgery in [**3-27**] weeks for follow up regarding your
spine fracture and for evaluation of continuing need for the
TLSO brace.
.
Please call ([**Telephone/Fax (1) 5238**] to make a follow up appointment in 2
weeks with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1005**] from Orthopedic Surgery.
.
Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks to discuss your
injuries and hospitalization and to review your medication list
Completed by:[**2199-4-6**]
|
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
[
[
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] |
5978, 6090
|
2658, 4056
|
348, 480
|
6414, 6535
|
1244, 2635
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|
972, 976
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508, 823
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845, 875
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891, 956
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,000
| 111,892
|
37280
|
Discharge summary
|
report
|
Admission Date: [**2127-5-12**] Discharge Date: [**2127-6-5**]
Date of Birth: [**2041-2-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Aspirin / Gantrisin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2127-5-13**] elective intubation
[**2127-5-13**] Pericardiocentesis with placement of drain
[**2127-5-22**] Cardiac arrest, Intubated, Central line placement,
bronchoscopy
[**2127-5-23**] Transesophageal echocardiogram
History of Present Illness:
86M s/p AVR, CABG [**2127-4-23**] with Dr. [**Last Name (STitle) **]. Post-op course was
relatively uncomplicated. He did revert to AFib and coumadin
was
resumed. He was started on Kefzol for a small amount of sternal
drainage, which resolved. Beta blockade was held due to 2nd
degree AV block. He was discharged to rehab on POD 5. He left
on IV diuresis via his PICC. He developed a pneumonia last week
and has been treated with antibioitcs and a steroid taper.
Additionally, he has received multiple blood transfusions for
anemia. Reportedly, diuresis was discontinued at rehab on [**5-9**].
The patient was seen at this cardiologist office today and was
noted to be significantly SOB and appeared fluid overloaded. He
was sent directly to the ER for evaluation and admission. He
remained hemydynamically stable. Stat bedside echo showed
moderate effusion. Creat elevated at 1.5. CXR clear. He was
admitted to the CVICU for monitoring. Stat TTE was obatined
which
showed large pericardial effusion with RV collapse, no pulses
paradoxes. Interventional cardiology was consulted and the
decesion was to hold off on doing percutaneous drainge of
effusion until AM. INR 2.0 coumadin held and FFP and vitamin K.
Past Medical History:
Aortic stenosis s/p AVR
Coronary artery disease s/p CABG
Chronic obstructive pulmonary disease
Peripheral vascular disease.
Status post abdominal aortic aneurysm repair (endovascular
repair in [**2120**] at [**Hospital1 2025**]).
Hypertension.
Dyslipidemia
Paroxysmal atrial fibrillation
Probable ischemic cardiomyopathy with chronic systolic heart
failure with left ventricular ejection fraction of 30%.
Gout.
Mild obesity.
First and second degree Wenckebach.
Nephrolithiasis.
Vitiligo
Tuberculosis (45 years ago treated with INH).
Status post ventral hernia repair.
Status post right inguinal hernia repair x2.
Status post left wrist ganglion removal.
Left antecubital nerve repair, right heel spur.
Social History:
non-smoker, 2-3oz wine per day, married, 3 daughters
Family History:
father MI age 52, brother MI age 58
Physical Exam:
On Admission:
Pulse:70 Resp: 36 O2 sat: 100 on 3L
B/P Right:130/60
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: limitied ROM
Chest: Lungs clear bilaterally diminished in the bases
Heart: RRR [x]
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds[x]
Extremities: cool mottled
Varicosities: None [x]
Neuro: Grossly intact [x] weak with upper ext tremors
Pulses:
Femoral Right: +1 Left:+1
DP Right: dopp Left:dopp
PT [**Name (NI) 167**]: dopp Left:dopp
Radial Right: +1 Left:Trace
Carotid Bruit Right: None Left:None
Pertinent Results:
[**2127-6-5**] 01:05AM BLOOD WBC-8.0 RBC-2.69* Hgb-8.1* Hct-25.3*
MCV-94 MCH-30.1 MCHC-32.0 RDW-18.1* Plt Ct-163
[**2127-5-12**] 11:05AM BLOOD WBC-12.0*# RBC-3.17* Hgb-9.3* Hct-29.6*
MCV-94 MCH-29.4 MCHC-31.4 RDW-17.2* Plt Ct-199#
[**2127-6-5**] 01:05AM BLOOD PT-18.0* PTT-34.6 INR(PT)-1.7*
[**2127-5-12**] 11:05AM BLOOD PT-21.2* PTT-31.1 INR(PT)-2.0*
[**2127-6-5**] 01:05AM BLOOD Glucose-106* UreaN-119* Creat-1.8*
Na-147* K-5.3* Cl-115* HCO3-23 AnGap-14
[**2127-5-12**] 11:05AM BLOOD Glucose-129* UreaN-69* Creat-1.5* Na-126*
K-4.2 Cl-86* HCO3-28 AnGap-16
[**2127-6-4**] 03:34AM BLOOD ALT-25 AST-53* LD(LDH)-270* AlkPhos-96
Amylase-56 TotBili-0.4
[**2127-5-12**] 08:00PM BLOOD ALT-26 AST-34 LD(LDH)-410* AlkPhos-94
TotBili-0.6
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], I [**Hospital1 18**] [**Numeric Identifier 83902**]TTE (Complete) Done
[**2127-5-23**] at 2:55:49 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 18**] - Department of Cardiac S
[**Last Name (NamePattern1) 439**], 2A
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2041-2-6**]
Age (years): 86 M Hgt (in): 70
BP (mm Hg): 121/59 Wgt (lb): 180
HR (bpm): 83 BSA (m2): 2.00 m2
Indication: Evaluate ejection fraction and Pericardial effusion.
ICD-9 Codes: 785.0, 423.9, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2127-5-23**] at 14:55 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) **]
Doppler: Limited Doppler and color Doppler Test Location: West
Echo Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2012W000-0:00 Machine: E9-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm
Right Atrium - Four Chamber Length: *6.4 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 0.9 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 50% to 60% >= 55%
Left Ventricle - Stroke Volume: 69 ml/beat
Left Ventricle - Cardiac Output: 5.74 L/min
Left Ventricle - Cardiac Index: 2.87 >= 2.0 L/min/M2
Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *31 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Aortic Valve - LVOT pk vel: 1.70 m/sec
Aortic Valve - LVOT VTI: 22
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Pressure Half Time: 411 ms
Mitral Valve - E Wave: 0.8 m/sec
TR Gradient (+ RA = PASP): *30 to 36 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2127-5-15**].
LEFT ATRIUM: Elongated LA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Suboptimal technical quality, a focal LV wall motion abnormality
cannot be fully excluded. Overall normal LVEF (>55%).
Trabeculated LV apex. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Dilated RV cavity. RV function depressed.
Abnormal septal motion/position.
AORTIC VALVE: Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. No MS. Mild (1+) MR.
PERICARDIUM: Very small pericardial effusion. Effusion echo
dense, c/w blood, inflammation or other cellular elements. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Conclusions
The left atrium is elongated. The right atrium is moderately
dilated. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded (basal to mid infero-lateral hypokinesis is suggested
on some images.). Overall left ventricular systolic function is
preserved (LVEF>50%). There is no ventricular septal defect. The
right ventricular cavity is dilated with depressed free wall
contractility. There is abnormal septal motion/position. Mild
(1+) aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Mild (1+) mitral regurgitation is seen. There
is a very small pericardial effusion. The effusion is echo
dense, consistent with blood, inflammation or other cellular
elements. There are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of [**2127-5-15**],
the pericardial effusion appears smaller. RV systolic function
cannot be compared due to poor RV visualization on prior. LVEF
is probably similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2127-5-23**] 15:39
?????? [**2117**] CareGroup IS. All rights reserved.
[**Known lastname **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Medical Record Number 83903**] M 86 [**2041-2-6**]
Neurophysiology Report EEG Study Date of [**2127-6-2**]
OBJECT: NO IMPROVEMENT IN MENTAL STATUS POST-CARDIAC ARREST.
ASSESS
FOR EPILEPTIC ACTIVITY.
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
FINDINGS:
ABNORMALITY #1: Frequent generalized bifrontally dominant
broad-based
sharp discharges.
ABNORMALITY #2: The background was diffusely slow and
discontinuous
with admixed theta and delta activity reaching maximal for 5-5.5
Hz with
no anterior-posterior gradient.
BACKGROUND: The same as Abnormalities #2 and #1.
HYPERVENTILATION: Is not performed as the patient is intubated.
INTERMITTENT PHOTIC STIMULATION: Is not performed due to
portable
equipment.
SLEEP: No normal sleep morphologies are present.
CARDIAC MONITOR: A single EKG channel shows a generally regular
rhythm
with an average rate of 78 bpm.
IMPRESSION: This is an abnormal awake and sleep EEG because of
frequent generalized bifrontally dominant epileptic discharges
indicative of areas of cortical irritability with potential
epileptogenicity. In addition, background activity is diffusely
slow
and discontinuous suggestive of severe diffuse cerebral
dysfunction in
this case most likely related to hypoxic brain injury. Other
potential
causes include medication effect or toxic or metabolic
disturbances. No
electrographic seizures are present.
INTERPRETED BY: [**Last Name (LF) 96**],[**First Name3 (LF) 125**] H.
([**Numeric Identifier 83904**])
[**Known lastname **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Medical Record Number 83903**] M 86 [**2041-2-6**]
Radiology Report MR HEAD W/O CONTRAST Study Date of [**2127-5-25**]
10:16 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2127-5-25**] 10:16 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 83905**]
Reason: eval for embolic event/ ischemic regions
[**Hospital 93**] MEDICAL CONDITION:
86 year old man unresponsive after code x 72 hours
REASON FOR THIS EXAMINATION:
eval for embolic event/ ischemic regions
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Addendum
Degenerative changes are noted at C4/5 level.
DR. [**First Name (STitle) 10627**] PERI
Approved: MON [**2127-5-26**] 12:05 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2127-5-25**] 10:16 PM
MR HEAD W/O CONTRAST Clip # [**Clip Number (Radiology) 83905**]
Reason: eval for embolic event/ ischemic regions
[**Hospital 93**] MEDICAL CONDITION:
86 year old man unresponsive after code x 72 hours
REASON FOR THIS EXAMINATION:
eval for embolic event/ ischemic regions
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Final Report
INDICATION: Unresponsive, aftercode x 72 hours; to evaluate for
embolic
event/ischemic regions, 72 hours.
COMPARISON: None.
TECHNIQUE: MR of the head without contrast.
FINDINGS:
There is no obvious focus of slow diffusion to suggest an acute
infarct.
Evaluation for subacute infarcts can be limited on the DWI
sequence given the
long interval.
There are extensive periventricular and subcortical FLAIR
hyperintense foci,
some of which are discrete and others are confluent in the
frontal and the
parietal lobes on both sides. There is moderate dilation of the
lateral and
the third ventricles including the temporal horns on both sides.
The
bifrontal diameter of the lateral ventricles at the level of
foramen of [**Last Name (un) 2044**]
measures 39.4 mm. The right temporal [**Doctor Last Name 534**] is larger than the
left. A few
small scattered foci of negative susceptibility in the brain
parenchyma
scattered in the cerebral hemispheres and a few faint foci in
the right
cerebellar hemisphere.
The major intracranial arterial flow voids are noted. The right
vertebral
artery is dominant. The left vertebral artery is markedly
diminutive in size.
There is increased signal intensity in the mastoid air cells on
both sides
from fluid and mucosal thickening. Slightly increased signal
intensity in the
right transverse sinus, may relate to slow flow. There is
diffuse increased
signal intensity in the paranasal sinuses and the ethmoid and
the maxillary
sinuses, right more than left and the sphenoid sinus along with
fluid in the
nasal cavity and nasopharynx related to intubation.
IMPRESSION:
1. No large area of obvious acute infarct. Evaluation for
subacute infarcts
can be limited on the present study.
2. FLAIR hyperintense areas in the cerebral white matter,
non-specific in
appearnace and a few scattered T2 susceptibility foci related to
microhemorrhages as described above.
3. Diffuse paranasal sinus disease with fluid in the
nasopharynx; fluid and
mucosal thickening diffusely in the mastoid air cells.
4. Moderate dilation of the lateral and the third ventricles as
described
above-? related to parenchymal volume loss with or without a
component of
communicating hydrocephalus such as NPH. Correlate clinically.
DR. [**First Name (STitle) 10627**] PERI
Approved: MON [**2127-5-26**] 12:03 PM
Imaging Lab
There is no report history available for viewing.
[**Known lastname **],[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Medical Record Number 83903**] M 86 [**2041-2-6**]
Radiology Report CT CHEST W/O CONTRAST Study Date of [**2127-5-20**]
8:40 AM
[**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2127-5-20**] 8:40 AM
CT CHEST W/O CONTRAST Clip # [**Clip Number (Radiology) 83906**]
Reason: assess for dehisence of sternum
[**Hospital 93**] MEDICAL CONDITION:
86 year old man s/p AVR CABG [**4-23**]- now w/unstable sternum
REASON FOR THIS EXAMINATION:
assess for dehisence of sternum
CONTRAINDICATIONS FOR IV CONTRAST:
None.
Wet Read: SJBj TUE [**2127-5-20**] 11:27 AM
There is dehisence of the superior and inferior ends of the
sternum. A 3.8 x
3.5cm dense collection at the sterno manubrial junction has
characteristics of
hematoma. The superior manubrial fragments are seperated by 7mm.
The upper
most 2 sternal wires do not encircle the right sternal fragment.
There is
14mm of dehiscence of the inferior left sternum lateral to the
sternotomy with
a non-hemorrhagic collection between the seperated fragments.
Moderate
pericardial effusion with layering density suggestive of
hematoma. Moderate
right and small left pleural effusions. Mild pulmonary edema.
Wet Read Audit # 1
Final Report
INDICATION: 86-year-old man with post AVR and CABG on [**4-23**]
with unstable
sternum.
COMPARISON: Chest radiographs [**4-28**] and [**2127-5-18**].
TECHNIQUE: MDCT data were acquired through the chest without
intravenous
contrast. Data were reconstructed using soft tissue and lung
kernels. Images
were displayed in multiple planes.
FINDINGS: The initial CT tomogram confirms abnormal alignment
of median
sternotomy wires as identified on prior radiographs. There is a
3.5 x 3.9 cm
dense fluid collection at the sternoclavicular articulation
(2.9, 400B:36).
Two surgical clips are seen adjacent to this area (2.7). The
two halves of
the manubrium are seperated by 7mm. The most superior two
sternal wires wind
around only the left sternal half (2:14). The third and fourth
sternal wires
surround both fragments of the sternum, which are in appropriate
relationship.
Although the fifth sternal wire appears to deviate towards the
left, this wire
appears to properly fixate both halves of the sternum. The most
inferior
three sternal wires are shifted to the right. There is
approximately 2.7 cm
of separation between the sternum and the left inferior costal
cartiladge
(2:38). Fluid with simple attenuation fills this space.
The thyroid has normal attenuation. No mediastinal, hilar or
axillary
adenopathy is present. There is a moderate pericardial
effusion. Dense
material layers in the pericardial effusion likely representing
blood products
(2:46). Severe three-vessel coronary artery atherosclerosis is
identified.
The aorta and aortic valve prosthesis is in expected position.
A left pleural
effusion is moderate and right pleural effusion is small.
Basilar dependent
atelectasis is present. Lung volumes are low and severe
respiratory motion
hampers their assessment. Pulmonary edema is mild. No focal
consolidation is
identified.
This exam is not tailored to evaluate subdiaphragmatic
structures. No right
adrenal nodule is identified.
BONE WINDOWS: Compression deformities of T7 and T11 are noted.
There is no
lytic or sclerotic lesion concerning for malignancy.
A left-sided SVC line terminates in the upper SVC. An enteric
catheter
extends into the stomach.
IMPRESSION:
1. Manubrial and inferior left sternal dehisence
2. 3.8 x 3.5cm sterno manubrial hematoma.
3. 2.7cm left lateral inferior sternal non-hemorrhagic fluid
collection
4. Moderate pericardial effusion with layering density
suggestive of
hematoma.
5. Moderate right and small left pleural effusions.
6. Mild pulmonary edema.
Discussed with [**First Name8 (NamePattern2) **] [**Doctor Last Name **] via phone at [**Pager number **].
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
Approved: TUE [**2127-5-20**] 7:36 PM
Imaging Lab
There is no report history available for viewing.
Brief Hospital Course:
Mr [**Known lastname 83900**] was transferred from cardiologist office to
emergency room for evaluation of dyspnea that was progressively
worsening at rehab that was thought to be related to pneumonia
and COPD exacerbation at rehab. He had echocardiogram that
revealed large pericardial effusion and right ventricular
compression. His creatinine was elevated due to cardiac
compromise with acute kidney injury and elevated troponin due to
demand ischemia from cardiac strain. He was on coumadin and
received fresh frozen plasma and vitamin K for reversal. He was
treated with IV fluids and levophed for hemodynamic management.
He was taken to the cardiac cath lab [**5-13**] and underwent
pericardiocentesis with placement of drain. Of note prior to
procedure he was electively intubated for the procedure in the
intensive care unit. He tolerated the procedure, he was started
on diuretics for diuresis as he was significantly volume
overloaded. On [**5-14**] he was extubated without any complications
and was continued to be diuresed and creatinine continued to
improve. On [**5-15**] he was note for diarrhea and stool was
positive for Clostridium dificile, flagyl was started. He
underwent echocardiogram as the drain had less than 50 ml, and
based on echo finding the drain was removed, the remaining
effusion was thought to be loculated. He was evaluated by
speech and started a modified diet however his oral intake was
not sufficient and dobhoff was placed for additional nutrition
on [**5-16**]. He continued to be diuresed but there was noted to be
paradoxical breathing at times that was thought to be related to
his sternum. He continued to be monitored. On [**5-18**] EP was
consulted due to arrythmia with concern for AV nodal block but
was diagnosed with atypical atrial flutter. On [**5-20**] he
underwent a CT scan due to ongoing paradoxical breathing,
Plastic surgery was consulted in regards to potential sternal
plating or flap coverage due to dehiscence of the sternum.
Additionally due to worsening rashes on skin dermatology was
consulted, the left lower extremity was felt to be
hyperkeratosis and facial rash was vitiligo but felt to be
chronic. He continued with diuresis, pulmonary exercises and
non invasive ventilation at night. On the night of [**5-22**] he had
difficulty breathing while completing respiratory treatment and
then became bradycardic with PEA arrest. ACLS protocol was
initiated see code sheet. He received chest compressions,
defibrillation, medications, and intubation. After he was
resuscitated he underwent bronchoscopy, echocardiogram, and
central line placement. He was noted for significant
secretions, was started on empiric antibiotics and BAL revealed
pseudomonas. He required vasopressors and inotropic support.
Infectious disease was consulted due to resistant pseudomonas
and antibiotics were adjusted per their recommendation. He
continued treatment for pneumonia, clostridium dificile, and
urinary tract infection. He hemodynamically improved post
cardiopulmonary arrest however was not waking up. Neurology was
consulted he underwent MRI that did not reveal any acute
findings and EEG that showed significant slowing which neurology
felt he was unlikely to have a meaningful recovery. There was
a family meeting on [**5-28**] and the family wanted to continue
treatment with plan for repeat EEG in 1 week. Mr.[**Known lastname 83900**]
remained unresponsive and without improvement. The EEG was
repeated and showed slowing, likely from anoxic brain injury.
The family discussed with Dr.[**Last Name (STitle) **] and the cardiac surgery team
making Mr.[**Known lastname 83900**] [**Last Name (Titles) **] care measures only. On [**2127-6-5**] under
the critical care guidelines, [**Date Range **] measures were instituted.
reporting protocol was followed. Medical Examiner denied case
and the family denied autopsy. Please refer to death report for
further information.
......stop [**5-29**]
Medications on Admission:
medications at rehab
aspirin 81 mg daily
tamsulosin 0.4 mg at bedtime
finasteride 5 mg Daily
probenecid 500 mg Daily
atorvastatin 80 mg Daily
allopurinol 300 mg daily
prednisone 5 mg QAM
prednisone 2.5 mg QPM
ranitidine HCl 150 mg [**Hospital1 **]
albuterol sulfate 2.5 mg /3 mL Neb Q6H as needed for dyspnea.
ipratropium bromide 0.02 % [**Male First Name (un) **] Inhalation Q6H as needed for
dyspnea.
warfarin 1 mg daily
Vancomycin
Cefapime
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory arrest leading to cardiac arrest
Acute on chronic systolic heart failure
Healthcare acquired pneumonia
Clostridium dificile
Anemia
Pericardial effusion with tamponade
Cardiogenic shock due to tamponade
Demand ischemia due to tamponade
Acute kidney injury
Atypical atrial flutter
Retention hyperkeratosis
Sternal dehiscence
Urinary tract infection
Secondary:
Aortic stenosis s/p AVR
Coronary artery disease s/p CABG
Chronic obstructive pulmonary disease
Peripheral vascular disease.
Status post abdominal aortic aneurysm repair (endovascular
repair in [**2120**] at [**Hospital1 2025**]).
Hypertension.
Dyslipidemia
Paroxysmal atrial fibrillation
Probable ischemic cardiomyopathy with chronic systolic heart
failure with left ventricular ejection fraction of 30%.
Gout.
Mild obesity.
First and second degree Wenckebach.
Nephrolithiasis.
Vitiligo
Tuberculosis (45 years ago treated with INH).
Status post ventral hernia repair.
Status post right inguinal hernia repair x2.
Status post left wrist ganglion removal.
Left antecubital nerve repair, right heel spur.
Discharge Condition:
expired
Completed by:[**2127-6-5**]
|
[
"427.1",
"414.00",
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"701.1",
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"997.31",
"599.0",
"707.03",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"38.91",
"37.0",
"37.21",
"33.24",
"96.6",
"96.72",
"96.04",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
22618, 22627
|
18143, 22124
|
326, 550
|
23744, 23782
|
3277, 10532
|
2608, 2645
|
14307, 14371
|
22648, 23723
|
22150, 22595
|
2660, 2660
|
279, 288
|
14403, 18120
|
578, 1796
|
2674, 3258
|
1818, 2521
|
2537, 2592
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,567
| 182,790
|
44714
|
Discharge summary
|
report
|
Admission Date: [**2124-7-25**] Discharge Date: [**2124-8-1**]
Date of Birth: [**2057-2-14**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Codeine / milk / chocolate
Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
bilateral buttock and posterior thigh pain
Major Surgical or Invasive Procedure:
[**7-25**]: L3-4,[**2-24**] DLIF
[**7-26**]: L3-5 fusion
(see op note for further details)
History of Present Illness:
67F with hx of bilateral buttock and posterior thigh pain
preventing her from walking upright. She had L4-S1 fusion [**2118**]
but some time after that she fell and the fusion screws were
removed (also sustained femur fx during this fall s/p rod
placement). Recent CT scan shows nonunion at L4-L5 with a new
spondylolisthesis. She has the severe stenosis at L3-L4 with
evidence of motion at that level.
Past Medical History:
PMH:
Spinal Stenosis
GERD
Osteoporosis
Migraine headaches
h/o heart murmur
Depression
Anxiety
PSH
L3-4,L4-5 lateral fusion ([**7-25**])
L3-S1 posterior fusion ([**7-26**])
ORIF of her femur.
Hysterectomy
Right carpal tunnel repair
Social History:
lives with family at home
Family History:
n/c
Physical Exam:
AVSS, Well appearing, NAD, comfortable
Abd: nontender, nondistended, soft
Cardio: rrr
Pulm: nonlabored breathing
Ext: BUE- SILT C5-T1, [**3-25**] [**Doctor First Name **]/Tri/Bic/WE/WF/FF/IO
BLE- SILT L1-S1 dermatomal distributions; RLE- 4/5 strength
Qu/GS otherwise [**3-25**]; LLE- [**3-25**] strength
Pertinent Results:
[**2124-7-31**] 10:15AM BLOOD Hct-29.1*#
[**2124-7-30**] 07:00AM BLOOD WBC-6.0 RBC-2.35* Hgb-7.3* Hct-21.5*
MCV-91 MCH-31.0 MCHC-33.9 RDW-12.1 Plt Ct-252
[**2124-7-25**] 04:52PM BLOOD WBC-9.2 RBC-3.40* Hgb-10.9* Hct-31.4*
MCV-92 MCH-32.0 MCHC-34.7 RDW-12.9 Plt Ct-271
Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedures. Refer to
the dictated operative note for further details.
The surgeries themselves were without complication except for a
dural leak, which was repaired, and postoperative
tongue/lip/facial edema from prone positioning and high volume
fluid infusion during second surgery. Pt stayed in SICU for 2
days intubated, sedated because of tongue/facial edema and pt
was unable to lay flat 48 hrs ([**12-23**] pain/agitation) as per
protocol for dural leak/repair.
Pt was extubated and transferred to the floor in stable
condition but had a drop in HCT; CT was negative for active
bleeding; transfused 2 units and improved symptomatically.
Pt became hypertensive to the 190's while on the floor; Medicine
was consulted and found no evidence of end organ hypertensive
damage. They recommended treating her hypertension as an
outpatient.
Physical therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.
The patient was eventually transitioned to PO pain medication
and was able to eat, drink, and void appropriately at discharge.
Medications on Admission:
forteo, lexapro, relafen, os-[**Last Name (LF) **], [**First Name3 (LF) **]-c, D3, skelaxin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN headache
2. Bisacodyl 10 mg PO/PR DAILY
3. Cyclobenzaprine 5 mg PO TID:PRN back spasm
hold for altered mental status
4. Docusate Sodium 100 mg PO BID
5. Escitalopram Oxalate 10 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. Senna 1 TAB PO QHS
9. Zolpidem Tartrate 5 mg PO HS
10. Omeprazole 20 mg PO DAILY
11. Amitriptyline 50 mg PO HS
12. Forteo *NF* (teriparatide) unknown Subcutaneous qdaily
pt has own supply
13. Maxalt *NF* (rizatriptan) 10 mg Oral q2hrs migraine
Duration: 3 Doses
10mg at symptom onset
may repeat after 2 hrs prn
do not exceed 30mg/24hrs
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Pseudoarthrosis, L4-5.
2. Lumbar stenosis.
3. Lumbar radiculopathy.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You have undergone the following operation: Lumbar Decompression
With Fusion
Immediately after the operation:
?????? Activity: You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit or
stand more than ~45 minutes without getting up and walking
around.
?????? Rehabilitation/ Physical Therapy:
◦ 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.
◦ Limit any kind of lifting.
?????? Diet: Eat a normal healthy diet. You may have some
constipation after surgery. You have been given medication to
help with this issue.
?????? Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
?????? You should resume taking your normal home medications.
?????? 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.
?????? Follow up:
◦ Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
◦ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
◦ We will then see you at 6 weeks from the day
of the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Activity as tolerated w/ assist if needed
Treatments Frequency:
Wound care:
Site: lumbar
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
Comment: nursing please change dressing daily. thank you
Wound care:
Site: left flank
Type: Surgical
Cleansing [**Doctor Last Name 360**]: Saline
Dressing: Gauze - dry
Change dressing: qd
Comment: nursing please change dressing once daily. thank you
Followup Instructions:
You will need to follow up with Dr. [**Last Name (STitle) 1352**] in clinic and have
xrays on that day prior to the appointment. The dates and times
for these appointments are below:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2124-8-11**] 10:20
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 8603**]
Date/Time:[**2124-8-11**] 10:40
Completed by:[**2124-8-1**]
|
[
"311",
"349.31",
"756.12",
"285.1",
"V45.4",
"733.00",
"724.4",
"530.81",
"564.00",
"E870.0",
"784.2",
"281.0",
"782.3",
"300.00",
"401.9",
"V15.51",
"338.18"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.06",
"03.59",
"84.52",
"80.51",
"81.62",
"96.6",
"96.71",
"84.51",
"77.79",
"00.94",
"81.37"
] |
icd9pcs
|
[
[
[]
]
] |
3976, 4046
|
1816, 3156
|
333, 426
|
4161, 4161
|
1524, 1793
|
7139, 7674
|
1176, 1181
|
3299, 3953
|
4067, 4140
|
3183, 3276
|
4312, 4392
|
1196, 1505
|
6636, 6690
|
6714, 6714
|
6080, 6618
|
4426, 4656
|
251, 295
|
6924, 7116
|
454, 861
|
4176, 4288
|
883, 1117
|
1133, 1160
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,460
| 115,685
|
25237
|
Discharge summary
|
report
|
Unit No: [**Numeric Identifier 63209**]
Admission Date: [**2195-8-13**]
Discharge Date: [**2195-8-16**]
Date of Birth: [**2167-8-4**]
Sex: M
Service: TRA
HISTORY OF PRESENT ILLNESS: A 28-year-old male who sustained
a fall while moving furniture. The patient stated that he was
lifting a mattress when he lost his balance and fell back
onto the cement hitting his head. He denied loss of
consciousness and full recollection of the events leading to
hospitalization. He had pain over the back of his head.
Denied headache and nausea.
PAST MEDICAL HISTORY: Nonsignificant.
ALLERGIES: NKDA.
MEDICATIONS: Nonsignificant.
SOCIAL HISTORY: Denied the use of tobacco. Occasional
alcohol; last drink the evening of admission.
PHYSICAL EXAMINATION: Vitals with a temperature was 98
degrees, heart rate was 100 upon arrival and then 80 later
on, blood pressure was 142/83, respiratory rate was 12, 100%.
He was alert and oriented x 3 in general. Neck with a
cervical collar was in place with no midline tenderness.
Lungs were clear to auscultation bilaterally. Cardiac with
regular rate and rhythm. Abdomen was soft, nontender and
nondistended. Extremities with palpable DP and PT
bilaterally. No gross deformities. Rectal was guaiac negative
with normal tone.
RADIOLOGY: Chest x-ray: Radiographic imaging was negative.
CT of C-spine was negative.
CT of abdomen was negative.
CT of the head showed small bilateral subdural hematomas,
right side greater than left. Both parietal/occipital with no
midline shift or compression of the ventricular system. There
was also bilateral temporal bone fractures.
LABORATORY DATA ON ADMISSION: Hematocrit was 41.8, potassium
was 3.3, INR was 1.2.
SUMMARY OF HOSPITAL COURSE: The patient was admitted to the
intensive care unit for q.1h. neurologic examinations. The
patient was given Dilantin. It was also decided the patient
would receive ceftriaxone and Flagyl for 48 hours due to the
bilateral temporal bone fractures. A repeat head CT was
obtained on [**8-14**] which showed no progression of the
head bleeds. C-collar was cleared clinically as well on
[**8-14**]. In consultation with the neurosurgery service
it was decided to continue Dilantin for 10 days. On [**8-15**], the patient was advanced to a regular diet. Antibiotics
were discontinued. Physical therapy saw the patient and
cleared the patient for discharge home. Another head CT on
[**8-15**] demonstrated a stable subdural hematoma.
CONDITION ON DISCHARGE: On [**8-16**] the patient was
stable for discharge home.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSES: Status post fall with bilateral
subdural hematoma and bilateral temporal bone fracture.
DISCHARGE MEDICATIONS: Valium 100 q.8h. for a total of 10
days.
DISCHARGE FOLLOWUP: The patient will follow up with Dr.
[**Last Name (STitle) **] from the neurosurgery service in 8 weeks with a head
CAT scan.
[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) **]
Dictated By:[**Name8 (MD) 368**]
MEDQUIST36
D: [**2195-9-2**] 15:04:49
T: [**2195-9-2**] 16:16:01
Job#: [**Job Number 63210**]
|
[
"E884.9",
"801.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2586, 2675
|
2699, 2741
|
1727, 2455
|
755, 1629
|
2762, 3172
|
189, 540
|
1644, 1698
|
563, 630
|
647, 732
|
2480, 2564
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,530
| 116,334
|
27396
|
Discharge summary
|
report
|
Admission Date: [**2200-2-4**] Discharge Date: [**2200-2-12**]
Date of Birth: [**2170-12-9**] Sex: M
Service: Surgical
This 59-year-old man with a history of esophagectomy for
esophageal cancer, was brought in for repair of an incisional
hernia.
His past medical history is notable for the above mentioned
esophageal cancer, status post no invasive esophagectomy. He
does have some underlying lung disease, COPD. He was
admitted for routine hernia repair.
HOSPITAL COURSE: Patient was admitted, underwent repair of a
small incisional hernia. During the operation he was
complicated by aspiration and aspiration pneumonitis. The
patient was then admitted to the hospital. At that time he
was intubated and sedated still on the ventilator. Lungs
sounds were coarse, especially at the left base, the abdomen
soft and the wounds were fine. An arterial blood gas has
shown reasonable oxygenation on the ventilator. He had
bilateral patchy infiltrates on chest x-ray, which is
consistent with aspiration pneumonitis. He was admitted to
the Intensive Care Unit where he was continued on the
ventilator with a fever. Antibiotics were not started
initially. He had small improvement in his oxygenation and
clinical status. He was extubated on [**2200-2-6**]. He
remained on fairly high levels of supplemental oxygen in a
face tent. He continued to have fever which was consistent
with a lung injury. Because of findings on his gram stain he
was placed on vancomycin and cefepime for continued fever. A
CT scan of the chest was performed to rule out pulmonary
embolism which was negative. He eventually grew out
Haemophilus influenzae and E. coli from his sputum and
remained on cefepime and the vancomycin was discontinued. He
made a slow but steady recovery from this event, continued
with physical therapy. He was then discharged on [**2200-2-12**].
FINAL DIAGNOSIS:
1. Incisional hernia.
2. Aspiration pneumonitis and pneumonia.
SURGICAL PROCEDURES: Incisional hernia repair with mesh
[**2200-2-4**].
DISCHARGE MEDICATIONS: Omeprazole, ciprofloxacin, home
oxygen.
DISPOSITION: Patient discharged. He will go home with
services and followed as an outpatient.
[**First Name11 (Name Pattern1) 333**] [**Last Name (NamePattern4) 366**], [**MD Number(1) 367**]
Dictated By:[**Last Name (NamePattern4) 24987**]
MEDQUIST36
D: [**2200-12-31**] 12:50:34
T: [**2200-12-31**] 13:17:54
Job#: [**Job Number 67089**]
|
[
"507.0",
"997.3",
"553.21",
"V10.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.61",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
2066, 2479
|
499, 1887
|
1904, 2042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,873
| 169,032
|
8099
|
Discharge summary
|
report
|
Admission Date: [**2161-7-11**] Discharge Date: [**2161-7-16**]
Service: MEDICINE
Allergies:
Aspirin
Attending:[**First Name3 (LF) 4891**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
PICC line placement, and removal
History of Present Illness:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 507**] [**Name12 (NameIs) 508**] [**Telephone/Fax (1) 133**] (APG)
Chief Complaint: SOB
Ms. [**Known lastname **] is an 89F with history of COPD on home O2 2LNC,
pulmonary hypertension, renal insufficiency and carotid
insufficiency who presented with acute onset SOB and was
admitted to the MICU with hypercarbic respiratory distress.
Patient recently admitted for similar symptoms earlier this
month, was discharged from rehab 1 week ago. The patient reports
she was doing well until the day of admission, when she noticed
acute onset SOB at 10:30 pm. Prior to that, she was using her
oxygen continuously, taking her inhalers as scheduled, and
walking around her house/doing daily tasks without any
difficulty breathing. ROS pertinent for a chronic cough without
sputum production. Ne fevers or chills. In the ED, patient's
vital signs were stable, but was noted to be lethargic with poor
air movment on pulmonary exam, both of which improved with
nebulizers, solumedrol, and azithromycin/CFTX. ABG with evidence
of CO2 retention. EKG with LBBB, LVH similar to prior (STE noted
on EKG in ambulance, but not present on arrival to the ED). CXR
with possible RLL infiltrate.
During the patient's ICU course, she was noted to be SOB with
limited air movement. She was started on continuous albuterol
inhalers and intermittent BiPAP. She was started on Levo/Flagyl
for presumed aspiration PNA vs CAP and had a PICC line placed.
She was also started on steroids (prednisone 60 mg PO daily) for
presumed COPD exacerbation. This morning she had an episode of L
sided SSC 'pain' that radiated to her right arm associated with
some diaphoresis but no LOC, nausea, or vomiting. Has not
experienced this pain before. EKG with reportedly no changes.
Her CP resolved completely with 0.3 mg SL nitroglycerin and did
not return during the remainder of the admission. Noted to be
having improved air movement during ICU stay, and was weaned
from continuous to q3H ipratroprium and q6H albuterol nebs, and
transitioned to oral prednisone prior to being called out to the
floor.
On the floor, patient states that her SOB is greatly improved
and denies any further episodes of chest pain.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denied palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Pt admits to some difficulty
swallowing and sometimes is concerned that food goes down her
windpipe, and states she needs new dentures b/c her current ones
are ill-fitting.
Past Medical History:
Hypertension
Moderate/Severe Pulmonary hypertension (PA pressures 66 + RA
last echo)
COPD (on home oxygen therapy)
Carotid stenosis
Chronic renal insufficiency (baseline 1.1-1.6)
Social History:
Social History:
Lives with granddaughter and family; has VNA at home.
Employment: Previously housekeeper in hotels eg [**Last Name (un) 28893**].
Tobacco: 15-60yo 1 ppd, 45 pack years. quit 40 years ago
Alcohol: None recently (years).
Family History:
Mother had smoking-associated lung disease. Son died of liver
cancer. Daughter died of domestic homicide.
Physical Exam:
On transfer from the ICU to the medicine floor:
VS: 98.0 118/60 102 20 92% on 2 L NC
Gen: elderly AA F AOx3, NAD
HEENT: PERRLA. MMM. + 15 cm JVD sitting at 90'. neck supple.
CV: PMI palpable at 5/6th IC space. RRR S1/S2 heard. +[**1-17**] SM at
LLSB.
Pulm: +inspiratory and expiratory wheezes. slightly decreased
air movement in all lung fields.
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: mild pitting edema. DPs, PTs 2+.
Neuro/Psych: CNs II-XII intact. interacting appropriately and
moving all extremities.
On discharge:
afebrile SBP 120s-140s HR 70s
Gen: patient breathing comfortably in no distress
CV: regular, S1S2.
Pulm: no rales, no wheezes, no rhonchi (resolved during the
admission)
Extremities: no pitting edema bilaterally
Pertinent Results:
Significant for WBC of 17.3, Hct of 32.0, Cre of 1.3, CK Trop-T
of 0.01, 0.02 ABG 7.4/40/76*/26 Lactate 4.0->3.3
Microbiology:
Urine Legionella Antigen - negative.
MRSA Screen - negative.
Imaging:
EKG - [**7-11**] - sinus tachycardia, + LVH, +LBBB, no new ischemic
changes compared to previous.
CXR - [**7-11**] -
Cardiac silhouette is normal in size. Mediastinal contours are
notable for a tortuous aorta as well as aortic calcification.
There is no pneumothorax. Left pleural effusion and atelectasis
are resolved. There is a new small right pleural effusion with
overlying atelectasis.
CXR - [**7-12**] - Cardiomediastinal contours are unchanged from [**7-11**], [**2160**]. Cardiac size is normal. The aorta is tortuous. Right
PICC tip remains in the right subclavian vein. Bibasilar
opacities, left greater than right, are stable due to a
combination of pleural effusion and atelectasis. There are no
new lung abnormalities.
TTE: [**2161-6-17**] -
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thicknesses
and cavity size are normal. Due to suboptimal technical quality,
a focal wall motion abnormality cannot be fully excluded. Left
ventricular systolic function is hyperdynamic (EF>75%). There is
no ventricular septal defect. The right ventricular cavity is
mildly dilated with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve is not well seen. There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. 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 severe pulmonary artery systolic hypertension. There is
no pericardial effusion.
Compared with the prior study (images reviewed) of [**2158-3-8**], no
major change. Pulmonary hypertension without clear cor pulmonale
or intracardiac shunt.
Brief Hospital Course:
A/P: 89 yo F with COPD on 2 L home O2, pulmonary hypertension,
CKD who presents with acute onset dyspnea likely c/w HCAP
requiring ICU admission with continuous nebs and NIPPV,
subsequently transferred to the medicine flow.
#. Shortness of Breath: Patient initially admitted to the MICU
with hypercarbic respiratory distress requiring continuous
inhalers, NIPPV (BiPAP) and IV steroids. Likely had a COPD
exacerbation, triggered by a PNA (initially ?aspiration vs HCAP,
but ultimately most likely HCAP given recent hospitalization and
rehab stay). Initially treated with Vanc/Cefepime/Cipro for
HCAP, briefly switched to Levofloxacin and Flagyl for aspiration
PNA in the MICU, subsequently switched to Vanc/Cipro for HCAP
once on the general floor. She completed a 7D course of vanc and
had 1 add'l day of cipro on discharge. Urine legionella antigen
negative. Patient low probability for PE per Well's criteria. Pt
without evidence of ACS on EKG and with several sets of negative
cardiac enzymes. Nebs were weaned on the floor to albuterol q4H
prn and ipratroprium q3H standing, which she tolerated well. By
[**7-14**], she was back to her baseline oxygen requirement of 2L NC
with minimal shortness of breath. Her home inhalers, spiriva and
advair, were held during this admission. We began a long
prednisone taper starting on [**7-15**] (40mg x 3 days) and will
continue with 20 mg qd x 3 days starting [**7-18**], then 10mg x 3 days
starting [**7-21**]. We asked for palliative care's recommendations
regarding symptom management and assistance with preventing
re-hospitalization. They recommended trying a small dose of
liquid morphine 30 mins before activity to see if this might
decrease shortness of breath (as trial for home). We encouraged
ambulation with walker and assistance, which she was eager to
do.
# Chest Pain: Pt with episode of CP on morning of [**7-12**], resolved
with SL nitro. Pt with multiple risk factors including HTN, CKD,
and previous smoking history. No known history of diabetes with
normal HgA1c in [**2158**]. Enzymes were cycled, troponin of 0.05 was
felt to be [**1-13**] demand ischemia in the setting of increased work
of breathing, no concerning changes on EKG. HbA1c of 6.4%. Lipid
panel: HDL of 67, LDL 83, TG 104. A distinct episode epigastric
pain on the morning of [**7-15**] was [**1-13**] gas/constipation and was
relieved with Milk of Magnesia, Tums, and a BM. EKG during this
episode revealed no changes.
# Tachycardia: Pt with HR to 102 on the floor, was 90s-100s in
the MICU. (Pulse is usually 70s-80s as an outpatient). Likely in
the setting of pt's respiratory distress, standing albuterol
nebs and holding patient's beta-blocker. Heart rate was
ultimately in the 70-80s by discharge on home meds.
#. Acute on Chronic Renal Failure: Patient initially with acute
on chronic renal failure on admission (Cre 1.5, baseline 1.2).
With known stage III CKD. Improved with IVFs in the MICU, Cre
back to baseline 1.3 on the floor throughout the rest of her
admission.
# Anemia: Pt with 8 pt Hct drop in the ICU (baseline 40, down to
33), stable on repeat check; likely dilutional due to IVFs and
in the setting of phlebotomy. Stable around 36-37 throughout the
rest of her stay with one drop from 41.5 to 36.8, though the
single 41.5 value was felt to be due to volume contraction.
Stool guaiac x1 was negative. No other concerns for bleeding.
#. HTN: Pt hypertensive in the ICU, normotensive on the floor.
The patient was restarted on her home medications, and had only
mild elevated BPs in the setting of the prednisone taper
(120s-140s today).
# Leukocytosis: Likely in the setting of steroids. WBC starting
to trend down by the time of discharge.
#. Pulmonary HTN: Continuous O2 supplementation via NC. To
follow-up with her outpt pulmonologist, Dr. [**Last Name (STitle) 18309**], on [**8-5**] to
discuss starting cilastazol. The team emailed with Dr [**Last Name (STitle) 18309**]
during the admission.
Medications on Admission:
Home Medications:
Atenolol 50 mg [**Hospital1 **]
Cilostazol 100 mg qday
Advair 100/50 1 puff daily
Nifedipine ER 60 mg qday
Spiriva 18 mcg daily
Calcium
Medications on Transfer:
Heparin 5000 UNIT SC TID
Docusate Sodium 100 mg PO BID
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
NIFEdipine CR 60 mg PO DAILY
Albuterol 0.083% Neb Soln 1 NEB IH Q6H SOB/wheezing
Insulin SC (per Insulin Flowsheet)
Olanzapine (Disintegrating Tablet) 2.5 mg PO TID:PRN agitation
Acetaminophen (Liquid) 650 mg PO/NG Q6H:PRN pain/headache
PredniSONE 60 mg PO/NG DAILY Duration: 5 Days
MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
Famotidine 20 mg IV Q24H
Ipratropium Bromide Neb 1 NEB IH Q3H
Levofloxacin 750 mg IV Q48H
TraZODONE 25 mg PO/NG HS:PRN insomnia
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
2. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 days: Taper instructions: Please give 40mg on [**7-17**]; 20mg on
[**7-24**], [**7-20**]; 10mg on [**8-14**], [**7-23**].
3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 1 days: Please administer final dose on
[**7-17**].
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO once a day.
7. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation once a day.
8. Advair Diskus 100-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation once a day.
9. Morphine 10 mg/5 mL Solution Sig: 2.5mg mg PO every eight (8)
hours as needed for shortness of breath: take 30 minutes prior
to walking to help with breathing.
10. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Primary Diagnosis
Hypercarbic Respiratory Distress
COPD Exacerbation
Health-Care Acquired Pneumonia
Acute on Chronic Renal Failure
Secondary Diagnosis
Chronic Obstructive Pulmonary Disease
Pulmonary Hypertension
Chronic Renal Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(walker)
Discharge Instructions:
You were admitted with a diagnosis of shortness of breath. You
were diagnosed with respiratory distress, pneumonia, and
required ICU admission. You improved with nebulizers, steroids,
and antibiotics.
Please continue the following new medications:
Ciprofloxacin x 1 dose left to take on [**7-16**]
Prednisone taper x 7 more days
Started albuterol inhaler as needed for shortness of breath
You can resume using your regular inhalers: Spiriva and Advair.
You can continue taking your home medications of Atenolol and
Nifedipine.
You were started on a small dose of Morphine before walking to
help improve your breathing so that you do not feel short of
breath.
Followup Instructions:
Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week of discharge
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2161-8-5**] at 8:00 AM
With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 612**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: VASCULAR SURGERY
When: MONDAY [**2161-11-16**] at 9:30 AM
With: VASCULAR LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
[
"433.10",
"584.9",
"518.81",
"491.21",
"403.90",
"285.9",
"416.0",
"486",
"585.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
12401, 12466
|
6441, 10403
|
235, 269
|
12745, 12745
|
4331, 6418
|
13604, 14225
|
3408, 3516
|
11188, 12378
|
12487, 12724
|
10429, 10429
|
12919, 13581
|
3531, 4085
|
10447, 10584
|
4099, 4312
|
2537, 2936
|
429, 2518
|
297, 412
|
12760, 12895
|
10609, 11165
|
2958, 3139
|
3171, 3392
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,213
| 130,738
|
52454
|
Discharge summary
|
report
|
Admission Date: [**2204-11-27**] [**Month/Day/Year **] Date: [**2205-2-1**]
Date of Birth: [**2168-10-6**] Sex: F
Service: MEDICINE
Allergies:
Insulin Pork Purified / Insulin Beef / Erythromycin Base /
Codeine / Aspirin / Compazine / Peanut / Reglan / Phenergan
Attending:[**First Name3 (LF) 465**]
Chief Complaint:
nausea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
35 year old female with multiple medical problems with multiple
hospitalization for DKA presents with nausea/vomiting
Of note, just recently admitted from [**Date range (1) 108366**] for DKA, MRSA
bactermeia(?HD line? and heel osteo on 6 weeks of meropenem and
linezolid to be completed [**2204-12-2**]. During this admission,
guardianship was also established. She was then discharged to NE
specilaties.
Patient was sent from NE specialties because she was
noncomplaint with medication, treatment and diet. Per NH
referral sheet, pateint was seen by multiple staff member
putting fingers down her throat to induce vomiting. In addition,
patient has increased agitation, requiring 2:1 sitter, "out of
control", screaming and hollering. Paitent reports 5 days
history of intermittent nausea/vomiting, but no coffee
grounds/hemetemesis/fever/chilss/nause/chest pain/SOB/melena.
Patient has diffuse abdominal pain.
In the ED, she was given [**Year (4 digits) 28920**], morphine, ativan and labetolol
Past Medical History:
1) DM1 - diagnosed initially in [**2174**]. Patient has had multiple
admissions for DKA and hypoglycemia, practically monthly.
Volatile blood sugars complicated by infections w/ recurrent
pyelonephritis, chronic diarrhea, severe gastroparesis, high and
low sugars. Poor blood sugar control has resulted in severe
diabetic neuropathy and diabetic retinopathy.
2) Gastroparesis and chronic nausea - as above [**1-3**] DM
3) ESRD - Has been on peritoneal dialysis 5x/week for
approximately past year. Patient has, in past, refused
hemodialysis. Has agreed and been started on HD during current
admission. Baseline Cr unknown as patient has had such frequent
admissions for DM1 (as above) and acute worsening of [**Month/Day (2) **]
failure due to inaccurate PD at home.
4) Seizure disorder - worked up in past by neurology. Thought to
be toxic-metabolic in nature and secondary to patient's
endocrine status (brought on by hyper or hypoglycemia)
5) Anemia - [**1-3**] ESRD. Now on procrit with HD.
6) HTN
7) Asthma
8) Chronic skin breakdown - secondary to DM1 and poor healing
due to poor vascularity. Also [**1-3**] patient scratching [**1-3**] itching
from uremia. Particularly on lower extremities bilaterally.
9) Chronic diarrhea, also with stool incontinence since removal
of absces in [**2194**]
10) Recurrent pyelonephritis
11) History of peritonitis [**1-3**] infection from peritoneal
dialysis
12) History of subdural hematoma
13) History of esophagitis/gastritis: admitted for hematemesis
in [**9-4**] - EGD revealed Grade IV esophagitis, bleeding in distal
esophagus, erythema in stomach body and fundus (consistent with
gastritis)
14) Cardiac function - last [**Date Range **] in [**6-5**] demonstrated dilated
left atrium, moderate symmetric left ventricular hypertrophy,
normal EF = 60-70%, no wall motion abnormalities
Social History:
The patient had lived [**Location 6409**] when she was admitted, but
was evicted from this residency (court ordered, prior to her
hospitalization) and was going to stay with her mother in
[**Name (NI) **] after the hospitalization. Her PCP was [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who
completed his residency and has passed along his patients to Dr.
[**First Name4 (NamePattern1) 915**] [**Last Name (NamePattern1) 29958**], who has yet to meet [**Known firstname 3608**]. Per his OMR note, her
children have recently been taken by DSS. She has a long history
of medical noncompliance. She previously noted that she smokes 2
packs of cigarettes every 5 days but says that she is smoking
less now (approximately 4 pk yr history). She denies use of
alcohol or illicit drugs. Had been in abusive home relationship
but denies current abuse.
Family History:
Father with type 2 DM, CHF, CVA
Physical Exam:
T98.2 P88 BP193/86 R18 100% on RA
Gen- lying in bed, ill appearing but nontoxic
HEENT- PERLA
neck- supple
chest- rales at right base, otherwise clear
CV- rrr, no r/m/g
abd- diffuse tenderness, no rebound/guarding, ulcers at PD site
w/ serosanguinous [**Known firstname **]
extremity- L?R heel ulcers- well granulated
Pertinent Results:
[**2204-11-27**] 11:15AM GLUCOSE-738* UREA N-39* CREAT-6.4*
SODIUM-130* POTASSIUM-4.7 CHLORIDE-89* TOTAL CO2-21* ANION
GAP-25
[**2204-11-27**] 11:15AM CALCIUM-8.1* PHOSPHATE-6.3*# MAGNESIUM-1.9
[**2204-11-27**] 11:15AM ACETONE-LARGE
[**2204-11-26**] 09:45PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014
[**2204-11-26**] 09:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-500
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2204-11-26**] 09:45PM URINE RBC-[**10-21**]* WBC-[**2-3**] BACTERIA-FEW
YEAST-NONE EPI-21-50
[**2204-11-26**] 08:02PM GLUCOSE-106* LACTATE-2.0 NA+-146 K+-4.1
CL--98* TCO2-28
[**2204-11-26**] 08:00PM GLUCOSE-104 UREA N-29* CREAT-5.5* SODIUM-142
POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-28 ANION GAP-21*
[**2204-11-26**] 08:00PM ALT(SGPT)-3 AST(SGOT)-18 ALK PHOS-179*
AMYLASE-70 TOT BILI-0.9
[**2204-11-26**] 08:00PM LIPASE-20
[**2204-11-26**] 08:00PM ALBUMIN-4.1 CALCIUM-9.7 PHOSPHATE-3.7#
MAGNESIUM-1.8
[**2204-11-26**] 08:00PM WBC-9.7 RBC-4.41# HGB-11.9*# HCT-37.6# MCV-85
MCH-27.0 MCHC-31.7 RDW-19.7*
[**2204-11-26**] 08:00PM NEUTS-68.7 LYMPHS-22.7 MONOS-4.8 EOS-1.9
BASOS-1.9
[**2204-11-26**] 08:00PM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MICROCYT-1+
[**2204-11-26**] 08:00PM PLT COUNT-380
[**2204-11-26**] 08:00PM PT-14.3* PTT-33.0 INR(PT)-1.4
.
.
KUB [**12-7**]: There is no free air. There is stool and gas in the
colon, which is normal in caliber. There are no pathologically
dilated small bowel loops to suggest obstruction.
.
CT Head [**12-12**]: 1) No evidence of acute intracranial hemorrhage or
skull fracture. 2) Polypoid mucosal thickening in the left
sphenoid sinus unchanged from prior.
.
blood cx [**12-7**]: negative
CDiff toxin [**12-7**]: negative
.
blood cx [**12-9**]: negative
blood cx [**12-15**]: negative
Brief Hospital Course:
35 year old female with history of type I diabetes w/ multiple
DKA, ESRD on HD, chronic N/V likely from severe gastroparesis,
chronic diarrhea and multiple other medical problems presents
with nausea/vomiting and abdominal pain for 5 days.
.
# abdominal pain/nausea: CT abdomen show mild colonic thickening
but otherwise unchanged, abdominal labs negative, no
fevers/leukocytosis; of note, her nausea often exacerbated
post-HD and frequently in association with narcotics in the
setting of pain. C diff was positive and she was initially
started on flagyll on [**2204-11-29**], she continued to have abdominal
pain, and after discussion with ID and GI, oral vancomycin
(started on [**2204-12-2**]) was also added as the patient has a previous
history of C.Diff and this would provide better coverage. The
patient completed a ..course of antibiotics. Her nausea was
controlled with antiemetics ([**Date Range 28920**]), and while initially NPO
she rapidly was advanced to a full diet. At the time of
[**Date Range **] the patient was not complaining of diarrhea.
.
# abdominal wound at site of old PD cath: Plastics evaluated
patient during this admission and no surgical intervention at
this time. She was evaluated by a wound care nurse, and wound
dressing was continued with xeroform, and vitamin C, Zinc. The
patient was discharged with wound care instructions.
.
# Heel Osteo- Completed 6 wk course of linezolid and meropenem
finished on [**2204-12-2**]. Was recently discharged from [**Hospital1 18**] on a
6-week course of meropenem and linezolid, to complete on [**2204-12-2**]. She is now on imipenem on admission, instead. No
documentation in her records why this was changed. Given her hx
of seizure d/o and the fact that imipenem can lower sz
threshold, switched back to meropenem/linezolid. Finished abx
course [**12-2**]. Consulted [**Month/Day (4) **] for followup evaluation of osteo
for further management as necessary. The [**Month/Day (4) **] service
continued to see her on a periodic basis during this admission.
They were satisfied with the healing of her R heel, felt that
the L heel would benefit from an appligraft, however, this can
only be obtained as an outpatient. They were investigating for
a substitute, no plans for further surgical intervention at this
time.
.
The patient has follow up scheduled with Dr. [**Last Name (STitle) **]. She will
need to have an apligraft placed prior on her first visit.
.
# hypertension- Her blood pressure was controlled with
lopressor, and eventually changed to toprol for more convenient
dosing. Her procardia had recently stopped for hypotension post
dialysis. At the time of [**Last Name (STitle) **] her Toprol 100 daily.
.
# chronic diarrhea w/ negative w/u. She was ruled out for
C-diff on multiple occasions.
.
# Chronic skin breakdown - secondary to DM1 and poor healing,
also poor vascularity. Patient also constantly
scratching/itching from uremia. Provided Atarax for symptoms
control, along with dialysis for uremia. Wound care nursing
followed her while she was hospitalized.
.
# type I DM w/ triopathy- poorly controlled
The patient was followed by [**Last Name (un) **] and her insulin regimen was
carefully titrated to provide maximum control over her sugars.
She was provided with nutrition teaching and a dietician helped
to monitor her food choices/limit her carbohydrates. The
patient was initially poorly compliant with her diet by buying
high sugar foods from the vending machine, hiding snacks in her
room, and stacking food from her meal trays. In addition, she
would often leave the floor without permission, which would
result in her becoming hyperglycemic to the point of critically
high sugars. This was addressed and restrictions were placed on
the patient's diet; limiting her snacks to only those provided
to her on her meal trays. She also required a sitter to ensure
that she would not leave the floor. She was somewhat stable
initially on a regimen of 18 units lantus at lunch and 32 units
of NPH at night, with a Humalog sliding scale for meal time
coverage. Her glucose levels improved for a short period of
time on this regimen. However this was short-lived. Her course
became complicated by critically high sugars at night which were
often in the range of 400. The patient would be treated per
sliding scale. On these occasions her sugars would fall below
60. She was then treated with amps of D50. The patient's
sugars would improve to a level above 100. After extensive work
with the [**Last Name (un) **] consultants, the decision was made for them to
manage any questions surrounding her insulin regimen in order to
avoid these extreme highs and lows. Despite this intervention,
the patient continued to have labile sugars. At the time of
[**Last Name (un) **] the patient was on glargine 20U at lunch and 38U of
NPH at night. The patient was provided several copies of a
tailored sliding scale. [**Last Name (un) **] felt that we had achieved
optimal insulin regimen give the patient's labile glucose
levels.
.
Prior to [**Last Name (un) **] the patient, personal care attendants and
guardian had diabetic teaching by the [**Name (NI) **] consultants.
.
At the time of [**Name (NI) **] the patient had prescriptions for her
insulin, glucometer, and glucose strips. She also had a copy of
her insulin sliding scale.
.
# Vitreous hemorrhage
In addition, she experienced a vitreous hemorrhage in her right
eye as a complication of her diabetes. She was evaluated at the
[**Last Name (un) **] Eye Center, and will need to follow-up within 6-8 weeks.
.
# Neuropathy
For her neuropathy, she was given gabapentin, amitriptyline, and
oxycodone on a PRN basis.
.
# ESRD- she was on a 3-4x per week dialysis schedule via
tunneled L subclavian HD catheter. The patient was hyperkalemic
on multiple occasions with K+ up to 6.5. EKGs were routinely
checked, and did not demonstrate change, but did demonstrate
peaked T waves. The patient refused kayexalate, lasix, calcium
gluconate on multiple occasions despite being told that
hyperkalemia could lead to a life threatening arrythmia. There
was discussion about placing permanent access via graft, and
transplant surgery was consulted. The patient underwent vein
mapping, and based on these results, the surgeons felt she would
be a poor candidate with no guarantee for success given her
vasculopathy and the multiple lines she has had. She would be
at high risk for steal and possible limb loss. This was
discussed with her nephrologist, Dr. [**First Name (STitle) 805**] and it was thought
to defer permanent access for now. She was arranged to have
outpatient HD at [**Location (un) 4265**] [**Location (un) **] M,W,F.
.
# Fever- She had persistent fever spikes during the first week
of [**Month (only) 956**] with temp up to 102. She was pan-cultured and ruled
out for C-diff. No obvious source of infection was found.
Given the concern for a line infection from either her L PICC or
the HD cath site, she was treated with a week course of
Vancomycin, dosed by level. Because she also had an episode of
seizure- like activity one day at hemodialysis an LP was
attempted on two occasions, but was unsuccessful. She did not
exhibit signs of meningitis, and her fever resolved within one
week.
Neuro was consulted for this seizure-like activity and a CT head
was done, which was negative. An EEG was consistent with
encephalopathy, and the patient was thought to have been
exhibiting severe contractions from Narcan administration rather
than a true seizure. Her Keppra level was checked, and found to
be therapeutic.
.
At the time of [**Month (only) **] the patient was afebrile.
.
# Dispo- The patient was discharged home with VNA and personal
care attendants. Prior to [**Month (only) **] the personal care attendant
had diabetic teaching at [**Last Name (un) **]. On the day of [**Last Name (un) **] a
meeting was held with the attendants outlining the patient's
[**Last Name (un) **].
Medications on Admission:
imipenem 500 Iv QD
keppra 500 po BID
Linezolid 600mg po Q12
Ca carb 1250mg po TID w/ meals
colace
protonix
lipitor 40
nephrocaps QD
heparin sc
epogen 20,000 q HD'seroquel 75 QHS, 25 [**Hospital1 **]
hydroxyzine
MSIR prn
zofran prn
[**Hospital1 **] Medications:
1. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
5. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for itching.
Disp:*30 Tablet(s)* Refills:*2*
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
8. Kayexalate 30ml qd on Sat/Sunday for doses.
9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*30 Capsule(s)* Refills:*2*
10. Quinine Sulfate 325 mg Capsule Sig: One (1) Capsule PO HS
(at bedtime).
Disp:*30 Capsule(s)* Refills:*2*
11. Sevelamer 800 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*2*
12. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)).
Disp:*30 Tablet(s)* Refills:*2*
13. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
14. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
15. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
16. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*30 Tablet(s)* Refills:*1*
17. Calcium Acetate 667 mg Capsule Sig: Four (4) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*120 Capsule(s)* Refills:*2*
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*2*
19. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*qs inhalers* Refills:*2*
20. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **]/PRN
().
Disp:*qs tubes* Refills:*2*
21. Calcium Carbonate 500 mg Tablet, Chewable Sig: Four (4)
Tablet, Chewable PO QHS (once a day (at bedtime)).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
22. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
23. Gabapentin 100 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
24. Glucagon Emergency 1 mg Kit Sig: One (1) Injection when
glucose is critically low.
Disp:*1 kit* Refills:*2*
25. Glargine
Sig: per sliding scale regimen
Disp: qs
Refills: 5
26. Humalog
Sig: per sliding scale regimen
Disp: qs
Refills: 5
27. NPH
Sig: per insulin sliding scale
Disp: qs
Refills: 5
28. Glutose 40 % Gel Sig: One (1) PO For critically low sugars.
Disp:*30 tubes* Refills:*2*
29. glucometer
Please provide patient with a glucometer
Disp: 1 kit
Refills: 1
30. Glucose test strips
Sig: use with glucometer
Disp: qs
Refills: 2
31. Syringes
Please provide with 50cc syringes for the administration of
insulin.
Disp: qs
Refills: 5
32. Lanthanum 1,000 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
Disp:*90 Tablet, Chewable(s)* Refills:*2*
Lunch (noon) Glargine 20 Units daily
Bedtime (10PM) NPH 38 Units if glucose greater than 300
30 Units if glucose less than 300
Humalog Insulin SC Sliding Scale
Breakfast Lunch Dinner Bedtime
Glucose
0-80
81-100 0 Units 0 Units 0 Units 0 Units
101-180 2 Units 0 Units 5 Units 0 Units
181-200 3 Units 3 Units 8 Units 0 Units
201-250 5 Units 5 Units 10 Units 0 Units
251-300 7 Units 7 Units 12 Units 2 Units
301-350 9 Units 9 Units 13 Units 4 Units
351-400 11Units 11Units 15 Units 6 Units
> 400 call [**Last Name (un) **]
[**Last Name (un) **] Disposition:
Home With Service
Facility:
[**Hospital1 **] Family & [**Hospital1 1926**] Services
[**Hospital1 **] Diagnosis:
Primary Diagnosis
DM1 with labile blood sugars ketoacidosis/hypoglycemia
CDiff colitis
.
Secondary Diagnosis
) DM1 - diagnosed initially in [**2174**]. Patient has had multiple
admissions for DKA and hypoglycemia. Volatile blood sugars
complicated by infections w/ recurrent pyelonephritis, chronic
diarrhea, severe gastroparesis, severe diabetic neuropathy and
diabetic retinopathy.
2) Gastroparesis and chronic nausea - as above [**1-3**] DM
3) ESRD on HD
4) Seizure disorder - worked up in past by neurology.
toxic-metabolic in nature and secondary to patient's endocrine
status (brought on by hyper or hypoglycemia)
5) Anemia - [**1-3**] ESRD. Now on procrit with HD.
6) HTN
7) Asthma
8) Chronic skin breakdown - [**1-3**] DM1, poor healing from impaired
vascularization, patient scratching [**1-3**] uremic pruritus.
9) Chronic diarrhea, also with stool incontinence since removal
of abscess in [**2194**]
10) History of peritonitis [**1-3**] infection from peritoneal
dialysis
11) History of subdural hematoma
12) History of esophagitis/gastritis: admitted for hematemesis
in [**9-4**] - EGD revealed Grade IV esophagitis, bleeding in distal
esophagus, gastritis
13) Cardiac function - last [**Date Range **] in [**6-5**] demonstrated dilated
left atrium, moderate symmetric left ventricular hypertrophy,
normal EF = 60-70%, no wall motion abnormalities
14)staph epi bacteremia s/p 1 week vancomycin with resolution
[**Month/Day (1) **] Condition:
Stable, still with labile sugars at baseline, normotensive, on
room air, alert
[**Month/Day (1) **] Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters per day
.
Please keep a diary of your glucose levels. You must record
your before meals before bed time (10pm) and at 3AM. Also check
sugars if you are feeling symptoms of low/high blood sugars.
Call [**Last Name (un) **] for any questions regarding insulin dosing.
.
We are advising you not to drive.
Followup Instructions:
.
[**Last Name (un) **]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 2378**] [**2205-2-5**] 11
AM
.
Primary Care Physician
[**Name Initial (PRE) 2169**]: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 16717**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2205-2-7**] 3:30
.
[**Year/Month/Day **]
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2205-2-8**] 8:00
.
[**Hospital6 6841**] in [**Location (un) **] every Monday, Wednesday,
Friday at 4pm [**Telephone/Fax (1) 5972**]
.
[**Last Name (un) **] Eye appointment on [**3-11**] at 1pm with Dr [**Last Name (STitle) 108367**]
.
Psychiatrist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for management of your medications--
[**Telephone/Fax (1) 1387**] on Friday [**2-22**] at 10:00 in [**Hospital Ward Name 452**] Bldg [**Location (un) 1385**] [**Apartment Address(1) 8379**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 472**]
Completed by:[**2205-2-1**]
|
[
"250.13",
"379.23",
"707.14",
"008.45",
"362.01",
"536.3",
"403.91",
"250.53",
"337.1",
"285.21",
"780.39",
"250.43",
"585.6",
"730.27",
"250.63"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
6412, 14402
|
397, 403
|
4572, 6389
|
20990, 22159
|
4186, 4220
|
14428, 14661
|
4235, 4553
|
351, 359
|
14691, 18935
|
431, 1432
|
18963, 20967
|
1454, 3286
|
3302, 4170
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,442
| 144,749
|
25332
|
Discharge summary
|
report
|
Admission Date: [**2179-9-7**] Discharge Date: [**2179-9-11**]
Date of Birth: [**2099-10-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Congestive heart failure
Major Surgical or Invasive Procedure:
[**2179-9-7**] CABG x 2 (LIMA->LAD, SVG->PDA)
History of Present Illness:
79 year old female increasing dyspnea on exertion. Sustained an
MI in early [**Month (only) **]. A cardiac catheterization was peformed which
revealed severe three vessel disease.
Past Medical History:
NIDDM
Hyperlipidemia
Diverticulosis
Anemia
Osteoporosis
Renal caluli
PUD
MI
Kyphosis
Social History:
Lives alone. Quit smoking 2 ppd 6 years ago after 120 pack year
history. Does not drink alcohol.
Family History:
Mother, sisters and brothers all with [**Name (NI) 5290**]
Physical Exam:
GEN: WDWN in NAD
SKIN: Benign
HEENT: Benign
NECK: No bruits, no JVD
CHEST: Clear
HEART: RRR, II/VI systolic murmur
ABD: Soft, nontender, nondistended.
EXT: Warm. No varicosities, [**2-7**]+ pulses.
Pertinent Results:
[**2179-9-9**] 06:45AM BLOOD Plt Ct-108*
[**2179-9-10**] 06:05AM BLOOD UreaN-18 Creat-0.7 K-4.1
CXR [**2179-9-8**]
Comparison is made to [**2179-9-7**]. The endotracheal tube and
NG tube have been removed. The right internal jugular approach
Swan-Ganz catheter tip remains in the right main pulmonary
artery. There is no pneumothorax. Stable mild cardiomegaly.
There is improving pulmonary edema. Residual patchy left lower
lobe atelectasis and small bilateral effusions.
EKG [**2179-9-7**]
Sinus rhythm. Occasional ventricular premature beats. Diffuse
non-specific
T wave changes. Compared to the previous tracing of [**2179-9-1**]
non-specific
diffuse T wave changes are present.
[**Last Name (NamePattern4) 4125**]ospital Course:
Ms. [**Known lastname 53328**] was admitted to the [**Hospital1 18**] on [**2179-9-7**] and taken directly
to the operating room where she underwent coronary artery bypass
grafting to two vessels. Postoperatively she was taken to the
cardiac intensive care unit for monitoring. On postoperative day
one, Ms. [**Known lastname 53328**] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
She was then transferred to the cardiac surgical step down unit
for further recovery. She was gently diuresed toward her
preoperative weight. The physical therapy service was consulted
for assistance with her postoperative strength and mobility.
Coreg and Valsartan were resumed and titrated for optimal heart
rate and blood pressure support. Her pacing wires and drains
were removed per protocol. She continued to make steady progress
and was discharged to her home on postoperative day four. She
will follow-up with Dr. [**Last Name (Prefixes) **], her cardiologist and her
primary care physician as an outpatient.
Medications on Admission:
Coreg 6.25mg twice daily
Lasix 20mg daily
Atacand 8mg daily
Lipitor 30mg daily
Aspirin 81mg daily
Glyburide 10mg daily
Fosamax 70 weekly
Vtamins/Minerals daily
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 7 days: [**Hospital1 **] x 7 days, then daily.
Disp:*45 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days: [**Hospital1 **] for 7 days then daily.
Disp:*60 Capsule, Sustained Release(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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
6. Atorvastatin Calcium 10 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
CAD
NIDDM
hypercholesterolemia
anemia
hital hernia
diverticulosis
osteoporosis
renal calculi
PUD
kyphosis
cataracts
appy
vaginal hysterectomy
Discharge Condition:
Good.
Discharge Instructions:
[**Month (only) 116**] shower, wash incision with mild soap and water and pat dry.
No baths, no creams, lotions, powders.
Call with temperature more than 101.5, redness or draingae from
incision.
No lifting more than 5 pounds or driving until followup with
surgeon.
Call with weight gain more than 2 pounds in one day or five in
one week.
[**Last Name (NamePattern4) 2138**]p Instructions:
Dr. [**Last Name (Prefixes) **] 4 weeks
Dr. [**Last Name (STitle) 1159**] 2 weeks
Dr. [**Last Name (STitle) 6051**] 2 weeks
Completed by:[**2179-9-22**]
|
[
"535.50",
"424.0",
"414.01",
"250.00",
"737.10",
"285.9",
"733.00",
"428.0",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"36.15",
"36.11",
"88.72",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
4551, 4600
|
345, 393
|
4786, 4794
|
1133, 1819
|
840, 900
|
3104, 4528
|
4621, 4765
|
2920, 3081
|
4818, 5158
|
5209, 5364
|
915, 1114
|
1870, 2894
|
281, 307
|
421, 602
|
624, 710
|
726, 824
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,612
| 170,976
|
44805
|
Discharge summary
|
report
|
Admission Date: [**2184-12-21**] Discharge Date: [**2184-12-26**]
Date of Birth: [**2102-3-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Fatigue/Lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
82M with hx polycythemia [**Doctor First Name **] (jak2+), afib, hypothyroidism who
presents with increased fatigue and lethargy x several days. The
wife states that at baseline the pt walks with a walker, is
interactive, and feeds himself, early dementia. However for the
past several days he has had decreased appetite, increased
fatigue, and has stopped ambulating. He also became tachypneic,
with wheezing and gasping and so she brought him in to [**Hospital1 2519**]. She denies that the pt had a fever, nausea, vomiting,
diarrhea, or any similar episodes. He does have chills at
baseline and some chronic back pain. She also denies that the
patient complained of chest pain or abdominal pain.
At the [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] the patietn was found to hav ea BNP >1500, afib
to 110, and expiratory rales improved with ntg, lasix, and O2.
He also had a WBC 40.9. He was transfered to [**Hospital1 18**] for presumed
new chf/potential cath.
On arrival to [**Hospital1 18**], the pt was found to be hypotensive,
jaundiced. The ED felt the pt had been overdiuresed so he was
given 2L IVF after which he became more hypoxic requiring 4L nc.
He had sluggish speech, was A&Ox1. Surgery was consulted and did
not feel pt had a surgical issue given benign abdomen. Pt was
given zosyn 4.5mg IV, Vanc 1g IV, and Asa 325mg PR. Repeat labs
showed a WBC 45.3, trop 0.15, Cr 2.5, anion gap 21, mildly
elevated ast/alt, LDH 532, t.bili 7.1. Pt was also found to be
guiaic positive. Pt was admitted to MICU for further work-up.
In the MICU the pt was afebrile, 103/61 82, satting 100% on face
tent. He was in no acute distress but was complained of
weakness. He had a flat affect and responded minimally to
interaction. He denied pain, diaphoresis, sob, n/v.
.
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 nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.
Past Medical History:
-polycythemia [**Doctor First Name **] (>5y), treated with frequent phlebotomies
however none in the past year.
-HTN
-Hyperlipidemia
-A.fib on dabigatran
-broken pelvis 5y ago
-hypothyroidism
Social History:
Formerly worked for [**Company 65042**] and raced motorcycles. Rode
motorcycles up until 5y ago. Lives with wife.
- Tobacco: quit [**2136**]
- Alcohol: none x5y
- Illicits: none
Family History:
significant for heart disease in multiple relatives
Physical Exam:
Vitals: HR 116, BP 124/71, RR 30, sat 100% on 4L NC
General: sleepy, not alert, does not answer orientation
questions
HEENT: dry mucous membranes
Lungs: bibasilar crackles, rapid shallow breathing
CV: irregular rhythm, regular rate, holosystolic murmur
throughout.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, +splenomegaly
GU: no foley
Ext: cool, mottled LE and knees bilaterally; initially unable to
doppler pulses, but on repeat we were able to hear them
Pertinent Results:
OSH records:
[**2183-12-11**]
wbc 29.9/hct 15.6/plt 430
Na 138 K 5.5 Cl 100 Bicarb 26 BUN 28 cr 1.5
t.bili 0.86 AP 101 ALT 1 AST 20
Admission Labs:
[**2184-12-21**] 05:10PM BLOOD WBC-45.3* RBC-7.48* Hgb-12.9* Hct-44.6
MCV-62* MCH-17.9* MCHC-28.9* RDW-21.3* Plt Ct-502*
[**2184-12-22**] 02:01AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-3+ Polychr-OCCASIONAL Ovalocy-1+ Tear
Dr[**Last Name (STitle) **]1+
[**2184-12-21**] 05:10PM BLOOD PT-27.7* PTT-93.7* INR(PT)-2.7*
[**2184-12-21**] 05:10PM BLOOD Fibrino-371
[**2184-12-23**] 07:00AM BLOOD Ret Aut-2.7
[**2184-12-23**] 03:30PM BLOOD SerVisc-1.5
[**2184-12-21**] 05:10PM BLOOD Glucose-96 UreaN-69* Creat-2.5* Na-141
K-4.7 Cl-107 HCO3-13* AnGap-26*
[**2184-12-21**] 05:10PM BLOOD ALT-88* AST-65* LD(LDH)-532* AlkPhos-98
TotBili-7.1* DirBili-2.5* IndBili-4.6
[**2184-12-21**] 05:10PM BLOOD CK-MB-8 cTropnT-0.15*
[**2184-12-22**] 02:01AM BLOOD CK-MB-11* cTropnT-0.26*
[**2184-12-23**] 07:00AM BLOOD CK-MB-5 cTropnT-0.16*
[**2184-12-23**] 09:55PM BLOOD CK-MB-6 cTropnT-0.23*
[**2184-12-24**] 07:00AM BLOOD CK-MB-6 cTropnT-0.27*
[**2184-12-24**] 07:05PM BLOOD cTropnT-0.24*
[**2184-12-25**] 03:55PM BLOOD CK-MB-8 cTropnT-0.57*
[**2184-12-21**] 05:10PM BLOOD UricAcd-18.6*
[**2184-12-22**] 05:09PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
[**2184-12-22**] 05:09PM BLOOD HCV Ab-NEGATIVE
[**2184-12-22**] 02:11AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-29* pCO2-34*
pH-7.33* calTCO2-19* Base XS--7 Intubat-NOT INTUBA
[**2184-12-21**] 05:25PM BLOOD Lactate-4.0*
Labs prior to expiration:
[**2184-12-26**] 03:03AM BLOOD WBC-41.2* RBC-7.10* Hgb-12.6* Hct-43.2
MCV-61* MCH-17.7* MCHC-29.1* RDW-21.7* Plt Ct-492*
[**2184-12-24**] 07:00AM BLOOD Neuts-88.8* Bands-0 Lymphs-5.9* Monos-2.1
Eos-2.5 Baso-0.8
[**2184-12-24**] 07:00AM BLOOD Hypochr-OCCASIONAL Anisocy-3+ Poiklo-2+
Macrocy-NORMAL Microcy-3+ Polychr-1+ Tear Dr[**Last Name (STitle) 833**]
[**Name (STitle) 12850**]2+
[**2184-12-26**] 03:03AM BLOOD Plt Ct-492*
[**2184-12-21**] 05:10PM BLOOD Fibrino-371
[**2184-12-26**] 03:03AM BLOOD Glucose-110* UreaN-72* Creat-3.1*# Na-144
K-5.0 Cl-104 HCO3-21* AnGap-24*
[**2184-12-25**] 03:55PM BLOOD CK(CPK)-48
[**2184-12-26**] 03:03AM BLOOD cTropnT-0.80*
[**2184-12-26**] 03:03AM BLOOD Calcium-9.7 Phos-5.4* Mg-2.1
[**2184-12-22**] 02:01AM BLOOD TSH-7.6*
[**2184-12-23**] 07:00AM BLOOD calTIBC-283 Hapto-31 Ferritn-88 TRF-218
[**2184-12-26**] 03:30AM BLOOD Type-[**Last Name (un) **] Temp-37.3 FiO2-50 pO2-23*
pCO2-34* pH-7.42 calTCO2-23 Base XS--2 Intubat-NOT INTUBA
[**2184-12-26**] 03:30AM BLOOD Lactate-4.4*
[**2184-12-26**] 03:30AM BLOOD O2 Sat-25
[**2184-12-22**] 02:11AM BLOOD freeCa-1.13
Microbiology: blood cultures - no growth to date
urine cultures - no growth to date
HBV viral load - negative
HCV viral load - HCV RNA detected, less than 43 IU/mL.
Performed using the Cobas Ampliprep / Cobas Taqman HCV
Test.
Linear range of quantification: 43 IU/mL - 69 million
IU/mL.
Limit of detection: 18 IU/mL.
Imaging:
Head CT: [**12-23**]
IMPRESSION:
1. No hemorrhage or edema.
2. Generalized atrophy, sequelae of chronic small vessel
ischemic disease and
pontine lacunes.
3. Preferential atrophy of the rostral midbrain; this finding
should be
correlated with any history of neurodegenerative disorder, e.g.
progressive
supranuclear palsy.
4. Significant intracranial vascular calcification.
CXR: [**12-25**]
FINDINGS: As compared to the previous radiograph, there is
stable evidence of massive bilateral mainly alveolar opacities
with subtle interstitial markings. Moderate cardiomegaly. The
findings have not substantially changed since [**2184-12-24**].
The findings could represent both pulmonary edema and pneumonia,
or a
combination of both than pneumonia.
[**12-21**] Liver Ultrasound :
1. Extensive gallbladder sludge, layering stones without
secondary signs
of cholecystitis, however in the appropriate clinical setting,
acute
cholecystitis is nto excluded.
2. Right pleural effusion.
3. Splenomegaly measuring up to 14.6 cm.
EKG: Afib @94, LAD, poor r-wave prog, TWI I, aVL, V2.
Brief Hospital Course:
82 male with previous history of polycythemia [**Doctor First Name **],
hypertension, Atrial fibrillation on dabigatran, and
hypothyroidism who presented with increased fatigue/lethargy for
several days, with elevated leukocytosis, elevated bilirubin,
and troponin leak concerning for NSTEMI.
# Lethargy/Altered Mental Status: Pt presented with worsening
functional status and energy for several several days. Given
history of polycythemia [**Doctor First Name **] (with JAK2+ mutation) with
increasing WBC, hyperuricemia, elevated LDH, with relative
anemia, concerning for transformation to a leukemic process
(risk factor age >70). However differential did not have
precursor cells so the initial evaluation was not classic for
AML. Patient has a history of hypothyroidism, but TSH was only
slightly elevated, so no evidence of myxedema coma. Patient
likely had an NSTEMI given his troponin leak, which could have
lead to hypoperfusion in setting of MI, acute renal failure, and
elevated liver function tests. No evidence of intracranial acute
process on Head CT. Renal failure likely also contributed to
altered mental status due to uremia. Hematology consult was
obtained, and lab abnormalities were thought to not be due to
leukemic conversion, but rather due to continued hemolysis from
her polycythemia [**Doctor First Name **]. Pt was transferred to the medicine floor
further work-up, but returned to the ICU on [**2183-12-26**] after
multiple triggers on the floor for worsening respiratory
distress and tachycardia/atrial fibrillation with RVR
unresponsive to IV metoprolol and diltiazem boluses on the
floor, and decreased responsiveness. CT scan did not show any
evidence of RP bleed or decreased hematocrit concerning for
bleed. Overnight in the ICU, he developed multi-organ system
failure with worsening pulmonary infiltrates (pneumonia and
pulmonary interstitial infiltrates) likely in the setting of
cardiogenic shock from her NSTEMI along with liver failure and
renal failure. His multi-organ failure may also have been
induced in the setting of leukostasis and sludging from the
elevated leukocytosis. The family and HCP did not want any
further interventions, so the patient was made DNR/DNI and
comfort measures only. He was given dilaudid and oxygen as
needed for respiratory distress and passed away.
# Acute Kidney Injury: Patient with peak creatinine of 3.0
during this admission increased from 1.5 a year ago with
worsening anion gap acidosis. Likely in setting of decreased
renal perfusion from NSTEMI. Patient had worsening acute renal
failure during his ICU stay. Due to goals of care, patient was
made DNR/DNI CMO and expired.
# Elevated troponins: Patient likely had NSTEMI. Troponins also
accumulated in setting of renal failure. Enzymes trended 0.15
to peak of 0.8 prior to expiration. TTE showed extensive
regional LV dysfunction, concerning for ischemia/infarction in
the LAD distribution. EF 30-35%. No EKG changes. Cardiology was
consulted and did not think patient was a candidate for cardiac
catherization. Heparin drip started for presumed NSTEMI but was
eventually discontinued when patient was made comfort measures
only and expired.
# Hyperuricemia: Uric acid elevated to 18.6, likely due acute
renal failure versus tumor lysis, versus undiagnosed gout versus
continued lysis of red blood cells from polycythemia [**Doctor First Name **]. IVFs
were given with little improvement. Patient was made
DNR/DNI/CMO and expired.
# Hyperbilirubinemia: Bilirubin on admission noted to be total
7.1, direct 2.5, concerning for hepatic process vs hemolysis.
Hemolysis possible in setting of underlying RBC defect for
Polycythemia [**Doctor First Name **], LDH elevated however haptoglobin was normal,
indicating possible chronic hemolysis. Peripheral smear was
sent but did not show any acute forms concerning for acute
leukemic conversion. RUQ U/S shows sludging but no acute
choleycystitis. Surgery consulted, felt that there was no
surgical process. Bilirubin continued to rise this admission,
also concerning for hypotensive shock in setting of NSTEMI
versus arterial/venous sludging in the liver from leukostasis
given elevated WBC. Patient was made DNR/DNI/CMO and expired.
# Atrial fibrillation: Patient was on dabigatran and atenolol at
admission. Dabigatran held on HD #1 due to elevated INR and
likely poor clearance secondary to renal failure. Patient was
made DNR/DNI/CMO and expired.
# Hypothyroid: Continued home synthroid. TSH 7.6, no evidence
of myxedema coma. Patient was made DNR/DNI/CMO and expired.
Medications on Admission:
Atenolol 50mg daily
Levothyroxine 75mcg daily
Dabigatran 50mg [**Hospital1 **]
Cymbalta 30mg daily
Aricept 5mg daily
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY:
Non-ST Elevation Myocardial Infarction
Altered Mental Status
Cardiogenic Shock
Acute Renal Failure
Acute Liver Failure
SECONDARY:
Polycythemia [**Doctor First Name **]
Discharge Condition:
Expired
Discharge Instructions:
It was a pleasure taking care of you, Mr. [**Known lastname **]. You were
admitted to the hospital with changes in your mental status that
were most likely caused by a heart attack. You progressively
went into shock, multi-organ failure, and respiratory distress.
You were made DNR/DNI and comfort measures only and passed away
in the hospital.
Your medications have CHANGED as follows:
NONE - Expired
Followup Instructions:
None
Completed by:[**2184-12-26**]
|
[
"785.51",
"276.2",
"486",
"238.4",
"403.90",
"584.9",
"585.3",
"244.9",
"570",
"427.31",
"410.71",
"428.0",
"V49.86",
"428.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
12520, 12529
|
7752, 8065
|
323, 329
|
12751, 12761
|
3646, 3779
|
13212, 13249
|
3045, 3098
|
12491, 12497
|
12550, 12730
|
12350, 12468
|
12785, 13189
|
3113, 3627
|
2168, 2616
|
267, 285
|
357, 2149
|
6659, 7729
|
3795, 6650
|
8080, 12324
|
2638, 2831
|
2847, 3029
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,224
| 175,186
|
10844+56185
|
Discharge summary
|
report+addendum
|
Admission Date: [**2166-5-8**] Discharge Date: [**2166-5-12**]
Date of Birth: [**2101-12-24**] Sex: M
Service: Medicine
DISCHARGE DIAGNOSES:
1. Choledocholithiasis.
2. Gastrointestinal bleed.
REFERRING PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **]
PROCEDURE:
1. Endoscopic retrograde cholangiopancreatography Thursday,
[**2166-5-8**].
2. Esophagogastroduodenoscopy [**Last Name (LF) 2974**], [**2166-5-9**].
HISTORY OF PRESENT ILLNESS: The patient is a 64 year old male
with a history of hypertension, HBV and diabetes mellitus who
presented with abdominal pain and abnormal liver function tests.
The patient was referred to [**Hospital1 69**]
for an ERCP. During the ERCP small ductal stones were removed
and a large diverticula was noted near the papilla. The patient
underwent sphincterotomy complicated by mild bleeding from the
diverticulum, which was later cauterized by epinephrine injection
on EGD.
The patient was transferred to the floor and developed
hypotension and fevers to 102.0 F.
PHYSICAL EXAMINATION: On admission, the patient's blood
pressure is 105/75; heart rate 110; respiratory rate 12;
saturation at 100% on two liters. HEENT: Extraocular
muscles are intact. Mildly icteric sclerae. Neck: Jugular
venous distention flat; supple. Lungs clear to auscultation
bilaterally. Heart is regular rate and rhythm, no murmurs,
rubs or gallop. Abdomen was soft, nontender, with decreased
bowel sounds. Extremities cool, no edema. Palpable pulses.
ADMISSION LABORATORY: The patient had a white blood cell
count of 11.6, hematocrit 28, platelets 172. Sodium 140,
chloride 112, carbon dioxide 17, BUN 20, creatinine 1.1,
glucose 187. Coagulation studies were 14.1, 33 and 1.4.
ALT was 372, AST 483, alkaline phosphatase 76, total
bilirubin 2.8 with a direct of 1.3. Albumin 4.2.
Arterial blood gas showed 7.4/36 and 127. Lactate 2.8.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit with hypotension and fever of ERCP
complication.
1. Cardiac: The patient admitted to the Unit with hypotension.
He became hemodynamically stable after packed red blood cell
transfusion and fluids.
2. Respiratory: Stable without any event.
3. Gastrointestinal: Choledocholithiasis status post ERCP and
sphincterotomy with resultant bleeding from papilla. The patient
then received EGD with epinephrine injection to stop bleeding
which was successful. Pancreatitis from post-ERCP, lipase and
amylase were elevated but became normal. Of note, the patient
also had an increased bilirubin.
4. Infectious Disease: The patient was febrile after procedure.
Started on Ampicillin and Flagyl in the unit and changed to
Levaquin and Flagyl. There was no evidence of ascending
cholangitis on the ERCP, but due to increased white blood cell
count and fever, these antibiotics were started for GI pathogens.
Blood cultures remained negative.
5. Endocrine: The patient was placed on insulin sliding
scale and blood sugars were followed.
He will f/u with his PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **].
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**]
Dictated By:[**Last Name (NamePattern1) 6834**]
MEDQUIST36
D: [**2166-5-12**] 16:18
T: [**2166-5-13**] 21:36
JOB#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname 6290**] [**Doctor Last Name 6291**] Unit No: [**Numeric Identifier 6292**]
Admission Date: [**2166-5-8**] Discharge Date: [**2166-5-13**]
Date of Birth: [**2101-12-24**] Sex: M
Service:
CONTINUATION OF PREVIOUS DISCHARGE SUMMARY:
Gastrointestinal Course: Patient continued to spike fevers
to 101 and obtained CT scan of the abdomen on [**5-11**]
significant only for pancreatic stranding, but patient had
normal LFTs and clinically appeared well and was tolerating a
diet.
DISPOSITION: Patient discharged to home.
MEDICATIONS:
1. Flagyl 500 mg three times a day for ten days.
2. Levofloxacin 500 mg once a day for ten days.
PATIENT INSTRUCTIONS: Patient to not work for the next week.
Normal diet and told to go to doctor if any signs of
gastrointestinal bleding, dizziness.
FOLLOW-UP APPOINTMENTS: Follow-up appointments with Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] or a partner at [**Hospital3 1381**] on Friday or [**Name (NI) 228**] at
[**Telephone/Fax (1) **].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6293**], M.D. [**MD Number(1) 2609**]
Dictated By:[**Doctor Last Name 6294**]
MEDQUIST36
D: [**2166-5-13**] 22:04
T: [**2166-5-13**] 22:04
JOB#: [**Job Number 6295**]
|
[
"577.0",
"998.11",
"576.1",
"574.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.88",
"51.85",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
157, 477
|
1957, 4275
|
4300, 4768
|
1096, 1938
|
507, 1072
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,028
| 131,911
|
35481
|
Discharge summary
|
report
|
Admission Date: [**2122-3-13**] Discharge Date: [**2122-3-19**]
Date of Birth: [**2047-3-21**] Sex: F
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 9853**]
Chief Complaint:
Dyspnea, hemodynamic monitoring
Major Surgical or Invasive Procedure:
PICC line placement and removal
History of Present Illness:
Ms. [**Known lastname 80827**] is a 74 year-old woman with a history of CHF, COPD
on home O2, transferred from [**Hospital6 **] for further
management of a newly diagnosed, 20 cm hepatic lesion, and also
found to be dyspneic. She has been doing poorly at home for the
past several months, with worsening Pickwickian syndrome. Her
son states that she has been falling alseep at meals and sleeps
approximately 16 hours per day. This pattern was gradually
worsening until two days prior to arrival when she developed a
nonproductive cough and more labored breathing. Her son brought
her to the [**Name (NI) **], however, because she had an episode of possible
uterine bleeding where they noted dried blood on a chair after
she stood up. She has a history of significant uterine bleeding
and her son was concerned that she was having a recurrence so he
brought her to the ED. At the OSH, she was noted to have left
sided chest pain and LUQ pain. She was also found to be
hypotensive to the 90s and a Hct was found to be 26. A
non-contrast CT torso was attained and demonstrated a 20cm low
attenuation mass with possible areas of bleeding, a small amount
of perihepatic fluid, and ?new bibasilar atelectasis. However,
her management also addressed her dyspnea, and the initial
impression was that she was also experiencing a COPD
exacerbation secondary to pneumonia. She was therefore given
levofloxacin, solumedrol, and 1 unit of blood, and transferred
to [**Hospital1 18**] for hepatology management, hemodynamic monitoring, and
possible IR procedure for hemostasis.
On arrival, her VS were 98.8 100/62 120 22 93%4L (on home O2 at
baseline). She was found to be mildly dyspneic and was given
nebs. Our Radiology department assessed his OSH scans and
provided the read described above. The liver transplant service
was also contact[**Name (NI) **] and concluded that they did not feel that
this was an acute bleed, and that there was no role for acute
operative or IR intervention. The surgical service was also
consulted were concerned about a PE given her dyspnea; they also
felt that anticoagulation with heparin would be reasonable.
Review of systems is otherwise negative for N/V/D/F/C.
Past Medical History:
Atrial fibrillation ([**2121**]; briefly anticoagulated in [**2121**] but
not currently)
CHF
COPD
DM2 ([**2113**])
CVA ([**2-/2121**]) w/ left sided weakness (resolved)
S/p cholecystectomy ([**2086**])
Uterine fibroid
Social History:
She has a 75-100 pack year smoking history (~2 packs per day for
50 years) but quit smoking 15 years ago. She does not drink
alcohol or use any other drugs. She lives with her son, who also
has COPD, and her husband. [**Name (NI) **] son notes increasing problems
with [**Name2 (NI) 80828**] and alertness and states that she has been
falling asleep at the dinner table.
Family History:
NC
Physical Exam:
General Appearance: Overweight / Obese
Eyes / Conjunctiva: PERRL
Head, Ears, Nose, Throat: Normocephalic
Lymphatic: Cervical WNL, Supraclavicular WNL
Cardiovascular: (S1: Normal), (S2: Normal)
Peripheral Vascular: (Right radial pulse: Present), (Left radial
pulse: Present), (Right DP pulse: Present), (Left DP pulse: Not
assessed)
Respiratory / Chest: (Expansion: Symmetric), (Percussion:
Resonant : ), (Breath Sounds: Diminished: )
Abdominal: Soft, Non-tender, Bowel sounds present, Obese
Extremities: Right: 1+, Left: 1+
Skin: Warm
Neurologic: Follows simple commands, Responds to: Verbal
stimuli, Movement: Not assessed, Tone: Not assessed, Very
sedated and moving slowly, appears encephalopathic
Pertinent Results:
cxr [**3-12**]: Bibasilar atelectasis, however, no evidence of CHF
exacerbation.
.
ct abd:
Suggestion of lipomatous deposition in the interatrial septum of
the heart. Clincial correlation advised as this can be
associated with
arrhythmias. MRI would be a more definitve examination to
confirm this
finding.
2. Vascular atherosclerotic calcifications.
3. Large, 20-cm predominantly low-density mass occupying the
majority of the right lobe of the liver, with internal regions
of hyperattenuation consistent with blood. Calcified rim
suggests a slow growing lesion. Based on the characteristics,
giant hemangioma is favored, but this remains incompletely
characterized on this non-contrast study. Further evaluation
with multiphasic CT or MRI is recommended as allowed by the
patient's renal function.
4. Additional hypoattenuating lesions within the caudate and the
left lobe of the liver are incompletely characterized.
5. Small amount of perisplenic and perihepatic free fluid.
6. Degenerative changes of the spine with grade 1
anterolisthesis of L4 on
L5.
.
[**3-12**] echo: The left atrium is markedly dilated. The right atrium
is moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). [Intrinsic left ventricular systolic function is
likely more depressed given the severity of valvular
regurgitation.] The right ventricular cavity is mildly dilated
with normal free wall contractility. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
mildly thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. Moderate (2+) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is a small pericardial effusion. The effusion appears
circumferential.
IMPRESSION: Suboptimal technical quality. Global left
ventricular function is probably normal, but a focal wall motion
abnormality cannot be fully excluded. Mild right ventricular
dilation with normal systolic function. Moderate mitral
regurgitation. Mild pulmonary hypertension. Small pericardial
effusion without echocardiographic signs of tamponade.
.
LENI: Slightly limited exam without evidence of DVT.
.
CXR: As compared to the previous radiograph, there is a minimal
increase of bilateral basal parenchymal opacities suggestive to
represent atelectasis. No clear evidence of overhydration. No
focal parenchymal opacity suggestive of pneumonia. Unchanged
position of the right PICC line.
.
Brief Hospital Course:
Ms. [**Known lastname 80827**] is a 74 year-old woman with a history of CHF, COPD
on home O2, transferred from [**Hospital6 **] for further
management of a newly diagnosed, 20 cm hepatic lesion, and also
found to be dyspneic.
.
#. Acute on chronic hypoxic respiratory failure: Initially,
multiple etiologies were considered including CHF exacerbation
vs pneumonia/COPD exacerbation vs PE. Despite the fact she had
no wheezing suggesting worsening COPD and was afebrile, as she
appeared quite ill she was initially treated for pneumonia/CHF
exacerbation with furosemide for diuresis as well as
levofloxacin. There was considerable concern for PE as well but
due to concern about her liver mass as well as possible vaginal
bleeding anticoagulation was held. On hospital day two,
however, her respiratory status began to improve significantly
with diuresis and further control of her atrial fibrillation
(see below). As she had had no fevers and there was no clear
infiltrate on chest radiograph with no wheezing antibiotics were
stopped and she was just kept on inhalers. She diuresed greater
than two liters over her first 18 hours in the hospital and
this, along with improved rate control in the setting of her
probable diastolic dysfunction, significantly improved her
subjective dyspnea and O2 requirement so that she was having
reasonable O2 sats of 92-97 on 2 L by NC. Initially there were
some attempts to increase her to greater than 95 % and she
received increasing O2 but this seemed to contribute to a
depressed respiratory drive (attributed to her COPD and
appearance of chronic CO2 retention) so this was stopped. As of
her second hospital day given negative LENIS, resolution of her
chest pain, and improvement of her respiratory status to near
her baseline the primary team felt comfortable not empirically
treating for PE, and her respiratory status eventually returned
to near baseline.
#Chronic hypercarbic respiratory failure: The patient has COPD
and Pickwickian syndrome and a chronically elevated bicarbonate
suggesting an ongoing respiratory acidosis. As she had no
significant wheezing steroids were held though she did continue
to receive her home meds. After falling asleep in a chair on
her second night in the hospital she was extremely difficult to
arouse the following morning with ABG showing a worsening of her
chronic respiratory acidosis. This was thought due to
hypoventilation due to habitus and perhaps increased O2 provided
during the night due to fear of ACS (as the patient complained
of some chest pain), which could cause decreased respiratory
drive in a chronic CO2 retainer such as this. This improved
with BiPAP as did her mental status. She would benefit from a
BiPAP trial as an outpatient; this was not done as an inpatient
because she will not be following up at [**Hospital1 18**] so CPAP will be
continued until then.
#. ?Congestive heart failure: The patient was dyspneic on
presentation and has evidence of chronic diastolic CHF on TTE.
She was empirically diuresed with some improvement in her
symptoms. She was discharged to rehab on her home dose of Lasix
that may continue to be titrated.
#. A. fib with RVR: Was in SVT on arrival to [**Hospital Unit Name 153**] and
ventricular rate slowed with metoprolol 5mg IV x 1 and diltiazem
10mg IV x 2. Eventually, she was placed on a diltiazem drip for
improved rate control which led to improvement in her chest
discomfort and dyspnea. On her second hospital day she was
transitioned back to her PO diltiazem with good effect.
Metoprolol and digoxin were also continued with good rate
control.
#Chest Pain: The patient had chest pain on her first and second
hospital nights. These incidents of pain were atypical, there
were no EKG changes, and cardiac enzymes remained flat. The
first night this improved with diuresis and rate control. On
the second this resolved with positioning and was thought
largely due to the patient's habitus and difficult positioning
herself in bed.
#. Hepatic hemangioma: Surgery and her primary team remained
convinced this lesion was an incidental finding that had
probably developed slowly. No specific management was attempted
though transplant surgery did follow her and recommended
outpatient followup.
#. Chronic kidney disease: The patient reported a history of CKD
of unclear etiology. Her Cr was 2.4 at presentation and
improved over her hospital course to 1.3 on the day of
discharge. All medications were renally dosed.
#. History of uterine bleeding: The patient had a history of
uterine bleeding and had a questionable incident of bleeding
prior to presentation. Obstetrics and gynecology was consulted
on the morning after admission and managed to find records
indicating the patient was undergoing a significant post
menopausal bleeding work-up at Brown. They deferred pelvic exam
as there was no further bleeding noted and her Hct remained
stable.
Medications on Admission:
Colace 100 mg po qd
MVIA 1 tab qd
Aspirin 81 mg po qd
Synthroid 0.175 mg po qd
Glipizide 10mg po bid
Prozac 20 mg po qd
Lisinopril 5 mg po qd
Toprol 50 mg po bid
Cardizem 180 mg po qd
Lasix 60 mg po bid
Lyrica 100 mg tid
Omeprazole 20 mg po qd
Potassium chloride 40 mg [**Hospital1 **]
Digoxin 0.125 mq po qSMW (not Tues/Thurs)
Zocor 20 mg po qhs
Ipratroprium and albuterol nebs
Albuterol inhaler
Flovent/Advair
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
9. DILT-XR 120 mg Capsule,Degradable Cnt Release Sig: One (1)
Capsule,Degradable Cnt Release PO once a day.
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
11. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO TID (3
times a day).
12. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO 5X/WEEK
([**Doctor First Name **],MO,WE,FR,SA).
14. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
15. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
16. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig:
Three (3) ML Inhalation q4h ().
17. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
18. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
19. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
20. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
21. Insulin Regular Human 100 unit/mL Solution Sig: per sliding
scale Injection ASDIR (AS DIRECTED).
22. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
23. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
24. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
25. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed.
Discharge Disposition:
Extended Care
Facility:
Southeastern MA Health & Rehabilitation Center
Discharge Diagnosis:
Primary: hepatic hemangioma, COPD, atrial fibrillation with RVR
Secondary: chronic diastolic CHF, DM2, h/o CVA
Discharge Condition:
good, stable, mental status at baseline, not somnolent,
breathing comfortably at rest with 0-2L O2
Discharge Instructions:
You were evaluated for consideration of treatment of a hepatic
hemangioma as well as for respiratory distress. The surgeons do
not feel any intervention for the hemangioma is warranted at
this time. Your respiratory status improved with control of your
heart rate, nebulizers, and gentle diuresis. You would benefit
from a trial of BiPAP, but as you are not going to follow up
here at [**Hospital1 18**], this may be done as an outpatient.
If you have worsening shortness of breath, fevers, chills, chest
pain, confusion, or any other concerning symptoms, have the
doctors at rehab [**Name5 (PTitle) 4656**] you.
Followup Instructions:
Follow up with your primary care physician 1-2 weeks after being
discharged from rehab. You should undergo a trial of BiPAP that
your primary care phsyician can set up for you. Call Dr. [**Name (NI) 80829**] office at [**Telephone/Fax (1) 9674**] to make an appointment.
You may follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of surgery regarding
your hepatic hemangioma. Call his office at ([**Telephone/Fax (1) 3618**] to
make an appointment. If you would rather follow up with a
surgeon closer to home, have your primary care physician refer
you.
|
[
"584.9",
"250.00",
"585.9",
"518.84",
"228.04",
"428.0",
"427.31",
"403.90",
"496",
"428.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
14276, 14349
|
6615, 11539
|
299, 333
|
14504, 14605
|
3951, 6592
|
15267, 15859
|
3199, 3203
|
12002, 14253
|
14370, 14483
|
11565, 11979
|
14629, 15244
|
3218, 3932
|
228, 261
|
361, 2553
|
2575, 2795
|
2811, 3183
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,342
| 102,412
|
40704
|
Discharge summary
|
report
|
Admission Date: [**2200-1-23**] Discharge Date: [**2200-1-31**]
Date of Birth: [**2149-3-13**] Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
Liver transplant failure
Major Surgical or Invasive Procedure:
liver transplant [**2200-1-24**]
History of Present Illness:
50 M here for repeat OLT. He is s/p deceased donor liver and
kidney transplant c/b hepatic artery thrombosis leading an
ex-lap, resection of distal CBD and debridement of segments 4
and
5. The graft ultimately failed and he was relisted. He has no
complaints and denies any recent fevers, chills, nausea,
vomiting, or general malaise. He also denies any erethema or
purulent drainage from his multiple drains.
Past Medical History:
hepatitis C ([**2184**]) c/b cirrhosis, salmonella gastroenteritis
with acute renal failure, chronic kidney disease with renal
stones s/p lithotripsy ([**2192**]), DM (dx [**2188**], off medications,
diet-controlled), HTN ([**2196**], well-controlled, off medications),
ITP s/p splenectomy ([**2173**]), asthma
PSH: splenectomy [**2173**], lithotripsy [**2192**], Combined liver/kidney
transplant [**2199-10-17**], repeat liver transplant [**2200-1-24**]
Social History:
SH: Lives with sister, has two children. Prior heroin user,
sober for two years, on methadone program.
Family History:
FH: His family history is significant for an aunt and uncle with
diabetes.
Physical Exam:
Phx: 96.6 61 149/76 20 100RA
GEN: A&O, NAD
HEENT: mild ly jaundiced, thin male, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses, incision CDI well
healed, G tube capped, medial and lateral drains ss, PTC capped
Ext: No LE edema, LE warm and well perfused
Brief Hospital Course:
50 M s/p CKT/OLT c/b hepatic artery thrombosis, and graft
failure underwent repeat liver transplant on [**2200-1-24**]. Surgeon
was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for
details. Postop, he went to the SICU intubated. [**Doctor Last Name 406**] drain
outputs were non-bilious. LFTs decreased daily. Initial liver
duplex noted abnormal vascularity seen proximal to the porta
hepatis with a color thrill and high velocity within the
extrahepatic main portal vein suggestive of an AV fistula.
Parvus tardus waveforms were seen within the right and left
hepatic arteries with very low resistive indices. Hepatic veins
were patent. There was no biliary dilatation and no hepatic
collections were seen within the transplanted liver. Duplex was
repeated on [**1-25**] that revealed interval improvement in waveforms
within the main hepatic artery and portal vein. Portal vein had
focal
area of considerable acceleration but was improved. An ABD CTA
was done to evaluate vasculature. This demonstrated patent
arterial anastomosis with an arterial conduit extending from the
infrarenal abdominal aorta to the donor liver. Stenosis at the
site of insertion of the arterial conduit into the aorta was
noted. There was no convincing CT evidence of an arterial-portal
fistula. Marked narrowing of the portal vein at the level of the
porta hepatis adjacent to one of the surgical drains,was noted,
however no thrombosis of the portal vein was seen.
LFTs continued to decrease. He required blood products on postop
day 1 and 2 then Hct and coags remained stable. He was
extubated on [**1-25**]. IV Dapto, Micafungin and Unasyn were
continued given past micro data and the plan was to continue for
a 2 week course. Diet was slowly advanced. J tube feedings were
started.
Creatinine was 2.0 on [**1-27**]. Renal transplant US was wnl. He
transferred out of the SICU on postop day 4. Renal function
improved with creatinine decreasing to normal. Lasix was given
for generalized edema. Blood cultures were drawn on [**1-27**] and
isolated GNR. Unasyn was switched to Meropenum which was given
for 3 days until blood culture speciated Klebsiella Oxytoca
sensitive to Cefepime. Meropenem was switched to Cefepime on
[**1-29**]. The plan was to continue all antibiotics (Micafungin,
Cefepime and Dapto until [**2-4**]. Daily surveillance blood cultures
were drawn and remained negative to date ([**1-28**], [**1-29**], [**1-30**], [**1-31**]).
A right IJ picc line was inserted on [**1-30**].
Dietary intake improved. Tube feeds were switched to cycled
feeds (6p to 6a) . He became more ambulatory. Medial JP was was
removed on [**1-30**]. Lateral JP was removed on POD 7.
Physical therapy worked with him. He did well ambulating and was
independent by postop day 6. The plan was to transfer to rehab
when a bed was available given need for multiple antibiotics and
tube feed.
Immunosuppression consisted on Cellcept, steroid taper per
transplant protocol and Prograf which was adjusted up to 6mg [**Hospital1 **]
for trough level of 5.9 (goal of [**10-10**]). Pentamidine (PCP
prophylaxis was given on [**1-30**]).
Medications on Admission:
FK 4'', MMF 500'', micafungin 100', daptomycin 500', valcyte
450'', pentamidine 300' Q month, dilaudid 1 Q3H PRN, lantus 14'
HS, SSI, methadone 40', metoprolol 25'', zofran 4''' PRN,
trazadone 50' HS, albuterol 90 HFA 2 puffs PR
All: bactrim
Discharge Medications:
1. prednisone 5 mg Tablet [**Month/Day (2) **]: Four (4) Tablet PO DAILY (Daily):
follow printed taper schedule.
2. mycophenolate mofetil 500 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO
BID (2 times a day).
3. docusate sodium 100 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2
times a day).
4. aspirin 81 mg Tablet, Chewable [**Month/Day (2) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. trazodone 50 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
7. hydromorphone 2 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
8. amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily):
hold for sbp <110 or HR <60 .
9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
10. dextrose 50% in water (D50W) Syringe [**Month/Day (2) **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.
11. ondansetron HCl (PF) 4 mg/2 mL Solution [**Month/Day (2) **]: One (1)
Injection Q8H (every 8 hours) as needed for nausea/vomiting.
12. methadone 10 mg Tablet [**Month/Day (2) **]: Four (4) Tablet PO DAILY
(Daily).
13. metoprolol tartrate 25 mg Tablet [**Month/Day (2) **]: 1.5 Tablets PO TID (3
times a day): hold for sbp <110 or HR <60.
14. acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: no more than 2000mg per day.
15. glucagon (human recombinant) 1 mg Recon Soln [**Month/Day (2) **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
16. insulin regular human 100 unit/mL Solution [**Month/Day (2) **]: follow
printed sliding scale Injection ASDIR (AS DIRECTED).
17. valganciclovir 450 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO Q24H
(every 24 hours): cmv prophylaxis.
18. cefepime 2 gram Recon Soln [**Month/Day (2) **]: One (1) Recon Soln Injection
Q12H (every 12 hours): for Klebsiella bacteremia.continue until
[**2-7**]
.
19. micafungin 100 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): continue until [**2-7**].
20. daptomycin 500 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln
Intravenous Q24H (every 24 hours): continue until [**2-7**].
21. Outpatient Lab Work
Stat every Monday and Thursday for
cbc, chem 10, ast, alt, alk phos, t.bili, albumin, UA and trough
prograf level
Fax to [**Telephone/Fax (1) 697**] attention Transplant Coordinator
22. tacrolimus 1 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO twice a day.
23. tacrolimus 5 mg Capsule [**Telephone/Fax (1) **]: One (1) Capsule PO twice a day.
24. furosemide 40 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times
a day): stop if weight decreases by 5kg. wt 68kg on [**1-31**].
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **]/ [**Hospital1 8**]
Discharge Diagnosis:
h/o liver and kidney transplant c/b HA thrombosis with hepatic
abscesses s/p liver transplant.
re-transplanted liver
malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You will be transferring to [**Hospital **] [**Hospital 8**] Rehab
Call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the
warning signs listed below
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-2-6**] 2:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 14254**], [**Name12 (NameIs) 1046**] Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-2-6**] 3:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2200-2-13**] 1:45
Completed by:[**2200-1-31**]
|
[
"444.89",
"570",
"V18.0",
"250.00",
"785.0",
"996.82",
"998.11",
"041.3",
"997.1",
"V42.0",
"E878.0",
"568.0",
"304.01",
"V13.01",
"997.49",
"401.9",
"285.1",
"452",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"96.6",
"50.59",
"00.93",
"99.21",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
8388, 8450
|
1904, 5072
|
292, 327
|
8624, 8624
|
8971, 9478
|
1385, 1462
|
5366, 8365
|
8471, 8603
|
5098, 5343
|
8775, 8948
|
1477, 1881
|
228, 254
|
355, 767
|
8639, 8751
|
789, 1247
|
1263, 1369
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,142
| 198,248
|
45228
|
Discharge summary
|
report
|
Admission Date: [**2136-12-28**] Discharge Date: [**2136-12-29**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 78-year-old
woman with a history of coronary artery disease, status post
coronary artery bypass graft who was at the hairdresser's
today and collapsed. EMS was called. Patient was intubated
in the Emergency Department. A stat head CT showed a large
cerebellar bleed pressing on the brain stem and effacing the
fourth ventricle.
The patient was taken emergently to the Operating Room for
craniotomy and evacuation of the hematoma. Pre Operating
Room, patient's pupils were midline and nonreactive. The
patient was withdrawing upper extremities and lower
extremities to pain, not localizing, had positive corneals.
The patient was taken to the Operating Room and underwent a
suboccipital craniotomy and drainage of a hematoma without
intraoperative complications. Postoperatively, the patient
was monitored in the Neurosurgical Intensive Care Unit. She
never regained consciousness. On [**2136-12-29**] on exam, pupils
were fixed and dilated. She had no doll's, no corneals, no
cough or gag. She had triple flexion in her lower
extremities and no withdrawal to pain in her upper
extremities.
Situation was discussed with family. The family had opted to
make patient a DNR/DNI and to extubate the patient. The
patient passed away at 5:22 p.m. on [**2136-12-29**] with family
present.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2137-1-17**] 09:43
T: [**2137-1-17**] 09:48
JOB#: [**Job Number 96665**]
|
[
"431",
"401.9",
"V45.81",
"331.4",
"272.4",
"530.81",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.2",
"01.39",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
115, 1708
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,257
| 146,226
|
36913
|
Discharge summary
|
report
|
Admission Date: [**2131-2-23**] Discharge Date: [**2131-3-2**]
Date of Birth: [**2073-8-13**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 896**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
central venous cannulation
arterial cannulation
History of Present Illness:
57 year old male with past history of ETOH abuse, COPD/asthma
(no O2 requirement, medications unknown), Hypertension, HCV s/p
interferon who was brought to the ED by police after being found
in the street with AMS. Patient reported to be repeating the
word "[**Location (un) **]", but answering yes/no. He was found to be
hypoglycemic (50), recieved glucagon in the field. He was
brought to the ED for evaluation.
In the ED, he continued to have AMS. Blood glucose 201. Serum
ETOH 15. Acute renal failure with acidosis and anion gap of 27.
UA negative, urine tox negative. Calculated Osm 328; Measured
Osm 316. EKG was reported to have. ABG 7.29/51/66. Was given
Haldol 5mg IV and Ativan 2 mg IV for CT Head, which was negative
for acute intracranial process. Chest X-ray with no effusions or
consolidations. EKG with sinus tachycardia, old RBBB, difficult
to interpret inferior leads due to artifact, no ST or Twave
changes noted.
Past Medical History:
- HTN
- COPD/asthma
- HCV: treated with interferon and ribavirin in [**2119**], neg viral
load currently per pt
- EtOH abuse
- h/o ethylene glycol ingestion with hospitalization at [**Hospital1 2177**]
Social History:
Lives in a "dorm." Smoked 1 ppd since age 9. EtOH use as above.
H/o marijuana use but denies IVDU.
Family History:
Mother with mental illness. Father alcoholic. Grandmother with
congenital heart disease. Grandfather with DM, renal failure.
Also with h/o DM. No h/o cancers.
Physical Exam:
VS: Temp: 96.9 BP: 165/56 HR: 132 RR: 22 O2sat 95% 4L
GEN: agitated, diaphoretic
HEENT: 2mm pupils, constrict to light, dry mucous membranes,
sclera anicteric, no JVD
RESP: CTA bilaterally, no wheeze or rhonchi
CV: tachycardic, regular rate, no m/g/r
ABD: soft, non-tender, non-distended, hypoactive BS, no gaurding
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
NEURO: Easily awakens to voice, spontaneously moves all 4
extremities, tremulous, no asterexis.
withdraws from painful stimuli
Pertinent Results:
[**2131-2-22**] 09:25PM BLOOD WBC-9.5 RBC-3.89* Hgb-12.9* Hct-36.7*
MCV-94 MCH-33.2* MCHC-35.2* RDW-14.1 Plt Ct-170
[**2131-2-22**] 09:25PM BLOOD Neuts-80.0* Lymphs-14.5* Monos-4.3
Eos-0.8 Baso-0.4
[**2131-2-22**] 09:25PM BLOOD PT-12.1 PTT-25.3 INR(PT)-1.0
[**2131-2-22**] 09:25PM BLOOD Glucose-201* UreaN-49* Creat-3.2*# Na-142
K-4.2 Cl-96 HCO3-19* AnGap-31*
[**2131-2-23**] 01:32AM BLOOD Glucose-75 UreaN-49* Creat-2.5* Na-140
K-4.6 Cl-101 HCO3-19* AnGap-25*
[**2131-2-23**] 04:00PM BLOOD Glucose-192* UreaN-40* Creat-1.4*# Na-137
K-3.6 Cl-101 HCO3-26 AnGap-14
[**2131-2-24**] 03:41AM BLOOD Glucose-139* UreaN-24* Creat-1.0 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
[**2131-2-25**] 03:42AM BLOOD Glucose-79 UreaN-19 Creat-1.1 Na-139
K-4.2 Cl-108 HCO3-24 AnGap-11
[**2131-2-26**] 03:44AM BLOOD Glucose-124* UreaN-14 Creat-1.1 Na-137
K-4.1 Cl-105 HCO3-23 AnGap-13
[**2131-2-23**] 01:32AM BLOOD ALT-61* AST-62* CK(CPK)-319 AlkPhos-59
TotBili-0.7
[**2131-2-23**] 04:00PM BLOOD ALT-50* AST-49* AlkPhos-56 TotBili-1.0
[**2131-2-24**] 03:41AM BLOOD ALT-42* AST-39 AlkPhos-51 TotBili-0.8
[**2131-2-25**] 03:42AM BLOOD ALT-35 AST-34 CK(CPK)-192 AlkPhos-53
TotBili-1.0
[**2131-2-23**] 01:32AM BLOOD CK-MB-9 cTropnT-<0.01
[**2131-2-22**] 09:25PM BLOOD Calcium-9.4 Phos-10.0*# Mg-2.0
[**2131-2-26**] 03:44AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.9
[**2131-2-23**] 01:32AM BLOOD VitB12-801 Folate-16.0
[**2131-2-22**] 09:25PM BLOOD Osmolal-316*
[**2131-2-23**] 10:48AM BLOOD Ammonia-29
[**2131-2-23**] 01:32AM BLOOD TSH-1.2
[**2131-2-22**] 09:25PM BLOOD ASA-NEG Ethanol-15* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2131-2-22**] 11:17PM BLOOD Type-ART pO2-66* pCO2-51* pH-7.29*
calTCO2-26 Base XS--2
[**2131-2-23**] 01:59AM BLOOD Type-ART pO2-140* pCO2-45 pH-7.30*
calTCO2-23 Base XS--3
[**2131-2-23**] 09:47AM BLOOD Type-ART Temp-36.6 pO2-79* pCO2-38
pH-7.40 calTCO2-24 Base XS-0 Intubat-NOT INTUBA
[**2131-2-26**] 11:18AM BLOOD Type-ART Temp-36.4 FiO2-40 pO2-115*
pCO2-40 pH-7.39 calTCO2-25 Base XS-0 Intubat-NOT INTUBA
[**2131-2-23**] 01:59AM BLOOD Lactate-1.1
[**2131-2-22**] 10:50PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Sputum cultures from [**2-23**] and [**2-24**]: MSSA
.
[**2-22**]:
CT head
Left maxillary sinus retention cyst. No acute intracranial
process.
CXR:
The lung volumes are low. There is mild vascular congestion.
There is no
focal consolidation, no pleural effusion, and no pneumothorax.
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
57 M with past history of ETOH abuse, HCV, hypertension brought
to ED by police with AMS, found to be in ARF and found to have
ingestion of ethylene glycol.
# Alcohol withdrawal: After extubation and propofol and precedex
were discontinued, he developed increasing agitation as well as
hypertension and tachycardia consistent with alcohol withdrawal.
He was treated with clonidine and valium which were both weaned
off prior to discharge. Social work counseled on
discontinuation of alcohol abuse. Patient to follow up as an
out patient in a treatment program. Contact information
provided.
# Ethylene glycol ingestion: Confirmed by positive level.
Received fomepizole x 1 which was not continued further as renal
function improved, gap closed and level < 20.
# Delirium: Felt to be secondary to alcohol withdrawal. Was also
treated with high dose thiamine for possible wernicke??????s
encephalopathy but delirium resolved prior to dischage.
# Pneumonia: MSSA on sputum culture. Treated for a total of 8
days to complete with augmentin as an out patient. Last dose
[**2131-3-4**].
# Acute Kidney Injury: Pre renal, resolved with fluids back to
baseline of 1.
# Anemia: Stable. MCV elevated. Likely [**12-20**] ETOH, discharged on
thiamine and folate.
Medications on Admission:
lisinopril 40mg daily
aspirin 81mg daily
baclofen 50mg TID
zocor ?20mg
Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Zocor 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. baclofen 10 mg Tablet Sig: Five (5) Tablet PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol abuse
Ethylene glycol ingestion
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with alcohol intoxication and ethylene glycol
poisoning. You also developed a lung infection (pneumonia)
while you were here and required intubation. You are being
treated with antibiotics and your lung infection has improved.
The following medication change was made:
- ADDED: Amoxicillin/Clavulanic acid: take 1 tablet twice a day
for another three days, last dose on the evening on [**2131-3-4**]
- ADDED: folate, thiamine and a multivitamin
No other medication changes were made, you should continue all
your other home medications as previously directed.
You were seen by social work for help with alcohol abuse. Your
drinking is very dangerous and it's important to stop.
It was a pleasure meeting you and participating in your care.
Followup Instructions:
Please follow up with your PCP as needed
|
[
"275.3",
"E862.4",
"276.2",
"V46.2",
"482.41",
"303.91",
"305.1",
"401.9",
"785.0",
"982.8",
"518.81",
"780.97",
"493.20",
"265.1",
"584.9",
"287.5",
"291.81",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.6",
"38.91",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
7046, 7052
|
4938, 6203
|
324, 411
|
7149, 7149
|
2430, 4915
|
8093, 8137
|
1734, 1894
|
6324, 7023
|
7073, 7128
|
6229, 6301
|
7300, 8070
|
1909, 2411
|
263, 286
|
439, 1373
|
7164, 7276
|
1396, 1600
|
1616, 1718
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
340
| 139,131
|
45644+58840
|
Discharge summary
|
report+addendum
|
Admission Date: [**2182-1-19**] Discharge Date: [**2182-2-8**]
Date of Birth: [**2121-7-11**] Sex: F
Service: NSU
HISTORY OF PRESENT ILLNESS: The patient is a 60-year-old
female, who was in her usual state of health, who developed
severe headache in the afternoon, laid down on the couch,
awoke, stood up and got a severe occipital headache and
became suddenly nauseated. She has a history of migraines
being treated through the Emergency Room with a protocol of
Demerol and Phenergan. She received this once or twice a
month in the Emergency Room. She states this headache was
much worse than usual migraine. She took an aspirin, and she
called EMS.
PAST MEDICAL HISTORY: Migraines x 40 years, cervicalgia,
myofascial pain syndrome, hypertension, GERD,
history of a PE and DVT, status post cholecystectomy,
hysterectomy, vein stripping of the right leg, pilonidal
cyst, laminectomy.
The patient was admitted through the Emergency Room. CTA of
the head showed suprasellar cistern subarachnoid hemorrhage
which extends into the sulci bilaterally with no shift of
normally midline structures. CTA shows a right ACA aneurysm.
ALLERGIES: Bactrim.
MEDICATIONS ON ADMISSION:
1. Prozac 10 once daily.
2. Premarin 0.9 once daily.
3. Ativan 1 [**Hospital1 **].
4. Protonix 40 once daily.
PHYSICAL EXAM: Temp 97.9, heart rate 102, BP 153/71,
respiratory rate 16, sats 97 percent. HEENT: Pupils equal,
round and reactive to light, 2 down to 1.5. EOMs full.
NECK: Pain with movement. PULMONARY: Lungs clear
bilaterally. CARDIOVASCULAR: Regular rate and rhythm.
ABDOMEN: Soft, nontender, positive bowel sounds.
EXTREMITIES: No edema. NEUROLOGICALLY: Awake, alert and
oriented x 3. Prefers eyes closed. Complaining of
photophobia. Pupils equal, round and reactive to light.
EOMs full. Visual fields intact. Strength is [**4-18**] in all
muscle groups. Her reflexes are 2 plus throughout. Her toes
are mute.
HOSPITAL COURSE: The patient is admitted to the
neurosurgical service to the ICU for close neurologic
observation. On [**2182-1-20**], diagnostic angio showed a right
A1, A2 bifurcation aneurysm which could not be coiled. The
patient was taken to the ICU post procedure and remained
neurologically stable, was intubated prior to the procedure,
awakened easily, following commands, wiggling toes. Femoral
A-line was in place. Positive pedal pulses. Blood pressure
was kept at 110-130 range. The patient was on close
neurologic observation in the ICU.
She was taken to the OR on [**2182-1-20**] for craniotomy for
clipping of a right ACOM aneurysm. There were no intraop
complications. Postop, the patient was intubated with
minimal sedation, nodding yes and no appropriately to
questions, following commands. Pupils equal, round and
reactive to light. EOMs full. Grasps were [**4-18**]. The patient
was able to wiggle her toes. The patient had a vent drain
placed in the OR which was leveled at the tragus. Her vital
signs were stable. The patient had lower extremity Dopplers
done on [**2182-1-21**] that showed no evidence of DVT. Her IV
fluids decreased to 50 cc/h. Her CVP was kept [**7-26**]. She was
neurologically stable, following commands, awake, alert and
attentive on postop day 1.
The patient was taken back to angio on [**2182-1-21**]. Angio
showed no vasospasm, and no residual aneurysm. KUB was done.
The patient was transfused with 1 unit of packed red blood
cells for a crit of 26.6, and repeat post-transfusion 30.4.
The patient had a JP drain in place which was removed. The
vent drain continued to drain CSF and was leveled at 10 cm
above the tragus.
On [**2182-1-23**], the patient was alert, attentive, opening
eyes, moderately confused, following commands, no drift.
Goal CVP again [**7-26**]. IV fluids kept at 120/h. Drain was
leveled at 12 cm above the tragus. She had a repeat head CT
that showed a right head of the caudate infarct without any
other changes. The patient's neurologic status remained
stable.
On [**1-25**], she spiked to 101.5. She was pancultured. CSF
showed 21 red cells and 7,250 white cells. On [**1-26**], the
patient had a CTA which was negative for vasospasm. The
patient was out-of-bed to the chair. Decadron was weaning.
She was awake, alert and oriented x 3. Pupils equal, round
and reactive to light. EOMs full. No nystagmus. She had no
drift. Her grasps were full. IPs were full.
On [**2182-1-28**], the vent drain was removed, and the patient
had a lumbar drain placed without complication. Patient
awake and alert, but only oriented to herself, which has been
her baseline since admission. Following commands x 4 with
good strength, no drift, face symmetric. Her dressing was
clean, dry and intact. Her lumbar drainage was down to 5 cc
q 2 h. The patient was seen by physical therapy,
occupational therapy and felt to require short rehab stay.
On [**2182-2-4**], the patient complained of a headache. She had
no drift. Repetition intact. Face was symmetric. Moving
all four extremities. IPs were full. EOMs full. The
patient had an LP. Opening pressure was 15, closing pressure
6. CSF was tea-colored. The patient was seen by GI service
for a rising amylase and lipase which were asymptomatic.
They recommended following daily LFTs, an MRCP to evaluate
biliary tree, as well as to reevaluate cystic pancreatic
lesion. She was transferred to Step Down Unit on [**2182-2-5**].
The patient had repeat lower extremity Dopplers done on
[**2182-2-6**] which were negative for DVT. The patient's
neurologic status remained stable, although the patient
continued to be confused. She was awake, alert and oriented
x [**12-16**], moving all extremities with good strength, following
commands.
MEDICATIONS ON DISCHARGE:
1. Dilantin 100 mg po tid.
2. Lansoprazole 30 po once daily.
3. Miconazole powder to groin topically [**Hospital1 **].
4. Heparin 5,000 units subcu tid.
5. Colace 100 mg po bid.
6. Estrogen conjugated 0.9 mg po once daily.
7. Fluoxetine 10 mg po once daily.
8. Ibuprofen 400 mg po q 8 prn.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: She will follow-up with Dr. [**Last Name (STitle) 1132**] in 2 weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2182-2-7**] 10:54:07
T: [**2182-2-7**] 11:44:45
Job#: [**Job Number 69479**]
Name: [**Known lastname 9440**], [**Known firstname **] Unit No: [**Numeric Identifier 15515**]
Admission Date: [**2182-1-19**] Discharge Date: [**2182-2-11**]
Date of Birth: [**2121-7-11**] Sex: F
Service: NSU
ADDENDUM: The patient's discharge was delayed until [**2182-2-11**]. The patient had positive blood cultures on
[**2182-1-29**] thought most likely to be contaminant;
however, repeat cultures were sent and to date have been
negative. The patient was given one dose of IV vancomycin 1
gram after consulting with the Infectious Disease Service.
The patient's condition remained stable. She was
neurologically intact with no fever and stable vital signs.
She was discharged on [**2182-2-11**] in stable condition
with followup with Dr. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 365**] in two weeks.
[**Name6 (MD) **] [**Last Name (NamePattern4) 2483**], [**MD Number(1) 2484**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2182-2-11**] 11:04:17
T: [**2182-2-11**] 11:30:54
Job#: [**Job Number 15516**]
|
[
"780.09",
"V12.51",
"430",
"790.5",
"401.9",
"530.81",
"780.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.39",
"38.93",
"03.31",
"99.04",
"39.51",
"88.41"
] |
icd9pcs
|
[
[
[]
]
] |
5779, 6071
|
1203, 1315
|
1968, 5753
|
1331, 1950
|
6117, 7577
|
164, 678
|
701, 1177
|
6096, 6105
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,160
| 188,027
|
51407
|
Discharge summary
|
report
|
Admission Date: [**2172-3-8**] Discharge Date: [**2172-3-11**]
Date of Birth: [**2124-1-30**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old
with HIV1, CD4 count of 46, viral load of 286, and history of
polysubstance abuse who was found his 17-year-old son lying
on the snow after arriving/departing from methadone clinic.
His son stated that the patient took a large amount of Xanax
the night before and became lethargic. The patient denied
taking Xanax. He limits herself to one in the morning and
one in the evening. EMS found the patient to have a heart
rate of 96, blood pressure of 110/80, oxygen saturation 95%,
unable to communicate. The patient was more responsive after
given Narcan.
The patient was taken to the Emergency Department where he
was given Narcan IV, 0.01 mg x 5, Levaquin 500 mg IV, Bactrim
250 IV for possible PCP. [**Name10 (NameIs) **] patient denied fever, weight
loss, chills and also history of headaches, vomiting. No
night sweats. He has had appropriate appetite. Normal bowel
and bladder movement.
Later the family questioned whether the patient had been
tired due to lack of fatigue. The patient denied falling in
snow. The patient reported only some weakness when
attempting to mobilize due to pain in her legs. The mother
reported that the patient might have taken the nighttime dose
and took them in the morning.
PAST MEDICAL HISTORY: HIV1. Hepatitis B/C, polysubstance
abuse. No cocaine. No heroine. Depression/anxiety.
Bilateral leg fractures secondary to MVA with recent cast
removal. ............
MEDICATIONS: Methadone, Xanax, Neurontin, Multivitamin.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: See prior history for social history.
Father died of ethanol abuse. He has one son with abuse
problems.
LABORATORY DATA: White blood cell count 7.9, hematocrit
37.8, platelet count 305; sodium 136, potassium 3.6, chloride
100, bicarb 26, BUN 22, creatinine 0.6; ABG 7.37, 51/52; INR
1.1; toxicology screen negative; urine screen positive for
opiates and methadone.
PHYSICAL EXAMINATION: Vital signs: Temperature 97.5??????, blood
pressure 94/43, heart rate 81, respirations 15, oxygen
saturation 99% on room air. HEENT: Clear. Pupils equal,
round and reactive to light. Extraocular movements intact.
Neck: ................... Lungs: Clear to auscultation
bilaterally. Cardiovascular: Regular, rate and rhythm.
Abdomen: Nondistended, nontender. No masses. Extremities:
Slightly edematous with multiple scarring from surgery.
Neurological: Alert and oriented. Cranial nerves II-XII
intact. Upper motor strength ................... secondary
to pain. Reflexes ...................
LABORATORY DATA: Chest x-ray with no effusions, reticular
opacities probably secondary to his ...................
Electrocardiogram normal sinus rhythm, 95, normal axis,
normal intervals, normal ...................
HOSPITAL COURSE: 1. Mental status change: The patient
responded to Narcan.
2. Pulmonary: No sign of infiltrates. The patient is on
PCP [**Name Initial (PRE) 1102**].
3. Infectious disease: The patient is with a history of HIV
and continued on HEART therapy, continued on Bactrim.
4. Cardiac: The patient was with normal electrocardiogram.
No chest pain.
5. Electrolytes: Were repeated as needed.
6. Prophylaxis: The patient was initially placed on Heparin
subcue.
7. Social: The patient was seen by rehabilitation service
and abuse counselors in-house. The patient agreed to be
discharged to the [**Hospital 4223**] Rehabilitation Center.
DISCHARGE MEDICATIONS: Tylenol 325 q.6 hours p.r.n.,
Novopramine 200 mg p.o. b.i.d., .................. 40 mg p.o.
b.i.d., Magnesium Hydroxide 400 mg/..... q.6 hours p.r.n.,
Multivitamin 1 cap p.o. q.d., .................. p.o. b.i.d.,
.................. p.o. q.d., Bactrim 1 tab p.o. q.d.,
Gabapentin 300 mg p.o. q.d., Methadone 30 mg p.o. q.d., Xanax
1 mg p.o. b.i.d. p.r.n., Dilaudid 2 mg p.o. q.6 hours,
Aspirin 81 mg p.o. q.d., the patient was given scripts for
two weeks. The patient was not given scripts for narcotics
or benzodiazepines. The patient will be given medications in
a monitored environment.
DISCHARGE RECOMMENDATIONS: The patient should have physical
therapy, occupational therapy, social and rehabilitation
services. The patient should be weaned off narcotics. The
patient's primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], should be
notified at the time of discharge for additional medications.
The patient should be discharged from rehabilitation services
with VNA for physical therapy, occupational therapy and
social services.
FOLLOW-UP: The patient should follow-up with Orthopedic
Surgery in six weeks to further evaluate lower extremities.
The patient should follow-up with Social Services at [**Hospital3 **] to follow-up on medications.
[**Doctor First Name **] [**First Name8 (NamePattern2) 1243**] [**Name8 (MD) **], M.D. [**MD Number(1) 3025**]
Dictated By:[**Last Name (NamePattern1) 201**]
MEDQUIST36
D: [**2172-3-11**] 08:56
T: [**2172-3-11**] 08:57
JOB#: [**Job Number 106580**]
|
[
"294.10",
"070.51",
"311",
"V15.81",
"969.4",
"304.70",
"E980.3",
"042",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
3624, 5210
|
2955, 3600
|
2111, 2937
|
159, 1411
|
1434, 1702
|
1719, 2088
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,379
| 131,506
|
21923
|
Discharge summary
|
report
|
Admission Date: [**2179-9-10**] Discharge Date: [**2179-9-15**]
Service: [**Hospital Unit Name 196**]
Allergies:
Ivp Dye, Iodine Containing / Amoxicillin
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization with stents to LAD and RCA
Left femoral groin line
History of Present Illness:
81 yo female with HTN, hypercholesterolemia, known CAD s/p cath
in [**9-26**] showing 75% lesion of ostial LAD and 90% proximal LAD,
LCX which were medically managed as patient refused cath at that
time. Since has had numerous OSH admissions for CP and +enzymes
(last 3 weeks ago). She has used SLNTG in past with some relief.
Her chest pain occurs at rest and on exertion. Pt presented to
[**Hospital **] Hosp on [**9-10**] with left sided chest pain, with a troponin
i of 0.19. Agreed to cath and was transferred to [**Hospital1 18**] on NTG
and heparin gtt.
Past Medical History:
1. HTN,
2. high chol,
3. CAD 2VD medically managed
4. anxiety,
5. h/o right THR,
6. interstitial lung disease, O2 dependent
7. h/o MRSA/VRE UTI
Social History:
No tobacco, ETOH, IVDU.
Family History:
Mother with CAD.
Physical Exam:
Afeb, 150/50, 68, 18, 99%RA
Gen: pale, NAD
HEENT: increased JVP
CV: irregular rate, normal S1S2, [**2-27**] syst murmur at apex
Lungs: CTAB
Abd: soft, NT +BS
Ext: 1+ DP pulses, warm, no edema
Neuro: alert and oriented x3
Pertinent Results:
Echo: [**2179-9-14**]:
1. The left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
2. The aortic valve leaflets are moderately thickened. There is
mild aortic valve stenosis. Mild (1+) aortic regurgitation is
seen.
3. The mitral valve leaflets are moderately thickened. Mild (1+)
mitral regurgitation is seen.
Cardiac Cath: [**2179-9-13**]
1. Three vessel coronary artery disease status post successful
stenting
of the RCA and LAD.
2. Severe central hypertension.
3. Large hematoma at the right femoral arteriotomy site.
EKG ([**9-13**]) with chest pain:
sinus at 70bpm, normal axis and intervals, 1mm ST depressions in
II, aVF, V4-V6. Biphasic T waves V3-V6.
Abd CT ([**9-13**])
Large right thigh hematoma
Labs:
[**2179-9-15**] 05:35AM BLOOD WBC-9.8 RBC-3.66* Hgb-11.8* Hct-34.4*
MCV-94 MCH-32.3* MCHC-34.3 RDW-15.3 Plt Ct-150
[**2179-9-15**] 05:35AM BLOOD Plt Ct-150
[**2179-9-15**] 05:35AM BLOOD Glucose-84 UreaN-13 Creat-0.8 Na-143
K-3.8 Cl-105 HCO3-29 AnGap-13
[**2179-9-14**] 06:34PM BLOOD CK(CPK)-126
[**2179-9-10**] 07:30PM BLOOD CK(CPK)-38
[**2179-9-14**] 06:34PM BLOOD CK-MB-9 cTropnT-0.38*
[**2179-9-14**] 06:15AM BLOOD CK-MB-14* MB Indx-9.2* cTropnT-0.50*
[**2179-9-10**] 07:30PM BLOOD CK-MB-NotDone cTropnT-0.02*
[**2179-9-13**] 05:20AM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2179-9-14**] 06:15AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.7 Cholest-110
[**2179-9-14**] 06:15AM BLOOD Triglyc-182* HDL-35 CHOL/HD-3.1
LDLcalc-39
Brief Hospital Course:
She was admitted to [**Hospital Unit Name 196**] for cardiac catherterization.
By system:
1. Cardiac: On the morning of [**9-11**] patient developed [**10-3**] SSCP
with SBP >200 and EKG showing ST depressions in II, aVF and
V5-V6 and psuedonormalization of T waves in v2-v4. Pain
relieved with NTG, morphine and lopressor. She was stabilized
over the weekend and started on integrillin. Patient remained
pain free was pre-hydrated for cath (underwent AM of [**9-13**]) with
stent to mRCA and LAD. A few hours post-cath, she had
hypotension with SBP to 70s, diaphoresis and pallor. BP
improved with 500cc NS bolus. Stat hematocrit was 24 down from
34 post cath and CT showed 5x3x4 cm right thigh hematoma. Of
note, pt bled spontaneously in same leg 1 month prior when on
heparin for NSTEMI. She was transferred to the CCU and received
3 units of PRBC and was stabilized with thigh pressure. A left
femoral sheath was placed for rapid transfusion. Heparin and
integrillin were discontinued. Her hematocrits remained stable
for 36 hours, however she had a troponin leak likely due to
demand ischemia with her low hematocrit, her CK's were flat. For
her CAD, we continued lipitor, full dose aspirin, plavix,
lopressor and added lisinopril. Her lipid panel was normal with
some mildly elevated triglycerides. We continue her lipitor at
her admission dose of 20 mg daily. She had a normal
echocardiogram.
2. Respiratory: She has a history of interstitial lung disease.
She did require oxygen througout her stay. With any type of
exertion she desats to 89% on room air on day of discharge. She
sats >95% on room air while lying in bed. She will continue to
need home oxygen for now.
3. GI: SHe was given a cardiac diet. On abdominal CT, her liver
was noted to be hyeprdense, her LFT's were normal. She should
have this followed up by her PCP.
4. Neuro/Psych: SHe has a history of anxiety disorder and xanax
was continued. She also became somewhat confused at night and
was given zyprexa, with some improvement.
5. Code status: We discussed code status with her and her family
and it is her wish to be DNR/DNI.
6. Function: PT was consulted and recommeded home PT for
endurance training and mobility training.
Medications on Admission:
Heparin gtt
Nitroglycerine gtt
ASA 81 mg daily
Lopressor 75 mg daily
Lipitor 20 mg daily
Protonix 40 mg daily
Colace
Xanax 0.25 TID
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day).
Disp:*30 Tablet(s)* Refills:*2*
2. Atorvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO once
a day.
Disp:*60 Tablet(s)* Refills:*2*
3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 30 days.
Disp:*30 Tablet(s)* Refills:*2*
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*90 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Healthcare
Discharge Diagnosis:
Coronary Artery Disease
Hypertension
Hypercholesterolemia
Transient demand ishemia with hematocrit drop in setting of
hematoma
Right thigh hematoma
Anxiety disorder
Gall stones
Interstitial lung disease
Anemia
S/p hip replacemnt
h/o MRSA in urine
h/o VRE in urine
Discharge Condition:
Stable
Discharge Instructions:
Please take all medications as prescribed. You should continue
plavix for 9 months.
Please return to care for chest pain, worsening shortness of
breath, fever >100.5.
Followup Instructions:
Follow up with your PCP [**Last Name (NamePattern4) **] 1 week
Follow up with your cardiologist in 2 weeks
Please follow up with yor PCP regarding CT results that showed a
hyperdense liver.
|
[
"574.20",
"272.0",
"998.12",
"285.9",
"414.01",
"515",
"401.9",
"E879.0",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.07",
"99.04",
"37.22",
"88.55",
"36.05",
"38.93",
"88.52",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
6429, 6486
|
3003, 5219
|
279, 355
|
6794, 6802
|
1446, 2980
|
7017, 7210
|
1171, 1189
|
5401, 6406
|
6507, 6773
|
5245, 5378
|
6826, 6994
|
1204, 1427
|
229, 241
|
383, 947
|
969, 1114
|
1130, 1155
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,334
| 119,868
|
1490
|
Discharge summary
|
report
|
Admission Date: [**2169-6-2**] Discharge Date: [**2169-6-9**]
Date of Birth: [**2108-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Lisinopril / Vancomycin / Keflex
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
recurrent pleural effusion
Major Surgical or Invasive Procedure:
[**6-2**] Flexible bronchoscopy, VATS (video-assisted
thoracic surgery), right total pulmonary decortication and
talc pleurodesis.
[**6-6**] Ultrasound-guided thoracentesis
History of Present Illness:
Mr. [**Known lastname 7749**] is a 61-year-old gentleman who underwent open heart
surgery and suffered bilateral recurrent pleural effusions. He
has had multiple thoracenteses but the effusions continue to
recur.
Past Medical History:
-Hodgkins Lymphoma - located in neck, treated with surgical
resection and radiation therapy in [**2129**], in remission
-Bilateral Subclavian Stenosis s/p left and right subclavian
arteries in [**7-19**] with Genesis stents
-Paroxysmal atrial fibrillation
-HTN
-Hyperlipidemia
-Carotid Stenosis s/p L carotid endarterectomy in [**2168-12-26**] for
70-79%
left ICA and 60-69% right ICA
-Dual Chamber Pacemaker ([**Company 1543**] EnRhyrhm dual chamber
pacemaker) on [**2166-9-8**] for sinus pause, type II 2nd degree AV
block, presyncope on ETT MIBI in [**2166-9-5**].
-Anxiety
-Chronic cervical spine/shoulder pain - takes tylenol. Lumbar
and cervical spondylosis.
-Gout
-History of rheumatoid arthritis
-GERD
-History of thyroid nodule
Social History:
denies current tobacco use, last cig >10 years ago. There is a
history of alcohol abuse, stopped 2 years ago.
Single and lives in [**Location 1268**] with his brother. [**Name (NI) 4084**] married
and no children. Retired telephone company employee.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
At discharge
General: NAD alert and oriented x3
Cards: Regular rate and rhythm, no murmurs rubs or gallops
Lungs: lungs clear to auscultation bilaterally
Abd: soft nontender, nondistended
extremities: no clubbing cyanosis or edema
incision: clean, dry, intact
Pertinent Results:
[**2169-6-2**] 09:40PM PLT COUNT-470*
[**2169-6-2**] 09:40PM WBC-6.7 RBC-3.74* HGB-9.9* HCT-31.8* MCV-85
MCH-26.4* MCHC-31.1 RDW-15.2
[**2169-6-2**] 09:40PM CALCIUM-8.5 PHOSPHATE-4.6* MAGNESIUM-2.0
[**2169-6-2**] 09:40PM CK-MB-3 cTropnT-<0.01
[**2169-6-2**] 09:40PM CK(CPK)-110
[**2169-6-2**] 09:40PM estGFR-Using this
[**2169-6-2**] 09:40PM GLUCOSE-111* UREA N-26* CREAT-1.1 SODIUM-137
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-16
Brief Hospital Course:
Mr [**Known lastname 7749**] had his R VATS decortication, pleurodesis on 7/18and
tolerated the procedure very well. On POD2 the pt had 2 episodes
of emesis but was doing well otherwise. Over the next several
days, the pt continued to have occasional emesis despite
restricting his diet to sips only. In addition he was triggered
several times for low urine output. His urine output was
managed with increased fluid and his continued bouts of emesis
required placement of any NG tube. During placement of the tube,
the patient continued to vomit and bilious stomach contents were
evacuated. Following placement of the NGT an CXR was ordered and
it was found to have been placed in the right mainstem bronchus
on chest x-ray, so it was removed and replaced with correct
placement confirmed on chest xray. During placement of the NGT
and the vomiting episodes, the patient had episodes of
desaturation that improved with supplemental oxygen. It was
felt that he may have developed an aspiration
pneumonia/pneumonitis and a higher level of care would be
appropriate and he was transferred to the SICU. Because of his
recurrent emesis, a general surgery consult was called for a
possible small bowel obstruction, but their reccomendations were
to continue conservative managment (NGT, IV fluids, PPI,
minimize narcotics, and consider a abdomen/pelvis CT for eval of
retroperitoneal mass) of a likely post-surgical ileus. While in
the SICU a Chest x-ray showed a reaccumulation of pleural
effusion on the left chest. A thoracentesis of this effusion was
performed and the fluid sent to pathology. Because his level of
nutrition was suboptimal prior to his surgery as well as in the
days following, a PICC line was placed and TPN started. After a
few days in the SICU, his oxygen requirement was decreased from
15L on face mask to 6L nasal cannula. In addition, his [**Doctor Last Name **]
drain was put to water seal and then bulb suction. On POD 6 the
[**Doctor Last Name **] drain was discontinued and followup chest x-ray showed no
evidence of pneumothorax. In addition, a video swallow
evaluation was performed and showed that there was little
swallowing dysfunction. The only recommendation was that his
pills be crushed. On POD 7 his TPN was d/ced and he was given
ice-cream to eat. He tolerated this well and did not have
repeat emesis.
Medications on Admission:
allopurinol 100mg qday
lasix 60mg qday
amiodarone 200mg qday
ativan .5mg [**Hospital1 **]
toprol xl 50mg qday
potassium chloride sustained release 40 meq qday
simvastatin 40 mg qday
ASA delayed release 81mg qday
Calcium carbonate 500mg tab [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Ferrous sulfate 325mg (65 mg iron)
MVI qday
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
s/p CABG with recurrent bilateral pleural effusions
Discharge Condition:
Hemodynamically stable, tolerating oral intake, voiding without
difficulty.
Discharge Instructions:
Please call dr. [**Last Name (STitle) 8785**] ([**Telephone/Fax (1) 1504**] if you develop
fever, chills, chest pain, shortness of breath, pain swelling or
redness at your incision site.
Medications:
Please take all medications as ordered.
Diet:
You have been evaluated by speech and swallow and may resume
your regular diet. Please crush your pills to make taking them
easier. A copy of the recommendations will be included in this
discharge paperwork. please keep a strict calorie count
- You may shower on 2 days after discharge. After showering,
remove your chest tube site dressings and cover the areas with
clean bandaids daily until healed. The steri-strips on your
incision will fall off in time.
- Do not drive while you are taking narcotic pain medicine
- take stool softeners every day you take pain medication:
colace, senna, dulcolax, and mild of magnesia are all good
options
- you should eat a regular diet in accordance with the
recommendations given to you by our speech and swallow personel.
- you should continue to do your breathing exercises with the
incentive spirometry, coughing, and deep breathing.
- you should remain as active as tolerated and gradually
increase your activity level on a daily basis.
Followup Instructions:
Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2169-6-20**] 10:30
Please arrive 45 minutes early to the [**Location (un) 470**] clinical center
for a chest xray on the day of your followup appointment with
Dr. [**Last Name (STitle) **].
Please come to the Chest Disease Clinic on [**Location (un) **] [**Hospital Ward Name 121**]
building for your appointment with Dr. [**Last Name (STitle) **].
Please also bring your calorie count log with you when you come
to your appointment.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**], MD Phone:[**Telephone/Fax (1) 7477**] Date/Time:[**2169-7-19**]
1:30
Provider: [**Name10 (NameIs) 640**] [**Name11 (NameIs) 747**] [**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 1844**]
Date/Time:[**2169-7-27**] 1:00
Completed by:[**2169-6-9**]
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,188
| 100,715
|
38936
|
Discharge summary
|
report
|
Admission Date: [**2117-5-6**] Discharge Date: [**2117-5-12**]
Date of Birth: [**2052-5-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / gemfibrozil / ibuprofen
Attending:[**First Name3 (LF) 602**]
Chief Complaint:
dyspnea, stable [**First Name3 (LF) 8813**] dissection
Major Surgical or Invasive Procedure:
Endotracheal intubation and mechanical ventilation
History of Present Illness:
History of Present Illness: Mr. [**Known lastname 7474**] is a 64M with a history
of active prostate cancer s/p completion of radiation tx
yesterday, who presented to [**Hospital3 **] with dyspnea on
exertion. [**First Name8 (NamePattern2) **] [**Hospital1 **] documentation, he was walking upstairs to
do laundry, and when he came back down he had persistent
shortness of breath. He has had some intermittent DOE for the
last several months, but is usually able to catch his breath
with rest whereas today he felt persistently SOB. According to
his wife, he was told that his grandson (to whom he is very
attached) was in a MVA, and after that he became very anxious
and SOB. She thinks anxiety may play a large role in his SOB.
At [**Hospital1 **], he had O2 sat 92% on 4L by NC. Labs were notable for
WBC of 7.0 with 15% bandemia, Hct of 24.9, creatinine of 4.0,
and lactate of 0.8. He underwent chest x-ray that showed
enlarged aorta, and subsequent CT (noncontrast given renal
failure) that showed dissection extending from arch to beyond
the level of the renal arteries. At that time, it was not known
that he has a history of [**Hospital1 8813**] dissection, and this was felt to
be acute. He was started on BIPAP for his SOB and an esmolol gtt
to control blood pressures. He received levofloxacin for
possible pneumonia and was transferred to [**Hospital1 18**] for further
management of the dissection. In transit to the ED, he removed
BIPAP so he was placed on NRB.
In the ED, initial VS were Pulse: 113, RR: 22, BP: 149/91,
O2Sat: 100, O2Flow: 100NRB. While in the ED, he developed a
temperature to 102.4 rectal. He received 1 g of vancomycin, 4.5
g Zosyn, and acetaminophen for fever/infection. He was continued
on esmolol gtt and started on nitroprusside gtt. At the time of
arrival to ED, chronicity of patient's [**Hospital1 8813**] dissection was
unknown. He was intubated for planned TEE and MRI prior to
purported surgical intervention. He was sedated with propofol
but BP dropped so changed to fentanyl/versed.
.
On arrival to the MICU, he is intubated and sedated. Has drool
coming from mouth, so suctioned which causes patient to
wince/appear uncomfortable. Otherwise minimally responsive to
Qs.
Past Medical History:
- Prostate cancer: [**Doctor Last Name **] Grade is 4+3. He is followed by
radiation oncology Dr. [**Last Name (STitle) 12354**] undergoing radiation treatment.
- [**Last Name (STitle) **] dissection: First noted in [**2114**]. Most recent assessment
[**3-/2116**] in Atrius records: Type B [**Year (4 digits) 8813**] dissection with proximal
descending thoracic aorta measuring five centimeters and
dimension. The dissection flap extends into the left common
iliac artery. The celiac, SMA, and right renal artery arise from
the true lumen while the left renal artery arises from the false
lumen.
- Hypertension
- Gout
- Claustrophobia
- CKD (chronic kidney disease) stage 3, GFR 30-59 ml/min (recent
baseline creatinine 2.5-3.0)
- Spinal stenosis (lumbar region)
- Chronic back pain
- Arthritis (? RA)
- Hypertriglyceridemia
- Positive PPD
- Bilateral total knee replacements
Social History:
Lives with his wife and her two sons ages 17 and 18 (they were 2
and 3 when he was married, so he treats them as his own
children). Has an infant grandson to whom he is very attached.
Mows lawns in his neighborhood for money, otherwise no income.
Was in jail for 23 years.
- Tobacco: Smoke [**2-1**] pack per day since age 30, quit [**2116**] but
recently sneaking cigarettes per wife.
- Alcohol: None
- Illicits: None (wife concerned too much oxycodone)
Family History:
father with htn, passed away at age 75
mother 82 healthy
Physical Exam:
Admission Exam:
ED vital signs: 113, RR: 22, BP: 149/91, O2Sat: 100, O2Flow:
100NRB.
Exam in MICU:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: Supple, JVP not visibly elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops appreciated though referred ventillator sounds somewhat
obscure heart sounds
Lungs: Referred upper airway sounds from ventillator but no
clear rales or wheeze
Abdomen: Soft, non-distended, bowel sounds present, no
organomegaly
GU: + foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Toes misshapen possibly [**3-4**] gout
Neuro: Moving all extremities; remainder of exam deferred
Discharge Exam:
Vitals: 98.4, hr 73, 132/84 19 rr 97% RA.
Physical Exam:
Gen: AAOx3, NAD, pleasant conversant gentleman.
Neck: supple, no JVD.
Heart: nl s1 s2, no mrg
Lungs: CTA BL
Abdomen: Soft, nt, nd. No rebound or guarding.
Extremities: 2+ pulses, no lower extremity edema, deformed right
knee from s/p several knee replacements, dry atrophic skin
changes b/l.
Neuro: AAOx3, conversant.
CN 2-12 grossly intact
Motor: [**6-5**] u/e and le
sensation grossly intact.
Pertinent Results:
I) Admission Labs:
COMPLETE BLOOD COUNT:
[**2117-5-6**] 06:50PM BLOOD WBC-7.8 RBC-2.66* Hgb-8.1* Hct-26.4*
MCV-99* MCH-30.5 MCHC-30.8* RDW-14.2 Plt Ct-204
[**2117-5-6**] 06:50PM BLOOD Neuts-88.7* Lymphs-6.1* Monos-4.0 Eos-1.0
Baso-0.1
BASIC COAGULATION (PT, PTT, PLT, INR
[**2117-5-6**] 06:50PM BLOOD PT-13.3* PTT-28.0 INR(PT)-1.2*
RENAL & GLUCOSE
[**2117-5-6**] 06:50PM BLOOD Glucose-166* UreaN-65* Creat-3.9* Na-137
K-3.8 Cl-105 HCO3-19* AnGap-17
Enzymes:
[**2117-5-6**] 06:50PM BLOOD ALT-28 AST-33 AlkPhos-133* TotBili-0.3
[**2117-5-6**] 06:50PM BLOOD cTropnT-0.03*
ABG:
[**2117-5-6**] 07:02PM BLOOD Type-ART pO2-267* pCO2-31* pH-7.42
calTCO2-21 Base XS--2 Intubat-NOT INTUBA
[**2117-5-7**] 01:11AM BLOOD Type-ART Rates-/14 Tidal V-500 PEEP-5
FiO2-80 pO2-170* pCO2-40 pH-7.33* calTCO2-22 Base XS--4
AADO2-353 REQ O2-64 -ASSIST/CON Intubat-INTUBATED
UA:
[**2117-5-6**] 07:55PM URINE RBC-2 WBC-50* Bacteri-FEW Yeast-NONE
Epi-1 TransE-<1
[**2117-5-6**] 07:55PM URINE Blood-TR Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
II) Micro:
URINE CULTURE (Final [**2117-5-7**]): NO GROWTH.
Blood Culture, Routine (Final [**2117-5-12**]): NO GROWTH.
MRSA SCREEN (Final [**2117-5-9**]): No MRSA isolated.
GRAM STAIN (Final [**2117-5-8**]):
>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.
III) Imaging:
CT Chest/Abdomen without Contrast:
IMPRESSION
1. Limited non-contrast CT of the chest and abdomen
demonstrating a type B
[**Year/Month/Day 8813**] dissection extending to the level of the infrarenal
aorta, inferior
aspect not included on the images. The distal extent is not
assessed in this study. Allowing for differences in technique,
this has not significantly changed since the earlier study of
[**2115-7-18**]. Assessment of the false and true lumens and the
visceral branches is limited in this study.
2. New since the prior study are small simple bilateral pleural
effusions
with bibasilar atelectasis.
3. Moderate centrilobular emphysema, apical predominant.
4. 3.8 cm left renal cyst is not characterized in this study, a
non-emergent
renal ultrasound can be performed for further assessment if not
already
obtained.
Renal Doppler US:
IMPRESSION:
1. Normal bilateral main renal artery waveforms and resistive
indices.
2. Left main renal artery cannot followed back to the aorta due
to technical
reasons.
3. Abdominal [**Year (4 digits) 8813**] dissection.
MRA TORSO:
IMPRESSION:
1. Redemonstration of type B [**Year (4 digits) 8813**] dissection with slight
interval increase
in size of the aorta.
2. Moderate-sized pleural effusions with adjacent compressive
atelectasis
bilaterally.
IV) Studies:
Renal Ultrasound:
FINDINGS:
The right kidney measures 10.7, the left kidney measures 11.9
cm without
evidence of hydronephrosis or stones. There is a 1 cm left upper
pole kidney
cyst and a 5-mm right lower pole hyperechoic lesion, likely
representing AML
(angiomyolipoma).
There is normal perfusion of both kidneys. Both renal arteries
show normal
waveforms, RIs and flow velocities.
The right main renal artery can be followed to the aorta and
demonstrates
normal waveform. The right renal vein is patent. There is a
normal resistive
indix at the right main renal artery (0.65).
At the left kidney, the main renal artery and vein demonstrate
normal
waveforms. The left renal artery cannot be followed to the aorta
due to
technical reasons. The resistive index of the left main renal
artery is 0.61.
TTE:
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is 0-5
mmHg. 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. The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. The [**Year (4 digits) 8813**] root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The
descending thoracic aorta is mildly dilated. No dissection flap
is seen (best assessed by thoracic/chest MRI/CT or TEE). The
[**Year (4 digits) 8813**] valve leaflets are mildly thickened (?#). There is no
[**Year (4 digits) 8813**] valve stenosis. No [**Year (4 digits) 8813**] regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Dilated thoraic aorta. Pulmonary artery
hypertension. Mild mitral regurgitation. Pulmonary artery
hypertension.
If clinically indicated, a thoracic/chest MRI/CT or TEE is
suggested to better characterize an [**Year (4 digits) 8813**] dissection.
V) Discharge Labs:
CBC:
[**2117-5-12**] 06:41AM BLOOD WBC-5.1 RBC-2.61* Hgb-7.9* Hct-26.3*
MCV-101* MCH-30.1 MCHC-29.9* RDW-14.4 Plt Ct-287
CHEM:
[**2117-5-12**] 06:41AM BLOOD Glucose-105* UreaN-33* Creat-2.3* Na-141
K-4.2 Cl-110* HCO3-23 AnGap-12
[**2117-5-12**] 06:41AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8
Urine:
[**2117-5-10**] 06:49PM URINE RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE
Epi-<1
[**2117-5-10**] 06:49PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
VI) Studies Pending at Discharge:
None.
Brief Hospital Course:
64 year old man with a past medical history signficant for
chronic kidney disease, hypertension, prostate cancer s/p XRT,
and type [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 11916**] [**Last Name (NamePattern4) 8813**] dissection (dxed [**2114**]) transferred
from outside hospital for hypoxemic respiratory failure.
Hospital course notable for finding of stable type B [**Year (4 digits) 8813**]
dissection, acute on chronic diastolic heart failure due to
malignant uncontrolled hypertension, and acute on chronic renal
failure.
#Acute on chronic diastolic heart failure/Malignant
Hypertension:
Patient presented to [**Hospital3 **] with shortness of breath
and hypoxia requiring high flow oxygen. He had a chest CT which
showed type B [**Hospital3 8813**] dissection (old, but not clear at OSH).
Transferred to [**Hospital1 18**] for management of [**Hospital1 8813**] dissection (see
below). Upon transfer patient required escalating oxygen support
and was intubated for both hypoxia and to facilitate workup of
dissection. Patient admitted initially to the ICU and was
diuresed and blood pressure controlled. Following extubation
patient was transferred to the medical floor where he required
intensive titration of blood pressure medications to maintain
goal SBP <130 although BPs on the floor were 120-160. Patient
was euvolemic on discharge and it was felt that initial hypoxia
was due to malignant hypertension. Medications were uptitrated
and patient was discharged on a regimen of max dose labetalol,
clonidine 0.2 mg TID, amlodipine 10, and hydralazine 75mg TID. A
TTE prior to discharge showed a preserved EF with mild symmetric
LVH. Patient was euvolemic breathing on RA prior to discharge.
On follow up could consider uptitratring clonidine or hydral or
starting diltiazem for better BP control if needed. Goal SBP
<130. Lasix 20mg po daily was started for chronic diastolic CHF
as well. Home VNA was arranged to help keep BP within goal.
#Acute On Chronic Renal Failure:
The patient presented to [**Hospital1 **] with a creatinine of 4. His best
creatinine on record was from [**Hospital1 **] in [**2115**] at 1.7. Recently his
baseline has been approximately 2.5. His elevated creatinine was
felt to be related to malignant hypertension and improved with
treatment of blood pressure and CHF. Renal doppler ultrasound
did not show renal artery stenosis, however, it is possible that
his [**Year (4 digits) 8813**] dissection partly into the renal artery may be
creating RAS physiology. That said, an ACEI/[**Last Name (un) **] was not started
due to ARF. Addition, of these medications could be considered
in the future once renal function returns to baseline.
#Chronic [**First Name7 (NamePattern1) 11916**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Dissection:
MRA showed no interval progression in the size of his [**Last Name (NamePattern4) 8813**]
dissection. The patient was seen by Vascular Surgery and blood
pressure was treated aggressively as stated above. He is
scheduled for follow up with vascular surgery in 6 months with a
screening MRA to monitor for progression of his [**Last Name (NamePattern4) 8813**]
dissection.
#Presumed UTI/PNA:
While on the floor the patient lacked any signs or symptoms of a
UTI or pneumonia. After verifying with [**Hospital1 **] that his cultures
were negative. His antibiotics which were empirically started in
the ED (Rocephin/Azithromycin) were discontinued. His cultures
at [**Hospital1 **] were also negative.
Medication Changes:
-Increased labetalol to 800mg TID
-Increased Amlodipine to 10mg QD
-Started Lasix 20mg PO QD
-Held allopurinol in the setting of his acute renal failure.
-Stopped nifedipine xl (as the patient was already taking
amlodipine)
Transitional Issues:
1. Blood pressure control. Home VNA has been arranged for the
patient to help with his medications and blood pressure
measurements. Ideally, his blood pressure should be in the 130's
or less. His blood pressure medication will likely require
titration in the future to achieve these goals.
2. Monitoring [**Hospital1 **] Disease: The patient has follow up with
vascular surgery in 6 months. There has been no progression in
his [**Hospital1 8813**] dissection when compared to films from the last year.
3. Since the patient was started on lasix during this
hospitalization, we recommend drawing a chem 10 in one week to
check for electrolyte abnormalities and renal function.
Medications on Admission:
Medications: Per Atrius records.
- Oxycodone 15 mg PO Q6H PRN pain
- Clonidine 0.3 mg PO TID
- Amlodipine 5 mg PO daily
- Labetalol 300 mg PO TID
- Zoladex administered monthly in urology
- Fluoxetine 40 mg PO daily
- Allopurinol 300 mg PO daily
- Nifedepine ER 30 mg PO daily
- Colchicine 0.3 mg PO daily for gout pain
- Hydralazine 75 mg PO TID
Discharge Medications:
1. labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day).
Disp:*360 Tablet(s)* Refills:*1*
2. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 1 months.
Disp:*60 Tablet(s)* Refills:*1*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
5. oxycodone 15 mg Tablet Sig: 1-2 Tablets PO four times a day
as needed for pain.
6. clonidine 0.3 mg Tablet Sig: One (1) Tablet PO three times a
day.
7. colchicine 0.6 mg Tablet Sig: 0.5 Tablet PO once a day as
needed for pain.
8. hydralazine 50 mg Tablet Sig: 1.5 Tablets PO three times a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
1. Chronic [**First Name7 (NamePattern1) 11916**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Dissection
2. Hypertension
3. Compensated acute heart failure with a preserved ejection
fraction of 55%.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 7474**],
You were admitted to the hospital with acute shortness of breath
and pulmonary edema. We believe that this is due to something
called congestive heart failure. Your congestive heart failure
which has now resolved was most likely caused by your high blood
pressure and excess fluid and salt retention. We resolved this
condition by controlling your blood pressure and starting you on
a water pill to help keep your lungs from becoming congested.
You have something called a TYPE B [**Known lastname **] DISSECTION. Your Aorta
(the biggest blood vessel in your body) has a small tear in it.
You have had this [**Known lastname 8813**] dissection for more than two years.
Type B [**Known lastname 8813**] dissections are treated medically with very good
blood pressure control. Your blood pressure should be around
120/80 or slightly lower if possible. If your blood pressure
gets too high, the tear in your aorta can increase in side and
your dissection could get worse which is a LIFE THREATENING
CONDITION.
1. IT IS INCREDIBLY IMPORTANT THAT YOU TAKE YOUR BLOOD PRESSURE
MEDICATION AS DIRECTED.
2. IT IS INCREDIBLY IMPORTANT THAT YOU FOLLOW UP WITH YOUR
PRIMARY CARE DOCTOR ON A FREQUENT BASIS.
We have made some changes to your home medications to help
control your blood pressure.
We have also arranged for you to have a visting home nurse to
help you with your blood pressure medications and helping you to
take your blood pressure every day.
It is a good habit to weigh yourself every day. If you weight
goes up more than three pounds in one day, call your PCP.
[**Name10 (NameIs) **] you find that you are becoming short of breath, please call
your PCP. [**Name10 (NameIs) 2172**] visiting nurse will help you arrange your
medications that you are supposed to take which are listed on
the included sheet. You may resume any other medication that is
not listed below.
1. We have increased your labetalol to 800mg by mouth 3 times
per day ( take four 200mg tablets by mouth three times per day)
.
2. We have increased your amlodipine to 10mg by mouth once a day
(take two 5mg tablets by mouth once a day)
3. We have started you on a diuretic called lasix 20mg
(furosemide) by mouth once a day.
4. We have STOPPED your nifedipine.
5. We have held your allopurinol. Please talk to your PCP about
resuming this medications.
IF YOU HAVE ANY QUESTIONS ABOUT YOUR MEDICATIONS PLEASE CALL THE
OFFICE OF DR. [**First Name (STitle) **] [**First Name (STitle) 38274**].
If you experience any of the danger signs listed below please
call your doctor or go to the emergency department.
PCP: [**Name10 (NameIs) 38274**],[**First Name3 (LF) **] X. [**Telephone/Fax (1) 3530**]
Followup Instructions:
Name: [**First Name8 (NamePattern2) 2411**] [**Last Name (NamePattern1) 38279**], NP
Specialty: Primary Care
When: Friday [**5-14**] at 10:30
Location: [**Hospital1 641**]
Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 19604**]
Phone: [**Telephone/Fax (1) 3530**]
Department: VASCULAR SURGERY
When: WEDNESDAY [**2117-11-10**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD
Phone: [**Telephone/Fax (1) 2625**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: RADIOLOGY
When: WEDNESDAY [**2117-11-10**] at 3:00 PM
With: XMR [**Telephone/Fax (1) 327**]
Building: CC [**Location (un) 591**] [**Hospital 1422**]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"511.9",
"428.33",
"185",
"401.9",
"428.0",
"300.00",
"441.02"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
16603, 16660
|
11044, 14561
|
351, 404
|
16922, 16922
|
5304, 5307
|
19813, 20651
|
4046, 4104
|
15903, 16580
|
16681, 16901
|
15531, 15880
|
17073, 19790
|
10482, 11000
|
4888, 5285
|
4831, 4873
|
11014, 11021
|
14827, 15505
|
14581, 14806
|
257, 313
|
460, 2655
|
5324, 10465
|
16937, 17049
|
2677, 3557
|
3573, 4030
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
64,168
| 188,441
|
36788
|
Discharge summary
|
report
|
Admission Date: [**2186-8-24**] Discharge Date: [**2186-8-29**]
Date of Birth: [**2113-5-6**] Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
pericardial tap and drain
History of Present Illness:
Mrs. [**Known firstname **] [**Initial (NamePattern1) **]. [**Known lastname 83147**] is a very nice 73 year-old woman with prior
history of PAFib on coumadin, s/p PPM, with myocardial bridge
s/p stend and bleeding 2 weeks ago who comes with SOB and was
found to hve pericardial effusion and tamponade now s/p
pericardiosentesis. Patient was in her prior state of health and
had a "check up" and was found to have an abnormal perfusion in
the anterio-apical region. However, she was able to walk 9
minutes. Then, she underwent cardiac cath that showed myocardial
bridge 2 weeks ago; she was stented and then started with
bleeding. Balloon was inflated for 10 minutes and no further
bleeding was reported. Patient was discharged home on Plavix and
her home-dose Coumadin for PAfib. She did not get ASA for
possible allergy. Then, she flew to [**Location (un) 86**] from [**Location (un) 2848**] 2 days
after the procedure and was very active, but 3 days ago started
noticing shortness of breath on excertion. Patient denies any
orthopnea, PND, chest pain. However, she noted that was gaining
2 pounds daily, despite watching her diet and taking her
medications as prescribed. The shortness of breath kept
progressive until today morning where she was unable to take a
deep breath and went to the ER of [**Hospital1 **]. She had an
echocardiogram done that showed a poericardial effusion with 3cm
surrounding all faces of heart; there were signs of tamponade.
Her INR was elevated and she received 10 mg of PO Vitamin K. Her
WBC 10.4, HCT 32.6, PLT 400, Electrolytes 135/4.6 98/26 19/0.8
and gluc of 165. AST 43, ALT 53, AP 105, CPK 67, Trop T <0.01,
NT-proBNP 369. Given the posibility of bleeding through the
myocardial bridge that was stented she was transfered to [**Hospital1 18**]
for further care. In the cath lab her pressures were PCW
35/36/32, HR 109, PA 43/33/38, RV 47/25/30, dP/dt 624, RA
31/31/29, AO 131/88/104. Coronary angiogram showed normal [**Hospital1 **],
long stent in mid LAD and intra-myocardial segment widely
patent; 30% of narrowing proximal to stent, no perforation prior
o after pericardioscentesis. Normal LCx and RCA. They drained
970cc of bloddy fuild, which was sent to the lab. She is
admitted to the CCU for close monitoring.
.
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.
.
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:
PAST CARDIOVASCULAR HISTORY:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension
2. CARDIAC HISTORY: None.
-CABG: None.
-PERCUTANEOUS CORONARY INTERVENTIONS: 2 weeks ago as per HPI.
-PACING/ICD: PPM in [**2182**] for "bradycardia" (per pt).
PAST MEDICAL HISTORY:
PAFib - Diagnosed in [**2182**] rate controlled and anticoagulared.
PPM - For "Bradycardia" to the 40s symtpomatic
Obesity
History of Colon cancer s/p parcial colectomy [**2166**]
Dyslipidemia
.
Surgical History
Cholecystectomy
Appendectomy
Tonsilectomy
Parcial colectomy
Social History:
She lives by herself in [**State 108**] and has a daughter and a son
that live very close to her. She is very active at baseline and
works as a realtor. She has prior history of smoker quitting in
[**2141**]. Has history of 10 pack-year. She drinks alcohol socialy, 1
drink/week on average. Denies any illegal drug use. She walks in
her treadmil multiple days per week.
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Mother with
AFib, grandfather with [**Name2 (NI) 83148**] cancer.
Physical Exam:
VITAL SIGNS - Temp 98.8 F, BP 120/80 mmHg, HR 80 BPM, RR 16 X',
O2-sat 100% RA; Pulsus 8 mmHg
GENERAL - well-appearing woman in NAD, Oriented x3, comfortable,
Mood, affect appropriate.
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear,
Conjunctiva were pink, no pallor or cyanosis of the oral mucosa.
No xanthalesma.
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI located in 5th intercostal space, midclavicular
line. RRR, normal S1, S2. SEM [**3-10**] in RUSB no radiations. No
thrills, lifts. No S3 or S4.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding. Abd aorta not enlarged by palpation. No
abdominial bruits. Drain in place and bag empty.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials,
DPs), No c/c/e. No femoral bruits.
SKIN - no rashes or lesions. No stasis dermatitis, ulcers,
scars, or xanthomas.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**6-6**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
On Admission:
[**2186-8-24**] 12:10PM WBC-10.5 RBC-3.29* HGB-10.2* HCT-30.2* MCV-92
MCH-31.0 MCHC-33.7 RDW-13.2
[**2186-8-24**] 12:10PM PLT COUNT-434
[**2186-8-24**] 12:10PM PT-34.0* PTT-41.8* INR(PT)-3.5*
[**2186-8-24**] 12:10PM GLUCOSE-184* UREA N-19 CREAT-0.7 SODIUM-135
POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
.
Pericardial Fluid:
[**2186-8-24**] 03:53PM OTHER BODY FLUID WBC-1833* HCT-12.0* POLYS-61*
LYMPHS-31* MONOS-8*
[**2186-8-24**] 03:53PM OTHER BODY FLUID TOT PROT-5.6 GLUCOSE-104
LD(LDH)-839 ALBUMIN-3.2
Culture: No growth and negative Gram stain
Cytology: Negative cytology for malignant cells.
.
Admission Echocargrdiogram:
The left ventricular cavity is unusually small. Overall left
ventricular systolic function is normal (LVEF>55%). The right
ventricular cavity is unusually small. The aortic valve leaflets
are mildly thickened (?#). There is no aortic valve stenosis.
The mitral valve leaflets are mildly thickened. There is a large
pericardial effusion. The effusion appears circumferential. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There is right ventricular diastolic
collapse, consistent with impaired fillling/tamponade
physiology. IMPRESSION: Large, circumferential pericardial
effusion with evidence of tamponade physiology. Both ventricles
are small secondary to external compression. The minimum size of
the anterior effusion in diastole is 1.8cm.
.
Post-pericardiosentesis Echocardiogram:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened (?#). The mitral
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion. IMPRESSION: Small residual effusion located anterior
to the right ventricle. No echo evidence of tamponade. Compared
with the prior study (images reviewed) of [**2186-8-24**], most of the
pericardial fluid has been removed. The right and left
ventricles are normal in size and there is no tamponade.
.
Echocardiogram [**2186-8-25**]:
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. There is a trivial/physiologic pericardial
effusion. IMPRESSION: Trivial residual pericardial effusion.
Large pleural effusions.
.
Echocardiogram [**2186-8-28**]:
There is a promient partially echofilled anterior space which
most likely represents a fat pad. There is a prominent left
pleural effusion. Compared with the prior study (images
reviewed) of [**2186-8-25**], the findings are similar.
.
Cardiac Cath:
[**2186-8-24**]
Coronary angiogram showed normal [**Last Name (LF) **], [**First Name3 (LF) **] stent in mid LAD and
intra-myocardial segment widely patent; 30% of narrowing
proximal to stent, no perforation prior o after
pericardioscentesis. Normal LCx and RCA.
HEMODYNAMICS:
[**2186-8-24**]
PCW 35/36/32, HR 109, PA 43/33/38, RV 47/25/30, dP/dt 624, RA
31/31/29, AO 131/88/104.
.
EKG:
Atrial fibrillation with variable ventricular conduction and a
ventricular heart rate of 80 BPM. QRS axis -40 degrees and
duration of 120 ms, rQ in D3 and aCF and D2. Transition in
V2-V3, ITD 30 ms, RBBB morpholoy.
.
CXR [**2186-8-25**]:
Left pectoral pacemaker in situ. Marked cardiomegaly with marked
homogeneous opacification of the left hemithorax, presumably,
due to a large pleural effusion. Only the upper half of the lung
parenchyma is ventilated. The rest of the left lung parenchyma
is atelectatic. On the right, no evidence of pneumonia or
overhydration. The most lateral right part of the hemithorax are
not included on the image.
Brief Hospital Course:
Mrs. [**Known firstname **] [**Initial (NamePattern1) **]. [**Known lastname 83147**] is a very nice 73 year-old woman with prior
history of PAFib on coumadin, s/p PPM, with myocardial bridge
s/p stent and bleeding 2 weeks ago who comes with SOB,
pericardial effusion and tamponade.
.
#. Pericardial Effusion - Patient with myocardial bridge and
stent 2 weeks ago complicated with bleeding requiring baloon
tamponade. Then, she was started on coumadin 10 mg daily for
paroxysmal atrial fibrillation. She traveled from [**State 108**] to
[**Location (un) 86**] and started noticing shortness of breath that worsened
throughout the days until the day of her admission at OSH. INR
was supratherapeutic (3.5 in our hospital). Pt was given 10 mg
of PO vitamin K. She had an echocardiogram showing global
pericardial effusion without apparent loculations of 3 cm and
signs of tamponade. Patient was transfered to our Medical Center
for pericardiosentesis given that OSH did not have cardiac
surgery in case it was needed for bleeding from myocardial
bridge and stent. On admission here patient had signs of
tamponade on echocardiogram and was taken to the cardiac cath
lab. Her pressures were PCW 35/36/32, HR 109, PA 43/33/38, RV
47/25/30, dP/dt 624, RA 31/31/29, AO 131/88/104; 970 cc of
bloody pericardial fluid were drained (HCT of 12). Gram stain
was negative and culture has been negative so far. There were no
malignant cells. Patient went to the cardiac care unit for
observation overnight with pericardial drained placed. Her
coumadin was stopped. There was minimal drainage throughout the
pericardial drain ant it was pulled 24 hours after insertion
without complications. Her pulsus has been 5-6 mmHg throughout
her admission. Serial echocardiograms showed minimal ammount of
fluid, but a mass in apex that most-likely represents a clot,
but cannot rule out fat pad (to big and distal make it
unlikely). However, given patient's recent bleed and history she
is at high risk for restrictive/constrictive physiology and
constrictive pericarditis in the future. She has positive
Kussmaul sign. Patient had bilateral pleural effusion (L>>>R)
with bibasilary atelectases that improved throughout admission.
Thoracic surgery was consulted regarding her clot and effusion
and suggested conservative management. We discussed with patient
thoracosentesis and further work up and close monitoring, but
she opted out and wants to follow up with her cardiologist. She
was able to tell us and manifest her full understanding of the
risk of shortness of breath, recurring bleed, constrictive
pericarditis requiring surgery in the near-future.
.
#. Rhythm - Patient with PAFib rate controlled with diltiazem
120 mg daily and was anticoagulated at home with 10 mg of
coumadin. She was supra-therapeutic with INR of 3.5 on
admission. Her CHADS2 score is 1 having a ~2% annual risk of
stroke, which would be similar to the risk of bleeding with a
therapeuric anticoagulation and even higher in supra-therapeutic
range. However, given her rencet bleeding into his pericardium
with tamponade and recent procedure, we decided to hold
anticogaulation for now and resume once her pericardial issues
are resolved. Patient is in aspirin and plavix, which are not as
good a warfarin, but less risk of bleeding as she did this time.
She was rate-controlled with her home-dose Digoxin 0.25 mg PO
DAILY and her Diltiazem Extended-Release was increased to 240 mg
PO DAILY given she was having RVR in the setting of atrial
irritation after pericardial bleeding.
.
#. CAD - Patient with not known CAD, myocardial bridge s/p stent
and bleeding as above. She had questionable allergy to aspirin,
but patient stated anaphylaxis to Alka-Seltzer. Given the
superiority of aspirin for coronary artery disease and stents,
she underwent aspirin de-sensitation in the ICU. She tolerated
Aspirin 81 mg Daily and Plavix 75 mg Daily without
complications. She is also on Rosuvastatin Calcium 10 mg PO
DAILY. No need for ACEI/[**Last Name (un) **] or beta-blocker at this time given
no CAD, normal EF.
.
#. Pump - Patient with no signs of heart failure on exam or
echo.
.
#. Dyslipidemia - Continuing pt pravastatin as above.
Medications on Admission:
Plavix 75 mg Tablet 1 (One) Tablet(s) by mouth once a day
Digoxin 250 mcg Tablet 1(One) Tablet(s) by mouth once a day
Diltiazem HCl [Cartia XT] 120 mg Capsule, Sust. Release 24 hr
one Capsule(s) by mouth daily
Ranitidine HCl 150 mg Capsule one Capsule(s) by mouth daily
Rosuvastatin [Crestor] 10 mg Tablet 1 (One) Tablet(s) by mouth
once a day
Warfarin 10 mg Tablet 1 (One) Tablet(s) by mouth once a day
Calcium Carbonate-Vitamin D3 [Os-Cal 500 + D] 500 mg (1,250
mg)-400 unit Tablet
one Tablet(s) by mouth daily
.
ALLERGIES:
Alka-Seltzer: Angioedema / Anaphylaxis.
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Calcium 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1)
Tablet PO twice a day.
5. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Magnesium Oxide 140 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 1.5 Tablets
PO DAILY (Daily).
9. Cartia XT 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2*
10. Cartia XT 240 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO once a day.
Disp:*90 Capsule, Sust. Release 24 hr(s)* Refills:*3*
11. Ranitidine HCl 150 mg Capsule Sig: One (1) Capsule PO twice
a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Pericardial effusion
Pleural Effusion
Atrial Fibrillation with rapid ventricular response
Coronary Artery Disease
Discharge Condition:
stable. O2 sat 90% on RA with activity, 95% on Ra at rest.
Discharge Instructions:
You had some blood in the lining around your heart called a
pericardial effusion. This was drained and has not
reaccumulated. However, there is a residual blood clot remaining
that may be causing inflammation and leading to fluid buildup in
your lungs called a pleural effusion on the left side. This
effusion is interfering with oxygen uptake from the lung and is
causing your oxygen level to drop when you are active. We did
not restart your coumadin in case your cardiologist in FLA wants
to do any tests. You should continue to take your Plavix and
aspirin for your stent. Please call Dr. [**Last Name (STitle) 363**] as soon as you
get home to arrange follow up care. You were advised to stay in
[**Location (un) 86**] for treatment but have decided to go home to FLA for
this. You should get an Echocardiogram in [**4-5**] weeks and a chest
x ray in 1 month.
.
Medication changes:
1. Cartia Xt was increased to 240 mg daily
2. STOP taking Warfarin
.
Please call Dr. [**Last Name (STitle) 363**] if you have any increased shortness of
breath, chest pain, persistant palpitations, pain when you take
a deep breath, dizziness or fainting, or any other unusual
symptoms.
Followup Instructions:
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] Phone: [**Telephone/Fax (1) 83149**] Date/time: please call Dr. [**Last Name (STitle) 363**]
as soon as you get home to set up appt.
|
[
"V45.82",
"272.4",
"V45.89",
"414.01",
"511.9",
"V10.05",
"427.31",
"278.00",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
15337, 15343
|
9522, 13710
|
296, 324
|
15501, 15562
|
5651, 5651
|
16784, 17001
|
4125, 4306
|
14326, 15314
|
15364, 15480
|
13736, 14303
|
15586, 16453
|
4321, 5632
|
3286, 3427
|
16473, 16761
|
236, 258
|
352, 3149
|
5665, 9499
|
3449, 3722
|
3738, 4109
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,852
| 171,137
|
52226+59410
|
Discharge summary
|
report+addendum
|
Admission Date: [**2142-7-16**] Discharge Date: [**2142-7-25**]
Service: CARDIOTHORACIC
HISTORY OF PRESENT ILLNESS: This is a 78 year old male with
a history of coronary artery disease, status post myocardial
infarction thirty years ago who presented with increasing
angina over the past year associated with nocturnal
orthopnea. The patient suffers from anginal symptoms two to
three times per week. Dobutamine stress test done [**2142-2-1**],
showed progressive anginal symptoms at low workload without
significant electrocardiographic changes. However,
echocardiogram showed evidence of prior myocardial infarction
with inducible ischemia at achieved workload and persistent
apical hypokinesis.
The patient underwent cardiac catheterization [**2142-5-8**], which
showed three vessel disease, mild mitral regurgitation, left
main 30%, left anterior descending 90%, right coronary artery
80%, left circumflex totally occluded with ejection fraction
of 50%. Since he was an otherwise healthy older gentleman,
it was determined that he would benefit from coronary artery
bypass grafting.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post myocardial
infarction thirty years ago.
2. Insulin dependent diabetes mellitus with retinopathy.
3. Gout.
4. Hypercholesterolemia.
MEDICATIONS ON ADMISSION:
1. Atenolol 25 mg q.d.
2. Dyazide 25/37.5 q.d.
3. Atorvastatin 10 mg q.d.
4. Aspirin 325 mg p.o. q.d.
5. Insulin 70/30 60 units q.a.m.
6. Nitroglycerin p.r.n.
7. Colchicine p.r.n.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient discontinued cigar smoking.
Prior alcohol use, he quit thirty years ago.
PHYSICAL EXAMINATION: Vital signs revealed heart rate 68,
respiratory rate 20, blood pressure 150/78. In general, he
is an engaging older gentleman in no apparent distress. Skin
no rashes, scars or lesions. Head, eyes, ears, nose and
throat - The pupils are equal, round, and reactive to light
and accommodation. Extraocular movements are intact.
Anicteric sclera. The neck is supple. The chest is clear to
auscultation bilaterally, no costovertebral angle tenderness.
Heart regular rate and rhythm, S1 and S2, no murmurs. The
abdomen is soft, nontender, nondistended, normal bowel
sounds, no hepatosplenomegaly. Extremities are warm and well
perfused, no cyanosis, clubbing or edema. No varicosities
noted. Neurologic - Cranial nerves II through XII are intact
and sensation is intact. Strength is [**5-19**] in both
extremities. The patient is alert and oriented times three.
Pulses 2+ femoral bilaterally, 1+ dorsalis pedis and radial
bilaterally. No carotid bruits.
LABORATORY DATA: White blood count 6.3, hemoglobin 12.7,
hematocrit 37.9, platelet count 249,000. Prothrombin time
13.0, partial thromboplastin time 29.5, INR 1.1. Chem7
revealed sodium 140, potassium 5.4, chloride 107, CO2 20,
blood urea nitrogen 41, creatinine 1.8, glucose 194. AST 14,
LDH 183.
Chest x-ray revealed no acute cardiopulmonary process, no
pleural effusions, elevated left hemidiaphragm with
associated gastric distention, tortuous aorta, normal heart
size.
Cardiac catheterization results as noted above.
Echocardiogram results as noted above also.
HOSPITAL COURSE: The patient was admitted the morning of
[**2142-7-16**], and underwent coronary artery bypass grafting,
saphenous vein graft to OM1, saphenous vein graft to left
anterior descending, saphenous vein graft to posterior
descending artery under general anesthesia. He was
transferred to the Intensive Care Unit and extubated on the
evening of [**2142-7-16**].
He was transferred to [**Hospital Ward Name 121**] 6 on postoperative day number one
for continued cardiopulmonary recovery, however, on
postoperative day number two, the patient went into sinus
tachycardia with heart rate to the 160s. He was given p.o.
Lopressor with good response. On postoperative day number
three, he went into rapid atrial fibrillation with rate in
the 130s while ambulating. Blood pressure was 140 systolic.
The patient spontaneously converted but continued to have
bursts of atrial fibrillation and was therefore started on
Amiodarone p.o. The patient was also started on his
preoperative insulin 70/30 at 60 units q.a.m.
Later in the day, the patient was found sitting up in a chair
unresponsive, not following commands. He was placed in the
bed. He was hemodynamically stable at that time. Heart rate
was in the 100s, blood pressure 140/70, oxygen saturation 96%
on two liters. His blood sugar was found to be 80. The
patient was given an amp of D50 in addition to an additional
25 mg Lopressor. Blood sugar increased to 134. The patient
started to awaken, became more responsive, was following
commands and moving all extremities, however, was still
somewhat confused.
The patient was then transferred to the Cardiothoracic
Intensive Care Unit for close neurologic monitoring.
Neurologic consultation was obtained. On further
investigation, it was found that the patient had a history of
over one year of having a sella turcica mass which was
completely compressing his internal carotid artery on the
left per magnetic resonance scan., The patient's neurologic
status continued to improve to baseline at which he was alert
and oriented times four with sensation grossly intact,
cranial nerves grossly intact except for mild right ptosis
and motor strength intact bilaterally.
The patient had a transthoracic echocardiogram done which
showed normal left ventricular function, ejection fraction of
55%. No effusions, no vegetations. Bilateral carotid duplex
showed 100% left internal carotid artery occlusion, no
pathology on the right internal carotid artery with normal
antegrade flow, right to left, of his vertebral arteries.
The patient remained stable hemodynamically with his rate
controlled on Lopressor and in sinus rhythm on Amiodarone.
Neurologically, he remained oriented, however, had difficulty
ambulating and it was felt that an acute rehabilitation
facility would best serve his needs for cardiopulmonary
recovery.
On discharge, with suspected patient mental status change, it
was felt to possibly be multifactorial taking into effect his
history of an intracranial mass which is chronic with no
acute changes found on CT, possibly metabolic with tighter
glucose control sought, his postoperative atrial fibrillation
controlled on Lopressor and Amiodarone.
Th[**Last Name (STitle) 1050**] is to be discharged to rehabilitation facility to
follow-up with neurology consultation service, telephone
number [**Telephone/Fax (1) **], in one to two weeks, Dr.[**Name (NI) 108036**] pager
number [**Serial Number 108037**]. The patient also scheduled for outpatient
electroencephalogram on [**2142-7-28**], to evaluate for possible
seizure activity. The patient is also to follow-up with Dr.
[**Last Name (Prefixes) **] in seven to ten days.
DISCHARGE MEDICATIONS:
1. Lopressor 100 mg p.o. b.i.d.
2. Amiodarone 400 mg p.o. t.i.d. times two days, then
Amiodarone 400 mg p.o. b.i.d. times seven days and then
Amiodarone 400 mg p.o. q.d. times seven days.
3. Colace 100 mg p.o. b.i.d.
4. Aspirin 81 mg p.o. q.d.
5. Insulin 70/30 at 40 units subcutaneous q.a.m.
6. Insulin sliding scale.
7. Ranitidine 150 mg p.o. q.d.
8. Colchicine 0.5 mg p.o. q.d. p.r.n. gout.
9. Tylenol 650 mg p.o. q6hours p.r.n. pain.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern1) 2682**]
MEDQUIST36
D: [**2142-7-24**] 17:59
T: [**2142-7-24**] 19:09
JOB#: [**Job Number 40218**]
Name: [**Known lastname 441**], [**Known firstname **] Unit No: [**Numeric Identifier 17657**]
Admission Date: [**2142-7-16**] Discharge Date:
Date of Birth: [**2064-4-8**] Sex: M
Service:
ADDENDUM: Discharge medications also include Lasix 20 mg po
q day times one week, potassium chloride 20 mEq po q day
times one week, and Lipitor 10 mg po q day.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2142-7-24**] 18:03
T: [**2142-7-24**] 21:58
JOB#: [**Job Number 17658**]
|
[
"250.41",
"583.81",
"362.01",
"427.31",
"250.51",
"997.1",
"293.9",
"414.01",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
6916, 8260
|
1331, 1557
|
3236, 6893
|
1683, 3218
|
127, 1103
|
1125, 1305
|
1574, 1660
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,786
| 112,404
|
9323
|
Discharge summary
|
report
|
Admission Date: [**2110-10-25**] Discharge Date: [**2110-10-27**]
Date of Birth: [**2060-5-13**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Shortness of breath, Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
50 y/o F with metastatic adenoid cystic carcinoma, GERD, PE,
recent esophageal stent placement presents with increasing
cough. She presented intially to her PCP 2 days back with cough
and was given levoflox. However continued to have worsening
cough with phlegm and difficulty swallowing. Of note, she had
esophageal stents placed twice in the last month.
.
ED: Initial vitals were 99.3, 156, 122/81, 18, 100%/2L. Imaging
showed aspiration PNA and did not show any PE or significant
pericardial effusion. Started on Ceftriaxone, Zithro, Flagyl.
She remained tachycardiac to 120s non-responsive to fluids. She
was admitted to the ICU given her low pulm reserve and likely
semi-urgent esophageal stent placement.
Past Medical History:
1. Adenoid cystic carcinoma, diagnosed [**3-/2103**], details below
2. Left vocal cord paralysis
3. GERD
4. History of PE, [**2099**], [**2107**]
5. Cerebral vein thrombosis
6. Depression? (found in ED note)
7. CVA? (found in ED note)
8. Esophogeal stent [**2110-9-30**]
.
Onc Hx:
[**2102**]: diag after work-up 8 months of cough, L pneumonectomy and
carinal resection and postop radiation.
[**2105**]: Recurrent dz in pleural space.
[**2106**]: palliative radiation with concurrent low-dose Taxotere.
[**2107**]: Hepatic involvement --> 4 cycles of cisplatin and
Adriamycin.
[**2107**]: CT showed progression in lungs/liver. 2 cycles of
carboplatin and Taxol given, still with pulm progression. Tx
complicated by thrombocytopenia and PE on CT, started on
Lovenox.
[**2108**]: Brachial plexus MRI showed tumor L paraspinal region from
T2-T5
[**2108**]: 4 cycles of dose-reduced cisplatin, Navelbine
[**2108**]: CT showed renal hepatic progression.
[**2108**]: started on gemcitabine, held sev times for
myelosuppression.
[**2108**]: MRI showed leptomeningeal enhancement L frontal lobe.
[**2109**]: seizure, vein of Trolard thrombosis.
[**2109**]: weekly epirubicin, received 3 cycles, but multiple doses
were held because of poor performance status.
[**2109**]: onc team and pt decided upon symptom managment as CT scan
showed progression, she received single [**Doctor Last Name 360**] cisplatin.
Social History:
She does not smoke cigarettes or drink alcohol. She moved from
[**Country 3594**] to [**State 350**] in [**2091**]. She has a daughter who lives
in [**Location 17065**]. She also has a brother and sister who live in
the Greater [**Name (NI) 86**] area. She denies tobacco or alcohol use and
is currently not working. In the past, she has worked in a
bakery.
Family History:
Her mother is alive and healthy. Her father died at age 80 from
a stroke and heart attack. She has 5 sisters and 2 brothers, and
some of them have hypertension, hypercholesterolemia, and
diabetes. She has 6 daughters and a
son; they are all healthy.
Physical Exam:
PE: T 99, BP 105/80, HR 130, RR 18, 100% 2L
Gen: cachectic, chronically ill-appearing F in moderate
discomfort [**12-27**] neck pain; mostly Spanish speaking.
HEENT: EOMI. dry mucous membranes, clear oropharynx without
thrush.
Neck: flat JVP, tenderness diffusely along right paracervical
muscles without associated LAD, erythema or discrete mass
palpated. full ROM on neck. mild distension of neck veins on
right.
Lungs: good air movement R, decreased left, w/o focal
ronchi,rales, or wheeze
Cardiac: tachycardic, RRR, S1, S2, no murmurs
Abd: SNTND, +bs
Extr: thin, warm, well perfused. no clubbing/cyanosis/edema.
Skin: no rashes or other lesions. port on right chest c/d/i, no
erythema, tenderness to palpation.
Neuro: A&O, CNs grossly intact, no focal deficits
Affect: appropriate
Pertinent Results:
Labs on Admission:
[**2110-10-25**] WBC-11.8* RBC-3.43* Hgb-9.7* Hct-29.1* MCV-85 MCH-28.3
MCHC-33.3 RDW-15.2 Plt Ct-398 Neuts-92.2* Bands-0 Lymphs-4.2*
Monos-3.4 Eos-0.1 Baso-0.1 Hypochr-2+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Target-1+ Plt Smr-NORMAL Plt Ct-398
[**2110-10-26**] PT-17.3* PTT-60.6* INR(PT)-1.6*
[**2110-10-25**] Glucose-95 UreaN-5* Creat-0.4 Na-139 K-3.5 Cl-98
HCO3-31 AnGap-14 Calcium-7.9* Phos-3.4 Mg-1.0*
[**2110-10-26**] 12:20AM BLOOD Type-ART pO2-84* pCO2-55* pH-7.32*
calTCO2-30 Base XS-0 Intubat-NOT INTUBA
[**2110-10-26**] Lactate-2.2*
Imaging:
[**2110-10-25**] CXR FINDINGS: Single bedside AP examination labeled
"erect, 16:45 hours" is compared with the recent study dated
[**10-23**], as well as previous study, dated [**2110-10-9**]. There has been
progressive opacification of the right hemithorax over the
series of studies, which may represent confluent aspiration
pneumonitis. The patient is s/p left pneumonectomy and tubular-
appearing, presumably pleural, calcifications in the medial left
hemithorax are unchanged. Again demonstrated are esophageal
stent in situ, with slight narrowing at its mid-portion, as
before, as well as right subclavian venous access device with
tip likely at the cavo-atrial junction or high right atrium.
[**2110-10-25**] CTA
IMPRESSION:
1. No PE and no significant pericardial effusion.
2. Patchy airspace disease in the right lower lobe consistent
with aspiration pneumonitis.
3. Study is otherwise overall unchanged since the recent study
dated [**2110-9-25**].
Brief Hospital Course:
50 y/o F w/ h/o adenoid cystic carcinoma, GERD, PE, presented
with aspiration pneumonitis in the setting of likely obstructed
esophageal stent.
# Aspiration PNA: Aspiration from obstructed esophageal stent in
the setting of widely metastatic adenoid cystic carcinoma.
Patient was maintained NPO and started on Ceftriaxone,
Azithromycin, Flagyl for aspiration pneumonia. Given end-stage
carcinoma and high likelihood of repeated aspiration events in
the setting of esophageal obstruction and stent failure, goals
of care were changed to comfort measures only after discussion
with family on day 2 of admission. Patient received morphine
for respiratory distress.
# adenoid cystic carcinoma: Patient with known widely metastatic
disease on admission; was home hospice but family reversed it 2
days prior to admission as the service was not helping the
patient to be comfortable. Extensively discussed with patient
and family about goals of care: they would like comfort care and
minimal intervention to help make her comfortable. Patient was
given morphine for pain and comfort.
.
# Code: DNR/DNI on admission, made comfort measures only on day
2 of admission. The patient died the following day from
respiratory failure.
.
# FEN: The patient was maintained NPO during this hospital
admission.
.
# Dispo: The patient died one day after decision to continue
comfort measure care.
Medications on Admission:
Levoquin
Codeine,couh suppresant
Neurontin
Fentanyl patch
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Aspiration Pneumonitis
Esophageal Stent Occlusion
Adenoid cystic carcinoma, metastatic
Respiratory Failure
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
"197.0",
"V12.51",
"V66.7",
"161.9",
"197.7",
"799.4",
"530.81",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7113, 7122
|
5591, 6975
|
347, 353
|
7272, 7282
|
3984, 3989
|
7335, 7342
|
2911, 3162
|
7084, 7090
|
7143, 7251
|
7001, 7061
|
7306, 7312
|
3177, 3965
|
278, 309
|
382, 1095
|
4003, 5568
|
1117, 2518
|
2534, 2895
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,795
| 155,509
|
20606
|
Discharge summary
|
report
|
Admission Date: [**2125-9-10**] Discharge Date: [**2125-9-13**]
Date of Birth: [**2054-5-7**] Sex: M
Service: VSU
DATE OF DEATH: [**2125-9-13**].
ADMISSION DIAGNOSES:
1. 5.5 cm juxta-renal abdominal aortic aneurysm.
2. History of colon cancer status post abnormal peroneal
resection with end left-sided colostomy.
3. Coronary artery disease, status post coronary artery
bypass grafting in [**2125-4-17**].
4. Congestive heart failure.
5. Hypertension.
6. Hypercholesterolemia.
7. Implantation of pacemaker.
8. Status post varicose veins ligation.
9. Incisional hernia, status post herniorrhaphy.
DISCHARGE DIAGNOSES:
1. As above.
2. Status post repair of juxta-renal abdominal aortic
aneurysm via right retroperitoneal approach with 18 mm
tube graft ([**2125-9-10**]).
3. Status post exploratory laparotomy, revision of
abdominal aortic aneurysm repair for aortic thrombosis,
bilateral lower extremity angiography bullectomy,
bilateral femoral patch angioplasty.
4. Status post decompressive laparotomy with placement of
__________ patch.
5. Status post exploratory laparotomy.
6. Congestive heart failure, acute, systolic dysfunction.
7. Acute respiratory distress syndrome.
8. Respiratory failure.
9. Acute renal failure.
10.Hepatic insufficiency.
11.Hyperkalemia.
ADMISSION HISTORY AND PHYSICAL: Mr. [**Known lastname 216**] is a 71-year-old
male with progressively enlarged juxta-renal abdominal aortic
aneurysm who had been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on the
vascular surgery service for about a year and a half. His
abdominal aneurysm had been slowly enlarging and therefore it
was decided that he would need to undergo elective repair.
His operative planning was complicated by the presence of a
large parastomal hernia at the site of his left end
colostomy. The plan was for him to undergo an aneurysm via a
right retroperitoneal approach. Preoperatively the patient
was noted to have symptomatic coronary artery disease and
underwent coronary artery bypass grafting 4 months before the
planned surgery. He was given several months to recover from
this and presented for an elective repair of an aneurysm on
[**2125-9-10**].
HOSPITAL COURSE: The patient presented electively as noted
on [**2125-9-10**], and underwent a repair of his juxta-
renal abdominal aortic aneurysm using a right retroperitoneal
approach with an 18 mm tube graft. Intraoperatively the
anatomy of the aneurysm required placement of the aortic
cross clamp above the renal arteries. In addition significant
thrombus was idenytified and removed form the aortic segment.
Otherwise there was no
noted significant intraoperative complication, but he did not
make very much urine during the case. He was brought
intubated to the cardiovascular intensive care unit
postoperatively and his course was initially noted for
minimal urine output of approximately 5 cc per hour. The
nephrology service was consulted and followed along making
management recommendations, but this was a possible
anticipated outcome given the position of the aortic cross
clamp. The patient was aggressively hydrated and resuscitated
on the evening of postoperative day 0. He remained
hemodynamically normal but required continued ventilatory
supports. Early on the morning of postoperative day 1 the
patient was noted to have increasing IV fluid requirements
with a rising base deficit and a progressively rising lactic
acidosis. His pulses were noted to be diminished in his lower
extremities and there was a small degree of mottling along
his thigh. Given that the aorta was quite calcified
intraoperatively there was concern that he may have dislodged
some debris and embolized distally into his mesenteric
circulation or his lower extremities. Aggressive IV fluid
resuscitation was continued and intravenous antibiotics were
started over a concern for possible mesenteric ischemia. The
patient's creatinine kinase continued to rise, raising
concern for ischemia to the lower extremities. The general
surgery service was consulted for evaluation for the possible
mesenteric ischemia. After fluid
resuscitation as there was no significant improvement, the
patient was taken urgently back to the operating room and at
that time was found to have thrombosis in his distal aorta
proximal to bifurcation of the iliac. The massive fluid
resuscitation had caused a significant degree of edema in the
abdomen, and the general surgery service performed a
decompressive laparotomy for the presence of abdominal
compartment syndrome. The patient was transferred back to the
cardiovascular intensive care unit after his decompressive
laparotomy, his aortic thrombectomy, revision of his repair,
and restoration of flow to his lower extremities. It was
noted that he had likely showered emboli to his gluteal
arteries for which he was heparinized. He continued to remain
critically ill and developed progressively increasing
requirements for ventilatory support with significant
pulmonary edema postoperatively. His renal function continued
to deteriorate and continuous [**Last Name (un) **]-[**Last Name (un) **] hemodialysis was
started in conjunction with nephrology consultation. The
cardiology and electrophysiology services were following for
recommendations regarding his pacemaker. By postoperative day
2 the patient continued to remain critically ill. He was
requiring high dose vasopressors including continuous
epinephrine infusion, norepinephrine infusion, and
vasopressor infusion to maintain a mean arterial pressure of
60 mmHg. Given his multi-system organ failure which had
developed by postoperative day 2, a family meeting was held
with the daughter and the decision was made to withdraw care
on the morning of postoperative day 3 if no significant
change occurred overnight. Late in the evening of
postoperative day 2 the patient went into a V-tach arrest.
Advanced cardiac life support was initiated and the patient
was resuscitated and regained a perfusing rhythm. Several
hours later, early on the morning of postoperative 3, the
patient again went into a V-tach arrest for which advanced
cardiac life support was again reinitiated. This progressed
into episodes of asystole. CPR and ACLS were continued for
approximately 60 minutes without maintainable restoration of
his perfusing rhythm. As we were unable to resuscitate the
patient at this time, he was pronounced dead at 12:42 a.m. on
[**9-13**], postoperative day 3. The coroner declined to
perform an autopsy. The family declined an autopsy. The [**Location (un) **] Organ Bank was notified for protocol.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3186**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2125-9-13**] 19:43:49
T: [**2125-9-14**] 11:47:14
Job#: [**Job Number 55085**]
|
[
"038.9",
"428.23",
"276.2",
"995.92",
"557.0",
"V10.05",
"441.4",
"428.0",
"V45.81",
"440.0",
"785.52",
"V45.01",
"272.0",
"444.89",
"998.59",
"276.7",
"584.9",
"997.79",
"401.9",
"427.1",
"569.69",
"729.73",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.12",
"99.60",
"38.16",
"38.18",
"39.71",
"96.71",
"00.41",
"99.04",
"88.47",
"38.44"
] |
icd9pcs
|
[
[
[]
]
] |
649, 2246
|
2264, 6901
|
190, 628
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,400
| 126,049
|
15046+15047+56624
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2188-4-8**] Discharge Date: [**2188-4-18**]
Date of Birth: [**2130-12-20**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old
male with alcoholic cirrhosis, status post transjugular
intrahepatic portosystemic shunt in [**2185-9-25**] which was
complicated by occlusion, and status post revision with
reocclusion in [**2187-2-23**], who was referred from the Liver
Clinic for an increase in creatinine.
The patient recently was admitted from [**2188-3-28**] to [**2188-4-1**] for gastrointestinal bleed. The patient had an
esophagogastroduodenoscopy done at that time which showed no
evidence for bleeding varices; however, he was
hemodynamically unstable and required a Medical Intensive
Care Unit stay. A paracentesis was also done during that
admission and showed no evidence of spontaneous bacterial
peritonitis, and the patient was placed on ciprofloxacin for
prophylaxis.
Since discharge, the patient has noted persistent fatigue,
weakness, increasing bilateral lower extremity edema (right
greater than left), but he denies any calf tenderness or
erythema. The patient has been nauseous which is chronic.
He denies any vomiting, abdominal pain, hematemesis, melena,
bright red blood per rectum, upper respiratory infection
symptoms, shortness of breath, cough, chest pain, or
palpitations. He denies any change in his mental status. He
has chills which is chronic, but he denies any fevers.
The patient says that since discharge, his urine output has
decreased. The patient had a large volume paracentesis of
approximately 3.5 liters at an outside hospital on [**4-4**]
without any albumin afterwards. The patient went to the
Liver Clinic on [**2188-4-8**] and was noted to have a rise
in his creatinine from 2.7 to 4.5 over the last five days.
The patient is now being admitted for a workup of his renal
failure.
PAST MEDICAL HISTORY:
1. Alcoholic cirrhosis; status post transjugular
intrahepatic portosystemic shunt in [**2185-9-25**] with
occlusion and status post revision with reocclusion in [**2187-2-23**].
2. Grade I esophageal varices; status post banding.
3. Portal gastropathy.
4. History of hepatic encephalopathy requiring intubation.
5. Depression.
6. Posttraumatic stress disorder.
7. Mild pulmonary artery systolic hypertension.
MEDICATIONS ON ADMISSION:
1. Protonix 40 mg p.o. twice per day.
2. Ciprofloxacin 500 mg p.o. once per day (with the last
dose on [**2188-4-3**]).
3. Flagyl 250 mg p.o. twice per day
4. Lactulose.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**State 792**]with his
wife. [**Name (NI) **] is a former alcohol abuser, but he has been sober
for the last three to four years. He denies any illicit drug
use. The patient smokes approximately four to five
cigarettes per day.
PHYSICAL EXAMINATION ON PRESENTATION: Physical examination
revealed in general that the patient was awake and alert,
chronic ill-appearing, but in no acute distress. Bilateral
temporal wasting was noted. Temperature was 97.2, blood
pressure was 122/64, heart rate was 90, respiratory rate was
20, and oxygen saturation was 97% on room air. Head, eyes,
ears, nose, and throat examination revealed pupils were
equal, round, and reactive to light. Extraocular movements
were intact. Sclerae were anicteric. Mucous membranes were
dry. The oropharynx was clear. The neck was supple. Lung
examination revealed coarse breath sounds but clear to
auscultation without wheezes or crackles. Cardiovascular
examination revealed a regular rate and rhythm with a normal
first heart sounds and second heart sounds. No murmurs,
rubs, or gallops. The abdomen was soft and nontender.
Mildly distended. Positive bowel sounds. Bulging flanks
were present with shifting dullness. Extremity examination
revealed right lower extremity with 2 to 3+ pitting edema to
the knee. The left lower extremity with 1+ pitting edema.
The extremities were warm with 2+ dorsalis pedis pulses, and
no Homans' sign or palpable cords present. The calf was
nontender to palpation, and there was no erythema.
Neurologic examination revealed alert and oriented times
three. Cranial nerves II through XII were intact. No
asterixis.
PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories
revealed white blood cell count was 13.3, hematocrit was 39,
and platelets were 199. INR was 1.5. Sodium was 131,
potassium was 5.1, chloride was 100, bicarbonate was 15,
blood urea nitrogen was 70, creatinine was 4.5, and blood
glucose was 91. ALT was 18, AST was 35, alkaline phosphatase
was 329, total bilirubin was 1.7, and direct bilirubin was
0.7. Albumin was 2.9. Arterial blood gas revealed pH was
7.35, PCO2 was 21, and PO2 was 114.
HOSPITAL COURSE BY ISSUE/SYSTEM:
1. RENAL ISSUES: The patient's increase in creatinine was
thought to be secondary to both a prerenal state as well as
hepatorenal syndrome.
A urine sediment was examined by the Renal Service and was
found to have granular and hyaline casts without any protein
and small blood. The patient was given intravenous fluids
with improvement in his creatinine; suggesting a prerenal
state. However, midodrine and octreotide were also started
for presumed hepatorenal syndrome.
Throughout the [**Hospital 228**] hospital course, the patient's
creatinine continued to improve. The patient's creatinine
upon discharge ranged from 3.2 to 3.6.
The patient's midodrine and octreotide were titrated up to
maintain a systolic blood pressure of greater than 110. The
patient no longer required intravenous fluids as he was able
to take adequate fluids by mouth. The patient's urine output
still remained marginal.
In addition, the patient's potassium was monitored closely as
hypokalemia can precipitate hepatic encephalopathy. The
patient's potassium was closely monitored and repleted to
greater than 4.
In addition, the patient will require midodrine and
octreotide perhaps indefinitely given his hepatorenal
syndrome. The patient did receive albumin intermittently
throughout his hospital course as well to replete his
intravascular volume.
2. HEPATIC ENCEPHALOPATHY ISSUES: The patient was admitted
with a relatively clear mental status examination on
lactulose/Kristalose and remained relatively clear until the
morning of [**2188-4-11**] when the patient was found
completely obtunded with grade IV hepatic encephalopathy.
At that time, an arterial blood gas was obtained which
revealed a pH of 7.38, PCO2 was 22, and PO2 was 103.
The patient was emergently evaluated by the Medical Intensive
Care Unit and transferred to the Intensive Care Unit for
elective intubation for airway protection.
Since the patient had been started recently on heparin during
the hospital course, there was a concern for intracranial
hemorrhage. A STAT computed tomography scan was obtained
which showed no evidence of an intracranial hemorrhage. In
addition, a magnetic resonance imaging of the brain was also
obtained which showed an essentially normal study.
The patient had a nasogastric tube inserted in the Medical
Intensive Care Unit with the administration of 60 cc of
laceration every two hours, and the patient eventually awoke
on [**2188-4-13**]. In addition, the patient was successfully
extubated at that time.
Given the patient's hepatic encephalopathy, the patient's
potassium level was monitored closely for a goal of 3.5 to 4
to prevent exacerbation of hepatic encephalopathy. Of note,
an ammonia level was drawn during his encephalopathic period
and it was noted to be evaluated at 300. In addition, the
Neurology Service was consulted for further management of his
encephalopathy and again agreed that the patient's current
obtundation was likely due to a metabolic process; likely
hepatic encephalopathy.
Once the patient was transferred out of the Medical Intensive
Care Unit on [**2188-4-14**], his mental status slowly
improved with continued administration of lactulose 45 mL
p.o. q.4h. as needed.
3. GASTROINTESTINAL ISSUES: Initially, the patient was
admitted as a possible transplant candidate. However,
because of the patient's history of transjugular intrahepatic
portosystemic shunt occlusion as well as the presence of a
right lower extremity deep venous thrombosis, the patient was
no longer considered a transplant candidate as the risks of a
transplant would be extremely high.
Upon admission, the patient had a diagnostic paracentesis
which was negative for any evidence of spontaneous bacterial
peritonitis. When the patient became obtunded in the Medical
Intensive Care Unit, ceftriaxone was empirically started for
a possible spontaneous bacterial peritonitis as an
exacerbation factor for his obtundation; however, because the
patient did not have any clinical signs of peritonitis, the
ceftriaxone was discontinued once the patient was transferred
out of the Medical Intensive Care Unit.
The patient did have another therapeutic paracentesis
performed on [**2188-4-17**] with removal of approximately 5
liters of peritoneal fluid with 50 g of albumin given
afterwards to support his intravascular volume. The Gram
stain and culture, as well as a self-cath of the peritoneal
fluid were still pending at the time of this dictation.
4. HEMATOLOGIC ISSUES: Upon admission, a right lower
extremity ultrasound was obtained given the asymmetric edema.
A partially occlusive right lower extremity deep venous
thrombosis extending from the right common femoral vein into
the popliteal vein was noted, as well as a small
nonobstructive mural thrombus at the confluence of the left
superficial femoral and profunda veins.
Because of the patient's high risk of gastrointestinal
bleeding, given his prior history and his alcoholic
cirrhosis, along with the history of a transjugular
intrahepatic portosystemic shunt occlusion and reocclusion,
as well as this new deep venous thrombosis, the Hematology
Service was consulted for further management of this
complicated patient.
Initially, the Hematology Service recommended the initiation
of heparin with a low partial thromboplastin time goal of 50
to 60 and the placement of an inferior vena cava filter. The
Hematology Service did not recommend long-term
anticoagulation at this point; especially given the risk of
gastrointestinal bleeding in this patient.
As noted above, on [**2188-4-11**], with the initiation of
heparin, the patient's partial thromboplastin time was found
to be supratherapeutic at 150. Concomitantly, the patient
was also found to be extremely obtunded. There was a concern
for an intracranial bleed, and as noted above there was no
evidence hemorrhage intracranially both on computed
tomography scan and magnetic resonance imaging of the head.
As a result, the heparin dose was adjusted in order to
achieve a goal partial thromboplastin time of 50 to 60, and
an inferior vena cava filter was placed on [**2188-4-15**]
without any difficulties.
A partial hypercoagulability workup was also started in the
hospital, and activated protein C resistance as well as
prothrombin gene mutation were sent, and the results were
pending at the time of this dictation. A full
hypercoagulable workup should be pursued once the patient is
followed as an outpatient.
Once the inferior vena cava filter was placed, the heparin
was discontinued. The patient's hematocrit remained
completely stable during his hospitalization, and there was
no evidence of gastrointestinal bleeding.
5. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient's
chronic hyponatremia initially was corrected during his
hospital course with intravenous fluids. The patient's
sodium ranged from the 130s to 140s.
In addition, the patient was noted to have a non-gap
metabolic acidosis; likely secondary to his renal failure.
The patient was not given any further bicarbonate as the
patient had a respectively alkalosis secondary to
hyperventilation from his ascites.
As noted above, the patient's potassium levels were monitored
closely to prevent the precipitation of hepatic
encephalopathy.
CONDITION AT DISCHARGE: Condition on discharge was stable.
DISCHARGE STATUS: Discharge status was to rehabilitation.
DISCHARGE DIAGNOSES:
1. Alcoholic cirrhosis; status post transjugular
intrahepatic portosystemic shunt with occlusion, status post
revision and reocclusion.
2. History of gastrointestinal bleeds.
3. Right lower extremity deep venous thrombosis; status post
inferior vena cava filter.
4. Ascites.
5. Hepatic encephalopathy.
6. Acute renal failure secondary to prerenal and hepatorenal
syndrome.
7. Chronic hyponatremia.
MEDICATIONS ON DISCHARGE:
1. Octreotide 100 mcg subcutaneously q.8h.
2. Lactulose 45 mL p.o. q.4h. as needed (titrate to four
loose bowel movements per day).
3. Midodrine 12.5 mg p.o. three times per day.
4. Epogen 10,000 units subcutaneously two times per week
(every Wednesday and Saturday).
5. Protonix 40 mg p.o. once per day.
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to follow
up with Dr. [**Last Name (STitle) 43994**] [**Name (STitle) 5456**] to reassess the need for a repeat
therapeutic paracentesis.
DISCHARGE DIET: The patient was discharged on a low-protein,
renal, low-sodium diet.
ADDENDUM: In addition, Epogen was started during his
hospital course given his renal failure and persistent anemia
due to anemia of chronic disease and renal failure.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Last Name (NamePattern1) 1336**]
MEDQUIST36
D: [**2188-4-17**] 15:55
T: [**2188-4-17**] 18:25
JOB#: [**Job Number 43995**]
Admission Date: [**2188-4-8**] Discharge Date: [**2188-4-18**]
Date of Birth: [**2130-12-20**] Sex: M
Service: MEDICINE
ADDENDUM: Results of the 5 liter paracentesis performed on
[**2188-4-17**] revealed no signs of spontaneous bacterial
peritonitis. The patient will be continued on Octreotide and
Midodrine for a total of 14 days to end on [**2188-5-1**] or
sooner per Dr. [**Last Name (STitle) 5456**] the patient's gastroenterologist and
primary care physician in [**Name9 (PRE) **].
The patient will follow up with Dr. [**Last Name (STitle) 5456**] next week for
repeat paracentesis as needed. On repeat paracentesis the
patient will need 8 grams of albumin per liter of fluid
removed in the paracentesis to replete his intravascular
volume. The patient also was started on a multivitamin on
the day of discharge.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**]
Dictated By:[**Last Name (NamePattern1) 14486**]
MEDQUIST36
D: [**2188-4-18**] 01:08
T: [**2188-4-18**] 13:46
JOB#: [**Job Number 43996**]
Name: [**Known lastname 8102**], [**Known firstname 2794**] C Unit No: [**Numeric Identifier 8103**]
Admission Date: [**2188-4-8**] Discharge Date: [**2188-4-18**]
Date of Birth: [**2130-12-20**] Sex: M
Service: Medicine
ADDENDUM: The patient also had a VQ scan performed to rule
out the presence of a pulmonary embolus, given his history of
right lower extremity deep venous thrombosis and history of
hemoptysis upon admission. VQ scan showed low probability of
pulmonary embolus. The patient's oxygenation remains stable
throughout his hospitalization. As noted above, the patient
did require transient intubation for airway protection during
his period of obtundation secondary to hepatic
encephalopathy.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4098**], M.D. [**MD Number(2) 5314**]
Dictated By:[**Last Name (NamePattern1) 1667**]
MEDQUIST36
D: [**2188-4-17**] 04:11
T: [**2188-4-17**] 19:16
JOB#: [**Job Number 8104**]
|
[
"584.9",
"572.2",
"789.5",
"572.4",
"276.1",
"453.8",
"303.93",
"571.2",
"996.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.7",
"38.93",
"54.91",
"96.71",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
12212, 12618
|
12644, 12955
|
2359, 2572
|
12989, 15840
|
4794, 12080
|
12095, 12191
|
160, 1894
|
1916, 2333
|
2589, 4760
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,316
| 178,589
|
34170
|
Discharge summary
|
report
|
Admission Date: [**2140-1-29**] Discharge Date: [**2140-2-4**]
Date of Birth: [**2085-2-5**] Sex: F
Service: MEDICINE
Allergies:
Adhesive Tape / Ativan
Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
s/p cardiac arrest, ? need for plasmapheresis
Major Surgical or Invasive Procedure:
[**1-31**] Laryngoscopy.
[**2-1**] Flexible bronchoscopy with secretion aspiration.
[**2-2**] Rigid bronchoscopy and button-on tracheostomy placement.
History of Present Illness:
This is a 54 yo female with history of myasthenia [**Last Name (un) 2902**],
tracheomalacia s/p Y stent placement, history of multiple
admissions for respiratory failure presents from OSH s/p cardiac
arrest. She was in her usual state of health until about 2 days
prior to her presentation at OSH, when she began to have SOB
associated with greenish brownish sputum. On [**2140-1-22**], she
activated EMS. Upon EMS arrival, she was apparently noted to be
in PEA arrest. Received CPR, epinephrine, atropine and had LMA
placed. In ED at OSH, had LMA tube exchanged for ETT. ETT then
noted to be placed outside of Y stent. Bronchoscopy performed
and ETT replaced over stent and secretions removed. X-rays
thought to be consistent with bilateral infiltrates c/w ARDS.
She was treated with vancomycin and zosyn for pneumonia,
apparently required pressors briefly. Culture data negative. She
was extubated today on the day of transfer without event. Pt was
also noted to have new global CM with EF 20%, thought to be
seconadry to sepsis per OSH cardiology c/s and started on ASA,
lisinopril. Currently denies SOB, chest pain, palpitations. She
does not recall the events leading up to her hospitalization.
ROS: The patient denies any fevers, chills, weight change,
nausea, vomiting, abdominal pain, diarrhea, constipation,
melena, hematochezia, chest pain, orthopnea, PND, lower
extremity oedema, cough, urinary frequency, urgency, dysuria,
lightheadedness, gait unsteadiness, focal weakness, vision
changes, headache, rash or skin changes.
Past Medical History:
--myasthenia [**Last Name (un) 2902**] (+MUSK Ab): dx [**4-29**], treated with
pyridostigmine, prednisone, cellcept, IVIG, plasmapheresis;
difficult fibroscopic intubation, unable to tolerate BiPAP.
--tracheomalacia s/p flexible and rigid bronchoscopy with stent
placement on [**2139-5-7**], Y stent replacement [**2139-10-15**]
--sinus tachycardia when awake or anxious, thought [**1-25**] to
autonomic instability from myasthenia [**Last Name (un) 2902**]
--DMII, diet controlled, on ISS while on steroids
--anxiety
--GERD
--obesity
--anxiety
--s/p cholecystectomy, appendectomy, tonsillectomy
--nephrolithiasis
Social History:
No smoking, etoh, illicit drug use. Lives alone. Does not use
home O2 since she has a gas stove, feels uncomfortable with
BiPAP. used to work as a case manager.
Family History:
father with CAD and DM, brother with bronchitis, no family hx of
myasthenia [**Last Name (un) 2902**], autoimmune disease.
Physical Exam:
VS: 96.8 96/40 80 20 99% 2L
Gen: NAD, not using accessory muscles to breathe
HEENT: PERRL, sclera anicteric, MMM, O/P clear
Neck: No LAD
Cor: RRR nl s1 s2 no m/r/g
Pulm: rhonchorous bronchial sounds diffusely
Abd: obese, soft, NT ND
Ext: +DP and PT pulses b/l
Neuro: alert, oriented x 3. mild eyelid droop, CN otherwise in
tact,5/5 strength upper and lower extremities. [**4-26**] neck
extension and
flexion.
Pertinent Results:
[**2140-1-30**] 01:26AM BLOOD WBC-5.9# RBC-3.83*# Hgb-10.5* Hct-32.5*#
MCV-85 MCH-27.5 MCHC-32.4 RDW-20.4* Plt Ct-156#
[**2140-1-31**] 07:20AM BLOOD WBC-5.9 RBC-4.11* Hgb-11.4* Hct-34.3*
MCV-83 MCH-27.6 MCHC-33.1 RDW-19.5* Plt Ct-160
[**2140-2-2**] 07:05AM BLOOD WBC-6.6 RBC-4.00* Hgb-11.5* Hct-33.6*
MCV-84 MCH-28.7 MCHC-34.2 RDW-19.8* Plt Ct-308#
[**2140-2-3**] 06:45AM BLOOD WBC-5.4 RBC-4.09* Hgb-11.2* Hct-34.2*
MCV-84 MCH-27.4 MCHC-32.7 RDW-19.9* Plt Ct-411
[**2140-2-4**] 08:05AM BLOOD WBC-5.8 RBC-3.80* Hgb-10.6* Hct-32.0*
MCV-84 MCH-28.0 MCHC-33.3 RDW-19.0* Plt Ct-296
[**2140-1-30**] 01:26AM BLOOD PT-13.3 PTT-30.4 INR(PT)-1.1
[**2140-1-31**] 07:20AM BLOOD PT-13.1 PTT-30.9 INR(PT)-1.1
[**2140-1-30**] 01:26AM BLOOD Glucose-44* UreaN-19 Creat-0.5 Na-140
K-3.5 Cl-100 HCO3-32 AnGap-12
[**2140-1-31**] 07:20AM BLOOD Glucose-104 UreaN-13 Creat-0.5 Na-142
K-3.3 Cl-104 HCO3-33* AnGap-8
[**2140-2-2**] 07:05AM BLOOD Glucose-121* UreaN-16 Creat-0.6 Na-141
K-4.3 Cl-101 HCO3-32 AnGap-12
[**2140-2-3**] 06:45AM BLOOD Glucose-118* UreaN-11 Creat-0.6 Na-139
K-4.3 Cl-98 HCO3-34* AnGap-11
[**2140-2-4**] 08:05AM BLOOD Glucose-102 UreaN-12 Creat-0.7 Na-139
K-4.0 Cl-101 HCO3-32 AnGap-10
[**2140-1-30**] 01:26AM BLOOD ALT-37 AST-22 AlkPhos-57 TotBili-0.4
[**2140-1-30**] 01:26AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.1
[**2140-1-31**] 07:20AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.9
[**2140-2-3**] 06:45AM BLOOD Cholest-149
[**2140-2-3**] 06:45AM BLOOD Triglyc-167* HDL-40 CHOL/HD-3.7
LDLcalc-76
[**2140-1-30**] 01:26AM BLOOD TSH-0.53
[**2140-1-30**] 01:26AM BLOOD Ferritn-37
.
Imaging:
.
CXR [**1-29**]:FINDINGS: There is a right IJ catheter with tip in the
superior vena cava. There is a orogastric tube, with tip in the
stomach. Linear opacity is present at the left base, likely
representing discoid atelectasis. Similar opacity is present at
the right base. Otherwise, there is no gross infiltrate or
effusion. There is no pneumothorax. IMPRESSION: Likely
atelectasis as described above. Support lines and tubes
as described above.
.
CXR [**1-31**]: FINDINGS: The subsegmental atelectatic changes do not
appear differently compared to the prior study. A right CVL has
been removed, and there is no PTX. I do not clearly see the
Y-stent on this radiograph. However, I do note a narrowing of
the trachea just above the carina overlying vertebral body
interspace T4-5, a finding that was not apparent on the prior
study. IMPRESSION: New apparent narrowing of the trachea just
above the carina at the T4-5 interspace level. CT scan might be
helpful in further evaluation. Status post line removal. No
interval change in basilar atelectatic features.
.
CXR [**2-2**]: FINDINGS: AP single view obtained with patient in
sitting semi-upright position is analyzed in direct comparison
with a preceding similar study of [**2140-1-31**]. A metallic
ring shape, approximately 1.5 cm diameter, structure has been
placed in the trachea at the level of C7. There is no evidence
of any pneumothorax or soft tissue emphysema in the lower neck
area. Comparison with the preceding study, heart size is
unchanged. There is no evidence of pulmonary vascular
congestion. Plate atelectasis on left base without significant
progression. Lateral pleural sinuses are free. No new
parenchymal infiltrates. As on previous examination a simple
radiograph does not clearly identify the previously mentioned
Y-shaped tracheobronchial stent. A certain degree of narrowing
is present as it was described before. IMPRESSION: No
pneumothorax or any other significant changes status post
bronchoscopy.
.
TTE [**2-3**]: The left atrium is dilated. Left ventricular wall
thicknesses and cavity size are normal. There is moderate global
left ventricular hypokinesis (LVEF = 30-35 %). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. IMPRESSION: Moderate global hypokinesis
(the septum may have relatively worse function). Mild mitral
regurgitation. Compared with the prior study (images reviewed)
of [**2139-5-19**], hypokinesis is now global and overall EF has
decreased slightly.
Brief Hospital Course:
# Respiratory distress and cardiomyopathy s/p PEA arrest -
initially transferred from OSH to [**Hospital1 18**] ICU on [**1-29**] after
extubation and treatment of ARDS/sepsis with IV antibiotics. As
clinical status had improved and CXRs were clear, IV abx were
stopped. Echocardiogram at OSH showed global hypokinesis w/ EF
20-25%, decline from baseline EF 45% on echo in [**4-/2139**], and
thought due to a septic state at the OSH. Repeat echocardiogram
prior to discharge showed partial improvement to EF 30-35%. A
TSH was checked and was normal. Patient was continued on home
diuretic. No hemodynamic instability (sinus tachycardia
discussed below) or breathing difficulties.
.
# Airway clearance: Evaluted by interventional pulmonology with
significant mucous plugging cleared by bronchoscopy on [**2-1**],
likely precipitant of PEA arrest on [**1-22**]. Pt underwent a
button-hole tracheostomy placement on [**2-2**] for self-suctioning
at home. Received mucomyst and saline nebs while hospitalized,
however did not tolerate mucomyst due to taste/smell. Physical
therapy evaluated and cleared patient. Teaching was provided
concerning self-suctioning by respiratory therapy and
interventional pulmonology.
.
# Myasthenia [**Last Name (un) 2902**] - on transfer to [**Hospital1 18**] ICU, evalauted by
neurology service who found myasthenia to be well-controlled
with no indications for plasmapheresis or IVIG. Remained
clinically well with no diplopia or other CN palsies or overt
muscle fatiguability and good NIF's while hospitalized. Stayed
on her home regimen of azathioprine, prednisone, pyridostigmine.
Bactrim prophylaxis had been initially held due to illness but
was restarted prior to discharge.
.
# Throat soreness: Developed after extubation and noted by ENT
to have viral pharyngitis, with pink/white papules and
non-displacable plaques. Sent throat cx for strep, HSV, and
other viruses. Started Nystatin, acyclovir, and fluconazole for
possible candidal and HSV pharyngitis. Pain relief provided
with visouc lidocaine. Throat cultures negative for strep and +
for HSV. Fluconazole and acyclovir were continued on discharge
for 7 day courses.
.
# s/p NSTEMI: Noted to have an NSTEMI on presentation to OSH in
PEA arrrest ([**1-22**]), thought likely related to demand ischemia.
Was started on aspirin 81 mg. Lipid profile was normal.
.
# Diarrhea: on [**2-3**], had multiple bouts of abdominal cramping
followed by watery, non-bloody diarrhea, w/ resolution of
cramping with bowel movement, with resolution by afternoon. No
further bowel movements to test for C. diff.
.
# Sinus tachycardia: Long-standing sinus tachycardia thought due
to autonomic instability from myasthenia [**Last Name (un) 2902**]. While
hospitalized, HR ranged at baseline was 100's-110's with no
symptoms/complaints.
.
# Diabetes mellitus, type II: Diet-controlled at home and placed
on insulin sliding scale while hospitalized and on prednisone,
with blood sugar's in 100's-200's.
.
# Asthma: Was well-controlled without symptoms/complaints and
was continued on fluticasone nasal spray, ipratropium nebs.
Albuterol nebs were not given due to baseline sinus tachycardia,
and xopenex nebs were given instead.
.
# GERD: Was at baseline during stay, continued PPI treatment.
Medications on Admission:
Medications at time of transfer:
ASA 325
Calcium carbonate 1250 TID
Fluticasone 50 [**Hospital1 **]
Lasix 20 QD
Hycosamine 0.125
Glargine 20 units QHS
Atrovent 1 neb
Lansoprazole 30 [**Hospital1 **]
Lisinopril 2.5
Ativan 2 q4H prn
Mestinon 60 QID
Morphine 2 mg q4H prn
Mucinex 1200 mg
Omeprazole 40 [**Hospital1 **]
Paroxetine 15
Zosyn
Vancomycin
Azathioprine 100 [**Hospital1 **]
Methylprednisolone 125 [**Hospital1 **]
Discharge Medications:
1. Portable suction machine with supplies
Needs portable suctions for health care appointment for 6
hours/week Dx: Myasthenia [**Last Name (un) 2902**], tracheobronchomalacia
Medicaid ID# [**Telephone/Fax (3) 78745**]
2. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week: On
Sunday. Tablet(s)
3. Acyclovir 400 mg Tablet Sig: One (1) Tablet PO five times a
day for 5 days.
Disp:*25 Tablet(s)* Refills:*0*
4. Fluconazole 100 mg Tablet Sig: One (1) Tablet PO every
twenty-four(24) hours for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Mucinex 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1)
Tab, Multiphasic Release 12 hr PO twice a day.
Disp:*60 Tab, Multiphasic Release 12 hr(s)* Refills:*2*
7. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO 3x/week
on MWF.
Disp:*90 Tablet(s)* Refills:*2*
8. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
QID (4 times a day) as needed for throat pain for 7 days.
Disp:*140 ML(s)* Refills:*0*
9. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 7 days.
Disp:*140 ML(s)* Refills:*0*
10. Hyoscyamine Sulfate 0.125 mg Tablet, Sublingual Sig: [**12-25**]
Tablet, Sublinguals Sublingual QID (4 times a day) as needed.
11. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
12. Paroxetine HCl 30 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Calcium Carbonate 500 mg (1,250 mg) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Pyridostigmine Bromide 60 mg/5 mL Syrup Sig: One (1) PO Q6H
(every 6 hours).
17. Azathioprine 50 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
18. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
19. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab
Sust.Rel. Particle/Crystal PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Myasthenia [**Last Name (un) 2902**].
PEA arrest.
Respiratory distress.
Tracheostomy placement.
Discharge Condition:
Stable with baseline vital signs. Able to ambulate without
assistance.
Discharge Instructions:
You were transferred to the [**Hospital3 **] [**Hospital 1225**] Medical
Center for further management of your respiratory failure and
myasthenia [**Last Name (un) 2902**] after cardiac arrest on [**2140-1-22**].
You came from another hospital after being extubated. While
here, you were initially in the ICU and the antibiotics you were
receiving were stopped, as your chest x-rays showed significant
improvement, with no fluid or infection in the lungs. You were
evaluated by the neurology service, who felt your myasthenia was
well-controlled and did not recommend urgent plasmapheresis or
IVIG treatment. You underwent laryngoscopy by the ENT service
on [**1-31**], who felt you had a viral infection/inflammation of your
throat. You also underwent bronchoscopy by the interventional
pulmonology service on [**2-1**] with thick secretions cleared and had
a new button-on tracheostomy placed on [**2-2**]. We continued
giving you your medications for your myasthenia [**Last Name (un) 2902**]. For
your throat soreness, we gave you medications to help numb the
pain and treat possible viral and fungal infections. You should
complete the full course of these medications, acyclovir and
fluconazole, unless instructed to stop by your physician. [**Name10 (NameIs) 6**]
ultrasound of your heart on [**2-3**] showed that you have gained
back some of your pump function, though it has not yet
completely normalized. It is important that you talk to your
physician about getting [**Name Initial (PRE) **] repeat echocardiogram in several
months.
.
You should continue to do suctioning through your tracheostomy
at home as you practiced in the hospital and continue to do
saline nebulizer treatments at least 3 times daily.
.
If you experience increased cough or secretions, [**Name Initial (PRE) 7186**] of
breath, wheezing, worsening or persistent sore throat, inability
to swallow, neck pain, chest pain, nausea, vomiting, diarrhea or
abdominal pain, or weakness, seek immediate medical attention.
Followup Instructions:
You have the following appointments scheduled with [**Hospital1 18**]
providers, including plasmapheresis next week.
.
Provider: [**Name10 (NameIs) 1248**],BED FOUR [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2140-2-9**]
10:15
Provider: [**Name10 (NameIs) 1248**],BED THREE [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2140-2-10**]
10:15
Provider: [**Name10 (NameIs) 1248**],CHAIR FIVE [**Name10 (NameIs) 1248**] ROOMS Date/Time:[**2140-2-11**]
10:15
.
You have an appointment with your neurologists, Dr. [**Last Name (STitle) 557**] and
[**Doctor Last Name 575**] on [**2-16**] at 10am on the eighth floor of the
[**Hospital Ward Name 23**] building.
.
On the same day as your neurology appointment, you have a
follow-up appointment with the Ear Nose and Throat specialist,
Dr. [**Last Name (STitle) **] on [**2-16**] at 1:15om on the [**Location (un) **] of the
[**Hospital Unit Name **] at [**Last Name (NamePattern1) **].
.
You have an appointment with your primary care doctor, Dr. [**First Name (STitle) **],
on [**2140-2-18**] at 4:00 pm.
.
You have an appointment with your interventional pulmonary
physicians, [**Year (4 digits) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) **], on [**2140-2-19**] at
8:30 am.
|
[
"410.71",
"300.00",
"E912",
"278.00",
"530.81",
"493.90",
"358.00",
"054.79",
"934.9",
"250.00",
"425.4",
"112.0",
"519.19",
"787.91",
"518.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"33.24",
"31.42"
] |
icd9pcs
|
[
[
[]
]
] |
13709, 13767
|
7861, 11147
|
328, 481
|
13907, 13981
|
3450, 7838
|
16033, 17265
|
2881, 3005
|
11619, 13686
|
13788, 13886
|
11173, 11596
|
14005, 16010
|
3020, 3431
|
243, 290
|
509, 2047
|
2069, 2686
|
2702, 2865
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,531
| 148,450
|
29393
|
Discharge summary
|
report
|
Admission Date: [**2170-1-3**] Discharge Date: [**2170-1-11**]
Date of Birth: [**2093-2-17**] Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending:[**First Name3 (LF) 330**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
Intubation
Central venous line
PA catheter
History of Present Illness:
76 yo male w/ vague PMH of arrhythmia presents after being found
down by his family. Patient was apparently found by family in
the basement after being down for an unknown period of time
(hours?). They were unable to get him upstairs so they brought a
mattress down into the basement. The daughter slept down in the
basement with him overnight and at around 5 am he was calling
out for watter but did not seem to recognize her. The family
called the [**Doctor First Name **] Scientist nurse advisor who told them that
they were legallly bound to call the ambulance in the state of
MA. EMS found him to be unresponsive w/ GCS 5 and a FS of 20 on
the scene; he received an amp of D50. When the patient arrived
in the ED his vitals were as follows: T 78.9 F/26.1 C, HR 93, BP
86/55, RR 14, sat 94% on face mask. He was intubated and started
on warm O2 in attempt to warm him. He was also noted to be
coagulopathic with an INR of 7.7. He received 3 U PRBCs, 2 [**Location 70589**], 6 [**Location 16678**] and Vit K 10 mg SC x 1. Also, was started
empirically on broad spectrum abx - vancomycin, ceftriaxone, and
flagyl - and a dose of dexamethasone 10 mg IV x 1. He was
started on a levophed gtt for blood pressure support. He had a
FAST exam which noted free fluid in the abdomen, but it was
unclear if this blood or ascites. He also went to the OR and was
going to get warmed via ECMO. Since his temp was up to 85 F at
that time, the surgeons decided against this, but a L subclavian
cordis was placed. Swanned in MICU and found to have high right
sided pressures and waveforms c/w severe TR. Echo confirmed
3+TR.
Past Medical History:
hx of a fib - dx in summer [**2168**], not rate controlled or
anticoagulated
hx of edema (testicular) - attributed to heart failure, per wife
Social History:
SH: Patient is originally from the [**Country 13622**] Republic, has lived
in [**Male First Name (un) 1056**], and came to the US about one year ago. Is
retired and lives with his wife and daughter.
Family History:
FH: no hx of liver disease
Physical Exam:
Gen: intubated
HEENT: periorbital edema, pupils reactive
Lungs: clear
Heart: irreg, irreg, no murmurs appreciated
Abd: no bowel sounds, firm, ? ascites, could not palpate liver
or spleen
Ext: diffuse, severe total body pitting edema
Skin: eccymoses under arms bilat, skin over feet is also
ecchymotic, has cracked skin over fingernail beds
Neuro: not responsive to voice/commands
Pertinent Results:
ADMISSION LABS:
[**2170-1-3**] 03:50PM BLOOD WBC-12.6* RBC-2.82* Hgb-7.5* Hct-23.8*
MCV-85 MCH-26.6* MCHC-31.5 RDW-17.6* Plt Ct-34*
[**2170-1-3**] 04:00PM BLOOD Neuts-79* Bands-14* Lymphs-1* Monos-4
Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0
[**2170-1-3**] 03:50PM BLOOD PT-48.7* PTT-73.4* INR(PT)-5.7*
[**2170-1-3**] 03:50PM BLOOD Plt Smr-VERY LOW Plt Ct-34*
[**2170-1-3**] 03:50PM BLOOD Fibrino-72*
[**2170-1-3**] 11:07PM BLOOD ESR-0
[**2170-1-3**] 04:00PM BLOOD Glucose-62* UreaN-62* Creat-1.3* Na-133
K-4.4 Cl-101 HCO3-21* AnGap-15
[**2170-1-3**] 10:04PM BLOOD ALT-142* AST-476* LD(LDH)-1168*
CK(CPK)-6363* AlkPhos-89 Amylase-190* TotBili-4.9*
[**2170-1-3**] 10:04PM BLOOD Lipase-107*
[**2170-1-3**] 10:04PM BLOOD CK-MB-401* MB Indx-6.3* cTropnT-0.08*
[**2170-1-3**] 10:04PM BLOOD Albumin-2.5* Calcium-7.9* Phos-4.2 Mg-2.5
[**2170-1-4**] 03:18AM BLOOD Hapto-<20*
[**2170-1-4**] 03:18AM BLOOD TSH-2.2
[**2170-1-4**] 07:41AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
[**2170-1-3**] 11:07PM BLOOD ANCA-NEGATIVE B
[**2170-1-3**] 11:07PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2170-1-4**] 07:41AM BLOOD HCV Ab-NEGATIVE
[**2170-1-3**] 03:45PM BLOOD Glucose-22* Lactate-4.4* Na-129* K-4.7
Cl-98* calHCO3-26
[**2170-1-3**] 11:07PM BLOOD ANTI-JO1 ANTIBODY- 0.07
[**2170-1-3**] 11:07PM BLOOD C2-Test-1.3 (RANGE 1.6-3.5 MG/DL)
CHAGAS - ANTIBODY NOT DETECTED
.
CXR [**2170-1-3**]:
1. No evidence of definite parenchymal consolidation. Unchanged
appearance to pleural effusions and interstitial pulmonary
edema.
2. Endotracheal tube approximately 8 cm from carina, recommend
repositioning. Swan-Ganz catheter tip likely within right
ventricle.
.
CT CHEST/ABDOMEN [**2170-1-3**]:
1. Extremely limited study secondary to artifact.
2. Free fluid seen throughout the abdomen, tracking into the
pelvis, measuring simple fluid density in most areas. Some areas
of higher attenuation fluid measurements are likely secondary to
artifact, although hemoperitoneum cannot be totally excluded.
There is no evidence of layering hematocrit level. No active
extravasation identified.
3. Diffuse anasarca.
4. Large bilateral pleural effusions with associated
atelectasis/consolidation.
.
CT HEAD [**2170-1-3**]:
No evidence of acute intracranial hemorrhage.
.
CT C-SPINE [**2170-1-3**]:
1. No evidence of acute fracture.
2. Cervical spondylosis.
3. Bilateral pleural effusions and atelectasis.
.
TTE [**2170-1-5**]:
The left atrium is dilated. The right atrium is dilated. There
is moderate global left ventricular hypokinesis. There is no
ventricular septal defect. The right ventricular cavity is
dilated. There is severe global right ventricular free wall
hypokinesis and moderate global left ventricular hypokinesis
(ejection fraction 30-40 percent). The number of aortic valve
leaflets cannot be determined; there is significant focal
thickening of the noncoronary cusp, suggestive of a vegetation.
The aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild (1+) mitral regurgitation is seen.
Moderate to severe [3+] tricuspid regurgitation is seen. There
is a trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade. Compared to previous
study of [**2170-1-4**], the left ventricular ejection fraction
is increased.
.
CT HEAD [**2170-1-8**]:
1. Interval development of large wedge-shaped area of low
attenuation consistent with infarct in the left parietal region.
Numerous other new low- attenuation foci, bilaterally, are also
concerning for infarction, and do not correspond to any
particular vascular territory. This pattern raises concern for
possible watershed infarction rather than embolic or thrombotic
etiology, and should be correlated with history of
shock/hypotension.
2. No evidence of intracranial hemorrhage.
3. Air-fluid levels in the paranasal sinuses, possibly sequela
from intubation and supine positioning.
.
CT CHEST/ABDOMEN [**2170-1-8**]:
1. Extremely limited study due to artifact and lack of
intravenous contrast.
2. Slight interval decrease in large bilateral pleural effusions
with associated bibasilar atelectasis/consolidation.
3. Large amount of low-attenuation fluid throughout the abdomen
tracking into the pelvis. No definite evidence of
retroperitoneal hematoma or acute hemorrhage.
4. Apparent thickening of the wall of the sigmoid and distal
descending colon, incompletely characterized due to lack of
distention with oral contrast, while the rectum appears spared.
In the appropriate clinical context, findings may represent
colitis, either infectious or ischemic given the segments
involved, and may be new since the earlier study.
5. Anasarca, as before.
.
EEG [**2170-1-9**]:
This is an abnormal EEG due to the low voltage, slow background
activity and bursts of generalized slowing. This suggests a
severe encephalopathy, which may be seen with infections,
ischemia, medication effect or toxic metabolic abnormalities. No
epileptiform features were noted. A repeat EEG to evaluate for
evolution would be recommended if patient remains unresponsive.
Brief Hospital Course:
This is a 76 yo male intially admitted after being found down
with hypothermia, coagulopathy, hypotension, free fluid in
abdomen. Intubated in the ED.
.
# Shock: Unclear etiology. Initially had chracteristics of both
cardiogenic shock and vasodilatory shock. Had increased R sided
pressures and R ventricular dysfunction (ECHO w/ severe BiV
systolic dysfunction, RV not functioning, EF < 20%, mod MR,
severe TR). Also had acute systemic illness characterized by
hypothermia, hypotension, coagulopathy, diffuse capillary leak.
No infectious source identified, and only localizing complaint
prior to admission was three days of increasing abdominal girth
and episode of diarrhea on day of admission. Had considered
vasculitis, auto-immune process, dermatomyositis but ESR, CK,
[**Doctor First Name **], ANCA, anti-[**Doctor First Name **] were all unremarkable. Had been on levophed,
neosynephrine, and vasopressin; then weaned to only levophed.
Levophed turned off yesterday after family made pt [**Name (NI) 3225**]. He
received a 7 day course of empiric vancomycin, ciprofloxacin,
and flagyl. He also received stress dose steroids during this
admission. Pressor support was discontinued after the patient's
family requested that he be made comfort measures only.
.
# Unresponsiveness: The patient remained unresponsive for
several days off sedation. His head CT was consistent with
anoxic brain injury demonstrating large ischemic infarcts. EEG
showed diffuse encephalopathy. The neurology service was
involved and felt that meaningful neurologic recovery was
unlikely. Given the poor prognosis, the patient's family
decided to make him comfort measures only. This decision was
made on [**2170-1-10**].
.
# Respiratory failure: Initially the patient was intubated for
obtundation and hypoxia. He required high PEEP (up to 24), but
this was later weaned down to 5, and hypoxia improved. ABG was
consistent with metabolic acidosis, possibly secondary to acute
renal failure, and his respiratory rate was set at 30 to
compensate for this. The patient was extubated after the he was
made [**Date Range 3225**] on [**2170-1-10**].
.
# RV/Biventricular failure: ECHO w/ severe BiV systolic
dysfunction, non functioning RV not functioning, EF < 20% with
mod MR and severe TR. Biventricular failure could be secondary
to acute coronary syndrom, PE, or severe valvular disease. He
was initally on a lasix drip, which was later discontinued. He
then proceeded to autodiurese well.
.
# Coagulopathy: Initally, his labs were indicative of DIC with
low platelets, fibrinogen, and hapto, and elevated LDH. INR
eventually improved to 1.8, down from 7.7. He recieved a total
of 10 u FFP, 5 u PRBCs, 7 u PLTs.
.
# Tachycardia: Initially thought to be SVT vs. atrial
fibrillation. This tachycardia was poorly tolerated resulting
in hypotension. Later, patient had atrial bigeminy. He was on
amiodarone drip, which was latered discontinued on [**2170-1-10**] given
patient's [**Date Range 3225**] status.
.
# Rhabdomyolysis: Patient found down and CK was elevated to the
6000s at admission. CK's eventually improved.
.
# Renal Failure: Creatinine trended up to 2.2 from 1.2 early in
admission. Urine lytes suggested pre-renal etiology, likely
secondary to hypotension.
.
# Elevated liver enzymes: Unclear etiology. Possibly secondary
to shock liver vs cholangitis vs chronic liver disease with
acute exacerbation. Difficult to ascertain synthetic function in
this acute settting. LFTs slowly improved. Hepatitis panel
negative.
.
# Possible NSTEMI: Initially had positive trop and MBI. Then MBI
negative, trop peaked at 0.39, then trended down. EKG was
without concerning ischemic changes.
.
# Ascites: This was thought to be due to IV fluids. Paracentesis
was performed with no growth in culture. Abdomen continued to
drain large amounts of fluid from tap site.
.
# Anemia: baseline unknown, no obvious source of blood loss.
Likely secondary to hemolysis, and phlebotomy. Transfused as
above.
.
# Hyponatremia: Possibly secondary to CHF and cirrhosis. This
improved throughout his admission, likely secondary to diuresis.
.
# [**Date Range 3225**] STATUS: Given the patient's poor prognosis, the patient
was made [**Date Range 3225**] on [**2170-1-10**] by his family (wife and daughter).
Patient's family informed the MICU team that this would be
consistent with patient's wishes. After this decision was made
all non-comfort medications were discontinued. He was given
morphine and ativan prn. Social work followed with the family.
The patient was extubated on [**2170-1-10**]. He later expired on [**2170-1-11**]
at 18:45. Permission was granted by his wife for autopsy.
.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Shock
Unresponsiveness
Respiratory failure
Congestive heart failure
Coagulopathy
Rhabdomyolysis
Renal failure
Ascites
Discharge Condition:
expired
Discharge Instructions:
none
Followup Instructions:
none
|
[
"038.9",
"276.1",
"728.88",
"428.0",
"790.4",
"785.52",
"789.5",
"995.92",
"V66.7",
"427.89",
"348.1",
"518.81",
"434.91",
"286.6",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.04",
"96.72",
"96.04",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
12795, 12804
|
8030, 12711
|
281, 326
|
12966, 12975
|
2812, 2812
|
13028, 13035
|
2368, 2396
|
12766, 12772
|
12825, 12945
|
12737, 12743
|
12999, 13005
|
2411, 2793
|
231, 243
|
354, 1967
|
2828, 8007
|
1989, 2134
|
2151, 2352
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,477
| 127,064
|
17710
|
Discharge summary
|
report
|
Admission Date: [**2195-12-7**] Discharge Date: [**2195-12-27**]
Date of Birth: [**2141-6-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
shortness of breath
rash
Major Surgical or Invasive Procedure:
Epicardial Left Ventrical Lead Placement
Hemodialysis Central Catheter Placement
History of Present Illness:
Mr. [**Known lastname 49249**] is a 54 year old gentleman with HTN, DM2, CKD
(baseline Cr 2.0-2.2), CAD s/p CABG [**2186**], as well as systolic
and diastolic heart failure (EF had been as low as 20% but last
known to be 30%), who was recently admitted to the [**Hospital1 18**] between
[**Date range (1) 24418**] for congestive heart failrue, [**Last Name (un) **], and venous catheter
induced bacteremia who came today for rash and weight gain.
During last admission, pt was found to have new inferior HK.
Workup was complicated by significantly worsening [**Last Name (un) **], and LHC
were deferred. He also finished two weeks course antibioitics
for IV catheter induced bacteremia with no evidence of
vegetation on [**Last Name (un) **]. He was aggressively diuresed, and discharged
home on torsemide and dobutamine gtt. Since coming home, pt was
noticed to have worsening pruritis and a new rash. The rash was
maculopapular and patchy, erythematous, pruritic with scratch
marks. Pt was started on prednisone 40 mg, diphenhydramine 50 mg
q6h and keflex 500 q8h, without much improvement. Besides the
rash, pt complained of NYHA class III symptoms, feeling "extreme
fatigue" with DOE from minimal ambulation within the room,
positive orthopnea and PND. He also noticed a ~ 4 lbs weight
gain in the past week, although his weight is unchanged from
last discharge.
On interview this afternoon, pt denies SOB at rest, chest pain,
n/v/diarrhea. He denies any changes in his diet, and reports
compliance with his medications. His weight today is 211.
On review of systems, he denies any prior history of stroke,
TIA, 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,
palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: CHF, CABG
-CABG: [**2186**] (LIMA-LAD, SVG-PDA, and radial-OM1-OM2)
3. OTHER PAST MEDICAL HISTORY:
Chronic kidney disease (baseline Cr 2.0-2.2)
Congestive heart failure
-[**4-/2195**]: B&WH admission with EF of 20% in CHF, improved to 40%
on discharge
Deep vein thrombosis x1 (s/p Warfarin in the past)
s/p Right knee arthroscopy
Iron deficiency anemia
Venous stasis ulcers
retinopathy s/p laser surgery
peripheral neuropathy with ulcers
Gout
Social History:
-Home: Lives in [**Location **] with his wife. Married 20 years.
-Occupation: Works as a financial planner, lawyer, runs a
property company.
-Tobacco: used to smoke one cigar daily since high school until
stopping after CABG. No cigaretters.
-EtOH: None
-Illicits: None
Family History:
Mom had CABG in 60s.
3 brothers all without heart disease or diabetes.
Father with ?lymph cancer.
Physical Exam:
Admission Weight 100.7kg
Discharge Weight: 86.9kg
ADMISSION EXAM
VS: 112, 165/94, 24, 97% on RA
weight: 100.7
GENERAL: Alert, oriented x3. Sitting in bed with wife at
bedside. No respiratory direstress.
HEENT: MMM, R eye seems ptotic
NECK: Supple with JVP 12 cm (sitting position)
CARDIAC: PMI closer to midline, RR, S1, S2 w/ prominent P2 + S3.
No murmur or rub.
LUNGS: bibasilar crackles, no wheeze or rales
ABDOMEN: Softly distended. Abd aorta not enlarged by palpation.
No abdominal bruits. BS present. +hepatojugular reflex
EXTREMITIES/SKIN: severe stasis dermatitis with anterior
weeping ulcers on lower extremities. Tight skin, with 1+ pitting
edema bilaterally
SKIN: maculopapular erythematous rash, nonblanching, over the
ant/pos trunk and upper extremities, with scratch marks and
convaslent patch and yellow crusty scab.
DISCHARGE EXAM
weight = 86.8kg. 97.2, 157/76, 69, 100%RA
No JVP, no peripheral edema, no crackles. Continues to have
stasis dermatitis, bandaged. Also has resolving crusty patches
and excoriations scattered over his body.
Pertinent Results:
ADMISSION LABS
[**2195-12-7**] 05:20PM BLOOD WBC-10.3 RBC-3.88* Hgb-9.9* Hct-32.6*
MCV-84 MCH-25.5* MCHC-30.3* RDW-19.6* Plt Ct-324
[**2195-12-7**] 05:20PM BLOOD Neuts-82.9* Lymphs-8.0* Monos-5.8 Eos-2.6
Baso-0.7
[**2195-12-7**] 05:20PM BLOOD PT-17.1* PTT-32.8 INR(PT)-1.6*
[**2195-12-7**] 05:20PM BLOOD Glucose-424* UreaN-107* Creat-3.5*
Na-127* K-4.2 Cl-92* HCO3-19* AnGap-20
[**2195-12-7**] 05:20PM BLOOD ALT-194* AST-164* CK(CPK)-350*
AlkPhos-193* TotBili-0.8
[**2195-12-7**] 05:20PM BLOOD Albumin-3.5 Calcium-8.5 Phos-4.5 Mg-2.4
PERTINENT LABS
[**2195-12-9**] 02:51AM BLOOD Cortsol-24.1*
[**2195-12-8**] 05:33PM BLOOD %HbA1c-7.8* eAG-177*
CARDIAC BIOMARKERS
[**2195-12-7**] 05:20PM BLOOD CK-MB-14* MB Indx-4.0 cTropnT-0.20*
[**2195-12-8**] 05:30AM BLOOD CK-MB-9 cTropnT-0.21*
[**2195-12-9**] 12:07AM BLOOD CK-MB-6 cTropnT-0.22*
[**2195-12-9**] 02:51AM BLOOD CK-MB-6 cTropnT-0.22*
[**2195-12-9**] 08:00AM BLOOD CK-MB-6 cTropnT-0.24*
LFT
[**2195-12-7**] 05:20PM BLOOD ALT-194* AST-164* CK(CPK)-350*
AlkPhos-193* TotBili-0.8
[**2195-12-8**] 05:30AM BLOOD ALT-153* AST-88* CK(CPK)-180 AlkPhos-171*
TotBili-0.9
[**2195-12-9**] 02:51AM BLOOD ALT-110* AST-54* AlkPhos-162* TotBili-0.8
PERTINENT STUDIES
CXR (portable) [**12-7**]
As compared to the previous radiograph, the patient has received
a
new PICC line. The tip of the line projects over the lower SVC.
The course of the line is unremarkable. There is no evidence
of complications, notably no pneumothorax.
Otherwise, unchanged radiograph with borderline size of the
cardiac
silhouette, left pectoral pacemaker, and absence of acute lung
changes.
Chest US [**12-8**]
Complex fluid anterior to the ICD device which may represent a
hematoma;
however, an infection at this site cannot be excluded with
ultrasound.
ECHO (TTE) [**12-10**]
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 20-25%). The right ventricular cavity is
dilated with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Mildly dilated left ventricle with severe global hypokinesis -
the basal inferior and inferolateral segments have relatively
better function. Dilated and hypokinetic right ventricle. Mild
mitral regurgitation.
If clinically indicated, a transesophageal echocardiogram may
better assess for valvular vegetations.
CT Chest [**2195-12-16**]:
IMPRESSION:
1. Moderate left lower lobe opacity with volume loss and
partial collapse of the left lower lobe bronchi, consistent with
lower lobe collapse(atelectasis).
2. Anterior component of atelectasis is slightly hyperdense,
likely
representing moderate amount of superimposed parenchymal lung
hemorrhage.
3. Moderate left intermediate density pleural effusion without
evidence of
hemothorax.
4. Mild pulmonary edema.
[**2195-12-15**]:
Findings
Baseline AV delay 100 ms ; LVOT VTI 15.1 cm AV delay 180 ; LVOT
VTI 14.7 cm AV delay 100 ms; LVOT VTI 13.2 cm LV to RV delay 10
ms; LVOT VTI 13.9 20 ms; LVOT VTI 15.0 40 ms; LVOT VTI 15.0 50
ms; LVOT VTI 15.0
Conclusions
The AV delay was adjusted to various intervals to assess effects
on LVOT VTI.The LV to RV delay was then adjusted to various
intervals to assess effects on LVOT VTI.
[**2195-12-10**] ECHO:
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Overall left ventricular systolic function is severely
depressed (LVEF= 20-25%). The right ventricular cavity is
dilated with depressed free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. Mild (1+) mitral regurgitation is seen. The
tricuspid valve leaflets are mildly thickened. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: No echocardiographic evidence of endocarditis.
Mildly dilated left ventricle with severe global hypokinesis -
the basal inferior and inferolateral segments have relatively
better function. Dilated and hypokinetic right ventricle. Mild
mitral regurgitation.
If clinically indicated, a transesophageal echocardiogram may
better assess for valvular vegetations.
Compared with the prior study (images reviewed) of [**2195-11-11**],
overall systolic function is not as vigorous. The right
ventricle is seen more clearly on the current study - it is
mildly dilated with mildly depressed function.
[**12-17**] CXR:
There is no evidence of pneumothorax. Transvenous pacemaker
leads are in
standard positions. Right supraclavicular central catheter tip
is in the
right atrium. Left IJ catheter tip cannot be accurately
assessed and is
obscured by the other leads and catheters. Mild-to-moderate
left pleural
effusion and adjacent lung consolidation and mild fluid overload
are stable.
Cardiomediastinal contours are unchanged.
[**12-17**] CXR:
FINDINGS: As compared to the previous radiograph, the
radiographic appearance of the lung parenchyma and the cardiac
silhouette is unchanged. Unchanged low lung volumes. Small
left pleural effusion. Status post epicardial pacemaker
lead. Mild fluid overload, retrocardiac atelectasis, but no
evidence of
interval appearance of new parenchymal opacities. No
pneumothorax.
[**2195-12-8**]:
Skin, left thigh, punch biopsy:
Perforating folliculitis with bacterial overgrowth within the
surface debris.
Discharge Labs:
[**2195-12-27**] 05:51AM BLOOD WBC-10.4 RBC-3.62* Hgb-9.1* Hct-29.9*
MCV-83 MCH-25.2* MCHC-30.5* RDW-19.5* Plt Ct-436
[**2195-12-27**] 05:51AM BLOOD PT-30.0* PTT-47.1* INR(PT)-2.8*
[**2195-12-27**] 05:51AM BLOOD Glucose-99 UreaN-104* Creat-2.7* Na-134
K-3.0* Cl-83* HCO3-42* AnGap-12
[**2195-12-11**] 04:00PM BLOOD STRONGYLOIDES ANTIBODY,IGG- negative
Brief Hospital Course:
Admission Weight 100.7kg
Discharge Weight: 86.9kg
Mr. [**Known lastname 49249**] is a 54y/o gentleman with HTN, HLD, DM2, CKD
(baseline Cr 2.0-2.2), CAD s/p CABG [**2186**] (LIMA-LAD, SVG-PDA, and
radial-OM1-OM2) with systolic and diastolic heart failure, who
is re-admitted from clinic for management of congestive heart
failure and rash.
#. Acute on Chronic systolic & diastolic CHF: Pt has known
systolic and diastolic CHF. There is concern for new ischemic
cardiomyopathy given new wall motion abnormality. Pt was
switched to milrinone from dobutamine for concerns of dobutamine
induced eosinophilia on [**12-9**]. Since then, pt had gained 6 kg.
Pt has evidence of severe dyssynchrony, but had failed BiV
pacemaker placement in the past. During this admission he was
transferred to CCU for milrinone and dopamine drips. Patient
maintained on isosorbide, hydralazine. He was also started on
lasix drip and metolazone to continue diuresis; however, with
patient's renal failure, this was challenging (see below). On
[**12-14**], the patient went for epicardial lead placement. He had
significant intraoperative oozing requiring chest tube placement
(see below). EP followed the patient and adjusted his pacer
settings to increase the delay. Anticoagulation was held in the
setting of bleed and was restarted when Hct stabilized. His
isosorbide dinitrate and hydralazine were adjusted to optimize
afterload reduction and blood pressures. Upon discharge, patient
was sent home with 100mg [**Hospital1 **], KCL 80 meq daily, metolazone 5mg
daily.
# Hemothorax/pleural effusion: After chest tube placement,
hematocrit continued to trend down and a chest CT on [**12-16**] showed
a fluid collection which was felt LDH, bilirubin and haptoglobin
were checked with no evidence of hemolysis. Stools were guaiaced
which were negative. Hematocrit stabilized and was 29.9 on the
day of discharge. He was transfused a total of 3 units during
this stay.
#Constipation - resolved with lactulose.
# Acute on chronic renal failure: Baseline Cr 2.0-2.5. This is
likely secondary to CHF. Other etiology include infectious vs
ATN vs AIN (antibiotics). His urine eos negative. Renal was
consulted who recommened dialysis but patient refused initially.
On [**12-15**] after discussion with the team, the patient agreed to
CVVH. A tunneled dialysis catheter was placed and CVVH was
started to aid in fluid removal. The patient was overall
negative 12L and CRRT-cessation was undertaken on [**12-19**]. The
patient's creatinine rose to 3.2 and his urine output was
minimal. He was given a lasix bolus, started on a drip at
40mg/hr and started on metolazone twice daily with good
response, >160 cc/hr of urine. Iron studies were ordered which
are consistent with anemia of chronic disease. Creatinine on
discharge was 2.7.
# Urinary tract infection: On [**12-19**] the patient developed a
leukocytosis to 12. UA and urine cultures were sent which showed
enterobacter aerogenes sensitive to Ciprofloxacin. He was
treated with a 10 day course, to end on [**12-28**].
# Eosinophilia: Pt was found to have worsening eosinophilia
since admission. This was first identified since pt was started
on dobutamine on [**11-20**]. Dobutamine induced cardiomyopathy is a
well documented hypersensitivity that potentially leads to
myocarditis. His peripheral eosinophlia improved in the setting
of prednisone use, however, is currently getting worse when off
steroid. Other medication induced eosinophilia is also
possible. Per allergy rec, eos count should decline after d/c
dobutamine if it were caused by dobutamine induced
hypersensitivity. As a result, dobutamine was stopped and
patient changed to dopamine and milrinone as above.
Strongyloides antibody titers were negative. Discharge eos % was
6.8, down from 11% in the setting discontinuation of dobuatmine.
# Aflutter: Patient briefly went into atrial flutter which
resolved with cardioversion. He was started on anti-coagulation
with heparin which was being held with active bleeding. Once
hematocrit stabilized, heparin was restarted and he was started
on coumadin. Will need to be anticoagulated for at least a
month.
# Transaminitis: Currently improving. Pt presented with mixed
pattern with hepatocellular dominance, and consistent with
congestive hepatopathy. This is likely a result of worsening
R-sided heart failure.
# Rigors: Pt developed one episode of rigors on night of [**12-8**].
There was significant concerns of sepsis. Will hold on any
surgery until blood culture clear for > 48 hours. Patient
maintained on vancomycin out of concern for sepsis, this was
eventually d/c'd as there was no longer concern for sepsis.
# Perforating folliculitis: Dermatology was consulted who felt
this is likely multifactorial, uremic pruritis, perforating
folliculitis and impetigo secondary to scratching. He also has
evidence of venous stasis changes on his shins. Biopsy showed no
evidence for drug eruption and showed loss of epidermis
collagen, consistent with perforating folliculitis. Patient
maintained on doxepin, hydroxyzine, sarna lotion, hyrdolactum as
well as mupirocin to open lesions and nares.
# CAD s/p CABG: mildly elevated troponin was likely [**3-12**] to [**Last Name (un) **].
He is currently asymptomatic with no significant EKG changes
(LBBB pattern that does not meet Sgarbossa criteria). Last cath
in [**2191**] noted severe native 3VD with patent LIMA-LAD, SVG-PDA,
and Radial-OM1-OM2. TTE on prior showed new inferior HK. His
CK-MB and trop were trended and remained stable. He was
continued on ASA and pravastatin.
# Hyponatremia: This is likely secondary to heart failure and
CKD and free water intake. Patient was fluid restricted to 2
liter and this corrected.
# Neuropathic & venous stasis ulcers: This is a chronic issue,
that has been exacerbated in the setting of CHF and poor wound
care. Ulcers were treated with Adaptic/Telfa/Kerlex
# Diabetes mellitus/Hyperglycemia: Pt has long history of
hyperglycemia, and has recently worsened in the setting of
steroid use. Currently stable. Improved when prednisone was
discontinued. Patient maintained on standing lantus and ISS.
# Elevated INR, resolved: this is also a chronic issue. The
underlying etiology is likely nutritious vs hepatic secondary to
congestive hepatopathy. Pt is s/p vitamin K 5 mg IV X2.
Eventually his INR normalized and he was started on coumadin. On
discharge, INR was 2.8
CHRONIC ISSUES
# Dyslipidemia: Stable. Cholesterol panel in [**6-/2195**]: TChol 132,
TG 99, HDL 42, LDL 77. Continued pravastatin.
# h/o Deep vein thrombosis: Heparin SC TID for DVT prophylaxis.
# Iron deficiency anemia: Hct stable during last admission
30-33. Continued home iron supplements.
TRANSITIONAL ISSUES:
#CHF - patient is being discharged on torsemide 100mg [**Hospital1 **], KCL
80 meq daily, metolazone 5mg daily.
#CAD - Isosorbide mononitrate was decreased to 90mg daily,
hydralazine decreased to 25mg q8 hours. Metoprolol succinate
50mg daily was started.
#CKD - started on calcium acetate 667mg with meals
#UTI - Will finish one more day of cipro
#Skin - apply mupirocin twice daily, sarna lotion prn
#Aflutter - on coumadin for at least one month, Please have your
labs drawn by Wednesday [**12-30**] and faxed to Dr.[**Name (NI) 10159**] office.
fax# ([**Telephone/Fax (1) 49261**]
Cardiology follow up will be arranged for this week. He will
also follow up this week with his PCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
3. Pravastatin 80 mg PO DAILY
4. HydrALAzine 75 mg PO Q8H
please hold for SBP <100
5. DOBUTamine 5 mcg/kg/min IV DRIP INFUSION
Please double concentrate if possible
6. Torsemide 100 mg PO DAILY
Hold for SBP <90
7. HydrOXYzine 25 mg PO Q6H pruritus
pt may refuse
8. Potassium Chloride 40 mEq PO DAILY
9. Glargine 44 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Heparin Flush (10 units/ml) 2 mL IV PRN Flush daily and as
needed
Discharge Disposition:
Home With Service
Facility:
chatam-[**Location (un) **] VNA
Discharge Diagnosis:
1. Acute exacerbation of systolic and diastolic heart failure,
Acute on chronic renal failure
2. Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 49262**],
You were admitted to the hospital for rash and weight gain. You
were admitted to the cardiac intensive care unit for management
of decompensated heart failure with symptoms of low blood
pressure and kidney failure. You were given intravenous
medications to assist with removal of this volume. For your
renal failure - you intermittantly required continuous
hemodialysis. Ultimately we were able to stop dialysis and
transition you to oral medications.
While hospitalized, cardiac surgery evaluated you and were able
to place an epicardial left ventricular lead. As you remember,
during your last admission, as part of management of your heart
failure, cardiac resyncronization therapy was attempted by
placement of a device in your heart. Unfortunately, they were
unable due to technical difficulty to place an lead in your left
ventrical. The cardiac surgeons during this admission were able
to successfully place this lead on the outside of your heart.
Lastly, while hospitalized, you developed an irregular heart
rythym. We were able to cardiovert you (provide an electric
shock) to your heart which put you back in a normal rhythm.
However, because if this abnormal heart rythm you will need to
be on anticoagulation for at least 1 month. Please discuss with
your primary care physician regarding long term management of
your atrial flutter.
Your medication regimen has again changed. It is very important
that you take your medications as directed daily. Do not miss a
dose, if you are unable to take your medications, obtain refills
of your medications please contact your physicians immediately.
Please weigh yourself every day. If you gain 3lbs please call
your physician [**Name Initial (PRE) 2227**].
The following changes were made to your medication list:
1. INCREASE torsemide to 100mg TWICE a day
2. INCREASE potassium chloride to 80meq daily
3. DECREASE isosorbide mononitrate to 90mg daily
4. DECREASE hydralazine to 25mg every 8 hours
5. START metoprolol succinate 50mg daily
6. START metolazone 5mg daily
7. START ciprofloxacin for 1 additional day
8. START calcium acetate 667mg with meals
9. START warfarin 1mg daily
10. START mupirocin cream to be applied twice daily to your skin
11. START sarna lotion to be applied to your skin
12. STOP dobutamine infusion
Followup Instructions:
Name: NP [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]
Location: [**Location (un) **] PHYSICIANS
Address: 100 [**Last Name (un) **] WAY, [**Location (un) 10068**],[**Numeric Identifier 10069**]
Phone: [**Telephone/Fax (1) 49260**]
Appointment: Wednesday [**2195-12-30**] 3:00pm
We are working on a follow up appointment for your
hospitalization in Cardiology. It is recommended you be seen
within 1 week of discharge. The office will contact you at home
with an appointment. If you have not heard by Monday ([**12-28**])
please call the office at [**Telephone/Fax (1) 62**].
Please have your labs drawn by Wednesday [**12-30**] and faxed to Dr. [**Name (NI) 49263**] office. fax# ([**Telephone/Fax (1) 49261**]
|
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27,440
| 137,818
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49282
|
Discharge summary
|
report
|
Admission Date: [**2105-5-25**] Discharge Date: [**2105-6-15**]
Date of Birth: [**2034-2-15**] Sex: F
Service: SURGERY
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
71 year old female s/p laparoscopic ventral hernia repair on
[**2105-5-4**] presents with nausea and vomiting and weakness.
Major Surgical or Invasive Procedure:
PICC Line Placement
1. Exploratory laparotomy.
2. Lysis of adhesions (greater than 1 hour).
3. Drainage of intra-abdominal abscess.
4. Resection of small intestine (ileum 20 cm).
5. Ileostomy creation.
6. Cecal mucous fistula creation.
7. Excision of infected prosthetic mesh.
8. Appendectomy.
9. Closure of abdomen with prosthetic mesh (Vicryl).
History of Present Illness:
[**First Name8 (NamePattern2) **] [**Known lastname **] is a 71-year-old woman who underwent
a laparoscopic hernia repair approximately a month ago. She
developed abdominal pain, nausea, vomiting and symptoms
consistent with ileus versus bowel obstruction. She was
initially treated with nonoperative management. She developed
abdominal pain as well as leukocytosis necessitating surgical
treatment.
Past Medical History:
[**Known firstname 103294**] past medical history is significant
for a possible heart attack, mitral valve prolapse, and a stroke
in [**2096**]. She is uncertain as to whether she had a heart attack
or not. She has had several echos of the heart, which have been
negative. She has had stress test in the past. After her stroke
in [**2096**], she underwent an endarterectomy. Diagnosed with ovarian
cancer in [**2103**].
Social History:
SOCIAL HISTORY: She smoked in the past, but denies tobacco use
for the past 5 years. She denies IV drug use or alcohol. She
lives alone and has four cats.
Family History:
FAMILY HISTORY: She denies any family history of cancer.
Physical Exam:
97.7 heartrate 144 blood pressure 80/60 respiratory rate 20 96%
on room air.
NAD
comfortable
NCAT
slight anterior cervical LAD
RRR
Decreased breath sounds at right base
Abdomen: Non-distended, normal active bowel sounds, soft,
nontender throughout, well healing scars, no hernias
Rectal guiac negative, no masses, small amount of brown stool.
Pertinent Results:
[**2105-5-24**] 11:45PM BLOOD WBC-19.7*# RBC-4.84 Hgb-14.7 Hct-43.6
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.0 Plt Ct-289
[**2105-6-1**] 04:50AM BLOOD WBC-18.2*# RBC-3.73* Hgb-11.4* Hct-34.6*
MCV-93 MCH-30.4 MCHC-32.9 RDW-14.4 Plt Ct-264
[**2105-6-9**] 04:31AM BLOOD WBC-10.3 RBC-2.89* Hgb-9.0* Hct-26.9*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.9 Plt Ct-289
[**2105-5-24**] 11:45PM BLOOD Glucose-145* UreaN-36* Creat-1.0 Na-129*
K-4.4 Cl-96 HCO3-21* AnGap-16
[**2105-5-30**] 04:26AM BLOOD Glucose-187* UreaN-16 Creat-0.5 Na-139
K-2.9* Cl-105 HCO3-29 AnGap-8
[**2105-6-11**] 04:42AM BLOOD Glucose-120* UreaN-17 Creat-0.6 Na-138
K-4.4 Cl-108 HCO3-23 AnGap-11
[**2105-5-24**] 11:45PM BLOOD ALT-15 AST-42* AlkPhos-75 TotBili-1.2
[**2105-6-10**] 05:06AM BLOOD ALT-25 AST-23 AlkPhos-119* TotBili-0.7
[**2105-5-25**] 05:25AM BLOOD Albumin-2.7* Calcium-8.1* Phos-2.1*
Mg-2.0
[**2105-6-11**] 04:42AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.9
[**2105-5-28**] 06:05AM BLOOD calTIBC-147* Ferritn-203* TRF-113*
[**2105-6-10**] 05:06AM BLOOD calTIBC-131* Ferritn-205* TRF-101*
[**2105-5-24**] 11:48PM BLOOD Lactate-3.2*
[**2105-6-5**] 10:51AM BLOOD Glucose-148* Lactate-1.3 Na-137 K-3.4*
Cl-99*
[**2105-5-25**] CT Scan 1. Interval development of small bowel
dilatation with relative decompression of distal ileal and large
bowel loops, concerning for small-bowel obstruction.
Transitional point is not definitely identified.
2. Interval development of right greater than left pleural
effusions and perihepatic ascites.
3. Bilateral adrenal nodules, previously characterized as
adrenal adenomas..
4. Interval decrease in size of low-density fluid collection
anterior to the anterior abdominal wall mesh.
[**2105-5-28**] CT Scan IMPRESSION:
1. Findings of persistent small-bowel obstruction, with
transition point not definitely identified, but thought to be
within distal ileum.
2. Slight increase in size of right greater than left pleural
effusions.
3. No evidence of drainable fluid collection in the abdomen or
pelvis.
Brief Hospital Course:
Patient admitted on [**2105-5-25**] approx. one month after a
laparoscopic ventral hernia repair. She complains of nausea,
abdominal pain, heaving, unable to eat and vomiting. Her last
bowel movement was 2 days prior and was not passing flatus. An
NGT was placed and she was kept NPO. She became tachycardic and
was bolused several times for low urine output. Leukocytosis
developed and CT scan showed R>L pleural effusions and bowel
dilations. On HD3, some flatus developed and patient looked
better. Patient started receiving TPN through a PICC line. On
HD4, patient felt better and wanted to discontinue TPN, take out
the NGT and eat a regular diet. However, tachycardia and
leukocytosis continued and patient was no longer having flatus.
On HD8, surgery was discussed with the patient, as no-operative
management of the ileus/SBO has failed so far. 20 cm of
necrotic small intestine was found upon operation along with
right abdominal abscess. The following procedures were
performed: 1) laparotomy, 2) lysis of adhesions, 3) drainage of
intrabdominal abscess, 4) resection of small intestine, 5)
ileostomy creation, 6) cecal mucous fistula, 7) closure with
prosthetic mesh, 8) appendecomy, 9) excision of prosthetic mesh.
The abdominal wound was left open for delayed closure at a
later date.
On POD0, patient was taken to the SICU. Sedation was not
reversed and patient was placed on CMV ventilation. Patient was
given pressors to SBP>100. Antibiotics (zosyn, fluc, vanc) were
started. Pressors were weaned. On POD4, a delayed primary
closure of the abdominal wound was performed. Upon return to
the SICU, the ventilator and sedation were weaned. Pon POD7,
patient was transferred to [**Wardname 7911**]. A neurology consult was
called to check patient's mental status. Brain and Cspine MRI
was ordered for hyperreflexia and [**Wardname 2841**] was ordered for nerve
conduction to be done on a outpatient basis. PT was consulted
for discharge to rehab.
Current Issues:
1. Nutrition- TPN as well as a regular diet with ensure tid to
be given at rehab. Calorie counts of patient's diet last couple
of days has been minimal.
2. Neurology - Patient is alert and orientated and has not been
confused for the last 4 days. Neurology has recommended to get
the rest of the MRI/[**Wardname **] testing on a outpatient basis. Those
appointments have been made and are included in the discharge
plan.
3. Mobility/Ostomy teaching - patient is being sent to a
rehabilitation center to increase strength to preoperative level
and to learn how to manage her ostomy by herself.
4. She will follow up with Dr. [**Last Name (STitle) **] on [**6-26**] and will call
and make an appointment with her oncology physician (Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **])
Medications on Admission:
avapro 225', citalopram 40', ASA 81', colace, percocet prn
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
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 BID (2 times
a day).
9. TPN
Please see TPN sheet.
10. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous daily and PRN as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **]-[**Location (un) 686**]
Discharge Diagnosis:
bowel ischemia and necrotic ileum
Discharge Condition:
Stable
Discharge Instructions:
You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
Please call your doctor or return to the emergency room if you
have 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.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
Provider:[**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**6-26**] at 2:45 [**Hospital Ward Name 23**] building [**Location (un) 470**].
Provider: [**Name10 (NameIs) 2841**] on Friday [**2105-7-10**], at 8:30, on [**Hospital Ward Name 23**] 8.
[**Telephone/Fax (1) 558**]
Provider: [**Name Initial (NameIs) **]. [**Last Name (STitle) 2442**] and [**Name5 (PTitle) 10340**] [**2105-7-15**] at 4 PM [**Hospital Ward Name 23**] 8
[**Telephone/Fax (1) 3506**].
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2105-6-23**]
4:55 [**Hospital Ward Name 23**] 4.
Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2105-6-23**]
5:35
Please follow up with your oncology physician and your primary
care provider.
Completed by:[**2105-6-15**]
|
[
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"998.59",
"401.9",
"511.9",
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"996.69",
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"276.51",
"567.29",
"357.6",
"569.83",
"560.81",
"V10.43",
"557.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.3",
"47.09",
"99.77",
"45.62",
"46.21",
"38.93",
"99.15",
"54.59",
"54.72",
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] |
icd9pcs
|
[
[
[]
]
] |
7957, 8024
|
4261, 7062
|
393, 742
|
8102, 8111
|
2246, 4238
|
9134, 9953
|
1825, 1868
|
7171, 7934
|
8045, 8081
|
7088, 7148
|
8135, 9110
|
1883, 2227
|
230, 355
|
770, 1171
|
1193, 1616
|
1649, 1792
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,659
| 133,081
|
6543
|
Discharge summary
|
report
|
Admission Date: [**2128-5-20**] Discharge Date: [**2128-5-29**]
Service: MEDICINE
Allergies:
Cipro
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Diarrhea/hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
86 y/o man with hypertension, PAF/flutter (on ASA and
Carvedilol, CHADSS 2) who p/w diarrhea. Brought to the ED by
his daughter [**Name (NI) 25070**] because of multiple bowel movements the day
prior presentation with abdominal pain in the lower abdominal
region. Daughter denies fevers. Diarrhea was nonbloody per the
daughter.
[**Name (NI) **] recent travel and no raw food consumption. No nausea or
vomiting.
.
In the ED, initial vitals were T 97.7, HR 110, BP 89/55, and RR
31 satting 96% on RA. Patient triggered for hypotension and was
bolused a total of 3200 cc's over several hours with increase in
his blood pressures to about 110 mmHg. Labs showed a flat
lactate at 1.7, leukocytosis of 14.7 with 88 percent PMN's
without bandemia, and HCT of 50.1 (baseline low 40's).
Addiitonally, his creatinine was found to be 2.7 from baseline
of about 1.5-1.9. He was found to be in atrial fibrillation on
EKG with evidence of a LBBB, and negative for Scarbosa's
criteria. A troponin was checked which was 0.04 (baseline
around 0.03). Given his abdominal pain, a CT scan of the
abdomen was done which showed a left sided inguinal hernia with
a portion of the sigmoid colon with fat stranding surrounding
it. Additionally, upstream of the loop of bowel within the
hernia, there was a featureless colon with hyperemia indicating
a possible component of obstruction, though the there is no
frank dilatation.
Also incidentally seen was cholelithiasis without cholecystitis.
A chest xray was done which showed no acute processes. Given
his CT abdomen findings, he was empirically given IV
ciprofloxacin and metronidazole. Of note, as his ciprofloxacin
was being provided, he developed a rash at the insertion site.
Regarding his hernia, surgery evaluated the patient in the ED
and was able to manually reduce his hernia without complication.
Upon transfer to the MICU, vitals were HR int he 110's, and SBP
in the 100's. Patient afebrile and mentating well.
.
On arrival to the MICU, patient is alert and communciating with
no acute issues. Stool is noted to be guiac positive.
Past Medical History:
- Gout
- CHF (per [**Last Name **] problem list, h/o BNP 1700, EF 50% [**2123**] cath)
- Dyspepsia
- HLD
- HTN
- Atrial Fibrillation/Flutter
- Chronic Renal Insufficiency (baseline SCr 1.4-2.0)
- Spinal Stenosis
- Vasomotor Rhinitis
Social History:
Retired painter. Lives with wife and daughter. Non-[**Name2 (NI) 25071**] and
no alcohol use.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T:97..5 BP:108/58 P:126 R:21 O2:100%
General: Alert. Can answer if in pain and say where. Otherwise
Vietnamese.
speaking only.
HEENT: Sclera anicteric, dry crusted skin around eyes, MMM,
oropharynx clear, EOMI, PERRL
Neck: supple, JVP about 4 cm about clavicle at 45 degrees
CV: Irregularly irregular. no murmurs, rubs, gallops.
Lungs: Some faint crackles bilaterally otherwise no wheezes or
ronchi
Abdomen: Firm abdomen with TTP subumbilically, NBS, no
organomegaly apprecaited. Cannot appreciate inguinal hernias on
exam.
GU: clear urine
Ext: trace edema. warm, well perfused, 2+ pulses
Neuro: MAE. Can say thank you and point out where he is in pain.
Alert and communicating in Vietnamese.
Pertinent Results:
ADMISSION LABS
[**2128-5-20**] 02:10PM BLOOD WBC-14.7*# RBC-4.98 Hgb-16.4 Hct-50.1
MCV-101* MCH-33.0* MCHC-32.8 RDW-13.8 Plt Ct-174
[**2128-5-20**] 02:10PM BLOOD Neuts-88.0* Lymphs-6.0* Monos-5.7 Eos-0.2
Baso-0.1
[**2128-5-20**] 02:10PM BLOOD PT-10.9 PTT-33.5 INR(PT)-1.0
[**2128-5-20**] 02:10PM BLOOD Glucose-139* UreaN-77* Creat-2.7* Na-132*
K-5.0 Cl-102 HCO3-18* AnGap-17
[**2128-5-20**] 02:10PM BLOOD ALT-39 AST-35 AlkPhos-89 TotBili-0.8
[**2128-5-20**] 02:10PM BLOOD Albumin-4.0 Calcium-8.1* Phos-4.1 Mg-2.9*
[**2128-5-20**] 02:32PM BLOOD Lactate-1.7
Pertinent Labs:
[**2128-5-25**] 03:39AM BLOOD WBC-13.9* RBC-4.46* Hgb-14.4 Hct-46.8
MCV-105* MCH-32.2* MCHC-30.7* RDW-14.3 Plt Ct-137*
[**2128-5-25**] 03:39AM BLOOD PT-14.8* PTT-32.9 INR(PT)-1.4*
[**2128-5-25**] 03:39AM BLOOD Glucose-123* UreaN-59* Creat-2.9* Na-144
K-4.8 Cl-113* HCO3-22 AnGap-14
[**2128-5-25**] 03:39AM BLOOD CK(CPK)-1312*
[**2128-5-25**] 12:19AM BLOOD CK-MB-10 MB Indx-0.7 cTropnT-0.07*
[**2128-5-25**] 03:39AM BLOOD CK-MB-7 cTropnT-0.08*
[**2128-5-25**] 03:39AM BLOOD Calcium-7.3* Phos-2.8 Mg-2.0
IMAGING
- CXR [**5-20**]
SEMI-UPRIGHT AP VIEW OF THE CHEST: The cardiac silhouette size
is mildly
enlarged but stable. The mediastinal and hilar contours are
unchanged. The
pulmonary vascularity is within normal limits. Mild patchy
opacities at lung bases likely reflect atelectasis. No definite
focal consolidation, pleural effusion or pneumothorax is
present. There are no acute osseous
abnormalities.
IMPRESSION: Minimal atelectasis at the lung bases.
- CT Abdomen/Pelvis [**5-20**]
FINDINGS: Please note without IV contrast, the findings within
the abdomen
will be limited.
CT ABDOMEN: At the base of the lungs, bilateral patchy opacities
consistent with atelectasis. Apex of the heart is unremarkable.
Liver is unremarkable. The gallbladder has small layering
gallstones. Bilateral kidneys are atrophic; however,
unremarkable. Spleen is also atrophic. The pancreas is
unremarkable. No mesenteric lymphadenopathy is appreciated.
CT OF THE PELVIS: Bilateral inguinal hernias are present with
bowel within
both of them. The right sided hernia contains bowel, however PO
contrast flows freely through it without any evidence of
obstruction. Within the left, there is fat stranding around the
portion of the sigmoid colon and mild thickening of the bowel
wall. At the entrance of the sigmoid colon into the hernia,
there is narrowing of the diameter and a transition of the
caliber of the colon. While there is no frank dilatation, there
may be a component of impending obstruction with congestion of
the sigmoid mesentery. In addition, there is mild mesenteric
hyperemia and a featureless colon upstream of the colon prior to
the entrance into the hernia (601b:26) suggestive of an
inflammatory process.
OSSEOUS STRUCTURES: No concerning sclerotic or lytic lesions are
seen. The
patient is status post lumbar fusion of L4-L5.
IMPRESSION:
1. Left sided inguinal hernia contains a portion of the sigmoid
colon with fat stranding in the sac and narrowing or bowel as it
enters and leaves. Beyond the hernia, the colon is mostly quite
collapsed. Upstream of the loop of bowel within the hernia,
there is a featureless sigmoid colon with hyperemia indicating
there may be some component of obstruction or inflammation,
although without dilatation. Whether this abnormality would
explain the patient's overall presentation is uncertain, but the
findings raise concern that the hernia may be clinically
significant; correlation with physical findings is recommended.
The possibility of mild colitis through the area could also be
considered clinically given the history of dirrhea.
2. Right sided bowel containing inguinal hernia appears
unremarkable and
incident without obstruction.
3. Cholelithiasis without cholecystitis.
- Echocardiogram [**2128-5-24**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild regional
left ventricular systolic dysfunction with akinesis of the basal
and mid septum and inferior walls and apex. The remaining
segments contract normally (LVEF = 40%). Right ventricular
chamber size is mildly increased with hypokinesis of apical
segments. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. Mild (1+) mitral regurgitation is seen. An
eccentric jet of moderate [2+] tricuspid regurgitation is seen
directed towards the interatrial septum. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal left ventricular chamber size with regional
dysfunction consistent with CAD. moderate pulmonary artery
hypertension. Mild aortic regurgitation. Mild mitral
regurgitation. Moderate tricuspid regurgitation with
Compared with the prior study (images reviewed) of [**2128-2-18**] the
findings are new.
- KUB [**2128-5-24**]
FINDINGS: Single supine portable abdominal radiograph is limited
due to
motion artifact. There is otherwise little change from 1:37 a.m.
No
evidence of pneumatosis or obstruction is visualized. Hernial
orifices are
not imaged. NG tube and right femoral vein catheter are imaged.
- EEG [**2128-5-25**]
CONTINUOUS EEG: The background activity is abnormal. The
background is
invariant and shows a repetitive moderate to high voltage spike
and wave
and sharp slow wave discharge that appears synchronous over both
central
regions and broadly present across the midline. These bursts
occur at a
frequency that varies between two per second to one every two
seconds.
Between the bursts, the EEG is suppressed and shows a mixture of
[**1-26**] Hz
delta activity with low voltage theta superimposed.
SPIKE DETECTION PROGRAMS: There were numerous automated spike
detections predominantly for the paroxysmal epileptiform
activity
described above.
SEIZURE DETECTION PROGRAMS: There were no automated seizure
detections.
There were no electrographic seizures.
QUANTITATIVE EEG: Trend analysis was performed with Persyst
Magic
Marker software. Panels included automated seizure detection,
rhythmic
run detection and display, color spectral density array,
absolute and
relative asymmetry indices, asymmetry spectrogram, amplitude
integrated
EEG, burst suppression ratio, envelope trend, and alpha delta
ratios.
Segments showing abnormal trends were reviewed and showed the
invariant
appearance to this EEG.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: No sleep was seen.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 60-65 bpm with frequent premature ventricular beats.
IMPRESSION: This is an abnormal continuous ICU monitoring study
because
of a relatively invariant severely abnormal EEG. It shows
paroxysmal
pseudo-periodic activity of an epileptiform appearance with an
interval
between discharges of a half a second to two seconds. No
sustained
seizure activity however was seen. The record appears much as it
did
near the end of the previous today's record.
- [**2128-5-25**] CXR portable
As compared to the previous radiograph, there is no substantial
change. Low lung volumes, normal and unchanged position of the
monitoring and
support devices. Moderate cardiomegaly with relatively extensive
retrocardiac atelectasis and signs of mild-to-moderate fluid
overload. No larger pleural effusions. Interposition of colon
between the liver and the abdominal wall.
Brief Hospital Course:
86 y/o man with hypertension, PAF/flutter (on ASA and
Carvedilol, CHADSS 2) who p/w diarrhea and hypotension,
complicated by PEA arrest and pulseless VT, subsequently made
CMO on [**2128-5-25**] and terminally extubated on [**2128-5-28**]. Patient
expired on [**2128-5-29**] at 2:05 AM from cardiac arrest/cardiac
arrhythmia in the presence of his family. His PCP was [**Name (NI) 653**]
via e-mail.
MICU Course # 1
# Hypotension. Thought [**2-26**] volume depletion [**2-26**] diarrhea and
poor po intake. Patient apparently received > 3000 cc of fluid
in the ED with proper BP response. BP stablized post-fluid
boluses. Patient's carvedilol, furosemide, and valsartan were
held.
# Guaiac positive diarrhea. Acute onset. There was no evidence
of pancreatitis or heaptitis on initial presentation. Stool was
sent for C. diff and culture to rule out for infectious
etiology, and the result showed no infectious etiology. His
abdominal pain apparently resolved by the time that the patient
arrived to the ICU. Diarrhea subsided by the end of the initial
MICU stay. He was treated with levofloxacin and Flagyl given
concern for GIB and gastroenteritis.
# Inguinal hernia. This was noted on initial CT. It was
reduced in the ED per report. General surgery followed patient
and there was thought about an eventual herniorrhaphy.
# Acute on chronic renal failure. Initially noted on admission,
thought to be pre-renal in the setting of volume depletion from
diarrhea. Creatinine improved initially with IVF.
# Paroxysmal atrial fibrillation, chronic. He was found to be
in atrial fibrillation on EKG with evidence of a LBBB, and
negative for Scarbosa's criteria. A troponin was checked which
was 0.04 (baseline around 0.03). Carvedilol was held initially
given hypotension.
# Dyspepsia. Patient was continued on omeprazole
# HLD. Patient was not on statin on arrival. This diagnosis
was based on history.
# Gout. Allopurinol was held in the setting of acute renal
failure
Medicine Floor Course
# HERNIA: Patient presented with left sided abdominal pain,
found to have left sided inguinal hernia that contained a
portion of the sigmoid colon with fat stranding in the sac and
narrowing of bowel as it enters and leaves. Overall abdominal
pain improved although still w/ discomfort w/ PO intake,
distension on exam although passing flatus. General surgery
evaluated patient, given ability to reduce hernia and absence of
ongoing obstruction no urgent surgical need. The patient's diet
was advanced. KUB performed for persistent abdominal distension,
revealed non-dilated loops of colon, air-filled loops of small
bowel without fluid levels, no free intra-abdominal gas.
# Diarrhea: No recurrence. As cultures and C diff toxin were
negative, there was concern for ischemia in the setting of
obstruction. Levofloxacin and Flagyl d/c given negative
cultures.
# Hypotension resolved, home medications held pending improved
PO intake.
# PEA arrest/pulseless VT. At 12:34AM on [**5-24**], Code Blue was
called because the patient was found on routine rounds to be
unresponsive and pulseless. CPR initiated for PEA arrest.
Received Epi x 3, 1 amp bicarb, 1 amp CaCl and 3L IVF. Right
femoral trauma CVL placed by Surgery. Intubated by Anesthesia
at 12:45AM. Remained pulseless but on rhythm check was found to
be in pulseless VT so was shocked at 12:48AM. CPR was continued
and pulse found at 12:50AM so he was transferred to MICU6.
Prior to transport, was given amiodarone 150mg IV. During
transfer, was noted to be bradycardic to low 40s and received 1
amp atropine with minimal improvement to low 50s.
MICU Course # 2
# PEA arrest.
On arrival to MICU, patient was noted to have weak pulse and
then lost pulse. CPR was resumed for PEA arrest. Underwent 2
more rounds of epi, 1 of bicarb before ROSC. BP was ~160/110
but then quickly dropped to 60s/40s and patient was started on
levophed and phenylephrine. These medications were discontinued
when patient was made CMO.
# Shock. Noted post PEA arrest/pulseless VT with initial
elevation in lactate. PEA arrest/pulseless VT likely led to
shock. Cause of the arrest was thought to be [**2-26**]
intra-abdominal process given extent of abdominal distention.
There was concern for bowel perforation or mesenteric ischemia.
Bladder pressure was monitored closely, initially found to be
45. Bedside decompression was considered but not performed as
it would not improve his long term out-come significantly. OG
tube and Flexiseal placed for decompression, bladder pressures
dropped to mid-20s. Shock was further complicated by shock
liver and LAD infarct based on echocardiogram. Subclavian
central line was placed with subsequent removal of the femoral
line. Vancomycin, cefepime, and Flagyl were started. He was
also started on levophed for persistent hypotension. Given the
catastrophic event, patient had EEG monitoring for prognostic
purposes, and it did not show evidence of epileptiform waves.
Patient did have brain stem function given spontaneous
respiratory effort. However, goals of care discussion
ultimately led to CMO status with discontinuation of antibiotics
and pressor support.
# Respiratory failure, [**2-26**] PEA arrest/pulselessness. Patient
was intubated on the floor given the arrest. He was terminally
extubed on [**2128-5-28**].
# Goals of Care. Extensive discussion was held with the
presence of patient's families- daughters, son, and wife. It
was clear that his health care proxy does not think patient
would want to have life prolonged without quality. Patient was
transitioned to CMO on [**2128-5-25**] with the plan to extubate once
one of his daughters returns from [**Country 3992**]. Antibiotics and
pressors were stopped with the plan to maintain comfort only.
Patient was terminally extubated on [**2128-5-28**].
# PAF. He was noted to have more irregular rate and tachycardia
after the arrest. Patient initially received metoprolol and
diltiazem, which were discontinued after one of his daughters
arrived from [**Country 3992**].
# Leukocytosis. Thought to be a stress response to the code
received on the floor although it is certainly possible that it
was also from an intra-abdominal source. Leukocytosis improved
over time while patient was on antibiotics prior to the CMO
transition.
Medications on Admission:
(from DC summary [**1-/2128**]):
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
2. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID
3. fluoxetine 10 mg Capsule Sig: One (1) Capsule PO QHS
4. fluticasone 50 mcg/Actuation Spray, (1) Nasal once a day.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. lidocaine 5 %(700 mg/patch) Adhesive Patch 2 patches qday prn
pain
7. omeprazole 20 mg Capsule 1 PO qday
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
10. dextromethorphan-guaifenesin 10-100 mg/5 mL Syrup Sig: [**6-3**]
MLs PO Q6H (every 6 hours) as needed for cough.
11. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough. Disp:*30 Capsule(s)*
Refills:*0*
12. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Inguinal hernia
PEA arrest
Pulseless VT
Expiration
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2128-5-29**]
|
[
"428.0",
"V45.81",
"574.20",
"427.31",
"288.60",
"272.4",
"585.9",
"550.92",
"274.9",
"570",
"403.90",
"584.5",
"V45.4",
"V15.88",
"428.22",
"427.5",
"785.51",
"787.91",
"518.81",
"427.1",
"276.51",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.93",
"96.27",
"96.72",
"38.91",
"99.60"
] |
icd9pcs
|
[
[
[]
]
] |
18447, 18456
|
11161, 17493
|
242, 249
|
18550, 18559
|
3597, 4154
|
18615, 18789
|
2748, 2830
|
18415, 18424
|
18477, 18529
|
17519, 18392
|
18583, 18592
|
2845, 3578
|
181, 204
|
277, 2362
|
4170, 11138
|
2384, 2619
|
2635, 2732
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,985
| 199,930
|
33710
|
Discharge summary
|
report
|
Admission Date: [**2114-3-19**] Discharge Date: [**2114-4-7**]
Date of Birth: [**2044-6-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 668**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
[**2114-3-20**]: Endovascular repair of aortoenteric fistula with
modular aortic stent graft
[**2114-3-28**]: Exploratory laparotomy and takedown aortoenteric
fistula
History of Present Illness:
69 year-old male with history of ruptured AAA repaired at an OSH
in [**2112**] and s/p polypectomy in early [**2114-3-2**], now admitted
to the MICU from [**Hospital 78002**] Hospital with syncopal episode
following passage of BRBPR x 5, hypotension (70/50), and emesis
of reddish material. En route to [**Hospital1 18**], he received 4U pRBCs, 3L
normal saline, and PPI.
In [**Hospital1 18**] ED initial vitals were T 97.6, BP 102/70, HR 76, RR 24,
O2 97% RA. He became hypotensive with BP 82/56 and continued to
have BRPBR. NGL was negative for blood; he received an
additional 1u pRBC with repeat Hct = 34%. He was transferred to
the MICU for further evaluation and management.
Past Medical History:
PMH: HTN, gout, hypercholesterolemia, gastritis
PSH: AAA '[**12**], polypectomy [**3-/2114**]
Social History:
lives alone, works as a supervisor, smoker 10+ yrs, no NSAIDs
Family History:
non-contributory
Physical Exam:
In ED:
T 97.6 HR 76 BP 102/70 RR 24 O2 97% RA
gen- NAD, AxOx3
neck- NC/AT, supple, no bruits
heart- normal S1 and S2, no murmurs
lungs- tachypneic, clear to auscultation, bilaterally
abd- BS +, soft, NT/ND
rectal - +bright red blood, no masses, nL sphincter tone
ext- no c/c/e, no ulcers
Pertinent Results:
[**2114-4-6**]: CT abdomen / pelvis
IMPRESSION:
1. Pigtail catheter noted in place immediately anterior to the
aorta with no significant fluid collection in this vicinity.
2. Post-operative changes within the peritoneal cavity including
small air and several small collections of fluid as detailed
above.
3. Inflammation and small lymph nodes again noted about the
patient's abdominal aorta. Small foci of air are again seen
within the aneurysm sac itself as on prior examinations.
[**2114-4-3**]: CT Retroperitoneal Drainage
IMPRESSION:
1. Successful CT-guided pigtail catheter placement into the
patient's post- surgical fluid collection
[**2114-4-3**] CTA abdomen
CONCLUSION:
1. Free air and free fluid in the abdomen and pelvis in keeping
with a recent operative management of the abdominal aortic
aneurysm.
2. Overall stable size of the abdominal aortic aneurysm with
surrounding inflammatory changes and pockets of air within the
native aorta.
3. Partial mural thrombosis of the left external iliac artery,
unchanged since the prior examination
[**2114-3-28**] Pathology
Segment jejunum (clinical history of aorto-jejunal fistula):
1. Focal serosal fibrosis, adhesions, edema, mild chronic
inflammation.
2. Focal atheroemboli.
3. No evidence of malignancy.
[**2114-3-26**]: Persantine MIBI
IMPRESSION: 1. Normal myocardial perfusion. 2. Normal LV cavity
size and
systolic function (EF 54%).
[**2114-3-19**] Mesenteric Arteriogram
IMPRESSION: No active bleeding, neovascularity, or signs of
angiodysplasia in the celiac, SMA, and [**Female First Name (un) 899**] territories
[**2114-3-19**] EGD:
Normal mucosa in the whole esophagus, erythema in the stomach
body and antrum compatible with mild gastritis, mormal mucosa in
the first part of the duodenum, second part of the duodenum and
third part of the duodenum.
Brief Hospital Course:
The patient was admitted to the MICU for evaluation and
management. An NG lavage showed no bright red blood or coffee
grounds. He underwent an angiogram which was non-revealing for
etiology of the bleed and an EGD which showed gastritis without
evidence of bleeding source. Shortly following admit, he had an
episode of massive
hematemesis with associated hypotension and diaphoresis and went
emergently for a RBC scan (no evidence of bleed) followed by CTA
abdomen with suggestion of aorto-enteric fistula. He
subsequently was covered empirically with antibiotics
(vancomycin and zosyn) prior to any cultures being sent and
transferred to the vascular surgical service. On [**2114-3-20**] he was
transferred to the SICU with Hct=33.9 and subsequently underwent
an endovascular repair of aortoenteric fistula with modular
aortic stent graft by Dr [**Known firstname **] [**Last Name (NamePattern1) **]. Post-operatively,
Hct=27.5 and was transfused appropriately, with serial hemocrits
checked q8h. Infectious disease was consulted regarding
antibiotic management. Vancomycin and zosyn were continued, with
fluconazole added until discharge when switched to oral
levofloxacin, fluconazole, and flagyl per ID recommendations.
For nutritional support, a PICC line was placed and TPN
initiated. On [**2114-3-22**], cardiology was consulted, recommendations
included obtaining persantine MIBI, which revealed normal LV
cavity size and systolic function (EF 54%), in addition to
starting aspirin 325 daily and a beta-blocker. The
hepaticobiliary service was additionally consulted for further
recommendations regarding the aorto-enteric fistula and on
[**2114-3-28**] he underwent an exploratory laparotomy with takedown of
aortoenteric fistula by Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. He tolerated the
procedure well with no complications. He was kept NPO and TPN
was continued for nutritional support until return of bowel
function. Post-operatively, Hct=35%. On [**2114-4-2**], temperature rose
to 102.1 with chills / rigors. A CTA abdomen revealed free air
and free fluid in the abdomen and pelvis, and overall stable
size of the abdominal aortic aneurysm with surrounding
inflammatory changes and pockets of air within the native aorta.
On [**2114-4-3**], the patient underwent CT-guided pigtail catheter
placement into postoperative fluid collection with approximately
70 cc of purulent fluid drained. From [**3-19**] - [**2114-4-3**], blood,
urine, and wound cultures reported no growth. Per ID
recommendations, antibiotics (levofloxacin, flagyl, fluconazole)
should be continued until definitive aortic graft repair. On
discharge, the patient will continue aspirin 325mg daily and
metoprolol 25mg twice daily. He was tolerating a regular diet
with no nausea or vomiting. He denied grossly bloody bowel
movements, and Hct=30.7%. He ambulated independently and
reported adequate pain control on oral medication. VNA was
arranged for drain and wound cares. He will followup with
vascular and hepaticobiliary surgical services and obtain an
interval CT scan in approximately 3-4 weeks.
Medications on Admission:
Atorvastatin 40mg daily
Allopurinol, dose unknown
Discharge Medications:
1. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
2. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*1*
3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*1*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Aorto-enteric fistula
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 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.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Drain Care:
*Please look at the site every day for signs of infection
(increased redness, swelling, tenderness, odorous or purulent
discharge).
*Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
*Be sure to empty the drain frequently and record the output.
*Maintain the site clean, dry, and intact.
*Keep drain attached safely to body to prevent pulling and
possible dislodgement.
Incision:
*Staples will be removed at followup appointment
*Monitor wound for redness/swelling/purulent drainage
Medications:
*Resume home medications
*Take antibiotics (levofloxacin, flagyl, fluconazole), as
instructed
*No driving while taking narcotic pain medication
*Take Aspirin 325mg daily and Metoprolol 25mg twice daily
Activity:
*No heavy lifting or strenuous exercise. Gradually increase your
activities and distance walked as you can tolerate.
Followup Instructions:
Please call [**Telephone/Fax (1) 673**] to schedule followup appointment with
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next week
Please call [**Telephone/Fax (1) 18181**] to schedule followup appointment with
Dr [**Known firstname **] [**Last Name (NamePattern1) **] in [**1-31**] weeks
Please call your primary care physician and schedule appointment
1-2 weeks from discharge.
|
[
"285.9",
"996.74",
"272.0",
"998.6",
"458.9",
"998.59",
"996.62",
"E878.8",
"305.1",
"441.4",
"401.9",
"E879.8",
"274.9",
"578.9",
"V12.72",
"567.22"
] |
icd9cm
|
[
[
[]
]
] |
[
"46.74",
"38.93",
"45.91",
"99.15",
"88.42",
"88.47",
"54.91",
"45.13",
"39.71"
] |
icd9pcs
|
[
[
[]
]
] |
7810, 7865
|
3608, 6727
|
317, 486
|
7931, 7940
|
1755, 3585
|
9662, 10074
|
1409, 1427
|
6827, 7787
|
7886, 7910
|
6753, 6804
|
7964, 9639
|
1442, 1736
|
272, 279
|
514, 1197
|
1219, 1314
|
1330, 1393
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,156
| 192,335
|
43858
|
Discharge summary
|
report
|
Admission Date: [**2121-7-21**] Discharge Date: [**2121-8-4**]
Service:
ADMISSION DIAGNOSIS: Gallstone pancreatitis.
DISCHARGE DIAGNOSIS: Massive liver bleeding secondary to
percutaneous cholecystostomy tube placement and subsequent
Adult Respiratory Distress Syndrome and death.
HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is an
82-year-old man with a past medical history significant for
coronary artery disease, status post MI, pulmonary fibrosis
and hypertension who was transferred to the [**Hospital6 1760**] on [**2121-7-21**] with gallstone
pancreatitis. His laboratory examination at that time was
significant for a white count of 30 and transaminases greater
than 1,000. His total bilirubin was 6.2 and his amylase was
1,600 at this time. A CT scan at the outside hospital was
read as having ductal dilatation.
HOSPITAL COURSE: He was admitted to the GI Service where he
underwent a failed attempt at ERCP and then proceeded to
Interventional Radiology for percutaneous transhepatic
cholangiography which was very difficult but ultimately
revealed a patent nondilated biliary tree with filling of
both the gallbladder and duodenum. Because of clinical
concern for cholangitis, a percutaneous cholecystostomy tube
was placed by the interventional radiologist as ordered by
the medical team. He was admitted to the Medical Intensive
Care Unit for antibiotics and resuscitation.
Over the following 24 hours, he was noted to have a
hematocrit drop from 36 to 23 and required a total of 6 units
of packed red blood cells for resuscitation. A CT scan was
obtained which revealed a large subcapsular hematoma with
free extravasation of contrast into the peritoneal cavity.
At this time, surgery was consulted initially to evaluate him
for future cholecystectomy but then eventually after learning
of the CT scan to manage his liver hematoma.
Because of the extravasation seen on CT scan, the ongoing
blood requirement and pressor requirement, the surgical team
decided to take him urgently to the Operating Room. On
expiration, there were about 2 liters of free blood in the
abdomen encountered and a large right-sided liver hematoma
with active bleeding from two different lacerations in the
right lateral lobe of the liver. Bleeding was unable to be
controlled despite several liver sutures and Argon beam
coagulation and it was decided to pack the liver and transfer
the patient to the SICU for correction of coagulopathy and
warming.
Over the following 48 hours, the bleeding from the liver
stopped. His coagulations were corrected and he remained
hemodynamically stable. At that point, we returned to the
Operating Room where packs were removed and points of
bleeding were able to be stopped with Argon electrocautery,
Surgicel application, liver sutures, and direct pressure.
Over the first five postoperative days, the patient did well
and had no further episodes of bleeding and was slowly being
weaned from pressors and from the ventilator. He was
supported with antibiotics, TPN, and was getting Lasix for
diuresis. Subsequently, his progress halted and he began to
deteriorate and developed multisystem organ failure with
progressive cardiogenic shock and respiratory failure
secondary to ARDS.
His ventilator settings were maximized. He was paralyzed and
placed on pressure control ventilation and with maximal
support.
Finally, on postoperative day number 13 and 11, a family
meeting was held to discuss the gravity of the situation and
his family agreed to make the patient comfort measures only.
At that time, pressors were withdrawn and the patient expired
shortly thereafter. Postmortem examination was declined by
the family.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**]
Dictated By:[**Name8 (MD) 94179**]
MEDQUIST36
D: [**2121-8-18**] 02:23
T: [**2121-8-20**] 19:44
JOB#: [**Job Number 94180**]
|
[
"286.6",
"518.5",
"998.2",
"998.11",
"584.5",
"864.14",
"427.5",
"577.0",
"576.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"51.98",
"96.72",
"87.51",
"45.13",
"50.61",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
150, 853
|
871, 3957
|
103, 128
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,410
| 197,584
|
5266
|
Discharge summary
|
report
|
Admission Date: [**2176-8-16**] Discharge Date: [**2176-8-26**]
Date of Birth: [**2104-10-10**] Sex: M
Service: SURGERY
Allergies:
Lipitor / Lisinopril
Attending:[**First Name3 (LF) 5569**]
Chief Complaint:
ESRD
Major Surgical or Invasive Procedure:
[**2176-8-16**] renal transplant
[**2176-8-20**] washout of hematoma
History of Present Illness:
Patient is 71 year old male with ESKD stage 5 secondary to
hypertension and history of MI and PCI in [**2167**], presenting for
renal transplant. Patient has been stable with minimal uremic
symptoms and minimal edema, never had a requirement for
hemodialysis. He reports good appetite, but does not eat much
[**2-5**]
dysgeusia. He denies any nausea, vomiting, diarrhea,
constipation, headaches, chest pain, SOB. He denies insomnia,
muscle weakness or cramping. He denies any pruritus. He denies
any recent infections, has not taken any antibiotics recently.
Patient had a LUE AV fistula placed in [**Month (only) 404**] of this year, but
it failed to mature. In [**2176-4-3**] he had fistulogram with an
8mm
baloon angioplasty of a segment of vein just beyond the arterial
anastomosis, side branch was ligated. Fistula has subsequently
matured and may be used if needed.
.
Past Medical History:
HTN
- Mild/moderate left distal SFA stenosis ([**2176-8-8**])
- MI in [**2167**] s/p PCI
- CAD. stable chronic angina (no chest pain or nitro use for
almost 10 years)
- questionable stent in iliac vessels - per pt report, is
uncertain
- left upper extremity AV fistula - [**2176-1-4**]
[**2176-8-16**] renal transplant
NSTEMI [**2176-8-19**]
Hematoma, wash out [**2176-8-21**]
Social History:
lives alone, is divorced
- has 2 children and 5 grandchildren
- denies etoh, stopped cigarettes 20 years ago
.
Family History:
n/c
Physical Exam:
99.9kg 96.3 56 123/66 18 98%RA
gen: WA/WD, NAD pleasant
HEENT: EOMI, PERRL
CV: RRR, nl S1, S2
pulm: CTAB
abdominal: NBS, ND/NT, mildly obese
extremities: palpable DP bilaterally, minimal edema
.
Pertinent Results:
[**2176-8-26**] 05:00AM BLOOD WBC-9.6 RBC-2.86* Hgb-7.8* Hct-24.4*
MCV-85 MCH-27.3 MCHC-32.0 RDW-16.3* Plt Ct-176
[**2176-8-26**] 09:05AM BLOOD Hct-28.2*
[**2176-8-24**] 05:13AM BLOOD PT-16.0* PTT-26.2 INR(PT)-1.4*
[**2176-8-26**] 05:00AM BLOOD Glucose-99 UreaN-55* Creat-3.2* Na-140
K-4.0 Cl-111* HCO3-16* AnGap-17
[**2176-8-26**] 05:00AM BLOOD Calcium-7.2* Phos-3.6 Mg-2.3
[**2176-8-26**] 05:00AM BLOOD tacroFK-7.0
Brief Hospital Course:
On [**2176-8-16**], he had an ECD kidney transplant into left iliac
fossa. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Per operative note, there was
severe calcification of the iliac artery making anastomosis
quite difficult and requiring a much more extensive dissection
into the femoral canal than usually done. The anastomosis was
done like a live donor transplant. Induction immunosuppresion
was administered (cellcept, simulect, and solumedrol) Postop,
urine output averaged between 360 and 525cc per hour. Creatinine
started to trend down.
He developed chest pain on postop day 2, at 6am with ST changes
in the lateral leads. Chest pain was relieved with NTG SL and
paste. EKG normalized. Enzymes were cycled. Chest pain recurred
at 10pm. SBP was elevated to 180s. This was treated with NTG
paste and SL nitro with relief of chest pain. Cardiology was
consulted and Lopressor was increased. Enzymes continued to be
cycled. Troponin increased from baseline of 0.02 to 0.12.
Cariology felt that he had suffered a NSTEMI and recommended
ASA, IV heparin drip, pravastatin and BP control. A cardiac
catheterization was anticipated. IV heparin drip was initiated
on [**8-19**].
On [**8-20**], ptt was supratherapeutic and heparin was held then
restarted at a lower rate. During the day he complained of
increased incision pain. A repeat hematocrit was checked and
noted to be decreased to 22.5 from 25.6. IV heparin was stopped.
Two units of PRBC were ordered and a stat renal transplant
duplex was done without visualization of the renal transplant
kidney. Vasculature was unable to be assessed secondary to a
large amount of blood in the LLQ. Urine output was stopped and a
foley was placed. He was transferred to the SICU. Cardiology was
contact[**Name (NI) **] and planned catheterization for [**8-21**] was deferred.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] took him to the OR on the PM of [**8-20**] for
exploratory lap due to concern for compromise of renal
vasculature of the kidney and control of hemorrhage. A number of
small bleeding points were controlled with argon beam. There
were no large activevessels that were bleeding. A drain was
placed.
Postop, he went to the SICU where he received further PRBC and
FFP. Hematocrit stablized. Urine output increased. Creatinine
continued to decrease with good urine output into the 3 liter
range. He was transferred out of the SICU after several days.
Diet was advanced and tolerated. Incision had a small amount of
serosanuinous drainage. The JP drainage decreased and was dark,
old bloody fluid averaging 50cc/day by [**8-26**].
Immunosuppression consisted of cellcept 1 gram [**Hospital1 **] which was
well tolerated. Steroids were tapered off per protocol. Simulect
was repeated on postop day 4 and prograf was initiated on postop
day 1 and adjusted by daily trough levels which ranged between
8.5-11.3 on 3mg [**Hospital1 **]. Trough level decreased to 7.0 on [**8-26**].
Prograf was increased to 4mg [**Hospital1 **].
Blood sugars were mildly increased to 140s. Minimal sliding
scale insulin was used and he was taught how to check his
glucose at home twice daily and record.
Cardiology continued to follow throughout this hospital course
recommending that hydralazine be added. Aspirin continued.
Lopressor was increased and pravastatin was continued. Of note,
he did complain of some bilateral leg/thigh discomfort with
movement that requires monitoring for SE of pravastatin. On
[**8-23**], he experienced a junctional bradycardia/arrythmia.
Lopressor was decreased. No further episodes occured. CXR showed
improvement with only a tiny left pleural effusion noted. He
denied any further chest pain.
On [**8-26**], he was discharged to home with Care Group VNA services
([**Telephone/Fax (1) 13046**]). Medication teaching was reviewed. PT cleared him
for home without further PT. Although, cardiac rehab should be
investigated. Cardiology followup was scheduled for [**9-12**] with
Dr. [**Last Name (STitle) 5543**] to determine cardiac risk stratification (ie.
stress test vs. cardiac catheterization). Of note, hematocrit
was 24.4 on [**8-26**]. This was repeated and found to be 28.2.
He was discharged to home on [**8-26**].
Medications on Admission:
diovan 320mg qd
aspirin 325mg qd
isosorbide mononitrate 30mg qd
pravistan 40mg qd
sodium bicarbonate 650mg 6xday
gemfibrozil 60mg [**Hospital1 **]
allopurinol 100mg [**Hospital1 **]
calcacetate 667mg 6xday
calcitrol 0.25mg [**Hospital1 **]
nifedepine 60mg [**Hospital1 **]
metoprolol 100mg [**Hospital1 **]
folic acid 1mg qd
aranesp injection qweek
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. One Touch Ultra System Kit Kit Sig: One (1)
Miscellaneous twice a day.
Disp:*1 * Refills:*0*
3. One Touch UltraSoft Lancets Misc Sig: One (1)
Miscellaneous twice a day.
Disp:*1 box* Refills:*0*
4. One Touch Ultra Test Strip Sig: One (1) In [**Last Name (un) 5153**] twice a
day.
Disp:*1 box* Refills:*1*
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
11. Pravastatin 20 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
13. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
17. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
19. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
esrd
renal transplant
NSTEMI
hematoma
Discharge Condition:
good
Discharge Instructions:
please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
chest pain/shortness of breath, increased abdominal pain,
incision redness/bleeding/drainage, decreased urine output, JP
drainage stops or any concerns
Labs at [**Last Name (NamePattern1) 439**] [**Location (un) 86**] every Monday and Thursday
empty JP drain and record output. bring record of output to next
appointment
check blood sugar before breakfast and supper and record. bring
record of glucoses to next appointment
Followup Instructions:
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2176-9-2**] 1:10
Provider: [**Name10 (NameIs) 2105**] [**Name11 (NameIs) 2106**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2176-9-12**] 8:40
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2176-9-12**] 2:40
Completed by:[**2176-8-26**]
|
[
"998.11",
"V45.82",
"V15.82",
"998.12",
"285.21",
"440.21",
"564.09",
"403.91",
"V58.65",
"584.5",
"427.1",
"272.4",
"997.1",
"997.5",
"414.01",
"274.9",
"410.71",
"E878.0",
"V45.4",
"E934.2",
"285.1",
"413.9",
"278.00",
"585.5",
"412"
] |
icd9cm
|
[
[
[]
]
] |
[
"55.69",
"54.12",
"00.93"
] |
icd9pcs
|
[
[
[]
]
] |
8888, 8946
|
2492, 6772
|
286, 357
|
9028, 9035
|
2051, 2469
|
9648, 10088
|
1809, 1814
|
7171, 8865
|
8967, 9007
|
6798, 7148
|
9059, 9625
|
1830, 2032
|
242, 248
|
386, 1264
|
1286, 1664
|
1680, 1793
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,933
| 123,253
|
7602
|
Discharge summary
|
report
|
Admission Date: [**2116-11-20**] Discharge Date: [**2116-12-1**]
Date of Birth: [**2039-11-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Morphine
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
difficulty breathing
Major Surgical or Invasive Procedure:
[**2116-11-21**] endotracheal intubation
[**2116-11-23**] bronchoscopy x 2
[**2116-11-23**] renal biopsy
History of Present Illness:
Mr. [**Known lastname 27548**] is a 77M with extensive PMH including CHF, CAD c/b
MI, DMII, lung cancer s/p VATS, and ESRD s/p kidney transplant
in [**2104**] (on immunosuppresion), who presents from clinic with
pneumonia, new thrombocytopenia and hyperkalemia.
.
Mr. [**Known lastname 27548**] was diagnosed with a UTI in [**9-/2116**] and was treated
with Ciprofloxacin x7 days. He then became ill one week ago with
upper respiratory symptoms including congestion and cough
productive of phlegm streaked with blood which has evolved into
phlegm with clots. He has noted some epistaxis with dripping
down the back of his throat. He also noticed atraumatic bruises
over his extremities over the past two days. He has had diarrhea
for 7-10 days all prompting him to be evaluated today at [**Company 191**] and
was found to have a new pneumonia. He was started on
levofloxacin and sent home. His labs returned with a critical
value with platets of 22 and creatinine of 7.3. He was notified
and asked to be evaluated in the ED.
.
Review of systems also positive for air hunger and anxiety
related to his feeling of being unable to get enough air. He
also endorses a decreased appettite. However, he denies N/V,
hematemsis, F/C, HA. He denies any medication non-compliance,
new medications or supplements. He follows with Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) 805**], who Mr. [**Known lastname 27548**] saw "a few months ago."
.
recently, patient has been having difficulty breathing,
described as inability to get air in. Increased bruising noted
over the past two days. Nosebleeding also noted. Diarrhea on and
off for the past 7-10 days. No fevers, chills, hematochezia,
hematuria, dysuria, gum bleeding, melena
.
In the ED, initial VS were: 97.7 84 120/44 24 96% RA. CXR showed
RLL/RML pneumonia. Sputum cx, urine cx, blood cx sent. For the
hyperkalemia he was given kayexalate x1, insulin 10 u x2, 1 amp
d50, calcium gluconate. He was guaiac negative.
.
On arrival to the MICU, he is tachypneic, restless and obviously
uncomfortable. He is tripoding to help make his breathing more
comfortable.
.
Review of systems:
(+) Per HPI, all else negative.
Past Medical History:
1. DMII
2. HTN
3. hypercholesterolemia
4. CAD s/p MI ([**2104**])
5. severe osteoarthritis of the hips/shoulders/knees
6. spinal stenosis
7. ESRD s/p LRRT ([**9-/2105**])
8. PVD s/p R SFA-tib/peroneal trunk NRSVG (99), jump graft from
R tib/peroneal trunk to distal R PT NR cephalic VG ([**4-/2105**]), PTA
of R SFA-PT bypass ([**10-1**]), angioplasty L CIA ([**11/2104**]), L CFA-PT
[**Name (NI) **] with in-situ SVG ([**1-30**]), b/l TMA, b/l sesamoidectomies, R
AKA
9. lung adenoca s/p VATS/wedge resection of nodule [**2111**]
10. BPH
11. diastolic heart dysfunction
12. Klebsiella bacteremia/urosepsis ([**2-3**])
13. Phimosis s/p circumcision in [**2116-8-27**]
Social History:
He smoked cigarettes until [**2083**] (50 pack-years). He does not use
alcohol. He lives at home with his wife who helps him with his
medications and ADLs. He retired approximately 10 years ago
from his job as a truck driver. He has 3 children that are
doing well.
Family History:
Significant for lung cancer in the patient's father who
developed this at age 75, but subsequently died of a stroke.
His mother died at the age of 86 from stroke. He has one
brother with mental retardation that died at the age of 69. He
has another healthy brother.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 96.9 BP: 125/51 P: 89 R: 26 O2: 86-90% on RA, 98% on
5L
General: Alert, oriented, uncomfortable, restless
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP ~12 cm, no LAD
CV: [**2-2**] LSB SEM, borderline, no murmurs, rubs, gallops
Lungs: diffuse rhonchi, most prominent in the bases of the lungs
R>L, no wheezes, tripoding, accessory muscle use
Abdomen: soft, tenderness over the transplant graft in the LLQ,
non-distended
GU: foley, gross hematuria
Ext: warm, AKA on right, with transmetatarsal amputation on
left, multiple skin erosions on left calf and medial and lateral
ankles. 2+ edema
Neuro: Mildly confused (time of day), moving all 5 extremities.
.
Pertinent Results:
ADMISSION LABS:
[**2116-11-20**] 01:03PM BLOOD WBC-8.7 RBC-3.04* Hgb-8.4* Hct-27.9*
MCV-92 MCH-27.5 MCHC-30.0* RDW-21.6* Plt Ct-22*#
[**2116-11-20**] 01:03PM BLOOD Neuts-79.0* Lymphs-14.4* Monos-5.1
Eos-1.1 Baso-0.3
[**2116-11-21**] 03:52AM BLOOD PT-14.1* PTT-27.5 INR(PT)-1.2*
[**2116-11-21**] 03:52AM BLOOD Fibrino-373#
[**2116-11-21**] 03:52AM BLOOD Ret Aut-5.7*
[**2116-11-20**] 01:03PM BLOOD UreaN-138* Creat-7.3*# Na-138 K-5.9*
Cl-101 HCO3-21* AnGap-22*
[**2116-11-20**] 01:03PM BLOOD ALT-12 AST-25 AlkPhos-59 TotBili-0.5
[**2116-11-20**] 07:42PM BLOOD LD(LDH)-718* TotBili-0.5
[**2116-11-24**] 03:20PM BLOOD Lipase-7
[**2116-11-21**] 03:52AM BLOOD Calcium-8.1* Phos-7.0*# Mg-2.8*
[**2116-11-20**] 07:42PM BLOOD Hapto-64
[**2116-11-22**] 09:15AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2116-11-21**] 04:10PM BLOOD ANCA-NEGATIVE B
[**2116-11-22**] 09:15AM BLOOD HCV Ab-NEGATIVE
[**2116-11-20**] 06:15PM BLOOD Lactate-1.4
[**2116-11-21**] 04:29AM BLOOD Hgb-8.3* calcHCT-25 O2 Sat-66
[**2116-11-20**] 11:40PM BLOOD freeCa-1.14
.
Brief Hospital Course:
Mr. [**Known lastname 27548**] is a 77 year old male with extensive history
including heart failure (CHF), coronary artery disease
complicated by myocardial infarction (CAD c/b MI), diabetes
mellitus, type 2 (DMT2), lung cancer status post VATS, and end
stage renal disease (ESRD) status post kidney transplant in [**2104**]
(on immunosuppresion), who presented from clinic with pneumonia,
new thrombocytopenia and hyperkalemia.
.
# Acute on chronic renal failure: Ultimately, the cause of his
acute renal failure was not found. It was suspected that he had
a TTP/HUS-like syndrome or possibly ATN from sepsis which he
never recovered from. A renal biopsy of his transplanted kidney
did not show acute graft rejection, blood vessel thrombosis, or
other pathologic diagnoses. His ADAMSTS13 was indeterminate.
He was tried on CVVH and CRRT for dialysis, however, he was
ultimately unable to maintain euvolemia with this and was
continuing to have pulmonary edema resulting in respiratory
failure. His immunosuppression (rapamune and cellcept) was
discontinued when it became clear that his kidneys were not
recovering and his thrombocytopenia was worsening.
.
# Thrombocytopenia: Cause was never discovered. As discussed
above, it is possible that he had a TTP/HUS-like syndrome,
sepsis, or a smoldering DIC. ITP was also on the differential.
His hemolysis labs showed a mixed picture with largely normal
total bilirubin and haptoglobin, variable fibrinogen sometimes
under 100, and elevated LDH. He was tried on plasmapheresis x3
for possible TTP, however this did not raise his platelets.
Then, he was given a trial of prednisone for possible TTP/HUS,
which worked for only one day and was confounded by platelet
transfusions at the same time. Finally, his immunosuppression
was held to let his bone marrow replace the platelets, which
showed potential with a reticulocyte count of >7. He continued
to have bleeding through pulmonary hemorrhage
Differential diagnosis includes TTP/HUS vs. sepsis vs. acute
rejection, graft thrombosis. Likely source of infection is
urinary with a UA positive. In terms of TTP/HUS, he has anemia,
thrombocytopenia, and renal failure. He has been on prednisone
chronically and may be playing a role in suppression of his
fever response in the case of TTP/HUS and sepsis. His peripheral
morphology shows occassional schisotcytes. LDH is elevated
(though the sample was slightly hemolyzed). He has had symptoms
of diarrhea for 7-10 days though non-bloody.
.
On [**11-30**] during a family meeting it was decided that the patient
should be made comfort measures only. We held labs, discontinued
any unnecessary medications that did not contribute directly to
patient comfort, discontinued dialysis. His vent was changed to
pressure support. Social work and the chaplain were consulted.
On the morning of [**12-2**] the patient died.
Medications on Admission:
*fentanyl 25 mcg/hr q72
*Epogen 4,000 unit/mL Injection 2 injections 8,000 u q 7 days
*levofloxacin 250 mg Tab -Please take 2 tablets on day one and 1
tablet daily thereafter
*Lipitor 80 mg qPM
*Flomax 0.4 mg 24 hr Cap qHS
*Rapamune 3 mg PO qHS
*Hectorol 2.5 mcg PO daily
*Protonix 40 mg Tab 1 Tablet(s) by mouth once a day
*Lantus Solostar 300 unit/3 mL Sub-Q Insulin Pen inject 34 units
subcutaneously at bedtime once a day at bedtime
*Senna 8.6 mg Tab 1 Tablet(s) by mouth prn
*Humalog 100 unit/mL Sub-Q SLIDING SCALE, AS DIRECTED
*Bactrim DS 160 mg-800 mg Tab 1 Tablet(s) by mouth three times a
week, mon/wed/fri
*aspirin 81 mg Tab PO daily
*Niaspan 500 mg PO qHS
*CellCept [**Pager number **] mg PO BID
*furosemide 80 mg PO BID
*Hydralazine 25 mg Tab PO QID
*Isosorbide Mononitrate SR 30 mg 24 hr Tab -3 (Three) Tablet(s)
by mouth Daily
*metoprolol tartrate 100 mg PO twice a day
*ondansetron HCl 4 mg PO twice a day
*oxycodone-acetaminophen 5mg-325mg Tab; 2 Tabs PO daily prn pain
*prednisone 1 mg Tab; 3 tabs PO once a day
*docusate sodium [Colace] 100 mg Cap; 1 Cap PO BID prn
constipation
*sennosides [senna] 8.6 mg Tab; 1 Tab by mouth prn
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Acute renal failure, respiratory failure
Discharge Condition:
Expired
Discharge Instructions:
N/A
Followup Instructions:
N/A
Completed by:[**2116-12-1**]
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31,871
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32303
|
Discharge summary
|
report
|
Admission Date: [**2171-11-18**] Discharge Date: [**2171-11-25**]
Date of Birth: [**2092-8-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1666**]
Chief Complaint:
subdural hematoma/ subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a 79F with a h/o hypercholesterolemia who
presented to an OSH after an unwitnessed fall on [**11-18**] and was
found to have a 7mm left sided SDH and SAH on CT. She does not
remember the fall, and was found by a neighbor who reported she
was unconscious at first but then arousable. The patient denies
any preceding events/ movements/ auras to her knowledge. She
denies any CP, SOB, dizziness, tongue biting, incontinence,
weakness/ motor deficits, sensory deficits, and change in speech
or vision before or after the time of fall. The patient was very
confused upon arousal and reports a severe throbbing HA and neck
pain with flexion after the fall. She denies any other recent
falls.
.
The patient was transferred from the OSH to [**Hospital1 18**] on [**11-18**] where
CT showed a 5mm left-sided subdural hematoma (possibly acute on
chronic) and a small L temporal subarachnoid hemorrhage with no
evidence of acute infarct. Vital signs were stable and exam was
nonfocal on admission. The patient was admitted to the trauma
ICU for frequent neurochecks, where she was started on dilantin
for seizure prophylaxis. Repeat CT on [**11-19**] was unchanged, and
the patient was transferred to the floor on telemetry.
.
Of note, the patient does report word-finding difficulties that
the daughter reports are intermittent since the fall. Previous
documentation notes word finding problems for the last 1 and [**1-22**]
years that were attributed to Zoloft, but the patient's daughter
notes that these symptoms are far more pronounced than usual.
Past Medical History:
Hypercholesterolemia
Depression
Question early dementia - recent forgetfulness
Hypothyroidism treated with Synthroid
The patient also reports a cardiac catheterization at the [**Hospital1 112**]
6yrs ago which was normal. The cath was done for a "lab
abnormality". She also had a normal carotid ultrasound about 2
yrs ago after her sister was diagnosed with a carotid stenosis.
Social History:
lives in group home- [**Hospital1 **] House in [**Hospital1 6687**], no tobacco, no
Etoh; adult children live in the area as well and are very
supportive. The patient is independent in her ADLs and drives on
her own.
Family History:
father CAD, MI at age 66yrs, sister with carotid stenosis at age
76
Physical Exam:
VS: Tc/m 101.4 BP 122/70 (118-136/60-72) HR 86 (74-86) RR 18
O2sat 97%RA (93-97%RA)
Gen: pleasant elderly female sitting in chair in NAD. Oriented
x3. Mood, affect appropriate.
HEENT: NCAT, PERRL, EOMI, sclera anicteric. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. OP clear
Neck: Supple, JVP not elevated, no carotid bruit
CVS: PMI located in 5th intercostal space, midclavicular line.
RRR, normal S1, S2. Very mild systolic [**1-26**] murmur best over
RUSB. No r/g/ thrills. No S3 or S4.
Chest: normal respiratory effort, no accessory muscle use. CTAB,
no crackles, wheezes or rhonchi.
Abd: +BS, Soft, NT, ND. No HSM or tenderness. No abdominial
bruits. No suprapubic tenderness.
Ext: No c/c/edema. Pneumoboots in place. 2+ distal pulses
Skin: stasis dermatitis, no ulcers or scars.
Neuro: AAOx3. CN II-XII intact, 5/5 strength throughout in
proximal and distal muscle groups. 2+ biceps, triceps, and
patellar reflexes. Sensation to light touch intact throughout.
[**3-23**] registration and recall. Patient can name days of week and
months of year backwards without difficulty. + occasional word
finding difficulties. Appropriate behavior throughout.
Pertinent Results:
LABS:
[**2171-11-18**] 04:30PM WBC-10.5 RBC-4.53 HGB-13.6 HCT-40.8 MCV-90
MCH-30.0 MCHC-33.3 RDW-13.5
[**2171-11-18**] 04:30PM PLT COUNT-210
[**2171-11-18**] 04:30PM PT-11.5 PTT-24.1 INR(PT)-1.0
[**2171-11-18**] 04:30PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2171-11-18**] 04:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2171-11-19**] 05:10AM BLOOD Glucose-106* UreaN-14 Creat-0.9 Na-141
K-4.5 Cl-105 HCO3-29 AnGap-12
[**2171-11-19**] 05:10AM BLOOD CK(CPK)-129
[**2171-11-19**] 05:10AM BLOOD CK-MB-4 cTropnT-<0.01
[**2171-11-19**] 04:29PM BLOOD CK(CPK)-129
[**2171-11-19**] 04:29PM BLOOD CK-MB-4 cTropnT-<0.01
[**2171-11-20**] 12:35AM BLOOD CK(CPK)-117
[**2171-11-20**] 12:35AM BLOOD CK-MB-4
[**2171-11-21**] 05:30AM BLOOD VitB12-367 Folate-11.6
[**2171-11-21**] 05:30AM BLOOD TSH-2.9
.
EKG: SR, Left axis consistent with LAFB, LVH, normal intervals
.
[**11-18**] CT head: Left-sided suboccipital subdural hematoma about
5mm in greatest thickness. Small L temporal subarachnoid
hemorrhage. No evidence of acute infarct. Findings not
significantly changed compared to OSH CT.
.
[**11-19**] CT head: IMPRESSION: Unchanged L convexity subdural
hematoma and small subarachnoid hemorrhage
.
[**11-19**] CXR (port AP): FINDINGS: Opaque tubes somewhat obscure
the right lower lung. The cardiac silhouette is mildly enlarged
and there is some tortuosity of the aorta. However, no evidence
of vascular congestion, pleural effusion, or acute pneumonia.
.
[**11-20**] carotid U/S: IMPRESSION: Less than 40% right ICA stenosis.
40% to 59% left ICA stenosis.
.
[**11-20**] Echo: IMPRESSION: Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function
(LV EF > 55%). Mild mitral regurgitation. No structural cardiac
cause of syncope identified.
.
[**11-22**] CT head w/o contrast: IMPRESSION:
1. Unchanged subdural hematoma along the left convexity, left
anterior falx and left tentorium.
2. Probable evolving contusion in the left posterior/inferior
temporal lobe. An evolving infarction may also be considered.
The planned brain MRI will be helpful for further evaluation.
.
[**11-22**] MRI brain & neck w/o contrast: IMPRESSION:
1. Left temporal abnormality visualized on the recent CT
consistent with hemorrhagic contusion and not with recent
infarction.
2. Irregularity of the left posterior cerebral artery may be due
to trauma from impact onto the nearby tentorium or alternatively
could relate to intrinsic arterial disease such as
atherosclerosis. Given the lack of evident arterial disease
elsewhere, in context, the former seems more likely.
3. Small multifocal subdural hematomas, probably unchanged,
allowing for differences in technique between CT and MR.
4. Old lacunar infarct in the left caudate.
.
[**11-23**] MRA neck: FINDINGS: Neck MRA demonstrates normal flow
signal in the carotid and vertebral arteries. No evidence of
stenosis or occlusion seen.
.
[**11-24**] EEG: IMPRESSION: This is an abnormal routine EEG in the
waking and drowsy states due to intermittent bursts of focal
slowing arising in the left temporal and left fronto-temporal
regions suggesting a region of
subcortical dysfunction in that area. Vascular disease would be
among
the common causes for such a finding. There were no epileptiform
features. No electrographic seizures were noted.
Micro:
[**11-19**] UA: neg, [**1-22**] UCx: 10-100K enterococcus
URINE CULTURE (Final [**2171-11-21**]):
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=1 S
.
[**11-19**] BCx neg x 2
[**11-20**] BCx: neg x 4
.
Brief Hospital Course:
A/P: 79 yo with hypercholesterolemia and depression who
presents after an unwitnessed fall possibly secondary to a
syncopal episode with subsequent SDH/SAH.
.
# SDH/SAH: The patient was initially admitted to the Neuro ICU,
where she remained neurologically intact with stable findings on
serial CT scans. She was started on dilantin for seizure
prophylaxis and was transferred to the floor in stable
condition. The patient's daughter expressed concern that
existing word-finding difficulties had worsened from her
baseline, and during admission the patient complained of
intermittent episodes of emesis and headaches. There were no
meningeal signs on exam and neurologic exam remained unchanged.
A repeat CT head was negative for rebleed and expansion of
bleed. An MRI was performed, with findings consistent with
hemorrhagic concussion and surrounding edema. Neurology was
consulted and felt that symptoms were consistent with a
post-concussive syndrome. Symptoms resolved prior to discharge,
with return of mental status to baseline per the patient's
daughter. Dilantin was tapered off prior to discharge with no
evidence of seizures during admission. The patient's aspirin was
held for 7 days per neurosurgery, and this was restarted upon
discharge.
.
# Syncope: The patient presented after an unwitnessed fall that
she does not recall. The patient denies any preceding symptoms
consistent with mechanical fall, vasovagal event, or
orthostatis; however, details are unclear. The patient was ruled
out for MI with cardiac enzymes negative x 3 with no concerning
EKG changes for ischemia. The patient was monitored on telemetry
during admission with no significant events. The patient has a
very mild systolic heart murmur on exam with no history of
syncope, chest pain or dyspnea suggestive of severe valvular
disease. Echo showed normal heart function and no evidence of
valvular stenosis. Carotid US and MRA of the neck were without
significant stenosis on both sides. EEG was negative for
epileptiform foci. The patient was ambulating well with no
symptoms of orthostasis during admission. Circumstances
surrounding fall still remain unclear, but syncope workup was
negative with no further evidence of syncope.
.
# Fever: During the admission the patient spiked a temperature
to 101.4 with no leukocytosis and no localizing symptoms.
Urinalysis was negative but cultures were positive for 10-100K
enterococcus without urinary symptoms. The possibility of drug
fevers was entertained given new addition of dilantin, but this
was felt to be unlikely per neurology. The patient was started
on a 7 day course of ampicillin for UTI and was afebrile by the
time of discharge.
.
# Possible dementia: The patient was evaluated by neurology and
was found to have evidence of word-finding difficulties
intermittently during admission. Symptoms were felt by the
primary medical team and neurology consult service to be
consistent with sundowning and/or post-concussive syndrome.
Patient also exhibited evidence of early mild-cognitive
impairment, given word-finding difficulties and finger apraxia
on exam which may be more pronounced after recent head trauma.
However, these symptoms could also be secondary to edema
surrounding contusion in left temporal lobe on CT. Metabolic/
infectious workup was negative, with negative RPR and TSH, B12,
and folate within normal limits. The neurology service
recommended that alternative medications to amytriptyline may be
considered upon discharge, and the patient may benefit from
Aricept.
.
# Hypothyroidism: The patient was continued on her outpatient
dose of Synthroid.
.
# CVS/Hyperlipidemia: The patient has no cardiac history by
recent cath. Echo with normal cardiac function and LV EF > 55%.
During admission the patient was continued on Simvastatin and
Zetia with ASA held, as above, for SDH/SAH.
.
# Code: During this admission the patient's code status was
FULL.
.
# The patient was discharged to home in good condition;
afebrile, VSS, ambulating and taking PO well with return of
mental status to baseline. She was given instructions to
follow-up with Dr. [**Last Name (STitle) 739**] in 4wks with a head CT prior to
the appointment.
Medications on Admission:
Zocor 80 mg PO DAILY
Synthroid 50mcg PO DAILY
Ezetimibe 10 mg PO DAILY
Zoloft 50mg PO DAILY (per psychiatrist)
Acetaminophen 325-650 mg PO/PR Q6H:PRN
Oxycodone-Acetaminophen [**1-22**] TAB PO Q6H:PRN pain
Amitriptyline HCl 25mg PO HS
Prilosec OTC prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
Disp:*10 Tablet(s)* Refills:*0*
5. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) ML Injection ASDIR8 (ASDIR).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every
6 hours) for 3 days.
Disp:*24 Capsule(s)* Refills:*0*
9. Sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 6X/D ().
Disp:*1 tube* Refills:*2*
11. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] vna
Discharge Diagnosis:
Primary: L sided subdural hematoma and subarachnoid hemorrhage,
post-concussive syndrome
Secondary:
Hypercholesterolemia
Depression
Hypothyroidism treated with Synthroid
Discharge Condition:
Neurologically stable with resolution of headaches. Low-grade
fever (100.0) without source of infection upon workup with other
VSS. Ambulating well and taking po well. Mental status at
baseline.
Discharge Instructions:
You were transferred to [**Hospital1 18**] after sustaining head trauma from
a fall. No clear cause for the fall was found. You were found to
have a small amount of bleeding called a subdural and
subarachnoid hemorrhage on admission. This was found to be
stable on CT scans throughout your hospital course. During your
hospitalization your aspirin was held because this increases the
risk of bleeding immediately following the fall. This should be
restarted upon discharge from the hospital. You were also
diagnosed with a urinary tract infection for which you should
complete a course of ampicillin.
.
Please continue to take all of your medications as prescribed.
Please attend all of your follow-up appointments.
.
DISCHARGE INSTRUCTIONS FOR HEAD INJURY
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
.
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
Followup Instructions:
Please contact your PCP upon discharge for a follow-up
appointment within 1-2 weeks.
Please call [**Telephone/Fax (1) 1669**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] (Neurosurgery) to be seen within 4 weeks. You will
need a CT scan of the brain with or without contrast prior to
this visit.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**]
|
[
"599.0",
"310.2",
"438.19",
"426.2",
"272.0",
"244.9",
"780.2",
"E888.9",
"041.04",
"311",
"851.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
13205, 13256
|
7739, 11925
|
359, 366
|
13470, 13667
|
3882, 4829
|
15146, 15594
|
2605, 2674
|
12226, 13182
|
13277, 13449
|
11951, 12203
|
13691, 15123
|
2689, 3863
|
277, 321
|
394, 1953
|
5063, 7716
|
1975, 2355
|
2371, 2589
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,699
| 153,809
|
822
|
Discharge summary
|
report
|
Admission Date: [**2195-4-4**] Discharge Date: [**2195-4-16**]
Date of Birth: [**2112-12-21**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Sulfa (Sulfonamides)
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Pleural effusion/Pericardial effusion
Major Surgical or Invasive Procedure:
[**2195-4-7**] - Mediastinal exploration and mediastinal
hematoma evacuation.
History of Present Illness:
This 82-year-old gentleman with known atrial fibrillation and an
atrial myxoma who underwent serial echocardiograms that have
revealed worsening aortic
insufficiency and mitral regurgitation. Based on these findings,
he underwent an aortic valve replacement as well as mitral valve
replacement and atrial myxoma excision. This was performed on
[**2195-3-23**]. He was discharged home and while he was in a hotel
where he was staying, several days after he was discharged, he
had a syncopal episode. During the syncopal episode, the family
dialed 911 , the patient was hypotensive w/respiratory distress
and was intubated. A large left pleural effusion was drained for
1400 cc serosanguinous
fluid. After the patient was hemodynamically stabilized, he was
transferred to [**Hospital1 18**]. he underwent an echocardiogram which
revealed a large mediastinal hematoma with some signs of early
tamponade. Based on these findings, it was decided to take the
patient back to the operating room .
Past Medical History:
Congestive Heart Failure(diastolic), Aortic Insufficiency,
Mitral Regurgitation, Atrial Myxoma, Dilated Ascending Aorta,
Atrial Fibrillation, Hypertension, Hyperlipidemia, Benign
Prostatic Hypertrophy, Sleep Apnea - on CPAP, Obesity
Social History:
Retired, lives with wife in [**Name (NI) 108**]. Quit cigars over 10 years
ago. Admits to social ETOH consumption.
Family History:
Denies premature coronary disease(before age 55)
Physical Exam:
Admission
94 139/80 100% on Vent
WDWN man intubated and sedated
Irregular rate and rhythm
Obese, NT/ND, NABS, Triple lume in groin
EXT: 2+ LE edema, Pulses 2+
Discharge
VS T97.9 HR 82AF BP 112/86 RR 20 O2sat 96% 3LNP
Neuro A&Ox3, nonfocal exam
Pulm Diminished bases bilat
CV Irreg-irreg S1-S2
Abdm soft, NT/ND/+BS
GU 3-way foley-gravity, clear urine
Ext warm, trace edema
Pertinent Results:
[**2195-4-4**] 06:08PM PT-16.0* PTT-32.5 INR(PT)-1.5*
[**2195-4-4**] 06:08PM WBC-13.6*# RBC-3.39* HGB-10.7* HCT-31.1*
MCV-92 MCH-31.5 MCHC-34.3 RDW-15.7*
[**2195-4-4**] 06:08PM UREA N-23* CREAT-1.1 SODIUM-138 CHLORIDE-106
TOTAL CO2-24
[**2195-4-4**] 08:57PM GLUCOSE-150* UREA N-22* CREAT-1.2 SODIUM-139
POTASSIUM-4.0 CHLORIDE-106 TOTAL CO2-27 ANION GAP-1005/17/07
06:10AM BLOOD WBC-7.0 RBC-3.14* Hgb-9.9* Hct-30.0* MCV-95
MCH-31.4 MCHC-32.9 RDW-15.5 Plt Ct-385
[**2195-4-16**] 06:10AM BLOOD Plt Ct-385
[**2195-4-16**] 06:10AM BLOOD PT-17.2* PTT-33.5 INR(PT)-1.6*
[**2195-4-16**] 06:10AM BLOOD Glucose-158* UreaN-24* Creat-1.2 Na-143
K-3.6 Cl-100 HCO3-37* AnGap-10
[**2195-4-5**] ECHO
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is moderately depressed with mid to distal
anteroseptal and apical hypokinesis/akinesis and mild/moderate
hypokinesis elsewhere. Anterior wall may be hypokinetic but is
not fully visualized. A bioprosthetic aortic valve prosthesis is
present and appears well-seated (gradients not assessed). No
aortic regurgitation is seen. A bioprosthetic mitral valve
prosthesis is present and appears well-seated with probably
normal gradients. No mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is a moderate to
large sized pericardial effusion (most prominent inferolateral
to the left ventricle and adjacent to the right ventricle in the
subcostal view). The effusion is partially echodense consistent
with the presence of blood and/or partial organization. No
mitral respirophasic variation seen (limited views). The right
ventricle may be compressed - clinical correlation recommended.
[**2195-4-14**] CXR
Compared with [**2195-4-12**], the left pleural effusion may be somewhat
decreased. There has been partial re-expansion of the
atelectasis at the left base medially. There is minor
atelectasis at the right lung base.
[**2195-4-8**] CT Chest
1. Left-sided opacity on recent portable chest x-ray is shown to
be predominantly due to atelectasis of the lingula and left
lower lobe, although moderate left pericardial effusion
accumulating preferentially on the left side also contributes to
this appearance. There is only a small left pleural effusion.
2. Peristernal, retrosternal and pericardial fluid and gas,
probably postoperative in etiology, although infection is not
excluded considering the time interval since surgery; clinical
correlation suggested.
3. Small dependent right pleural effusion with adjacent
atelectasis.
4. Diffuse severe tracheobronchomalacia.
Brief Hospital Course:
Mr. [**Known lastname 5784**] was admitted to the [**Hospital1 18**] on [**2195-4-4**] via transfer from
the [**Hospital3 2576**] [**Hospital3 **] for further management of his pleural
and pericardial effusions. Diuresis was initiated. An
echocardiogram was performed which showed normal functioning
aortic and mitral bioprosthetic valves and a large pericardial
effusion. On [**2195-4-6**], Mr. [**Known lastname 5784**] was taken to the operating room
where he underwent a re-exploration with mediastinal washout and
clot evacuation. Postoperatively he was returned to the cardiac
surgical intensive care unit. He was slowly weaned form the vent
and extubated on [**2195-4-7**]. Anticoagulation was resumed for his
chronic atrial fibrillation. As his rate was somewhat rapid at
times, amiodarone was started for rate control with good effect.
Given his left pleural effusion continued to drain, the thoracic
surgery service was consulted for assistance in his care. A
chest CT scan was obtained which showed small bilateral pleural
effusions and normal postoperative changes. He remained in the
CSRU given his slowly improving respiratory status. On [**2195-4-13**],
Mr. [**Known lastname 5784**] was well enough to transfer to the step down unit for
further recovery. He continued to be diuresed and
anticoagulated. The physical therapy service worked with him
daily. His foley was removed and he developed hematuria and a
3way foley was reinserted and a [**Doctor Last Name **] drip was started.
On [**4-15**] the foley irrigant was stoppped, urine remained clear
and on [**4-15**] @MN the foley was removed. He voided appropriately.
On [**2195-4-16**] it was decided he was stable and ready for discharge
to rehabilitation at [**Hospital1 **] Rehabilitaion Center.
Medications on Admission:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
4. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed.
Disp:*20 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please check INR Friday [**2195-4-3**]. Send result to Dr.[**Name (NI) 5786**]
office at F([**Telephone/Fax (1) 5787**].
Discharge Medications:
1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): 40mg [**Hospital1 **] x 10 days then QD.
6. Warfarin 1 mg Tablet Sig: pt to received 4mg on [**4-16**] Tablet
PO DAILY (Daily): Target INR 1.5-2.
7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 400mg QD until [**4-19**] then 200mg QD.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
12. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
13. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
14. Potassium Chloride 10 mEq Capsule, Sustained Release Sig:
Two (2) Capsule, Sustained Release PO BID (2 times a day): [**Hospital1 **]
x10 days then QD.
15. Olmesartan 20 mg Tablet Sig: 0.25 Tablet PO daily ().
16. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
17. Temazepam 15 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime) as needed.
18. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Left hemothorax
Pericardial effusion
s/p AVR/MVR (Porcine)and resection of atrial myxoma
CHF
AF
[**Location (un) **]
[**Location (un) 5783**]
Sleep apnea
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. 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) Coumadin dosing to be managed by Dr. [**Last Name (STitle) 911**]. Please have INR
checked daily and take coumadin as instructed by Dr. [**Last Name (STitle) 911**].
7) Call with any questions or concerns.
Followup Instructions:
Provider: [**Name10 (NameIs) 412**] [**Last Name (Prefixes) 413**], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2195-4-30**] 1:15
Please follow-up with cardiologist in [**1-3**] weeks.
Please follow-up with primary care physician Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5788**] in 2
weeks. [**Telephone/Fax (1) 5789**]
Call all providers for appointments.
Completed by:[**2195-4-16**]
|
[
"428.30",
"V15.82",
"600.00",
"401.9",
"423.8",
"780.57",
"518.81",
"427.31",
"428.0",
"998.12",
"V42.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.03",
"88.72",
"93.90",
"96.71",
"96.6",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9398, 9468
|
4965, 6738
|
325, 405
|
9666, 9675
|
2295, 4942
|
10559, 10978
|
1830, 1880
|
7698, 9375
|
9489, 9645
|
6764, 7675
|
9699, 10536
|
1895, 2276
|
248, 287
|
433, 1425
|
1447, 1681
|
1697, 1814
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,926
| 136,103
|
8584
|
Discharge summary
|
report
|
Admission Date: [**2102-3-10**] Discharge Date: [**2102-3-26**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] yo F with PM active at baseline, p/w 5 d of DOE worsening
over the week. She is currently having trouble even walking
accross the kitchen. Dry cough, no blood, no phlegm. Also she
has notioced intermittent tightness across her chest which
radiates to her left shoulder and arm. No diaphoresis, N/V.
.
Denies sick contacts, recent travel, dysuria, hematuria,
dizziness, numbness, tingling, weakness. She has diarrhea but
this has been stable since her colon surgery operation.
Past Medical History:
1)Colon Cancer - dx 4 yrs ago, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], recurred 1 year later
with LN involvement. Inoperable.
2) PM for 30 years, for irreg HR
3) Blind R eye
4) s/p b/l cataract [**Doctor First Name **]
5) CAD - 1 vessle dz, cath [**2097**]
Social History:
lives with daughter
very active, cooks, reads, drives
distant tob hx
rare etoh
Family History:
NC
Physical Exam:
99.3 172/74 60 18 99 on 2L
A+Ox3 NAD
EOMI, OP clear, MMM
supple, no lad, no JVD
RRR late sys murmur
mild crackles over L base and R entire lung
s/nt/nd +BS
no CVA tend, no pain over spine with palpation
no c/c/e, venous stasis changes
normal strength and [**Last Name (un) 36**] x 4 ext
Pertinent Results:
[**2102-3-10**] 02:30PM WBC-7.0# RBC-3.03* HGB-9.6* HCT-30.0* MCV-99*
MCH-31.6 MCHC-31.9 RDW-18.3*
baseline hct is low 30's
[**2102-3-10**] 02:30PM NEUTS-74* BANDS-2 LYMPHS-12* MONOS-9 EOS-2
BASOS-0 ATYPS-1* METAS-0 MYELOS-0 NUC RBCS-1*
[**2102-3-10**] 02:30PM PLT SMR-NORMAL PLT COUNT-422 LPLT-3+
PLTCLM-1+
[**2102-3-10**] 02:30PM PT-13.9* PTT-28.5 INR(PT)-1.2
.
[**2102-3-10**] 02:30PM GLUCOSE-93 UREA N-33* CREAT-1.4*(baseline)
SODIUM-138 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
.
[**2102-3-10**] 02:32PM K+-4.3
[**2102-3-10**] 02:30PM CK(CPK)-114
[**2102-3-10**] 02:30PM cTropnT-<0.01
[**2102-3-10**] 02:30PM CK-MB-5
.
CXR : Right upper lobe pneumonia
EKG: 61bpm paced LBBB
.
CTA - no PE
Brief Hospital Course:
[**Age over 90 **] yo F with pacemaker, active at baseline, presents with 5 days
of dyspnea on exertion and found to have RUL pna. Patient
started on levofloxacin and ruled out for MI. She was improving
with decreased O2 requirements and decreased symptoms. [**2102-3-13**],
her hct decreased to 26 from 29-30 and she was transfused 1 u
PRBC. 4 hours later the patient became tachypneic. She was
placed on NRB and o2 sat was 94%. (Previously 92% on 2 L NC) At
the time, she denied CP, abd pain, cough improved, no sputum.
.
She was given lasix and her BP dropped to 88/palp from 144/80.
On exam elevated JVP and diffuse crackles. EKG unchanged but
paced with a RBBB. Cardiac enzymes rose with a trop peak of
0.23. An echo revealed new wall motion abnormalities and a
decreased EF to 40% compared to [**2098**]. Patient's fluid status
was difficult to manage. She developed hypotension/renal
failure from diuresis and severe pulmonary edema from hydration.
A swan was placed and her pressure was maintained with
dobutamine transiently. Natrecor tried on [**3-18**], but became
hyponatremic. This was weaned and the patient was given hydral
and nitro for afterload reduction.
.
During her cardiac event, she also developed acute on chronic
renal failure with a creat peaking at 2.1 (baseline 1.4). This
was likely pre renal [**1-11**] diuresis and low BP. Urine Na < 10 on
[**3-12**]. With decreasing diuresis and stabalized BP her Cr has been
improving. At time of floor transfer was 1.6.
.
With any hydration, the patient would develop significant
pulmonary edema/effusions thought to be secondary to her new
heart failure. Her effusion was tapped on [**2102-3-18**] revealing a
exudative effusion (LDH 287). Cytology was sent which was
negative.
.
She was stable upon transfer to the floor. However she still
required a great deal of oxygen. CXR was consistent with volume
overload however she was going into renal failure and thus
difficult to diurese. She was transferred back to the [**Hospital Unit Name 153**] for
a natrecor trial. While she did diurese, her resp status did
not improve. She continued to decline and was eventually passed
away on [**2102-3-26**].
Medications on Admission:
amiodarone 200mg qday
B12 1000mcg qday
Imdur 60mg qday
Tenolol ou
Iosopt
Ferrous Gluconate 300 qday
Hydroxyurea 500mg MWF
mvi
Tylenol 500mg tid
omeprazole
Ca, Vit D, B6, Zinc
Metamucil
Discharge Medications:
none
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1) Community Acquired Pneumonia
Secondary:
2) h/o inoperable colon cancer x [**2-10**] yrs
3) CAD - single vessel
4) s/p Pacer [**26**] yrs ago for "irregular heart beat"
5) Macrocytic anemia with h/o B12 deficiency
6) Chronic Renal Failure
7) ? Myelodysplasia vs myelofibrosis with anemia and abnormal
differential on smear; Transfusion dependent anemia
8) Thrombocytosis on hydroxyurea
9) h/o SVT on amiodarone
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"V45.01",
"196.2",
"518.81",
"276.1",
"584.9",
"276.4",
"281.9",
"414.01",
"289.9",
"564.00",
"369.60",
"427.89",
"153.9",
"428.0",
"410.71",
"787.91",
"585",
"458.29",
"486",
"514",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"00.13",
"99.04",
"38.93",
"89.64",
"89.45"
] |
icd9pcs
|
[
[
[]
]
] |
4715, 4773
|
2256, 4451
|
222, 229
|
5240, 5250
|
1509, 2233
|
5307, 5318
|
1178, 1182
|
4686, 4692
|
4794, 5219
|
4477, 4663
|
5274, 5284
|
1197, 1490
|
179, 184
|
257, 758
|
780, 1066
|
1082, 1162
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
70,191
| 105,580
|
38187
|
Discharge summary
|
report
|
Admission Date: [**2171-12-17**] Discharge Date: [**2171-12-30**]
Date of Birth: [**2088-7-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
pulled out g-tube
Major Surgical or Invasive Procedure:
Right sided thoracentesis [**12-18**]
History of Present Illness:
83yo M with HTN, COPD, Atrial fibrillation, CABGx4 [**8-17**]
complicated by sternal dehiscence, who is s/p partial transverse
colectomy with primary anastomosis and partial gastrectomy on
[**2171-11-5**] (for feculent peritonitis) who presents with dislodgment
of his G-J tube today.
.
The patient has a long, complicated medical course that begins
in [**8-/2171**] when he was transferred to [**Hospital1 18**] for chest pain. He
was found to have 3VD and underwent 4 vessel CABG. His course
was complicated by sternal wound infection and dehiscence. The
patient was readmitted in [**9-/2171**] with a severe CDiff infection
treated with Vancomycin and Metronidazole.
.
The patient was again readmitted late [**2171-10-9**] for abdominal
distention and pain and was found to have feculent peritonitis.
The patient was treated with antibiotics and was s/p partial
transverse colectomy. His course was also complicated by wound
dehiscence.
.
After speaking to the physician at [**Hospital3 **], the patient
was referred to [**Hospital1 18**] for admission because of increasing
agitation in the past several days leading patient to pull his
GJ tube last night. Additionally, the patient was found to have
a positive UA last wednesday, started on Levofloxacin initially,
but transitioned to Imipenem on Monday after Cx grew Klebsiella.
.
The patient's son was also available to speak to and he stated
that his dad has become increasingly agitated over the past
several days. He stated that he also had increasing difficulty
breathing while laying back that was relieved by sitting upright
that has been worsening over the past several days.
.
In the ED, initial vs were 98.5 71 128/57 20 99% Trachmask.
General surgery placed a foley in patient's G tube site
temporarily. He was treated with CTX for his UTI. Pt was stable
on arrival to floor.
.
On the floor, the patient was rather lethargic, but was
intermittantly responsive. He denied any pain. Otherwise was
unable to get a thorough ROS.
Past Medical History:
- Coronary Artery Disease s/p CABG x 4 [**8-17**]; course c/b sternal
wound infection and dehiscence s/p sternal debridement with
plating and pectoral flap advancement; respiratory failure
necessitating tracheostomy and eventual PEG
- Chronic Atrial Fibrillation
- Ischemic Cardiomyopathy
- Stage 4 Sacral decubitus ulcer
- Peripheral vascular disease
- Hypertension
- Hypercholesterolemia
- h/o C Diff sepsis
- s/p Transverse colectomy [**10-18**] for feculant peritonitis, course
complicated by lower abdominal wound dehiscence.
- Loculated left sided pleural effusion s/p Pigtail toracentesis
- Chronic obstructive pulmonary disease
Social History:
Previously lived with wife (in-law apartment- daughter +fam live
nearby) but came to [**Hospital1 18**] from rehab. He is retired. Tobacco:
1ppd x 64yrs. ETOH: occasional but none recent.
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Exam on admission:
General: lethargic, responsive to commands, difficult to assess
orientation
HEENT: Sclera anicteric, MMM, oropharynx clear, trach in place
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse fine crackles in L lung, decrease BC at R base
with crackles
CV: Irregular rate and rhythm, II/VI SEM at RUSB
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Lower
abdominal wound appears to be clean and healing by secondary
intention. G tube site appears non erythematous.
Ext: Warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
[**2171-12-17**] 02:31AM BLOOD WBC-10.1 RBC-2.89* Hgb-8.6* Hct-26.2*
MCV-91 MCH-29.9 MCHC-33.0 RDW-19.9* Plt Ct-213
[**2171-12-24**] 05:59AM BLOOD WBC-6.9 RBC-2.59* Hgb-8.1* Hct-23.9*
MCV-93 MCH-31.1 MCHC-33.6 RDW-19.2* Plt Ct-173
[**2171-12-18**] 07:40AM BLOOD PT-13.2 PTT-27.0 INR(PT)-1.1
[**2171-12-17**] 02:31AM BLOOD Glucose-90 UreaN-57* Creat-1.4* Na-133
K-5.1 Cl-97 HCO3-28 AnGap-13
[**2171-12-24**] 06:38PM BLOOD Glucose-120* UreaN-44* Creat-0.8 Na-136
K-5.0 Cl-95* HCO3-33* AnGap-13
[**2171-12-18**] 07:40AM BLOOD Calcium-8.6 Phos-5.5* Mg-2.4
[**2171-12-24**] 06:38PM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
[**2171-12-18**] 07:40AM BLOOD LD(LDH)-204
[**2171-12-24**] 05:59AM BLOOD Vanco-27.5*
[**2171-12-17**] 04:17AM BLOOD Type-ART FiO2-50 pO2-105 pCO2-49* pH-7.45
calTCO2-35* Base XS-8
[**2171-12-22**] 09:16AM BLOOD Type-ART pO2-79* pCO2-58* pH-7.40
calTCO2-37* Base XS-8
[**2171-12-22**] 09:16AM BLOOD Lactate-0.7
.
CT chest/abd/pelvis [**2171-12-24**]:
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
.
CXR [**2171-12-23**]:
FINDINGS: Large right pleural effusion is likely unchanged.
Fluid layers
over the minor fissure and may be masking opacification of the
inferior aspect of the right upper lobe. The left base is not
included on this image. Mildpulmonary edema and stable severe
cardiomegaly also seen. Unchanged position of tracheostomy and
sternal fixation devices. No pneumothorax is seen.
IMPRESSION: Likely unchanged large right pleural effusion and
mild pulmonary edema with possible opacification of the right
upper lobe, cannot exclude pneumonia.
.
Pleural fluid [**2171-12-18**]:
NEGATIVE FOR MALIGNANT CELLS.
.
[**2171-12-18**] 9:15 am PLEURAL FLUID
GRAM STAIN (Final [**2171-12-18**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2171-12-21**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2171-12-24**]): NO GROWTH.
.
Replacement of g-tube [**2171-12-17**]:
IMPRESSION: Uncomplicated image-guided replacement of a 22
French MIC
gastrojejunostomy tube. The tube is ready for use.
.
[**2171-12-22**] 5:41 pm BRONCHOALVEOLAR LAVAGE
GRAM STAIN (Final [**2171-12-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): SQUAMOUS EPITHELIAL CELLS.
3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CLUSTERS.
RESPIRATORY CULTURE (Preliminary):
Further incubation required to determine the presence or
absence of
commensal respiratory flora.
GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML..
POTASSIUM HYDROXIDE PREPARATION (Final [**2171-12-22**]):
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (7-2306).
FUNGAL CULTURE (Preliminary):
YEAST.
.
[**2171-12-22**] blood cx: pending
.
[**2171-12-17**] urine cx:
URINE CULTURE (Final [**2171-12-18**]): <10,000 organisms/ml.
.
MRSA SCREEN (Final [**2171-12-24**]): No MRSA isolated.
.
CT THORAX:
There is a tracheostomy. No pathologically enlarged mediastinal,
hilar,
internal mammary or axillary adenopathy. There is focal stenosis
identified at the bifurcation of the pulmonary artery with no
filling defects identified.
There is enlargement of the left atrium with associated
cardiomegaly and
three-vessel coronary artery disease. No pericardial effusion.
There is a
loculated right pleural effusion with a maximum thickness along
the
mediastinum of 2.5 cm (series 2, image 17) and also along the
lateral chest wall, maximum thickness 2.2 cm (series 2, image
25). It appears simple -no enhancement to suggest empyema. There
is a small dependent effusion identified within the left lower
lobe. There is atelectasis and consolidation of the right lower
lobe and the posterior segment of the left lower lobe. There is
a nodule identified at the inferior segment of the lingula
measuring 7 mm (series 2, image 40), unchanged and stable when
compared to prior imaging. No new nodules. There is some pleural
nodularity identified along the left lateral chest wall within
the left upper lobe measuring maximum thickness of 8 mm (series
2, image 30) anteriorly. Close attention to this on followup is
recommended.
.
CT ABDOMEN:
There is a low-density 6-mm lesion identified within segment VII
of the liver (series 2, image 50) too small to characterize but
most likely consistent with a simple hepatic cyst. The portal
vein is patent. No intra- or extra-hepatic biliary dilatation.
There has been prior cholecystectomy. There has been interval
decrease in size and the volume of abdominal ascites since prior
imaging. Spleen and pancreas are unremarkable. There is a left
adrenal nodule measuring 1.6 x 2.6 cm (series 2, image 59) and
this is stable in size since prior imaging. The previously
described calculus within the right mid ureter is not visualized
on today's study. No focal kidney lesion. No
retroperitoneal masses or adenopathy. There is extensive
vascular
calcification of the abdominal aorta with calcification seen at
the origin of both the SMA and celiac arteries and renal
arteries bilaterally. No
abnormally dilated thickened small or large bowel loop in the
visualized upper abdomen. There is an open abdominal wound as
before and within the lower midline there is a ventral hernia
containing a small bowel loop and fluid which appears simple
(series 2, image 95). No proximal obstruction and isunchanged
since prior CT.
.
CT PELVIS:
Small trace of ascites is identified in the right lower quadrant
(series 2,
image 94). Urinary catheter is noted within the bladder. The
prostate,
rectum are unremarkable. Uncomplicated sigmoid diverticulae. No
pelvic
adenopathy or free fluid. There is a gastrostomy tube in situ.
.
CT OSSEOUS SKELETON: There is a convex scoliosis of the lower
lumbar spine
convex to the right. There is a block vertebra of L4 on L5.
There is
multilevel degenerative change of the lumbar spine with vacuum
disc phenomenon and syndesmophytosis. SI joints are
unremarkable. Both hip joints are preserved. No osseous
destructive lesion. Sternostomy closure device is noted in situ.
.
IMPRESSION:
1. Loculated right pleural effusion with locules identified
along the right lateral chest wall and mediastinum. It appears
simple with no enhancement to suggest empyema.
2. Stable left lower lobe pulmonary nodule and pleural
nodularity and
attention on follow-up is recommended.
3. Interval reabsorption of the abdominal ascites since prior
imaging with a small ventral hernia with a small bowel loop
(series 301b, image 37) in the midline inferior to the
umbilicus.
Brief Hospital Course:
83yo M with HTN, COPD, Atrial fibrillation, CABG [**8-17**]
complicated by sternal dehiscence, who is s/p partial transverse
colectomy with primary anastomosis and partial gastrectomy on
[**2171-11-5**] for feculent peritonitis, severe tracheobronchomalacia
s/p bronch being transferred out of the MICU s/p respiratory
decompensation thought [**3-12**] to a mucous plug and acute delerium
now with improvement in both.
.
Respiratory distress: During the patient's hospitalization, the
patient was noted to be acutely tachypneic with a RR in the 40s
and saturations in the low 90s overnight on trach mask with a
radiographic/clinical evidence of pulmonary evidence. The
patient's clinical status improved initially with diuresis,
however he had similar symptoms on [**12-22**] prompting transfer to
the MICU. He responded well to a nebulizer treatment and
suctioning through his trach. His sats were maintained on a
trach mask throughout these episodes, but he did require
ambu-bag on the floor. He is afebrile with no leukocytosis,
however, was noted to have more sputum production. Bronchoscopy
was performed on admission to the ICU and showed severe
tracheobronchomalacia; erythema at the superior segment of the
right lower lobe, take off of the lingula, and LLL subsegments;
as well as granulation tissue at the LLL segment. His
presentation seems to be most consistent with mucous plugging
layered on top of severe tracheobronchomalacia noted on [**Last Name (un) 1066**]
when he arrived to the ICU.
.
The patient was initially started on empiric coverage for
pnemonia pending BAL cultures (vancomycin added to his ongoing
meropenem but vancomycin was discontinued on [**2171-12-24**]). He
remained quite short of breath and there was concern for a COPD
exacerbation. Prednisone was started on [**2171-12-23**] at 40mg daily
and was tappered to 20mg on [**12-27**] for a total of a 7 day course.
He was diuresed further with 80mg IV lasix. His BAL gram stain
showed gram negative rods and gram + cocci in clusters, however
his culture grew stenotrophomonas which and was thought to be a
contaminant.
.
His CXR was concerning for opacity in the lower aspect of his
right upper lobe. A CT chest/abd/pelvis was done which showed a
loculated and non loculate right pleural effusion. A pigtail
catheter was placed and 1L of sero-sanguinous fluid immediately
drained. An air leak was initially present but resolved. He put
out 400cc over the next 48hrs. His pigtail drain was pulled by
interventional pulmonary on [**2171-12-27**].
.
Agitation/Encephalopathy: On arrival to [**Hospital1 18**], the patient was
noted to be agitated and encephalopathic, likely in the setting
of his UTI and infection. The patient was initally restrained,
however improved with antibiotics. After the patient was
transferred to the MICU he acutely agitated and again required
restaints. He was likely having delirium in the setting of his
hospitalization and infection. He was continued on the trazodone
and his risperdone was up titrated. His reglan was discontinued
in case this was contributing to his AMS. Pt became somewhat
oversedated after risperidone uptitrated to 0.5mg at night so
dose was decreased back down to 0.25mg Qhs and mental status
stayed fairly stable on this dose.
- Continue Risperdone 0.25mg qHS and 0.25mg prn agitation
.
Atrial Fibrillation: Rate controlled on metoprolol tartrate
25mg [**Hospital1 **] which was uptitrated to 37.5mg [**Hospital1 **] given several
episodes of non-sustained ventricular tachycardia. The patient
was not on anticoagulation on admission, likely given his
multiple surgeries and and possible slow GI bleeding
necessitating intermittent blood transfusions. Given that the
patient has been intermittantly self removing his tracheostomy
and G tube, and multiple co-morbidies, anticoagulation was
deferred.
- Continue Metoprolol 37.5mg [**Hospital1 **]
- Continue ASA 81mg daily
.
Ventricular tachycardia: He had several long runs of his
ventricular tachycardia while in the ICU (30-40 beat runs). He
remained hemodynamically stable during these episodes. His
metoprolol was uptitrated from 25mg po BID to 37.5mg po BID and
it was expected that he would have baseline bradycardia as his
heart rate was trending between the 40s-60s. Further, during
sleep, patient was found to develop asymptomatic bradycardia
with heart rates in the 30s, which required no intervention in
the setting of other vital signs. This level of heart rate was
deemed acceptable in order to prevent his bursts of elevated HR
as there was no evidence of symptoms or reduced organ perfusion
during these episodes.
.
Klebsiella UTI: He completed a 7 day course of meropenem which
was discontinued on [**2171-12-24**]. He remained afebrile while in the
ICU with a normal white count.
.
Stage 4 Sacral Ulcer: The ulcer probes to bone, however per
orthopedics, the periosteum is intact with overlying granulation
tissue. His ESR/CRP were elevated. The wound appeared clean
with minimal drainage. The wound appears clean with minimal
drainage. Will need continued dressing changes.
.
Abdominal Wound Dehiscence: Lower abdominal wound appeaed to be
healing well by secondary intention, but does have some
yellowish drainage. There were no issues with this wound while
he was in the hospital.
.
Code Status: He is DNR but is trached and OK to be put on the
vent if he decompensates.
Medications on Admission:
Ferrous Sulfate 300mg liquid daily
Proscar 5mg daily
Fluoxetene 20mg daily
Furosemide 20mg daily
SCH
Reglan 5mg qAC and qHS
Metoprolol Tartrate 25mg [**Hospital1 **]
Ranitidine 150mg/10mL syrup [**Hospital1 **]
Risperdone 0.25mg qHS
Simethicone [**Hospital1 **]
Tiotropium 18mcg daily
Trazodone 12.5mg qHS
Zinc 220mg daily
Tylenol prn
Albuterol q6hrs prn
Opium tincture 3mg TID prn
Risperdal 0.25mg [**Hospital1 **] prn
Oxycodone 2.5mg q3hrs prn pain
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) ml
Injection TID (3 times a day).
2. finasteride 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
3. metoclopramide 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO qachs.
4. fluoxetine 20 mg Capsule [**Hospital1 **]: One (1) Capsule PO DAILY
(Daily).
5. ferrous sulfate 300 mg (60 mg Iron)/5 mL Liquid [**Hospital1 **]: One (1)
5ml PO DAILY (Daily).
6. furosemide 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily).
7. metoprolol tartrate 25 mg Tablet [**Hospital1 **]: 1.5 Tablets PO BID (2
times a day).
8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
9. risperidone 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
10. simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO BID (2 times a day).
11. zinc sulfate 220 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device [**Last Name (STitle) **]:
One (1) Inhalation once a day.
13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Last Name (STitle) **]: One (1) Inhalation Q6H (every 6 hours) as
needed for SOB.
14. 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.
15. opium tincture 10 mg/mL Tincture [**Last Name (STitle) **]: 3mg (0.33ml) PO TID
PRN.
16. Tylenol 325 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO Q6hr PRN.
17. risperidone 0.25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily) as needed for agitation.
18. aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Primary Diagnosis:
-G-tube repair
-Klebsiella UTI
-Loculated right sided pleural effusion s/p thoracentesis with
bilius fluid
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to [**Hospital1 69**] for
evaluation of shortness of breath, treatment of multi-drug
resistant Klebsiella urinary tract infection, and replacement of
your G-J tube which was dislodged. You had an extensive amount
of fluid in your right lung which was drained and improved with
antibiotics. You were briefly in the ICU when you had difficulty
breathing likely due to a plug of mucous in your airway. You
received 1 blood transfusion in the ICU because your blood
levels were found to be low. You were also noted to have
elevated heart rate thought [**3-12**] to your atrial fibrillation so
your metoprolol was increased to control this.
.
The following changes were made to your medications:
- Metoprolol was increased to 37.5mg by mouth twice each day
- Rantitidine was stopped and replaced with lansoprazole 30mg
daily as extra protection against GI bleeding
- Furosemide was increased to 80mg by mouth daily
- Reglan was decreased to only Qhs
- Trazadone was stopped
- Oxycodone was stopped
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow-up with the physicians at your rehab facility.
Completed by:[**2171-12-31**]
|
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"V55.4",
"428.0",
"707.24",
"427.31",
"511.9",
"E912",
"E879.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"33.24",
"97.03",
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] |
icd9pcs
|
[
[
[]
]
] |
18857, 18993
|
11056, 16463
|
335, 375
|
19163, 19163
|
4020, 6621
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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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|
2420, 3059
|
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,180
| 144,883
|
44072
|
Discharge summary
|
report
|
Admission Date: [**2171-8-12**] Discharge Date: [**2171-8-23**]
Service: Blue Surgery
REASON FOR ADMISSION: Recurrent colon adenocarcinoma.
CAUSE OF DEATH: Respiratory and circulatory arrest.
HISTORY OF PRESENT ILLNESS: A [**Age over 90 **]-year-old male with a
history of right cecal adenocarcinoma resected in [**2169-7-21**]. On follow-up colonoscopy, a lesion was noted at the
anastomosis with a patch of mucinous adenocarcinoma and
necrosis. The patient noted no change in bowel habits, no
bright red blood per rectum, no abdominal pain, or nausea or
vomiting.
A preoperative stress echocardiogram on [**7-18**] showed a
reversible moderate inferior wall perfusion defect, mild
apical perfusion defect, ejection fraction of 48%, no wall
motion abnormalities.
Review of systems reveals occasional dyspnea, questionable
angina with exertion. No chest pain at rest. No shortness
of breath at rest. No dysuria.
PAST MEDICAL HISTORY:
1. Status post myocardial infarction in [**2134**], status post
percutaneous transluminal angiography in [**2160**] to left
anterior descending artery and diagonal I.
2. Angina.
3. Insulin dependent-diabetes mellitus.
4. Diabetic neuropathy.
5. Colon cancer as above.
6. Benign prostatic hypertrophy.
MEDICATIONS ON ADMISSION: Captopril 12.5 [**Hospital1 **], atenolol 50 q
day, isosorbide dinitrate 20 [**Hospital1 **], Senna [**Hospital1 **], Betoptic one
drop OD [**Hospital1 **], Humulin N 30 units q am and 5 units q pm.
Allergies to aspirin which causes bleeding.
PAST SURGICAL HISTORY: Right ileocolectomy in [**2168**] and TURP.
SOCIAL HISTORY: Tobacco 50 pack year history, quit in [**2133**],
35 year cigar history, smokes 2-3 per day from age 65 to
present, rare ethanol use. No IV drug use. The patient is
widowed and lives alone. Is a former owner of a upholstery
shop.
EXAMINATION ON ADMISSION: Vitals: Temperature 97.5, heart
rate 60, blood pressure 142/80, respirations 16. Sat 95% on
room air. General: Pleasant-elderly male in no acute
distress. HEENT: Pupils are equal, round, and reactive to
light. Sclerae are anicteric. Oropharynx is clear. Mucous
membranes are moist. Neck is supple without lymphadenopathy.
There is no carotid bruit. Pulmonary: Crackles at the bases
bilaterally. Heart is regular, rate, and rhythm, no murmur.
Abdomen is soft, nontender, nondistended, bowel sounds are
present. There is a faded right perimedial incision scar and
a right lateral hernia without hepatosplenomegaly.
Extremities are without edema. There is a dorsalis pedis and
PT pulses are 2+ bilaterally.
Chest x-ray from the [**7-12**] showed a small right
pleural effusion, a nodular opacity in the right upper field,
bibasilar interstitial opacities, no evidence of congestive
heart failure.
Electrocardiogram shows sinus bradycardia at 49. ST
depression in I, II, and V6, ST elevation in V1 and V2.
Echocardiogram shows ejection fraction of 48% per the history
of present illness.
Admit laboratories: ALT 25, AST 10, alkaline phosphatase
113, amylase 51, lipase 49, total bilirubin 0.3, uric acid
5.9. White count 6.4, hematocrit 31.2, platelets of 138. PT
of 13.0, PTT 27.0, INR 1.2. Sodium 145, potassium 4.3,
chloride 110, CO2 28, BUN 29, creatinine 1.6, and glucose
125, albumin 3.4, calcium 9.0, phosphorus 3.2, and magnesium
2.0. Urinalysis negative.
ASSESSMENT: This is a [**Age over 90 **]-year-old male with recurrent colon
cancer presenting for resection. He was admitted for
preoperative and typed and crossed 2 units, made NPO past
midnight, except medications, and Hibiclens scrub to his
abdomen. He was seen by Dr. [**Last Name (STitle) 957**].
HOSPITAL COURSE: The patient was taken to the operating room
and underwent exploratory laparotomy and ileocolectomy at the
ileocolonic anastomosis as well as a small bowel resection.
His blood loss is 300. There are no complications. This was
done under epidural and local anesthesia, and required no
transfusions. Was given 3100 cc of Crystalloid and sent to
Recovery Room in stable condition. Refer to operative
dictation for details.
Postoperatively, the patient had a nasogastric tube with a
pO2 of 73. His hypertension which was controlled with
Nipride, plan was to take his nasogastric tube out the
following morning. Postoperative, the patient's temperature
is 95 po, his heart rate was 50-60, blood pressure 187/70,
respirations 15 and again he was given IV Lopressor,
nitropaste. He was transferred to the SICU for postoperative
monitoring. He was continued on his captopril and isosorbide
and plan was to begin a nitroglycerin drip if his systolic
blood pressure increased over 150.
Respiratory he was diuresed with Lasix and supplemental
oxygen was continued. Aggressive pulmonary toilet was
instituted. He was on perioperative antibiotics at this
time. Patient's epidural was left in postoperatively for
perioperative pain control. Narcotic was taken out of the
mixture.
Patient on overnight postoperatively became agitated, and
combative, and was given some Ativan for sedation. He was
hemodynamically stable making urine. He had no chest pain.
Postoperative day one, the patient was continued on
Lopressor, Captopril, and Isordil for blood pressure control.
Pulmonary toilet was continued. He is still on IV fluids, no
feedings. He was also given prn Lasix for diuresis. His
hematocrit was stable.
On postoperative day one, approximately 4 pm in the
afternoon, patient had desaturation into the 50s, which
increased to the 90s with bagging. His blood pressure is in
the 170s sinus tachycardia, ST depression in V3 through V5.
He had no complaint of chest pain. He had faint rales on
examination with rhonchi throughout. Plan was to check
laboratories, give Lasix IV, and Lopressor for rate control
to rule out for myocardial infarction, given pulmonary
toilet, and contact Cardiology for consultation.
Cardiology saw the patient and recommendations were to cycle
cardiac enzymes to rule out ischemia and to recommend aspirin
from a cardiac perspective, to proceed with diuresis to
control heart rate and blood pressure with beta blocker and
ACE, nitroglycerin, and Morphine.
Postoperative day three, the patient's Lopressor was
continued. CK was 974 with a MB of 12 and troponin of less
than 0.3. Patient was also diuresed prn. Patient did rule
in for myocardial infarction by troponin, however, the CKs
remained relatively flat and his electrocardiogram changes
resolved. He did remain tachycardic and hypertensive. My
recommendation is to continue aspirin, to increase beta
blocker for rate control. Check his echocardiogram to
evaluate for systolic function, diurese to goal of [**11-21**] liters
negative for the day, follow CKs. Hold on the Heparin drip.
On the [**7-16**] in the afternoon, the patient had
been suffering from progressive respiratory distress due to
the complications of his heart condition as well as
congestive heart failure, and had developed increasing
acidosis and hypertension and decreasing renal function. He
was placed on mechanical ventilation and a PA catheter was
also placed to guide fluid therapy as well as pressors if
needed. Echocardiogram obtained today showed an ejection
fraction of 40%, 2+ mitral regurgitation, and anteroseptal
hyperkinesis.
At that time, his picture appeared to be consistent with
sepsis in the setting of perioperative ischemia, and plan was
to start Levophed to support blood pressure, to begin Heparin
drip, to broaden his antibiotic coverage to attempt further
diuresis. He is placed on amp of levo and Flagyl.
After discussion with family after these events, it was
decided to make the patient DNR with no chest compressions,
shock. He did begin to respond to a Lasix boluses and was
finally put on a Lasix drip for which he diuresed well.
Pressors were able to be weaned, however, the patient did at
one point require Dobutamine for support as his Levophed was
weaned off.
On the [**6-21**], the patient was able to be extubated
to a shovel mask. Additionally, his dobutamine was weaned to
off. He had been restarted on trophic tube feeds and showed
some bowel activity with a small bowel movement. Patient did
not show any signs of regaining his mental status, however,
after extubation, this is felt possibly due to prolonged
sedative effect as he had been given Ativan earlier in his
hospital course. Additionally, the patient developed
progressive uremia up to as high as 105-108. This is thought
secondary to progressive renal failure earlier in his
hospital course with cardiogenic shock with myocardial
infarction as well as a possible sepsis picture. However,
the patient's cultures never grew out any organisms.
Patient's nutrition while he was intubated was supported with
TPN, and this could also have effected his blood-nitrogen
levels. At any rate after the patient was extubated two days
ago, he did not regain his mental function, remained
unresponsive. On examination the patient can only open his
eyes to deep pain and would only withdraw slightly to deep
pain. Additionally, he had no verbal response.
Per the patient's family request, he is made a DNI as well as
kept DNR. His Lasix drip was able to be stopped and the
patient continued to make urine well on his own over the last
couple of days. His tube feeds were kept the same and his
TPN was stopped yesterday. He continued to require
supplemental oxygen which the requirements have increased
overnight.
This morning he was on 60% and his saturations dropped to the
low 90s throughout the morning. Around 9 am, the patient
desaturated markedly to 60s and became bradycardic. He
quickly progressed to asystole, and on examination he had no
heart sounds and no breath sounds. The family was notified
as well as the attending, and the time of death is declared
at 9:20. Cause of death is likely secondary to respiratory
failure.
PROCEDURES DURING THIS ADMISSION:
1. Ileocolectomy and small bowel resection.
2. Oral intubation.
3. PA catheter placement.
4. Arterial catheter placement.
5. Echocardiography.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**]
Dictated By:[**Last Name (STitle) 45848**]
MEDQUIST36
D: [**2171-8-23**] 09:57
T: [**2171-8-28**] 05:48
JOB#: [**Job Number **]
|
[
"250.61",
"153.6",
"276.2",
"428.0",
"357.2",
"V10.05",
"518.81",
"197.7",
"410.91"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.4",
"96.04",
"45.62",
"99.15",
"96.72",
"45.73"
] |
icd9pcs
|
[
[
[]
]
] |
1286, 1531
|
3687, 10322
|
1555, 1600
|
235, 935
|
1878, 3669
|
957, 1259
|
1617, 1863
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,817
| 171,390
|
36605
|
Discharge summary
|
report
|
Admission Date: [**2141-7-7**] Discharge Date: [**2141-7-14**]
Date of Birth: [**2097-12-7**] Sex: F
Service: MEDICINE
Allergies:
Iodine; Iodine Containing
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
Vaginal bleeding
Major Surgical or Invasive Procedure:
Plasma pheresis
Bone marrow biopsy
History of Present Illness:
Ms. [**Known lastname 1356**] is a 43 year old female with a PMH significant for
hepatitis C and cocaine abuse transferred from an outside
hospital for anemia and thrombocytopenia concerning for
thrombotic thrombocytopenic purpura. The patient initially
presented to an outside hospital with menorrhagia that had not
resolved 3-4 weeks after onset of menses. Her normal menses
lasts seven days ans is accompanied by back pain.
She describes increased bleeding and passage of blood clots,
initially presenting to an OSH ED on [**6-20**] with plts of 44. She
was evaluated by an outside hematologist on [**6-29**] with platelets
of 29 and prescribed 100 mg prednisone daily that the patient
did not take.
Due to persistent menorrhagia, the patient was admitted to
[**Hospital3 **] on [**7-3**] for a hct 30.4 and platelet count of 27
with a LDH of 1738 and undetectable haptoglobin. She was
transfused 2 units PRBCs and started on solumedrol 125 mg IV Q8H
and folate 2 mg daily, and was also treated with IVIG for
presumed ITP. She was also started on oral contraceptives for
persistent menorrhagia.
She also had a positive HCV antibody (no HCL VL), HBV core but
negative for HBV surface antigen and HIV. The day prior to
transfer, the patient experienced acute onset of right-sided
numbness, slurred speech, and possible facial droop per family
report with neurologic symptoms resolving after 25 minutes. A
head CT did not demonstrate any acute intracranial process. The
patient also underwent a bone marrow biopsy on [**7-6**] with slides
currently under the review of [**Hospital1 18**] hematology-oncology.
Throughout the course of the patient's outside hospital stay,
her platelets remained in the 20s, and she remained afebrile
with preserved renal function. Over concern for thrombotic
thrombocytopenic purpura, the patient was transferred to [**Hospital1 18**]
for further evaluation.
.
At [**Hospital1 18**], the patient was evaluated by hematology-oncology and
blood bank, who felt plasmapheresis for suspected thrombotic
thrombocytopenic purpura was indicated. She was then transferred
to the [**Hospital Unit Name 153**] for pheresis catheter placement and urgent
plasmapheresis intiation.
Past Medical History:
- Bipolar disorder
- Two prior vaginal deliveries; three prior elective
terminations; two prior miscarriages; no C-sections
- Hepatitis C infection (discovered at [**Hospital3 **])
Social History:
Lives with fiancee in [**Location (un) 2498**]. On SSDI. Denie EtOH use. Tobacco
- [**12-30**] ppd x10 years. Illicit - cocaine last snorted 1 week ago.
Past history of percocet abuse.
Family History:
Diabetes, hypertension, and cancer runs in her family
Physical Exam:
VS: 98.7 150/80 49 16 99%RA
Gen: Age appropriate female in NAD
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate or erythema. Neck supple.
CV: Nl S1+S2, no m/r/g.
Pulm: CTAB
Abd: S/NT/ND +bs, -hsm
Ext: No c/c/e, 2+ dp bilaterally.
Skin: Multiple echymosses on upper extremities. No rashes noted.
Neuro: AOx3, CN II-XII intact. 5/5 strength throughout.
Pertinent Results:
Heme-onc peripheral smear review:
"Review of the peripheral blood smear demonstrates markedly
decreased platelet count, [**10-17**] schistocytes per high-powered
field as well as bite cells and helmet cells.
.
OSH
[**2141-6-20**]
Plt 44
.
[**2141-7-3**]
BUN 15 / Na 138 / K 4.1 / Cl 106 / CO2 29 / Cr .76
Serum Iron 65 / TIBC 300 / Percent Saturation 21.7 / Ferritin
120
TB 1.2 / LDH 1768
beta hcg < 2
WBC 12.4 / Hct 24.3 / Plt 27
.
[**2141-7-4**]
BUN 15
Na 139 / K 4 / Cl 108 / CO2 27 / Cr .7
LDH [**2116**]
INR 1.04 / PTT 26.5
.
[**2141-7-5**]
BUN 16 / Na 136 / K 4.1 / Cl 107 / CO2 27 / Cr .7
.
[**2141-7-6**]
BUN 19
Na 136 / K 4.1 / Cl 104 / CO2 28 / BUN 19 / Cr .8
.
[**2141-7-7**]
Na 136 / K 4 / Cl 105 / CO2 30 / BUN 17 / Cr .8
WBC 10.7 / Hct 26.4 / Plt 28
N 68 / Bands 8 / L 15 / m 4
[**2141-7-8**] 12:28AM BLOOD HIV Ab-NEGATIVE
[**2141-7-8**] 12:28AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-POSITIVE IgM HBc-NEGATIVE
[**2141-7-9**] 07:10AM BLOOD WBC-15.0* RBC-3.56* Hgb-10.8* Hct-32.4*
MCV-91 MCH-30.3 MCHC-33.3 RDW-20.6* Plt Ct-62*
[**2141-7-10**] 09:25AM BLOOD WBC-21.1* RBC-3.64* Hgb-11.1* Hct-32.7*
MCV-90 MCH-30.4 MCHC-33.8 RDW-19.6* Plt Ct-115*#
[**2141-7-11**] 06:20AM BLOOD WBC-21.2* RBC-3.49* Hgb-10.6* Hct-32.8*
MCV-94 MCH-30.5 MCHC-32.4 RDW-19.9* Plt Ct-165
[**2141-7-12**] 06:30AM BLOOD WBC-19.9* RBC-3.31* Hgb-10.0* Hct-31.3*
MCV-95 MCH-30.4 MCHC-32.1 RDW-19.4* Plt Ct-197
[**2141-7-13**] 07:20AM BLOOD WBC-20.6* RBC-3.31* Hgb-10.0* Hct-31.9*
MCV-96 MCH-30.2 MCHC-31.4 RDW-19.2* Plt Ct-255
[**2141-7-14**] 07:20AM BLOOD WBC-21.9* RBC-3.23* Hgb-10.1* Hct-30.4*
MCV-94 MCH-31.2 MCHC-33.3 RDW-19.0* Plt Ct-299
[**2141-7-11**] 06:20AM BLOOD PT-12.2 PTT-23.3 INR(PT)-1.0
[**2141-7-14**] 07:20AM BLOOD Glucose-129* UreaN-18 Creat-0.8 Na-137
K-4.9 Cl-99 HCO3-31 AnGap-12
[**2141-7-7**] 09:15PM BLOOD ALT-231* AST-95* LD(LDH)-659* AlkPhos-70
TotBili-1.9* DirBili-1.1* IndBili-0.8
[**2141-7-14**] 07:20AM BLOOD LD(LDH)-199
[**2141-7-12**] 06:30AM BLOOD Calcium-8.5 Phos-3.7 Mg-2.2
[**2141-7-7**] 09:15PM BLOOD calTIBC-324 Hapto-<20* Ferritn-299*
TRF-249
[**2141-7-14**] 07:20AM BLOOD Hapto-152
ADAMTS13 activity: <5%
ADAMTS13 inhibitor level: 0.6 (normal <0.4)
Trans Vaginal pelvic Ultrasound [**2141-7-11**]:
FINDINGS: Limited images of the kidneys are unremarkable.
By transabdominal imaging, the uterus measures 9.0 x 5.1 x 5.7
cm and is
anteverted. Endometrial stripe measures 6 mm. The right ovary is
not
visualized. The left ovary is unremarkable.
By transvaginal imaging, the endometrial stripe measures 7 mm.
There is no
evidence of increased flow to the endometrium. There is a 2.3 x
1.5 x 2.4 cm posterior fibroid which is partially exophytic. The
remainder of the
myometrium is unremarkable. The right ovary is normal, measuring
1.3 x 2.6 x 1.3 cm, with normal follicular pattern. The left
ovary demonstrates a normal follicular pattern and measures 2.0
x 2.2 x 1.8 cm. There is no free fluid in the pelvis.
IMPRESSION: Partially exophytic posterior fundal fibroid,
measuring up to 2.4 cm. Normal endometrial stripe, without
evidence of increased vascular flow
Brief Hospital Course:
Ms. [**Name13 (STitle) 4643**] is a 43 year old female with history of bipolar
disorder and recent cocaine use transferred from [**Hospital3 **]
in [**Location (un) 2498**] with persistent vaginal bleeding, anemia and
thrombocytopenia later diagnosed with idiopathic thrombotic
thrombocytopenic purpura requiring ICU level care for a day and
subsequently stabilized following four days of plasma exchange
with restoration and stabilization of platelet count.
Her initial blood work showed evidence of hemolysis with
schistocytes on smear, low haptoglobin, anemia, and
thrombocytopenia, without renal involvement. Of note, her
ADAMTS13 activity was <5% (normal > 67%), with elevated level of
ADAMTS13 inhibitor (0.6, with normal level <0.4), consistent
with acute idiopathic TTP. Elevated level of ADAMTS13 can be
congenital or immune mediated. Severe congenital ADAMTS13
deficiency ([**Last Name (un) 67758**] [**Doctor Last Name 1147**] syndrome) is an autosomal recessive
condition which may present in children or adults as episodes of
TTP. In these patients however, the inhibiting antibody level is
low. The presence of elevated in this patient suggests the
diagnosis of idiopathic (immune) TTP. Her platelet count
recovered from 33 on [**7-8**] to 255 on [**7-13**] after four days of
plasmapheresis. Her platelet continued to rise to 299 on [**7-14**]
more than 24 hours after her last plasmapheresis. Her pheresis
line was changed from femoral to internal jugular vein after two
days out of concern for infection in the setting of her
continued vaginal bleeding. Concurrent with her plasma exchange,
she was treated with Prednisone 60mg [**Hospital1 **] from [**7-8**] to [**7-11**], and
transitioned to 40mg [**Hospital1 **] after that. Her vaginal bleeding was
assessed by gyn consult, and a pelvic ultrasound showed a 2.5cm
exophytic fibroid which should not have attributed to her
persistent (>5 wk) of vaginal bleeding. Her vaginal bleeding
improved with restoration of her platelet level. She will be
followed up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11636**], hematologist at [**Location (un) 2498**],
within a week of discharge to trend her CBC and monitor her
prednisone therapy. Her ADAMTS13 activity and ADAMTS13 inhibitor
level should be rechecked, as persistence of severe ADAMTS13
deficiency during remission is associated with an increased risk
for recurrent clinical episodes of TTP.
Patient's hepatitis C history is confirmed in this
hospitalization. Her liver enzymes were initially elevated on
presentation, but subsequently resolved following initiation of
plasmapheresis. Her HCV viral DNA is negative.
During her hospitalization, she developed hyperglycemia with
glucose as high as 180's. Her glucose was controlled with 10
unts of Lantus in the morning in addition to insulin sliding
scale, and her sugar ranged between 160 to 180. As such, upon
discharge, her Lantus was increased to 15 units on discharge,
and patient was given prescription to continue lantus at home.
She was instructed to follow up with her PCP for glucose
management.
Medications on Admission:
HOME MEDICATIONS:
- Seroquel 150mg PO daily
.
TRANSFER MEDICATIONS:
- pantoprazole 40 mg PO daily
- Aygestin OCPs once daily
- hydromorphone 2 mg IV q2h PRN
- methylprednisolone 125 mg IV q8h since [**2141-7-3**]
- nicotine patch 21 mg
- quetiapine 150 mg QHS
- folic acid 2 mg daily
- docusate 100 mg [**Hospital1 **]
- senna 2 tabs QHS
Discharge Medications:
1. Quetiapine 150 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO QHS.
2. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Folic Acid 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
Disp:*120 Tablet(s)* Refills:*2*
6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply
to back for 12 hours at a time, remove for 12 hours before
placing new patch.
Disp:*60 Adhesive Patch, Medicated(s)* Refills:*2*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
8. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Lantus 100 unit/mL Cartridge Sig: Fifteen (15) units
Subcutaneous QAM.
Disp:*1 cartridge* Refills:*2*
10. One Touch Glucometer
Measure glucose each morning before breakfast. Do not
administer insulin if glucose is under 100
11. Outpatient Lab Work
Please have CBC and fasting glucose measured the morning of
[**2141-7-18**]. The results should be faxed to your primary care
physician's office at [**Telephone/Fax (1) 39191**]
12. One Touch SureSoft Lancing Dev Misc Sig: One (1) device
Miscellaneous once a day.
Disp:*1 device* Refills:*0*
13. One Touch UltraSoft Lancets Misc Sig: One (1) lancet
Miscellaneous once a day.
Disp:*60 lancets* Refills:*0*
14. One Touch Ultra Test Strip Sig: One (1) strip In [**Last Name (un) 5153**]
once a day.
Disp:*60 strips* Refills:*2*
15. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Acute Idiopathic Thrombotic thrombocytopenic purpura
2. Vaginal bleeding
3. Hyperglycemia
Discharge Condition:
Good
Discharge Instructions:
You were admitted to the hospital because of thrombotic
thrombocytopenic purpura (TTP) and persistent vaginal bleeding.
Your platelet count recovered with five days of plasma exchange,
and it stayed well above normal after you were weaned off from
the plasma exchange.
Your blood glucose during this hospitalization was elevated
because of the prednisone and was lowered with insulin.
Your insulin therapy will need to be continued with the
assistance of your PCP.
[**Name10 (NameIs) **] will need to continue with lantus 15 units of insulin each
day. You will need to measure your glucose every morning. If
the glucose level is under 100 it is advised that you NOT inject
the insulin.
You were started on prednisone 40mg PO twice daily. You should
continue this until instructed to stop by your
Hematologist/Oncologist.
You should continue to take omeprazole to prevent symptoms of
heartburn.
You should continue with the lidocaine patch to help your back
pain.
You were given 7-day prescription of percocet as well.
Please have fasting labs drawn the morning of [**7-18**]. These
results should be faxed to your PCP. [**Name10 (NameIs) **] not eat anything after
midnight the evening before.
Please call your physician or return to the hospital if you
experience chest pain, shortness of breath, bleeding, fever,
lightheadedness, or any other concerning symptom.
Followup Instructions:
MD: Dr. [**Last Name (STitle) 82835**] [**Name (STitle) 4899**]
Specialty: PCP
Date and time: [**2141-7-18**] 3:00pm
Location: [**Street Address(2) 82836**], [**Location (un) 2498**]
Phone number: [**Telephone/Fax (1) 62076**]
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11636**]
Specialty: Hematology Oncology
Date and time: [**2141-7-20**] 3:45pm
Location: [**State **], [**Location (un) 2498**]
Phone number: [**Telephone/Fax (1) 62315**]
|
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icd9cm
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[
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icd9pcs
|
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12072, 12078
|
6592, 9701
|
302, 339
|
12215, 12222
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3474, 6569
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3073, 3455
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246, 264
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9795, 10066
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367, 2580
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2602, 2784
|
2800, 2987
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,954
| 181,066
|
4513
|
Discharge summary
|
report
|
Admission Date: [**2151-2-26**] Discharge Date: [**2151-3-6**]
Date of Birth: [**2088-9-16**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4377**]
Chief Complaint:
neck swelling
Major Surgical or Invasive Procedure:
Fiberoptic intubation
History of Present Illness:
Ms. [**Known lastname **] is a 62 year old female with a h/o of DVT on coumadin
and multiple myeloma with amyloid s/p allo-transplant in [**2143**] in
remission until recent evidence of slow disease progression, who
presents with chief complaint of pain with swallowing since
yesterday evening, accompanied by hoarse voice. She denies any
difficulty breathing. She states that she is able to swallow
liquids with some difficulty but is unable to swallow solids.
Onset of symptoms was yesterday evening with sudden onset of
neck swelling, preceded by a sore throat which has since
resolved. She states that the episode of neck swelling may have
been preceded by some coughing, but otherwise is unable to
identify a trigger for her symptoms.
.
Of note, she received donor lymphocyte infusion on [**2151-2-5**] and
due for follow up today in clinic. She has had two prior
episodes of epiglottitis/supraglottitis in [**2145**] and [**2149**]
requiring intubation.
.
On arrival to the ED, her VS were: T98.9, HR 103, BP 134/71, RR
12, and SpO2 95% on RA with no evidence of respiratory distress.
Her INR was 10 and she received Vitamin K 10 mg PO x 1. She was
scoped by ED resident and epiglottis was visualized; reported as
non-inflamed, non-beefy, and non-exudative.
.
ROS: She currently has no problems voiding. She has also had
hematuria since yesterday morning. Urine was initially the color
of cranberry juice but is now a slightly lighter shade. She has
no dysuria, fevers, chills, nausea, vomiting, or pain.
Past Medical History:
1) Multiple myeloma stage III with amyloidosis dx'd in [**2142**], s/p
melphalan, vincristine, adria and prednisone and then
vincristine, doxorubicin and dexa, with recurrence followed by
auto BMT and then mini-allo-BMT in 99 and again with recurrence
had donor lymphocyte infusion from brother in [**2145**]
2) Osteopenia s/p zometa infusions
3) HTN
4) Bladder/tongue amyloid
5) DVT [**2142**] L IJ, L sup femoral, L popliteal
6) s/p tonsillectomy
7) Supraglottitis x 2
8) Hx of disseminated herpes in [**2146**]
9) Urge incontinence
Social History:
She is married and lives in [**Location 3786**], 2 children, one grandson.
She admits to occasional etoh and denies any h/o tobacco/IVDU.
She is a retired office manager in a law firm.
Family History:
Hyertension, no malignancies
Physical Exam:
VS: T98.9, BP 146/90, HR 96, RR 20, SpO2 95% on RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normacephalic, atraumatic. Clear oropharynx.
Neck: Supple with soft, non-fluctuant symmetric midline
swelling. No masses or palpable lymphadenopathy. No carotid
bruits on auscultation.
Lungs: Normal respiratory effort. Lungs CTA bilaterally. No
stridor.
Cardiac: RRR. nl S1 and S2. no m/r/g
Abd: Soft, non-distended. No suprapubic or flank pain. +BS
Extrem: Warm and well-perfused. No clubbing/cyanosis/edema.
Skin: Multiple papular lesions with hyperpigmentation over lower
back and abdomen with satellite lesions extending over similar
areas as well as inner left thigh. Some healing areas of
excoriation on back.
Pertinent Results:
62 F with multiple myeloma with amyloid s/p allo-transplant
[**2143**], received donor lymphocyte infusion [**2151-2-5**], Coumadin on
DVT, here with supraglottitis and elevated INR.
.
1) Supraglottitis: CT neck without contrast showed a large
phlegmon with 80 percent supraglottal narrowing and edema,
aretinoid edema. She was given decadron, PPI, unasyn for
epiglottitis, IVIG to help with infections because of her
acquired hypogammaglobulinemia from multiple myeloma. ENT
emergently assessed the patient following admission and found
her to have significant supraglottic edema, edematous
aretinoids, with low threshold for additional swelling. She was
planned for awake intranasal fiberoptic intubation and
transferred to the ICU. She was intubated while awake with 6.0
fiberoptic ETT, then subsequently self-extubated, was
reintubated under sedation again with fiberoptic scope. CT neck
on [**3-1**] showed improvement in swelling but still unsafe to
extubate. Per ENT recommendations, she was treated with
decadron, IV diphenhydramine, and IV ranitidine as empiric
therapy for allergic angioedema. Ultimately, patient
self-extubated on [**3-2**], doing well, ENT eval appreciated.
Continue to monitor respiratory status. Unasyn has been
converted to augmentin.
.
Etiology may be epiglottitis, for which she has a previous
history in [**2145**] and [**2149**]. Infectious causes of supraglottitis
possible, as are non-infectious causes in this BMT patient such
as post-transplant lymphoproliferative disorder and graft-versus
host disease. C1 esterase deficiency also possible. - ID
consulted, will continue unasyn. Need to consider possible
involvement (infection) of vasculature in the neck. H.flu likely
as patient susceptible to encapsulated organisms.
- Await tryptase, C1 esterase to eval for C1 esterase deficiency
- ID recommends MRI of neck w/o contrast to eval. possible
involvement of vessels.
.
2) DVT: Most recently [**11-30**]. Supratherapeutic INR elevated to 10
on admission, now resolved. On coumadin for DVT, started on
fluconazole after DLI, interaction with warfarin known, likely
contributing to INR 10. She received Vitamin K 10 mg PO in the
ED and 2 [**Location 16678**] [**Location (Universities) 19263**] which normalized INR. Heparin
gtt initiated with normalization of INR, bridging back to
therapeutic coumadin level.
.
3) HTN: Consider restarting home meds of HCTZ and verapamil
while NPO. Blood pressure has been under fairly good control
while intubated.
-restarted HCTZ 25mg po qday.
.
4) Hematuria: Urology consulted and felt her hematuria to be
possibly c/w urinary obstructive symptoms, likely secondary to
elevated INR. Renal US was negative for hydronephrosis or any
abnormality identified within the kidneys. Hematuria now
resolved.
- Plan to restart Detrol
.
5) Hyperglycemia: Likely [**2-26**] steroids. Continue RISS.
- will decrease decadron to 5mg [**Hospital1 **] and continue to wean as
above. s
.
6) FEN: advance diet to regular as tolerated.
.
7) PPX: H2 blocker, bowel regimen
Brief Hospital Course:
62 F with multiple myeloma with amyloid s/p allo-transplant
[**2143**], received donor lymphocyte infusion [**2151-2-5**], Coumadin on
DVT, p/w with supraglottitis and elevated INR.
.
1) Patient was admitted to the BMT service with SpO2 of 95% on
room air. On arrival to the floor, her primary complaint was
difficulty swallowing and "gurgly" voice since last night. She
denied any difficulty breathing. CT of her neck performed on the
evening of admission revealed a large phlegmon with supraglottal
narrowing and edema, aretinoid edema. She was given decadron,
PPI, and was started on unasyn for epiglottitis. She received a
transfusion of IVIG given her hypoglobulinemia secondary to
multiple myeloma. ENT emergently assessed the patient following
admission and found her to have significant supraglottic edema,
edematous aretinoids, with low threshold for additional
swelling. She was planned for awake intranasal fiberoptic
intubation and transferred to the ICU. Per ENT recommendations,
she was treated with decadron, IV diphenhydramine, and IV
ranitidine as empiric therapy for allergic angioedema.She was
intubated while awake with 6.0 fiberoptic ETT, then subsequently
self-extubated, was reintubated under sedation again with
fiberoptic scope. CT neck on [**3-1**] showed improvement in swelling
but still felt to be unsafe to extubate. Ultimately, patient
self-extubated again on [**3-2**] and at that point it was felt safe
to monitor expectantly without reintubation. ID team was
consulted and recommended continuation of unasyn. Prior to
discharge, Unasyn was converted to augmentin.
.
Etiology of this event is likely epiglottitis, for which she has
a prior history in [**2145**] and [**2149**]. Infectious causes of
supraglottitis possible, as are non-infectious causes in this
BMT patient such as post-transplant lymphoproliferative disorder
and graft-versus host disease. C1 esterase deficiency was ruled
out with C1 esterase functional assay WNL. Suspect recurrent
H.flu infection, as patient is particularly susceptible to
encapsulated organisms.
.
2) DVT: Most recently [**11-30**]. Supratherapeutic INR elevated to 10
on admission, now resolved. On coumadin for DVT, started on
fluconazole after DLI, interaction with warfarin known, likely
contributing to INR 10. She received Vitamin K 10 mg PO in the
ED and 2 [**Location 16678**] [**Location (Universities) 19263**] which normalized INR. Heparin
gtt initiated with normalization of INR, bridging back to
therapeutic coumadin level. Prior to discharge, she was
discovered to have multifocal intracranial hemorrhage, and all
anti-coagulation plans were aborted. IVC filter placement is
indicated in this scenario and will be pursued as an outpatient.
.
3) Subdural hematomas: On the evening of [**3-6**], Ms. [**Known lastname **]
complained of headache with radiation to her neck. Her husband
also reported that she seemed more somnolent and that mental
status was not at baseline. Neurologic exam was non-focal. At
this time, her heparin gtt had been very recently discontinued
with plan to transition to Lovenox for anticoagulation in the
setting of her recent DVT. CT head was performed and revealed
bilateral subdural hematomas, right greater than left,
predominantly
composed of acute blood but also demonstrating subacute
components. An MRI of the head was performed which revealed no
lesion or focus of the bleed and stable area of hemorrhage.
Prior to discharge, a repeat CT of the head was performed, which
showed interval decrease in size of extra-axial collection of
the left lateral posterior fossa. She was neurologically intact
throughout, and she was discharged home with instructions to
return with any changes in status.
.
4) Hematuria: Urology consulted and felt her hematuria to be
possibly c/w urinary obstructive symptoms, likely secondary to
elevated INR. Renal US was negative for hydronephrosis or any
abnormality identified within the kidneys. Hematuria resolved
with reversal of INR.
.
5) HTN: Restarted on home regimen of Verapamil and HCTZ
following ICU course and prior to discharge to home.
.
5) Hyperglycemia: Likely [**2-26**] steroids. Covered with RISS.
Medications on Admission:
HCTZ 25 mg daily
Detrol XL
Verapamil 180 mg once a day
Discharge Medications:
1. Verapamil 180 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q24H (every 24 hours).
2. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 6 days.
Disp:*18 Tablet(s)* Refills:*0*
3. Dexamethasone 1 mg Tablet Sig: 3 tablets on Sunday [**3-7**]. 2
tablets on Monday [**3-8**]. 1 tablet on Tuesday [**3-9**]. Tablets PO
once a day for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
4. 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*
5. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Epiglottitis
Subdural hematoma
Supratherapeutic INR
Hematuria
Multiple myeloma
h/o DVT
Discharge Condition:
Neurologically intact, alert and oriented x 3, guarded for any
changes in neurologic status
Discharge Instructions:
You were admitted for epiglottitis, and you were intubated to
protect your airway. You are being treated with a 10-day course
of antibiotics, now Day 4.
.
You were found to have a subdural bleed in your head, likely due
to spontaneous bleeding while on coumadin and/or heparin. You
should NOT take any anticoagulation in the setting of this
bleed. You were evaluated by Neurosurgery who felt this to be
stable at the time of discharge. You should follow-up with Dr.
[**Last Name (STitle) 548**] in one week for reassessment.
.
If you experience any neck swelling or difficulty bleeding, you
should seek immediate medical attention. You should come to the
emergency room immediately if you experience any changes in your
vision, balance, memory, or alertness.
Followup Instructions:
You should follow-up with your Oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next
week. Please call ([**Telephone/Fax (1) 3936**] to schedule your appointment.
.
Dr. [**Last Name (STitle) 548**] in the Department of Neurosurgery in one week. Please
call ([**Telephone/Fax (1) 88**] to schedule an appointment.
|
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82,049
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49546
|
Discharge summary
|
report
|
Admission Date: [**2132-8-18**] Discharge Date: [**2132-8-21**]
Date of Birth: [**2051-1-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7651**]
Chief Complaint:
Chest pain of sudden onset.
Major Surgical or Invasive Procedure:
Cardiac catheterization and placement of drug-eluting stent to
RCA
History of Present Illness:
Mr. [**Known lastname 54731**] is an 81yo M with history of HTN, questionable
dyslipidemia and OSA, admitted to 6-CCU on [**2132-8-18**] via ED, w/
complaint of one hour episode of substernal chest
pressure/tightness radiating up into the neck awaking him from
sleep. The pain was associated with diaphoresis but no
shortness of breath. His wife gave him a full aspirin and the
pain went away. She called EMS, and he was chest pain free upon
available to the ER.
.
In the ER, initial vitals were 97.5, 84, 162/80, 16, 97% 2L NC.
Initital EKG showed first degree AV block and ST elevations in
the inferior leads. While in the ED, his CP recurred, and he
was sent to the cath lab as a [**Year (4 digits) **]. He was plavix loaded with
600mg, started on heparin drip and given morphine. Patient was
hemodynamically stable the whole time with heart rates in the
80s and blood pressures 150s-160s/80s.
.
In the cath lab, he had a subtotal ostium PL branch RCA lesion
and DES was placed. He developed increased respiratory distress
with some coughing and questionable SVT with cough. Patient
received lasix 20mg IV for this and was transiently on NRB. His
PCW on cath was 33.
.
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 current
chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle
edema, palpitations, syncope or presyncope. Upon reflection, he
has felt more fatigued that usual with exertion but denies frank
dyspnea.
Past Medical History:
1. CARDIAC RISK FACTORS: Hypertension, questionable dyslipidemia
2. CARDIAC HISTORY: Evidence of prior inferior MI on EKG in [**2123**]
3. OTHER PAST MEDICAL HISTORY:
Rhinitis
OSA on CPAP
BPH
Gout
Obesity
Hard of hearing.
s/p ventricular shunt years ago.
Hypogonadism (low T)
Social History:
- Tobacco history: none
- ETOH: rare
- Illicit drugs: none
Family History:
Father had history of CAD. No family history of cancer or
diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T= 97.1 BP= 173/85 HR= 61 RR= 15 O2 sat= 95% 5L NC
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva were pink, no pallor
or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 4 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB anteriorly, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
.
DISCHARGE PHYSICAL EXAMINATION:
VS: Tm/Tc:99.8/98.2 HR:65-91 BP:127-134/78-88 RR:18-20 02
sat:94% RA
In/Out: 24H:720/925, last 8H: 480/400
Weight: 106.5
Tele: AF to SR with conversion pause. Rate of AF up to 120. No
VT noted.
.
GENERAL: 81 yo M in no acute distress
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, JVP non elevated
CHEST: CTABL no wheezes, no rales, no rhonchi
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive.
EXT: wwp, no edema. No sig hematoma or ecchymosis at left groin
site. DPs, PTs 2+.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. gait
WNL.
SKIN: no rash
PSYCH: A/O, making jokes
Pertinent Results:
ADMISSION LABS
[**2132-8-18**] 05:14AM BLOOD WBC-8.2 RBC-5.16 Hgb-18.2* Hct-50.2
MCV-97 MCH-35.4* MCHC-36.3* RDW-15.2 Plt Ct-195
[**2132-8-18**] 05:14AM BLOOD Neuts-68.5 Lymphs-24.6 Monos-3.5 Eos-2.5
Baso-0.9
[**2132-8-18**] 05:14AM BLOOD PT-12.6 PTT-22.1 INR(PT)-1.1
[**2132-8-18**] 05:14AM BLOOD Glucose-157* UreaN-19 Creat-1.5* Na-142
K-3.7 Cl-104 HCO3-26 AnGap-16
[**2132-8-18**] 05:14AM BLOOD CK(CPK)-145
[**2132-8-18**] 01:36PM BLOOD CK(CPK)-798
[**2132-8-19**] 05:05AM BLOOD CK(CPK)-319
[**2132-8-18**] 05:14AM BLOOD cTropnT-0.40*
[**2132-8-18**] 01:36PM BLOOD CK-MB-69* MB Indx-8.6* cTropnT-2.53*
[**2132-8-18**] 08:57PM BLOOD CK-MB-45* MB Indx-8.1* cTropnT-2.73*
[**2132-8-19**] 05:05AM BLOOD CK-MB-23* MB Indx-7.2* cTropnT-2.50*
[**2132-8-18**] 05:14AM BLOOD %HbA1c-5.1 eAG-100
[**2132-8-18**] 05:14AM BLOOD Cholest-174
[**2132-8-18**] 05:14AM BLOOD Triglyc-137 HDL-43 CHOL/HD-4.0
LDLcalc-104
.
DISCHARGE LABS
[**2132-8-21**] 06:20AM BLOOD WBC-6.6 RBC-4.53* Hgb-16.2 Hct-44.0
MCV-97 MCH-35.8* MCHC-36.8* RDW-15.1 Plt Ct-155
[**2132-8-21**] 06:20AM BLOOD Glucose-99 UreaN-17 Creat-1.3* Na-141
K-3.8 Cl-105 HCO3-24 AnGap-16
.
IMAGING
[**2132-8-18**] CARDIAC CATH:
1. Coronary angiography in this right dominat system
demonstrated single
vessel disease. The LMCA was patent. The LAD had <50% proximal
stenosis,
and diffuse irregularities. The LCX had no angiographically
apparent
disease. The RCA had a subtotal ostium occlusion posterolateral
branch.
2. Resting hemodynamics revealed elevated right and left sided
filling
pressures with RVEDP of 16 mmHg and PCW of 33 mm Hg. There was
moderate
pulmonary arterial systolic hypertension with PASP 54 mm Hg. The
cardiac
index was low at 2.2 L/min/min2. There was normal arterial
systolic and
mildly elevated diastolic pressures at the aortic level with sBP
136
mmHg and DBP of 94 mmHg.
3. Left Ventriculography was differed.
4. Successful PTCA and stenting of the distal RCA into the PL
branch
with a 3.0 x 18 mm Promus DES (see PTCA comments).
5. Successful LFA AngioSeal (see PTCA comments).
FINAL DIAGNOSIS:
1. Single vessel coronary artery disease.
2. Moderate biventricular diastolic dysfunction.
3. Moderate pulmonary arterial hypertension.
4. Successful PCI of the distal RCA into the RPL with a 3.0 x 18
mm
Promus DES.
5. Successful LFA AngioSeal.
.
[**2132-8-18**] ECG: Sinus rhythm. A-V conduction delay. ST segment
elevations in
leads II, III and aVF with ST segment depressions in leads V2-V3
and V5-V6
and leads I and aVL consistent with acute transmural ischemia in
the
inferoposterior distribution. Relatively flat ST segment in lead
V1
raises suspicion for acute right ventricular infarction.
Compared to the
previous tracing ST segment changes are new.
.
[**2132-8-18**] Trans-thoracic Echocardiography
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
to moderate regional left ventricular systolic dysfunction with
severe hypokinesis of the basal inferior and inferolateral
walls. The remaining segments contract normally (LVEF = 45-50
%). Right ventricular chamber size and free wall motion are
normal. The aortic root is mildly dilated at the sinus level.
The ascending aorta and arch are mildly dilated.The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild to moderate ([**11-25**]+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**11-25**]+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional systolic dysfunction c/w CAD (PDA distribution).
Mild-moderate aortic regurgitation. Mild-moderate mitral
regurgitation. Dilated thoracic aorta.
Brief Hospital Course:
Mr. [**Known lastname 54731**] is a 81yo M with history of HTN and OSA, who was
admitted with an inferior [**Known lastname **].
.
ACUTE
# Inferior [**Name (NI) **] - Pt taken to cath and shown to have a subtotal
ostium occlusion in the posterolateral branch of the RCA. There
was successful PTCA and stenting of the distal RCA into the
posterolateral branch with a 3.0 x 18 mm Promus drug-eluting
stent. He was continued on aspirin and started on plavix, ACEI,
statin, and switched to metoprolol from his home atenolol.
.
# CHF: No history of CHF but has not had an echo since stress
echo in [**2122**]. ECHO showed EF 45-50% with mild to moderate
regional left ventricular systolic dysfunction with severe
hypokinesis of the basal inferior and inferolateral walls,
Mild-moderate aortic and mitral regurgitation, and dilated
thoracic aorta.
.
# RHYTHM: Evidence of first degree AV block on EKG back in [**2123**]
as well as now. He was monitored on telemetry and found to be in
paroxysmal atrial fibrillation. He was anticoagulated with
heparin drip and bridged to Pradaxa for long-term
anticoagulation.
.
CHRONIC
# Hypertension: His home amlodipine was held in favor of
starting ACEI, and he was switched from his home atenolol to
metoprolol for better cardioprotection. He was slowly titrated
up to 50 mg metoprolol [**Hospital1 **], which was equivalent to his home
atenolol dose. He was also put on lisinopril 5mg.
.
# Hyperlipidemia: Per notes, he has history of
hyperlipidemia,but patient reports good cholesterol levels.
Lipid panel showed HDL 43, CHOL/HDL 4.0, LDL 104. He was started
on atorvastatin 80mg daily for cardioprotection.
.
# Obstructive Sleep Apnea: He was continued on CPAP.
.
# BPH: He was continued on home tamulosin and finasteride.
.
# Low testosterone: Wife reports pt takes 200mg every 2 weeks.
He was put on testosterone patch while in-house.
.
TRANSITIONAL
# Pt will have follow-up with Dr. [**Last Name (STitle) 171**] on MONDAY [**2132-9-8**].
.
# Pt will have follow-up with Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] on MONDAY [**2132-8-25**].
Medications on Admission:
AMLODIPINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day
ATENOLOL - 50 mg Tablet - 1 Tablet(s) by mouth once a day
FINASTERIDE - 5 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN - 0.4 mg Capsule, Ext Release 24 hr - 1 Capsule(s)
by mouth once a day
TESTOSTERONE CYPIONATE - 200mg/ml, 1ml every two weeks
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
BISACODYL [DUCODYL] - Dosage uncertain
CALCIUM CITRATE-VITAMIN D3 [CITRACAL + D] - (OTC) - Dosage
uncertain
MULTIVITAMIN - (Prescribed by Other Provider) - Dosage
uncertain
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - (OTC) - Dosage
uncertain
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*11*
2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. metoprolol succinate 100 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:*2*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO
twice a day.
Disp:*60 Capsule(s)* Refills:*2*
6. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. testosterone cypionate (bulk) Miscellaneous
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Oral
9. Calcium Citrate + D Oral
10. multivitamin Tablet Sig: One (1) Tablet PO once a day.
11. Omega 3 Fish Oil Oral
12. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior myocardial infarction
Hypertension
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 54731**],
It was a pleasure taking care of you during your hospitalization
at [**Hospital1 69**]. You were admitted
because you had a heart attack. Images of your heart showed that
critical vessels that supply blood to your heart were blocked,
and so a stent was placed in order to keep the blood vessel
open. it is extremely important that you take aspirin and plavix
every day for one year to prevent the stent from clotting off
and causing another heart attack. Do not stop taking aspirin and
plavix or miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] unless Dr. [**Last Name (STitle) 171**] says it is OK. You
developed a very common irregular heart rhythm called atrial
fibrillation. You have tolerated this well but you now have an
increased risk of stroke. Therefore, we have started [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 55863**]
blood thinner called Dabigitran or Pradaxa to prevent a stroke.
This medicine can cause easy bleeding so you may bruise easily
or your gums could bleed with vigorous brushing. However, you
also could have bleeding in your bowel that will give you dark
or bloody stools, lightheadedness and dizziness. Call Dr.
[**Last Name (STitle) 171**] right away if you experience these symptoms.
Please START taking the following medications in addition to
your home medications:
1. Metoprolol succinate to lower your heart rate and help you
heart recover from the heart attack
2. Rosuvastatin (Crestor) to lower your cholesterol
3. Plavix to prevent the stent from clotting off and causing
another heart attack.
4. Aspirin to prevent the stent from clotting off and causing
another heart attack.
5. Lisinopril to lower your blood pressure and help your heart
recover
6. Pradaxa: to prevent a stroke from your atrial fibrillation
Please STOP taking the following medications:
1. Amlodipine (the Lisinipril will replace Amlodipine)
2. Atenolol (the Metoprolol will replace Atenolol)
Followup Instructions:
Department: CARDIAC SERVICES
When: MONDAY [**2132-9-8**] at 10:40 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: MONDAY [**2132-8-25**] at 9:20 AM
With: [**First Name11 (Name Pattern1) 20**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3070**]
Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground
Campus: OFF CAMPUS Best Parking: Parking on Site
Completed by:[**2132-8-21**]
|
[
"272.4",
"428.22",
"257.2",
"600.00",
"585.9",
"278.00",
"410.41",
"396.3",
"428.0",
"403.90",
"427.31",
"327.23"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"37.23",
"36.07",
"00.40",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11952, 11958
|
8056, 10150
|
332, 401
|
12066, 12066
|
4201, 6250
|
14216, 14926
|
2614, 2684
|
10851, 11929
|
11979, 12045
|
10176, 10828
|
6267, 8033
|
12217, 13571
|
2699, 2709
|
2328, 2380
|
13589, 14193
|
3486, 4182
|
265, 294
|
429, 2220
|
12081, 12193
|
2411, 2522
|
2242, 2308
|
2538, 2598
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,060
| 170,598
|
16847
|
Discharge summary
|
report
|
Admission Date: [**2162-6-26**] Discharge Date: [**2162-8-2**]
Date of Birth: [**2083-2-25**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
infected right BKA stump
Major Surgical or Invasive Procedure:
Right AKA [**2162-6-29**]
History of Present Illness:
patient trnasfered from [**Hospital 47490**]Hospital after being admitted
for fever and mental status changes. Head CT was negative for
any acute findings. Amputation summp with gangrenous necrosis
and erythema. Patient was given IV ancef and levaquin and
transfered to here for further evaluation and treatment.
Past Medical History:
histroy of DM2, uncontrolled, insulin dependant
history of PVD,s/p left CFA endartectomy with dacron patch
[**7-17**],s/p right cfa-at bpgw issvg [**7-17**],right cfa+PFA endartectomy
with dacroin patch angioplasty and akpop exploration [**1-16**] ,s/p
right BKA.
history of ischemic heart diseases/p MI,S/P CABG's
history of systolic CHF-chroinc, compensated (EF 20-25%)
history of polycythemia [**Doctor First Name **]
history of prostate cancer s/p radium seed implantations
history of dyslipdemia
history of gall bladder disease s/p ccy
history of CVA with residual left sided deficet
Social History:
retired, lives with daughter
tobacco use: 120 pk yrs
Denies etoh use
Family History:
N/C
Physical Exam:
Vital signs: 101-97.3-79-22 B/P 126/68 O2 sat 99.3% @3l/nc
Gen: AAOx3, no acute distress
lungs: clear to auscultation
Heart: RRR
ABD: soft nontender,non distended, well healed midline scar
EXT: right amnp site with open wound 6x4cm in size. outer 2cm
with escharremainaing area with clean base and fbrinous
excudate. no pus ,doesnot probe. surrounding erythema 2cm
pulses: femorals -palpable bilaterally, [**Doctor Last Name **] rt. dopperable,[**Doctor Last Name **]
lt. palpable
lt. AT dopperaable-monophasic, absent lt. DP/PT.
Neuro: nonfocal
Pertinent Results:
[**2162-6-26**] 03:45AM GLUCOSE-144* UREA N-53* CREAT-1.7* SODIUM-135
POTASSIUM-4.5 CHLORIDE-98 TOTAL CO2-24 ANION GAP-18
[**2162-6-26**] 03:45AM estGFR-Using this
[**2162-6-26**] 03:45AM ALT(SGPT)-15 AST(SGOT)-31 ALK PHOS-234* TOT
BILI-1.8*
[**2162-6-26**] 03:45AM LIPASE-19
[**2162-6-26**] 03:45AM ALBUMIN-3.4 CALCIUM-7.7*
[**2162-6-26**] 03:45AM WBC-23.37*# RBC-3.65* HGB-10.0* HCT-32.5*
MCV-89# MCH-27.5# MCHC-30.9* RDW-17.6*
[**2162-6-26**] 03:45AM NEUTS-75* BANDS-7* LYMPHS-5* MONOS-13* EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2162-6-26**] 03:45AM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-1+ STIPPLED-1+ TEARDROP-1+ ELLIPTOCY-1+
[**2162-6-26**] 03:45AM PLT SMR-HIGH PLT COUNT-544* LPLT-1+ PLTCLM-1+
Brief Hospital Course:
[**2162-6-26**] admitted. IV antibiotics vanco, po levo,flagyl
began.wound c/s MSSA
blood c/s negative.coumadin held for anticipate AKa.
[**2162-6-28**] Episode of desaturation 86% improved with O2@ 5/lnc-95%,
symptoms associated with nauses and confusion. EKG no acute
changes.enzymes cycled.Enzymes flat.ABG: po2113/pco2
33/ph7.57/base x 8 lactate 2.8 Patient diuresed with improvement
of symptoms.Transfered to VICU for continued monitering. AKA
cancelled.
[**2162-6-30**] SURGERY: RT. AKA
[**2162-7-1**] -[**2162-7-3**] POD#1 -3 low urinary out put and hpotension
associated with mild confusion and drowsyness. Fluid boluses
given with out improvement of Urinary output.Narcan administered
with improvement of somulence and confusion. Enzymes cycles and
blood c/s obtained. WBC 23.2 hct 31.6 bun/cr 48/1.6 inr 3.3
coumadin continued to be held.
left subclavian vein line placed.transfered to VICU.CVP
monitered for fluid volume assesment.transfused for hct 25.3,
post transfusion hct 31.0 INR 5.3 Vitamin K given
coumadin continued to be held.
[**2080-7-1**] POD#[**5-15**] creatinine continues to rise. 3.9 renal
conslulted. urinne na 57,cr 33,urea 285 fen 5% FeBun 47%.
continue to moniter renal function. start phosphate binders if
necessary low phos,k diet. Hold diuresis , only diurese if
oxygenation issues. urine eso pending renal u/s to r/o
obstructiion pending.
5/27-28/08 POD#[**7-17**] creatinine continues to remain elevated. WBC
continues to rise.
ID consulted, and patient started on Zosyn. The patient
experienced some wheezing overnight, for which he received
nebulized treatments.
[**7-8**] POD#8 Per ID recommendations, the patient was continued on
Zosyn, blood cultures were obtained, and the CVL was removed.
The patient was made Floor status, and his telemetry order was
d/c'd. He also received Lasix 20 mg IV x1 as the patient was
noted to have crackles over bilateral lung fields. His foley
catheter was removed.
[**7-9**] POD 9 The patient again received 20 mg IV lasix. The
patient's BUN/Cr had plateaud at 4.2-4.5. The patient had a
bladder scan for >500cc, and a Foley catheter placement was
attempted multiple times, however penil/foreskin edema and
phimosis precluded placement. Urology was called for placement,
which was successful.
[**7-10**] POD 10 The patient had some bleeding at the amputation
site, for which [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was placed with good result. A CT of
the torso was obtained as the patient continued to have
leukocytosis without a definitive source, which was not
revealing. FLuconazole was started for yeast in the urine
[**7-11**] POD 11 The patient had some shortness of breath,
disorientation, and dizziness while sitting up, and an EKG was
performed, which was stable, and cardiac enzymes were sent,
which were negative.
[**7-12**] POD 12 The patient's lasix was increased to [**Hospital1 **] dosing.
Flagyl was started empirically for c. diff given the persistent
leukocytosis, and ZOsyn was stopped. Hematology was consulted
for further evaluation given the patient's history of
polycythemia [**Doctor First Name **].
[**7-13**] The patient was confused and hypoxic; and abg was drawn,
and the patient received supportive care. His hypoxia resolved
somewhat. An echo was ordered to assess for other
abnormalities. The patient received 60 of PO lasix
[**7-14**] The patient began having melena, and the patient received
multiple units of blood and FFP. He was subsequently
transferred to the unit as he became hemodynamically unstable.
Pressors were required to maintain his pressure. Serial
hematocrits were performed. The patient was intubated and
sedated and an upper endoscopy was performed. For details,
please see report. No active bleeds were identified.
[**7-15**] The patients hematocrits were continued to be serially
followed. An echo was performed. Flagyl and fluconazole were
d/c'd
[**7-16**] Tube feeds were started for nutritional support. Zosyn was
stopped.
6/7 Per renal recommendations, the patient received 40 mg of IV
lasix. Vent was weaned.
[**7-18**] The patient was extubated and pulmonary toilet was
performed. Lasix dosing was adjusted to 40 IV BID. A CT of the
head was ordered as the patient had a persistently altered
mental status; no major abnormalities were noted. Please see
report for details
[**7-19**] Tube feeds were continued.
[**7-20**] An MRI of the head was going to be performed, however, the
patient was noted to have a BB in his face from a prior
incident, and the MRI could not be performed.
A PICC was placed for IV access. Neurology was consulted for
further recommendations, and an EEG was performed.
[**7-21**] Speech and swallow was involved to determine if the
patient would tolerate a diet.
[**7-22**]: The patient was stable for transfer to the VICU
[**7-23**]: The patient was stable, and a PT consult was obtained.
Medications were transitioned to oral medications. NT
suctioning was performed as the patient had thick secretions.
That afternoon, the patient became hypotensive to an SBP of
70s-80s, and was hypoxic with an spO2 in the 70s-80s. He was
transferred back to the CVICU for further care. Pan cultures
were performed to assess for a possible source of infection. The
patient was intubated and sedated, and received supportive care
for his hypotension. CTs were ordered, however the patient was
not stable for transfer. An LP was performed, and more cultures
were sent. The patient was restarted on Zosyn per consultation
service recommendations.
[**7-24**]: CT of the head, pelvis and abdomen was performed, however
no acute collections were seen. Bilateral pleural effusions
were noted, however, and IP was contact[**Name (NI) **] for a possible
thoracentesis.
During the patient's remaining hospital course, the patient's
white blood count decreased to a low of 13.9. A trach and peg
were performed on [**7-28**]. On [**7-29**], the patient was weaned from the
vent to trach collar, which he tolerated well. Rehab screening
was started. On [**7-30**], the patient was doing well on trach
collar, and his antibiotics were stopped, as there was no
definite source of infection. During the remainder of his stay,
the patient was afebrile, with stable vital signs, tolerating
trach mask/collar well. He was stable for trasfer to rehab.
Medications on Admission:
coumadin 1', lasix 20', metolazone 1.5', coreg 3.125',
lovastatin 40', lisinopril 40', neurontin 600', NPH 70/30 20qam
& 10qpm, prilosec 20', singulair 10', calcium 600', folate 1',
albuterol prn, percocet prn, dulcolax prn
Discharge Medications:
1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for wheeze, dyspnea.
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours).
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
10. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
12. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
13. Heparin Flush (10 units/ml) 1 mL IV PRN line flush
Temporary Central Access-Floor: Flush with 10 mL Normal
Saline followed by Heparin as above daily and PRN.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day).
15. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
16. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection once a day: per insulin sliding scale.
17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed.
18. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
20. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
21. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
22. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
23. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
24. 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.
25. Sodium Chloride 0.9% Flush 3 mL IV PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
26. Pantoprazole 40 mg IV Q12H
Discharge Disposition:
Extended Care
Discharge Diagnosis:
infection right BKA stump
history of perpheral vascular diseases s/p left CFA endartectomy
with dacron patch,s/p right CFA-AT bpg with SSVG,rt. CFA&PFA
endartectomy dacron profundaplasty, akpop exploration,rt. BKA
history of DM2, insulin dependant, controlled
history of ischemic heart disease s/p Mi,CABG's
history of systolic congestive heart failure,
chroinic-compensated (EF 20-25%)
history of polycythemia [**Doctor First Name **]
history of prostate cancer s/p radium seeds
history of hypercholestremia
history of gall bladder disease s /p CCY
history of CVA with left sided deficet
history of 120pk yrs tobacco use
postop hypotension secondary to intravascular depletion
postop confusion secondary to narcotics-narcan
postop elevated INR secondary to antibiotics -reversed
postoperative chroinc CHF compounded by acue-diureses
postoperative blood loss anemia -transfused
postoperative ARF secondary to hypotension
postoperative fever [**3-13**] UTI w leukcytosis-treated
postoperative leukocytosis, persistant
upper GI bleed
Discharge Condition:
stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOLLOWING ABOVE KNEE OR BELOW KNEE
AMPUTATION
This information is designed as a guideline to assist you in a
speedy recovery from your surgery. Please follow these
guidelines unless your physician has specifically instructed you
otherwise. Please call our office nurse if you have any
questions. Dial 911 if you have any medical emergency.
ACTIVITY:
There are restrictions on activity. On the side of your
transmetatarsal amputation you are non weight bearing for [**5-16**]
weeks. You should keep this amputation site elevated when ever
possible.
No driving until cleared by your Surgeon.
PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS:
Redness in or drainage from your leg wound(s).
New pain, numbness or discoloration of your foot or toes.
Watch for signs and symptoms of infection. These are: a fever
greater than 101 degrees, chills, increased redness, or pus
draining from the incision site. If you experience any of these
or bleeding at the incision site, CALL THE DOCTOR.
Exercise:
Limit strenuous activity for 6 weeks.
Do not drive a car unless cleared by your Surgeon.
No heavy lifting greater than 20 pounds for the next 14 days.
Try to keep leg elevated when able.
BATHING/SHOWERING:
You may shower immediately upon coming home. No bathing. A
dressing may cover you??????re amputation site and this should be
left in place for three (3) days. Remove it after this time and
wash your incision(s) gently with soap and water. You will have
sutures, which are usually removed in 4 weeks. This will be done
by the Surgeon on your follow-up appointment.
WOUND CARE:
Sutures / Staples may be removed before discharge. If they are
not, an appointment will be made for you to return for staple
removal.
When the sutures are removed the doctor may or may not place
pieces of tape called steri-strips over the incision. These will
stay on about a week and you may shower with them on. If these
do not fall off after 10 days, you may peel them off with warm
water and soap in the shower.
Avoid taking a tub bath, swimming, or soaking in a hot tub for
four weeks after surgery.
MEDICATIONS:
Unless told otherwise you should resume taking all of the
medications you were taking before surgery. You will be given a
new prescription for pain medication, which can be taken every
three (3) to four (4) hours only if necessary.
Remember that narcotic pain meds can be constipating and you
should increase the fluid and bulk foods in your diet. (Check
with your physician if you have fluid restrictions.) If you feel
that you are constipated, do not strain at the toilet. You may
use over the counter Metamucil or Milk of Magnesia. Appetite
suppression may occur; this will improve with time. Eat small
balanced meals throughout the day.
CAUTIONS:
NO SMOKING! We know you've heard this before, but it really is
an important step to your recovery. Smoking causes narrowing of
your blood vessels which in turn decreases circulation. If you
smoke you will need to stop as soon as possible. Ask your nurse
or doctor for information on smoking cessation.
Avoid pressure to your amputation site.
No strenuous activity for 6 weeks after surgery.
DIET:
There are no special restrictions on your diet postoperatively.
Poor appetite is expected for several weeks and small, frequent
meals may be preferred.
For people with vascular problems we would recommend a
cholesterol lowering diet: Follow a diet low in total fat and
low in saturated fat and in cholesterol to improve lipid profile
in your blood. Additionally, some people see a reduction in
serum cholesterol by reducing dietary cholesterol. Since a
reduction in dietary cholesterol is not harmful, we suggest that
most people reduce dietary fat, saturated fat and cholesterol to
decrease total cholesterol and LDL (Low Density Lipoprotein-the
bad cholesterol). Exercise will increase your HDL (High Density
Lipoprotein-the good cholesterol) and with your doctor's
permission, is typically recommended. You may be self-referred
or get a referral from your doctor.
If you are overweight, you need to think about starting a weight
management program. Your health and its improvement depend on
it. We know that making changes in your lifestyle will not be
easy, and it will require a whole new set of habits and a new
attitude. If interested you can may be self-referred or can get
a referral from your doctor.
If you have diabetes and would like additional guidance, you may
request a referral from your doctor.
FOLLOW-UP APPOINTMENT:
Be sure to keep your medical appointments. The key to your
improving health will be to keep a tight reign on any of the
chronic medical conditions that you have. Things like high blood
pressure, diabetes, and high cholesterol are major villains to
the blood vessels. Don't let them go untreated!
Please call the office on the first working day after your
discharge from the hospital to schedule a follow-up visit. This
should be scheduled on the calendar for seven to fourteen days
after discharge. Normal office hours are 8:30-5:30 Monday
through Friday.
PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR
QUESTIONS THAT MIGHT ARISE
no stump shrinkers
call if stump develps redness, drainage or swelling
call if develops fever >101.5
Followup Instructions:
2 weeks Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**]
|
[
"E935.8",
"V15.3",
"V15.82",
"349.82",
"428.0",
"790.7",
"292.81",
"785.59",
"578.9",
"403.90",
"272.0",
"585.3",
"V10.46",
"414.01",
"584.9",
"428.23",
"518.81",
"286.9",
"997.5",
"997.62",
"285.1",
"238.4",
"443.9",
"112.2",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"31.1",
"96.04",
"44.14",
"33.24",
"43.11",
"38.93",
"99.07",
"96.6",
"96.71",
"99.04",
"45.13",
"34.91",
"84.17",
"96.72",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
11927, 11942
|
2821, 9179
|
338, 366
|
13017, 13025
|
2012, 2798
|
18332, 18430
|
1423, 1428
|
9453, 11904
|
11963, 12996
|
9205, 9430
|
13049, 14646
|
1443, 1993
|
274, 300
|
14658, 17537
|
17560, 18309
|
394, 708
|
730, 1321
|
1337, 1407
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,280
| 142,397
|
17333
|
Discharge summary
|
report
|
Admission Date: [**2184-2-16**] Discharge Date: [**2184-2-18**]
Date of Birth: [**2141-6-15**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
needs bone flap replaced
Major Surgical or Invasive Procedure:
Cranioplasty
History of Present Illness:
The patient is a 42-year-old male who is coming
for replacement of the bone flap and cranioplasty after the
craniectomy done about 2 months ago.
Past Medical History:
Medically refractory epilepsy as above (followed by [**Last Name (un) 48510**]
[**Doctor Last Name 437**])
Hit with baseball bat at age 8, no LOC
OSA on CPAP
arthritis (knees, elbows)
carpel tunnel & tarsal tunnel syndrome
plantar fasciitis left foot
peripheral neuropathy (?while on many AEDs, v sedated)
Social History:
No tob, EtOH, drugs. Worked for [**Company **] company last several
yrs however is on temp disability next 6 mo d/t spells unable to
drive or use heavy equipment. Patient has been married for 12
yrs and has no children lives in [**Location 48511**], CT.
Family History:
Father alcoholic, mother ?tremor
Physical Exam:
AVSS
WD/WN NAD
PERRLA, EON Full
lungs: cta
Cor: RRR
ADB: soft/nt
ext: no CCE
Neuro: AAOx3
Cn2-12 intact
motor full
[**Last Name (un) 36**] intact
obvious left cranial defect
Pertinent Results:
[**2184-2-16**] 09:33AM GLUCOSE-115* UREA N-13 CREAT-1.1 SODIUM-145
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-22 ANION GAP-15
[**2184-2-16**] 09:33AM estGFR-Using this
[**2184-2-16**] 09:33AM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.1
[**2184-2-16**] 09:33AM WBC-5.0 RBC-4.83 HGB-13.5* HCT-40.1 MCV-83
MCH-28.0 MCHC-33.7 RDW-13.7
[**2184-2-16**] 09:33AM PLT COUNT-214
Brief Hospital Course:
Pt was admitted to the hospital electively and brought to OR
where under general anesthesiaq he had replacement of his bone
flap. H etolerated this procedure well and was extubated and
transfered to the PACU for close neurologic monitoring. He had
post op head CT that should good appearance. On first post op
morning his diet and activity were advanced. His incision was
clean dry and intact with staples. H eremained neurologically
intact.
Medications on Admission:
lamotrigine
zonisamide
Discharge Medications:
1. 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*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): TAKE WHILE ON NARCOTICS.
Disp:*60 Capsule(s)* Refills:*0*
3. Lamotrigine 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Zonisamide 100 mg Capsule Sig: Five (5) Capsule PO HS (at
bedtime).
Discharge Disposition:
Home
Discharge Diagnosis:
s/p cranioplasty
Discharge Condition:
stable
Discharge Instructions:
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO YOUR PCP OFFICE ON [**2184-2-25**] DAYS FOR REMOVAL OF
YOUR STAPLES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST
YOUR APPOINTMENT WITH DR. [**First Name (STitle) **] SHOULD BE CANCELLED AS YOU SAW
HIM WHILE IN THE HOSPITAL
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2184-2-18**]
|
[
"345.11",
"355.8",
"327.23",
"738.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.03"
] |
icd9pcs
|
[
[
[]
]
] |
2747, 2753
|
1788, 2235
|
344, 358
|
2814, 2823
|
1393, 1765
|
4059, 4561
|
1150, 1184
|
2308, 2724
|
2774, 2793
|
2261, 2285
|
2847, 4036
|
1199, 1374
|
280, 306
|
386, 532
|
554, 862
|
878, 1134
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,554
| 167,466
|
26086
|
Discharge summary
|
report
|
Admission Date: [**2195-5-11**] Discharge Date: [**2195-5-12**]
Date of Birth: [**2123-12-1**] Sex: F
Service: MEDICINE
Allergies:
Diuril
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
carotid stenosis
Major Surgical or Invasive Procedure:
Right ICA stent
History of Present Illness:
71 year old woman with a complicated medical history including
but not limited to CAD s/p recent PCI, aortic stenosis,
Diabetes, HTN and carotid artery disease who was referred for
right carotid angiography and possible intervention. Per pt, her
ophthalmologist had noticed something in her left eye while
evaluating her for slowly decreasing visual acuity in that eye.
She was then referred byt her PCP for bilateral carotid
ultrasounds that revealed peak internal carotid artery
velocities on the right of 437/98 and on the left of 340/60
cm/sec with ratios of greater than 7 on the right and
approximately 2 on the left. From a neurovascular standpoint,
she has been asymptomatic and neurologically intact. She denies
any symptoms of amaurosis [**Last Name (LF) 64735**], [**First Name3 (LF) 691**] motor or sensory changes,
or any expressive or receptive aphasias.
.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock pain but does note LE
cramps after walking [**11-18**] block; no rest Sx. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
but she does have stable dyspnea on exertion, w/o paroxysmal
nocturnal dyspnea, orthopnea, recent ankle edema, palpitations,
syncope or presyncope.
.
Past Medical History:
Hypertension
CAD s/p RCA stenting [**2193**] (Cypher stent x 2 to ostial and mid
RCA, two bare metal stents to distal RCA)
Bilateral carotid artery disease
Aortic stenosis [**Location (un) 109**] 1.1cm and mean gradient 37
LE claudication
Possible COPD
Obstructive sleep apnea (not on CPAP)- uses 2 liters O2 at night
Diabetes
Hyperlipidemia
Left LE ORIF c/b infection
Glaucoma
GERD
s/p cataract surgery of right eye with lens replacement
Percutaneous coronary intervention, in [**2193**] anatomy as follows:
Cypher stent x 2 to ostial and mid RCA, two bare metal stents to
distal RCA
Social History:
Husband died in [**2192-3-17**] of cancer. She lives alone and has
three children who are very helpful. Her son is [**Name (NI) 4468**] [**Name (NI) **] and
her daughter [**Name (NI) **] [**Name (NI) **]. [**Doctor First Name 4468**] can be reached at
[**Telephone/Fax (1) 64736**]. [**Doctor First Name **] can be reached by cell phone at
[**Telephone/Fax (1) 64737**]. Patient has smoked >50 years. She used to smoke
two and a half to three packs a day. Currently smoking half a
pack a day. Min EtoH. Used to work as a bookeeper.
Family History:
(+) FHx CAD. Mother had CAD. Father had MI and died at 52.
Physical Exam:
VS: T 98.1 , BP 85/44 , HR 80 , RR 16 , 99% O2 % on 2L nC
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.
Neck: Supple with JVP of cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No S4, no S3.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles, wheeze,
rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP
Pertinent Results:
[**2195-5-11**] 06:45PM GLUCOSE-159* UREA N-16 CREAT-0.8 SODIUM-136
POTASSIUM-3.5 CHLORIDE-95* TOTAL CO2-32 ANION GAP-13
[**2195-5-11**] 06:45PM WBC-6.3 RBC-3.85* HGB-10.9* HCT-32.8* MCV-85
MCH-28.2 MCHC-33.1 RDW-14.3
[**2195-5-11**] 06:45PM estGFR-Using this
CARDIAC CATH performed on [**1-20**] demonstrated:
1. Selective coronary angiography of the right coronary artery
demonstrated a tortuous and mildly calcified artery with an 80%
ostial lesion, a mid vessel 90% lesion, and a distal 80% lesion.
2. Successful PCI of the ostial RCA (3.0 x 18 mm Cypher DES,
post-dilated with a 3.5 mm balloon), the mid-RCA (3.0 x 13 mm
Cypher DES), and the distal RCA (two overlapping 2.5 x 12 mm
Minivisions, post-dilated with a 2.75 mm balloon).
3. Right femoral angiography demonstrated diffuse disease in the
right external iliac artery/common femoral artery of up to
50-60%.
.
HEMODYNAMICS:
.
[**3-23**] carotid u/s: severe heterogenous calcified plaquing in
both carotid systems. Flow velocities in the right ICA suggest a
91-99% ICA stenosis. Flow velocities in the left ICA suggest a
71-90% ICA stenosis. Bilateral severe ECA stenosis. Vertebral
flow is antegrade on the right and retrograde on the left
suggestive of possible left sided subclavian stenosis.
.
[**2193-10-7**] echo: normal LVEF of 60%. Aortic stenosis with a mean
gradient of 36 mmHG. 1+ MR. Doppler evidence of diastolic
dysfunction.
.
ECG-NSR at 83, nl axis, TWI in I AVl V4-6 all present on old
ECG but more pronounced
.
Carotid angiography-90% stenosis of [**Country **] stented, full report to
follow
.
Brief Hospital Course:
Patient is a 71 year old woman with a complicated medical
history including but not limited to CAD s/p recent PCI, aortic
stenosis, Diabetes, HTN and carotid artery disease who was
referred for right carotid angiography and possible
intervention. On [**5-11**] the patient underwent stenting of her
right carotid artery and tolerated the procedure well. Metformin
was held prior to the procedure due to the dye load; she was
continued on glyburide while she was taking PO's and covered
with Humalog sliding scale. Avandia was also held given concern
for increased risk of [**Doctor First Name **] after the intervention. Atenolol was
held after the procedure due to increased vagal tone post
carotid stenting and was restarted upon discharge. After the
procedure she was treated with neosynephrine to maintain SBP
80-130 per Dr. [**First Name (STitle) **] recommendations given large discrepancy in
pressure between peripheral cuff pressures and aortic pressure;
this was weaned as tolerated. Frequent neuro exams were
performed without any abnormalities. The patient did not display
any signs or symptoms suggestive of cerebral ischemia or embolic
phenomenon.
While in the hospital the patient was continued on ASA, statin,
and plavix. She remained in NSR with no concerning changes on
telemetry monitoring.
The patient was maintained on a PPI and remaining outpatient
medications for the duration of admission.
Medications on Admission:
Oxygen 2 liters NC while sleeping
Aspirin 81mg daily every morning
Atenolol 25mg daily every morning
Avandia 8mg daily every morning
Vytorin 10/80mg daily every evening
Lasix 40mg daily every morning
Plavix 75mg daily every morning
Glyburide 5mg one tablet twice a day
Aciphex 20mg daily every morning
MVI daily every morning
Spiriva inhaler 18mcg one two puffs every morning
Timolol eye drops .5% one drop OU every morning
Metformin 500mg, one tablet twice a day
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
4. Vytorin [**8-/2168**] 10-80 mg Tablet Sig: One (1) Tablet PO once a
day.
5. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
6. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.
8. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
9. Avandia 8 mg Tablet Sig: One (1) Tablet PO once a day.
10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
11. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) Inhalation twice a day.
12. Aciphex 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Right Internal Carotid Artery Stenosis s/p Right internal
carotid artery stent
Discharge Condition:
Good
Discharge Instructions:
You were admitted for stenting of your carotid artery.
.
Please ensure that you take all of your medications as directed.
.
Please follow up as listed below.
.
Please contact your doctor or go to the nearest emergency room
if you experience any chest pain, shortness of breath, fever,
blurry vision, change in vision, headache, bleeding or any other
problems.
Followup Instructions:
Follow up with Dr. [**First Name (STitle) **]. Please contact Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **] at
([**Telephone/Fax (1) 7236**] to schedule an appointment.
.
Please make a follow-up appointment with your primary care
doctor in [**11-18**] weeks. [**Last Name (LF) **],[**First Name3 (LF) 1955**] M. [**Telephone/Fax (1) 3183**]
|
[
"424.1",
"433.10",
"401.9",
"V45.82",
"443.9",
"414.01",
"433.30",
"272.4",
"365.9",
"530.81",
"496",
"327.23",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.63",
"00.46",
"00.61",
"00.41"
] |
icd9pcs
|
[
[
[]
]
] |
8338, 8344
|
5535, 6952
|
284, 302
|
8467, 8474
|
3927, 5512
|
8883, 9254
|
3007, 3067
|
7466, 8315
|
8365, 8446
|
6978, 7443
|
8498, 8860
|
3082, 3908
|
228, 246
|
330, 1832
|
1854, 2442
|
2458, 2991
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,620
| 153,812
|
49842
|
Discharge summary
|
report
|
Admission Date: [**2167-9-22**] Discharge Date: [**2167-10-2**]
Date of Birth: [**2120-9-25**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Benzodiazepines / Percocet
Attending:[**First Name3 (LF) 1148**]
Chief Complaint:
Hyperglycemia, displaced nephroureteral stent
Major Surgical or Invasive Procedure:
1. Right cephalic vein PICC line placement on [**2167-9-24**] and
removal on [**2167-9-28**].
2. Nephroureteral stent replacement on [**2167-9-22**].
History of Present Illness:
46F with DM I, ESRD s/p LRT [**2163**] brought in from nursing home
with persistent hyperglycemia. During the night of [**9-21**], she was
noted to have fingersticks of >550. Her mental status appeared
to be at baseline, alert and chronically moaning. Her stat lab
glucose on the morning of [**9-22**] was 742. She was sent to [**Hospital1 18**]
for further management.
.
On admission the patient states she has pain "all over" but will
not answer other questions. Spoke to nursing staff at NH for
further history: No fever, abdominal pain, N/V, diarrhea, cough,
headache over the last few days. Complained of back pain over
the last day, has chronic back pain, given Vicodin. Has had
normal urine output, no hematuria, dark, or cloudy urine. Last
night, was more agitated, complaining of back pain, high blood
sugars as above. She was seen by IR on [**9-16**] where she had a
normal nephrostogram, and her nephrostomy tube was capped.
Past Medical History:
1. s/p LRT- ESRD [**1-22**] DM, failed 1st tx ([**2150**], lasted [**12-3**] yrs,
donor was sister), 2nd transplant from unrelated donor in [**10-23**],
postop course c/b Klebsiella UTI and ureteral necrosis requiring
stent and percutaneous nephrostomy tube in [**11-22**]
2. Type I DM- dx at age 10; c/b ESRD, severe neuropathy, chronic
heel ulcers, DKA, autonomic dysfunction; on Lantus as outpatient
3. Hypertension
4. Hypercholesterolemia
5. Hypothyroidism
6. s/p multiple AV access surgeries - hx. of AV fistula
infection
7. Squamous cell carcinoma of the vulva
8. Legally blind- impaired visually guided reaching, inability
to see the whole but only pieces at a time (simultanagnosia),
and impaired volitional saccades (optic apraxia) as evaulated by
Dr. [**First Name (STitle) 2523**] of neuroophthalmology likely related to her
tacrolimus toxicity
9. Osteoporosis
10. Posterior leukoencephalopathy [**1-22**] tacrolimus toxicity- found
by MRI during a prolonged hospital course in [**3-24**] c/b coma
requiring intubation, aspiration pneumonitis with methicillin
resistant Staphylococcus aureus and Aspergillus in her sputum
11. Psych- Narcotic and benzodiazepine dependence, eating
disorder, Depression, Personality disorder
12. Chronic constipation/diarrhea since her second transplant.
13. Shingles
Social History:
college graduate in English and social psychology and former
medical assistant. Lives in a NH since [**Month (only) 547**] after long hospital
stay. Sister [**Name (NI) 7798**] [**Name (NI) 5586**] [**Telephone/Fax (1) 104109**] is very involved in her
care and is HCP. Applying now for guardianship.
Family History:
Cancer; 1 uncle may be alcoholic; no other psych
Physical Exam:
Vitals- 96.1F HR 86 BP 140/90 RR 16 98%RA
General- awake, eyes closed, responsive, just finished eating
dinner by herself, hoping to listen to the TV
HEENT- Cushingoid face, R eye w/ surgical pupil, left pupil
sluggish but reactive, MMM, OP clear
Neck- obese neck, no thyromegaly, ?of buffalo hump, has thick
subcutaneous tissue on sides of neck, clavicular scar
Pulm- CTAB, very minimal crackles clear with deep inspiration
CV- Regular rate and rhythm, normal S1, S2
Abd- (+) BS, soft, obese, mild, diffuse TTP without rebound or
guarding, palpable left transplanted kidney, 30cm scar on RLQ
from previous kidney transplant, left nephrostomy with dressing
c/d/i and changed on [**9-25**]
Extrem- warm, well-perfused
Neuro-AAOx3. 5/5 strength throughout except in 4+/5 in deltoids
and 4+/5 on left side humeral. 2+ DTR in knees, ankle reflexes
absent, fingers with chronic stigmata of finger sticks, 1+
pitting edema in arms and legs. tissue paper skin, charcot feet.
Pertinent Results:
Admission Labs:
[**2167-9-22**] 11:00AM GLUCOSE-450* UREA N-72* CREAT-3.6*# SODIUM-122*
POTASSIUM-6.0* CHLORIDE-92* TOTAL CO2-20* ANION GAP-16
OSMOLAL-305 LACTATE-1.7
.
CK(CPK)-893* CK-MB-13* MB INDX-1.5 cTropnT-0.52*
.
WBC-8.0 RBC-3.20* HGB-9.8* HCT-28.7* MCV-90 MCH-30.6 MCHC-34.2
RDW-17.0*
PLT COUNT-236 NEUTS-85.0* LYMPHS-6.9* MONOS-7.0 EOS-0.9
BASOS-0.2
.
[**2167-9-22**] 11:34AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
.
[**2167-9-22**] 07:00PM CK(CPK)-1690* CK-MB-20* MB INDX-1.2
cTropnT-0.48*
.
MICRO:
URINE CULTURE (Final [**2167-9-23**]):
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
.
URINE CULTURE (Final [**2167-9-25**]): NO GROWTH.
.
URINE CULTURE (Final [**2167-9-27**]): NO GROWTH.
.
AEROBIC BOTTLE (Final [**2167-9-30**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 7087**] [**Last Name (NamePattern1) 394**], FA6B [**Numeric Identifier 28124**] @ 1626 ON
[**2167-9-23**].
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
WORK-UP SENSITIVITY PER DR. [**Last Name (STitle) 6531**],[**First Name3 (LF) **] PAGER [**Numeric Identifier 6532**]
[**2167-9-27**].
FINAL SENSITIVITIES.
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.
LINEZOLID 2 MCG/ML MINIMAL INHIBITORY CONCENTRATION:
= S.
Please contact the Microbiology Laboratory ([**6-/2467**])
immediately if
sensitivity to clindamycin is required on this
patient's isolate.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
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
ANAEROBIC BOTTLE (Final [**2167-9-27**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE
SET ONLY.
SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE.
.
AEROBIC BOTTLE (Final [**2167-9-30**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2167-9-30**]): NO GROWTH.
.
AEROBIC BOTTLE (Final [**2167-10-1**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2167-10-1**]): NO GROWTH.
.
CATH TIP-Patient pulled herself and thought to be ?contaminated.
WOUND CULTURE (Final [**2167-9-30**]):
DUE TO MIXED BACTERIAL TYPES ( >= 3 COLONY TYPES) NO
FURTHER WORKUP
WILL BE PERFORMED.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies.
Isolate(s) identified and susceptibility testing
performed because
of concomitant positive blood culture(s) Comparison of
the
susceptibility patterns may be helpful to assess
clinical
significance.
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.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. <15 colonies.
Isolate(s) identified and susceptibility testing
performed because
of concomitant positive blood culture(s) sensitivity to
clindamycin is required on this patient's isolate.
SECOND STRAIN.
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.
.
.
*STUDIES*
[**2167-9-22**]: CXR: No evidence of pneumonia.
[**2167-9-22**]: Renal US: No hydronephrosis. Linear echogenic foci in
transplanted renal collecting system. Some of these could be the
patient's catheter. Others are likely air bubbles, either
related to catheter manipulation or potentially urinary tract
infection.
[**2167-9-22**]: EKG: Sinus rhythm. Compared to the previous tracing of
[**2167-1-13**] there are new downsloping ST segment depressions and T
wave inversions in leads I and aVL. Downsloping ST segment
depressions in leads V5-V6. These findings are consistent with
active lateral ischemic process.
[**2167-9-23**]: EKG: Sinus rhythm. Compared to the previous tracing of
[**2167-9-22**] the ischemic appearing ST segment abnormalities are less
prominent in leads I, aVL and leads V4-V6. However, there is ST
segment flattening. Rule out myocardial infarction. Followup and
clinical correlation are suggested.
.
[**2167-9-30**] Echo:
Conclusions:
1. The left atrium is normal in size. The left atrium is
elongated.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Regional left ventricular
wall motion is normal. Overall left ventricular systolic
function is normal (LVEF>55%).
3. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No masses or vegetations are seen on the
aortic valve. No aortic regurgitation is seen.
4.The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen.
5. Moderate to severe [3+] tricuspid regurgitation is seen.
6.There is severe pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
Impression: No echocardiographic evidence of endocarditis.
.
[**2167-10-1**]-UENIs: 1. No evidence of left upper extremity DVT.
Right subclavian, axillary, and brachial veins appear patent. 2.
Right internal jugular not visualized. 3. Right AV graft seen,
without evidence of flow consistent with occlusion.
Brief Hospital Course:
*ED COURSE:
VS on presentation were T 97.1, HR 61, BP 106/50, RR 20, O2sat
97% RA, FS 496. Her creatinine was 3.6, K 6.0, Na 122, CK 893,
tropT 0.52, WBC 8.0, lactate 1.7. A Foley was placed, with smal
amount of very cloudy white output, sent for UA and culture.
Blood cultures were sent and CXR was performed. Her SBP was
92-107 in the ED. A R femoral TLC was placed. She received
insulin 10U IV, NaHCO3 1 amp, vancomycin 1g IV, ASA 325mg, 1L NS
bolus, and 1L NS at 100mL/hr. FS came down to 355.
.
*MICU COURSE:
Patient was treated for hyperglycemia, nephrostomy tube was
replaced by IR on [**9-22**] and capped on [**9-24**]. She was treated for
UTI and bacteremia with vancomycin and meropenum started on
[**9-23**]. She was stable in the unit and called out on [**9-25**] to the
internal medicine team. Renal and renal transplant were
involved in the patient's care. CXR was unremarkable. EKG
showed some ischemic changes that appeared to be resolving.
.
*REMAINDER OF HOSPITAL STAY*
1) S/p Renal Transplant/Nephrostomy tube: Patient had her
nephrostomy tube replaced and capped. During her
hospitalization she had no evidence of leakage. The renal
transplant team followed her. They debated nucleotide renal
scan, but it was delayed secondary to access issues. She will
be seen by renal transplant as an outpatient on [**10-16**]. Patient
was maintained on cyclosporine which was increased. She will
need a cyclosporine level on [**2167-10-6**] for follow up.
Azathioprine was restarted on [**9-26**].
.
2) Acute renal failure in transplanted kidney: Patient presented
with Cr of 3.6 which has decreased to 1.9-2.3(baseline 2.4) with
hydration. Thought to be secondary to dehydration from
hyperglycemia. Her creatinine trend at discharge was 1.9 to 2.1
to 2.3 after restarting her home dose of furosemide for
extremity edema. These values are still below her baseline of
2.4 but she should be carefully managed.
.
3) DM/Hyperglycemia: Glucose on presentation was >550, but she
did not have an anion gap or ketones in her urine. She was
controlled on insulin injections (no insulin drip). She was
initially placed on her home doses of Glargine 10 QAM, 13 QPM
and HumalogISS. Her insulin was decreased secondary to episodes
of hypoglycemia (possibly secondary to an interaction with
linezolid). [**Last Name (un) **] was consulted and recommended 6 QAM, 10 QPM
and a reduced sliding scale. This may need to be adjusted again
once she finishes the antibiotic.
.
4) Bacteremia: Had one set of blood cultures from ED on [**9-22**]
that were positive for Coag negative Staph. It remained unclear
whether this represented true bacteremia or just a skin
contaminant. Patient had no leukocytosis or fever. Blood
cultures from [**9-24**], [**9-25**] were negative. She self discontinued
her PICC line and tip was cultured and also grew coag negative
staph. ID was consulted and recommended linezolid x 7 days.
.
5) UTI: It was reported that patient presented with frank pus in
urine and nephrostomy tube out of place. Admission UA had mod
leuks, RBCs, WBCs, bacteria but culture grew mixed flora
consistent with fecal contamination. Repeat UAs were unchanged.
Repeat Urine cultures were negative ([**9-24**]) and pending ([**9-25**]).
The patient was initially started on meropenem because of a
history of resistant E.coli UTI. On [**9-26**], meropenem was
stoppped because of low suspicion of UTI.
.
6) Elevated troponin: Troponin-T was elevated at 0.52 on
admission, and EKG was showed some ST changes in lateral leads.
Repeat EKG on [**9-23**] changes. Troponin T
trended downward from 0.52 to 0.30 on [**9-26**]. CK-MB was 13 and
then 20 on [**9-22**] and then decreased to 3 by [**9-26**]. CK was
elevated and normalized as well. Troponin thought to have been
elevated because of ESRD. Patient had no symptoms of acute
coronary syndrome. Repeat EKG on [**9-26**] was unremarkable.
.
7) Hypothroidism: Last TSH was 4.2 in [**2165**]. TSH on [**9-26**] was 6.6
but with a normal free T4 of 1.3. Patient was continued on
levothyroxine 112mcg.
.
8) Psych: Has narcotic/benzo issues, Depression, personality
disorder, eating disorder, and chronic pain. Psychiatric issues
remained stable during hospitalization, and she was maintained
on risperidal, ambien qhs PRN insomnia and vicodin PRN pain.
.
9) Anemia: HCT had been stable at 28-31 since [**7-26**]. Anemia is
likely secondary to renal disease/ or anemia of chronic disease.
.
10) HTN: Patient's metoprolol was discontinued in the MICU
because of borderline low blood pressures on [**9-22**] and [**9-23**] in
MICU. Upon transfer out of the MICU, the patient's blood
pressures returned to 120-160 systolic and metropolol was
restarted.
.
11) Code status: DNR/DNI, confirmed with HCP
.
12) Communication: sister is [**Name (NI) 3508**] [**Name (NI) 7798**] [**Name (NI) 5586**] ([**Telephone/Fax (1) 104140**]
(home), ([**Telephone/Fax (1) 104141**] (cell)
Medications on Admission:
Azathioprine 50mg qd
Cyclosporine 50mg q12h
Levothyroxine 112mcg qd
Furosemide 80mg qd
Lantus 10U qam, 13U qhs
Prilosec 40mg qd
Metoprolol 25mg [**Hospital1 **]
Risperdal 1mg [**Hospital1 **]
Colace 100mg [**Hospital1 **]
Senna 1 tab qhs
Novolin sliding scale
Immodium prn
Albuterol MDI prn
Lunesta 2mg qhs prn
Vicodin prn
Tylenol prn
Discharge Medications:
1. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed.
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. Insulin Glargine 100 unit/mL Solution Sig: One (1) 6 units
Subcutaneous QAM.
7. Insulin Glargine 100 unit/mL Solution Sig: One (1) 10 units
Subcutaneous at bedtime.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for back pain.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Humalog 100 unit/mL Solution Sig: sliding scale units
Subcutaneous four times a day: Before meals (breakfast, lunch,
dinner) <120 0U; 121-160 2U; 161-200 3U; 201-240 4U; 241-280 5U;
281-320 6U; 321-360 7U; > 361 8U. Before bed: <200 0U; 201-240
1U; 241-280 2U; 281-320 3U; 321-360 4U; > 361 5U. .
13. LUNESTA 2 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
14. Cyclosporine 25 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours): Please check level on [**10-7**].
15. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours) for 9 doses.
Discharge Disposition:
Extended Care
Facility:
HUNT RETIREMENT HOME
Discharge Diagnosis:
Primary
Hyperglycemia
Bacteremia (Coag negative staph)
Diabetes Type I
ESRD s/p kidney transplant
Secondary
anemia
hypothyroidism
Discharge Condition:
Good
Discharge Instructions:
Call or return to hospital if you experience any of the
following
symptoms: urine leaking from nephrostomy tube, fever, chills,
nausea, vomiting, diarrhea, chest pain, shortness of breath or
any other symptoms concerning to you.
Followup Instructions:
1. Please see Dr. [**Last Name (STitle) 9978**] on [**10-6**] at 11:30am. Please have
her check your cyclosporine level and a chem 10.
.
2. Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2167-10-16**] 10:30
|
[
"272.0",
"599.0",
"250.43",
"790.7",
"285.21",
"337.1",
"584.9",
"244.9",
"733.00",
"276.7",
"397.0",
"401.9",
"996.81",
"E878.0",
"276.51",
"250.63"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"55.93"
] |
icd9pcs
|
[
[
[]
]
] |
17209, 17256
|
10264, 15199
|
348, 500
|
17430, 17437
|
4194, 4194
|
17714, 18011
|
3138, 3189
|
15585, 17186
|
17277, 17409
|
15225, 15562
|
17461, 17691
|
3204, 4175
|
263, 310
|
528, 1467
|
4210, 10241
|
1489, 2803
|
2819, 3122
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,550
| 157,358
|
24812
|
Discharge summary
|
report
|
Admission Date: [**2128-1-5**] Discharge Date: [**2128-1-11**]
Date of Birth: [**2055-7-13**] Sex: M
Service: CARDIOTHORACIC
Allergies:
lisinopril
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2128-1-5**]
Coronary Artery Bypass Graft Surgery x 2 Left internal mammory
artery to Left anterior descending artery, reverse saphenous
vein graft to posterior descending artery
History of Present Illness:
72yo man with dyspnea on exertion for last several months. Also
notes occasional palpitation and occasionally lightheaded. He is
relatively sedentary because of chronic knee pain. Does note
dyspnea w/minimal activity such as walking around house or
showering. Cath shows multi-vessel CAD with depressed
EF 30-35%. MRI reports mixed viability with low-intermediate
likelihood of recovery. He presented for surgical evaluation.
Past Medical History:
Chronic Systolic Heart Failure
Hypertension
Hypercholesterolemia
Prostate CA s/p TURP and Radiation ([**2121**])
incontinence
cataracts
Past Surgical History:
Left Shoulder surgery
Knee surgery x3 (left)
Prostate surgery
Drainage of cyst on chest
Social History:
Married w/3 children
Race: Caucasian
Last Dental Exam: last week
Lives with: wife
Occupation: retired accts manager
Tobacco: 1PPD quit 5 yrs ago
ETOH: rare
Family History:
Mother died at 49yo/MI
Physical Exam:
Pulse: 66 Resp: O2 sat: 97%-RA
B/P Right: 144/86 Left:
Height: 5'3" Weight: 187 lbs/84.8 kg
General: NAD, WGWN, overweight, appears stated age
Skin: Dry [x] intact [x] 1" x .25" cyst mid-sternum, no erythema
or rash
HEENT: PERRLA [] EOMI [x] pupils fixed- cataracts
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [] non-distended [x] non-tender [x] bowel sounds
+
[x] obese
Extremities: Warm [x], well-perfused [x]
Edema- trace
Varicosities: None [x]
well healed surgical scars on left knee
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: Left:
no bruits
Pertinent Results:
[**2128-1-8**] 06:32AM BLOOD WBC-11.1* RBC-3.28* Hgb-9.4* Hct-28.3*
MCV-86 MCH-28.8 MCHC-33.3 RDW-14.7 Plt Ct-139*
[**2128-1-8**] 06:32AM BLOOD Glucose-130* UreaN-22* Creat-1.1 Na-135
K-3.9 Cl-100 HCO3-32 AnGap-7*
[**2128-1-7**] 05:35AM BLOOD WBC-12.3* RBC-3.43* Hgb-10.1* Hct-30.1*
MCV-88 MCH-29.5 MCHC-33.6 RDW-14.9 Plt Ct-124*
[**2128-1-7**] 05:35AM BLOOD Glucose-86 UreaN-17 Creat-1.1 Na-136
K-4.1 Cl-102 HCO3-28 AnGap-10
Intraop TEE [**2128-1-5**]
PRE-CPB:1. The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is top normal/borderline dilated.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are three aortic valve leaflets. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen.
5. Physiologic mitral regurgitation is seen (within normal
limits).
POST-CPB: On infusion of phenylephrine. AV pacing for slow
ventricular rate. Preserved biventricular systolic function from
pre-cpb. LVEF = 35%. MR is now trace. Aortic contour is normal
post decannulation
Brief Hospital Course:
The patient was admitted to the hospital and brought to the
operating room on [**2128-1-5**] where the patient underwent coronary
Artery Bypass Graft Surgery x 2 Left internal mammory artery to
Left anterior descending artery, reverse saphenous vein graft to
posterior descending artery. See operative note for full
details. Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring. POD 1 found the
patient extubated, alert and oriented and breathing comfortably.
The patient was neurologically intact and hemodynamically
stable on no inotropic or vasopressor support. Beta blocker was
initiated and titrated up as blood pressure tolerated and the
patient was gently diuresed toward the preoperative weight. He
did go into atrial fibrillation and was loaded with Amiodarone.
After 24 hours of paroxysmal atrial fibrillatiion, he was
started on Coumadin on post operative day 3. Coumadin follow up
with INR goal of [**12-25**] was arranged with this PCP Dr [**First Name (STitle) **]. The
patient was transferred to the telemetry floor for further
recovery. Chest tubes and pacing wires were discontinued without
complication per protocol. The patient was evaluated by the
physical therapy service for assistance with strength and
mobility. By the time of discharge on POD **** the patient was
ambulating freely, the wound was healing and pain was controlled
with oral analgesics. The patient was discharged home with VNA
services in good condition with appropriate follow up
instructions.
Medications on Admission:
Doxazosin 8 qd
Zocor 40 QD
ASA 81 QD
Losartan 50mg daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
7. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 7 days: then swith to 200 mg qd untill follow up.
Disp:*44 Tablet(s)* Refills:*0*
8. doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
9. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO once a day: PCP
to follow INR goal is [**12-25**].
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right and Left - healing well, no erythema or drainage.
1+ Edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr [**Last Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2128-1-22**]
2:30
Cardiologist: Dr [**Last Name (STitle) 5874**] on [**2128-1-26**] @ 1:30
Please call to schedule appointments with your
Primary Care Dr. [**First Name (STitle) **] in [**2-24**] weeks [**Telephone/Fax (1) 8036**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication A fib
Goal INR 2.0-3.0
First draw [**2128-1-11**]
Results to phone Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 8036**]
Completed by:[**2128-1-11**]
|
[
"428.0",
"272.0",
"414.01",
"428.22",
"V58.67",
"458.29",
"719.46",
"427.31",
"278.00",
"401.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
6300, 6359
|
3458, 5057
|
296, 479
|
6427, 6655
|
2259, 3435
|
7495, 8233
|
1400, 1425
|
5165, 6277
|
6380, 6406
|
5083, 5142
|
6679, 7472
|
1120, 1210
|
1440, 2240
|
237, 258
|
507, 939
|
961, 1097
|
1226, 1384
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,641
| 142,150
|
53300
|
Discharge summary
|
report
|
Admission Date: [**2126-12-27**] Discharge Date: [**2127-1-1**]
Date of Birth: [**2054-3-19**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
Left-sided craniotomy for resection,
decompression, adhesiolysis.
History of Present Illness:
72F with fall in [**2126-11-19**] with resulting B SDH. L SDH
evacuated by Dr. [**Last Name (STitle) 548**] on [**12-12**]. Sent to rehab and developed a L
proximal DVT. Repeat head CT on [**12-23**] showed no progression of
SDHs so started on coumadin. Sent in from rehab today for
altered mental status - not feeding self and more disoriented.
No history of trauma. Denies Nausea, vomiting, abd pain, HA, or
changes in vision. History somewhat limited by slowed mental
status.
Past Medical History:
Anxiety, Bipolar
B/L SDH s/p evacuation [**2126-12-15**]
Social History:
-Lives alone in [**First Name4 (NamePattern1) 3340**] [**Last Name (NamePattern1) 19128**]. Originally from [**University/College **] has
lived in US many years >40yrs.
-Denies TOB, or ETOH.
Family History:
NC
Physical Exam:
PHYSICAL EXAM upon admission:
T: afebrile BP: 126/52 HR: 50 R 13 100 O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 5 to 3 EOMI
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: drowsy but arousable and cooperative with exam,
normal affect.
Orientation: With minimal help is oriented to person, place, and
date.
Language: Speech fluent with decreased comprehension that could
be due to decreased comprehension or slight language barrier.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength 4/5 Right Deltoid otherwise full power [**3-24**]
throughout.
Sensation: Intact to light touch all 4 ext.
Reflexes: B T Br Pa Ac
Right 2+, 2+
Left 2+, 2+
Toes downgoing bilaterally
Coordination: dysmetria with finger-nose-finger movements
Pertinent Results:
BILATERAL LOWER EXTREMITY VENOUS ULTRASOUND [**2126-12-27**]:
Grayscale and Doppler son[**Name (NI) 1417**] of the right and left common
femoral, superficial femoral, and popliteal veins were
performed. Normal augmentation, compressibility, waveforms and
flow were demonstrated. There is no evidence of intraluminal
thrombus. Note is made of paired superficial femoral veins on
the left.
IMPRESSION: No evidence of DVT within the lower extremities
bilaterally.
CT HEAD WITHOUT CONTRAST, [**2126-12-27**] 9:05 AM
HISTORY: Rebleeding into subdural hematoma.
Contiguous axial images were obtained through the brain. No
contrast was administered. Comparison to a head CT scan
performed earlier on [**12-27**].
FINDINGS: There have been no significant changes since the prior
study. Again identified are bilateral chronic-appearing subdural
hematomas with fresh blood in the left frontal collection. Left
to right midline shift persists. There is no evidence of new
hemorrhage in the interval from midnight until 9:00 a.m.
CONCLUSION: No change since the head CT performed earlier on
[**2126-12-27**]. Again seen are bilateral subdural hematomas
that appear chronic with superimposed acute hemorrhage on the
left. Left hemispheric mass effect and left to right shift
persist, unchanged.
CT HEAD W/O CONTRAST [**2126-12-27**] 12:04 AM
FINDINGS:
On the left, there has been an increase in size of the left
subdural fluid collection with new layering hyperdensity seen
within an anterior compartment to this subdural as well as a
posterior compartment. These findings are concerning for acute
on chronic subdural hematoma.
On the right, there is a stable moderate-sized hypodense
subdural fluid collection consistent with evolving subacute
subdural hematoma located along the frontoparietal and temporal
region.
There is a greater shift of the midline rightward with 6 mm of
shift, previously 4 mm, at the same level the left subdural
hematoma measures 19 mm in width, previously 17 mm. There is no
evidence of mass effect exerted on the basal cisterns. There is
no hydrocephalus. The patient is status post burr hole placement
in left frontal lobe and presumed evacuation.
IMPRESSION:
1. Worsened left large subdural hematoma with slightly increased
rightward shift of the midline and mild subfalcine herniation of
the left frontal lobe.
2. New blood within large left subdural hematomas, indicating
acute on subacute/chronic bleed.
CT HEAD W/O CONTRAST [**2126-12-30**] 7:04 PM
FINDINGS: Compared to the prior study of [**2126-12-27**] at 9:06 a.m.,
there is a new left frontal craniotomy. Again demonstrated is
the mixed density subdural collection extending around the left
cerebral convexity, which measures maximal thickness of 19 mm
similar to the prior study. As before, there are areas of
hyperdensity within the collection consistent with more recent
hemorrhage. Compared to [**2126-12-27**] at 9:06 a.m., there are
a few small subcentimeter punctate hyperdense foci posteriorly
in the left subdural collection consistent with new small foci
of hemorrhage. There is expected pneumocephalus layering along
the left frontal lobe. Again seen is the right subdural
collection, which is also mixed density, which as before on
[**2126-12-27**] has relative higher density material
peripherally consistent with more recent hemorrhage. This
collection is similar in size to the prior study measuring
maximal thickness of about 16 mm. There remains rightward shift
of the septum pellucidum by about 5 mm similar to the recent
study. The ventricular system is stable in size and
configuration. The basilar cisterns are not effaced. There is no
evidence of new major vascular territorial infarction. There
remains mucosal thickening and fluid within the right sphenoid
sinus air cell.
IMPRESSION:
1. No appreciable change in size of bilateral subdural acute on
chronic hematomas. Compared to [**2126-12-27**] at 9:06 a.m., there are a
few small punctate hyperdense foci layering posteriorly in the
subdural collection on the left consistent with more recent
hemorrhage. New pneumocephalus.
2. Stable rightward subfalcine herniation.
Brief Hospital Course:
The patient was re-admitted with a SDH that had re-accumulated.
Initially she was admitted to the ICU. The patient had been on
coumadin for a left DVT that was found on her previous
admission. She had LENIs on the day of re-admission, which were
negative so her coumadin was discontinued. The patient was
neurologically doing well so she was transferred to the floor on
[**2126-12-28**]. On [**2126-12-30**] the patient was taken to the OR for a
craniotomy for SDH evacuation. Post-operatively she did have
some confusion but was oriented x 3 with some assistance. She
was following commands with all extremities. The patient stayed
in the PACU overnight and was transferred back to the floor on
[**2126-12-31**]. She continued to improve neurologically. She was
evaluated by physical therapy and occupational therapy who
recommended rehab. On [**2127-1-1**] she was oriented x 3, PERRL, no
pronator drift. Her RLE was [**2-22**] and her left IP was [**2-22**]. Her
right biceps and triceps were 5- and she was full strength
everywhere else. The patient was deemed safe to be discharged
and went to rehab on [**2127-1-1**].
Medications on Admission:
Phenytoin 50 TID
Coumadin
Levothyroxine 50mcg
Omeprazole 20
Trazadone 50 hs
Docusate
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day) as needed for bipolar.
7. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
9. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
10. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day) for 8 doses.
11. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 4 doses.
12. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
13. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
left SDH
Discharge Condition:
neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after staples have been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR
STAPLES. Please call the office to make an appointment.
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS. You will need a non-contrast head
CT at that time.
You had lower extremity dopplers which showed that that your
deep vein thrombosis has resolved. Please follow-up with your
PCP [**Name Initial (PRE) 176**] 2 weeks for completion of care.
Completed by:[**2127-1-1**]
|
[
"432.1",
"300.00",
"348.4",
"E934.2",
"296.80"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
9260, 9330
|
6777, 7902
|
341, 409
|
9383, 9407
|
2614, 6754
|
10778, 11286
|
1230, 1234
|
8038, 9237
|
9351, 9362
|
7928, 8015
|
9431, 10755
|
1249, 1265
|
280, 303
|
437, 924
|
1859, 2595
|
1279, 1516
|
1531, 1843
|
946, 1005
|
1021, 1214
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,571
| 117,918
|
54867
|
Discharge summary
|
report
|
Admission Date: [**2103-7-5**] Discharge Date: [**2103-7-26**]
Date of Birth: [**2037-2-24**] Sex: M
Service: SURGERY
Allergies:
Precedex
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
chronic mesenteric ischemia
Major Surgical or Invasive Procedure:
Mesenteric Angio [**7-9**]
R heart cath [**7-11**]
Open Antegrade Superior Mesenteric Artery bypass with graft
[**2103-7-12**]
History of Present Illness:
66M with PVD and left fem to PT bypass with RGSV four months
ago for claudication who presented to an outside hospital
several
days ago with one month of intermittent abdominal pain and 100
pound weight loss over the past three years and 20 pounds over
the last month. Imaging was concerning for celiac and SMA
stenosis with infra-renal aortic aneurysm and bilateral renal
artery infarcts. Catheterization was attempted but aborted given
SMA occlusion. Given multiple comorbid conditions and the
complexity of his disease, he was transferred to [**Hospital1 18**] for
further management. At [**Hospital1 18**] he reports chronic abdominal pain
which is rather diffuse. He states that it has been worse over
the past week, is exacerbated by eating and is associated with
diarrhea. He reports that his claudication resolved after his
lower extremity bypass.
Past Medical History:
CAD w severe MI ten years ago, CHF, Grave's disease
treated with PTU, SBO, history of [**Last Name (un) **] now resolved, COPD, afib
(hx of coum), parastomal hernia, renal infarct, SMA stenosis,
active smoker (75 pack yr; cut down to 4-5/day), cirrhosis, Pulm
htn, right heart strain, ischemic left leg
Social History:
100 pack year smoking history. heavy history of etoh with
over 24 beverages consumed daily but has not had an alcoholic
beverage in several years
Family History:
sister with lung cancer at 37 yeras of age and another sister
with stomach cancer in 70's. Brother with CAD.
Physical Exam:
At time of admission:
Vital Signs: 98.1 80 133/85 20 98 RA
General: awake, alert, NAD
HEENT: NCAT, EOMI, anicteric
Heart: RRR, NMRG
Lungs: wheezes bilaterally
Abdomen: soft, mildly tender to palpation in epigastrium
Extremities: right foot is warm, left foot is slightly cooler.
well-healed bypass incision along LLE. cap refill < 2 seconds.
Pulse Exam (P=Palpation, D=Dopplerable, N=None)
RLE Femoral: P. Popiteal: P. DP: N. PT: D.
LLE Femoral: P. Popiteal: N. DP: N. PT: D.
Pertinent Results:
PFTS:
SPIROMETRY 8:37 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred %chg
FVC 2.27 4.18 54
FEV1 1.74 2.88 61
MMF 1.66 2.74 61
FEV1/FVC 77 69 111
LUNG VOLUMES 8:37 AM Pre drug Post drug
Actual Pred %Pred Actual %Pred
TLC 4.74 6.52 73
FRC 3.84 3.68 104
RV 2.51 2.34 107
VC 2.25 4.18 54
IC 0.90 2.83 32
ERV 1.33 1.34 99
RV/TLC 53 36 148
He Mix Time 2.50
DLCO 8:37 AM
Actual Pred %Pred
DSB 11.35 25.24 45
VA(sb) 4.49 6.52 69
HB 14.00
DSB(HB) 11.55 25.24 46
DL/VA 2.57 3.87 66
NOTES:
Dx: SOB, Pre-operatory Assessment Medication: Unidentified
inhaler not
taken prior to testing BMI: 21 Hgb: 14.0 ([**2103-7-10**]) Good
test
quality and reproducibility for spirometry and lung volumes.
FVC may be
underestimated due to early termination of exhalation in all
efforts. Effort
reported is a composite. SVC is likely underestimated due to
early
termination of exhalation in all efforts. Good/fair test
quality with poor
reproducibility for diffusion capacity. only one effort
reported due to
unreportable test quality in all other efforts.
Mechanics: The FVC and FEV1 are moderately reduced. The
FEV1/FVC ratio is
elevated.
Flow-Volume Loop: Moderate restrictive pattern with an abrupt
and early
termination of exhalation.
Lung Volumes: The TLC is mildly reduced. The FRC and RV are
normal. The
RV/TLC ratio is elevated.
DLCO: The Diffusing Capacity corrected for hemoglobin is
moderately reduced.
Impression:
Mild restrictive ventilatory defect with a moderate gas
exchange defect.
The FVC is likely underestimated due to an early termination
of exhalation
and for this reason a coexisting obstructive component cannot
be excluded.
There are no prior studies available for comparison.
Right heart cath [**6-/2103**]: HEMODYNAMICS RESULTS BODY SURFACE AREA:
1.73 m2
HEMOGLOBIN: 14 gms %
FICK 100% FIO2 NITRIC OXIDE
**PRESSURES
RIGHT ATRIUM {a/v/m} */[**8-30**]
RIGHT VENTRICLE {s/ed} 48/12
PULMONARY ARTERY {s/d/m} 48/24/34 47/20/34 42/19/30
PULMONARY WEDGE {a/v/m} */18/14 */30/24 */17/15
**CARDIAC OUTPUT
CARD. OP/IND FICK {l/mn/m2} 2.08 2.43 2.31
**RESISTANCES
PULMONARY VASC. RESISTANCE 444 301
FICK 100% FIO2 NITRIC OXIDE
**% SATURATION DATA (NL)
SVC LOW 63
PA MAIN 64 76 75
AO 96 99 100
**ARTERIAL BLOOD GAS
INSPIRED O2 CONCENTR'N 100 100
pO2 49 47
OTHER HEMODYNAMIC DATA: The oxygen consumption was assumed.
TECHNICAL FACTORS:
Total time (Lidocaine to test complete) = 2 hours 18 minutes.
Arterial time =
Fluoro time = 36 minutes.
Effective Equivalent Dose Index (mGy) = 208 mGy.
Contrast injected:
None
Premedications:
Midazolam 0.5 mg IV
Fentanyl 25 mcg IV
Anesthesia:
1% Lidocaine subq.
Cardiac Cath Supplies Used:
- [**Company **], MAGIC TORQUE 180CM
- ALLEGIANCE, CUSTOM STERILE PACK
- MERIT, RIGHT HEART KIT
4FR TERUMO, GLIDESHEATH
7FR [**Company **], PULMONARY WEDGE PRESSURE CATHETER
5FR ARROW, BALLOON WEDGE PRESSURE CATHETER 110CM
COMMENTS:
1. Resting hemodynamics had marked variation due to atrial
fibrillation
and respiration. Resting measurements revealed a maximal PASP 58
mmHg
with an average of 48 mmHg, a mean PA pressure of 34 mmHg, and a
mean
PCWP of 14 mmHg.
2. Measurements on 100% FiO2 were obtained after over 50 minutes
due to
difficulties with arterial access and ability to record a wedge
pressure
with the PA catheter. The average PASP was 47 mmHg with a
maximal value
of 60 mmHg with a mean PA pressure of 34 mmHg. The PCWP was
measured to
be 24 mmHg but this was most likely a damped PA [**Location (un) 1131**] and not
a true
wedge pressure given subsequent PCWP after 100% inhaled NO.
3. With 100% inhaled NO, the PCWP was 15 mm Hg. There was a mild
improvement in PASP with an average of 42 mmHg, 52 mmHg maximal,
and
mean PA 30 mmHg. PVR improved from a baseline of 5.55 [**Doctor Last Name **] to 3.76
[**Doctor Last Name **].
FINAL DIAGNOSIS:
1. Mild to moderate pulmonary arterial hypertension with mild
elevation
of PCW at baseline (consistent with mild left ventricular
diastolic
dysfunction) and severely elevated PVR (using assumed oxygen
consumption).
2. Technically challenging RHC and vasodilator study due to
extreme
difficulty delivering catheters into the PCW position, requiring
>30
minutes of effort and 3 different catheters.
3. No improvement in PA pressure with 100% O2.
4. Mild improvement in PA systolic pressure, mean PA pressure
and PVR
with addition of inhaled nitric oxide 40 ppm to 100% O2.
5. No evidence of right-to-left or left-to-right shunts.
6. Additional plans per Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 1391**].
Echo: Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.3 cm <= 5.2 cm
Left Atrium - Peak Pulm Vein S: 0.7 m/s
Right Atrium - Four Chamber Length: *6.7 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *0.5 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *6.0 cm <= 5.6 cm
Left Ventricle - Systolic Dimension: 4.7 cm
Left Ventricle - Fractional Shortening: *0.22 >= 0.29
Left Ventricle - Ejection Fraction: 45% >= 55%
Left Ventricle - Stroke Volume: 45 ml/beat
Left Ventricle - Cardiac Output: 3.69 L/min
Left Ventricle - Cardiac Index: 2.03 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.09 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': *0.07 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 13 < 15
Aorta - Sinus Level: 3.1 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.0 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 13
Aortic Valve - LVOT diam: 2.1 cm
Mitral Valve - E Wave: 1.0 m/sec
Mitral Valve - E Wave deceleration time: 151 ms 140-250 ms
TR Gradient (+ RA = PASP): *40 to 42 mm Hg <= 25 mm Hg
Pulmonic Valve - Peak Velocity: 0.9 m/sec <= 1.5 m/sec
Findings
pt intubated on vent.
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA. A
catheter or pacing wire is seen in the RA and extending into the
RV.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Mild regional LV systolic dysfunction. No LV
mass/thrombus. No resting LVOT gradient. No VSD.
RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV
systolic function.
AORTA: Mildly dilated ascending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. No
MS. Mild (1+) MR.
TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. No
TS. Mild [1+] TR. Moderate PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: No PS.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity is moderately dilated.
There is mild regional left ventricular systolic dysfunction
with infero-lateral akinesis. No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. The
right ventricular cavity is mildly dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
NAIS: Doppler waveform analysis reveals monophasic waveforms at
the
common femoral, superficial femoral and popliteal arteries
bilaterally. The
right DP and PT are monophasic. The left DP and PT are absent.
The right ABI
is 0.7, the left ABI is 0.
Pulse volume recordings show dampening in the thigh bilaterally,
worse on the
left than the right. There is appropriate calf augmentation and
only mild
additional dampening at the right metatarsal. On the left,
there is
substantially dampened waveform in the thigh with further
dampening at the
calf and nearly flat trace at the ankle and a flat trace at the
metatarsal.
IMPRESSION: Bilateral aortoiliac disease and severe left SFA
and tibial
disease.
[**2103-7-26**] 04:52AM BLOOD WBC-6.7 RBC-2.83* Hgb-8.8* Hct-27.9*
MCV-99* MCH-31.1 MCHC-31.5 RDW-16.8* Plt Ct-370
[**2103-7-26**] 04:52AM BLOOD Plt Ct-370
[**2103-7-26**] 04:52AM BLOOD PT-17.2* INR(PT)-1.6*
[**2103-7-25**] 05:04AM BLOOD Plt Ct-334
[**2103-7-25**] 05:04AM BLOOD PT-17.5* PTT-33.1 INR(PT)-1.6*
[**2103-7-24**] 03:31AM BLOOD Plt Ct-268
[**2103-7-24**] 03:31AM BLOOD PT-19.9* PTT-32.8 INR(PT)-1.9*
[**2103-7-25**] 05:04AM BLOOD Glucose-112* UreaN-57* Creat-0.8 Na-140
K-4.8 Cl-109* HCO3-23 AnGap-13
[**2103-7-20**] 03:47AM BLOOD ALT-46* AST-74* LD(LDH)-221 AlkPhos-174*
Amylase-52 TotBili-2.0*
Brief Hospital Course:
Patient was admitted to the vascular surgery service after being
transferred from OSH for further managment of Mesenteric
ischemia on [**7-6**]. He was made NPO and TPn started as well as a
heparin drip given a fib and thrombectomy of recent LLE bypass.
Angiography was perfromed on [**7-9**] with evidence for severe
celiac and SMA disease that was not ammendable to percutaneous
intervention. Decision was made at that time to persue open
bypass. Due to the patient's multiple comorbidities a cardiac
and pulmonary workup was pursued preoperativley. He was noted
to be of high operative risk by cadiology and right heart cath
was performed on [**2103-7-11**] with results showing severe pulmonary
htn. He was medically optimized and on [**7-12**] he underwent a
single vessel antegrade SMA bypass. He failed extubation and was
admitted to the CVICU where he had labile pressures requiring
multiple pressure support. On [**7-13**] he demonstrated post-op
transaminitis. On [**7-15**] he went into sepsis with respiratory
decopensation with hypotension requiring 3 pressors. This was
suspected to be from volume overload and severe pulmonary
hypertension. A CXR showed a multifocal PNA, urine and sputum
grew E Coli. Antibiotic coverage was changed. On [**7-17**] he had a
cold foot, demonstrating that he had thrombosed a prior bypass
graft in his leg despite the fact that he was on sub q heparin
prophylaxis. He was restarted on his heparin drip. He continued
to improve and on [**7-20**] had weaned down to one pressor though he
continued to fail spontaneous breathing trials. He developed
thrombocytopenia on the 27th and Hem-onc was consulted. The
recommendations from the consulting team were that his
thrombocytopenia was likely secondary to his septic shock and
that he ought to continue his heparin drip therapy. He was
extubated on the 30th. A speech and wallow consult was retained
and they recommended that it was ok for him to take PO. On the
31st he was at his baseline mental status and getting out of bed
to chair. On [**7-25**] he was admitted to the floor, worked with PT
and expressed a desire to go home. He tolerated PO medication,
was normotensive, returned to his baseline activity level,
tolerated food and was ready to be discharged. He was discharged
on [**2103-7-26**] in good/stable condition.
Medications on Admission:
coumadin 2 daily, coreg 6.25 daily, lisinopril 2.5 daily, ASA 81
daily, vicodin
5/500 prn, PTU 50 daily, lasix 20 prn, symbicort 160/80 [**Hospital1 **],
xopenex neb
prn, ipratropium neb prn
Discharge Medications:
1. Albuterol Inhaler 4 PUFF IH Q4H:PRN SOB
2. Artificial Tear Ointment 1 Appl BOTH EYES TID:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO BID
Hold for HR<60,SBP<90
5. Enoxaparin Sodium 60 mg SC BID
RX *enoxaparin 60 mg/0.6 mL ingect 60 mg twice daily Disp #*30
Each Refills:*0
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
7. Furosemide 20 mg PO DAILY
8. Ipratropium Bromide MDI 6 PUFF IH QID:PRN SOB
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**12-25**] tablet(s) by mouth q 4hr Disp #*60 Tablet
Refills:*0
10. Propylthiouracil 50 mg PO Q 24H
11. traZODONE 25 mg PO HS:PRN insomnia
12. Warfarin 3 mg PO DAILY16
RX *Jantoven 1 mg 3 tablet(s) by mouth daily Disp #*50 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Chronic mesenteric ischemia
Ischemia of Left lower extremity secondary to failure of
previous bypass graft
Severe Pulmonary hyptertension
Right heart dysfunction
Respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
What to expect when you go home:
It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
Increase your activities as you can tolerate- do not do too
much right away!
It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (81mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
Call if yur develope discoloration, pain or signs of infection
of the left lower leg
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 1391**] in 2 weeks, please call ([**Telephone/Fax (1) 29063**] to schedule
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] for 10 am appt.
Completed by:[**2103-8-1**]
|
[
"790.4",
"305.1",
"V45.72",
"285.9",
"287.5",
"E878.2",
"557.1",
"518.51",
"401.9",
"571.2",
"427.31",
"414.01",
"V44.3",
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"V45.82",
"557.0",
"995.92",
"482.82",
"447.4",
"440.20",
"416.8",
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"427.1",
"785.52",
"276.2",
"599.0",
"250.00",
"783.21",
"412",
"496",
"038.42",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"96.72",
"39.26",
"99.15",
"88.42",
"96.6",
"38.97",
"88.47",
"37.21",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
14915, 14998
|
11560, 13889
|
295, 424
|
15224, 15224
|
2443, 4867
|
17470, 17732
|
1818, 1929
|
14131, 14892
|
15019, 15203
|
13915, 14108
|
6442, 11537
|
15375, 17447
|
1944, 2424
|
4886, 6425
|
228, 257
|
452, 1311
|
15239, 15351
|
1333, 1638
|
1654, 1802
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,267
| 119,213
|
48383
|
Discharge summary
|
report
|
Admission Date: [**2193-3-23**] Discharge Date: [**2193-3-27**]
Date of Birth: [**2138-3-6**] Sex: F
Service: MEDICINE
Allergies:
Lisinopril
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypotension at HD
Major Surgical or Invasive Procedure:
Dialysis on [**3-25**]
History of Present Illness:
55F with ESRD on HD, PVD s/p R AKA, HTN, DM, presents with
hypotension at HD. Pt was feeling in her usual state of health
until she went to HD this morning. At HD, her BP was found to be
56/12. EMS was called and BP per the EMTs was 58/41. She was
brought to the [**Hospital1 18**] ED.
.
On arrival to the ED, vitals were T 97.6, BP 62/34, HR 72, RR
17, SaO2 98% 2L. SBP initially maintained in the 60s but
improved to 110s with manipulation on exam and attempts at IV
access. She was initially very lethargic, and then became
agitated, yelling out in pain. At best, she was answering yes/no
questions. CXR negative. CT abd/pelvis showed mild increase in R
pleural effusion but no acute intraabdominal process. Received
vanco, zosyn, and 200cc IVF. Admitted to the MICU for close
monitoring.
Past Medical History:
- Peripheral Vascular Disease s/p L SFA-DP bypass for L
gangrenous heel in [**2187**]; s/p R proximal SF-proximal AT bypass in
[**4-4**]; s/p multiple debridements of b/l LE for
infected/non-healing wounds; s/p L BKA [**12-6**], L AKA for
non-healing BKA ulcer (prior MRSA, VRE and MDR Klebsiella) [**1-6**]
- Likely left AKA stump osteomyelitis requiring admission in
[**3-/2192**], on IV antibiotics, VAC dressing in place
- ESRD on HD. Last HD yesterday. Usually MWF schedule.
- HTN
- Diabetes Mellitus
- Renal Cell Carcinoma s/p right nephrectomy
- Obesity
- Depression
- s/p CCY
- Gastric Ulcer
- Obstructive Sleep Apnea. The patient reports that she used to
use a CPAP however her machine broke and she no longer uses it.
- Gastroparesis
- COPD on 3-4L NC baseline
- h/o ischemic colitis
- left adrenal adenoma
Social History:
Admitted from rehab. Has two sisters, one daughter. [**Name (NI) **] is
a former smoker with a 30 pack year history, quit 20 years ago.
Family History:
Mother died of stomach cancer in her 40s. Father had an unknown
cancer in his 70s. Stated that diabetes, high cholesterol, and
high blood pressure run in her family.
Physical Exam:
T 98.1, BP 120/doppler, HR 75, RR 75, SaO2 95% 2L
General: obese female, alert and interactive.
Neck: obese, unable to determine JVP
Heart: RRR, distant HS [**12-31**] body habitus
Chest: L subclavian tunneled HD line without surrounding
erythema, CTAB anteriorly but difficult to auscultate
Abdomen: +BS, obese, soft, non-tender with stethescope exam.
Extrem: L upper arm incision with sutures in place, no erythema,
s/p L BKA (stump is mildly edematous but no erythema or
drainage), dopplerable R DP pulse, 1+ RLE edema, +anasarca
Back: sacral decub ulcers by report
Neuro: A+Ox2 (name and place), she believes this is [**2191**] and is
unable to repeat date when told. CN2-12 grossly intact.
Pertinent Results:
Admission labs:
[**2193-3-23**] 12:45PM NEUTS-66.9 LYMPHS-27.4 MONOS-5.0 EOS-0.3
BASOS-0.4
[**2193-3-23**] 12:45PM WBC-8.0 RBC-3.13* HGB-10.0* HCT-32.7*
MCV-104* MCH-32.0 MCHC-30.7* RDW-19.7*
[**2193-3-23**] 12:45PM GLUCOSE-128* UREA N-25* CREAT-4.5* SODIUM-141
POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-21* ANION GAP-21*
Cardiac enzymes:
[**2193-3-23**] 12:45PM BLOOD CK-MB-NotDone cTropnT-0.15*
[**2193-3-23**] 08:10PM BLOOD CK-MB-NotDone cTropnT-0.16*\
CXR:
1. Cardiomegaly, pulmonary vascular engorgement, interstitial
edema, and bilateral pleural effusions are consistent with
volume overload.
2. Right lung base infiltrate. Please ensure follow-up to
clearance.
3. No focal consolidation to suggest pneumonia.
CT abdomen:
CT ABDOMEN WITH CONTRAST AND RECONSTRUCTIONS: There has been
interval
increase in size to a small-to-moderate right simple pleural
effusion.
Bibasilar atelectasis is again demonstrated. Calcification of
the mitral
annulus and aortic valve is only partially visualized is of
unknown
hemodynamic significance. No pericardial effusion is
demonstrated. Right
atrial enlargement is again suspected.
No change is identified to the appearance of the liver.
Gallbladder is not
detected consistent with prior resection. The spleen is stable
on appearance with enhancing 1-cm rounded lesion in the inferior
pole consistent with a hemangioma or hamartoma. No change in an
8 x 10 mm left adrenal adenoma since [**2192-2-16**]. A small amount
of perihepatic fluid is again demonstrated, becoming confluent
with the right abdominal subcutaneous anasarca. Asymmetric
diffuse anasarca has been stable since at least 2/[**2191**]. No
evidence of bowel obstruction is demonstrated. Severe calcified
atherosclerotic plaque within the abdominal aorta, celiac axis,
SMA and [**Female First Name (un) 899**] as well as iliac vessels again appreciated with
gross luminal patency.
CT PELVIS WITH CONTRAST AND RECONSTRUCTIONS: Extensive vascular
calcifications in the pelvis. Rectum, sigmoid colon and
unopacified loops of small bowel appear stable. No diffuse free
pelvic fluid identified.
OSSEOUS STRUCTURES: Extensive scoliosis and multilevel
degenerative changes.
IMPRESSION:
Little change since prior study aside from increase in size to
moderate right pleural effusion. No evidence of new inflammatory
change or acute bowel pathology within the abdomen.
Brief Hospital Course:
55F with ESRD on HD, PVD s/p R AKA complicated by chronic
osteomyelitis, HTN, DM, was admitted to the ICU on [**3-23**] after
being found to be hypotensive and with altered mental status at
HD.
.
.
# Hypotension: BP normalized after only 250cc of fluid in the
ED. BP was only attainable using Doppler on right upper
extremity, with manual cuff, which brings into question accuracy
of previous BP recordings. She was admitted to the ICU where
her blood pressure was 120s-140s systolic using the above
technique. She was afebrile, no leukocytosis, no acute process
on CXR or CT abd/pelvis. However, she was covered empirically
with Vanco/Zosyn initially given her chronic osteo and history
of bacteremia. This was later narrowed to vancomycin, as below.
In the future, BP measurement should be done in right arm, with
manual cuff and doppler.
.
# Positive blood cultures: Blood cultures showed 1/4 bottles
with gram positive cocci. Zosyn was discontinued. Vancomycin
was continued, and her line was changed over a wire. When her
blood cultures speciated as coagulase negative staph, this was
thought to most likely be a contaminant; however, given her
history of bacteremia the renal team elected to continue
vancomycin, to be dosed by level at HD for a total 3 week course
(16 more days).
.
# Altered mental status: Patient's mental status improved with
holding benzodiazepenes and narcotics. Per discussion with rehab
facility, patient has been receiving increased doses of
narcotics recently. As she was not having any pain, she was
discharged off all narcotics. Benzodiazepenes and narcotics
should be avoided if possible in this patient.
.
# CAD: Troponins flat x 2, there was no chest pain, no EKG
changes. [**Month/Year (2) **], Plavix, and statin were continued. Of note, she is
not on a beta blocker or ACE inhibitor because of hypotension.
.
# ESRD on HD: There was no indication for urgent HD. Recently
had AV graft to upper left arm (lower left arm graft failed)
which was complicated by hematoma and perioperative NSTEMI. This
admission, the graft appeared intact, but she had a tunnelled
line that was used instead. She had missed her recent Saturday
dialysis session [**3-23**]. She received HD on [**3-25**], but this was
limited by hypotension, so she underwent another session on [**3-26**]
and then ultrafiltration on [**3-27**]. Sevelamer, lanthanum, and
cinacalcet were continued. She should now resume her outpatient
Tues/Thurs/Sat hemodialysis, next due [**3-28**].
.
# Chronic osteomyelitis: Followed in [**Hospital **] clinic. Currently taking
Doxycycline 100mg PO BID and rifampin 300mg PO bid for chronic
suppression of MRSA vertebral osteomyelitis (hardware in place)
for indefinite period of time. Doxycycline and rifampin were
continued, and she was discharged with ID follow-up on [**3-29**] as
previously scheduled.
.
# DMII: Insulin sliding scale was continued. FSBG were mid
100s.
.
# COPD: The patient had O2 Saturation ~95% on 2L O2. She
should continue supplemental oxygen as needed.
.
# OSA: CPAP was continued.
.
The patient clearly stated that she wanted to be full code
status.
Medications on Admission:
[**Month (only) **] 325mg PO daily
Plavix 75mg PO daily
Simvastatin 80mg PO daily
Rifampin 300mg PO q12
Doxy 100mg PO q12
Regular insulin sliding scale
Protonix 40mg PO daily
Reglan 5mg PO QIDACHS
Lanthanum 500mg PO PO TID w/meals
Cinacalcet 60mg PO daily
Nephrocaps 1mg PO daily
Sevelamer 2400mg PO TID with meals
Percocet 5-325mg 1-2 tabs q4-6h prn
Gabapentin 300mg PO qHD
[**Month (only) 95641**]
Mirtazapine 15mg PO qHS
Tramadol 50mg PO BID
Colace prn
Senna prn
Discharge Disposition:
Extended Care
Facility:
Roscommon
Discharge Diagnosis:
primary: hypotension, altered mental status
secondary: coronary artery disease, peripheral vascular
disease, diabetes, hypertension
Discharge Condition:
stable
Discharge Instructions:
You came to the hospital because of low blood pressure and
confusion. You were given fluids, and your pain medications
were stopped. Your blood pressure and confusion improved.
The following medications were changed:
Percocet was stopped
Gabapentin was stopped
Mirtazapine was stopped
Tramadol was stopped
Reglan was stopped
Please call your doctor or return to the emergency room for
chest pain or shortness of breath, fevers and chills, or other
symptoms that are concerning to you.
Followup Instructions:
You will need to continue dialysis every Tuesday, Thursday, and
Saturday.
Please follow up with the nurse practitioner who works with Dr.
[**Last Name (STitle) 2450**]:
Provider: [**Name10 (NameIs) 10160**] [**Name11 (NameIs) 10161**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 250**]
Date/Time:[**2193-4-15**] 11:00
Also follow up as previously scheduled with infectious disease
and cardiology:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2193-3-29**]
11:00
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2193-7-15**] 10:20
Completed by:[**2193-3-27**]
|
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"585.6",
"327.23",
"250.00",
"V49.76",
"403.91",
"V10.52",
"730.18",
"458.9",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
9099, 9135
|
5447, 6754
|
288, 312
|
9313, 9322
|
3046, 3046
|
9860, 10566
|
2148, 2315
|
9156, 9292
|
8608, 9076
|
9346, 9837
|
2330, 3027
|
3389, 5424
|
231, 250
|
340, 1134
|
3063, 3371
|
6769, 8582
|
1156, 1977
|
1993, 2132
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,991
| 164,956
|
10078
|
Discharge summary
|
report
|
Admission Date: [**2173-10-15**] Discharge Date: [**2173-11-1**]
Service: MICU
HISTORY OF PRESENT ILLNESS: This is a 77-year-old gentleman
status post left lower lobe lung lobectomy who was
transferred to the Medical Intensive Care Unit team from the
Surgical Intensive Care Unit team on [**2173-10-30**] for
failure to wean off ventilation.
The patient is a 77-year-old gentleman with a history of
throat cancer who presented to [**Hospital1 188**] in [**2173-5-28**] for leg claudication and at that time
an admission chest x-ray showed right upper lobe and left
lower lobe lung masses. At that time he had a right upper
lobe wedge resection and pleural biopsy which was negative
for malignancy on pathology, and he also had a negative bone
scan and head MRI for metastatic disease.
In [**Month (only) 216**] of this year he was admitted again for an
uncomplicated left femoral peroneal bypass surgery for his
leg claudication, and further workup at that time revealed a
left lower lobe 3-cm mass. So, he was electively admitted on
[**2173-10-15**] for a left lower lobectomy. He had no
immediate complications post surgery and was easily
extubated. However, on postoperative day one he had an
episode of atrial fibrillation and hypotension, and he was
transferred to the Intensive Care Unit. A Swan-Ganz catheter
was placed with initial of right atrium 4, pulmonary artery
pressure of 38/14, cardiac output of 5.9, cardiac index
of 3.2, and systemic vascular resistance of 1038. He was
aggressively volume resuscitated and then intubated for
progressive respiratory distress. A Neo-Synephrine drip was
initiated. He also had several bronchoscopies during this
admission which showed multiple mucous plugs and left upper
lobe collapse. Sputum from the bronchoscopy grew Klebsiella
and Serratia which were pan sensitive, and he was started on
ciprofloxacin and ceftazidime. He was briefly extubated
between [**10-21**] and [**10-22**]; however, he was
reintubated for respiratory distress on [**10-22**]. His
chest x-ray showed progressive bilateral multilobar pneumonia
versus acute respiratory distress syndrome. Efforts at
weaning were limited by secretions, high oxygen requirement,
and increased respiratory rate if pressure support was
decreased, and he was requested to be transferred to the
Medical Intensive Care Unit for further management.
PAST MEDICAL HISTORY:
1. Throat cancer, status post radiation therapy complicated
by esophageal stricture requiring dilation.
2. Bilateral leg claudication, status post left femoral
peroneal bypass in [**2173-7-28**].
3. Hypertension.
4. Hypothyroidism.
5. Diverticulitis.
6. Cervical spine fusion.
7. Status post appendectomy.
8. Status post colectomy secondary to diverticulitis.
9. Bilateral carotid asymptomatic 60% stenosis.
MEDICATIONS ON ADMISSION: Ciprofloxacin 400 mg intravenous
q.12h., ceftazidime 2 g intravenously q.8h., Lopressor 5 mg
intravenously q.6h., nitroglycerin q.h.s., Neo-Synephrine
drip, procainamide drip, Ativan drip 2 mg per hour, morphine
drip 2 mg to 4 mg per hour, Haldol 1 q.2h., sliding-scale
regular insulin, Synthroid 0.1 mg intravenously q.d.,
Reglan 10 mg intravenously q.8h., albuterol/Atrovent
meter-dosed inhalers, Flovent 2 puffs b.i.d., Colace 100 mg
p.o. b.i.d., Dulcolax 1 p.r. q.d., and Nystatin
swish-and-swallow.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient lives in [**State 2748**] with his
wife. [**Name (NI) **] has two sons who are actively involved in his life.
He has a history of tobacco for 40 years and quit 20 years
ago. He is an occasional alcohol drinker. Prior to this
admission the patient was in a wheelchair with a decreased
quality of life that he was unhappy with.
PHYSICAL EXAMINATION ON PRESENTATION: Vital signs were
temperature maximum of 99.5, pulse of 92, blood pressure
between systolic 103 to 169 and diastolic 40 to 60. In
general, on ventilation at AC with a tidal volume of 550,
respiratory rate of 20, FIO2 of 0.7, PEEP of 8; most recent
arterial blood gas 7.28/59/78. Ins were 1841, outs 1535, net
positive 306. Length of stay fluid balance -11.9 liters. In
general, an elderly gentleman lying in bed, intubated and
sedated. HEENT revealed pinpoint pupils, minimally reactive.
Neck was supple. No jugular venous distention.
Cardiovascular revealed distant heart sounds, regular rate
and rhythm. Normal S1 and S2. Lungs revealed left lung with
coarse breath sounds, right upper quadrant coarse breath
sounds. No wheezes. Abdomen was soft, slightly distended,
very hypoactive bowel sounds. Extremities were thin, muscle
wasting. No edema. Neurologically, intubated and sedated.
PERTINENT LABORATORY DATA ON ADMISSION: White blood cell
count 21.1, hematocrit 32.5, platelets 382. Sodium 140,
potassium 3.9, chloride 107, bicarbonate 27, BUN 42,
creatinine 1.2, glucose 129, anion gap 10. Calcium 8.1,
ionized calcium 1.18, phosphorous 2.7, magnesium 2.
Urinalysis was negative on [**10-27**]. Microbiology on
[**10-18**] bronch growing pan-sensitive Klebsiella and
Serratia. On [**2173-10-24**], sputum growing oropharyngeal
flora. On [**2173-10-27**], catheter tip growing
vancomycin-sensitive enterococcus. Blood cultures negative
to date. Urine cultures negative to date. Pulmonary
function tests on [**2173-8-16**] revealed FEV1 of 1.34 (57%
of predicted), FEV1:FVC 106% of predicted, TLC 75% of
predicted, DSBVA 53% of predicted, BL/VA 85% of predicted;
with conclusion consistent with an interstitial process.
RADIOLOGY/IMAGING: Chest x-ray on [**2173-9-29**] revealed
extensive left lung consolidation throughout, right upper
lobe consolidation, probable left lower lobe effusion.
Abdominal ultrasound on [**2173-10-21**] revealed biliary
sludge, no obstruction, fatty liver.
Most recent electrocardiogram on [**2173-10-25**] revealed
sinus at 90, normal axis, intervals 0.2/0.12/0.36, diffuse T
wave flattening in limb leads which were new compared to
preoperative electrocardiogram on [**2173-9-30**]. No acute
ST-T wave changes.
Echocardiogram stress in [**2173-5-28**] showed an ejection
fraction of 60% to 70%, no wall motion abnormalities, no
ischemia.
Left lower lobe pathology revealed squamous cell carcinoma
with no lymph node involvement.
IMPRESSION: A 77-year-old gentleman status post left lower
lobectomy on postoperative day 15 with diffuse alveolar
infiltrates and consolidations suggestive of pneumonia
bilaterally; now with difficulty weaning from mechanical
ventilation.
HOSPITAL COURSE:
1. PULMONARY: The patient was status post left lower
lobectomy. This fact, and his diffuse pneumonia would cause
a decrease in ventilation. The patient was hypoxic on an
FIO2 of 5.55. He also had a decreased compliance suggestive
of possible acute respiratory distress syndrome. His
hypercarbia was secondary to poorly ventilated areas of his
lungs. He was followed on arterial blood gas and was on
assist control ventilation while in the Medical Intensive
Care Unit. He became progressively acidotic by his followed
arterial blood gas, and his set respiratory rate was
increased to compensate for his metabolic acidosis. He was
continued on ciprofloxacin and ceftazidime for his
Serratia/Klebsiella pneumonia. A repeat chest x-ray showed
continuation of diffuse alveolar infiltrations bilaterally,
left greater than right. His metabolic acidosis was most
likely secondary to his progressive renal failure.
On the night of [**10-31**], he was started on a bicarbonate
drip given his worsening acidosis. His lactate was 1.5. It
was decided to increase his sedation by increasing the amount
of Ativan he was receiving and morphine he was receiving. On
[**11-1**], his morphine was changed to Fentanyl. With
increased sedation his arterial blood gas results remained
steady, and he seemed to be more in synchronization with the
ventilation.
2. CARDIOVASCULAR: (a) RHYTHM: His of atrial
fibrillation during this hospitalization with rapid
ventricular rate. He was started on procainamide drip by the
surgical team; however, since postoperative day one he had
normal runs of atrial fibrillation and once he was
transferred to the Medical Intensive Care Unit, the
procainamide drip stopped. He had no more runs of atrial
fibrillation under the Medical Intensive Care Unit's care.
The patient was hypotensive; thought to be secondary to
possible sepsis. However, in order to rule out cardiogenic
shock, and echocardiogram was done on [**11-1**] which was
within normal limits. The Neo-Synephrine drip was unable to
be weaned off; and in fact, because of his progressive
hypotension, vasopressin drip was added on [**10-31**]. He
was also given intravenous fluids boluses which only helped
temporarily to support his blood pressure.
On [**11-1**], his Neo-Synephrine drip was changed to
Levophed drip for more beta agonist effects. Cortisol was
added to his laboratories to check for adrenal insufficiency
as an etiology for his hypotension.
3. INFECTIOUS DISEASE: The patient with multilobar
pneumonia with sputum growing Klebsiella and Serratia pan
sensitive. He was continued on ciprofloxacin and
ceftazidime. His subclavian tip grew vancomycin-sensitive
enterococcus and was removed. He was given one dose of
vancomycin for this at 1 g. Blood cultures did not grow
anything to date.
On [**10-31**], two more blood cultures were checked as they
were on [**11-1**] given his rising temperature. Urine
cultures were also negative to date. His white blood cell
count continued to rise despite his antibiotic treatment, and
with his hypotension this was consistent with a septic
picture. A sputum culture was sent on [**11-1**].
4. RENAL: The patient developed progressive acute renal
failure. This was thought to be secondary to acute tubular
necrosis from his hypotension. His kidneys did not seem to
respond well to intravenous fluids boluses. Urine
electrolytes were checked, and his FENa was calculated at
1.3; not consistent with a prerenal etiology. Free water was
restricted and all intravenous medications were placed in
normal saline. All of his medications were renally doses on
[**11-1**], and his urine output progressively decreased and
became darker in coloration.
5. ONCOLOGY: Squamous cell carcinoma of the lung; staging
unclear. [**Name2 (NI) **] lymph node involvement.
6. GASTROINTESTINAL: The patient was on total parenteral
nutrition. He had a Dobbhoff feeding tube in place situated
correctly in post pyloric; however, because of his increasing
liver function tests tube feeds were held off, and then they
were never started because of his lack of bowel sounds and
lack of peristalsis. He was continued on total parenteral
nutrition. The patient's liver function tests were also
noted to be increasing, particularly his AST, alkaline
phosphatase, and direct bilirubin. This was thought to be
secondary to mixed picture of shocked liver versus
obstructive due to total parenteral nutrition versus
ceftazidime or other medications causing hepatic obstruction.
Enzyme elevation: A right upper quadrant ultrasound was done
on [**10-31**] which revealed no gallbladder wall thickening
or pericholecystic fluid, no biliary obstruction. Coarse
hypoechoic appearance to the liver which was suggestive of
fatty liver versus other forms of liver disease including
significant hepatic fibrosis/cirrhosis; unchanged from his
previous right upper quadrant.
Because of his increasing blood glucose levels the amount of
insulin in his total parenteral nutrition was increased
accordingly.
7. HEMATOLOGY: The patient's hematocrit remained stable
while in the Medical Intensive Care Unit, although he did
require 2 units of packed red blood cells transfusion on
[**10-29**] under the surgical team's care. Hemolysis
laboratories were negative and reticulocyte count was 4,
indicating an appropriate bone marrow response to anemia.
Rectal examination was empty of stool, and therefore could
not be guaiaced. However, he did have diarrhea on [**11-1**]
which was guaiac-negative. Clostridium difficile toxin was
sent on his diarrhea.
8. FLUIDS/ELECTROLYTES/NUTRITION: The patient was on total
parenteral nutrition. His phosphorous was climbing with his
renal insufficiency, and therefore it was not added to his
total parenteral nutrition. Tube feeds were not initiated.
His blood glucose did increase, most likely secondary to the
total parenteral nutrition and insulin was added to the total
parenteral nutrition. An insulin drip was considered but
never started, although his insulin sliding-scale was
adjusted accordingly.
9. LINES: Right subclavian line, left arterial line placed
on [**10-27**]. Peripheral access, Protonix, and subcutaneous
heparin.
10. CODE STATUS: When the patient was transferred from the
Surgical Intensive Care Unit to the Medical Intensive Care
Unit his code was reported as full. However, on [**11-1**] a
family meeting was called given his progressive multiorgan
failure. I, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 805**], and the pulmonary critical care
fellow, Dr. [**Last Name (STitle) 33670**], met with the patient's wife and two sons
at 4 p.m. on [**11-1**] to discuss his medical status.
Dr. [**Last Name (STitle) 33671**] was present for the first portion of the
discussion. It was explained to the family that
Mr. [**Known lastname 33672**] was in multisystem failure; namely:
1. PULMONARY: He was ventilator dependent, increasingly so,
requiring increased sedation to passively ventilate him. His
respiratory status was complicated by his underlying lung
cancer. His recent left lower lobectomy which reduced his
lung volumes, his multilobar pneumonia, and acute respiratory
distress syndrome. He was approaching intubation for 10
days, and therefore if aggressive care was continued a
tracheostomy would be considered; however, in his current
status he may not tolerate a tracheostomy placement
especially given his underlying throat cancer.
2. RENAL: The patient was in worsening renal failure and
worsening acidosis as a result with decreased urine output,
and the next therapeutic step would be to involve the Renal
team and initiate hemodialysis. They were also told that a
bicarbonate drip was started for his acidosis.
3. HEMODYNAMICS: Hemodynamic wise, he was hypotensive and
dependent on two pressors; namely, Levophed and vasopressin
drip to maintain his blood pressure. He also had the history
of atrial fibrillation during his hospital stay.
4. GASTROINTESTINAL: Gastrointestinal wise, the patient
would not be able to be tubed fed yet and was dependent on
total parenteral nutrition which is not an ideal form of
nutrition.
5. LIVER: The patient has having increasing liver function
tests and was in moderate liver dysfunction. It was
discussed that his prognosis was very grave given this
multisystem failure and that there was a small chance of
survival and recovery from this.
His wife brought with her the patient's living will which was
signed by him in [**2161**] in which he states that if he is in no
position to speak for himself and in a state from which there
was no hope of recovery he would desire no means of
life-sustaining methods including no artifical ventilation,
antibiotics or hemodialysis. His wife reiterated that he has
verbally expressed this opinion to her in the recent past.
The patient was recently in acute acidotic coma, and when he
recovered expressed regret at surviving through hit. Prior
to this admission he was handicapped in a wheelchair and
would not want to go back to his prior or worse quality of
life. Her sons were in agreement of this and confirmed that
his status was do not resuscitate.
After leaving his wife and sons on their own to discuss their
father for 20 minutes they came to the decision to stop his
two pressors and leave everything else going. His Levophed
drip and vasopressin drips were stopped at 6 p.m. on
[**11-1**] in his family's presence. Dr. [**Last Name (STitle) 33670**] discussed
the family discussion with the attending, Dr. [**Last Name (STitle) **], and he
was in full agreement with the plan.
The patient's blood pressure and heart rate continued to
decline off of the pressors, and at approximately 7:30 p.m.
his monitor showed a flat line. The intern, [**First Name8 (NamePattern2) 33673**] [**Last Name (NamePattern1) **] was
called to pronounce him. The patient was not breathing. He
had no pulse. Pupils were unreactive to light. He did not
respond to noxious stimuli. He had no breath sounds, and he
was pronounced dead at 7:30 p.m. The family declined an
autopsy and were informed of his death.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 7069**]
MEDQUIST36
D: [**2173-11-2**] 17:20
T: [**2173-11-4**] 13:03
JOB#: [**Job Number 33674**]
(cclist)
|
[
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"427.31",
"584.5",
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icd9cm
|
[
[
[]
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[
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icd9pcs
|
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[
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] |
2846, 3389
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6544, 17007
|
118, 2379
|
4728, 6525
|
2401, 2819
|
3406, 4713
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,593
| 171,259
|
4235
|
Discharge summary
|
report
|
Admission Date: [**2108-8-26**] Discharge Date: [**2108-9-19**]
Date of Birth: [**2039-8-22**] Sex: F
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: The patient is a 69 year-old
female with a past medical history of coronary artery disease
status post myocardial infarction in [**2099**], hypertension,
noninsulin dependent diabetes mellitus, peripheral vascular
disease, congestive heart failure, ischemic cardiomyopathy
who presents from [**Hospital3 **] in congestive heart
failure. The patient initially presented to [**Hospital3 **]
Emergency Room on the [**12-25**] reportedly feeling
more and more short of breath despite sitting up in bed and
in her chair. The patient admits to feeling chest pressure.
No pain, however. The patient felt it was initially an
asthma attack. In the [**Hospital1 **] Emergency Room the patient was
given 100 mg of IM Lasix followed by 80 mg and subsequently
had a urine output of 750 cc and felt much better afterwards.
The patient reported increased edema over the past few days
in her right below the knee amputation stump.
In [**Hospital3 **] the physicians were unable to give her
intravenous Lasix, because of failure to find a central
access and poor peripheral access. They attempted to place a
central line in her right neck and subsequently failed. The
left side of her neck and arm were being saved for an AV
shunt. The patient was subsequently given intravenous Lasix
and Bumex 3 mg po times one. On admission to the outside
hospital the patient was also found to be in atrial
fibrillation and she was given 0.5 mg of Digoxin times one.
On admission to the outside hospital the patient was also
found to have electrocardiogram changes consisting of .[**Street Address(2) 18425**] depression in 1, AVL and .[**Street Address(2) 1755**] elevation in lead 3, AVF
and T wave inversions in V4 through V6. The patient also had
a troponin of 0.7, which was indeterminate. The patient was
started on aspirin, Atenolol and IM Lasix, the doses of which
we do not know.
Subsequently the patient was transferred to [**Hospital1 **], because the physicians who took
care of her Dr. [**Last Name (STitle) 73**] for cardiology, Dr. [**First Name (STitle) 805**] for
renal and Dr. [**Last Name (STitle) **] her primary care physician were all from
[**Hospital1 69**]. The patient was still
complaining of shortness of breath on transfer to [**Hospital1 346**], however, she states that she was
feeling better then when she initially presented to [**Hospital3 9683**]. The patient states that her baseline is that she
has two pillow orthopnea minimally, however, recently she has
been short of breath even with sitting up and has been
complaining of increased leg edema. The patient also
complains of some mild blood in the urine since the [**12-26**]. The patient denies any recent changes in her diet
or recently eating fast food or not taking her medications.
PAST MEDICAL HISTORY: 1. Congestive heart failure NYHA
class four with an EF of 25 to 30%. 2. Ischemic
cardiomyopathy. 3. Hypertension. 4. Noninsulin dependent
diabetes mellitus for forty years complicated by peripheral
vascular disease, neuropathy and nephropathy. 5. Peripheral
vascular disease status post right above the knee amputation.
6. Chronic renal insufficiency with a baseline creatinine of
approximately 3 for the last three years. 7. Coronary
artery disease status post myocardial infarction in [**2099**]. 8.
Asthma. 9. Gastroesophageal reflux disease. 10. The
patient is status post cholecystectomy. 11. Anemia status
post gastric bypass procedure.
MEDICATIONS ON TRANSFER FROM OUTSIDE HOSPITAL: 1. Atenolol
50 mg once a day. 2. Lovenox 100 mg twice a day. 3.
Lipitor 10 mg once a day. 4. Neurontin 600 mg three times a
day. 5. Erythropoietin 5000 units subQ Monday and Thursday.
6. Imdur 60 mg once a day. 7. Prevacid 30 mg once a day.
8. NPH insulin 15 units subQ in the morning. 9. Flovent
110 mcg two puffs b.i.d. 10. Aspirin 325 mg once a day.
11. Regular insulin sliding scale.
PHYSICAL EXAMINATION: Vital signs, blood pressure 137/65.
Pulse 68 and regular. Temperature 98.6. Respiratory rate
20. Oxygen saturation was 94% on 2 liters nasal cannula. In
general, the patient appeared her stated age and was in
moderate respiratory distress. HEENT pupils are equal, round
and reactive to light. There was jugulovenous distention.
There were no carotid bruits appreciated. Oropharynx was
clear. Mucous membranes are moist. Cardiac, normal S1 and
S2. There was a positive S3. Regular rate and rhythm. 2
out of 6 systolic murmur appreciated best at the left upper
sternal border with radiation to the apex. Lung examination,
there were crackles bilaterally two thirds up both lung
fields. There were no wheezes and no rhonchi. Abdomen had
multiple abdominal scars, soft, nontender, obese and bowel
sounds were present, which were normoactive. Extremities,
the patient is status post right above the knee amputation
with 2 to 3+ pitting edema in the stump as well as 2 to 3+
edema in the lower extremity up to her knee. She also had an
excoriated scar on her left lower extremity, which was
approximately 2 cm by 2 cm, which was in the process of
healing.
LABORATORY VALUES ON ADMISSION: White blood cell count was
9.2, hemoglobin 11.4, hematocrit 36, platelets 234, PT 12.1,
PTT 30, INR 0.93, potassium 5.1, chloride 115, bicarb 25, BUN
69, creatinine 3.6, blood glucose 187, calcium 8.5, CK 44,
troponin 0.7. Chest x-ray showed congestive heart failure
with severe interstitial edema pattern. Chest x-ray on the
30th at [**Hospital1 **] showed pulmonary vascular
congestion and bilateral pleural effusions consistent with
congestive heart failure. Cardiac catheterization in [**2098**]
showed ostial left anterior descending coronary artery 60%
lesion, mid left anterior descending coronary artery 60%
lesion, subtotal occlusion of obtuse marginal two, total
occlusion of the proximal right coronary artery and EF of 35%
at the time. Electrocardiogram at the outside hospital
showed T wave inversion in V4 through V6, .[**Street Address(2) 1755**] depression
in 1 and AVL and .[**Street Address(2) 1755**] elevation in 3 and AVF.
Electrocardiogram at [**Hospital1 69**] on
the 30th showed normal sinus rhythm at 72 beats per minute
and was unchanged from prior electrocardiogram.
HOSPITAL COURSE: 1. Cardiovascular: The patient was ruled
out for an ischemic event by cardiac enzymes. The first CPK
was 43, second 51. Troponin was 0.4. Given the fact that
cardiac enzymes had been cycled at the outside hospital, no
further enzymes were drawn. She was initially given po
diuretics, however, until a PICC line was placed on the first
of [**Month (only) 359**], which allowed for intravenous Lasix and for
further diuresis. The patient diuresed well with 120 mg of
Lasix intravenously b.i.d. She had approximately 3 to 4
liters net urine output over the first week of admission.
Subsequently she felt much symptomatic relief and
echocardiogram done on the first of [**Month (only) 359**] showed left
atrium, which was mildly dilated, left ventricular cavity,
which was mildly dilated. Overall left ventricular systolic
function was severely depressed with an estimated ejection
fraction of 30% There was moderate to severe global left
ventricular hypokinesis especially involving the lateral and
posterior walls. The ascending aorta was mildly dilated.
The aortic valve leaflets were mildly thickened. There was
mild 1+ mitral regurgitation. There was no pericardial
effusion. The left atrium was 4.2 cm slightly above normal
of less then 4.0 cm. The left atrium four chamber length was
6.1 slightly above the normal of less then 5.2. With the
aggressive diuresis unfortunately the patient also developed
worsening of her renal insufficiency as evidenced by the
slowly increasing creatinine throughout this admission.
Given her extensive history of three vessel disease the
patient underwent a stress test on the [**12-5**], which
was a Persantine thallium stress test. She achieved a 48% of
her maximal heart rate. The Persantine MIBI showed fixed
defects in the lateral and apical myocardial walls. In
addition there was a partial reversibility of an inferior
wall defect with reversible left ventricular dilatation and
reduced ventricular function. Given the partial
reversibility of the defect, the patient was taken for
cardiac catheterization on the [**2108-9-5**] after the
risks were explained to her given her worsening renal
insufficiency.
Cardiac catheterization on the 10th showed elevated right and
left sided filling pressures with a mean right atrial
pressure of 18, pulmonary capillary wedge pressure of 30 and
LVEDP of 37 mmHg. Pulmonary hypertension was noted with a
systolic pressure of 65. Cardiac index was 3.5 liters per
minute per minute squared. Coronary angiography revealed a
right dominant system with three vessel disease. The left
main was normal. The left anterior descending coronary
artery was diffusely diseased with serial 80% and 70%
stenosis in its middle segment. The left circumflex had a
90% stenosis in its proximal segment. The first and second
obtuse marginal branches were totally occluded and filled by
left to left collaterals. The right coronary artery was
totally occluded in its proximal segment. The distal right
coronary artery territory was filled by left to right
collaterals. After the initiation of I&O vasodilatory
therapy with Milrinone, the cardiac index was increased to
4.6.
After the catheterization the patient was sent to the
Coronary Care Unit for a Milrinone drip and hemodynamic
monitoring. Given her elevated filling pressures the patient
was started on Dopamine drip to support her blood pressure.
The patient developed chest pain with [**Street Address(2) 4793**] elevations in
lead 3, AVF and .[**Street Address(2) 1755**] elevation in lead 2.
Electrocardiogram change resolved completely after the
discontinuation of the Dopamine. Heparin was started and the
dose of Milrinone was halved. The Coronary Care Unit team
continued to attempt further diuresis with the decreased dose
of Milrinone and intravenous Lasix and subsequently had very
little success. It was felt that the poor diuresis was
likely secondary to her renal disease. Cardiac surgery was
consulted regarding her triple vessel disease as evidenced by
cardiac catheterization. The patient had poor sites for
revascularization and a myocardial viability scan was
recommended before coronary artery bypass graft was
attempted.
The patient really did not want any surgery at all even after
the risks of three vessel disease were explained to her. The
patient was transferred back to the [**Hospital Unit Name 196**] Service on the floor
on the [**9-6**]. In the next subsequent days further
options for revascularization such as an off pump bypass were
discussed with the patient and the patient was seen by Dr.
[**Last Name (STitle) 1537**], however, he did not feel that the patient was a great
candidate for the procedures. Further discussion was had
with the patient about the possibility of a high risk
interventional cardiac catheterization and she opted for
cardiac catheterization. The patient did not want any
surgery.
On the [**9-8**] the patient went for percutaneous
coronary angiography, which showed limited view of the left
coronary artery. There was mild left main disease. There
was moderate calcification of the left main, left anterior
descending and left circumflex. The left anterior descending
was diffusely diseased with a 50% proximal stenosis, a
tubular 80% mid left vessel stenosis and a long 50% distal
stenosis. The three diagonals were all small vessels with
severe diffuse disease. The left circumflex had a severe
proximal stenosis and was occluded proximal to the obtuse
marginal one and obtuse marginal two and just distal to a
large atrial branch. The atrial branch ran parallel to the
AV groove and supplied a distal posterior left ventricular
branch, which in turn supplied collaterals to the right
coronary artery. The obtuse marginal one and obtuse marginal
two were filled via left to left collaterals. The right
coronary artery was known to be dominant and totally
occluded. Resting hemodynamics revealed severely elevated
biventricular pressure with RVEDP of 24 mmHg and a mean
pulmonary capillary wedge pressure of 34 mmHg. There was
moderate pulmonary hypertension with a pulmonary arteriole
pressure of 65/35 mmHg. The cardiac index was 3.6 liters
per minute per meter squared.
At the end of the procedure the patient had intravenous
nitroglycerin and intra-aortic balloon pump after which the
mean pulmonary capillary wedge pressure was decreased to 28
and then pulmonary artery pressure was decreased to 40/30
mmHg. The mid left anterior descending coronary artery was
treated with successful percutaneous transluminal coronary
angioplasty and stenting. The proximal left circumflex was
unsuccessfully treated due to an inability to cross with a
guidewire.
Subsequently the patient was again transferred to the
Coronary Care Unit secondary to having the intra-aortic
balloon pump. The patient was given 200 mg intravenous Lasix
at the end of the case and was transferred in stable
condition. The patient had a urine output of 3500 cc in
response to the intravenous Lasix, which was given at the end
of the catheterization. The Integrilin was continued until
the patient returned to the floor. While in the Coronary
Care Unit on the 16th the patient again went into atrial
fibrillation with rapid ventricular rate to about 110 to 120
and complained of chest pressure and her blood pressure
decreased to a mean arteriole pressure of 50 mmHg.
Electrocardiogram showed ST depression in V3 and V4
inferiorly. Lopressor 15 mg intravenous was given without
any change in her rate. Diltiazem 5 mg decreased the rate to
the 70s and as the rate slowed the patient's chest pressure
as well as electrocardiogram changes resolved. The patient
was maintained on a Diltiazem drip, which was subsequently
weaned to off. While on the Diltiazem the patient converted
spontaneously to normal sinus rhythm and was transferred back
to the medical floor in normal sinus rhythm.
In the days after transfer from the Coronary Care Unit, the
patient was again diuresed with a net fluid goal of negative
500 cc to about even each day and the patient was no longer
on oxygen to maintain her oxygen sats. Her O2 sats remained
in 95% range on room air. The patient was continued to be
monitored on telemetry and had another run of atrial
fibrillation with a __________ and subsequently converted on
her own. The patient's rhythm remained mostly sinus with
frequent premature ventricular complexes. The patient was
started on Plavix and continued on Plavix after the
catheterization on the 16th for which she received the stent.
2. Renal: The patient has acute on chronic renal failure.
The renal failure was exacerbated by extensive diuresis
during this admission. The patient's nephrologist Dr.
[**First Name (STitle) 805**] was present throughout her hospital course and was
involved in her care. He suggested increasing her Procrit to
8000 units subQ on Monday and Thursday given her anemia. The
patient also had vein mapping done for an AV fistula and the
patient subsequently had a left sided AV graft placed of the
left brachial artery to the left brachial vein with a forearm
loop. The operation was performed on the [**9-14**] and
postop there was no thrill present, but there was doppler
flow in the graft. Throughout the [**Hospital 228**] hospital course
there was no indication for dialysis, however, it was
discussed with the patient that she would need dialysis in
the near future and agreed to the course of treatment that
she received. The patient's BUN increased throughout the
admission to 109 at the time of discharge and the patient's
creatinine was 5.2 at the time of discharge. The patient was
to follow up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**] her nephrologist one to
two weeks after discharge from [**Hospital1 188**].
3. Infectious diseases: The patient had a fever of 101 on
the [**8-28**]. Blood and urine cultures were sent.
Urine cultures were positive for E-coli. The patient was
subsequently treated with Ciprofloxacin, which was renally
dosed for a seven day course for urinary tract infection and
subsequently her fever had resolved.
4. Hematologic: For the patient's anemia, the patient was
guaiac negative. Her B-12 dose was continued throughout the
hospital course. The patient received transfusions of 2
units on the [**9-8**] as well as 2 units on the [**9-17**]. It was attempted to keep her hematocrit above 28
to 30 given her extensive cardiac disease. After both
transfusions the patient had an appropriate rise in her
hematocrit. Part of the reason for her anemia was believed
to be secondary to her gastric bypass. Her B-12 deficiency
as well as frequent blood draws throughout her hospital
course as well as the patient was status post AV shunt for
her dialysis. Upon discharge the patient's hematocrit was
approximately 32.
DISCHARGE MEDICATIONS: 1. Aspirin 325 mg once a day. 2.
Plavix 75 mg once a day until [**2108-10-13**]. 3. Lopressor 50 mg
twice a day. 4. Lasix 120 mg twice a day. 5. Zaroxolyn
2.5 mg twice a day given 30 minutes prior to the Lasix dose.
6. Lipitor 10 mg once a day. 7. Hydralazine 50 mg four
times a day. 8. Isordil 40 mg three times a day. 9.
Protonix 40 mg once a day. 10. Flovent inhaler two puffs
b.i.d. 11. Albuterol inhaler two puffs b.i.d. 12. NPH
insulin 15 units subQ in the morning. 13. Iron supplements
three times a day with meals. 14. Procrit 4000 units Monday
and Friday. 15. Neurontin 600 mg three times a day. 16.
Regular insulin sliding scale.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: The [**Hospital **] Rehabilitation Center.
DISCHARGE DIAGNOSES:
1. Congestive heart failure.
2. Coronary artery disease.
3. Diabetes.
4. Gastroesophageal reflux disease.
5. Asthma.
6. Anemia.
7. Chronic renal insufficiency.
8. Urinary tract infection.
9. Hypertension.
The facility, which should receive this discharge summary is
the [**Hospital **] Rehabilitation Center.
[**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**MD Number(1) 2144**]
Dictated By:[**Name8 (MD) 9784**]
MEDQUIST36
D: [**2108-9-19**] 05:26
T: [**2108-9-19**] 06:03
JOB#: [**Job Number 18426**]
|
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24,601
| 193,151
|
21851
|
Discharge summary
|
report
|
Admission Date: [**2181-9-22**] Discharge Date: [**2181-10-18**]
Date of Birth: [**2106-1-8**] Sex: F
Service: SURGERY
Allergies:
Gluten / Heparin Sodium
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
left leg pain/ulcer
Major Surgical or Invasive Procedure:
left Femoral-Popleteal bypass
History of Present Illness:
75 yo f w/ mult med problems, recently started on coumadin, px
w/ melana INR=8, PE, transfused->CHF->MI>HIT>Argatroban dc'd (?
no PE). Chronic cellulitis on levo, flagyl, transferred for
vasc eval for b/l lower ext ischemia. Pt previously sched to
see Dr. [**Last Name (STitle) 1391**] as outpt. Pt currently complains of decreased
appetite, several months. Ambulated with RN but c/o "feet hurt"
when walking. No nausea,vomiting, abd pain, diarrhea. Denies
chest pain, shortness of breath, chest pain, palpitations.
Denies blood in stool.
Pmhx: SBO [**1-8**] incarcerated hernia, h/o transfusion dep Fe Def
anemia, celiac dz, brittle DM, diastCHF w/ TR and MR, Acute on
CRI, GIB on coumadin, currently guiac positive, osteoporosis,
kyphosis, htn, paf, hypothyroid, depression, ?HIT, b/l LE
ischemia, h/o Ecoli and resistant pseudomonas UTI, COPD.
PE: 97.1 97.6 149/D 57 20 96%RA FS 125<-244 on [**9-22**]
GEN: NAD, eating breakfast
HEENT: NCAT, PERRL, EOMI, MMM, no op lesions, anicteric
CV: RRR S1 S2 no ?SEM
Resp: bibasilar crackles
ABD: NABS, soft, reducible ventral hernia, midline well healed
surgical scar, moderately distended. nontender.
EXt: b/l tender LE, RLE non blanching erythema at shin,
pale/cool foot, pulse not palpable. LLE pale, foot dressing
c/d/i, L 2nd digit dry gangrene. no clubbing, no calf tenderness
Neuro: AAOx3, nonfocal, MAE, wiggles toes.
EKG: SR 59, LAD, TWI in V1-V6, QTc 501
A/P: 75 yo F with mult medical problems, as above here for
workup of her b/l LE ischemia:
1) LE ischemia-seen by vascular today, recs appreciated. for
PVR's. For peripheral angiogram in am. Mucomyst and NaHCO3 pre
and post procedure. may need bypass.
2) NSTEMI-cont BB, statin, amlodipine, nitrate. Add ACEI as
creatinine appears back to baseline. cards consult in am for
poss cath. echo in am. no asa, plavix for now given h/o
bleeding.
3) GIB-cont guaiac stools. cont ppi. GI consult re: colonoscopy.
will obtain outside records
4) ?HIT-heme consult appreciated. will start argatroban for now
(at least until platelets >200), will monitor closely for
evidence of thromboembolism.
5) ?PE-will start argatroban, check LENIs, obtain outside VQ
scan.
6) Celiac sprue-cont prednisone as this seems to have helped her
in the past, per patient/family. obtain outside records.
7)Anemia-Ferritin [**2176**] is not c/w Fe deficiency. ? hemolysis,
given high LDH, low haptoglobin, elevated bili, occ schistocytes
on smear. will send DIC labs. transfuse HCt <30, but may need
steroids. on epo at osh but doubt if this can all be attributed
to CRI.
8)Renal Failure-appears to be back to baseline. cont monitor.
gentle hydration and mucomyst before dye loads.
DM-monitor Glucose tightly. cont Glargine and RISS
9)HTN-cont BB, CCB, nitrate, added ACEI
10)h/o PAF-no heparinoids given ?HIT, no coumadin given possibly
going to OR. cont argatroban.
11)PPx-argatroban, ppi
12)FEN-diabetic/cardiac diet, replete lytes w/ goal K>4.0, Mg
>2.0
13)Code: Full
14)Dispo: pending cardiac, gi, heme, vascular, anemia workup.
Past Medical History:
Pmhx: SBO [**1-8**] incarcerated hernia, h/o transfusion dep Fe Def
anemia, celiac dz, brittle DM, diastCHF w/ TR and MR, Acute on
CRI, GIB on coumadin, currently guiac positive, osteoporosis,
kyphosis, htn, paf, hypothyroid, depression, ?HIT, b/l LE
ischemia, h/o Ecoli and resistant pseudomonas UTI, COPD.
Social History:
Former smoker
No ETOH
Family History:
Non-contributory
Physical Exam:
PE: 97.1 97.6 149/D 57 20 96%RA FS 125<-244 on [**9-22**]
GEN: NAD, eating breakfast
HEENT: NCAT, PERRL, EOMI, MMM, no op lesions, anicteric
CV: RRR S1 S2 no ?SEM
Resp: bibasilar crackles
ABD: NABS, soft, reducible ventral hernia, midline well healed
surgical scar, moderately distended. nontender.
EXt: b/l tender LE, RLE non blanching erythema at shin,
pale/cool foot, pulse not palpable. LLE pale, foot dressing
c/d/i, L 2nd digit dry gangrene. no clubbing, no calf tenderness
Neuro: AAOx3, nonfocal, MAE, wiggles toes.
Pertinent Results:
[**9-23**] EKG: SR 59, LAD, TWI in V1-V6, QTc 501
EKG: NSR 62bpm, QTC 453, diffuse nonspecific T wave flattening
in limb leads, TWI v2-v6, no acute change from previous EKG
[**9-26**]: slightly increased QTc interval, 515, from previous,
otherwise no change.
.
Echo: EF 75-80%, mild tr and mr, mild pa htn (31mm)
.
LENIs: no dvt
.
PVR: no signif RLE dz, signif LLE arterial occlusive dz, likely
SFA/tibial
.
CXR: diffuse widening mediastinum, mod hiatal hernia, interval
improvment in bibasilar atelectasis, increased LLL opacity and L
pleural effusion
.
pmibi [**9-25**]: no anginal sx or EKG change from baseline, fixed
inferior wall defect. EF 65%
.
CTchest: Marked kyphosis of the thoracic cage. Enlarged main
pulmonary artery. Bilateral pleural effusion with atelectasis.
Extensive calcifications of the arteries in the abdomen,
.
UCX: +pseudomonas >100k,Sensitive to ceftazidime; enterococcus
10-100k.
.
CXR [**9-27**] : grossly improved atelectasis. No new infiltrate or
effusion. Upper lung fields obscured by ?radioopaque
structure-?skull
.
[**2181-9-23**] 06:28AM BLOOD WBC-6.2 RBC-3.29* Hgb-9.9* Hct-32.0*
MCV-97 MCH-30.0 MCHC-30.9* RDW-17.2* Plt Ct-177
[**2181-9-23**] 06:28AM BLOOD Neuts-68 Bands-2 Lymphs-17* Monos-7 Eos-2
Baso-0 Atyps-2* Metas-2* Myelos-0
[**2181-9-23**] 06:28AM BLOOD PT-12.8 PTT-25.3 INR(PT)-1.0
[**2181-9-23**] 08:00PM BLOOD Fibrino-280 D-Dimer-386
[**2181-9-23**] 06:28AM BLOOD Glucose-98 UreaN-85* Creat-2.2* Na-135
K-4.7 Cl-96 HCO3-30* AnGap-14
[**2181-9-23**] 06:28AM BLOOD ALT-28 AST-37 LD(LDH)-1089* CK(CPK)-20*
AlkPhos-146* TotBili-1.6*
[**2181-9-30**] 03:50PM BLOOD Lipase-41
[**2181-9-23**] 06:28AM BLOOD CK-MB-3 cTropnT-0.05*
[**2181-9-23**] 06:28AM BLOOD TotProt-5.7* Albumin-3.2* Globuln-2.5
Calcium-7.8* Phos-3.8 Mg-2.0 Iron-123
Brief Hospital Course:
This patient was admitted status post angio to evaluate LLE for
gangrenous toes. Her PT was almost completely occluded. She
was then brought to the operating room for Lef fem-[**Doctor Last Name **] BPG. The
operation was relativly uneventful. The renal team saw the
patient pre-op and at the time dialysis was not started. She
went to the operating room and while the operation went
uneventfully, she went to the SICU afterwards for failure to
wean vent. She was started on tube feeds which went well.
While in the SICU, she developed the need for dialysis and CVVHD
was started. She developed low platlet count, which was treated
with platelet transfusion. HIT was suspectied but a HIT panel
was negative. She was continued on Vanco and meropenem. The
Meropenem was d/c'ed and she was continued for her ulcerated
toes. She was brought back to the OR on POD2 for bleeding which
was stopped without issue. She was put on insulin drip in the
SICU due to difficult to control sugars on her tube feeds. She
was then changed to normal hemodialysis, which she has been
tolerating well. On POD5/6 she was extubated and did well with
out the ventalatory assistance. On POD [**5-14**] she was transfered
to the VICU where she did well. On the morning of transfer
however, she had breating difficulty and was felt to be be
acutly fluid overloaded, she was brought to dialysis acutely,
and her tachypnea improved. She imroved from this and was
transfered to the floor. She did well on the floor and she was
[**Hospital 57325**] rehab on [**10-16**]. By [**10-18**] rehab was aranged and she was
dischared on PO flagyl for a newly diagnosed C.Diff.
Medications on Admission:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-8**]
Drops Ophthalmic PRN (as needed).
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4 ().
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
9. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO once a day.
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-8**]
Drops Ophthalmic PRN (as needed).
2. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q4H (every 4 hours).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q4 ().
5. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
6. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
9. Prednisone 1 mg Tablet Sig: Three (3) Tablet PO once a day.
10. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4-6H (every 4 to 6 hours) as needed.
12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 4480**] [**Hospital 4094**] Hospital, [**Hospital1 **]
Discharge Diagnosis:
Peripheral vascular disease
Discharge Condition:
Good
Discharge Instructions:
Return to clinic if you experience increasing pain or coldness
in your left foot. Also for pus or other concering signs at
your incision. Resume taking all of your preadmission
medications. Please continue insulin on included sliding scale
Followup Instructions:
in [**1-9**] weeks with Dr. [**Last Name (STitle) 1391**], call his office for an
appointment
Completed by:[**2181-10-18**]
|
[
"440.24",
"272.0",
"998.11",
"250.13",
"410.71",
"E878.2",
"599.0",
"428.0",
"250.43",
"737.41",
"283.9",
"518.5",
"041.04",
"244.9",
"276.5",
"041.7",
"287.5",
"V58.83",
"584.5",
"496",
"250.73",
"599.7",
"V58.61",
"008.45",
"733.00",
"403.91",
"285.1",
"428.30",
"579.0",
"427.31",
"440.0",
"V15.81",
"553.20",
"578.9",
"V15.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"99.05",
"99.04",
"99.07",
"88.45",
"39.98",
"96.6",
"96.72",
"39.29",
"88.42",
"88.48",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9830, 9928
|
6161, 7820
|
303, 334
|
10000, 10006
|
4355, 6138
|
10297, 10423
|
3776, 3794
|
8741, 9807
|
9949, 9979
|
7846, 8718
|
10030, 10274
|
3809, 4336
|
244, 265
|
362, 3390
|
3412, 3721
|
3737, 3760
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,170
| 141,090
|
29131
|
Discharge summary
|
report
|
Admission Date: [**2130-7-4**] Discharge Date: [**2130-7-7**]
Date of Birth: [**2055-2-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Left hemothorax
Major Surgical or Invasive Procedure:
Video-assisted thorascopic surgery, left hemothorax evacuation
and ligation of bleeding intercostal artery.
History of Present Illness:
Ms. [**Known lastname 1968**] is a 75-year-old woman who had a VATS left upper
lobectomy on [**2130-6-15**] for a stage IA lung cancer. She did quite well
postoperatively and was seen in clinic 5 days ago with a
pristine chest x-ray. The night before admission she developed
pleuritic chest pain and woke up feeling lightheaded and was
found to have a new left-sided effusion consistent with
hemothorax.
Past Medical History:
congestive heart failure
hypertension
AAA
Social History:
50 pack year smoker
Family History:
non-contrib
Physical Exam:
T 97.5, HR 73, BP 112/62, RR 20, O2 sat 93% on 2L NC
Well-appearing
Lungs clear bilaterally
Heart regular rate & rhythm
Abd soft, NTND
Ext warm, no edema
Pertinent Results:
[**2130-7-4**] 08:37PM HCT-27.5*
[**2130-7-4**] 03:38PM PT-13.1 PTT-28.1 INR(PT)-1.1
Brief Hospital Course:
Ms. [**Known lastname 1968**] was admitted to the ICU and resuscitated with one unit
of blood for a Hct of 27. She was taken to the operating room
for evacuation of a left hemothorax (see operative notes for
details). She did well post-operatively, receiving one more unit
of blood on post op day 1 for a Hct 27. She transferred to the
floor on post op day one. Her chest tube was placed to water
seal on post op day 3. Her Hct on post op day 3 was 32.9. Her
chest tube was removed on post op day 4 with no pneumothorax
afterward, and she was discharged home in good condition with
instructions for follow-up.
Medications on Admission:
Pravastatin 40 daily, Carvedilol 12.5 [**Hospital1 **], Colace 100 [**Hospital1 **],
Oxycodone 5 prn, home oxygen [**3-11**] LPM continuous via nasal
cannula
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and hospice
Discharge Diagnosis:
Left hemothorax
Discharge Condition:
Good
Discharge Instructions:
Please call the Thoracic clinic [**Telephone/Fax (1) 170**] if you have any
questions or concerns, fever >101.5, shortness of breath, chest
pain, redness or drainage from your incisions.
Do not shower for 2 days, and leave dressings on. After 2 days,
you may remove the dressing and shower, but no baths or soaking.
You may place a bandaid over the incisions, changing daily.
Leave steri strips on to fall off on their own.
Take all medications as prescribed and do not drive while taking
narcotic pain medication. You should take a stool softener such
as Colace (available over the counter) as long as you are taking
narcotic pain medication to avoid constipation.
Followup Instructions:
Please call Dr.[**Name (NI) 2347**] office ([**Telephone/Fax (1) 170**]) to schedule
a follow-up appointment in [**8-15**] days.
Keep all other scheduled appointments.
Completed by:[**2130-7-7**]
|
[
"428.22",
"492.8",
"428.0",
"998.11",
"E878.6",
"511.8",
"V10.11",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"99.04",
"34.09",
"38.85"
] |
icd9pcs
|
[
[
[]
]
] |
2129, 2200
|
1310, 1921
|
334, 443
|
2259, 2265
|
1197, 1287
|
2981, 3179
|
995, 1008
|
2221, 2238
|
1947, 2106
|
2289, 2958
|
1023, 1178
|
279, 296
|
471, 876
|
898, 941
|
957, 979
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,414
| 106,238
|
243
|
Discharge summary
|
report
|
Admission Date: [**2186-6-7**] Discharge Date: [**2186-6-11**]
Date of Birth: [**2124-11-5**] Sex: M
Service: [**Hospital Ward Name **] ICU
CHIEF COMPLAINT: "Black stools" x one day.
HISTORY OF PRESENT ILLNESS: The patient is a 61 year-old
male with a history of ischemic cardiomyopathy with an EF of
30 to 35%, status post left anterior descending coronary
artery stent [**2182**], history of colonic polyps in [**2177**] status
post resection, history of recurrent left lower extremity
deep venous thrombosis on chronic anticoagulation who was in
his usual state of health until two days prior when he noted
onset of fatigue, nausea, loss of appetite. Yesterday one
day prior to admission he had one episode of black stool. He
denies any abdominal pain. He denies any vomiting or bright
red blood per rectum. Of note, he had a light bowel movement
on the day prior. He denies any history of heavy alcohol use
or non-steroidal anti-inflammatory drugs use. No prior
retching. No back pain. He does have a history of abdominal
aortic aneurysm repair. He denies any changes in his
Coumadin dosing. No lightheadedness. No loss of
consciousness. The patient came to the clinic for a
scheduled phlebotomy for his hemochromatosis at which time
his systolic blood pressure was 88. He reported having black
stool and was sent to the Emergency Room. In the Emergency
Room he was OB positive. Nasogastric lavage was performed,
which returned clear fluid. He was given 2 liters of saline
intravenous with no improvement in systolics. His hematocrit
was 31 initially and dropped to 24. INR was 2.3. He was
given 2 mg of po vitamin K and sent to the [**Hospital Ward Name 332**] Intensive
Care Unit.
REVIEW OF SYSTEMS: He denies any fevers or chills. He
denies any abdominal pain. He does admit to taking Dilantin
200 mg in [**Doctor Last Name 2434**] of his usual 300 dose of one to two weeks.
He also admits to persistent reflux symptoms for several
years, but it has been untreated. He uses Rolaids prn.
PAST MEDICAL HISTORY:
1. Coronary artery disease status post non Q wave myocardial
infarction in [**2180**] with left anterior descending coronary
artery [**Last Name (un) 2435**]. Status post myocardial infarction in [**2182**] with
percutaneous transluminal coronary angioplasty to left
anterior descending coronary artery stent.
2. History of congestive heart failure with an EF of 30 to
35%.
3. Hemochromatosis with early cirrhosis requiring q 3 month
phlebotomies.
4. Noninsulin dependent diabetes mellitus.
5. Status post abdominal aortic aneurysm repair in [**2178**].
6. History of recurrent left lower extremity deep venous
thrombosis now on anticoagulation.
7. History of seizure disorder.
8. Status post L4-L5 discectomy in [**2181**].
9. History of benign colonic polyp resection in [**2177**].
MEDICATIONS AT HOME:
1. Aspirin 81.
2. Atenolol 50.
3. Zestril 10.
4. Lipitor 10.
5. Coumadin 5 Tuesday to Sunday, 7.5 on Monday.
6. Metformin 1000 twice a day.
7. Glyburide 20 twice a day.
8. Folate one.
9. Dilantin 300.
ALLERGIES: The patient admits to an allergy to intravenous
dye many years ago. The reaction was some bumps on his hand.
No shortness of breath or choking.
SOCIAL HISTORY: The patient lives with his wife in
[**Name (NI) 2436**]. He is retired from the furniture upholstery
business. He smoked 35 years times half a pack a day. Quit
in [**2182**]. Very rare alcohol. No non-steroidal
anti-inflammatory drugs or Ibuprofen use.
PHYSICAL EXAMINATION: The patient's temperature was 98.4.
Heart rate 76 to 79. Blood pressure 90/50. Respirations 15.
Sat 94 to 99% on 2 liters. In general, well appearing and in
no acute distress. Pupils are equal, round and reactive to
light. No scleral icterus. Oropharynx is clear.
Conjunctiva were slightly pale. No lymphadenopathy. No
bruits. JVP approximately 8 cm. Chest rales at the right
base. Cardiac regular. S1 and S2. No murmurs. Abdomen was
benign, soft, nontender. Good bowel sounds. He had a
midline ventral hernia, which was soft. Liver was palpated 2
cm below the costal margin. The patient was OB positive in
the Emergency Department. Extremities revealed 1+ pedal
edema with venostasis changes bilaterally. Skin examination
had no rashes. The patient s alert and oriented times three
with a chronic left foot drop.
INITIAL LABORATORIES: White blood cell count 6.3, hematocrit
31.4, which then dropped to 24.3, baseline is 41. Platelets
138. SMA 7 notable for a sodium of 136, K of 4.7, bicarb 24,
BUN 32, creatinine 0.5, glucose 158, INR 2.3. Dilantin level
was 3.0. ALT 35, AST 51, alkaline phosphatase 203. Total
bilirubin .5, LDH 215, albumin 3.0. Enzymes were cycled,
which were negative. The patient's electrocardiogram
revealed normal sinus rhythm, PR prolongation at 206. Left
axis deviation, inferior Qs, all of which were old. There
were some new T wave flattening in V2 to V6.
HOSPITAL COURSE: 1. Gastrointestinal bleed: The patient
was admitted with melena likely an upper gastrointestinal
bleed given history of abdominal aortic aneurysm, question of
enteric fistula. Given history of hemochromatosis and early
cirrhosis, question of varices, given history of reflux
symptoms, question of esophagitis, gastritis. The patient
was again admitted with gastrointestinal bleed and was typed
and crossed. He was initially transfused 2 units for a
hematocrit of 24. He had two peripheral intravenouses in
place. INR was corrected with vitamin K 2 mg and 4 units of
fresh frozen platelets and hematocrit revealed a change from
24 up to 26 after 4 units. INR corrected to 1.7. The
patient was also started on Protonix 40 intravenous b.i.d.
Aspirin and Coumadin were held. The patient underwent an
esophagogastroduodenoscopy on the following morning, which
revealed grade 1 esophageal varices and mild gastritis
esophagitis as well as portal gastropathy. There was no
active bleeding at any site. The patient then underwent an
abdominal CT, which was negative for aortic enteric fistula.
On the following day the patient underwent a colonoscopy,
which was normal up until the ascending colon. However, they
were not able to go all the way to the cecum and recommended
virtual colonoscopy in the future and the patient had then
underwent a repeat esophagogastroduodenoscopy with banding
times four to the esophageal varices. The patient will need
a repeat banding procedure in ten days. After the banding
the patient was started on Sucralfate 1 gram q.i.d. and was
continued on Protonix. Again aspirin and Coumadin were held
throughout. After 4 units hematocrit stabilized from 24 up
to 32 and remained stable at 32 upon discharge.
2. Hypotension: The patient was initially in the systolics
in the 90s likely hypovolemic in the setting of a
gastrointestinal bleed. However, given the history of
cardiac disease the patient's enzymes were cycled times
three, which were negative. He was resuscitated with fluid,
fresh frozen platelets and packed red cells and blood
pressure remained stable throughout. After the
esophagogastroduodenoscopy the Atenolol was switched to
Nadolol given the history of cirrhosis and varices and
Zestril was held up until discharge due to low blood
pressures.
3. Coronary artery disease: Patient with a history of
myocardial infarction in [**2180**] and [**2182**] and is status post
stent of the percutaneous transluminal coronary angioplasty
in [**2182**]. Enzymes were cycled, which were negative. Aspirin
and Coumadin were held due to gastrointestinal bleed. Beta
blocker and ace were initially held due to low blood
pressures. Lipitor was held secondary to new cirrhosis. The
patient was restarted on Nadolol upon discharge, however,
aspirin, Coumadin, Zestril and Lipitor were held prior to
discharge to be restarted by primary care physician at his or
her discretion.
4. Deep venous thrombosis: Patient with recurrent left
lower extremity deep venous thrombosis, but admitted with
gastrointestinal bleed. INR 2.3, Coumadin was held due to
multiple procedures and held upon discharge. The patient
will undergo repeat banding in ten days after which time the
patient may or may not resume anticoagulation per primary
care physician.
5. Hemachromatosis: The patient with hemachromatosis for
long standing, now with evidence of cirrhosis on examination.
The patient will continue with further phlebotomies as per
Dr. [**Last Name (STitle) **] and may need further workup for cirrhosis.
6. History of abdominal aortic aneurysm: Patient ruled out
enteric fistula with negative abdominal CT.
7. Seizure disorder: The patient was given additional dose
of Dilantin 400 times one and then restarted on his regular
does of 300 and will continue on his regular dose. No
further seizure activity.
8. Diabetes: The patient was initially held NPO diabetic
medications due to NPO status. Was covered with a sliding
scale. Sugars remained stable and can restart Glyburide upon
discharge. Metformin held secondary to cirrhosis.
DISCHARGE DIAGNOSES:
1. Esophageal varices s/p banding.
2. Portal gastropathy.
3. Gastritis esophagitis.
4. Hemachromatosis with early cirrhosis.
5. Coronary disease.
6. Recurrent deep venous thrombosis.
7. Congestive heart failure.
8. Diabetes.
9. s/p abdominal aortic aneurysm repair.
10. Seizure disorder.
MEDICATIONS ON DISCHARGE:
1. Nadolol 20 q.d.
2. Sucralfate one q.i.d. times seven days.
3. Protonix 40 po q.d.
4. Dilantin 300.
5. Folate 1.
MEDICATIONS HELD:
1. Aspirin.
2. Coumadin.
3. Lipitor.
4. Zestril.
5. Atenolol switched to Nadolol.
FOLLOW UP: The patient will follow up with primary care
physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 410**]. Follow up with hematologist [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] and follow up with liver specialist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] for repeat
banding in ten days. At the time of follow up, the timing for
resuming anticoagulation should be addressed.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**], M.D. [**MD Number(1) 2438**]
Dictated By:[**Name8 (MD) 2439**]
MEDQUIST36
D: [**2186-6-12**] 03:36
T: [**2186-6-19**] 08:59
JOB#: [**Job Number 2440**]
cc:[**Last Name (NamePattern4) 2441**]
|
[
"V12.51",
"428.0",
"414.01",
"V58.61",
"780.39",
"V45.82",
"412",
"250.00",
"578.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"42.33",
"45.23",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
9099, 9398
|
9424, 9651
|
4982, 9078
|
2877, 3246
|
9663, 10443
|
3545, 4964
|
1746, 2038
|
175, 202
|
231, 1726
|
2060, 2856
|
3263, 3522
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,686
| 195,089
|
28011
|
Discharge summary
|
report
|
Admission Date: [**2148-6-16**] Discharge Date: [**2148-6-21**]
Date of Birth: [**2082-3-15**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
sigmoidoscopy
History of Present Illness:
66yo male with recurrent BRBPR. S/P Completion left
hemicolectomy ([**5-24**]) including prior ileorectal anastomosis down
to upper rectum, Ileorectal anastomosis, Repair multiple
abdominal wall ventral hernias on [**5-25**]. Pt notes he has been
having diarrhea for the past few days, which was not bloody or
melenotic. Yesterday he began having BRBPR and today came to the
ED where again BRBPR was noted. In ED HCT was 29 and he recieve
2 units prbcs at ~5am.
Past Medical History:
CVA [**2144**] c/b residual facial droop, dysarthria, dysphagia
urinary incontinence
diverticulosis (?diverticulitis)
recent colectomy on [**5-24**] for a lower GI bleed and repair of
several abd wall ventral hernias on [**5-25**]
HTN, Vitamin D deficiency,
s/p appendectomy
Social History:
Currently at [**Hospital3 537**] rehab facility. Former cook at B&WH
now retired. Previously married x 2 but now single. 10 children.
20 pack years, quit 20 years ago. 2 beers/week prior to staying
at [**Name (NI) **], unclear now. Pt eats ground solids and drinks nectar
thick liquids at [**Last Name (un) **].
Family History:
Mother - HTN
Physical Exam:
P 97, BP 164/57, RR 14, O2 100%RA
Awake, alert
HEENT: no jaundice , MM dry
Lungs: CTA
CVS: tachycardic, no murmers
Abd: soft, NT, ND BS+
Ext: No edema/jaudice
Pertinent Results:
[**2148-6-16**] 08:22PM HCT-21.8*
[**2148-6-16**] 03:38PM WBC-9.6 RBC-2.72* HGB-8.1* HCT-24.3* MCV-89
MCH-29.7 MCHC-33.3 RDW-16.3*
[**2148-6-16**] 03:38PM PLT COUNT-300
[**2148-6-16**] 07:00AM GLUCOSE-124* UREA N-29* CREAT-1.3* SODIUM-141
POTASSIUM-5.0 CHLORIDE-116* TOTAL CO2-16* ANION GAP-14
[**2148-6-16**] 07:00AM PT-12.8 PTT-27.7 INR(PT)-1.1
[**2148-6-17**] 03:50PM BLOOD WBC-5.7 RBC-2.78* Hgb-8.4* Hct-23.8*
MCV-86 MCH-30.2 MCHC-35.2* RDW-15.8* Plt Ct-213
[**2148-6-18**] 04:36AM Hct-22.5*
[**2148-6-18**] 03:53PM BLOOD Hct-25.3*
[**2148-6-19**] 04:25AM BLOOD Hct-24.6*
[**2148-6-20**] 08:45AM BLOOD Hct-23.0*
[**2148-6-21**] 07:40AM BLOOD Hct-29.3*#
[**2148-6-19**] 7:34 pm STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
EKG [**6-16**]: Normal sinus rhythm. Short P-R interval. Compared to
the prior tracing of [**2148-6-9**] the axis has shifted rightward.
[**2148-6-16**]: Sigmoidoscopy:
Blood in the colon
Normal mucosa in the ileum to 35 cm
There was clotted blood, many sutures and small ulcers found
around the anastamosis site, no active bleeding was seen.
Brief Hospital Course:
Mr. [**Known lastname 1007**], a pt. of Dr. [**Last Name (STitle) **], was admitted to surgery after
evaluation of for BRBPR in the ED. In the [**Name (NI) **] pt Hct was 29.9 on
arrival and [**Month (only) **] to 26. He was transfused 1 U PRBC and admitted
to surgery. Te patient first went to TSICU and was then t/f to
floor on day 2 when Hct stabilized. The pt. remained on proper
GI/DVT prophylaxis throughout his stay, and the rest of the
course is described by systems below:
Neuro: Pt remained A/O throughout hospital stay, pain was well
controlled with only tylenol throughout.
Pulm: pt had no issues, maintained sats of 98-100% on RA
CV: Pt remained on home B-blocker, ACEI and Statin. Despite
issues of anemia, pt was normocardic/tensive w/ P in the 70-80's
and BP 120-30's systolic. EKG was unremrkable for ischemia on
admission.
GI/FEN: Pt received anoscopy without obvious source of bleed,
and then sigmoidoscopy with the findings described in pertinent
results section. The pt's abd surgical wound was C/D/I and had
no Si's of infection/bleeding. Pt was not able to take adequate
PO and ws started on TF on the second day of admission, and
remains on the TF at d/c. Electrolytes were repleted
appropriately, and only had issues with low Ca. Fluids status
was maintained as well without any issues.
Heme/ID: Pt received a total of 3 units of PRBC. In the ED,
first unit did not see an appropriate bump in Hct,(26.2->25.4)
but was during active bleeding. The second 2 units were given in
TSICU overnight the 1st night with Hct response (23.7->25.7).
Over the next day, pt did not have frank blood, though Giuac
remained +, and Hct stabilized. On day 3, nurse noted increased
in loose stools, but C.Diff was NEG.
GU/Renal: UOP remained adequate throughout and pt had no issues.
Medications on Admission:
ASA 81mg po qd
Prilosec OTC 20mg 2 tabs po qd
Vit D3
Aggrenox 1 [**Hospital1 **]
Metoprolol 25mg tid
Sertraline
Colace 200mg po qpm
Simvastatin 20mg po qd
Zoloft 75mg po qd
Senna 8.6mg po bid
Tylenl PRN
Fleets/MOM PRN
Discharge Medications:
1. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
2. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Last Name (STitle) **]: One (1)
Tablet PO DAILY (Daily).
3. Captopril 25 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO TID (3 times a
day).
4. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
5. Sertraline 50 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO HS (at bedtime).
6. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime).
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: [**12-12**] PO HS (at
bedtime).
10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Month/Day (2) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 537**]- [**Location (un) 538**]
Discharge Diagnosis:
Lower GI bleed
Discharge Condition:
good
Discharge Instructions:
You have been admitted to [**Hospital1 18**] for bleeding from you rectum.
You were evaluated with anoscopy and sigmoidoscopy and it was
determined that bleeding was likely from the anastomosis site of
your colostomy. You were treated with blood transfusion.
Please take medications as directed. Follow up with Dr. [**Last Name (STitle) **],
your surgeon, as directed below. Please continue to follow with
Dr. [**Last Name (STitle) 5351**] for your general care.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week, call ([**Telephone/Fax (1) 68195**]
to make an appointment.
Completed by:[**2148-6-21**]
|
[
"268.9",
"285.9",
"998.11",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"48.23"
] |
icd9pcs
|
[
[
[]
]
] |
5981, 6052
|
2837, 4630
|
320, 336
|
6111, 6118
|
1682, 2814
|
6630, 6784
|
1473, 1487
|
4899, 5958
|
6073, 6090
|
4656, 4876
|
6142, 6607
|
1502, 1663
|
275, 282
|
364, 827
|
849, 1126
|
1142, 1457
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,054
| 131,018
|
3450
|
Discharge summary
|
report
|
Admission Date: [**2103-10-18**] Discharge Date: [**2103-10-19**]
Date of Birth: [**2031-8-15**] Sex: M
Service: MEDICINE
Allergies:
Epinephrine / Lidocaine / Percocet / Imuran / Heparin Agents
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Hypercarbic respiratory failure, pneumothorax, mental status
changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a 72 yo male with pmhx Myasthenia [**Last Name (un) **] x 10 yrs,
diaphragmatic weakness, Esophageal CA s/p partial partial
esophagectomy, TIA s/p R CEA, CAD w/ MI s/p stent [**7-4**] w/ nl EF
who p/w hypercarbic respiratory failure (Co2= 150),
pneumothorax, mental status changes. Recently discharged from [**Hospital1 **]
in early [**Month (only) **] with myasthenia crisis after surgery.
Originally presented for chest pain and sob. He went to surgery
for baloon dilation of pylorus with improvemtn of chest pressure
and tolerated po diet. Transferred to MICU. He was
plasmapheresed and placed on Bipap. He was also started on
bipap. He was discharged to [**Hospital1 **], on prednisone 125 mg.
Tapered too quickly at rehab.
Presents today with increased sob and weakness starting one week
ago. He was diagnosed with a UTI earlier in the week and treated
with antibiotics. His wife also reported mental status changes
and reported that he had "difficulty focusing". Also notes
decreased po intake in the last week.
ABG in ED 7.20/150/381. ED vitals: T 97.8 HR 80 BP 136/65 RR 23
O2 sat 100%.
Past Medical History:
Myasthenia [**Last Name (un) 2902**] dx [**2092**] and started with diplopia
Bilateral Diaphragmatic weakness
Esophageal cancer s/p partial esophagectomy, XRT, chemo
Coronary Artery Disease w/ MI s/p cypher stent of mid RCA
[**6-/2102**], EF 60% 9/06
TIA
hypercholesterolemia
sleep apnea on night bipap 15/5 and O2 at 2 liters
malnutrition s/p j tube placemtn and removal
glaucoma
Social History:
Patient currently lives at [**Hospital **] Rehab, but prior to this
admission he was living at home with his wife. Retired [**Name2 (NI) **]
warehouse worker. No children. 15 pk/yr history of smoking but
quit 25 years ago. Denies ETOH or drug abuse. Uses walker at
baseline, but more weak recently. O2 requirement 24 hours per
day.
Family History:
Notable for many family members with CAD. His brother had lung
cancer. There is no myasthenia [**Last Name (un) 2902**] or other neurological
problems in the family.
Physical Exam:
VS T 94.8 ax, BP 113/64 P 108 RR 30 O2 sat 60% by VM
Gen-elderly man in acute respiratory distress, able to speak a
few words at a time
HEENT-NCAT, PERRLA, anicteric, no injections, OP with thrush, MM
dry
Neck-no JVD
Cor- tacchycardic, normal rythm, S1S2 no MGR
Lungs- no breath sounds appreciated on right side anteriorly and
upper posterior lung fields.
Abd- +bs, soft, nt, nd, no masses or hsm
Extrem- no CCE, cold extremities, poor peripheral pulses-thready
Neuro-confused, disoriented to place and time
Pertinent Results:
pH 7.20
pCO2 150
pO2 381
HCO3 61
.
151 99 25
----------< 224
4.6 >50 0.5
.
wbc 10.2 hgb 11.2 hct 35.2 plt 218 MCV 106
CK 36 MB not done Trop 0.07
PT 11.4 PTT 24.9 INR 1.0
.
CXR-right apical pneumothorax, no evidence of tension
pneumothorax by CXR.
Brief Hospital Course:
Pt is a 72 yo man with pmhx myasthenia [**Last Name (un) 2902**] w/ last crisis 3
weeks ago s/p surgery, esophageal cancer s/p resection,
chemotherapy and XRT, CAD who presented with one weak of
increased weakness, sob and pneumothorax and decreased mental
status. Hypercarbic respiratory failure probably multifactorial
and related to weakness 2/2 MG, diaphragmatic weakness which
would not allow him to blow off CO2. He was also found to have a
new right apical pnuemothorax of unclear etiology but without
signs of tension pneumothorax on imaging or exam. The family
and patient declined thoracocentesis. The patient was dyspneic
and did not tolerate BiPAP. His code was changed from DNR/DNI to
comfort measures only per his health care proxy. The patient
died on [**2103-10-19**] at 9:15am secondary to respiratory failure
secondary to diaphragmatic weakness/pneumothorax secondary to
[**First Name9 (NamePattern2) 15917**] [**Last Name (un) 2902**]. The family was present at the time of death.
They declined autopsy.
Medications on Admission:
albuterol nebs
asa 81 mg QD
plavix 75 mg QD
Anzemet 12.5 mg q8
bisacodyl suppository
brimonidine .15% 1 drop OU q 12 hrs
celexa 20 mg QD
cyanocobalamin 1,000 mcg QD
Dorzolamide-timolol 2-0.5% 1 gtt OU q 12
Fludrocortisone 0.1 mg po QD
insulin sliding scale
MOM
mupirocin cream QD to nose
Mycophenylate 1000 mg [**Hospital1 **]
Protonix 40 mg IV QD
Pyridostigmine 2 mg injection q 6 hours
Quetiapine 25 mg QHS
Travatan 0.004% 1-2 gtt OU q MWF
Discharge Disposition:
Expired
Discharge Diagnosis:
n/a
Discharge Condition:
n/a
Discharge Instructions:
n/a
Followup Instructions:
n/a
|
[
"365.9",
"512.8",
"V66.7",
"327.23",
"272.0",
"311",
"V12.59",
"414.01",
"V10.03",
"112.0",
"276.0",
"518.81",
"251.8",
"E932.0",
"412",
"358.00",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4811, 4820
|
3291, 4318
|
392, 398
|
4867, 4872
|
3018, 3268
|
4924, 4930
|
2305, 2473
|
4841, 4846
|
4344, 4788
|
4896, 4901
|
2488, 2999
|
284, 354
|
426, 1534
|
1556, 1939
|
1955, 2289
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,234
| 103,597
|
25239
|
Discharge summary
|
report
|
Admission Date: [**2147-8-30**] Discharge Date: [**2147-9-22**]
Date of Birth: [**2115-12-18**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
Exploratory laparotomy with Splenectomy [**2147-8-31**]
ORIF right distal tibia fracture with medial locking plate
[**2147-9-1**]
Mandible repair with wiring of jaw [**2147-9-2**]
History of Present Illness:
31 y/o male s/p car vs. tree at high rate of speed, confused and
c/o of chest pain. Unrestrained, +airbag deployment, heavy
front end damage.
Past Medical History:
Hep B
Hep C
Social History:
non-contributory
Family History:
Noncontributory
Physical Exam:
exam on arrival to ED:
140 70/P 14 99%RA
HEENT: multiple facial and head lacerations including forehead
lac and 4cm chin lac
Neck: +bleeding back of head and neck
Chest: CTAB, R chest ecchymosis
CV: RRR
ABD: soft, NT/ND FAST neg
Pelvis: Stable
GU: guiac neg, normal tone
Back: no step offs
Ext: RLE knee edema, defect in patella, pulses x2 LE's
Pertinent Results:
[**2147-8-30**] 10:16PM LACTATE-1.5
[**2147-8-30**] 09:16PM GLUCOSE-140* UREA N-10 CREAT-0.8 SODIUM-138
POTASSIUM-4.7 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16
[**2147-8-30**] 09:16PM ALT(SGPT)-315* AST(SGOT)-317* ALK PHOS-82
AMYLASE-426* TOT BILI-1.8*
[**2147-8-30**] 09:16PM CALCIUM-7.8* PHOSPHATE-2.9 MAGNESIUM-1.4*
[**2147-8-30**] 09:16PM WBC-29.7* RBC-4.78 HGB-15.4 HCT-43.5 MCV-91
MCH-32.2* MCHC-35.4* RDW-13.7
[**2147-8-30**] 09:16PM PLT COUNT-231
[**2147-8-30**] 09:16PM PT-15.2* PTT-30.7 INR(PT)-1.6
[**2147-8-30**] 09:16PM FIBRINOGE-192
MRI ABDOMEN W/O & W/CONTRAST [**2147-9-21**] 9:58 PM
MRI ABDOMEN W/O & W/CONTRAST; MR CONTRAST GADOLIN
Reason: second attempt visualize gall bladder--please call
before ex
Contrast: MAGNEVIST
[**Hospital 93**] MEDICAL CONDITION:
31 year old man s/p MVC, rib fx's, mandible surgery to repair fx
with RUQ pain, inc alk phos, 9mm dilated GB duct on U/S, no
stones, no edema.
REASON FOR THIS EXAMINATION:
second attempt visualize gall bladder--please call before exam
today so that we may sedate pt. appropriately
INDICATION: Right upper quadrant pain, increased alk phos,
dilated common bile duct on ultrasound. Status post trauma, MVC.
COMPARISONS: CT abdomen [**2147-9-21**] and ultrasound [**9-20**], [**2146**].
TECHNIQUE: Multiplanar T1- and T2-weighted images were obtained
of the abdomen. Dynamically acquired T1-weighted images were
obtained of the abdomen before, during and after administration
of intravenous gadolinium.
MRI OF THE ABDOMEN WITH AND WITHOUT CONTRAST: There is evidence
of central intrahepatic biliary dilatation. The common bile duct
is dilated measuring up to 12 mm. The common bile duct is
dilated down to the ampulla where it tapers and there is no
evidence of stones, strictures or masses. Post-gadolinium
administration, no abnormal masses are identified. The cause for
this common bile duct and intrahepatic biliary dilatation is not
identified. The pancreatic duct is normal. The pancreas is
normal without evidence of masses within the head. There is a
tiny, T2 bright lesion within the right lobe of the liver, which
does not enhance, is compatible with simple cysts. Otherwise,
the liver, gallbladder, adrenals, kidneys, and pancreas are
normal. The patient is status post splenectomy. Postsurgical
changes are identified within the midline. There are multiple
right-sided rib fractures as seen previously. There is no
abnormal lymphadenopathy. The patient is status post
splenectomy. There is minimal atelectasis at the lung bases.
IMPRESSION:
1. Mild-to-moderate central intrahepatic and common bile duct
dilatation as seen on previous studies. The cause for this
dilatation is not identified. There is no evidence of
strictures, stones or duodenal masses.
2. The patient is status post splenectomy with multiple
right-sided rib fractures.
CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2147-9-19**] 9:09 AM
CT SINUS/MANDIBLE/MAXILLOFACIA; CT RECONSTRUCTION
Reason: SP.MANDIBLE FX SURGICAL REPAIR ASSESSMENT OF ALIGNMENT
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with s/p mandible fracture surgical repair
REASON FOR THIS EXAMINATION:
please perform 3d reconstruction of mandible for assesment of
alignment?
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 31-year-old man, status post mandible fracture and
surgical repair. Followup evaluation.
TECHNIQUE: Axial, sagittal, and coronal images of the paranasal
sinuses and maxillofacial bones with 3D reconstructions.
FINDINGS: Comparison is made with [**2147-8-30**] exam. The
right comminuted mandibular ramus fracture is grossly unchanged
in appearance. The left mandibular ramus fracture is again seen
to be overriding and is grossly unchanged from prior exam. The
right paracentral mandibular body fracture is significantly
improved in alignment and now shows minimal displacement with
fixation hardware crossing the fracture lines. Fixation hardware
is also seen in the maxilla adjacent to the upper teeth and may
be connected to the lower teeth and mandible by non-opacified
material.
3D reformations revealed the presence of the above-mentioned
hardware as well as the previously described mandibular rami and
body fractures.
IMPRESSION:
1. Status post fixation of mandibular body fracture with
improved alignment.
2. Bilateral mandibular rami fractures, relatively unchanged
since the prior study.
TIB/FIB (AP & LAT) RIGHT [**2147-9-15**] 2:09 PM
TIB/FIB (AP & LAT) RIGHT
Reason: alignment. f/u surgery 2 weeks
[**Hospital 93**] MEDICAL CONDITION:
31 year old man with s/p MVA, R tib/fib ORIF. now 2 weeks out.
Needs 2 wk f/u films.
REASON FOR THIS EXAMINATION:
alignment. f/u surgery 2 weeks
INDICATION: ORIF patella and tibia.
COMPARISON: [**2147-8-30**].
FINDINGS: AP and lateral views of the tibia and fibula
demonstrate comminuted oblique fracture through the distal
tibia, transfixed by medial fixation plate and multiple
penetrating screws. Fracture lines are still visible. Also noted
is a transverse patellar fracture, transfixed by two K-wires and
cerclage wire. Incidental note is made of a spur along the
plantar fascia insertion of the calcaneus.
IMPRESSION: Interval ORIF distal tibia and patellar fractures.
Brief Hospital Course:
Upon arrival to the emergency dept. pt. was immediately
evaluated by the emergency medicine and trauma surgery teams. Pt
was sedated and intubated. Pt was imaged and revealed splenic
laceration, R tib/patella fractures, mandibular fractures with
tooth loss, R frontal brain contusion, bilateral rib fractures
including 1st rib, and inflammation of the superior pole of the
kidney. Pt was also noted to have multiple facial lacerations, a
large chin laceration, and gross hematuria of unknown origin.
Neurosurgery was consulted and stated nothing to do. Trauma took
pt. to OR for an exploratory laparotomy and performed a
splenectomy on [**2147-8-31**], after which he was admitted to the
TSICU. Orthopedics was consulted and took pt to OR for ORIF
right distal tibia fracture with medial locking plate on
[**2147-9-1**]. [**Date Range 40530**] was consulted and took pt. to OR for Mandible
repair with wiring of jaw on [**2147-9-2**]. Pt. was extubated without
incident. Pt. subsequently was requiring large amounts of pain
medication for injuries. Pt experienced an acute GI bleed while
in TSICU with associated tachycardia and hypotension to 60-70
systolic pressure. Pt. received transfusions of PRBC's, after
which his pressure and heart rate quickly normalized. GI was
consulted emergently during this event and pt's jaw wiring was
cut so as to perform emergent upper GI endoscopy. At that time
fresh blood was found in the stomach, but no point source was
found. On follow up endoscopy, a non-bleeding ulcer at the G-E
junction was identified and pt. was kept on tele and started on
an H-pylori eradication regimen. Pt. maintained his stability
and was subsequently transferred to the floor. Pt's jaw was
rubber banded by [**Name (NI) 40530**], pt. was instructed by nutrition on how to
follow a proper purreed diet, and pt. was advanced as tolerated
on PO's. Pt received PT & OT and was able to walk with walker.
Pt. continued to complain of constant [**9-25**] pain in chest and
abdomen, reproducible by palpation, no N/V, no diaphoresis, no
radiation. CXR and EKG were performed that were negative for any
changes. RUQ U/S, Abd CT and MRCP revealed a dilated CBD to 12mm
and mild to moderate hepatic duct dilitation without
stones/strictures/masses identified. GI ERCP fellow was
consulted and stated that there was nothing to do at this time
and that pt did not currently need to remain in the hospital for
this reason. Pt was evaluated by psychiatry and social work who
stated that pt. need strict boundries for pain medications and
that anxiety medications need to be increased, which they were
subsequently. Pt. was weened off IV pain medication and d/c'd on
PO pain meds as well as a low dose fentnyl patch for basal pain
coverage as taper from in hospital methadone coverage. Pt to
follow up with Trauma clinic, ortho-spine, [**Hospital **] clinic, [**Hospital 40530**], and
was given information about selecting a primary care physician
with whom to follow.
Medications on Admission:
Alprazolam
Discharge Medications:
1. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H
(every 4 to 6 hours) as needed.
2. Chlorhexidine Gluconate 0.12 % Liquid Sig: Fifteen (15) ML
Mucous membrane QID (4 times a day).
Disp:*1800 ML(s)* Refills:*2*
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day) as needed.
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
5. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*0*
6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-18**] Sprays Nasal
QID (4 times a day) as needed.
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed.
Disp:*500 ML(s)* Refills:*0*
8. Alprazolam 1 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
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. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
11. Amoxicillin 250 mg/5 mL Suspension for Reconstitution Sig:
One (1) 20ml PO BID (2 times a day) for 5 days.
Disp:*1 200ml* Refills:*0*
12. Clarithromycin 250 mg/5 mL Suspension for Reconstitution
Sig: One (1) 10ml PO Q12H (every 12 hours) for 5 days.
Disp:*1 100ml* Refills:*0*
13. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Transdermal
every seventy-two (72) hours as needed for pain.
Disp:*2 0* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
s/p Motor Vehicle Crash
Splenic rupture and splenectomy
Right Tibia/fibula/patella fracture
Right frontal contusion
Mandibular fracture with tooth loss
Bilateral rib fractures including 1st rib
Gastrointestinal Bleeding
Right pulmonary contusion and pneumothorax
Dilated CBD at 12mm & mild intrahepatic duct dilitation
Discharge Condition:
Stable
Discharge Instructions:
-Take your medications as prescribed.
-Be sure to keep your schedule your follow up appointments.
-Return to emegency room if you develop fever, chills, abdominal
pain, nausea or vomiting.
-You will need to select a primary care physician, [**Name Initial (NameIs) 138**]
[**Telephone/Fax (1) 250**], [**Hospital6 733**]; [**Last Name (NamePattern4) 4113**] [**Last Name (NamePattern4) **] [**Last Name (NamePattern1) **] and
[**Last Name (NamePattern1) 54090**]are now accepting new patients.
Followup Instructions:
Follow up in 2 weeks in [**Hospital **] Clinic, call [**Telephone/Fax (1) 1228**] for
an appointment.
Follow up with Trauma Surgery in 3 weeks, call [**Telephone/Fax (1) 6439**] for
an aappointment.
Follow up with Dr. [**Last Name (STitle) 2866**], Oral Maxillo Facial Srgery in 1
week, call [**Telephone/Fax (1) 27823**].
Follow up with the [**Hospital **] clinic in 1 week regarding
your dilated common bile duct at: [**Telephone/Fax (1) 1954**] or [**Telephone/Fax (1) 1983**]
Follow up with a Primary care [**Name10 (NameIs) 63211**] [**Hospital **] to select your doctor: [**Telephone/Fax (1) 250**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
|
[
"802.24",
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"865.12",
"822.0",
"864.01",
"851.40",
"824.8",
"518.5",
"070.30",
"599.7",
"860.0",
"070.70",
"873.49",
"576.8",
"305.90",
"578.9",
"864.02",
"285.1",
"868.03"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"41.5",
"76.76",
"23.09",
"50.61",
"96.48",
"96.05",
"93.55",
"38.93",
"45.13",
"96.72",
"38.91",
"96.04",
"96.6",
"86.59",
"79.36",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
11111, 11169
|
6421, 9398
|
339, 521
|
11532, 11541
|
1175, 1933
|
12084, 12820
|
778, 795
|
9459, 11088
|
5718, 5803
|
11190, 11511
|
9424, 9436
|
11565, 12061
|
810, 1156
|
276, 301
|
5832, 6398
|
549, 693
|
715, 728
|
744, 762
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,358
| 143,701
|
26825
|
Discharge summary
|
report
|
Admission Date: [**2120-3-25**] Discharge Date: [**2120-4-2**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2186**]
Chief Complaint:
respiratory distress, hemoptysis
transferred from OSH
Major Surgical or Invasive Procedure:
debridement of mass from tracheal lumen by interventional
pulmonary
History of Present Illness:
[**Age over 90 **] yo male with PMH large right thyroid cystic mass eroding into
trachea, who presented to [**Hospital6 **] [**2120-3-24**] with
hemoptysis and respiratory distress, now diagnosed with
anaplastic thyroid carcinoma.
.
Pt reports that he noticed a right neck mass last [**Month (only) 359**]. The
mass grew larger, to the size of a baseball. It appears that FNA
was performed but was non-diagnostic (probably because
anaplastic tumors tend to be necrotic). The mass appears to be
cystic in nature and has been aspirated at least 3 times, which
decrease in size each time. Now size is 6.5cm*6.5cm. Plan for
surgery in [**Month (only) **] was deferred [**3-7**] syncope and pacer placement for
SSS; again deferred 2 weeks ago [**3-7**] URI; was planned for surgery
this Thurday.
.
Pt was o/w in his USOH until 2-3 weeks ago when he developed a
URI with symptoms of dry cough; no fever, chills, sore throat,
myalgias. Pt was treated with 3 days of an antibiotics, followed
by a 10 day course of levaquin (completed 2 days PTA). Per pt
and son, no [**Name2 (NI) 66025**] pna. 2 days prior to admission, pt
developed hemoptysis; states he coughed up 4 tsp of blood. 1 day
PTA, pt developed stridorous breathing and respiratory distress.
Pt was initially seen at [**Hospital1 **], where he was given steroids,
with improvement in respiratory status. Pt was transferred to
[**Hospital6 2561**], where his surgeon is located. There he
was admitted to the MICU. Thyroid cyst was aspirated with
removal of 300cc of fluid. Pt was given racemic epinephrine and
Decadron 10mg IV x1. CT neck showed tracheal mass per nursing
s/o (pt brought CT).
.
Pt now breathing more comfortably. He has not had fever and
night sweats but reports weakness and weight loss for several
months recently.
Past Medical History:
R thyroid cyst (as above)
Goiter
CRI
HTN
SSS (s/p pacer [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 66026**])
prostate cancer -dx 10 years ago; received monthly shots which
were discontinued recently.
anemia
Afib (19 episodes since [**2119-11-4**], as documented on pacer
interogation [**2120-3-6**])
Social History:
Was living alone in ALF. Walks with walker. Able to take care of
himself; home health aide visits once a week. Denies history of
tobacco, etoh, drugs. Used to work as hat manufacturer.
Family History:
No history of thyroid disease. Sister with lung ca. Brother with
gastric ca. sister with unknown ca. Father with stroke.
Physical Exam:
VS: T 99.4, BP 119/59, HR 76, RR 18, 99%RA
Gen: NAD
HEENT: PERRL, EOMI, clear OP, MMM
Neck: Large ~6 x 6 cm sized right thyroid mass, soft, possibly
cystic, non-tender. L lobe of the thyroid gland also prominent.
CVS: RRR, nl s1 s2, no m/g/r
Lungs: transmitted upper airway stridor; otherwise clear
Abd: soft, NT, ND, +BS
Ext: no edema
Neuro: CN 2-12 intact, [**6-7**] bilateral upper and lower extremity
strength.
Pertinent Results:
CT Neck-IMPRESSION:
1. 7-cm diameter right neck mass, with direct invasion of the
subglottic, cervical and proximal thoracic trachea. The mass is
reportedly thyroid in origin. Differential diagnosis includes
primary head/neck cancer and lymphoma.
2. Left lobe thyroid enlargement with heterogeneous appearance.
3. Right upper paratracheal and prevascular lymphadenopathy as
well as additional nodes in the right side of the neck.
Dedicated MR of the neck may be helpful for more complete
assessment of the neck mass and lymphadenopathy if warranted
clinically.
.
Pathology: The tumor is composed of a relatively monotonous
proliferation of spindle cells which grow in sheets with a
prominent vascular pattern. Immunostains for cytokeratin AE1/3
and CAM 5.2, CD-68, CD-79a, CD-138, S-100, LCA absorbed CEA,
EMA, CD34, CD31, TTF-1, actin, desmin, MNF-116, calcitonin, and
thyroglobulin are negative. These results exclude both melanoma
and hematopoietic neoplasms. The differential diagnosis
includes, but is not limited to, sarcoma, spindle cell
carcinomas (sarcomatoid carcinoma of the upper aerodigestive
tract and anaplastic thyroid carcinoma), and malignant salivary
gland neoplasms.
Brief Hospital Course:
Pt was transferred here for further mgmt of airway and large
thyroid mass by our IP team. IP found endotracheal obstructing
tumor and extrinsic
compression of the high trachea by thyroid mass. After rigid
bronchoscopy with removal of the intratracheal tumor component
on [**2120-3-26**], stat pathology showed anaplastic tumor. He was
tranferred to the MICU. Subsequently extubated and his
respiratory Sx are now improved. Pt was seen by Rad Onc, who
recommended transfer to the [**Hospital Ward Name 516**] for XRT. On the morning
of possible radiation, patient and family met with
interventional pulmonary team who explained that the most recent
CT showed further invasion of the tumor into the trachea. After
a long discussion, patient and family asked to be made CMO.
Patient was started on morphine drip and palliative care team
was consulted with recommendations to ensure comfort. Mr.
[**Known lastname 66027**] died approximately 24 hours after decision to be CMO,
on [**2120-4-2**].
Discharge Disposition:
Expired
Discharge Diagnosis:
NC
Discharge Condition:
NC
Discharge Instructions:
NC
Followup Instructions:
NC
Completed by:[**2120-4-7**]
|
[
"193",
"518.81",
"403.91",
"197.3",
"V10.46",
"427.31",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"32.01",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
5563, 5572
|
4545, 5540
|
273, 342
|
5618, 5622
|
3330, 4522
|
5673, 5705
|
2756, 2878
|
5593, 5597
|
5646, 5650
|
2893, 3311
|
179, 235
|
370, 2158
|
2180, 2538
|
2554, 2740
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,516
| 180,036
|
29906
|
Discharge summary
|
report
|
Admission Date: [**2152-12-29**] Discharge Date: [**2153-1-1**]
Date of Birth: [**2083-2-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Tx from [**Hospital6 1109**] for crescendo angina with plan
for high-risk PCI.
Major Surgical or Invasive Procedure:
[**2152-12-29**] cardiac cath
[**2152-12-30**] cardiac cath
History of Present Illness:
HPI: this is a 69 year-old man with CAD s/p CABG in [**2145**] at [**Hospital1 2025**]
and transmyocardial laser revascularization [**3-/2148**] at [**Hospital1 112**] with
PCI [**5-/2148**] with stenting to L circ. post CABG anatomy:
SVG to PDA with R to left collateral to OM3
old occlusion of OM2
SVG to D1 with jump graft to OM1 (occluded [**2147**])
LIMA to distal LAD
[**2147**] cath: intervention PCI to osteal and distal LCX, TIMI 3
flow
70% distal LMCA lesion;
L circ osteal stenosis, serial mid and distal lesions;
OM2 with 95% stenosis:
LAD with 70% osteal stenosis, 100% mid-vessel stenosis
Diag filled by L collat
Rt-dominant RCA 40-50% dz
PDA 70% proximal
LIMA-LAD patent
SVG PDA patent
JVG (D1 to OM1) occluded at aortic root
.
He was doing fairly well, then presented to his cardiologist in
[**Month (only) **] with crescendo angina requiring NTG 75x/[**Last Name (un) **] (previous
30-35/month). He describes substernal CP/R arm pain brought on
by cold/large meals, and walking up stairs; no associated SOB.
He cannot define a set amount of physical activity which induces
angina because of limitation from plantar fascitis and PVD;
likewise he endorses DOE but cannot quantify the amt of exertion
required. He was referred for p-MIBI which showed large areas of
anterior, anterolateral, inferolateral, apical infarction +
ischaemia with almost complete anterior reversibility. He was
then referred for diagnostic cath at [**Hospital1 **] today which
showed as below.
.
[**2152-12-28**] cath:
90% distal LMCA lesion at bifurcation to L circ
90% L circ lesion
LIMA to LAD not completely characterized? vs 100% LAD lesion
SVG to D1 is proximally occluded; jump graft to OM1 patent
SVG to PDA patent supplies collaterals to OM1 and D1
SVG to OM1 occluded 100% (old)
.
His cardiac catheterization was complicated by dizziness, [**7-20**]
CP, nausea, diaphoresis and 2mm inferior STD during LIMA
angiography and thus only achieved a limited look. He was
admitted to [**Hospital1 **] CCU where he was treated with ASA, plavix,
heparin, integrellin, BB, nitro drip but had 2 further episodes
of substernal CP that were releaved w/in 10 min by increased NTG
drip and SL nitro. EKG showed 2mm STD in II, III, aVF, CE's were
negative x 2. He was therefore transferred to [**Hospital1 18**] o/n for
monitoring and planned high-risk PCI tomorrow AM
.
On transfer to our CCU he was initially feeling well, then
within a few minutes began feeling [**5-20**] substernal CP radiating
to his R arm + nausea, no diaphoresis or SOB. This was relieved
within 5 minutes by increasing his nitro drip (.5 to 1), 2mg
morphine, and 1 SL NTG. EKG showed 2mm STD in V3-V5 and lead I.
Past Medical History:
CAD s/p CABG in [**2145**]; ?PCI in [**2147**]
EF 55%
DM
Obesity
HTN
? PVD L leg
plantar fasciits
OA of knees
Carpal tunnel syndrome
Erectile dysfunction
Social History:
40 pack-yr smoking history; quit [**2115**]'s. occasional EtOH.
Family History:
Father with DM and angina
Physical Exam:
T: AF BP: 136/78 HR: 66 RR: 21 SaO2 96% 2L n/c
Gen obese gentleman, NAD
HEENT: NCAT, PERRL
CV: RRR no m/r/g
Pulm: clear anteriorly
Abd: obese; s/nd/nt + BS
Groin: R arterial sheath in-place; ?sutures malpostioned?; no
hematoma, some oozing
Extremities: warm, well-perfused. 1+ R DP pulse; trace L DP
pulse
Pertinent Results:
[**2152-12-29**] EKG: Sinus rhythm. ST segment flattening and slight
depression in I, aVL, V4-V6 which may represent an active
lateral ischemic process.
.
[**2152-12-29**] Cath: FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Widely patent LIMA-LAD and SVG-RCA.
3. Moderately to severely elevated right sided filling pressures
and
pulmonary artery pressures.
4. Severely elevated PCWP with giant V waves from ischemic
mitral
regurgitation.
5. Preserved cardiac output.
6. Calcified but nonobstructive lower abdominal, bilateral
iliac, and
femoral artery disease. Extravastion of contrast around RFA
sheath.
7. Successful PTCA and stenting of the distal LM/CX with a drug
eluting
stent. Unsuccessful PTCA of a small distal LPL lesion.
8. Vascular surgery consult for possible surgical closure of
RCFA
arteriotomy versus manual compression.
.
[**2152-12-29**] ECHO during cath lab: EF 40% 1. The left atrium is
normal in size.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is at least mildly depressed with inferior and
inferolateral hypokinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Lateral wall not well seen but limited views
suggest that it is probably normal.
3.The mitral valve leaflets are mildly thickened. Mild to
moderate (2+) mitral regurgitation is seen. With coronary
intervention, the mitral regurgitation becomes more severe to at
least moderate to moderately severe.[Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.]
4. There is no pericardial effusion.
.
[**2152-12-29**] ECHO after cath: LVEF 45% Conclusions:
1.The left atrium is mildly dilated. Probable PFO present
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is mildly dilated. Overall left ventricular
systolic function is mildy depressed.
3.Right ventricular chamber size is normal.
4.The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. No aortic regurgitation is seen.
5.The mitral valve leaflets are mildly thickened. At least
moderate ([**1-13**]+) mitral regurgitation is seen (within normal
limits).
6.There is moderate pulmonary artery systolic hypertension.
7.There is no pericardial effusion.
.
[**2152-12-30**] Cath: FINAL DIAGNOSIS:
1. Three vessel coronary artery disease. (see report [**2152-12-29**])
2. 60% ostial LM lesion prior to stent.
3. 90% LPL/distal CX lesion.
4. Successful PTCA of the 90% LPL lesion.
5. Successful PTCA and stenting of the ostial left main with a
drug
eluting stent.
6. Normal right sided filling pressures with borderline normal
pulmonary
artery pressures.
7. Mildly elevated PCWP after revascularization and diuresis.
8. Preserved cardiac output.
.
[**2152-12-30**] CXR: IMPRESSION: Diffuse bilateral pulmonary infiltrates
consistent with edema.
.
[**2152-12-30**] U/S groin: IMPRESSION: Hypoechoic mass in the right
groin, which is consistent with a hematoma in the appropriate
clinical setting. No evidence of pseudoaneurysm.
.
.
Labs:
Brief Hospital Course:
Mr. [**Known lastname 71472**] is a 69 year old male s/p CABG with complicated
coronary anatomy (LIMA to LAD, SVG to D1, SVG to PDA, known
occluded JVG D1 to OM3 with R to L collaterals to OM3) who
presented with crescendo angina with recent p-MIBI showing
reversible anterior defects and one EKG with anterior STD, and
one with infero-lateral ST depression associated with anginal
pain.
.
#) Cardiac: Patient presented with an NSTEMI and persistent CP.
He was taken to the cath lab and had a drug eluting stent
placed to the LMCA towards the LCX. He subsequently had three
episodes of chest pain that night and his cardiac enzymes
continued to rise. He was taken back to the cath lab the next
morning with angioplasty to a more distal lesion on the LCX.
His medications were optimized for BP and HR control. He was
discharged on plavix (for at least one year uninterrupted),
aspirin, metoprolol 125mg [**Hospital1 **], losartan 100mg daily and
atorvostatin 80mg. His norvasc and imdur was discontinued as he
should no longer have anginal pain after intervention and his
other BP meds were titrated upwards (concern over hypotension).
An ECHO during his first cath suggested moderate MR in response
to intervention to his LCX with EF of 45%. An ECHO on the day of
discharge showed a preliminary read of LVEF of 35% with inferior
lateral hypokinesis. He should have a repeat ECHO in [**12-12**] months
looking for any recovery of function.
.
He was given fluids after his second cath for renal protection
given two large dye loads in two days. This likely caused some
fluid overload as he became short of breath and a chest x-ray
showed some pulmonary congestion. This resolved with some IV
furosemide and the patient was thought to be euvolemic at
discharge. He was sent home with 20mg PO furosemide daily.
.
# R Groin bleed: He was transferred to [**Hospital1 18**] with a sheath in
place on his right groin. This was dislodged during transfer
and resulted in a right groin hematoma. Pressure was held and
his HCT remained stable. Vascular surgery was consulted and an
ultrasound of the groin revealed a 4-5 cm hematoma with no
aneurysm. No further intervention was needed.
.
# urology: During cath at the OSH his penile implant device was
perforated. A urology consult was obtained and they suggested
an empiric course of ciprofloxacin for 7 days to prevent
infection. He should follow up with his outpatient urologist to
have this fixed.
.
# Diabetes: His HA1C was 7.5% suggesting he could use stronger
glucose control at home. He was sent out on his home regimen of
NPH [**Hospital1 **] and sliding scale insulin. He should monitor his blood
sugars and follow this up as an outpatient.
.
# Physical therapy: He was evaluated by physical therapy and was
found to have no acute needs. He should follow up with cardiac
rehab closer to his home.
.
# code status: full code.
.
# ppx: Patient was given the pneumovax vaccine. He said he
already receieved the influenza vaccine this year.
Medications on Admission:
home meds:
cozaar 100 daily
plavix
ASA 81
lopressor 100 [**Hospital1 **]
isosorbide 60mg dilay
lipitor 20
norvasc 5
xalatan eye grops
SL nitro
lasix 20
potassium 10
insulin NPH 12 [**Hospital1 **] and ISS
.
meds on transfer:
ASA 325
plavix
protonix 40
xalatan eye drops
lipitor 80
isosorbide 60
norvasc 5
metoprolol 100 [**Hospital1 **]
cozaar 100 daily (at home)
SSI
morphine
nitro drip
integrillin drip
heparin drip
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).
Disp:*30 Tablet(s)* Refills:*2*
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 50 mg Tablet Sig: 2.5 Tablets PO BID (2
times a day).
Disp:*150 Tablet(s)* Refills:*2*
6. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve
(12) units Subcutaneous twice a day.
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain.
10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*8 Tablet(s)* Refills:*0*
11. Potassium 2.5 mEq Tablet Sig: Four (4) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
-NSTEMI
-CAD s/p cath with stents placed to the left main to circumflex
and LAD POBA
-CHF with systolic dysfunction and LVEF of ~35%
-DM
-HTN
Discharge Condition:
stable vital signs
ambulating well and taking in good oral intake
Chest pain free
Discharge Instructions:
You were admitted with chest pain and underwent cardiac
catheterization twice with stent placed. You must remain on
aspirin and plavix for at least one year uninterrupted. You
should also continue to take your medications as prescribed.
(Please note that some changes have been made to your
medications as noted below.)
.
You had an ECHO of your heart which showed some hypokinesis of
your anterior wall and apex of the heart giving an ejection
fraction which is lower than normal at around 35%. You should
have a repeat ECHO of your heart in [**12-12**] months to re-evaluate
your heart function.
.
You should limit your salt intake to 2g/day. You should limit
your fluid intake to 1.5L/day. You should weigh yourself daily
and if you gain more than 3lbs, please call your physician.
.
You should return to your physician or to the emergency room if
you have further chest pain, shortness of breath, fevers >101,
chills, bleeding from your cath site (groin area), or any other
symptoms which are concerning to you.
.
You are being treated with an antibiotic ciprofloxacin for a
complication to your penile implant device. You should complete
a total of a 7 day course. You should follow up with your
urologist about this.
Followup Instructions:
Please follow up with your cardiologist Dr. [**Last Name (STitle) **]. An
appointment has been made for you on Monday [**2153-1-8**] at 3:40pm.
Please call his office at [**Telephone/Fax (1) 71473**] to change this
appointment.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**12-12**] weeks.
An appointment could not be made with his office before you were
discharged. Please call [**Telephone/Fax (1) 71474**] to make an appointment.
Please follow up with your urologist in [**12-12**] weeks.
Completed by:[**2153-1-2**]
|
[
"E879.0",
"414.01",
"998.12",
"V45.81",
"428.0",
"424.0",
"428.30",
"250.00",
"401.9",
"410.71"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.45",
"37.22",
"00.40",
"88.52",
"88.55",
"00.41",
"37.23",
"36.07",
"99.20",
"00.66",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
11541, 11547
|
6989, 9699
|
393, 455
|
11752, 11836
|
3806, 3985
|
13112, 13726
|
3437, 3464
|
10464, 11518
|
11568, 11568
|
10021, 10228
|
6226, 6966
|
11860, 13089
|
3479, 3787
|
9717, 9995
|
275, 355
|
483, 3162
|
11587, 11731
|
3184, 3340
|
3356, 3421
|
10246, 10441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,126
| 171,107
|
18894
|
Discharge summary
|
report
|
Admission Date: [**2135-9-5**] Discharge Date: [**2135-9-11**]
Date of Birth: [**2085-8-6**] Sex: F
Service: CT SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 49 year old
Caucasian female who has experienced dyspnea on exertion with
associated wheezing since her 20s. She was labeled with the
diagnosis of asthma and for the last three decades has been
treated with bronchodilator therapy and parenteral
corticosteroids. Her dyspnea on exertion and wheeze have
only been associated with exercise, and there have been no
trigger exacerbations consistent with asthma. She was
referred to Division of Pulmonary and Critical Care Medicine
in [**Hospital **] Medical College by her primary care physician for
pulmonary function testing which revealed clipping of the
expiratory phase consistent with variable intrathoracic
obstruction. Bronchoscopy was performed on [**2135-5-30**], at that
site which revealed external compression of the trachea two
thirds of the way to the carina with posterior and lateral
wall impingement. The lumen was assessed to be approximately
5.0 millimeters in diameter. There was also approximately a
30% lumen diameter decrease with forced expiration. Followed
with contrast CT at that same site was performed revealing a
double aortic arch with right side larger than left with
respective carotid and subclavian arteries on the ipsilateral
arches. Tracheal narrowing at the level of the double arch
was approximately 8.0 millimeters. She was then referred to
the [**Hospital1 69**] for correction of
double aortic arch and pulmonary follow-up. She was referred
to [**Hospital1 69**] on [**2135-8-25**], and
admitted to the hospital on [**2135-9-5**], for surgery.
PAST MEDICAL HISTORY:
1. Recurrent sinusitis requiring antibiotics approximately
four times per year.
2. Intolerance to lactose.
3. Degenerative joint disease of the neck and back.
PAST SURGICAL HISTORY: Partial hysterectomy for fibroids in
the remote past.
ALLERGIES: Tetanus Diphtheroid.
MEDICATIONS ON ADMISSION: The patient was only on Advair as
her current medication.
SOCIAL HISTORY: The patient is married with two children,
age 32 and 25. She is employed as an accountant clerk in the
State of [**State 531**]. She is a life long nonsmoker and
nondrinker.
FAMILY HISTORY: Father died at age 60 of renal disease.
Mother age 82 with hypertension. Brother died at age three
of laryngeal mass. Sister age 26 with thyroid disease.
Sister age 32 with asthma.
PHYSICAL EXAMINATION: On admission, physical examination
revealed the patient was afebrile with stable vital signs.
Generally, the patient was mildly obese. The skin had good
tone, no obvious skin disease. Head, eyes, ears, nose and
throat examination - The pupils are equal, round, and
reactive to light and accommodation. Extraocular movements
are intact. Anicteric, not injected. Neck without jugular
venous distention, without bruits. The chest was clear to
auscultation bilaterally, occasional expiratory wheezes were
heard. The heart was regular rate and rhythm, occasional
faint I/VI systolic ejection murmur was heard. The abdomen
was soft, nontender, nondistended without hepatosplenomegaly.
Negative for costovertebral angle tenderness. Hypoactive
bowel sounds. Well healed scars. Extremities were warm and
well perfused without cyanosis, clubbing or edema. No
varicosities were seen on the extremity examination with
positive spider veins bilaterally. Neurologically, cranial
nerves II through XII are grossly intact. Examination is
focal with excellent strength in all four extremities. Pulse
examination showed 1+ femoral right and left, dorsalis pedis
and posterior tibial were 2+ bilaterally. Radial right was
1+ and left was 2+.
LABORATORY DATA: On admission, the patient had MR of chest,
mediastinum with and without contrast with magnetic resonance
imaging which showed right sided aortic arch and descending
aorta with mirror image, branching of the arch vessels, no
cardiac structural abnormality was seen. Large diverticulum
arising from the proximal descending aorta nearly forming a
complete double aortic arch. The left subclavian artery and
diverticulum were in close approximation, nonvisualized
ligament could exist between the two and form a complete
ring. The trachea was focally narrowed at that level.
White blood cell count on admission was 9.3, hematocrit 39.8,
platelet count 255,000. Prothrombin time was 12.2, partial
thromboplastin time 26.0 and INR was 1.0. Urinalysis was
negative . Chemistries were sodium 144, potassium 3.6,
chloride 102, bicarbonate 31, blood urea nitrogen 19,
creatinine 0.6, glucose 136. AST 21, total bilirubin 0.3.
the patient had cardiac catheterization done preoperatively
which showed no mitral regurgitation and a left ventricular
ejection fraction of 60%. Right dominant coronary
angiography. Left main coronary artery was normal, left
anterior descending was normal, left circumflex was normal,
right coronary artery was normal and dominant vessel.
Supravalvular aortography revealed normal appearing but right
sided offending but likely double arch. There was a common
left sided great vessel origin in ascending with a LCCA and
LSCA. The RCCA was next and the right SCA was last. There
is no evidence of diverticulum in the cine images obtained.
HOSPITAL COURSE: The patient was taken to the operating room
for double arch decompression and tracheomalacia. The
patient was operated [**2135-9-6**], and had aortic segmentectomy
and tracheoplasty. On postoperative day one, the patient did
extremely well, was on insulin drip of three, Nitroglycerin
of one, was weaned off Neo-Synephrine, and was transferred to
the floor. On postoperative day two, the patient continued
to do well, however, on chest x-ray, slight pneumothorax in
the left apices was found. Repeat chest x-ray showed
resolution of pneumothoraces. Physical therapy began working
with the patient and continued to work with the patient
throughout hospital course until the patient was cleared one
day before discharge. The patient was discharged on
[**2135-9-11**], postoperative day five, with lungs clear to
auscultation bilaterally, cardiac examination regular rate
and rhythm, abdomen soft, nontender, nondistended and the
patient was afebrile and vital signs were stable on
discharge.
MEDICATIONS ON DISCHARGE:
1. Colace 100 mg p.o. twice a day.
2. Zantac 150 mg p.o. twice a day.
3. Percocet one to two tablets p.o. q4-6hours p.r.n. pain.
4. Fluticasone 110 mcg two puffs twice a day.
5. Albuterol Ipratropium one to two puffs q6hours p.r.n.
6. Lopressor 50 mg p.o. twice a day.
7. Lasix 20 mg p.o. twice a day times one week.
8. Potassium Chloride 20 meq p.o. twice a day times one
week.
FO[**Last Name (STitle) **]P PLANS: The patient was instructed to follow-up
interventional pulmonary for bronchoscopy in four weeks and
was instructed to call [**Telephone/Fax (1) 51692**], for consultation
bronchoscopy with Dr. [**Last Name (STitle) **]. The patient had CT of neck with
tracheal reconstruction without contrast the day of discharge
and the patient was also instructed to follow-up with Dr. [**Last Name (Prefixes) 2545**] four weeks after discharge. The patient was also
instructed to follow-up with primary care physician in one to
two weeks and cardiologist in two to three weeks.
CONDITION ON DISCHARGE: Good.
DI[**Last Name (STitle) 408**]E STATUS: To home to [**State 531**]. The patient was told
that Dr. [**Last Name (STitle) **] [**Last Name (Prefixes) 2546**] office will be in touch with her for
follow-up appointments.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Last Name (NamePattern4) 7013**]
MEDQUIST36
D: [**2135-9-11**] 11:11
T: [**2135-9-11**] 11:36
JOB#: [**Job Number 51693**]
|
[
"747.21",
"519.1",
"998.12",
"E878.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.53",
"37.22",
"31.79",
"88.55",
"38.84"
] |
icd9pcs
|
[
[
[]
]
] |
2325, 2509
|
6399, 7392
|
2055, 2114
|
5376, 6373
|
1939, 2028
|
2532, 5358
|
170, 1730
|
1752, 1915
|
2131, 2308
|
7417, 7908
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,521
| 186,187
|
39694
|
Discharge summary
|
report
|
Admission Date: [**2167-8-11**] Discharge Date: [**2167-8-16**]
Date of Birth: [**2117-8-4**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Pulmonary emboli bilateral
Major Surgical or Invasive Procedure:
None during this admission
History of Present Illness:
Pt is s/p RNYGBypass ([**Doctor Last Name **]) [**2076-7-27**] - discharged [**2167-8-1**]
p/w left sided flank pain 3AM [**2167-8-10**]. She had been doing well
post-surgery until this time. She called our service [**2167-8-10**] at
11PM and was told to present to the ER if her pain did not
resolve with tylenol. Instead, she presented to the ER this
morning ([**2167-8-11**]). In the interim, her pain gradually worsened.
The pain increases with deep inspiration and laying down, is
dull, non-radiating in nature, and [**2165-7-18**] in intensity. It is
associated with orthopnea and some dyspnea. Not improved with
pain medications. She denies any nausea, vomiting, cough,
sputum, hemoptysis. No fever/ chills/ dysphagia/ reflux/
odynophagia. She is passing gas and having BM and tolerating her
diet. The patient was active until the pain started and she was
moving adequately. She denies any fever or chills. The patient
has not taken any NSAIDS, and has been taking her medications as
ordered.
Past Medical History:
PMH: osteoarthritis(knees), Vit D deficiency, and fatty liver by
ultrasound, amennorheic
Social History:
Married, not employed, denies tobacco, alcohol, drugs.
Family History:
No breast, colon, or gynecologic malignancy.
Physical Exam:
General: Awake, alert, oriented x 3
HEENT: EOMI, PERRLA
CV: RRR
PULM: CTAB
ABD: Soft, non-tender, non-distended, + BS
EXTREM: WWP, 2+ radial and DP pulses, no LE edema
NEURO: No focal deficits
Pertinent Results:
[**2167-8-16**] 08:00AM BLOOD PT-28.6* PTT-56.7* INR(PT)-2.8*
[**2167-8-15**] 03:46PM BLOOD PT-26.4* PTT-55.1* INR(PT)-2.5*
[**2167-8-15**] 04:53AM BLOOD PT-25.6* PTT-96.4* INR(PT)-2.5*
[**2167-8-13**] 03:48AM BLOOD Glucose-115* UreaN-5* Creat-0.8 Na-137
K-3.6 Cl-102 HCO3-29 AnGap-10
Brief Hospital Course:
The patient presented to to [**Hospital1 18**] Emergency Department on
[**2167-8-11**] with complaints of pleuritic chest pain x 1-2 days. In
the ED, a CT chest/abd showed multiple bilateral pulmonary
emboli, WBC 13.9, Hct 38.1, LFTs and lytes WNL, D-dimer 2661,
and CXR with bibasilar opacities - possible atelectasis. The
patient was started on IV heparin and transferred to the ICU for
respiratory management - requiring nasal cannula at 4L to
maintain O2 saturations above 92%. Lower extremity dopplers
negative for thrombi. On HD 2, she was transferred to a regular
floor for further management of PTT and bridging to coumadin.
Neuro: The patient was alert and oriented throughout the
hospitalization; pain was well controlled with a dilaudid PCA
initially, and later transitioned to PO dilaudid and tylenol at
time of discharge.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient required oxygen supplementation via nasal
cannula to maintain O2 sat above 92% until HD 3, at which time
she was transitioned to room air. Vital signs were routinely
monitored.
HEME: The patient was intially started on heparin IV and
maintained at goal PTT 60-90 with PTT checks every 6 hours.
Heparin was discontinued on discharge. Coumadin was started on
HD 4 with INR checks to maintain INR goal [**2-13**]. The patient was
therapeutic in this range on 3mg coumadin daily at discharge.
GI/GU/FEN: She was maintained on a bariatric stage 4 diet once
stable and out of the ICU. The diet was well-tolerated.
Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **]
dyne boots were used during this stay; s/he was encouraged to
get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient received discharge teaching
and follow-up instructions with understanding verbalized and
agreement with the discharge plan to obtain regular INR checks,
which will be monitored by her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 87480**]. The first INR
draw scheduled for [**2167-8-17**].
Medications on Admission:
- Docusate (Liquid) 100 mg PO BID
- OxycoDONE-Acetaminophen Elixir [**5-21**] mL PO Q4H:PRN pain
- Ranitidine (Liquid) 150 mg PO BID
- Ursodiol 300 mg PO BID
- MVI
- Vitamin D 5000 units daily
Discharge Medications:
1. Warfarin 3 mg PO DAYS ([**Doctor First Name **],MO,TU,WE,TH,FR,SA)
3mg daily starting 4PM today
RX *Coumadin 3 mg 1 tablet(s) by mouth daily at 4PM Disp #*14
Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 160 mg [**1-14**] tablet(s) by mouth Q6H:PRN Disp
#*225 Tablet Refills:*0
(continuing home ursodiol, ranitidine, docusate, MVI as prior to
admission)
Discharge Disposition:
Home
Discharge Diagnosis:
Pulmonary emboli
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Bariatric Surgery Service at [**Hospital1 1535**] on [**2167-8-11**] for treament of
multiple pulmonary emboli following laproscopic RNYGBypass
performed on [**2167-7-29**].
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, or any other symptoms which are concerning to you.
Diet: Stage 4 diet. Do not drink out of a straw or chew gum.
Medication Instructions:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. Coumadin 3mg daily with REQUIRED INR checks to be monitored
by your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 87480**]
2. Ursodiol, Zantac, and stool softener should be continued as
prior to admission.
3. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
Activity:
You may resume normal activity
Followup Instructions:
Follow up with PCP (Dr. [**Last Name (STitle) 87480**] for managment of coumadin dosing.
Call [**Telephone/Fax (1) 87481**] at 9AM [**2167-8-17**] to schedule a blood draw to
check INR.
|
[
"V45.86",
"715.36",
"268.9",
"571.8",
"415.19",
"278.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5135, 5141
|
2173, 4490
|
329, 358
|
5202, 5202
|
1864, 2150
|
6471, 6660
|
1589, 1636
|
4733, 5112
|
5162, 5181
|
4516, 4710
|
5353, 5869
|
1651, 1845
|
263, 291
|
386, 1387
|
5894, 6448
|
5217, 5329
|
1409, 1500
|
1516, 1573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,658
| 134,436
|
27858
|
Discharge summary
|
report
|
Admission Date: [**2109-1-28**] Discharge Date: [**2109-2-4**]
Date of Birth: [**2087-9-22**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Ampicillin
Attending:[**First Name3 (LF) 3507**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
21 year old 6 days post-partum with PMH sig for depression. The
baby was [**Name2 (NI) **] premature. The patient noted b/l LE edema in the
hospital and eventually RLE edema and progressive pain, which
persists. She was visiting baby daughter on the day of admission
in [**Hospital1 **] NICU. She got up to hand her baby to the nurse, and felt
lightheaded after getting up from a chair. Her friend caught
her, lowered her back to the chair as she collapsed. A nurse
palpated her pulse at 40bpm, but it quickly rebounded to 100bpm.
Code was called, the EKG was significant for sinus tachycardia.
Pt brought to ED and found to have subsegmental PE and RLE DVT.
.
Pt currently has RLE pain, no other complaints.
Past Medical History:
?Non-epileptiform seizure disorder
Social History:
Immigrated from Guatemal 1yr ago. No etoh or tobacco.
Family History:
Mother died during childbirth, father died (?suicide) about
12yrs ago.
Physical Exam:
VS: T 98.6 BP 97/66 HR 81 RR 20 Sat 96% RA
Gen: Pleasant spanish speaking woman in no apparent distress
HEENT: OP clear, MMM, PERRL
CV: Normal s1/s2, RRR
PUL: CTA b/l no wheezes or rales
Abd: Soft, TTP near recent suprapubic incision
Ext: RLE swollen, painful calf, DP 2+ b/l
Pertinent Results:
[**2109-1-30**] 07:10AM BLOOD calTIBC-499* Ferritn-15 TRF-384*
[**2109-1-28**] 03:00PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2109-1-30**] 09:14PM BLOOD CK-MB-1 cTropnT-<0.01
[**2109-2-4**] 07:15AM BLOOD PT-26.9* PTT-37.8* INR(PT)-2.8*
[**2109-1-28**] 03:00PM BLOOD WBC-14.2* RBC-3.88* Hgb-10.2* Hct-30.4*
MCV-78* MCH-26.3* MCHC-33.7 RDW-16.0* Plt Ct-357
[**2109-2-4**] 07:15AM BLOOD WBC-6.9 RBC-4.00* Hgb-10.1* Hct-30.3*
MCV-76* MCH-25.2* MCHC-33.3 RDW-16.0* Plt Ct-477*
.
RLE U/S:
Duplicated right popliteal venous system, with acute DVT in the
more anterior/superficial branch of the right popliteal vein.
.
CTA OF THE CHEST: Within the right lower lobe, there is an
isolated filling defect within a subsegmental (4th order)
pulmonary artery branch consistent with a subsegmental pulmonary
embolism. No additional pulmonary emboli are identified. There
is no evidence of thoracic aortic dissection. Lung windows
demonstrate a calcified granuloma within the right lower lobe.
In the area adjacent to the distal pulmonary embolism, there is
patchy opacity which may represent atelectasis or infarction.
Otherwise, the lungs are well aerated. The central airways are
patent. There is no pleural or pericardial effusion. No
pathologically enlarged lymph nodes within the mediastinum,
axillae, or hila. Within the imaged portion of the upper
abdomen, the visualized portion of the liver and spleen are
normal.
.
IMPRESSION: Isolated pulmonary embolism within a right lower
lobe subsegmental (4th order) branch, with associated
atelectasis (or early infarction).
.
Echo:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and systolic function are normal
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. The mitral
valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
.
IMPRESSION: Normal study. Preserved global and regional
biventricular systolic function. No structural cardiac cause of
syncope identified.
Brief Hospital Course:
#Deep Venous Thrombosis/Pulmonary Embolism: was likely etiology
for syncopal episode. ECG without significant changes or right
heart strain. Tele without events. No further episodes in
house. Echo obtained which showed preserved biventricular
function. Started on Heparin drip, and bridged to coumadin in
house. Will f/u at the [**Hospital6 **] center within 48 hours
of discharge for INR check.
.
#Non-epileptiform siezure: during the evening of [**1-30**], the
patient complained of chest pain to the nurse, who noted that
her eyes were rolling back in her head and she looked like she
was having difficulty breathing. She alerted the HO, who then
found her unresponsive and not breathing. She had a pulse, but
she was unresponsive to pain and her eyes were rolling side to
side and back and forth. He started to bag her, she was gagging,
and then she started to breath on her own. A code blue was
called. Her neurologic exam was intact. Patient was alert and
oriented times three, complaining of severe chest pain and left
sided "lung pain." Vitals at the time were RR 28, BP 88/60, O2
Sat 99%. Symptoms resolved spontaneously, and event ultimatley
felt to be a non-epileptiform seizure. No additional episodes
in house. Psychiatry was consulted and recommended low dose
ativan while in house.
.
#Urinary Tract Infection: treated with 3 days of Cipro.
.
#Low grade fever/leucocytosis: the day before discharge, the
patient developed a low grade fever (~100.0) and mild
leucocytosis (10.1-->13.5) that resolved spontaneously the next
day (6.9). No signs or symptoms of infection. However, she
remained afebrile for over 24 hours without change in clinical
status.
.
#Anemia: Fe deficiency by Fe studies. Started on Fe.
.
#s/p C-section: followed by OB/GYN team in house. Staples from
C-section removed.
Medications on Admission:
None
Discharge Medications:
1. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*1*
2. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Deep Venous Thrombosis
2. Pulmonary Embolism
3. ?Non-epileptiform siezure
4. Urinary Tract Infection
5. Fe deficiency Anemia
Discharge Condition:
stable, INR therapeutic
Discharge Instructions:
Please come back to the Emergency Room should you develop any
fevers, chills, sweats, nausea, vomiting, blood in your stools,
black stools, or any other complaints.
It is VERY important that you go to the [**Hospital6 **] Center
on Wendesday, [**2-6**] to get your coumadin levels
checked. Take two, 2.5 mg tonight and Tuesday night.
Followup Instructions:
[**Hospital6 **] Center
[**Street Address(2) 34193**], [**Hospital1 **], MA
|
[
"345.90",
"453.41",
"311",
"280.9",
"648.24",
"599.0",
"673.24",
"648.94",
"646.64",
"648.44"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5971, 5977
|
3868, 5690
|
288, 295
|
6153, 6179
|
1566, 3845
|
6563, 6642
|
1182, 1254
|
5745, 5948
|
5998, 6132
|
5716, 5722
|
6203, 6540
|
1269, 1547
|
241, 250
|
323, 1035
|
1057, 1095
|
1111, 1166
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,770
| 162,592
|
31985
|
Discharge summary
|
report
|
Admission Date: [**2152-11-2**] Discharge Date: [**2152-11-22**]
Date of Birth: [**2102-12-17**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
OSH transfer : mental status change, PE, pituitary adenoma
Major Surgical or Invasive Procedure:
L IJ central line
Foley catheter
PICC line x2
Dophoff tube
History of Present Illness:
This is a 49 yr old female s/p pituitary adenoma resection one
month prior. Had a post operative infection. Admitted 6 days ago
to OSH with sepsis from PICC line site. Sepsis 2 days ago.
Started on pressors. Discontinued 24 hours ago.
.
removal of pituitary tumor [**2152-9-22**]. Post operative course
complicated by UTI, SIADH and fever. Pt transferred to rehab on
[**2152-10-12**] on levaquin and vancomycin via PICC line. Pt continued
to be febrile at rehab and returned to the hospital [**10-26**] with a
temp to 102 and confusion. CXR -, CT head with decrease in
hemorrhage left frontal lobe. [**10-31**] transfer to the ICU for
increased HR, decreased BP and T to 104. Central line placed
[**10-31**]. Started on neo and levo. Weaned off [**11-1**]. Blood cx grew
out staph and [**Female First Name (un) **].
.
Decreased urine output [**Date range (1) 74935**]. 12cc UO in 8 hrs. [**11-2**] UO to
450 ml over 8 hrs. BUN/CR continued to be elevated at 38/4.2.
Unclear sequence of events, but patient started on a lasix drip
at 40 mg/hr [**2152-11-1**]. IVF to 1/2 NS with 1 amp sodium bicarb at
75 cc/hr.
.
Clot reported right arm, left leg. With high prob PE in RML, RLL
based on VQ scan [**10-31**]. 100% 2L. Crackles at bases. Heparin and
lovenox started but decreased secondary to low platelets at
52,000 on [**2152-11-2**]. Admission platelets 243,000. Filter not
placed given sepsis. Ct abdomen performed with peripancreatic
inflammation and kidney stones. LFTS elevated at that time.
.
Right pupil non reactive since surgery. Right ptosis since
surgery. Altered mental status since admission. CT head [**10-26**]
with right frontal craniotomy. Old hemorrhagic mass in left
frontal area which cont. to decrease in size, now 3.2cm in
greatest diameter. +Surrounding edema.
.
Pt transferred based on pt and family request in addition to
?need for ERCP and IVC filter.
.
On presentation, pt altered mental status, tachypneic. BP stable
without pressors. O2 sat 100% RA.
.
ROS: as per daughter
(+) Change in mental status, fever, recent weight gain, loss of
vision, headaches.
(-) Denies , chills, night sweats, loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
cough, shortness of breath. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
PSHx: Total Hysterectomy (8y ago, Fibroma)
.
PMH: Pituitary microadenoma s/p right craniotomy [**2152-9-22**] causing
panhypopituitarism including SIADH, hypothyroidism.
Hypertension
SIADH due to adenoma
hyponatremia
hx of uterine cyst
recurrent back and hip pain
nephrolithiasis
Social History:
6 months ago went to [**Country **] republic.
Family History:
Mother with hypertension, osteoarthritis
Father died unknown cause
Any hx of cancers in family members.
Physical Exam:
Vitals: T: 97.1 P: 76 BP: 125/86 R: 24 SaO2: 97% RA
General: Lethargic, anasarca.
HEENT: right craniotomy clean healing wound, bilateral
periorbital edema, facial edema. Ichteric sclerae. Ptosis,
non-reactive pupil right eye, Left pupil reactive with present
extraocular movement. Dry oral mucosa
Neck: pain with motion of neck, no JVD or carotid bruits
appreciated
Pulmonary: breath sounds decreased bilaterally; crackles at
bases
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: normoactive bowel sounds, distended, pain in deep
palpation, no guarding.
Extremities: Edema in all extremities, non palpable radial pulse
Lymphatics: No cervical, supraclavicular, axillary or inguinal
lymphadenopathy noted.
Skin: no rashes , Right clean nonerythematous, non-edematous
central line.
Neurologic:
-mental status: Lethargic. Follow commands, responsive to pain,
illogical verbalization
-cranial nerves: III - R ptosis, R pupil non reactive
-motor: decreased strength. No abnormal movements noted.
-sensory: No deficits to light touch throughout.
-cerebellar: unable to perform due to patients mental status.
Pertinent Results:
OSH Labs & Studies:
[**11-2**]- [**Hospital1 **] 7.43/25/94
ABG - [**2152-11-1**] 7.34/23/90 HCO3 14 O2Sat: 97.5
[**2152-10-31**] 7.46/25/84 HCO3 18 O2Sat: 97.5
CBC - [**2152-11-2**] WBC 10.1 RBC 4.11 HGB 12.3 HCT 34.8 PLT 52
[**2152-11-1**] WBC 8.4 RBC 3.24 HGB 9.2 HCT 27.4 PLT 18.7
Chem- [**2152-11-2**] Glu 98 BUN 38 Creat 4.2 Bun/creat 9.0
Na 127 K 4.3 Cl 99 CO2 16 Ca 5.9
T bili 3.2 Direct bili 1.9 AP 208 AST 59
ALT 141 albumin 2.3 total prot 4.0 amylase 282
[**2152-11-2**] B natriuretic peptide 146
[**2152-10-31**] TSH 1.07
[**2152-10-26**] TSH 0.11 T4 2.7
[**2152-10-26**] adenocorticotropic hormone <10 cortisol random 3.2
Coag- [**2152-11-1**] PT 22.9 INR 2.0 HPTT >200 Fibrinogen 325
D-Dimer >20.0
Micro- [**2152-10-29**] blood cx Alpha strep growth
[**2152-10-26**] blood cx [**Female First Name (un) 564**] Albicans growth
[**2152-10-31**] urine cx negative
.
EKG: Pending
Documented as NSR, no changes.
.
Radiologic Data:
CXR, CT head pending
.
B/L lower extrem U/S ([**11-1**]): Positive DVT in the L popliteal
vein. No DVT in R leg
.
Abdominal U/S ([**11-1**]): Small amt of fluid around pancreatic
head, no gallstones, bilateral pleural effusions, mild
hydronephtosis of the R kidney (L kidney wnl)
.
CT Abdomen/Pelvis w/o contrast ([**11-1**]): Small b/l pleural
effusions, minimal peripancreatic inflammation. Nonobstructing
stones in each kidney and and tubular partially calcified
structure next to the hilum of the L kidney measuring 7mm and
may represent vascular structure. Minimal free fluid in the
pelvis. Bowel is unremarkable.
.
RUE U/S ([**10-31**]):Extensive DVT in the R upper extremity involving
the axillary and brachial veins as well as superficial
thrombophlebitis in the basilic vein.
.
V/Q Scan ([**10-31**]): Mismatching ventilation-perfusion defects
involving regions of the R middle lobe and R lower lobe
suggestive of pulmonary thromboembolic disorder - High
probability for pumonary embolism.
.
CXR ([**10-31**]): Lungs clear, heart size normal.
.
Supine abdomen ([**10-31**]): Nonspecific bowel gas pattern, no
obstruction apparent.
.
CT Head w/o contrast ([**10-26**]): Pt had a right frontal craniotomy.
Old hemorrhagic mass in left frontal area which cont. to
decrease in size, now 3.2cm in greatest diameter. +Surrounding
edema, less pronounced from previous study. The hemorrhagic mass
above the sella is less pronounced than on previous study. No
new areas of abnormal attenuation. No abnormal extra-axial
masses. Persistent opacification of the sphenoid sinus.
[**2152-11-5**] 05:23AM BLOOD WBC-8.5 RBC-4.32 Hgb-12.7 Hct-36.4 MCV-84
MCH-29.4 MCHC-34.8 RDW-16.5* Plt Ct-67*#
[**2152-11-6**] 03:54AM BLOOD WBC-9.1 RBC-3.96* Hgb-12.0 Hct-33.6*
MCV-85 MCH-30.4 MCHC-35.9* RDW-17.6* Plt Ct-90*
[**2152-11-8**] 05:14AM BLOOD WBC-5.9 RBC-3.26* Hgb-9.7* Hct-27.9*
MCV-86 MCH-29.6 MCHC-34.6 RDW-18.2* Plt Ct-214
[**2152-11-10**] 06:10AM BLOOD WBC-5.6 RBC-2.77* Hgb-8.4* Hct-24.5*
MCV-89 MCH-30.3 MCHC-34.2 RDW-18.8* Plt Ct-263
[**2152-11-12**] 05:55AM BLOOD WBC-5.4 RBC-2.79* Hgb-8.4* Hct-25.2*
MCV-90 MCH-30.3 MCHC-33.6 RDW-18.8* Plt Ct-298
[**2152-11-14**] 01:34AM BLOOD WBC-6.6 RBC-3.75*# Hgb-11.1*# Hct-31.9*#
MCV-85 MCH-29.6 MCHC-34.8 RDW-17.5* Plt Ct-271
[**2152-11-14**] 07:13AM BLOOD WBC-6.3 RBC-3.72* Hgb-11.0* Hct-31.9*
MCV-86 MCH-29.7 MCHC-34.6 RDW-17.8* Plt Ct-257
[**2152-11-17**] 03:12AM BLOOD WBC-4.9 RBC-3.63* Hgb-11.0* Hct-31.7*
MCV-87 MCH-30.2 MCHC-34.6 RDW-17.4* Plt Ct-217
[**2152-11-18**] 05:35AM BLOOD WBC-4.7 RBC-3.29* Hgb-10.0* Hct-29.2*
MCV-89 MCH-30.4 MCHC-34.3 RDW-17.4* Plt Ct-181
[**2152-11-19**] 05:48AM BLOOD WBC-3.9* RBC-3.35* Hgb-9.9* Hct-30.2*
MCV-90 MCH-29.4 MCHC-32.6 RDW-17.7* Plt Ct-192
[**2152-11-20**] 06:25AM BLOOD WBC-4.3 RBC-3.24* Hgb-9.6* Hct-29.1*
MCV-90 MCH-29.7 MCHC-33.2 RDW-17.5* Plt Ct-211
[**2152-11-21**] 07:00AM BLOOD WBC-4.1 RBC-3.26* Hgb-9.6* Hct-29.4*
MCV-90 MCH-29.5 MCHC-32.7 RDW-17.7* Plt Ct-227
[**2152-11-21**] 07:00AM BLOOD WBC-4.1 RBC-3.26* Hgb-9.6* Hct-29.4*
MCV-90 MCH-29.5 MCHC-32.7 RDW-17.7* Plt Ct-227
[**2152-11-22**] 05:40AM BLOOD WBC-4.0 RBC-3.12* Hgb-9.3* Hct-28.0*
MCV-90 MCH-29.9 MCHC-33.3 RDW-17.4* Plt Ct-237
[**2152-11-21**] 07:00AM BLOOD Neuts-55.3 Lymphs-18.5 Monos-4.3
Eos-21.6* Baso-0.3
[**2152-11-22**] 05:40AM BLOOD Plt Ct-237
[**2152-11-3**] 05:39PM BLOOD Fibrino-205
[**2152-11-3**] 03:55PM BLOOD FDP-10-40
[**2152-11-3**] 04:00AM BLOOD FDP-40-80
[**2152-11-3**] 04:00AM BLOOD D-Dimer-4100*
[**2152-11-10**] 06:10AM BLOOD Ret Aut-2.3
[**2152-11-15**] 03:33AM BLOOD LMWH-1.02
[**2152-11-2**] 09:07PM BLOOD Glucose-94 UreaN-49* Creat-4.6* Na-127*
K-4.1 Cl-95* HCO3-17* AnGap-19
[**2152-11-3**] 04:00AM BLOOD Glucose-91 UreaN-54* Creat-4.7* Na-129*
K-4.1 Cl-96 HCO3-17* AnGap-20
[**2152-11-3**] 03:55PM BLOOD Glucose-115* UreaN-62* Creat-5.2* Na-131*
K-4.0 Cl-95* HCO3-17* AnGap-23*
[**2152-11-4**] 05:07AM BLOOD Glucose-220* UreaN-63* Creat-4.7* Na-131*
K-3.7 Cl-98 HCO3-15* AnGap-22*
[**2152-11-5**] 05:23AM BLOOD Glucose-206* UreaN-75* Creat-5.3* Na-128*
K-3.2* Cl-93* HCO3-20* AnGap-18
[**2152-11-6**] 03:54AM BLOOD Glucose-124* UreaN-79* Creat-5.1* Na-126*
K-4.0 Cl-91* HCO3-18* AnGap-21*
[**2152-11-7**] 05:14PM BLOOD Glucose-175* UreaN-75* Creat-4.2* Na-138
K-3.5 Cl-103 HCO3-22 AnGap-17
[**2152-11-8**] 04:23PM BLOOD Glucose-144* UreaN-67* Creat-3.5* Na-142
K-3.6 Cl-107 HCO3-23 AnGap-16
[**2152-11-10**] 06:10AM BLOOD Glucose-118* UreaN-51* Creat-2.4* Na-146*
K-3.3 Cl-107 HCO3-28 AnGap-14
[**2152-11-12**] 05:55AM BLOOD Glucose-96 UreaN-29* Creat-1.7* Na-145
K-3.6 Cl-106 HCO3-29 AnGap-14
[**2152-11-14**] 07:13AM BLOOD Glucose-82 UreaN-20 Creat-1.6* Na-138
K-3.3 Cl-101 HCO3-27 AnGap-13
[**2152-11-16**] 05:45AM BLOOD Glucose-71 UreaN-13 Creat-1.2* Na-132*
K-3.4 Cl-100 HCO3-26 AnGap-9
[**2152-11-18**] 05:35AM BLOOD Glucose-92 UreaN-16 Creat-1.2* Na-137
K-3.5 Cl-106 HCO3-25 AnGap-10
[**2152-11-19**] 10:48PM BLOOD Glucose-89 UreaN-12 Creat-0.9 Na-142
K-3.8 Cl-113* HCO3-21* AnGap-12
[**2152-11-21**] 07:00AM BLOOD Glucose-72 UreaN-11 Creat-0.9 Na-144
K-3.3 Cl-112* HCO3-26 AnGap-9
[**2152-11-22**] 05:40AM BLOOD Glucose-78 UreaN-10 Creat-0.8 Na-145
K-3.2* Cl-113* HCO3-25 AnGap-10
[**2152-11-2**] 09:07PM BLOOD ALT-117* AST-51* LD(LDH)-517*
AlkPhos-209* Amylase-140* TotBili-2.1*
[**2152-11-3**] 04:00AM BLOOD ALT-113* AST-50* LD(LDH)-539*
CK(CPK)-751* AlkPhos-231* Amylase-143* TotBili-1.9*
[**2152-11-4**] 05:07AM BLOOD ALT-77* AST-31 LD(LDH)-496* CK(CPK)-348*
AlkPhos-252* Amylase-108* TotBili-0.8
[**2152-11-6**] 03:54AM BLOOD ALT-43* AST-16 LD(LDH)-430* AlkPhos-54
TotBili-0.7
[**2152-11-8**] 04:23PM BLOOD ALT-22 AST-13 AlkPhos-188* Amylase-127*
TotBili-0.5
[**2152-11-10**] 06:15AM BLOOD LD(LDH)-318* TotBili-0.4
[**2152-11-3**] 04:00AM BLOOD Lipase-45
[**2152-11-4**] 05:07AM BLOOD Lipase-103*
[**2152-11-5**] 05:23AM BLOOD Lipase-116*
[**2152-11-8**] 04:23PM BLOOD Lipase-73*
[**2152-11-3**] 03:55PM BLOOD CK-MB-5 cTropnT-<0.01
[**2152-11-4**] 05:07AM BLOOD CK-MB-4 cTropnT-<0.01
[**2152-11-2**] 09:07PM BLOOD Albumin-2.9* Calcium-5.9* Phos-4.8*
Mg-2.5
[**2152-11-3**] 03:55PM BLOOD Calcium-6.8* Phos-6.1* Mg-2.6
[**2152-11-5**] 05:23AM BLOOD Albumin-2.8* Calcium-6.9* Phos-6.1*
Mg-2.3
[**2152-11-6**] 03:54AM BLOOD Albumin-3.0* Mg-2.2
[**2152-11-7**] 05:14PM BLOOD Calcium-8.0* Phos-5.3* Mg-2.0
[**2152-11-8**] 04:23PM BLOOD Albumin-2.6* Calcium-7.8* Phos-4.2 Mg-1.8
Iron-34
[**2152-11-11**] 06:11AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.0
[**2152-11-13**] 07:06AM BLOOD Calcium-7.1* Phos-3.6 Mg-1.2*
[**2152-11-15**] 05:00AM BLOOD Albumin-2.4* Calcium-6.8* Phos-3.0
Mg-1.4*
[**2152-11-17**] 03:12AM BLOOD Albumin-2.0* Calcium-6.7* Phos-3.6#
Mg-1.4*
[**2152-11-19**] 05:48AM BLOOD Calcium-7.3* Phos-2.9 Mg-1.8
[**2152-11-21**] 07:00AM BLOOD Calcium-7.6* Phos-2.8 Mg-1.5*
[**2152-11-22**] 05:40AM BLOOD Calcium-7.7* Phos-3.0 Mg-1.8
[**2152-11-8**] 05:14AM BLOOD VitB12-623 Folate-6.9
[**2152-11-8**] 04:23PM BLOOD calTIBC-111* Ferritn-904* TRF-85*
[**2152-11-10**] 06:15AM BLOOD Hapto-274*
[**2152-11-2**] 09:07PM BLOOD TSH-0.023*
[**2152-11-10**] 06:10AM BLOOD TSH-0.020*
[**2152-11-17**] 03:12AM BLOOD TSH-0.021*
[**2152-11-21**] 07:00AM BLOOD TSH-0.022*
[**2152-11-3**] 04:00AM BLOOD T3-LESS THAN Free T4-0.55*
[**2152-11-5**] 05:23AM BLOOD PTH-230*
[**2152-11-10**] 06:10AM BLOOD T3-32* Free T4-0.84*
[**2152-11-17**] 03:12AM BLOOD T4-3.3* T3-42* Free T4-0.79*
[**2152-11-21**] 07:00AM BLOOD T4-5.1 T3-46* Free T4-0.94
[**2152-11-5**] 10:01PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
[**2152-11-5**] 10:01PM BLOOD HIV Ab-NEGATIVE
[**2152-11-4**] 05:07AM BLOOD Phenyto-5.7*
[**2152-11-5**] 05:23AM BLOOD Phenyto-8.7*
[**2152-11-6**] 03:54AM BLOOD Phenyto-8.1*
[**2152-11-7**] 05:31AM BLOOD Phenyto-10.1 Phenyfr-1.8 %Phenyf-18*
[**2152-11-8**] 05:14AM BLOOD Phenyto-15.2
[**2152-11-8**] 04:23PM BLOOD Phenyto-10.2
[**2152-11-8**] 04:23PM BLOOD Phenyto-10.2 Phenyfr-1.9 %Phenyf-19*
[**2152-11-9**] 08:20AM BLOOD Phenyto-10.9
[**2152-11-9**] 08:20AM BLOOD Phenyto-10.9 Phenyfr-2.0 %Phenyf-18*
[**2152-11-5**] 10:01PM BLOOD HCV Ab-NEGATIVE
CT ABDOMEN W/O CONTRAST [**2152-11-10**] 9:07 AM
CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST
Reason: retroperitoneal bleeding? R femoral bleeding to thigh
hemat
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with decreasing hematocrit without changing
exam. Anticoagulated with heparin. hx of R femoral central line,
now removed.
REASON FOR THIS EXAMINATION:
retroperitoneal bleeding? R femoral bleeding to thigh hematoma?
CONTRAINDICATIONS for IV CONTRAST: acute renal failure
CT OF THE ABDOMEN AND PELVIS WITHOUT CONTRAST:
CLINICAL HISTORY: 49-year-old woman with decreasing hematocrit
without change in exam. Anticoagulated with heparin. History of
right femoral central line now removed. Questionable
retroperitoneal bleeding.
COMPARISON: No prior CT is available for comparison.
Evaluation of the lung bases demonstrates a small left pleural
effusion. There is bibasilar airspace disease (left greater than
right). Additionally, there are several very small patchy
opacities at the right lung base laterally that are likely
related to focal areas of atelectasis.
There is a tiny calcification in the dome of the liver.
Otherwise , the liver is normal in size and contour. The
unenhanced morphology of the spleen, biliary tree, and pancreas
is unremarkable. The kidneys are symmetric in size. There is no
hydronephrosis. Tiny calcific densities are noted in both
collecting systems that may be related to tiny renal calculi or
vascular calcifications.
Note is made of bilateral tortuous, peripherally calcified
rounded structures along the course of the renal arteries that
likely represent renal artery aneurysms. The largest aneurysm is
seen on the left and measures at least 1.4 cm in diameter. These
findings cannot be further characterized on this unenhanced
study. There is no hydronephrosis in either kidney. There is an
IVC filter in place with its tip below the renal veins.
There is no intra-abdominal ascites. The visualized small and
large bowel are unremarkable. There is no free intraperitoneal
air. There is no evidence of groin or retroperitoneal hematoma.
CT OF THE PELVIS:
The urinary bladder contains gas in its nondependent portion
likely due to a Foley catheter in place. There is no significant
free pelvic fluid. The uterus is not clearly visualized.
Correlation with prior surgical history is recommended.
There are no pelvic masses or significant lymphadenopathy.
BONE WINDOWS: There are no suspicious lytic or sclerotic
lesions.
These findings were discussed with Dr.[**Last Name (STitle) **] at 5 pm on
[**2152-11-10**].
IMPRESSION:
1. No evidence of groin or retroperitoneal hematoma.
2. Bilateral renal artery aneurysms evaluation of which is
difficult on this unenhanced CT. The largest aneurysm is seen on
the left and measures at least 1.4 cm in diameter. These
findings cannot be further evaluated on this unenhanced study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 74936**] [**Doctor Last Name **]
DR. [**First Name (STitle) 8085**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 8086**]
Approved: SAT [**2152-11-11**] 8:45 AM
RADIOLOGY Final Report
NECK,SOFT TISSUE US [**2152-11-11**] 11:10 AM
NECK,SOFT TISSUE US
Reason: patient with transiently dropping Hct, anticoagulated,
recen
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with
REASON FOR THIS EXAMINATION:
patient with transiently dropping Hct, anticoagulated, recent L
IJ central line removed, now with eccymoses in area of IJ.
Hematoma? AV fistula? Pseudoaneurysm?
CLINICAL INDICATION: Transiently dropping hematocrit,
anticoagulated patient with ecchymosis in the area of left IJ
central line that was removed today for AV fistula and
pseudoaneurysm.
COMPARISON: None.
LIMITED ULTRASOUND OF THE SOFT TISSUES OF THE LEFT NECK:
Grayscale and color doppler imaging was performed. There is a
hypoechoic area adjacent to the left internal jugular with no
internal flow and no septations. It measures approximately 1.4 x
1.1 cm in its axial dimension.
IMPRESSION
Small hematoma adjacent to the left internal jugular vein
without evidence of AV fistula or pseudoaneurysm.
RADIOLOGY Final Report
ABDOMEN (SUPINE & ERECT) [**2152-11-14**] 2:07 PM
ABDOMEN (SUPINE & ERECT)
Reason: evaluate for obstruction, ileus
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with neuro deficits, vomiting with feeds. No
BM X4 days.
REASON FOR THIS EXAMINATION:
evaluate for obstruction, ileus
HISTORY: 49-year-old female with neurological deficits, vomiting
with food and no bowel movement for four days.
COMPARISON: CT of the abdomen and pelvis performed on [**2152-11-10**].
FINDINGS: Upright, left lateral decubitus, and supine views of
the abdomen reveal a normal bowel gas pattern. There is no
evidence of bowel distention or obstruction. No free air is seen
within the abdomen. An IVC filter is seen in the mid abdomen. No
gross abnormality is seen in the lung bases or in the osseous
structures on the current exam.
IMPRESSION: No evidence of obstruction or bowel dilatation.
RADIOLOGY Final Report
CHEST (PORTABLE AP) [**2152-11-14**] 8:07 AM
CHEST (PORTABLE AP)
Reason: Pneumonia, possible aspiration?
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with neuro deficits, vomiting with feeds now
with new low grade temps.
REASON FOR THIS EXAMINATION:
Pneumonia, possible aspiration?
HISTORY: Neurologic deficits with vomiting and now low-grade
temperatures; possible aspiration pneumonia.
FINDINGS: In comparison with study of [**11-6**], the Dobbhoff tube
has been removed. Specifically, no evidence of aspiration
pneumonia. Left central catheter remains with its tip in the
upper superior vena cava.
IMPRESSION: No evidence of aspiration pneumonia.
DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**]
RADIOLOGY Final Report
VENOUS DUP EXT UNI (MAP/DVT) LEFT [**2152-11-17**] 10:39 AM
VENOUS DUP EXT UNI (MAP/DVT) L
Reason: SWOLLEN LUE
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with known DVT in L leg and RUE, has new onset
of swelling in LUE. Pulses dopplerable. PICC line in LUE.
REASON FOR THIS EXAMINATION:
DVT?
VENOUS STUDY DATED 26TH
HISTORY: Left upper extremity swelling, history of DVT.
FINDINGS: Duplex and color Doppler demonstrate no left upper
extremity DVT. Of note, the cephalic vein (superficial vein) was
not identified during this exam.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
RADIOLOGY Final Report
VENOUS DUP EXT UNI (MAP/DVT) LEFT [**2152-11-17**] 10:39 AM
VENOUS DUP EXT UNI (MAP/DVT) L
Reason: SWOLLEN LUE
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with known DVT in L leg and RUE, has new onset
of swelling in LUE. Pulses dopplerable. PICC line in LUE.
REASON FOR THIS EXAMINATION:
DVT?
VENOUS STUDY DATED 26TH
HISTORY: Left upper extremity swelling, history of DVT.
FINDINGS: Duplex and color Doppler demonstrate no left upper
extremity DVT. Of note, the cephalic vein (superficial vein) was
not identified during this exam.
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**]
RADIOLOGY Final Report
CT HEAD W/O CONTRAST [**2152-11-15**] 10:55 AM
CT HEAD W/O CONTRAST
Reason: worsening hydrocephalus? bleeding?
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with pituitary adenoma s/p resection with new
vomiting. Baseline neuro defecits.
REASON FOR THIS EXAMINATION:
worsening hydrocephalus? bleeding?
CONTRAINDICATIONS for IV CONTRAST: None.
CLINICAL INDICATION: Post-pituitary adenoma resection 1-1/2
months ago. New vomiting, evaluate for hydrocephalus.
COMPARISON: [**2152-11-2**].
NON-CONTRAST HEAD CT: There is a hypodense approximately 3.0 x
2.0 cm lesion with peripheral hemosiderin in the left frontal
lobe with extension into the left lateral ventricle, unchanged.
There is minimal surrounding edema, unchanged. There is a
hyperdense suprasellar lesion that may represent hematoma or
residual tumor, unchanged. An area of encephalomalacia on the
right frontal lobe, unchanged. There is dilation of the temporal
horns of the lateral ventricles, unchanged. There is complete
opacification of the sphenoid sinuses, unchanged. There is left
ethmoid opacification noted. Post-surgical changes are noted,
unchanged.
IMPRESSION:
1. No evidence of worsening hydrocephalus and no acute
intracranial process.
2. Stable appearance of pituitary and left frontal lobe lesions.
3. Suprasellar mass may represent residual macroadenoma,
unchange
RADIOLOGY Final Report
ESOPHAGUS [**2152-11-15**] 10:08 AM
ESOPHAGUS
Reason: esophageal stricture?
[**Hospital 93**] MEDICAL CONDITION:
49 year old woman with pituitary adenoma resected with baseline
neuro deficits, passed speech and swallow, but vomits after each
feed with specs/streaks of blood.
REASON FOR THIS EXAMINATION:
esophageal stricture?
INDICATION: Vomiting.
COMPARISON: CT dated [**2152-11-10**].
FINDINGS: The study was performed in semi-upright position,
prone and supine position. Limted views were taken due to
patient's clinical condition.
The barium passes freely through the esophagus without evidence
of strictures. There are normal primary peristaltic
contractions. A small hiatal hernia is noted with
gastroesophageal reflux. The stomach distends and empties
normally. There is irregularity of the gastric mucosa suggestive
of mucosal edema, but is not fully characterized in this single
contrast study without distention of the stomach.
IMPRESSION:
1) No evidence of esophageal strictures or dilatation.
2) Small hiatal hernia with gastroesophageal reflux.
3) Irregular gastric wall suggestive of mucosal edema but not
fully characterized on this single contrast barium study.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17726**]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: FRI [**2152-11-17**] 12:28 AM
Brief Hospital Course:
49 yr old female s/p pituitary adenoma with altered mental
status, ARF, thrombocytopenia, DVT/PE.
.
#)Pituitary adenoma: s/p resection of microadenoma [**9-22**] with
hypopituitarism after surgery. Pt treated with fondaparinux for
DVT/PT at OSH. Continued altered mental status, hyponatremia.
Repeat CT Head and MRI here [**11-3**] showed pituitary mass
increased in size likely macroadenoma with extension to 3rd
ventricle and ?hydrocephalus. Also with intratumoral bleed
apparent in L frontal lobe.
-neurosurgery recs - no plan for surgery/shunt placement in the
near future, ok for anticoagulation by their standpoint. Head
CT on [**11-15**] showed no worsening hydrocephalus or significant
progression of tumor. Will follow up repeat head CT on [**12-4**]
and appointment with Dr. [**Last Name (STitle) **] on [**12-5**]. Patient on phenytoin
for seizure prophylaxis upon arrival to floor from MICU.
Dilantin was subsequently changed to keppra due to a skin
eruption consistent with drug hypersensitivity rash that
presented on [**11-13**]. No seizures during course of
hospitalization.
-Patient's neurological status and mental status remained
unchanged through course on floor. Patient arrived with R
ptosis and R non-reactive pupil and oriented only to person and
place. Patient laughs inappropriately and often speaks
non-sensically. Intermittently reported headaches and transient
neck pain, however, neck always remained supple and neuro status
was baseline at these times. Not related to febrile episodes.
Low suspicion for any meningeal infectious process. Head CT was
unchanged.
.
#)Infection: 1.) Strep bacteremia 2.) Candidemia: blood cx from
OSH with gram positive Alpha Strep (from PICC - [**10-29**]), [**Female First Name (un) **]
(peripheral - [**10-26**]). Potential PICC source (at least for
Strep), though concerning given possible strep pneumo, strep
viridans which can easily lead to brain involvement. Fungal
candidemia with possible eye involvement Patient on steroids
since panhypopituitarism from adenoma resection. ?infected
hematoma s/p surgery and urosepsis. At this time patient is off
pressors. All blood cx negative to date since admission, Stable
white count. Echocardiogram negative for vegetation.
-Patient completed a 13 day course of PCN and fluconazole;
termintated one day early for a skin eruption consistent with
hypersensitivity that presented on [**11-13**].
-Patient received blood and urine cultures on [**10-24**],
[**11-16**] for fevers spiking at night. All blood cultures negative,
however urine from [**11-16**] showing greater than 100,000 ESBL
producing E.Coli. Patient started on Cipro on [**11-17**], however,
subsequent sensitivities showed resistance so Meropenem started
on [**11-19**] for a 14 day course. No subsequent febrile episodes
after abx started. [**Month (only) 116**] also have been due to drug rash.
-Central line was DC'd and patient received PICC on [**11-8**].
Patient subsequently pulled PICC and had PICC replaced on [**11-20**].
-patients steroid replacement followed and tapered as
recommended by endocrine.
.
#)ARF: Likely ATN in the setting of sepsis and poor perfusion.
Patient started on lasix drip with 500 cc out but with high dose
at 40 mg/hr with an increasing creatinine over the course of 2
days. Lasix drip stopped on admission with improvement of urine
output, may be secondary to post-ATN diuresis. UOP remained wnl
throughout course on floor.
-D/C'd bicarb drip on admission, will follow HCO3
-Renal followed course on floor and patient's Cr subsequently
normalized to 0.8.
-When patients Cr had reached 0.9, patient was diuresed with
lasix to mobilize excess fluid. Decent UOP response to diuresis
and then patient's urine output increased and upon admission,
appeared to be autodiuresing.
.
#)Thrombocytopenia: HIT Ab negative. [**Month (only) 116**] have been due to
sepsis, antibiotic suppression of marrow. DIC labs wnl.
-platelet count improved
-subsequently tolerated heparin
#Anemia: Hematocrit trended down by approx 2pts per day to a low
of 23 without clear source of bleeding and hemolysis labs neg.
Belly and thigh CT neg for bleed, neck US with only small
hematoma after L IJ removal, stool guiaic neg. Patient was
transfused 2u PRBC and hct subsequently stabilized. Anemia may
have been due to [**Hospital1 **] labs.
.
#)DVT/PE: + LENIS, + v/Qscan. Had been on heparin, with
subsequent thrombocytopenia. INR 1.7.
-s/p IVC filter placement, negative HIT panel, patient restarted
and maintained on heparin IV until Hct stable and plt count
improved and then switched to Lovenox. Hct stable on lovenox.
-LUE ultrasound on [**11-17**] for LUE swelling ruled out LUE DVT.
-98% on RA currently
.
#)Elevated LFTS: Slight decrease from prior. On exam in MICU
diffusely tender across entire abdomen --> may be due to shock
liver
-LFTs normalized and upon transfer to floor, patient no longer
had tender abdomen
-Abdominal CT on [**11-10**] essentially neg except incidental renal
artery aneurysms
.
#)Hyponatremia: as low as 121 on admission. Sodium tablets and
demeclocyline given. Question SIADH. Renal followed course on
the floor.
-D/C'd demeclocycline
-Sodium supported with IV fluids as needed.
-On discharge, sodium 145 and stable
.
#)Hypertension: patient maintained on PO labetolol 200mg [**Hospital1 **]
through course on floor.
.
#)Hypopituitarism: -endocrine followed during course: Hormone
replacement:patient received hydrocortizone 50mg [**Hospital1 **] and was
subsequently weaned to 25mg [**Hospital1 **] and subsequently to 25mg Qam and
12.5mg Qpm. No adverse issues with taper. 2.) levothyroxine
75mcg IV daily - will repeat TSH, free T4, T3 on [**12-8**] and
follow up with endocrine on [**12-27**].
#)FEN: replete Calcium, lytes.
Nutrition: Patient received Dophoff tube for feeding while in
MICU. While on the floor, patient passed a speech and swallow
eval and Dophoff was removed. Patient has intermittent episodes
of vomiting with feeds which are thought to be due to central
causes at this point after neg KUB, regular BMs, neg upper GI
for esoph stricture, no worsening hydrocephalus on head CT.
Receives zofran and reglan. Often tolerates food from family.
Nutrition followed course on floor and patient's diet is being
supplemented to support nutrition. Electrolytes have been
supported PRN throughout course.
.
#) Hypersensitivity rash: patient presented with
hypersensitivity appearing rash on [**11-13**]. PCN/Fluconazole
stopped one day prior to scheduled end of course. Dilantin then
DC'd and switched to Keppra. Derm consulted and agreed with
hypersensitivity assessment. Recommended clobetasol cream which
was applied. Rash subsequently improved. No mucous membrane
involvement. Upon discharge shows some superficial desquamation
and vastly improved erythema. Serum EOS were elevated during
rash, consistent with hypersensitivity.
#) Prophylaxis: PPI, anticoag, bowel regimen
.
#) Access: PICC LUE
.
#) Code Status: Full
.
#) Dispo: to rehab facility on [**11-22**]
.
#) Communication: [**First Name9 (NamePattern2) 74937**] [**Known lastname **] [**Telephone/Fax (1) 74938**].
Daughter [**Name (NI) 775**] [**Telephone/Fax (3) 74939**]
Medications on Admission:
Home Medications:
Prednisone
Dilantin
Protonix
Atenolol
Synthroid
Calcium and vitamin D
Tylenol
.
Meds on transfer:
Ertapenem 0.5gm IV daily
vancomycin 1 gm IV BID
fluconazole premix 200 mg iv daily
miconazole powder aplly topic tid
Demeclocycline 150 mg po qid
Hydrocortisone 100mg IV q8h
Fludrocortisone 0.2mg po daily
Fondaparinux 3.5mg sc daily
Levothyroxine 60mcg IV daily
Metoclopromide 10mg IV qid
Tylenol 650mg pr q4hr
Oxycodone/APAP 5/325mg po q4hr prn
Furosemide drip 40mg/hr
Sodium bicarbonate 50EQ in 1/2NS @ 30mL/hr
Albumin 25% - 12.5 gm IV tid
Ascorbic Acid 500mg po daily
Docusate Sodium 100 mg po bid
esomeprazole 40 mg iv daily
senna 8.6 mg 2 ea po qhs
Ondansetron 4mg IV q4hr prn
ferrous sulfate 300 mg po bid
Magnesium 10mL po qhs prn
calcium carbonate/Vit D - 500mg po tid
sodiium chloride 2 gm po tid
modafinil 200 mg po daily
phenytoin 300 mg iv qhs
atenolol 50 mg po daily
ISS
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
4. Labetalol 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: 2.5 Tablets
PO DAILY (Daily).
7. Enoxaparin 80 mg/0.8 mL Syringe Sig: Seventy (70) mg
Subcutaneous Q12H (every 12 hours).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID
(2 times a day).
11. White Petrolatum-Mineral Oil Cream Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for PRN superficial
desquamation.
12. Clobetasol 0.05 % Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
13. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day).
14. Ondansetron 4 mg IV Q8H:PRN nausea
15. Pantoprazole 40 mg IV Q24H
16. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
17. Metoclopramide 5 mg IV TID
Infuse over 1-2 mins before meals
18. Levothyroxine Sodium 75 mcg IV DAILY
When tolerating PO meds, will switch back to PO
19. Hydrocortisone Na Succ. 12.5 mg IV QPM
Will restart PO when tolerating PO meds
20. Hydrocortisone Na Succ. 25 mg IV QAM
21. Meropenem 500 mg IV Q6H
Day 1 [**11-19**]. For 14 days.
22. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
23. Sliding scale insulin
Insulin sliding scale as attached.
24. Outpatient Head CT
Outpatient Head CT on [**12-4**] 10:30 am [**Location (un) 470**] [**Hospital Unit Name **]
25. Outpatient Lab Work
[**12-8**]- T3 uptake, total t4, free t4, TSH, T3.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Pituitary adenoma
Sepsis
Acute Renal Failure
DVT/PE
Hypersensitivity rash
Hypopituitarism
Anemia
Urinary tract infection
Discharge Condition:
stable
Discharge Instructions:
You were evaluated and treated in the hospital for an infection
and the subsequent complications of that infection including
blood clots, kidney failure, rash and anemia. We also continued
to treat the hormonal complications of your original tumor.
Please keep your follow up appointments and take all medicines
as directed. Return for worsening neurological status, fevers
or hemodynamic instability.
Followup Instructions:
Please keep your scheduled head CT in radiology on [**12-4**] at 10:30 on the [**Location (un) 470**] of the [**Hospital Unit Name **].
Nothing to eat or drink for three hours before appointment.
Also please keep appointment with Dr. [**Last Name (STitle) **] in Neurosurgery
([**Telephone/Fax (1) 1669**]) on [**12-5**] at 9:15 am. Also please follow
up with endocrinology on [**12-27**] at 2:30pm. Also recommend
follow up with ophthalmology [**Telephone/Fax (1) 253**] regarding any eye
involvement from original infection.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
|
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5,909
| 160,240
|
49710
|
Discharge summary
|
report
|
Admission Date: [**2183-3-20**] Discharge Date: [**2183-3-29**]
Date of Birth: [**2125-9-30**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Gentamicin / Tessalon Perle
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
rapid atrial fibrillation.
Major Surgical or Invasive Procedure:
Placement of left subclavian tunneled dialysis catheter
History of Present Illness:
Mr. [**Name13 (STitle) 76791**] is a 57 year old man with type 1 DM s/p failed
kidney/pancreas in [**2164**], CAD with stents, rapid A fib, C fid
colitis, hypotension, and end stage [**Year (4 digits) **] disease who presents
in transfer from [**Hospital3 **]. He was recently hospitalized
at [**Hospital1 18**] from [**Date range (1) 90767**] and was discharged to rehab. He was
admitted to [**Hospital3 3765**] on [**3-17**] from dialysis for rapid
atrial fibrillation to the 130's, and had associated shart mid
sternal chest pain. He also developed multiple watery stools in
the preceding hours before dialysis.
.
At [**Hospital3 **], his issues included rapid A fib, diarrhea,
and hypoerkalemia. For his A fib, he was loaded on amiodarone
and converted to sinus rhythm. He went back into A fib with
further attempts at dialysis, and he was still in A fib at the
time of transfer with stable blood pressure. For his diarrhea, a
C dif test was positive, and he was started on flagyl and moved
to the ICU. Since the time of admission, he has gone into atrial
fibrillation three separate dialysis attempts. He was
trasnferred for consideration of CVVH and alternative
anti-arrhythmogenic agents or a definitive A fib procedure.
.
Currently he is complaining of chest pain with inspiration, some
abdominal pain, and left knee pain. All of these are complaints
he's had for the last few days. He denies fever, chills,
shortness fo breath.
Past Medical History:
1. ESRD: status pancreas-kidney transplant [**2164**], status post
cadaveric [**Year (4 digits) **] transplantation in [**2172**], now requiring dialysis
3x/wk
2. CAD: s/p myocardial infarction in [**2164**], s/p LCX stenting in
[**2174**], s/p LCX and OM3 stenting in [**2175**], s/p mid-LCX stenting on
'[**78**], s/p OM3 restenting in '[**78**]
3. DM type I
4. Hypothyroidism
5. Hypercholesterolemia
6. Cirrhosis from Hep C (dx in '[**75**]), viral load and Hep B
7. CVA in [**2174**] with residual left-sided weakness
8. PVD
9. Diverticulitis, status post colostomy and Hartmann's pouch in
[**2175**], status post reversal in [**6-3**], last Colonscopy ([**12-4**]):
Erythema,
friability and granularity in the very distal portion of the
colon, just inside the afferent limb of the stoma, with
overlying clot. Brown stool with no bleeding proximal to this.
10. PVD s/p multiple digit amputations
11. GERD
12. Wheelchair bound after gentamicin related vertigo
13. PAF: diagnosed in [**2175**], continued on CCB and started on Amio
at that time, s/p pacer [**10-5**]
14. Benign prostatic hypertrophy, status post transurethral
resection of the prostate.
15. SBP [**1-31**]
16. CHF with an EF:60% 8/05
17. C dif colitis [**3-6**]
Social History:
Patient lives with his wife in [**Name (NI) 5176**] and presented from home.
They have two children who live nearby. He previously worked as
a plummer but is now retired. He has a 30pk year smoking hx but
quit 10 years ago. He denies IVDU and alcohol use. He uses a
wheelchair. He uses a walker for transfers.
Family History:
[**Name (NI) 1094**] father died at age 56 of MI, with DM and a "big heart".
Mother died age 84 of "old age" s/p CVA, with DM and HTN. Sister
has Grave's dz and brother died of 56 with DM.
Physical Exam:
VS: T 97.8 98/40 83 R12 98% RA
GEN: no apparent distress
HEENT: pupils surgical bilaterally. MM dry.
Neck: no JVD
Resp: lungs clear bilaterally
CV: RRR nl s1s2 no MGR
ABD: soft, diffusely TTP. +BS.
Ext: multiple amputated digits. Warm, well perfused.
Neuro: alert, oriented, able to move all extremities and
cooperative with commands.
Pertinent Results:
[**2183-3-20**] 08:46PM BLOOD WBC-6.3 RBC-3.51* Hgb-11.0* Hct-33.5*
MCV-95 MCH-31.2 MCHC-32.8 RDW-15.8* Plt Ct-191
[**2183-3-24**] 09:30AM BLOOD Neuts-90.5* Lymphs-4.3* Monos-4.1 Eos-0.4
Baso-0.6
[**2183-3-20**] 08:46PM BLOOD PT-13.7* PTT-31.4 INR(PT)-1.2*
[**2183-3-20**] 08:46PM BLOOD Plt Ct-191
[**2183-3-20**] 08:46PM BLOOD Glucose-239* UreaN-35* Creat-5.1*# Na-136
K-4.0 Cl-99 HCO3-22 AnGap-19
[**2183-3-20**] 08:46PM BLOOD ALT-26 AST-24 LD(LDH)-198 AlkPhos-344*
TotBili-0.3
[**2183-3-22**] 03:32AM BLOOD ALT-19 AST-20 LD(LDH)-184 AlkPhos-274*
Amylase-11 TotBili-0.3
[**2183-3-24**] 12:23PM BLOOD CK(CPK)-30*
[**2183-3-25**] 04:49AM BLOOD CK(CPK)-23*
[**2183-3-22**] 03:32AM BLOOD Lipase-7
[**2183-3-24**] 12:23PM BLOOD CK-MB-NotDone cTropnT-0.10*
[**2183-3-25**] 04:49AM BLOOD cTropnT-0.10*
[**2183-3-20**] 08:46PM BLOOD Albumin-2.1* Calcium-7.5* Phos-5.7*#
Mg-1.9
[**2183-3-23**] 05:24AM BLOOD TSH-1.3
[**2183-3-22**] 05:46PM BLOOD Type-[**Last Name (un) **] pO2-37* pCO2-43 pH-7.36
calHCO3-25 Base XS--1
.
CXR: No acute cardiopulmonary process.
.
ECG: Atrial fibrillation with a rapid ventricular response.
Since the previous tracing of [**2183-2-2**] the atrial fibrillation has
developed. The Q-T interval is shorter but still prolonged.
Clinical correlation is suggested.
.
chest CT: 1. No evidence for pulmonary embolus or aortic
dissection. Coronary artery and aorta atherosclerotic
calcifications. 2. Mild pneumobilia, unchanged from the CT of
the abdomen and pelvis from [**2182-10-27**] presumably related to prior
sphincterotomy. 3. Mild anasarca and fluid within the visualized
portion of the abdomen, incompletely evaluated on this Chest CT.
.
L knee XR: AP and lateral radiographs of the left knee are
reviewed. There is severe diffuse osteopenia, with extensive
calcification of the vasculature. There is no evidence of
fracture or dislocation. There is no evidence of osteomyelitis
identified.
.
UE u/s: No evidence of DVT.
.
L humerus XR: AP and lateral radiographs of the left humerus are
reviewed. There is diffuse osteopenia, with screws overlying the
proximal ulna. There is no evidence of acute fracture or
osteomyelitis identified. There is extensive vascular
calcification seen.
.
L elbow XR: AP and lateral radiographs of the left humerus are
reviewed. There is diffuse osteopenia, with screws overlying the
proximal ulna. There is no evidence of acute fracture or
osteomyelitis identified. There is extensive vascular
calcification seen.
.
TTE: 1.The left atrium is moderately dilated. The left atrium is
elongated. 2. Left ventricular wall thicknesses are normal. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). 3.Right ventricular
chamber size is normal. Right ventricular systolic function is
normal. 4.The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve. No aortic regurgitation is seen. 5.The
mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. Physiologic mitral
regurgitation is seen (within normal limits). 6.There is mild
pulmonary artery systolic hypertension. 7.There is no
pericardial effusion.
.
LEFT GLENO-HUMERAL SHOULDER (W/ Y VIEW):
.
LUE u/s:
Brief Hospital Course:
#) GNR bacteremia/line infection: Follow up blood cultures cont
to be negative and the pt remained afebrile since [**3-23**] with
normal WBC. His shoulder was painfuls and initially thought to
have been seeded, but plain film xray showed rotator cuff
evulsion fracture. He was seen by orhtpedics for evaluation of
the shoulder and they recommended physical therapy and possible
steroid injection in the future if pain continues. TTE was
negative for endocarditis and source still remained unclear.
[**Name2 (NI) **] is to continue a 14 day course of levofloxacin now day
[**7-14**].
.
#) Hypotension: Was due to bacteremia and sepsis syndrom along
with relative adrenal insufficiency although no cortisol
stimulation test was done. We restarted on stress dose steroids
on [**3-23**] and started a wean 50mg qd on [**3-28**] for the next 5 days
and slowly taper by 10mg every 5 days until dose down to 10mg
and then decrease by 2.5mg over 10 day intervals until back to
baseline dose of 5mg qd.
.
#) Paroxysal AFib- remained either atrially paced or NSR since
[**3-24**] . TSH 1.3. Metoprolol was administered prior to dialysis
until it wsa discintinued on [**3-23**] due to persistent hypotension
and Afib did not recur for dialysis. We continue amiodarone for
rhythm control and held coumdadin for placement of dialysis
access but restarted on discharge.
.
#) ESRD: Pt initially had suboptimal dialysis due to hypotension
with afib, but CVVHD was not considered a long term solution. As
sepsis syndrome resolved and diarrhea improved his hypotension
and atril fibrillation resolved. Tunneled line was placed by IR
on [**3-28**] and dialysis done for 2 days straight to get him back on
his Tues Thurs Sat schedule. We continued phoslo and calcium
supplementation.
.
#) C diff: positive at OSH; We continued flagyl PO vanco but
stopped the vancomycin on [**2183-3-24**]. Pt will need prolonged course
of at least 14 days due to peristent diarrhea. Using
lactobacillus to reinstate GI flora.
#) pleuritic chest pain: Differential diagnosis included
cardiac, pulmonary, vascular. CXR was normal, CTA was neg for
PE, ECG was unchanged and pain sponstaneously resolved and was
of unclear etiology.
.
#) IDDM:We continued his lantus 4 QHS and RISS. FS were high
initially with high dose steroids but improved with steroid
taper.
.
#) abdominal pain: Pt reported this is chronic and stable on
current pain regimen. It remained unclear if there was GI source
of Klebs Pneumoniae bacteremia although GI flora was well
covered with Levofloxacin and flagyl except for enterococcus. No
official CT abdomen read was obtained from the OSH but
impression was no acute pathology beyond colitis. We continued
pain control with dilaudid prn, methadone, and amytriptylline.
.
#) anemia likely [**1-2**] [**Month/Day (2) **] failure: epogen with dialysis,
transfuse for Hct<21.
.
CODE FULL
Medications on Admission:
Medications at home:
Hectorol, Epogen, Venofer given at dialysis center
amiodarone 200mg QD
amitriptyline 10mg QHS
ASA 325mg QD
lipitor 10mg QD
Phoslo
Colace
Fentanyl 100mcg Q72hrs
Folate
Lantus 4U qhs
ISS
Isosorbide mononitrate 30mg QD
Levothyroxine 200mcg QD
Toprol XL 25mg [**Hospital1 **]
MVI
Protonix
Prednisone 5mg QD
.
Meds on transfer:
SL NTG 0.4mg Q5min PRN
ISS
D50 and glucagon PRN hypoglycemia
nephorcaps QD
phoslo 1334mg PO TID w/meals
Epogen 6000U SQ qMWF with dialysis
Zemplar 1mcg IV qMWF
Zofran 4mg PO q6hrs
Lantus 2U QHS
Benadryl 25 IV/PO q4-6
Hydroxyzine 25mg IM/PO q4-6
Narcan 0.4mg IV PRN
Toprol XL 12.5mg QD
Protonix 40mg IV QD
Vancomycin 250mg PO q6hrs
Amiodarone 200mg [**Hospital1 **]
Falgyl 500mg PO TID
Dilaudid 0.5-1mg PO q1hr PRN
Methadone 2.5mg PO q8hrs
Solumedrol 20mg IV q8hrs
Discharge Medications:
1. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
4. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Methadone 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
9. Amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed.
11. Insulin Glargine 100 unit/mL Solution Sig: Four (4) u
Subcutaneous at bedtime.
12. Insulin Regular Human 100 unit/mL Cartridge Sig: One (1)
Injection four times a day: RISS
FS 150-200 2u
201-250 4u
251-300 6u
301-350 8u
351-400 10u
>400 [**Name8 (MD) 138**] MD.
13. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three
times a day for 4 days.
14. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
15. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
Please take 50mg for 5 days
40mg for 5 days
30mg for 5 days
20mg for 5 days
10mg for 5 days
7.5mg for 10 days
5 mg thereafter.
17. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-2**] Sprays Nasal
TID (3 times a day) as needed.
18. Lactobacillus Acidophilus 500 million cell Tablet Sig: One
(1) Tablet PO qd () for 5 days.
19. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO q48h for
10 days.
20. Dolasetron Mesylate 12.5 mg IV Q8H:PRN
21. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 23973**] [**Hospital1 **]
Discharge Diagnosis:
Klebsiella Pneumoniae sepsis
Clostridium difficile colitis
Discharge Condition:
Afebrile in normal sinus rhythm with diarrhea improving
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:1500cc
If you experience any fever, chills, diziness, worsening
diarrhea, shortness of breath, bleeding from your catheter site
you should call your doctor but if no doctor is available you
should go back to the emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2183-5-27**]
2:00
Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 3512**]
Date/Time:[**2183-5-27**] 2:30
Please call PCP: [**Name10 (NameIs) **],[**First Name3 (LF) 2946**] S. [**Telephone/Fax (1) 2936**] to schedule an
appointment for post hospitalization follow-up.
|
[
"038.49",
"008.45",
"996.62",
"285.21",
"585.6",
"403.91",
"995.91",
"250.41",
"244.9",
"070.54",
"571.5",
"V45.82",
"427.31",
"414.01",
"272.0",
"255.4",
"070.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.95"
] |
icd9pcs
|
[
[
[]
]
] |
13088, 13153
|
7370, 10245
|
324, 382
|
13256, 13314
|
4008, 7347
|
13708, 14151
|
3448, 3638
|
11104, 13065
|
13174, 13235
|
10271, 10271
|
13338, 13685
|
10292, 10597
|
3653, 3989
|
258, 286
|
410, 1849
|
1871, 3105
|
3121, 3432
|
10615, 11081
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,710
| 144,109
|
9317
|
Discharge summary
|
report
|
Admission Date: [**2127-11-1**] Discharge Date: [**2127-11-10**]
Date of Birth: [**2075-4-4**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1854**]
Chief Complaint:
HEADACHE, NAUSEA, VOMITING
Major Surgical or Invasive Procedure:
Suboccipital craniectomy and resection of mass
Placement EVD
History of Present Illness:
HPI: Mrs. [**Known lastname 27584**] is a 52 y/o right-handed woman with a history
of colon cancer (adenocarcinoma) with metastasis to the
cerebellum and insular cortex. At initial diagnosis, none of
the
lymph nodes was positive, and she was staged as T3. She was
followed with her physicians until [**2122-10-6**] when pulmonary
metastases were discovered. She underwent a wedge resection of
the lower lobe of left lung. After that she was followed by
serial CTs of the lungs. In [**2127-1-6**], she experienced
occipital and neck pain. A head MRI disclosed 1 left cerebellar
metastasis and a right insula metastasis; the left cerebellar
metastasis was about 1 cm in diameter and there was edema
effacing the fourth ventricle. She underwent Cyberknife
radiosurgery to the left cerebellar metastasis on [**2127-4-3**] to
1,800 cGy to 85% isodose line, and to the right insula
metastasis
on [**2127-4-9**] to 2,200 cGy to 87% isodose line. Dr. [**Last Name (STitle) **]
recently discussed resection of the cerebellar mass with the
patient due to continued posterior fossa swelling, but the
patient did not wish to consider surgery at that time.
Yesterday, however, she noted severe headache with
nausea/vomiting and presented to [**Hospital1 18**] ER for evaluation.
Past Medical History:
Past Medical History:
colon Ca with metastatic disease
Past Surgical History:
pulmonary wedge rection [**2123**]
colectomy [**2121**]
Social History:
Social History: She is a computer programmer. She does not
smoke cigarettes or drink alcohol.
Family History:
Family History: Her mother died of colon cancer. Her father
died of old age. She has a brother who is healthy. She does
not
have any children.
Physical Exam:
Physical Examination:
HEENT examination is remarkable for Cushingnoid
face. Neck is supple. Cardiac examination reveals regular rate
and rhythms. Her lungs are clear. Her abdomen is soft. Her
extremities do not show clubbing, cyanosis, or edema.
Neurological Examination:
She is awake, alert, and oriented times 3. There is no
right-left confusion or finger agnosia. Her language is fluent
with good comprehension, naming, and repetition. Her recent
recall is good. Cranial Nerve Examination: Her pupils are
equal
and reactive to light, 4 mm to 2 mm bilaterally. Extraocular
movements are full. Visual fields are full to confrontation.
Funduscopic examination reveals sharp disks margins bilaterally.
Her face is symmetric. Facial sensation is intact bilaterally.
Her hearing is intact bilaterally. Her tongue is midline.
Palate goes up in the midline. Sternocleidomastoids and upper
trapezius are strong. Motor Examination: She does not have a
drift. Her muscle strengths are [**5-10**] at all muscle groups. Her
muscle tone is normal. Her reflexes are 2- and symmetric
bilaterally. Her ankle jerks are absent. Her toes are
downgoing. Sensory examination is intact to touch and
proprioception. Coordination examination does not reveal
dysmetria. Her gait is normal. She can do tandem. She does
not
have a Romberg.
Pertinent Results:
radiographic Evaluation:
CT of head revealed increased posterior fossa swelling but no
evidence of new blood. She has slighly more ventriculomegaly
than previously seen on prior exams.
[**2127-11-1**] 04:57AM GLUCOSE-90 UREA N-13 CREAT-0.6 SODIUM-134
POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-25 ANION GAP-13
[**2127-11-1**] 04:57AM CALCIUM-8.8 PHOSPHATE-4.0 MAGNESIUM-1.8
[**2127-11-1**] 04:57AM WBC-8.4 RBC-3.63* HGB-11.6* HCT-35.4* MCV-98
MCH-31.9 MCHC-32.7 RDW-17.2*
[**2127-11-1**] 04:57AM NEUTS-85.6* LYMPHS-9.2* MONOS-4.0 EOS-0.8
BASOS-0.4
[**2127-11-1**] 04:57AM PLT COUNT-125*
[**2127-11-1**] 04:57AM PT-12.4 PTT-28.9 INR(PT)-1.1
Brief Hospital Course:
Pt was admitted to neurosurgery service and ICU for close
neurological monitoring. She was pre-oped and taken to the OR
on [**11-5**] where under general anesthesia she underwent
suboccipital craniectomy with resection of mass and placement of
EVD. She tolerated these procedures well and transferred back
to ICU. Post op MRI showed resection of the left cerebellar
ring-enhancing lesion with no definite residual tumor
identified. She was transferred to neuro stepdown on POD#1. Her
diet and activity were advanced. Her foley was removed and she
voided spontaneously. Her incisions were clean and dry. EVD was
removed [**11-8**] 24 hrs after clamping with stable CT. She was
ambulating in halls independently.
Medications on Admission:
Medications:
Decadron 1.5 mg po daily
xelata 500 two weeks then off one week
Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): Take while on pain meds.
Disp:*60 Capsule(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 2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Posterior fossa mass
Metastatic colon cancer
Discharge Condition:
Neurologically stable
Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY
?????? Have a family member check your incision daily for signs of
infection
?????? Take your pain medicine as prescribed
?????? Exercise should be limited to walking; no lifting, straining,
excessive bending
?????? You may wash your hair only after sutures and/or staples have
been removed
?????? You may shower before this time with assistance and use of a
shower cap
?????? Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
?????? New onset of tremors or seizures
?????? Any confusion or change in mental status
?????? Any numbness, tingling, weakness in your extremities
?????? Pain or headache that is continually increasing or not
relieved by pain medication
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**7-15**] DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] TO BE SEEN IN 2 WEEKS. CHECK WITH DR. [**Last Name (STitle) **] IF
FURTHER IMAGING STUDIES ARE NEEDED.
FOLLOW UP WITH PCP FOR BLOOD PRESSURE CHECHS, AND APPROPRIATE
USE METOPROLOL
Completed by:[**2127-11-10**]
|
[
"331.4",
"V10.05",
"198.3",
"197.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"02.2"
] |
icd9pcs
|
[
[
[]
]
] |
5737, 5743
|
4202, 4918
|
346, 409
|
5832, 5856
|
3530, 4179
|
7091, 7486
|
2018, 2150
|
5046, 5714
|
5764, 5811
|
4944, 5023
|
5880, 7068
|
1812, 1871
|
2165, 2165
|
2187, 3511
|
280, 308
|
437, 1711
|
1755, 1789
|
1904, 1985
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,602
| 153,166
|
51356
|
Discharge summary
|
report
|
Admission Date: [**2189-10-11**] Discharge Date: [**2189-10-20**]
Date of Birth: [**2108-2-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Cardiac catherization [**2189-10-13**]
Redo sternotomy, s/p Aortic valve replacemetn with 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
Regent mechanical, Tricuspid valve replacement with 31mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**]
Epic tissue valve, removal of pacemaker leads with placement of
epicardial left ventricular leads and new pacemaker generator
[**2189-10-15**]
History of Present Illness:
81 year old female with increasing dyspnea that has had serial
echocardiograms to monitor valvular disease. Most recent
echocardiogram revealed severe aortic stenosis and tricuspid
regurgitation.
Past Medical History:
CAD
'[**71**] CABG
'[**71**] s/p mechanical mitral valve replacement ([**Doctor Last Name 14714**])
Atrial fibrillation
Tachybrady syndrome
s/p pacemaker [**2169**]
Mitral stenosis
Aortic stenosis
Prior CVA??????s
Urinary frequency, hyperactive bladder
Cataracts s/p surgery
'[**83**] Right hip replacement
Appendectomy
Anemia
Osteoporosis
Social History:
Retired mill worker
Lives with spouse
[**Name (NI) 1139**] 50 pack year history quit in [**2151**]
ETOH denies
Family History:
non-contributory
Physical Exam:
Admission
General Elderly appearing female in no acute distress, mild
speech impairment
Skin warm dry
HEENT NCAT PERRLA Anicteric sclera, OP benign
Neck supple full ROM no JVD
Chest CTA mildly diminished at bases
Heart murmur retrograde 2/6 SEM irregular rhythm, 3/6 systolic
murmur
Abdomen soft, nondistended, nontender, +Bowel sounds no
hepatosplenomegally
ext warm well perfused no edema
neuro a/o x3 [**Month (only) **] strength on right, gait slow and slightly
unsteady
Pertinent Results:
[**2189-10-20**] 05:31AM BLOOD WBC-9.9 RBC-3.05* Hgb-8.8* Hct-25.7*
MCV-84 MCH-28.9 MCHC-34.2 RDW-16.8* Plt Ct-182#
[**2189-10-11**] 05:42PM BLOOD WBC-5.6 RBC-4.59 Hgb-13.4 Hct-39.6 MCV-86
MCH-29.1 MCHC-33.7 RDW-15.6* Plt Ct-150
[**2189-10-20**] 05:31AM BLOOD Plt Ct-182#
[**2189-10-20**] 05:31AM BLOOD PT-15.3* PTT-78.2* INR(PT)-1.3*
[**2189-10-11**] 05:42PM BLOOD Plt Ct-150
[**2189-10-11**] 05:42PM BLOOD PT-24.6* PTT-37.0* INR(PT)-2.4*
[**2189-10-18**] 02:25AM BLOOD Fibrino-588*
[**2189-10-20**] 05:31AM BLOOD Glucose-85 UreaN-29* Creat-1.0 Na-138
K-4.4 Cl-103 HCO3-30 AnGap-9
[**2189-10-11**] 05:42PM BLOOD Glucose-100 UreaN-43* Creat-1.3* Na-136
K-4.7 Cl-101 HCO3-26 AnGap-14
[**2189-10-13**] 06:30AM BLOOD ALT-30 AST-41* AlkPhos-123* TotBili-0.8
[**2189-10-20**] 05:31AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.5
[**2189-10-11**] 05:42PM BLOOD Calcium-9.1 Phos-3.5 Mg-2.4
[**2189-10-13**] 11:15AM BLOOD %HbA1c-5.6
[**Known lastname 56817**],[**Known firstname **] [**Medical Record Number 106501**] F 81 [**2108-2-1**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2189-10-19**]
12:09 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2189-10-19**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 106502**]
Reason: r/o ptx s/p CT d/c
[**Hospital 93**] MEDICAL CONDITION:
81 year old woman with
REASON FOR THIS EXAMINATION:
r/o ptx s/p CT d/c
Final Report
HISTORY: 81-year-old woman status post chest tube removal.
COMPARISON: Comparison is made to chest radiograph from
[**2189-10-19**] at 11:15
a.m.
FINDINGS: There has been interval removal of the chest tubes
bilaterally as
well as of the right internal jugular central venous line. There
is no
pneumothorax. The nasogastric tube, epicardial pacing wires,
sternotomy
wires, aortic and mitral valve replacements and multiple
abandoned cardiac
pacer leads are all unchanged from previous examination.
Small bilateral pleural effusions are unchanged. Bibasilar
opacities, likely
atelectatic are unchanged. There are no new consolidations. Mild
cardiomegaly is unchanged. Mediastinal and hilar contours are
normal.
Visualized soft tissue structures and bony thorax are
unremarkable.
IMPRESSION:
1. Interval removal of chest tubes and right IJ central line. No
pneumothorax.
2. Multiple support lines/tubes, small bilateral effusions and
bibasilar
atelectasis, all of which are unchanged from previous
radiograph.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: TUE [**2189-10-20**] 9:27 AM
[**Known lastname 56817**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 106503**] (Complete)
Done [**2189-10-15**] at 9:00:24 AM PRELIMINARY
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: [**2108-2-1**]
Age (years): 81 F Hgt (in):
BP (mm Hg): / Wgt (lb):
HR (bpm): BSA (m2):
Indication: Aortic valve disease. Left ventricular function.
Preoperative assessment. Prosthetic valve function. Shortness of
breath.
ICD-9 Codes: 440.0, 395.2, 424.2
Test Information
Date/Time: [**2189-10-15**] at 09:00 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW5-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Four Chamber Length: 4.1 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 0.8 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.0 cm <= 5.6 cm
Aorta - Annulus: 2.0 cm <= 3.0 cm
Aorta - Sinus Level: 2.8 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.6 cm <= 3.0 cm
Aorta - Ascending: 2.9 cm <= 3.4 cm
Aorta - Arch: 1.9 cm <= 3.0 cm
Aorta - Descending Thoracic: 1.7 cm <= 2.5 cm
Aortic Valve - Peak Velocity: *3.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *60 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 43 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Mitral Valve - Peak Velocity: 1.2 m/sec
Mitral Valve - Mean Gradient: 5 mm Hg
Mitral Valve - Pressure Half Time: 48 ms
Mitral Valve - MVA (P [**1-21**] T): 4.6 cm2
Findings
LEFT ATRIUM: Normal LA size. No spontaneous echo contrast is
seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness and cavity size.
RIGHT VENTRICLE: Moderately dilated RV cavity. Mild global RV
free wall hypokinesis.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Moderately thickened aortic valve leaflets. Severe
AS (AoVA <0.8cm2). Moderate (2+) AR.
MITRAL VALVE: Mechanical mitral valve prosthesis (MVR). Normal
MVR leaflet motion. Normal MVR gradient.
TRICUSPID VALVE: Rhematic deformity of tricuspid valve. Severe
[4+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. Results were
Conclusions
PREBYPASS
1. The left atrium is normal in size. No spontaneous echo
contrast is seen in the left atrial appendage. No atrial septal
defect of PFO is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
3. The right ventricular cavity is moderately dilated with mild
global free wall hypokinesis.
4. There are simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets are moderately thickened. There is
severe aortic valve stenosis (area <0.8cm2). Moderate (2+)
aortic regurgitation is seen.
6. A mechanical mitral valve prosthesis is present. The motion
of the mitral valve prosthetic leaflets appears normal. The
transmitral gradient is normal for this prosthesis.
7. There is a rhematic deformity of the tricuspid valve. Severe
[4+] tricuspid regurgitation is seen.
8. There is no pericardial effusion.
9. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2189-10-15**]
at 803.
POSTBYPASS
1. Patient is on phenylephrine infusion
2. Left ventricle wall motion is difficult to assess, the walls
that are seen are moving well. In the short axis view all walls
are moving well. Right ventricular function is difficult to
assess, but appears to be moderately reduced in function
compared to prebypass.
3. A well seated, well functioning prostetic valve is noted in
the tricuspid position. No perivalvular leak.
4. A well seated, well functioning prostetic valve is noted in
the aortic position. No perivalvular leak.
5. Mitral St Jude valve continues to function well.
6. The aortic contour is smooth after decannulation.
7.
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
Brief Hospital Course:
Admitted for intravenous heparin prior to cardiac catherization
to bridge off coumadin due to mechanical mitral valve.
Underwent preoperative workup including cardiac catherization,
carotid ultrasound, and head CT, Was brought to the operating
[****] for aortic and tricuspid valve replacement and
epicardial leads with new pacemaker generator. See operative
report for further details. She was transferred to the
intensive care unit for hemodynamic monitoring. In the first
twenty foru hours she was weaned from sedation, awoke
neurologically intact, and was extubated without complications.
She was started on coumadin for mechanical valves and lasix for
diuresis. On POD 2 she was started on heparin drip and remained
in the intensive care unit for monitoring. Dobhoff tube was
placed due to absent gag and swallow evaluation ordered. POD 4
she was cleared for thin liquids, dobhoff removed, and started
on supplements with meals. She was ready for discharge to acute
rehab on heparin drip for mechanical valve until INR > 2.5 via
PICC line.
Medications on Admission:
Lasix 20 mg daily
Toprol XL 50 daily
Coumadin 2 or 5mg as directed
Iron 325mg daily
Forteo 750mcg/3ml inj every other day
Folic acid 1 mg daily
Vitamin D 400 units [**Hospital1 **]
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 1 months.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): dose
to change daily [**Name8 (MD) **] MD, goal INR 2.5-3.5.
7. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: Six [**Age over 90 1230**]y (650) units/hour Intravenous
continuous gtt : Adjust dose for goal PTT 60-80 - check daily if
no dose adjustment, if adjusting drip check 6 hours after change
in rate. D/C when INR >2.5.
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
9. Forteo 750 mcg/3 mL Pen Injector Sig: One (1) Subcutaneous
every other day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO twice a
day.
12. Metoprolol Tartrate 25 mg Tablet Sig: [**1-21**] Tablet PO BID (2
times a day).
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
14. Outpatient [**Month/Day (2) **] Work
[**Month/Day (2) **]: PT/INR daily until off heparin drip then Mon-Wed-Fri for
coumadin dosing, goal INR 3.0-3.5 for mechanical mitral valve
15. Outpatient [**Month/Day (2) **] Work
LFT in 1 month - started on statin
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
Tricuspid Regurgitation s/p TVR
Hypertension
Tachy-brady syndrome s/p PPM
Anemia
Osteoporosis
Hyperactive bladder
CVA
Chronic atrial fibrillation
Coronary artery disease
Rheumatic heart disease
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
[**Telephone/Fax (1) **]: PT/INR daily until off heparin drip then Mon-Wed-Fri for
coumadin dosing, goal INR 3.0-3.5 for mechanical mitral valve
[**Name (NI) **] PTT for heparin dosing daily if no change, if change in drip
- 6 hours after change in drip - goal PTT 60-80 until INR 2.5 or
greater than heparin can be discontinued
Followup Instructions:
Please call to schedule appointments
Dr [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] after discharge from rehab [**Telephone/Fax (1) 1144**]
Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] after discharge from rehab [**Telephone/Fax (1) 62**]
[**Telephone/Fax (1) **]: PT/INR daily until off heparin drip then Mon-Wed-Fri for
coumadin dosing, goal INR 3.0-3.5 for mechanical mitral valve
[**Name (NI) **] PTT for heparin dosing daily if no change, if change in drip
- 6 hours after change in drip - goal PTT 60-80 until INR 2.5 or
greater than heparin can be discontinued
Completed by:[**2189-10-20**]
|
[
"428.32",
"397.0",
"599.0",
"998.2",
"V58.61",
"V45.81",
"401.9",
"276.52",
"V43.3",
"427.31",
"584.9",
"E878.1",
"V43.64",
"428.0",
"276.7",
"733.00",
"396.2",
"426.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.32",
"37.74",
"35.22",
"37.86",
"88.56",
"37.23",
"38.93",
"88.52",
"39.61",
"35.27"
] |
icd9pcs
|
[
[
[]
]
] |
12684, 12754
|
9778, 10833
|
341, 768
|
13016, 13023
|
2033, 3385
|
13864, 14581
|
1505, 1523
|
11064, 12661
|
3425, 3448
|
12775, 12995
|
10859, 11041
|
13047, 13841
|
1538, 2014
|
282, 303
|
3480, 9755
|
796, 994
|
1016, 1360
|
1376, 1489
|
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