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28413
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Discharge summary
|
report
|
Admission Date: [**2189-12-2**] Discharge Date: [**2189-12-6**]
Date of Birth: [**2143-2-18**] Sex: F
Service: NEUROSURGERY
Allergies:
Compazine / Penicillins
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headaches
Major Surgical or Invasive Procedure:
Right frontal craniotomy for tumor
History of Present Illness:
Ms. [**Known lastname 41671**] initially began with headaches in [**2183**]. An MRI was
done, which showed a 7-mm meningioma in the right frontal area.
At that time, the
headaches were thought not to be contributed by this presumed
meningioma and she was followed up. She has been serially
followed up with investigations. More recently, she has had a
scan on [**2189-7-15**]. This did not show any change from last
year. However, it was compared to way back to [**2184**], and there
was thought to be a couple of millimeters increase in size.
Today, she was seen for discussion of management for this.
Ms. [**Known lastname 41671**] still has occasional headaches. These are not
significantly increased in seriousness. However, she is
extremely distressed from the fact that this has grown, and she
wished to consider some treatment and I would discuss all the
treatment options.
She denies any other higher function, cranial nerves, sensory,
motor, or neurological dysfunction.
Past Medical History:
Migraine headaches, fibromyalgia, low back
pain, abdominal surgery for removal of fallopian tube with cyst
formation, question nerve damage after that, TAH-BSO, and
depression.
Social History:
She is married and has two sons. + 15-pack-year smoking history
and states that she occasionally smokes. She does not drink and
denies any alcohol use.
Family History:
Depression and diabetes in the family but no history of any
cancer.
Physical Exam:
On Discharge:
teary otherwise non focal
sutures at crani site
Pertinent Results:
[**2189-12-2**] 03:00PM GLUCOSE-116* UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-28 ANION GAP-11
[**2189-12-2**] 03:00PM CALCIUM-8.3* PHOSPHATE-3.0 MAGNESIUM-1.9
[**2189-12-2**] 10:38AM TYPE-ART PO2-138* PCO2-33* PH-7.43 TOTAL
CO2-23 BASE XS-0
[**2189-12-2**] 10:38AM GLUCOSE-80 LACTATE-2.3* NA+-129* K+-3.3*
CL--102
[**2189-12-2**] 10:38AM HGB-9.4* calcHCT-28
[**2189-12-2**] 10:38AM freeCa-1.00*
[**12-2**] MRI Brain:
IMPRESSION: Presumed right frontal meningioma, unchanged in size
or
appearance compared to [**2189-7-15**] study.
CT head [**2189-12-2**]
IMPRESSION: Expected post-operative changes, immediately after
right frontal craniotomy with focal craniectomy and resection of
presumed meningioma.
MRI brain [**12-3**]
IMPRESSIONS: Status post right frontal craniotomy and resection
of
extra-axial right frontal probable meningioma. Expected
postoperative changes are as described above, with no evidence
of residual mass seen. Small area of cytotoxic edema noted along
the resection bed in the right frontal lobe.
Brief Hospital Course:
Ms. [**Known lastname 41671**] was taken to the OR on [**2189-12-2**] for a right frontal
craniotomy for tumor. She was transfered to the SICU intubated.
Post-op CT showed no hemorrhage. She was extubated.
On [**12-3**] she was neurologically stable therefore she was
transferred to the floor. Post op MRI was performed which
revealed excellent resection. She was ambulating independently
without assistance.
On [**11-23**] she remained neurologically stable but emotional. She
also had frequent nausea and complained of lack of sleep. On [**12-6**]
she was feeling better and was ready to be discharged home.
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
4. lamotrigine 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**11-29**]
Tablets PO Q6H (every 6 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
7. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. topiramate 25 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Discharge Disposition:
Home
Discharge Diagnosis:
Right Frontal Tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed. If your wound closure uses dissolvable sutures,
you must keep that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your surgery, you may
not safely resume taking this until cleared by your surgeon.
?????? If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**6-6**] days(from your date of
surgery) for removal of your staples/sutures and/or a wound
check. This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast before
this appointment.
Completed by:[**2189-12-6**]
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57,314
| 140,429
|
40791
|
Discharge summary
|
report
|
Admission Date: [**2110-7-19**] Discharge Date: [**2110-7-30**]
Date of Birth: [**2038-12-27**] Sex: M
Service: NEUROSURGERY
Allergies:
Altace
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Right Craniotomy for evacuation of mass
History of Present Illness:
This is a 71 year old man with history of prostate CA and
melanoma presents to OSH with 1 week of headaches. Patient
states that headaches are a [**10-4**] and are located in the R
frontal region. He states that he was seen at an OSH for similar
headaches where head CT showed old injury and he was discharged
home on pain medication. He returned to the hospital after his
wife noticed that he was having gait instability.
Patient states that he felt like he was stumbling more than
usual and felt like his LLE was dragging. He denies any
dizziness, n/v, visual changes, or dysarthria. Head CT was done
which revealed a R area of hypodensity. Patient was transferred
to [**Hospital1 18**] for further neurosurgical evaluation.
Past Medical History:
CAD, stent, pacemaker, a-fib, HTN, DM2, hypercholesterolemia, GI
bleeding, arthritis, malignant melanoma, prostate CA
Social History:
Retired, lives with wife and daughter in [**Name (NI) **]. Denies tobacco or
ETOH.
Family History:
NC
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atraumatic
Pupils: 2-1.5mm bilaterally EOMs: intact, no nystagmus
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**3-27**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,2 to 1.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: slight L nasolabial flattening.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-29**] throughout. No pronator drift
Sensation: Intact to light touch
Toes downgoing bilaterally
At discharge [**7-29**]: Left Nasolabial fold flattening. No motor or
sensory deficit. ST memory issues. No VF deficit.
Pertinent Results:
[**7-19**] CT Head /c contrast: IMPRESSION: Large area of vasogenic
edema in the right temporoparietal lobes, with significant mass
effect and leftward shift of midline structures. The above
findings are concerning for an underlying mass lesion, a primary
versus a secondary brain neoplasm. Recommended contrast-enhanced
CT study for further evaluation as the patient is unable to
undergo MRI due to a pacemaker.
[**7-20**] Chest CT - tiny bilateral effusion L>R, 1.1cm right pleural
nodule. no lymphadenopathy
[**7-23**]: CT Head Post-op
Pneumocephalus with a small simple fluid hygroma in the right
temporal fossa causing leftward shift of the normally midline
structure and effacement of the perimesencephalic cistern as
expected postoperatively. No significant change compared to the
prior examination except for resection of the known tumor.
EKG [**2110-7-24**]:
Demand atrial pacing with ventricular conduction. Non-diagnostic
Q waves
in leads I and aVL. Q-T interval prolongation. T wave
abnormalities. Since
the previous tracing of [**2110-7-21**] the rate is slower. Otherwise,
unchanged.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
70 0 84 [**Telephone/Fax (2) 89133**]8
[**2110-7-29**] CT head
1. Decreased pneumocephalus with resolution of right frontal
sulcal
effacement and reexpansion of the frontal [**Doctor Last Name 534**] of the right
lateral ventricle.
2. Increased epidural fluid/air collection underlying the
craniotomy site,
with slightly increased right opercular sulcal effacement.
Brief Hospital Course:
Mr. [**Known lastname 2433**] was admitted from the ED to the Neurosurgery service.
Imaging of the brain revealed a right He was started on
dilantin and decadron, while his ASA and coumadin were held.
Neuro Oncology and Radiation were consulted for assistance with
planning. A CT torso was ordered for metastatic work up. While
ambulating from the bathroom to his bed the patient fell. No LOC
but a head CT was obtained and negative.
On [**7-20**], Pt had a CCT which showed a tiny R pleural nodule and
tiny pleural effusions.
He was discussed on the Brain Tumor Conference on Mon [**7-21**] and
it was recommended that a resection was the best treatment. The
patient was pre-op for [**7-23**] and underwent a right sided
craniotomy for tumor removal. He was monitored overnight in the
ICU and on the morning of [**7-24**] his BP was liberalized to 160
systolic and his nicardipine was discontinued. He was determined
fit for transfer to the step down unit and transfer orders were
written and he [**Hospital 89134**] transfer to a step down bed.
Overnight, pt had a run of Vtach and cardiology recommended no
further work-up as he is already on a beta-blocker atenolol.
Additionally, pt continued to have issues with his pacemaker and
EP was consulted to interrogate his pacemaker.
He was transferred to floor in stable condition.
On [**2110-7-26**], PT/OT recommended home with 24 hour supervision vs.
short term rehab. 24 hour supervision was discussed with the
family and they were more comfortable with the patient staying a
a rehab facility close to where the patient lives for a short
period of time. The Dilantin level was 11.8. The patient was
restarted on Metformin at his home dose. Phosphorus and calcium
levels were low and repleated.
On [**2110-7-27**], the patient's neurological exam was stable. He had
bowel sounds and a bowel movement. The serum Dilantin level was
9.6
On [**2110-7-28**],the patients exam was stable with constinued
nasolabial fold flattening, No pronator drift and full strength.
The incision was clean dry and intact. There are staples in
place for wound closure.
Now on the day of discharge, patient is afebrile, VSS, and
neurologically stable. Patient's pain is well-controlled and
the patient is tolerating a good oral diet. Pt's incision is
clean, dry and inctact without evidence of infection. He is set
for discharge home vs. rehab in stable condition and will
follow-up accordingly.
Medications on Admission:
lipitor, coumadin, asa, sotalol, metformin, lasix, atenolol,
doxazosin, diovan, niacin, potassium, norvasc
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. metformin 500 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
4. metformin 500 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
8. niacin 500 mg Capsule, Extended Release Sig: Two (2) Capsule,
Extended Release PO DAILY (Daily).
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. doxazosin 4 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
11. sotalol 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. phenytoin sodium extended 100 mg Capsule Sig: One (1)
Capsule PO TID (3 times a day).
13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. insulin regular human 100 unit/mL Solution Sig: Two (2)
units Injection ASDIR (AS DIRECTED): see sliding scale.
16. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for headache/pain: max APAP 4g/24hrs.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for headache.
18. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): Continue until follow up appointment with the
Brain [**Hospital 341**] Clinic.
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Right temporal mass
Ventricular tachycardia
Brain compression due to cerebral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair on [**7-30**]. Do not scrub.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? Restarting your Coumadin medication will be discussed at your
follow up in the Neurosurgery office in 2 weeks
?????? You have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
Followup Instructions:
Follow-Up Appointment Instructions
??????You will need a follow up in 2 weeks with a head CT without
contrast. At this time we will determine when to continue your
coumadin for AFIB.
- You have an appointment in the Brain [**Hospital 341**] Clinic on [**8-18**]. You will have a CT scan at 2pm (their phone number is
[**Telephone/Fax (1) 327**]) and will meet with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] in the Brain [**Hospital 341**]
clinic at 3pm. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
- Please make an appointment to see your PCP upon discharge
from hospital
- You were found to have a small pulmonary nodule on CT of
chest, you should follow up with additional imaging in 6 months
with primary care.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2110-7-30**]
|
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"511.9",
"401.9",
"V45.82",
"427.31",
"427.1",
"V10.46",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
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8367, 8414
|
4110, 6558
|
281, 323
|
8542, 8542
|
2571, 4087
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10047, 11196
|
1339, 1343
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6716, 8344
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8435, 8521
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6584, 6693
|
8693, 10024
|
1358, 1358
|
233, 243
|
351, 1080
|
1798, 2552
|
1372, 1505
|
8557, 8669
|
1102, 1222
|
1238, 1323
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,218
| 130,366
|
46321+58897
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-4-13**] Discharge Date: [**2169-4-19**]
Date of Birth: [**2101-7-1**] Sex: M
Service: ACOVE
HISTORY OF PRESENT ILLNESS: Sixty-seven-year-old male with
history of CAD status post MI, type 2 diabetes, history of
DVT on Coumadin, status post renal transplant on
immunosuppressants, who presents with fevers and hypoxia x1
day. The patient reports that he initially felt chills,
feeling tired all over for the last several days, and then
developed acute worsening of shortness of breath over the
last day prior to admission. Denies headache, chest pain,
diarrhea, pain of any kind, dysuria, lower extremity pain,
recent surgeries, cough, or sputum. He does note decreased
p.o. over recent days. His last bowel movement was
yesterday, which was normal.
In the Emergency Department: He was febrile to 101.6 with
saturations of 83% on room air improving to 97% on 100%
nonrebreather. He received Lasix, vancomycin, levofloxacin,
and was placed on BiPAP and transferred to the SICU on
[**2169-4-13**].
PAST MEDICAL HISTORY:
1. CAD status post stent x2 to the LAD in [**2164**]. EF of 35%
with regional left ventricular dysfunction.
2. Type 2 diabetes diagnosed in [**2159**] complicated by
peripheral neuropathy and retinopathy.
3. End-stage renal disease on hemodialysis status post
cadaveric renal transplant in [**2163**].
4. Hypertension.
5. Hyperlipidemia.
6. Peripheral vascular disease status post left fem-[**Doctor Last Name **] in
[**2168-7-19**], status post multiple toe amputations.
7. DVT on Coumadin "for years".
8. MRSA toe ulcers.
9. Group G Strep bacteremia in [**2169-2-13**] treated with
intravenous antibiotics complicated by MRSA bacteremia line
infection of his PICC in [**2169-2-19**].
MEDICATIONS ON ADMISSION:
1. Alprazolam 1-2 mg p.o. q.h.s.
2. Aspirin 325 mg p.o. q.d.
3. Cyclosporin 100 mg p.o. b.i.d.
4. Colace 100 mg p.o. b.i.d.
5. Gabapentin 900 mg p.o. t.i.d.
6. Hydralazine 75 mg p.o. t.i.d.
7. Metoprolol 150 mg p.o. b.i.d.
8. Senna.
9. Mycophenolate 1 gram p.o. b.i.d.
10. Lisinopril 20 mg p.o. b.i.d.
11. Multivitamin.
12. Pantoprazole 40 mg p.o. q.d.
13. Insulin 26 units NPH q.a.m., 35 units NPH q.p.m.
14. Warfarin 7.5 mg p.o. q.h.s.
ALLERGIES: Atorvastatin (elevated creatine kinase).
SOCIAL HISTORY: Retired car salesman. Denies tobacco,
ethanol, or other drug use. Lives at home alone with VNA.
FAMILY HISTORY: Father with diabetes.
PHYSICAL EXAM ON ADMISSION: Temperature 98.5, blood pressure
150/64, pulse 74, respirations 18, and 94% on nonrebreather.
General: Obese, chronically ill-appearing male in mild
distress. HEENT: Oral mucosa dry, nonrebreather in place,
conjunctivae pink. Neck is supple, JVP at 9 cm. Pulmonary:
Difficult to examine. Decreased breath sounds everywhere,
but clear to auscultation bilaterally. Cardiac: Regular
rate and rhythm, [**2-24**] holosystolic murmur at the left upper
sternal border radiating to the apex. Abdomen: Distended,
soft, nontender, tympanitic, no hepatosplenomegaly.
Extremities: Bilateral erythema anterior lower extremities
consistent with venous stasis skin changes, multiple toe
amputations, 4 x 3 cm left heel ulcer with minimal drainage
right lateral malleolar ulcer appears to be healing well.
Neurologic: 5/5 strength bilaterally in upper and lower
extremities.
LABORATORY STUDIES ON ADMISSION: Notable for a white blood
cell count of 18.7 with 81% polys and 6 % bands, hematocrit
of 35.1. Potassium 5.5, BUN 36, creatinine 1.8 from a
baseline of 1.2. INR 4.3. CK 91, troponin 0.04. Lactate
2.5. ABG on nonrebreather: 7.27/46/130/22.
Chest x-ray on admission with right base atelectasis and
right hilar prominence.
EKG: Normal sinus rhythm, ST depressions in II, no peaked T
waves, and no change since last EKG.
SUMMARY OF HOSPITAL COURSE:
1. Hypoxia: Patient was admitted to the ICU in order to be
placed on BiPAP. Given the initial read on the chest x-ray,
there was a concern for aspiration versus community acquired
pneumonia in the setting of immunosuppression. He was
initially treated with levofloxacin, vancomycin, and Zosyn.
Given the concern congestive heart failure as a possible
contributor for exam, the patient had an echocardiogram,
which showed a moderately depressed left ventricular
function.
Following the institution of antibiotics, patient's oxygen
requirements markedly improved. Subsequent chest x-rays
showed no evidence of clear pneumonia. At time of discharge,
the patient was saturating 96% on 2 liters. He will require
close following of his oxygen saturation with a hope to
gradually wean oxygen as tolerated.
2. Sepsis: Patient has septic physiology on admission with
hypotension with systolic blood pressures in the 80s and
fever. The differential diagnosis includes pneumonia, but
there was no evidence on chest x-ray, UTI, bacteremia
(history of MRSA bacteremia as well as Strep bacteremia),
cellulitis (no evidence on physical exam), other seeded sites
in the setting of prior MRSA bacteremia. As such, the
patient will continue on levofloxacin and vancomycin to cover
for potential pneumonia as well as MRSA. He will complete a
total 14-day course.
3. Acute renal failure: Creatinine rose to a maximum of 2.4
from a baseline of 1.2. The differential diagnosis included
ATN from transient hypotension versus cyclosporin, prerenal,
AIN (no new medications). Patient had urine electrolytes
performed while he was in the unit with a FENa of 1%.
Sediment of his urine was consistent with tubular necrosis.
The Transplant Renal service was consulted, who felt that the
patient's acute tubular necrosis was likely secondary to his
transient episode of hypertension.
In order to rule out cyclosporin toxicity, a cyclosporin
level was drawn and his cyclosporin was held. Cyclosporin
level returned at 114 indicating that patient was not toxic
on cyclosporin at admission. Patient was restarted on home
doses of cyclosporin. Patient also had a renal ultrasound on
admission of his transplanted kidney, which showed no
abnormalities. Patient's creatinine gradually improved over
the course of admission with good urine output. At time of
discharge, creatinine was 1.1.
4. Transaminitis: Patient had a mild transaminitis with
elevated T bilirubin occurring late in the course. This is
felt to be secondary to mild hypoperfusion during his
transient hypotensive episodes while in the unit.
Differential diagnosis included hepatic congestion secondary
to right heart failure and Zosyn toxicity. Zosyn was
discontinued three days into the hospital course. Hepatitis
panels were negative.
Patient's LFTs gradually trended down. He will required
additional monitoring of his LFTs until they return to
baseline.
5. Anemia: Patient's hematocrit gradually drifted down
following admission to 26. Iron studies from [**2169-1-19**]
were consistent with anemia of chronic disease (iron 27, TIBC
224, ferritin 82). Patient received 1 unit of packed red
blood cells and hematocrit was stable at time of discharge at
32. Patient maybe considered for erythropoietin subcutaneous
injections as an outpatient.
6. Coronary artery disease: Patient was noted to have a
troponin leak to 0.09 in the setting of hypoxia, acute renal
failure, and possible CHF. There were no significant EKG
changes compared to prior EKGs. No further workup was
pursued at this time, although an outpatient stress test may
be considered.
7. Coagulopathy: Despite holding Coumadin on admission, INR
rose to a maximum of 5.4. Patient received 2.5 mg of vitamin
K and subsequently patient's INR decreased to 1.4. Coumadin
was restarted. He will require monitoring of his INR as an
outpatient with a goal level of 2 to 3.
8. Hypertension: In the unit, the patient was intermittently
hypotensive likely secondary to a sepsis physiology. For
this reason, his antihypertensive medications were held while
he was seen in the unit. However, following treatment with
antibiotics, patient returned to baseline hypertension and
his antihypertensives were restarted. His blood pressure was
monitored closely. His medications were gradually adjusted
over the course of his hospital stay.
On day of discharge, lisinopril was increased to 40 mg p.o.
b.i.d. and hydralazine was discontinued. Should patient's
blood pressure remain elevated, an addition of a
calcium-channel blocker such as Norvasc may be considered.
9. Pulmonary hypertension: On echocardiogram of [**2169-4-14**],
moderate pulmonary artery systolic hypertension was noted.
However, this echocardiogram was obtained in the setting of
possible left ventricular failure and pneumonia. Patient
will require a follow-up echocardiogram in [**4-27**] weeks
following discharge to monitor for possible resolution of
pulmonary artery systolic hypertension.
10. Foot ulcers: As mentioned above, patient is noted to
have a right lateral malleolar ulcer as well as left heel
ulcer. A Podiatry consult was obtained, who recommended
obtaining bilateral x-rays of the feet. These showed
multiple toe amputations, but no areas of bone destruction to
suggest osteomyelitis. Patient will continue to have
wet-to-dry dressing changes b.i.d. with feet placed in
Multipodus boots, nonweightbearing status on the left with
full weightbearing status on the right.
DISCHARGE CONDITION: Good.
DISCHARGE STATUS: Discharged to rehabilitation facility.
DISCHARGE DIAGNOSES:
1. Sepsis of unclear etiology.
2. Acute renal failure.
3. Hypertension.
4. Hyperlipidemia.
5. Coronary artery disease.
6. History of deep venous thromboses.
7. Status post renal transplant.
MEDICATIONS ON DISCHARGE:
1. Lisinopril 40 mg p.o. b.i.d.
2. Heparin 5000 units subq q.8 until the patient becomes
therapeutic on his Coumadin.
3. Vancomycin 1 gram IV q.12. x7 days to complete on [**2169-4-26**].
4. Warfarin 5 mg p.o. q.h.s.
5. Levofloxacin 500 mg p.o. q.d. x7 days to complete [**2169-4-26**].
6. Metoprolol 100 mg p.o. b.i.d.
7. Neoral 100 mg p.o. q.12h.
8. Alprazolam 2 mg p.o. q.h.s. prn.
9. Tramadol 50 mg p.o. q.4-6h. prn pain.
10. Ferrous gluconate 300 mg p.o. t.i.d.
11. Celexa 10 mg p.o. q.d.
12. Cyanocobalamin 100 mcg p.o. q.d.
13. Folic acid 1 mg p.o. q.d.
14. NPH 20 units q.a.m., 16 units q.p.m.
15. Humalog sliding scale q.i.d.
16. Pantoprazole 40 mg p.o. q.d.
17. Multivitamin one capsule p.o. q.d.
18. Mycophenolate 1 gram p.o. b.i.d.
19. Senna one tablet p.o. b.i.d.
20. Gabapentin 600 mg p.o. q.12.
21. Colace 100 mg p.o. b.i.d.
22. Aspirin 325 mg p.o. q.d.
FOLLOW-UP APPOINTMENTS:
1. Patient should follow up with primary care physician
[**Name Initial (PRE) 176**] 1-2 weeks following discharge from rehabilitation
facility.
2. Discharge services: Patient will require close monitoring
of blood pressure with titration up of metoprolol as needed
and may consider adding another [**Doctor Last Name 360**] such as a
calcium-channel blocker like Norvasc. Patient will require
monitoring of his INR to a goal of [**2-21**]. At time of
discharge, the patient is taking Coumadin 5 mg p.o. q.h.s.
This will changed as needed for a goal INR of [**1-20**].
3. Patient will require monitoring of LFTs at least 2x/week
in order to ensure that they return to baseline.
4. Patient will require wet-to-dry dressings to foot ulcers
changed twice a day.
5. He also requires physical therapy to increase strength and
mobility.
6. Patient will also need gradually to wean off oxygen as
tolerated for an oxygen saturation greater than 93%.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 2506**]
Dictated By:[**Last Name (NamePattern1) 6008**]
MEDQUIST36
D: [**2169-4-19**] 12:48
T: [**2169-4-19**] 13:13
JOB#: [**Job Number 98479**]
Name: [**Known lastname **], [**Known firstname 651**] R Unit No: [**Numeric Identifier 15713**]
Admission Date: [**2169-4-13**] Discharge Date: [**2169-4-20**]
Date of Birth: [**2101-7-1**] Sex: M
Service: ACOVE
This is an addendum to previously dictated discharge summary.
ADDENDUM TO HOSPITAL COURSE:
1. Hypertension: Given the patient's continued hypertension,
his metoprolol was increased to 100 mg p.o. b.i.d. and
amlodipine was added 5 mg p.o. q.d. He will require
monitoring of his blood pressure with titration of
medications as tolerated.
2. Hypoxia: Given the patient's persistent hypoxia (94% on 4
liters), chest x-ray was obtained on [**2169-4-20**], which showed a
retrocardiac infiltrate and evidence of volume overload.
Patient was placed on Lasix 20 mg p.o. q.d, a low dose given
his history of renal failure. The infiltrate may represent
atelectasis or infiltrate or pneumonia. He will complete a
14-day course of levofloxacin and vancomycin for sepsis and
possible pneumonia. Patient's pulmonary status will need to
be closely monitored as an outpatient and oxygen titrated
down as tolerated for oxygen saturation greater than 93%.
His diuretics may also need to be increased determined by his
volume status. He will also need to have his creatinine
monitored twice weekly as this patient is on a diuretic.
DISCHARGED TO: Extended care facility.
DISCHARGE CONDITION: Fair.
DIAGNOSES:
1. Primary sepsis.
2. Secondary pneumonia.
3. Acute renal failure.
4. Congestive heart failure.
5. Transaminitis.
6. Hypertension.
7. Hyperlipidemia.
8. Coronary artery disease.
9. History of deep venous thrombosis.
RECOMMENDED FOLLOWUP: Please follow up with PCP [**Name Initial (PRE) 1091**] 1-2
weeks following discharge from rehabilitation facility.
DISCHARGE SERVICES:
1. Monitor patient's INR including Coumadin as necessary for
a goal INR of [**2-21**].
2. Monitor he patient's oxygen saturation and titrate down
oxygen as tolerated for oxygen saturation greater than 93%.
The patient may require additional diuresis (adjustment of
furosemide dose).
3. Please check trough vancomycin level [**2169-4-22**] to make sure
that it is therapeutic (less than 15).
4. Please monitor blood pressure. He may need to increase
the patient's amlodipine dose.
5. Dressing changes to bilateral foot ulcers; wet-to-dry
change twice a day.
6. Check LFTs twice a week to ensure normalization.
7. Check Chem-7 twice a week particularly given diuresis and
recent increase in lisinopril dose.
8. Once antibiotics are completed, please remove PICC line.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Docusate sodium 100 mg p.o. b.i.d.
3. Gabapentin 600 mg p.o. q.12h.
4. Senna 6.6 mg p.o. b.i.d.
5. Mycophenolate mofetil 1 gram p.o. b.i.d.
6. Multivitamin one cap p.o. q.d.
7. Pantoprazole 40 mg p.o. q.d.
8. Folic acid 1 mg p.o. q.d.
9. Cyanocobalamin 100 mcg p.o. q.d.
10. Citalopram hydrobromide 10 mg p.o. q.d.
11. Ferrous gluconate 300 mg p.o. t.i.d.
12. Tramadol 50 mg p.o. q.4-6h. prn pain.
13. Acetaminophen 325 to 650 mg p.o. q.4-6h. prn.
14. Alprazolam 1 mg p.o. q.h.s.
15. Cyclosporin modified 100 mg p.o. q.12h.
16. Metoprolol tartrate 100 mg p.o. q.8h.
17. Levofloxacin 500 mg p.o. q.24h. x7 days to complete
[**2169-4-26**].
18. Vancomycin 1 gram IV b.i.d. x7 days to complete [**2169-4-26**].
19. Warfarin 7.5 mg p.o. q.h.s.
20. Heparin 5000 units subq q.8h. Please discontinue once
patient's INR is therapeutic ([**2-21**]).
21. Lisinopril 40 mg p.o. b.i.d.
22. Amlodipine 5 mg p.o. q.d.
23. Furosemide 20 mg p.o. q.d.
24. NPH 20 units subq q.a.m., 16 units subq q.p.m.
25. Humalog sliding scale q.a.c. and q.h.s.
26. Epoetin alpha 10,000 units injection 3x a week (Mondays,
Wednesdays, and Fridays).
[**First Name4 (NamePattern1) 77**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1977**]
Dictated By:[**Last Name (NamePattern1) 834**]
MEDQUIST36
D: [**2169-4-20**] 19:38
T: [**2169-4-21**] 05:58
JOB#: [**Job Number 15714**]
|
[
"995.92",
"038.9",
"996.81",
"486",
"428.0",
"707.15",
"584.5",
"707.0",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
13192, 14355
|
2410, 2447
|
9426, 9617
|
14378, 15800
|
9643, 10513
|
1784, 2277
|
12098, 13170
|
3823, 9317
|
10537, 12081
|
166, 1048
|
3368, 3795
|
1070, 1758
|
2294, 2393
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,100
| 150,385
|
39931
|
Discharge summary
|
report
|
Admission Date: [**2122-11-22**] Discharge Date: [**2122-12-1**]
Date of Birth: [**2054-1-7**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Bactrim / Keflex / Ciprofloxacin Hcl / Hayfever
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
transfer from OSH for treatment of acute cholecystitis
Major Surgical or Invasive Procedure:
[**2122-11-26**]
Coronary artery bypass grafting x2 with left internal mammary
artery, left anterior descending coronary artery; reverse
saphenous vein graft from the aorta to the first obtuse marginal
coronary artery. Endoscopic left greater saphenous vein
harvesting.
Epiaortic duplex scanning.
[**2122-11-25**] Cardiac catheterization
[**2122-11-24**] EGD
History of Present Illness:
68year old male with Coronary artery disease just diagnosed
(slowly accelerating angina) also with epigastric to right-sided
abd pain, radiation to back thought to have cholecystitis.
Besides the mid-epigastric pain, patient also reports right
upper
quadrant pain and pain in the back as well as a "band-like pain"
across the entire torso. The pain in constant, mostly an ache,
at
times sharp. The pain increases for about 45 minutes following
meals. Patient reports and overall feeling of pressure and
fullness following meals. He occasionally experiences nausea,
but
there isno vomiting. He is being referred to caridac surgery for
revascularization
Past Medical History:
-GERD
-CAD based on positive stress test [**11-17**]
-Back Pain
-Nasal Allergies
-R ICA stenosis
.
Past Surgical History:
s/p appendectomy 30 years ago
s/p umbilical hernia repair years ago
Social History:
Lives in [**Location **] ma w/ wife. [**Name (NI) 1403**] as an electrician part
time.
Denies smoking, alcohol or drug use.
Family History:
Father had CABG at age 65, died of Parkinson's disease. Has 3
brothers with coronary disease (ages 64, 52, 69 at onset of CAD,
2 have CABGs, 1 with a stent). 4th brother with DM. Mother with
DM
Physical Exam:
On admission:
Vitals: T: 97.3F 140/80 63 18 99RA
General: Alert, oriented, no acute distress, tired appearing
man.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, TTP in b/l Upper quarants w/ R >> L. TTP along
b/l flanks. No guarding or rebound. hernia scar. + [**Doctor Last Name 515**]
sign.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
OSH pertinent results:
Abdominal U/S [**2122-11-21**]: There is no evidence of intra or
extrahepatic biliary ductal dilatation. The common bile duct
measures 0.4cm. The gallbladder is unremarkable son[**Name (NI) 5326**]
although the patient did elicit a [**Doctor Last Name 515**] sign.
Impression: Normal abdominal U/S. No significant abnormality is
seen.
.
CT Chest [**2122-11-19**]: Impression: Normal Chest Ct. No evidence of
dissection or aneurysm.
.
Abdominal CT [**2122-11-19**]: Impression: No significant abnormality is
seen in the abdomen.
.
EKG: NSR at 70 bpm. Nl axis, nl intervals. Borderline criteria
for LVH. No ST/T wave changes.
[**2122-11-23**] 12:21AM BLOOD WBC-5.0 RBC-4.60 Hgb-14.7 Hct-40.5 MCV-88
MCH-32.0 MCHC-36.4* RDW-13.1 Plt Ct-198
[**2122-11-23**] 12:21AM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2*
[**2122-11-23**] 12:21AM BLOOD Glucose-106* UreaN-18 Creat-1.0 Na-140
K-4.9 Cl-103 HCO3-29 AnGap-13
[**2122-11-23**] 12:21AM BLOOD ALT-20 AST-20 LD(LDH)-143 CK(CPK)-76
AlkPhos-61 TotBili-0.4
[**2122-11-23**] 12:21AM BLOOD CK-MB-2 cTropnT-<0.01
[**2122-11-23**] 12:21AM BLOOD Lipase-46
[**2122-11-23**] 12:21AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0 Cholest-243*
[**2122-11-23**] 12:21AM BLOOD Triglyc-236* HDL-44 CHOL/HD-5.5
LDLcalc-152*
[**2122-11-25**] 05:00PM BLOOD %HbA1c-5.8 eAG-120
Studies:
HIDA [**11-23**]:
IMPRESSION: Early visualization of the gallbladder with normal
response to CCK.
KUB [**11-23**]:
IMPRESSION: Normal bowel gas pattern. No evidence of free air.
ECHO [**11-24**]:
The left atrium is mildly dilated. The estimated right atrial
pressure is 0-5 mmHg. 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%). Tissue Doppler imaging
suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
Carotid dopplers [**11-25**]:
Impression: Right ICA stenosis 40-59%.
Left ICA with no stenosis .
[**2122-11-30**] 08:40AM BLOOD WBC-7.5 RBC-3.21* Hgb-10.2* Hct-28.6*
MCV-89 MCH-31.9 MCHC-35.8* RDW-13.6 Plt Ct-186
[**2122-11-29**] 04:45AM BLOOD WBC-6.7 RBC-2.84* Hgb-9.2* Hct-24.9*
MCV-88 MCH-32.4* MCHC-37.0* RDW-13.6 Plt Ct-141*
[**2122-11-30**] 08:40AM BLOOD Glucose-129* UreaN-17 Creat-1.0 Na-136
K-4.4 Cl-99 HCO3-31 AnGap-10
[**2122-11-29**] 04:45AM BLOOD Glucose-132* UreaN-15 Creat-1.0 Na-138
K-4.2 Cl-100 HCO3-31 AnGap-11
Intra-op TEE [**2122-11-26**]
PRE BYPASS No spontaneous echo contrast or thrombus is seen in
the body of the left atrium or left atrial appendage. No atrial
septal defect is seen by 2D or color Doppler. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). The right ventricular cavity is mildly dilated with
normal free wall contractility. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). Epi-Aortic ultrasound exam performed by Dr.
[**Last Name (STitle) 914**], who was notified in person of the results of the TEE
exam in the operating room at the time of the study.
Post Bypass:
The visible contours of the thoracic aorta are intact.
The biventricular systolic function is preserved.
There is mild aortic insufficiency.
There is no mitral regurgitation.
Brief Hospital Course:
Preoperative workup was completed inhouse. The patient was
brought to the operating room on [**2122-11-26**] where the patient
underwent urgent CABG x 2 with Dr. [**Last Name (STitle) 914**]. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. Vancomycin was used for surgical
antibiotic prophylaxis as he was inpatient greater than 24
hours.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home with VNA in good condition
with appropriate follow up instructions.
Medications on Admission:
Medications at home:
ASA 81mg daily - only recently started taking this
Fonase
Ibuprofen PRN
Omeprazole 20mg PO daily
Toprol XL 25mg PO daily - had only recently started taking this
Mylanta PRN
Medications on Transfer:
Simvastatin 40mg PO qHS - pt states he is not taking due to side
effects
Cefoxitin 1gm IV q8H - unclear when this was started
Fluticasone nasal spray [**Hospital1 **]
Metoprlol 25mg PO BID
Miralax 17gm daily
ASA 81mg PO daily
Omeprazole 20mg PO BID
Nitroglycerin ointment 1 inch q6H
Zofran 4mg IV q8H PRN
Tyelenol 650mg PO q6H PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
Disp:*qs qs* Refills:*0*
5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
please take two tablets each morning for 10 days then decrease
to 1 tablets each morning until follow up with cardiologist .
Disp:*40 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) gram PO DAILY (Daily).
Disp:*30 gram* Refills:*0*
7. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
8. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
9. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO
BID (2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
11. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
Disp:*5 Tablet(s)* Refills:*0*
12. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5
days.
Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Coronary artery disease s/p CABG
Post operative atrial fibrillation
Abdominal Pain - EGD showing Barrets
Hyperlipidemia
Peripheral vascular disease
Gastroesophageal reflux disease
Schatzki ring
Hiatal hernia
Esophagitis
Hypertension
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with Ultram and tylenol
Incisions:
Sternal - healing well, no erythema or drainage
Leg Right - healing well, no erythema or drainage.
Edema trace bilateral lower extremities
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) 914**] [**Telephone/Fax (1) 170**] Tuesday [**2122-12-8**] 2:30
Cardiologist: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 2258**] - appt this thrusday is
cancelled and office working on arranging appointment for 4
weeks
PCP: [**Name10 (NameIs) **] [**First Name (STitle) **] [**Telephone/Fax (1) 31019**] Tuesday, [**12-15**], 2:40PM
**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:[**2122-12-1**]
|
[
"535.50",
"443.9",
"272.4",
"530.3",
"250.00",
"724.5",
"997.1",
"414.2",
"530.85",
"427.31",
"411.1",
"285.9",
"E878.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.15",
"88.56",
"37.22",
"45.13",
"88.47",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
10112, 10161
|
6595, 7824
|
368, 730
|
10438, 10697
|
2596, 6572
|
11538, 12155
|
1784, 1979
|
8427, 10089
|
10182, 10417
|
7850, 7850
|
10721, 11515
|
7871, 8046
|
1556, 1625
|
1994, 1994
|
274, 330
|
758, 1412
|
2009, 2553
|
8071, 8404
|
1434, 1533
|
1641, 1768
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,075
| 190,376
|
49544
|
Discharge summary
|
report
|
Admission Date: [**2133-4-7**] Discharge Date: [**2133-4-9**]
Date of Birth: [**2063-6-13**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 70-year-old man with
a history of coronary artery disease, congestive heart
failure, atrial fibrillation, type 2 diabetes mellitus,
chronic renal insufficiency, and was previously admitted with
a right groin bleed approximately six weeks after his
catheterization on [**2133-3-2**], with a mid left anterior
descending artery lesion of 70%, PTCA plus stent, and 100%
right coronary artery. He also had some congestive heart
failure and was diuresed and was incidentally sent home with
[**Year (4 digits) 269**] on [**2133-3-3**].
He reports that he had been doing well until one week ago
when he had no shortness of breath, no chest pain, no groin
pain, but he noticed a little expansion in his right groin.
He called and discussed this with his primary cardiologist,
Dr. [**Last Name (STitle) **], two days ago and a small hematoma was evident as
per his [**Last Name (STitle) 269**]. He was asked to come in today for an
ultrasound, and during the ultrasound the hematoma was noted
to be rapidly expanding during the study anterior to the
right femoral artery. At the time, there was no
pseudoaneurysm noticed. He was transferred and admitted
directly to the floor as per Radiology but then initially
transferred to Coronary Care Unit for further management.
Currently, he has no complaints other than a moderate right
groin discomfort. No chest pain. No shortness of breath.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Congestive heart failure, ejection fraction with mild
left ventricular dysfunction.
3. Left ventricular hypertrophy with 2+ mitral
regurgitation.
4. Atrial fibrillation.
5. Type 2 diabetes mellitus.
6. Hypertension.
7. Chronic renal insufficiency with a baseline creatinine
between 2 and 3.
8. Status post DDD pacer.
9. Polycythemia [**Doctor First Name **].
10. Spinal stenosis.
11. Obstructive sleep apnea; he uses CPAP at night.
MEDICATIONS ON ADMISSION: Coumadin 2.5 mg alternating
with 1.25 mg, Lasix 80 mg and 40 mg, NPH 30 and 30, regular
insulin sliding-scale, Aldactone 12.5 mg p.o. q.d.,
aspirin 325 mg p.o. q.d., allopurinol 100 mg p.o. q.d.,
Prilosec 20 mg p.o. q.d., Prazosin 1 mg p.o. q.d., Neurontin
100 mg and 300 mg, Isordil 10 mg p.o. t.i.d., amiodarone 200
mg p.o. b.i.d., hydralazine 40 mg p.o. t.i.d., folate 2 mg
p.o. q.d.
ALLERGIES: PENICILLIN.
SOCIAL HISTORY: He lives at home with his wife and [**Name (NI) 269**].
PHYSICAL EXAMINATION: He had a temperature of 98.9, with an
a V-paced rhythm, blood pressure 147/85, satting 93% on room
air. Generally, mildly uncomfortable man, talkative, in no
acute distress. Head and neck examination revealed pupils
were equal, round, and reactive to light and accommodation.
Sclerae were anicteric. Mucous membranes were moist.
Jugular venous pressure was 8 cm. Respiratory, he had rales
only at the bases which were mild. He was in a regular rate
and rhythm with a normal S1 and S2, a 2/6 systolic murmur
radiating to the axilla, and a [**12-6**] crescendo-decrescendo
murmur at the right sternal border. Abdomen, right lower
quadrant showed prominence of expanding hematoma, clearly
demarcated borders, firm, nonpulsatile, with a mild bruit.
Extremities revealed right lower extremity was cool. Distal
pulses were not palpable, but upper was okay. He currently
has two C-clamps placed over his groin which were placed by
Interventional Radiology at the site.
LABORATORY FINDINGS: He had a hematocrit of 31.9, a white
count of 9.9, a platelet count of 238. INR of 2.7, with a
BUN and creatinine of 41 and 2.9.
Ultrasound at the time just showed a groin hematoma of
approximately 6 cm to 8 cm during the study.
ASSESSMENT AND PLAN: A 70-year-old white male with a history
of catheterization six weeks ago with a recently expanding
hematoma in the right groin in the setting of an INR of 2.7.
HOSPITAL COURSE: The patient was initially admitted to the
Coronary Care Unit where the bleeding was controlled. The
hematoma did not increase in size. It was very well
demarcated. It did not exceed beyond the boundaries of the
demarcation, and we continued to slowly release the tension
of the C-clamp. He was noted on that day to have a
hematocrit of approximately 27. He was transfused with
2 units of packed red blood cells, in addition with 2 units
of fresh frozen plasma. He was also given 2 mg IV of
vitamin K, as well as 10 mg subcutaneous of vitamin K, and
his INR initially decreased from 2.7 to approximately 1.4.
He continued to do well. He did not show any signs of
increased bleeding. The following day he was given another
2 mg IV of vitamin K. Approximately six hours after the last
unit was transfused, his hematocrit was measured at 32 and
remained stable for greater than 24 hours. He was discharged
the following day after being seen by Vascular Surgery, who
had apparently explained to us that the patient will need no
further bed rest.
He will be sent home on aspirin only. He will not be a
candidate for anticoagulation at least for six weeks to two
months, which can be re-evaluated in the future, but
currently his only anticoagulation will be aspirin 325 mg
p.o. q.d. for his atrial fibrillation.
FOLLOWUP: He was told to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
and Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] in approximately four to six weeks.
CONDITION AT DISCHARGE: He was stable upon discharge without
any complaints.
DISCHARGE DIAGNOSES: Right groin hematoma, which remained
stable for greater than 24 hours with a stable hematocrit of
approximately 33 for greater than 24 hours. No evidence of
current bleeding. The patient was told to only take aspirin
and to discontinue taking his Coumadin.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 12205**]
MEDQUIST36
D: [**2133-4-9**] 10:06
T: [**2133-4-12**] 07:28
JOB#: [**Job Number **]
|
[
"998.12",
"278.00",
"274.9",
"593.9",
"428.0",
"414.01",
"427.31",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
5657, 6175
|
2075, 2488
|
4011, 5566
|
2585, 3993
|
5581, 5635
|
155, 1551
|
1573, 2048
|
2505, 2562
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,357
| 120,657
|
20380
|
Discharge summary
|
report
|
[** **] Date: [**2132-6-10**] Discharge Date: [**2132-6-13**]
Date of Birth: [**2059-4-8**] Sex: M
Service: MEDICINE
Allergies:
Haloperidol / Ativan
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72yo Russian speaking M with CAD s/p NSTEMI in [**February 2132**] with
peak CK 1500, MB 85, Trop 2.41, DM as well as ESLD with
thrombocytopenia and variceal bleeding in the past who presents
with back pain and malaise. On his prior [**Year (2 digits) **] with NSTEMI,
he was conservatively managed with BB, ASA and heparin gtt
without GPIIb/IIIa given his thrombocytopenia and varices. Pt
is currently non-responsive and unable to cooperate with
interview. However as per report from [**Hospital1 5595**], the pt was more
confused than his baseline this AM and was having respiratory
distress with stridor. The pt was given racemic epi neb at [**Hospital1 5595**]
and EMS was called. With the arrival of EMS, the pt denied any
chest pain, palpitations or sob. The VS as per EMS was the
follows: 92/64, 96, 20, SaO2: 100% on RA FS of 232 with ECG in
NSR. He was found to be actively stridorous with 2+ pitting
edema. As per staff at [**Hospital1 5595**], the pt has been non-compliant with
his lactulose recently.
.
In th ED, the pt was initially afebrile with stable VS but
was hypoxic with SaO2 of 100% on 3L. As he was combative and
oriented x2, he was given ativan 2mg x2 and restrained with 1:1
sitter. He was also given lasix 80mg IV x1 with diuresis of
1800cc.
Past Medical History:
1. CAD s/p NSTEMI in [**2132-2-6**].
2. Cirrhosis, s/p Portacaval shunt in [**Hospital1 336**] in [**2130-1-5**]
possibly due to EtOH or Hepatitis C.
---Hx of Variceal bleeding
---Hx of Splenomegaly
---Hx of Thrombocytopenia
---Hx of Anemia
---Elevated bilirubin with a baseline of 3.4.
3. History of diabetes mellitus complicated by orthostatic
hypotension
4. History of Citrobacter urinary tract infection.
5. Hypercholesterolemia.
6. Hemorrhoids
7. Dementia with agitation
6. Status post appendectomy
Social History:
Lives at [**Hospital 100**] Rehab.
Russian speaking only.
Daughters involved in his care.
Former Etoh use
No tob/drug use.
Family History:
NC
Physical Exam:
VS: 96.9, 94/49, 77, 24, 100% on 3L
GEN: elderly gentleman, mildly obese, NAD. non-conversant.
HEENT: cataracts, sclera anicteric, mm dry, op clear, +
telancgiectasias on cheeks
NECK: no JVD appreciated at 30 degrees, pt non-compliant to
truly assess
THYROID: deferred
LYMPH NODES: no LAD appreciated in post aurciular, cervical,
submandibular, supraclavlicular chains
CHEST: coarse BS bilaterally anteriorly
CV: RRR, no m/r/g
ABD: distended, ?fluid wave, no caput, no hepatosplenomegaly
appreciated on exam, BS+
EXT: wwp, [**2-8**]+ LE edema bilaterally
VASC: + 2+ pulses bilaterally
NEURO: Unresponsive to verbal stimuli, withdraws from pain (by
sitting up some). 1:1 sitter in presence
Pertinent Results:
STUDIES:
Head CT [**2132-6-10**]:
"Overall unchanged appearance of brain, without acute
intracranial
hemorrhage."
.
CXR [**2132-6-10**]:
"Cardiomegaly, pulmonary vascular congestion and bilateral
moderate amount of pleural effusion suggested on this portable
chest examination. If confirmation is needed, a lateral view
could be very helpful to confirm the presence of pleural
effusion. Efforts were made to deliver stat report to referring
physician [**Name Initial (PRE) **]."
.
CXR [**2132-6-13**]
"Continued cardiomegaly with improving mild congestive heart
failure.
More focal opacity in the right lung base likely reflects
pneumonia.
Persistent bibasilar atelectasis and small bilateral pleural
effusions, unchanged."
.
TTE [**2132-3-3**]:
LA: mildly dilated. No atrial septal defect
LV: mild symmetric left ventricular hypertrophy. cavity size is
normal. distal inferior/infero-septal hypokinesis. Overall left
ventricular systolic function is low normal (LVEF 50-55%).
RV: chamber size and free wall motion are normal.
Aortic root: mildly dilated. The ascending aorta is moderately
dilated.
Aortic valve: leaflets (3) are mildly thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis/sclerosis. No aortic regurgitation is seen.
Mitral valve: leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen.
Pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
[**2132-6-10**] 12:00PM WBC-6.6 RBC-3.21* HGB-8.7* HCT-27.5* MCV-86
MCH-27.0 MCHC-31.5 RDW-18.7*
[**2132-6-10**] 12:00PM NEUTS-68.0 LYMPHS-21.4 MONOS-7.7 EOS-2.7
BASOS-0.3
[**2132-6-10**] 12:00PM PLT SMR-VERY LOW PLT COUNT-73*
[**2132-6-10**] 12:00PM PT-18.2* PTT-36.8* INR(PT)-1.7*
[**2132-6-10**] 12:00PM AMMONIA-58*
[**2132-6-10**] 12:00PM CK-MB-28* MB INDX-6.0
[**2132-6-10**] 12:00PM cTropnT-4.37*
[**2132-6-10**] 08:20PM CK-MB-26* MB INDX-6.3* cTropnT-5.03*
[**2132-6-10**] 08:20PM CK(CPK)-413*
[**2132-6-11**] 04:15AM BLOOD CK-MB-20* MB Indx-5.5 cTropnT-4.76*
[**2132-6-12**] 05:18AM BLOOD CK-MB-11* MB Indx-3.2
Brief Hospital Course:
A/P: 73yo M with CAD s/p NSTEMI in [**2132-2-6**] as well as DM, HTN
and ESLD with cirrhosis complicated by esophageal varices,
encephalopathy and thrombocytopenia who presents with shortness
of breath and found to have elevated cardiac enzymes.
.
1. CV:
A. NSTEMI/CAD: Given his history of CAD s/p NSTEMI recently,
his shortness of breath in combination with positive cardiac
enzymes and ECG are consistent with another episode of ACS.
However as he is DNR/DNI and has significant liver disease
complicated by history of esophageal varices and
thrombocytopenia he was considered high risk for further
intervention (cardiac catheterization or thrombolytics). After
discussion with cardiology service who saw the pt on the floor,
the pt was transferred to the CCU for medical management of his
ACS. Patient was monitored on telemetry and followed with serial
ECGs. No heparin gtt, GPIIb/IIIa or Plavix at this time given
his coagulopathy and bleeding risk. Patient was also not taken
for cardiac catheterization given his bleeding risk and overall
poor functional status. He was continued on ASA 325 mg once
daily. Patient was initially on metoprolol but this was briefly
switched to sotalol in the setting multiple runs of
non-sustained ventricular tachycardia. He was switched back to a
low dose of metoprolol on discharge. No statin was initiated
given his known underlying liver disease.
.
B. CHF: The pt has intact biventricular function as per last
TTE, however has clinical evidence of volume overload which may
be due to RHF/LHF or due to ESLD. The patient received Lasix IV
in the ED with good diuresis and was then slightly hypotensive.
Additional diuretics were held initially and then were restarted
as his blood pressure tolerated. His volume status was monitored
and he was restarted on his home dose of spironolactone.
Furosemide was also restarted on day of discharge. His volume
status should continue to be followed at rehab.
.
C. Rhythm: Had multiple runs of VT [**Date range (1) 54651**]. Initially given
lidocaine 50 mg x 2, with little effect, then sotalol 40 mg,
with good response. Sotalol was discontinued on [**6-13**] (last dose
on am of [**6-12**]) with no further episodes of ventricular
tachycardia. He was restarted on his usual low dose beta
blocker.
.
d. Valves: No murmurs on exam. Pt previously had an TTE in
[**2132-3-3**]. ECHO was not repeated during this [**Date Range **] as was
unlikely to change clinical management.
.
2. Altered MS: The differential for this is broad, but includes
ACS, hepatic encephalopathy, possibly secondary to acute
decompensation of liver disease (Portal vein thrombosis, tips
failures, etc), med/toxin (given Ativan in ED x 2). Head CT was
negative for any acute bleed. Patient was initially very
agitated in the ED and received Ativan. He was then
intermittently agitated and confused during his stay; he was
oriented to self only. By report patient is confused at baseline
and had some non-compliance with lactulose at rehab, so this was
most likely hepatic encephalopathy in setting of ESLD. Lactulose
PO/PR was titrated to [**3-8**] BM/day and he was also started on
rifaximin. Could consider RUQ US with dopplers to assess portal
veins and tips after ACS is resolved.
.
3. ESLD: Etiology EtOH/HCV, with clinical history consistent
with decompensated liver disease including ascites, varices and
encephalopathy. Continued on beta blocker for portal HTN and
secondary ppx of varices. Continued on Protonix. Diuretics
initially held. Spironolactone and furosemide restarted prior
to discharge. Patient continued on lactulose and started on
rifaximin for treatment of his hepatic encephalopathy.
.
4. DM: Oral hypoglycemics were held and patient was started on
an insulin sliding scale. He will be discharged on his usual
dose of oral hypoglycemics along with the sliding scale for
additional coverage.
.
5. Abnormal Chest X-ray: Patient with evidence of volume
overload on [**6-10**], repeat chest x-ray on [**6-13**] suspicious for
pneumonia, however, patient without any clinical evidence of
pneumonia: afebrile, no cough, increasing O2 requirement, or
increasing WBC. Decision was made refrain from treatment with
antibiotics and to follow clinically. If patient should have
increased O2 requirement, cough, fever, would recommend repeat
CXR and consideration of a course of antibiotics.
.
5. EtOH abuse: No signs/symptoms of withdrawal while
hospitalized.
.
Medications on [**Month/Day (4) **]:
MEDICATIONS:
1. Lasix 40mg once daily
2. Aldactone 25mg once daily
3. Lopressor 37.5mg [**Hospital1 **]
4. Lactulose
5. Glyburide 2.5mg once daily with Insulin sliding scale
6. Trazodone 25mg QHS
7. Protonix 40mg once daily
8. Folic Acid.
9. Thiamine
10. Aranesp
11. Ultram PRN
12. Docusate
13. Ativan PRN
.
ALLERGIES: Haldol/Ativan/Risperdal
Discharge Medications:
1. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Spironolactone 25 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): please hold for SBP < 100, HR < 60.
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day.
7. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Insulin
Regular sliding scale insulin, per previous [**Hospital 100**] Rehab regimen
9. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO qHS.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
11. Thiamine HCl 50 mg Tablet Sig: One (1) Tablet PO once a day.
12. Aranesp
Per previous [**Hospital 100**] Rehab regimen
13. Ultram 50 mg Tablet Sig: One (1) Tablet PO once a day as
needed for pain.
14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 102**] center
Discharge Diagnosis:
Non ST-Elevation Myocardial infarction
Hepatic Encephalopathy
Discharge Condition:
Stable.
Discharge Instructions:
You were admitted with a myocardial infarction, which is being
managed medically with aspirin and metoprolol. No further
intervention for this is needed. You are being transferred back
to [**Hospital1 100**] Rehabiliation Center for further care.
Followup Instructions:
You should follow up with Dr. [**Last Name (STitle) 4749**] as previously scheduled.
Your care will also continue to be followed at [**Hospital1 **].
|
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icd9cm
|
[
[
[]
]
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[] |
icd9pcs
|
[
[
[]
]
] |
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5173, 10021
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288, 294
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11263, 11273
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3032, 5150
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238, 250
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,431
| 146,452
|
54088
|
Discharge summary
|
report
|
Admission Date: [**2201-3-16**] Discharge Date: [**2201-3-31**]
Date of Birth: [**2118-12-13**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2201-3-16**] - exploratory laparotomy, ileotomy, gallstone removal
History of Present Illness:
82M with dementia transfered from OSH with a 3-day history of
nausea and vomiting. Per patient/family report, pt developed
nausea with a few episodes of nonbloody, nonbilious emesis three
days ago. He became progressively weaker in the setting of
almost no oral intake during this time. The patient and family
otherwise deny complaints of abdominal pain, fevers/chills,
diarrhea, or hematochezia. He cannot recall his last bowel
movement, but feels he has not passed stool or flatus in at
least 48 hours. He presented to [**Hospital 1562**] Hospital last evening
for evaluation, and CT imaging revealed findings consistent with
gallstone ileus causing small bowel obstruction. He was
transfered to [**Hospital1 18**] for further management.
On arrival to [**Hospital1 18**], pt was found to be tachycardic (HR 115)
with mild hypotension (SBP 90), for which he was started on IVF
resuscitation. During placement of a nasogastric tube the pt
vomited, suffering a concomitant aspiration. He subsequently
developed respiratory distress and eventually required
intubation after failing noninvasive support.
Past Medical History:
PMH: HTN, Dementia, HLD
PSH: denies
Social History:
Lives at home with wife; has strong support from children. 25-yr
tobacco history; quit 35 yrs ago. Social EtOH. No illicits.
Family History:
N/C
Physical Exam:
Admission Exam:
Vitals: 98.9 110 105/68 18 95% facemask
GEN: NAD. Alert w/ mild confusion.
HEENT: No scleral icterus. Mucous membranes dry.
CV: Reg rhythm but tachycardic.
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender to deep palpation.
DRE: Normal tone. No gross blood. Heme-occult negative.
Ext: LE warm with palpable DP pulses and no edema.
Physical examination upon discharge: [**2201-3-31**]:
Vital signs: t=97.9, bp=135/80, hr=72, rr=20
General: Sitting comfortably in chair
CV: Ns1, s2, -3, -s4
LUNGS: Clear
ABDOMEN: soft, non-tender, midline incision with steri-strips
EXT: no pedal edema bil., + dp bil., no calf tenderness bil
NEURO: oriented to name, disoriented to time, place,
cooperative, follows commands
Pertinent Results:
[**2201-3-31**] 06:55AM BLOOD WBC-6.9 RBC-3.84* Hgb-11.8* Hct-37.3*
MCV-97 MCH-30.8 MCHC-31.7 RDW-12.9 Plt Ct-348
[**2201-3-31**] 06:55AM BLOOD Glucose-110* UreaN-20 Creat-0.9 Na-140
K-3.9 Cl-111* HCO3-22 AnGap-11
[**2201-3-31**] 06:55AM BLOOD Calcium-8.5 Phos-2.7 Mg-2.0
[**2201-3-29**] 01:55PM BLOOD WBC-7.2 RBC-3.83* Hgb-11.9* Hct-37.3*
MCV-98 MCH-31.1 MCHC-31.9 RDW-12.9 Plt Ct-383
[**2201-3-21**] 02:06AM BLOOD WBC-12.5* RBC-3.40* Hgb-10.5* Hct-32.3*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.2 Plt Ct-212
[**2201-3-16**] 07:15PM BLOOD WBC-6.0 RBC-4.26* Hgb-13.6* Hct-41.6
MCV-98 MCH-32.0 MCHC-32.7 RDW-13.3 Plt Ct-155
[**2201-3-16**] 09:21AM BLOOD WBC-5.0 RBC-4.57* Hgb-14.3 Hct-42.9
MCV-94 MCH-31.3 MCHC-33.4 RDW-12.9 Plt Ct-170
[**2201-3-16**] 01:20AM BLOOD WBC-5.4 RBC-5.06 Hgb-16.1 Hct-46.7 MCV-92
MCH-31.8 MCHC-34.5 RDW-12.8 Plt Ct-219
[**2201-3-18**] 01:57AM BLOOD Neuts-69 Bands-5 Lymphs-12* Monos-7 Eos-0
Baso-0 Atyps-0 Metas-5* Myelos-2*
[**2201-3-29**] 01:55PM BLOOD Plt Ct-383
[**2201-3-29**] 02:16AM BLOOD Plt Ct-326
[**2201-3-20**] 12:34AM BLOOD PT-13.4* PTT-28.6 INR(PT)-1.2*
[**2201-3-16**] 01:20AM BLOOD PT-12.9* PTT-28.6 INR(PT)-1.2*
[**2201-3-29**] 01:55PM BLOOD Glucose-130* UreaN-21* Creat-1.0 Na-140
K-4.7 Cl-108 HCO3-19* AnGap-18
[**2201-3-29**] 02:16AM BLOOD Glucose-116* UreaN-22* Creat-0.9 Na-140
K-3.6 Cl-108 HCO3-19* AnGap-17
[**2201-3-28**] 01:54AM BLOOD Glucose-115* UreaN-25* Creat-1.0 Na-143
K-3.8 Cl-110* HCO3-25 AnGap-12
[**2201-3-16**] 07:15PM BLOOD Glucose-142* UreaN-77* Creat-1.5* Na-137
K-3.7 Cl-106 HCO3-23 AnGap-12
[**2201-3-16**] 09:21AM BLOOD Glucose-133* UreaN-91* Creat-1.8* Na-139
K-3.9 Cl-105 HCO3-23 AnGap-15
[**2201-3-16**] 01:20AM BLOOD Glucose-162* UreaN-102* Creat-2.1* Na-134
K-3.6 Cl-97 HCO3-21* AnGap-20
[**2201-3-22**] 06:04PM BLOOD CK(CPK)-25*
[**2201-3-17**] 10:04PM BLOOD Lipase-49
[**2201-3-24**] 01:08AM BLOOD CK-MB-1 cTropnT-0.40*
[**2201-3-23**] 02:00AM BLOOD cTropnT-0.68*
[**2201-3-22**] 06:04PM BLOOD CK-MB-1 cTropnT-0.78*
[**2201-3-29**] 01:55PM BLOOD Calcium-8.6 Phos-2.8 Mg-2.1
[**2201-3-29**] 02:16AM BLOOD Calcium-8.5 Phos-3.0 Mg-2.0
[**2201-3-18**] 01:57AM BLOOD Triglyc-254*
[**2201-3-17**] 10:04PM BLOOD Cortsol-28.3*
[**2201-3-24**] 08:30AM BLOOD Vanco-20.3*
[**2201-3-24**] 01:20AM BLOOD freeCa-1.09*
[**2201-3-23**] 06:51PM BLOOD freeCa-1.17
[**2201-3-16**]: EKG:
Sinus rhythm. A-V conduction delay. Inferior myocardial
infarction, age
indeterminate. No previous tracing available for comparison.
[**2201-3-16**]: chest x-ray:
1. Enlarged aortic arch and extensively calcified aortic arch,
worrisome for aneurysmal dilatation. If warranted by clinical
situation, further evaluation could be performed with Chest CTA.
2. Reticular pulmonary opacities, most compatible with chronic
lung disease.
3. Bibasilar atelectasis
[**2201-3-16**]: chest x-ray:
FINDINGS: New right internal jugular line tip is at lower
SVC/cavoatrial
junction approximately 3.2 cm from the carina. Orogastric tube
courses below the diaphragm and ends into the body of the
stomach and is appropriately positioned. Since prior radiograph
acquired several hours apart, bibasilar atelectasis persists
with interval worsening on the right side and unchanged on the
left side. Small pleural effusion on the right side is similar.
Upper lungs are clear. There is no pneumothorax. Heart size,
mediastinal and hilar contours have stable appearance.
[**2201-3-17**]: EKG:
Supraventricular rhythm at the upper limits of normal rate with
P-R interval
prolongation. Low amplitude P waves merged with the T wave.
Cannot rule out atrial tachycardia with 2:1 block. RSR' pattern
in leads V1-V2. Q waves in leads III and aVF - consider inferior
myocardial infarction. Since the previous tracing the rate is
faster. The P-R interval is longer with a difference in the P
wave which may be related to fusion with a T wave.
Clinical correlation is suggested.
TRACING #1
[**2201-3-18**]: ECHO:
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global systolic function. The left ventricle is
compressed by a severely dilated and hypokinetic right
ventricle. The RV apical function is relatively preserved which
is a non-specific sign but could be due to pulmonary embolism.
Moderate tricuspid regurgitation and at least moderate pulmonary
hypertension.
[**2201-3-19**]: EKG:
Sinus bradycardia with sinus arrhythmia and P-R interval
prolongation.
Prolonged Q-T interval. Borderline low precordial QRS votlage. T
wave
inversions in leads VI-V4 and in the inferior leads. Slightly
delayed anterior R wave progression - cannot exclude prior
anteroseptal myocardial infarction.
Compared to the previous tracing of [**2201-3-17**] T wave inversion is
more prominent in leads II and V3. RSR' pattern has resolved,
likely due to changes in electrode placement. Anterior R wave
progression has improved.An ongoing inferior and anterior
ischemic process cannot be excluded. Clinical correlation is
suggested
[**2201-3-20**]: chest x-xay:
Moderate cardiomegaly is stable. Left lower lobe retrocardiac
consolidation and ill-defined opacities in the right mid and
lower lungs are stable, concerning for aspiration. There are no
new lung abnormalities, pneumothorax or enlarging pleural
effusions. Lines and tubes are in unchanged standard
position
[**2201-3-20**]: x-ray of the abdomen:
IMPRESSION: Findings consistent with resolving small-bowel
obstruction from [**2201-3-15**] with decreased gaseous distention of the
small bowel and progression of oral contrast into the proximal
colon.
[**2201-3-20**]: cat scan of abdomen and chest:
Multifocal pneumonia/aspiration pneumonia within the right
upper, middle,
and lower lobes.
2. Small bilateral pleural effusions with associated
atelectasis.
3. Fusiform infrarenal abdominal aortic aneurysm as well as
aneurysmal
dilatation of the right common iliac artery and a saccular
aneurysm arising off the right internal iliac artery with
significant mural thrombus.
4. Dilatation of loops of small bowel within the left abdomen
and pelvis.
The degree of small bowel dilatation overall has generally
decreased and this likely reflects a persistent ileus, although
a partial small bowel obstruction is not entirely excluded.
5. Enlarged right hilar lymph node presumably reactive.
Following resolution of acute symptoms a follow-up Chest CT is
recommended.
6. Emphysema.
7. Pulmonary arterial hypertension.
8. Probably duodenal lipoma
[**2201-3-22**]: EKG:
Sinus bradycardia. P-R interval prolongation. Borderline low
limb lead
voltage. Mild Q-T interval prolongation. Early R wave
progression.
RSR' pattern in lead V1. Borderline intraventricular conduction
delay.
ST-T wave abnormalities. Since the previous tracing of [**2201-3-11**]
the Q-T interval is now shorter. Otherwise, unchanged.
TRACING #1
[**2201-3-23**]: EKG:
Probable sinus rhythm with atrial premature beats. Since the
previous tracing the rate has increased. Atrial ectopy is new.
The QRS complex is narrower. ST-T wave abnormalities are less
prominent.
[**2201-3-24**]: chest x-ray:
FINDINGS: As compared to the previous radiograph, the known
multifocal
pneumonia, with a maximum manifestation at the right lung base,
is unchanged in extent and severity. Unchanged moderate
cardiomegaly without pulmonary edema. Unchanged monitoring and
support devices. No newly appeared focal parenchymal opacities.
[**2201-3-26**]: chest x-ray:
Compared to the prior radiograph, there has been no change.
Right sided
extensive opacities remain. Left-sided patchy opacities also
remain. Moderate cardiomegaly and areas of atelectasis
bilaterally is unchanged. Right-sided IJ terminates in the
mid-to-distal SVC.
[**2201-3-29**]: chest x-ray:
Rotated lordotic positioning. Allowing for this, the
cardiomediastinal
silhouette is likely stable. There are patchy opacities at the
right and left bases, similar, possibly minimally improved,
compared with [**2201-3-28**] at 5:46 a.m. Doubt CHF. No gross
effusion.
[**2201-3-17**] 5:01 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2201-3-20**]**
GRAM STAIN (Final [**2201-3-17**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2201-3-20**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
[**2201-3-21**] 12:29 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2201-3-24**]**
GRAM STAIN (Final [**2201-3-21**]):
[**10-1**] PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final [**2201-3-24**]):
Commensal Respiratory Flora Absent.
YEAST. SPARSE GROWTH.
[**2201-3-24**] 8:28 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2201-3-25**]**
MRSA SCREEN (Final [**2201-3-25**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
Brief Hospital Course:
The patient presented to the [**Hospital1 1170**] with gallstone ileus. He had a gastric tube placed, but
was removed during transport. He was hypoxic upon admission. A
[**Last Name (un) **]-gastric tube was replaced with subsequent vomitting. He
was emergently intubated and taken to the operating room on
[**2201-3-16**] for exploratory laparotomy, ileotomy and stone
extraction. He tolerated the procedure well and was transferred
to the intensive care unit for further care:
Posoperatively, the patient was hypotensive and required fluid
boluses. A NICOM was placed that showed adequate cardiac output.
He was then started on intermittent levophed, vasopressin, and
dopamine. As his hemodynamic status improved, the pressors were
weaned off by HD# 5. The patient was also noted to have a
troponin increase to 0.8 and was intermittently bradycardic. He
underwent an Echocardiogaram which showed left ventricular
hypertrophy with an ejection fraction of >55%. He was seen by
Cardiology who atributed the changes to demand ischemia. On HD#4
the patient developed an arrythmia and there was concern for a
pulmonary embolism. A CTA was performed which was negative for
a pulmonary embolism. He otherwise had no cardiovascular
issues.
During the hospital course, the patient required fluid
resuscitation and became fluid overloaded. As a result of this,
he was difficult to ventilate and had to be paralyzed and
required several ventilatory mode changes. He was started on a
lasix drip to help decrease his overload. This was discontinued
after 48 hours because of an increase in his creatinine. He
subsuequently auto-diuresised down to his dry weight. On HD #5,
he was started on tube feedings and gradually advanced to his
goal. He was slowly weaned and extubated on POD#8. He was
maintained on a face mask throught POD #9 and weaned to nasal
cannula on POD #11. He was placed on a 1 week course of zosyn
and vancomycin for his aspiration pneumonitis. His oxygen
requirement slowly resolved. He was evaluated by Speech and
Swallow to determine his ability to safely swallow without
aspiration.
On HD #5, the patient was started on tube feedings and slowly
advanced to goal. He was evaluated by Speech and Swallow who
advanced him to a soft solid diet. By POD 10 he was on a
regular diet and calorie counts were begun to measure the
magnitude of his oral intake. He was tolerating a regular diet
upon discharge.
He was transferred to the surgical floor on HD #13. His vital
signs have been stabie and he has been afebrile. His white blood
cell count has normalized and his hematocrit has been stable.
He was tolerating a regular diet. He has been evaluated by
physical therapy and recommendations made for discharge to an
extended care facility where he can futhter regain his strength
and mobility.
****Of note: x-ray of the abdomen on [**2201-3-20**] showed enlarged
right hilar lymph node and recommendation per radiology for a
repeat cat scan in the future.
Medications on Admission:
Atorvastatin 20', Amlodipine 10', Losartan 100', Vitamin B12,
ASA (unknown dosage), Exelon patch 9.5mg/24hrs
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
2. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for fungal infection.
3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
once a day as needed for constipation.
4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
6. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for systolic blood pressure <110, hr <60.
7. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. quetiapine 25 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stool.
12. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed) as needed for dry eyes.
13. Exelon 9.5 mg/24 hour Patch 24 hr Sig: One (1) patch
Transdermal daily ().
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Hospital3 **] ([**Hospital **]
Hospital of [**Location (un) **] and Islands)
Discharge Diagnosis:
aspiration
gallstone ileus
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with nausea and vomitting.
You were found on cat scan to have a gallstone ileus and a small
bowel obstruction. You had a tube placed into your stomach for
decompression and you subsequently vomitted with some fluid
entering your lungs and causing pneumonia. You were taken to
the operating room where you had an exploratory laparotomy and
removal of the gallstone which was causing the obstruction. You
were monitored in the intensive care unit after the surgery
where you required intravenous medication to support your blood
pressure. You vital signs gradually improved and you were
transferred to the surgical floor. You are now preparing for
discharge where you can regain your strength and mobility.
Followup Instructions:
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
Name: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 853**]
When: TUESDAY [**2201-4-14**] at 4:15 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
*Please discuss with the staff at the facility a follow up
appointment with your PCP when you are ready for discharge.
Name: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **],MD
Location: UPPER CAPE INTERNAL MEDICINE ASSOCIATES
Address: 99 [**Location (un) **] STRAITS, [**Hospital1 **],[**Numeric Identifier 27861**]
Phone: [**Telephone/Fax (1) 33277**]
Completed by:[**2201-4-8**]
|
[
"E878.8",
"426.13",
"751.0",
"518.81",
"272.4",
"575.5",
"416.8",
"507.0",
"995.92",
"038.9",
"294.20",
"584.9",
"E849.7",
"427.89",
"560.31",
"427.31",
"397.0",
"411.89",
"401.9",
"998.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"38.97",
"96.07",
"45.02",
"33.24",
"96.6",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
15955, 16082
|
11559, 14549
|
319, 390
|
16177, 16177
|
2542, 11536
|
17128, 17957
|
1743, 1749
|
14709, 15932
|
16103, 16156
|
14575, 14686
|
16360, 17105
|
1764, 2155
|
265, 281
|
2172, 2523
|
418, 1524
|
16192, 16336
|
1546, 1584
|
1600, 1727
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,026
| 129,148
|
32279
|
Discharge summary
|
report
|
Admission Date: [**2125-11-21**] Discharge Date: [**2125-11-23**]
Service: MEDICINE
Allergies:
Flexeril
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
admission for elective cath
Major Surgical or Invasive Procedure:
Catheterization and placement of a drug eluting stent in the
left anterior descending artery.
History of Present Illness:
Mr [**Known lastname 65453**] is a pleasant 86yo M with h/o CAD and DES to LAD and
RCA in '[**21**], who presented to on [**2125-10-3**] for SOB in the setting
of recent d/c of aspirin ([**12-26**] GIB) was found to have thrombosed
LAD stent (mildly elevated trops) and new sCHF, now re-presents
for elective cath. Cath was initially held given that occlusion
was thought to be subacute and because of concern for worsening
of GI bleed with plavix. Subsequent viability showed no
anterior wall viability and pt has been asymptomatic, but given
low exercise tolerance and suggestion of possible benefit from
intervention therefore he returned today for cath. Pt states
that since his last admission he has been feeling well, without
CP, SOB, or diziness, however he has not been exerting himself
significantly.
.
Cath today showed occulded proximal LAD. Endeavor 2.5 x 18
stent was placed. Procedure was complicated by SBP of 80-90s
(baseline 100), therefore dopamine was started basline. Also
complicated by crit drop from 33-->25 (unclear time frame of
this drop), with no evidence of GI bleed. Given recent hx of GI
bleed he was transfused 1 U PRBCs.
.
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 does endorse a 9 lb wt loss over the last month in the
setting of removal of his teeth. All of the other review of
systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia (+), Hypertension (+)
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS: [**Name Prefix (Prefixes) **]'[**Last Name (Prefixes) **] to LAD and RCA in
[**2122-9-24**]
-PACING/ICD:
3rd degree AV block s/p AVNRT ablation - [**Company 1543**] Adapta dual
chamber pacemaker implanted all in '[**21**]
3. OTHER PAST MEDICAL HISTORY:
Gastric ulcers, erosive gastritis, hx GI bleed in [**8-/2125**]
Aflutter
Hematuria s/p foley placement on prior cardiac cath
Social History:
Patient is a WWII veteran. Worked in steel industry after the
war, and later made saws for the lumber industry. Lives with
wife, independent in all ADLs. 5 children.
-Tobacco history: 30 years of 1/2ppd, quit 35 years ago
-ETOH: none
-Illicit drugs: none
Family History:
Brother with stroke. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
VS: T=98.7 BP=92/59 HR=96 RR=16 O2 sat=97% on 2.5 L NC
GENERAL: WDWN male 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 7 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. [**12-30**] crescendo murmur heard loudest at
RUSB, holosystolic murmur at apex. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi anteriorly
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits. Cath site is clean and
dry with no evidence of hematoma or bleeding.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
NEURO: CNs [**1-5**] intact. Moves extremities freely.
Pertinent Results:
[**2125-11-23**] 12:30PM BLOOD WBC-3.9* RBC-4.21* Hgb-10.5* Hct-31.9*
MCV-76* MCH-24.9* MCHC-32.8 RDW-17.9* Plt Ct-115*
[**2125-11-23**] 04:56AM BLOOD WBC-5.2 RBC-3.90* Hgb-9.8* Hct-29.3*
MCV-75* MCH-25.1* MCHC-33.4 RDW-17.9* Plt Ct-116*
[**2125-11-22**] 11:26PM BLOOD Hct-25.7*
[**2125-11-22**] 04:17PM BLOOD Hct-24.9*
[**2125-11-22**] 05:51AM BLOOD WBC-6.9 RBC-4.15* Hgb-10.1* Hct-30.4*
MCV-73* MCH-24.5* MCHC-33.4 RDW-17.2* Plt Ct-110*
[**2125-11-21**] 10:12PM BLOOD WBC-8.7# RBC-4.24* Hgb-10.2* Hct-31.2*
MCV-74* MCH-24.0* MCHC-32.6 RDW-17.5* Plt Ct-107*
[**2125-11-21**] 04:00PM BLOOD Hct-25.8*
[**2125-11-21**] 10:12PM BLOOD PT-13.2 PTT-21.4* INR(PT)-1.1
[**2125-11-21**] 02:05PM BLOOD PT-13.2 PTT-25.4 INR(PT)-1.1
[**2125-11-23**] 04:56AM BLOOD Glucose-99 UreaN-26* Creat-0.9 Na-137
K-3.8 Cl-106 HCO3-26 AnGap-9
[**2125-11-22**] 05:51AM BLOOD Glucose-127* UreaN-25* Creat-1.0 Na-142
K-4.2 Cl-107 HCO3-29 AnGap-10
[**2125-11-21**] 10:12PM BLOOD Glucose-130* UreaN-25* Creat-0.9 Na-139
K-4.2 Cl-107 HCO3-24 AnGap-12
[**2125-11-22**] 05:51AM BLOOD CK(CPK)-211
[**2125-11-21**] 10:12PM BLOOD CK(CPK)-111 Amylase-62
[**2125-11-22**] 05:51AM BLOOD CK-MB-21* MB Indx-10.0*
[**2125-11-21**] 10:12PM BLOOD CK-MB-9
[**2125-11-23**] 04:56AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
[**2125-11-22**] 05:51AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
[**2125-11-21**] 10:12PM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1 Iron-70
[**2125-11-22**] 05:51AM BLOOD Hapto-249*
[**2125-11-21**] 10:12PM BLOOD calTIBC-454 Ferritn-17* TRF-349
[**2125-11-23**] 04:56AM BLOOD Cortsol-11.1
.
CT abdomen and pelvis [**2125-11-22**]:
IMPRESSION:
1. No fluid collection or hematoma to account for hematocrit
drop.
2. Significantly enlarged prostate gland.
3. Foci of air within the urinary bladder can be seen with
recent Foley
catheterization. Clinical correlation recommended.
4. Diverticulosis.
5. Aneurysmal dilation of the infrarenal abdominal aorta
measuring up to 3.0 cm in diameter.
Brief Hospital Course:
Mr [**Known lastname 65453**] is an 86 year old gentleman with a history of
pacemaker placement for AVNRT, CAD status post stent in [**2121**],
who was admitted for catheterization for in-stent restenosis and
is status DES to LAD.
.
# CORONARIES: History of coronary disease with instent
re-stenosis in the setting of recent discontinuation of aspirin,
which likely precipitated the event. A drug eluting stent was
placed in the LAD. He was restarted on aspirin and plavix.
- Restarted aspirin and plavix
.
# HYPOTENSION: The patient presented with low pressures at
baseline with reported home systolic pressures in the 80s to
90s. Post procedure, his pressures were noted to be [**9-12**] below
this baseline most likely secondary to peri-procedure
medications in the setting of poor ejection fraction at
baseline. Given the patients history of recent GI bleed there
was also concern for acute GI bleed although no signs of active
bleed. No suggestion of sepsis. He was placed on a dopamine IV
drip for several days and weaned off on the day of discharge
with systolic pressures in the 80s-90s off dopamine. His home
sotalol, lisinopril and metoprolol were held with instructions
for the patient to follow up with his primary care physician and
cardiologist in the following weeks.
- Held Lisinopril, sotalol, metoprolol
.
# ANEMIA: Baseline hematocrit appears to be in the low 30s, with
a hematocrit of 25 on admission. Given post-operative low
pressures he was transfused one unit of pRBCs in the PACU with
concern for acute GI bleed. His hematocrit dropped again on the
day prior to discharge from 30 to 24.9 and he was given two more
units of pRBCs. A CT abdomen revealed no evidence of RP bleed
or thrombus at the catheterization site. His stool were guaic
negative and rectal exam was unremarkable. His hematocrit was
stable at discharge at 31.9.
.
# PUMP: Known Systolic CHF. Newly decreased EF (20-25%) as of
last admission, no evidence of volume overload on admission. He
was continued on his home statin.
.
# RHYTHM: Paced rhythm. Home sotalol was held given
hypotension.
.
# HYPERLIPIDEMIA: Continued home simvastatin.
.
# HISTORY OF GI BLEED: No evidence of active bleed, home
omeprazole continued.
Medications on Admission:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. sotalol 80 mg Tablet Sig: [**11-25**] Tablet PO twice a day.
6. Ocuvite q day
Discharge Medications:
1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*14 Tablet(s)* Refills:*2*
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
4. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Ocuvite Tablet Sig: One (1) Tablet PO once a day.
6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Thrombosis of cardiac stent in the LAD
2. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for management of a bloot clot in one of your
stents. It is likely that discontinuation of your daily aspirin
caused this blot formation. You underwent catheterization of
your coronary blood vessels and a drug eluting stent was placed.
You were restarted on both plavix and aspirin. Your blood
pressures were low following your procedure and required medical
support for several days. Your home anti-hypertensive
medications were held for this reason. You should not restart
these medications until directed by your primary care physician
or you cardiologist. You also required several blood
transfusions due to low blood counts. A CT imaging study of
your abdomen revealed no bleeding source. You should have your
blood counts follow-up by your primary care physician.
In Summary the following medications changes were made:
1. Please restart Plavix daily
2. Please restart Aspirin daily
3. Please discontinue Sotalol
4. Please discontinue Metoprolol
5. Please discontinue Lisinopril
Followup Instructions:
Please call you primary care physician [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) 21775**] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 75455**] to schedule a follow up appointment within the next
two weeks.
Please call your cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6105**] [**Doctor Last Name 11493**] at
[**Telephone/Fax (1) 11650**] to schedulre a follow-up appointment within the
next two weeks.
|
[
"996.72",
"E879.0",
"414.01",
"428.0",
"285.9",
"428.22",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"00.66",
"88.56",
"36.07",
"99.20",
"00.45",
"37.22"
] |
icd9pcs
|
[
[
[]
]
] |
9470, 9476
|
6185, 8412
|
247, 343
|
9572, 9572
|
4215, 6162
|
10792, 11265
|
2928, 3180
|
8933, 9447
|
9497, 9551
|
8438, 8910
|
9755, 10769
|
3195, 4196
|
2214, 2481
|
179, 209
|
371, 2112
|
9587, 9731
|
2512, 2638
|
2134, 2194
|
2654, 2912
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,473
| 152,258
|
21313
|
Discharge summary
|
report
|
Admission Date: [**2129-8-19**] Discharge Date: [**2129-8-23**]
Date of Birth: [**2057-3-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Tylenol
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
R lung nodules
Major Surgical or Invasive Procedure:
right vats wedge biopsy
History of Present Illness:
Mr. [**Known lastname 1356**] is a 72-year-old gentleman who underwent a liver
transplant for ETOH cirrhosis and hepatocellular carcinoma in
[**2126**]. On his follow-up CT scns, He was found to have growing
rightlower lobe nodules as well as a left lower lobe nodule. He
presented on [**8-19**] for diagnosis of the lower lobe nodules by R
VATS and wedge biopsy. At the time of presentation, he was
asymptomatic from a pulmonary standpoint - no coughs, shortness
of breaths, or fevers.
Past Medical History:
1) EtOH cirrhosis w/ variceal bleed
2) HCC (6x4cm originally) s/p RFA
3) s/p OLT [**2126-2-22**] (CBD-CBD)
4) ITP/GIB refractory to IVIG, steroids
5) s/p lap splenectomy [**2126-8-9**]
6) c/b portal & splenic vv thromboses, Coumadin DC'ed [**5-1**]
7) CMV [**8-30**] tx foscarnet > valganciclovir
8) duodenitis, telangectasia of stomach
9) BCC of nose
10) CRI improved since NSAIDs stopped
11) htxn
12) hyperlipidemia
13) CAD
14) s/p CABG 1v '[**19**]
15) s/p R ing hernia repair
16) latent TB ([**2119**]) PPD+, INH post transplant
Social History:
prior EtOH abuse quit '[**20**], ex-smoker quit '[**06**], 20 pk-yr
Family History:
Non-contributory
Physical Exam:
VS: T99.2, HR 80, BP 122/60, RR 22, O2 94% on RA
GEN: AAOx3, NAD, appears healthy
HEENT: non-icteric sclera, not jaundiced, PERRL
CV: RRR, nl S1 S2, no m/r/g
LUNGS: CTA B/L, no crackles or rales
ABD: soft, ND, NT
EXT: no edema
Pertinent Results:
[**2129-8-18**] 08:20AM ALT(SGPT)-16 AST(SGOT)-23 LD(LDH)-166 ALK
PHOS-61 AMYLASE-102* TOT BILI-0.6
Brief Hospital Course:
Patient was admitted on [**2129-8-19**] and underwent R VATS and wedge
biopsy x 2 of his RLL. The surgery occurred without
complication. One [**Doctor Last Name **] drain was left in place during the
surgery, and the drain followed bulb protocol from the patient's
time in the PACU. Patient did well on the night of his
operation with his [**Doctor Last Name **] drain to bulb suction, however he had a
sudden episode of desaturation and a temperature spike on PD#1.
The patient's O2 sats were 70% while on the floor, thus he was
transferred quickly to the T-SICU. In the T-SICU, his temp was
104.0, though his sats improved to 94% on 3L N/C. Patient
denied chest pain or SOB. The patient was started on
broad-spectrum antibiotics (levaquin, vanco, flagyl, and
transplant hepatlogy and ID were consulted for recs of fever
management. ID suggested the fever was likely secondary to
perioperative reasons (i.e., entrance of skin flora into system
during operation) versus thrombophlebitis/cellulitis, as the
patient had an IV infiltrate in his Right arm. The patient's O2
sats normalized by PD#2, and he was able to be transferred out
of the ICU on that day. Furthermore, the patient's temperature
came down considerably, and the patient's white blood cell count
fell from 35 to 16 by POD#3. Duplex U/S of R arm on PD#2 showed
no clot. On, [**2129-8-22**], PD#3, ID reevaluated the patient. IN the
face of normal temperatures and a declining fevers and WBC
counts, the patient was thought to be stable for discharge on a
5-day course of Doxycycline po. The patient was discharged to
home in stable condition on [**2129-8-22**]. Patient's pathology was
pending at the time of discharge.
Medications on Admission:
1. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
2. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed. Disp:*75 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
10. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Medications:
1. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
2. Cyclosporine Modified 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
3. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
5. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*75 Tablet(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed.
10. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 5 days.
Disp:*10 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
liver Tx [**2126**] for HCC/cirrhosis, B/L lung nodules. r/o mets
PMH: CRF, HTN, Hyperlipidemia, CAD, s/p CABG, hernia repair,
splenectomy, TB
right vats wedge biopsy.
Discharge Condition:
good
Discharge Instructions:
call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 170**] if you develop chest
pain, shortness of breath, fever, chills, redness or drainage
from your incision site or any symptoms that concern you.
Followup Instructions:
You have a follow up appointment with Dr. [**Last Name (STitle) **] at
Date/Time:[**2129-9-1**] 3:30 on the [**Hospital Ward Name **] [**Hospital Ward Name **] clinical
center. please arrive 45 minutes prior to your appointment and
report to the [**Location (un) **] radiology for a chest XRAY.
|
[
"197.0",
"V42.7",
"272.4",
"V10.07",
"414.00",
"401.9",
"V45.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.20"
] |
icd9pcs
|
[
[
[]
]
] |
6077, 6128
|
1915, 3613
|
302, 328
|
6340, 6347
|
1789, 1892
|
6601, 6899
|
1505, 1523
|
4793, 6054
|
6149, 6319
|
3639, 4770
|
6371, 6577
|
1538, 1770
|
248, 264
|
356, 846
|
868, 1403
|
1419, 1489
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,775
| 155,524
|
9183
|
Discharge summary
|
report
|
Admission Date: [**2184-10-15**] Discharge Date: [**2184-10-29**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
81 yo Portuguese-speaking F w prior CVA, atrial fibrillation not
on coumadin, critical aortic stenosis, hypertension, and AAA, w/
grade IIIa follicular lymphoma s/p rituxan [**10-8**] presenting from
home with fevers to 101.
.
The patient has been living with her two daughters after a
recent stay in rehab. Over the past several months, the patient
has largely relied on her daughters for her ADLs. Per her
family, she has had confusion/dementia for quite sometime and
this is stable and chronic.
.
Over the past week however the patient has been having fevers at
home. Her son states this may have been going on for up to one
month (since about the time her pacer was placed) but the
patient takes tylenol regularly and this may have blunted her
fevers.
.
She last received rituximab on [**10-8**] and was noted to be febrile
at home on [**10-9**]. Since that time, her temps have fluctuated
between normal and 101.2 without intervention. Given her fevers,
her family took her to her PCP who obtained [**Name Initial (PRE) **] urine sample which
was reportedly negative for infection. Given her complex medical
history, recent rituxan, and ongoing fevers she was referred
into the ED.
.
While in the ED, her temp was 100.4 with otherwise stable vital
signs. Labs were notable for wbc 2.1 (pmns 59%,), hct 32.7 w MCV
106, and 72K plts. [**Name Initial (PRE) **] and urine cultures were drawn. CXR was
notable for possible infiltrate and bilateral pleural effusions.
She was given cefepime for neutropenic fever. VS prior to
transfer were: 97.3, 92, 138/62, 18 98% on RA.
.
On arrival to the floor, her family is able to interpret. The
patient reports some intermittent recent headaches but no neck
stiffness, she denies cough or sob although her family reports
recent mild cough with scan mucous production. She denies chest
pain, abd pain, skin rashes or sores, dysuria or diarrhea.
Past Medical History:
Mrs. [**Known lastname **] and her family report that since [**Month (only) 547**] of this year,
she has had a slow decline in her activity and functioning. She
usually walks with a walker with curvature of the spine, but
this has become more and more difficult. She also has had
decreased appetite with weight loss, night sweats, cough, and
increasing fatigue. She noted no fevers or shaking chills, and
over the past one to two weeks prior to admission to [**Hospital1 31548**], her family also noted some changes in mental status.
Her family also reports that since she broke her wrist in
[**8-/2183**], she has had a overall slow decline as well, as she
needed more help with activities of daily living and this had
prevented her from being more independent. Because of her
increased lethargy and decreased appetite and intake along with
night sweats, she did follow up with her primary care provider.
[**Name10 (NameIs) **] work at that time showed pancytopenia, and a chest x-ray
done on [**2184-6-9**] showed a new large right pleural effusion.
She was subsequently admitted to [**Hospital1 5991**]/[**Hospital 8**] Hospital, for further evaluation on [**2184-6-10**].
CTA of the chest on [**2184-6-10**] revealed no evidence of pulmonary
embolism with a confirmation of the large right pleural
effusion. There was also note of subcarinal and paratracheal
adenopathy. CT scan of the abdomen and pelvis on [**2184-6-11**]
revealed a large mesenteric soft tissue mass and right
paraaortic and retroperitoneal lymphadenopathy as well as
inguinal lymphadenopathy. The paraaortic lymph nodes measure up
to 7.1 cm x 3.9 cm and the mesenteric soft tissue mass measures
7.6 x 3.2 cm. Note is made of atherosclerotic disease of the
aorta with a 4.9 cm infrarenal abdominal aortic aneurysm, as
well as a right common iliac artery aneurysm with focal
dissection. There are also multiple hypodense lesions within
the spleen which were nonspecific.
.
Mrs. [**Known lastname **] then underwent a thoracentesis on [**2184-6-12**] with
removal of 1.5 liters of fluid from the right lung. Results of
flow cytometry and cytology from the pleural fluid are not
available, but Mrs. [**Known lastname **] subsequently underwent a right
inguinal lymph node excision on [**2184-6-18**]. This revealed a
follicular lymphoma, grade IIIA. The entire lymph node is
replaced by homogenous population of lymphocytes, of relatively
uniform size and shape with focal extension into perinodal
tissue. Flow cytometry revealed a monoclonal population of kappa
positive B cells, positive for CD19 (dim), CD20, CD10, CD23,
FMC7, CD22, and CD38. The cells are negative for CD5. Mrs.
[**Known lastname **] was discharged to [**Location 24442**] Nursing Facility for
rehabilitation and was seen by Dr. [**Last Name (STitle) 31549**] yesterday for a
consultation regarding treatment. Dr. [**Last Name (STitle) 31549**] recommended
rituximab, however, the family wished for a second opinion so
they presented.
.
<I>Past medical/surgical history:</I>
1. CVA in [**2179**] with left-sided weakness. Although this
improved, she used a cane for ambulation for a while, but has
moved more to a walker due to increasing weakness.
2. Atrial fibrillation, on Coumadin and digoxin.
3. Seizures at the time of her CVA in [**2179**], currently on
Dilantin.
4. Aortic stenosis.
5. Hypertension.
6. Osteoporosis with osteoarthritis.
7. Venous stasis, status post varicose vein surgery.
8. Skin cancer on the left cheek.
9. Hypothyroidism.
10. Wrist fracture in 9/[**2182**].
11. Depression.
12. Thrombocytopenia since [**2174**].
13. Anemia since [**2179**].
14. Leukopenia since [**77**]/[**2183**].
Social History:
Mrs. [**Known lastname **] lives in [**Hospital1 8**] in a two-family
home with her children, one daughter lives on one floor with her
family, with a second daughter on the upper floor with her
family. The daughter who she lives with is her primary
caregiver, but her other daughter cares for her and assists with
her activities of daily living during the daytime. Mrs. [**Known lastname **]
was married. Her husband died 20 years ago of a heart attack.
She had six children, one of whom died of heart failure. She has
been in the United States for many years. She worked on a farm
in [**Country 6257**], then worked as a seamstress at [**Doctor First Name 31550**] and also
in a shoemaker's facility.
Family History:
Significant for heart disease, high cholesterol,
and hypertension, as well as diabetes and CVA's. An older
daughter had breast cancer. No other reported cancers in the
family.
Physical Exam:
VS: 100.3 130/78 90 20 99% on 2L
GEN: alert, oriented to person, place, able to answer simple
questions appropriately, NAD
HEENT: PERRLA. MMM. no LAD. neck supple.
Cards: tachy, harsh 3/6 systolic murmur; pacer in place with no
overlying erythema or tenderness
Pulm: decreased bs in bilateral lower lung fields
Abd: soft, NT, +BS. no rebound/guarding. neg HSM.
Extremities: wwp, no edema.
Skin: no rashes or bruising
Pertinent Results:
[**2184-10-15**] 12:36PM [**Month/Day/Year 3143**] WBC-2.1* RBC-3.09* Hgb-10.9* Hct-32.7*
MCV-106* MCH-35.2* MCHC-33.3 RDW-16.1* Plt Ct-72*
[**2184-10-15**] 12:36PM [**Month/Day/Year 3143**] Neuts-59 Bands-0 Lymphs-20 Monos-17*
Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-0
[**2184-10-15**] 12:36PM [**Month/Day/Year 3143**] Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-3+ Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
[**2184-10-15**] 12:36PM [**Month/Day/Year 3143**] PT-12.3 PTT-28.8 INR(PT)-1.0
[**2184-10-16**] 07:00AM [**Month/Day/Year 3143**] Gran Ct-672*
[**2184-10-15**] 12:36PM [**Month/Day/Year 3143**] Glucose-104* UreaN-22* Creat-1.0 Na-138
K-4.3 Cl-102 HCO3-26 AnGap-14
[**2184-10-16**] 07:00AM [**Month/Day/Year 3143**] ALT-16 AST-46* AlkPhos-112* TotBili-0.3
[**2184-10-15**] 12:36PM [**Month/Day/Year 3143**] Calcium-8.5 Phos-3.6 Mg-2.0
[**2184-10-16**] 03:10PM [**Month/Day/Year 3143**] Phenyto-9.1*
Imaging:
Brief Hospital Course:
88-year-old Portuguese-speaking woman with follicular lymphoma
admitted with fever and a declining neutrophil count. She was
treated with broad spectrum antibiotics for neutropenic fever
and had intermitted episodes of RVR from AFIB while on rate
controlling medications. Her episodes of RVR correlated with
fevers. ID was consulted and recommend continued anti-microbial
therapy. Subsequently she developed increasing stool output
from a clostridum difficle infection. She was started on Oral
vancomycin but developed acute altered mental status and
decreased PO intake. This was followed by hypotension
necessitating a ICU addmission. Her hypotension was fluid
responsive and an NGT was placed to administer PO vancomycin and
start nutrition while she was in the ICU. She was transfered to
the floor with delerium, and subsequently spiked fevers while on
antibiotics. Her condition was discussed extensively with her
family, and due to her age, comorbidities (critical AS, Afib,
AAA), worsening lymphoma, and worsening clinical status, she was
admitted to hospice and made CMO. She was strated on a morphine
drip and given Ativan PRN for breathing. She passed peacefully
in front of family and friends.
Medications on Admission:
acyclovir 400mg [**Hospital1 **]
amiodarone 200mg dialy
gabapentin 200mg qhs
levothyroxine 88 mcg daily
metoprolol 12.5 mg [**Hospital1 **]
zyprexa 5 mg qhs
phenytoin 200 mg alt with 300 mg daily
tylenol 500 mg q6h prn pain
vit D
docusate 100mg [**Hospital1 **]
senna 2 tabs qhs
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired due to Sepsis.
Discharge Condition:
none
Discharge Instructions:
none
Followup Instructions:
none
Completed by:[**2184-10-29**]
|
[
"038.9",
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"441.4",
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"288.00",
"427.31",
"995.92",
"785.52",
"424.1",
"V58.69",
"244.9",
"780.61",
"427.81",
"276.1",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9798, 9807
|
8222, 9439
|
270, 276
|
9873, 9879
|
7266, 8199
|
9932, 9968
|
6634, 6813
|
9769, 9775
|
9828, 9852
|
9465, 9746
|
9903, 9909
|
6828, 7247
|
225, 232
|
304, 2191
|
2213, 5898
|
5914, 6618
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,100
| 149,111
|
53798
|
Discharge summary
|
report
|
Admission Date: [**2120-12-27**] Discharge Date: [**2120-12-30**]
Date of Birth: [**2066-10-13**] Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Lisinopril
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
54-year-old woman with a history of obesity hypoventilation,
COPD on home CPAP with multiple hospital admissions for
hypercarbic respiratory failure, OSA, panhypopituitarism,
pulmonary HTN, diastolic CHF, ASD with shunting presented with
weakness and was found to be hypoxic.
.
Of note, patient was discharged on [**2120-12-17**] after a 9-day
admission for hypercarbic respiratory failure requiring
intubation.
.
In ED, T 98.4, HR 50, BP 106/62, RR 18, 99%RA. But then patient
desated to the 60s on room air and was placed on BIPAP. Her SBP
dropped to the 70s with HR to 30s. ECG showed sinus bradycardia.
Was given atropine with reportedly no response. She was started
on dopamine 10 mg/hr and intubated fiberoptically. OGT placed.
SBP gradually improved to 180s; dopamine was d/c'ed; SBP dropped
to 70s; dopamine was restarted. CXR showed severe cardiomegaly,
?unchanged from prior. Bedside u/s revealed pericardial
effusion. Head CT was negative by prelim. Chest CT showed no
clear dissection and minimal to no pericardial effusion. Cards
fellow saw patient, found no pulsus, thought bradycardia not
likely to cause hypotension; no indication for emergent pacer.
Got 2L of NS, vanco 1gm, pip-tazo 4.5 gm, solumedrol 125 mg.
Past Medical History:
1)Obstructive Sleep Apnea on home CPAP, 16cm H20
2)Obesity Hypoventilation
- Multiple admissions for hypercarbic respiratory failure; PFT's
consistent with a restrictive defect
- PFTs: FVC 39%, FEV1 37%, FEV1/FVC 96%, TLC 59%, DLCO reduced
3)ASD with right-left shunt (12% shunt fraction documented in
nuclear study from [**2116-3-30**])
4)Pulmonary artery hypertension: Echo in [**10/2118**] demonstrated a
TR gradient of 33mmHg ?????? followed by [**Location (un) 4507**]
5)Hypertension
6)Pan-hypopituitarism with partially empty sella on
desmopressin, levothyroxine, prednisone ?????? followed by Dr.
[**Last Name (STitle) **]
7)Diastolic CHF with dilated RA/LA on previous echo
8)Angioedema (unclear history, possibly related to ACE-I)
Social History:
Lives with daughter and 3 grandchildren [**Location (un) 6409**]. Originally
from [**Male First Name (un) 1056**]. Goes to [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Program. History of
tobacco use, no h/o ETOH or IVDU
Family History:
non-contributory
Physical Exam:
MICU admission:
GEN: Middle-aged woman intubated, morbidly obese
HEENT: Pupils minimally reactive bilaterallyNECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Coarse breath sounds throughout, no wheezing.
ABD: Soft, obese, no HSM
EXT: No c/c/e
SKIN: No rash
Pertinent Results:
([**2120-12-27**] -> [**2120-12-30**]): WBC 12.4->11.2, Hct 25.5->24.4,
platelets 277->194, Na 137->147, K 5.3->4.6, Cl 97->105, Bicarb
32->33, BUN/Cr 40/4.2 ->29/1.4, INR 1.3, ALT 8, AST 17, LD 284,
Alk Phos 78, T Bili 0.5, CK-MB 1, Trop T 0.02->0.02, Albumin
3.9.
.
TSH 0.56
.
Lactate 2.1->1.5
.
ABG ([**2120-12-27**]): 7.25/76/294 -> 7.39/54/92
.
Tox screen ([**2120-12-27**]) negative.
.
UA 3-5RBC, 3-5WBC, neg nit, sm leuk
UA [**12-19**] RBC, 0-2 WBC, neg nit, neg leuk
.
Micro:
Urine culture ([**2120-12-27**]): 1000 CFU gram negative rods
Blood cultures ([**2120-12-27**] x2, [**2120-12-28**]): No growth to date.
.
EKG ([**2120-12-27**]): Sinus bradycardia with a single atrial premature
beat. Q-T interval prolongation. Since the previous tracing of
[**2120-12-7**] the rate is slower. Blocked atrial premature beat is no
longer seen.
.
CXR
([**2120-12-27**]): Markedly limited study. There is suggestion of edema
with
massive but stable cardiomegaly.
([**2120-12-28**]): The heart is markedly enlarged. Mediastinum is
within normal limits. There is patchy consolidation of the left
lower lobe with small left pleural effusion. The endotracheal
tube terminates at the thoracic inlet. Nasogastric tube courses
towards the stomach but the tip is not seen. There is probable
mild congestive failure, which appears to have decreased
somewhat since the prior study.
([**2120-12-29**]): The heart is enlarged. The aorta is tortuous.
Nasogastric tube ends in the stomach. The patient has been
extubated. There is mild congestive failure. There is no
appreciable change since the prior study.
.
CT head ([**2120-12-27**]): Prelim read, no intracranial hemorrhage or
edema.
.
CT chest non-contrast ([**2120-12-27**]): Prelim read, no pericardial
effusion,
no caliber change of aorta or intramural hematoma to suggest
dissection.
Ill-defined lingular opacity, bibasilar atelectasis.
.
Renal ultrasound ([**2120-12-27**]): No hydronephrosis.
.
TTE ([**2120-12-28**]): The left atrial volume is markedly increased
(>32ml/m2). The left atrium is dilated. The right atrium is
markedly dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). Transmitral Doppler and tissue velocity
imaging are consistent with Grade I (mild) LV diastolic
dysfunction. There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with normal free wall
contractility. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Moderate (2+) mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
tricuspid valve leaflets are mildly thickened. Moderate [2+]
tricuspid regurgitation is seen. The tricuspid regurgitation jet
is eccentric and may be underestimated. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion. IMPRESSION: Mild symmetric LVH with preserved regional
and global LV systolic function. Diastolic dysfunction. Dilated
and hypokinetic RV with at least moderate tricuspid
regurgitation and moderate pulmonary artery systolic
hypertension. Massive biatrial enlargement. Compared with the
prior study (images reviewed) of [**2120-8-22**], the findings are
similar. The right ventricular size was described as normal on
the prior study but it was dilated then also.
Brief Hospital Course:
54 yo F with panhypopituitarism, diastolic CHF,
obesity-hypoventilation and OSA recurrently admitted with
hypercarbic respiratory failure, admitted for the same.
The patient has a history of multiple and recent admissions for
hypercarbic respiratory failure. On the day of admission, the
patient presented to the ED with weakness, headache and
respiratory distress. She was noted to develop profound
shortness of breath and desaturated to the 60's% while in the ED
with ambulation to the bathroom. She was maintained on a 100%
NRB and CPAP while in the ED. Due to desaturation to 76% with
respiratory rate = of 33 and findings of hypercarbia to pCO2 76,
the patient was intubated by fiberoptic bronchoscope. She
received vancomycin, zosyn for a possible pulmonary infiltrate
and pulse dose solumedrol out of concern for a COPD
exacerbation. The patient was noted to have stable massive
cardiomegaly on CXR with possible volume overload. Initial [**Year (4 digits) **]
were remarkable for ARF (Cr 4.2), BNP >6000 and 2 sets of
negative cardiac enzymes (trop 0.02 and unchanged). Lactate was
2.1, improved to 1.5 on repeat 12 hours later. UA was noteworthy
only for some blood in the setting of foley placement and blood
and urine cultures were sent and without significant growth.
Head and chest CT without contrast were largely unremarkable
with some bibasilar atelectasis and an ill-defined lingular
opacity. The patient was admitted to the ICU and rapidly weaned
from the vent and successfully extubated on the day after
admission. Echocardiogram confirmed severe right heart failure
with associated mitral and tricuspid regurg. The patient had
received 2L NS and diuretics were held in the setting of
hypotension (see below). Her condition rapidly improved and she
was transferred to the floor. The most likely explanation (as
described in a note by Dr. [**Last Name (STitle) 217**] for her decompensation
was hypoxemia prior to admission causing worsening pulmonary
hypertension and RV pressure increase causing interventricular
septal deviation and compromised LV function. Declining cardiac
function with poor forward flow precipitated acute renal
failure. Due to the profound, life-threatening and recurrent
nature of [**Last Name **] problem she was evaluated by thoracic surgery team
for consideration of surgical tracheostomy. Given the complex
nature of her apnea including a likely component of central
apnea, the thoracic surgery team was not certain that trach
would improve the patient's respiratory status any more than
CPAP. The patient was scheduled for short-term outpatient pulm
follow-up for further evaluation of her problems and for further
consideration on the utility of a trach.
The patient was noted in the ED, around the time of respiratory
decompensation, to develop sinus bradycardia to 36 (confirmed on
EKG) and hypotension to 70/60. The patient received atropine and
was transiently on a dopamine drip while in the ED. Out of
concern for pulmonary or other source of sepsis, the patient
received doses of vancomycin and zosyn though these treatments
were not continued after the first 2 days of hospitalization.
The patient was evaluated by cardiology consult service in the
ED. They recommended holding all nodal and antihypertensive
agents. Subsequent telemetry monitoring revealed no further
bradycardic episodes. It is possible that this represented a
medication effect in the setting of renal failure or a vasovagal
response to a primary pulmonary process. Another possibility and
most likely is that the patient lives in a preload dependent
state that was compromised by BiPAP treatment causing
underfilling and significant decline in cardiac output. There
are no signs that this was due to sepsis or adrenal
insufficiency though the patient did transiently receive
treatment for both of these potential etiologies. The patient
was discharged back on her home meds except clonidine and
valsartan which were held throughout the hospitalization. The
patient maintained good blood pressure control off of these
agents. She was told to discuss restarting these medications
with her primary care doctor.
The patient had a BNP of >6000 up from past measurements in the
4000 range on a recent admission. She did not have signs of
obvious volume overload and improved with holding diuretics and
volume rescucitation for unclear reasons. Prior to discharge,
the patient was restarted on maintenance diuretic dosing.
Acute renal failure with a Cr of 4.3 was noted on admission.
This rapidly improved to 1.4 with optimization of the patient's
fluid status. Renal ultrasound was negative for hydronephrosis.
UA was noteworthy for RBC's in the setting of foley placement.
Diuretics and [**Last Name (un) **] were held in the setting of acute renal
failure and re-instituted prior to discharge.
The patient continued on treatment for panhypopituitarism with
steroids (initially stress dose, then maintenance),
levothyroxine and desmopressin.
Medications on Admission:
Levothyroxine 75 mcg PO DAILY
Desmopressin 0.1 mg PO DAILY
Prednisone 5 mg PO DAILY
Aspirin 81 mg PO once a day
Clonidine 0.1 mg PO DAILY
Calcium Carbonate 500 mg PO TID
Cholecalciferol (Vitamin D3) 400 unit PO DAILY
Metoprolol Tartrate 25 mg PO twice a day
Pantoprazole 40 mg PO Q12H
Albuterol nebs prn
Lasix 40 mg PO once a day
Valsartan 40 mg PO QAM, 80 mg PO QPM
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Desmopressin 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed.
9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO
twice a day.
11. Home oxygen
Continue use of home oxygen during the day as you were prior to
admission.
12. CPAP
Continue use of CPAP machine at night as you were prior to
admission.
Discharge Disposition:
Home With Service
Facility:
Americare at Home Inc
Discharge Diagnosis:
Multi-factorial hypercarbic respiratory failure
.
Complex apnea
Obesity-hypoventilation
Diastolic heart failure
Panhypopituitarism
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with shortness of breath and required a
breathing machine while in the hospital. This was likely due to
multiple problems including your history of apnea,
hypoventilation and right-sided heart failure. Take all
medications as prescribed. Use your CPAP at night, every night,
as prescribed and oxygen during the day. Weigh yourself daily
and call your doctor for any fluctuation in your weight of >3
lbs.
You must follow-up with Dr. [**Last Name (STitle) 575**] in the pulmonary medicine
department on Friday [**1-3**]. Arrive for this appointment
at 10:30AM for a breathing test followed by a clinic
appointment. At this appointment you should discuss further
treatment of your problems including possible tracheostomy.
For the time being, do NOT take your home clonidine or
valsartan. Discuss restarting these medications with your
primary care doctor. All other medications are unchanged from
prior to admission.
Call your doctor or return to the hospital for any new or
worsening shortness of breath, chest pain, headaches, fatigue or
any other concerning symptoms.
Followup Instructions:
Dr. [**Last Name (STitle) 575**] ([**Telephone/Fax (1) **]) Friday, [**2121-1-3**] 10:30AM
[**Last Name (un) 469**] [**Location (un) 436**] medical specialites for breathing test
followed by clinic appointment.
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) **]) Tuesday, [**2121-1-7**]
2:10PM
|
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"427.89",
"V58.65",
"253.2",
"428.0",
"745.5",
"458.9",
"428.33",
"424.0",
"276.0",
"584.9",
"V46.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
12943, 12995
|
6533, 11505
|
297, 322
|
13170, 13179
|
2984, 6510
|
14317, 14660
|
2654, 2672
|
11922, 12920
|
13016, 13149
|
11531, 11899
|
13203, 14294
|
2687, 2965
|
250, 259
|
350, 1580
|
1602, 2345
|
2361, 2638
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,736
| 149,611
|
2795+55409
|
Discharge summary
|
report+addendum
|
Admission Date: [**2123-5-18**] Discharge Date: [**2123-5-24**]
Date of Birth: [**2042-11-26**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Failure to thrive
Major Surgical or Invasive Procedure:
Expired
History of Present Illness:
EAST HOSPITAL MEDICINE ATTENDING ADMISSION NOTE .
Date: [**2123-5-19**]
Time: 0130 am
_
________________________________________________________________
PCP: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **], [**Name8 (MD) **] MD
Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **]
Address: [**State **],[**Apartment Address(1) 12228**], [**Location (un) **],[**Numeric Identifier 13707**]
Phone: [**Telephone/Fax (1) 7477**]
Fax: [**Telephone/Fax (1) 12227**]
Email: [**University/College 13708**]
.
_
________________________________________________________________
HPI: > or equal to 4 ( location, quality, severity, duration,
timing, context, modifying factors, associated signs and sx)
80M PMHx Bladder Ca, recent history notable for right-sided
cervical mass of uncertain etiology as well as monocyte
prevalence on recent CBC diff for which he was going to be
worked up for a malignancy, now presenting with 1 month of
progressive fatigue/malaise, initially presented to [**Hospital3 **] today, was sent here for further workup; on history
here, pt reports 2-4wks of worsening fatigue/malaise,
nightsweats, several months of weight loss. He was then
tranferred here.
Upon arrival to the floor he states that his abdominal pain is
improved but he is now reporting a lit ittle bit of pain in his
throat which goes to his head at the site of a left swollen
gland.
COUGH x 2-3 months. No phlegm. He only coughs when turning
from side to side. + weight losss but he cannot tell me how
much. + night sweats.
He is not a good historian and thus the ROS is limited as below.
Diagnosis: Abd pain [**3-4**] liver mass
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger:
- Exam large R cervical mass, fixed, nontender, nonfluctuant;
thyroid wnl; fixed nodule near nasolabial fold, nontender;
[x] EKG - sinus @ 76bpm, L axis, biphasic T in V3 (likely lead
placement) otherwise unchanged
[x] UA trace ketones
[x] Labs Cr 1.3 (baseline), WBC 11.9 (N77.1, L10.5, M11.5),
ALT/AST 119/221, AP509, Tbili1.3
[x] CXR - no acute process
*Update@6:30pm - c/o worsening abdominal pain*
[x] CT abd - Diffuse metastatic disease as demonstrated by
enlarged liver with multiple metastasis, wall thickening at the
splenic flexure suggestive of bowel involvement, bilateral lung
nodules as well as a right lower lobe 2.5 cm lung mass, and soft
tissue thickening along the left kidney
[x] pain control - 2mg IV morphine
Contact: Wife [**Telephone/Fax (1) 13709**]
In ER: (Triage Vitals:
7 98.2 74 118/60 16 95% RA
) Meds Given: , Fluids given: Radiology Studies:, consults
called.
.
PAIN SCALE: 0/10
________________________________________________________________
REVIEW OF SYSTEMS: 10 or 2 with "all otherwise negative"
CONSTITUTIONAL: [] All Normal
[ -] Fever [- ] Chills [ ] Sweats [ ] Fatigue [ ] Malaise
[ ]Anorexia [ ]Night sweats
[+ ] _?____ lbs. weight loss over __?___ months
Eyes
[] All Normal
[ ] Blurred vision [ +] Loss of vision - chronic- ? Legally
blind [] Diplopia [ ] Photophobia
ENT [x] WNL
[ ] Dry mouth [ ] Oral ulcers [ ] Bleeding gums [ ] Sore throat
[] Sinus pain [ ] Epistaxis [ ] Tinnitus
[ ] Decreased hearing [ ] Other:
RESPIRATORY: [] All Normal
[ ] Shortness of breath [ ] Dyspnea on exertion [ ] Can't
walk 2 flights [ +] Cough [ ] Wheeze [ ] Purulent sputum
[ ] Hemoptysis [ ]Pleuritic pain
[ ] Other:
CARDIAC: [X] All Normal
[ ] Palpitations [ ] Edema [ ] PND [ ] Orthopnea [ ]
Chest Pain [ ] Dyspnea on exertion [ ] Other:
GI: [] All Normal
[ ] Nausea [] Vomiting [+] Abd pain [] Abdominal swelling [
] Diarrhea [ ] Constipation [ ] Hematemesis
[ ] Blood in stool [ ] Melena [ ] Dysphagia: [ ] Solids
[ ] Liquids [ ] Odynophagia [ ] Anorexia [ ] Reflux
[ ] Other:
GU: [X] All Normal
[ ] Dysuria [ ] Incontinence or retention [ ] Frequency
[ ] Hematuria []Discharge []Menorrhagia
SKIN: [X] All Normal
[ ] Rash [ ] Pruritus
MS: [X] All Normal
[ ] Joint pain [ ] Jt swelling [ ] Back pain [ ] Bony pain
NEURO: [X] All Normal
[ ] Headache [ ] Visual changes [ ] Sensory change [
]Confusion [ ]Numbness of extremities
[ ] Seizures [ ] Weakness [ ] Dizziness/Lightheaded [ ]Vertigo
[ ] Headache
ENDOCRINE: [X] All Normal
[ ] Skin changes [ ] Hair changes [ ] Heat or cold
intolerance [ ] loss of energy
HEME/LYMPH: [X] All Normal
[ ] Easy bruising [ ] Easy bleeding [ ] Adenopathy
PSYCH: [X] All Normal
[ ] Mood change []Suicidal Ideation [ ] Other:
[X]all other systems negative except as noted above
Past Medical History:
HYPERTENSION
HYPERLIPIDEMIA
AZOTEMIA
BLADDER CANCER
PROSTATIC HYPERTROPHY
Social History:
He lives with his wife. His wife does his pills. He does not
use a cane or walker but it sounds as though he furniture surfS.
He quit smoking in [**2082**]. 45 pack year history. He was in the
military and then completed law school.
Family History:
His son died from a hospital acquired infection. He does not
know which one. His parents both died of old age in their late
70s/ early 80s.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
VITAL SIGNS:
GLUCOSE:
PAIN SCORE
1. VS Tm T 97.0 P BP 142/87 RR 18 O2Sat on ___93% on RA _
GENERAL: Thin emaciated male, laying in bed. + temporal wasting
Nourishment : greatly at risk
Grooming: good
Mentation
2. Eyes: [X] WNL
PERRL, EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
LARGE R FIRM peri parotid growth
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[+] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
[**Last Name (un) 13710**] black coating on tongue
4. Cardiovascular [X] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [?] Systolic Murmur [**2-1**]
/6, Location:LUSB
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[x] Edema RLE None [] Bruit(s), Location:
[X] Edema LLE None [] PMI
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
[] CTA bilaterally [ X] B/l bibasilar Rales [ ] Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
[X] Firm [] Rebound [] No hepatomegaly [+] Non-tender []
Tender [] No splenomegaly
Liver 4 cm below costal margin
[] Non distended [] distended [] bowel sounds Yes/No []
guiac: positive/negative
7. Musculoskeletal-Extremities [] WNL
[ ] Tone WNL [ +]Upper extremity strength 5/5 and symmetrical
[ ]Other:
[ ] Bulk WNL [+] Lower extremity strength 5/5 and symmetrica
[ ] Other:
[] Normal gait []No cyanosis [ ] No clubbing [] No joint
swelling
8. Neurological [] WNL
[ ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ ] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [+ ] Delirious/confused - unable to do MOYB [ ]
Asterixis Present/Absent [ ] Position sense WNL
[ ] Demented [ ] No pronator drift [] Fluent speech
9. Integument [] WNL
[] Warm [+] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[+] Pleasant [] Depressed [] Agitated [] Psychotic
[] Combative
11. Hematologic/Lymphatic [ ]WNL
[+] [**First Name9 (NamePattern2) 13711**] [**Doctor First Name **] ? growth
TRACH: []present [x]none
PEG:[]present [X]none [ ]site C/D/I
COLOSTOMY: :[]present [X]none [ ]site C/D/I
Pertinent Results:
[**2123-5-18**] 06:00PM URINE HOURS-RANDOM
[**2123-5-18**] 06:00PM URINE GR HOLD-HOLD
[**2123-5-18**] 06:00PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2123-5-18**] 06:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-5.5 LEUK-NEG
[**2123-5-18**] 06:00PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE
EPI-1 TRANS EPI-<1
[**2123-5-18**] 06:00PM URINE HYALINE-17*
[**2123-5-18**] 06:00PM URINE MUCOUS-RARE
[**2123-5-18**] 05:40PM GLUCOSE-105* UREA N-28* CREAT-1.3* SODIUM-143
POTASSIUM-3.1* CHLORIDE-99 TOTAL CO2-27 ANION GAP-20
[**2123-5-18**] 05:40PM estGFR-Using this
[**2123-5-18**] 05:40PM ALT(SGPT)-119* AST(SGOT)-221* ALK PHOS-509*
TOT BILI-1.3
[**2123-5-18**] 05:40PM ALBUMIN-3.4* CALCIUM-9.1 PHOSPHATE-4.0
[**2123-5-18**] 05:40PM WBC-11.9*# RBC-4.54* HGB-12.1* HCT-39.0*
MCV-86 MCH-26.7* MCHC-31.1 RDW-15.7*
[**2123-5-18**] 05:40PM NEUTS-77.1* LYMPHS-10.5* MONOS-11.5* EOS-0.6
BASOS-0.3
[**2123-5-18**] 05:40PM PLT COUNT-202
-------------
ReportIMPRESSION: There is mild prominence of the right
hilar/infrahilar region
Preliminary Reportwhich may be suggestive of a developing
consolidation, prominent hilar
Preliminary Reportvasculature, or lymphadenopathy. Clinical
correlation recommended. A followup
Preliminary Reportradiograph after resolution of symptoms is
recommended to ensure resolution
-----
Admission abdominal CT:
ReportIMPRESSION:
Preliminary ReportDiffuse metastatic disease as noted by
multiple bilateral pulmonary nodules.Preliminary Reportwith the
greatest being a right middle lobe nodular density measuring 2.5
x
Preliminary Report1.8 cm, enlarged lymph node adjacent to the
aorta, innumerable metastatic
Preliminary Reportlesions in the liver, soft tissue thickening
along the left kidney, and bowel
Preliminary Reportwall thickening along the splenic flexure at
the transverse colon.
Preliminary ReportAdditionally, there is increased prominence of
the right adrenal gland to 1.9
Preliminary Reportx 1.6 cm. A dedicated chest CT is also
recommended in a non-urgent setting
Preliminary Reportfor further characterization of full extent of
metastatic disease in the
Preliminary Reportchest.
DR. [**First Name (STitle) 251**] [**Name (STitle) 8580**]
Brief Hospital Course:
Mr. [**Known lastname 13712**] is an 80 y/o man who was admitted with metastatic
cancer of unknown primary including liver, lung and brain mets
who passed away on [**2123-5-24**] from septic shock.
.
On [**2123-5-23**] Mr. [**Known lastname 13712**] [**Last Name (Titles) 4605**] rapidly worsened and required
intubation. It is suspected that he developed a pneumonia,
likely post-obstructive from his lung mass. Despite initiation
of broad spectrum antibiotics he rapidly deteriorated. He
required intubation and initiation of pressors. He ultimately
passed away on [**2123-5-24**] from septic shock. His wife was at his
bedside at the time of his passing.
.
# Metastatic Cancer of Unknown primary: A Biopsy of mass in LUE
was done on [**2123-5-20**]-however pathology was still pending at the
time of this report. His daughter would like to be contact[**Name (NI) **]
with the pathology results on her cell phone at 1-[**Telephone/Fax (1) 13713**].
Medications on Admission:
Taken from OMR
amlodipine 5 mg Tablet 1 (One) Tablet(s) by mouth once a day
[**2123-1-4**]
finasteride 5 mg Tablet 1 (One) Tablet(s) by mouth once a day
[**2123-1-4**]
furosemide 40 mg Tablet 1 (One) Tablet(s) by mouth once a day
[**2123-1-4**]
moexipril 15 mg Tablet 2 (Two) Tablet(s) by mouth once a day
[**2123-1-4**]
nitrofurantoin macrocrystal 100 mg Capsule 1 Capsule(s) by mouth
twice a day to start day before treatment for 3 days then again
before 2nd treatment for 3 days [**2122-10-19**]
phenazopyridine 100 mg Tablet 1 Tablet(s) by mouth three times a
day as needed for dysuria [**2121-12-19**]
tamsulosin [Flomax]
* OTCs *
acetaminophen 325 mg Tablet 2 Tablet(s) by mouth twice a day
as needed for aspirin 81 mg Tablet 1 Tablet(s) by mouth once a
day (Prescribed by Other docusate sodium 100 mg Capsule 1
Capsule(s) by mouth twice a day [**2121-12-19**]
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Name: [**Known lastname 2094**],[**Known firstname 2095**] Unit No: [**Numeric Identifier 2096**]
Admission Date: [**2123-5-18**] Discharge Date: [**2123-5-24**]
Date of Birth: [**2042-11-26**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 2097**]
Addendum:
The biopsy results from the patient's shoulder lesion returned
after the patient's death. It showed urothelial carcinoma, which
is consistent with patient's previous diagnosis of bladder
cancer.
Discharge Disposition:
Expired
[**First Name11 (Name Pattern1) 126**] [**Last Name (NamePattern4) 2098**] MD [**MD Number(1) 2099**]
Completed by:[**2123-5-27**]
|
[
"293.0",
"369.4",
"276.2",
"783.7",
"486",
"198.3",
"348.5",
"600.00",
"V15.82",
"785.52",
"038.9",
"V87.41",
"V10.51",
"197.0",
"518.81",
"401.1",
"995.92",
"197.7",
"288.60",
"198.89",
"790.4",
"338.3",
"783.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"83.21",
"96.04",
"92.29",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
12914, 13083
|
10278, 11231
|
311, 320
|
12251, 12260
|
7982, 10255
|
12316, 12891
|
5412, 5558
|
12159, 12168
|
12221, 12230
|
11257, 12136
|
12284, 12293
|
5589, 7963
|
3073, 5043
|
254, 273
|
348, 3054
|
5065, 5141
|
5157, 5396
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,829
| 101,406
|
10482
|
Discharge summary
|
report
|
Admission Date: [**2109-10-14**] Discharge Date: [**2109-10-28**]
Service: ACOVE
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **] year old
resident of [**Hospital **] Nursing Home who was transferred to [**Hospital1 1444**] for shortness of breath,
tachypnea, fever, history of right middle lung nodule without
workup in the past, with possible history of aspiration on
the day of admission. He had a history of right lower lobe
pneumonia in [**Month (only) **].
He was in the Emergency Department with a heart rate of 130,
blood pressure 100/60, respiratory rate 30, given Clindamycin
600 mg and Levaquin 500 mg intravenously. Blood pressure
decreased to 94 systolic with further respiratory distress.
Therefore, the patient was intubated. Postintubation blood
pressure was 60 systolic. The patient was given Dopamine
drip and taken to the Medical Intensive Care Unit.
PAST MEDICAL HISTORY:
1. Dementia.
2. Gastroesophageal reflux disease.
3. Constipation.
4. Decreased hearing.
5. Right midlung nodule.
PHYSICAL EXAMINATION: Blood pressure is 96/34, pulse 92,
respiratory rate 12. In general, the patient was sedated.
The pupils are equal, round, and reactive to light and
accommodation. The lungs were clear to auscultation
bilaterally. Heart - regular rate and rhythm, III/VI
systolic ejection murmur that radiates to the carotids and
across the precordium. The abdomen was soft, mildly
distended with active bowel sounds.
LABORATORY DATA: White blood count 31.6, hematocrit 32.8,
platelets 683,000. Chemistries were notable for a blood urea
nitrogen of 44, creatinine 2.3, lactic acid of 5.5. Arterial
blood gases on admission were pH 7.42, 35 and 72.
HOSPITAL COURSE: The patient was treated for aspiration
pneumonia and respiratory failure in the Medical Intensive
Care Unit. He was then transferred to the floor on the
following medications: Vancomycin intravenously, Flagyl
intravenously, Lopressor, Zestril, Xalatan, Heparin,
Protonix, Iron Sulfate, Tylenol and Morphine. The patient
had been transferred to the floor after discussion to make
him DNR/DNI. On the medicine floor, discussion was had with
the patient's family about making him comfort measures as it
appeared he would not be able to tolerate p.o. feeding and
the family was against gastrostomy tube placement.
Therefore, the patient was made comfort measures on [**2109-10-26**],
and given Morphine drip. The patient finally expired on
[**2109-10-28**], at 1:30 a.m. at which time the attending, Dr.
[**Last Name (STitle) 5762**], and the patient's wife were notified.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], M.D. [**MD Number(1) 292**]
Dictated By:[**Name8 (MD) 6069**]
MEDQUIST36
D: [**2109-12-31**] 17:51
T: [**2110-1-6**] 14:36
JOB#: [**Job Number 34596**]
|
[
"331.0",
"424.1",
"507.0",
"518.81",
"162.4",
"584.9",
"428.0",
"482.41",
"427.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"96.6",
"38.93",
"96.04",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1723, 2873
|
1066, 1705
|
120, 902
|
924, 1043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,070
| 120,258
|
36325
|
Discharge summary
|
report
|
Admission Date: [**2158-7-21**] Discharge Date: [**2158-7-26**]
Date of Birth: [**2078-9-9**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5790**]
Chief Complaint:
Right upper lobe mass
Major Surgical or Invasive Procedure:
[**2158-7-21**]: Right thoracotomy with right upper lobectomy
History of Present Illness:
Mr. [**Known lastname **] is a pleasant 77-year-old gentleman who was seen in
clinic
regarding his metastatic renal cell carcinoma. In [**2141**], Mr.
[**Known lastname **]
initially was diagnosed with right kidney mass after falling off
from a tree and breaking several rib bones. CT scan at that
time
found a right kidney mass and was resected at that time. He was
being followed routinely with CT scan until [**2151**]. He was found
to have right chest wall soft tissue mass measuring 14.5 x 6 x
5.5 cm in [**2151**]. This was resected and he underwent radiation
therapy to this area. He has had a right carotid endarterectomy
done at this time.
In a [**1-/2156**] follow up CT scan, it revealed a right upper lung
nodule measuring 12 mm. He had no other lesions in his CT scan.
In [**2156-5-7**], his f/u CT scan of chest revealed this nodule to be
14 mm. Otherwise, there are no new lung nodules or any lesions
in
other areas of the CT scan.
Mr. [**Known lastname **] has been follwed by Dr. [**Last Name (STitle) 41471**] with CT of chest
every 6 months since that time to follow a solitary lung nodule.
This increased from 14 mm to 3.3 x 1.5 x 1.7 cm as of [**2158-6-9**]. CT
of chest and ABD did not reveal other areas of concern.
He does not note any fatigue, shortness of breath, chest
pain, nausea or vomiting, diarrhea, fever, chills, night sweats,
difficulty urinating. He maintains good po intake and he is
very
active according to him and his wife.
Past Medical History:
Enlarging pulmonary nodule
Renal cell carcinoma
Hypertension
Carotid stenosis
Right Carotid endarterectomy [**2151**]
Right thoracotomy with resection of renal cell metastasis [**2151**]
Right nephrectomy
Bilateral inguinal hernias
Open appendectomy
Social History:
Married and lives with his family. 20 pack-year history
ex-smoker who quit 20 years ago. No alcohol.
Family History:
non-contributory
Physical Exam:
VS: T: 97.3 HR: 93 SR BP: 118/72 Sats: 96% RA
Gen: No acute distress
CV: RRR, nl S1 and S2
Resp: bibasilar crackles
GI: abd soft, non-tender, non-distended
Incision: R VATs site clean dry intact, margins well
approximated
Neuro: awake, alert oriented
Pertinent Results:
[**2158-7-25**] WBC-10.2 RBC-3.12* Hgb-10.4* Hct-28.9 Plt Ct-241
[**2158-7-20**] WBC-7.2 RBC-4.64 Hgb-15.1 Hct-43.3 Plt Ct-227
[**2158-7-26**] Glucose-116* UreaN-24* Creat-1.2 Na-138 K-3.9 Cl-97
HCO3-29
[**2158-7-20**] UreaN-21* Creat-1.3* Na-139 K-4.2 Cl-99 HCO3-28
Abdomen:
[**2158-7-26**] Supine and upright view of the abdomen were provided.
Multiple air-fluid levels are seen. Both small and large bowel
are dilated. Air is seen within the rectum suggesting that this
is most likely an ileus in a recently postop patient. NG tube
seen in the stomach.
CXR
[**2158-7-24**]: Right chest tube has been removed. No appreciable
interval pleural effusion has been demonstrated. Mediastinal
contour is stable. Several areas of linear opacities in the left
lung were noted.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted following [**2158-7-21**] Video-assisted
thoracic surgery (VATS) right upper lobectomy for Metastatic
renal cell carcinoma. He was extubated in the operating room,
monitored in the PACU prior transfer to the floor with a chest,
Foley and IV pain medication.
Respiratory: titrated off oxygen with saturations of 96%,
incentive spirometer, ambulation and good pain control.
Chest-tube right was removed [**2158-7-24**] once drainage subsided
Cardiac: episode of atrial fibrillation [**2158-7-23**]. His verapamil
was increased to 160 tid from 120 tid and titrated back to his
home dose. He converted to sinus rhythm 80-90's within 24
hours. Blood pressure 90-120's.
GI: Abdomen distention noted [**2158-7-24**] associated with nausea. He
was NPO, narcotics were minimized, an NGT was placed with 990
output. KUB confirmed ileus. Dulcolax suppository with mild
results. Overtime his ileus improved. He was started on clear
liquid diet transition as tolerated.
Renal: Foley was removed with delayed urine output. He was
straight cath for 260 cc of urine. Flomax was started and he
voided. His renal function and output was monitored closely.
His electrolytes were replete as needed.
Disposition: he continued to make steady progress and was
discharged to home with his wife on [**2158-7-26**]. [**Name2 (NI) **] will follow-up
with Dr. [**Last Name (STitle) **] as an outpatient.
Medications on Admission:
Furosemide 20 mg [**Hospital1 **]
Diovan 160 mg daily
Verapamil 120 mg TID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every six (6) hours
as needed for pain for 21 doses.
Disp:*21 Tablet(s)* Refills:*0*
5. verapamil 120 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
6. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO DAILY (Daily).
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Right upper lobe mass
Hypertension
Carotid stenosis s/p Right carotidendarectomy [**2151**]
PSH:
thoracotomy with resection of renal cell metastasis '[**51**],
Right nephrectomy
B/l inguinal hernias
open appy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, cough (it is normal to cough up
a small amount of blood-tinge sputum for a few days) or chest
pain
-Incision develops drainage or increased redness
-Chest tube site with a bandaid until healed
Pain
-Acetaminophen 650 mg every 6 hours as needed for pain
-Oxycodone 5 mg every 6 hours as needed for pain
-No driving while taking narcotic
-Take stool softners with narcotics
Activity
-Shower daily. Wash incision with mild soap & water, rinse, pat
dry
-No tub bathing, swimming or hot tubs until incision healed
-No lifting greater than [**10-21**] pounds until seen
-Walk 4-5 times a day increase as tolerates
Medications:
-Hold Furosemide until seen by your Dr. [**Last Name (STitle) **].
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] [**0-0-**] Date/Time:[**2158-8-8**]
1:00 on the [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 24**]
Chest X-Ray [**Location (un) 861**] Radiology 30 minutes before your
appointment
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 45495**],
within 1 week of discharge to discuss your blood pressure
medication changes
Completed by:[**2158-7-26**]
|
[
"560.1",
"V10.52",
"427.31",
"197.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.23",
"33.99",
"32.41"
] |
icd9pcs
|
[
[
[]
]
] |
5704, 5710
|
3414, 4849
|
331, 395
|
5964, 5964
|
2614, 3391
|
6971, 7513
|
2306, 2324
|
4974, 5681
|
5731, 5943
|
4875, 4951
|
6115, 6948
|
2339, 2595
|
270, 293
|
423, 1898
|
5979, 6091
|
1920, 2172
|
2188, 2290
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,973
| 145,973
|
6878
|
Discharge summary
|
report
|
Admission Date: [**2143-1-29**] Discharge Date: [**2143-2-5**]
Date of Birth: [**2084-5-2**] Sex: M
Service: MEDICINE
Allergies:
Percocet / Bactrim Ds / Lisinopril
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Chills, concern for infection, [**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
None
History of Present Illness:
58yo man w hc chronic progressive MS, quadriplegia, hx
aspiration PNA, chronic foley who was transferred from OSH ED
with increasing fatigue and productive cough. He was recently
treated at [**Hospital1 **] [**Location (un) 620**] for aspiration PNA w cefpodoxime/flagyl
(d4). Last night noted to be more fatigued and had temp to 96
(baseline 95). This morning noted to have chills and increased
weakness so wife called 911. [**Name2 (NI) **] and wife deny new cough but
do report increased SOB at nighttimes. Pt denies abd pain but
reports nausea and constipation. Taken to [**Location (un) **] ED and
transferred here.
.
In the ED: 96 119/81 55 16 99% RA. EKG: NSR NA NI, no ST-T
changes. Lactate 1.0. WBC at baseline. CXR showed resolution of
RLL infiltrate. Received 2L NS, vanco 1g and levaquin 750 for ?
untreated PNA. Trop 0.15 w flat CK so cards was reportedly
curbsided. Morphine 2-4mg IV and ASA 325 given.
.
Currently, patient feels better. Wife reports he appears more
like his usual self. ROS as above. Additionally, denies
photophobia or neck stiffness. Reports constipation. Reports
decreased UOP for the last 2d.
Past Medical History:
- Multiple sclerosis, diagnosed in [**2119**] c/b neurogenic bladder
requiring suprapubic catheter
- h/o UTIs including: Enterobacter, Proteus, P.aeruginosa,
K.pneumo, Enterococcus (pan-[**Last Name (un) 36**]), yeast/[**Female First Name (un) 564**] parapsilosis
- Automonic dysreflexia
- Quadraplegia
- Autonomic dysreflexia
- Quadraplegia
- Hypertension
- Carotid stenosis
- GIB [**12-24**] esophageal ulcer disease
- GERD
- Glaucoma, legally blind
- Sleep Apnea
- deafferentation-type sensory illusion syndrome
- ? colonoization of Pseudomonas in the urine
Social History:
He is married 32 years and lives with his wife at home. He has
three children and three grandchildren. He was a professor [**First Name (Titles) **] [**Last Name (Titles) 25931**] engineering at [**University/College 25932**], but
retired on disability after the [**2128**] spring semester due to his
MS. [**Name13 (STitle) **] is wheelchair-bound. He denies tobacco, alcohol, and
recreational drug use. Has personal care assistant.
Family History:
Father had CAD and CVA. Mother has [**Name (NI) 2481**] disease. Brother
has diabetes.
Physical Exam:
VS afebrile, satting well on room air
Gen: pleasant, tired and intermittently falling asleep during
interview.
HEENT: Moon facies. Anicteric. No photophobia or neck stiffness.
MMM, JVP cannot be assessed
Cards: RRR no MGR
Lungs: Rales at both bases L>R
Abd: BS+ mild TTP LLQ. No rebound or guarding. No suprapubic
tenderness
Rectal: not done
Ext: mild edema
Neuro: AAO to person, place, situation, time
- CN: face symmetric, tongue midline, strength intact
- Motor: [**2-24**] bilat upper prox/distal. flaccid paralysis lower
bilat
- Reflexes: 0/5 brachiorad bilat. 0/5 knees bilat
Pertinent Results:
[**2143-1-29**] 05:22PM BLOOD WBC-5.1 RBC-3.49* Hgb-10.3* Hct-31.1*
MCV-89 MCH-29.4 MCHC-33.0 RDW-15.0 Plt Ct-227
[**2143-2-5**] 06:44AM BLOOD WBC-13.3*# RBC-3.34* Hgb-9.7* Hct-29.8*
MCV-89 MCH-29.0 MCHC-32.6 RDW-15.2 Plt Ct-448*
[**2143-1-29**] 05:22PM BLOOD Glucose-90 UreaN-12 Creat-0.8 Na-134
K-4.3 Cl-94* HCO3-33* AnGap-11
[**2143-2-5**] 06:44AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-137
K-4.4 Cl-101 HCO3-30 AnGap-10
[**2143-1-29**] 05:22PM BLOOD ALT-26 AST-26 CK(CPK)-94 AlkPhos-81
TotBili-0.2
[**2143-1-31**] 11:42PM BLOOD ALT-21 AST-20 LD(LDH)-201 CK(CPK)-114
AlkPhos-68 TotBili-0.2
[**2143-1-29**] 05:22PM BLOOD Lipase-25
[**2143-1-29**] 05:22PM BLOOD cTropnT-0.15*
[**2143-1-29**] 10:45PM BLOOD CK-MB-18* MB Indx-18.0* cTropnT-0.16*
[**2143-1-31**] 11:42PM BLOOD CK-MB-14* MB Indx-12.3* cTropnT-0.22*
[**2143-1-31**] 11:42PM BLOOD Albumin-3.6 Calcium-9.5 Phos-2.4* Mg-2.0
[**2143-2-4**] 06:10AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.1
ECHO:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation.
Compared with the prior study (images reviewed) of [**2142-3-9**],
the findings are similar.
Video Swallow:
PHARYNGEAL PHASE: Limited evaluation due to patient positioning
and poor
visualization of the structures. However, pharyngeal phase
demonstrated mild residue in the valleculae after puree and
solid boluses which cleared with sips of liquid. Pharyngeal
phase was within normal limits for swallow
initiation, palatal elevation, laryngeal valve closure,
epiglottic deflection, and bolus propulsion. Please note,
piriform sinuses or upper esophageal sphincter was not imaged.
AP POSITION: Not able to be obtained.
ASPIRATION/PENETRATION: Laryngeal penetration of thin liquids
via teaspoon
and aspiration of thin liquids via straw occurred due to
premature spillover. Patient had coughing which cleared
aspirated material.
IMPRESSION: Mild oropharyngeal dysphagia as described above.
Please see
speech pathology note for further details.
CXR:
Portable AP chest radiograph was compared to [**2143-2-1**]
obtained at 03:40 a.m. The heart size is normal. Mediastinal
position, contour and width are unremarkable. Slight worsening
in bibasilar opacities might represent worsening of atelectasis,
although bilateral, in particular on the left aspiration cannot
be excluded. There is no pleural effusion or pneumothorax. No
evidence of failure is present. Followup with chest radiograph
to exclude the possibility of worsening basal pneumonia is
recommended.
LENI:
IMPRESSION: No evidence of deep vein thrombosis in either leg.
Brief Hospital Course:
A/P: 58yo man w hc chronic progressive MS, quadriplegia, hx
aspiration PNA, chronic foley who was transferred from OSH ED
with increasing fatigue and productive cough.
.
# Progressive fatigue and cough - Patient had recently been in a
hospital and was still being treated with cefpodoxime and flagyl
for a presumed aspiration pneumonia. There was a concern for a
worsening pneumonia and was changed to levo flagyl until his
cultures were negative. He was then changed back to
cefpodoxime/flagyl and completed his ten day course while in
house. He was seen by speech and swallow who recommended that
his liquids be thickened.
.
# Cards: He has hx of chronic diastolic CHF. EKG without
ischemic changes. Pt without chest pain. Troponin elevated but
CK normal. His troponin continued to be high. This was thought
to be related to demend ischemia in the setting of labile
hypertension.
.
# HTN: Continue coreg but at 1/2 dose. Continue clonidine. His
blood pressures were difficult to control and at times he
required extra doses of hydralazine to bring his blood pressure
down. No hypertensive medications were changed.
.
# MS [**First Name (Titles) **] [**Last Name (Titles) **] of seizures: Continue lamictal. Recently titrated
off of keppra. He had a [**Last Name (Titles) 862**] in house and neurology was
consulted. They recommended adding back keppra and increasing
the dose of lamictal. This was done and he can continue to have
his keppra taper and increase lamictal as outpatient.
.
# Resp: continue nebs. BiPAP at night for OSA
.
# Autonomic Dysfunction: hx of labile BPs. Monitor and continue
meds as above.
.
# Lower Extremity Edema: Pt has chronic LE edema. His lasix were
initially held in the setting of concern for an infection. They
were restarted and he was discharged on his home dose of lasix.
.
# Code: DNR DNI per d/w wife and patient.
.
# Comm: HCP Wife [**Name (NI) 2048**] [**Telephone/Fax (1) 25951**] or [**Telephone/Fax (1) 25952**]. She is
medical decision maker.
.
# Proph: bowel regimen and SQH and PPI
Medications on Admission:
Albuterol prn
Baclofen pump
Coreg 25 [**Hospital1 **]
Fentanyl patch 12 q72
lasix 40 daily
lactulose 30 q8h prn
tylenol 650 q6h prn
oxybutynin 15 qhs
ascorbic acid 5 [**Hospital1 **]
colace 100 [**Hospital1 **]
senna 1 [**Hospital1 **] prn
calcium 500 tid
omeprazole 20 [**Hospital1 **]
simvastatin 20 daily
brimonidine 0.15% drops [**Hospital1 **] left eye
clonidine 0.2 [**Hospital1 **]
bisacodyl prn
combivent prn
travatan 0.04% left eye daily
Omega 3 FA [**Hospital1 **]
Vitamin D
Lamotrigine 50 [**Hospital1 **]
Flagyl 500 q8h and Cefpodoxime d4
simvastatin 20 daily
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Oxybutynin Chloride 5 mg Tablet Sig: Three (3) Tablet PO
DAILY (Daily).
4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
9. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
11. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for SOB.
14. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
17. Carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
19. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation
once a day as needed for shortness of breath or wheezing.
20. Keppra 750 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
21. Lamictal 100 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*
22. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
23. Baclofen Intrathecal
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Home Health Care
Discharge Diagnosis:
Urinary tract infection
Aspiration
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for concern of worsening
infection. You were evaluated and it looked like your infection
was improving. Please continue your course of antibiotics as
previously directed. A swallowing study was done which showed
that you do have aspiration events. You should continue your
diet of thickened liquids and soft solid food. Crush your pills
into thick liquids when possible.
.
You had a [**Hospital 862**] while you were in the hospital your
antiseizure medications were changed.
.
Medication changes:
You [**Hospital 862**] medications were changed: Please continue to take
them at these doses until you follow up with your neurologist.
Lamictal 100mg twice a day
Keppra 750 twice a day
You completed your course of antibiotics and do not need any
more for your aspiration pneumonia
Please stop your cefpodoxine and flagyl.
You were given lidocaine patches for pain and started on a daily
aspirin for your heart.
.
Please return to the hospital or call your doctor if you have
temperature greater than 101, shortness of breath, worsening
difficulty with swallowing, chest pain, abdominal pain,
diarrhea, or any other symptoms that you are concerned about.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1575**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 8645**]
Date/Time:[**2143-2-26**] 2:30
Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2143-3-5**] 4:30
Provider: [**Name10 (NameIs) 161**] [**Name8 (MD) 6476**], MD Phone:[**Telephone/Fax (1) 2998**]
Date/Time:[**2143-3-28**] 3:30
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
[
"458.9",
"V46.3",
"344.00",
"253.6",
"369.4",
"401.9",
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"729.5",
"433.10",
"788.30",
"428.0",
"345.90",
"428.32",
"790.5",
"530.81",
"337.3",
"787.22",
"530.20",
"596.54",
"327.21",
"507.0",
"365.9",
"E935.9",
"340",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11236, 11299
|
6396, 8440
|
347, 354
|
11378, 11387
|
3271, 6373
|
12628, 13224
|
2565, 2653
|
9063, 11213
|
11320, 11357
|
8466, 9040
|
11411, 11928
|
2668, 3252
|
11948, 12605
|
253, 309
|
382, 1513
|
1535, 2098
|
2114, 2549
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,975
| 155,777
|
49828
|
Discharge summary
|
report
|
Admission Date: [**2134-8-10**] Discharge Date: [**2134-8-19**]
Date of Birth: [**2068-1-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Dilaudid
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
[**2134-8-10**] Aortic Valve Replacement (#23mm [**Company 1543**] mosaic),
Coronary Artery Bypass Graft x 2 (Left internal mammary artery
grafted to left anterior descending, Saphenous vein grafted to
diagonal), Aortic Root Enlargement
History of Present Illness:
Ms. [**Known lastname 91180**] is a 66 year old woman with a recent worsening of
dyspnea. Work-up for this complaint revealed severe aortic
stenosis with 2+ AI, 1+ MR. [**First Name (Titles) **] [**Last Name (Titles) **] revealed left anterior
descending and diagonal disease. Dr.[**Last Name (STitle) **] was consulted for
coronary revascularization and Aortic Valve Replacement.
Past Medical History:
Aortic Stenosis
Coronary Artery Disease
Hypertension
Type 2 Diabetes Mellitus
Asthma
Obesity
Depression
s/p Right cataract surgery
s/p Tonsillectomy
s/p Partial hysterectomy s/p incisional hernia repair
Social History:
Occupation: retired
Last Dental Exam > 1 year
Lives with her spouse [**Name (NI) 4100**] [**Last Name (NamePattern1) 66320**]
Race caucasian
Tobacco never
ETOH very occasionally
Family History:
non-contributory
Physical Exam:
Pulse: 58 Resp: 15 O2 sat: 94% RA
B/P Right: Left: 126/31
Height: 5 feet 3 inches
Weight: 278 lbs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur III/VI SEM radiating to
carotids [x]
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 [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:radiated murmur Left:radiated murmur
Pertinent Results:
[**2134-8-10**] Echo: Prebypass:
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is normal (LVEF>55%). [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. There are simple atheroma
in the ascending aorta. There are simple atheroma in the aortic
arch. There are simple atheroma in the descending thoracic
aorta. The aortic valve leaflets are severely
thickened/deformed. There is severe aortic valve stenosis (valve
area 0.8-1.0cm2). Moderate to severe (3+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**2-5**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was
notified in person of the results on[**2134-8-10**] at 1045 am.
Post bypass:
Patient is AV paced and receiving an infusion of phenylephrine.
LV systolic function is mildly depressed (septal and anterior
septal walls are hypokinetic). RV systolic function is
unchanged. Bioprosthetic valve seen in the aortic position.
There is no aortic insufficiency. The gradient across the aortic
valve is 25 to 30 mm Hg. Dr [**Last Name (STitle) **] aware. Mild mitral
regurgitation persists. Aorta is intact post decannulation.
[**2134-8-14**] 07:30AM BLOOD WBC-11.0 RBC-3.25* Hgb-9.3* Hct-27.9*
MCV-86 MCH-28.5 MCHC-33.2 RDW-15.5 Plt Ct-292
[**2134-8-10**] 02:39PM BLOOD WBC-18.2*# RBC-2.64*# Hgb-7.6*#
Hct-23.3*# MCV-88 MCH-28.7 MCHC-32.5 RDW-14.3 Plt Ct-215
[**2134-8-14**] 07:30AM BLOOD PT-33.8* PTT-34.7 INR(PT)-3.4*
[**2134-8-10**] 02:39PM BLOOD PT-17.1* PTT-30.1 INR(PT)-1.5*
[**2134-8-14**] 07:30AM BLOOD Glucose-88 UreaN-31* Creat-1.1 Na-138
K-4.5 Cl-103 HCO3-23 AnGap-17
[**2134-8-11**] 01:53AM BLOOD Glucose-95 UreaN-18 Creat-0.9 Na-137
K-4.8 Cl-108 HCO3-24 AnGap-10
[**2134-8-16**] 05:35AM BLOOD WBC-9.2 RBC-3.15* Hgb-9.1* Hct-27.3*
MCV-87 MCH-29.0 MCHC-33.5 RDW-15.6* Plt Ct-351
[**2134-8-17**] 06:00AM BLOOD PT-22.5* INR(PT)-2.1*
[**2134-8-16**] 05:35AM BLOOD Glucose-92 UreaN-27* Creat-1.1 Na-137
K-4.4 Cl-104 HCO3-25 AnGap-12
Brief Hospital Course:
[**8-10**] Ms.[**Known lastname 91180**] went to the operating room and underwent coronary
artery bypass graft x 2 (Left internal Mammary artery grafted to
Left anterior Descending arterty)/Aortic Valve Replacement
(#23mm [**Company 1543**] Mosaic)with root enlargement. Cross clamp
time=109 minutes. Cardiopulmonary Bypass time=133 minutes.Please
refer to Dr[**Last Name (STitle) **] operative report for further details. She
tolerated the procedure wella nd was transferred to the CVICU
incritical but stable condition.She weaned from sedation, awoke
neurologically intact, and was extubated without difficulty. All
lines and drains were discontinued in a timely fashion.
Beta-blocker and diuresis was initiated. POD#2 she continued to
progress and was transferred to the step down unit for further
monitoring. Anticoagulation was started for 3 month duration
secondary to pericardial patch placement. Physical therapy was
consulted and evaulation was made. POD#3 Ms.[**Known lastname 91180**] went into
Atrial Fibrillation and was treated medically with increased
beta-blocker and Amiodarone. She did have some episodes of
bradycardia with the combination of lopressor and amiodarone.
The electrophysiology service was consulted and recommended to
continue amiodarone, but hold lopressor however her rapid afib
persisted and so LOW dose lopressor wa sstarted w/ excellent
response. Resting HR was 60 and ambulatory HR was 80. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of
hearts monitor was placed prior to discharge per the request of
the electrophysiology service. The patient developed a small
area of erythema (without drainage) at the distal pole of the
sternal incision and was started on kefzol for this. On POD# 8
she was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA.
All followup appointments were advised.
Medications on Admission:
Zocor 40 mg daily
Fluoxetine 60 mg daily
Flonase 2 inhalations each nostril daily
Glipizide 10 mg daily
Hydrochlorothiazide 25 mg daily. Pt has been taking 50 mg when
she notices ankle edema. She decided this with out consulting
her
doctor.
Lisinopril 20 mg daily
Trazodone 50 mg 1-2 tablets at bedtime
Coenzyme XQ10 200 mg daily
Zyrtec daily
MVI 1 tablet daily
Aspirin 81 mg daily
Metformin 500 mg twice a day
fish oil 1,000 mg daily
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
5. Glipizide 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
6. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times 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. Metoprolol Tartrate 25 mg Tablet Sig: 6.25mg Tablets PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 1 weeks.
Disp:*28 Capsule(s)* Refills:*0*
10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
10 days.
Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day: Dr.
[**Last Name (STitle) **] to manage daily dose for goal INR [**3-9**].
Disp:*30 Tablet(s)* Refills:*2*
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
VNA of Southeastern Mass.
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 2
Hypertension
Type 2 Diabetes Mellitus
Asthma
Obesity
Depression
Discharge Condition:
Good
Discharge Instructions:
no lotions, creams, powders or ointments to incision
no driving for one month
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100, redness, drainage, or weight
gain of 2 pounds in 2 days or 5 pounds in one week
shower daily at pat incison dry; no baths or swimming
The VNA will check your coumadin level and Dr. [**Last Name (STitle) **] will dose
your coumadin. Goal INR 2-2.5
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks, Please call for appointment [**Telephone/Fax (1) **]
Dr. [**Last Name (STitle) **] in [**3-9**] weeks [**Telephone/Fax (1) 4105**]
Dr. [**Last Name (STitle) **] in [**2-5**] weeks [**Telephone/Fax (1) 3329**]
Dr. [**Last Name (STitle) **] will follow your INR and dose your coumadin. The VNA
will check your INR and fax the results to [**Telephone/Fax (1) 16236**].
Follow instructions for [**Doctor Last Name **] of Hearts, if questions:
[**Telephone/Fax (1) 3104**]
Completed by:[**2134-8-19**]
|
[
"278.01",
"997.1",
"424.1",
"428.30",
"414.01",
"E878.1",
"401.9",
"311",
"427.31",
"427.89",
"E942.0",
"250.00",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.39",
"35.21",
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
8255, 8311
|
4380, 6249
|
282, 520
|
8525, 8531
|
2113, 4357
|
8984, 9525
|
1368, 1386
|
6734, 8232
|
8332, 8504
|
6275, 6711
|
8555, 8961
|
1401, 2094
|
235, 244
|
548, 930
|
952, 1156
|
1172, 1352
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,679
| 153,532
|
268
|
Discharge summary
|
report
|
Admission Date: [**2171-8-10**] Discharge Date: [**2171-8-14**]
Date of Birth: [**2086-10-29**] Sex: F
Service: MEDICINE
Allergies:
Calcium Channel Blockers / Ace Inhibitors / Amoxicillin
Attending:[**First Name3 (LF) 2605**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
none
History of Present Illness:
84yo w/PMHx significant for HTN, CKD, CVA (L sided weakness in
[**2155**]), chronic diastolic heart failure, hyperlipidemia, PVD p/w
BRBPR. The pt is a resident of [**Hospital 100**] Rehab, where she was found
to have dark stools and abdominal pain. HCT was checked and was
found to be 30, down from 32 on [**8-6**]. She was transferred to
[**Hospital1 18**] and en route EMS noticed significant bright red blood,
systolic blood pressure trending down from 130 to 110 at [**Hospital 100**]
Rehab and down to 100 in the ambulance.
.
In the ED the pt was 95.0 96 105/57 18 100% 4L Nasal Cannula.
She had significant BRBPR and was found to have HCT 25.7.
Because of a Cr 2.0 CTA was not done. The family was at bedside
and reinforced that the the pt was DNR/DNI, no CVL, but ok to
give peripheral blood. GI was made aware. She was given 2L NS,
started on protonix gtt, type and crossed, and one bag of pRBCs
was hung. On repeat, VS HR 85 BP 104/49 RR 25 O2 100% 2L NC.
.
On the floor, the patient was comfortable, A&Ox3, afebrile with
BP 151/63 HR 70 satting 100% on 2Lnc. She continued to complain
of diffuse abominal pain but no symptoms of lightheadedness,
dizziness, CP, or SOB. Her family decided that they would be ok
with CVL and intubation for procedure if necessary.
.
Of note, the pt has macroglossia and asymmetric lip swelling
that was thought to be angioedema during an admission in [**Month (only) 116**].
Per the family her current appearance has been stable for
several months. The pt denies sob, increased tongue swelling,
throat swelling, or respiratory distress.
.
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, hematemesis. Denies dysuria, frequency,
or urgency. Denies arthralgias or myalgias. Denies rashes or
skin changes.
Past Medical History:
- CORONARY ARTERY DISEASE
- HEART FAILURE, DIASTOLIC
- HYPERTENSION
- HYPERCHOLESTEROLEMIA
- DM-2
- RENAL INSUFFICIENCY [**6-/2153**]
- ?ATHEROEMBOLIC DISEASE
- BELL'S PALSY
- STROKE [**8-/2156**] CVA w/L hemiplegia, wheelchair bound; has
decreased speech at baseline but generally good comprehension
- GASTROINTESTINAL BLEEDING [**11/2155**]
- MULTINODULAR GOITER
- LOWER EXTREMITY EDEMA 99
- HEADACHES
- ANEMIA (IRON/B12)
- CHRONIC NONHEALING UCLER ON TOE--> Left lower extremity
ischemia with ulceration of left 3rd toe
- glaucoma
- cataracts
-dementia
-constipation
-diabetic retinopathy
- macular degeneration
- a fib
- peripheral edema
Social History:
coming from [**Hospital **] rehab. Russian speaking but some English.
Married, but husband passed away one year prior, has a daughter
and son.
Family History:
Non-contributory
Physical Exam:
On Admission:
Vitals: T: 98 BP: 104/49 P: 85 R: 18 O2: 100% 2L
General: Alert, oriented, no acute distress
HEENT: macroglossia, asymmetric lip swelling
Neck: supple, JVP not elevated, no LAD
Lungs: anteriorly clear to auscultation bilaterally, no wheezes,
rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, 3/6 systolic murmur
Abdomen: diffusely tender abdomen with some voluntary guarding,
grabs hand and moves away during exam, hyperactive bowel sounds
GU: no foley
Ext: L sided clean dry ulcer b/t 4th and 5th toes
DISCHARGE
VS 98.7, 150/64, 70, 18, 94% RA
Gen: NAD, AOx3
HEENT: asymmetric face swelling L>R, periorbital edema
Lungs: CTAB
Cards: 3/6 systolic murmur, RRR, normal S1, S2
Abd: some tenderness to deep palpation, normal BS, no
rebound/guarding
Ext: no edema, iodine on ulcer
Pertinent Results:
ADMISSION LABS
.
[**2171-8-10**] 02:10AM BLOOD WBC-7.8 RBC-3.12* Hgb-8.3* Hct-25.7*
MCV-82 MCH-26.5* MCHC-32.2 RDW-14.1 Plt Ct-226
[**2171-8-10**] 02:10AM BLOOD Neuts-62.6 Lymphs-31.6 Monos-3.8 Eos-1.2
Baso-0.8
[**2171-8-10**] 02:10AM BLOOD PT-12.4 PTT-24.1 INR(PT)-1.0
[**2171-8-10**] 02:10AM BLOOD Glucose-343* UreaN-42* Creat-2.0* Na-137
K-5.2* Cl-107 HCO3-19* AnGap-16
[**2171-8-10**] 08:34AM BLOOD ALT-11 AST-18 AlkPhos-58 TotBili-0.3
[**2171-8-10**] 02:10AM BLOOD Calcium-8.5 Phos-4.6* Mg-2.2
[**2171-8-10**] 08:34AM BLOOD TSH-1.4
[**2171-8-10**] 08:34AM BLOOD Free T4-0.82*
[**2171-8-10**] 02:35AM BLOOD Glucose-327* Lactate-4.0*
.
DISCHARGE LABS
.
[**2171-8-14**] 01:10PM BLOOD WBC-5.1 RBC-3.31* Hgb-9.5* Hct-28.3*
MCV-86 MCH-28.7 MCHC-33.6 RDW-16.3* Plt Ct-183
[**2171-8-14**] 06:10AM BLOOD Glucose-121* UreaN-33* Creat-1.8* Na-144
K-3.7 Cl-108 HCO3-25 AnGap-15
[**2171-8-14**] 06:10AM BLOOD Calcium-8.4 Phos-3.3 Mg-2.5
[**2171-8-12**] 03:35PM BLOOD Lactate-1.5
.
KUB:
PORTABLE ABDOMEN STUDY DATED [**2171-8-10**]
No prior abdominal radiographs for comparison.
A nonspecific, non-obstructive bowel gas pattern is visualized.
A large
amount of stool is seen throughout the colon which appears
nondistended.
Several nondistended loops of air-filled small bowel are also
demonstrated, especially in the left side of the abdomen. There
is no evidence of free intraperitoneal air. Prominent vascular
calcifications are observed in the thoracoabdominal aorta and
its branches. There is also a possible rounded calcification in
the central pelvis, which could represent a calcified fibroid.
This is difficult to assess due to overlying stool in the colon.
.
Abd Xray [**8-12**]: IMPRESSION: Nonspecific bowel gas pattern with no
evidence of intraperitoneal free air or obstruction.
.
Brief Hospital Course:
84 yo w/ PMHx significant for HTN, CKD, CVA ([**2155**]), chronic
diastolic heart failure, hyperlipidemia, PVD p/w hematochezia of
unknown etiology.
.
1. Hematochezia/Abdominal Pain: On admission, the patient had
BRBPR associated with diffuse abdominal pain, decreased systolic
BPs, and a HCT drop from 32-->25.7. GI was consulted and the
etiology was thought to be colitis, ischemic vs infectious.
Given her history of CAD and PVD, along with the pain out of
proportion to exam, we thought about mesenteric ischemia. Her
lactate was 4.0 on admission, but normalized with fluid and
PRBCs. In the ICU, the patient received 3u of pRBCs with
stabilization of her hematocrit. She did not get a CTA/CT
contrast because of CKD nor did she get an NG lavage. GI did not
recommend a scope at the time, as the patient was stabilized
with tranfusions and had no further signs of active bleeding.
The patient was placed on empiric cipro/flagyl, which was
switched to cefpodoxime and flagyl to cover a Proteus UTI. The
patient did not have further bleeding once she arrived on the
floor. She continued to c/o diffuse abdominal pain. We ordered a
subsequent KUB, which showed a nonspecific bowel gas pattern, no
obstruction, and large stool burden. The patient was transfused
one more PRBC unit on the floor for a Hct 25, and her Hct bumped
to 28 and stayed constant for the remaining 2 days of her
admission. The patient was given multiple laxatives including a
lactulose enema. She had some clotted blood with stool after the
enema, but no reason to believe that she was still bleeding. GI
signed off wanting to continue her on ABX and follow-up as an
outpatient.
.
2. Hypertension: The patient had labile blood pressures on this
admission. Her Procardia was discontinued for possible
development of slight facial swelling, possibly consistent with
mild angioedema without respiratory compromise. The patient's BP
was SBP around 200 after stopping the Procardia. Instead, the
patient was started on labetalol 200mg [**Hospital1 **]. The patient had her
hydralazine increased to 50mg QID. She was continued on her
lasix and isosorbide mononitrate. Her BP on discharge was
150-160, which is acceptable for her at this time.
.
3. Angioedema: This was diagnosed in the past and hypothesized
to be secondary to CCB usage. The patient's Procardia was
stopped here. Her swelling was stable and she did not require
any intervention.
.
CHRONIC ISSUES
.
1. DM2: The patient was put on sliding scale insulin here. She
will be placed back on Glucotrol on discharge.
.
2. Chronic dCHF: No s/s of fluid overload. Patient was never
hypoxic or dyspnic during admission. Patient was continued on
her lasix and BP control.
.
3. CAD/PVD: The patient's aspirin was held during this
admission. Now that patient is HD stable, she will be restarted
on Aspirin 81mg Qday.
.
4. CKI: Creatinine 2.0 on admission, improved slightly with
gentle hydration. Patient is on Calcitriol and her electrolytes
were stable on admission.
.
5. Depression: Continued on home oxcarbazepime and duloxetine
.
TRANSITIONAL ISSUES
.
The patient received a lactulose enema and had some blood in her
stool. This blood had clots and seemed like old blood. Her Hct
was stable since then, and there is little evidence that she is
actively bleeding. She may continue to have some old blood that
passes with her subsequent bowel movements. The geriatric fellow
discussed this with the rehab attending. GI will follow patient
in clinic. They will discuss possibility of colonoscopy in the
future.
Medications on Admission:
cymbalta 20mg PO BID
KCL 20meq [**Hospital1 **]
Hydralazine 25mg PO QID standing
Ferrous sulfate 325mg PO daily
Glucatrol 2.5mg PO daily
Imdur 30mg PO daily
Lasix 40mg PO daily
Miralax 17g PO daily
prilosec 20mg daily
Procardia XL 60mg PO BID
Rocaltrol 0.15mcg PO daily
Trileptal 150mg PO daily
dulcolax 10mg PO qhs
artificial 1 drop OU daily at 8pm
.
oxycodone IR 5mg PO q4h prn
tylenol 650mg PO q6h prn
Aspirin 81mg
Motrin 400mg q6h PO PRN
Discharge Medications:
1. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
4. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**11-18**]
Drops Ophthalmic once a day: At 8PM.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. hydralazine 50 mg Tablet Sig: One (1) Tablet PO four times a
day.
8. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
11. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
12. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
One (1) Tablet, ER Particles/Crystals PO twice a day.
13. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day
for 8 doses: Last day [**8-22**].
14. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 8 days: Last Day [**8-22**].
15. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
16. Rocaltrol 0.25 mcg Capsule Sig: One (1) Capsule PO once a
day.
17. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4)
hours as needed for pain.
18. Glucotrol 5 mg Tablet Sig: 0.5 Tablet PO once a day.
19. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - LTC
Discharge Diagnosis:
Lower GI bleed
Infectious Colitis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital with bleeding from your
rectum. You were initially brought to the ICU and stabilized
with blood transfusions. The GI doctors examined [**Name5 (PTitle) **] and were
not able to find a source of bleeding. They thought that there
could be an infectious component that caused colon irritation,
so you were started on antibiotics. We monitored your blood
counts and they remained stable. You did not have any more
bleeding when you were transferred to the floor. You did have
abdominal pain while here, which was due to constipation and
possibly infection. We gave you laxatives to help move your
bowels and you did have some small, loose stools. Otherwise, we
controlled your blood pressure into an acceptable range.
NEW MEDICATIONS ON DISCHARGE:
- Stopped Procardia for possible angioedema
- Started labetalol 200mg [**Hospital1 **]
- Started Cefpodoxime 200mg once a day (last day [**8-22**])
- Started Flagyl 500mg three times a day (last day [**8-22**])
- Stopped Dulcolax
- Started Senna 1 tab [**Hospital1 **]
- Started Colace 100mg [**Hospital1 **]
- Increased Hydralazine to 50mg QID
Followup Instructions:
Department: DIV. OF GASTROENTEROLOGY
When: TUESDAY [**2171-9-24**] at 1 PM
With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**]
Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2608**] MD, [**MD Number(3) 2609**]
|
[
"311",
"403.90",
"440.23",
"585.9",
"599.0",
"V49.86",
"428.32",
"707.15",
"250.00",
"009.0",
"428.0",
"041.6"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11610, 11675
|
5880, 9413
|
345, 351
|
11753, 11753
|
4066, 5857
|
13079, 13545
|
3213, 3231
|
9906, 11587
|
11696, 11732
|
12710, 13056
|
9439, 9883
|
11931, 12684
|
3246, 3246
|
1979, 2371
|
278, 307
|
379, 1960
|
3260, 4047
|
11768, 11907
|
2393, 3036
|
3052, 3197
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,996
| 123,643
|
10598
|
Discharge summary
|
report
|
Admission Date: [**2167-6-24**] Discharge Date: [**2167-6-30**]
Date of Birth: [**2099-5-1**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
NSTEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
The patient is a 68 yo man with h/o CAD s/p CABG in [**2158**], who
presented with 12 hour history of chest pain and was transferred
to [**Hospital1 18**] for cardiac catheterization. The patient states that
he began to experience chest pain last night at approximately 5
PM, when he was laying in bed. The pain was an [**7-20**],
substernal, non-radiating sharp pain. He also experienced
associated shortness of breath and nausea. The patient states
that he believes he lost consciousness after this event and then
woke up multiple times throughout the night with similar chest
pain. When he woke up this morning at 5 am, he continued to
experience the pain, so he called EMS. He was found to have a
FSBG of 46. He was then brought to [**Hospital 26580**] Hospital for further
evaluation.
.
In the ED, his VS were T 98.7, P 101, R 24, BP 124/99, O2 97% on
RA. He had an ECG which showed ST depressions in II, III, AVF,
V4-V6 and TWIs in V4-V6. Cardiac enzymes were drawn and were
found to be elevated (CK [**2100**], TroponinI 60.83). He was given
ASA 325 mg, Plavix 300 mg, Zofran for nausea, and was started on
heparin gtt. He was then transferred to [**Hospital1 18**] for cardiac
catheterization.
.
In the cath lab, the patient was found to have known severe 3VD.
His LIMA-LAD graft was patent but had moderate diffuse disease
and distal collaterals. His other three SV grafts were all
occluded at the origins, and one of the OM grafts appeared to be
newly occluded. It was thus decided that the patient would
undergo medical management of his CAD.
.
On arrival to the floor, the patient is no longer experiencing
chest pain. He states that he is short of breath and has a
productive cough, which has been present for the past three
days. Of note, the patient states that he also lost
consciousness five days ago while at home and believes that his
shortness of breath began at this time.
.
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 dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations,
syncope or presyncope. He does endorse a recent increase in his
peripheral edema (2 months).
Past Medical History:
1. CABG: 4 vessel CABG in [**2158**]. LIMA to LAD, SV to OM1, SV to
OM2, SV to posterior descending coronary artery.
2. Type 2 Diabetes, Diagnosed 14 years ago
3. Hypertension
4. Obstructive Sleep Apnea
Social History:
The patient currently lives with his 20 year old daughter in
[**Name (NI) 34849**], MA. He is a retired Army [**Last Name (un) 34850**]. He has never
smoked, does not drink, denies any illicit drug use.
Family History:
The patient has an extensive family history of CAD. His mother
and father both had MIs in their 70s and multiple aunts and
uncles also had MIs.
Physical Exam:
VS: T 97.8, BP 109/76, HR 76, RR 16, O2 sat 98% on 2L
GENERAL: Elderly man, pleasant, in NAD. AAO x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Left eyelid and
surrounding tissue appeared edematous. Conjunctiva were pink,
no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVD to angle of mandible with prominent A
waves.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, fixed split S2. No m/r/g. No thrills,
lifts. No S3 or S4.
LUNGS: Poor inspiratory effort secondary to coughing. Fine
bibasilar crackles bilaterally. No chest wall deformities,
scoliosis or kyphosis.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: 1+ edema in lower extremities bilaterally. No
femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
ADMISSION LABS:
CBC: WBC 11.9, HgB 13.3, Hct 40.4, Plt 165K
BMP: Na 136, K 4.4, Cl 101, CO2 25, Glucose 153, BUN 24, Cr 1.6
Ca 9.0
LDH: 603
AST: 164
ALT: 43
TBili: 1.7
CPK: [**2100**], TroponinI: 60.83
CARDIAC CATH ([**2167-6-24**]):
1. Coronary angiography in this right dominant system
demonstrated three
vessel disease. THe LMCA had diffuse disease on angiographical
examination. The LAD had a total occlusion at the origin on
angiography.
The Cx had a total occlusion at the origin on angiography. The
Ramus had
an 80% occlusion at the origin on angiography and also had
diffuse
disease throughout. The RCA had a 100% occlusion in the mid
portion of
the vessel on angiography.
2. Arterial condui angiography revealed the LIMA to be widely
patent and
if feeds the LAD which subsequent [**Last Name (un) 36**] collaterals to the RCA
and the
Cx. On angiography of the LIMA, moderate diffuse disease of the
LAD was
noted. All three SVG grafts are occluded at the origin with
thrombus
present within one of the vein grafts.
3. Resting hemodynamics revealed elevated right and left sided
filling
pressures with an RVEDP of 13 mmHg and a PCWP of 28 mmHg. There
was
severe pulmonary arterial systolic hypertension with PASP of 72
mmHg.
The Cardiac index was low at 1.7 l/min/m2. Central aortic
pressure was
109/74 mmHg. The SVR was increased at 1624 dynes-sec/cm5 and the
PVR was
increased at 447 dynes-sec/cm5.
TTE ([**2167-6-25**]): The left atrium is normal in size. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is moderately dilated. There is severe regional left
ventricular systolic dysfunction with anterior, lateral, septal
and apical akinesis. There is moderate hypokinesis of the
remaining segments (LVEF = 15-20%). No masses or thrombi are
seen in the left ventricle. Right ventricular chamber size and
free wall motion are normal. Right ventricular chamber size is
normal. with focal hypokinesis of the apical free wall. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. There are filamentous strands on
the aortic leaflets consistent with Lambl's excresences (normal
variant). The mitral valve leaflets are structurally normal.
Moderate (2+) mitral regurgitation is seen. There is no
pericardial effusion.
PERTINENT LABS:
[**2167-6-24**] CK(CPK)-1358 CK-MB-54* MB Indx-4.0 cTropnT-4.12*
[**2167-6-24**] ALT-41* AST-146* LD(LDH)-824* AlkPhos-98 TotBili-1.2
[**2167-6-25**] CK(CPK)-677 CK-MB-19* MB Indx-3.4 cTropnT-4.43*
[**2167-6-26**] ALT-38 AST-73* AlkPhos-101 TotBili-1.0
[**2167-6-28**] CK(CPK)-265 CK-MB-8 cTropnT-4.06*
DISCHARGE LABS:
[**2167-6-30**]: BLOOD WBC-7.1 RBC-3.35* Hgb-11.0* Hct-32.0* MCV-95
MCH-32.7* MCHC-34.3 RDW-16.7* Plt Ct-220
[**2167-6-26**]: BLOOD PT-14.6* PTT-32.4 INR(PT)-1.3*
[**2167-6-30**]: BLOOD Glucose-120* UreaN-27* Creat-1.4* Na-135 K-4.1
Cl-100 HCO3-26 AnGap-13
[**2167-6-28**]: BLOOD CK(CPK)-265*
[**2167-6-28**]: BLOOD CK-MB-8 cTropnT-4.06*
[**2167-6-30**]: BLOOD Calcium-8.4 Phos-2.9 Mg-2.1
[**2167-6-24**]: BLOOD Triglyc-71 HDL-39 CHOL/HD-3.6 LDLcalc-89
Brief Hospital Course:
68 year old male with history of CABG in [**2158**] presents with
NSTEMI s/p cardiac cath. No intervention could be done, so
patient will continue with medical management.
# CORONARY ARTERY DISEASE: The patient initially presented with
a 12 hour history of chest pain, elevated cardiac enzymes, and
ST depressions in the inferior leads and V2-V4. On cardiac
cath, he was found to have occluded SV grafts to the OMs, and
one of the grafts appeared to be acutely thrombosed. He is not
a surgical or PCI candidate, and it was determined that he will
be medically managed. He was continued on ASA 325mg po daily
and Plavix 75mg po daily. He was started on atorvastatin 80mg
po daily (lipid panel Tot Chol 142, Trigly 71 HDL 39, LDL 89),
but this was changed to pravastatin 40mg po daily due to leg
cramping with atorvastatin. He was started on carvedilol at one
point during his stay, but he dropped his blood pressures after
each dose. Therefore, he was switched to metoprolol. When he
blood pressures stabilized, he was started on Imdur 30mg po
daily in an effort to reduce right-sided pressures.
He intermittently experienced chest pain throughout his
admission. Each time, his pain resolved quickly with SL nitro
or morphine. During these episodes, he had no ECG changes and
his cardiac enzymes continued to trend down. He had a follow-up
echo that showed a dilated left ventricle with severe regional
systolic dysfunction, c/w multivessel CAD. There was moderate
regional right ventricular systolic dysfunction and moderate
mitral regurgitation. A previous echo in [**2158**] showed similar
apical akinesis and therefore it was felt that anticoagulation
to prevent LV thrombus was not indicated.
He will be transitioned to metoprolol succinate XL 25 mg daily
and is to remain on a proton pump inhibitor, Pantoprazole 40 mg
daily as he has a history of GI bleeding and will need to remain
on aspirin and plavix.
# Acute on Chronic Congestive Heart Failure: He does not have a
history of CHF, but he had extremely high RA, PA, PCWP on
cardiac catheterization. He was actively diuresed during his
stay with a Lasix gtt, and then he was started on Lasix 60mg po
daily. He was started on digoxin 0.125mg po daily as well.
# RHYTHM: The patient presented in normal sinus rhythm and
remained in this rhythm for much of his stay. He did have
occasional runs of non-sustained Vtach, likely related to
reperfusion.
# ACUTE ON CHRONIC RENAL FAILURE: Patient was diuresed a
significant amount during his stay, and his creatinine bumped to
2.1 during this admission. At discharge, it had resolved back
to 1.4. His acute renal failure was felt to be due to a prerenal
etiology.
# DIABETES MELLITUS TYPE 2: Metformin and Glyburide were held in
the setting of increasing creatinine and recent contrast
administration. He was maintained on a sliding scale insulin
regimen with Humulog and glargine. The patient experienced some
low blood sugars, and his insulin dosing has been reduced
compared to his outpatient regimen. He will be discharged on a
lower dose of insulin compared to his outpatient dosing. It is
advised he follow up with his PCP soon for further management of
his diabetes.
Also, upon discharge he was changed from Glyburide to
glipizide. Since Glyburide is renally cleared, and the patient
has a recent history of acute on chronic renal failure, it was
felt that glipizide would be a better sulfonylurea, as it is
hepatically cleared. He is to re-start his Metformin upon
discharge.
#DYSPHAGIA: Patient has a chronic history of coughing. It was
noted that choking occurred upon eating his meals and with a
concern for aspiration, a speech and swallow evaluation was
performed. Recommendations included a PO diet of thin liquids
and regular solids. Patient is encouraged to select soft foods.
Recommend GI consult for further evaluation of upper esophageal
sphincter and candidacy for dilation. Patient is to follow up in
the outpatient setting for further evaluation. He had no signs
of aspiration during his hospital stay.
#Obstructive Sleep Apnea: Patient has history of OSA, but has
never had a sleep study or used a CPAP machine. During his
hospital stay, he had numerous episodes of apnea at night along
with desaturating oxygen levels into the 80s. He was placed on a
CPAP machine which ameliorated his symptoms. It is advised he
have a sleep study in the outpatient for further management of
this problem.
# DISPOSITION: Physical therapy saw the patient and felt that he
would benefit from rehabilitation. He is to be discharged to a
rehab facility.
Medications on Admission:
Benzonatate 200 mg Capsule 1 Capsule(s) by mouth twice a day
Furosemide 40 mg Tablet
1 Tablet(s) by mouth once a day
Furosemide 20 mg Tablet 1 Tablet(s) by mouth once a day total of
60 mg QD Glyburide 5 mg Tablet 2 Tablet(s) by mouth twice a
day
Insulin Glargine [Lantus] 100 unit/mL Solution 65u once a day
Lisinopril 20 mg Tablet 1 Tablet(s) by mouth once a day
Metformin 1,000 mg Tablet 1 Tablet(s) by mouth once a day
Potassium Chloride [Klor-Con M20] 20 mEq Tab Sust.Rel.
Particle/Crystal
one Tab(s) by mouth daily
Ranitidine HCl 150 mg Tablet one Tablet(s) by mouth twice a day
Insulin NPH & Regular Human [Humulin 70/30] 100 unit/mL (70-30)
Suspension
prn prn
Discharge Medications:
1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-13**] Tablet,
Sublinguals Sublingual PRN (as needed) as needed for chest pain.
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five
(5) ML PO Q6H (every 6 hours) as needed for cough.
6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. Pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) syringe
Injection twice a day.
9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
11. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
13. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO twice
a day.
14. Polyethylene Glycol 3350 100 % Powder Sig: One (1) packet PO
DAILY (Daily).
15. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Non ST Elevation Myocardial Infarction
Acute on Chronic Systolic Congestive Heart Failure
Mild Dysphagia
Discharge Condition:
stable
VSS
Discharge Instructions:
You had a heart attack and a cardiac catheterization that showed
severe coronary artery disease. The decision was made that the
best treatment was to optimize your medicines to help your heart
beat better and prevent another heart attack. We made the
following changes to your medicines:
1. Lisinopril was decreased to 2.5 mg.
2. Metoprolol was started to help your heart recover from the
heart attack.
3. Plavix and Aspirin was added to prevent blood clots and
another heart attack.
4. Imdur was started to prevent chest pain
5. Glyburide was changed to Glipizide.
6. Ranitidine was changed to Pantoprazole to protect your
stomach
7. Metformin, Benzonatate and 70/30 insulin was discontinued
8. Pravastatin was started to lower your cholesterol
.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day
or 6 pounds in 3 days.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500cc/day
Followup Instructions:
Primary Care:
[**Last Name (LF) **],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 18509**] Please call after you get
home to see in the first one to two weeks.
.
Cardiology:
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
[**Last Name (un) 34851**]
[**Location (un) 3320**], [**Numeric Identifier 34852**] Phone: ([**Telephone/Fax (1) 5319**] Date/Time: Monday
[**7-20**] at 2:40pm
.
Gastroenterology:
Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2520**]
Digestive Diseases Assoc.
[**Last Name (un) 34853**]
[**Location (un) 3320**], [**Numeric Identifier 34854**] Phone: ([**Telephone/Fax (1) 32401**]
Date/Time: Tuesday [**7-28**] at 4:00pm
|
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icd9cm
|
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[
[]
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[
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icd9pcs
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[
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329, 355
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383, 2869
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6843, 7147
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2891, 3096
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3112, 3318
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9,286
| 139,128
|
47627
|
Discharge summary
|
report
|
Admission Date: [**2168-2-5**] Discharge Date: [**2168-2-14**]
Date of Birth: [**2124-5-29**] Sex: F
Service:
HISTORY OF PRESENT ILLNESS: This is a 43 year old woman with
a history of hypertension, schizo-affective disorder, asthma,
and possible emphysema who presents to the Emergency Room
with a three week history of progressive shortness of breath
and dyspnea on exertion. The day of admission, the patient
complained of acutely worsening shortness of breath and she
was unable to speak in complete sentences at home and
therefore came to [**Hospital1 69**]
Emergency Department.
In the Emergency Department, the patient had moderate
respiratory distress, only able to speak in two to three word
sentences. The patient was given 5 unit doses of 2.5 mg
Albuterol nebulizers in series with 2 doses of 0.5 mg of
Atrovent. Her respiratory rate dropped from 34 to 28 with
this treatment and the patient demonstrated improved air
movement by examination. The patient was admitted to the
Medical Intensive Care Unit for monitoring and contiunous
nebulizers on the night of admission.
PAST MEDICAL HISTORY:
1. Schizo-affective disorder.
2. Hypertension.
3. Asthma.
4. Possible emphysema.
5. Positive exercise treadmill test in the past.
ALLERGIES: Sulfa, codeine, penicillin and aspirin.
MEDICATIONS ON ADMISSION:
1. Prolixin 20 mg p.o. q. day.
2. Zyprexa 10 mg p.o. q. day.
3. Depakote 1500 mg p.o. q. day.
4. Neurontin 800 mg p.o. three times a day.
5. Cogentin 0.5 mg p.o. twice a day.
6. Vioxx 12.5 mg p.o. q. day.
7. Claritin 10 mg p.o. q. day.
8. Ditropan XL 30 mg p.o. q. day.
9. Norvasc 5 mg p.o. q. day.
10. Inderal 80 mg p.o. q. day.
11. Azmacort 4 puffs twice a day.
12. Albuterol two puffs four times a day.
13. Prevacid 30 mg p.o. q. day.
14. Tylenol.
15. Trazodone.
PHYSICAL EXAMINATION: On admission, heart rate 98.0 F.;
blood pressure 119/70; respiratory rate 30 q. minute; oxygen
saturation not available. In general, the patient was
somnolent but arousable with a prolonged expiratory phase of
respiration. HEENT: Normocephalic, atraumatic. Oxygen mask
in place. Cardiovascular: Regular rate and rhythm. S1, S2
normal. Pulmonary: Diffuse expiratory wheezes. Abdomen
soft, nontender. Extremities with one plus bilateral lower
extremity edema up to the mid-shin.
LABORATORY: On admission, white count 6.5, hematocrit 33.7,
platelets 202, with a differential of 59% neutrophils, 22%
lymphocytes, 6% basophils, 16% monocytes. Sodium 133,
potassium 3.9, chloride 96, bicarbonate 29, BUN 9, creatinine
0.6, glucose 82.
Chest x-ray was clear.
HOSPITAL COURSE: The patient was admitted directly to the
Intensive Care Unit for continuous Albuterol and Atrovent
nebulizer treatments and observation. Hospital course by
organ systems:
1. Cardiovascular: The patient denied any chest pain on
admission, however, was noted to have T wave inversions in V1
through V4 on her admission EKG. She did not have an old EKG
here available for comparison. The patient was therefore
ruled out for myocardial infarction as a cause of her
shortness of breath. On the night of admission, the patient
ruled out by serial enzymes.
For her hypertension, the patient was continued on her
Norvasc 5 mg p.o. q. day. The patient was not given Inderal
as an in-patient, however, this will be continued upon
discharge. Her blood pressure was under good control
throughout her hospital stay.
2. Pulmonary: The patient was initially admitted to the
Intensive Care Unit for around-the-clock Albuterol and
Atrovent nebulizer therapy and observation. The patient was
also started on intravenous Solu-Medrol. The patient's
breathing gradually improved and the patient was able to go
to the Regular Medical Floor the day after admission. She
was then switched to p.o. Prednisone 60 mg p.o. q. day and
started on a Prednisone taper. The patient was continued on
around-the-clock nebulizers until [**2-12**], and at that time
was switched over to Metered-Dose Inhalers.
On Friday, [**2-12**], the patient began ambulating and was
able to do so without becoming excessively dyspneic. In
order to improve compliance with her Metered-Dose Inhalers,
we changed her regimen to Flovent two puffs twice a day,
Serevent two puffs twice a day and Combivent two puffs four
times a day p.r.n. The patient also is a smoker. She did
not smoke throughout her hospital stay and was maintained on
a nicotine patch. The patient requested to have a
prescription for nicotine patch as an outpatient and this was
provided to her. Of note, the patient's peak flows were
followed, however, the patient is unable to use the
spirometer correctly and it was felt that her peak flows were
not accurate in measuring her progress.
3. Infectious Disease: The patient reported a three week
history of cough productive of yellow sputum. The patient
had no fever or chills but in general felt under the weather
from this cough. A sputum was sent which showed four plus
Gram negative rods, as well as one plus Gram positive cocci
in pairs and clusters. The final culture revealed
Staphylococcus aureus, coagulase positive, Oxicillin
sensitive, beta Streptococcus and Hemophilus influenzae. The
patient was treated with a seven day course of Levaquin. Her
cough gradually improved and was no longer productive of
purulent sputum. By the time she was discharged home, repeat
chest x-ray was again clear.
4. Neuro/Psych: The patient has a history of
schizo-affective disorder. She was without acute symptoms on
admission and denied any suicidal or homicidal ideation, and
also denied hearing any voices in her head or having any
visual or auditory hallucinations. She stated that she was
happy with her current psychiatric care and felt there were
no issues which required in-house assessment by the
Psychiatry Service here. She was continued on her Prolixin,
Zyprexa, Depakote, Neurontin and Cogentin.
5. Gastrointestinal: The patient was put on Protonix while
on her steroids. She will be instructed to continue to take
her usual Prevacid at home while taking steroids.
6. Fluids, Electrolytes and Nutrition: The patient was
euvolemic upon transfer to the floor. Her electrolytes were
within normal limits. She was maintained on a regular diet.
DISCHARGE DIAGNOSES:
1. Asthma exacerbation.
2. Bronchitis.
DISCHARGE MEDICATIONS:
1. Serevent two puffs twice a day.
2. Flovent two puffs twice a day.
3. Prevacid 30 mg p.o. q. day.
4. Neurontin 800 mg p.o. three times a day.
5. Prednisone taper.
6. Combivent two puffs four times a day.
7. Depakote 500 mg q. a.m. and 1000 mg q. p.m.
8. Levofloxacin 500 mg p.o. q. day to complete a seven-day
course.
9. Cogentin 0.5 mg p.o. twice a day.
10. Ditropan 5 mg p.o. twice a day.
11. Zyprexa 10 mg p.o. q. h.s.
12. Norvasc 5 mg p.o. q. day.
13. Prolixin 20 mg p.o. q. h.s.
14. Nicotine patch 22 mg q. 24 hours.
15. Inderal 80 mg p.o. q. day.
DISCHARGE STATUS: To her group home.
CONDITION AT DISCHARGE: Improving.
DISCHARGE INSTRUCTIONS:
1. Follow-up will be with her regular primary care physician
as needed.
DR.[**Last Name (STitle) 970**],[**First Name3 (LF) 971**] 12-888
Dictated By:[**Last Name (NamePattern1) 7896**]
MEDQUIST36
D: [**2168-2-14**] 14:23
T: [**2168-2-16**] 13:09
JOB#: [**Job Number 15228**]
|
[
"307.81",
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6309, 6351
|
6374, 6988
|
1341, 1817
|
2626, 6288
|
7039, 7352
|
1840, 2608
|
7003, 7015
|
155, 1104
|
1126, 1315
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,853
| 195,738
|
33808
|
Discharge summary
|
report
|
Admission Date: [**2129-2-25**] Discharge Date: [**2129-4-7**]
Date of Birth: [**2086-1-23**] Sex: M
Service: MEDICINE
Allergies:
Nafcillin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Sepsis and Acute Renal Failure
Major Surgical or Invasive Procedure:
Renal Biopsy ([**2129-2-25**])
TEE x2
Right sided PICC line
Left-sided thoracentesis
History of Present Illness:
43 year old male with no significant PMH who p/w 2 weeks of
malaise, myalgias, fevers/chills. Over this time period he was
seen at multiple EDs ([**Hospital3 **], [**Hospital3 **], [**Hospital1 112**]) for
dehydration/viral illness:
[**2-18**]: seen at [**Hospital3 **], found to have a clear CXR, WBC 5,
HCT 39 and Cr 1.1. Given fluids. Prescribed cipro, took it QD
x5 days.
[**2-20**]: seen at New [**University/College **], flu swab negative, again given
fluids.
[**2-22**]: seen at [**Hospital1 112**], negative orthostatics.
.
As above, patient had malaise, myalgias, headaches and episodes
of the 'shivers.' He noted decreased POs and fluids, as well as
episodes of confusion. He notes dark urine and decreased urine
output. He did endorse some diarrhea and later some lower
abdominal pain. He denies cough/congestion though he endorsed
this elsewhere in the chart. He denies sore throat or runny
nose. He has had no recent travel outside of [**Location (un) 511**], no
dental procedures, no unusual foods, no pets, denies IVDU. He
does have a co-worker with recent bronchitis.
.
ED Course: VS on arrival: t 97.2, HR 100, BP 134/64, RR 17, SPO2
97%. Patient had BUN 159 and Cr of 7.1; U/A showed casts, large
leuk and blood, few bacteria, 100 protein. Patient received 6L
IVF with minimal urine output.
.
Pt c/o SOB with O2 saturation in mid 90s, found to have mild end
expiratory wheeze. Repeat CXR showed persistent left lower lobe
atelectasis, new left mid lobe atelectasis, small left effusion
and new interstitial edema. Looked like fluid overload (had
gotten 6L IVF for ARF), received neb and Lasix 20mg IV --> put
out 200 cc urine and felt better.
.
He was seen by renal team, found to have an active urine
sediment with WBC/RBC casts and bacteria. Initially thought to
have post-strep or post-viral glomerulernephritis, and due to
this concern he received a renal biopsy. Soon after this he
spiked a temperature to 102.8, with tachycardia in 120's,
tachypnea and rigors. Blood cultures revealed 4/4 bottles with
GPC. He received Cipro 500mg PO, Vancomycin 1gm IV. BP range
106-142/50-60s.
.
Patient was then sent to the MICU for close observation before
transfer to floor.
Past Medical History:
No known PMH, has not had medical care in many years.
Social History:
Lives by himself, is self employed as a heating and AC engineer.
He does not smoke, occasional alcohol, and denies any IVDU. He
is not currently sexually active, has not been screened for
HIV/STDs.
Family History:
mother w/ breast cancer, father healthy, no siblings
Physical Exam:
on arrival to ICU
.
VS: Temp: 100.5 BP: 124/53 HR: 116 RR: 18 O2sat: 95% on 1L
nc.
GEN: talkative, completing full sentences, in NAD.
HEENT: PERRL, EOMI, anicteric, MMM, op without lesions or
erythema
NECK: JVP at jawline
RESP: decreased breath sounds and scattered crackles at bases
CV: RRR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e, warm, good pulses, lichenified plaques on dorsum
of feet b/l but no cracking. No splinter hemorrhages or Osler
nodes.
NEURO: AAOx3, no focal deficits.
PSYCH: rambling, tangential thinking.
Pertinent Results:
Labs:
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW
Plt Ct
[**2129-4-6**] 05:06AM - - - 25.3*
[**2129-2-26**] 04:27AM 9.4 2.86* 8.0* 23.6* 83 28.1 34.1
15.0 111*
[**2129-2-25**] 11:04PM 11.0 3.10* 8.7* 25.8* 83 28.0 33.7
14.9 123*
[**2129-2-25**] 03:02AM 8.2 3.34* 9.4* 27.0* 81* 28.0 34.6
14.7 119*
[**2129-2-25**] 01:45AM 9.5 3.85* 10.9* 31.3* 81* 28.3 34.9
15.1 136
.
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso
[**2129-3-21**] 06:17AM 78.2* 10.8* 5.5 4.8* 0.7
[**2129-2-25**] 01:45AM 93.7* 3.3* 2.2 0.4 0.3
.
[**2129-3-6**] 07:30AM 80*
.
RENAL & GLUCOSE Glu BUN Cr Na K Cl HCO3
AnGap
[**2129-4-6**] 05:06AM - 5 2.0
[**2129-2-25**] 01:45AM 118 159 7.2 131 3.9 99 12
24
.
[**2129-2-26**] 05:39PM Lipase: 23
.
HEMATOLOGIC calTIBC Hapto Ferritn TRF
[**2129-4-5**] 05:00AM 236*
[**2129-3-23**] 05:29AM 430*
[**2129-3-16**] 01:05PM 441*
CHEMS ADDED 3:14PM
[**2129-3-9**] 07:35AM 381*
[**2129-3-6**] 07:30AM 172* - 1245* 132*
[**2129-2-25**] 03:02AM 178* 284* 633* 137*
.
[**2129-3-18**] 06:52AM Cortisol: 22.9
.
COMPLEMENT C3 C4
[**2129-2-25**] 08:00AM 30* 13
.
PLEURAL
PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso
Macro
[**2129-3-23**] 02:09PM 900* 9000* 54* 15* 12* 3* 7* 9*
PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Amylase Albumin
[**2129-3-23**] 02:09PM 3.4 103 148 19 1.9
.
[**2129-3-23**] 2:09 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final [**2129-3-23**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2129-3-26**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2129-3-29**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2129-3-24**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
.
C. diff negative x4.
.
Blood Bank Diagnosis of new Big E antigen:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname **] has a new
diagnosis
of Anti-E antibody. E-antigen is a member of the Rhesus blood
group
systems. Anti-E antibody is clinically significant and capable
of
causing hemolytic transfusion reactions.
In the future, Mr. [**Known lastname **] should receive E-antigen negative
products for
all red cell transfusions. Approximately 71% of ABO compatible
blood
will be E-antigen negative. A wallet card and a letter stating
the
above information will be sent to the patient.
.
BCx [**2-25**]: ([**4-22**] positive blood cx on [**2-25**]):
[**2129-2-25**] 5:25 am BLOOD CULTURE Site: ARM
**FINAL REPORT [**2129-2-27**]**
Blood Culture, Routine (Final [**2129-2-27**]):
STAPH AUREUS COAG +.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 78162**] ([**2129-2-25**]).
Aerobic Bottle Gram Stain (Final [**2129-2-25**]):
REPORTED BY PHONE TO [**First Name9 (NamePattern2) 78163**] [**Doctor Last Name **] @[**2072**] ON [**2-25**]/0/.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Anaerobic Bottle Gram Stain (Final [**2129-2-25**]):
REPORTED BY PHONE TO [**Last Name (LF) 78163**],[**First Name3 (LF) **] @[**2072**] ON [**2129-2-25**].
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
.
All subsequent blood cultures negative
Ucx: negative
ASO [**2-25**]: negative
.
EKG: NSR @ 86, TWI in III.
.
IMAGING:
CXR ([**2129-2-25**] @ 1AM): Left lung base atelectasis. No definite
evidence of pneumonia or CHF.
.
CXR ([**2129-2-25**] @ 7AM): Persistent left lower lobe atelectasis, new
left mid lobe atelectasis, small left effusion and new
interstitial edema.
.
CT Head ([**2129-2-25**]): Normal study (no infarction, hemorrhage, mass
effect, or shift of normally midline structures. Normal sized
ventricles. Clear paranasal sinuses and mastoid air cells.
Unremarkable osseous structures.
.
Renal Ultrasound ([**2129-2-25**]): Normal renal ultrasound. No
hydronephrosis.
.
ECHO ([**2129-2-26**]): The left atrium is mildly 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%). Right ventricular
chamber size and free wall motion are normal. There are three
aortic valve leaflets. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. No aortic regurgitation is seen. No masses or
vegetations are seen on the mitral valve, but cannot be fully
excluded due to suboptimal image quality. Trivial mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
.
Renal Biopsy ([**2129-2-25**]): per renal team - post infectious
glomerulernephritis with minimal scarring (hopeful for good
prognosis).
.
[**3-2**] CT chest/pelvis/abdomen no contrast:
IMPRESSION:
1. Small subcapsular hematoma on the left kidney, post-renal
biopsy. Hemorrhagic material is seen within the left renal
collecting system, and a large amount of blood is seen within
the urinary bladder, which is not drained by the indwelling
Foley catheter.
2. Mild simple ascites fluid in the left paracolic gutter and
elsewhere within the abdomen, possibly related to generalized
fluid overload and/or renal causes. Fluid is seen in the
subcutaneous left flank, in addition to moderate bilateral
pleural effusions, a small pericardial effusion, and mild
interstitial edema in the lungs.
3. Consolidation at the left base raises concern for pneumonia.
4. Bilateral noncalcified lung nodules, measuring up to 8 mm in
diameter. Three-month CT followup is recommended.
5. Splenomegaly, an enlargement of the splenic vein.
6. Distended gallbladder.
.
[**3-4**] TEE
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. No thormbus or spontaneous echo
contrast is seen in the left atrium/left atrial appendage/right
atrium or right atrial appendage. Left ventricular systolic
function is good. The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque to 48 cm from the incisors. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve leaflets
are structurally normal. Mild (1+) mitral regurgitation is seen.
There is a 3.1 x 1.5cm mobile heterogeneous echodensity attached
to the ?anterior leaflet of the tricuspid valve and herniating
through the annulus with systole and diastole c/w a vegetation
on the tricuspid valve. There is no pericardial effusion.
.
IMPRESSION: Large echogenic mass on the tricuspid valve c/w
vegetation. Mild-moderate tricuspid regurgitation.
These findings were discussed with the housestaff (Dr [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]) and the attending on [**2129-3-4**] at 11:15 am.
.
[**3-6**] CXR
Comparison is made with prior study [**2129-2-28**].
Cardiomediastinal contours are normal. Left lower lobe
retrocardiac opacity may be due to atelectasis or pneumonia.
Bilateral pleural effusions are small. There is no pneumothorax,
discoid atelectasis are also present in the lower lung zone
laterally.
.
[**3-9**] CT Chest/abdomen/pelvis
IMPRESSION:
1. Findings consistent with a new interval multifocal pneumonia
at the lung bases compared to the CT of [**2129-3-2**].
2. Numerous scattered pulmonary nodules stable compared to
examination one week prior. A follow-up examination following
treatment of underlying condition or in 3 months is again
recommended.
3. There has been some interval improvement in ascites, pleural
effusions, and anasarca. A small pericardial effusion is
relatively stable in size.
4. Status post left renal biopsy with persistent small amount of
high-density material within the collecting system and along the
renal capsule, likely hematoma.
5. Probable thickening of the bladder wall although given the
overall decompression of the bladder, this is difficult to
assess.
.
Chest CT without contrast ([**2129-3-13**]).
1. Bilateral lower lobe pneumonia slightly increased, more
prominently on the left. 2. Slight increase in bilateral
pleural effusions without specific evidence of loculation. 3.
Bilateral pulmonary nodules and nodular patchy opacities little
changed. While these are likely infectious in nature, followup
imaging after resolution
of symptoms is recommended to assess resolution. 4. Increased
pericardial effusion. 5. Unchanged fullness of imaged portion
of left renal collecting system.
.
Repeat TEE ([**2129-3-14**]): Demonstrated large, mobile vegetation on
the tricuspid valve (2.7 x 1.7 cm on anterior leaflet), with
moderate [2+] tricuspid regurgitation. No abcess seen. There is
a small pericardial effusion. "Compared with the findings of
the prior study (images reviewed) of [**2129-3-4**] there are
no significant changes."
.
[**3-22**] bilateral lower extremity veins:
IMPRESSION:
1. No evidence of DVT in either lower extremity.
2. Significant bilateral calf subcutaneous edema.
.
[**3-22**] V/Q scan
IMPRESSION:
Lobar matched defect in the left lower lobe, correlating with
CXR and CT
findings is indeterminate for pulmonary embolism.
.
[**3-22**] CT chest no contrast:
IMPRESSION:
1. Interval increased size of large left and small right simple
pleural effusions with left lower lobe and lingula atelectasis.
No evidence for pneumonia.
2. Slight interval increase in size of simple pericardial
effusion without evidence of tamponade.
3. Stable subcarinal mediastinal lymphadenopathy measuring 18
mm. This may be secondary to the patient's history of
endocarditis.
.
[**3-23**] Post-thoracentesis CXR
IMPRESSION: Little overall change.
.
Blood crossmatch:
DIAGNOSIS, ASSESSMENT AND RECOMMENDATIONS: Mr. [**Known lastname **] has a new
diagnosis
of Anti-E antibody. E-antigen is a member of the Rhesus blood
group
systems. Anti-E antibody is clinically significant and capable
of
causing hemolytic transfusion reactions.
This information was communicated to the clinical team on [**4-5**]
by
telephone, and they were advised to follow hemolytic markers
(hapto,
bili, LDH) as well as renal function in case this patient is
experiencing a delayed hemolytic transfusion reaction. His
current
laboratory parameters as well as a negative DAT argue against
ongoing
hemolysis.
In the future, Mr. [**Known lastname **] should receive E-antigen negative
products for
all red cell transfusions. Approximately 71% of ABO compatible
blood
will be E-antigen negative. A wallet card and a letter stating
the
above information will be sent to the patient.
Brief Hospital Course:
43 yo man with prolonged hospital course for MSSA bacteremia, TV
endocarditis, pneumonia, and acute renal failure.
.
#)ID:
Fever/Abx hx: After [**Hospital **] transfer to the floor, the patient
experienced daily fevers. His antibiotic course on the floor is
as follows, as formulated in consultation with the ID team,
which followed along. The patient received ciprofloxacin and
vancomycin in the ED on [**2-25**] and was switched to nafcillin after
transfer to the floor. He remained on nafcillin for 3 days,
developed a rash, and was switched back to vancomycin. He was
on vanc for 6 days, the rash disappeared, but he continued to be
febrile. Levaquin was added on [**2129-3-10**] when pneumonia was
identified. He was febrile for two more days, and so he was
switched to cefepime. Fevers continued, so 1 day later
linezolid was added, but he remained febrile for 2 days. During
this time the rash never reappeared but given his original
reaction to nafcillin, it was thought that he might be cross
reacting to cefepime. On [**2129-3-13**] he was switched back to vanc
and ciprofloxacin. The patient's fevers decreased, with
temperatures in the 99-100.5 range, and ciprofloxacin was
discontinued after a total of 7 days of gram negative coverage.
The patient remained on vancomycin 1 gm q24 (dosed by trough
15-20) for the remainder of his hospital stay (completing a
total of 6 weeks of abx), and his fever curve slowly improved.
A PICC line was placed and removed before discharge.
.
#) Endocarditis: While in the MICU, patient got a TTE ([**2129-2-26**])
which was read as negative for vegetations or regurgitation,
although the image quality was "suboptimal". After having
persistent fevers on the floor, on appropriate abx, without a
clear source, a TEE was done ([**2129-3-4**]) which demonstrated a
large echogenic mass on the tricuspid valve, 2.7x1cm, with no
evidence of abscess. He continued to spike fevers through abx so
a repeat TEE was done on [**2129-3-14**], specifically looking for
abscess, and none was seen, with no change in size of
vegetation. A TTE performed on [**3-25**] showed persistence of 2.1x1
cm vegetation. The patient remained on telemetry monitoring for
most of his hospital stay, and was observed to have tachycardia,
PVCs and occasional short runs of NSVT, but remained
asymptomatic during the NSVT events, with stable vitals. The
cause of these events was unclear, although his first episode
occurred initially after the placement of his PICC line,
possibly due to stimulation by the PICC line guide-wire.
Cardiac surgery was consulted about the patient, and they did
not favor surgical intervention at the time of the consult.
Cardiology was consulted about his NS VT events, and they saw
the patient and deemed no further workup necessary, but wanted
to see him for follow-up (appointment made with Dr. [**Last Name (STitle) **], and
Dr. [**Last Name (STitle) **]. The patient's antibiotic course is as described
above; after switching to vanc/Cipro, the Cipro was stopped
(after 7 days of gram negative coverage), and the patient was
maintained on vancomycin 1gm Q24, with therapeutic levels
verified by trough 15-20 for the remainder of his admission, and
discharged on [**4-7**] after 6 weeks of antibiotics.
.
#)Pneumonia: A CT torso was done on [**2129-3-2**] in an effort to
identify a source for his persistent fevers while on what was
thought to be appropriate abx. At that time chest findings were
limited to two noncalcified lung nodules of unclear
significance. A repeat CT torso was done on [**2129-3-9**] after his
fevers failed to resolve, and bilateral pneumonia was
demonstrated, and he was immediately started on Levaquin. The
etiology of the pneumonia included a hospital acquired pneumonia
and septic staph emboli. (The patient's antibiotic course is as
described above.)Multiple attempts at induced sputum sufficient
for culture failed. CXR performed on [**3-21**] showed worsening of
left pleural effusion. A V/Q scan was performed to rule out
pulmonary embolism, given the patient's persistent tachycardia,
and it was read as indeterminate for PE, but it was felt low
suspicion given lack of hypoxia. Pulmonology was re-consulted
and they recommended thoracentesis, which was performed by the
procedures team. 1.6 liters of fluid were drained. Gram stain,
1+ PMNs, no organisms. Acid fast smear negative. No bacterial
or fungal growth. Acid fast culture still pending at time of
discharge. Cytology negative for malignant cells. Pleural
fluid was intermediate in composition between a transudate (by
LDH criteria) and an exudate (by protein criteria). Follow-up
CXR showed little change in appearance of left lung.
Pulmonology recommended not repeating thoracentesis unless
patient became symptomatic. They also did not think pulmonology
follow up was necessary. Patient remained asymptomatic from a
pulmonary standpoint for remainder of stay and reported
significant improvement in his breathing.
.
#) Bacteremia: Blood cultures on admission and the day after
both grew methicillin sensitive Staph aureus. Antibiotic course
as described above. On his presenting exam there were no focal
sites of infection. All blood cultures were negative after
[**2129-2-26**]. The patient also had negative urine cultures, and stool
cultures (including 4x negative C. diff cultures done for loose
stools during the admission). He was also found to be HIV and
HepB negative.
.
#) GU:
- Renal failure: Cr. on admission 7.9. Renal consulted and
assisted in formulating care. Renal biopsy from admission
showed post infectious glomerulonephritis, with negative ASO
titer. He was initially treated with bicarb supplemented
fluids, but was ultimately dialyzed between [**Date range (1) 64568**] after
persistent uremia, acidemia and what appeared to be the
development of mental status changes. After 4 dialysis sessions
his renal function began to recover on its own. The patient
developed hyperkalemia, with a highest K of 5.9. He was placed
on a low potassium renal diet, and his beta blocker was stopped,
and given a couple of doses of Kayexalate. His hyperkalemia
resolved, and did not return, and diet restrictions were
liberalized. On discharge, the patient's Cr had improved
dramatically to 1.8-2.0. The renal team signed off with the
recommendation that the patient have outpatient renal follow up,
and an outpatient appointment has been made.
.
- Hematuria and urinary obstruction: The initial renal biopsy
led to hematuria that persisted until [**2129-3-3**]. Throughout this
time the patient had a 3way foley with continuous bladder
irrigation. Urology was consulted. The hematuria stopped after
a large bladder clot was manually removed, suggesting the
possibility that the hematuria was not due to active bleeding,
but possibly clot erosion. The patient subsequently had [**3-22**]
additional clots over his stay, with no further bleeding (and
negative urine culture). These subsequent clots caused
temporary urinary obstruction, and straight cath was attempted
to drain bladder. These clots passed spontaneously, and urology
was called about future management. They recommended hand
irrigation of the bladder with a 2-way catheter. The patient
refused to have his bladder irrigated in this way, so it was not
done, and clots did not present any further problems during the
rest of his admission.
.
#) Anemia: Admission HCT was 31, with MCV of 81; iron studies
showed Iron 17, TIBC 178, Haptoglobin 284, Ferritin 633,
Transferrin 137. He continued to have a gradual Hct drop even
after the hematuria stopped, requiring transfusion on two
occasions. The patient received 8 units of blood during his 6
week hospital course; his hct hovered in the 21-25 range, and
the patient was transfused when his hct dropped below 21.
During his first transfusion, the patient developed chills,
which was determined not to be due to transfusion reaction by
the blood bank. The patient was also started on ferrous sulfate
at the recommendation of the renal team, given the possibility
that an iron deficiency was obscured by an acute-phase elevation
of his ferritin. He was also given one doese of EPO, for the
case that his renal failure was contributing to his anemia, but
it was decided not to give any further EPO injections. The
patient was guaiac negative on admission, but was subsequently
found to be guaiac positive, with no evidence of gross blood at
any time in stool. The patient's stools were monitored for the
duration of his stay, and it was felt that any potential source
of GI bleeding could safely be worked up on an outpatient basis.
After the patient's last transfusion (1 unit of pRBC) on [**4-4**],
the blood bank found that the patient had developed a big E
antigen. The patients hemolysis labs were checked and his LDH,
and bilirubin were found to be normal, and haptoglobin 236.
Additionally, his hct went from 21.8-25.3, and the patient
remained afebrile, suggesting that the patient had not developed
a hemolytic transfusion reaction. However, given that reactions
can be delayed, the patient was told to monitor himself for
fever or other symptoms after discharge (jaundice or discolored
urine) and seek immediate medical attention if they developed.
.
#) Transaminitis: The patient developed a transaminitis during
his admission. He was found to be hepB and hepC negative. The
transaminase levels returned to [**Location 213**] by [**3-22**].
.
#) Code: Full
.
The patient was discharged to home with ID, renal, Cardiology,
and PCP [**Name9 (PRE) 702**] in [**Name9 (PRE) 86**]. In addition, he was instructed to
have repeat blood cultures drawn as an outpatient.
Medications on Admission:
None, minimal amounts of acetaminophen and ibprofen for his
recent illness.
Discharge Medications:
1. Outpatient Lab Work
Please draw surveillance blood cultures on [**4-19**]. Go to the LOWRE
Building at [**Hospital1 18**] to have these done
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Actute bacterial endocarditis with TV vegitation
- MSSA bacteremia
- Post-infectious glomerulonephritis
- Pneumonia
Secondary diagnoses:
- Hypertention
- Hyperkalemia
Discharge Condition:
Stable, ambulating independently, no oxygen requirement.
Discharge Instructions:
You were admitted for treatment for acute bacterial endocarditis
with a vegitation on the tricuspid valve (bacterial infection of
your heart valve), MSSA bacteremia (methacillin-sensitive Staph
aureus bacteria in your blood), pneumonia, pleural effusions,
and acute renal failure (found to be caused by post-infectious
glomerulonephritis by biopsy).
.
Please seek immediate medical attention if you develop fevers,
chills, shortness of breath, chest pain, palpitations, swelling
of your ankles, or any other concerning symptoms.
.
We have started you on iron replacement, please take this as
instructed. Please maintain all of your follow-up appointments
that are listed below.
Followup Instructions:
The following appointments have been made for you. You must
call each of these offices with your new insurance information
as soon as possible (phone numbers are listed below with each
appointment). You are currently listed as self-pay. You will
also need to have surveillance blood cultures drawn on [**4-19**]/8 in
the [**Hospital Unit Name **] at [**Hospital1 18**], to be followed up by Dr. [**Last Name (STitle) **] on
your [**2129-4-22**] appointment. You will need a repeat echo, [**2-21**]
weeks after your last dose of vancomycin ([**4-7**]), to be arranged
by your PCP or ID physician.
.
1.) New Primary Care Provider: [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD
Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2129-4-22**] 8:00
.
2.) Infectious Disease Clinic: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2129-4-25**] 11:30 (located at [**Last Name (NamePattern1) 78164**])
.
3.) [**Hospital 10701**] Clinic: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2129-4-26**] 8:30. Location: [**Hospital Ward Name 23**]
building [**Location (un) 436**] Medical Specialties.
.
4.) Cardiology Clinic: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 62**]) [**2129-5-10**] 10:00AM.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
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|
5732, 14676
|
229, 261
|
414, 2617
|
2639, 2694
|
2710, 2910
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,173
| 142,683
|
3462
|
Discharge summary
|
report
|
Admission Date: [**2105-4-17**] Discharge Date: [**2105-4-22**]
Date of Birth: [**2060-4-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
found down
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
45 y/o F with h/o cardiomyopathy with EF 20%, Hep B, Hep C,
current EtOH and former heroin abuse, seizure in the setting of
EtOH and drug use who was found down on [**4-17**] by her husband
under her kitchen table for an unknown length of time. She was
taken to [**Hospital1 18**] [**Location (un) 620**] where at 12:40 pm she had a witnessed 30
second generalized tonic-clonic seizure for which she was given
2 mg of IM Ativan with resolution of seizure. A head CT showed a
SDH. She was then transferred to [**Hospital1 18**] for neurosurgery eval. On
[**4-15**] she reported falling down 9 stairs after drinking, and
hitting a wall with her head and L shoulder.
.
In the [**Hospital1 18**] ED, she was febrile to 103.8. Pt was given 2 gm IV
Ceftriaxone, 2 gm IV vancomycin, and 10 mg dexamethasone and was
loaded with 1 gm Dilantin. Neurosurgery, trauma surgery, and
neurology were consulted. Head CT was repeated which showed a
left temporparietal SDH max thickness 10 mm with a 2 mm midline
shift. Neurosurgery and trauma surgery did not feel there were
any acute surgical issues and patient was admitted to the MICU.
Past Medical History:
1) Hepatitis B: dxed [**2098**] per pt
2) Hepatitis C: dxed [**2098**] per pt
3) Pancreatitis: h/o pseudocyst drainage
4) h/o EtOH abuse: last drink 4 days PTA per pt, h/o DTs
5) h/o heroin abuse: unclear when last used, told neurology &
MICU residents [**3-21**] yrs ago, told neurosurg PA & [**Hospital1 18**] [**Location (un) 620**] 2
mos ago
6) h/o seizures: in setting of EtOH and drugs
7) cardiomyopathy: dx in [**2-23**] at NWH. EF 20%. unknown etiology
-> thought to be likely EtOH vs. hiv/other viral/thiamine
8) h/o NSVT: at OSH in [**2-23**]
9) h/o depression: dx at NWH in [**2-23**], unsure if bipolar d/o.
Social History:
The patient is married and lives in [**Location 745**] with husband. [**Name (NI) **] 2
children, ages 21 and 26 who do not live with her. Drinks Vodka
at least 1 pint per day. Smokes 2 pk cig/day x 30 yrs. H/o
heroin and cocaine use as above, last used cocaine over 10 yrs
ago. Unclear when last used heroin (2 mos or 4 yrs ago).
Family History:
Father with HTN. No h/o seizure disorder.
Physical Exam:
Tm 100.2 Tc 99.3 BP 118/64 (105-143/22-71) P 106 (86-112) R 18
Sat 96% RA
Gen: Alert and oriented x 3 (though she thought she was still in
[**Location (un) 620**], did know date), cooperative, able to answer ?s, NAD,
pleasant
HEENT: PERRL, EOMI, OP clear with MMM, bruising around left eye
Neck: supple, NT, no LAD, no meningismus
CV: reg rhythm, tachy, no m/r/g
Pulm: CTA bilaterally
Abd: soft, NT, nd, +BS, no HSM
Ext: no edema, no CT, +2 DP pulses bilaterally, slight
tenderness to palpation of bilateral shoulders L>R with nl ROM,
extensive bruising to left shoulder but no swelling, normal
range of motion
Neuro: CN 2-12 intact though pt with b/l horizontal nystagmus
which fatigues, strength 5/5 equal and symmetric, DTRs
2+throughout, nl sensation to light touch, no pronotor drift,
+asterixis, no intention tremor, nl FNF and nl heel to shin.
Babinski was downgoing bilaterally. Gait not tested
Pertinent Results:
[**2105-4-17**] 08:00PM WBC-8.1 RBC-2.30*# HGB-8.6*# HCT-24.8*#
MCV-108*# MCH-37.5* MCHC-34.8 RDW-16.7*
[**2105-4-17**] 08:00PM NEUTS-91.2* BANDS-0 LYMPHS-7.4* MONOS-1.3*
EOS-0.1 BASOS-0
[**2105-4-17**] 08:00PM PLT COUNT-273
[**2105-4-17**] 08:00PM PT-13.8* PTT-25.4 INR(PT)-1.2*
[**2105-4-17**] 08:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2105-4-17**] 08:00PM ALBUMIN-3.9 CALCIUM-7.4* MAGNESIUM-1.0*
[**2105-4-17**] 08:00PM ALT(SGPT)-27 AST(SGOT)-72* ALK PHOS-79
AMYLASE-73 TOT BILI-0.7
[**2105-4-17**] 08:00PM GLUCOSE-112* UREA N-6 CREAT-0.6 SODIUM-143
POTASSIUM-2.9* CHLORIDE-105 TOTAL CO2-27 ANION GAP-14
[**2105-4-17**] 08:39PM LACTATE-1.3
[**2105-4-17**] 09:28PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2105-4-17**] 09:28PM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE
EPI-[**6-27**]
[**2105-4-17**] 09:28PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2105-4-18**] 12:00AM CALCIUM-7.6* MAGNESIUM-1.5*
[**2105-4-18**] 12:00AM GLUCOSE-251* UREA N-5* CREAT-0.7 SODIUM-141
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-19
.
CXR: no PTX, clear lungs, LIJ in R atrium
.
EKG: sinus tach, nl axis, no st/t changes, nl intervals
.
CT C-spine: no fracture
.
CT head:There is a left temporoparietal subdural hematoma. The
maximal thickness is measured as 10 mm. There is a 2 mm
contralateral midline shift. There is mass effect on the
temporal [**Doctor Last Name 534**] of the left lateral ventricle. The basal cisterns
are preserved without evidence of transtentorial herniation. No
intraparenchymal hemorrhage is seen. There is no evidence for a
major or
minor vascular territorial infarct. No skull fractures are seen.
The visualized portions of the paranasal sinuses, mastoid air
cells are well pneumatized.
IMPRESSION: Acute left temporoparietal hematoma. Maximal
thickness 1 cm. Small midline shift of 2 mm. No fractures are
seen. There is no evidence for intraparenchymal hemorrhage or
infarction.
.
repeat CT [**4-18**]: unchanged
.
X ray L shoulder: negative for fracture or dislocation
.
Blood cx [**4-17**] pending, urine cx negative
.
TTE [**4-22**]: The left atrium is elongated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is normal (LVEF>55%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic regurgitation. The mitral valve leaflets are structurally
normal. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Brief Hospital Course:
45 y/o F with history of Hep B, Hep C, EtOH abuse, and prior
seizure in setting of alcohol and drug use in the past who was
admitted after being found down on [**4-17**], with witnessed seizure
and subdural hemorrhage. In the MICU she was initially
combative, receiving ativan/haldol at a Code Purple. Recommended
LP could not be performed, and she was empirically started on
vanco, ctx 2g, and acyclovir for possible meningitis. Her fevers
improved. EEG showed no active seizure activity but she was
continued on dilantin. She was given valium per CIWA scale. Her
mental status improved and patient was A&O x 3 upon transfer to
the floor, although she had no memory of what happened to her
other than falling. She complained of pain in her left shoulder
and lower back.
.
1) Seizure: The patient was started on ceftriaxone, vancomycin,
and acyclovir for possible meningitis/encephalitis. This was
discontinued on the floor. Her dilantin was continued per
neurology recomendations, with therapeutic dilantin levels.
.
2) Fever: She had a low-grade temperature upon transfer to the
floor. She had no clear infectious source with neg U/A and neg
CXR. Her fever curve improved by discharge. Blood cultures
remained negative to date.
.
3) Subdural hematoma: CT findings appear to be stable; there was
no acute indication for surgery. Neurology and neurosurgery
consulted on this patient. She was put on dilantin for 4 weeks.
She needs repeat CT scan and EEG in 6 months time.
.
4) Altered MS/agitation: This was much improved upon transfer to
the floor. Psychiatry followed the patient. She improved with
valium for etoh withdrawal.
.
5) Tachycardia: This remained stable during her admission, with
sinus tach on EKG. She took adequate POs, had a stable Hct, and
was continued on CIWA scale with valium.
.
6) Cardiomyopathy: This was recently diagnosed at NWH in [**2-23**].
Workup was initiated and records are in chart. Her cardiac meds
were restarted including metoprolol, lisinopril, lasix, and
aldactone. Repeat TTE was done prior to discharge with normal
EF. She was advised to stop taking her spironolactone and
lasix.
.
7) Hepatitis B/Hep C: There was no evidence of cirrhosis on
exam. LFTs were normal other than elevated AST. Hep B and Hep C
VL were not detected.
.
8) Anemia: Hct was down to 24, macrocytic, nl b12/folate. Per
NWH records, her hct in d/c summary was 39! The patient had no
source of bleeding other than SDH. Her Hct reamined stable in
house.
.
9) EtOH abuse: the patient's seizure was attributed to SDH,
triggered by EtOH induced fall. Psychiatry and addictions
consulted. She received IV Thiamine, MVI, and folate. She also
received diazepam [**5-27**] PO q2h prn per ciwa scale.
She was given information to transfer her primary care to [**Hospital1 18**].
Medications on Admission:
1) metoprolol s 50 mg PO daily
2) lisinopril 10 mg PO daily
3) Lasix 20 mg PO daily
4) Spironolactone 25 mg PO daily
5) Mag oxide 400 mg PO TID
6) Protonix 40 mg PO daily
7) Calcium and Vit D 500 mg PO BID
8) Thiamine 100 mg PO daily
9) MVI 1 tab PO daily
10) Folate 1 mg PO daily
11) Ambien prn
ativan
nicotine patch
Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO at bedtime for 1 months.
Disp:*90 Capsule(s)* Refills:*0*
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Dilantin Oral
9. Please do NOT take your spironolactone or lasix anymore.
Discharge Disposition:
Home
Discharge Diagnosis:
seizure
EtOH abuse
subdural hematoma
cardiomyopathy
Discharge Condition:
stable, mentating well.
Discharge Instructions:
Please return if you experience chest pain, shortness of breath,
fever >101.5, confusion, seizure, fall, or any other worrisome
symptoms.
You should take all medications as directed. You should no
longer take your lasix or spironolactone.
You have been started on dilantin (phenytoin) for seizure
prevention. You need to take this for 1 month. In 1 month you
will need to follow-up with a Neurosurgeon and have a repeat Cat
scan of your brain. At 6 months you will need to follow-up with
a neurologist here. You will need to get an EEG here.
You should not drink alcohol any more. You have been given
contact information for AA programs. If you are having trouble
with your alcohol problem, please contact your doctor.
Followup Instructions:
You should follow-up with your primary care doctor in 2 weeks at
[**Telephone/Fax (1) 15948**]. If you would prefer to be seen here, you should
call Mass Health and switch your primary care to [**Hospital3 **].
Then you can call [**Telephone/Fax (1) **] to be seen in clinic here.
You should follow up with Dr [**Last Name (STitle) **] in Neurosurgery about your
Brain bleed within 4 weeks. Please call [**Telephone/Fax (1) 1669**] to make
your appointment.
You will need to have a Cat Scan of your brain in 4 weeks,
before your appointment with Dr [**Last Name (STitle) **]. Please call
[**Telephone/Fax (1) 327**] to schedule your appointment.
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2105-11-27**]
1:00
.
You will also need a repeat EEG in [**2105-10-18**]. Please call
[**Telephone/Fax (1) 5285**] to make an appointment.
|
[
"780.39",
"070.30",
"428.0",
"425.5",
"852.26",
"276.52",
"E888.9",
"070.70",
"305.01",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10133, 10139
|
6248, 9055
|
325, 349
|
10234, 10259
|
3492, 4822
|
11036, 11931
|
2509, 2552
|
9424, 10110
|
10160, 10213
|
9081, 9401
|
10283, 11013
|
2567, 3473
|
275, 287
|
377, 1502
|
4830, 6225
|
1524, 2145
|
2161, 2493
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,290
| 168,633
|
36199
|
Discharge summary
|
report
|
Admission Date: [**2171-3-26**] Discharge Date: [**2171-4-3**]
Date of Birth: [**2102-8-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
semi-elective cath
Major Surgical or Invasive Procedure:
coronary cath
intubation
MVA
CVVH
History of Present Illness:
68 year old man with severe COPD (2L NC O2 dependent), ischemic
cardiomyopathy, LVEF 40%, CAD s/p unprotected LM stenting in
[**2168**] with DES (not surgical candidate), PVD s/p femoral bypass,
diabetes type 2 with diabetic neuropathy, s/p multiple
hospital/nursing home admissions over the past several months
for COPD exacerbations, CHF, pneumonia, NSTEMI and transferred
to [**Hospital1 18**] for possible cath.
.
Per patient and OSH records, he had worsening SOB for 5 weeks
ago with decreased activity tolerance and worsening dyspnea on
exertion. At his local hospital in early [**Month (only) **], he was treat
for PNA and was noted to be in AFib. He was started on coumadin
and then discharged to a nursing home for rehab. From rehab, he
was readmitted to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 23925**] Hospital in early [**Month (only) **] with
a COPD exacerbation. There his course was complicated by an
NSTEMI and was briefly intubated. He survived the episode was
treated with Cipro for a presumed PNA and was sent to [**Hospital1 **]
again.
.
At [**Last Name (un) 8612**], he developed recurrent AFib and tachycardia for
which he was admitted to [**Hospital3 **] on [**2171-3-22**]. There
he was treated with sotalol and digoxin but had persistent
tachycardia so was transferred to [**Hospital3 **] for further
management. He was admitted to the ICU at [**Hospital3 **] and
placed on a cardizem gtt. They considered amio but given the
COPD were hesitant to do this given the risk of amio pulmonary
toxicity. He was given sotalol and then converted to sinus
rhythm. A TTE revealed EF 45%. Per cardiology consult his
sotalol was increased to 80mg [**Hospital1 **]. He was transferred to [**Hospital1 18**]
for cardiac catheterization. Coumadin was held in anticipation
of cardiac cath.
.
For his COPD and possible PNA he was started on rocephin and
azithromax on the day of transfer. He was started also on
prednisone taper for COPD exacerbation with plan to taper to
20mg on [**2171-3-27**].
.
Here at [**Hospital1 18**], he did well overnight. He was taken to cath lab
for diagnostic cath. Cath showed progressive LCx (ostial 80%
lesion involve origin of AV branch) and RCA (80% proximal
instent restenosis, 70% mid lesion, 70% distal lesion) disease.
PCI to RCA with DESx3. Post cath groin angio showed a small
perforation of fem-fem graft. This was compressed with Femstop.
He was transferred to CCU with Femstop in place for 3 hr till
bivalirudin worn off. Femoral sheath left in place overnight.
Plan for holding heparin gtt for now, but continue ASA 325 mg
daily, plavix 75 mg daily x12mths.
.
When seen in ccu, he was in mild distress with pain at fem-stop,
he had dopplerable pulses throughout.
.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: turned down in [**2168**] because of end stage COPD
-PERCUTANEOUS CORONARY INTERVENTIONS: unprotected left main
stenting on [**2169-3-6**]
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY: ischemic cardiomyopathy, LVEF
40-45% by echo on [**2171-3-22**], Chronic bronchitis, peripheral
neuropathy, amputation of toes of left foot, sleep apnea, GERD,
BPH, Severe COPD w/ multiple intubations
.
.
Social History:
Retired salesman. Lives with his significant other (girlfriend)
-Tobacco history: Prior smoker, 2ppdX 40 years, quit 12 years
ago
-ETOH: none since diagnosed with DM. Prior social drinking only.
-Illicit drugs: none
.
.
Family History:
Mother with DM. CAD in both parents and brothers had heart
attacks in their 50s.
Physical Exam:
PHYSICAL EXAMINATION on ICU admission
VS: T=98.8 BP=165/66 HR=63 RR=20 O2 sat=95% on 3L NC
GENERAL: Obese M in mild distress. A&Ox3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP difficult to assess given body habitus.
CARDIAC: irregularly irregular, normal S1, S2. No m/r/g.
LUNGS: Resp were slightly labored, but no accessory muscle use.
crackles at right base and expiratory wheezes throughout.
ABDOMEN: Obese, soft, NTND.
EXTREMITIES: 2+ edema bilaterally, noted to have femoral-a line
and a fem-stop.
.
.
Pertinent Results:
.
LABORATORY DATA:
OSH Labs:
[**2171-3-22**] 07:30 Trop I 0.13 17:40 TropI 0.15
[**2171-3-22**] Chol 179 TG 252 HDL 52 LDL 77
INR 1.9 today, PT 21, WBC 10.6 HCT 30.5 PLT 187 GL 264 BUN 27 CR
0.7 NA 140 K 4.4 Mag 2.1, peak troponin .15 on admission
BNP 466 (normal is <100)
.
.
.
[**2171-3-26**] 08:10PM BLOOD WBC-9.8 RBC-3.69* Hgb-10.4* Hct-33.6*
MCV-91 MCH-28.2 MCHC-31.0 RDW-17.6* Plt Ct-207
[**2171-3-27**] 06:10AM BLOOD Neuts-80* Bands-0 Lymphs-10* Monos-4
Eos-4 Baso-1 Atyps-0 Metas-0 Myelos-1*
[**2171-3-27**] 06:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Tear
Dr[**Last Name (STitle) 833**]
[**2171-3-26**] 08:10PM BLOOD PT-20.0* PTT-23.0 INR(PT)-1.8*
[**2171-3-26**] 08:10PM BLOOD Glucose-443* UreaN-31* Creat-0.7 Na-136
K-5.5* Cl-92* HCO3-39* AnGap-11
[**2171-3-29**] 02:42AM BLOOD ALT-19 AST-14 LD(LDH)-201 AlkPhos-41
TotBili-0.1
[**2171-3-26**] 08:10PM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9
.
.
[**2171-4-2**] 01:53PM BLOOD WBC-10.2 RBC-4.00* Hgb-11.6* Hct-34.6*
MCV-87 MCH-28.9 MCHC-33.4 RDW-17.5* Plt Ct-112*
[**2171-4-2**] 05:33AM BLOOD Neuts-54 Bands-20* Lymphs-8* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-10* Myelos-5* NRBC-4*
[**2171-4-2**] 05:33AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL
Schisto-OCCASIONAL Burr-1+ Stipple-OCCASIONAL
.
[**2171-4-2**] 01:53PM BLOOD FDP-10-40*
[**2171-4-2**] 01:53PM BLOOD Fibrino-561*
[**2171-4-2**] 06:03PM BLOOD Glucose-158* UreaN-24* Creat-1.2 Na-129*
K-4.5 Cl-92* HCO3-23 AnGap-19
[**2171-4-2**] 05:33AM BLOOD ALT-1603* AST-1700* LD(LDH)-1399*
CK(CPK)-663* AlkPhos-277* TotBili-0.3
[**2171-4-2**] 05:33AM BLOOD CK-MB-11* MB Indx-1.7 cTropnT-0.09*
[**2171-4-2**] 06:03PM BLOOD Calcium-8.2* Phos-3.4 Mg-2.0
[**2171-4-2**] 01:53PM BLOOD D-Dimer-3311*
[**2171-4-2**] 11:47PM BLOOD Type-[**Last Name (un) **] pH-7.26* Comment-GREEN TOP
[**2171-4-2**] 08:15PM BLOOD Lactate-3.9*
.
.
EKG on admission to OSH: Narrow complex tachycardia at 150bpm.
likely atrial flutter with nl axis STD V3-V6. TWI I, II, III,
AVF.
ECG Later in admission to OSH: Wandering atrial pacemaker with
irregular rhythm, nl axis, STD V3-V6.
.
Cath report:
1. Selective coronary angiography of this right-dominant system
demonstrated 2 vessel coronary artery disease. The LMCA had a
widely
patent stent with minimal proximal in-stent narrowing. The LAD
had <50%
stenosis at mid-vessel. The LCx had an 80% ostial stneosis
involving
the origin of a very small AV branch. The RCA had 80% proximal
in-stent
restenosis with a 70% mid-vessel lesion and a 70% distal lesion.
2. Femoral angiography demonstrated a very small perforation of
the
fem-fem bypass graft.
3. Limited resting hemodynamics revealed severe systemic
systolic
arterial hypertension.
4. Successful PCI to RCA with DES.
5. Monitoring in CCU as above. Femoral sheath left in place
overnight.
6. Aspirin 325mg daily, Plavix 75mg daily for a minimum of 12
months.
.
Echo
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. The pulmonary artery systolic pressure
could not be determined. There is an anterior space which most
likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
Compared with the prior report (images unavailable for review)
of [**2169-2-14**], the findings are similar.
.
.
Brief Hospital Course:
68 yoM with significant cardiac and pulmonary comorbidities
including advanced COPD, IHD and sCHF (EF 42%) who was admitted
to the CCU for observation following perforation of fem-fem
graft during semi-elective coronary catheterization who??????s post
cath course was complicated by unstable Afib/Aflutter, GI
bleeding, aspiration, respiratory failure, sepsis, renal and
hepatic failure from which he unfortunately expired.
.
.
.
Mr. [**Known lastname 82074**] was initially admitted for coronary cath after recent
OSH hospitalziations for NSTEMI, CHF exacerbation and new AF.
Upon admission he underwent coronary cath with PCI to RCA with
DESx3. Post cath groin angio showed a small perforation of
fem-fem graft. He was hemodynamically stable and transferred to
CCU for observation. Anti-coagulation was stopped and follow-up
imaging of groins and retroperitoneum did not show ongoing
bleed. In the CCU he developed continued to have AFib/flutter
with difficult to control RVR. He developed upper GI bleeding
with hematemesis complicated by aspiration and respiratory
failure. EGD showed deudonitis without active bleed. He was
intubated and ventilated and broad spectrum antibiotics were
started for possible aspiration pneumonia and suspected sepsis.
Subsequently in the setting of low BP's and AF/RVR underwent
cardioversion which resulted in a VF rythm which was terminated
with shock. He further deteriorated with worsening renal
functions, hyperkalemia and metabolic acidosis requiring CVVH,
shock requiring 3 pressors, rising lactate, liver failure
consistent with shock liver, advanced anasarca. On day 8 after
admission held family meeting with patient??????s 2 daughters
including his HCP. Discussed patient??????s poor prognosis in light
of multi-system failure. Family requested to avoid any
escalation of care and to change code-status to DNR. Later
overnight patient??????s condition worsened including recurring
atrial fibrillation and low blood pressures. After further
discussion and in accordance with the family??????s wishes pressors
and CVVH were withdrawn. Patient expired on [**4-3**] in the AM with
his family at the bedside.
Medications on Admission:
Levemer 25mg qhs - started at osh
ISS
NPH 100u in AM, 10u at night
Colace 100mg PO BID
MVI PO daily
Bisacodyl suppositories
Lactinex 2mg PO BID
Lasix 40mg PO daily
Protonix 40mg PO daily
Crestor 10mg PO qhs - started at OSH
Sotalol 80mg PO BID - started at OSH
Pravastatin 80mg PO daily - home med
Digoxin 0.125mg PO daily - started at OSH
Advair 500/50 inh [**Hospital1 **]
Neurontin 300mg PO qAM, 600mg qhs
Spiriva 18mcg daily
Lopressor 25mg PO BID
Prednisone taper 40mg PO daily currently, usually maintenance
15mg PO daily
Celexa 10mg PO daily - started at OSH
Flomax 0.4mg PO daily
Vitamin D 50,000 units Thursday
Ciprofloxacin 500mg PO BID x 7days
Coumadin (stopped due to concern for GI bleed)
Plavix 75mg PO QD (stopped due to concern for GI bleed)
ASA 81mg QD
.
MEDICATIONS ON TRANSFER from [**Hospital3 **]:
Prednisone 20mg PO daily
Sotalol 80mg PO BID
Flomax 0.4mg PO daily
Coumadin held
Simvastatin 40mg PO daily
Prilosec 40mg PO daily
MVI 1tab PO daily
Nystatin swish and swallow 5mL PO QID
Rocephin 1g IV q24h
Zithromax 500mg IV q24h
Lactinex 1tablet PO TID
Dulcolax 10mg PR daily prn
Celexa 10mg PO daily
Digoxin 125mcg PO daily
Colace 100mg PO BID
Vitamin D 50,000units PO daily qThursday
Advair 500/50mcg 1puff [**Hospital1 **]
Lasix 40mg PO daily
Neurontin 300mg PO daily, 600mg PO qhs
Robitussin 200mg q6h prn
Levemir 20units SC HS
ISS
Atrovent neb q6h
Xopenex neb q6h
.
.
MEDICATIONS ON TRANSFER to CCU:
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheezing
Ipratropium Bromide Neb 1 NEB IH Q6H
Docusate Sodium 100 mg PO BID
Bisacodyl 10 mg PR HS:PRN constipation
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
PredniSONE 20 mg PO/NG DAILY Start: In am
Simvastatin 40 mg PO/NG DAILY
Omeprazole 40 mg PO DAILY
Multivitamins 1 TAB PO/NG DAILY
Nystatin Oral Suspension 5 mL PO QID swish and swallow
Lactulose 30 mL PO/NG Q8H:PRN constipation
Digoxin 0.125 mg PO/NG DAILY
Citalopram 10 mg PO/NG DAILY
Vitamin D 50,000 UNIT PO/NG 1X/WEEK (TH)
Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **]
Furosemide 40 mg PO/NG DAILY
Gabapentin 300 mg PO/NG QAM
Gabapentin 600 mg PO/NG HS
Guaifenesin [**4-2**] mL PO/NG Q6H:PRN cough
Aspirin 325 mg PO/NG DAILY
Clopidogrel 75 mg PO/NG DAILY
Insulin SC (per Insulin Flowsheet)
Metoprolol Tartrate 25 mg PO/NG [**Hospital1 **] Start: In am Hold for
SBP<100, HR<60
Lisinopril 10 mg PO/NG DAILY Start: today, after cath.
hold for SBP<100
Furosemide 40 mg IV ONCE Duration: 1 Doses Hold for SBP <100
Atropine Sulfate 0.5 mg IV X1 PRN symptomatic bradycardia &
hypotension [**Month (only) 116**] repeat up to 2 mg total (including Atropine
during procedure)
Oxycodone-Acetaminophen [**11-25**] TAB PO/NG Q6H:PRN pain hold for
sedation or RR < 10
.
Discharge Medications:
NA
Discharge Disposition:
Expired
Discharge Diagnosis:
NA
Discharge Condition:
NA
Discharge Instructions:
NA
Followup Instructions:
NA
Completed by:[**2171-4-3**]
|
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3446, 3652
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3668, 3891
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,828
| 199,418
|
23764
|
Discharge summary
|
report
|
Admission Date: [**2133-3-10**] Discharge Date: [**2133-3-14**]
Date of Birth: [**2061-8-12**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
sepsis, hypotension, cellulitis
Major Surgical or Invasive Procedure:
Central line placement
Intubation
History of Present Illness:
71 YO M w AFIB, vasculopath w 4.5cm AAA s/p R profunda-[**Doctor Last Name **]
bypass ([**11-20**]) and left common femoral to anterior tibial bypass
([**12/2131**]) who presented after his son noted him to be altered for
several hours at home. The patient's sister spoke with the
patient at 6pm on the night prior to admission at which time he
was alert, oriented and acting normally.
.
In the ED, the patient was initially triggered for nursing
concern. His first documented VS were: 98.6 --> 104 108 145/67
24 99% on NRB --> 96%4L. He was oriented to self only and had
extensive RLE cellulitis from the groin covering the entire leg
with initial c/f Fournier's. Labs were notable for WBC 13.6 with
left shift (3% bands, 1% metas), Plts 84K, lactate 4.4 --> 4.0.
U/A was negative for infection. Blood and urine cultures were
sent. CXR showed mild pulm congestion. The patient was intubated
w a 7.5 ett, etomidate and succinylcholine for airway protection
in order to complete a CT torso. CT torso was c/f bibasilar
aspiration but no evidence of Fournier's or abscess. After
return from CT, the patient was noted to be in a SVT to the
160s. He was given bolus amiodarone and started on an amio gtt.
He was thereafter hypotensive to the high 70s so was started on
levophed. A subclavian CVL was placed. He was given vanc, cipro
and flagyl along with 6-8L NS. [**Year (4 digits) **] and general surgery were
called and neither team reportedly felt there was any indication
for surgical intervention. VS prior to transfer: 87 99/62 22
100% VENT 500/22/5/0.5.
Past Medical History:
PMH: Hypertension, hyperlipidemia, atrial fibrillation (s/p
cardioversion), rheumatoid arthritis, prostate cancer (XRT),
neuropathy, lumbar spinal stenosis, rosacea, ocular migraines,
RA, AAA-being followed
PSH: right right profunda to BK-[**Doctor Last Name **] bypass ([**2131-11-16**]),
angioplasty left [**Doctor Last Name **] artery and left AT ([**9-19**]), debridement
left lateral malleolar ulcer ([**10-20**]), split-thickness skin [**Month/Year (2) **]
to left lateral malleolar ulcer ([**10-20**]), dx angio ([**11-19**])
Social History:
Normally lives alone, independent. Previously in [**Hospital 38**]
Rehab. Retired security guard. H/o tobacco use 2 ppd x 40
years, quit 18 years ago. H/o heavy EtOH use (beer) for many
years, stopped few months ago. Denies illicit drug use. Able to
drive on his own, buys his own groceries. Has son and sister who
are his support structure.
Family History:
Parents both smokers and died of lung cancer, father at 57 [**Name2 (NI) **]
and mother at [**Age over 90 **] [**Name2 (NI) **].
Physical Exam:
VS: 97, HR 69 BP 144/86 16 96% on RA
In: 1000cc Out 1700cc
GENERAL: Well-appearing obese man in NAD, alert and oriented X3.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
LUNGS: rhoncorous, no crackles auscultated, no wheezes.
HEART: regular,no murmurs auscultated, distant heart sounds, S1
, S2.
ABDOMEN: Soft/NT/ND, no masses or HSM, + BS no rebound/guarding,
obese.
EXTREMITIES: B/L medial scars from bypass surgery appear
well-healed, dopplerable peripheral pulses, + chronic venous
dermatitis; mild warmth, mild erthema (mostly ant tibial and
groin - not involving the scrotum), , pitting (1+ of RLE to mid
calves, + right inguinal LAD . Non pitting edema to 1+ edema of
left lower extremity to mid calf.
Pertinent Results:
Admission Labs
[**2133-3-10**] 10:37PM TYPE-MIX COMMENTS-GREEN-TOP
[**2133-3-10**] 10:37PM LACTATE-1.7
[**2133-3-10**] 10:37PM O2 SAT-87
[**2133-3-10**] 10:26PM GLUCOSE-178* UREA N-21* CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-11
[**2133-3-10**] 10:26PM CK(CPK)-113
[**2133-3-10**] 10:26PM CK-MB-6 cTropnT-0.08*
[**2133-3-10**] 10:26PM CALCIUM-7.5* PHOSPHATE-4.7*# MAGNESIUM-2.1
[**2133-3-10**] 10:26PM WBC-20.9* RBC-3.49* HGB-10.0* HCT-31.2*
MCV-89 MCH-28.7 MCHC-32.2 RDW-17.3*
[**2133-3-10**] 10:26PM PLT COUNT-68*
[**2133-3-10**] 04:29PM TYPE-MIX COMMENTS-GREEN-TOP
[**2133-3-10**] 04:29PM LACTATE-2.5*
[**2133-3-10**] 04:29PM O2 SAT-94
[**2133-3-10**] 04:09PM TYPE-ART PO2-95 PCO2-36 PH-7.36 TOTAL CO2-21
BASE XS--4
[**2133-3-10**] 04:09PM LACTATE-2.2*
[**2133-3-10**] 11:50AM TYPE-ART TEMP-38.0 RATES-22/22 TIDAL VOL-500
PEEP-5 O2-50 PO2-113* PCO2-38 PH-7.35 TOTAL CO2-22 BASE XS--3
INTUBATED-INTUBATED VENT-CONTROLLED
[**2133-3-10**] 11:50AM LACTATE-2.9*
[**2133-3-10**] 11:50AM O2 SAT-97
[**2133-3-10**] 11:50AM freeCa-1.09*
[**2133-3-10**] 11:31AM GLUCOSE-147* UREA N-20 CREAT-1.2 SODIUM-142
POTASSIUM-2.9* CHLORIDE-108 TOTAL CO2-22 ANION GAP-15
[**2133-3-10**] 11:31AM CK(CPK)-118
[**2133-3-10**] 11:31AM CK-MB-4 cTropnT-0.13*
[**2133-3-10**] 11:31AM CALCIUM-7.3* PHOSPHATE-1.5* MAGNESIUM-1.4*
[**2133-3-10**] 11:31AM WBC-31.2*# RBC-3.89* HGB-11.0* HCT-34.3*
MCV-88 MCH-28.3 MCHC-32.1 RDW-17.1*
[**2133-3-10**] 11:31AM NEUTS-85* BANDS-3 LYMPHS-7* MONOS-5 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2133-3-10**] 11:31AM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
[**2133-3-10**] 11:31AM PLT SMR-LOW PLT COUNT-92*
[**2133-3-10**] 10:38AM TYPE-MIX COMMENTS-GREEN TOP
[**2133-3-10**] 10:38AM LACTATE-4.1*
[**2133-3-10**] 10:38AM O2 SAT-86
[**2133-3-10**] 08:23AM freeCa-1.08*
[**2133-3-10**] 05:40AM LACTATE-4.4*
[**2133-3-10**] 05:30AM GLUCOSE-149* UREA N-25* CREAT-1.2 SODIUM-140
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17
[**2133-3-10**] 05:30AM estGFR-Using this
[**2133-3-10**] 05:30AM ALT(SGPT)-17 AST(SGOT)-26 LD(LDH)-244
CK(CPK)-75 ALK PHOS-68 TOT BILI-0.4
[**2133-3-10**] 05:30AM CK-MB-2 cTropnT-0.04*
[**2133-3-10**] 05:30AM ALBUMIN-3.7 CALCIUM-9.2 PHOSPHATE-1.5*#
MAGNESIUM-1.7
[**2133-3-10**] 05:30AM TRIGLYCER-83
[**2133-3-10**] 05:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2133-3-10**] 05:30AM WBC-13.6*# RBC-4.36*# HGB-12.5*# HCT-37.7*#
MCV-87 MCH-28.6 MCHC-33.0 RDW-17.5*
[**2133-3-10**] 05:30AM NEUTS-91* BANDS-3 LYMPHS-3* MONOS-2 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-0
[**2133-3-10**] 05:30AM PT-12.7 PTT-19.1* INR(PT)-1.1
[**2133-3-10**] 05:30AM PT-12.7 PTT-19.1* INR(PT)-1.1
[**2133-3-10**] 05:30AM FIBRINOGE-463*#
[**2133-3-10**] 05:20AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007
[**2133-3-10**] 05:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
Discharge Labs
[**2133-3-14**] 07:15AM BLOOD WBC-10.5 RBC-3.58* Hgb-10.0* Hct-31.1*
MCV-87 MCH-27.9 MCHC-32.1 RDW-17.4* Plt Ct-106*
[**2133-3-13**] 06:30AM BLOOD WBC-17.2* RBC-3.33* Hgb-9.3* Hct-29.2*
MCV-88 MCH-27.8 MCHC-31.7 RDW-17.2* Plt Ct-88*
[**2133-3-13**] 06:30AM BLOOD Neuts-93.6* Lymphs-3.9* Monos-1.5*
Eos-0.8 Baso-0.2
[**2133-3-12**] 07:25AM BLOOD Neuts-94.6* Lymphs-3.2* Monos-2.0 Eos-0.1
Baso-0.1
[**2133-3-11**] 04:16AM BLOOD Neuts-84* Bands-14* Lymphs-0 Monos-2
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2133-3-14**] 07:15AM BLOOD Plt Ct-106*
[**2133-3-13**] 06:30AM BLOOD Plt Ct-88*
[**2133-3-12**] 07:25AM BLOOD Plt Ct-73*
[**2133-3-11**] 04:16AM BLOOD Plt Ct-67*
[**2133-3-10**] 05:30AM BLOOD Fibrino-463*#
[**2133-3-12**] 07:25AM BLOOD Ret Aut-1.6
[**2133-3-14**] 07:15AM BLOOD Glucose-100 UreaN-16 Creat-0.9 Na-144
K-4.1 Cl-106 HCO3-32 AnGap-10
[**2133-3-13**] 06:30AM BLOOD Glucose-112* UreaN-22* Creat-1.0 Na-137
K-3.6 Cl-104 HCO3-27 AnGap-10
[**2133-3-12**] 07:25AM BLOOD Glucose-117* UreaN-19 Creat-1.1 Na-138
K-4.0 Cl-106 HCO3-28 AnGap-8
[**2133-3-13**] 06:30AM BLOOD CK-MB-3 cTropnT-0.12*
[**2133-3-11**] 05:56AM BLOOD CK-MB-6 cTropnT-0.09*
[**2133-3-10**] 10:26PM BLOOD CK-MB-6 cTropnT-0.08*
[**2133-3-10**] 11:31AM BLOOD CK-MB-4 cTropnT-0.13*
[**2133-3-10**] 05:30AM BLOOD CK-MB-2 cTropnT-0.04*
[**2133-3-14**] 07:15AM BLOOD Calcium-8.5 Phos-4.1 Mg-1.8
[**2133-3-13**] 06:30AM BLOOD Calcium-8.4 Phos-3.3 Mg-1.7
[**2133-3-12**] 07:25AM BLOOD Calcium-8.0* Phos-3.0 Mg-2.1 Iron-19*
[**2133-3-12**] 07:25AM BLOOD calTIBC-251* Ferritn-214 TRF-193*
[**2133-3-11**] 05:56AM BLOOD Digoxin-0.5*
[**2133-3-10**] 10:38AM BLOOD Lactate-4.1*
[**2133-3-10**] 11:50AM BLOOD Lactate-2.9*
[**2133-3-10**] 10:37PM BLOOD Lactate-1.7
[**2133-3-11**] 06:12AM BLOOD Lactate-1.4
[**2133-3-11**] 11:02AM BLOOD Lactate-1.4
.
Reports
[**3-10**] EKG
Atrial tachycardia. Leftward axis. RSR' pattern in leads V1-V2.
ST-T wave
abnormalities. Since the previous tracing of [**2132-1-3**] the rate is
faster.
Atrial tachycardia is new. Axis is more leftward. ST-T wave
abnormalities are more marked.
.
[**3-10**] CT head
IMPRESSION: No evidence of an acute pathologic intracranial
process. MRI
would be more sensitive for small lesions, if indicated.
.
[**3-10**] CXR
IMPRESSION: Low lung volumes. Stable moderate cardiomegaly. No
acute
cardiopulmonary process.
.
[**3-10**] Ct abdomen
1. No CT evidence of intra-abdominal infection or Fournier
gangrene. 2.4 cm
necrotic-appearing right inguinal lymph node, likely reactive
from the known
right lower extremity cellulitis.
2. Fusiform infrarenal abdominal aortic aneurysm measures up to
4.7 cm in
diameter, which has increased from the last documented size of
4.2 cm in the
inhouse abdominal ultrasound on [**2130-9-10**]. Unchanged
thrombosed [**Female First Name (un) 899**].
3. Focal airspace consolidation in the right medial base,
compatible with
pneumonia.
4. Cholelithiasis without acute cholecystitis.
5. Bypass grafts originating the left superficial femoral artery
and the
right deep femoral artery, incompletely imaged but grossly
patent.
.
[**3-12**] CXR
IMPRESSION:
1. No evidence of aspiration.
2. Stable cardiomegaly.
3. Stable mild bibasilar atelectasis and small pleural
effusions.
Brief Hospital Course:
Mr [**Known lastname 12130**] is 71 year old Male with Atrial Fibrillation and
vasculopathy presented with hypotension and chills/fever with
evidence of bilateral aspiration and right leg cellulitis. He
was briefly intubated and on vasopressors in the ICU and was
subsequently hemodynamically stable after transfer to the floor.
.
# Septic shock. Hypotension may be largely attributed to
amiodarone and propofol given the ED although given additional
evidence of infection, he was treated as though he had septic
shock with vancomycin and Zosyn initially. He responded to
intravenous fluids and was hemodynamically stable off
vasopressors. His left lower extremity cellulitis was the
likely source of his infection. He additionally had evidence of
aspiration on CT, however he never had signs or symptoms of a
pneumonia and follow up Chest xray was negative for pneumonia.
Given this, he was transitioned to clindamycin to cover MRSA
cellulitis. He was initially covered with 20mg
methylprednisolone given home steroid use, which was later
transitioned back to his 8mg daily methylprednisone dose after
he was hemodynamically stable. Sputum cultures grew sparse yeast
and Blood cultures are pending at the time of discharge Surgery
recs for lower extremities included bilateral ACE wraps and leg
elevation
.
# SVT. He had an episode of heart rate in the 160s after
intubation, by ECG this was diagnosed as either atrial
tachycardia or atrial flutter. This responded to amiodarone. He
had no further episodes of tachycardia while monitored on
telemetry. He has a history of atrial fibrillation with a CHADS
score of 1. However he is not on Coumadin because his INR was
difficult to control. Therefore, he has been managed on
full-dose aspirin which was continued on discharge.He had his
home metoprolol, and home digoxin restarted.
.
# Altered mental status requiring intubation. This was likely
secondary to infection. CT head was negative for any acute
process. This had resolved by the time of transfer to the
floor.
.
# Questionable Initial hypoxia. While on the floor, he
tolerated room air well with oxygen saturation above 96% and no
complaints of significant cough. Despite receiving 6-8 liters
of fluid he did not appear fluid overloaded on exam on the
wards. His home Lasix was initially held in the setting of
hypotension and subsequently restarted after transfer to the
floor.
.
# Thrombocytopenia. Relatively chronically stable in the 60s to
70s. No evidence of cirrhosis on CT scan of abdomen, INR and
fibrinogen is normal. Blood smear did show evidence of MDS which
he needs outpatient hematology oncology followup for.
.
#Anemia- His Hct has been around 30 for several years. His Hct
trended down during his hospitalization, however this likely
just reflects recussication with large volumes. Sent iron
studies which indicated iron deficiency and was started on iron
supplements.
.
#HTN: Restarted home Lasix and metoprolol after transfer to the
floor.
.
#Troponin leak- had troponin elevation in the setting of
hypotension and tachycardia up to 0.14 with normal CK-MB. His
EKG was unremarkable on the floor with some nonspecific lateral
ST changes in V5-V6. The patient denied chest pain or pressure.
His troponin remains elevated to 0.12 with normal CK Mb and
without EKG changes and clinical symptoms. Cardiology was not
impressed with the clinical scenario and the patient was
discharged with cardiology follow up. Consider outpatient
cardiac stress test.
Blood smear and thrombocytopenia is concerning for MDS- please
have the patient see Hematology/Oncology as a outpatient.
Consider outpatient cardiac stress test given troponin leak per
above.
Needs podiatry follow up for small ulcer on the third right
digit on right foot.
Medications on Admission:
FUROSEMIDE - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METHYLPREDNISOLONE - (Prescribed by Other Provider; Dose
adjustment - no new Rx) - 4 mg Tablet - 2 Tablet(s) by mouth
METOPROLOL SUCCINATE - 100mg qd
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by
mouth as needed for pain
SIMVASTATIN - 10 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily)
DIGOXIN - unknown dose
Medications - OTC
ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1
Tablet(s) by mouth once a day
CALCIUM CARBONATE - (Prescribed by Other Provider) - Dosage
uncertain
MULTIVITAMIN,TX-MINERALS [MULTI-VITAMIN HP/MINERALS] -
(Prescribed by Other Provider) - Capsule - 1 Capsule(s) by
mouth DAILY (Daily)
Discharge Medications:
1. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. clindamycin HCl 150 mg Capsule Sig: Three (3) Capsule PO Q6H
(every 6 hours) for 7 days: Please take to [**3-19**].
Disp:*63 Capsule(s)* Refills:*0*
8. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea .
Disp:*30 Capsule(s)* Refills:*0*
9. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: 1.5 Tablet Extended Release 24 hrs PO once a day.
Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*0*
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: Do not take if have diarrhea.
Disp:*60 Capsule(s)* Refills:*0*
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation: Do not take if have diarrhea.
Disp:*30 Tablet(s)* Refills:*0*
12. methylprednisolone 4 mg Tablet Sig: Two (2) Tablet PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary Diagnosis
-Altered mental status
-Hypotension
-Aspiration pneumonitis
Secondary Diagnosis
-PVD
-HTN
-Atrial fibrilliation/flutter
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure to care for you as your doctor.
You were brought to the hospital after you were observed to be
confused. You were briefly put on a respiratory machine and
given medication to support your blood pressure. After
intravenous fluids and antibiotics you stabilized and were
transferred to the medical floor. Your intravenous antibiotics
were converted to oral antibiotics and you were discharged home.
We made the following changes to your home medication list:
-INCREASE metoprolol from 100mg to 150mg daily
-START Clindamycin (an antibiotic to treat your skin infection)
until [**2133-3-19**].
-START loperamide as needed for diarrhea
-START ferrous sulfate (iron) for anemia
--> while taking ferrous sulfate (iron), you may have
constipation, so please also START docusate and senna for
constipation once your diarrhea resolves
See below for outpatient follow-up appointments.
Followup Instructions:
Department: [**Year (4 digits) **] SURGERY
When: THURSDAY [**2133-3-26**] at 10:00 AM
With: [**Year (4 digits) **] LAB [**Telephone/Fax (1) 1237**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital **] HEALTHCARE OF [**Location (un) **]
When: FRIDAY [**2133-3-20**] at 11:40 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
Department: PODIATRY
When: FRIDAY [**2133-3-20**] at 3:50 PM
With: [**Known firstname **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 542**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 122**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Specialty: Cardiology
Address: [**Street Address(2) 3001**] [**Location (un) 620**] [**Numeric Identifier 3002**]
Phone: [**Telephone/Fax (1) 4105**]
Appointment: Monday [**3-23**] at 3:45PM
|
[
"272.4",
"682.6",
"714.0",
"427.32",
"507.0",
"287.5",
"441.4",
"995.92",
"443.9",
"V10.46",
"427.31",
"285.9",
"038.9",
"401.9",
"785.52",
"427.89",
"V58.65"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
15982, 16031
|
10191, 13957
|
305, 341
|
16214, 16214
|
3813, 10168
|
17317, 18700
|
2865, 2995
|
14709, 15959
|
16052, 16193
|
13983, 14686
|
16397, 17294
|
3010, 3794
|
233, 267
|
369, 1930
|
16229, 16373
|
1952, 2487
|
2503, 2849
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,905
| 187,771
|
52187
|
Discharge summary
|
report
|
Admission Date: [**2149-11-20**] Discharge Date: [**2149-11-26**]
Date of Birth: [**2090-3-22**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Shellfish
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Asymptomatic
Major Surgical or Invasive Procedure:
[**2149-11-20**] Redo-sternotomy, Pulmonic valve replacement, Tricuspid
valve repair, ICD lead removal
[**2149-11-24**] AICD placement
History of Present Illness:
This is a 59 year old male with a history of Tetralogy of
Fallot, s/p repair [**2099**]. He has been followed for pulmonary
regurgitation. Currently he is asymptomatic, however, admits to
decreasing his activity. He denies chest discomfort or shortness
of breath. He does occasionally feel palpitations. He was
referred for surgical management of his severe pulmonary
insufficiency and tricuspid regurgitation.
Past Medical History:
Tetralogy of Fallot, s/p transannular patch repair [**2099**]
?membranous VSD leak (noted on MR, not present on more recent
echo)
History of VF arrest [**2144**], s/p AICD (St.[**Male First Name (un) 923**] dual chamber)
severe Pulmonary Insufficiency
moderate to severe Tricuspid Regurgitation
moderate Pulmonary hypertension
GERD
Stable right pulmonary nodules
[**2144**] left cephalic vein thrombus, briefly on coumadin
Social History:
Lives with: wife, has 3 children
Contact: [**Name (NI) **] [**Name (NI) 107971**] (wife): [**Telephone/Fax (1) 107972**]
Occupation: Painter at BU
Cigarettes: Patient smoked up to 2 ppd x approximately 30
years. He quit [**2144**]
ETOH: < 1 drink/week [] [**3-4**] drinks/week [] >8 drinks/week [x] (2
beers per night)
Illicit drug use: occasional marijuana
Family History:
Family history notable for brother deceased from "a heart
attack" in his 30's -history is unclear as brother was estranged
and living on the street - ? drug overdose, mother deceased in
50's from cancer, father in his 80's w/o significant medical
history.
Physical Exam:
PREOPERATIVE EXAM
General: NAD
Skin: Warm [x] Dry [x] intact [x]
well healed median sternotomy
HEENT: NCAT [x] PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart:RRR [x] Irregular [] Murmur [] grade. no murmur
appreciated
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+
[x]
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 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:
[**2149-11-20**] Intraop TEE: Pre-Bypass: The left atrium is mildly
dilated. The right atrium is dilated. No spontaneous echo
contrast is seen in the body of the left or right atrium. There
is mild symmetric left ventricular hypertrophy. The left
ventricular cavity size is top normal/borderline dilated.
Overall left ventricular systolic function is normal (LVEF>55%).
There is no ventricular septal defect. The right ventricular
free wall is hypertrophied. The right ventricular cavity is
markedly dilated with normal free wall contractility. There is
abnormal diastolic septal motion/position consistent with right
ventricular volume overload.
The aortic root is mildly dilated at the sinus level. There are
simple atheroma in the ascending aorta, aortic arch and in the
descending thoracic aorta. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. The
tricuspid valve leaflets are mildly thickened. Moderate to
severe [3+] tricuspid regurgitation is seen. There is mild
pulmonary artery systolic hypertension. Severe pulmonic
regurgitation is seen.
Post-Bypass: The patient is in SR on a phenylephrine and
epinephrine infusion s/p pulmonary valve replacement and
triscuspid ring annuloplasty.
Left ventricular function is preserved with an estimated
EFR>55%. The right ventricle remains dilated and mildly
depressed. There is a well seated #27 bioprosthetic pulmonary
valve. There is no evidence of perivalvular leak. There is no
pulmonic regurgitation. Peak/mean gradients are [**4-28**] at a CO of
4.3. Tricuspid regurgitation is no longer present. Peak/ mean
gradients are [**3-27**]. There is no echocardiographic evidence of
aortic dissection s/p decannulation. The remainder of the exam
is unchanged.
.
Echo [**2149-11-25**]: Overall left ventricular ejection fraction
appears normal (LVEF 57%) (by fractional area change measurement
in the short axis window) during intrinsic conduction. The right
ventricular free wall is hypertrophied. The right ventricular
cavity is dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. However, the degree of
ventricular interaction appears reduced compared to the prior
study. There is no pericardial effusion. During right
ventricular apical pacing, marked pacing-induced left
ventricular mechanical dyssynchrony is seen, with a reduction of
left ventricular ejection fraction to approximately 45 percent
(by fractional area change measurement in the short axis
window).
.
Chest X-ray [**2149-11-25**]: As compared to the previous radiograph,
the left pectoral generator has been changed. There is one lead
projecting over the right ventricle and one over the right
atrium. No evidence of pneumothorax. Borderline size of the
cardiac silhouette. No pulmonary edema. No other acute lung
parenchymal changes.
.
[**2149-11-20**] 11:47AM BLOOD WBC-20.7*# RBC-2.94*# Hgb-9.8*#
Hct-29.2*# MCV-100* MCH-33.2* MCHC-33.4 RDW-12.3 Plt Ct-180
[**2149-11-26**] 07:10AM BLOOD WBC-11.5* RBC-3.13* Hgb-10.6* Hct-32.0*
MCV-102* MCH-33.9* MCHC-33.2 RDW-12.7 Plt Ct-277#
[**2149-11-20**] 11:47AM BLOOD PT-15.4* PTT-33.5 INR(PT)-1.4*
[**2149-11-24**] 01:00AM BLOOD PT-11.2 PTT-27.2 INR(PT)-1.0
[**2149-11-20**] 01:43PM BLOOD UreaN-16 Creat-1.0 Na-142 K-4.0 Cl-113*
HCO3-21* AnGap-12
[**2149-11-26**] 07:10AM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-25 AnGap-15
[**2149-11-26**] 07:10AM BLOOD ALT-42* AST-49* AlkPhos-51 Amylase-36
TotBili-0.7
[**2149-11-21**] 02:41AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.2
Brief Hospital Course:
Mr. [**Known lastname 107971**] was a same day admit and on [**2149-11-20**] was brought to
the operating room where he underwent a redo-sternotomy,
pulmonic valve replacement, tricuspid valve repair and partial
ICD lead removal. Please see operative note for surgical
details. Following surgery he was transferred to the CVICU for
invasive monitoring in stable condition. Within 24 hours he was
weaned from sedation, awoke neurologically intact and extubated.
He remained on pressors for several days and were eventually
weaned. He remained in the ICU with both epicardial wires and
transcutaneous pacer pads on patient while he awaited a new ICD
placement. On post-op day four he underwent an AICD placement.
Following procedure he was transferred to the step-down floor
for further care. Chest tubes and epicardial pacing wires were
removed per protocol. He continued to work with physical therapy
for strength and mobility while making good progress. On post-op
day six he was ready for discharge home with VNA services and
the appropriate medications and follow-up appointments.
Medications on Admission:
Lisinopril 2.5mg daily
Toprol XL 75mg daily
Protonix 40mg daily
Aspirin 81mg daily
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Pantoprazole 40 mg PO Q24H
4. Metoprolol Tartrate 25 mg PO TID
5. Furosemide 20 mg PO DAILY Duration: 5 Days
6. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
7. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain Duration: 40
Doses
8. Cephalexin 500 mg PO Q6H Duration: 5 Days
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] vna
Discharge Diagnosis:
Severe pulmonic valve insufficiency and tricuspid valve
regurgitation s/p Redo-sternotomy, Pulmonic valve replacement,
Tricuspid valve repair, ICD lead removal
Past medical history:
Tetralogy of Fallot, s/p transannular patch repair [**2099**]
?membranous VSD leak (noted on MR, not present on more recent
echo)
VF arrest [**2144**]
ICD (St.[**Male First Name (un) 923**] dual chamber) [**2144**]
moderate Pulmonary hypertension
GERD
Stable right pulmonary nodules
[**2144**] left cephalic vein thrombus, briefly on coumadin
Discharge Condition:
Alert and oriented x3 nonfocal exam
Ambulating with steady gait
Incisional pain managed with Dilaudid
Incisions:
Sternal - healing well, no erythema or drainage
AICD pocket- CDI w/steri strips
Edema- trace bilat LE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for one month or while taking narcotics. Driving will
be discussed at follow up appointment with surgeon.
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **]#[**Telephone/Fax (1) 170**] on [**2149-12-24**] at 1:15p
Wound Check in [**Hospital 2577**] Medical Building, [**Hospital Unit Name **] on [**2149-12-4**] at
10:15a
Cardiologist: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 62**] on
[**2149-12-16**] at 10:30a ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] NP) [**Hospital Ward Name 23**] 7
Device Clinic:Phone:[**Telephone/Fax (1) 62**] [**2149-12-4**] at 9:00a
Please call to schedule appointments with your
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5717**] [**Telephone/Fax (1) 2010**] in [**5-1**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2149-11-26**]
|
[
"V12.53",
"E878.1",
"416.8",
"424.2",
"530.81",
"V13.65",
"V12.51",
"424.3",
"996.04",
"276.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.33",
"35.39",
"39.61",
"35.25",
"35.31",
"37.94",
"37.75"
] |
icd9pcs
|
[
[
[]
]
] |
7950, 8005
|
6363, 7448
|
291, 427
|
8573, 8789
|
2626, 6340
|
9591, 10550
|
1705, 1962
|
7582, 7927
|
8026, 8186
|
7474, 7559
|
8813, 9568
|
1977, 2607
|
239, 253
|
455, 867
|
8208, 8552
|
1329, 1689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,172
| 181,096
|
16908
|
Discharge summary
|
report
|
Admission Date: [**2187-6-16**] Discharge Date: [**2187-7-4**]
Date of Birth: [**2133-2-11**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
gentleman status post a fall down four to six stairs and
found unconscious and intoxicated by EMS. The outside
hospital obtained a head CT which demonstrated a small right
subdural hematoma and subarachnoid blood, right greater than
left on the tentorium and fourth ventricle. The patient was
transferred to [**Hospital1 69**] for
further management.
PHYSICAL EXAMINATION: The patient was in atrial fibrillation
with a heart rate in the 80s. Blood pressure was 183/89,
respiratory rate was 18, saturations 98%. The patient was
intubated, withdrawing extremities x 4, right greater than
left. Pupils were symmetric at 2-3 mm and sluggishly
reactive. The patient had a contusion on his occiput.
His laboratory studies at the outside hospital were a white
count of 10.1, hematocrit 39.7, platelet count 251, 132/3.3,
94/27, 8/0.7 and 110.
Head CT showed massive left cerebellar bleed with fourth
ventricle effacement and subarachnoid hemorrhage on the
tentorium and contusions in the right frontal lobe. His
serum ETOH level was 215 on admission. He had a ventricular
drain placed without complication and he was taken emergently
to the operating room for evacuation of the cerebellar
hematoma and placement of ventricular drain.
HOSPITAL COURSE: There were no intraoperative complications.
Postoperatively he was monitored in the intensive care unit.
His temperature was 99.5. Neurologically his pupils were 2
mm and reactive. He was intubated. He withdrew his lower
extremities, left greater than right. He had brisk
withdrawal of the left upper extremity and left lower
extremity and weaker on the right side.
On [**2187-6-17**] the patient's sedation was weaned off. He opened
his eyes to voice at times and painful stimuli at other
times. The patient was following commands. The patient
would lift and hold the left arm and left leg up off the bed.
He did not move the right arm or right leg on the bed. He
did show two fingers on the left hand and pupils were equal
and reactive to light. He was following the CIWA scale due
to ETOH with possible ETOH withdrawal.
On [**2187-6-18**] the patient's sodium level was 129, fluid
restriction was initiated. The patient's drain put out 400
cc. His ICP was [**1-22**]. He opened his eyes to tactile
stimulation. He localized to the left upper extremity,
extended the right upper extremity and withdrew bilateral
lower extremities. His pupils were 4 down to 3 mm and brisk.
His white count was 14.1, temperature 99.1.
On [**2187-6-23**] the patient was taken for angiogram to rule out
residual
arteriovenous malformation and there was no evidence of that
on angiogram. The patient's condition continued to remain
stable. He was opening his eyes, following commands, not
moving the right upper or lower extremity. He continued to
have a drain in place leveled at 15 cm above the tragus.
On [**2187-6-25**] the vent drain was removed and the patient was
transferred to the regular floor. He was awake, alert and
oriented x 1, following commands on the left side, wiggling
his toes on the right. He had antigravity strength in the
right upper extremity which was an improvement. He was
transferred to the regular floor. He was evaluated by the
speech and swallow service which he failed and then had a PEG
placed on [**2187-6-29**].
He was seen by physical therapy and occupational therapy and
found to require rehabilitation. He also developed a
pressure ulcer on the back of his head in the midline area
where the incision was due to lying on that. He had some
debridement done to that and is getting normal saline
wet-to-dry dressing changes twice a day to that incision.
His PEG site is clean, dry and intact.
He is now improving neurologically, more cooperative, less
agitated, off sitters, awake, alert and oriented x 2. He
still has a right drift and is ready for transfer to
rehabilitation.
DISCHARGE MEDICATIONS:
1. Trazodone 25 mg p.o. q.h.s.
2. Colace 100 mg p.o. b.i.d.
3. Famotidine 20 mg p.o. b.i.d.
4. Dilantin 200 mg p.o. b.i.d.
5. Metoprolol 25 mg p.o. b.i.d.
6. Captopril 6.25 mg p.o. t.i.d.
7. Percocet 1-2 tablets p.o. q. 4 hours p.r.n.
8. Sodium chloride 1 gram p.o. b.i.d.
9. Subcutaneous heparin 5,000 units q. 12 hours.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: He will follow up with Dr. [**First Name (STitle) **] in one month with
repeat head CT.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2187-7-3**] 11:29
T: [**2187-7-3**] 12:43
JOB#: [**Job Number 47625**]
|
[
"427.31",
"787.2",
"801.32",
"291.81",
"707.0",
"303.90",
"253.6",
"E880.9",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"43.11",
"88.41",
"96.72",
"96.6",
"96.04",
"02.2",
"02.12"
] |
icd9pcs
|
[
[
[]
]
] |
4097, 4420
|
1446, 4074
|
4466, 4833
|
565, 1428
|
159, 542
|
4445, 4454
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,645
| 170,059
|
48027
|
Discharge summary
|
report
|
Admission Date: [**2141-8-15**] Discharge Date: [**2141-8-19**]
Date of Birth: [**2077-6-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
angina
Major Surgical or Invasive Procedure:
[**2141-8-15**] CABG x3 (LIMA to LAD, SVG to OM, SVG to PDA)
History of Present Illness:
64 yo male with CAD and prior PTCA [**47**] years ago. Transferred in
from OSH with unstable angina and + MIBI for infero-septal
ischemia. Cardiac enzymes were negative x 2. Went home for
plavix washout, to return for CABG in a few days.
Past Medical History:
HTN
Hyperlipidemia
CAD /PTCA ~15 yrs ago - balloon angioplasty
Social History:
Social history is significant for the absence of current tobacco
use- quit 20 yrs ago. There is no history of alcohol abuse.
Family History:
Father died 69 with cerebral hemorrhage, mother died at 80 "old
age". There is no family history of premature coronary artery
disease or sudden death.
Physical Exam:
5'9 [**12-7**] " 212 #
skin HEENT unremarkable
neck supple , full ROM, no carotid bruits appreciated
CTAB anteriorly
RRR no murmur
soft, NT, ND + BS
warm, well-perfused with no edema or varicosities noted
neruo grossly intact
2 + bil. fem/DP/PT/radials
Pertinent Results:
Conclusions
PREBYPASS
1. The left atrium is normal in size. No atrial septal defect or
PFO is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses and cavity size are normal.
3. Right ventricular chamber size and free wall motion are
normal.
4. There are simple atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta.
5. The aortic valve leaflets (3) are mildly thickened. There is
mild aortic valve stenosis (area 1.2-1.9cm2). No aortic
regurgitation is seen.
6. The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
7. There is no pericardial effusion.
8. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2141-8-15**]
at 928.
POST CPB:
Preserved [**Hospital1 **]-ventricular systolic function.
No change in valve structure or function.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2141-8-15**] 11:03
[**Known lastname **],[**Known firstname **] J [**Medical Record Number 101303**] M 64 [**2077-6-16**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2141-8-17**] 8:14
AM
[**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2141-8-17**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 101304**]
Reason: ? PTX s/p CT removal
[**Hospital 93**] MEDICAL CONDITION:
64 year old man s/p CABG
REASON FOR THIS EXAMINATION:
? PTX s/p CT removal
Provisional Findings Impression: SP [**Doctor First Name **] [**2141-8-17**] 4:01 PM
No pneumothorax after instrument removal.
Final Report
TYPE OF EXAMINATION: Chest AP portable single view.
INDICATION: Status post bypass surgery. Now extubated and tube
removal.
The patient is extubated and the previously described central
venous line,
pulmonary catheter, mediastinal and chest tubes have been
removed. There is
no pneumothorax and no significant pulmonary vascular
congestion. When
comparison is extended to the pre-operative single view study of
[**2141-8-9**], postoperative findings include moderate enlargement of the
heart
silhouette and some retrocardiac density consistent with
atelectasis. No new
acute parenchymal infiltrates are identified.
DR. [**First Name (STitle) **] [**Initials (NamePattern5) 3250**] [**Last Name (NamePattern5) 3251**]
Approved: [**Doctor First Name **] [**2141-8-17**] 5:26 PM
?????? [**2135**] CareGroup IS. All rights reserved.
[**2141-8-19**] 08:40AM BLOOD WBC-7.9 RBC-3.14* Hgb-10.3* Hct-28.4*
MCV-91 MCH-32.8* MCHC-36.2* RDW-11.9 Plt Ct-187
[**2141-8-15**] 12:15PM BLOOD WBC-19.3*# RBC-3.69* Hgb-12.1* Hct-32.9*
MCV-89 MCH-32.6* MCHC-36.6* RDW-12.6 Plt Ct-168
[**2141-8-19**] 08:40AM BLOOD Glucose-112* UreaN-13 Creat-0.8 Na-136
K-4.5 Cl-103 HCO3-26 AnGap-12
[**2141-8-16**] 02:59AM BLOOD Glucose-130* UreaN-13 Creat-0.7 Na-137
K-4.1 Cl-107 HCO3-26 AnGap-8
Brief Hospital Course:
Admitted [**8-15**] and underwent CABG x3 with Dr. [**Last Name (STitle) **]. Please
refer to Dr[**Last Name (STitle) **] operative report for further details.
Transferred to the CVICU in stable condition on phenyleprine and
propofol drips. Extubated later that afternoon. Gently diuresed
toward his preop weight. Beta blockade titrated.Tubes and drains
were discontinued in a timely fashion. POD#1 he was transfered
to SDU for further telemetry monitoring and recovery. The
remainder of his postoperative course was essentially
uneventful. He continued to progress and on POD#4 he was
discharged to home with VNA. All follow up appointments were
advised.
Medications on Admission:
HCTZ 25 mg daily
atenolol 75 mg [**Hospital1 **]
lipitor 80 mg daily
imdur 60 mg daily
norvasc 2.5 mg daily
folic acid
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Packet(s)* Refills:*0*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*
8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
.[**Hospital1 1474**] VNA
Discharge Diagnosis:
CAD s/p cabg x3
HTN
elev. lipids
Discharge Condition:
good
Discharge Instructions:
no lotions, creams or powders to any incision
no lifting greater than 10 pounds for 10 weeks
call for fever greater than 100.5, redness, or drainage
no driving for one month AND until off all narcotics
shower daily and pat incisions dry
Followup Instructions:
see Dr. [**Last Name (un) **] in [**12-7**] weeks
see Dr. [**Last Name (STitle) 7047**] in [**1-8**] weeks
see Dr. [**Last Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Completed by:[**2141-8-19**]
|
[
"401.9",
"272.4",
"E878.2",
"276.2",
"458.29",
"414.01",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6269, 6325
|
4378, 5035
|
328, 391
|
6402, 6409
|
1345, 2091
|
6694, 6907
|
904, 1056
|
5205, 6246
|
2865, 2890
|
6346, 6381
|
5061, 5182
|
6433, 6671
|
1071, 1326
|
282, 290
|
2922, 4355
|
419, 658
|
680, 745
|
761, 888
|
2102, 2825
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,978
| 123,003
|
53240
|
Discharge summary
|
report
|
Admission Date: [**2195-7-15**] Discharge Date: [**2195-7-28**]
Date of Birth: [**2133-5-26**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
hypotension, elevated creatinine
Major Surgical or Invasive Procedure:
Right heart catheterization with cardiac biopsy
Pacemaker evaluation with atrial and [**Hospital1 **]-ventricular lead
placement
History of Present Illness:
62M with hx of dilated CM (EF 35%), A fib on coumadin, AICD [**2183**]
for non-sustained VT, PV, hyperferritinitis, COPD, irritable
bowel syndrome with chronic diarrhea, presents with hypotension
and increased creatinine. Earlier today he presented to an
outpatient clinic for scheduled phlebotomy to treat
hyperferritinemia. His BP was found to be 86/56, well below his
baseline of 100s/70s. He was asymptomatic. Phlebotomy was
cancelled and he was sent to the emergency department for
evaluation.
.
For the last several months he has been followed by his primary
care, gastroenterology, and cardiology for increased fatigue,
hypotension, and irritible bowel syndrome with significant
diarrhea. Since [**Month (only) 116**] he has had [**4-21**] loose stools daily,
non-bloody, some greasy. Occasional blood on toilet paper [**1-14**]
hemorrhoids. Workup including EGD ([**7-2**]), colonoscopy ([**7-2**])
negative for clear causality. Multiple medications,
particularly anti-hypertensives, have been discontinued and
started in the last few months in an attempt to relieve any
medication effect exacerbating his diarrhea. Of note, his
metoprolol was increased from 25mg daily to 100mg daily one
month ago and he has felt weak ever since. He presented with
new-onset A fib in [**2195-4-12**] and was started on coumadin.
.
In the last week, he has had several episodes of diaphoresis, a
chronic issue now exacerbated. He complains of reduced
appetitite and reduced PO intake, partially due to fatigue and
partially due to feeling full. He denies nausea or vomiting.
He complains of mild lower back pain of several months duration,
no recent changes. Denies CP, SOB, palpitations, abd pain,
headache, dizziness, lightheadedness. Increased urinary urgency
in the last few weeks, no change in frequency or quality of
urine.
.
In the ED, he initially presented with BP 84/64 and HR 118. He
was given fluids (total 3L) and remained hypotensive to 85/60.
Lab values revealed a Cr of 2.1, significantly elevated from
last known value in [**2194-10-13**] of 0.8. He denied CP, SOB,
palpitations, abdominal pain, vomiting, HA, dizziness, or
lightheadedness.
.
In the ICU, he initially presented with BP 109/78, HR 109. He
was comfortable and complained of no chest or abdominal pain,
nor shortness of breath. He denies any symptoms associated with
his hypotension and asserts that his cardiologist is comfortable
with BP in the 100s/70s.
.
In the ICU, patient's hypotension resolved with holding of his
home metoprolol and losartan. He was then called out to the
floors, where he remained normotensive but went into persistent
AFib with RVR in the 130s-140s (at best he was in the
110s-120s). Digoxin, Metoprolol succinate and Diltiazem were all
given with no success decreasing rates below 110s-120s.
.
On [**7-16**], TTE was done to evaluate for new cardiac dysfunction,
and showed new extreme LV restrictive filling pattern. This is
suspected to be related to possible hemochromatosis, as patient
has polycythemia, high hematocrit and high ferritin. Initially
had been planning to follow this outpatient at heart failure
clinic, but because patient has been persistently tachycardic
there is now concern for connection between poor rate control
and restrictive physiology. Last night, he was slightly volume
overloaded (JVD, crackles) b/c holding diuretics, so he received
40mg Lasix. On transfer, he is on room air, BP 116/70, with HR
121.
Past Medical History:
1. Dilated cardiomyopathy (EF 35%, last echo in our system
[**11-18**])
2. AICD placed [**2183**] for non-sustained VT (recent interrogation)
3. Hyperferritin and polycythemia (ferritin up to 600s, Hct in
40s, possibly reactive to hepatic inflammation); therapeutic
phlebotomy Q 3 months, last [**2195-4-12**]. No hemachromatosis, but no
liver biopsy.
4. A fib on coumadin (previously on pradaxa)
5. Irritable bowel syndrome (diarrhea predominant)
6. Barrett's esophagus (last EGD [**2195-7-2**])
7. Colon polyps (last colonoscopy [**2195-7-2**])
8. GERD
9. Hiatal hernia
10. Hemorrhoids
11. h/o pancreatitis (date unknown)
12. Hypertriglyceridemia (832 [**10-22**])
13. Fatty liver disease
14. Emphysema [**1-14**] tobacco abuse
15. Obstructive sleep apnea
16. Urinary frequency
17. Erectile dysfunction
18. Restless leg syndrome
19. Osteopenia
20. Vit D deficiency
21. Inguinal hernia
22. Hydradenitis supurativa
23. Rosacea
24. Depression
25. Anxiety
26. Night sweats
27. Insomnia
28. s/p drainage of perirectal abscess ([**2180**])
Social History:
(per OMR)
retired (high school Spanish teacher), lives with spouse [**Name (NI) **]
[**Known lastname **]
- Tobacco: 1ppd
- Alcohol: 2/day
- Illicits: denies
Family History:
(per OMR)
His mother died at 81 of heart disease and she
had some form of dementia possibly Alzheimer's disease. His
father died at 55 of vascular complications. He has two
brothers, one older and one younger. The older brother has
sleep
apnea and heart trouble.
Physical Exam:
Admission Physical Exam:
Vitals: T: 96.2 BP: 109/78 P: 109 RR: 11 SpO2: 98% RA
General: Alert, oriented, no acute distress
HEENT: NCAT, PERRL, EOMI, Sclera anicteric, MMM, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Chest: ICD in place, site normal
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no edema.
.
Discharge Physical Exam:
Tele: Atrial and [**Hospital1 **]-V paced. Has occasional runs of [**1-16**] beats
NSVT.
Vitals: T 98.1, BP 105/67, P 61, RR 20, O2 Sat 92% RA
GENERAL: WDWN male 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 no JVD.
CARDIAC: RRR. Dressing over pacer on L chest wall C/D/I. PMI
located in 5th intercostal space, midclavicular line. No m/r/g.
No thrills, lifts. No S3 or S4.
LUNGS: Crackles 1/3 up bilateral lung bases. Resp were
unlabored, no accessory muscle use. No wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
Admission Labs:
[**2195-7-15**] 12:00PM GLUCOSE-92 UREA N-44* CREAT-2.1*# SODIUM-134
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-25 ANION GAP-16
[**2195-7-15**] 12:00PM CALCIUM-9.1 PHOSPHATE-4.5 MAGNESIUM-2.1
[**2195-7-15**] 12:00PM WBC-10.4 RBC-5.21 HGB-16.4 HCT-45.0 MCV-86#
MCH-31.4 MCHC-36.3* RDW-14.8
[**2195-7-15**] 12:00PM NEUTS-65.8 LYMPHS-24.5 MONOS-6.9 EOS-2.1
BASOS-0.7
[**2195-7-15**] 01:15PM ALT(SGPT)-15 AST(SGOT)-29 ALK PHOS-43 TOT
BILI-0.5
[**2195-7-15**] 03:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2195-7-15**] 03:15PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.004
[**2195-7-15**] 05:45PM LACTATE-1.1
[**2195-7-15**] 10:22PM PT-33.8* PTT-35.3* INR(PT)-3.4*
.
CARDIAC ENZYMES:
[**2195-7-15**] 01:15PM BLOOD cTropnT-0.02*
[**2195-7-16**] 05:41AM BLOOD CK-MB-3 cTropnT-<0.01
[**2195-7-17**] 06:35AM BLOOD CK-MB-3 cTropnT-0.01
[**2195-7-19**] 05:30AM BLOOD CK-MB-2 cTropnT-0.03* proBNP-[**Numeric Identifier **]*
[**2195-7-19**] 05:17PM BLOOD CK-MB-2 cTropnT-0.02*
.
Imaging: ECHO:
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity is moderately dilated. There
is moderate to severe global left ventricular hypokinesis (LVEF
= 30 %) with regional variation. The right ventricular free wall
thickness is normal. The right ventricular cavity is dilated
with depressed free wall contractility. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2191-11-24**], the left ventricular ejection fraction is
further reduced. The left ventricle now displays an extreme
restrictive filling pattern.
.
ECHO ([**7-28**]): Focused study to evaluate [**Hospital1 **]-V Pacer settings
Baseline atrial paced AV delay 150 ms: no atrial systolic
contribution to left ventricular filling; LVOT VTI = 17 cm
At atrial paced AV delay 200 ms: still no atrial systolic
contribution to left ventricular filling; LVOT VTI = 18 cm.
There was no diastolic mitral regurgitation at AV delay of 200
ms, and >90% biventricular pacing was preserved.
Conclusion: post-cardioversion atrial electromechanical
dissociation is present; atrial paced AV delay set at 200 ms.
Atrial sensed AV delay reprogrammed to 150 ms. [**First Name (Titles) **] [**Last Name (Titles) 109597**]m in 3 months, at which time atrial systolic
contribution to left ventricular filling, and left ventricular
stroke volume, should increase if atrial fibrillation does not
recur.
.
Discharge Labs:
[**2195-7-28**] 06:15AM BLOOD WBC-8.2 RBC-4.61 Hgb-13.8* Hct-41.4
MCV-90 MCH-30.0 MCHC-33.4 RDW-15.5 Plt Ct-252
[**2195-7-28**] 06:15AM BLOOD PT-25.6* PTT-29.8 INR(PT)-2.4*
[**2195-7-28**] 06:15AM BLOOD Glucose-84 UreaN-24* Creat-1.5* Na-142
K-4.3 Cl-104 HCO3-32 AnGap-10
[**2195-7-28**] 06:15AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.1
Brief Hospital Course:
#PUMP: Patient has history of idiopathic familial dilated
systolic CHF. He is co-managed by Dr. [**Last Name (STitle) **] who sees him
primarily for AFIB and device follow-up (s/p ICD for low EF &
previous VT) and Dr. [**Last Name (STitle) 11300**] at [**Hospital6 33**]. When he
went into AFib with RVR, TTE showed an EF of 30% and a new
extreme RV restrictive filling pattern. Due to his history of
hyperferritinemia (negative genetic testing for hemochromatosis
but patient declined liver biopsy in the past) there was concern
that iron deposition could be contributing to his heart failure,
causing diastolic dysfunction on top of his preexisting systolic
CHF. A right heart catheterization was performed on HD7, which
showed moderate LV diastolic dysfunction (PCWP 20), mild
pulmonary hypertension (PASP 44), mildly elevated right-sided
filling pressures (RVEDP 14), and a depressed cardiac index (1.7
L/min/m1). Endomyocardial biopsy was also done; specimens are
pending on discharge. Patient remained compensated throughout
hospitalization; clinically euvolemic with stable weights on
home diuretics. He will follow up with Dr. [**First Name (STitle) 437**] about the
results of his biopsy and for future management of his CHF.
#RHYTHM: Patient was hypotensive on presentation, likely
secondary to recent diarrhea and uptitration of Metoprolol to
100mg daily, so his antihypertensives were held and he was
volume rescuscitated and returned to normotensive status.
However, on transfer to the floors he then went into AFib with
RVR (rates in 130s-140s). Digoxin, metoprolol, and diltiazem
failed to rate control him (best rates in 110s-120s) so
dofetilide was added by EP for rhythm control. Unfortunately,
dofetilide caused the patient to have a brief episode of
torsades de pointes so had to be discontinued. Next verapamil,
dig and metoprolol were tried; however, the patient then had an
episode of vtach progressing to ventricular fibrillation,
terminated by his ICD. He was finally loaded with amiodarone
(not used initially due to concern that it may have caused
hypotension/pulmonary fibrosis in the past) and the verapamil
and digoxin were stopped. His pacemaker was then upgraded with
the addition of atrial and LV leads (DDD mode), and he is now AV
paced . Echo following pacer upgrade showed that he still had
suboptimal LV filling with, so AV conduction delay was increased
to 200ms. He will need an echo in 3 months to confirm improved
ventricular filling. Meds on discharge are amiodarone,
metoprolol and his home dose coumadin.
# Hypotension : presented with hypotension to the 80s/50s, not
resolved following 3L NS in the ED, but improved shortly
thereafter on transfer and with holding of metoprolol and his
[**Last Name (un) **]. At baseline the patient has blood pressure in the
100s/70s, partially due to liver disease and advanced systolic
HF. He has had episodes of asymptomatic hypotension into the
80s/50s previously in [**2193**] which were found to be due to
dehydration and over-medication with anti-hypertensives. His
pressure were in the low 100's throughout hospitalization and he
was asymptomatic throughout. His home metoprolol and losartan
were restarted at half dose before discharge, which he tolerated
well.
.
# Acute renal failure: Cr on presentation 2.1, last measurement
in OMR from [**2194-10-13**] is 0.8. This improved to 1.4 on discharge,
was likely result of initial hypovolemia.
.
# Diarrhea, irritable bowel syndrome: Currently under
evaluation by GI with no clear cause despite EGD, colonoscopy,
lab testing. Patient was tested for HIV many years ago and did
not agree to be tested again. He did not have any issues with
diarrhea during hospitalization. However, as he had been having
episodic diarrhea and diaphoresis prior to admission, the
question of whether he had a carcinoid tumor was suggested by
his gastroenterologist Dr. [**Name (STitle) 23173**]. As patient was
discharged before the requisite 3 days of holding dietary
indoles (caffeine, certain fruits etc) had ended, he could not
undergo 24 hour urine collection for metanephrine testing during
hospitalization. If his symptoms return and are suspicious for
carcinoid, this will be done by his gastroenterologist.
# Hyperferritin, polycythemia: Did not receive scheduled
Q3monthly phlebotomy. Hct currently at baseline in mid-40s.
Per their last note, the liver team does not feel Q3monthly
phlebotomy is necessary for disease management, at this time it
is continued for "patient comfort." This disease history is
somewhat unclear; as above, he will establish care with
hematology for further evaluation.
.
# Emphysema: All inhalers stopped in late [**Month (only) 116**] of this year, no
steroids currently in use. Patient is not dyspnic or hypoxic.
Patient on nebulizers as needed. Would recommend PFTs as
outpatient and pulmonary follow-up in fellows clinic with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4011**].
.
# Obstructive sleep apnea: Irregularly compliant with CPAP at
home, no paroxysmal nocturnal dyspnea events.
.
# Urinary frequency: UOP brisk on admission (100 cc/hr).
Tamsulosin may have impact on blood pressure and thus was
initially held. Urine cultures were negative. Tamsulosin was
restarted on discharge.
.
# Restless leg syndrome: Continued gabapentin, renal dose
adjustment made
.
# Depression and anxiety: Continued celexa
.
# Insomnia: continue QHS clonazepam
.
# Rib pain: secondary to mechanical fall 3 months ago.
Continued OxyContin home dose
TRANSITIONAL ISSUES
- heart biopsy f/u
- needs echo in 3 months to assess for improved LV filling s/p
increase in pacer AV delay, presuming AFib has not returned
- may need 24 hour urine collection for metanephrines if concern
for carcinoid tumor
Medications on Admission:
metoprolol 75mg daily (AM)
furosemide 40mg daily (AM)
Losartan 50mg daily (PM)
digoxin 0.250mg daily (PM)
simvastatin 20mg daily (PM)
fenofibrate 200mg daily (PM)
tamsulosin 0.4mg QHS
omeprazole 40mg [**Hospital1 **]
clonazepam 1mg QHS
gabapentin 600mg QHS
OxyContin 20mg QHS
citalopram 60mg daily
folic acid 1mg daily (AM)
MVI daily (AM)
Vitamin E 400units [**Hospital1 **]
thiamine 100mg daily (AM)
.
NOTE: over the last 4-6 weeks, has stopped the following:
Combivent
Flovent
prednisone (taper from [**Month (only) **] PNA)
modafenil
Benicar
amiodarone
lorazepam
atorvastatin
mesalamine
ASA
Discharge Medications:
1. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. clonazepam 0.5 mg Tablet Sig: Two (2) Tablet PO QHS (once a
day (at bedtime)).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
6. fenofibrate 50 mg Capsule Sig: Four (4) Capsule PO once a
day.
7. oxycodone 20 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO HS (at bedtime).
8. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: take 5mg one day per week per your regular schedule and have
your INR checked when you see Dr. [**First Name (STitle) 1395**] next week.
Disp:*32 Tablet(s)* Refills:*0*
9. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
12. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
14. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO at bedtime.
15. vitamin E 400 unit Capsule Sig: One (1) Capsule PO BID (2
times a day).
16. amiodarone 200 mg Tablet Sig: as directed Tablet PO as
directed: Take 1 pill twice a day for 7 days (first day =
[**2195-7-29**], last day = [**2195-8-4**]) and then 1 pill once a day every
day after that.
Disp:*37 Tablet(s)* Refills:*0*
17. clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO every
eight (8) hours for 7 days: Start date = [**7-29**]
Stop date = [**8-4**].
Disp:*21 Capsule(s)* Refills:*0*
18. Outpatient Lab Work
Please have INR drawn Thursday [**2195-7-30**] and faxed to Dr. [**First Name (STitle) **]
[**Name (STitle) 1395**] ([**Telephone/Fax (1) 92636**]
19. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
atrial fibrillation with rapid ventricular response
ventricular tachycardia
compensated dilated cardiomyopathy
SECONDARY DIAGNOSES:
Iatrogenic Hypotension, not shock
Acute renal failure
compensated chronic systolic Congestive Heart Failure
Atrial Fibrillation
Polycythemia
Hyper-ferritinemia (not hemochromatosis)
Irritable bowel syndroms, diarrhea predominant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were referred to the hospital for low blood pressure, most
likely caused by your recent diarrhea and recently increasing
your blood pressure medications. Your blood pressure improved
with IV fluids, but you then developed a rapid heart rate and
irregular rhythm (atrial fibrillation and ventricular
tachycardia). Your heart rhythm was ultimately stabilized when
we upgraded your pacemaker and made some changes to your heart
medications (see below). Because you have heart failure and high
iron levels, a cardiac biopsy was also done to determine whether
iron deposition in your heart muscle is contributing to your
heart failure (a potentially treatable condition). Results of
the biopsy are still pending and will be followed up on with you
by Dr. [**First Name (STitle) 437**].
We made the following changes to your medications:
1) ADDED Amiodarone 200 mg twice a day for 1 week (start=[**6-28**],
stop=[**7-4**]) then taper down to Amiodarone 200 mg once a day after
that
2) ADDED Clindamycin 300mg every 8 hours for 7 days (start=[**6-28**],
stop=[**7-4**])
3) DECREASED Metoprolol succinate to 50mg daily
4) STOPPED Digoxin 0.25mg daily
5) DECREASED Losartan to 25mg daily
6) DECREASED Gabapentin to 300mg at bedtime
You should take the rest of your medications as prescribed
before hospitalization.
Please attend the doctor's appointments scheduled for you listed
below.
Followup Instructions:
NEW APPOINTMENTS SCHEDULED FOR YOU:
Department: CARDIOLOGY (ELECTROPHYSIOLOGY)
With: Dr. [**Last Name (STitle) 20574**]
When: Please call ([**Telephone/Fax (1) 109598**] to schedule an appointment in
the next month
Department: DEVICE CLINIC
When: Tuesday, [**2195-8-4**] at 1:30 PM
Where: [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Department: CARDIAC SERVICES
When: MONDAY [**2195-8-10**] at 2:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2195-8-7**] at 9:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9052**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
=============================================
PREVIOUSLY SCHEDULED APPOINTMENTS (you should keep):
[**2195-9-16**] 02:00p DR. [**Last Name (STitle) **]
[**Name (STitle) **] CLINICAL CTR, [**Location (un) **]
CARDIOLOGY
[**2195-9-16**] 01:30p DEVICE CLINIC
[**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
DEVICE CLINIC
[**2195-9-7**] 11:30a [**Last Name (LF) 1383**],[**First Name3 (LF) 1382**] (LIVER CENTER)
LM [**Hospital Unit Name **], [**Location (un) **]
LIVER CENTER
|
[
"564.1",
"V12.72",
"300.00",
"780.52",
"530.85",
"238.4",
"272.1",
"V45.02",
"333.94",
"425.4",
"492.8",
"530.81",
"289.89",
"327.23",
"584.9",
"788.41",
"786.50",
"428.0",
"311",
"458.29",
"427.1",
"305.1",
"V15.88",
"428.23",
"733.90",
"427.31",
"E942.0",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.21",
"00.51",
"37.25"
] |
icd9pcs
|
[
[
[]
]
] |
18899, 18905
|
10262, 16052
|
346, 477
|
19329, 19329
|
6966, 6966
|
20890, 22373
|
5215, 5483
|
16697, 18876
|
18926, 18926
|
16078, 16674
|
19480, 20288
|
9906, 10239
|
5523, 6068
|
19077, 19308
|
20318, 20867
|
7761, 9890
|
273, 308
|
505, 3959
|
6982, 7744
|
18945, 19056
|
19344, 19456
|
3981, 5020
|
5036, 5199
|
6093, 6947
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,324
| 168,892
|
28787
|
Discharge summary
|
report
|
Admission Date: [**2150-8-8**] Discharge Date: [**2150-8-25**]
Date of Birth: [**2110-6-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
40yoM with h/o seizure disorder and alcohol abuse with prior
hospitalizations for DTs and withdrawal seizures, admitted to
MICU with obtundation after status epilepticus and fever.
According to the patient's mother, she was called by the
patient's neighbor who reported loud noises coming from his
apartment. She got there about 30minutes later to find him
actively seizing. EMS was called and 8mg valium administered
prior to transfer to [**Hospital1 18**] ED. On arrival to [**Hospital1 18**] ED T 103 HR
162 BP 168/114 RR 32 99%RA. He was unresponsive except to pain,
and intubated for airway protection. In the ED he received
thiamine, Narcan, and Tylenol. Adenosine was pushed without
resolution of his tachycardia, presumed sinus tachycardia.
Neurology was consulted, and he was loaded with 1000mg Dilantin.
On presentation to the ICU he was sedated, withdrew to pain in
all four extremities. His mother denied knowledge of any recent
illness, fevers, headaches, or sick contacts. She does not know
when his last drink was or how much alcohol he usually drinks.
Past Medical History:
Alcohol abuse c/b DTs and withdrawal seizures
Seizure disorder
Social History:
lives with his mother, works odd jobs in [**Name (NI) 3844**] for a
friend. +tob use. h/o EtOH abuse. no known h/o illicit drug use
Family History:
Non contributory
Physical Exam:
T 104.8 HR 136 BP 110/65 RR 18
A/C FiO2 100% Tv 450 RR 18 PEEP 5
GEN: thin, malnourished, sedated/obtunded
HEENT: PERRL, right lateral nystagmus, anicteric, ETT
Neck: supple, no LAD
CV: tachy, regular, no mrg
Resp: coarse bilaterally
Abd: +BS, soft, NT, ND, no masses
Ext: no edema, 1+ DPs B
Neuro: withdraws to pain x4, CN II-XII intact, right lateral
nystagmus, normal tone, +Babinski bilaterally, no clonus
Skin: abrasion/ulceration on sacrum, echymosis with abrasion on
left elbow, ulceration/fissure on dorsum of penis
Pertinent Results:
CXR: no acute cardiopulm disease; posterior right rib fractures
.
Head CT: no acute hemorrhage or mass effect
.
Pelvic/Abd CT: fluid and air throughout bowel, no obstruction,
no traumatic injury
.
ECG: sinus tach 160bpm, nml axis, ST-depressions V4-V5
.
[**2150-8-8**] 09:34PM CEREBROSPINAL FLUID (CSF) PROTEIN-42
GLUCOSE-121
[**2150-8-8**] 09:34PM CEREBROSPINAL FLUID (CSF) WBC-12 RBC-1300*
POLYS-97 LYMPHS-2 MONOS-0 MACROPHAG-1
[**2150-8-8**] 09:34PM CEREBROSPINAL FLUID (CSF) WBC-14 RBC-2725*
POLYS-94 LYMPHS-2 MONOS-0 MACROPHAG-4
[**2150-8-8**] 09:11PM TYPE-ART TEMP-40.4 PEEP-5 O2-50 PO2-101
PCO2-37 PH-7.32* TOTAL CO2-20* BASE XS--6 INTUBATED-INTUBATED
[**2150-8-8**] 09:11PM LACTATE-1.6
[**2150-8-8**] 09:11PM O2 SAT-96
[**2150-8-8**] 09:11PM freeCa-0.87*
[**2150-8-8**] 08:40PM GLUCOSE-156* UREA N-3* CREAT-0.7 SODIUM-138
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-19* ANION GAP-18
[**2150-8-8**] 08:40PM CALCIUM-5.7* PHOSPHATE-3.6 MAGNESIUM-1.6
Brief Hospital Course:
Mr. [**Known lastname **] is a 40 yo male with a history of seizure disorder
and EtOH abuse who presented with seizures likely secondary to
alcohol, fever, and possible bacterial meningitis now with
likely Korsakoff's encephalopathy.
.
# Anterograde Amnesia: Mr. [**Known lastname **] developed difficulty
forming new memories. According to his mother, this was a [**Last Name **]
problem for the patient. He did not remember family members who
had visited him the day before nor examiners who had seen him
that morning. He was unable to state the date without looking
at a wall chart and could not name the hospital despite being
reminded frequently throughout the day. He was however, able to
give an accurate medical history and details of events occuring
prior to his admission. He continued to have selective memory
deficits, exhibiting signs of anterograde amnesia likely
secondary to Korsakoff's syndrome. He was treated with IV
thiamine for possible Wernicke's encephalopathy with no
improvement in his symptoms. He was followed by psychiatry and
neurology who felt his differential could be Korsakoff's vs.
Toxic/metabolic encephalopathy vs. medication induced delirium.
Neuropsychological testing was recommended one month after
discharge for evaluation out of the acute setting. After this
testing, he will follow up with neurology. He was discharged in
the care of his mother.
.
# Seizure: On arrival to the MICU, his seizures were thought to
be most likely related to alcohol withdrawal, especially given
the history from his mother that these seizures only occurred in
the context of him drinking EtOH. The PCP who was prescribing
his Dilantin was also unclear as to whether his seizure disorder
was distinctly separate from his EtOH abuse, and the patient was
noncompliant with his medications most of the time. Although
EtOH withdrawl can cause fevers, there was concern for the
possibility of an infection causing the seizures and an LP was
performed in the unit to exclude this possibility. The LP did
not rule out the possibility of meningitis resulting in
seizures, however the leading diagnosis was alcohol withdrawal
seizures. A CT of head, abdomen, chest and C-spine were
negative for any acute injury. He was maintained on a CIWA
scale with Valium and required multiple doses due to agitation.
His anti-epileptic drugs were discontinued given the likelihood
of his seizure being secondary to alcohol as well as a negative
EEG. However, once it was felt that he was no longer
withdrawing and his vital signs normalized, a repeat EEG was
done which did show a focal spike. The neurology service
recommended institution of Trileptal at 300mg [**Hospital1 **], titrated up
to 600mg [**Hospital1 **] as the possibility existed for an underlying
seizure disorder. Trileptal was felt to be a good choice based
on it's relatively benign side effect profile. The patient
remained seizure free while in the hospital.
.
# Fever: In the ED, he received Vancomycin, Ceftriaxone,
Ampicillin and Acyclovir prior to having an LP. An LP was
performed on the unit which had WBC slightly greater than the
amount one would expect for the amount of red cells, therefore
he was continued on Vancomycin, Ceftriaxone, and Acyclovir.
Ampicillin was discontinued and Acyclovir was discontinued after
HSV 1 and 2 DNA were negative. A PICC line was placed and the
patient completed a 14 day course of ceftriaxone and vancomycin.
.
#. Hypothyroidism: The patient had no active symptoms, but was
found to have an elevated TSH and a low free T4. As his TSH
elevation may be secondary to recent seizures and
hospitalization no therapy was started. Mr. [**Known lastname **] will
require a repeat TSH and free t4 levels in [**3-7**] weeks to further
evaluate.
.
# EtOH abuse: The patient likely suffered from alcohol
withdrawal seizures and is known to have a history of alcohol
abuse. He was observed to have visual and tactile
hallucinations and hemodynamic instability secondary to alcohol
withdrawal. He was put on a CIWA scale and was given valium as
needed for withdrawal symptoms. He was also given thiamine,
folate, and a multivitamin for supplementation. A sitter was
put in his room for monitoring. He was seen by social work and
the patient admitted that he had a problem with alcohol. He
stated that he would not drink alcohol in the future. Due to
his memory difficulties as above, he was not a candidate for
acute rehab.
.
#. LUE swelling: The patient developed a cold, painful, white,
and numb LUE which raised concern for acute compartment
syndrome. The cause was an infiltrated IV. The radial pulse
was intact. Plastic surgery was consulted who recommended
elevation of the arm and felt the diagnosis was acute carpal
tunnel syndrome. LUE US was negative for DVT. The upper
extremity swelling resolved in 2 days.
.
#. Elevated CK: During the hospitalization the patient developed
an elevated CK. He denied any symptoms of myopathy. The
elevated CK was felt to be likely drug induced myopathy from
etoh abuse which can occur in the setting of hypophosphatemia
which was present in this patient. The elevated CK likely also
contributed to the patient's transient transaminitis. He was
hydrated aggressively and his CK and LFTs trended down.
.
# Leukocytosis: Patient had fever on admission with elevated
WBC. As above, this was felt to be possible bacterial
meningitis. Cultures remained negative and the patient received
a full course of antibiotics.
.
#. Elevated troponin: Patient had elevated troponin x2 on
admission which trended down. No changes on ECG compared to
[**2150-8-8**]. The troponin elevation was felt to be due to demand in
the setting of seizures.
.
# Tachycardia: On admission, patient had an episode of sinus
tachycardia to 168 likely due to fever vs withdrawal,
accompanied by hypotension in ED. He was given adenosine in ED.
Pt continued to be tachycardic on transfer to the floor. He
was treated with hydration, antibiotics for possible meningitis,
and valium for alcohol withdrawal. He was monitored on
telemetry and his heart rate returned to [**Location 213**].
Medications on Admission:
Dilantin 300mg po BID
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*30 Patch 24HR(s)* Refills:*2*
3. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
Disp:*30 patches* Refills:*2*
4. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Trileptal 300 mg Tablet Sig: One (1) Tablet PO twice a day
for 2 days.
Disp:*4 Tablet(s)* Refills:*0*
6. Trileptal 600 mg Tablet Sig: One (1) Tablet PO twice a day:
Please begin after completing 1 week of trileptal at 300mg [**Hospital1 **].
Disp:*60 Tablet(s)* Refills:*0*
7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: EtOH withdrawal seizures
Anterograde amnesia
Myopathy
Bacterial meningitis
Secondary: EtOH dependence
Discharge Condition:
Stable. The patient is hemodynamically stable, however his
memory deficits persist. He remains unable to form new memories
and does not remember individuals from day to day.
Discharge Instructions:
Please take all medications as prescribed.
**You are on a new anti-seizure medication called Oxcarbazepine.
You will be taking 300mg two times per day until [**8-27**]. Then
you should switch to 600mg twice per day and remain at that
dose.
**You should also take thiamine one time per day.
Please keep all outpatient appointments as scheduled. You will
need to follow up with Neurology and Neuropsychology.
If you begin to experience any hallucinations, become confused,
or feel as though you want to drink alcohol please call 911 or
your MD.
Followup Instructions:
Please follow up with your PCP within the next two weeks.
You will need to go for Neuropsychological testing with Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13795**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2150-9-15**] 1:00 and
follow up with Neurology DRS. [**Last Name (STitle) 43**] AND [**Name5 (PTitle) **]
Phone:[**Telephone/Fax (1) 44**] on[**2150-11-23**] at 2:30
You will need to have your thyroid function tested as an
outpatient.
|
[
"291.3",
"410.71",
"303.00",
"244.9",
"729.81",
"303.90",
"790.7",
"276.8",
"707.03",
"780.39",
"320.9",
"359.4",
"263.9",
"291.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"38.93",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10279, 10285
|
3245, 9389
|
321, 329
|
10440, 10618
|
2257, 2324
|
11215, 11707
|
1679, 1697
|
9461, 10256
|
10306, 10419
|
9415, 9438
|
10642, 11192
|
1712, 2238
|
273, 283
|
357, 1427
|
2333, 3222
|
1449, 1514
|
1530, 1663
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,873
| 138,089
|
11540
|
Discharge summary
|
report
|
Admission Date: [**2106-7-4**] Discharge Date: [**2106-7-13**]
Date of Birth: [**2056-12-21**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: This is a 49-year-old gentleman
with a known history of ischemic cardiomyopathy with an
estimated ejection fraction of approximately 20%. He had
been accepted by the [**Hospital 4415**] heart
transplant service and was at home listed as a status 2
awaiting cardiac transplantation.
On [**2106-7-4**] the patient had new onset chest pain and was
admitted to the hospital where he ruled in for myocardial
infarction.
PAST MEDICAL HISTORY: 1. Type 1 diabetes. 2. Known coronary
artery disease status post multiple cardiac catheterizations.
He is status post automatic implantable
cardioverter-defibrillator placement. He has ischemic
cardiomyopathy. 3. Hypothyroidism.
MEDICATIONS ON ADMISSION: 1. Coreg 25 mg p.o. q.d. 2.
Toprol 25 mg p.o. q.d. 3. Plavix 75 mg p.o. q.d. 4. Aspirin
325 mg p.o. q.d. 5. Aldactone 12 mg p.o. q.d. 6. Synthroid
0.125 p.o. q.d. 7. Lantus insulin 25 q.d. 8. Humalog
sliding scale subcutaneous insulin coverage.
ALLERGIES: ACE inhibitor cause a cough.
HOSPITAL COURSE: The patient was taken to the cardiac
catheterization laboratory where he was found to have
significant multivessel coronary artery disease including a
30% left main and 99% left anterior descending coronary
artery, totally occluded left circumflex and totally occluded
right coronary. His left ventricular ejection fraction was
estimated at 13% at cardiac catheterization. The patient was
then referred to the cardiothoracic surgery service for
assessment for coronary artery bypass grafting.
The patient subsequently preoperatively was managed on the
cardiology service approximately [**2106-7-8**], was noted to have
a dropping hematocrit and was sent for an urgent CT scan of
his abdomen and pelvis to rule out a source of hematocrit
drop. He was found to have no intra-abdominal nor
retroperitoneal hematoma at that time however it was noted
that he had a pericardial effusion. The patient also on
[**2106-7-8**] underwent a myocardial viability study which showed
diffuse uptake consistent with diffuse viability of left
ventricular wall. The patient remained on the cardiology
service and was taken to the operating room on [**2106-7-12**] where
he underwent coronary artery bypass grafting x 4 by Dr. [**First Name (STitle) **]
[**Last Name (Prefixes) **]. He had a LIMA to the LAD, saphenous vein to the
RPL, saphenous vein to the D1, to the OM. The patient had a
preoperative intra-aortic balloon pump placed at the
beginning of the case prophylactically due to his poor
ejection fraction. The patient did wean from cardiopulmonary
bypass and his chest was being closed when he was noted to
have significant problems with hypotension. At that time it
was felt appropriate to place him on a left ventricular
assist device. He was also placed on vasopressin,
epinephrine, Levophed, and milrinone drips. With the support
of the left ventricular assist device and the pressors and
inotropic agents the patient was successfully transported
from the operating room to the cardiac surgery recovery unit
in the evening of [**2106-7-12**] where he proceeded to wake up from
general anesthesia. He required some fluid resuscitation
with blood products over the course of the first few
postoperative hours and remained relatively stable on the
support.
On physical examination at this time, neurologically the
patient is sedated on propofol but is easily awoken, follows
commands, nods his head appropriately and moves all
extremities. From a cardiac standpoint the patient has a
blood pressure from 90 to 110s systolic with a mean arterial
pressure of 65 to 70, presently on vasopressin, epinephrine,
Levophed and milrinone drips. He is on an left ventricular
assist device, Abiomed BVAD 5000 I, with liter flows between
5 and 5.6 liters per minute. His thermodilution cardiac
output has also been in the 5 to 6 liter per minute range
with an SvO2 of approximately 70%. The patient's lungs are
rhonchorous. The patient has adequate oxygenation at this
time. His abdomen is soft, nontender. His extremities are
warm with minimal edema and he has positive Doppler signals
in both of his feet. Immediately postoperatively the
patient's intra-aortic balloon pump was removed at the
bedside. Manual pressure was held for 35 minutes. The groin
looks good without signs of bleeding or hematoma and the
pulse remains audible by Doppler in his balloon foot, which
is the right.
CURRENT MEDICATIONS: 1. IV vasopressin drip at 0.8 units per
minute. 2. Epinephrine 0.025 mcg per kg per minute. 3.
Levophed 0.02 mcg per kg per minute. 4. Milrinone 0.5 mcg
per kg per minute. 5. Propofol 30. 6. Vancomycin 1 gram q.
12 hours. 7. Carafate 1 gram q. 6 hours. 8. Aspirin 325 mg
q.d. 9. Ranitidine 150 mg b.i.d. 10. Insulin drip at 29
units per hour, maintaining a blood sugar in the 120-140
range at this time.
MOST RECENT LABORATORY DATA: White blood cell count 10.4,
hematocrit 30.6, platelet count 167. Sodium 138, potassium
3.7, chloride 103, CO2 17, BUN 16, creatinine 0.9, glucose
131. His most recent prothrombin time is 15.1 with an INR of
1.5, PTT is 42.6. Blood gas from this morning is pH 7.42,
PaCO2 32, PaO2 116, bicarbonate 21, base deficit -2.
Initially postoperatively the patient had a significant
metabolic acidosis which resolved with a total of [**3-1**] amps of
bicarbonate over the course of the night, blood products and
fluid resuscitation.
DISCHARGE DIAGNOSES: Ischemic cardiomyopathy with left
ventricular assist device placement status post coronary
artery bypass grafting x 4.
CONDITION: His condition remains critical.
DISPOSITION: He is being transported to the [**Hospital 8503**] under the care of Dr. [**Last Name (STitle) 36737**] for assessment
for heart transplant as well as possible HeartMate left
ventricular assist device placement in the next few days.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**Name8 (MD) 964**]
MEDQUIST36
D: [**2106-7-13**] 09:36
T: [**2106-7-13**] 10:06
JOB#: [**Job Number 36738**]
|
[
"428.40",
"E947.8",
"414.01",
"416.0",
"410.71",
"250.01",
"428.0",
"458.2",
"423.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.23",
"37.61",
"99.20",
"37.66",
"88.56",
"88.53",
"36.13",
"39.61",
"37.64"
] |
icd9pcs
|
[
[
[]
]
] |
5608, 6271
|
885, 1180
|
1198, 4591
|
4613, 5586
|
184, 602
|
625, 858
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
44,270
| 112,520
|
40589
|
Discharge summary
|
report
|
Admission Date: [**2182-12-3**] Discharge Date: [**2182-12-8**]
Date of Birth: [**2115-4-23**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Ace Inhibitors
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2182-12-3**] Aortic Valve Replacement (21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue)
History of Present Illness:
This is a 67 year old female with known history of aortic
stenosis that is followed by serial echocardiograms. She
complains of progressively worsening dyspnea on exertion.
Cardiac cath revealed no coronary artery disease.
She is now scheduled for aortic valve replacement this month.
Overall she feels well and has no major change in symptoms from
[**2182-8-1**].
Past Medical History:
Past Medical History:
Aotic Stenosis
Hypercholesterolemia
Hypertension
Hyperthyroidism with thyroid nodule
Nonspecific Thrombocytopenia ( mild)
Obesity
Depression
Meralgia paresthetica
Asthma
GERD
Dysglycemia
Thoracic back pain/sciatica
SVT ( episode during stress test)
remote esopagitis
Past Surgical History:
s/p Tonsillectomy
Social History:
Race:Caucasian
Dental: clearance letter obtained
Lives with: Daughter
Contact: [**Name (NI) **] [**Name (NI) 88836**], [**First Name3 (LF) **] Phone #[**Telephone/Fax (1) 88837**]
[**Name2 (NI) 27057**]tion: Runs coat checking business (has summer off)
Cigarettes: Smoked no [] yes [X] last cigarette [**2147**] Hx: 1.5 ppd
Other Tobacco use: no
ETOH: < 1 drink/week [] [**1-7**] drinks/week [X] >8 drinks/week []
Illicit drug use: Denies
Family History:
Family History: Denies premature coronary artery disease
Physical Exam:
VS:
B/P Right: 118/66 Left: 116/60
Height: 5'7 [**12-2**]" Weight: 190 lbs
General: WDWN female in NAD
Skin: Dry []x intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable
Neck: Supple [x] Full ROM []no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] grade ___3/6 systolic
radiates throughout chest to carotids___
Abdomen: Soft [x] non-distended [x] non-tender [x] +BS [x] no
HSM
Extremities: Warm [x], well-perfused [x] Edema none
Varicosities: R lat thigh
Neuro: Grossly intact [x];nonfocal exam;MAE [**4-5**] strengths
Pulses:
Femoral Right: 2+ Left:2+
DP Right: 1+ Left:1+
PT [**Name (NI) 167**]:NP Left:NP
Radial Right:2+ Left:2+
Carotid Bruit -murmur radiates to carotids
Pertinent Results:
Admission labs:
[**2182-12-3**] 10:31AM WBC-8.5# RBC-2.67*# HGB-7.8*# HCT-23.7*#
MCV-89 MCH-29.0 MCHC-32.7 RDW-13.7
[**2182-12-3**] 12:15PM PT-11.6 PTT-30.5 INR(PT)-1.1
[**2182-12-3**] 12:15PM WBC-7.0 RBC-3.02* HGB-9.0* HCT-27.0* MCV-90
MCH-29.9 MCHC-33.3 RDW-13.8
[**2182-12-3**] 12:15PM UREA N-12 CREAT-0.6 SODIUM-143 POTASSIUM-4.0
CHLORIDE-114* TOTAL CO2-24 ANION GAP-9
Discharge labs:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: 60% to 65% >= 55%
Aorta - Ascending: 3.4 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.2 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *81 mm Hg < 20 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.9 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast
or thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No mass/thrombus in
the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. Good (>20 cm/s) LAA ejection velocity. No
thrombus in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Severe symmetric LVH. Normal LV cavity size.
Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV free wall thickness. Normal RV
chamber size. Normal RV systolic function.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Severely
thickened/deformed aortic valve leaflets. No masses or
vegetations on aortic valve. Severe AS (area 0.8-1.0cm2).
Moderate (2+) AR.
MITRAL VALVE: Moderate mitral annular calcification. No MS.
Moderate (2+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: The patient was under general anesthesia
throughout the procedure. The patient received antibiotic
prophylaxis. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
Pre-CPB: 1.The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left atrium
or left atrial appendage. No mass/thrombus is seen in the left
atrium or left atrial appendage. No thrombus is seen in the left
atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is severe symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%).
4. The right ventricular free wall thickness is normal. Right
ventricular chamber size is normal. with normal free wall
contractility.
5. There are simple atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. There was minimal
movement of the NCC and RCC. The aortic valve leaflets are
severely thickened/deformed. No masses or vegetations are seen
on the aortic valve. There is severe aortic valve stenosis
(valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is
seen.
7. Moderate (2+) mitral regurgitation is seen.
8. There is a trivial/physiologic pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
Post-CPB: On infusion of phenylephrine, AV-pacing for slow CHB
(initially). Well-seated bioprosthetic valve in aortic position
with trivial valvular AI, transvalvular gradient measured at
15mmHg. Preserved biventricular systolic function, 1+ MR, aortic
contour normal post-decannulation.
Brief Hospital Course:
Ms [**Known lastname 88836**] was a same day admission to the operating room for a
scheduled aortic valve replacement. Please see the operative
report for details,in summary she had:
Aortic valve replacement with a 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] tissue valve. Her
cardiopulmonary bypass time was 57 minutes with a crossclamp
time of 42 minutes.
She tolerated the operation well and was transferred from the
operating room to the cardiac surgery ICU in stable condition
with minimal vasopressor support.
She remained hemodynamically stable in the immediate post-op
period, her anesthesia was reversed, she woke neurologically
intact and was extubated.
On POD1 she was transferred from the cardiac surgery ICU too the
stepdown floor for continued post-op care. All tubes lines and
drains were removed per cardiac surgery protocol. She was
transfused one unit PRBC for post-op anemia. She reports
postoperative intermittent visual changes, lasting only seconds.
No focal defecit appreciated. As discussed with Dr.[**Last Name (STitle) **],
Ms.[**Known lastname 88836**] will alert the cardiac surgery service if these
symptoms persist. Dr[**Last Name (STitle) **] office will also follow up in 1
week after discharge to ascertain whether Ms.[**Known lastname 88836**] will require
an outpatient eval by Neuro and/or Opthamologist.
The remainder of her hospital course was uneventful. She worked
with nursing and physical therapy to increase her strength and
endurance. By POD# 5 she was ready for discharge home with
visiting nurses. She is to follow up with Dr [**Last Name (STitle) **] in 1week at
wound clinic and at 1 month in cardiac surgery clinic.
Medications on Admission:
METHIMAZOLE - 15 mg once a day
METOPROLOL SUCCINATE -50 mg Extended Release once a day
ROSUVASTATIN 5 mg once a day
CALCIUM CARBONATE - 500 mg calcium (1,250 mg) - 1 Tablet once a
day
CHOLECALCIFEROL 1,000 unit once a day
LYSINE -500 mg once a day
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO Q12H (every 12 hours) for 5 days.
Disp:*20 Tablet Extended Release(s)* Refills:*0*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
6. rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
8. methimazole 10 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis s/p AVR
PMH:
Hypercholesterolemia
Hypertension
Hyperthyroidism with thyroid nodule
Nonspecific Thrombocytopenia ( mild)
Obesity
Depression
Meralgia paresthetica
Asthma
GERD
Dysglycemia
Thoracic back pain/sciatica
SVT ( episode during stress test)
remote esopagitis
PSH:
Tonsillectomy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with oral analgesia
Incisions: Sternal - healing well, no erythema or drainage
Leg Edema:
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check on [**12-12**] at 11:00am [**Hospital **] Medical Office Building
[**Hospital Unit Name **] [**Telephone/Fax (1) 1504**]
Surgeon: Dr [**First Name (STitle) **] [**Name (STitle) **] on [**1-8**] at 1:15pm [**Hospital **] Medical Office
Building [**Hospital Unit Name **] [**Telephone/Fax (1) 1504**]
Cardiologist:Dr [**First Name8 (NamePattern2) 88838**] [**Last Name (NamePattern1) 1923**] on [**12-31**] at 2:30pm
Please call to schedule appointment with:
Primary Care: Dr [**Last Name (STitle) **],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 88839**] in [**3-6**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Completed by:[**2182-12-8**]
|
[
"E932.8",
"355.1",
"493.90",
"278.00",
"242.10",
"724.3",
"287.49",
"311",
"285.9",
"V15.82",
"401.9",
"511.9",
"424.1",
"458.29",
"272.4",
"530.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
9428, 9503
|
6477, 8169
|
302, 424
|
9847, 10022
|
2516, 2516
|
10946, 11780
|
1668, 1711
|
8468, 9405
|
9524, 9826
|
8195, 8445
|
10046, 10923
|
2914, 4871
|
1153, 1173
|
4915, 6454
|
1726, 2497
|
242, 264
|
452, 819
|
2532, 2897
|
863, 1130
|
1189, 1636
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,206
| 158,647
|
847
|
Discharge summary
|
report
|
Admission Date: [**2128-6-16**] Discharge Date: [**2128-6-20**]
Date of Birth: [**2059-3-29**] Sex: F
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5883**]
Chief Complaint:
Asymmetric breast tissue as a result of mastectomy secondary to
breast cancer
Major Surgical or Invasive Procedure:
1. Left delayed deep inferior epigastric perforator flap ([**Last Name (un) 5884**]
flap).
2. Harvest of deep inferior epigastric artery and vein pedicle
at pelvis.
3. Autologous fat grafting vascular pedicle.
History of Present Illness:
The patient is a 68-year-old woman with a history of left breast
cancer. She underwent a mastectomy followed by chemotherapy and
radiation therapy. She
finished her radiotherapy in [**2126-8-29**]. She presented to Dr
[**First Name (STitle) **] interested
in breast reconstruction and was admitted to the hospital for
[**Last Name (un) 5884**] (deep inferior epigastric perforator) flap reconstruction
to her left chest wall.
Past Medical History:
1. Left breast cancer status post treatment with Taxol and
Herceptin. Initially underwent left partial mastectomy but
returned for left modified radical mastectomy in [**5-1**].
2. Hypertension
3. Status post excision of ganglion cyst in hand
Social History:
The pt is married and lives with her husband. Homemaker.
Emigrated from [**Country 2045**] "a long time ago". Previously independent
in all ADLs. No tobacco, alcohol, drug use.
Family History:
Noncontributory.
Physical Exam:
Gen: No acute distress
Chest: CTA bilateral
Chest wall: [**Last Name (un) 5884**] (deep inferior epigastric perforator) flap on
left chest wall appears viable. Doppler signal with strong echo
signal. Generally slightly edematous.
Abd: Incision clean dry and intact without any dehiscience, no
signs of infection. Abd soft, non-distended, mildly tender
along incision.
Pertinent Results:
[**2128-6-17**] 05:08AM BLOOD WBC-9.6 RBC-3.00*# Hgb-9.7*# Hct-27.3*#
MCV-91 MCH-32.3* MCHC-35.5* RDW-13.8 Plt Ct-183
[**2128-6-17**] 05:08AM BLOOD Plt Ct-183
Brief Hospital Course:
The patient is a 69-year-old F s/p Left partial mastectomy
followed by radiation and chemotherapy who was admitted to Dr. [**Last Name (STitle) 5885**] Plastic Surgery service at the [**Hospital1 1444**] on [**2128-6-16**] for
immediate right deep inferior epigastric perforator
([**Last Name (un) 5884**]) flap breast reconstruction. Pt was
preoperatively screened per protocol w/o issue and
taken to the OR on [**2128-6-16**]; for details of the operation,
please refer to the operative report. Her
postoperative course was uncomplicated. Immediately
postoperatively the flap doppler signal remained
strong.
.
On POD 1, the flap doppler signal remained strong. She
was afebrile and her pain well-controlled with a PCA.
Her diet was advanced as to a clear liquid diet, which
she tolerated well.
.
On POD 2, the flap doppler signal remained strong. She
was afebrile. She was transitioned to PO pain
medication with good control. Her diet was advanced
as tolerated to a regular diet.
.
On POD 3, the flap doppler signal remained strong. She
was afebrile. She continued PO pain medication with
good control.
.
On POD 4, she was deemed stable for discharge, and was
discharged home with VNA. She was instructed to
follow-up with Dr. [**First Name (STitle) **].
Medications on Admission:
Atenolol 50mg 1 tablet daily
Lipitor Oral
Discharge Medications:
1. 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*
2. Duricef 500 mg Capsule Sig: One (1) Capsule PO twice a day
for 1 weeks.
Disp:*14 Capsule(s)* Refills:*0*
3. Aspirin 81 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO
DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain, HA, T>100 degrees.
6. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Lipitor Oral
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Left breast cancer with resultant breast tissue asymmetry
Discharge Condition:
Stable
Discharge Instructions:
Please [**Name8 (MD) 138**] MD or return to emergency department if any of the
following occur:
-Fever>101.5
-Increased pain, redness, swelling incision sites, worsening of
rash
-Any other concerning symptoms
.
-Please do not place any pressue on your chest, especially the
left side.
-Please keep track of JP drain output for your follow-up visit.
-Do NOT wear a compressive bra until instructed to do so by Dr.
[**First Name (STitle) **]
[**Name (STitle) **] may shower, but do NOT take a bath
-Do NOT perform any strenuous exercise
.
Please resume previous medications as prior to your surgery.
Please take pain medications and stool softener as prescribed.
.
Please follow-up as directed - you have a follow-up appointment
with Dr. [**First Name (STitle) **] on [**2128-6-25**] at 10:30am.
.
Followup Instructions:
Please attend your follow-up appointment with [**First Name11 (Name Pattern1) 1216**] [**Last Name (NamePattern4) 2612**], MD
Phone:[**Telephone/Fax (1) 5343**]. You have an appointment with him on
[**2128-6-25**] at 10:30am. You may call to confirm. We also recommend
you follow-up with your primary care physician within one week.
|
[
"401.9",
"V10.3",
"V45.71",
"424.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"85.84"
] |
icd9pcs
|
[
[
[]
]
] |
4227, 4284
|
2147, 3410
|
392, 604
|
4386, 4395
|
1964, 2124
|
5239, 5577
|
1540, 1558
|
3502, 4204
|
4305, 4365
|
3436, 3479
|
4419, 5216
|
1573, 1945
|
275, 354
|
632, 1061
|
1083, 1330
|
1346, 1524
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,135
| 117,105
|
36330
|
Discharge summary
|
report
|
Admission Date: [**2127-10-6**] Discharge Date: [**2127-10-28**]
Date of Birth: [**2083-9-20**] Sex: M
Service: MEDICINE
Allergies:
Reglan
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
altered mental status, unresponsive
Major Surgical or Invasive Procedure:
none
History of Present Illness:
43 year old man with end-stage liver disease transferred to
[**Hospital1 18**] from [**Hospital3 **] Hospital with altered mental status.
According to his wife he has been taking extra lactulose lately
because of asterixis. He seemed more confused this morning and
he went to [**Hospital3 **] hospital. She denies that he has had recent
sickness or other symptoms other than some vomiting last night.
He was intubated for airway protection. Of note, he was
discharged on [**9-30**] with similar sx of hepatic encephalopathy and
was treated for a pneumonia with levofloxacin (last dose as
outpt [**10-3**]). He was also taken off of the [**Month/Day (2) **] list due to
malnutrition.
.
Review of sytems:
(+) Per HPI; Patient unable to answer ROS questions
.
Past Medical History:
-Alcoholic cirrhosis diagnosed [**3-9**] c/b portal vein thrombosis,
severe portal htn gastropathy, 3 cords of grade I varices; no
history of variceal bleed; currently gets paracentesis q1-2
weeks.
-Seizures from EtOH withdrawal
-No evidence of HCC on recent CT
Past Medical History:
-Alcoholic cirrhosis diagnosed [**3-9**] c/b portal vein thrombosis,
severe portal htn gastropathy, 3 cords of grade I varices; no
history of variceal bleed; currently gets paracentesis q1-2
weeks.
-Seizures from EtOH withdrawal
-No evidence of HCC on recent CT
Social History:
Lives on cape with wife, no kids, previous heavy etoh for 20
years ([**6-8**] drinks per day; vodka, sober since diagnosis of
cirrhosis in [**3-9**], attends AA). No other drugs or smoking.
Worked as a chef.
Family History:
NC
Physical Exam:
Physical Exam: T 96 HR 106 BP 125/72 HR 85 RR 20 O2 100% on RA
GENERAL: Sedated, cachectic man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/conjugate gaze. MM dry. Sm blood in
mouth. Neck Supple, No LAD
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or [**Last Name (un) 549**]. JVP flat
LUNGS: CTA b/l, decreased breath sounds at b/l bases
ABD: +BS, very distended, dull to percussion
EXTREMITIES: dry, warm and well perfused
SKIN: No rashes/lesions, ecchymoses. No jaundice
NEURO: Somnolent but reponds to painful stimuli. does move all
limbs.
Pertinent Results:
Please see OMR for lab results/reports during hospitalization.
Brief Hospital Course:
43 year old man with end-stage liver disease admitted with
altered mental status, thought to be [**2-3**] hepatic encephalopathy.
.
# Altered Mental Status: Acute change in mental status per wife.
Ammonia level very elevated and he was noted to have asterixis
when he was not sedated. No clear precipitant was identified.
Given history of multiple previous admissions for
encephalopathy, he was treated with aggressive lactulose and
rifaximin. He was put on ciprofloxacin for SBP prophylasis. He
was also worked up for infection, which was negative. Blood and
urine tox screens were negative for illicit substances.
His mental status progressively worsened. He became
significantly more obtunded. On [**10-8**] he developed new seizures,
for which he was empirically treated for viral and bacterial
mengingits. CT of the head showed diffuse cerebral edema,
thought to be [**2-3**] end stage liver disease.
.
# Acute on chronic renal failure- Creatinine worse than prior
admissions at 3.3. Pt appeared to be volume depeleted. He
received several boluses of fluid challenge, with catution given
affinity of fluids to settle in the abdomen. His urine output
however continued to worsen. It was believed that he had a
component of hepatorenal syndrome, for which treatment was
initiated. He showed some response, which was shortlived. His
kidney function continued to worsen until he was anururic. He
developed a significant metabolic acidosis which was treated
with IVF with bicarbonate which which temporized his electrolyte
disturbances. Dialysis was not initiated as it is not
considered a treatment for hepatorenal syndrome.
.
# Seizures - Seizure activity was thought to be due [**2-3**] to
cerebral edema. However LP was done to rule out infectious
etiology. LP was negative. Antibiotics were discontinued. He
was started on seizure prophylaxis per neurology, who followed
his course through the remainder of his hospitalization.
# Respiratory: On ventilator for airway protection. He
continued on mechanical ventilation until he passed away from
distrubances of the cardiac conduction system.
.
# ETOH cirrhosis - GI was consulted for consideration of liver
[**Month/Day (2) **]. Unfortunatley, given h/o of poor nutritional status
with history of inability to gain wait, he was not considered to
be an ideal candidate. This was solidified after images of his
CT scan which showed defiinitive cerebral edema. He was
maintained on TPN for nutrition as his bowel was unable to
tolerate sufficient tube feeds. There were numerous
interdisciplinary meetings to discuss with the family the
prognosis of Mr [**Known lastname **], which was generally poor even prior to
the acute causes leading to his hospitalization. The decision
to not pursue aggressive measures was made several weeks into
his hospitalization.
.
#Cardiac failure: Pt was noted to develop bradycardia and
conduction abnormalities most likely due to electrolyte
disturbances before his heart stopped beating. No intervention
was made as pt was DNR/DNI.
Medications on Admission:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): Should have [**3-5**] bowel movements daily. Increase
if confusion or not 3 bowel movements.
2. Clotrimazole 10 mg Troche Sig: One (1) troche Mucous membrane
every 4-6 hours as needed for thrush.
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. Prochlorperazine Maleate 5 mg Tablet Sig: One (1) Tablet PO
every eight (8) hours as needed for nausea.
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
7. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
8. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO once a day.
10. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO QOD for 2
doses: To be given [**2127-10-1**] and [**2127-10-3**].
Disp:*2 Tablet(s)* Refills:*0*
.
Discharge Medications:
.
Discharge Disposition:
Expired
Discharge Diagnosis:
primary: end stage liver disease, hepatorenal disease, cerebral
edema, seizure disorder, respiratory failure, cardiac failure
Discharge Condition:
deceased
Discharge Instructions:
.
Followup Instructions:
.
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
Completed by:[**2127-11-4**]
|
[
"276.2",
"303.91",
"995.92",
"V02.54",
"799.4",
"537.89",
"585.9",
"452",
"780.39",
"V15.81",
"276.8",
"486",
"518.81",
"263.9",
"571.2",
"572.2",
"038.12",
"785.52",
"578.9",
"456.21",
"599.70",
"584.9",
"112.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"99.15",
"54.91",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
6701, 6710
|
2656, 2798
|
312, 318
|
6879, 6889
|
2569, 2633
|
6939, 7107
|
1914, 1918
|
6675, 6678
|
6731, 6858
|
5724, 6652
|
6913, 6916
|
1948, 2550
|
237, 274
|
1049, 1103
|
346, 1031
|
2813, 5698
|
1410, 1673
|
1689, 1898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,637
| 162,878
|
35535
|
Discharge summary
|
report
|
Admission Date: [**2107-3-25**] Discharge Date: [**2107-4-5**]
Date of Birth: [**2030-8-10**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Intraventricular Hemorrhage
Major Surgical or Invasive Procedure:
[**3-26**]: Stereotactic Drainage of Intraventricular blood, placement
of External ventricular drainage.
History of Present Illness:
The pt is a 76 year-old woman (handedness unknown) who was
transferred from an OSH for an ICH. This history is obtained
from her transfer records. She reportedly presented to [**Hospital 8**]
hospital with right sided weakness, slurred speech and
confusion. Her family had reportedly last seen her 2 days prior.
Per report she had also had an episode of emesis prior to
presentation.
At the OSH she was given 10 unit of Vit K and 1gm of dilantin.
She was then intubated for airway protection with lidocaine
100mg IV, vecuronium 1mg, Etomidate 20mg IV, succinylcholine
120mg and a total of 6mg of Ativan. Her BP was 145/79 and her
FS was 124. A head CT was done which showed a large L ICH in the
temporal lobe w/ ventricular extension and mild mass effect on
the L midbrain. She was transferred here for further care.
ROS unavailable.
Past Medical History:
A-fib on Coumadin, HTN, Asthma
Social History:
-spanish speaking only
-EtOh, tobacco, drugs: denied
-Daughter= [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (3) 80911**]
Family History:
unknown
Physical Exam:
Vitals: T: 96.9 BP: 148/86 R: 15 P: 109 SaO2: 100% on ET
General: intubated, sedated .
HEENT: NC/AT, no scleral icterus noted, ET in place
Neck: no carotid bruits appreciated but difficult to assess with
mechanical ventilation, No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregular, no prominent systolic ejection murmur
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 1+ pedal edema bilaterally
Skin: no rashes
Neurologic:
-Mental Status: intubated, sedated, grimace to nox stim but no
purposeful movements
CN
I: not tested
II,III: no blink to threat, pupils .75mm and slightly reactive
(e-centric bilaterally)
III,IV,V: eyes in primary position, no dolls, no nystagmus
V: no corneals, + nasal tickle bilaterally
VII: no gross facial asymmetry but ET in place
VIII: UA
IX,X: + gag
[**Doctor First Name 81**]: UA
XII: UA
Motor: nl tone, withdraws UE bilaterally weakly, LE have triple
flexion bilaterally
Reflex: No clonus
[**Hospital1 **] Tri Bra Pat An Plantar
C5 C7 C6 L4 S1 CST
L 0---------------- up
R 0---------------- up
-Sensory: withdrawal to nox stim in all extremities but triple
flexion in LE bilaterally
-Coordination: UA
-Gait: UA
Pertinent Results:
Labs on Admission:
[**2107-3-25**] 02:50PM BLOOD WBC-9.4 RBC-3.53* Hgb-9.7* Hct-28.6*
MCV-81* MCH-27.5 MCHC-33.9 RDW-15.4 Plt Ct-179
[**2107-3-25**] 02:50PM BLOOD Neuts-84.1* Lymphs-9.9* Monos-5.9 Eos-0.1
Baso-0
[**2107-3-25**] 02:50PM BLOOD PT-79.1* PTT-47.0* INR(PT)-10.0*
[**2107-3-25**] 02:50PM BLOOD Glucose-112* UreaN-24* Creat-0.8 Na-145
K-2.3* Cl-114* HCO3-22 AnGap-11
[**2107-3-25**] 02:50PM BLOOD ALT-18 AST-21 LD(LDH)-162 CK(CPK)-161*
AlkPhos-35* TotBili-0.9
[**2107-3-25**] 02:50PM BLOOD CK-MB-2 cTropnT-<0.01
[**2107-3-26**] 02:57AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.1
[**2107-3-25**] 02:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging:
Head CT [**3-25**]:
NON-CONTRAST HEAD CT: There has been no significant interval
change with
persistent left lateral ventricle hemorrhage which appears to be
maximal in
the region of the temporal [**Doctor Last Name 534**] causing dilation of the temporal
[**Doctor Last Name 534**]. There is mass effect on the surrounding white matter
causing sulcal effacement and vasogenic edema. A concomitant
intraparenchymal component in the region of the temporal lobe is
questioned. The hemorrhage also extends from the third ventricle
into the fourth ventricle, overall unchanged since prior study.
There are no obvious masses. There are no new hemorrhagic foci.
There are no major vascular territorial infarcts. The [**Doctor Last Name 352**] and
white matter differentiation in remainder of the unaffected
regions of the brain is normal. There are no other short- term
interval changes. Previously noted minimal 3-mm subfalcine
herniation is unchanged.
IMPRESSION:
1. No short-term interval changes with persistent large
intraventricular
hemorrhage predominantly involving the left lateral ventricle.
2. No underlying masses were discernible, however MRI with
gadolinium may have added sensitivity towards detection of
masses.
MRI/MRA Head [**3-26**]:
TECHNIQUE: T1 sagittal, axial and FLAIR T2 susceptibility and
diffusion axial images of the brain were acquired. Following
gadolinium T1 axial and MP-RAGE sagittal images were obtained.
3D time-of-flight MRA of the circle of [**Location (un) 431**] acquired.
Correlation was made with the head CT obtained earlier on
[**2107-3-25**].
FINDINGS: As seen on the head CT there is an acute hemorrhage
identified in
the left basal ganglia region extending to the left lateral
ventricle. The
hemorrhage has central component of mixed signal intensities
with hyperintense T2 signal indicating fluid and combination of
fluid and blood clot. There is surrounding edema identified.
Following gadolinium minimal marginal enhancement is seen at the
anterior portion of the hematoma. Subtle enhancement also is
seen posterosuperiorly. The degree of enhancement is more in
favor of enhancement at the margin of hematoma from loss of
bloodbrain barrier than an underlying neoplasm. Additional foci
of susceptibility indicating microhemorrhages are seen in the
right periventricular region, right basal ganglia and right
temporal lobe as well as in the inferior vermis region. These
findings favor suggestion of amyloid angiopathy as an underlying
cause for hemorrhage. There is mass effect on the left side of
the mid brain with impending uncal herniation. There is no
hydrocephalus seen. Mild midline shift to the right is
visualized without subfalcine herniation. Diffuse
hyperintensities in the white matter indicate small vessel
disease.
IMPRESSION:
1. Acute left basal ganglia temporal lobe hematoma with
surrounding edema and extension to the left lateral ventricle.
Mild marginal enhancement at the hematoma could result from loss
of blood brain barrier around hematoma than underlying neoplasm.
However, followup examination would help for further
confirmation. The hematoma has mixed characteristics as
described above.
2. Several foci of susceptibility in the right cerebral
hemisphere and
posterior fossa suggest amyloid angiopathy is an underlying
abnormality.
3. Diffuse hyperintensities due to small vessel disease.
4. Impending uncal herniation.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal for the arteries of
anterior and posterior circulation. Slightly bulbous tip of the
basilar artery is noted, an incidental finding. Slightly bulbous
origin of the right posterior communicating artery is also seen
due to an infundibulum.
IMPRESSION: No significant abnormalities on MRA of the head.
Head CT [**3-26**]:
FINDINGS: Left frontal burr hole and ventricular drain
terminating in the
third ventricle are new since 5 hours prior. Extensive
left-sided
intraventricular hemorrhage involving the left lateral ventricle
and mild
periventicular vasogenic edema causing 3-mm rightward midline
shift is
unchanged since five hours prior. There is no evidence of
herniation and the basilar cisterns are patent. There is no new
hemorrhage identified. Minimal amount of hemorrhage in the right
occipital [**Doctor Last Name 534**] is unchanged since five hours prior. The
paranasal sinuses demonstrate diffuse mild thickening which is
unchanged from five hours prior.
IMPRESSION: New left frontal burrhole with drain terminating in
the third
ventricle. Otherwise, no change since 5 hours prior.
Brief Hospital Course:
Patient is a 76 year old woman who has a large temporal
hemorrhage with intraventricular extension. Etiology may be due
to coagulopathy due to INR of 10. Other etiologies could be
amyloid angiopathy or underlying neoplasm or vascular
malformation.
Given the large hemorrhage with ventricular extension and mass
effect, neurosurgery was consulted for drainage. She underwent
stereotactical drainage per Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on HD#2 with EVD
placement and returned to the neurology service on HD#4 ([**3-28**]).
A brain biopsy was also performed which simply showed a hematoma
on pathology.
On transfer to the floor, her arterial line was removed. On [**4-1**]
her EVD was raised to 20 cm which pt has tolerated well. On [**4-4**]
EVD was removed (prophylactic Cefazolin as discontinued) and
follow-up CT imaging showed no significant change in size of the
intraventricular hemorrhage or the surrounding edema and mass
effect. No new hemorrhage is seen. Ventricular size is stable.
Status post removal of left frontal ventricular catheter.
Since it was felt that the hemorrhage was most likely related to
hypertension and a supratherapeutic INR, Aspirin 325mg and SC
heparin were restarted on [**4-5**].
She continued to became more alert and her diet was advanced.
At time of discharge she was following simple commands in
Spanish and attempting to speak. She will follow-up in
Neurosurgery and Stroke clinics as an outpatient.
Medications on Admission:
- Coumadin 5mg PO (2.5mg Qd except 5mg M/W/S)
- prednisone 20mg PO taper for 5 days
- albuterol nebs
- triamcinolone cream
- lactulose 10mg PRN
- fluticasone 110mcg inhaller 2 puffs [**Hospital1 **]
- diltiazem CD 240mg PO QD
- MVI
- Famotidine 40mg
- Amlodipine 5mgp QDay
- Maxzide 25mg PO QD
- Vit D 400 units
- Tyelenol # 3 PRN
- flovent 110 MCG [**Hospital1 **]
- Alomid OP QID PRN
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed.
3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
5. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
6. Insulin Regular Human 100 unit/mL Solution Sig: per ISS UNITS
Injection ASDIR (AS DIRECTED).
7. Diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
11. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
12. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) mg
Intravenous Q6H (every 6 hours) as needed for SBP>160 or HR>120.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
large left Intraventricular hemorrhage, intraparenchymal
hemorrhage
Discharge Condition:
Neurologically Stable.
Discharge Instructions:
You had a large left intracranial hemorrhage in the temporal
lobe with ventricular extension in the setting being
supratherapeutic on Coumadin (elevated INR 10). You also
underwent stereotactic hematoma evacuation and stereotactic
insertion of an external ventricular drain (EVD). The EVD was
discontinued on [**4-2**]. Pathology was still pending at time of
discharge.
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? You may wash your hair only after sutures and/or staples have
been removed.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Please take medications as prescribed.
Please keep your follow-up appointments.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD ([**Hospital 4038**] Clinic) Phone: [**Telephone/Fax (1) 2574**]
Date/Time: [**2107-5-13**] 10:30am. A Spanish interpreter will be
provided at this clinic visit.
Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) 3947**], MD Phone: ([**Telephone/Fax (1) 80912**]
Date/Time: [**2107-4-11**] 11:45am [**Last Name (un) **] Square
Follow-Up Appointment Instructions
??????Please return to the office in [**7-8**] days(from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2107-4-5**]
|
[
"431",
"331.4",
"401.9",
"530.81",
"729.89",
"V58.61",
"348.4",
"784.3",
"311",
"493.90",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"02.39",
"38.93",
"93.59",
"38.91",
"96.72",
"01.39"
] |
icd9pcs
|
[
[
[]
]
] |
11204, 11274
|
8109, 9596
|
343, 450
|
11386, 11411
|
2848, 2853
|
13464, 14674
|
1566, 1575
|
10033, 11181
|
11295, 11365
|
9622, 10010
|
11435, 13441
|
1590, 2095
|
276, 305
|
478, 1317
|
3579, 6930
|
6947, 8086
|
2867, 3570
|
2110, 2829
|
1339, 1372
|
1388, 1550
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,558
| 123,289
|
50021
|
Discharge summary
|
report
|
Admission Date: [**2109-5-10**] Discharge Date: [**2109-5-21**]
Date of Birth: [**2049-1-21**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Coumadin / Percocet / Anesthesia Tray
Attending:[**First Name3 (LF) 2641**]
Chief Complaint:
Left knee pain.
Major Surgical or Invasive Procedure:
Arthrocentesis, wash-out.
AV fistulagram.
History of Present Illness:
Mrs. [**Known lastname 104435**] is a 60 year-old woman with type 1 DM, ESRD on HD,
breast cancer, and pulmonary sarcoidosis who presented to the ED
on the morning of admission with left knee pain and swelling.
.
Arthrocentesis demonstrated 129,000 WBCs. Gram stain revealed no
organisms and no crystals were seen in the synovial fluid. She
received vancomycin and was taken to the operating room for
irrigation under general anesthesia (received etomidate,
fentanyl and cisatracurium) prior to presumed transfer to the
floor. Once on the medicine floor, the pt's daughter reported
that the pt's face appeared to be swollen, and she was
transferred back to the PACU. In the PACU, she received
diphenhydramine 12.5 mg IV, famotidine 40 mg PO and
methylprednisolone 80 mg IV.
.
The patient does not complain of shortness of breath, but does
have throat soreness. She does not report throat swelling or
tongue swelling. She denies visual changes.
.
ROS was unobtainable as the patient was markedly somnolent.
Past Medical History:
1. End stage renal disease on HD T,Th,Sat
2. Diabeted mellitus, Type 1
3. Hypertension
4. Coronary artery disease
5. Gout
6. Asthma
7. Atrial fibrillation
8. Sarcoidosis
9. Pulmonary HTN
10. Obstructive sleep apnea
11. Ventral hernia
12. HIT positive
13. Breast CA
[**14**]. Multiple fistula revisions
14. s/p unilateral oophorectomy
Social History:
She spends most days at home in the house. She is ambulatory
mainly within the home and does not require oxygen. She
currently lives with her son. She quit smoking 30 years ago
after a 20-pack-year history. She denies alcohol consumption.
Family History:
Brother: sarcoidosis.
Mother/father with heart disease, MIs.
Physical Exam:
Physical exam on arrival to medical floor:
Vitals: T: 97.6 BP: 112/49 P: 60 R: 15 SaO2: 91% RA, 100% 3LNC
General: Drowsy, but rousable, no audible stridor or wheeze
HEENT: NCAT, EOMI, conjunctival injection, puffy eyes and lips,
tongue appears mildly thick
Neck: no significant JVD, no stridor, L tunnelled IJ in place
without tenderness or erythema
Pulmonary: diminished BSs bilaterally, no wheeze
Cardiac: RR, distant S1 S2, no appreciable murmurs
Abdomen: obese, soft, NT, ND
Extremities: L knee wrapped with drain in place
.
On discharge:
Afebrile, normotensive, last oxygen saturation 99% on room air.
Knee, left: minimal discomfort on full range of motion, some
residual swelling. Drain now removed. Able to achieve >90
degrees with PT.
Pertinent Results:
[**2109-5-10**] 08:20AM BLOOD WBC-6.1 RBC-4.04* Hgb-10.5* Hct-37.0
MCV-92 MCH-25.9* MCHC-28.4* RDW-18.9* Plt Ct-130*
[**2109-5-10**] 08:20AM BLOOD Neuts-80* Bands-1 Lymphs-5* Monos-13*
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2*
[**2109-5-10**] 08:20AM BLOOD Glucose-78 UreaN-16 Creat-4.7*# Na-141
K-7.2* Cl-98 HCO3-33* AnGap-17
[**2109-5-10**] 08:20AM BLOOD UricAcd-3.4
[**2109-5-10**] 08:29AM BLOOD Lactate-1.9 K-5.5*
[**2109-5-10**] 09:31AM JOINT FLUID WBC-[**Numeric Identifier 104436**]* RBC-[**Numeric Identifier 6085**]* POLYS-94*
LYMPHS-1 MONOS-5
[**2109-5-15**] 07:20AM BLOOD Glucose-65* UreaN-23* Creat-4.5*# Na-136
K-5.1 Cl-99 HCO3-25 AnGap-17
[**2109-5-14**] 01:10PM BLOOD CRP-69.5*
[**2109-5-14**] 01:10PM BLOOD ESR-34*
[**2109-5-15**] 07:20AM BLOOD Calcium-7.3* Phos-3.2 Mg-2.0
------------
CXR: [**2109-5-10**] 10:29 PM
IMPRESSION: No significant interval change.
------------
Knee Films: [**2109-5-10**] 8:36 AM
IMPRESSION:
No acute fracture or alignment abnormality. Severe degenerative
change.
------------
AV Fistulogram: [**2109-5-14**] 9:26 AM
IMPRESSION:
1. Moderate-to-severe right central venous stenosis at the
brachiocephalic/SVC confluence which was angioplastied with a
10-mm balloon with no residual stenosis identified
post-procedure.
2. Moderate stenosis involving the proximal venous outflow tract
with prestenotic dilatation which was angioplastied multiple
times using a 6-mm cutting balloon with no residual stenosis
identified post-procedure.
3. Unchanged stenosis at the arterial anastomosis which was not
instrumented during current procedure and does not appear
significantly changed from prior examination.
Please keep V-pack dressing in place for 24 hours.
------------
ECG: Sinus rhythm. A-V conduction delay. Prior inferior wall
myocardial infarction. Prior anteroseptal myocardial
infarction. Diffuse low voltage. Left axis deviation.
Intraventricular conduction delay. Q-T interval prolongation.
Compared to the previous tracing of [**2109-3-26**] the voltage has
diminished. Followup and clinical correlation are suggested.
------------
Microbiology:
Joint:
GRAM STAIN (Final [**2109-5-10**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2109-5-13**]): NO GROWTH.
Blood Culture
[**2109-5-10**] 8:20 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
------------
[**2109-5-10**] 1:40 pm TISSUE LEFT KNEE SYNOVIUM.
GRAM STAIN (Final [**2109-5-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2109-5-13**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2109-5-11**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final [**2109-5-13**]):
NO FUNGAL ELEMENTS SEEN.
Due to the low sensitivity of a KOH preparation a fungal
culture is
recommended.
-----------
[**2109-5-10**] 1:40 pm SWAB LEFT KNEE DEEP.
GRAM STAIN (Final [**2109-5-10**]):
2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final [**2109-5-12**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2109-5-12**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
POTASSIUM HYDROXIDE PREPARATION (Final [**2109-5-10**]):
TEST CANCELLED, PATIENT CREDITED.
Inappropriate specimen for Fungal Smear (KOH).
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
---------------
Blood Cultures [**2109-5-12**], [**2109-5-14**] - Negative.
Lyme Serology: Negative
--------------
Brief Hospital Course:
Ms. [**Known lastname 104435**] is a 60 year-old female with multiple comorbidities
who presented with a swollen, tender, warm left knee.
.
Hospital course by problem:
.
# Septic Arthritis: On arrival to the ED, the patient was
afebrile (T 98.4) with a blood pressure of 144/40. Physical
exam was notable for a swollen left knee that was exquisitely
tender to palpation. Arthrocentesis revealed 15 cc of cloudy,
viscous fluid with 129,000 WBC, >90% polys. Gram stain did not
reveal any organisms. Crystals were not detected. She received
vancomycin for a presumed septic joint and was taken to the
operating room for arthrotomy and drain placement. She was
started on ceftriaxone on [**5-10**] for potential gonococcal
infection. Lyme serology was negative for lyme antibody.
Tissue cultures and swab cultures did not reveal organisms on
gram stain and showed no anaerobic growth to date as well as no
fungal or acid fast bacilli. Blood cultures have not grown
anything to date. The patient has remained afebrile throughout
her hospital stay and without leukocytosis. ID was consulted,
and recommended continuing vancomycin for a 6 week course.
Ceftriaxone was stopped on [**5-15**]. The patient reports that her
knee pain is less than when she arrived. She is able to move
her left knee without significant pain and has been working with
physical therapy. She was followed by orthopedics, who were
pleased with her recovery. Extensive discussion was given
regarding repeat thoracentesis prior to discharge, but patient
had good range of motion at the joint and felt pain had improved
since admission, and it was uncelar what diagnostic benefit
would be gained from a second thoracentesis. Patient developed
thrombocytopenia prior to discharge that was thought possibly
[**1-12**] to vancomycin. Vancomycin was initially continued given it
was the optimal [**Doctor Last Name 360**] and patient had other possible agents
(such as famotidine) that may have contributed to
thrombocytopenia. Hematology was consulted and felt
thrombocytopenia was more likely related to marrow suppression
than vancomycin toxicity, and vanco was continued. She was
monitored for several days and showed no progression of her
thrombocytopenia on vancomycin. The decision was made to
continue vancomycin and to monitor her paltelets as an
outpatient.
- Would consider further thoracentesis if patient experiences
increasing pain and swelling, or difficulty with range of
motion. Do anticipate some pain/swelling from post-operative
changes.
- Patient will follow-up with PCP and Orthopaedics, Vancomycin
levels to be monitored at HD.
.
# Thrombocytopenia: Patient with chronic mild thrombocytopenia
and history of HIT - although no documented work-up in [**Hospital1 **]
system. Patient became progressively thrombocytopenic in house,
and immediately prior to initial discharge had significant drop
in platelets to 50's. Patient was held in house for a further 5
days, and was without further decrease in her platelets. No
bleeding complications. Medical record was very carefully
examined and patient had no known exposure to heparin during
this hospitalization. Further, the decrease in platelets was
felt not to be typical of HIT or reactivation of HIT in
previously exposed patient. DIC work-up also non-revealing.
Hematology was consulted who felt decrease was not likely HIT,
and ultimately decided it was due to marrow suppression from
infection. Evidence for vancomycin toxicity was felt to be
minimal as time course did not fit appropriately. Plan on
discharge is as follows:
- Please check platelet count twice weekly at hemodialysis
- If platelets drop below 30K patient should be referred to
hospital for evaluation.
- Continue vancomycin for 6 weeks as long as platelet count
stable.
- Patient to follow-up with Hematology if thrombocytopenia
persists after completion of her course of vancomycin.
.
# Allergic reaction/angioedema: After the
arthrotomy/synovectomy, the patient's daughter noticed her face
was more swollen than normal. She was was exposed to
vancomycin, morphine, and anesthetic agents during the
arthrotomy. It is not clear which agents may have contributed to
the swollen state, and whether her swelling was an allergic
reaction at all or fluid accumulation in setting of not being
dialyzed. She was transferred from medicine and monitored in
the PACU. She did not appear to have any respiratory
compromise, and there was no stridor on exam. She did not
complain of throat tightness or tongue swelling. She did
complain of throat discomfort, which was felt to be related to
her recent intubation. She was given diphenhydramine 12.5 IV
q8hrs, famotidine 40 mg PO bid, and she received
methylprednisolone once, though this was not continued given her
history of DM1 and likely septic joint. She was monitored in the
ICU overnight. Her ACEI was held. She became more alert and
oriented, was able to speak, drink, and swallow without problem,
so she was called out to the floor. On the medicine floor, the
patient did not exhibit any episodes of facial swelling or
oropharyngeal discomfort. ACE was restarted on the floor prior
to discharge without difficulty. Facial swelling resolved with
dialysis and may have been due to volume overload rather than
angioedema. Furthermore, question whether there may be a
component of central vein stenosis as patient had
brachiocephalic veing - SVC stenosis that was dilated by IR.
.
# Nonresponsiveness at hemodialysis: The patient became
transiently hypotensive to the 70s and briefly non-responsive on
[**5-11**]. The session was stopped and she was monitored in the ICU.
She did not have any other episodes of non-responsiveness,
though she does have a long history of these events at
hemodialysis sessions. She remained normotensive on the medical
floor throughout her stay.
.
# End stage renal disease on hemodialysis: Patient had an
episode of hypotension and nonresponsiveness, as described
above. Her schedule is T, Th, Sat. She recieved erythropoietin.
Cinacalcet was also administered for calcium control.
Cinacalcet was discontinued prior to discharge due to
hypocalcemia. Tunnelled dialysis catheter removed in house.
Some residual swelling after removal, evaluated with ultrasound
that showed a small hematoma. Continue to followed clinically
and was stable prior to discharge.
.
#Breast Swelling: patient noted her breast to be swollen. Given
history of untreated breast cancer on Arimidex concern was for
progression of malignancy. Oncology recommended outpatient
mammogram/USD for further evaluation. Swelling improved with
dilation of brachiocephalic - SVC stenosis by IR, and exam was
otherwise unremarkable.
- Outpatient follow-up as outlined.
.
# Type 1 diabetes mellitus: Remained stable. She was continued
on insulin NPH 10 [**Hospital1 **] and a humalog sliding scale. Had some
elevated finger sticks during the day and so AM NPH was
increased to 12 units qAM.
.
# Hypertension: Remained stable. The ACE inhibitor was held
until after hemodialysis on those days to decrease the risk of
hypotension during these sessions.
.
## CAD: Patient not takin aspirin (due to bleeding), metoprolol
or statin as an outpatient. Continued on ACE inhibitor as
above.
.
## Gout: She was continued on allopurinol 150 every other day.
Acute monoarthritis felt not c/w gouty flare.
.
## Atrial fibrillation: Remained in sinus rhythm, not
anticoagulated given low CHADS Score (2), history of HIT and not
anticoagulated for atrial fibrillation on admission.
.
## Hypothyroidism: Continued levothyroxine 25
.
## FEN/Lytes: NPO for now, cardiac, renal diet in a.m., replete
lytes prn
.
## Prophylaxis: No heparin given allergy, pneumoboots
.
## Access: PIVs
.
## Communication: Daughter [**Name (NI) 104437**] ([**Telephone/Fax (1) 104438**] cell,
[**Telephone/Fax (1) 104439**] home)
.
## Code status: FULL CODE
Medications on Admission:
Quinapril 5 mg daily
Anastrazole 1 mg daily
Albuterol prn
Prednisone 5 mg qod
Amitriptyline 25 mg daily
Vitamin D 400 mg daily
Cinacalcet 30 mg daily
Gabapentin 200 mg daily
Levothyroxine 25 mcg daily
Amiodarone 200 gm daily
? atorvastatin 20 mg daily
? aspirin 81 mg daily
? metoprolol 12.5 [**Hospital1 **]
Insulin NPH ? 20 units [**Hospital1 **] and insulin regular
Discharge Medications:
1. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
2. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
One (1) nebulizer Inhalation Q6H (every 6 hours) as needed.
3. Prednisone 5 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Quinapril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/fever.
9. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) tablet PO BID
(2 times a day).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
13. Vancomycin 1,000 mg Recon Soln Sig: One (1) gm Intravenous
qHD for 5 weeks: for total of 6 weeks, to complete on [**2109-6-21**].
14. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twelve
(12) units Subcutaneous qAM.
15. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Ten (10)
units Subcutaneous qPM.
16. Insulin Lispro 100 unit/mL Cartridge Sig: as per sliding
scale units Subcutaneous qACHS: as per sliding scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 81219**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Septic Arthritis
Angioedema
ESRD
Sarcoid
Breast Cancer
Diabetes
Thrombocytopenia
Discharge Condition:
Good, weight bearing as tolerated
Discharge Instructions:
You were admitted to the hospital for evaluation of left knee
pain. It was found that you had an infection in your knee. You
will need to take antibiotics for a full 4 week course to treat
this infection. You also had an evaluation of your AV fistula
that showed a narrowing. This narrowing (or stenosis) was
opened up with a balloon to improve flow in your graft.
Finally, there was some concern you may have had an allergic
reaction after going to the Operating Room. This reaction was
likely related to the anesthetic agents used in the Operating
Room, and did not appear to be related to your BP medications
which were restarted prior to discharge without any difficulty.
.
Please call your doctor or return to the Emergency Department if
you have any fevers, increasing knee pain, or any other
complaint concerning to you.
.
Followup Instructions:
Please have your platelet counts checked with hemodialysis
within the next 3 days. Please call primary care provider [**Last Name (NamePattern4) **].
[**Last Name (STitle) 6924**], at ([**Telephone/Fax (1) 30577**] with the result.
--------
Please follow up with [**Doctor Last Name **] Derosiers, Orthopaedic Trauma NP,
([**Telephone/Fax (1) 5238**]: Tuesday [**5-28**] 9:20AM, arrive at 9AM to [**Last Name (un) 469**]
Building, [**Location (un) **].
------
Please follow-up for your mammogram and breast ultrasound on
[**Last Name (LF) 2974**], [**5-17**] at 10:30AM, [**Hospital Ward Name 23**] [**Location (un) 861**], [**Hospital1 **] [**Last Name (Titles) 516**], ([**Telephone/Fax (1) 104440**].
------
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:
[**2109-5-27**] 2:30pm, [**Hospital Ward Name 23**] Building [**Location (un) 24**]. Please call to
reschedule if needed.
------
Please follow-up with Dr. [**Last Name (STitle) 6924**], your Primary Doctor, on
Wednesday, [**5-29**] that 10:10AM, ([**Telephone/Fax (1) 30577**], [**Street Address(2) 104441**].
[**Location (un) 538**].
------
Provider: [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 17898**]
Date/Time:[**2109-6-13**] 2:40
|
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[
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icd9pcs
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[
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16921, 16997
|
7178, 7318
|
331, 374
|
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|
2890, 5255
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,143
| 114,095
|
14653
|
Discharge summary
|
report
|
Admission Date: [**2108-8-4**] Discharge Date: [**2108-9-10**]
Service:
HISTORY OF PRESENT ILLNESS: This is an 84-year-old female
with a past medical history of hypertension, vascular
disease, increased cholesterol, laryngeal carcinoma 10 years
ago, status post laryngectomy, cervical carcinoma status post
TAH, angina and appendectomy, who presented to [**Hospital1 346**] Emergency Room on [**2108-8-4**]. She was
transferred from [**Hospital 8**] Hospital. This whole issue
started on [**2108-7-20**] when patient presented to [**Hospital 8**]
Hospital for an ischemic right fifth toe. The patient had at
that time bilateral iliac stenting. She left the procedure
with suprapubic hematoma. She received three units of packed
red blood cells and 6 units of platelets and she was
discharged home on [**7-30**]. The patient was noted to be
lethargic over the subsequent days and returned to [**Hospital 8**]
Hospital on [**8-2**]. When she got to [**Hospital 8**] Hospital she was
anemic with hematocrit of 24 and thrombocytopenic with a
platelet count of 25,000. She received two units of packed
red blood cells and 6 units of platelets and she continued to
have low counts. Hematology was consulted at that point and
LDH was increased. The patient was transferred t [**Hospital1 346**] on [**8-4**] for further management of a
presumed TTP. On [**8-4**] she complained of left hand numbness,
paresthesias and a left sided facial droop that lasted 15
minutes, which resolved on its own. Neuro consult felt TIA
was the most likely cause with right MCA territory. CAT scan
of the head was negative. MRI and MRA demonstrated
atherosclerotic changes of intracranial carotids, right
greater than left, but no stroke.
Mrs. [**Known lastname 32495**] began plasmapheresis on [**8-5**], though during her
first episode she developed hypotension with systolic blood
pressure to the 80's, responded to fluid boluses and she was
also hypocalcemic at the time. Therefore, patient was
transmitted to the MICU where plasmapheresis continued there.
On [**8-10**] she completed a course of plasmapheresis, her
platelets had maxed at 238,000 and her LDH was 271. She
needed plasmapheresis again on [**8-12**] for decreasing platelets,
increasing LDH and decreasing haptoglobin. Subsequently on
[**8-12**] she developed a fever to 101. She was cultured and
blood cultures grew coag negative staph aureus four bottles
and the patient was started on Vancomycin. She had a line
exchange on [**8-17**]. During that time her platelet count was
decreasing and there was a question of infection vs DIC and
HIT. She had an HIT positive antibody at that time.
Plasmapheresis continued through the right subclavian
catheter placed by IR with completion of plasmapheresis on
the [**9-6**].
PHYSICAL EXAMINATION: She had temperature 98.9, blood
pressure 150/70, pulse 85, respirations 20, 95% on room air.
She was in no apparent distress. She was normocephalic,
atraumatic, equal ocular movements intact. Chest clear to
auscultation. Cardiovascular showed a regular rate and
rhythm, normal S1 and S2, no murmurs, rubs or gallops.
Abdomen was benign. Extremities, no clubbing, cyanosis or
edema but there was a large ecchymoses in the right groin
area. Neuro, she is alert and oriented times three, cranial
nerves II through XII grossly intact, muscle strength 5/5
throughout. Back without tenderness.
PAST MEDICAL HISTORY: As previously noted. She has
hypertension, vascular disease, increased cholesterol,
laryngeal carcinoma 10 years ago, status post laryngectomy,
cervical cancer status post total abdominal hysterectomy,
angina status post epi.
MEDICATIONS: On admission, Meclizine 25 mg once a day,
Atenolol 50 mg once a day, iron 325 mg tid and Lipitor 10 mg
once a day.
ALLERGIES: No known drug allergies.
LABORATORY DATA: She had a white count of 8.3, hematocrit
29.9, platelet count 35, PT 13.6, PTT 26 and INR 1.1, d dimer
greater than 1,000, FTP between 10 and 40, SMA 10 was within
normal limits. Head CT on the [**8-3**] was negative. Head CT on
[**8-4**] showed no acute blood.
HOSPITAL COURSE: Partially stated during HPI, patient was
admitted on [**8-4**] to [**Hospital1 69**] from
[**Hospital 8**] Hospital. The patient had a hematocrit of 29.9 and
platelet count 35 and white appeared to be a TIA, so it was
believed that patient was suffering from TTP. The patient
developed a plasmapheresis on [**8-5**] at which point she became
hypotensive with systolic blood pressure to the 80's and
hypocalcemia. Therefore, patient was transferred to the MICU
where she tolerated plasmapheresis very well. The patient's
platelets came up to 238,000, LDH came down to 271 on [**8-12**],
though it was noted that the patient's platelets were
decreasing again. LDH was rising and haptoglobin was low.
The patient restarted plasmapheresis on [**8-12**]. On subsequent
exam on [**8-12**], the patient developed a fever to 101.5 with
coag negative staph in [**4-26**] bottles from the blood. She was
started on Vancomycin and her line was exchanged on [**8-17**].
When patient had a fever on [**8-12**] and the line needed
exchanging, the patient was sent to the [**Hospital Unit Name 153**] on the [**Hospital Ward Name 8559**]. The patient received right subclavian and continued
on Vancomycin for one week. A new line was placed on [**8-17**].
During that time there was question of infection and DIC vs
HIT. The patient had HIT positive lab test results. Patient
had good renal function throughout the whole hospitalization.
Creatinine ranged from 0.9 to 1.1. Some time on the floor
the patient had one episode of chest tightness that resolved
with Nitroglycerin. Cardiology consult believed this to be
demand ischemia with minor ST-T changes. Troponin maxed at
1.7 and patient was treated with increased beta blockers. At
that time patient was not a candidate for Aspirin therapy.
The patient completed plasmapheresis on [**9-6**] for a total of
25 sessions of plasmapheresis. Upon discharge the patient's
platelets normalized at 298,000, LDH remained within the
normal limits. The patient was discharged home with home
services.
CONDITION ON DISCHARGE: Patient is stable at discharge.
DISCHARGE MEDICATIONS: Calcitrol 0.25 mcg q day, Insulin
sliding scale, Prednisone taper, Atenolol 100 mg q day,
Protonix q 40 mg q day, Meclizine 12.5 mg q day, Folic Acid 1
mg q day, Iron 325 mg q day and Alendronate 5 mg q day.
DISCHARGE DIAGNOSIS:
1. TTP.
DISCHARGE STATUS: Stable. Home with services.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**]
Dictated By:[**Doctor Last Name 10188**]
MEDQUIST36
D: [**2108-9-10**] 13:45
T: [**2108-9-16**] 14:24
JOB#: [**Job Number 43158**]
|
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icd9cm
|
[
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[
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icd9pcs
|
[
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|
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|
2818, 3413
|
110, 2795
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6205, 6238
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,589
| 161,005
|
31062
|
Discharge summary
|
report
|
Admission Date: [**2105-7-5**] Discharge Date: [**2105-7-15**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1**]
Chief Complaint:
abdominal pain, acute onset afternoon of [**2105-7-5**].pain in left
lower quadrant
Major Surgical or Invasive Procedure:
expoloratory laporatomy
History of Present Illness:
patient had sudden onset of left lower quadrant pain. EMT's
called. HR=40's. Brought to [**Hospital1 18**]- CT scan consistant with
ischemic ileitis.Went to the OR emergently. Had exploratory
laparotomy. No significant findings. Transfered to 12 [**Hospital Ward Name 1827**],
diet and mobility advanced. INR elevation [**2105-7-11**]. Coumadin held,
vitamin K given x 2. [**2105-7-15**] INR= 1.7 Will be d/c home with
services
Past Medical History:
-Hypertension
-BPH- history of hematuria after foley placement
-CAD?- NSTEMI- [**4-15**] dx at OSH, cath [**4-15**] at [**Hospital1 18**] showed no
coronary artery disease
-Paroxsysmal afib- diagnosed with afib with rvr [**4-15**],
spontaneous conversion after transfer from OSH, no
anticoagulation
-Aortic stenosis- diagnosed [**4-15**], echo showed moderate stenosis
with valve area 1.0-1.2cm2
Social History:
Patient states he lives with his wife, daughter and son-in-law.
[**Name (NI) **] is an ex veteran. Formerly owned a restaurant. Nonsmoker,
drinks 1 glass of wine with dinner, no drug use.
Family History:
NC, does not know of any premature heart disease.
Physical Exam:
Gen: NAD
CARD: RRR
Lungs: CTAB
ABD: BS+, soft, appropriatly tender
wound: C,D,I
EXT: no c/c/e
Pertinent Results:
[**2105-7-10**] 07:30PM BLOOD PT-59.4* INR(PT)-7.0*
[**2105-7-10**] 09:37PM BLOOD PT-61.1* INR(PT)-7.3*
[**2105-7-11**] 06:05AM BLOOD PT-71.2* PTT-39.5* INR(PT)-8.8*
[**2105-7-11**] 05:20PM BLOOD PT-43.6* INR(PT)-4.8*
[**2105-7-12**] 05:50AM BLOOD PT-38.2* INR(PT)-4.1*
[**2105-7-12**] 05:50AM BLOOD Plt Ct-318
[**2105-7-12**] 03:30PM BLOOD PT-39.0* PTT-39.4* INR(PT)-4.2*
[**2105-7-13**] 06:25AM BLOOD PT-39.9* PTT-40.5* INR(PT)-4.3*
[**2105-7-14**] 06:45AM BLOOD PT-55.3* INR(PT)-6.5*
[**2105-7-14**] 03:45PM BLOOD PT-46.6* INR(PT)-5.2*
[**2105-7-14**] 06:45AM BLOOD PT-55.3* INR(PT)-6.5*
[**2105-7-14**] 03:45PM BLOOD PT-46.6* INR(PT)-5.2*
[**2105-7-15**] 06:45AM BLOOD PT-18.4* INR(PT)-1.7*
Brief Hospital Course:
86 year old male patirnt- Recently discharged from hospital
after cardioversion for AFIB. Presented with new onset of left
lower quadrant pain. CT indicated ischemic ileitis. Went to OR
for exploratory laparotomy. No specific pathology was found.
[**2105-7-10**] INR elevated, required 2 doses of vitamin K. [**2105-7-15**]
INR 1.7. Dischared to home with plan for VNA to draw INR in am
and call results to Dr [**Last Name (STitle) 8446**].Will take one mg coumadin
tonight.
Medications on Admission:
asa 325 one pill daily
amiodarone 200mg tab 0.75 tab po bid
metoprolol 25mg take [**12-10**] tab po bid
coumadin one mg PO tonight
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: 0.75 Tablet PO BID (2 times a
day).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day) as needed for htn.
4. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*14 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
mesenteric ischemia
atrial fibrillation
Discharge Condition:
vss- tol regular diet- ambulates with assistance
Discharge Instructions:
General:
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.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2105-7-17**] 11:40
Dr [**Last Name (STitle) 73348**] [**2105-7-17**] 1:00 pm
Provider: [**Name10 (NameIs) 39063**] [**Last Name (NamePattern4) 39064**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2105-7-21**] 2:30
Dr. [**Last Name (STitle) **] in [**1-12**] weeks [**Numeric Identifier 73349**]
Completed by:[**2105-7-15**]
|
[
"424.1",
"427.31",
"276.2",
"412",
"557.0",
"600.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
3374, 3423
|
2375, 2851
|
341, 367
|
3507, 3558
|
1656, 2352
|
4762, 5210
|
1468, 1522
|
3032, 3351
|
3444, 3486
|
2877, 3009
|
3582, 4739
|
1537, 1637
|
218, 303
|
395, 826
|
848, 1246
|
1262, 1452
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,400
| 188,006
|
3091
|
Discharge summary
|
report
|
Admission Date: [**2101-11-23**] Discharge Date: [**2101-12-2**]
Date of Birth: [**2030-3-26**] Sex: M
Service: NEUROSURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Burr hole
Craniotomy
History of Present Illness:
The patient is a 71-year-old male status post a fall a month
prior to admission. He came to our hospital with a CT scan that
showed acute subdural hematoma.
Past Medical History:
Hyperlipidemia, COPD, fem [**Doctor Last Name **] bypass 6 years ago, hip and knee
replacements, smoker/drinker
Social History:
Widowed; 3 grown children
+Tobacco, 1 ppd x 60 yrs
+EtOH, 3 highballs per day
Physical Exam:
On admission:
Vital signs stable, afebrile.
General- awake and alert
HEENT- NCAT, PERRL, no otorrhea/rhinorrhea
CV- RRR, nl S1S2, no M/G/R
Pulm- Bibasilar expiratory wheezes
Abd- +BS, soft, NTND
Ext- warm, no C/C/E
[**Name (NI) 298**] Pt awake, alert, and oriented x 3; PERRL; EOMI; facial
sensation intact; slight flattening of nasal-labial fold on left
side; tongue midline; speech clear and appropriate; no drift.
Motor:
Delt [**Hospital1 **] Tri IP Ham Quad AT G [**Last Name (un) 938**]
Right 5 5 5 5 5 5 5 5 5
Left 4 5 4 5 5 5 4 5 4
Pertinent Results:
[**2101-11-23**] 05:45PM GLUCOSE-94 UREA N-15 CREAT-0.9 SODIUM-143
POTASSIUM-4.2 CHLORIDE-107 TOTAL CO2-22 ANION GAP-18
[**2101-11-23**] 05:45PM WBC-9.2 RBC-4.56* HGB-14.9 HCT-41.7 MCV-92#
MCH-32.8* MCHC-35.9* RDW-15.3
[**2101-11-23**] 05:45PM NEUTS-67.4 LYMPHS-27.1 MONOS-3.8 EOS-1.5
BASOS-0.2
[**2101-11-23**] 05:45PM PLT COUNT-228
[**2101-11-23**] 05:45PM PT-26.4* PTT-35.4* INR(PT)-5.1
Brief Hospital Course:
The patient was taken to the OR for an attempt to use a burr
hole to evacuate the subdural hematoma. Unfortunately, multiple
membranes were encountered and the repeat head CT did not show
significant improvement of the subdural hematoma. Based on that
and after discussion with the family, it was decided to take the
patient back to the operating room to perform a large craniotomy
for evacuation of the subdural and also removal of the subdural
membranes. The patient was monitored in the ICU postoperatively,
then transferred to the stepdown unit on post op day 1. He went
into atrial fibrillation, Diltiazem was initiated, and he was
transferred back to the ICU. He had one episode of a 3-second
pause in the ICU. Diltiazem was discontinued and an Amiodarone
drip started. He converted back to normal sinus rhythm. The
patient was asymptomatic throughout this episode of dysrhythmia.
A transthoracic echo revealed an EF 50-55%, [**1-9**]+ MR, mild
symmetric LVH. The patient was given oral Amiodarone and he was
transferred to the floor on post op day 3. Please evaluate
pateint thyhroid function, liver functions, and eye exam
periodically while on amiodarone.Coumadin can be started 2 weeks
from surgery date on [**2101-11-25**].
He was evaluated by PT/OT who recommended discharge to
rehabilitation.
Medications on Admission:
Coumadin 5mg MWF, 7.5mg TuThSaSu
Niacin 500mg qd
Atrovent INH
Tylenol prn headache
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
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. Niacin 500 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
6. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day) for 1 months: Please discontinue after 1
month.
Disp:*93 Capsule(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Sliding scale.
12. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day) for 5 days: Through [**12-4**].
13. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 7 days: [**12-5**] through [**12-11**].
14. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day
for 1 months: Beginning [**12-12**], discontinue after 1 month
completed.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Ativan 1 mg Tablet Sig: One (1) Tablet PO three times a day:
wean to off over one week if patient tolerates. It was started
post op for DT's.
Discharge Disposition:
Extended Care
Facility:
[**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**]
Discharge Diagnosis:
Chronic subdural hematoma
Discharge Condition:
neurologically Stable
Discharge Instructions:
PLEASE TAKE MEDICATIONS AS PRESCRIBED AND READ WARNING LABELS
CAREFULLY. IF CONDITION WORSENS, SUCH AS DECREASED MOBILITY AND
SENSATION, GO TO THE EMERGENCY ROOM IMMEDIATELY. IF SIGNS AND
SYMPTOMS OF INFECTION, SUCH AS FEVERS/CHILLS, PURULENT DISCHARGE
FROM WOUND/INCISION SITE, INCREASED REDNESS, INCREASED PAIN,
PLEASE CALL OR GO TO THE EMERGENCY ROOM. REMEMBER TO CALL TO
SCHEDULE YOUR FOLLOW UP APPOINTMENT (BELOW). LIGHT ACTIVITIES
UNTIL SEEN IN CLINIC. [**Month (only) **] SPONGE BATH OR SHOWER, BUT KEEP
WOUND/INCISION AS DRY AS POSSIBLE.
can be Started on coumadin 2 weeks from [**2101-11-25**] which will
be [**2101-12-9**].
Please wean ativan to off over one week if patient tolerates.
Followup Instructions:
Please have staples removed on Monday [**12-5**]. (Staples can be
removed at the rehabilitation facility, by your primary care
doctor, or on [**Hospital Ward Name 121**] 5 between 9am-12pm, 1-5pm.) Please see Dr.
[**Last Name (STitle) 14667**] in 6 weeks, Please call [**Telephone/Fax (1) 3571**] for an
appointment.
[**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]
Completed by:[**2101-12-2**]
|
[
"432.1",
"781.2",
"V43.65",
"V58.61",
"496",
"305.1",
"427.31",
"291.0",
"303.90",
"443.9",
"V43.64",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"01.51",
"99.04",
"01.31",
"01.23"
] |
icd9pcs
|
[
[
[]
]
] |
4955, 5090
|
1810, 3118
|
279, 302
|
5160, 5184
|
1386, 1787
|
5933, 6376
|
3251, 4932
|
5111, 5139
|
3144, 3228
|
5208, 5910
|
733, 733
|
235, 241
|
330, 488
|
747, 1367
|
510, 623
|
639, 718
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,389
| 188,167
|
9204
|
Discharge summary
|
report
|
Admission Date: [**2132-3-25**] Discharge Date: [**2132-4-7**]
Date of Birth: [**2052-11-16**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on Exertion
Major Surgical or Invasive Procedure:
Aortic Valve Replacement w/ 23mm CE Pericardial Tissie Valve on
[**2132-3-25**]
Coronary Artery Diseas s/p PCI/Stent on [**2132-4-2**]
History of Present Illness:
79 y/o male with known AS diagnosed 1 year ago. Recent Echo
revealed severe AS with a normal EF. Progressive DOE over the
past 6 months and past two Echo's have shown an increase in AS.
Past Medical History:
Aortic Stenosis
s/p Pneumonia [**2130**]
s/p Bilat. Inguinal hernia repair
s/p Deviated septum repair
s/p Tonsillectomy
s/p Bilat. saphenous vein stripping
Social History:
He lives alone in [**Hospital1 8**], MA. He is a retired physics
professor. He never smoked, drank ETOH or used illicit drugs.
Family History:
No known cardiopulmonary disease. His parents lived until they
reached ages greater than 90.
Physical Exam:
P 64 Reg Ht 6' Wt 145
General: WD/WN male, NAD, appears stated age
Skin: W/D -lesion or rashes
Neck: Supple, FROM, -JVD
Chest: CTAB -w/r/r
Heart: RRR, +S1S2 w/ harsh 4/6 SEM with radtion to carotids and
occassional skipped beat
Abd: Soft, NT/ND, +BS. Well healed inguinal hernia scar
Ext: Warm, well-perfused, -c/c/e, superficial varicosities on
rt.
Neuro: A&Ox3, [**3-20**] strengths, -focal deficits
Pulses: 2+ throughout
Pertinent Results:
[**2132-4-4**] 05:40AM BLOOD WBC-6.6 RBC-3.60* Hgb-10.8* Hct-31.9*
MCV-89 MCH-30.0 MCHC-33.9 RDW-13.1 Plt Ct-284
[**2132-4-4**] 05:40AM BLOOD Plt Ct-284
[**2132-4-5**] 05:20AM BLOOD Glucose-107* UreaN-22* Creat-1.4* Na-136
K-3.7 Cl-102 HCO3-22 AnGap-16
Brief Hospital Course:
Pt. was originally seen in clinic on [**2132-2-28**]. After PAT, pt was
directly admitted to [**Hospital1 18**] on [**2132-3-25**] and went to the OR and
underwent a AVR with a 23mm CE pericardial tissue valve. He was
also planned to have a CABGx1, but did not receive this b/c pt.
had b/l saphenous vein stripping. He would receive PCI/stent
later during hospital course. Please see op note for full
surgical details. Pt. tolerated the procedure well and had total
bypass time of 90 minutes and cross-clamp time of 72 minutes. He
was transferred to CSRU in stable condition with a MAP of 75,
CVP 14, PAD 15, [**Doctor First Name 1052**] 25, HR 84 A-paced and being titrated on
Propofol and Neo. Once in the OR, Neo was off and NTG and
Nipride were started secondary to hypertension. He continued to
have adequate amount of chest tube output despite deligent
efforts with products(FFP/Cryo/platelets/Protamine/PRBC). Do to
this continued postoperative hemorrhage, he was brought back to
the OR and re explored for bleeding. Please see op note. Pt was
then brought back to the CSRU in stable condition. He remained
on mechanical ventilation until early POD #1 when propofol and
ventilation were weaned and he was extubated. He was awake,
[**Last Name (LF) 3584**], [**First Name3 (LF) 2995**], and following all commands at time of extubation. On
this day, diuresis and B-blockade were started and he remained
on a Nitro gtt. Throughout day pt cont. to have slightly tenuous
respiratory status and required repeated alb/Atrovent nebs,
Lasix, IS and coughing exercises. POD #2 pt's chest tubes were
removed and his was now weaned off of Nitro. Had some course
breath sounds and cont. to receive diuretics. On early POD #3,
despite repeated CPT, nebs, OOB, and diuretics pt had to be re
intubated for pending respiratory failure. Pt. also went into
AFIB, and after Lopressor dose and Amio bolus pt converted to
SR. An Amio drip was started. Sputum, Blood, Urine, and CVL
cultures were taken and Levo was started due to increased WBC
(12,000). ABX were changed to Zosyn and Vanco. CXR revealed LUL
infiltrate. Pt. remained on ventilatory support until POD #5
when he was successfully weaned from vent. support. Pacing wires
were removed and tube feeds began on POD #4. On POD #6 a swallow
eval was done secondary to difficulty taking meds. Pt passed
swallow. POD #7 he was given a Plavix load for preparation of
cardiac cath the next day and was also transferred to telemetry
floor. POD #8 he was brought for a cath and had PCI/stenting to
RCA. Lasix was held due to increased Creatinine but was started
again on POD#9, creatinine 1.2. He continued to be
hemodynamically stable and was encouraged to get OOB and
ambulate. On POD #10, his lasix was discontinued as he was below
his pre operative weight and his creatinine was elevated to 1.4.
On POD#12 his antibiotics were discontinued, he remained
afebrile and was cleared for discharge to rehab on POD#13.
Medications on Admission:
1. ASA 81mg qd
2. Toprol XL 12.5mg qd
3. Lisinopril 10mg qd
4. MVI qd
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. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 1 months.
5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
8. Amlodipine Besylate 2.5 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Aortic Stenosis s/p Aortic Valve Replacement on [**2132-3-25**]
Coronary Artery Disease s/p PCI/Stent to Right Coronary Artery
Post-operative Pneumonia
Post-operative Atrial Fibrillation
s/p Pneumonia [**2130**]
s/p Bilat. Inguinal hernia repair
s/p Deviated septum repair
s/p Tonsillectomy
s/p Bilat. saphenous vein stripping
Discharge Condition:
Good
Discharge Instructions:
Can take shower. Wash incisions with warm water and gentle soap.
Gently pat dry.
Do not bath or swim.
Do not apply lotions, creams, ointments to incisions.
Do not lift greater than 10 pounds for 2 months.
Do not drive for 1 month.
Make/keep follow-up appointments
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 4 weeks.
Follow-up with Dr. [**First Name (STitle) **] in [**11-18**] weeks.
Follow-up with Dr. [**Last Name (STitle) **] in [**12-20**] weeks.
Completed by:[**2132-4-7**]
|
[
"997.1",
"998.11",
"486",
"272.0",
"518.5",
"427.31",
"285.9",
"424.1",
"401.9",
"414.01",
"997.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.72",
"37.22",
"39.61",
"99.04",
"96.04",
"35.21",
"36.07",
"99.07",
"34.03",
"96.71",
"36.01",
"38.91",
"38.93",
"37.78",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
5684, 5754
|
1861, 4817
|
341, 477
|
6124, 6130
|
1584, 1838
|
1031, 1125
|
4937, 5661
|
5775, 6103
|
4843, 4914
|
6154, 6419
|
6470, 6693
|
1140, 1565
|
282, 303
|
505, 692
|
714, 871
|
887, 1015
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,093
| 184,773
|
29887
|
Discharge summary
|
report
|
Admission Date: [**2150-2-2**] Discharge Date: [**2150-2-24**]
Date of Birth: [**2150-2-2**] Sex: F
Service: Neonatology
HISTORY: Baby Girl [**Known lastname **] was a newborn 33-5/7 week of
gestation infant who was admitted to the Neonatal Intensive
Care Unit with prematurity and respiratory distress. She was
born on [**2150-2-2**] at 10:45 p.m. as a 2440 gram product
of a 33-5/7 week pregnancy. Mother was a 26-year-old gravida
V, para [**Name (NI) 25509**] mother with estimated date of confinement
mother [**2150-3-18**]. Prenatal laboratories: O positive,
antibody negative, RPR nonreactive, Rubella immune, hepatitis
B surface antigen negative and GBS unknown. Maternal history
was notable for bipolar disorder and she was not getting
treatment at the time of delivery. She also had a history of
HSV lesions but there were no lesions present around the time
of delivery. Pregnancy was notable for shortened cervix which was
treated with bed rest and intermittent preterm contractions.
The infant was born on the evening of [**2-2**] by repeat
cesarean section after mother presented with preterm contractions
and abdominal pain. Rupture of membranes was at delivery and no
sepsis risk factors were identified.
Infant emerged vigorously with Apgars of 8 and 8. Work of
breathing was noted and infant was brought to the Neonatal
Intensive Care Unit.
PHYSICAL EXAMINATION: Weight 2440 grams (75th to 95th
percentile). Head circumference 33.5 cm (75th to 90th
percentile). Length was 43 cm (25th to 50th percentile).
Vital signs: Temperature 98.9, heart rate 150s, respiratory
rate 50 to 70s, blood pressure 67/30 (49), oxygen saturation
95% in room air. General: A well developed premature infant
in moderate respiratory distress with grunting and retraction
responsive to examination. Skin: Warm, pale, no rash, mild
mottling. HEENT: Fontanelle soft and flat. Ears and nares
normal. Palate intact, +RR bilaterally. Neck supple, no
lesions. Chest: Coarse moderate aeration, positive grunting
and retraction. Cardiac: Rate and rhythm regular. No murmur.
Femoral pulses 2+. Abdomen soft, no hepatosplenomegaly, no
masses. Quiet bowel sounds. Genitourinary: Normal female,
anus patent. Extremities, hips and back normal. Capillary
refill sluggish. Neuro: Appropriate tone and activity, intact
Moro.
SUMMARY OF HOSPITAL COURSE BY SYSTEMS:
Respiratory system: Due to initial grunting she was placed on
nasal CPAP of 6 and she continued to be on CPAP of 6 with
decreasing oxygen requirements from 40% to 21% from day of life 1
to 3. On day of life 4 she was switched to room air and continued
to be doing well on room air until the day of discharge which was
day of life 22. An initial chest x-ray was performed at the
time of admission which showed changes consistent with mild
respiratory distress syndrome.
At the time of discharge she has clear breath sounds bilaterally.
There are mild subcostal retractions.
Cardiovascular system: She remained stable from the day of
admission. A soft intermittent murmur was auscultated from
day of life 1 to day of life 4 which disappeared. At the time
of discharge she has stable blood pressures, normal pulses 2+,
femoral pulses equal, branchial pulses. Rate and rhythm
regular, normal first and second heart sounds with no added
sounds.
Fluid, electrolytes and nutrition: She was initially placed
n.p.o. for the first 2 days of life and was started on IV
fluids. She was gradually started with feeds with breast milk
or Special Care 20 kilocalories per ounce on day of life 3
and was advanced on feeds and IV fluids were decreased. On
day of life #6 she reached full feeds of Similac Special Care
20 at 140 cc per kg per day and then the calories were
gradually advanced to 24 kilocalories per ounce. On day of
life #17, on [**2150-2-19**], she was once again placed
n.p.o. due to grossly bloody mucousy stools and she remained
n.p.o. until day of life #19. On day of life 20 she was restarted
feeds with Nutramigen 20 kilocalories per ounce and were
gradually advanced. She reached full feeds on [**2150-2-22**],
day of life #25 of Nutramigen 20 kilocalorie per ounce. Her last
set of electrolytes were done on [**2150-2-19**] and showed
sodium 139, potassium 4.8, chloride 104 and bicarb 28.
Most recent on [**2-23**] HC=32cm and L=47cm. Weight on discharge day
[**2-24**] was 2635g.
Gastrointestinal: Her initial serum bilirubin was 13.6 and
0.3 on day of life #5 and she was started on phototherapy
which she continued from day f life 5 to day of life 6. Her
last serum bilirubin was performed on day of life #18 on
[**2150-2-20**] which showed total bilirubin of 7.2 and
direct of 0.4. She was noted to grossly bloody mucousy stools on
day of life #17 on [**2150-2-19**], and she was immediately
placed n.p.o. and started on IV fluids and KUBs were nonspecific.
She stopped having these bloody stools on day of life #19 and her
KUBs were normal. So she was started feeds with Nutramigen 20 and
was gradually advanced. Of note, there is a strong family
history of milk allergy and this infant had 10% eosinophil count
on CBC. Infant's stools were sent for culture and were all
negative. Recent stools all heme negative.
At the time of discharge she has soft nontender, nondistended
abdomen. Umbilical site has healed well. Anus is patent. There is
no hepatosplenomegaly and bowel sounds are present.
Hematology: Her initial CBC at the time of birth showed WBC
15,000, hematocrit 41 and platelets 301,000. There were 18
neutrophils, 1 band and 70 lymphocytes. She was started on
iron on day of life 10, on [**2150-2-12**], and
multivitamin on day of life 15 on [**2150-2-17**]. Both
iron and multivitamins were held on day of life 18 to 20 and
were restarted on day of life 21. Her last hematocrit and CBC
was performed on [**2150-2-20**] on day of life #18 which
showed white count 13,000, hematocrit 31.6 and platelets 511.
There were 28 neutrophils, 3 bands and 53 lymphocytes.
Infectious disease: Initial blood culture was drawn at the
time of admission and she was started on ampicillin and
gentamicin pending cultures. The culture result was negative
in 48 hours and ampicillin and gentamicin were discontinued.
A repeat culture was drawn on [**2150-2-14**] on day of
life #17 and was started on ampicillin and gentamicin. The
repeat culture was negative and her stool culture was also
negative and the antibiotics were discontinued after 48
hours.
Neurology: Given the gestational age, more than 32 weeks, and
no overt neurologic issues there was no screening head
ultrasound performed. She has normal tone and age appropriate
reflexes, alert and feeding well.
Sensory: Audiology/hearing screen: passed
Ophthalmology: Not examined. Patient is more than 32 weeks of
gestation with no overt ophthalmic issues.
Psychosocial: [**Hospital1 69**] social
work is involved with family. The contact social worker's
name was provided to the family and she can be reached at [**Telephone/Fax (1) **].
CONDITION ON DISCHARGE: Stable.
DISCHARGE DISPOSITION: Home.
NAME OF PRIMARY CARE PEDIATRICIAN: [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) 30207**], M.D. at
[**Location (un) **] Peds, phone: [**Telephone/Fax (1) 37875**]
CARE RECOMMENDATIONS AT DISCHARGE: Feeds at discharge:
Nutramigen 20 kilocalorie per ounce p.o. feed, ad lib on
demand.
Medications: Ferrous sulfate 0.25 ml p.o. daily and
multivitamin 1 ml p.o. daily.
Car Seat Position Screening: passed
State Newborn Screening: State Newborn Screen was performed
on [**2150-2-7**] which showed slightly elevated 17-OH
progresterone levels of 88. Infant with normal lytes and no
signs of congenital adrenal hyperplasia and this is most likely a
falsely positive result due to prematurity. A second screen was
sent on [**2-16**] and is pending at the time of this dictation that
will need to be followed up by the pediatrician.
Immunizations received: Hepatitis B vaccine on [**2150-2-10**].
Immunizations recommended:
1. Synagis RSV prophylaxis should be considered from
[**Month (only) **] throughout [**Month (only) 958**] for infants who meet any of the
following 3 criteria: 1) born at less than 32 weeks, 2)
born between 32 and 35 weeks with 2 of the following: Day
care during RSV season, a smoker in the household,
neuromuscular disease, airway abnormalities or school age
siblings, or 3) with chronic lung disease.
2. Influenza immunization is recommended annually in the
fall for all infants once they reach 6 months of age.
Before this age and for the first 24 months of the
child's life immunization against influenza is
recommended for household contact and out of home care-
givers.
FOLLOW UP APPOINTMENTS: With the pediatrician within 2 days
of discharge.
DISCHARGE DIAGNOSES:
1. Respiratory distress syndrome, resolved
2. Rule out sepsis.
3. Prematurity at 33-5/7 week of gestation.
4. Mild protein allergy, resolved on Nutramigen
5. Slightly elevated 17-OH Progesterone on newborn state screen
most likely due to prematurity. repeat pending.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 56662**]
Dictated By:[**Name8 (MD) 67568**]
MEDQUIST36
D: [**2150-2-23**] 11:14:51
T: [**2150-2-23**] 12:57:39
Job#: [**Job Number 71446**]
|
[
"774.2",
"V30.01",
"765.27",
"V29.0",
"770.89",
"765.18",
"E944.5",
"V05.3",
"770.81",
"995.27"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.83",
"99.55",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
7044, 7257
|
8817, 9347
|
2368, 6986
|
1405, 2340
|
7292, 7968
|
7995, 8720
|
8745, 8796
|
7011, 7020
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,324
| 171,095
|
31996
|
Discharge summary
|
report
|
Admission Date: [**2107-4-14**] Discharge Date: [**2107-4-27**]
Date of Birth: [**2063-7-31**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Egg / Peanut / Pollen Extracts / Cat Hair Std
Extract
Attending:[**First Name3 (LF) 3948**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2107-4-22**]:
1. Rigid bronchoscopy using the black Dumon bronchoscope.
2. Flexible bronchoscopy.
3. Mechanical tumor debridement using the flexible biopsy
forceps.
4. Therapeutic aspiration of secretions.
[**2107-4-20**]: Flexible bronchoscopy with PTK activation.
[**2107-4-17**]: Rigid bronchoscopy using the black Dumon bronchoscope.
2. Flexible bronchoscopy.
3. Tumor ablation with argon plasma coagulation.
4. Tumor debridement mechanically and using the cryoprobe.
5. Therapeutic aspiration of secretions.
6. Balloon dilatation of the left lower lobe up to 7 mm.
[**2107-4-15**]: Flexible fiberoptic bronchoscopy with
transbronchial biopsies and bronchoalveolar lavage.
[**2107-4-15**]: Tube thoracostomy right side, 14-French pigtail
catheter.
History of Present Illness:
43 year old male with metastatic renal cell cancer to the lungs
with endobronchial involvement. Patient had had total occlusion
of the LLL and partial occlusion of the LUL due to tumor burden.
He is status post photodynamic therapy and rigid bronchoscopy
x3 for tumor debridement. He is currently on Sutent. Had
radiation treatment to right knee approximately 3
weeks ago for bony met. Patient also reports an oral infection
for which he took z-pack about three weeks ago. Has had SOB,
fatigue, and cough acutely since Sunday when he was snowblowing.
Reports he felt fine until he went out in the cold. Has been
exercising and doing cardio almost every day and reports a good
activity tolerance until Sunday. Denies fever, chills,
hemoptysis. Reports fatigue and decreased appetite for [**3-15**]
days. Patient reports that both son and wife were [**Name2 (NI) **] with
flu-like symptoms last week.
Past Medical History:
childhood asthma, RCC w/endobronchial/intrathoracic mets
PSH: L radical nephrectomy [**7-/2105**], flex bronch [**2107-1-7**]
Social History:
former tennis pro -unable to work d/t present illness.
Lives w/ wife
Family History:
non-contributory
Physical Exam:
VS: T: 98.6 HR: 116 ST SBP: 106/80 Sats: 01% 5L
General: 43 year-old male with SOB
Card: RRR
Resp: no breath sounds on left, right with crackles at bases
GI: benign
Extr: RUE with pitting edema to hand.
Neuro: withdrawn
Pertinent Results:
[**2107-4-25**] WBC-3.9* RBC-3.24* Hgb-9.6* Hct-28.6* Plt Ct-154
[**2107-4-24**] WBC-5.7 RBC-3.45* Hgb-10.4* Hct-30.4* Plt Ct-161
[**2107-4-24**] WBC-5.9 RBC-3.38* Hgb-10.1* Hct-30.0* Plt Ct-164
[**2107-4-14**] WBC-6.0 RBC-4.16* Hgb-12.5* Hct-35.2* Plt Ct-195
[**2107-4-23**] Neuts-94.3* Lymphs-4.5* Monos-0.6* Eos-0.4 Baso-0.2
[**2107-4-25**] Glucose-87 UreaN-21* Creat-1.1 Na-136 K-4.5 Cl-100
HCO3-31
[**2107-4-24**] Glucose-89 UreaN-20 Creat-1.0 Na-135 K-4.4 Cl-100
HCO3-28 AnGap-11
[**2107-4-24**] Glucose-87 UreaN-20 Creat-1.0 Na-134 K-4.5 Cl-99
HCO3-28 AnGap-12
[**2107-4-23**] Glucose-135* UreaN-20 Creat-1.0 Na-134 K-4.2 Cl-98
HCO3-27
[**2107-4-19**] Glucose-87 UreaN-17 Creat-1.1 Na-138 K-4.2 Cl-101
HCO3-29 AnGap-12
[**2107-4-18**] Glucose-99 UreaN-21* Creat-1.2 Na-132* K-4.3 Cl-99
HCO3-26
[**2107-4-16**] Glucose-104 UreaN-27* Creat-1.1 Na-138 K-4.4 Cl-101
HCO3-28
[**2107-4-25**] Calcium-8.8 Phos-3.6 Mg-1.9
CT [**4-14**]
IMPRESSION:
1. No pulmonary embolism.
2. Significant interval progression of lymphangitic
carcinomatosis changes of the lungs.
2. Interval increase in the size of the mediastinal
lymphadenopathy.
4. Interval progression of attenuation of the right middle lobe
bronchus,
left upper lobe bronchus and near-complete obstruction of the
left lower lobe bronchus.
5. Interval progression of consolidation of the left lower lobe
secondary to progression of the mass lesion. However, underlying
pneumonia cannot be
excluded.
CT [**4-25**]
IMPRESSION:
1. No pulmonary embolism.
2. Significant interval progression of the lymphangitic
carcinomatosis
changes of the lungs.
3. Interval increase in the size of mediastinal and hilar
lymphadenopathy.
4. Interval progression of consolidation of the left lung
secondary to
progression of the left hilar mass lesion. Underlying pneumonia
cannot be
excluded.
Brief Hospital Course:
Mr. [**Known lastname 1968**] was admitted on [**2107-4-14**] with increased shortness of
breath with increased lymphagetic spread and collopse of left
lung. A chest CT was negative for pulmonary embolism with
increased disease process. On [**2107-4-15**] he had a flexible
bronchoscopy. He developed a right pneumothorax with
respiratory comprise. A right pigtail was placed with
re-expansion of lung. He was transferred to the SICU, the
pigtail was to suction with a persistent air leak. His oxygen
saturations were > 88-90% on 4L NC. On [**2107-4-17**] was taken for
rigid and flexible bronchoscopy with tumor debridment, tumor
ablation with APC, and balloon dilation. On [**2107-4-18**] he had PDT
infection. The pigtail remained with to suction with minimal
leak but water seal trial attempted. Palliative care following
patient. Taken for PDT activation and transferred to general
surgical floor on [**2107-4-20**]. Medical oncology following and plan
to start sutent [**2107-4-21**]. Patient remained stable on 4L oxygen.
After PDT activation, apparent there was reaccumulation of right
pnuemothorax. CT placed back on suction. Plan to take patient to
OR on [**2107-4-22**] for tumor debridement to LMB. Chest tube kept at
wall suction. On [**2107-4-24**], triggered for tachycardia with fever.
Started on levaquin for 5 days. Chest to waterseal for trial.
Right pneumothorax spontaneously resolved. Patient tolerated
waterseal trial without respiratory distress. Clamp trial for
chest tube, which continued throughout night. Patient requiring
6L of oxygen. Taken to vascular lab for lower extremity
ultrasound which was negative for any clot. He was taken to OR
on [**2107-4-26**] for chest tube removal. CT scan of chest also showing
marked interval deteroration of left lung with consolidation and
prominent adenopathy. Plan to discharge patient after
chemotherapy on [**2107-4-27**].
Medications on Admission:
Medications - Prescription
ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler -
2
puffs inhaled every six (6) hours as needed for cough
CELAPRO - (Prescribed by Other Provider) - Dosage uncertain
FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other
Provider) - 500 mcg-50 mcg/Dose Disk with Device - 1 puff(s) IH
twice a day
LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] - 400
mg-400
mg-40 mg-25 mg-200 mg/30 mL Mouthwash - rinse mouth and spit
three times a day as needed for sore mouth
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day in the morning
PHYTOCYTO - (Prescribed by Other Provider) - Dosage uncertain
QUERCETIN & BROMEL - (Prescribed by Other Provider) - -
1000mg
three times a day
SILYMARIN - (Prescribed by Other Provider) - Dosage uncertain
SUNITINIB [SUTENT] - (Prescribed by Other Provider) - 50 mg
Capsule - 1 Capsule(s) by mouth once a day
Medications - OTC
COENZYME Q10 - (Prescribed by Other Provider) - 100 mg Capsule
-
1 Capsule(s) by mouth three times a day
GRAPE SEED EXTRACT [GRAPE SEED] - (Prescribed by Other
Provider)
- Dosage uncertain
OMEGA-3 FATTY ACIDS [FISH OIL] - (Prescribed by Other Provider)
- Dosage uncertain
SELENIUM - (Prescribed by Other Provider) - Dosage uncertain
THIOCTIC ACID [ALPHA LIPOIC ACID] - (Prescribed by Other
Provider) - Dosage uncertain
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Home oxygen
Home oxygen 4-6LPM continuous via nasal cannula
Conserving device for portability
2. Morphine Concentrate 5 mg/0.25 mL Solution Sig: [**6-24**] ML PO
Q2h as needed for pain.
Disp:*500 ML* Refills:*0*
3. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] ().
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO as directed as needed for nausea: take 1 hour
before chemo treatment or prn for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Midstate VNA and Hospice
Discharge Diagnosis:
Renal Cell Carcinoma
Lung Cancer
Discharge Condition:
stable
Discharge Instructions:
Call Dr.[**Name (NI) 14679**] office [**Telephone/Fax (1) 7769**] if develops increased
shortness of breath, cough, sputum production or chest pain
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] oncology [**Telephone/Fax (1) 38171**] call for a
follow-up appointment
Follow-up with Dr. [**Last Name (STitle) **]
[**Name (STitle) **] with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74957**] [**Telephone/Fax (1) 74958**]
|
[
"198.89",
"196.1",
"197.0",
"519.19",
"V10.52",
"518.0",
"198.5",
"338.3",
"512.1",
"518.82",
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icd9cm
|
[
[
[]
]
] |
[
"33.91",
"96.05",
"34.09",
"33.27",
"32.01",
"99.25",
"33.24"
] |
icd9pcs
|
[
[
[]
]
] |
8741, 8796
|
4439, 6343
|
354, 1116
|
8873, 8882
|
2585, 4416
|
9079, 9368
|
2308, 2326
|
7873, 8718
|
8817, 8852
|
6369, 7850
|
8906, 9056
|
2341, 2566
|
295, 316
|
1144, 2055
|
2077, 2205
|
2221, 2292
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,786
| 167,296
|
18524
|
Discharge summary
|
report
|
Admission Date: [**2125-9-26**] Discharge Date: [**2125-10-18**]
Date of Birth: [**2068-9-13**] Sex: M
Service: MEDICINE
Allergies:
Ibuprofen / Levaquin
Attending:[**First Name3 (LF) 7934**]
Chief Complaint:
Hypoxia
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
57yo M w/ PMH of poorly controlled DM type II, cirrhosis, HCV,
HTN, and a h/o TB who presents with hypoxic respiratory failure
requiring intubation in the ER. He presented to the ER on [**9-26**]
with SOB x 1 week that became progressively worse, culminating
in CP on deep inspiration. VS on arrival were T 99.2, HR 82, BP
145/60 and sats of 60% on RA -> 90% on NRB. Per the ED records,
a CXR was obtained and revealed white out of his R lung. ABG was
significant for 7.5/29/48/23. Findings were discussed with the
patient who agreed with intubation. He was intubated w/o event,
using succinylcholine and etomidate. A prpofol gtt was started
for sedation, but the patient also required 9mg of versed for
adequate sedation and 50mcg fentanyl for pain. BP was then noted
to dip to 78, likely due to propofol bolus. He was given an IVF
bolus w/ improvement in his SBP to 106. He required an
additional 10mg versed and 100mcg fentanyl for sedation/pain. A
central line was placed for access and labs were sent off. His
BP remained in the range of 89-142/42-71, with HR in the range
of 82-91. Once he was hemodynamically stable, he was transferred
to the [**Hospital Unit Name 153**] for further monitoring.
Past Medical History:
1. Hepatitis C cirrhosis
2. ETOH cirrhosis
3. S/P TIPS in [**2122**] and a revision in [**5-/2123**]
4. [**Name (NI) 947**] Pt is s/p banding s/p TIPS after massive GI bleed in
[**2119**] and [**2122**]. Pt required 23 units PRBC during the 2nd bleed
and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube.
5. Past ETOH, cocaine, and heroin abuse
6. HTN
7. Hepatitis B virus
8. Type 2 diabetes mellitus
9. H/P positive PPD- Per records, pt was treated with INH for
one year.
10. H/P hypoglycemic episodes
Social History:
prior use of tobacco, IV coccaine, heroin until [**2115**] when
incarcerated for parole violation when he quit. Attends AA and
NA. Lives w/ fiancee in [**Hospital1 **] apt. Completed bachelors and
masters degree in prison. In the army x4 years. Active duty x1
year in [**Country 3992**] with probable [**Doctor Last Name **] [**Location (un) **] exposure. Mild PTSD.
Married but legally separated, 1 child living in [**State 108**] with
whom he is not close. Two sisters.
Family History:
mother alive with heart disease; father died in [**Name (NI) 8751**]. Sisters
x 2, both with HTN and one with a heart murmur
Physical Exam:
VS - T 99.6, BP 121/67, HR 85, RR 26, sats 93%
AC 600x15, FiO2 100%, PEEP 8
I/O: 4000/220
Gen: WDWN AfAm male, sedated and intubated, on vent.
HEENT: NCAT. Sclera anicteric, mildly edematous. Pupils pinpoint
bilaterally, nonrxtive. OP clear, no thrush, no erythema or
exudate. No LAD.
CV: RR, normal S1, S2. No m/r/g.
Lungs: Coarse breath sounds throughout, but no crackles/wheezes.
Abd: Soft, protuberant, but NTND. + BS. No appreciable HSM.
Ext: No c/c/e. 2+ radial and PT pulses bilaterally. Skin dry.
Neuro: Sedated.
Pertinent Results:
Admission Labs:
[**2125-9-26**] 05:55AM WBC-4.5# RBC-2.56* HGB-9.7*# HCT-28.9*#
MCV-113*# MCH-37.9* MCHC-33.6 RDW-15.4
[**2125-9-26**] 05:55AM NEUTS-87.4* BANDS-0 LYMPHS-8.9* MONOS-3.1
EOS-0.4 BASOS-0.3
[**2125-9-26**] 05:55AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
[**2125-9-26**] 05:55AM PLT SMR-VERY LOW PLT COUNT-61* LPLT-2+
[**2125-9-26**] 05:55AM PT-20.4* PTT-36.0* INR(PT)-2.0*
[**2125-9-26**] 05:05AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2125-9-26**] 05:55AM GLUCOSE-56* UREA N-18 CREAT-1.1 SODIUM-133
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-21* ANION GAP-11
[**2125-9-26**] 05:55AM ALT(SGPT)-18 AST(SGOT)-75* LD(LDH)-502*
CK(CPK)-49 ALK PHOS-56 AMYLASE-61 TOT BILI-4.4*
[**2125-9-26**] 06:06AM LACTATE-3.2*
[**2125-9-26**] 05:55AM CK-MB-2 cTropnT-<0.01
[**2125-9-26**] 05:55AM ALBUMIN-1.7* IRON-116
[**2125-9-26**] 05:55AM calTIBC-122* VIT B12-693 FOLATE-9.6
HAPTOGLOB-<20* FERRITIN-901* TRF-94*
.
[**10-12**] ECHO: The left atrium is normal in size. Agitated saline
contrast study suggests the presence of an intracardiac shunt
(probably stretched patent foramen ovale or atrial septal
defect). Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic 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
a trivial/physiologic pericardial effusion.
.
[**10-13**] Sputum gram stain: yeast ([**Female First Name (un) **]), mold
[**10-16**] CT:
1. Interval worsening of airspace consolidation and mild ground
glass changes with prominent consolidation at the bases
bilaterally. The differential includes ARDS and multifocal
pneumonia.
2. Development of mediastinal air most likely secondary to
barotrauma related to ventilation.
3. Shaggy irregular wall thickening of descending and sigmoid
colon. The appearance seems to suggest a possible underlying C.
diff colitis, however, in the presence of ascites this may be
related to a low-protein state.
4. Cholelithiasis, without evidence of cholecystitis.
.
[**10-17**] CXR: Widespread pulmonary consolidation predominantly
bibasilar has worsened appreciably between [**10-13**] and
[**10-16**]. Worsening opacification since [**10-16**]
probably represents an overlay of mild pulmonary edema. There
may be small bilateral pleural effusion as well. Heart size is
top normal. ET tube in standard placement. Tip of the right
jugular line projects over the SVC. Nasogastric tube passes into
the stomach and out of view. No pneumothorax.
Brief Hospital Course:
1) Goals of Care: Initially Full code, but as disease progressed
family made patient CMO.
.
2) RESPIRATORY FAILURE/ARDS: Patient presented with fluminant
bilateral patchy pneumonia and intubated in the ED. It
progressed to ARDS. It was complicated by a GNR VAP. He later
developed fungemia. His respiratory status continued to decline
and it became impossible to oxygenate him on maximal therapy.
.
3) PNEUMONIA: Initially thought of as CAP/hospital acquired/asp
and treated with azithro/ceftaz/vanco/flagyl changed to
zosyn/flagyl/vanco. Then grew GNR in sputum and thought to have
VAP and started on meropenum. Pt now growing yeast in blood
cultures, may also be the cause of his pneumonia. Caspofungin
was started [**10-11**] and changed to fluconazole on [**10-12**].
.
4) HYPOTENSION/SEPSIS: Had two discrete episodes of hypotension
in conjunction with episodes of sepsis.
.
5) ACUTE RENAL FAILURE: Patient had 2 episodes of ARF that both
resolved in setting of underperfusion and sepsis.
.
6) ANEMIA: Has a chronic anemia, but baseline is usually low to
mid 30's. He was transfused as necessary.
.
7) THROMBOCYTOPENIA: Likely due to splenic
sequestration/splenomegaly from his cirrhosis. Also a chronic
problem, with baseline plts in the 80-100 range. They were
monitored and he never required transfusion.
.
8) COAGULOPATHY: Pt has poor synthetic liver function and he was
given FFP for procedures.
.
9) DM TYPE II: He was treated with Insulin drip, NPH and RISS as
needed throughout hospitalization.
.
10) HEP C/CIRRHOSIS: Had h/o hep C genotype Ib, but not on
treatment. Was on liver transplant list at one point. LFT's were
mildly elevated. At times was on propranolol for esophageal
varices. Pantoprazole given for esophageal varices. Lactulose
for bowel regimen
.
11) elevated pancreatic enzymes: occured late during
hospitalization. No pain associated.
.
12) HTN: Had history of htn at home occasionally required
hydralazine.
.
13) FEN: He received tube feeds while intubated.
Medications on Admission:
albuterol 90mcg IH QID
fluticasone 110mcg 2puffs IH [**Hospital1 **]
glipizide 20mg PO BID
NPH 16u [**Hospital1 **], RISS
lactulose prn
omeprazole 20mg PO QD
propranolol 90mg PO BID
triamcinolone/acetonide 0.025% cream TP [**Hospital1 **]
Discharge Medications:
None-expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased.
Followup Instructions:
Deceased.
|
[
"518.84",
"507.0",
"070.54",
"286.7",
"250.00",
"482.83",
"117.9",
"287.5",
"572.3",
"571.2",
"304.70",
"303.90",
"785.52",
"456.21",
"995.92",
"038.9",
"584.5",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.05",
"96.04",
"96.72",
"99.07",
"33.24",
"99.04",
"38.91",
"00.17",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
8438, 8447
|
6114, 8111
|
290, 302
|
8499, 8509
|
3270, 3270
|
8567, 8579
|
2585, 2712
|
8401, 8415
|
8468, 8478
|
8137, 8378
|
8533, 8544
|
2727, 3251
|
243, 252
|
330, 1534
|
3286, 6091
|
1556, 2079
|
2095, 2569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,997
| 159,344
|
42246
|
Discharge summary
|
report
|
Admission Date: [**2155-10-3**] Discharge Date: [**2155-10-14**]
Date of Birth: [**2075-11-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 29226**]
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 79 year old man with a history of colon cancer s/p
colectomy in [**2144**], relapse in [**2150**] with metastasis to liver and
lung s/p TACE and multiple chemotherapy regimens, recently
admitted to the [**Hospital1 18**] from [**Date range (3) 91580**] for further work up
for biliary obstruction secondary to malignancy, s/p
sphincterotomy and biliary stent placement with malignant
appearing stricture noted at the hilum [**2155-9-17**], now presenting
with fever and rigors.
.
Per the [**Hospital 2287**] medical record, the patient's wife called the
primary oncologist's office [**10-3**] early afternoon a few hours
after the patient had the acute onset of rigors.
.
The patient was given five days of Ciprofloxacin after the stent
procedure.
.
Pt had chemo yesterday and today has been having shaking chills.
Pt denies CP, SOB, abd pain, diarrhea or constipation. No blood
in stool Pt denies urinary symptoms but did note a little blood
in his urine yesterday that has resolved. Pt states he had some
nausea and vomitting after chemo yesterday that has resolved. Pt
notes his chemo regimen was changed last week.
.
In the emergency department, vitals initally 101 95 140/61 16
98% RA. The patient was given 1 L NS, Cefepime, Vancomycin, and
500 mg Acetaminophen. Blood cultures were drawn, and albs were
notable for lactate of 0.9, Cr 1.7, BUN 44, ALT/AST 148/114, AP
475, Tbili 3.4, WBC 1.2, HCT 27.6, Plt 151. A CXR done showed
subtle nodules in the left mid and right lower lung, for which
non-emergent CT may be obtained to further assess.
.
Of note, he was discharged fromt he hospital recently on [**2155-9-18**]
with for three weeks of puritis, anorexia, fatigue, and jaundice
due to biliary obstruction secondary secondary to metatstic
colon cancer, with an ultrasound showing liver mets leading to
bile duct obscturtion, for which he was taken to ERCP [**2155-9-17**]
with successful placement of metal stent.
Past Medical History:
Colon CA Dx [**2144**] Tx with colectomy only with anastamosis
Repalse of disease in [**2150**] with metastasis to liver and lung s/p
TACE and multiple chemotherapy regimens last dose 8/11.
HTN
anxiety
Social History:
per OMR, lives with his wife near [**Name (NI) 86**], originally from Sicily
and speaks Itialian as primary language, 20 pack year smoking
history, quit decades ago, no EtOH or illegal drug use.
Family History:
FH: no cancer or blood disorders
Physical Exam:
Admission Physical Exam:
Vitals - T: 102.1 BP: 150/96 HR: 97 RR: 23 02 sat: 94% RA
SKIN: warm and well perfused, no excoriations or lesions, no
rashes, trace edema bilaterally
HEENT: AT/NC, EOMI, PERRLA, sclera mildly icteric, dry MMM
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
.
Discharge Physical Exam:
HEENT: AT/NC, EOMI, PERRLA, sclera mildly icteric, MMM, healing
herpetic lesions on lips
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
Admisson Labs:
[**2155-10-3**] 07:09PM BLOOD WBC-1.2*# RBC-3.02* Hgb-9.1* Hct-27.6*
MCV-92# MCH-30.1 MCHC-32.8# RDW-17.6* Plt Ct-151
[**2155-10-3**] 07:09PM BLOOD Neuts-87.1* Lymphs-11.5* Monos-0.8*
Eos-0.3 Baso-0.3
[**2155-10-4**] 05:57AM BLOOD Gran Ct-2430
[**2155-10-4**] 05:57AM BLOOD Ret Aut-1.0*
[**2155-10-3**] 07:09PM BLOOD Glucose-84 UreaN-44* Creat-1.7* Na-135
K-4.4 Cl-102 HCO3-23 AnGap-14
[**2155-10-3**] 07:09PM BLOOD ALT-148* AST-114* AlkPhos-475*
TotBili-3.4*
[**2155-10-3**] 07:09PM BLOOD Calcium-8.5 Phos-2.7 Mg-1.7
[**2155-10-4**] 05:57AM BLOOD Hapto-182
[**2155-10-4**] 05:57AM BLOOD Osmolal-291
[**2155-10-3**] 07:10PM BLOOD Lactate-0.9
.
Discharge Labs:
[**2155-10-14**] 05:28AM BLOOD WBC-1.8* RBC-3.14* Hgb-9.7* Hct-29.6*
MCV-94 MCH-30.9 MCHC-32.8 RDW-17.4* Plt Ct-257
[**2155-10-14**] 05:28AM BLOOD Gran Ct-680*
[**2155-10-14**] 05:28AM BLOOD Glucose-95 UreaN-11 Creat-1.4* Na-145
K-3.7 Cl-109* HCO3-28 AnGap-12
[**2155-10-14**] 05:28AM BLOOD ALT-54* AST-43* AlkPhos-437* TotBili-1.9*
[**2155-10-14**] 05:28AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
.
MICRO:
[**2155-10-3**] 7:09 pm BLOOD CULTURE PORT [**Last Name (un) **].
**FINAL REPORT [**2155-10-12**]**
Blood Culture, Routine (Final [**2155-10-12**]):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
Ertapenem 0.023 MCG/ML, SENSITIVE : Sensitivity testing
performed
by Etest , REQUESTED BY DR.[**Last Name (STitle) 2323**] [**Name (STitle) 2324**] ([**Numeric Identifier 38654**]).
GRAM NEGATIVE ROD #2.
CONSISTENT WITH THE MORPHOLOGY OF ORGANISM #1.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final [**2155-10-4**]):
GRAM NEGATIVE ROD(S).
Reported to and read back by DR [**Last Name (NamePattern4) 91581**] [**2155-10-4**] 905AM.
Anaerobic Bottle Gram Stain (Final [**2155-10-4**]): GRAM
NEGATIVE ROD(S).
.
IMAGING:
CXR ([**2155-10-3**])
Subtle nodules in the left mid and right lower lung, for which
non-emergent CT may be obtained to further assess.
Alternatively, if patient has prior chest CTs, comparison is
recommended.
CXR [**2155-10-8**]: Previous pulmonary vascular congestion has not
recurred. There are no findings to suggest pneumonia. At least
one lung nodule is present at the right base and another in the
axillary region of the left lung. Central adenopathy, if
present, is mild. There is no pleural effusion. Heart size is
normal. An infusion port catheter ends close to the superior
cavoatrial junction.
RUQ u/s:1. Stable known hepatic metastases. No evidence of
intrahepatic abscess. 2. Stable intrahepatic biliary ductal
dilatation. Common bile duct stent in standard unchanged
position. 3. Normal appearance of the gallbladder without wall
thickening or pericholecystic fluid. 4. Mild splenomegaly.
Brief Hospital Course:
This is a 79 year old man with a history of metastatic colon
cancer with known metastases to the liver and lung, s/p recent
ERCP with biliary stent placement who presented with fever and
hypotension requiring initial ICU admission, found to be
bacteremic on admission.
# Hypotension: Upon presentation in the ED, the patients SBP was
noted to be 140s. He later became hypotensive to 90s without
compensatory tachycardia (of note, patient is on a beta-blocker
at home). His lactate was not elevated. He was given IVFs and
received 1 unit PRBCs. His blood pressures remained stable
during his stay in the ICU and he did not require pressors at
any time. His BP averaged around 120/60 upon transfer to the
oncologic service. His beta blocker was later added back on for
hypertension, but was switched from atenolol to metoprolol in
the setting of renal failure.
# Febrile Neutropenia: The etiology of his fever was not clear
upon presentation. He endorsed a cough with clear sputum as
well as sick contacts. Viral cultures were sent which were
negative. He recently had stent placed, increasing his risk for
a GI infection source. He was started in empiric Vancomycin and
Zosyn in the ICU and surveillance cultures were sent. These
antibiotics were continued on the OMED service until admission
blood cultures grew out E. coli, pansensitive except to cipro.
He was switched to CTX and clindamycin (CTX for e. coli, clinda
for concerns about oral infection because he was complaining of
tooth pain). He was afebrile on admission to OMED but began
spiking fevers again after switching to CTX. At this time his
ANC had also begun to drop and he became neutropenic, which was
expected to occur due to chemo regimen. He was re-broadened to
vanc/cefepime. He remained febrile and began complaining of
sore throat, so ID was consulted. He was switched to vanc/zosyn
per their recs and started on nystatin for oral thrush. He was
also started on valtrex for outbreak of herpes labialis. Repeat
CXR was neg for pneumonia. RUQ u/s was neg for biliary
pathology (originally a concern due to stent). ANC recovered
and pt was switched to ertapenem monotherapy for ease of home
dosing for a total course of 14 days. He was discharged when
his ANC was over 500. He will switch to maintenance therapy
with acyclovir after a 7d course of valtrex.
# tooth pain: pt complained of tooth pain on admission. He said
he had a tooth that was supposed to be pulled but he had been
waiting to have that done until after chemo because of the risk
of infection. His pain was severe enough to interfere with
eating do a dental consult was called and he was empirically
placed on clindamycin. A panorex film was obtained. Dental
felt the tooth needed to be pulled but wanted to defer to oral
surgery about the urgency of extraction, especially in a
neutropenic patient. Oral surgery evaluated the patient and did
not feel there was infection or abscess present, and that the
tooth could be extracted at the patient's convenience, per onc
recs on timing. Clinda was stopped after oral infection had been
ruled out.
# [**Last Name (un) **]: The patient's Cr was elevated above baseline upon
admission and appeared most likely prerenal in origin. He was
started on IVF, however his Cr remained elevated. It improved
to 1.3 at the time of discharge. Etiology was uncertain but
could be medication vs. pre-renal (pt appeared dry and required
a lot of fluids on the floor). Recommend PCP follow up.
# H. pylori: pt was c/o epigastric pain with acidic or spicy
foods. Had duodenal ulcers on ERCP 1 month prior to admission
with no further work up. Checked H. pylori Ag which was
positive. Pt will require triple therapy at some point, but ID
recommended pursuing this after completion of his current
treatment for bacteremia.
# Anemia: Patients hematocrit was noted to be down from 33.5 to
27.6. It was normocytic and patient denied any blood loss. He
was given 1 unit PRBCs as above and it was felt that his anemia
was most likely secondary to his recent chemotherapy. Hemolysis
labs did not reveal evidence of hemolysis. His Hct stabilized
after the transfusion and no further intervention was required.
# CXR nodules: Patient was noted to have nodules on CXR. The
etiology and time course of these nodules is not fully known.
The patient may require a CT of the chest for further work up.
# HTN: Given his ICU stay for hypotension, his home atenolol was
initially held. His BP stabilized in the ICU and he became
hypertensive again on the OMED floor, so he was restarted on his
beta blocker, though started metoprolol instead of atenolol in
the setting of renal failure.
# Anxiety: Patient was continued on his home antianxiety
medications - Lorazepam and citalopram
TRANSITIONAL ISSUES:
1. Triple therapy for H. pylori
2. follow up renal function
3. follow up CXR nodules
Medications on Admission:
1. Clindamycin Phosphate 1 % Topical Gel apply to affected areas
three times a day
2. Ondansetron HCl 8 mg Oral Tablet take 1 tablet as directed
3. Lorazepam 0.5 mg Oral Tablet 1-2 tablets Q6 hours PRN nausea
4. Cholestyramine-Aspartame (CHOLESTYRAMINE LIGHT) 4 gram Oral
Packet 1 PACKET THREE TIMES DAILY AS DIRECTED
5. Omeprazole 20 mg Oral Capsule, Delayed Release(E.C.) TAKE 1
CAPSULE DAILY FOR 2 WEEKS
6. Atenolol 50 mg Oral Tablet one tablet daily
7. Citalopram 40 mg Oral Tablet take [**12-29**] tablet(20mg) daily
8. Darbepoetin Alfa In Polysorbat (ARANESP, POLYSORBATE,) 200
mcg/0.4 mL Injection Syringe 200mcg sub q
9. MULTIVITAMIN CAPSULE PO (MULTIVITAMINS) 1 po qd
Discharge Medications:
1. ertapenem 1 gram Recon Soln Sig: One (1) Recon Soln Injection
daily () as needed for e.coli bacteremia for 3 days: last dose
[**10-17**].
Disp:*3 grams Recon Soln(s)* Refills:*0*
2. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Tablet, Rapid Dissolve(s)
3. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for anxiety.
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*28 Tablet(s)* Refills:*0*
6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. clindamycin phosphate 1 % Gel Sig: One (1) appl Topical three
times a day: to affected area.
8. cholestyramine-aspartame 4 gram Packet Sig: One (1) packet PO
three times a day: as directed.
9. Multiple Vitamins Tablet Sig: One (1) Tablet PO once a
day.
10. oral wound care products Gel in Packet Sig: Fifteen (15)
ML Mucous membrane TID (3 times a day) as needed for mucositis.
Disp:*42 packets* Refills:*0*
11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*140 mL* Refills:*0*
12. valacyclovir 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 doses: last dose [**2155-10-15**] PM.
Disp:*3 Tablet(s)* Refills:*0*
13. lidocaine-diphenhyd-[**Doctor Last Name **]-mag-[**Doctor Last Name **] 200-25-400-40 mg/30 mL
Mouthwash Sig: 15-30 mL Mucous membrane four times a day as
needed for mucositis.
Disp:*1 bottle* Refills:*0*
14. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Febrile neutropenia
E. Coli bacteremia
Secondary Diagnoses:
metastatic colon cancer
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:
Thank you for letting us take part in your care at [**Hospital1 771**]. You came to the hospital because you
had an infection in your blood. Your white blood cell count was
also low, which is a side effect of your chemotherapy. You were
given antibiotics and your white blood cell count came up on its
own. You should follow up with Dr. [**First Name (STitle) 3459**] (appointments below).
You should also talk to your primary care doctor about being
treated for H. Pylori, which causes stomach ulcers.
The following changes were made to your medications:
STOPPED
1. atenolol
INCREASED
2. omeprazole 20mg by mouth twice a day
STARTED
3. ertapenem 1000mg intramuscular injection every 24 hours for 3
doses (last dose [**2155-10-17**])
4. metoprolol tartrate 25mg by mouth twice a day
5. gelclair gel packet 15mL three times a day as needed for oral
irritation
6. nystatin suspension 5mL by mouth four times a day as needed
for thrush
7. valacyclovir 500mg one tab by mouth every 12 hours for 3
doses (last dose [**2155-10-15**] PM)
8. Magic Mouthwash (lidocaine/diphenhydramine/maalox) 15-30mL
four times a day as needed for oral irritation
9. acyclovir 400mg by mouth twice a day for HSV prophylaxis
Followup Instructions:
Appointments:
Dr. [**First Name (STitle) 3459**] on [**2155-10-15**] at 10:00am
Dr. [**First Name (STitle) 3459**] on [**2155-10-22**] at 10:30am
****You should ask Dr. [**First Name (STitle) 3459**] about when it will be safe to have
your tooth extracted.
Please also follow up with your primary care doctor in one week.
Please talk to your primary care doctor about starting
antibiotics for H. pylori, a bacteria that causes stomach
ulcers.
|
[
"790.7",
"041.49",
"584.9",
"300.00",
"531.90",
"780.61",
"E933.1",
"458.9",
"284.11",
"197.0",
"576.2",
"V10.05",
"041.86",
"288.00",
"401.9",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
14604, 14661
|
7242, 12019
|
320, 326
|
14808, 14808
|
3710, 4369
|
16223, 16670
|
2744, 2779
|
12855, 14581
|
14682, 14682
|
12152, 12832
|
14990, 16200
|
4385, 7219
|
2819, 3315
|
14762, 14787
|
12040, 12126
|
275, 282
|
354, 2290
|
14701, 14741
|
14823, 14966
|
2312, 2516
|
2532, 2728
|
3340, 3691
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,866
| 148,063
|
10146+56111
|
Discharge summary
|
report+addendum
|
Admission Date: [**2185-11-20**] Discharge Date: [**2185-12-3**]
Date of Birth: [**2138-10-6**] Sex: M
Service: GENERAL SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 47-year-old
male with a history of diabetes mellitus, coronary artery
disease, hepatitis B, who complains of four days of right
upper quadrant pain, not related to activity. No fever,
chills, nausea, vomiting, chest pain or shortness of breath.
Pain is worse with eating. He describes the pain as sharp,
but goes up and down in intensity, with anorexia and
hiccoughs. Last bowel movement was prior to beginning of
this pain.
PAST MEDICAL HISTORY: Diabetes mellitus Type 2, history of
hepatitis B infection, coronary artery disease status post
coronary artery bypass graft x 5 in [**2184-5-9**], status
post percutaneous transluminal coronary angioplasty in [**2182**].
MEDICATIONS: Lipitor 5 mg once daily, Glucovance 500 mg
three times a day, Epivir 300 mg once daily, atenolol 25 mg
once daily, aspirin 325 mg once daily, folate once daily, B6
once daily.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Temperature 98.7, pulse 102, blood
pressure 149/83, oxygen saturation 99% on room air.
Tachycardic, regular rhythm. Lungs clear to auscultation
bilaterally. Abdomen distended, tympanic, severe right upper
quadrant tenderness, positive [**Doctor Last Name 515**] sign. Rectal
examination normal tone, guaiac negative.
LABORATORY DATA: White blood cells 18.9, hematocrit 39.1,
platelets 218. Sodium 135, potassium 3.9, chloride 93,
bicarbonate 29, BUN 16, creatinine 1.4, glucose 286. PT
13.0, PTT 24.2, INR 1.2. Chest x-ray showed bilateral
atelectasis. Right upper quadrant ultrasound showed sludge
in the gallbladder as well as gallstones. The gallbladder
wall is 3 to 4 mm. The common bile duct is 2 to 3 mm. No
pericholecystic fluid, no intrahepatic duct dilatation. KUB:
Stool in intestine, no free air, no obstruction.
Electrocardiogram: Regular rhythm, normal.
HOSPITAL COURSE: The patient was admitted to Gold Surgery
service. Due to his pervious cardiac history, a Cardiology
consult was obtained which, based on the patient's history
(stated that he had a normal stress test two months ago) and
history of coronary artery bypass graft in the past five
years, he was at no significant risk for cardiac event during
surgery. The patient remained stable overnight and was taken
to the operating room on [**2185-11-20**], where laparoscopic
cholecystectomy was attempted, however, failed due to
severity of the patient's disease. Open cholecystectomy was
performed. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 406**] drain was placed intraoperatively. The
patient was transferred to the Post-Anesthesia Care Unit in
stable condition.
On postoperative day number one, the patient had a fever of
102.8, tachycardic. He complained of incisional pain. No
nausea or vomiting. He was started on ampicillin,
levofloxacin and Flagyl for his cholecystitis. His Lopressor
dose was increased, which was approved by Cardiology, who
decided to sign off due to the patient's condition being
well.
In the evening, however, the patient had an episode of
nausea. An electrocardiogram was obtained, which showed
sinus tachycardia. At approximately the same time, the
patient had desaturation to 84% on 4 liters. A stat portable
chest x-ray was obtained, which showed a picture consistent
with adult respiratory distress syndrome or flash pulmonary
edema. The patient had, at that time, fever of 102.2, heart
rate of 118, blood pressure 160/48, oxygen saturation 85% on
10 liters, respiratory rate of 44. An arterial blood gas was
done, which showed a pH of 7.32, CO2 of 47, O2 of 47,
bicarbonate 25, base excess -2.
The patient was emergently transferred to the Intensive Care
Unit. He was intubated. On postoperative day number two, an
echocardiogram was obtained, which showed normal ejection
fraction of 45%. The patient has a low-grade fever. His
sedation was decreased. He is alert.
On postoperative day number three, the patient is afebrile.
Vital signs are stable. The patient self-extubated
overnight, however, was doing fine, with 98% oxygen
saturation on room air. The patient was transferred to the
floor.
On postoperative day number two, the patient had a low-grade
fever, otherwise vital signs stable, ambulating, tolerating
clears well. His medication was switched to oral.
Overnight, the patient had another episode of nausea.
Electrocardiogram was performed, which showed T wave
inversions in the precordial leads, V1 through V4.
Cardiology was consulted and felt that this cardiac ischemia
was significant, and he will need cardiac catheterization,
which was performed the next morning, which showed a very
tight lesion on the patient's left internal mammary artery
insertion to the left anterior descending, which was
plastied.
On postoperative day number six, the patient is afebrile.
Vital signs stable. He was transfused one unit of blood for
a low hematocrit in the face of cardiac disease. Over the
next couple of days, the patient had a low-grade fever,
otherwise feeling well, ambulating, tolerating oral intake.
On postoperative day number eight, the patient had a fever of
102.5, some erythema over his CVL was noted. The patient had
PA and lateral which showed bilateral effusion and question
of pulmonary effusion in the left lower lobe. He had blood
cultures performed as well as urinalysis and urine culture,
which were all clear. His central venous line was removed
and cultured, which was also negative. He was started on
Kefzol empirically.
On postoperative day number nine, he still had a fever of
102. CT of the abdomen was performed, which just showed some
perioperative changes in the right upper quadrant, but
otherwise negative for abscess, colitis, and otherwise
normal. Infectious Disease consult was obtained, which
recommended CT of the chest, given the patient's possible
pleural effusions and pneumonia.
On postoperative day number ten, he had another set of
cultures drawn. CT of the chest was performed, and showed
bilateral pleural effusions, left more than right, some
epicardial nodes, and very low possibility of left lower lobe
pneumonia, more likely being atelectasis.
On postoperative day number 11, the patient still had a fever
up to 102. His bilateral pleural effusions were tapped with
ultrasound guidance, which showed no bacteria on the Gram
stain, normal CBC of the fluid, and fluid chemical analysis
consistent with transudate.
On postoperative day number 12, the patient is remaining
afebrile. Vital signs stable. All cultures are negative to
date. The most likely cause at this time is considered to be
a drug fever due to antibiotics given to the patient. If the
patient remains fever-free until tomorrow morning, which
would make it 36 hours fever-free, he is planned to be
discharged on [**2185-12-3**].
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged to home.
DISCHARGE INSTRUCTIONS: The patient should follow up with
Dr. [**Last Name (STitle) 468**] in two to three weeks for postoperative check.
DISCHARGE MEDICATIONS:
1. Enteric-coated aspirin 325 mg by mouth once daily
2. Lipitor 5 mg by mouth once daily
3. Colace 100 mg by mouth twice a day
4. Lopressor 75 mg by mouth three times a day
5. Nitroglycerin sublingual .4 mg as needed
6. Glucovance 500 mg three times a day
7. Epivir 300 mg once daily
DISCHARGE DIAGNOSIS:
1. Gangrenous cholecystitis status post open cholecystectomy
2. Respiratory distress status post intubation
3. Diabetes mellitus Type 2
4. History of hepatitis B
5. Hypercholesterolemia
6. Hypocalcemia
7. Drug fever
8. Bilateral pleural effusions status post ultrasound-guided
drainage
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern4) 33884**]
MEDQUIST36
D: [**2185-12-2**] 19:25
T: [**2185-12-3**] 01:15
JOB#: [**Job Number 33885**]
Name: [**Known lastname 5936**], [**Known firstname 5937**] Unit No: [**Numeric Identifier 5938**]
Admission Date: [**2185-11-20**] Discharge Date: [**2185-12-7**]
Date of Birth: [**2138-10-6**] Sex: M
Service: [**Doctor Last Name **] MEDICINE
ADDENDUM: The patient was transferred to the Medicine
[**Doctor Last Name 633**] Service on [**2185-12-3**]. The patient was
discharged on [**2185-12-7**].
PRIMARY CARE PHYSICIAN: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5939**] in [**Location (un) 5940**].
CARDIOLOGIST: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5941**], [**Telephone/Fax (1) 5942**].
GASTROINTESTINAL ATTENDING:[**Last Name (NamePattern1) 5943**]
In summary, this is a 47-year-old male in his usual state of
health until four days prior to admission when he developed
nausea, decreased appetite, and right upper quadrant pain and
three days of tactile fevers. The patient was admitted and
found to have cholecystitis. The patient had an open
cholecystectomy which revealed a gangrenous gallbladder and
obvious pus on [**2185-11-20**].
The [**Hospital 1325**] hospital course was complicated by persistent
fevers beginning on postoperative day number one to 102 and
continued without an obvious source. The patient was
initially treated with ampicillin, levofloxacin, and Flagyl
through [**2185-11-24**] and then cefazolin through [**2185-11-30**]. The patient's fevers persisted off his antibiotics
and an extensive workup was unrevealing.
The [**Hospital 1325**] hospital course was also complicated by a
postoperative myocardial infarction. He had a cardiac
catheterization on [**2185-11-25**] via his right groin with
PTCA of LAD lesion. The patient is otherwise with
intermittent fatigue, chills and sweats with fevers. The
patient had nausea and vomiting which is now subsided. The
patient now reports a good appetite. He has no focal
complaints.
PAST MEDICAL HISTORY:
1. Noninsulin-dependent diabetes mellitus.
2. Hepatitis B infection diagnosed in [**2180**] treated with
Interferon and now treated with lamivudine. The patient has
a positive hepatitis B surface antigen.
3. History of CAD, status post a five vessel CABG in [**2184-5-9**] and PTCA in [**2174**] in addition to the PTCA he had on
this admission.
PAST SURGICAL HISTORY:
1. CABG in [**2184**].
2. Back surgery for herniated disk.
3. Cholecystectomy in [**2185-11-8**].
MEDICATIONS ON TRANSFER FROM THE SURGERY TEAM:
1. Sliding scale insulin.
2. Milk of magnesia.
3. Atorvostatin 5 mg p.o. q.d.
4. Glucovance 500 mg p.o. t.i.d.
5. Tylenol p.r.n.
6. Metoprolol 75 mg t.i.d.
7. Aspirin 325 mg q.d.
8. Zolpidem.
9. Lamivudine 300 mg p.o. q.d.
ALLERGIES: The patient has no known drug allergies.
SOCIAL HISTORY: The patient lives in [**Location 5940**] in an
apartment with his wife, his two young sons and a brother.
[**Name (NI) **] works as a computer network engineer. The patient smoked
cigarettes until his admission. He denied any alcohol or IV
drug use. The patient travelled to [**Country 5944**] in [**2171**], [**2175**],
[**2178**], and [**2181**]. He came to the United States in [**2161**]. He
had travelled to [**State 5945**] and the West Coast in [**2171**] and
also to [**State 675**]. Otherwise, no Southwest, Southeast,
Northwest, or mid U.S. travel. The patient denied any tick
exposure or of working on a house.
FAMILY HISTORY: The patient has a father with diabetes and
two brothers with diabetes as well.
REVIEW OF SYSTEMS: The patient reports fatigue, fevers,
chills, rigors, and night sweats with the fever. He also
reports nausea, vomiting, and abdominal swelling after
eating. He reports back pain which is chronic and increases
with bed rest.
PHYSICAL EXAMINATION ON TRANSFER: The temperature was 98.3.
His T max was 101.8. The blood pressure was 114/66, heart
rate 76, 02 saturations 95% on room air, respiratory rate 20.
HEENT examination revealed that the conjunctivae, mouth and
throat were within normal limits. The pupils were equally
reactive and responsive to light. Hearing was grossly
normal. Moist mucous membranes. No oropharyngeal lesions.
The neck was supple. The patient did have a 0.5 cm diameter
right posterior cervical lymph node which was nontender. The
lungs revealed a few crackles at the bases. Cardiovascular:
Regular rate and rhythm. No murmurs, gallops, or rubs. The
abdomen was soft, nontender, nondistended, normoactive bowel
sounds. No organomegaly. There was a small amount of
drainage from the medial portion of his scar. The
extremities revealed no edema, 2+ dorsalis pedis pulses,
warm.
LABORATORY DATA ON TRANSFER: White count 10.0, hematocrit
29.0, platelets 420,000. Sodium 136, potassium 4.4, chloride
102, bicarbonate 26, BUN 11, creatinine 1.1 and glucose 135.
ALT 10, AST 21, alkaline phosphatase 115, total bilirubin
0.6, amylase 59, albumin 2.4, calcium 8.4, phosphorus 3.2,
magnesium 1.8, lipase 23. Parasite smear was negative on the
thin prep. U/A negative. His urine culture had no growth.
Blood cultures had no growth to date from the start of his
temperatures.
The EKG showed a normal sinus rhythm, normal intervals, T
wave inversions in I, aVL, V4, V5, and ST elevations in V1
through V3.
ASSESSMENT: Hepatitis B surface antigen and hypertension who
was admitted with acute cholecystitis and found to have a
gangrenous gallbladder at open cholecystectomy.
The hospital course was then complicated by a perioperative
MI treated with PTCA and now asymptomatic. He has now had a
fever to 102 since postoperative day number one of unclear
etiology.
HOSPITAL COURSE:
1. INFECTIOUS DISEASE: The patient had an extensive
Infectious Disease workup to determine the etiology of his
persistent fevers. The patient had a CT of the abdomen done
which showed a small pleural effusion, left greater than
right, bilateral patchy and ground glass opacities, left
lower lobe consolidation, prominent epicardial lymph nodes,
1.3 cm, no focal liver lesions, stranding in the gallbladder
fossa without definite fluid collection, a few diverticula
stranding surrounding the hepatic flexure with subtle
thickening of the colon wall. The patient also had a CT of
the chest without contrast on [**2185-12-1**] which showed
numerous mediastinal lymph nodes, epicardial lymph nodes,
about 13 mm, no axillary or hilar lymph nodes, no pericardial
effusion, small left greater than right pleural effusion,
patchy ground glass opacities, mildly thickened septal line,
bibasilar atelectasis, fluid in the gallbladder fossa and
stranding, degenerative changes in the thoracic spine.
The patient subsequently had a thoracentesis with pleural
fluid revealing 199 white blood cells with nothing seen on
Gram's stain or culture, albeit anaerobic, AFP, and final
cultures were also negative. The pleural fluid analysis
seemed to be transudative. The patient also had a number of
urine cultures and blood cultures sent, all of which were no
growth to date. Also, his urinalyses were not suggestive of
a urinary tract infection.
The patient had LFTs rechecked which were not suggestive of
any acute biliary or hepatic process. The patient also had a
rectal examination to assess for prostatitis given recent
Foley while in the Intensive Care Unit and this examination
was also negative.
The patient had an echocardiogram to assess for a pericardial
effusion which could also contribute to fevers. The
echocardiogram was without any effusion and showed an EF of
45-50%, left atrium mildly dilated, left ventricular cavity
size normal, left ventricular systolic function mildly
decreased with inferior septal hypokinesis. The aortic valve
leaflets were mildly thickened, natural thickening of the
noncoronary left cusp. The mitral valve leaflets were mildly
thickened, mild 1+ mitral regurgitation and mild pulmonary
artery systolic hypertension.
The patient had bilateral lower extremity Dopplers to rule
out a DVT and these were also negative. The patient had
numerous serial chest x-rays which were never significant for
any infiltrative process. The patient did have some evidence
of CHF on examination and was treated with Lasix. The
etiology was essentially unclear. Drug fever was also on the
differential, however, many drugs were removed and the
patient was on the bare minimum and he continued to spike
regardless of these changes. A surgical site infection was
less likely given that he had no erythema or tenderness or
pus-like drainage from this area.
The patient eventually became afebrile with no clear source.
If the patient were to spike in the future, further workup
could include a CT of the spine. The patient has had back
surgery in the past and it is possible that during his recent
open cholecystectomy that he seeded to the spine area.
However, he does not have any spinal tenderness but it can
still remain in the differential. The patient could also
have a follow-up CT of the chest given the ground glass
opacities and mediastinal lymphadenopathy that was seen.
Finally, if the patient were to spike again, a further option
may be to do a CT of the abdomen subcutaneous fat as he may
have had an infection within the fat area that would not be
seen with a regular CT of the abdomen.
2. ENDOCRINE: The patient is a noninsulin-dependent
diabetic, however, while in the hospital and stressed with
his fevers, and recent surgeries, the patient was placed on
sliding scale insulin as well as NPH coverage. The patient's
insulin doses were altered and he was eventually discharged
with NPH 7 units q.a.m. and 7 units q.h.s. in addition to
sliding scale Humalog. The patient was also placed back on
his usual Glucovance dose.
CONDITION AT DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSIS:
1. Acute cholecystitis, status post open cholecystectomy for
gangrenous gallbladder.
2. Myocardial infarction, status post PTCA.
3. Persistent fevers of unknown origin.
DISCHARGE MEDICATIONS:
1. Humalog sliding scale.
2. NPH insulin 7 units q.a.m., 7 units q.h.s.
3. Glucovance 500 p.o. b.i.d.
4. Lamivudine 300 mg p.o. q.d.
5. Atorvostatin 5 mg p.o. q.d.
6. Acetaminophen as needed.
7. Ambien 5 mg p.o. q.h.s.
8. Metoprolol 75 mg p.o. t.i.d.
9. Aspirin 325 mg p.o. q.d.
10. Prescription for alcohol pads, lancets, syringes for his
insulin care.
FOLLOW-UP: The patient was instructed to follow-up with his
primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5939**] in [**Location (un) 5940**]
five days after discharge regarding his insulin regimen. The
patient was also instructed to follow-up with his
cardiologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5941**], [**Telephone/Fax (1) 5942**], regarding his
recent cardiac event. The patient was also instructed to
follow-up with the surgery physician with Dr. [**Last Name (STitle) 1099**]
regarding follow-up of his recent cholecystectomy.
[**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) 29**]
Dictated By:[**Name8 (MD) 5946**]
MEDQUIST36
D: [**2185-12-7**] 10:16
T: [**2185-12-7**] 12:30
JOB#: [**Job Number 5947**]
|
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1,791
| 178,458
|
27383
|
Discharge summary
|
report
|
Admission Date: [**2184-5-24**] Discharge Date: [**2184-6-10**]
Date of Birth: [**2126-12-7**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
septic shock
transfer from OSH MICU for management of pancreatitis, sepsis,
and ARDS
Major Surgical or Invasive Procedure:
Tracheal intubation at outside hospital
Hemodialysis
Temporary hemodialysis catheter placement
Endoscopic ultrasound
Bronchoscopy with bronchoalveolar lavage
History of Present Illness:
57yo man presented to OSH [**2184-5-17**] with abdominal pain and nausea,
also with some dyspnea on exertion. On admission he was noted to
have pancreatitis and was admitted for management. A CT showed
no common bile duct dilation, but stones were seen in the
gallbladder with borderline gallbladder wall edema vs.
peri-colicystic fluid. Several days after admission he became
febrile, and was found to have klebsiella bacteremia. He
developed worsening respiratory distress with hypoxia shortly
after taking po barium contrast for a planned CT, at which time
he was diagnosed with ARDS by films and intubated. Shortly after
intubation he had a code for pulseless electrical activity. He
was resuscitated, and after a day on pressors was weaned off
successfully. His urine output decreased, however, and he
developed acute renal failure. He was transferred to [**Hospital1 18**] for
management with the possibility of requiring hemodialysis or
cholecystectomy.
Past Medical History:
hypertension
Social History:
Polish, works as machine operator. Denies tobacco and alcohol.
Wife and kids live in Poland.
Family History:
father with MI at 38yo, siblings with hypertension
Physical Exam:
On admission:
VS: T 98 BP 140/80 HR 80 RR 20 97%
Vent settings: AC 500x12 40% PEEP 8
Genl: Intubated, sedated
HEENT: Pinpoint pupils
Neck: + 9 cm JVD
No TM
CV: RRR nl s1s2, no mrg
Lungs: rare soft wheeze
Abd: tense, non tender
Ext: 1+edema
Neuro: Awakens to loud voice
Pertinent Results:
Admission labs:
WBC-14.3* RBC-3.18* Hgb-10.1* Hct-28.8* MCV-91 MCH-31.9
MCHC-35.2* RDW-13.7 Plt Ct-93*
Neuts-93* Bands-0 Lymphs-4 Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0
Myelos-0
PT-14.8* PTT-23.2 INR(PT)-1.3*
Glucose-112* UreaN-110* Creat-8.9* Na-137 K-4.6 Cl-98 HCO3-19*
AnGap-25*
ALT-63* AST-22 LD(LDH)-338* AlkPhos-66 Amylase-89 TotBili-0.5
Lipase-75*
Albumin-2.6* Calcium-6.6* Phos-8.8* Mg-2.7*
freeCa-0.9*
Lactate-1.5
Type-[**Last Name (un) **] pO2-163* pCO2-47* pH-7.23* calHCO3-21 Base XS--7
Comment-GREEN TOP
Other labs:
[**2184-5-25**] Iron-34* calTIBC-147* Hapto-272* Ferritn-686* TRF-113*
[**2184-5-24**] Triglyc-713*
[**2184-5-26**] HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE HCV
Ab-NEGATIVE
Discharge labs:
WBC-8.5 RBC-3.27* Hgb-10.2* Hct-29.6* MCV-90 MCH-31.0 MCHC-34.3
RDW-14.0 Plt Ct-130*
Glucose-95 UreaN-47* Creat-3.0* Na-134 K-4.7 Cl-96 HCO3-26
AnGap-17
Calcium-9.2 Phos-4.9* Mg-1.7
Imaging:
CXR at OSH: b/l opacities
CT at OSH: Pancreatic edema, no dilation of CBD
MRA at OSH: no RAS, >1cm stone in gall bladder
[**5-25**]: Renal Ultrasound: CONCLUSION: Kidneys are normal in size
and appearance without hydronephrosis. Incidental note of
splenomegaly, minimal ascites, and cholelithiasis.
[**5-25**]: CXR: Lung volumes are low, bilateral essentially perihilar
consolidation is symmetric, heart is enlarged and mediastinal
veins and hila are dilated. Cardiogenic pulmonary edema would be
the presumptive diagnosis.
[**5-25**] CXR (to assess earlier ptx):
1. Normal position of tubes and lines.
2. Worsening of the bilateral pulmonary consolidations.
3. Left lower lobe atelectasis in addition to consolidations.
4. No evidence of pneumothorax.
[**5-25**] KUB: IMPRESSION: No evidence of ileus
[**5-26**] CXR: Lung volumes are low, bilateral essentially perihilar
consolidation is symmetric, heart is enlarged and mediastinal
veins and hila are dilated. Cardiogenic pulmonary edema would be
the presumptive diagnosis. With benefit of a subsequent film,
one can see a small medial and basal left pneumothorax. Given
the history of a remote left-sided line placement, this may be
longstanding
[**5-26**] KUB: IMPRESSION: No evidence of small or large bowel
obstruction. No progression of contrast through the colon
[**5-27**] HIDA: IMPRESSION: No evidence of cholecystitis or common
bile duct obstruction
[**5-31**] MRCP: 1. No intra- or extra-hepatic biliary dilatation or
pancreatic ductal dilatation. 2. Small (less than 2.5 x 2 cm)
hypoenhancing area in the anterior pancreatic neck may represent
an area of necrosis. Small amount of anterior peripancreatic
fluid. No pancreatic ductal dilatation. 3. Cholelithiasis
without findings of acute cholecystitis or choledocholithiasis
on MRI. 4. Small amount of intra-abdominal ascites and small
bibasilar pleural effusions.
[**6-3**] EUS: Using a radial echoendoscope, the pancreas and
surrounding structures were imaged. No lymph nodes identified in
the region of the celiac axis. The pancreas was diffusely mildly
hypoechoic with some focal stranding and mild increase in
pancreatic duct wall echogenicity. No other features of chronic
pancreatitis. At the level of the pancreatic head adjacent fluid
collection identified - some peripancreatic ascites. No mass
lesions within the pancreatic head identifed but within the head
a mild diffuse area of reduced echogenicity more in keeping with
edema was identified. GB wall not thickened but large solitary
gallstone identified (2cm). CBD 3.3 mm PD 1.7 mm.
Brief Hospital Course:
57yo man with pancreatitis, ARDS, Klebsiella bacteremia,
gallstones, and acute renal failure status post pulseless
electrical activity arrest, transferred from outside hospital
with subsequent resolution of above problems.
Hospital course is reviewed below by problem:
1. Klebsiella bacteremia - The patient came to [**Hospital1 **] s/p septic
shock w/ resuscitation at OSH. He was noted to have Klebsiella
bacteremia. He was originally put on ceftriaxone, b/c Klebsiella
sensitive to this at OSH, but vancomycin was added when he
continued to spike temperatures. His line was removed and he
became afebrile with negative blood cultures, thus the
vancomycin was discontinued. On [**5-27**] meropenem was started, and
on [**5-29**] ceftriaxone was discontinued. He was treated with a 14
day course of antibiotics, ending on [**6-10**] (day of discharge).
Surveillance blood cultures were negative. He remained afebrile
throughout the rest of his hospital stay.
2. Pancreatitis - Per OSH records, the patient had mild
pancreatitis and a gallstone w/ thickened gallbladder wall but
no frank evidence of cholecystitis. His pancreatic enzymes
continued to trend down here and HIDA scan showed no evidence of
cholecystitis. A pancreatic specialist was consulted. An MRCP
showed evidence of cholelithiasis and a focal area of
necrotizing pancreatitis for he underwent endoscopic ultrasound.
This showed only peripancreatic fluid; the area of possible
necrosis by MRCP appeared to be edema by EUS. A cholecystectomy
may be indicated in the future, but not immediately given his
recent events. He was tolerating a regular diet on discharge. He
was discharged with a follow up appointment with Dr. [**Last Name (STitle) 174**],
gastroenterologist.
3. respiratory failure - He was admitted with hypoxic
respiratory failure and intubated at the OSH. This was thought
to be secondary to ARDS in the setting of septic shock. Upon
arrival to the [**Hospital1 **], the ARDS seemed improved by CXR. His P/F
ratio was 190 upon arrival, so lung protective ventilation was
started. Within a few days, the P/F ratio had improved to the
300s so weaning trials with PS were started. On [**5-30**], he was
successfully extubated. A bronchoscopy with BAL was performed on
[**5-27**] without evidence of ventilator-associated pneumonia.
4. acute renal failure - On transfer, the patient had ARF of
unknown etiology, possibly ATN from contrast. A renal u/s showed
no hydronephrosis. He was followed by the renal service
throughout the hospitalization. He was put on hemodialysis after
temporary line placement on hospital day 2 given uremia and some
delirium. His last dialysis was on [**5-31**]. His renal function
continued to improve and his temporary dialysis catheter was
pulled on [**6-8**] without complications. His creatinine was 3.0 on
the day of discharge.
5. hypertension - In accordance with his history of
hypertension, he was hypertensive in the ICU and restarted on
his home medications for hypertension. He was discharged on
clonidine patch, verapamil, metoprolol, and nifedipine. These
can be adjusted by his PCP.
6. triglyceridemia - He was noted to have elevated
triglycerides, which may have been a cause of his pancreatitis.
Recommend outpatient treatment.
7. constipation - He had mild abdominal distension during the
hospitalization. KUBs showed no ileus or obstruction. He was
treated with lactulose, colace and senna with success.
8. anemia - The patient had low hematocrits that remained
stable and did not require transfusion. He was gastroccult
positive, but had no evidence of active bleed. It was thought
this could be due to his OGT sucking against his stomach wall.
He remained hemodynamically stable throughout the
hospitalization. Would recommend outpatient EGD/colonoscopy.
9. cardiac murmur - He was noted to have a murmur that was not
appreciated on admission exam. This may be due to increased flow
with infection, but, if persistent, he would benefit from
outpatient echocardiogram.
Code status - full
Medications on Admission:
Meds @ home: Toprol, catapress, verapamil, hytrin, procardia
.
Meds @ OSH: cipro ([**Date range (1) 13508**]), zosyn ([**Date range (1) 21720**]), ceftriaxone
[**5-24**]-, insulin drip, prop, fentanyl, erythromycin, reglan,
risperdal
Discharge Medications:
1. Clonidine 0.1 mg/24 hr Patch Weekly Sig: Two (2) Patch Weekly
Transdermal QSAT (every Saturday).
2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO once a day.
3. Nifedipine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
Disp:*30 Tablet Sustained Release(s)* Refills:*0*
4. Terazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
5. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID
(3 times a day).
Disp:*270 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 17436**] Home Care
Discharge Diagnosis:
Pancreatitis
Klebsiella bacteremia
Respiratory distress and arrest
Status post pulseless electrical activity cardiac arrest
Cholelithiasis
Hypertension
Acute renal failure
Discharge Condition:
Good; he is ambulating independently, afebrile, without
complaints.
Discharge Instructions:
Please take all medications as prescribed.
Follow up with Dr. [**Last Name (STitle) 67064**] and Dr. [**Last Name (STitle) 174**] as described.
Call your doctor or go to the emergency room if you have any
abdominal pain, nausea, vomiting, fevers, chills,
lightheadedness, dizziness, chest pain, difficulty breathing,
change in urination, or any other concerning symptoms.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 67064**] ([**Telephone/Fax (1) 67065**]) on Wednesday,
[**2184-6-16**] at 10am in the [**Location (un) 5583**] office, [**Location (un) 67066**].
Please ask Dr. [**Last Name (STitle) 67064**] to check your sugars and your kidney
function.
Please follow up with Dr. [**Last Name (STitle) 174**] ([**Telephone/Fax (1) 1954**]) on Tuesday, [**7-6**], [**2184**] at 9:40am in the [**Hospital Ward Name 23**] Building, [**Location (un) 436**] Medical
Specialties.
|
[
"272.9",
"790.7",
"577.1",
"401.9",
"785.2",
"792.1",
"276.2",
"285.9",
"518.81",
"486",
"275.3",
"041.3",
"584.5",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.95",
"39.95",
"96.72",
"33.24",
"38.93",
"38.91",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
10475, 10537
|
5580, 9609
|
399, 559
|
10753, 10823
|
2069, 2069
|
11244, 11754
|
1711, 1764
|
9894, 10452
|
10558, 10732
|
9635, 9871
|
10847, 11221
|
2791, 5557
|
1779, 1779
|
275, 361
|
587, 1549
|
2085, 2585
|
1793, 2050
|
1571, 1585
|
1601, 1695
|
2597, 2775
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,343
| 186,467
|
33427
|
Discharge summary
|
report
|
Admission Date: [**2184-1-26**] Discharge Date: [**2184-2-2**]
Date of Birth: [**2122-2-2**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamides) / Diamox Sequels / Septra
Attending:[**First Name3 (LF) 4748**]
Chief Complaint:
right ischemic toe ulcer
Major Surgical or Invasive Procedure:
Redo vein graft from right fem peroneal bypass to
the right anterior tibial using nonreversed right arm basilic
vein, angioscopy.[**2184-1-28**]
Ultrasound-guided puncture of left common femoral artery.
Contralateral second-order catheterization of right common
femoral artery. Abdominal aortogram. Serial arteriogram of the
right lower extremity.[**1-27**]
History of Present Illness:
61M known to Dr. [**Last Name (STitle) 1391**] known vasculopath s/p left lower
extremity revascularization and ultimatley left BKA on [**2183-12-24**].
Now presents with non healing quarter size ulcer of right great
toe. Pt was at rehb and the ulcer was noticed by the nurse at
rehab more than 1 week ago. Pt then presented to Dr.[**Name (NI) 1392**]
office where he was instructed to return for admission. Pt
denies
all other ROS. Baseline creat .7 was 1.1 on [**1-6**].
On [**383-12-18**] pt grew MRSA and Pseudomonas from left foot ulcer
prior to BKA.
Past Medical History:
history of DM2 with neuropathy and retinopathy-uncontrolled
history of coronary artery disease s/p CABG'sx3 [**2177**]
history of peripheral vascular disease s/p left 5th toe, left
fem-AK [**Doctor Last Name **] with PTFE, s/p left AK [**Doctor Last Name **]-PT w arm vein+STSG [**12-28**]
history of retinopathy s/p eye surgery
history of gall bladder disease s/p cholecstectomy
Social History:
lives alone
denies tobacco use
occasional ETOH use
Family History:
N/C
Physical Exam:
97.7 72 126/76 18 100RA
NAD
CTAB
RRR
pressure erythema over sacrum
obese, S, NT, ND
left stump well healed with mild abrasion afetr trauma
right foot with quarter size ulcer over right great toe no
surrounding erythema
Pulses Fem [**Doctor Last Name **] DP PT
r 1+ m m m
l 1+ m - -
Pertinent Results:
[**2184-1-26**] 08:30PM PT-13.2 PTT-26.4 INR(PT)-1.1
[**2184-1-26**] 08:30PM PLT COUNT-172
[**2184-1-26**] 08:30PM WBC-7.4 RBC-3.78* HGB-11.3* HCT-32.9* MCV-87
MCH-30.0 MCHC-34.5 RDW-20.3*
[**2184-1-26**] 08:30PM CALCIUM-9.3 PHOSPHATE-3.2 MAGNESIUM-1.7
[**2184-1-26**] 08:30PM estGFR-Using this
[**2184-1-26**] 08:30PM GLUCOSE-140* UREA N-13 CREAT-0.9 SODIUM-137
POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-10
[**2184-1-28**] U/S Patent right basilic and cephalic veins with
diameters described above.
Brief Hospital Course:
[**2184-1-26**] Admitted to surgical service.Started on triple
antibiotics Vanco,cipro,flagyl. IV hydrated for angio.
[**2184-1-27**] angio ,diagnostic.
[**2184-1-28**] DOS: Vein mapping prior to surgery . Underwent righ
redo [**Doctor Last Name **]-At bpg with arm vein
[**2184-1-29**] POD#1 Transfused for blood loss anemia. Hypotension
intraop. No overnight events. goal SBP >140. Diet advanced,
fluids at maintance fluids.cardiac enzymes cycled. Remains in
VICU.
[**2184-1-30**]: POD 2 pt continued with bedrest. Regular diet.
[**2184-1-31**]- [**2184-2-1**]:Swan discontinued and CVL changed from cordis
to triple lumen. PT given 2 units of PRBCwith 20 mg IV lasix
diueresis in between. PT consulted. Pt chaged to floor status.
[**2184-2-2**]: Foley discontinued. CVL dcd. Pt discharged to rehab
with appropirate follow up.
Medications on Admission:
ISS, Vit C 500", Zinc 220', Neurontin 300"', Iron 325",
Melatonin 1 hs, timnolol opth 1gtt OD", MVT, Polyvinyl alchohol
1.4% soln 2 gtt OU", prilosec 40', Senna 8.6", Lisinopril 10',
Norvasc 5', Plavix 75', Miralax, prednisolone .12% opthal OS",
Alphagan .15% OD "', Wellbutrin 150", primidone 50'
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Polyethylene Glycol 3350 100 % Powder Sig: Seventeen (17) Gm
PO DAILY (Daily).
13. Prednisolone Acetate 0.12 % Drops, Suspension Sig: One (1)
Drop Ophthalmic [**Hospital1 **] (2 times a day).
14. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H
(every 8 hours).
15. Bupropion 75 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
16. Primidone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
18. Polyvinyl Alcohol 1.4 % Drops Sig: [**11-21**] Ophthalmic [**Hospital1 **] (2
times a day).
19. Insulin Regular Human Subcutaneous
20. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
21. Minocycline 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 169**] Center
Discharge Diagnosis:
Rt. first toe ischemic ulcer
Diabetes
Peripheral vascular disease.
Discharge Condition:
VSS, tolerating a regular diet, pain controlled with PO pain
medications.
Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
-If you have staples, they will be removed during at your follow
up appointment.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-2**] lbs) until your follow up appointment.
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**12-23**]
pillows or a recliner) every 2-3 hours throughout the day and at
night
?????? Avoid prolonged periods of standing or sitting without your
legs elevated
3. It is normal to have a decreased appetite, your appetite will
return with time
?????? You will probably lose your taste for food and lose some
weight
?????? Eat small frequent meals
?????? It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
?????? To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
What activities you can and cannot do:
?????? No driving until post-op visit and you are no longer taking
pain medications
?????? Unless you were told not to bear any weight on operative foot:
?????? You should get up every day, get dressed and walk
?????? You should gradually increase your activity
?????? You may up and down stairs, go outside and/or ride in a car
?????? Increase your activities as you can tolerate- do not do too
much right away!
?????? No heavy lifting, pushing or pulling (greater than 5 pounds)
until your post op visit
?????? You may shower (unless you have stitches or foot incisions) no
direct spray on incision, let the soapy water run over incision,
rinse and pat dry
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing
over the area that is draining, as needed
?????? Take all the medications you were taking before surgery,
unless otherwise directed
?????? Take one full strength (325mg) enteric coated aspirin daily,
unless otherwise directed
?????? Call and schedule an appointment to be seen in 2 weeks for
staple/suture removal
What to report to office:
?????? Redness that extends away from your incision
?????? A sudden increase in pain that is not controlled with pain
medication
?????? A sudden change in the ability to move or use your leg or the
ability to feel your leg
?????? Temperature greater than 100.5F for 24 hours
?????? Bleeding, new or increased drainage from incision or white,
yellow or green drainage from incisions
Followup Instructions:
2 weeks, Dr. [**Last Name (STitle) 1391**], call for an appointment [**Telephone/Fax (1) 1393**]
Completed by:[**2184-2-2**]
|
[
"440.23",
"357.2",
"250.50",
"250.60",
"362.01",
"458.29",
"707.14",
"707.15",
"440.30",
"V49.75",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"39.49",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
5592, 5644
|
2661, 3500
|
329, 689
|
5755, 5831
|
2115, 2638
|
10336, 10463
|
1763, 1768
|
3849, 5569
|
5665, 5734
|
3526, 3826
|
5855, 5855
|
9929, 10313
|
5871, 9903
|
1783, 2096
|
265, 291
|
717, 1275
|
1297, 1678
|
1694, 1747
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,768
| 143,073
|
50245+59237
|
Discharge summary
|
report+addendum
|
Admission Date: [**2146-6-18**] Discharge Date: [**2146-6-26**]
Date of Birth: [**2080-5-6**] Sex: M
Service:
ADMISSION DIAGNOSES:
1. End-stage renal disease secondary to glomerulonephritis.
2. Coronary artery disease.
3. Myocardial infarction x2.
4. Congestive heart failure.
5. Autoimmune glomerulonephritis.,
6. Hypercholesterolemia.
7. Gastroesophageal reflux disease.
8. History of bladder cancer.
9. History of deep venous thrombosis.
10. Anemia.
11. Pseudogout.
DISCHARGE DIAGNOSES:
1. End-stage renal disease secondary to glomerulonephritis.
2. Coronary artery disease.
3. Myocardial infarction x2.
4. Congestive heart failure.
5. Autoimmune glomerulonephritis.,
6. Hypercholesterolemia.
7. Gastroesophageal reflux disease.
8. History of bladder cancer.
9. History of deep venous thrombosis.
10. Anemia.
11. Pseudogout.
12. Status post cadaveric renal transplant.
13. Postoperative junctional tachycardia.
14. Hematuria.
15. Delayed graft function.
HISTORY OF PRESENT ILLNESS: The patient is a 66-year-old
male with a history of end-stage renal disease secondary to
glomerulonephritis. The patient has been on hemodialysis
since [**2145-8-1**]. Although he has had a history of
bladder cancer, states that this is not active. Prostate
biopsies have been without evidence of malignancy.
PAST MEDICAL HISTORY:
1. End-stage renal disease.
2. Glomerulonephritis.
3. Coronary artery disease.
4. Myocardial infarction x2.
5. Congestive heart failure.
6. Autoimmune glomerulonephritis.
7. Hypercholesterolemia.
8. Gastroesophageal reflux disease.
9. Bladder cancer.
10. Deep venous thrombosis.
11. Anemia.
12. Pseudogout.
PAST SURGICAL HISTORY:
1. Coronary artery bypass graft.
2. Status post coronary artery stenting.
3. Right upper extremity A-V fistula.
ALLERGIES:
1. Bactrim.
2. Pravachol.
3. Tape.
4. Mevacor.
MEDICATIONS ON ADMISSION:
1. Aspirin 81 mg q day.
2. Lipitor 20 mg q day.
3. Digoxin 0.125 mg qod.
4. Amiodarone 200 mg q day.
5. Nephrocaps.
6. Colchicine 0.6 mg q day.
7. Lopressor 12.5 mg [**Hospital1 **].
8. Iron supplement.
9. PhosLo.
10. Prilosec.
11. Renagel.
PHYSICAL EXAMINATION ON ADMISSION: Vital signs: 98.1, 76,
151/74, 95.5 kg, 97% on room air. General: In no acute
distress. HEENT is atraumatic, normocephalic. Extraocular
movements are intact. Pupils are equal, round, and reactive
to light, anicteric. Throat is clear. Neck is supple,
midline with no masses or lymphadenopathy. Chest was clear
to auscultation bilaterally. Cardiovascular is regular,
rate, and rhythm without murmurs, rubs, or gallops. Abdomen
is obese, soft, nontender, nondistended. Extremities are
warm, cyanotic, nonedematous x4. There is an A-V fistula in
the right upper extremity. Positive bruit, positive thrill.
Neurologic is alert and oriented times three and grossly
intact.
HOSPITAL COURSE: The patient was admitted on [**2146-6-18**] for
cadaveric renal transplant. He had his renal transplant
implanted into the right ileac fossa. For details of the
operation, please see previously dictated operative note.
Postoperatively, the patient was transferred to the Surgical
Intensive Care Unit for problems with junctional tachycardia
as well as hematuria and bladder clotting. The patient was
emergently dialyzed. Afterwards, his junctional tachycardia
reverted to normal sinus rhythm. Multiple Foley attempts
were made, ultimately Urology was consulted and placed a 24
French [**Doctor Last Name **]-way coude catheter for continuous bladder
irrigation. After this, the patient had no more difficulty
with bladder clotting.
Cardiology was consulted in order to assess the junctional
rhythm. They felt his junctional tachycardia was likely
secondary to his potassium of 6.7, which dropped to 5.5 after
dialysis. Patient was restarted on amiodarone as well as a
beta blocker in junction with Cardiology consultation.
Later on postoperative day #1, the patient was transferred to
the floor. The patient was given intravenous fluids per
protocol at 50 cc an hour, plus 1 cc/cc of urine output
greater than 50 cc. The patient continued to make small
amounts of urine generally ranging between 15 and 30 cc an
hour. Because of his delayed graft function, the patient was
hemodialyzed on [**2146-6-23**]. His BUN and creatinine on that day
were 155 and 12.4 respectively.
The patient also had a G-6-P-D workup, which ultimately was
negative. This was done for his continued hematuria.
Eventually, the patient's urine output showed no more blood
and CVR was discontinued.
From an infectious disease standpoint, the patient was
prophylaxed with Valcyte 450 mg qod as well as nystatin 5 mL
qid. The patient has an allergy to Bactrim and will undergo
pentamidine inhalation therapy.
From an immunosuppression standpoint, the patient was given a
rapid taper Solu-Medrol dosing, three doses of thyroglobulin,
CellCept 1,000 mg [**Hospital1 **], and was ultimately discharged on
Neoral dose of 350 mg [**Hospital1 **]. Neoral doses were adjusted
according to am levels.
Ultimately, the patient was discharged on postoperative day
#8, doing well with the exception of his delayed graft
function. His BUN and creatinine were noted to be 136 and
9.8 respectively from the day prior, which was 123 and 9.9.
Given these stable values, the patient was discharged with
close followup from Renal, and a possibility of one more
hemodialysis.
The patient did have some electrolyte abnormalities which
were treated and trending in the correct direction upon
discharge. His calcium seemed to low as 5.5 and his
phosphorus was as high as 9.3. These were treated
aggressively with calcium repletion as well as PhosLo three
caps tid.
Ultimately, the patient was discharged on postoperative day
eight, tolerating regular diet, has had good pain control
with po pain medications, having made 1,450 cc of urine the
day prior, and with a BUN and creatinine of 123 and 9.9.
PHYSICAL EXAMINATION ON DISCHARGE: Chest was clear to
auscultation bilaterally. Cardiovascular is regular, rate,
and rhythm. Abdomen is obese, soft, minimally tender around
incision, nondistended. Wound is open approximately 2 cm at
the midpoint at his incision, but there is no erythema or
exudate, or other signs of infection. Extremities are warm,
noncyanotic, nonedematous x4.
LABORATORIES ON THE DAY OF DISCHARGE: Complete blood count:
10.4/29.3/122. PT 12.7, INR 1.1, PTT 31.6. Chemistries:
140/4.3/98/24/136/9.8/149. Calcium 6.3, magnesium 2.0,
phosphorus 8.2.
DISCHARGE CONDITION: Stable.
DISPOSITION: Home.
DIET: Cardiac and diabetic. Encourage fluid intake.
DISCHARGE INSTRUCTIONS: Patient is to followup with Renal on
Tuesday, [**2146-6-28**], for examination and blood draws. Patient
may undergo another hemodialysis treatment potentially on
Wednesday, [**2146-6-29**]. Encourage po intake. Record daily
urine output. No strenuous activity or heavy lifting greater
than 10 pounds. Follow up with Transplant Center on
[**2146-6-27**], Dr. [**Last Name (STitle) **].
[**Name6 (MD) 1344**] [**Name8 (MD) 1345**], M.D. [**MD Number(1) 1346**]
Dictated By:[**Last Name (NamePattern1) 5745**]
MEDQUIST36
D: [**2146-6-26**] 12:44
T: [**2146-7-6**] 14:34
JOB#: [**Job Number **]
Name: [**Known lastname 16679**], [**Known firstname 1523**] Unit No: [**Numeric Identifier 17023**]
Admission Date: [**2146-6-18**] Discharge Date: [**2146-6-26**]
Date of Birth: [**2080-5-6**] Sex: M
Service:
ADDENDUM:
DISCHARGE MEDICATIONS:
1. CellCept 1 gram b.i.d.
2. Protonix 40 mg q.d.
3. Colace 100 mg b.i.d.
4. Valcyte 450 mg q.o.d.
5. Nystatin 5 milliliters q.i.d.
6. Lopressor 25 mg b.i.d.
7. Aspirin 81 mg q.d.
8. Digoxin 0.125 mg q.o.d.
9. Lipitor 10 mg q.d.
10. Tums 1,000 mg t.i.d.
11. Lasix 60 mg b.i.d.
12. PhosLo three tablets t.i.d.
13. Calcitriol 0.5 micrograms q.d.
14. Neoral 350 mg b.i.d.
15. Amiodarone 200 mg q.d.
16. Percocet 5/325 one to two q. four hours p.r.n.
17. Insulin as directed.
DISCHARGE INSTRUCTIONS: The patient also needs Pentamidine
inhalation prophylaxis given his allergy to Bactrim. This
will be arranged as an outpatient.
[**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4043**]
Dictated By:[**Last Name (NamePattern1) 4523**]
MEDQUIST36
D: [**2146-6-26**] 04:46
T: [**2146-7-6**] 20:11
JOB#: [**Job Number 17024**]
|
[
"427.32",
"275.3",
"V10.51",
"276.7",
"275.49",
"403.91",
"V45.81",
"275.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
6522, 6607
|
507, 975
|
7553, 8034
|
1868, 2131
|
2846, 5942
|
8059, 8430
|
1670, 1842
|
147, 486
|
5957, 6500
|
1004, 1317
|
2146, 2828
|
1339, 1647
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,592
| 150,251
|
50404
|
Discharge summary
|
report
|
Admission Date: [**2199-11-23**] Discharge Date: [**2199-11-27**]
Service: MICU
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
gentleman with a history of diastolic congestive heart
failure, chronic obstructive pulmonary disease, hypertension,
and chronic renal insufficiency who presents from [**Hospital3 1761**] with respiratory distress.
The patient was in his usual state of health until one day
prior to admission when he was found with a respiratory rate
of 50, and bilateral rales, with an oxygen saturation of 84%.
He was tested for influenza A antigen and was found to be
positive. At that time, he was started on rimantadine and
azithromycin. The patient was also complaining of a sore
throat and malaise.
On the day of admission to [**Hospital1 188**], the patient's respiratory status worsened. His
oxygen saturations decreased to 84% on room air and improved
to 96% with a 15-liter nonrebreather masks. The patient was
transferred to the Emergency Department. The patient has had
four prior admissions to [**Hospital1 **] [**First Name (Titles) 14169**] [**2199-8-28**]; once for respiratory failure secondary to congestive
heart failure and three for chronic constipation.
The patient had previously been living alone in an [**Hospital3 12272**] facility with [**Hospital6 407**]. He was sent
to [**Hospital3 **] due to increased unsteadiness on his
feet and increased forgetfulness. At [**Hospital3 **],
he had been transferred to the Acute Care Division on
[**11-15**] for a urinary tract infection that was
methicillin-resistant Staphylococcus aureus positive.
En route for this admission, in the ambulance, the patient
was on 15 liters of oxygen with oxygen saturations of 96%.
He received 100 mg of intravenous Lasix and nitroglycerin
twice. In the Emergency Department, the patient received an
additional 40 mg of intravenous Lasix. His blood pressure
was 180/80. He was started on a nitroglycerin drip with
titration of his blood pressure to less than 120. He was
also started on [**Hospital1 **]-level positive airway pressure at 10 and
5. He was given Tylenol. A chest x-ray at that time showed
bilateral infiltrates and effusions bilaterally.
PAST MEDICAL HISTORY:
1. Diastolic dysfunction with an ejection fraction of 60%,
with 3+ tricuspid regurgitation, pulmonary hypertension, and
2+ mitral regurgitation on an echocardiogram in [**2199-10-28**]. The patient had a normal stress test in [**2187**].
2. History of coronary artery disease.
3. Status post pacemaker placement (VVI) in [**2190**].
4. History of chronic obstructive pulmonary disease and
reactive airway disease with frequent episodes of bronchitis.
5. History of atrioventricular nodal reentrant tachycardia;
status post ablation.
6. Hypertension.
7. Chronic renal insufficiency (with a baseline creatinine
of approximately 1.7 to 2).
8. History of lower gastrointestinal bleed in [**2196**] with a
colonoscopy revealing polyps.
9. History of gastroesophageal reflux disease.
10. History of glaucoma.
11. Status post appendectomy and cholecystectomy.
12. History of small-bowel obstruction and low anterior
resection twice.
13. History of B12 deficiency.
14. History of cataract surgery.
15. Status post total hip replacement bilaterally.
16. History of panic disorder.
17. History of depression.
ALLERGIES: The patient reports an allergy to PROSCAR (with
unknown effect), BENADRYL (with unknown effect), and
QUINIDINE (with unknown effect).
MEDICATIONS ON ADMISSION:
1. Rimantadine 100 mg by mouth once per day.
2. Lasix 40 mg by mouth once per day.
3. Aspirin 325 mg by mouth once per day.
4. Lipitor 10 mg by mouth once per day.
5. Lopressor 40 mg by mouth twice per day.
6. Hydralazine 10 mg by mouth four times per day.
7. Atrovent and albuterol meter-dosed inhaler as needed.
8. Ranitidine 150 mg by mouth once per day.
9. Paxil 20 mg by mouth once per day.
10. Colace 100 mg by mouth once per day.
11. Isordil 20 mg by mouth once per day.
12. Senna as needed.
13. Vancomycin (since [**11-15**]) renally dosed for
methicillin-resistant Staphylococcus aureus urinary tract
infection.
PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital
signs on admission revealed his temperature was 100.5 degrees
Fahrenheit, his blood pressure was 130/50, his heart rate was
65, his respiratory rate was 36, and his oxygen saturation
was 76% on room air and 95% on 100% nonrebreather. The
patient had tachypnea and 4 to 10 seconds of apnea. In
general, the patient was an elderly gentleman on [**Hospital1 **]-level
positive airway pressure in no acute distress. Neck
examination revealed jugular venous pressure at 9 cm. There
was no lymphadenopathy. Cardiovascular examination revealed
a regular rate. There was a 2/6 systolic murmur. No rubs or
gallops. Respiratory examination revealed bilateral rhonchi.
Crackles halfway up the bases (right greater than left).
There were intercostal retractions and abdominal breathing.
The abdomen was soft, nontender, and nondistended. There
were positive bowel sounds. Extremity examination revealed
1+ edema bilaterally.
PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent
laboratories on admission revealed the patient's white blood
cell count was 7, his hematocrit was 42.5, and his platelets
were 148. The differential was normal. Normal electrolytes
with a creatinine of 2. Arterial blood gas at that time was
7.43/41/89 on [**Hospital1 **]-level positive airway pressure at 10 and 5.
All blood cultures were negative. Influenza test was
positive for influenza A. Viral cultures were negative.
PERTINENT RADIOLOGY/IMAGING: An electrocardiogram revealed a
ventricularly paced rhythm at 61. No T waves. No ST-T wave
changes.
A chest x-ray revealed bilateral infiltrates and effusions.
IMPRESSION: Our impression was that the patient was a
[**Age over 90 **]-year-old gentleman with a past medical history of
diastolic congestive heart failure and chronic obstructive
pulmonary disease who had influenza A causing a congestive
heart failure exacerbation, possible chronic obstructive
pulmonary disease exacerbation, possible overlying pneumonia.
There was concern for methicillin-resistant Staphylococcus
aureus pneumonia as well as atypical nosocomial pneumonia
given the fact that he was staying in a rehabilitation
institution.
CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM:
1. PULMONARY ISSUES: The patient was weaned off [**Hospital1 **]-level
positive airway pressure and placed on nasal cannula. The
patient was weaned down to 5 liters nasal cannula within
three days of admission.
The patient became very anxious on [**Hospital1 **]-level positive airway
pressure and was much more calm and breathing well on nasal
cannula. The patient's saturations were maintained at 91% to
92%, and bicarbonate levels were monitored carefully given
his history of CO2 retention.
The patient was given Lasix 120 mg twice per day. He was
diuresing well with at least one liter per day, which
improved his breathing greatly. The patient was treated with
albuterol and Atrovent nebulizers four times per day with
much relief. He was treated with a 7-day course of
levofloxacin at 250 mg once per day as well as with
vancomycin renally dosed for a full 7-day course to cover for
methicillin-resistant Staphylococcus aureus pneumonia as well
as to complete the treatment of his history of a urinary
tract infection.
Incentive spirometry was encouraged, and chest x-rays
revealed almost complete resolution of effusions. The
infiltrates persisted, but this was expected given the
short-time interval and should be followed up in the future
clinically.
For influenza A, the patient was continued on amantadine for
five days. He was continued on droplet precautions. On the
day of discharge this was discontinued due to the completion
of the course and the no longer infectious nature.
2. CARDIOVASCULAR ISSUES: The patient has a history of
coronary artery disease. He was ruled out for a myocardial
infarction. The patient was continued on medical management
with aspirin, Lipitor, and Imdur (at their current doses), as
well as with metoprolol. Captopril was added.
3. RHYTHM ISSUES: The patient was maintained on telemetry
throughout his admission. He continued to have a
ventricularly paced rhythm. No ectopy was seen.
4. CONGESTIVE HEART FAILURE EXACERBATION ISSUES: Due to
congestive heart failure exacerbation due to hypertensive and
diastolic dysfunction, there was concern that he needed a
great deal of preload given his 3+ tricuspid regurgitation
and pulmonary hypertension in order to maintain perfusion
pressures; however, it was concerning with 2+ mitral
regurgitation would exacerbate the pulmonary edema. Diuresis
with Lasix was continued. He was maintained on a sodium
restriction with daily weights, and afterload reduction was
maximized to keep his systolic blood pressure at less than
120. This was done by starting the patient on captopril and
titrating it up to 25 mg by mouth three times per day as well
as maximizing his beta blockade with increasing it from 50 mg
by mouth twice per day to 50 mg by mouth three times per day.
5. CHRONIC OBSTRUCTIVE PULMONARY DISEASE EXACERBATION
ISSUES: For his chronic obstructive pulmonary disease
exacerbation, the patient was continued on around the clock
nebulizers. No steroids were given to the patient given the
concern for worsening congestive heart failure exacerbation.
As stated, his oxygen saturations were monitored and he
continued to be weaned off oxygen. He was requiring 5 liters
nasal cannula at the time of discharge. It was expected that
this would be weaned in the future.
6. CHRONIC RENAL INSUFFICIENCY ISSUES: For his chronic
renal insufficiency, it was thought that the patient was at
his baseline. His renal function was monitored with Lasix
diuresis and the start of an ACE inhibitor. It was
recommended that this be monitored in the future (in about
two weeks). All medications were renally dosed.
7. PROPHYLAXIS ISSUES: For prophylaxis, the patient was
maintained on a H2 blocker, heparin subcutaneous three times
per day, as well as a bowel regimen. He was also maintained
on droplet and methicillin-resistant Staphylococcus aureus
precautions. It was thought that he should be maintained on
methicillin-resistant Staphylococcus aureus precautions in
the future until he has nasopharyngeal and rectal swabs to
rule out colonization.
8. CODE STATUS ISSUES: As previously documented, his code
status is do not resuscitate/do not intubate.
9. COMMUNICATION ISSUES: The patient's children were
communicated with, and the patient was communicated with
through a Russian interpreter.
DISCHARGE DISPOSITION: On the day of discharge, the patient
was to be sent to [**Hospital3 **] for further
management. This was discussed with the primary attending,
Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] as well as geriatric attending.
ADDENDUM: Of note, the patient was admitted with a
peripherally inserted central catheter line in place. On the
day prior to discharge, some swelling was noted at this site
with erythema and some tenderness. The peripherally inserted
central catheter line was discontinued. An ultrasound of the
left upper extremity was completed and revealed no evidence
of clot.
DISCHARGE DIAGNOSES:
1. Chronic obstructive pulmonary disease exacerbation.
2. Congestive heart failure exacerbation.
3. Influenza A.
4. Pneumonia.
5. Hypertension.
6. Chronic renal insufficiency.
7. Hypoxic respiratory failure.
MEDICATIONS ON DISCHARGE:
1. Heparin 5000 units subcutaneously three times per day
(until the patient is ambulating regularly).
2. Imdur 30 mg by mouth once per day.
3. Paxil 20 mg by mouth once per day.
4. Albuterol nebulizer four times per day.
5. Atrovent nebulizer four times per day.
6. Hydralazine 10 mg by mouth four times per day.
7. Metoprolol 50 mg by mouth three times per day.
8. Lipitor 10 mg by mouth once per day.
9. Aspirin 325 mg by mouth once per day.
10. Senna one tablet as needed.
11. Docusate 100 mg by mouth twice per day.
12. Zantac 150 mg by mouth once per day.
13. Levofloxacin 250 mg by mouth every day (to be
discontinued on [**2199-11-29**]).
14. Vancomycin (discontinued due to completed course).
15. Lasix 40 mg by mouth once per day.
16. Tylenol as needed.
17. Ambien as needed.
CONDITION AT DISCHARGE: The patient's condition on discharge
was good. The patient was sitting up and breathing well on 5
liters via nasal cannula without wheezing. Normal urine
output. The patient was eating and drinking.
DISCHARGE STATUS: The patient was to be discharged to [**Hospital3 1761**].
DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed
to follow up with his geriatric physicians at [**Hospital3 1761**] within one week.
DR.[**Last Name (LF) **],[**First Name3 (LF) **] 12-AHZ
Dictated By:[**Last Name (NamePattern1) 6374**]
MEDQUIST36
D: [**2199-11-26**] 17:42
T: [**2199-11-26**] 18:00
JOB#: [**Job Number **]
|
[
"397.0",
"487.0",
"518.81",
"428.0",
"599.0",
"428.33",
"424.0",
"491.21",
"402.91"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10808, 11427
|
11448, 11664
|
11691, 12512
|
3547, 6420
|
12843, 13174
|
6454, 10783
|
12527, 12808
|
121, 2224
|
2247, 3520
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,489
| 126,299
|
51375
|
Discharge summary
|
report
|
Admission Date: [**2199-10-3**] Discharge Date: [**2199-10-6**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 3290**]
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
.
History of Present Illness:
This is a [**Age over 90 **] year old female with hypertension, diastolic CHF,
DM, and CKD who was hospitalized two weeks ago with flash
pulmonary edema in the setting of hypertension. Apparently, she
did well for a week after hospitalization and then over the past
week has developed worsening shortness of breath and weakness.
She vomited once yesterday but had no associated nausea. Today,
she presented to the ED with worsening shortness of breath and
was notably dyspeneic with vitals of T 98.2, HR 85, BP 201/64,
RR 22, O2 Sat 99% on 4L NC (86% on RA). CXR revealed volume
overload and basilar density c/w more likely atelectasis less
likely PNA. She received nitro paste and nitro SL before being
put on a nitroglycerine drip. She received 60 mg IV furosemide,
180 mg Nifedipine CR, 200 mg labetalol, and was tried on CPAP
but had difficulty tolerating it. She also received IV
ceftriaxone and azithromycin for the question of pneumonia on
CXR. Of note she denied chest pain, fevers, or chills.
On arrival to the ICU the patient was notably dyspneic and
unable to speak in complete sentences. Audible gurgling.
Crackles at bases to auscultation.
REVIEW OF SYSTEMS: Unobtainable due to distress.
Past Medical History:
-Chronic Diastolic CHF
-Diabetes type 2
-Dyslipidemia
-HTN
-Stage IV CKD
-recurrent right breast CA
-glaucoma, blind
-hypercholesterolemia
Social History:
Lives in [**Location 669**] with daughter. 17 stairs in house between
bedroom and kitchen. Spends significant time in bed. Denies hx
of bedsores. Meds dispensed by daughter.
[**Name (NI) 1139**]: remote hx
Etoh: denies
Drugs: denies
Family History:
Sister with Breast CA. +DM, unclear for the remainder.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
VS: T 96.2, P 86, BP 194/70, RR 22, O2 94% on 4L
GEN: appears distressed, gurgling breath sounds
HEENT: anicteric, bluish discoloration of lenses, MMM, op
without lesions, JVD difficult to assess due to CPAP but JVP
visible above the clavicle with patient at nearly 90 degrees
suggesting JVD
RESP: Loud crackles over both lung fields, pt unable to speak in
complete sentences
CV: RRR, S1 and S2 grossly normal (though difficult exam due to
loud breath sounds)
ABD: Soft, NT, ND, no organomegaly or masses
EXT: no C/C/E; 1+ DP and PT pulses bilaterally
SKIN: no rashes/no jaundice/no splinters
NEURO: couldn't fully assess orientation but responding
correctly if briefly given dyspnea, moving all extremities
Pertinent Results:
[**2199-10-3**] 09:36AM WBC-8.1# RBC-2.82* HGB-7.7* HCT-24.9* MCV-88
MCH-27.3 MCHC-30.9* RDW-17.0*
[**2199-10-3**] 09:36AM NEUTS-76.6* LYMPHS-16.1* MONOS-5.1 EOS-1.6
BASOS-0.6
[**2199-10-3**] 09:36AM PLT COUNT-265
[**2199-10-3**] 09:36AM PT-11.8 PTT-21.9* INR(PT)-1.0
[**2199-10-3**] 09:36AM GLUCOSE-86 UREA N-80* CREAT-6.1*# SODIUM-141
POTASSIUM-6.9* CHLORIDE-109* TOTAL CO2-17* ANION GAP-22*
[**2199-10-3**] 10:00AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
[**2199-10-3**] 10:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2199-10-3**] 10:00AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-[**5-23**]
[**2199-10-3**] 10:00AM URINE EOS-NEGATIVE
[**2199-10-3**] 09:36AM proBNP-[**Numeric Identifier 106527**]*
[**2199-10-3**] 09:36AM cTropnT-0.10*
[**2199-10-3**] 05:27PM CK-MB-4 cTropnT-0.17*
[**2199-10-3**] 05:27PM CK(CPK)-82
Imaging:
CXR: [**2199-10-3**]
Moderate congestive heart failure, worse in the interval. Small
bilateral pleural effusions. Opacities in both lung bases likely
represent atelectasis but infection cannot be excluded.
CXR: [**2199-10-4**]
Subtotal interval resolution of pulmonary edema and interval
improvement of right fissural pleural fluid.
Brief Hospital Course:
[**Age over 90 **] y.o. female with stage V CKD, Diastolic CHF, and diabetes
mellitus type II presenting with pulmonary edema and worsening
renal function.
1. Diastolic CHF/ Pulmonary Edema: Presented with frank
pulmonary edema in the context of hypertension and perhaps
slight volume overload. Most likely inciting factor was
hypertensive urgency given high pressures at presentation but
daughters reports she has similar pressures in the morning at
home and hasn't necessarily flashed in these circumstances.
Initially required CPAP to decrease work of breathing and NTG
drip for control of hypertension. Transitioned to oral
medications of nifedipine, labetalol, isosorbide at home doses.
Although given large doses of lasix- 60mg and then 120mg, put
out minimal urine, suggesting that chronic kidney disease may be
progressing to oliguric ESRD. Respiratory status improved and
repeat chest x-ray showed almost complete resolution of
pulmonary edema. Weaned successfully to 3LNC prior to transfer
to floor.
2. HTN: Hypertensive with SBP in 200s at presentation and likely
this increased afterload contributed to decreased forward flow
and her flash pulmonary edema. As above, patient was initially
placed on a nifedipine drip with administration of home
medications of nifedipine, labetolol and isosorbide. BP
normalized with SBP in 120s.
3. CKD: Presented with Cr of 6.1, which was worse than baseline
stage V CKD and significant electrolyte abnormalities including
nonanion gap acidosis, hyperkalemia and hyperphosphatemia. No
etiology for decompensation discovered with no urinary
eosinophils, FeNa of 1.4 and FeUrea of 39. Urine output
remained minimal despite lasix 120mg IV. Pt has refused HD in
past.
4. DM: Not on meds and glucose currently normal. Check glucose
daily
5. Glaucoma: Continue drops
6. Recurrent breast cancer: Continue home anastrazole
FEN: Regular, low K diet
Access: PIV
PPx: SC heparin, no indication for GI
Comm: Daughter [**Name2 (NI) 7346**] (number in [**Name (NI) **])
Code: DNR, children OK with limited duration intubations
DISPO: ICU
Medications on Admission:
1. furosemide 20 mg PO DAILY
2. multivitamin PO DAILY
3. dorzolamide-timolol 2-0.5 % one drop daily.
4. Anastrozole 1 mg once a day.
5. Isosorbide Mononitrate 60 mg QHS
6. Nifedipine ER 180 mg PO daily
7. Labetalol 200 mg PO twice a day
Discharge Medications:
1. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet
Sustained Release PO DAILY (Daily).
3. sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
4. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic DAILY ().
5. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO QHS (once a day
(at bedtime)).
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
7. oxycodone 20 mg/mL Concentrate Sig: 1-20 mg PO Q1H:PRN as
needed for pain, dyspnea : sublingual .
Disp:*30 ml* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Hospice of the Good [**Doctor Last Name 9995**]
Discharge Diagnosis:
Primary:
Acute congestive heart failure exacerbation
.
Secondary:
Chronic Kidney Disease stage IV
Chronic Diastolic Heart Failure (EF>75%)
Diabetes type 2
Dyslipidemia
Hypertension
glaucoma, blind
hypercholesterolemia
.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharged Home with Hospice.
Discharge Instructions:
Dear Ms. [**Known lastname **] [**Known lastname 106526**],
You were admitted to the hospital for acute shortness of
breath. This was due to sudden onset of pulmonary edema
(accumulation of fluid in your lungs) from high blood pressure.
You were treated with oxygen and taken to the intesnive care
unit. You were given anti-hypertensives (medications to bring
your blood pressure down). You were also given diuretics
("water pills") to help urinate off excess fluid around your
lungs. Your symptoms improved and you were transferred to the
general medical floors.
On the medical floors, your labs showed evidence of chronic
kidney disease. You were given medications to help manage
potassium levels in your blood. You are aware of your chronic
kidney disease, and have declined evaluation for hemodialysis.
You have had home hospice care in the past. After discussion
with you and your family, it appears that the best option for
you, now that you are stable, will be to go back home with help
from your visiting hospice nurses as well as your PCP [**Last Name (NamePattern4) **].
[**Last Name (STitle) **]. In the event that you become short of breath, using
morphine will help control feelings of shortness of breath.
This medication can be received from your hospice nurse.
.
No changes were made to your blood pressure medications.
The following changes have been made to your other medications:
- Please STOP your Anastrazole
- Please STOP your multivitamin
- We have ADDED sevelamir to be taken with each meal
The Hospice company will give you medications to help keep you
comfortable and will teach your family how to administer them as
well.
- You may use oxycodone sublingually 1-20mg every 1-2hours AS
NEEDED for pain or shortness of breath
.
Thank you for allowing us to participate in your care Ms. [**Known lastname **] [**Last Name (Titles) 106528**]q.
Followup Instructions:
You have scheduled follow up appointments in the [**Hospital1 18**] system.
In the event that you will continue with hospice care, you
should cancel these appointments at your leisure.
.
Department: CARDIAC SERVICES
When: WEDNESDAY [**2199-10-30**] at 8:00 AM
With: [**First Name8 (NamePattern2) 2890**] [**Last Name (NamePattern1) 2889**], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: NUTRITION
When: WEDNESDAY [**2199-10-30**] at 9:00 AM
With: LIPID NUTRITIONIST [**Telephone/Fax (1) 2207**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.4",
"428.33",
"276.7",
"403.90",
"V10.3",
"428.0",
"584.9",
"365.9",
"250.00",
"518.0",
"272.4",
"285.21",
"272.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7237, 7315
|
4169, 6257
|
271, 275
|
7579, 7579
|
2854, 4146
|
9702, 10482
|
1939, 2110
|
6545, 7214
|
7336, 7558
|
6283, 6522
|
7792, 9679
|
2125, 2835
|
1475, 1507
|
224, 233
|
303, 1456
|
7594, 7768
|
1529, 1670
|
1686, 1923
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,428
| 100,459
|
49380
|
Discharge summary
|
report
|
Admission Date: [**2108-1-25**] Discharge Date: [**2108-1-25**]
Date of Birth: [**2024-10-13**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
N/V/D, abdominal pain
Major Surgical or Invasive Procedure:
-central venous line, intubation
-CPR times 2
History of Present Illness:
This is an 83 year old female with PMH of HTN, chronic kidney
injury with baseline Cr=1.7-2, hyperlipidemia, hypothyroidism,
and osteoporosis presenting with 3-4 days of N/V/D and abdominal
pain. She was reportedly caring for her disabled brother in his
70s who also has gastroenteritis. She was found by EMS earlier
today with SBP in the 70s and was reportedly very dry and unable
to take POs. She reported no fevers or chills, but did endorse
non-bloody emesis and diarrhea.
.
In the ED, initial VS were not recorded, but she was reportedly
hypotensive to the 70s which responded to systolic in the 100s
after 4L of IVFs. Her WBC count was 14.1 and her initial
lactate was 5 which trended down to 2.1 after fluid
resuscitation. She was empirically treated with Cipro and
Flagyl. A right IJ central line was placed for the initial
resuscitation. CXR showed mild pulmonary vascular congestion.
SVO2=48 and her CVP was [**10-2**] after 3L of IVFs. Given the
concern for cardiogenic shock, a bedside ECHO was attempted by
the ED which showed a dilated right ventricle. She was guaiac
negative and the concern for PE was high given these findings so
she was empirically started on a heparin drip since her Cr=1.7
and the goal was to avoid a dye load for a CTA. Cardiology
fellow was consulted for bedside ECHO, but had poor windows and
during ECHO at around 12:30AM the patient had an acute change in
mental status complaining of sudden onset abdominal pain and
reported feeling as though she was going to die. She then
vagaled down to a HR in the 30s and dropped her blood pressures,
but reportedly did not lose consciousness. She was started on
dopamine which was soon maxed out and Levophed was added as
well. She was then intubated, given 4.5 grams of Zosyn, and a
CTA torso was obtained. No PE was seen, but diffuse bowel wall
edema was noted and surgery was consulted for this. Of note,
she had several failed attempts at a right femoral and left
radial A-lines on heparin with a lot of bleeding at the leg
site. Protamine was given to reverse the heparin. Transfer VS:
BP=155/120, HR=137, RR=22, 100% on vent of FiO2 95%, PEEP 5 on
dopa of 10 and levophed alone at 0.3 mcg.
.
On arrival to the MICU, patient was intubated/sedated. Social
work was consulted in the ED. She is the sole caretaker for her
younger 73 year old disabled brother who also has
gastroenteritis and is also in the ED. She has no other family.
Past Medical History:
Past Medical History:
-HTN
-Chronic kidney injury with baseline Cr=1.7-2
-Hypothyroidism
-Hyperlipidemia
-Osteoporosis
-h/o Non Hodgkins lymphoma in remission since [**2096**]
-h/o NSVT
-Remote history of endometrial cancer s/p chemo and radiation
-Severe scoliosis
.
Past Surgical History:
-s/p left radius/right humerus fractures in [**2070**]
-s/p TAHBSO and radiation for endometrial CA in [**2072**]
-s/p hip surgery [**2106**]
Social History:
She has been living with her stepbrother in a historic
brownstone on [**Doctor First Name **] street, which is the home she grew up in.
Occupation: worked as a researcher in radiation therapy at the
VA before she retired at 48 after she was diagnosed with
endometrial cancer. No smoking. No alcohol.
Family History:
Non-contributory
Physical Exam:
General: Intubated, sedated
HEENT: Sclera anicteric, dry MM, PERRL but sluggish
Neck: supple
CV: Tachycardic
Lungs: Clear to auscultation anteriorly
Abdomen: soft, non-distended, bowel sounds present
GU: Foley
Ext: warm, no clubbing or edema, massive right thigh hematoma
Neuro: intubated/sedated
Pertinent Results:
CTA abdomen/pelvis:
1. Active arterial extravasation in the right proximal medial
thigh, likely related to recent arterial puncture.
2. Right portal vein thrombus with hypoenhancement of the right
lobe of the liver. Differential diagnosis includes low-flow
state, hypercoagulability, and tumor.
3. Pericholecystic fluid, which could be secondary to recent
volume
resuscitation, but cholecystitis is also a possibility. Further
evaluation is recommended with ultrasound.
4. Heterogeneous enhancement of the right kidney, which could be
secondary to infection or low-flow state.
5. Bowel wall edema and mucosal hyperenhancement suggestive of
recent
hypoperfusion.
6. Non-acute findings: chronic-appearing severe left
hydroureteronephrosis, ascending aortic dilation, colonic
diverticulosis, mid-thoracic vertebra plana.
Brief Hospital Course:
This is an 83 year old female with PMH of HTN, chronic kidney
injury with baseline Cr=1.7-2, hyperlipidemia, hypothyroidism,
osteoporosis, and remote history of endometrial cancer and
Non-Hodgkin's lymphoma presenting with 3-4 days of N/V/D and
abdominal pain with ED course complicated by PEA arrest
requiring a round of CPR.
.
She was brought to the ED for further evaluation of N/V/D and
abdominal pain. She was markedly hypovolemic and hypotensive to
the 70s which initially responded to 4L IVFs. She was given
empiric abx and thought to be in cardiogenic shock. She then
developed severe abdominal pain and change in mental status.
Shortly thereafter, she vagaled down to the 30s and dropped her
blood pressures. She was intubated and central line was place.
Two pressors were started. She received one round of CPR in the
ED with return of spontaneous circulation. Unfortunately, she
passed away after 10 minutes of CPR upon admission to the ICU
for PEA arrest.
Medications on Admission:
-Atenolol 12.5mg daily
-Levothyroxine 88mcg daily
-Pravastatin 40mg at bedtime
-Calcium/vitamin D
Discharge Medications:
patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
patient expired
Discharge Condition:
patient expired
Discharge Instructions:
patient expired
Followup Instructions:
patient expired
|
[
"403.90",
"585.9",
"785.59",
"244.9",
"202.80",
"427.5",
"737.30",
"518.81",
"733.00",
"272.4",
"V10.42",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
5996, 6005
|
4832, 5807
|
327, 374
|
6064, 6081
|
3988, 4809
|
6145, 6163
|
3636, 3655
|
5956, 5973
|
6026, 6043
|
5833, 5933
|
6105, 6122
|
3156, 3300
|
3670, 3969
|
266, 289
|
402, 2843
|
2887, 3133
|
3316, 3620
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,255
| 136,657
|
6124
|
Discharge summary
|
report
|
Admission Date: [**2138-9-1**] Discharge Date: [**2138-9-7**]
Date of Birth: [**2062-1-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Fatigue, shortness of breath, cough
Major Surgical or Invasive Procedure:
dual chamber ICD placement
History of Present Illness:
HPI: 76 y/o man w/ a PMH of CAD (s/p stenting in '[**36**]), HTN, DM,
and hypercholesterolemia who presented w/ a several day hx of
fatigue, productive cough, and orthopnea. He also had poor PO
intake, mild hematemesis, melena, and epigastric pain during
this time period. It is unclear as to whether his hematemesis
is a primary GI problem or secondary to swallowing bloody
sputum. The pt denies current CP but says that he has been
having intermittant episodes of CP "since [**Holiday 1451**]". He
says that his breathing has gotten better since arriving on the
floor. He has not had any recent fevers, diarrhea, dizziness,
palpatations, or HA.
.
In the ER his EKG revealed a ventricular rate in the high 30s w/
2nd degree Mobitz block type II (3:1 conduction) in the context
of a LBBB. He hypertension and HR did not respond to atropine or
carotid massage and he was taken to the EP lab for placement of
a dual chambered ICD. He tolerated this procedure well and was
transfered to the CCU for diuresis for a possible CHF flare. He
was also sent for nitro gtt control of his hypertension.
Past Medical History:
1. diabetes mellitus
2. hypertension
3. Hypercholesterolemia
4. CAD s/p PCI in [**2134**], [**2136**] - stent to RCA and LCx
6. s/p appy
7. s/p hernia repair
8. h/o GIB - noted blood in his stools, has never had
colonoscopy
9. tinea versicolor
10. BPH
11. aortic ulcers discovered on CT in '[**38**]
12. CHF w/ EF of 20-25%
Social History:
nonsmoker, of Carribean origin, returns frequently to winter in
Barbados. Lives with daughter and wife in [**Name (NI) 1468**]. Just
returned from Barbados this saturday.
Family History:
no CAD
Physical Exam:
PE: 99.2, 151/89, 122 (V paced), 100% on 100%O2
Gen: Well appearing man, speaking in full sentences
HEENT: EOMI, MMM
Neck: +JVD to 8cm
CV: bradycardic regular rhythm, S1/S2 intact, -M/R/G appreciated
Lungs: inspiratory crackles b/l R>L
Abd: S/NT/ND, +BS, -HSM appreciated
Groin: -oozing/hematoma/bruit at the groin
Ext: -C/C, trace edema b/l R>L, peripheral pulses 1+ in the LE
Pertinent Results:
[**2138-9-1**] 08:22PM GLUCOSE-297* UREA N-31* CREAT-1.3* SODIUM-141
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
[**2138-9-1**] 08:22PM ALT(SGPT)-75* AST(SGOT)-39 LD(LDH)-292* ALK
PHOS-64 AMYLASE-52 TOT BILI-2.5* DIR BILI-0.7* INDIR BIL-1.8
[**2138-9-1**] 08:22PM LIPASE-21
[**2138-9-1**] 08:22PM ALBUMIN-3.8 CALCIUM-8.6 PHOSPHATE-3.3
MAGNESIUM-1.9 URIC ACID-7.8*
[**2138-9-1**] 08:22PM HCT-38.8*
[**2138-9-1**] 08:22PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2138-9-1**] 08:22PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2138-9-1**] 08:22PM URINE RBC->50 WBC-[**4-5**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2138-9-1**] 08:22PM URINE GRANULAR-0-2 COARSE & FINE GRANULAR
CASTS HYALINE-[**4-5**]*
[**2138-9-1**] 07:54PM TYPE-ART PO2-91 PCO2-38 PH-7.39 TOTAL CO2-24
BASE XS--1
[**2138-9-1**] 04:15PM GLUCOSE-266* UREA N-32* CREAT-1.4* SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-27 ANION GAP-12
[**2138-9-1**] 04:15PM MAGNESIUM-2.0 URIC ACID-7.5*
[**2138-9-1**] 04:15PM WBC-11.8*# RBC-4.34* HGB-11.4* HCT-34.6*
MCV-80* MCH-26.2* MCHC-32.9 RDW-13.8
[**2138-9-1**] 04:15PM PLT SMR-LOW PLT COUNT-132*
[**2138-9-1**] 04:15PM PT-13.9* INR(PT)-1.3
.
ECHO ([**2138-7-1**])
Conclusions:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is severe global
left ventricular hypokinesis. No masses or thrombi are seen in
the left ventricle. 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
structurally normal. There is no mitral valve prolapse. Moderate
(2+) mitral regurgitation is seen. There is mild pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the report of the prior study (tape unavailable
for review) of [**2136-7-27**], left ventricular cavity size is
smaller, but global systolic function is more depressed. The
severity of mitral regurgitation is minimally increased and mild
pulmonary artery systolic hypertension is now identified.
.
MIBI ([**2138-7-1**])
IMPRESSION: 1. Reversible, mild myocardial perfusion defects
involving the septum and apex at the level of exercise achieved.
2. Transit ischemic dilatation with EF of 29% raises the
possibility of more extensive perfusion abnormalities than
suggested by the relatively mild asymmetries in uptake.
Brief Hospital Course:
A/P: Pt is a 76 y/o man w/ a PMH of CAD (s/p stenting in '[**36**]),
HTN, DM, and hypercholesterolemia who presented w/ a several day
hx of fatigue, productive cough, and orthopnea. On further ROS,
he noted hemotypsis and weight loss over the past few months.
He received a dual chamber ICD in the EP lab for his heart block
and was transfered to the CCU for management of his CHF and HTN.
His hctz was d/c and he was started on lasix. He diuresed well
on this regimen and his SOB improved markedly throughout his
course. His HTN was controlled initally through nitro drip.
However, this was d/c on the 1st post-op day and his htn was
then controlled by titrating his captopril to 50tid and his
metoprolol xl to 50qd. He did well with these medications. His
initial Cxr was significant for chf and a questionable
infiltrate and he was started on renally dosed levoquin for
possilbe pna. As his CHF cleared, a LLL infiltrate was seen on
CXR and flagyl was added to cover possible aspiration pna. He
ran a low grade fever on the 2nd post-op day but defervesed w/
continued abx. His cx have all been negative to date. Because
of his travel hx and possible exposure, a ppd was placed and a
blood smear was performed and both were negative.
.
1. SOB - pt w/ a several day hx of SOB and fatigue, seen to be
in high degree block in the ER requiring ICD placement. pt also
w/ productive cough, cxr c/w pna, and wbc=12.8 during this time.
sob likely due to either an acute chf flare in the context of
his heart block or pneumonia
* cxr/cough/wbc c/w pna
-continue levoquin/flagyl
-follow fever curve and cbc -> pt has been afebrile since [**9-5**]
-CXR w/ new LLL infiltrate
-flagyl added for aspiration bugs
-blood smear negative
-ppd negative
* chf flare in setting of heart block and chronic CHF also
possible
-diurese in the CCU to a goal of negative 1-2L/day (euvolemic
last
night
-pt has diuresed well throughout admission
-d/c home on lasix 40mg po qd
.
2. Heart block - pt presented w/ a 2nd degree type 2 block w/
3-to-1 conduction and hypertension. he received a dual chamber
ICD and had been persistently hypertensive in the ccu but is
well controlled now
* f/u w/ EP as an outpatient at device clinic
.
3. HTN - pt persistently hypertensive in the ER and after his
ICD intervention despite atropine and carotid massage
* pt's bp well controlled now on his meds
* f/u w/ dr. [**Last Name (STitle) **] as an outpt
.
4. Abdominal pain/emesis - pt w/ hx of RUQ pain and emesis along
w/ decreased PO intake
* pt w/ guaiac positive stools and report of hematemesis
-pt w/out episodes of emesis since admission and tb test
negative
-outpt colonoscopy
* protonix as an outpatient
* diabetic diet as tolerated
.
5. DM - pt controlled at home on metformin monotherapy
* diabetic diet
* finger sticks qac
* continue home metformin
.
6. Hypercholesterolemia
* pravachol
.
7. Code
* Full
.
8. Dispo
* to home
Medications on Admission:
GLUCOPHAGE 1000MG--One by mouth every morning
HYDROCHLOROTHIAZIDE 25MG--One tablet daily.
NITROGLYCERIN 0.3MG--One under the tongue as needed for chest
pain; may repeat q5 minutes
PLAVIX 75MG--One by mouth every day
RAMIPRIL 10MG--2 by mouth every day
TOPROL XL 12.5MG--One by mouth every day
PRAVACHOL 40MG--One by mouth every day per cardiology
Discharge Medications:
1. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
2. Pravastatin Sodium 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
4. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
5. Ramipril 5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).
6. Metformin 500 mg Tablet Sustained Release 24HR Sig: Two (2)
Tablet Sustained Release 24HR PO DAILY (Daily).
7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Keflex 250 mg Capsule Sig: One (1) Capsule PO four times a
day for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
10. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual q5minutes prn chest pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Heart block, chf
Discharge Condition:
stable
Discharge Instructions:
Please take all your medications as directed.
Please keep your follow-up appointments.
Please call you PCP/go to the ER for:
1. chest pain
2. shortness of breath
3. fever to 101
4. redness/oozing from the ICD site
5. your icd shocks you
Followup Instructions:
1)We made an appointment for you to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 766**],
[**2138-9-8**] at 2pm.
2)Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC
SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2138-9-9**] 11:30
Completed by:[**2138-9-7**]
|
[
"401.9",
"786.3",
"792.1",
"V45.82",
"250.00",
"414.01",
"426.12",
"786.59",
"272.0",
"486",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.49",
"37.94"
] |
icd9pcs
|
[
[
[]
]
] |
9410, 9416
|
4991, 7945
|
347, 375
|
9477, 9485
|
2477, 4968
|
9770, 10090
|
2056, 2064
|
8342, 9387
|
9437, 9456
|
7971, 8319
|
9509, 9747
|
2079, 2458
|
272, 309
|
403, 1502
|
1524, 1849
|
1865, 2040
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
745
| 105,324
|
4859
|
Discharge summary
|
report
|
Admission Date: [**2203-10-17**] Discharge Date: [**2203-11-7**]
Date of Birth: [**2142-6-14**] Sex: M
Service: MEDICINE
Allergies:
Sulfamethoxazole/Trimethoprim / Aspirin
Attending:[**First Name3 (LF) 3624**]
Chief Complaint:
Transfer to [**Hospital1 18**] for PEG placement
Major Surgical or Invasive Procedure:
Placement of left subclavian central line (removed), and right
internal jugular central line (removed)
Right sided thoracentesis for pleural effusions
History of Present Illness:
61 year-old male with longstanding DM type 1 with triopathy,
status post CRT [**2196**] (baseline creat 2.9-3.0 in [**3-/2203**]),
recurrent UTIs with MDR organisms, history of MRSA sepsis/osteo,
initially transferred on [**10-17**] from [**Hospital3 2737**] for PEG
placement.
*
He was originally admitted to [**Hospital1 **] on [**2203-10-4**] with mental
status changes. His w/u was remarkable for VRE UTI (only 1000
colonies) and a LLL pneumonia. He was initially started on
Cefepime, changed to Imipenem and Flagyl. A repeat urine culture
grew Burkholderia cepacia sensitive to Zosyn, and Zosyn therapy
was initiated on [**10-12**]. Blood cx negative. A follow-up CXR
showed resolution of his LLL pneumonia. A tagged WBC scan was
also performed and negative for infection. He remained
disoriented despite treatment of his infection, and he was felt
to be continually scratching his left biceps and having facial
twitching. Neurology was consulted. Head CT showed mild atrophy
but was otherwise negative. MRI showed marked atrophy, as well
as subtle changes in the posterior limb of the internal capsule
that could possibly represent small subacute punctate infarcts.
EEG was requested, but deferred [**12-29**] "scheduling difficulties".
Per neurology, Mr. [**Known lastname 1001**] was loaded with Dilantin for possible
seizure activity, with some subsequent improvement in his mental
status.
*
Still at the OSH, his Hct on admission was noted to be 25, and
he was transfused 2 units of PRBCs. He failed a bedside swallow
evaluation, and a barium swallow showed evidence of penetration
and aspiration. An NGT was placed. The patient reportedly did
not want a PEG tube, but was deemed incompetent to make
decisions by psychiatry. While in the hospital, he was begun on
Risperdal and Celexa was increased.
*
On the day of transfer ([**10-17**]), his lab work was remarkable for
a HCO3 drop 20-->15, with development of an anion gap acidosis.
He was started on IVF with dextrose, and given 1 amp of sodium
bicarbonate. On arrival to [**Hospital1 18**], he was hemodynamically
stable. However, his initial lab work was remarkable for an
anion gap of 22, with HCO3 of 9, glucose of 362. ABG done
7.23/22/50 (?arterial). U/A positive for ketones. Of note,
standing insulin had been held at outside hospital. He was
given insulin SC X few doses, then started on insulin drip on
the floor on [**10-18**], along with IVF, with eventual closure of his
gap. Coincident with the metabolic derangements, however, he was
noted to have declining mental status (responsive only to pain
at time of transfer), and he was transferred to the MICU for
further care.
*
In the MICU, he was continued on the insulin drip overnight,
discontinued on [**10-19**] at 1000 after overlap with NPH. AG closed.
[**Last Name (un) **] consulted, with recommendation to start Lantus. Regarding
his mental status, neurology was consulted. LP was performed
with OP 9, WBC 4, RBC 0, TP 93, Gluc 145, gram stain negative,
cryptococcal antigen negative, cultures pending. He was loaded
with Dilantin on [**10-18**] at night pending EEG on [**10-19**].
Preliminary report negative for seizure activity. Per neurology,
Dilantin was tapered off.
Past Medical History:
1. DM type 1 with triopathy
2. Status post cadaveric renal transplant in [**2196**]
3. Chronic renal insufficiency with baseline creatinine 2.9-3.0
in [**3-/2203**]
4. Peripheral neuropathy
6. Hypertension
7. CAD, LVEF >55% in [**3-/2203**]
8. GERD
9. Hypercholesterolemia
10. History of MRSA osteomyelitis/sepsis
11. History of recurrent UTIs with MDR organisms
*
Other past surgical history:
Status post right THR
Status post left BKA
Status post open chlecystectomy
Social History:
Widowed, ex-meat cutter, no TOB, no ETOH, no IVDU
Family History:
Mother with DM and PM and Father with PM
Physical Exam:
VITALS: Tm 99.2, Tc 98.9, HR 60s-70s, BP 120-170/50-60s, RR high
teens to low 20s, Sat 98-100% on RA.
I/O: + 450 last 24 hours, then + 1700 cc today
GEN: Caucasian male, in NAD. Answers questions, recognizes his
name, not oriented to place or time. Makes eye contact.
[**Name (NI) 4459**]: Pupils sluggish, reactive. Dry MM.
NECK: No cervical LN.
RESP: Limited examination, clear anteriorly.
CVS: RRR. Normal S1, S2.
GI: BS +. Soft, non-tender.
EXT: 2+ pedal edema RLE. Left BKA.
NEURO: Moves all 4 extremities.
Pertinent Results:
Micro:
[**2203-10-19**] BLOOD CULTURE x2 negative
[**2203-10-19**] CSF SPINAL FLUID GS negative, cultures negative
[**2203-10-19**] CSF CRYPTOCOCCAL ANTIGEN negative
[**2203-10-18**] BLOOD CULTURE x 4 bottles negative
*
Labs:
[**10-25**] Trop 0.14
[**10-26**] Trop 0.16 CK-MB 2
[**10-26**] Trop 0.16
[**10-27**] Trop 0.20
Relevant imaging studies:
OSH:
CXR [**10-4**] with LLL pneumonia, resolved on CXR [**10-10**]
Tagged WBC scan negative
CT head: Atrophy, no focal disease
MRI head: MArked atrophic changes, possible subacute punctate
infarcts.
*
[**Hospital1 18**]:
[**10-18**] CXR: Probable bibasilar pneumonia
[**10-18**] Renal transplant U/S: Normal
[**10-19**] CT head: No intracranial hemorrhage. No major vascular
territorial infarction.
[**10-19**] EEG: Bursts of generalized slowing consistent with
encephalopathy. .
[**10-20**] MRI with gadolinium, stroke protocol: Mild-to-moderate
brain atrophy and a chronic lacune in the posterior limb of the
left internal capsule unchanged from the previous MRI of [**2202-3-31**].
There are no MRI signs of posterior encephalopathy seen. No mass
effect or hydrocephalus noted. No acute infarcts are seen.
[**10-24**] EGD: Gastric antrum, mucosal biopsy - negative for H.
pylori
[**10-27**] CT sinuses: No air-fluid levels to suggest acute
sinusitis. Mild mucosal thickening in the paranasal sinuses, as
described.
[**10-28**] V/Q Scan: Indeterminate lung scan. There are bilateral
areas of decreased perfusion within the lung bases,
asymmetrically with a larger defect on the right. Although the
pattern of this perfusion could be explained by bilateral
pleural effusion, in the face of these abnormalities, it is
difficult to exclude a pulmonary embolism.
[**10-31**] CT Chest without contrast: 1. Large bilateral pleural
effusions with associated compressive atelectasis that are
little changed when compared to [**2202-4-18**]. Otherwise, clear
lungs. 2. Slightly dilated esophagus 3. Dilatation of the
extrahepatic biliary system with a probable calcified filling
defect in the distal common duct. Clinical correlation is
advised.
Brief Hospital Course:
ASSESSMENT AND PLAN: 61 yo male with longstanding DM type 1 with
triopathy, s/p CRT in [**2196**] on immunosuppression, transferred
from OSH with UTI, change in mental status, in DKA. DKA
resolved. Also being anticoagulated for left DVT, likely PE.
Moderate to large pleural effusions bilaterally s/p right
thoracentesis. Pt has had chronic complaints of chest pain x >1
month, with negative work-ups, pain likely due to combination of
costochondritis plus possible PE. Pt also with UGIB,
esophagitis, duodenitis, duodenal ulcer not actively bleeding,
and Hct stable on anticoagulation. Treated for UTI with Zosyn,
however, pt found to have new UTI during admission with fever,
which was treated w/ Meropenem.
*
1) PE/DVT/Chest pain:
- Pt complaining of chest pain which he reports to have had for
greater than 1 month, pleuritic or with exertion. EKGs showed
no changes from baseline, no ischemic changes. He had elevated
cardiac enzymes, which were felt to be secondary to his poor
renal clearance in addition to possible demand ischemia as they
were drawn during a period of anemia/UGIB. He had lower
extremity dopplers which were positive for DVT in left
superficial femoral vein, extending to beginning of popliteal.
A V/Q scan was performed as the pt was unable to have a CTA due
to his renal status; however, the study was suboptimal, unable
to perform ventilation portion of study - on perfusion scan,
unable to visualize bases [**12-29**] bilateral pleural effusions,
therefore unable to r/o PE's. The pt was started on Heparin;
Coumadin was started [**11-1**] at 3 mg, then increased to 5 mg to
reach therapeutic INR of 1.7.
- The patient also had bilateral pleural effusions which were
present on chest CT's from a year ago. On [**2203-11-1**], an
ultrasound guided thoracentesis of right pleural effusion was
performed, 1.2L was removed. Pleural fluid showed no PMN's or
organisms, LDH ratio indicative of transudative process, pleural
cx's NEGATIVE bacteria, fungus, AFB smear, and cytology NEGATIVE
for malignancy.
- Pt also had reproducible CP on palpation over sternum,
possible costochondritis. Rib Xray [**10-31**] negative for fracture.
*
2) ID: The patient completed 2 week course of Zosyn for UTI as
described above on [**10-22**]. However, the pt subsequently became
febrile [**10-25**] accompanied by change in mental status, increased
WBC - now has been afebrile with much improved mental status and
decreasing WBC. Broad spectrum abx started [**10-27**], with
Vancomycin renally dosed (discontinued) and Zosyn; however,
[**10-26**] Urine Cx results + for non-fermenter not pseudomonas,
intermediate sensitivity to Zosyn, sensitive to Meropenem.
Ruled out for PNA, sinusitis, C. diff, line infection. Zosyn was
therefore discontinued, and pt was treated with Meropenem 500
[**Hospital1 **] IV x7 days, completed [**11-7**]. The patient also had yeast on
UA/UCx, and was started on Fluconazole [**11-5**] x ~10 day course.
The pt was subsequently afebrile with normal WBC, stable mental
status.
.
ID Work-up:
- Central line d/c'd [**10-27**], placed [**10-18**]; new RIJ placed [**10-26**].
- C.diff negative [**10-26**] - diarrhea, likely from GI blood.
- Blood cultures 11/22, 23 negative
- [**10-25**] KUB: No free air or obstruction
- [**10-27**] CXR: Small bilateral pleural effusions
- [**10-27**] CT Sinuses: No acute sinusitis; some paranasal sinus
thickening
- [**10-27**] Catheter tip: NO SIGNIFICANT GROWTH
- [**10-25**], 30 Blood cultures NO GROWTH
*
3) GI: Upper GI bleed coffee ground emesis [**10-22**], and again on
[**10-25**], requiring transfusions of PRBC's, total 4 units. EGD was
performed [**10-24**], and showed esophagitis, duodenitis, duodenal
ulcer, no active bleeding. An NGT was placed for gastric
decompression, d/c'd [**10-27**]. Hct stable on anticoagulation.
[**10-24**] EGD Biopsy negative for H. Pylori, Protonix PO BID,
Sucralfate QID.
- The pt also developed fleeting RUQ pain. Incidental finding
on chest CT [**10-31**], showed dilatation of the extrahepatic biliary
system with a calcific density in the expected location of the
distal common duct. RUQ resolved, LFT's and bilirubin normal
except for increased Alk Phos ([**10-18**] 208, [**11-3**] 439, [**11-4**] 452).
The pt may have some common bile duct stone/obstruction, given
CT finding, however, he has declined ERCP despite discussing
possibility for progression to infection.
*
4) DM type 1/DKA:
- DKA resolved. Basal insulin had been held at OSH (transferred
only on RISS). Pt's blood sugar was quite labile, fluctuating
depending upon PO status, infectious states, and had period of
both low FSG's to 30's necessitating D50, as well as
hyperglycemia to 477. He had FSG's checked qACHS, and at 3AM.
His current regimen includes Glargine 18 u at NOON daily, as
well as sliding scale included.
*
5) Delta MS:
- The pt had an extensive work-up for initial changes in mental
status, including an EEG which showed no epileptiform activity,
LP with elevated protein and glucose, no evidence of infection,
normal OP, negative cultures, negative for CMV, [**Male First Name (un) 2326**] Virus, VZV.
MRI showed mild-to-moderate brain atrophy and a chronic lacune
in the
posterior limb of the left internal capsule unchanged from the
previous MRI of [**2202-3-31**], no MRI signs of posterior encephalopathy
seen, no mass effect or hydrocephalus noted, no acute infarcts.
- The pt's mental status changes were attributed to combination
of acute infection as well as hyperglycemia/DKA. He
demonstrates mental status deterioration when febrile or
infected, and when blood sugars are either elevated or low. The
pt now at his new baseline, is awake and alert, speaking
fluently, and cooperative with exam.
*
6) S/p renal transplant:
- The pt's immunosuppresion regimen was adjusted several times
during course of admission. Regimen on discharge includes:
** Tacrolimus 1.5 mg [**Hospital1 **]
** Sirolimus 2 mg MWF, 1 mg TThSaSun
** Prednisone 4 mg qd
- The pt's Cr slightly increased during admission to peak of
2.9. This may have been in the context of taking sublingual
Tacrolimus while NPO, which per pharmacy causes greater
bioavailability of drug and possible renal effect. Cr
subsequently decreased to 2.6. Medications were adjusted for
CrCl <30.
*
7) Heme/Anemia: Upper GI bleed, plus anemia of chronic disease.
Hct decreased acutely in context of coffee ground emesis, with
Hct down to low of 20; received 1 unit PRBC's [**10-22**] after
initial GIB, and an additional 3 units [**10-26**]. Pt was on Epogen,
decreased steadily from 8000 units 3X/week to [**2197**] units
3x/week. Hct remained stable for the last several weeks of
admission, even while therapeutic on anticoagulation. Last Hct
prior to discharge was 36.2
*
8) FEN:
- Pt was initially NPO while he had initial mental status
changes. However, after treatment for DKA/hyperglycemia and
infections, he passed a bedside speech and swallow with no
aspiration, was allowed to commence PO diet.
*
9) CV: Patient with HTN, CAD.
-Pt had elevated blood pressures during last few weeks of
admission. Hydralazine had been d/c'd [**10-26**] and amlodipine
decreased to 5 qd in context of GI bleed and anemia. However,
amlodipine was increased back to 10 as pt subsequently
hypertensive. Lasix 20 mg qd was also started [**11-3**] secondary to
HTN
*
10) DERM: The pt was seen by dermatology for a scaling plaque,
possible squamous cell CA on left temple. Will need to schedule
excisional biopsy as outpatient in derm clinic [**Telephone/Fax (1) 1971**].
*
11) Psych: Pt seen by psych consult [**10-31**] for possible
depression, no active suicidal ideation, but expressed desire to
not pursue major interventions to prolong life; he is not
denying any specific procedures at this time. Per psychiatry,
pt does not appear to be suicidal, and his wishes to limit
invasive procedures is reasonable. Celexa increased to 30 mg
qd.
*
12) PT/OT: Evaluated by PT/OT during admission, rehab
recommmended for ambulation and mobilization given left BKA,
deconditioning.
Medications on Admission:
MEDS on admission to OSH (presumed)
Feosol 325 mg daily, Colace 100 mg daily, Senokot 1 tab qhs,
Flomax 0.4 mg qhd, Reglan 10 mg PO BID, Lopressor 75 mg twice
daily, Norvasc 10 mg daily, Plavix 75 mg daily, Nexium 40 mg
daily, Celexa 10 mg daily, Lasix 20 mg IV daily, Hydralazine 10
mg PO q6hours, Cefepime 1 gm IV daily, Prednisone 5 mg daily,
MVI daily, Tacrolimus 0.5 mg [**Hospital1 **], Heparin 5000 units SC BID
Humulin N 10 units qam, 5 units qhs
*
MEDS at time of transfer:
Rapamune 3 tabs 1 mg PO daily
Protonix 40 mg IV daily
Tacrolimmus 0.5 mg PO BID
Dilantin 300 mg PO qhs
Norvasc 10 mg PO QD
Zosyn 2.25 gm IV q6 hours (day 6 on transfer)
Lopressor 125 mg PO BID
Celexa 20 mg daily
Risperidone 0.5 mg PO BID
RISS
*
Current meds in MICU:
Metoprolol 75 mg PO BID
Pantoprazole 40 mg IV Q24H
Amlodipine 10 mg PO DAILY
Citalopram Hydrobromide 20 mg PO DAILY
Phenytoin 100 mg IV Q12H for 2 days, then 100 mg IV daily for 2
days
Daptomycin 300 mg IV Q48H day 2
Piperacillin-Tazobactam Na 2.25 gm IV Q6H
Docusate Sodium (Liquid) 100 mg PO BID
Epoetin Alfa 4000 UNIT SC QMOWEFR Start: HS
Senna 2 TAB PO BID:PRN
Folic Acid 1 mg IV DAILY
Sirolimus 3 mg PO DAILY
Heparin 5000 UNIT SC TID
Tacrolimus 1 mg PO BID renal transplant
Thiamine HCl 100 mg IV DAILY
Insulin SC
Glargine 10 units qhs (to receive first dose tonight)
*
Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
2. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Therapeutic Multivitamin Liquid Sig: One (1) Cap PO DAILY
(Daily).
5. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed for 1 weeks.
7. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
8. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily).
9. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
hold for SBP <110.
10. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed: please give 1/2 hr prior to PT.
11. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain.
14. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 1 weeks: perianal area.
15. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
16. Sirolimus 1 mg Tablet Sig: Two (2) Tablet PO QMOWEFR (Monday
-Wednesday-Friday).
17. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO QTUTHSA
([**Doctor First Name **],TU,TH,SA).
18. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
19. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
20. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 1 weeks.
21. Insulin Glargine 100 unit/mL Solution Sig: One (1)
Subcutaneous once a day: 18 units Glargine at NOON daily.
22. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
23. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day) as needed.
24. Outpatient Lab Work
Please check Tacrolimus and Sirolimus levels q3 days, please
send results to transplant center at [**Telephone/Fax (1) 20303**] or
[**Telephone/Fax (1) 673**].
25. Outpatient Lab Work
Please check coags/INR twice weekly, and adjust Coumadin level
accordingly.
26. Epoetin Alfa 2,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday): [**2197**] u MWF.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 20304**] Rehabilitation & Nursing Center - [**Location (un) 2498**]
Discharge Diagnosis:
Type I diabetes, cadaveric renal transplant, left DVT/?PE on
anticoagulation, pleural effusions, upper GI bleeds (resolved)
from esophagitis/duodenitis/duodenal ulcer, UTI and yeast in
urine
Discharge Condition:
Stable
Discharge Instructions:
Please continue taking your medications as written. Please call
your physician if you have any worsened chest pain, shortness of
breath, palpitations, cough, fever, urinary symptoms, vomiting
blood/"coffee ground" material, lightheadedness/dizziness,
confusion, other worrisome symptoms
Followup Instructions:
Please call Dr. [**Location (un) 20305**] for follow-up appointment once
discharged from Wedgemere [**Telephone/Fax (1) 20306**].
You will need your blood levels of Tacrolimus and Rapamycin
drawn every 3rd day, and results sent to Tranplant Center -
[**Telephone/Fax (3) 20307**]
Please call for an appointment to be seen in [**Hospital 2652**] clinic
after discharge from Wedgemere, for biopsy of lesion on left
temple, [**Telephone/Fax (1) 1971**]
[**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]
Completed by:[**2203-11-7**]
|
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icd9cm
|
[
[
[]
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4,631
| 157,501
|
10526
|
Discharge summary
|
report
|
Admission Date: [**2197-12-24**] Discharge Date: [**2197-12-27**]
Date of Birth: [**2141-10-13**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
pancreatitis, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear
Major Surgical or Invasive Procedure:
EGD, epinephrine cautery of distal GE junction tear
History of Present Illness:
56 year old male with a history of HCV ([**3-15**] IVDU; last biopsy
[**5-/2196**] with portal fibrosis, no viral load or genotype on file),
chronic pancreatitis, alcoholism, CAD, presented initially on
[**12-24**] with abdominal pain, elevated lipase, consistent with
acute exacerbation of his chronic pancreatitis, secondary to
recent alcohol use. Of note, on admission, he reported one
episode sometime the week prior to admission of hematemesis
(coffee-grounds, dark brown). On day prior to admission, had
non-bilious, non-bloody vomitus x1, one episode of yellowish
diarrhea, no melena or hematochezia. He admitted to [**6-16**] drinks
day prior to admission, last drink at 6 PM on day prior to
admission. CT abdomen [**12-24**] demonstrated new 31 x 23mm soft
tissue density peripherally enhancing mass extending
superiorally off the pancreatic tail; Mild surrounding soft
tissue stranding c/w recurrent or residual pancreatitis;
cholelithiasis; fatty liver. He was placed on bowel rest, pain
control, CIWA scale for alcohol withdrawal. On day after
admission, had an episode of hematemesis (bright red blood and
clots), remained hemodynamically stable throughout, but was
transferred to MICU for emergent EGD, which demonstrated [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] tear with stigmata of recent bleed (clot). Hematocrit
remained stable at 35-40 throughout. The area of erythema and
bleeding was injected with epinephrine without residual bleed.
Subsequently, remained stable without further episodes of
hematemesis or fall in hematocrit. Per GI, will follow-up with
repeat abdominal CT on [**1-1**] for re-evaluation of suspected
pancreatic pseudocyst.
Past Medical History:
1.)ETOH abuse
2.)HCV
3.)Frequent episodes of pancreatitis related to etoh abuse
4.)CAD with [**2195**] MIBI showing mod partially reversible defect in
LAD region
5.)Osteoarthritis
6.)s/p colectomy for ?SBO/bowel perforation, done at [**Hospital1 112**]
Social History:
ETOH: 5 beers and 3 shots every night, Tob: 1/2ppd since age 16,
Drugs: +ivdu, none since [**60**], +cocaine and marijuana but none
since 7 months.
Family History:
Dad with ETOH cirrhosis, uncle with Diabetes, Mom with MI at 72.
Physical Exam:
Vitals: T: 98.1 P: 73 BP: 162/73 R: 16 O2 sat 98% on RA
Gen: fatigued male in NAD, NGT in place
HEENT: pink conjunctiva, sclerae anicteric, MM dry
Neck: no jvd
CV: RRR S1 S2.
Pulm: CTAB, crackles at bases that cleared with repeat
respirations.
Abd: +bs. Soft. TTP in epigastric region with mild voluntary
guarding, no rebound . Non-distended. Liver edge palpable at
3cm below costal margin.
Ext: WWP. No edema. 2+ DP/PT pulses bilaterally
Neuro: A&Ox3
Pertinent Results:
Abd CT [**12-24**]:
1. New 31 x 23 mm soft tissue density rim-enhancing mass
extending superiorly off the pancreatic tail. This most likley
represents a hemorrhagic pancreatic pseudocyst given the
patient's history of pancreatitis.
2. Mild surrounding soft tissue stranding consistent with
residual or recurrent inflammation.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Fatty liver.
[**2197-12-24**] 08:50PM WBC-6.0 RBC-3.95* HGB-12.0* HCT-35.8* MCV-91
MCH-30.3 MCHC-33.5 RDW-14.6
[**2197-12-24**] 08:50PM PLT COUNT-180
[**2197-12-24**] 11:10AM GLUCOSE-105 UREA N-11 CREAT-0.9 SODIUM-137
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
[**2197-12-24**] 11:10AM ALT(SGPT)-96* AST(SGOT)-122* ALK PHOS-126*
TOT BILI-0.8
[**2197-12-23**] 11:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2197-12-23**] 11:13PM URINE RBC-1 WBC-1 BACTERIA-RARE YEAST-NONE
EPI-1
[**2197-12-23**] 10:30AM ALT(SGPT)-108* AST(SGOT)-148* ALK PHOS-170*
AMYLASE-206* TOT BILI-0.6
[**2197-12-23**] 10:30AM LIPASE-82*
[**2197-12-23**] 10:30AM ALBUMIN-3.8 CALCIUM-9.1 PHOSPHATE-2.3*
MAGNESIUM-1.5* IRON-153
[**2197-12-23**] 10:30AM calTIBC-250 VIT B12-575 FOLATE-7.6
FERRITIN-1165* TRF-192*
[**2197-12-23**] 10:30AM ASA-5 ETHANOL-103* ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
Initial assessment: Patient was admitted for alcoholic
pancreatitis, which rapidly resolved, but hematemesis was
concerning for variceal hemorrhage versus peptic ulcer disease
versus [**Doctor First Name 329**] [**Doctor Last Name **] tear, given history of HCV and possible
cirrhosis. Abdomen remained supple after transfer from MICU to
floor, and no further nausea, vomiting, hematemesis. EGD
demonstrated evidence of [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, which was injected
with epinephrine and did not rebleed per stable hematocrit, lack
of pain.
.
1. Abdominal pain: Pancreatitis as etiology given symptoms,
similar presentation to past episodes and abdominal CT findings;
patient was placed on bowel rest, PPI, and rapidly advanced on
day 2 to clear liquids, but given hematemesis and EGD, diet was
intermittently held throughout course; on discharge, patient was
hungry without abdominal pain. Abdominal CT disclosed pancreatic
pseudocyst, which will be followed by GI with repeat CT scan on
[**1-5**]. Patient was re-EGD on day of discharge to confirm
pharmacologic cure of [**Doctor First Name 329**] [**Doctor Last Name **] tear, and will follow-up
with Dr. [**First Name (STitle) **] [**Name (STitle) **] in [**Hospital **] clinic for pseudocyst, pancreatitis,
HCV management. Pain was controlled with dilaudid, discharged on
limited course of percocet for pain control.
.
2. Substance abuse: Patient was placed on CIWA scale, aggressive
fluid replacement. Electrolytes were repleted as needed, for
refeeding syndrome. Thiamine and folate and MVI were
administered daily throughout. Beta-blockers were held for
hypertension throughout given positive urine toxicology screen
for cocaine, and risk of hypertensive emergency. However, blood
pressure on return from MICU remained at 130-140 throughout off
anti-hypertensives.
.
3. Cardiovascular: Depressed EF on prior ECHO was felt to be
progressive ischemic disease (cocaine-related accelerated
atherosclerosis) or dilated (secondary to alcohol, cocaine,
HCV). Did not receive stress test in this admission, and this
should be pursued as an outpatient. ASA was held given bleed,
and will be held on discharge.
.
3. Prophylaxis: On PPI throughout. Held anticoagulation for DVT
prophylaxis given bleed.
.
Patient was full code throughout.
Medications on Admission:
None
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours for 4 days.
Disp:*20 Tablet(s)* Refills:*0*
3. Radiology
Please perform and abdominal CT scan with contrast to assess the
pancreas 31x23 mm pancreatic tail mass (suspected hemorrhagic
pseudocyst at [**Hospital1 18**]). Please page Dr. [**First Name (STitle) **] [**Name (STitle) **] ([**Hospital1 18**],
Gastroenterology) with the results. (Page Operator [**Telephone/Fax (1) 10339**],
Page ID# [**Serial Number 34686**].
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed secondary to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Tear
Acute on chronic pancreatitis complicated by hemorrhagic
pancreatic pseudocyst
Cocaine abuse
Alcohol abuse
Coronary artery disease
Discharge Condition:
stable
Discharge Instructions:
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], Gastroenterology, on
Tuesday [**2198-1-2**], in [**Hospital Ward Name 23**] 7 at the [**Hospital1 18**], at 1:20 PM. (Phone#
[**Telephone/Fax (1) 11048**])
You have an ABDOMINAL CT on Friday [**2198-1-5**] at [**Hospital3 9947**], [**Last Name (NamePattern1) 34687**], behind the gift shop; ARRIVE AT 4
PM. YOU NEED TO HAVE NOTHING BY MOUTH (no liquids or solid food)
AFTER 11:30 ON [**2198-1-5**] (THE DAY OF THE CAT-SCAN). Call
[**Telephone/Fax (1) 34688**] for details.
Please follow-up with Dr. [**Last Name (STitle) 410**] in [**3-16**] weeks [**Telephone/Fax (1) 2660**].
****PLEASE MAKE SURE TO TAKE YOUR COPY OF THE ABDOMINAL CT SCAN
(on a CD) WITH YOU TO [**Hospital6 **] ON [**2198-1-5**] FOR YOUR
REPEAT CT SCAN.*****
Followup Instructions:
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) 5376**] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 1954**] Date/Time:[**2198-1-2**]
1:20
Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) **], Gastroenterology, on
Tuesday [**2198-1-2**], in [**Hospital Ward Name 23**] 7 at the [**Hospital1 18**], at 1:20 PM. (Phone#
[**Telephone/Fax (1) 11048**])
You have an ABDOMINAL CT on Friday [**2198-1-5**] at [**Hospital3 9947**], [**Last Name (NamePattern1) 34687**], behind the gift shop; ARRIVE AT 4
PM. YOU NEED TO HAVE NOTHING BY MOUTH (no liquids or solid food)
AFTER 11:30 ON [**2198-1-5**] (THE DAY OF THE CAT-SCAN). Call
[**Telephone/Fax (1) 34688**] for details.
Please follow-up with Dr. [**Last Name (STitle) 410**] in [**3-16**] weeks [**Telephone/Fax (1) 2660**].
|
[
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icd9cm
|
[
[
[]
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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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483, 2174
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|
2467, 2617
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
76,925
| 160,916
|
33343
|
Discharge summary
|
report
|
Admission Date: [**2193-4-17**] Discharge Date: [**2193-4-19**]
Date of Birth: [**2142-2-28**] Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
headache
Major Surgical or Invasive Procedure:
[**2193-4-17**] Left Frontal Craniotomy for resection of mass
History of Present Illness:
51 yo M with history of Renal cell carcinoma w Lung mets s/p
resection, treated with two cycles of IL2 in [**2189**]-[**2190**],
presented
to Oncologist with complaints of frontal headache. The headache
first occured 1 month prior and has increased in frequency since
that time but remains intermittent, [**8-13**], not positional. He has
not taken any pain medications. He did have two episodes of
nausea over the last month with vomiting. He denies vertigo,
nightime awakenings with pain or any seizure-type activity. He
denies any changes in his thinking, orientation, ability to
focus. He family, who are with him during this appointment, deny
any changes in behavior.
Oncologist ordered a CT-scan which showed R frontal lesion
with
edema and midline shift. The concern was for metastatic lesion
from known RCC. He was prescribed decadron 4mg q6hr -which he
started taking yesterday without acute side effects. He has also
started a PPI prophylactically.
He presents for operative management.
Past Medical History:
Oncologic history:
Renal cell carcinoma: diagnosed in [**2188**] on routine exam which
found splenomegaly. Subsequently found to have lung metastasis
s/p VATS. Underwent 2 cycles of IL2 therapy. Recent growth in
the
size of carcinoma but has remained largely asymptomatic until
recent headache.
[**Hospital 8304**] medical issues:
GERD
Hernia repair
Social History:
He currently lives at home with his wife and son. [**Name (NI) **] works as a
truck driver. Of note, he also lives with his grandchildren ages
16 months, 3 years, and 8 years old.
Family History:
No known history of brain cancer, or any other neurological
disease otehr than a stroke in one grandfather (details unclear)
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4-->2mm bilaterally EOMs full and conjugate
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Recall: [**4-6**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**6-8**] throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Reflexes: B T Br Pa Ac
Right 2 2 2 1 0
Left 2 2 2 1 0
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
PHYSICAL EXAM UPON DISCHARGE:
non focal
incision- C/d/i, staples
Pertinent Results:
[**2193-4-17**]: MRI Brain IMPRESSION: Solitary enhancing left frontal
lesion. It is difficult to determine whether it arose in the
brain parenchyma or the dura, but it clearly involves both
structures at this point. There is mild decrease in the size of
the lesion with significant decrease in the amount of
perilesional edema and mass effect. There is no evidence of new
enhancing lesion.
[**2193-4-17**] CT Head: IMPRESSION: Interval resection of left frontal
mass with persistent left frontal vasogenic edema and mass
effect.
[**2193-4-19**] MRI BRAIN: pending
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the Neurosurgery service for
elective resection on a right frontal lesion on [**4-17**]. The
patient tolerated the procedure well, was extubated and
transferred to the ICU for frequent neuro checks and systolic
blood pressure control less than 140. He was maintained on
dexamethasone 4 Q6 for cerebral edema and perioperative
antibiotics. He was started on Keppra 500mg [**Hospital1 **]. Postoperative
Head CT shows resection of left frontal mass with persistent
left
frontal vasogenic edema and mass effect. On [**4-18**], exam remains
nonfocal and he was transferred to the floor. MRI head was
ordered to evaluate for residual tumor. Decadron was tapered.
On [**4-19**] the patient was neurologically intact, ambulating in the
hallway independently. Once his post op MRI was obtained, he was
cleared for discharge and he was in agreement with this plan. He
was given instructions for followup and discharge on the evening
of [**4-19**].
Medications on Admission:
Prilosec
Decadron 4mg PO q6h
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain or fever.
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. dexamethasone 2 mg Tablet Sig: taper Tablet PO taper for 7
days: 4mg Q8hrs on [**4-19**], 3mg Q8hrs x2 days, 2mg Q8hrs x2 days
2mg Q12hrs x 2days then d/c.
Disp:*qs Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Metastatic Renal Cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses staples, you must keep that area until
the staples are removed. They will be removed at your post op
visit.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin, prior to your injury,do not
resume taking these until cleared by your surgeon.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2193-4-29**]
@ 11:30. The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone number
is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
* Your staples will be removed at this appointment.
Completed by:[**2193-4-19**]
|
[
"198.3",
"348.5",
"197.0",
"V10.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59"
] |
icd9pcs
|
[
[
[]
]
] |
6132, 6138
|
4204, 5190
|
317, 381
|
6214, 6214
|
3613, 4021
|
8070, 8598
|
2003, 2130
|
5270, 6109
|
6159, 6193
|
5216, 5247
|
6365, 8047
|
2145, 2145
|
269, 279
|
3557, 3594
|
409, 1415
|
2669, 3527
|
4030, 4181
|
2159, 2377
|
6229, 6341
|
1437, 1789
|
1805, 1987
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,473
| 120,243
|
27571
|
Discharge summary
|
report
|
Admission Date: [**2153-8-6**] Discharge Date: [**2153-8-9**]
Date of Birth: [**2076-7-14**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1257**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
1. Central line placement
2. Arterial line placement
3. Flexible sigmoidoscopy
4. Argon Laser GI study
History of Present Illness:
Mr. [**Known lastname 67387**] is a 77 year old gentleman with a PMH significant for
MDS, prostate CA s/p XRT complicated by radiation proctitis and
repeated LGIB, and CAD s/p PCI with [**Hospital 18692**] transferred to the [**Hospital Unit Name 153**]
for BRBPR and hypotension. The patient initially developed
frequent episodes of BRBPR such that it would fill up his shoe
before he realized it on Saturday at 11 AM. He then presented to
an OSH yesterday with a hct of 9. While at the OSH, his SBP was
consistently 80-90. He was transfused a total of 11 units PRBC,
2 units FFP, and 1 bag plts and was then transferred to [**Hospital1 18**]
for colonoscopy. On arrival to the floor, the patient was noted
to a BP 80/50 RR 20 P 70 and was transferred to the [**Hospital Unit Name 153**] for
further management.
Of note, the patient has a history of prior LGIB secondary to
radiation proctitis, most recently in 11/[**2153**]. At that time, he
was transfused a total of 7 units of blood and had a colonscopy.
He was also admitted at [**Hospital1 2025**] in [**11/2151**] for BRBPR and was
transfused and also received a colonscopy.
Initial exam was interupted by one episode of BRBPR (~300 cc).
Currently, he denies any pain with defecation, CP, worsened SOB
above baseline, dysuria, hematuria, emesis, HA, palpitations.
Patient endorses having felt orthostatic this morning.
ROS: + nausea, dyspnea on exertion. Sycopal epsidoe 2 weeks ago,
found to have low hct requiring 7 units PRBCs.
Past Medical History:
- Prostate CA s/p lupron and XRT complicated by radiation
proctitis
- LGIB: [**11/2152**], [**11/2151**] requiring transfusions secondary to
radiation proctitis
- MDS: 2 units PRBC transfusion requirement weekly. Bone marrow
bx confirmed in [**9-2**]
- CAD s/p PCI with BMS in [**11/2152**]
Social History:
EtOH - 2 glasses of wine/night. Tobacco - none. No IV, illicit,
or herbal drug use. Lives with wife on [**Name (NI) 6687**], independent in
[**Name (NI) 12210**]. Retired fisherman.
Family History:
Non-contributory
Physical Exam:
Admission physical exam:
Vitals: BP 80/50, RR 20, P 70, O2 sat: 97% RA
Gen: Pale age appropriate male breathing comfortably
HEENT: Perrl, eomi, sclerae anicteric. MMM, OP clear without
lesions, exudate, or erythema. Neck supple without LAD.
CV: Nl S1+S2, no m/r/g
Pulm: CTAB
Abd: S/NT/ND +bs
Ext: 1+ pitting edema bilaterally
Neuro: AOx3. CN II-XII intact.
Pertinent Results:
Labs on admission:
[**2153-8-6**] 09:16PM WBC-2.9* RBC-2.09* Hgb-6.4* Hct-17.7* MCV-85
MCH-30.6 MCHC-36.2* RDW-15.9* Plt Ct-50*
[**2153-8-6**] 09:16PM PT-14.3* PTT-26.9 INR(PT)-1.2*
[**2153-8-6**] 09:16PM Glucose-98 UreaN-30* Creat-1.0 Na-139 K-3.8
Cl-105 HCO3-25 AnGap-13 Calcium-7.5* Phos-4.4 Mg-1.9
[**2153-8-6**] 10:13PM freeCa-1.07*
[**2153-8-6**] 09:16PM ALT-15 AST-14 LD(LDH)-240 AlkPhos-121*
TotBili-1.0 Lipase-22 Albumin-2.9*
[**2153-8-6**] 09:16PM CK(CPK)-30* CK-MB-3 cTropnT-<0.01
[**2153-8-7**] 02:26AM Lactate-1.7
[**2153-8-7**] 05:20PM Fibrinogen-200
Repeat CBCs:
[**2153-8-7**] 02:22AM Hgb-7.8* Hct-21.3* MCV-84 MCH-30.8 Plt Ct-150#
[**2153-8-7**] 05:20PM Hgb-9.0* Hct-24.9* Plt Ct-72*
[**2153-8-8**] 05:15AM Hgb-8.5* Hct-23.9* Plt Ct-65*
EKG: Normal sinus rhythm 78 bpm. Low limb lead voltage.
Imaging
CXR ([**2153-8-6**]): Interstitial pulmonary abnormality largely
localized to the right lung base. Heart size is normal.
Pulmonary vasculature is unremarkable and left pleural effusion
is small. Left infrahilar opacification could be atelectasis.
There is a suggestion of a small hiatus hernia. Configuration of
the trachea and absent vasculature in the upper lungs could be
due to emphysema. Whether the basal lung abnormalities are due
to edema in the setting of emphysema will require subsequent
followup.
Brief Hospital Course:
Upon being admitted to the floor, he had a 300 cc bowel movement
of BRBPR. He was then transferred to the ICU and received 5
units of blood and 3 units of platelets during the early AM on
[**2153-8-7**]. GI conducted a flexible sigmoidoscopy. It revealed a
large clot in the rectum adjacent to diffuse ulcerated mucosa in
the distal rectum with several areas of mild oozing of blood
from the surface and one area that is spurting blood, 2 cm above
the anorectal junction. Attempts to clip this x 3 were
unsuccessful because of the stiffness of the rectal wall and
friability of the mucosa. Epinephrine injection stopped the
bleeding. On [**2153-8-8**], GI conducted argon coagulation of known
bleeding lesions from radiation proctitis (a 2 cm lesion in the
distal rectum consistent with radiation injury). He was then
transferred to the floor and monitored for additional 24 hours.
His hematocrit remained stable after this treatment until the
day of discharge. On that day, his hematocrit dropped to 22.2
from 27. However, he remained asymptomatic and he had 2 brown
bowel movements without further bleeding. He was discharged
based on his request and at his own risk despite my advise to
stay inhouse for another 24 hours as he had to travel back to
Nuntucket and take care of his mentally challenged daughter. [**Name (NI) **]
understood the risk for leaving. He has transfusion dependent
MDS and he will get transfusion tomorrow at his local hospital.
He will have a follow up with his PCP and possible [**Name Initial (PRE) **] full
colonoscopy for near future for further workup. He was asked to
restart his low dose Coreg and Lasix.
Medications on Admission:
Coreg 3.125 mg po bid
Protonix 40 mg daily
Lasix 20 mg po daily
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day.
Tablet(s)
3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
1. Lower GI bleed
Discharge Condition:
Stable.
Discharge Instructions:
You had severe acute blood loss anemia related to radiation
proctitis. You had blood transfusions and sigmoidoscopy with
[**Doctor Last Name 67388**] coagulation of the rectal ulcer ( site of bleeding from
radiation proctitis). You were discharged based on your request
as your blood level has dropped again. you said you had to take
care of your daughter. Please get blood transfusion tomorrow at
your local hospital as we agreed. Please call your doctor if any
signs of bleeding. Please see you PCP within [**Name Initial (PRE) **] week for blood
count.
Followup Instructions:
PEARL,[**Doctor First Name **] R [**Telephone/Fax (1) 22442**]
|
[
"578.1",
"V45.82",
"238.75",
"285.1",
"569.41",
"569.49",
"E879.2",
"414.01",
"401.9",
"280.9",
"V10.46"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"45.43",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6284, 6290
|
4250, 5894
|
319, 423
|
6369, 6378
|
2886, 2891
|
6982, 7047
|
2475, 2493
|
6008, 6261
|
6311, 6348
|
5920, 5985
|
6402, 6959
|
2533, 2867
|
274, 281
|
451, 1945
|
2905, 4227
|
1967, 2260
|
2276, 2459
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,674
| 178,446
|
2293
|
Discharge summary
|
report
|
Admission Date: [**2197-5-4**] Discharge Date: [**2197-5-17**]
Date of Birth: [**2143-11-7**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Shellfish / Fish Product Derivatives
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
low back pain
Major Surgical or Invasive Procedure:
Anterior C4-7 Spinal Fusion/ Posterior laminectomy and fusion
C4-7
History of Present Illness:
53F with severe RA, recently diagnosed cervical spine stenosis
at BUMC after presenting with RUE numbness and tingling presents
today with increased low back pain and bilateral LE weakness.
Saw Dr. [**Last Name (STitle) 363**] of orthopedic surgery yesterday, and was ordered
for outpatient spine MR, but her low back pain was worse leading
to a fall x2 yesterday [**2-15**] weakness. No fever, chills, SOB, CP,
+vomiting x1 yesterday, no loss of bowel or bladder control.
Past Medical History:
Rheumatoid arthritis
asthma
pyelonephritis
horseshoe kidney
RLL nodule
cervical spinal stenosis with cord edema dx 2 weeks ago by MR
Social History:
Denies EtOH, tobacco, illicits
Family History:
NC
Physical Exam:
T 98.1 HR 88 BP 139/78 RR 20 O2Sat
Gen: pleasant, lying in bed, +cervical collar
HEENT: anicteric, MMM, OP clear
CV: regular, no mrg
Lungs: CTAB on anterior exam
Abd: soft NTND +BS
Rectal: normal tone, no stool
Ext: strength severely limited in all extremities [**2-15**] pain --
RUE worse than LUE. Sensation intact to light touch throughout.
Neuro: AOx3, strength limited as above, +clonus
Pertinent Results:
Chemistries
[**2197-5-4**] 10:50AM GLUCOSE-204* UREA N-19 CREAT-0.9 SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-17
CBC
[**2197-5-4**] 10:50AM WBC-9.5 RBC-4.24 HGB-11.5* HCT-36.3 MCV-86
MCH-27.2 MCHC-31.7 RDW-17.6*
[**2197-5-4**] 10:50AM NEUTS-84.7* BANDS-0 LYMPHS-9.2* MONOS-4.0
EOS-1.6 BASOS-0.5
[**2197-5-4**] 10:50AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
[**2197-5-4**] 10:50AM PLT COUNT-309
Coags
[**2197-5-4**] 10:50AM PT-13.5 PTT-23.9 INR(PT)-1.1
C-Spine MR
IMPRESSION:
1) Multilevel cervical spondylosis. Central canal stenosis at
C3-C4 through C6-C7 associated with central cord edema. Grade 1
anterolisthesis of C3 on C4.
2) Unusual configuration of the dens worrisome for a fracture
deformity although there is no marrow edema to suggest acute
injury. Thickened soft tissue in at the atlantoaxial joint
suggests pannus. Correlation with CT is recommended.
CT C-spine
IMPRESSION: Changes in the odontoid process from rheumatoid
arthritis. No evidence of atlantoaxial subluxation. No acute
fracture visible by CT. There may be ligamentous laxity and
instability from degenerative change, and this cannot be
assessed with the static imagese acquired.
L-Spine MR
IMPRESSION:
Bilateral L5 spondylolysis with grade 1/grade 2 anterolisthesis
of L5 on S1. Resultant narrowing of the bilateral neural foramen
at that level. Probable prominent synovial tissue versus
fibrosis projecting toward the right neural foramen; a
nonemergent contrast-enhanced lumbar spine MRI may be useful for
further characterization.
[**2197-5-8**] Cervical Decompression
PROCEDURE PERFORMED:
1. Total laminectomy of C4, C5, C6 and C7.
2. Fusion C4 - C7.
3. Autograft.
Brief Hospital Course:
Cervical Spinal Stenosis
The patient presented with cervical spinal stenosis with
associated cord edema between C3 and C7. Additionally, a
C-spine MR [**First Name (Titles) **] [**Last Name (Titles) 12039**] of a dens fracture but a CT c-spine
did not corroborate this finding. The patient was seen by Dr.
[**Last Name (STitle) 363**] of ortho spine in the emergency department, and a
cervical decompression was planned; meanwhile the patient was
admitted for pain control. The patient was started on oxycontin
and this was titrated up to 20mg [**Hospital1 **]. She was given initially
morphine and then oxycodone for breakthrough pain. She was
started on a beta-blocker preop. She underwent an uncomplicated
cervical decompression on [**2197-5-8**]. Post operatively she was
briefly on a morphine pca. She worked with the physical
therapists. She was transferred to the ortho-spine service, and
was taken back to the OR on ... for an anterior stabilization.
Low Back Pain
The patient also has L5-S1 disc bulge and neural foraminal
stenosis per L-spine MR, likely contributing to her low back
pain. Her pain was managed as above. Physical therapy was
consulted.
Left calf pain
The day after surgery the patient complained of pain in her left
calf, and on exam, the calf was more firm than the other side.
She undewent a left-sided LENI which did not show a DVT. Her
pain resolved, and she was able to ambulate with PT.
Rheumatoid arthritis
The patient was continued on her outpatient medications; her
naproxen was held prior to surgery. In addition to her daily
10mg of prednisone, she was given stress dose steroids the day
of her surgery.
Asthma
The patient was contined on her outpatient inhalers.
Ulcerative keratitis
The patient said that she no longer used the prednisolone eye
drops.
Diabetes
The patient was continued on avandia (held while she was NPO),
and additionally a long acting insulin and a HISS were added.
Medications on Admission:
Albuterol q6h prn
Flovent 2 puffs [**Hospital1 **]
Klonapin 1mg qhs
Darvacet 1 tab q4-6 hrs prn
Tylenol 3
Naproxyn 500 [**Hospital1 **]
Fosamax 70 weekly
Prilosec 20 daily
Prednisone 10 daily
Plaquenil 400 daily
Arava 20 daily
Avandia 4mg daily
Prednisolone drops for eyes [**Hospital1 **]
Discharge Medications:
Diazepam 5 mg PO Q6-8H:PRN spasm
Prochlorperazine 10 mg PO/IV Q6H:PRN [**5-14**] @ 1355 View
Lisinopril 5 mg PO DAILY
hold for sbp <130
Lactulose 30 ml PO Q8H:PRN
titrate to 1 BM daily [**5-14**] @ 1355 View
Insulin SC (per Insulin Flowsheet)
Sliding Scale & Fixed Dose
Bisacodyl 10 mg PO/PR DAILY:PRN
Senna 1 TAB PO BID
Metoprolol 25 mg PO BID
hold for HR <60 and SBP <100
Sarna Lotion 1 Appl TP TID:
Zolpidem Tartrate 5 mg PO HS:PRN
Oxycodone (Sustained Release) 20 mg PO q12
Acetaminophen 650 mg PO Q6H
Docusate Sodium 100 mg PO BID
Albuterol [**1-15**] PUFF IH Q6H:PRN
Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **]
Clonazepam 1 mg PO QHS
Hydroxychloroquine Sulfate 400 mg PO DAILY
Arava *NF* 20 mg Oral daily
Alendronate Sodium 70 mg PO QFRI
Pantoprazole 40 mg PO Q24H
Prednisone 10 mg PO DAILY [**5-14**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Cervical spinal stenosis with cord compression s/p surgical
decompression
Low back pain
Rheumatoid arthritis
Asthma
Discharge Condition:
Stable
Discharge Instructions:
Please take your medications as prescribed.
Followup Instructions:
Please see Dr. [**Last Name (STitle) 363**] in follow up as needed.
Keep the following appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6719**], M.D. Where: [**Hospital6 29**]
[**Hospital3 1935**] CENTER Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2197-5-26**] 9:00
Provider: [**First Name11 (Name Pattern1) 20**] [**Last Name (NamePattern4) 7176**], MD Where: LM [**Hospital Unit Name 4275**] Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2197-5-29**] 2:30
Provider: [**Name10 (NameIs) **] SCAN Where: [**Hospital6 29**] RADIOLOGY
Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2197-6-26**] 11:30
|
[
"285.9",
"721.1",
"737.10",
"714.0",
"733.00",
"493.90",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.02",
"81.03",
"80.51",
"77.79",
"81.63"
] |
icd9pcs
|
[
[
[]
]
] |
6473, 6531
|
3334, 5280
|
328, 396
|
6691, 6699
|
1557, 3311
|
6791, 7437
|
1121, 1125
|
5623, 6450
|
6552, 6670
|
5306, 5600
|
6723, 6768
|
1140, 1538
|
275, 290
|
424, 899
|
921, 1056
|
1072, 1105
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,012
| 154,973
|
42709
|
Discharge summary
|
report
|
Admission Date: [**2199-2-13**] Discharge Date: [**2199-2-18**]
Date of Birth: [**2139-8-24**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 633**]
Chief Complaint:
passed out
Major Surgical or Invasive Procedure:
None
History of Present Illness:
59 yo M with CAD, HTN and HCV found down at the Salvation Army
in [**Hospital1 1559**], brought to [**Hospital2 **] [**Hospital3 6783**] and found to be
hypotensive and bradycardic. He was fluid resuscitated with
resolution of hypotension. He was transferred to [**Hospital1 18**] due to
bed availability.
Patient is unable to provide extensive story. He reports that he
was eating lunch at Salvation Army when he passed out. He
reports feeling somewhat dizzy shortly before this occurred. EMS
found the patient somnolent, stating "I took too much" with
pinpoint pupils, narcan had no effect.
At [**Hospital2 **] [**Hospital3 6783**], he was bradycardic to the 30s and hypotensive
to the 80s. His ECG showed question of anterior ST elevations of
1mm. Trop-T 0.058 then <0.03. He was given lovenox and aspirin.
Cards consult called and considered for cath, but then
determined that his ECG elevations were consistent with prior.
Atropine was given without significant improvement in heart
rate. Pan scan was unremarkable. Transferred to [**Hospital1 18**]. Head CT
unremarkable
On arrival to the [**Hospital Unit Name 153**], he feels well. He has some dizziness,
worsening with sitting up. He noted a small amount of chest
pressure on arrival that resolved.
Past Medical History:
MI s/p stents 2-3 years ago
HTN
EtOH abuse
Arthritis
HCV
Asthma
Neuropathy
Social History:
Lives at Safe Haven in [**Hospital1 1559**] for the last 6 months.
Previously homeless. HIV negative as of about 6 months ago.
- Tobacco: [**12-31**] PPD for ~50 years
- Alcohol: about 160 oz of beer daily, last drink 8am
- Illicits: cocaine
Family History:
Mother - died of old age
Father - died of aneurysm
Brothers/sisters - died from AIDS
Physical Exam:
Admission:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
Lungs: Bilateral dry crackles at the bases
CV: Bradycardic, distant heart sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
mild tenderness in RUQ
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: multiple tattoos
Pertinent Results:
[**2199-2-18**] 08:55AM BLOOD WBC-5.4 RBC-4.29* Hgb-12.7* Hct-36.9*
MCV-86 MCH-29.6 MCHC-34.4 RDW-14.0 Plt Ct-223
[**2199-2-16**] 08:30AM BLOOD WBC-7.9 RBC-4.53* Hgb-13.2* Hct-38.9*
MCV-86 MCH-29.2 MCHC-34.0 RDW-13.6 Plt Ct-248
[**2199-2-15**] 06:57AM BLOOD WBC-6.5 RBC-4.18* Hgb-12.4* Hct-35.2*
MCV-84 MCH-29.6 MCHC-35.2* RDW-13.8 Plt Ct-231
[**2199-2-14**] 11:48AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.7* Hct-33.3*
MCV-86 MCH-30.4 MCHC-35.3* RDW-13.7 Plt Ct-207
[**2199-2-13**] 10:55PM BLOOD WBC-7.7 RBC-3.88* Hgb-12.3* Hct-33.8*
MCV-87 MCH-31.6 MCHC-36.3* RDW-13.7 Plt Ct-241
[**2199-2-13**] 10:55PM BLOOD Neuts-73.7* Lymphs-18.8 Monos-5.7 Eos-1.4
Baso-0.4
[**2199-2-13**] 10:55PM BLOOD PT-12.0 PTT-35.8 INR(PT)-1.1
[**2199-2-18**] 08:55AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-140
K-3.8 Cl-108 HCO3-23 AnGap-13
[**2199-2-16**] 08:30AM BLOOD Glucose-99 UreaN-7 Creat-0.8 Na-139 K-4.1
Cl-107 HCO3-20* AnGap-16
[**2199-2-15**] 06:57AM BLOOD Glucose-92 UreaN-8 Creat-0.8 Na-141 K-4.0
Cl-109* HCO3-23 AnGap-13
[**2199-2-14**] 11:48AM BLOOD Glucose-87 UreaN-11 Creat-0.8 Na-133
K-4.2 Cl-109* HCO3-21* AnGap-7*
[**2199-2-13**] 10:55PM BLOOD Glucose-73 UreaN-9 Creat-1.0 Na-141 K-4.3
Cl-113* HCO3-19* AnGap-13
[**2199-2-18**] 08:55AM BLOOD CK(CPK)-223
[**2199-2-14**] 11:48AM BLOOD CK(CPK)-2561*
[**2199-2-13**] 10:55PM BLOOD ALT-46* AST-125* CK(CPK)-4151* AlkPhos-80
TotBili-0.4
[**2199-2-18**] 08:55AM BLOOD CK-MB-4 cTropnT-<0.01
[**2199-2-13**] 10:55PM BLOOD CK-MB-82* MB Indx-2.0 cTropnT-0.04*
[**2199-2-13**] 10:55PM BLOOD TSH-0.32
[**2199-2-13**] 10:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2199-2-14**] 12:43AM BLOOD Lactate-0.9
[**2199-2-18**] 08:55AM BLOOD Calcium-9.3 Phos-3.3 Mg-1.9
[**2199-2-14**] 11:48AM BLOOD Calcium-8.2* Phos-2.2*# Mg-2.0
[**2199-2-13**] 10:55PM BLOOD Calcium-8.2* Phos-4.2 Mg-2.0
.
EKG [**2-14**]:
Sinus rhythm. Intraventricular conduction delay. ST segment
elevations
in leads V1-V4. Abnormal ST-T waves in leads V1-V3. Consider
acute
anteroseptal myocardial infarction. Consider Brugada syndrome,
if clinically indicated. No previous tracing available for
comparison.
.
MICROBIOLOGY:[**2199-2-13**] URINE URINE CULTURE-FINAL
INPATIENT
[**2199-2-13**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS} INPATIENT
[**2199-2-13**] BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
Brief Hospital Course:
59 yo M with HTN and CAD, found down at Salvation Army in
[**Hospital1 1559**], admitted with hypotension and bradycardia.
# Hypotension: Lactate of 2.9 at OSH, resolved to 0.9 on
arrival to [**Hospital1 18**]. Blood pressure also resolved to the 110s.
Received 6L of IV fluid in the ED at St Vincents, with blood
pressure of 111/48 prior to transfer. Most likely due to
hypovolemia from poor PO intake and alcohol abuse exacerbated by
slow rate. Patient was asymptomatic while in the ICU with
pressures in the 130s/80s at time of transfer to the floor. His
amlodipine, clonidine, and atenolol were discontinued given pt
with low-normal BP. Cardiology was also consulted who did not
favor use of nodal agents or clonidine with cocaine use.
.
# Orthostatic Hypotension: Prior to discharge patient noted to
have orthostatic hypotension that persisted somewhat despite
hydration. Possibly due to clonidine taken during overdose or
bioaccumulated. This improved at time of discharge. Pt was
evaluated by physical therapy who provided pt with a walker. In
addition, nodal agents/clonidine discontinued. Pt instructed on
how to arise with orthostatic hypotension. Pt encouraged to stay
hydrated.
.
# Bradycardia: Unclear etiology. Reportedly occurred before
about 2 weeks ago with a similar stay in the hospital.
Differential includes conduction disease/ sick sinus syndrome,
medication abuse, drug abuse, vagal response. Cardiology
evaluated patient and felt most likely toxic effect due to
substances in the context of resting low heart rate. All
anti-hypertensives were held on presentation and cardiology
recommended continuing to hold atenolol and clonidine. They
felt despite history of CAD given resting slow rate benefit of
this [**Doctor Last Name 360**] questionable and danger if actively using cocaine was
not insignificant. Pt is not a candidate for PPM at this time.
By the time of transfer to floor patient's rate was in high 50's
and never dropped lower again. Patient should follow with
cardiologist for history of CAD and bradycardia. Pt was
encouraged to speak to his PCP regarding cardiology referral.
# Rhabdomyolysis: Pt had an elevated CK at presentation likely
due to having been down and mild rhabdo. He never had renal
failure. Resolved by time of discharge. PT instructed he may
resume statin on [**2-25**].
# Alcohol Abuse/Cocaine abuse: Last drink at 8am day of
admission. Patient was on CIWA initially but never had any signs
of withdrawal. Pt was evaluated by social work during admission
to provide pt with resources for addiction. Pt expressed that he
was not suicidal and was motivated to stop drinking ETOH and
using drugs.
# CAD: Patient with EKG changes at presentation to OSH and
intermittently complaining of chest pressure but troponin flat
and review showed these were chronic changes. He was continued
on his aspirin. Statin held given elevated CK but should
restart in one week. BB stopped given low HR and BP and danger
of use with active cocaine.
.
Transitional:
-Patient will need f/u with PCP to discuss establishing
cardiology follow up. Unable to make follow up appointment given
the office was closed today.
-HCTZ, atenolol, clonidine all were stopped
-statin was held, ok to resume [**2-25**]
-consider SW and psychiatric referrals for ongoing care of
depression, substance abuse
Medications on Admission:
-lisinopril 40 mg daily
-HCTZ 25 mg daily
-folate 1 mg daily
-amlodipine 5 mg daily
-citalopram 40 mg daily
-risperidone 1 mg QHS
-gabapentin 300 mg in a.m. and afternoon with 600 mg QHS
-atenolol 25 mg daily
-aspirin 81 mg daily
-multivitamin 1 tab daily
-topiramate 50 mg [**Hospital1 **]
-simvastatin 20 mg PO daily
-clonidine 0.1 mg PRN
-lorazepam 0.5 mg PRN
-ProAir HFA PRN
-ibuprofen 600 mg PRN
Discharge Medications:
1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. gabapentin 300 mg Capsule Sig: [**12-31**] Capsules PO BREAKFAST
(Breakfast): take one tablet each morning, one each noon, and
two at night.
4. risperidone 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day:
Hold until [**2-25**] then restart
.
6. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: [**12-31**]
puffs Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
8. topiramate 50 mg Tablet Sig: One (1) Tablet PO twice a day.
9. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day:
PLEASE CONFIRM YOUR HOME DOSE. THIS DOSE WAS NOT CHANGED.
10. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Intoxication with alcohol and cocaine
Hypotension
Bradycardia
Secondary Diagnoses:
Coronary artery disease
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted after you were found with a slow pulse and low
blood pressure after using alcohol and cocaine. You received
fluids and supportive medications and your symptoms
resolved/improved.
.
Please be sure to rise slowly from lying and sitting positions.
Initially, you were found to have a lower blood pressure when
standing. Please be sure to drink plenty of fluids in order to
maintain proper hydration.
.
Your medications have been changed.
1.Your hydrochlorothiazide, amlodipine, atenolol, and clonidine
have all been held as your blood pressure remained normal to
low. Also, some of these medications are very dangerous to use
when using cocaine.
.
2.Your statin (simvastatin) was held for muscle inflammation due
to your time down. This can be restarted on [**2-25**].
.
3.please confirm your home dose of lisinopril. This dose was not
changed.
.
Otherwise, please confirm your doses with your housing agency.
NONE of your other medications were changed.
.
We strongly recommend you stop using alcohol and cocaine as you
had a very serious event related to overuse of these substances.
You were seen by social work who provided you with resources for
assistance in quitting. Please call the numbers provided if you
need further help or have any questions.
Followup Instructions:
Please be sure to call your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] tomorrow to schedule
an appointment to be seen within 1-2 weeks of discharge.
.
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]
Address: [**Doctor Last Name **]. NORTH, [**Hospital1 **],[**Numeric Identifier 46362**]
Phone: [**Telephone/Fax (1) 85202**]
Fax: [**Telephone/Fax (1) 92313**]
.
Please also talk with your PCP about the need for a referral to
a cardiologist (heart doctor).
|
[
"070.54",
"428.22",
"E860.0",
"305.01",
"970.81",
"E854.3",
"V45.82",
"458.0",
"585.9",
"304.21",
"414.01",
"980.0",
"403.10",
"E849.8",
"728.88",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9673, 9679
|
4932, 8277
|
314, 320
|
9863, 9863
|
2524, 4909
|
11310, 11868
|
1990, 2077
|
8729, 9650
|
9700, 9700
|
8303, 8706
|
10014, 11287
|
2092, 2505
|
9803, 9842
|
264, 276
|
348, 1612
|
9719, 9782
|
9878, 9990
|
1634, 1711
|
1727, 1974
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,113
| 191,180
|
4899
|
Discharge summary
|
report
|
Admission Date: [**2149-4-2**] Discharge Date: [**2149-4-14**]
Date of Birth: [**2103-6-23**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Amoxicillin / Blood-Group Specific Substance /
Adhesive Tape
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Respiratory distress; Acute renal failure
Major Surgical or Invasive Procedure:
Transesophageal [**First Name3 (LF) **]
Central Venous Line Placement
Swan Ganz Catheter Placement
History of Present Illness:
Ms [**Known lastname 19419**] is a 45 yo woman with pmh of DM1, CAD s/p CABG and
PCI, ESRD s/p living-related kidney transplant in [**10-31**], and
recent hospitalization for septic arthritis who was to be
directly admitted for acute renal failure today, but was also
found to be in respiratory distress with an echo significant for
new severe MR and pulmonary hypertension.
Of note the patient was admitted to [**Hospital1 18**] from [**Date range (1) 20432**] for
septic arthritis, for which she went to the OR for washout and
was started on 6 weeks of Vancomycin/Ceftazidime. During this
admission, her creatinine was increased to 1.6 on admission, and
decreased to her baseline of 1.2 without intervention. Her home
dose of Rapamune was stopped in order to assist in healing after
the procedure, her home Lasix dose was increased to 40 mg [**Hospital1 **],
and her Lisinopril was held on discharge.
On [**3-28**] her tacrolimus level was undetectable, despite being on
3 mg [**Hospital1 **] (on [**3-25**] it had been 2.7). Her creatinine was noted to
increase from 1.2 on [**3-28**] to 1.9 on [**3-31**]. She was supposed to be
a direct admission today, however when EMS picked her up to
bring her to the hospital, she was noted to have respiratory
distress so she was brought to the ED instead of the floor.
Her respiratory distress began two days ago. She states her
dyspnea began suddenly and slowly increased over the two days.
Per her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], she had had recurrent admissions to [**Hospital 7912**] for CHF exacerbations thought to be due to
acutely worsening mitral regurgitation in the setting of
ischemia. She states that her symptoms are similar to the
symptoms she had with previous admissions for heart failure. She
also does note that she had had decreased urine output for the
past few days.
In the ED, initial vitals were T 96 HR 80 BP 113/63 RR 20 Sat
97% on 15L high flow. She was given cefepime and vancomycin due
to concern for pneumonia. There was concern for PE, however she
could not undergo a CTA due to her ARF. LENIs were done, but not
yet read. A TTE was also done to look for evidence of right
heart strain and unexpectedly showed new severe mitral
regurgiation and new pulmonary hypertension. She had crackles on
exam and a BNP of [**Numeric Identifier 20433**] so she was given 40 mg IV lasix for
volume overload. She was placed on BiPAP 8/5 for respiratory
support with some improvement.
Her creatinine in the ED was 2.2. She was given 100 mg of
hydrocortisone for rejection. Plan per renal for her acute
rejection is hydrocortisone 100 mg q8h. She was also given
zofran for nausea.
Currently she feels tired and complains of dyspnea. She denies
chest pain, but does admit to pain in her left ankle of [**9-9**].
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope
or presyncope. She does admit to stable 3 pillow orthopnea.
Past Medical History:
1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: s/p CABG in [**5-1**] (LIMA-LAD, SVG-PDA, OMI-Diag)
- known occlusion of 2 SVGs with patent SVG to RCA and LIMA to
LAD
PERCUTANEOUS CORONARY INTERVENTIONS:
- [**9-8**] PTCA of the LCx for recurrent CHF episodes
1. Limited angiography in this right dominant system
demonstrated multi vessel disease. The LCx was diffusely
diseased in the mid to distal vessel. The RCA was not injected.
2. Successful PTCA of the LCx with a 2.0 x 30mm Voyager balloon.
Final angiography revealed 30% residual stenosis, no
angiographically apparent dissection, and TIMI 3 flow.
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Recent hospitalization [**2149-3-21**] for left ankle septic arthritis
L at ORIF site --> debrided in OR, cultures grew
coagulase-negative staphaureus (oxacillin resistance) and pt
d/c'ed on vanc. Hospitalization c/b pulmonary edema and
hyperglycemia treated with fluids.
- Diastolic congestive heart failure, EF 50-55%
- Diabetes Type I complicated by retinopathy (legally blind),
diabetic foot ulcers, hypoglycemic seizure, and gastroparesis
- ESRD s/p kidney transplant
- CAD s/p CABG [**2140**] and PTCA in [**9-8**]
- Hypertension
- Hyperlipidemia
- Hematemesis requiring multiple transfusions in [**2149-1-31**] at
[**Hospital6 **] in the setting of vomiting. No EGD done at
the time. Hct stable since then.
- PVD s/p R fem [**Doctor Last Name **] bypass graft, s/p L SFA [**Doctor Last Name **] ([**5-9**])
- Hx of intracranial bleed falling fall, [**2147**]
- Sarcoidosis
- Cataracts
- Depression
- s/p cholecystectomy
- s/p tubal ligation
- s/p left patella fracture
- s/p left wrist fracture
- s/p left ankle fracture, s/p ORIF [**10/2148**] complicated by
purulent drainage and OR debridement [**2149-3-25**].
Social History:
-Tobacco history: smokes half a pack per day
-ETOH: none
-Illicit drugs: smokes marijuana several times per week to help
with nausea and appetite
Family History:
There is no history of diabetes or kidney disease. Her father
had an MI at 74 and mother has hypertension. Grandfather had
leukemia and hypertension.
Physical Exam:
GENERAL: Middle-aged female sitting in bed with a BiPAP mask on,
in respiratory distress.
HEENT: NCAT. Sclera anicteric. PERRL. BiPAP mask in place.
NECK: Supple with JVP of 8 cm.
CARDIAC: RRR, [**4-5**] holosytolic murmur heard best at the apex.
LUNGS: Difficulty speaking in full sentences, on BiPAP with
accessory muscle use. Crackles present to the mid lung field
bilaterally.
ABDOMEN: +BS, abdomen soft, NTND. Well-healed scarn in her RLQ,
transplant nontender.
EXTREMITIES: No edema present. Left lower leg and ankle with
cast in place. Left brachial fistulae without thrill.
SKIN: Excoriations on her back.
PULSES:
Right: Carotid 2+ DP 2+ PT 2+
Left: Carotid 2+ DP 2+ PT 2+
Pertinent Results:
Admission Labs
[**2149-4-2**] 01:35PM BLOOD WBC-9.7# RBC-3.21* Hgb-8.7* Hct-27.9*
MCV-87 MCH-27.1 MCHC-31.2 RDW-16.2* Plt Ct-670*#
[**2149-4-2**] 01:35PM BLOOD Neuts-76.9* Lymphs-15.2* Monos-2.7
Eos-4.8* Baso-0.5
[**2149-4-2**] 01:35PM BLOOD PT-12.6 PTT-24.4 INR(PT)-1.1
[**2149-4-2**] 01:35PM BLOOD Glucose-107* UreaN-43* Creat-2.2* Na-137
K-4.6 Cl-100 HCO3-27 AnGap-15
[**2149-4-2**] 11:02PM BLOOD ALT-122* AST-54* LD(LDH)-179 CK(CPK)-32
AlkPhos-443* TotBili-0.3
[**2149-4-2**] 01:35PM BLOOD Calcium-9.2 Phos-4.3# Mg-1.9
[**2149-4-3**] 03:04AM BLOOD Vanco-36.0*
[**2149-4-2**] 01:35PM BLOOD tacroFK-12.7
[**2149-4-2**] 10:00PM BLOOD Type-ART pO2-64* pCO2-46* pH-7.36
calTCO2-27 Base XS-0
Discharge Labs
[**2149-4-12**] 04:51AM BLOOD WBC-4.1 RBC-2.84* Hgb-7.8* Hct-24.0*
MCV-85 MCH-27.4 MCHC-32.4 RDW-16.1* Plt Ct-385
[**2149-4-14**] 11:56AM BLOOD Glucose-97 UreaN-61* Creat-2.5* Na-132*
K-3.8 Cl-89* HCO3-31 AnGap-16
[**2149-4-14**] 11:56AM BLOOD Calcium-9.8 Phos-4.5 Mg-1.7
[**2149-4-12**] 04:51AM BLOOD Vanco-17.8
[**2149-4-12**] 04:51AM BLOOD tacroFK-5.5
Cardiac Enzymes
[**2149-4-2**] 01:35PM BLOOD CK(CPK)-24* CK-MB-NotDone cTropnT-0.07*
[**2149-4-2**] 11:02PM BLOOD CK(CPK)-32 CK-MB-NotDone cTropnT-0.06*
[**2149-4-3**] 03:04AM BLOOD CK(CPK)-28* CK-MB-NotDone cTropnT-0.06*
[**2149-4-2**] 01:35PM BLOOD proBNP-[**Numeric Identifier 20433**]*
Other Labs
[**2149-4-13**] 02:20PM BLOOD calTIBC-273 Ferritn-58 TRF-210
[**2149-4-2**] 01:35PM BLOOD D-Dimer-1389*
[**2149-4-5**] 06:27AM BLOOD %HbA1c-9.6* eAG-229*
Urine Studies
[**2149-4-2**] 06:50PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2149-4-2**] 06:50PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2149-4-2**] 06:50PM URINE RBC-0-2 WBC-0-2 Bacteri-FEW Yeast-NONE
Epi-0-2
[**2149-4-2**] 06:50PM URINE CastHy-[**4-4**]*
[**2149-4-2**] 06:50PM URINE Hours-RANDOM UreaN-442 Creat-95 Na-25
[**2149-4-2**] 06:50PM URINE UCG-NEGATIVE Osmolal-322
Micro Data
Blood Cx Negative x 2
Urine Cx Negative x 2
Imaging:
TTE ([**2149-4-2**]) - The left atrium is dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
inferolateral hypokinesis. [Intrinsic left ventricular systolic
function is likely more depressed given the severity of valvular
regurgitation.] Right ventricular chamber size is normal. with
moderate global free wall hypokinesis. The aortic valve leaflets
(3) are mildly thickened. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Severe (4+)
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. There is severe pulmonary artery systolic
hypertension. Significant pulmonic regurgitation is seen. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is a
trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2148-9-25**],
there is now severe mitral regurgitation and there is now severe
pulmonary hypertension. Right ventricular systolic function is
now impaired. Left ventricular systolic function is now more
impaired. Left ventricular regional wall motion dysfunction
appears similar.
TEE ([**2149-4-4**]) - 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. Left ventricular systolic
function is hyperdynamic (EF>75%). Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
(3) are mildly thickened. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. The mitral valve leaflets do not fully coapt with
restrictive P1 motion. No mass or vegetation is seen on the
mitral valve. Moderate to severe (3+) mitral regurgitation is
seen without reversal of flow within the pulmonary veins. There
is moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Moderate to severe mitral regurgitation in setting
of restrictive P1 motion resulting in failure to coapt with A1
scallop, consistent with ischemic papillary muscle dysfunction.
Moderate pulmonary hypertenison.
TTE ([**2149-4-9**]) - The left atrium is moderately dilated. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. There is mild regional
left ventricular systolic dysfunction with hypokinesis of the
basal to mid inferolateral wall. [Intrinsic left ventricular
systolic function is likely more depressed given the severity of
valvular regurgitation.] The right ventricular free wall is
hypertrophied. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Moderate to severe (3+)
mitral regurgitation is seen. [Due to acoustic shadowing, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: There is at least moderate-to-severe mitral
regurgitation. This is likely due to tethering of the posterior
leaflet of the mitral valve caused by hypokinesis of the basal
to mid inferolateral wall. Overall ejection fraction is
preserved as the other segments are near-hyperdynamic. A
vegetation or abscess cannot be seen (cannot exclude). Moderate
to severe pulmonary hypertension.
CXR ([**2149-4-2**]) - IMPRESSION: Worsening [**Month/Day/Year 1106**] congestion. New
moderate right pleural effusion. New right mid and lower lung
opacities may reflect atelectasis and edema, but consolidation
cannot be excluded
CXR ([**2149-4-6**]) - The heart is mildly enlarged. There is left lower
lobe consolidation with a small left pleural effusion. In
addition, there is prominence of the central pulmonary
vasculature consistent with mild congestive failure. There is
mild atelectasis at the right lung base as well. There is a
right IJ Cordis. The Swan-Ganz catheter has been removed. A
right PICC terminates in the superior vena cava.
Renal U/S ([**2149-4-3**]) - IMPRESSION: Normal right lower quadrant
transplant kidney without perinephric fluid collection or
hydronephrosis. Normal resistive indices and arterial waveforms.
LE U/S ([**2149-4-3**]) - IMPRESSION: No evidence of DVT in the
bilateral lower extremities.
Carotid Artery U/S ([**2149-4-7**]) - IMPRESSION: Less than 40% stenosis
of the bilateral internal carotid arteries.
Ankle Films ([**2149-4-7**]) - IMPRESSION:
1. Postoperative change at the distal fibula.
2. Persistent destruction of medial malleolus fracture with
adjacent cortical irregularity compatible with prior
debridement, but residual infection is not excluded.
3. Subtle increase in density at the posterior aspect of the
calcaneus raises possibility of insufficiency fracture. Clinical
correlation is advised.
Panorex ([**2149-4-11**]) - FINAL READ PENDING
Brief Hospital Course:
Ms [**Known lastname 19419**] is a 45 yo woman with pmh of DM1, CAD s/p CABG and
PCI, ESRD s/p living-related kidney transplant in [**10-31**], and
recent hospitalization for septic arthritis here with acute
renal failure, acute diastolic heart failure with newly
diagnosed severe MR and pulmonary hypertension.
# Acute Mitral Regurgitation: The patient presented with
worsening dyspnea, crackles on exam, and TTE showing new severe
mitral regurgitation and pulmonary hypertension. Her
presentation was consistent with acute worsening of her mitral
regurgiation. Swan-Ganz catheter was placed and showed [**Date Range **]
pulmonary pressures, decreased SVR, and [**Date Range **] CO and CI. She
was tried on various meds to control her blood pressure and
reduce her afterload, including a nitroglycerine drip, a
nitroprusside drip, and IV hydralazine. Out of concern for
thiocyanate toxicity in the setting of her renal failure, she
was not kept on the nitroprusside for an extended period of
time. With the afterload reduction achieved by these
medications, her dyspnea improved. She simultaneously was given
IV lasix, with and without metolazone, in attempts at diuresis.
Her urine output, while slow at first, ultimately improved. She
underwent a TEE, which showed tethering of the papillary muscle
(see above for full report). Prior to transfer from the CCU to
the cardiology floor, the patient's hydralazine was changed to
PO and she was started on nifedipine and labetalol. By the time
she was transferred from the CCU, it was felt that she was no
longer fluid overloaded and her lasix and metolazone were held.
Of note, while the patient was in the CCU, she was evaluated by
CT surgery for potential mitral valve surgery in the future. She
will follow-up with them as an outpatient. She was placed back
on PO lasix prior to discharge.
# Acute on Chronic Renal Failure (s/p renal transplant): Prior
to admission, the patient's creatinine was noted to rise after
she had been found to have an undetectable tacrolimus level,
making acute rejection a possibility. Per renal recommendations,
she was given pulse-dose steroids. Renal ultrasound was
performed and did not show any acute process in the transplanted
kidney. Her urine revealed hyaline casts (c/w dehydration) and
muddy brown casts (c/w ATN). Her prograf levels were followed
daily, and her dose was adjusted accordingly. When it appeared
likely that the patient's ARF was not due to acute rejection,
her steroids were tapered. She was diuresed as above. Her
creatinine initially worsened, peaking at 4.1, but then
improved. Her creatinine was still [**Date Range **] above baseline at
the time of dischare. She will have close renal follow-up.
# Coronary Artery Disease: The patient has known coronary artery
disease s/p CABG and PCI. On presentation, she did not have any
chest pain or concerning ECG changes. As above, TEE suggested
that her worsened MR was likely due to papillary muscle
tethering (likely [**3-4**] prior ischemia). However, she did not show
any signs of active ischemia during her presentation. She ruled
out for ACS with three sets of cardiac enzymes. She was
continued on her aspirin, plavix, and atorvastatin.
# Recent Septic Arthritis of her Left Ankle: She was initially
continued on the vancomycin and ceftazidine that she had been on
at home. Because her vancomycin level was high, her vanc was
initially held. Her vancomycin levels were monitored daily and
her dose was adjusted accordingly. She was seen by infectious
disease, who recommended to d/c cefatzidine and continue a 6
week course of vancomycin from the day of hardware explant. She
was also seen by orthopedic surgery, who felt that her left
ankle was healing appropriately. She will follow up with
orthopedic surgery as an outpatient. Her outpatient antibiotic
therapy will also be followed by ID.
# Anemia: The patient's Hct on admission was 27.9 (her recent
baseline is 25 to 27). She had no clinical evidence of bleeding.
Her anemia was felt to likely be secondary to anemia of chronic
disease. She was continued on oral iron supplementation. Her
hematocrit was trended and ranged 22 to 27.
# Diabetes: The patient was noted to have [**Month/Day (2) **] blood sugars
on admission, likely related to pulse-dose steroids. She was
briefly on an insulin gtt. Her blood sugars remained labile
throughout her admission. Her lantus dose was increased prior to
discharge.
# Depression: She was continued on citalopram and bupropion.
Medications on Admission:
Prednisone 4 mg po daily
Tacrolimus 3 mg po bid
Atorvastatin 40 mg PO DAILY
Insulin Regular Human 100 unit/mL Solution Injection QACHS
Sulfamethoxazole-Trimethoprim 400-80 mg Tablet PO QMWF
Citalopram 20 mg po daily
Calcium 500 + D (D3) 500-125 mg-unit Tablet po daily
Pantoprazole 40 mg po daily
Metoclopramide 10 mg PO QIDACHS
Prochlorperazine 25 mg Suppository q12h prn
Docusate Sodium 100 mg PO BID
Trazodone 100 mg PO qHS
Ferrous Sulfate 300 mg (60 mg Iron) Tablet po q12h
Gabapentin 300 mg po q8h
Bupropion HCl 75 mg po daily
Metoprolol Succinate 25 mg po daily
Atrovent HFA 17 mcg Two (2) puffs Inhalation q6h prn
Vancomycin 1 gram IV Q 24H for 39 days (from [**2149-3-25**])
Ceftazidime 1 gram IV q12h for 39 days (from [**2149-3-25**])
Hydromorphone 2-4 mg PO Q4H prn
Clopidogrel 75 mg po daily
Furosemide 40 mg po bid
Senna 8.6 mg po q12h prn
Polyethylene Glycol 17 gram po daily prn
Ascorbic Acid 500 mg po bid
Aspirin 325 mg po daily
Lantus 18 units qhs
Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
2. Bupropion HCl 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO twice a day. Tablet(s)
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Seventeen
(17) grams PO DAILY (Daily) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Prochlorperazine 25 mg Suppository Sig: One (1) suppository
Rectal every twelve (12) hours as needed for nausea.
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
13. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO QMonWedFri.
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
19. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
20. Hydralazine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
21. Tacrolimus 1 mg Capsule Sig: Four (4) Capsule PO Q12H (every
12 hours).
Disp:*240 Capsule(s)* Refills:*2*
22. Nifedipine 90 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2*
23. Vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) mg Intravenous every twenty-four(24) hours for 18
days: Dose should be adjusted based off of renal function. Labs
will be drawn weekly. Antibiotic course to end on [**2149-5-2**].
Disp:*1 quantity sufficient* Refills:*0*
24. Insulin Glargine 100 unit/mL Solution Sig: Twenty Two (22)
units Subcutaneous at bedtime.
Disp:*1 month's supply* Refills:*2*
25. Humalog insulin sliding scale
26. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
PICC, non-heparin dependent: Flush with 10 mL Normal Saline
daily and PRN per lumen.
27. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
28. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two
(2) puffs Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
29. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times
a day): hold for SBP<100 or HR<60.
Disp:*360 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions Infusion Therapy
Discharge Diagnosis:
Primary:
1. Acute on chronic mitral regurgitation
2. Acute on chronic diastolic heart failure
3. S/p renal transplantation, with acute kidney injury in
transplanted kidney
4. septic arthritis of left ankle
Secondary:
1. Hypertension
2. Diabetes mellitis, type 1
3. Coronary artery disease
Discharge Condition:
Alert and oriented, hemodynamically stable, satting well on room
air.
Discharge Instructions:
You came to the hospital with difficulty breathing and worsened
kidney function. You were found to have heart failure from
worsened mitral regurgitation. You were treated with blood
pressure and diuretic medications, with improvement in your
breathing. The kidney service was consulted and helped to adjust
your immunosuppressive medications. Your kidney function
improved throughout your hospital stay.
.
You will need surgery to replace your mitral valve. You were
seen by the cardiac surgery service while in the hospital. You
will need dental clearance for surgery, so please make an
appointment to see your dentist as soon as possible. When you
see your dentist, explain that you need a pre-operative
evaluation for cardiac surgery.
.
There are some changes to your medications:
START labetalol
START nifedipine
START hydralazine
STOP metoprolol
STOP ceftazidime
STOP gabapentin
CHANGE furosemide to 80 mg twice daily
CHANGE tacrolimus to 4 mg twice daily
CHANGE vancomycin to 750 mg IV daily. Continue this until [**2149-5-2**]
CHANGE Lantus to 22 units at night
.
You will need to continue IV antibiotics (vancomycin) due to
your recent ankle infection. It is very important that you
complete your course of antibiotics so that you are
infection-free for cardiac surgery.
.
It is very important that you take all of your medications as
directed and follow up closely with your doctors. We have
scheduled some follow up appointments for you. You should eat a
low-sodium diet and weigh yourself daily. If you notice a change
in your weight of more than 3 pounds, or increased difficulty
breathing, you should contact your doctor right away.
Followup Instructions:
MD: [**Last Name (LF) **], [**First Name3 (LF) **]
Specialty: kidney transplant
Location: [**Last Name (NamePattern1) 439**], [**Hospital **] Medical Office Building, [**Location (un) 3971**]
Phone number: ([**Telephone/Fax (1) 3618**]
Date and Time: Tuesday, [**2149-4-15**] at 10:00 a.m.
.
MD: [**Last Name (LF) **], [**First Name3 (LF) **]
Specialty: cardiology
Location: [**Hospital Ward Name 23**] Building, [**Hospital1 18**], [**Hospital Ward Name 516**], [**Location (un) 436**]
Phone number: ([**Telephone/Fax (1) 2037**]
Date and Time: [**2149-4-22**] at 10:20 am
.
NP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: orthopedics
Location: [**Hospital Ward Name 23**] Building, [**Hospital1 18**], [**Hospital Ward Name 516**], [**Location (un) **],
orthopedics
Telephone Number: ([**Telephone/Fax (1) 5238**]
Date and Time: Tuesday, [**2149-4-29**] at 10 a.m.
.
Cardiac Surgery Clinic ([**Hospital Unit Name **] [**Location (un) 551**])
[**2149-5-5**] 01:00p
.
[**Year/Month/Day **] Surgery Clinic ([**Hospital Unit Name **] [**Location (un) **])
[**2149-5-27**] 11:00a
|
[
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"403.90",
"250.51",
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"424.0",
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"V45.81",
"414.00",
"305.1",
"041.19",
"V45.82",
"362.01",
"996.81",
"428.0",
"311",
"E878.0",
"276.51",
"584.5",
"272.4",
"711.07",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"89.64",
"88.72",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
22734, 22796
|
14251, 18744
|
371, 472
|
23130, 23202
|
6704, 14228
|
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|
5837, 5988
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19760, 22711
|
22817, 23109
|
18770, 19737
|
23226, 23981
|
6003, 6685
|
3920, 4503
|
24010, 24873
|
290, 333
|
500, 3810
|
4534, 5658
|
3832, 3900
|
5674, 5821
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,187
| 179,637
|
55148
|
Discharge summary
|
report
|
Admission Date: [**2146-9-19**] Discharge Date: [**2146-9-27**]
Date of Birth: [**2074-12-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Aortic stenosis
Major Surgical or Invasive Procedure:
[**2146-9-22**]: Aortic valve replacement with a size 21-mm [**Doctor Last Name **]
Magna tissue valve.
History of Present Illness:
71 year old male who has been experiencing mild chest pressure
dizziness, fatigue and SOB over the past several months. He
presented to [**Hospital 11560**] [**Hospital3 **] [**9-15**] with worsenig SOB
and chest pain that extended into his left hand. He also notes
dyspnea on exertion when climbing stairs. He was admitted and
ruled out for myocardial infarction. His echocardiogram revealed
significant aortic stenosis. Cardiac cath revealed no sigificant
CAD and carotids were clear. Of note during this admission he
was noted to have thrombocytopenia with platelet counts around
70,000 and was seen by Hematology who felt that he had
idiopathic thrombocytopenic purpura. They ok's him to receive
ASA and to proceed with the cath. He was transferred to [**Hospital1 18**]
for surgical evaluation for an aortic valve replacement.
Past Medical History:
Aortic Stenosis
Benign Prostatic Hyperplasia
Thrombocytopneia I ITP
Past Surgical History:
Tonsillectomy
herniorrhaphy
Social History:
Race:Caucasian
Last Dental Exam:
Lives with: wife, has 3 daughters
Contact: [**Name (NI) **] (wife) Phone #[**Telephone/Fax (1) 112498**]
Occupation:
Cigarettes: Smoked no [x] yes []
Other Tobacco use:denies
ETOH: < 1 drink/week [x] [**2-8**] drinks/week [] >8 drinks/week []
Illicit drug use:denies
Family History:
Father died at 65 in sleep
Mother died at 90 with Diabetes
Sister had breast cancer
Brother had stomach cancer at 62
Physical Exam:
Physical Exam
Pulse:63 Resp:18 O2 sat:97/RA
B/P Right:134/81 Left:128/84
Height: 5'8" Weight:205 lbs
General:
Skin: Warm [x] Dry [x] intact [xX]
HEENT: NCAT [X] PERRLA [X] EOMI [x]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [X] grade [**4-8**] HSM______
Abdomen: Round Soft [X] non-distended [X] non-tender [X] bowel
sounds + []
Extremities: Warm [X], well-perfused [X] Edema [] _____
Varicosities: None [X]
Neuro: Grossly intact [X]
Pulses:
Femoral Right: +2 Left:+2
DP Right: +2 Left:+2
PT [**Name (NI) 167**]:+2 Left:+2
Radial Right: +2 Left:+2
Carotid Bruit: Right: referred Left:Referred
Pertinent Results:
Echocardgiogram [**2146-9-22**]
PREBYPASS: Normal LV wall motion and systolic function with LVEF
> 55%. Mild to moderated LVH. Right ventricular chamber size and
free wall motion are normal. The number of aortic valve leaflets
cannot be determined because of the level of calcification, but
it is functionally bicuspid.. The aortic valve leaflets are
severely thickened/deformed. There is critical aortic valve
stenosis (valve area <0.8cm2). The mitral valve appears
structurally normal with trivial mitral regurgitation. Normal TV
and PV. No clot in LAA. Intact interatrial septum with no PFO
seen. The descending thoracic aorta has mild diffuse
atherosclerotic plaque. The coronary sinus appears normal.
Normal transmitral diastolic inflow velocity spectral profile (E
> A)and pulmonary venous spectral Doppler profile (S >D) With e'
= 6-8 cm/sec indicating perhaps either normal diastolic function
or a mild decrease in active relaxation. There is no pericardial
effusion.
POSTBYPASS: Normallly functioning bioprosthetic AV with no
significant AS or AI. LVEF > 60%, Otherwise unchanged
Spleen Ultrasound [**2146-9-21**]: Transverse and sagittal images were
obtained of the spleen. There is borderline splenomegaly and
the spleen measures 13.3 cm in length. IMPRESSION: Borderline
splenomegaly.
Chest CT [**2146-9-20**]:
FINDINGS: Cardiac size is normal. The aorta is normal in
caliber. The
ascending aorta measures up to 3.4 cm. There is a tiny area of
calcification in the proximal medial ascending aorta. There is
also two small calcifications in the arch. The descending aorta
is normal in caliber. Mediastinal lymph nodes do not meet CT
criteria for pathologic enlargement. There is calcification of
the aortic valve. There is no pleural or pericardial effusion
Peripheral Blood Smear:
Normal RBC and WBC morphology, big platelets and rare
megakaryocyte fragments.
.
[**2146-9-27**] 06:10AM BLOOD WBC-6.5 RBC-3.37* Hgb-10.4* Hct-30.4*
MCV-90 MCH-30.9 MCHC-34.2 RDW-14.3 Plt Ct-132*
[**2146-9-26**] 05:22AM BLOOD WBC-5.4 RBC-3.30* Hgb-10.3* Hct-29.2*
MCV-89 MCH-31.2 MCHC-35.2* RDW-14.2 Plt Ct-113*
[**2146-9-25**] 04:54AM BLOOD WBC-6.4 RBC-3.19* Hgb-9.8* Hct-28.2*
MCV-88 MCH-30.8 MCHC-34.9 RDW-14.5 Plt Ct-85*
[**2146-9-24**] 01:31AM BLOOD WBC-7.9 RBC-3.54* Hgb-10.9* Hct-30.9*
MCV-87 MCH-30.8 MCHC-35.3* RDW-14.5 Plt Ct-120*
[**2146-9-27**] 06:10AM BLOOD PT-13.0* PTT-25.3 INR(PT)-1.2*
[**2146-9-24**] 01:31AM BLOOD PT-13.8* PTT-27.7 INR(PT)-1.3*
[**2146-9-27**] 06:10AM BLOOD Glucose-102* UreaN-17 Creat-0.8 Na-137
K-4.4 Cl-102 HCO3-30 AnGap-9
[**2146-9-26**] 05:22AM BLOOD Glucose-102* UreaN-20 Creat-0.7 Na-136
K-3.8 Cl-99 HCO3-32 AnGap-9
[**2146-9-25**] 04:54AM BLOOD Glucose-105* UreaN-16 Creat-0.8 Na-138
K-3.9 Cl-101 HCO3-30 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname **] was transfer from [**Hospital6 3105**] for
surgical evaluation for an aortic valve replacement. Hematology
was consulted for his underlying cause of
thrombocytopenia, which is unclear. Splenic Ultrasound showed
Borderline splenomegaly. Given the range of his current
platelet count it would be safe for him to undergo heart surgery
with the appropriate anticoagulation.
The patient was brought to the Operating Room on [**2146-9-22**] where
the patient underwent Aortic valve replacement with a size 21-mm
[**Doctor Last Name **] Magna tissue valve.
Overall the patient tolerated the procedure well and
post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. The patient was evaluated by the physical therapy
service for assistance with strength and mobility. By the time
of discharge on POD 5 the patient was ambulating freely, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged home with services in good condition
with appropriate follow up instructions.
Medications on Admission:
None
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
if extubated
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
4. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride [Klor-Con] 20 mEq 1 packet by mouth daily
Disp #*7 Packet Refills:*0
5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg [**1-3**] tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
6. Metoprolol Tartrate 25 mg PO TID
hold for hr less than 60 and sbp less than 100
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
Care Tenders
Discharge Diagnosis:
Aortic Stenosis
Benign Prostatic Hyperplasia
Thrombocytopneia I ITP
? MRSA UTI, Tonsillectomy
herniorrhaphy
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema: 1+
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments:
Wound Check at Cardiac Surgery Office [**Telephone/Fax (1) 170**], [**2146-10-4**]
10:45
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 170**]
Date/Time:[**2146-10-25**] 1:30
Cardiologist Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**] [**2146-10-20**] at 1:00pm ( Address:
[**Doctor Last Name **] [**Hospital1 3597**], NH Phone: [**Telephone/Fax (1) 37284**])
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) **],RAOUF [**Telephone/Fax (1) 112499**] in [**4-7**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-9-27**]
|
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"746.4",
"287.31",
"998.11",
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"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
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7872, 7915
|
5419, 6932
|
325, 432
|
8067, 8233
|
2632, 5396
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1773, 1892
|
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|
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|
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|
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|
270, 287
|
460, 1293
|
1315, 1383
|
1452, 1757
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
61,551
| 102,028
|
6195
|
Discharge summary
|
report
|
Admission Date: [**2119-12-6**] Discharge Date: [**2119-12-12**]
Date of Birth: [**2065-11-1**] Sex: F
Service: MEDICINE
Allergies:
Bactrim / daptomycin
Attending:[**First Name3 (LF) 2291**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms [**Known lastname 24166**] is a 54 y/o F with hx of long-standing T1DM,
long-standing tobacco abuse (recently quit) and chronic
osteomyelitis of the foot who came to the ED after calling EMS
for experiencing acute-onset shortness of breath while lying in
bed at home. She denied chest pain or palpitations. She was
found by EMS to be hypoxic to 70s on room air, with increased
work of breathing and tachycardia to the 110s. She was given
nebulizers en route to the ED, without significant improvement.
In the ED, initial VS were: 99.2 120 216/80 32 92% with neb.
Exam notable for respiratory distress with accessory muscle use
and decreased breath sounds bilaterally with expiratory wheeze.
Labs revealed anemia slightly below baseline, normal WBC count,
hyperglycemia > 600, hyponatremia, mild anion gap metabolic
acidosis, normal cardiac biomarkers, and BNP 2500. ECG
demonstrated sinus tachycardia @ 141 bpm with lateral ST
depressions. CXR showed vascular prominence and cephalization
of the vessels, with LLL consolidation. The pt was given
increasing amounts of supplemental O2 but remained hypoxic; she
was started on CPAP with improvement in O2 sats and respiratory
rate. Her hypertension was treated with nitro gtt. She was
started on heparin gtt for empiric treatment of ACS and PE. She
was given 8 units regular insulin; fingerstick was not
rechecked. Bedside echo did not reveal ventricular dysfunction
or tamponade. Pt was given 20 mg IV furosemide. Vitals prior
to transfer were HR 120, RR 18, BP 165/62 O2 100% on CPAP.
On arrival to the MICU, she reports significant relief in
regards to her breathing. She denies cough, fever, sick
contacts. She has never experienced similar symptoms. Her last
fingerstick check was with breakfast yesterday, when it was 101.
Of note, the patient was seen in the [**Hospital1 18**] ED yesterday
afternoon, after her outpatient provider referred her for
nausea, vomiting, and lateral ECG changes. She had two negative
troponins and no stress test, and was discharged home.
Past Medical History:
per d/c summary [**2119-11-18**], confirmed with patient
- DM1 - insulin dependent, poorly controlled HBA1c 12%, managed
by
[**Last Name (un) **] Dr. [**First Name (STitle) **]
- DM associated neuropathy
- HTN
- HLD - LDL 102 in [**2112**]
- Back pain s/p fall
- History of osteomyelitis left hallux s/p ulcer infection
debridement [**4-/2119**] and again 12/[**2118**].
- Trigger release right index and long fingers [**6-/2118**]
- s/p Left first toe and ray amputation [**2119-11-15**]- Dr.
[**Last Name (STitle) **]
Social History:
per d/c summary [**2119-11-18**]
Lives with husband, no children. Works as staff assistant at
[**University/College **] [**Location (un) **]. Smokes 2 cig/day, has been smoking for 20
years used to smoke 1ppd. No ETOH or IVDA.
Family History:
per d/c summary [**2119-11-18**]
Mother with DM2 and CVA, father died of MI at age 76, siblings
all healthy
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, JVP @8 cm H20, no LAD
CV: Tachycardic, regular, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Decreased breath sounds throughout. No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP/PT pulses bilaterally, no
clubbing, cyanosis or edema. S/p left toe amp, no erythema or
purulence
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation, 2+ reflexes bilaterally, gait deferred
Physical Exam on discharge:
VS: Tmax 99.3 Tc 99 BP 147/80(142/63-167/68) p 79 (79-84) 20 95
% RA
General: Alert, oriented, no acute distress, speaking in full
sentences
HEENT: Sclera anicteric, mild conjunctival injection, MMM,
oropharynx clear, EOMI
Neck: supple, no LAD
CV: Regular, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Decreased breath sounds throughout. No wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
Ext: warm, well perfused, 2+ radial/DP pulses bilaterally, no
clubbing, cyanosis or edema. S/p left toe amp with bandage in
place
Neuro: 5/5 strength upper/lower extremities, grossly normal
sensation
Pertinent Results:
Labs on admission:
[**2119-12-6**] 12:10AM ALBUMIN-3.6 CALCIUM-8.4 PHOSPHATE-4.3
MAGNESIUM-1.9
[**2119-12-6**] 12:10AM proBNP-2459*
[**2119-12-6**] 12:10AM cTropnT-0.02*
[**2119-12-6**] 12:10AM ALT(SGPT)-26 AST(SGOT)-21 CK(CPK)-49 ALK
PHOS-637* TOT BILI-0.4
[**2119-12-6**] 12:10AM GLUCOSE-619* UREA N-28* CREAT-1.8*
SODIUM-127* POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-19* ANION
GAP-20
[**2119-12-6**] 12:13AM LACTATE-2.5*
[**2119-12-6**] 04:54AM RET AUT-1.6
[**2119-12-6**] 04:54AM PT-13.5* PTT-76.5* INR(PT)-1.3*
[**2119-12-6**] 04:54AM PLT COUNT-234
[**2119-12-6**] 04:54AM WBC-5.4 RBC-2.68* HGB-7.4* HCT-22.7* MCV-85
MCH-27.6 MCHC-32.7 RDW-14.3
[**2119-12-6**] 04:54AM WBC-5.4 RBC-2.68* HGB-7.4* HCT-22.7* MCV-85
MCH-27.6 MCHC-32.7 RDW-14.3
[**2119-12-6**] 04:54AM CALCIUM-8.1* PHOSPHATE-4.1 MAGNESIUM-1.8
[**2119-12-6**] 04:54AM CK-MB-3 cTropnT-0.07*
[**2119-12-6**] 05:02AM LACTATE-2.4*
[**2119-12-6**] 11:27AM CK-MB-4 cTropnT-0.12*
[**2119-12-6**] 11:27AM CK(CPK)-59
[**2119-12-6**] 02:14PM GLUCOSE-175* UREA N-31* CREAT-1.9*
SODIUM-130* POTASSIUM-3.9 CHLORIDE-98 TOTAL CO2-21* ANION GAP-15
[**2119-12-6**] 07:49PM PT-12.0 PTT-43.8* INR(PT)-1.1
[**2119-12-6**] 07:53PM CK-MB-3 cTropnT-0.12*
[**2119-12-6**] 07:53PM CK(CPK)-46
ECHO [**2119-12-6**]:
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy with normal cavity size. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
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. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is mild
pulmonary artery systolic hypertension. There is an anterior
space which most likely represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Technically suboptimal to exclude focal wall
motion abnormality. Mild mitral regurgitation. Mild right
ventricular dilation with normal function. Compared with the
prior study (images reviewed) of [**2119-11-16**], estimated pulmonary
artery pressure is mildly elevated (previously undetermined).
CT chest w/o contrast [**2119-12-6**]:
1. Lytic process T2 vertebral body and small associated
paravertebral soft
tissue mass could be infectious or malignant. Dedicated neuro
imaging
recommended for assessment of the spinal canal.
2. Moderate left and small right nonhemorrhagic layering pleural
effusions
may have increased slightly since [**19**]:00 a.m. No evidence of
extensive
pneumonia, but small areas of infection could be missed given
the large scale
left lower lobe atelectasis and smaller atelectasis at the right
base.
3. Numerous borderline bilateral axillary lymph nodes and
possibly in the
left hilus, and less extensive lymph node enlargement in the
mediastinum.
MRI w/o contrast [**2119-12-7**]:
Compression fracture of T2 with signal abnormalities involving
the adjacent T1/T2 and T2/T3 intervertebral disc spaces and T1
as well as T3 enplates. Small contiguous anterior paraspinous
soft tissue component.
Differential diagnosis includes osteomyelitis or, far less
likely, metastatic process.
There is no evidence of cord compression or epidural abscess in
this
non-enhanced exam.
RUQ ultrasound with dopplers:
1. Low volume, nondistended gallbladder containing sludge and
small,
[**Doctor Last Name 5691**]-like stones. Nonspecific gallbladder wall thickening and
pericholecystic fluid. In combination with lack of elevated
white blood cell count, ultrasound findings are not suspicious
for acute cholecystitis.
2. Moderate bilateral pleural effusions.
Labs on discharge:
[**2119-12-12**] 06:35AM BLOOD WBC-6.5 RBC-2.91* Hgb-8.0* Hct-23.7*
MCV-82 MCH-27.5 MCHC-33.7 RDW-14.3 Plt Ct-341
[**2119-12-12**] 06:35AM BLOOD Glucose-65* UreaN-22* Creat-1.0 Na-133
K-4.3 Cl-105 HCO3-21* AnGap-11
[**2119-12-12**] 06:35AM BLOOD AlkPhos-98
[**2119-12-12**] 06:35AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1
Brief Hospital Course:
This is a 54-year-old female with hx T1DM, tobacco abuse,
osteomyelitis of left foot on chronic antibiotics, recent ED
visit for nausea/vomiting and ECG changes, admitted with acute
onset pulmonary edema, hypertensive crisis, and mild diabetic
ketoacidosis.
Active Issues:
# Flash pulmonary edema: The patient was admitted to the MICU
with flash pulmonary edema in the setting of hypertensive
urgency. She did have a troponin rise that peaked at 0.12
without MB elevation. The patient was started on a heparin drip
for possibility of ACS versus pulmonary embolism. She was
unable to undergo CTA for PE secondary to acute kidney injury.
The patient underwent a transthoracic ECHO that showed a normal
ejection fraction, left ventricular hypertrophy, and could not
exclude a wall motion defect. She was started on BIPAP and
diuresed with initial good response. BIPAP was subsequently
removed in the ICU and diuresis was continued. She was
transferred to the cardiology wards. On the floor, the patient
continued to diurese well with normalization of her oxygen
saturation on room air. Heparin drip was stopped upon transfer
to the floor due to low likelhood of acute coronary syndrome and
pulmonary embolism (given rapid improvement in A-A gradient).
Ms. [**Known lastname 24166**] was continued on aspirin, statin, and beta
blocker. She was discharged on lasix 20 mg daily.
# Elevated troponin: On admission, troponin rose from 0.02 and
peaked at 0.12 without elevation in CK-MB. She was initially
started on a heparin drip for ACS, but the heparin drip was
discontinued as elevated troponin was likely related to demand
ischemia in setting of hypertensive urgency, flash pulmonary
edema, and tachycardia. ECG did show rate-related ST depressions
in V4-V6. The patient remained chest pain free throughout
admission. She was started on aspirin, a statin, and continued
on home metoprolol. Her home valsartan was held given acute
kidney injury. The patient should undergo cardiac cath as an
outpatient with improvement in her renal function. A repeat
echocardiogram should also be performed in follow-up.
# Hypertension: The patient was admitted with hypertensive
urgency to 216/80 complicated by flash pulmonary edema. She was
initially started on a nitro drip, that was weaned in the ICU.
She was continued on home amlodipine initially, increased to 10
mg daily before discharge. Home metoprolol was titrated up to
150mg [**Hospital1 **] for blood pressure control. Valsartan was held in the
setting of acute kidney injury until the day of discharge when
her creatinine decreased to 1.0. The cause of hypertensive
urgency is unclear, but may relate to poorly controlled type 1
diabetes.
# DM1/Hyperglycemia: Glucose >600 on admission, with mild anion
gap acidosis (gap 15). The patient was briefly placed on an
insulin drip, and then transitioned to her home insulin regimen
with closure of her anion gap. Precipitant for hyperglycemia
was unclear, though potential etiologies include insulin
nonadherence (patient unclear if took med and does not remember
sliding scale), infection (possible infectious diarrhea, chronic
osteomyeltis), or flash pulmonary edema. The patient was seen
by [**Last Name (un) **], who made changes to her home sliding scale. With
inpatient adherence to her insulin sliding scale, glycemic
control improved.
# Nausea/vomiting: The patient was admitted with 5 days of
nausea. On admission, she began to also experience non-bloody
diarrhea. The patient was seen by infectious disease for
possible antibiotic side effect for cause of her symptoms.
Stool studies were negative for infectious diarrhea. The
patient was given zofran as needed for nausea, which
significantly improved before discharge.
# Pleural effusions: Noted on CXR and CT scan. Likely secondary
to flash pulmonary edema. No evidence of pneumonia - patient
did not had any cough or CP, and did not have a leukocytosis.
As patient had concerning T2 lesion on CT scan, there was
concern for malignant effusions. Interventional pulmonary was
consulted for possible thoracentesis; however, further diuresis
was recommended as onset and appearance of effusions on imaging
makes them less likely malignancy. On day 4 of admission,
effusions began to improve with diuresis.
# [**Last Name (un) **]: The patient has had an elevated creatinine (as high as
2.2) since the end of [**Month (only) **] (baseline Cr 0.9-1.1). Recent
renal ultrasound was negative for hydronephrosis. Recent
SPEP/UPEP negative. [**Last Name (un) **] likely represents prerenal azotemia
from poor forward flow, as the patient's creatinine began to
improve with diuresis. Due to [**Last Name (un) **], the patient's valsartan was
held until discharge when her creatinine decreased to 1.0.
# MRSA Osteomyelitis: Per patient, wound healing well with
regular dressing changes by VNA. She is followed closely by
outpatient ID, on vancomycin. The patient's vancomycin was
discontinued by outpatient ID physician on the day of admission
for possible drug reaction (vanco as source of nausea). She
received one dose of daptomycin, and developed a drug rash.
Daptomycin was discontinued and the patient was resumed on
vancomycin. The patient was followed by inpatient infectious
disease throughout admission.
# T2 Lytic lesion: On CT scan, the patient was incidentally
noted to have a large, concerning lesion that takes up much of
T2 vertebral body. The patient underwent thoracic MRI that
revealed associated compression fracture with the T2 lesion and
soft tissue changes in T1-T3. The patient was seen by
infectious disease, who felt the lesion was in fact consistent
with vertebral osteomyelitis. They recommended follow up
imaging in [**1-28**] weeks to look at interval chane in the lesion.
If at that time there is no interval change, IR-guided biopsy
should be considered.
# Normocytic anemia: Hct trending down over recent admissions.
Iron studies c/w anemia of chronic inflammation. B12 and folate
WNL. Recent SPEP/UPEP negative. Labs not suggestive of
hemolysis. Hematocrit was trended throughout admission.
# Hyponatremia: The patient was admitted with hyponatremia to
130 (baseline normal). Hyponatremia likely hypervolemic,
secondary to fluid overload, as it improved to baseline with
diuresis.
# Hyperlipidemia: Patient not on medication as outpatient, but
has been started on pravavastatin this admission given cardiac
risk factors.
# Elevated AlkPhos: The patient was admitted with elevated alk
phos and GGT, likely secondary to hepatic source. She underwent
a right upper quadrant ultrasound that showed mild gallbladder
sludge, but was otherwise normal. No evidence of congestive
hepatopathy, as AST and ALT normal. AST had decreased to normal
before discharge.
# Anxiety regarding multiple new diagnoses: Patient very
anxious about recent dyspnea and multiple recent
hospitalizations. She was followed by social work throughout
admission.
Transitional Issues:
-Pt was full code for this admission
-Pt will be followed by [**Hospital 4898**] clinic for her osteomyelitis and
follow up lumbar spine CT scan
-Pt should be considered for an outpatient catherization based
on her troponin bump and new diagnosis of congestive heart
failure
Medications on Admission:
AMLODIPINE - 5 mg daily
CIPROFLOXACIN - 500 mg [**Hospital1 **]
INSULIN GLARGINE [LANTUS] - 15 units at bedtime
INSULIN LISPRO [HUMALOG] - SS scale
LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - 1
once a day as needed for back pain
METOPROLOL SUCCINATE [TOPROL XL] - 50 mg daily
MOXIFLOXACIN [AVELOX] - 400 mg daily
VANCOMYCIN - 1.25 grams Q24hrs
ASPIRIN 325 mg daily
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
2. insulin glargine 100 unit/mL Solution Sig: Nineteen (19)
units Subcutaneous at bedtime.
3. insulin lispro 100 unit/mL Solution Sig: please take as
directed on sliding scale Subcutaneous -.
4. lidocaine Topical
5. metoprolol tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
Disp:*180 Tablet(s)* Refills:*0*
6. vancomycin in D5W 1 gram/200 mL Piggyback Sig: Seven Hundred
Fifty (750) mg Intravenous Q 24H (Every 24 Hours).
Disp:*30 gram* Refills:*2*
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
10. Outpatient Lab Work
1.Please check CBC, BMP and LFT's, ESR and CRP once a week and
fax results to infectious disease clinic at [**Telephone/Fax (1) 1419**], attn:
Dr. [**Last Name (STitle) **]
2. Please check a vancomycin trough level on [**2119-12-14**] and fax
results to infectious disease clinic at [**Telephone/Fax (1) 1419**], attn: Dr.
[**Last Name (STitle) **]
11. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Home Solutions
Discharge Diagnosis:
Primary:
- Acute Diastolic Heart Failure
- Osteomyelitis
- Hypertension
- Acute Kidney Injury
Secondary:
- Diabetes Mellitus type 1
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mrs. [**Known lastname 24166**],
It was a pleasure taking of you during your hospitalization at
[**Hospital1 69**]. You were admitted with
shortness of breath. This is the result of heart failure. You
were treated with removing fluid from your lungs and controlling
your blood pressure. You will need to follow-up with a
cardiologist who can continue to monitor this.
We continued treating your foot infection with IV antibiotics.
We discovered that you had an area in your spine that most
likely is also an infection. In order to make sure that it
improves with your antibiotics (and isn't something besides an
infection, like malignancy) you will need to have a repeat MRI
in [**1-28**] weeks to evaluate for improvement of the lesion. If it
is not improved then a biopsy will likely need to be performed.
You are now ready for discharge home.
PLEASE NOTE THE FOLLOWING MEDICATION CHANGES:
- STARTED VALSARTAN 80 MG DAILY FOR HIGH BLOOD PRESSURE
- STARTED PRAVASTATIN 20 MG DAILY FOR HIGH CHOLESTEROL
- STARTED FUROSEMIDE (LASIX) 20 MG DAILY FOR INCREASED FLUID
- INCREASED AMLODIPINE TO 10 MG DAILY FOR HIGH BLOOD PRESSURE
- INCREASED METOPROLOL TO 150 MG TWICE A DAY FOR HIGH BLOOD
PRESSURE
- INCREASED INSULIN GLARGINE TO 19 UNITS AT BEDTIME FOR HIGH
BLOOD SUGAR
- INCREASED SLIDING SCLAE HUMALOG (PLEASE SEE ATTACHED SHEET)
- DECREASED VANCOMYCIN TO 750 MG DAILY FOR INFECTION
- STOPPED CIPROFLOXACIN 500 MG TWICE A DAY
- STOPPED MOXIFLOXACIN 400 MG DAILY
Followup Instructions:
Department: INFECTIOUS DISEASE
When: MONDAY [**2119-12-25**] at 10:30 AM
With: [**Name6 (MD) 14621**] [**Last Name (NamePattern4) 14622**], MD [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: [**Hospital3 249**]
When: [**Hospital3 **] [**2119-12-15**] at 1:50 PM
With: [**Doctor First Name 306**] C-[**Name Initial (MD) **] [**Name8 (MD) 308**], M.D. [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: THURSDAY [**2119-12-28**] at 9:00 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: PODIATRY
When: MONDAY [**2120-1-1**] at 2:50 PM
With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
|
[
"584.9",
"357.2",
"730.17",
"272.4",
"250.83",
"731.8",
"428.0",
"285.9",
"730.28",
"722.92",
"787.91",
"250.63",
"300.00",
"250.13",
"787.01",
"401.9",
"428.31",
"276.1",
"041.12",
"790.5",
"V15.82",
"V58.67",
"411.89"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
18062, 18107
|
9046, 9305
|
302, 309
|
18284, 18284
|
4687, 4692
|
19931, 21277
|
3185, 3294
|
16750, 18039
|
18128, 18263
|
16346, 16727
|
18435, 19317
|
3334, 3991
|
4019, 4668
|
16042, 16320
|
19337, 19908
|
243, 264
|
9321, 16020
|
8705, 9023
|
337, 2381
|
4707, 8685
|
18299, 18411
|
2403, 2924
|
2940, 3169
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,363
| 123,420
|
54693
|
Discharge summary
|
report
|
Admission Date: [**2174-5-6**] Discharge Date: [**2174-5-18**]
Date of Birth: [**2112-8-24**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Known firstname 1406**]
Chief Complaint:
Dyspnea, orthopnea, and lower extremity edema
Major Surgical or Invasive Procedure:
[**2174-5-10**]
PROCEDURES:
1. Aortic valve replacement with a 21-mm St. [**First Name5 (NamePattern1) 923**] [**Last Name (NamePattern1) 4041**]
tissue valve, Ref # TF-21A, SN # [**Numeric Identifier 111846**]
2. Mitral valve replacement with a 31-mm St. [**Male First Name (un) 923**] epic
tissue valve, Ref # E100-31M-00, SN # [**Numeric Identifier 111847**]
3. Pericardial patch closure of a perimembranous
ventricular septal defect.
4. Exploration of tricuspid valve.
History of Present Illness:
Mr. [**Known lastname **] is a 61 year-old male admitted with fevers 102.6,
leukocytosis and Congestive Heart failure SOB and weakness. An
echocardiogram revealed endocarditis with vegetation seen on the
mitral leaflet. His blood cultures x2 with gram postive cocci in
pairs and chains. OSH urine culture Enterococcus.Cardiac surgery
consulted for surgical correction.
Past Medical History:
Endocarditis
mental disability: paramnesia (used to hear voices)
Myopic
Past Surgical History: none
Social History:
Lives alone in "complete isolation." Estranged from his two
sisters and both his parents are deceased. He is unemployed and
disabled from prior mental illness "paramenesia" and used to
have auditory hallucinations. He spends his days working on his
"project" which is [**Location (un) 1131**] philosophers such as [**Location (un) **] and [**Location (un) 5936**]
and taking notes and making analyses. No longer has
hallucinations. Quit smoking 15-20 years ago, was smoking [**12-20**]
pack of non-filters daily for 3 years. Drinks 12 beers in 24
hours once every 2 weeks. History of cocaine use "to investigate
the side effects of a friend who was using it". No illicit drugs
currently.
Family History:
father died of [**Name (NI) 6988**] disease age 47, mother died of a
cardiac arrythmia. health of sisters is unknown.
Physical Exam:
Admission Exam:
General: Alert, oriented, flat affect, cachetic with temporal
wasting
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP mildly elevated, no LAD
CV: Irregular tachycardia, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles at bases bilaterally, no wheeze
Abdomen: soft, RUQ with fullness and mild tenderness,
non-distended, bowel sounds present, no organomegaly
GU: foley
Rectal: external hemorrhoids, firm enlarged prostate, guaiac
negative brown stool
Ext: warm, well perfused, 2+ pulses, [**1-21**]+ pitting edema up to
knees bilaterally, no rashes
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally,
finger-to-nose intact
Pertinent Results:
CT of Chest/Abd/Pelvis ([**2174-5-7**]):
IMPRESSION:
1. Pulmonary edema. Please note that superimposed infection
cannot be
excluded. Follow-up after diuresis is recommended. No evidence
of pulmonary embolism.
2. No CT evidence of malignancy in the torso.
Head MRI ([**2174-5-10**]):
IMPRESSION:
1. Small area of acute infarct in the left parietal lobe.
Additional small areas of T2 shine-through in the right temporal
region with associated blood products and a subtle area of
enhancement. These findings indicate a combination of acute
infarcts and subacute infarcts with blood products. There is no
abscess identified or abnormal meningeal enhancement seen.
2. Diffuse decreased signal in the visualized bony structures
could be due to marrow hyperplasia or infiltration and clinical
correlation is recommended.
3. No evidence of mass effect or hydrocephalus.
Spine MRI ([**2174-5-10**]):
IMPRESSION:
1. No evidence of discitis or definite evidence of
osteomyelitis seen.
2. Foci of signal abnormality within the T4 and L4 vertebral
bodies are
likely due to hemangiomas which have atypical appearance
secondary to diffuse bony abnormality secondary to marrow
hyperplasia or infiltration. This foci are less likely
secondary to metastasis or foci of osteomyelitis given the
appearances on the post-gadolinium images. However, a followup
study can confirm this suspicion.
3. Diffuse low signal in the bony structures due to marrow
hyperplasia or
infiltration.
4. No evidence of epidural abscess or spinal cord compression.
5. Diffuse high signal on T2 images within the soft tissues
likely secondary to soft tissue edema. Other findings as above.
.
Intra-op TEE [**2174-5-10**]
PREBYPASS: The left atrium is moderately dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is mildly dilated. Regional left ventricular wall motion
is normal. Overall left ventricular systolic function is normal
(LVEF>55%) with mild LV dilation. The ascending, transverse and
descending thoracic aorta are normal in diameter and free of
atherosclerotic plaque. There is a large vegetation on the
aortic valve. Severe (4+) aortic regurgitation is seen. There is
a large vegetation on the mitral valve. Severe (4+) mitral
regurgitation is seen. There is a large vegetation on the
tricuspid valve attached to the TV subvalvular apparatus. There
is no significant pulmonic regurg and NO veg on the PV. Normal
PV leaflets. There is a very small pericardial effusion. There
is a large right pleural effusion. The interatrial septum is
intact. There is no clot in the LAA. The coronary sinus appears
normal.
POSTBYPASS: Normally functioning AV, MV bioprosthesis. Mild TR.
No sig valvular stenosis or regurgitation. Mildly decreased LV
systolic function with LVEF = 40-45%. Otherwise unchanged.
.
[**2174-5-17**] WBC-11.2* RBC-3.54* Hgb-10.3* Hct-34.1* MCV-96 MCH-29.0
MCHC-30.1* RDW-22.1* Plt Ct-207
[**2174-5-6**] WBC-19.8* RBC-3.33* Hgb-9.2* Hct-27.6* MCV-83 MCH-27.6
MCHC-33.3 RDW-15.7* Plt Ct-334
[**2174-5-17**] Glucose-75 UreaN-23* Creat-0.6 Na-137 K-4.5 Cl-104
HCO3-29
[**2174-5-10**] UreaN-52* Creat-1.6* Na-138 K-4.5 Cl-105 HCO3-20*
[**2174-5-10**] Glucose-105* UreaN-56* Creat-1.8* Na-137 K-4.3 Cl-99
HCO3-25
[**2174-5-6**] Glucose-95 UreaN-18 Creat-0.8 Na-126* K-4.8 Cl-93*
HCO3-24
[**2174-5-15**] ALT-87* AST-88* LD(LDH)-363* Amylase-35 TotBili-0.4
Cultures:
[**2174-5-6**] Blood Culture x2, Routine (Final [**2174-5-9**]):
ENTEROCOCCUS FAECALIS.
Anaerobic Bottle Gram Stain (Final [**2174-5-7**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Aerobic Bottle Gram Stain (Final [**2174-5-7**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 2 S
VANCOMYCIN------------ 1 S
[**Date range (3) 111848**] Blood cultures x 6 No Growth
[**2174-5-6**] URINE CULTURE (Final [**2174-5-8**]): ENTEROCOCCUS SP
[**2174-5-10**]: tissue Aortic Valve & Tricuspid Valve; GRAM STAIN
(Final [**2174-5-10**]): 3+ (5-10 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final [**2174-5-14**]): ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 347-3295H [**2174-5-10**].
ENTEROCOCCUS SP.. SPARSE GROWTH. SECOND MORPHOLOGY.
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ <=0.5 S
[**2174-5-18**] 05:57AM BLOOD WBC-11.6* RBC-3.32* Hgb-10.1* Hct-32.2*
MCV-97 MCH-30.4 MCHC-31.3 RDW-22.8* Plt Ct-257
[**2174-5-6**] 04:35PM BLOOD WBC-19.8* RBC-3.33* Hgb-9.2* Hct-27.6*
MCV-83 MCH-27.6 MCHC-33.3 RDW-15.7* Plt Ct-334
[**2174-5-8**] 04:12AM BLOOD Neuts-86.2* Lymphs-11.5* Monos-2.2
Eos-0.1 Baso-0.1
[**2174-5-11**] 04:42AM BLOOD PT-18.7* PTT-38.7* INR(PT)-1.8*
[**2174-5-6**] 04:35PM BLOOD PT-17.6* PTT-28.5 INR(PT)-1.7*
[**2174-5-18**] 05:57AM BLOOD Glucose-76 UreaN-26* Creat-0.5 Na-138
K-4.4 Cl-105 HCO3-28 AnGap-9
[**2174-5-6**] 04:35PM BLOOD ALT-127* AST-87* LD(LDH)-364* AlkPhos-66
TotBili-0.4
Brief Hospital Course:
MEDICAL COURSE:
Mr. [**Known lastname **] is a 61 year-old man without ongoing medical care
presents with 2 month failure to thrive with dyspnea and lower
extremity edema and hypoxia, found to have severe endocarditis
with destruction of multiple valve leaflets. Patient was
initially in MICU for ongoing work-up and treatment of his
endocarditis and was transferred to CT surgery for valve repair.
# Endocarditis: Patient presented with dyspnea, hypoxia and
heart failure. He was found to have severe degree of valve
destruction with wide open MR [**First Name (Titles) **] [**Last Name (Titles) **]. ECHO showed vegetations on
AV, MV, TV and possibly pulmonic valve. All the valve
destruction causing heart failure with accompanying problems of
[**Name2 (NI) **] edema, SOB, likely congestive hepatopathy. Blood cultures
with enterococcus. Cardiac surgery, infectious disease, and
cardiology were consulted. Patient was initially started on
vancomycin with gent for synergy. His CRP was 96 and ESR was 14
on the day of treatment initiation. Cultures returned VSE and
antibiotics were transitioned to Cefazolin and gentamicin for
synergy.
On [**2174-5-10**], patient was taken by cardiac surgery to OR for valve
replacement/repair.
# Heart Faiure: Patient presented with severe dyspnea. BNP
elevated. Due to severe valve destruction from endocarditis.
Attempted diuresis in MICU but patient with poor response to
lasix and BUN/Cr bumped. Patient was electively intubated on
[**2174-5-9**] given worsening tachypnea, inability to diurese and need
for patient to lie flat for studies and cardiac catheterization.
Patient underwent cardiac catheterization on [**2174-5-9**] showing
clean coronary arteries. Patient underwent cardiac surgery on
[**2174-5-10**].
# [**Last Name (un) **]: Cr initially 0.8 with BUN 18. However, after aggressive
diuresis + contrast load, Cr 1.5 and BUN 42. Also has started
gentamicin adding to renal insults. Patient was seen by renal,
who felt that his [**Last Name (un) **] was possibly secondary to CIN. He was
started on sevelemer for hyperphos. Renal team followed patient
during hospitalization.
# Back Pain: Concern that this is due to discitis/osteomyelitis
due to septic embolic from endocarditis as can complicate 10-15%
of endocarditis all comers. Patient had MRI on [**2174-5-10**] without
definite evidence of discitis or osteomyelitis. However,
patient did have foci of signal abnormality within the T4 and L4
vertebral bodies likely due to hemangiomas which have atypical
appearance secondary to diffuse bony abnormality secondary to
marrow hyperplasia or infiltration. There was no evidence of
epidural abscess or spinal cord compression.
# Transaminitis: Likely due to congestive hepatopathy from heart
failure above. Had hepatitis serologies at PCP couple days prior
and all negative (no evidence of hep B vaccination either).
.
SURGICAL COURSE:
Mr.[**Known lastname **] was brought to the Operating Room on [**2174-5-10**] where he
underwent AVR, MVR, TV debridement, debridement of abscess from
ventricular septal wall by DR.[**Last Name (STitle) **]. Please refer to operative
note for further surgical details. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. He underwent bronchoscopy in the immediate
post-op period for LUL collapse. By POD 2 the patient was
extubated, alert and oriented and breathing comfortably. He was
neurologically intact and hemodynamically stable, weaned from
inotropic and vasopressor support. Beta blocker and aspirin
were initiated and the patient was gently diuresed toward his
preoperative weight. ID continued to follow the patient and
adjusted his antibiotics accordingly as cultures resulted.
Final tissue cultures from the OR revealed Enterococcus. He
received a PICC for long term antibiotic therapy. The patient
was transferred to the telemetry floor for further recovery.
Pacing wires were discontinued without complication. Chest
tubes remained in for a prolonged period due to persistent air
leaks bilaterally. The tubes were clamped, CXR taken and
ultimately discontinued. A stable right apical pneumothorax
persists. He had a brief episode of post-op AFib which
converted to sinus rhythm with amiodarone. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD #8 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to [**Hospital3 **] and rehabilitation in good condition with
appropriate follow up instructions.
Medications on Admission:
FUROSEMIDE 20 MG TABS (FUROSEMIDE) one tablet po daily
Discharge Medications:
1. Gentamicin 100 mg IV Q12H
2. ampicillin sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q4H (every 4 hours) for 5 weeks: through [**2174-6-21**].
3. Antibiotics
Gentamicin and Ampicillin to continue through [**2174-6-21**]
4. Outpatient Lab Work
weekly safety labs: CBC with diff, CMP, LFTs, weekly gent
trough. results faxed to: [**Telephone/Fax (1) 1419**]
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
11. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO DAILY (Daily).
14. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): x 7 days then decrease to 200 mg [**Hospital1 **] x 7 days, then
decrease to 200 mg daily.
16. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
17. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
18. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain/fever.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehabilitation & [**Hospital **] Care Center - [**Location 1268**]
Discharge Diagnosis:
Endocarditis
mental disability: paramnesia (used to hear voices)
Myopic
Past Surgical History: none
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
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
Daily weights: keep a log
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 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:
Cardiology: [**Doctor Last Name **] [**2174-6-14**] at 2:20p [**Hospital Ward Name 516**] [**Hospital Ward Name 23**]
Clinical Center [**Location (un) **]
Surgeon Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**], [**2174-6-16**] at 1:00p in the [**Hospital **]
Medical Building [**Last Name (NamePattern1) **]
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2174-6-15**]
10:00
Provider: [**First Name11 (Name Pattern1) 3049**] [**Last Name (NamePattern4) 14666**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2174-5-27**] 8:30
Please call to schedule the following:
Primary Care Dr. [**Last Name (STitle) 5240**],[**First Name3 (LF) 5241**] [**Telephone/Fax (1) 798**] in [**3-24**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
weekly safety labs: CBC with diff, CMP, LFTs, ESR/CRP, Gent
trough q 3 days. results faxed to ID at: [**Telephone/Fax (1) 1419**]
Completed by:[**2174-5-18**]
|
[
"421.0",
"276.1",
"396.0",
"367.1",
"790.4",
"784.69",
"584.9",
"518.82",
"E878.8",
"512.1",
"041.04",
"276.2",
"285.9",
"745.4",
"427.31",
"599.0",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.14",
"96.70",
"38.91",
"33.23",
"38.93",
"35.23",
"35.21",
"88.56",
"39.61",
"35.72",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
14929, 15038
|
8368, 13072
|
354, 840
|
15182, 15340
|
2976, 8345
|
15941, 17107
|
2084, 2203
|
13178, 14906
|
15059, 15131
|
13098, 13155
|
15364, 15918
|
15154, 15161
|
2218, 2957
|
269, 316
|
868, 1239
|
1261, 1333
|
1379, 2068
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,131
| 115,920
|
42143
|
Discharge summary
|
report
|
Admission Date: [**2183-8-6**] Discharge Date: [**2183-8-16**]
Service: SURGERY
Allergies:
Versed / Lactose
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
painless jaundice
Major Surgical or Invasive Procedure:
ERCP with bile duct stent and sphincterotomy on [**8-6**]
History of Present Illness:
[**Age over 90 **]M h/o AAA repair in [**2154**], h/o CVA [**2175**], h/o iliac stenting who
developed painless jaundice 4d prior to admission. He is
admitted for observation following ERCP with biliary stenting
and sphincterotomy today. There was a stricture in his CBD with
evidence of gallstones and possible extrinsic compression found
on the ERCP. His LFTs are significant for a dirict bilibunemia
to above 5 with elevated ALT and AST above 500s. He was
hospitalized one year ago with cholecystitis at [**Hospital3 **], but was found to not be a surgical candidate and he was
treated with medical management and low fat diet. He has
intermittent episodes of RUQ pain but has not been for that
recently. He is not a drinker and he does not know if has been
diagnosed with hepatitis before if he has had blood
transfusions.
ROS:
denies SOB, DOE, orthopnea, CP, but he is minimally active given
L leg weakness. denies previous coronary stenting, prior MI, or
recent TTE
Past Medical History:
AAA s/p repair in [**2154**]
iliac stenting and embolization treatment (aneurysm?)
L leg weakness following AAA repair
CVA without residual symtpoms, presented with L arm weakenss
[**2175**]
bladder cancer [**2161**]
h/o diverticulitis
h/o falls
Social History:
lives alone, daughter lives in house next door
wife is in [**Name (NI) 1501**] for dementia
retired vet
former smoker
no ETOH
Family History:
father with diabetes
Physical Exam:
Physical Exam on Admission:
120/84, HR 60, afebrile
extremely pleasant elderly male with poor hearing, aox3, no
distress
heent: scleral icterus present
neck supple
CV: RRR NMRG, JVP not distended
PULM: CTAB no wheezes
abd: soft, trace RLQ tenderness, but no rebound, not distended
extremities: L foot with joint deformity
skin: jaundice, multiple sebhorric keratosis on back, no skin
breakdown or ulceration in LE
neuro: CN grossly intact, speech fluent, L leg strength
diminished
psych: calm
Pertinent Results:
[**2183-8-6**] 01:15PM BLOOD WBC-4.7 RBC-3.64* Hgb-10.1* Hct-31.2*
MCV-86 MCH-27.8 MCHC-32.4 RDW-14.2 Plt Ct-192
[**2183-8-6**] 01:15PM BLOOD PT-14.9* PTT-26.2 INR(PT)-1.3*
[**2183-8-6**] 01:15PM BLOOD UreaN-31* Creat-1.6* Na-142 K-4.6 Cl-105
HCO3-27 AnGap-15
[**2183-8-6**] 01:15PM BLOOD ALT-389* AST-454* AlkPhos-1059*
Amylase-37 TotBili-6.7* DirBili-5.0* IndBili-1.7
[**2183-8-6**] 01:15PM BLOOD Lipase-19
ERCP report:
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Cytology samples were obtained for histology using a brush.
A 13cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully.
Impression: Successful cannulation of bile duct (cannulation)
Successful sphincterotomy was performed
Irregular 2 cm common hepatic stricture
Cytology samples were obtained for histology using a brush.
A 13cm by 10FR Cotton [**Doctor Last Name **] biliary stent was placed
successfully.
Otherwise normal ercp to third part of the duodenum
EKG
sinus brady, first degree AV block, L axis deviation, poor R
wave progression,
Brief Hospital Course:
Primary reason for hospitalization:
[**Age over 90 **]M yo M with history of AAA repair in [**2154**], CVA [**2175**], iliac
stenting who developed painless jaundice 4d prior to admission,
and after ERCP with sphincterotomy developed a GI bleed with 10
point Hct drop, thus was transferred to the ICU.
Active Diagnoses:
#GI bleed: Upon admission to the ICU the patient had a 10 point
Hct drop after 2 maroon BMs on the floor. Also with 1 episode
of black emesis. Thus, upper GI bleed is most likely, and given
recent ERCP with sphincterotomy, source of bleeding is most
likely secondary to instrumentation. On arrival to ICU, another
bloody BM. Vital signs are stable, no hypotension/tachycardia
and patient asymptomatic. He was given a total of 4 units
pRBCs, and q6h hematocrits were checked. Asprin and plavix were
held in the setting of spincerotomy and bleed. He received a
PICC line for venous access. Hct stabilized over the course of
the day and patient did not require any further transfusions.
Patient received another ERCP in which no active bleeding was
seen.
#Jaundice: On ERCP, there was an irregular 2 cm common hepatic
stricture. Also, a single irregular stricture that was 2 cm
long was seen at the common hepatic duct. There was no
post-obstructive dilation. Two large stones were seen just
outside common hepatic duct. On CT scan, moderately dilated bile
ducts, hypodensities in R hepatic [**Last Name (LF) 3630**], [**First Name3 (LF) **] ill defined soft
tissue mass which may be neoplastic implant. The gallbladder
itself is decompressed and the wall is indistinct. This raised
concern for infiltrating gallbladder carcinoma into the adjacent
hepatic parenchyma. Patient afebrile and [**Last Name (LF) 3584**], [**First Name3 (LF) **] no concern
for cholangitis. [**Month (only) 116**] also be sclerosing cholangitis, but less
likely. Mirizzi syndrome on differential. Hepatitis is not
likely as no known history, but possible. Hepatitis serologies
were obtained and returned negative. Patient was empirically
covered on Unasyn. Patient was taken for ERCP and was found to
have purulent drainage and 2cm hepatic stricture, raising the
possibility of Mirizzi's syndrome. Previously placed stent had
migrated and was remove and two other stents placed. Surgery
was consulted and took the patient to the OR for open
cholecystectomy on [**2183-8-11**]. At the time of surgical
exploration, he had a gallbladder that was filled with 3 large
stones and severalsmaller stones. There were marked adhesions
around the gallbladder. Frozen sections of the gallbladder
obtained intra-op were sent to patholohy and demonstrated no
evidence of malignancy. During the procedure after removing the
stones in the upper portion of the gallbladder, a small glimpse
of stent in the common duct at the base of the inside of what
had been the gallbladder was noted, and was thought to most
likely be the base of the cystic duct communicating with the
common duct. There was no bile emanating from this site,and was
a very small pinpoint opening. A JP drain was placed. The
patient recovered well post-operatively and was tolerating a
clear liquid diet by POD#1 and was later advanced to a regular
diet on POD#2 without issue. However on POD#1 it was noted that
output from the JP drain had become bilious and the volumes
persisted in the range of 500-700 daily over the following days.
Due to concern that this might be secondary to obstruction or
further migration of his biliary stents, the patient was sent
for a repeat ERCP on POD#4 ([**2183-8-15**]) which demonstrated a
biliary leak as well as two small superficial non-bleeding
ulcerations in the wall of the bile ducts secondary to migration
of the previous biliary stents. The stents were replaced and
re-positioned in the R. and L. main hepatic ducts. The patient
did well post-procedure, with improvement in his serum bilirubin
levels.
#PVD: Patient with history of AAA repair: ASA and plavix were
held prior to sphincterotomy and continued to be held in the
setting of GI bleed following first ERCP. Aspirin and plavix
were re-started following the open cholecystectomy and third
ERCP.
#CKD: Patient with stage 3 chronic kidney disease, with previous
Cr measured at 1.6 in [**2179**] prior to admission. Medications were
renally dosed. Upon discharge, Cr was stabilized to 1.4-1.5
As the patient was working well with physical therapy,
tolerating PO, pain was well managed, and continued to recover
well post-op, he was determined to be stable for discharge to
[**Hospital **] nursing home on POD#5 with JP drain until follow-up
appointment with Dr. [**Last Name (STitle) **]. PICC line was removed prior to
discharge, without complication.
Medications on Admission:
simvastatin 40mg qhs
atenolol 25mg qd
aspirin 81mg qd (held 4d ago)
plavix 75mg qd (held 4d ago)
fluticasone nasal spray
remeron 7.5mg qhs
tylenol PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily): 2 sprays in each nostril once daily
as needed.
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain: Maximum 6 tablets daily.
8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. mirtazapine 7.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Nursing Home - [**Location (un) **]
Discharge Diagnosis:
Mirizzi's syndrome (status-post ERCP complicated by bleeding
from the sphincterotomy site and now status-post open
cholecystectomy)
CAD/atherosclerosis
AAA s/p repair
History of CVA ([**2175**])
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: [**Year (4 digits) **] and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Wound (Right abdominal incision along the costal border):
Incision is closed with subcutaneous sutures. Please leave the
overlying steri-strips in place as they will fall off on their
own with regular wear. Patient may shower as per usual routine.
Avoid baths/soaking. Avoid application of topical creams/lotions
to the incision. Can cover with dry gauze dressing as needed.
Drain (JP drain in the right mid-abdomen): This drain will
remain in place and will be re-evaluated upon follow-up. Please
empty the drain every four hours or sooner as needed if full. It
is very important that the amount of all drain output be
recorded on the sheets provided. Strip the drain hourly and
after each emptying.
Pain: Low dose oxycodone and tylenol (2 grams daily maximum)
Activity: Ambulate as tolerated. Avoid heavy lifting (>10lbs)
Followup Instructions:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD, [**Telephone/Fax (1) 673**]. Follow up appointment will be
arranged and you will receive a call regarding follow-up from
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] RN, Hepatobiliary Coordinator
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2183-8-16**]
|
[
"729.89",
"997.4",
"576.8",
"575.8",
"V12.54",
"574.91",
"443.9",
"996.59",
"E878.6",
"414.01",
"578.1",
"998.11",
"E878.1",
"285.1",
"585.3",
"V10.51",
"783.21",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.10",
"51.85",
"51.14",
"97.05",
"51.87",
"51.22",
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
9432, 9510
|
3422, 3725
|
239, 298
|
9749, 9749
|
2285, 3399
|
10801, 11252
|
1735, 1757
|
8355, 9409
|
9531, 9728
|
8180, 8332
|
9949, 10778
|
1772, 1786
|
182, 201
|
326, 1306
|
1800, 2266
|
9764, 9925
|
3743, 8154
|
1328, 1576
|
1592, 1719
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
42,351
| 105,836
|
796+797
|
Discharge summary
|
report+report
|
Admission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]
Date of Birth: [**2119-3-4**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 2597**]
Chief Complaint:
acute L leg ischemia
Major Surgical or Invasive Procedure:
Left femoral embolectomy and vein patch angioplasty.
History of Present Illness:
This 55-year-old gentleman presented to our emergency room last
night with an acutely ischemic left foot which had been present
for several hours. He was placed on heparin with significant
improvement in symptoms. He had absent pulses distal to the
groin on the left with intact pulses throughout on the right. He
is now being explored for possible embolectomy.
Past Medical History:
PMH:
MI,
HIV,
HTN
Social History:
He denies any use of alcohol or IV drugs. He has smoked [**1-30**]
packs of cigarettes per day for the last 30 years.
Family History:
non contributary
Physical Exam:
HEENT:
No thrush. Neck is supple.
Full range of motion. No lymphadenopathy.
CHEST:
is clear to auscultation bilaterally.
HEART:
regular rate and rhythm without gallops or rubs noted. There is
a III/VI murmur noted at the left lower sternal border to the
left upper sternal border.
ABDOMEN:
is soft, nontender, nondistended. There were
bowel sounds noted.
RECTAL:
There is no stool in the vault. The fluid in the vault is occult
blood negative.
EXTREMITIES:
without clubbing, cyanosis or edema.
NUEROLOGICAL EXAMINATION:
Awake, alert and oriented x3.
Cranial nerves, motor examination and sensory examination were
normal.
The toes were down-going bilaterally.
Pertinent Results:
[**2174-9-11**]
WBC-6.0 RBC-2.66* Hgb-11.9* Hct-31.4* MCV-118* MCH-44.7*
MCHC-37.8* RDW-13.4 Plt Ct-184
[**2174-9-11**]
Plt Ct-184
[**2174-9-11**]
PT-12.4 PTT-27.7 INR(PT)-1.0
[**2174-9-11**]
Glucose-93 UreaN-15 Creat-0.9 Na-141 K-4.1 Cl-107 HCO3-27
AnGap-11
[**2174-9-8**]
CK(CPK)-409*
[**2174-9-11**]
Calcium-8.9 Phos-2.9 Mg-1.7
Cardiology Report ECG Study Date of [**2174-9-8**] 11:30:44 AM
Baseline artifact. Sinus rhythm. Q waves in the anterior leads
consistent with prior infarction. Probable left atrial
abnormality. Compared to the previous tracing of [**2169-3-14**] the
rate is faster.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 168 96 [**Telephone/Fax (2) 5693**] 57
[**2174-9-8**] 2:07 PM
CHEST (PRE-OP PA & LAT)
Reason: pt preop vascular surgery
[**Hospital 93**] MEDICAL CONDITION:
55 year old man with new onset pain L leg/blanching and pulses
diminished. Arterial clot
REASON FOR THIS EXAMINATION:
pt preop vascular surgery
INDICATION: Left leg blanching and decreased pulses,
preoperative study for vascular surgery.
No studies are available for comparison on PACs.
AP UPRIGHT AND LATERAL VIEWS OF THE CHEST: The heart size is
normal. The mediastinal and hilar contours are normal. The lungs
are clear. There is no pleural effusion or pneumothorax. The
osseous structures are unremarkable.
IMPRESSION: No evidence of acute cardiopulmonary process.
GENERAL URINE INFORMATION
Type Color Appear Sp [**Last Name (un) **]
Straw Clear 1.008
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln pH Leuks
SM NEG NEG NEG NEG NEG NEG 6.5 NEG
RBC WBC Bacteri Yeast Epi
0-2 0-2 NONE NONE 0-2
Brief Hospital Course:
Pt admitted on [**2174-9-11**]
Stared on heparin.
Pt undergoes a Left femoral embolectomy and vein patch
angioplasty. Pt tolerates the procedure well. There were no
complications. Flow was re-established into
the profunda femoris first and then into the superficial femoral
artery. Doppler interrogation demonstrated good flow in both
branches and there was a strongly palpable dorsalis pedis pulse.
Pt extubated in the OR. Pt transfered to the PACU in stable
condition.
Once recovered from anesthesia. Pt transfered to the PACU in
stable condition.
Once recovered from anesthesia pt transfered to the VICU
instable condition.
IV Heparin started / coumadin started.
[**2174-9-12**]
Pt delined, diet was advanced as tolerated.
PT consult was obtained. Pt was allowed to get OOB to chair.
[**2174-9-13**] - Discharge
Pt stable PTT was monitered / On Discharge pt INR not at desired
level. Pt [**Name (NI) 1788**] on lovenox for bridge over to couamdin.
On discharge pt is stable / taking PO / ambulating / pos BM /
urinating without difficulty.
Medications on Admission:
lopressor 25',
combivir,
viramune,
lisinopril,
lipitor,
aspirin
Discharge Medications:
1. Lovenox 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous once a day: Continue lovenox daily until INR is at
least 2.0.
Disp:*30 syringes* Refills:*0*
2. Outpatient [**Name (NI) **] Work
PT, INR labs every other day until INR is at least 2.0. Please
have the [**Name (NI) **] fax the results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD.
3. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours.
Disp:*40 Tablet(s)* Refills:*0*
4. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO at
bedtime.
Disp:*30 Tablet(s)* Refills:*6*
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis
1) Thromboembolism s/p embolectomy and vein patch angioplasty.
secondary diagnosis
2) HIV
3) HTN
4) h/o MI
Discharge Condition:
good
Discharge Instructions:
Please resume all your home medications as before as well as the
ones prescribed to you upon discharge from the hospital. If you
experience fevers, chills, leg pain, or severe bleeding from
your incisions, please report to the emergency department.
Please do not drive for one week. Please keep your dressing on
till Monday. You may take a shower on Monday. Please do not
soak in baths or swim in pools.
Please be careful with falls and bumps because of increased risk
of bleeding with lovenox and coumadin.
Followup Instructions:
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in one week to follow
up your blood coagulation times (PT/INR). Please call ([**Telephone/Fax (1) 5694**] to make an appointment. Dr. [**Last Name (STitle) **] will also set up
a TTE to evaluate your heart. Thank you.
Please follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 2 weeks. Please
call [**Telephone/Fax (1) 3121**] to make an appointment.
Completed by:[**2174-11-1**] Admission Date: [**2174-9-8**] Discharge Date: [**2174-9-11**]
Date of Birth: [**2119-3-4**] Sex: M
Service: VSU
CHIEF COMPLAINT: Left leg ischemia.
HISTORY OF PRESENT ILLNESS: This is a 55 year old gentleman
with HIV, coronary artery disease, status post myocardial
infarction, who woke up at 1:00 a.m. with an ice cold left
leg from the upper thigh to the foot. He admits to pain in
the calf and numbness. Symptoms improved by 5:00 a.m., but
pain continued. The patient went to the emergency room at an
outside hospital at [**Hospital3 417**] Hospital in [**Hospital1 1474**],
where he was evaluated. The patient was begun on IV heparin
and transferred here for further evaluation and treatment.
On arrival to our emergency room, vascular service was
consulted. The patient was admitted to the vascular service
for definitive care.
PAST MEDICAL HISTORY: Allergies to penicillin,
manifestations unknown. Illnesses include coronary artery
disease and myocardial infarction at the age of 49, status
post angioplasty. History of HIV. History of hypertension.
PAST SURGICAL HISTORY: No past surgical history.
MEDICATIONS: Lopressor XL 25 mg daily; Combivir 1 puff
b.i.d.; Lisinopril 25 mg daily; Lipitor 40 mg daily; aspirin
325 mg daily.
SOCIAL HISTORY: Positive for smoking and occasional alcohol
use.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION: Vital signs: Temperature 98.4. Pulse
80. Respirations 18. Blood pressure 207/94, rechecked
172/107, rechecked 148/81. Oxygen saturation 96% on room air.
General appearance: Alert and oriented. HEENT exam was
unremarkable. There are no carotid bruits. Heart is irregular
rate and rhythm. Lungs are clear to auscultation. Abdominal
exam is unremarkable. Pulse exam shows palpable femoral's
bilaterally. On the left palpable popliteal, DP and PT
signals only. On the right palpable popliteal, palpable DP
and PT. The exam is remarkable numbness on the base of the
left foot and sensory motor is intact.
HOSPITAL COURSE: Admitting labs: The white count is 7.1,
hematocrit 42.0, platelets 249K. BUN 23, creatinine 1.1.
EKG was sinus rhythm with no acute changes.
The patient was continued on his IV heparin. A diagnostic
arteriogram would be done in the morning. Dr.[**Name (NI) 5695**]
initial exam he felt the patient either had an embolus or
embolic occlusion since he had a history of cath
claudication.
The patient proceeded to the OR and underwent a left femoral
embolectomy with a vein patch angioplasty. He tolerated the
procedure well. Findings showed an embolus in the left common
femoral at the bifurcation. The patient was extubated in the
OR and transferred to the PACU in stable condition with a
palpable DP. Immediately postoperatively there were no acute
events. He required nitroglycerin for systolic blood pressure
control. His postoperative hematocrit was 36.2. He continued
to do well and was transferred to the VICU for continued
monitoring and care.
Postoperative day 1 there were no overnight events. The
patient remained neurologically intact. The wounds were
clean, dry and intact. The patient's diet was advanced as
tolerated. IV fluids were Hep-Lock. Ambulation was begun and
the patient was D-lined and transferred to the regular
nursing floor.
The patient was begun on Lovenox with Coumadin conversion. An
echo would be done on an outpatient basis per his primary
care physician. [**Name10 (NameIs) **] patient is to follow up with his primary
care physician or [**Hospital 197**] Clinic for labs and adjustment in
his Coumadin dosing.
The patient was discharged on postoperative day 2 in stable
condition.
DISCHARGE DIAGNOSES:
1. Left femoral embolus, status post embolectomy and vein
patch angioplasty.
2. History of coronary artery disease, status post
myocardial infarction, status post coronary angioplasty.
3. History of HIV.
4. History of hypertension.
5. History of hyperlipidemia.
6. History of peripheral vascular disease.
DISCHARGE MEDICATIONS:
1. Lovenox 80 mg b.i.d. This should be continued until his
INR is in a steady state of 2.0 or greater. His labs
should be drawn every other day and the results called to
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5696**] for Coumadin dosing adjustment.
2. Percocet 5/325 tablets 1 to 2 q.4-6h p.r.n. for pain.
3. Coumadin 5 mg daily.
4. Colace 100 mg b.i.d.
The patient is to resume his preoperative medications of:
1. Lopressor XL 25 mg daily.
2. Combivir 1 puff b.i.d.
3. Lipitor 40 mg daily.
4. Lisinopril 25 mg daily.
5. Aspirin 325 mg daily.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 5697**]
Dictated By:[**Last Name (NamePattern1) 2382**]
MEDQUIST36
D: [**2174-11-1**] 13:56:32
T: [**2174-11-1**] 14:21:01
Job#: [**Job Number 5698**]
|
[
"401.9",
"444.22",
"V45.81",
"V08",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.56",
"38.08"
] |
icd9pcs
|
[
[
[]
]
] |
5233, 5239
|
3341, 4398
|
290, 345
|
5409, 5416
|
1641, 2429
|
5978, 6628
|
7846, 7864
|
10149, 10469
|
10492, 11351
|
2466, 2555
|
5260, 5388
|
4424, 4489
|
8506, 10128
|
5440, 5955
|
7603, 7762
|
962, 1622
|
7887, 8488
|
6646, 6666
|
2584, 3318
|
6695, 7354
|
7377, 7579
|
7779, 7829
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,220
| 138,473
|
3196
|
Discharge summary
|
report
|
Admission Date: [**2181-9-12**] Discharge Date: [**2181-9-14**]
Date of Birth: [**2117-5-27**] Sex: M
Service: NSU
CHIEF COMPLAINT: Cerebellar hemorrhage.
HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old
male with a past medical history significant for melanoma
with metastases to the brain, pelvis, and lungs. He had a
recent DVT, and he has been on Coumadin and presented to the
emergency department with nausea and vomiting for 1 day. He
had been seen in Hematology/[**Hospital **] Clinic the day prior to
presentation and was found to have an INR of 8. He received
vitamin K subcutaneous and was sent home. Apparently at
home, he fell asleep and awoke next morning with nausea and
multiple episodes of bilious emesis, which was nonbloody. He
also complained of a frontal headache. Per his wife, the
patient was agitated the day prior and very unsteady on his
feet, moving from side to side with his walker. She also
reported that he has been more lethargic than usual, but
denied any history of fevers, chills, speech changes, visual
changes, numbness, or weakness. The patient had been started
on Lovenox approximately 1 week prior to presentation and
Coumadin on Sunday and the Monday previous to admission,
which would have been 2 and 3 days prior to presentation.
PAST MEDICAL HISTORY: Significant for melanoma in [**9-3**].
Status post dissection of a lesion on the left chin.
He also had lymph node dissection in [**10-4**].
He is status post metastases to the brain, pelvis, and lungs.
Status post stereotactic radiosurgery to the left medial
frontal lobe and 2 metastases in the vermis in [**6-5**].
He is also status post DVT in [**9-5**].
He also has history of hypertension.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Phenytoin.
2. Sertraline.
3. Atorvastatin.
4. Hydrochlorothiazide.
5. Dilantin.
6. Percocet.
7. Senna.
8. Colace.
9. OxyContin.
10. Decadron.
11. Coumadin.
12. Terfenadine.
13. Ativan.
14. Ramipril.
PHYSICAL EXAMINATION: On admission, the patient's vital
signs were temperature 97.6, blood pressure 167/63, pulse of
72, respirations of 18, and saturating 96 percent on room
air. He was an ill-appearing gentleman, sleeping but
arousable to voice. His mucous membranes were moist. Neck
was supple. Good range of motion. His lungs were clear to
auscultation bilaterally. His heart rate was regular. His
belly was soft, nontender, and nondistended with positive
bowel sounds. His extremities were warm and well perfused.
No clubbing, cyanosis, or edema. Neurologically, he was
sleepy but arousable. He was oriented to person and year.
He was cooperative. His language was fluent with no
dysarthria, no apraxia. No gap was noted. Fund of knowledge
was normal. His visual fields were full. Extraocular
movements intact. Cranial nerves II through XII were intact
grossly. Tongue was midline. He had normal bulk and tone.
No noted tremors or drift. His strength was [**6-6**] throughout
outside of the right [**Last Name (un) 938**], which was noted to be [**5-7**].
Sensation was intact throughout, as was proprioception.
Reflexes were 2 in the upper extremities. His toes were
upgoing, and his lower extremity reflexes were 2 at the
patellar and 1 at the Achilles. Coordination revealed some
moderate dysmetria on fine finger movements, left greater
than right.
LABORATORY DATA: On admission included a white count of 8.9,
hematocrit of 31.2, and platelets of 230,000. His INR was
4.4. His panels revealed a sodium of 132, potassium of 3.2,
chloride of 91, bicarb 28, BUN 12, and creatinine 0.6.
Glucose was 260. His UA revealed elevated glucose and 15
ketones.
HOSPITAL COURSE: Head CT was consistent with an MRI, which
had been completed on [**2181-8-31**], and revealed a superior
vermian mass, which was enlarged from 1 cm to 2.3 cm,
hemorrhagic. The fourth ventricle was noted to be narrowed
but without any hydrocephalus present. He was ordered to
have every 1-hour neurochecks, and dexamethasone was started
for cerebral edema as well as seizure prophylaxis in the form
of Dilantin. He was also at admission ordered to have
mannitol started to reduce his cerebral swelling. He was
given some vitamin K to correct his coagulopathy. Due to his
history of hypertension, he required blood pressure control,
and this was accomplished with a combination of home
medications and p.r.n. hydralazine. He did require several
transfusions during his hospital course, FFP to correct his
coagulopathy, 1 unit of packed red blood cells to correct his
hematocrit, and his diet was advanced through his hospital
course. He was initially n.p.o., but by the time of
discharge, he was tolerating a regular diet. The family
informed that the teams that were involved that the patient
was DNR/DNI. The patient remained stable through his
hospital course. He did not require any aggressive
neurosurgical intervention. Neuro-oncology was involved in
his care due to his history of cancer, and they agreed that
at the time of discharge he would require some visiting nurse
involvement. This was set up for him. The setup was for
hospice care following the visiting nurse visits. The
patient was discharged to home on hospital day number 3. He
was stable at the time of discharge, tolerating p.o. diet,
working with physical therapy and occupational therapy.
DISCHARGE MEDICATIONS:
1. Pepcid 20 mg p.o. b.i.d.
2. Ativan 1 mg p.o. q.h.s.
3. Sertraline 100 mg p.o. q.d.
4. Lipitor 10 mg p.o. q.d.
5. Hydrochlorothiazide 12.5 mg p.o. q.d.
6. Ramipril 10 mg p.o. q.d.
7. Dilantin 300 mg p.o. t.i.d.
8. Senna 8.6 mg p.o. b.i.d.
9. Colace 100 mg p.o. b.i.d.
10. Percocet 5/325 mg 1 to 2 tablets p.o. q.4-6h. p.r.n.
pain.
11. Insulin sliding scale.
12. Dexamethasone 6 mg p.o. q.6h.
DISCHARGE INSTRUCTIONS: The patient was to follow up with
Dr. [**Last Name (STitle) 724**] in [**Hospital 878**] Clinic on [**2181-9-24**] at 3 o'clock and
with Dr. [**Last Name (STitle) **] in Hematology/[**Hospital **] Clinic on [**2181-9-25**]
at 2 o'clock, and he was to have an MRI on [**2181-9-24**] at 01:45
p.m. A was completed for the patient for his visiting nurse
visits as well as for hospice care. Discharge instructions
also included that the patient was to call Dr. [**Last Name (STitle) 724**] or Dr. [**First Name (STitle) **]
or the hospice nurse if he developed any questions or
concerns or if the symptoms were not controlled at home.
DISCHARGE DIAGNOSES: Metastatic vermal lesion with
hemorrhage.
Metastatic melanoma.
Deep venous thrombosis.
Hypertension.
OTHER INSTRUCTIONS: Please call with questions, pager number
[**Serial Number 15008**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 8632**]
Dictated By:[**Last Name (NamePattern1) 15009**]
MEDQUIST36
D: [**2181-9-14**] 09:55:46
T: [**2181-9-14**] 14:55:43
Job#: [**Job Number 15010**]
|
[
"198.5",
"V10.82",
"197.0",
"453.8",
"198.3",
"431"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6533, 6996
|
5437, 5851
|
1803, 2032
|
3736, 5414
|
5876, 6511
|
2055, 3718
|
154, 178
|
207, 1313
|
1336, 1777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,022
| 106,488
|
7151
|
Discharge summary
|
report
|
Admission Date: [**2185-8-25**] Discharge Date: [**2185-8-28**]
Date of Birth: [**2119-4-16**] Sex: M
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
right HNP of C5-C6 with compression of exiting nerve root
Major Surgical or Invasive Procedure:
right ACDF C5-C6
History of Present Illness:
66-year-old man with a history of diabetes type 2, CAD, status
post RCA PTCA, PVD, status post bilateral lower extremity PTCAs,
hypercholesterolemia
and a-fib who had presented to the hospital for elective ACDF of
C5-6.
Physical Exam:
Neuro:
Motor strength 5/5 deltoid, biceps, triceps, and hand intrinsics
bilaterally.
Sensory: decreased appreciation to pinprick in 1st 2 digits of
right hand.
Reflexes: 2+ in triceps and left biceps, but right biceps was
un-elicitable.
Lhermitte's phenomenon present.
No point tenderness or clonus.
Pertinent Results:
[**2185-8-25**] 10:27PM TYPE-ART PO2-332* PCO2-51* PH-7.32* TOTAL
CO2-27 BASE XS-0
[**2185-8-25**] 09:57PM GLUCOSE-187* UREA N-20 CREAT-1.3* SODIUM-141
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-23 ANION GAP-12
[**2185-8-25**] 09:57PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.6
[**2185-8-25**] 09:57PM PT-13.9* PTT-23.6 INR(PT)-1.2*
[**2185-8-25**] 05:34PM GLUCOSE-146* UREA N-20 CREAT-1.3* SODIUM-144
POTASSIUM-3.9 CHLORIDE-112* TOTAL CO2-24 ANION GAP-12
[**2185-8-25**] 05:34PM CALCIUM-7.9* PHOSPHATE-3.2 MAGNESIUM-1.6
[**2185-8-25**] 05:34PM WBC-8.5 RBC-3.83* HGB-11.7* HCT-33.3* MCV-87
MCH-30.6 MCHC-35.1* RDW-14.3
[**2185-8-25**] 05:02PM TYPE-ART PO2-304* PCO2-45 PH-7.34* TOTAL
CO2-25 BASE XS--1 INTUBATED-INTUBATED
[**2185-8-25**] 05:02PM GLUCOSE-124* LACTATE-2.3* NA+-143 K+-3.8
CL--112
[**2185-8-25**] 05:02PM HGB-11.4* calcHCT-34
[**2185-8-25**] 05:02PM freeCa-1.11*
Brief Hospital Course:
Patient is 66 year old male with h/o right NHP of C5-C6. He was
taken to the OR on [**2185-8-25**] where he had a right ACDF of C5-C6.
There were no complications during the procedure. However,
postoperatively, he experienced left hemiparesis and underwent
MRI/MRA of head and neck which were all within normal limits. He
remained intubated and in SICU overnight. The next morning his
motor function returned to almost normal with the exception of
left deltoid weakness. He was extubated. He was transferred out
of the ICU. Diet and activity were advanced. He continued to
improve. He was seen by PT who felt he would benefit from some
outpt PT. His incision was clean and dry with steristrips.
Medications on Admission:
levothyrox
lipitor
amiodarone
atenolol
Discharge Medications:
1. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours)
as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
HNP C5-C6 on the right with compression of the exiting C6 nerve
root
Discharge Condition:
neurologically stable
Discharge Instructions:
You may shower and pat dry but do not submerge in water for 2
weeks. Watch for bleeding, redness, swelling, drainage. Remove
steristrips in 10 days if they have not yet fallen off.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 548**] in 4 weeks. Call for appointment
[**Telephone/Fax (1) 2992**]
Completed by:[**2185-8-28**]
|
[
"427.31",
"722.0",
"244.9",
"272.0",
"250.00",
"V45.82",
"722.4",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.62",
"80.51",
"81.02",
"41.98"
] |
icd9pcs
|
[
[
[]
]
] |
3258, 3264
|
1896, 2594
|
377, 396
|
3376, 3400
|
980, 1873
|
3632, 3780
|
2683, 3235
|
3285, 3355
|
2620, 2660
|
3426, 3609
|
660, 961
|
280, 339
|
424, 645
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
523
| 196,271
|
27804
|
Discharge summary
|
report
|
Admission Date: [**2141-12-19**] Discharge Date: [**2141-12-26**]
Date of Birth: [**2087-2-13**] Sex: F
Service: SURGERY
Allergies:
Aspirin / Ibuprofen
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
abdominal pain, hiccups
Major Surgical or Invasive Procedure:
[**2141-12-20**]
Exploratory laparotomy with extensive lysis of adhesions,
resection of right colon with ileocolic anastomosis, small bowel
resection x2, drainage of retroperitoneal and intra-abdominal
abscess
History of Present Illness:
Ms. [**Known lastname 1349**] is a 54 year old female s/p aortobifemoral bypass
graft on [**12-7**] after a prior fem-fem crossover graft. She was
discharged on [**2141-12-12**] to home. 1 day following discharge she
began having intractable hiccups, worsening nausea, and
worsening abdominal pain. On [**12-16**] she reports having 4
episodes of bilious vomiting which has continued since that
time. Additionally she has been having worsening diffuse
abdominal pain. Was seen by PCP today who obtain a CT scan at
an outside facility. CT scan showed ? of fluid collection vs.
dilated small bowel with air fluid level. She was transferred
to the [**Hospital1 18**] ED for further care. Of note, she is unsure if she
is passing flatus but does reports daily normal bowel movements.
Past Medical History:
- Cholecystectomy
- Appendectomy
- Diverticulitis
- Gastric Ulcers
- Kidney Stones
- Partial Gastrectomy at 31
- SBO
PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**Location (un) 11269**], MA.
Past psych: No hospitalizations or formal psychiatric treatment.
Saw a counselor 15 years ago briefly. No previous suicide
attempts (confirmed by daughter). Daughter says she would often
threaten suicide when frustrated but never came to close to
acting out on it.
Social History:
Lives with her father and mother after her husband died, denies
EtOH, smoker, 30 pack/year history of smoking
Family History:
sister-etoh, [**Name2 (NI) 802**]-diagnosed with Bipolar
Physical Exam:
Vital Signs: Temp: 98.8 RR: 20 Pulse: 96 BP: 137/87
Gen: NAD, AAOx3
HEENT: anicteric, NGT to LCWS with bilious
CV: RRR
Pulm: CTA b/l
Abd: soft, distended. Tenderness over the right periumbilcal
region without rebound or guarding.
Ext: edema, warm. Large seroma in right groin.
Pertinent Results:
[**2141-12-19**] 05:40PM WBC-19.6*# RBC-3.10* HGB-9.1* HCT-28.9*
MCV-93 MCH-29.4 MCHC-31.6 RDW-15.0
[**2141-12-19**] 05:40PM NEUTS-91.2* LYMPHS-6.4* MONOS-1.9* EOS-0
BASOS-0.3
[**2141-12-19**] 05:40PM PLT COUNT-623*#
[**2141-12-19**] 05:40PM PT-13.1 PTT-24.8 INR(PT)-1.1
[**2141-12-19**] 05:40PM GLUCOSE-107* UREA N-9 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
[**2141-12-19**] 05:48PM GLUCOSE-113* LACTATE-1.1 NA+-138 K+-3.7
CL--101 TCO2-28
[**2141-12-19**] CT Abd/pelvis :
1. Large anterior intra-abdominal air and fluid collection
concerning for an abscess.
2. Focally dilated small bowel loop is concerning for internal
hernia and
closed loop obstruction.
3. Area of of free air and adjacent fluid within the right lower
quadrant,
separate from the primary abscess.
4. Multiple seromas overlying the groin incision sites
bilaterally.
5. No appreciable contrast enhancement across the
femoral-femoral bypass.
5. Status post aortobifemoral bypass, which appears patent, with
flow
demonstrated in the superficial femoral and profundus branches
bilaterally.
6. Unchanged mild extra- and intra-hepatic biliary ductal
dilatation.
[**2141-12-19**] Right femoral vasc US :
1. Occluded femoral-to-femoral bypass graft.
2. Large hematoma or seroma within the right groin.
3. Normal arterial and venous waveforms within the right common
femoral
artery and vein. No pseudoaneurysm.
[**2141-12-20**] KUB :
1. Dilated central loop of small bowel correlated with findings
on CT
concerning for partial bowel obstruction.
2. Extraluminal air seen in the right lower quadrant
corresponding to the
findings on CT.
3. Air fluid collection seen superior to the dilated loop of
small bowel,
correlating with fluid collection seen on CT, worrisome for
abscess.
[**2141-12-25**] CXR :
PICC projects just beyond superior cavoatrial junction. Pull
back 1 cm.
Brief Hospital Course:
Patient was admitted to the Acute Care Surgery service with
intraabdominal abscess. She was taken to the OR on hospital day
2 and underwent exploratory laparotomy, debridement, small bowel
resection x2 and right hemicolectomy. She tolerated the
procedure without complication. Post-operatively she spent a
short amount of time in the PACU before she was transferred to
the floor. She was maintained on IV antibiotics and ID was
consulted for recommendations regarding long term antibiotics.
On the floor, when bowel function returned she was first
advanced to clears and then to regular diet, which she tolerated
without nausea or vomitting. Her Foley was discontinued and she
voided spontaneously. She ambulated with PT and was cleared for
discharge home from a PT perspective. Pain was well controlled.
At time of discharge pain was well controlled, she was
tolerating a regular diet and voiding spontaneously. Follow-up
was arranged with infectious disease clinic in her town.
Physical therapy cleared her for discharge home from their
perspective.
Medications on Admission:
Duloxetine 60'', methadone 20'', Prilosec 40',trazodone 50',
aripiprazole 10', sucralfate 2'', Boniva 150 q monthly,Symbicort
80-4.5 ''prn sob, plavix 75'; simvastatin 10'; lopressor 12.5'''
Discharge Medications:
1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
2. aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. sucralfate 1 gram Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
6. methadone 10 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*45 Tablet(s)* Refills:*0*
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. 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*
11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a
day.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Services
Discharge Diagnosis:
Intra-abdominal and retroperitoneal abscesses with bowel
perforation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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 experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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 [**5-15**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
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.
* Your staples will be removed at your follow-up appointment.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
1) Call the Acute care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 1 week for staple removal. Call Dr.[**Name (NI) 1392**]
office at [**Telephone/Fax (1) 1393**] to schedule an appoitment for the same
day.
[**Last Name (un) 2577**] Buidling
[**Hospital1 69**]
[**Location (un) **]
[**Location (un) 86**], [**Numeric Identifier 718**]
2) You must follow-up with Infectious Diseases: Dr. [**Last Name (STitle) 28949**], who
has an office in your home-town. Please call [**Telephone/Fax (1) **] to
make an appoitment to see Dr. [**Last Name (STitle) 28949**] in 1 week.
3) Call Dr. [**Last Name (STitle) **], your primary care doctor, for a follow up
appointment in [**1-7**] weeks.
|
[
"E878.8",
"998.13",
"996.74",
"569.83",
"560.81",
"567.38"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.73",
"54.59",
"45.93",
"38.97",
"45.61"
] |
icd9pcs
|
[
[
[]
]
] |
6819, 6887
|
4269, 5332
|
305, 517
|
7001, 7001
|
2359, 4246
|
9678, 10390
|
1985, 2043
|
5575, 6796
|
6908, 6980
|
5358, 5552
|
7152, 8610
|
8626, 9655
|
2058, 2340
|
242, 267
|
545, 1335
|
7016, 7128
|
1357, 1841
|
1857, 1969
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,906
| 160,615
|
22687
|
Discharge summary
|
report
|
Admission Date: [**2194-10-16**] Discharge Date: [**2194-11-5**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
bright red blood per rectum
Major Surgical or Invasive Procedure:
Colonscopy
Right hemicolectomy
History of Present Illness:
[**Age over 90 **] yo M whose PMH includes HTN, BPH, and ? rheumatic heart
disease as well as recent diagnosis of Hemophilia C (Factor [**Doctor First Name 81**]
deficiency) and bacteremia/C diff. colitis (at [**Hospital1 756**] in [**Month (only) 116**]).
He presented to the ED after being sent in from [**Hospital 3589**]
Clinic today feeling weak, looking pale, and reporting a large
bloody stool today.
Pt reports that over the last 2 weeks he has been constipated
with only limited small hard bowel movements. He also reports
feeling weaker and more tired than normal with a decreased
appetite and a small amount of weight loss over the last few
months. Pt also reports intermittent problems with [**Name2 (NI) **] bleeds
and coughing up small amounts of frothy tinged sputum. Pt says
this is never large in amount and happens every few weeks, but
more in the last few months than previously. At noon today he
reports a large, soft bowel movement that was dark in nature and
which also contained bright red blood in the toilet bowl. He
went to [**Hospital 18**] [**Hospital 3589**] Clinic (Dr.[**Last Name (STitle) **]) later today to
establish care with a new PCP. [**Name10 (NameIs) 2351**] this office visit his
symptoms prompted a referal to the ED.
.
In the ED, initial vs were: T:97.1 HR:72 BP:99/53 RR:18
sat:100%. Pt was given 2 units of FFP. Two 18G IVs were placed
and GI was consulted.
.
On the floor, initial VS were Temp 97.8/HR 80/BP 134/58/RR
21/98% on 2L. Pt able to tolerate RA after a few minutes on the
floor with sats in high 90s.
Past Medical History:
# Hemophilia C: diagnosed in [**2194-4-24**]
# hypertension
# valvular CHF: TEE [**2194-6-24**]: Severe, possibly flail TR,
moderate AS, severe MR, EF 65-75%, PAP of 35
# question of prior rheumatic fever
# glaucoma
# BPH, s/p TURP.
# bacteremia of unknown source c/b C.diff colitis ([**2194-5-24**],
[**Hospital1 112**])
# hernia repair x 3
# Hip and Shoulder Surgery 3yrs ago
Social History:
- Tobacco: past history of 3ppd (stopped 50-60yrs ago)
- Alcohol: rare and small amounts per family (pt says not at
all)
- Ambulates with walker. Supportive and involved children.
Family History:
non-contributory
Physical Exam:
97.8 62 106/50 18 93% RA
General: Alert, oriented to person, place, no acute distress,
HEENT: Sclera anicteric, MMM,
Lungs: no respiratory distress
CV: Regular rate and rhythm, normal S1 + S2, holosystolic murmur
Abdomen: soft, non-tender, non-distended, bowel sounds
normoactive, no rebound tenderness or guarding, no organomegaly,
incision healing well, clean, dry, and intact
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
PRBCx1 Hct 24.5--> 29.9-> 30.7
FVII (74) and [**Doctor First Name 81**] (17), vitB12 (1616) and folate (15.6)
PTT - 10/1242.5
CT ABDOMEN: Pleural plaques are noted suggestive of prior
asbestos exposure. There are bilateral pleural effusions with
associated compressive atelectasis, moderate on the right, small
on the left. The heart is top normal in size without pericardial
effusion. Thick mitral annular calcifications, aortic valve
calcifications and multivessel coronary arterial disease are
noted. A 1.2-cm low-density left hepatic lobe lesion (2, 14)
likely represents a cyst. More superiorly in the medial dome (2,
11), there is a 1.5-cm ovoid lesion, which could represent a
hemangioma, but is incompletely evaluated on this single phase
study. Additional subcentimeter liver hypodensities are too
small to fully characterize. There is no biliary dilatation. A
nondistended gallbladder contains multiple stones as well as
amorphous lower density material. The spleen contains a
subcentimeter hypodensity (2, 9), too small to fully
characterize. The pancreas is diffusely atrophic. The right
adrenal gland is unremarkable. The left adrenal gland
demonstrates slight thickening along the lateral limb, without
definite nodularity. Bilateral kidneys demonstrate cortical
thinning and contain multiple cysts, some of which are too small
to fully characterize. Multiple parapelvic cysts are seen on the
left. Of note, a 3.2 x 1.7 cm exophytic left renal mass
demonstrates heterogeneous enhancement, highly concerning for
RCC. The stomach, duodenum, small and large bowel loops are
normal in caliber. The colon appears redundant. There is no
dilated bowel loop to suggest obstruction. There is no focal
mural thickening to suggest inflammation. There are extensive
atherosclerotic calcifications involving the entire extent
of descending aorta and origin of major branches. Vessels
however remain
patent. There is no free air or free fluid. Mild anasarca is
present.
.
CT PELVIS:
1. Left renal mass with appearance highly concerning for RCC.
Appropriate
evaluation and potential treatment are recommended.
2. Gallbladder contains stones and amorphous material.
Ultrasound is
recommended for further evaluation to assess vascularity and
exclude mass.
3. No evidence of colitis. Diverticulosis without
diverticulitis.
4. Moderate right and small left pleural effusions. Pleural
plaques
suggestive of asbestos exposure.
5. Livers cyst and possible hemangioma, incompletely assessed
due to single phase study.
6. Large left flank seroma, of unknown chronicity.
Brief Hospital Course:
Mr. [**Known lastname 46**] is a [**Age over 90 **] year old man with PMH including HTN, moderate
AS, severe MR, Hemophilia C (Factor [**Doctor First Name 81**] deficiency), and recent
bacteremia/C diff ([**Hospital1 756**] in [**Month (only) 116**]) who presented to the ED on
[**2194-10-16**] with 1 episode of BRBPR, weakness. HCT nadir at 18,
received total of 2 units of FFP and 2 units of PRBCS (last
transfusion on [**10-17**]). He was not scoped by GI due to his
advanced age and active CHF. HCT stablized at 29-31. He had
acute systolic CHF s/p blood transfusions while in the ICU,
requiring furosemide.
He did not required further diuresis since transfer to the floor
on [**10-19**]. He was not maintained on a B-blocker due to borderline
blood pressures.
On HD6, he again developed maroon stool. Hct remained stable,
and the decision was made to pursue colonoscopy on HD7. Per
Hematology recs he received Amicar prior to the procedure. He
was found to have diverticulosis and a cecal mass with bleeding,
suspcious for carcinoma. An endoclip was placed with partial
hemostasis. Surgical intervention was planned at this point and
the patient had an echocardiogram and a cardiology consultation
for pre-operative risk stratification.
Mr [**Known lastname 46**] [**Last Name (Titles) 1834**] R hemicolectomy on HD 12. He tolerated the
procedure well and after a brief stay in the PACU he was brought
to the ICU for close hemodynamic monitoring. On POD1 his Hct was
found to be 24.9 from a preoperative level of 30. Therefore he
was transfused 1U of PRBC with adequate response
(post-transfusion Hct 29.7). His foley was discontinued on POD2
and replaced later that day because of hematuria and possible
urethral obstruction due to blood cloths. A urology consult was
obtained and a three way foley was place. His foley was flushed
as needed throughout the remainder of his stay and the pt's
urine remained clear. His foley was discontinued 24 hrs prior to
discharged and the patient voided without difficulty. He was
also started on finasteride which he will be discharged on. The
paient will follow up with Urology as an outpatient for further
management of his urinary retention and hematuria, as well as
for work up and further treatment of possible RCC.
Heme/Onc followed the patient throughout his stay for his
hemophilia C and Factor [**Doctor First Name 81**] deficiency, they recommended no
anticoagulation and Amicar +/- FFP if bleeding reccured.
On HD 18 the patient developed new onset Afib which was
controlled with PO metoprolol. He remained rate controlled for
the remaider of his hospital course and will follow up with
Cardiology as an outpatient.
The patient was discharged to a [**Hospital1 1501**], and will follow up with Dr
[**Last Name (STitle) **], as well as with Heme-Onc and Cardiology.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating
with assistance, voiding without assistance, and pain was well
controlled.
Medications on Admission:
-Finasteride 5mg daily
-Gabapentin 300mg QHS
-Tramadol 50mg QHs
-Vitamins (B12, B1, C, D, E)
-Eye Drops: Timolol 0.5% and Xaltan 0.005%
-Iron supplments
-Advil 200mg (not on now - took recently)
Discharge Medications:
1. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic
DAILY (Daily).
2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic QHS
(once a day (at bedtime)).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
5. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
7. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
8. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours)
as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
10. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for afib/rvr.
Disp:*40 Tablet(s)* Refills:*0*
12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) for 7 days.
Disp:*42 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] Nursing Care Center
Discharge Diagnosis:
## lower GI bleed: found to be secondary to colon cancer
## Acute blood loss anemia
## Factor [**Doctor First Name 81**] deficiency, required FFP on presentation and Amicar
for procedures
## Acute sytolic heart failure related to volume overload
## Severe valvular heart disease (moderate AS, severe MR)
## Possible Renal Cell Carcinoma: 3.2 x 1.7 cm exophytic left
renal mass, highly concerning for renal cell carcinoma, seen on
CT scan.
## suspected squamous cell skin cancer on right forehead
## Macrocytic anemia with normal B12
## Hypertension
## BPH with urinary retention
## Multifactorial gait disorder requiring a walker at baseline
## Glaucoma
## New Onset Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* You may take a bath and shower regularly.
* No strenuous activity until instructed by your surgeon.
You were admitted to the hospital with severe anemia from a
bleeding source in your large intestine. You also had congestive
heart failure which responded well to diuretic medications.
Ultimately, colonoscopy confirmed the source to be a mass in
your colon very suspicious for cancer. General Surgery was
consulted and recommended a right colectomy to remove the tumor,
which was performed on. Unfortunately we also found a tumor in
your left kidney that is quite worrisome for a kidney cancer
(renal cell carcinoma). The Urology consult team recommended
that you follow-up in clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3748**].
.
Please take all of your medications as directed. Please see Dr.
[**Last Name (STitle) 3748**] from Urology for the tumor in your kidney and to follow
up on the postoperative urinary retention.
Followup Instructions:
Department: HEMATOLOGY ONCOLOGY
When: [**2194-11-12**] at 9:00 AM
With: Dr [**Last Name (STitle) 1852**]
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2194-11-6**] at 3:30 PM
With: DR. [**First Name (STitle) **] [**Doctor Last Name **] [**Telephone/Fax (1) 3752**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2194-11-10**] at 1 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2359**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Doctor First Name **]. GARAGE
Completed by:[**2194-11-5**]
|
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"455.9",
"578.0",
"596.7",
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] |
icd9cm
|
[
[
[]
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] |
[
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|
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|
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|
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|
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|
2560, 3023
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223, 252
|
351, 1911
|
10923, 11067
|
1933, 2313
|
2329, 2511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,043
| 127,710
|
14227
|
Discharge summary
|
report
|
Admission Date: [**2176-8-1**] Discharge Date: [**2176-8-7**]
Service: MEDICINE
Allergies:
Amoxicillin / Penicillins / Coumadin / Oxycodone / Megestrol
Acetate / Remeron / Ritalin
Attending:[**First Name3 (LF) 800**]
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
Foley and suprapubic catheter change [**2176-8-3**]
History of Present Illness:
Mr. [**Known lastname 42290**] is an 87 year old male with a history of type II
diabetes on insulin, prostate cancer s/p XRT, recent admission
for bladder rupture and repair in [**2176-5-31**] at which time a
suprapubupic catheter and indwelling foley catheter were placed.
His course in [**Month (only) 116**] was complicated by prolonged delerium for
which he was actually admitted and treated with a course of
antibiotics for empiric coverage of meningitis in early [**Month (only) **]
during that hospitalization he also had a PEG tube placed for
aspiration risk. He was readmitted one week later for hematuria
thought to be secondary to receiving TPA for a clogged PICC
line. He was discharged to [**Hospital 100**] Rehab on [**2176-7-10**] at which
time he was continuing to have waxing and [**Doctor Last Name 688**] mental status
but per his family was alert, conversant and enjoyed watching
tv. He was diagnosed with clostridium difficle during his most
recent hospitalization and completed a course of flagyl on
[**2176-7-31**]. Over the past 72 hours he has appeared more lethargic
and has developed a mild cough. He spiked a fever to 100.0 on
[**2176-7-31**] and was pancultred and started on vanomycin and zosyn.
He continued to worsen and in the evening developed rapid atrial
fibrillation with rates in the 140s. He received low doses of
IV lopressor initially with good effect but over the next 12
hours began to drop his blood pressures and was transferred here
for further management.
In the ED, initial vs were: T: 100.6 P: 140 BP: 144/64 R: 28 O2
sat 93% on a non-rebreather. He received 2.5 liters of normal
saline. He received metoprolol 2.5 mg IV x 1, meropenem 1 gram
IV x 1, tylenol 1 gram PR and vancomycin 1 gram x 1. He spiked
a fever to 103.4 degrees rectally. Blood and urine cultures
were sent. HR remained in the 140s. He had a CXR which showed a
small amount of free air under the diaphragm which was seen on
prior studies post g-tube insertion. He was admitted to the
MICU for further management.
On arrival to the MICU he is alert to person only. He is
coughing intermittently but not bringing up any sputum. He has
no complaints. Unable to obtain accurate review of systems.
Past Medical History:
- Type II Diabetes on Insulin
- Prostate cancer s/p XRT [**2156**]
- Chronic Urinary Incontinence s/p TURP [**10-6**]
- History of UTIs, including prior MRSA, klebsiella, proteus,
pseuduomonas
- s/p bladder rupture and repair x2, [**2-8**], [**6-8**]
- Atrial fibrillation, not anticoagulated due to h/o bleeding
- Hyperthyroidism
- Depression
- Hypertension
- Moderate aortic stenosis on TTE [**5-/2176**]
- Peripheral vascular disease
- h/o CVA [**2172**]
- Severe chronic axonal neuropathy, radiculopathy and plexopathy
(due to XRT) per Dr. [**Last Name (STitle) **], with right foot drop for many
years
- L3 compression fracture
- cataract s/p bilateral laser surgery, also with "macular
edema"
- hard of hearing
- left thyroid nodule, benign
.
Social History:
Smoked 2 ppd tobacco x24 years. Quit in [**2137**]. Denies EtOH.
Former WWII vet. Former Fire Fighter. Wife is HCP. Daughter is
RN, son is engineer. Now coming from [**Hospital 100**] Rehab MACU.
Family History:
No illnesses, strokes, DM or early heart attacks run in the
family.
Physical Exam:
On presentation to the MICU:
Vitals: T: 101.3 (rectal) BP: 107/45 P: 142 R: 26 O2: 100% on
4L
General: Somnolent, opens eyes to voice, does not respond to
questions
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP flat, no LAD
Lungs: Upper airway wheezes, intermittent cough, otherwise clear
to auscultation bilaterally
CV: Tachycardic, s1 + s2, II/VI SEM at right upper sternal
border non-radiating
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, PEG tube in
place without erythema, suprapubic catheter without erythema or
drainage
GU: Suprapubuc and indwelling catheters draining clear yellow
urine
Ext: cool, 1+ pulses, no clubbing, cyanosis, 1+ edema
Neurologic: Moves all extremities to painful stimuli, alert,
not oriented, PERRL, blinks to threat
Pertinent Results:
ADMISSION LABS:
[**2176-8-1**] 10:30AM WBC-17.2*# RBC-3.47*# HGB-10.9*# HCT-34.1*#
MCV-98 MCH-31.3 MCHC-31.8 RDW-16.5*
[**2176-8-1**] 10:30AM NEUTS-86.0* LYMPHS-8.4* MONOS-3.9 EOS-1.4
BASOS-0.3
[**2176-8-1**] 10:30AM PLT COUNT-654*# PLTCLM-1+
.
[**2176-8-1**] 10:30AM PT-13.3 PTT-21.0* INR(PT)-1.1
.
[**2176-8-1**] 10:30AM GLUCOSE-209* UREA N-38* CREAT-1.1 SODIUM-142
POTASSIUM-6.1* CHLORIDE-112* TOTAL CO2-21* ANION GAP-15
.
[**2176-8-1**] 10:30AM ALT(SGPT)-47* AST(SGOT)-86* CK(CPK)-23* ALK
PHOS-385* TOT BILI-0.3
[**2176-8-1**] 10:56AM LACTATE-3.3* K+-6.0*
[**2176-8-1**] 12:11PM LACTATE-1.4 K+-4.7
.
[**2176-8-1**] 11:35AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
.
[**2176-8-1**] 10:30AM BLOOD cTropnT-0.03*
[**2176-8-1**] 10:30AM BLOOD CK-MB-NotDone
[**2176-8-1**] 10:30AM BLOOD CK(CPK)-23*
.
[**2176-8-3**] 03:26AM BLOOD Albumin-2.2* Calcium-7.7* Phos-2.5*
Mg-2.1
.
[**2176-8-2**] 04:30AM BLOOD Phenyto-2.1*
[**2176-8-3**] 03:26AM BLOOD Phenyto-1.8*
.
[**2176-8-2**] RUQ U/S: Wet Read: ENYa FRI [**2176-8-2**] 9:32 AM
Multiple gallstones in a non-distended GB. GB wall normal. Neg
sono [**Name (NI) **]. No pericholecystic fluid. CBD normal. No evidence
of acute cholecystitis.
.
[**Hospital 100**] Rehab Micro (faxed [**2176-8-3**]):
[**2176-8-1**] Sputum cx: MRSA, C. albicans
[**2176-7-31**] Bcx: Staph spp (prelim)
[**2176-7-31**] Bcx: NGTD
[**2176-7-30**] Ucx: [**Numeric Identifier 389**] C. albicans
MICROBIOLOGY:
BCx - no growth
Urine - yeast
Penile swab - PSEUDOMONAS AERUGINOSA. RARE GROWTH
Stool - C.diff positive
IMAGING:
CXR [**8-5**] - Cardiomediastinal contours are stable. Increasing
ill-defined opacity in the right lower lobe with associated new
small right pleural effusion could be just atelectasis, but
pneumonia cannot be excluded. Atelectasis in the left base is
unchanged. There is no pneumothorax or pleural effusion.
Resolved pneumoperitoneum. Catheter projects in the left upper
quadrant.
ECHO [**8-5**] - The left atrium and right atrium are normal in cavity
size. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
[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 are moderately thickened. There is mild
aortic valve stenosis (valve area 1.2-1.9cm2). Mild [1+] aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Moderate to severe (3+) mitral regurgitation is seen.
The estimated pulmonary artery systolic pressure is high normal.
There is a trivial/physiologic pericardial effusion.
Compared with the prior study (images reviewed) of [**2176-6-19**],
the severity of mitral regurgitation is increased, though the
technical quality of the current study is better and may explain
the difference. Aortic and mitral valve morphology are grossly
similar.
RUQ U/S [**8-2**] - Cholelithiasis without evidence of acute
cholecystitis. No
biliary ductal dilatation. Small bilateral pleural effusions.
CXR [**8-1**] - No definite acute process. Possible small amount of
free air
beneath the left hemidiaphragm versus summation of shadows.
Repeat chest x-ray could be performed for confirmation.
DISCHARGE LABS ([**2176-8-7**]):
WBC 11 Hb 8.2 Hct 25.5 Plt 666
Na 134 K 4.8 Cl 101 CO2 25 BUN 24 Cr 0.7 Glc 178 Ca 8.0 Mg 1.8 P
3.7
Phenytoin 3.8
Brief Hospital Course:
Mr. [**Known lastname 42290**] is a 87 year old male with a history of type II
diabetes on insulin, prostate cancer s/p XRT, with multiple
recent hospitalizations since [**2176-5-31**] for bladder rupture s/p
repair, altered mental status, and hematuria who presents from
[**Hospital 100**] Rehab with fevers, tachycardia and somnolence.
Fevers/Tachycardia/Leukocytosis: The patient intially presented
from [**Hospital 100**] Rehab with increased altered mental status and
fevers. He had cultures drawn there and a PICC replaced on
[**2176-7-31**].
In the MICU: Blood pressures were transiently low when treating
for A-fib with RVR (see below) much improved after d/c??????ing
diltiazem gtt. Creatinine improved and lactate trended down with
hydration and he remained without evidence of end organ lack of
perfusion. RUQ ultrasound with stones but no signs of
cholecystitis. Started empiricially on vanc, meropenem, and po
vanc. Cultures with 4 possible sources of infection (+ C diff,
MRSA in sputum, GPC in [**3-6**] OSH blood cx, and yeast in urine) He
was started on IV vancomycin, meropenem and PO vancomyin. His
suprapubic and Foley catheters were changed by Urology, and
recommended to stay in for the next couple weeks. An ECHO was
done, and there was no evidence of endocarditis.
On the floor: the patient continued to have fevers overnight. PO
Fluconazole was added to his antibiotic regimen for yeast UTI.
He was seen by ID - they recommended to d/c IV Vanc and [**Last Name (un) **],
and to continue PO Vanc 125mg q6h and PO fluconazole 200mg
daily. The patient improved and stopped having fevers 2 nights
prior to discharge. Currently afebrile at 99.8. Penile swab
results mixed flora including rare Pseudomonas aeruginosa.
Treatment was not recommended by ID, as the patient is most
likely sick due to C.diff infection and further antibiotic
treatment is interfering with C.diff treatment.
Hypoxia: On arrival he was satting only 93% on a non-rebreather
with tachypnea. Tachypnea may have been related to underlying
infection. The patient has been off oyxgen and breathing
comfortably since admission. Sputum sample here contaminated but
[**2176-8-1**] sputum cx from [**Hospital 100**] Rehab grew MRSA, he was started on
vancomycin. IV vancomycin has been discontinued given no
evidence of pneumonia.
C. diff colitis: He was scheduled to complete course of flagyl
on [**2176-7-31**] at [**Hospital1 100**] but there was continued given clinical
deterioration. C diff was positive again here and the patient
was started on PO Vancomycin. Still has soft stooling and
external rectal pouch was placed to avoid contamination of
sacral decubitus ulcers. Needs to continue PO Vancomycin 125mg
q6h.
Yeast in Urine: Patient with complicated GU history including
bladder rupture x2, now with neobladder drained by suprapubic
cath and foley cath. Foley and suprapubic cath changed [**2176-8-3**],
ok per Urology. Pt was started on PO Fluconazole 200mg daily.
End date: [**2176-8-10**].
Atrial Fibrillation with rapid ventricular response: HR on
admission was in the 140s. It was unclear whether the
underlying rhythm was SVT versus atrial fibrillation. There was
no improvement with carotid massage. In the MICU, he was given
IV diltiazem with slowing of his rate to 90s with clear atrial
fibrillation but rate control initially limited by hypotension
with dilt gtt. He was transitioned to PO diltiazem. Dig load
was started [**2176-8-2**] with good effect. He has a significant past
history of bleeding so he is not on anticoagulation.
On the floor, the patient was continued on PO digoxin and
switched from diltiazem to PO metoprolol. The patient was
tachycardic likely due to concurrent infection, but rate is
better controlled now. Please check dig level on Friday [**8-9**], as
he was loaded in the MICU, and adjust dosing as necessary. (1.2
is optimal for treatment of a.fib)
Altered Mental Status: Most likely related to critical illness
and infection. Mental status much improved since admission. Is
at high risk for ichemic stroke given atrial fibrillation not on
anticoagulation but neurologic exam was non-focal. The patient
is awake, answering questions, and speaking more coherently than
prior.
Pressure Ulcer: Patient with large sacral decubitus ulcer - was
100% necrotic. Wound care was consulted and Plastics debrided
the wound. This is likely a stage 4 ulcer. Wound care recs were
followed (included in referral page).
Seizure Disorder: Dilantin level was low on admission: 1.8 and
corrects to 2.8 with the corresponding albumin level. Per Pharm,
dilantin can adhere to tube, so the patient was reloaded with
800 mg fosphenytoin and transitioned to 100mg tid fosphenytoin.
He was transitioned back to PO phenytoin with instructions to
flush the PEG well both before and after administration. Current
dilantin level is 3.8. Please f/u dilantin levels and adjust
dosing as necessary.
Type II Diabetes: Was kept on half dose insulin initially given
his illness and holding tube feeds. Tube feeds were restarted.
Continue insulin sliding scale.
Anemia: Hematocrit 34 on presentation, likely concentrated, and
came down to 25 in the setting of significant IVF. 25 is his
recent baseline. Past workup revealed iron deficiency and
inappropriately low reticulocyte count. Pt was given his iron
supplements. HCT remained at his baseline throughout his stay
and is currently 25.5.
FEN: Patient was followed by nutrition. Additional protein was
added to tube feeds given declining albumin and need for
increased nutritional support to promote wound healing.
Access: PICC line placed on [**2176-8-3**].
Medications on Admission:
Zosyn 3.375 mg Q6H (start [**2176-7-31**])
Potassium 20 meq TID
Senna QHS
Vancomycin 1000 mg IV
Tylenol 650 mg Q4H:PRN
Iodosorb daily
Iron 325 mg daily
Insulin lantus 30 U daily
Regular insulin sliding scale
Magnesium Oxide 400 mg [**Hospital1 **]
Metoprolol 25 mg Q6
Metronidazole 500 mg TID
Phenytoin 162.5 mg [**Hospital1 **]
Discharge Medications:
1. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily): rub into wound bed daily during dressing change.
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
4. Fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 3 days.
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please check dig level Friday [**8-9**], as patient was dig loaded in
MICU. and adjust dosing as necessary.
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO Q 8H
(Every 8 Hours).
7. Phenytoin 125 mg/5 mL Suspension Sig: One Hundred (100) mg PO
Q8H (every 8 hours): please flush well before and after
administration, as dilantin sticks to plastic. .
8. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
9. Heparin Flush 10 unit/mL Kit Sig: One (1) Intravenous every
eight (8) hours: and follow with 10ml saline flush.
10. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime: and see attached insulin sliding
scale.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
Primary Diagnosis
Colitis
Atrial Fibrillation
Secondary Diagnoses
Seizure disorder
Anemia
Discharge Condition:
Stable, improved.
Discharge Instructions:
You came into the hospital with fevers and increased heart rate.
You likely had an infection, but it was difficult to pinpoint a
source. Chest xrays did not show an active pneumonia. Blood
cultures sent here were negative for bacteria. You were given
antibiotics, and your fever decreased. You have not had a fever
for the last 2 days. The most likely cause of your fevers is
C.diff - a bug that lives in your colon. You will continue to
get antibiotics (Vancomycin) to treat this infection. You are
also getting Fluconazole, a medication to treat the yeast in
your urine.
Your heart rate was increased while you were here, due to the
infection in addition to your atrial fibrillation. You were
given medications to control the heart rate. You are doing much
better now that the infection is better controlled. You will
continue on Metoprolol and Digoxin to keep your heart rate
stable.
The following changes were made to your medications:
1. Vancomycin 125mg every 6 hours through your feeding tube for
14 days
2. Fluconazole 200mg daily through your feeding tube for 3 days
3. Lantus was decreased from 30mg to 15mg daily, with regular
insulin sliding scale
4. Dilantin 100mg every 8 hours through your feeding tube.
Please flush the tube well before and after administering
Dilantin, as the medication tends to stick to plastic.
5. Digoxin 0.125 mg daily through your feeding tube.
6. Metoprolol 50mg daily through your feeding tube.
If you experience fevers, chills, shortness of breath, chest
pain, altered mental status, or any other concerning symptoms,
please call your physician or return to the emergency
department.
It was a pleasure meeting you and taking part in your care.
Followup Instructions:
Please follow-up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4390**]:
Tuesday [**8-13**] @ 11:15am
[**Telephone/Fax (1) 3070**]
You also have the following appointments scheduled for you:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7025**], MD Phone:[**Telephone/Fax (1) 5285**] Date/Time:[**2176-8-8**] 10:00a
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 5727**] Date/Time:[**2176-9-16**]
3:50p
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]
|
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"112.2",
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"250.00",
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"707.24",
"707.05",
"401.9",
"285.9",
"787.6",
"345.90",
"V44.1",
"427.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.28"
] |
icd9pcs
|
[
[
[]
]
] |
15281, 15347
|
8096, 12005
|
305, 358
|
15482, 15502
|
4573, 4573
|
17241, 17891
|
3622, 3691
|
14116, 15258
|
15368, 15461
|
13762, 14093
|
15526, 17218
|
3706, 4554
|
254, 267
|
386, 2618
|
4589, 8073
|
12611, 13736
|
12021, 12597
|
2640, 3392
|
3408, 3606
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,956
| 188,042
|
17391
|
Discharge summary
|
report
|
Admission Date: [**2138-9-14**] Discharge Date: [**2138-10-26**]
Date of Birth: [**2103-2-1**] Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Demerol / Vancomycin
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
nausea, vomiting and productive cough.
Major Surgical or Invasive Procedure:
PICC placement
Pheresis catheter placement and removal
History of Present Illness:
Ms. [**Known lastname **] is a 35 y/o F with h/o AML M5a s/p MUD in [**6-13**] who
returns to 7 [**Hospital Ward Name 1826**] today because of nausea, emesis, and
worsening productive cough. Ms. [**Known lastname **] has GVHD and was
recently admitted for diarrhea and fever. She was placed on a
higher dose of steroids and antibiotics and discharged. She is
chronically on Rituxan monthly (last dose 8/3/6) and Prograf.
Past Medical History:
AML, M5a first diagnosed in [**2134**], treated with chemotherapy and
MUD peripheral stem cell transplant in [**6-13**]. Her post-transplant
course has been complicated by chronic GVHD - involving mouth,
liver, and eyes. She is currently being treated with Rituxan
every 2 months. Her last dose was [**2138-8-14**].
.
PMH:
* Essential tremor.
* Thrombocytopenia.
* s/p bilateral cataract surgery.
Social History:
Living at home. She also reports alot of stress with her
children. She drives a school bus. She doesn't drink, smoke,
do any drugs
Family History:
Mother with uterine or cervical cancer requiring hysterectomy.
Grandmother with breast cancer.
Physical Exam:
BP 89/66 P 91 T 96.5 R 20 94%RA
Heent: anicteric sclera, dry mucosa
Neck: supple, trachea midline
Nodes: no supraclavicular, cervical, axillary, submandibular
adenopathy
Lungs: rhonchi Bilateral. Wheezing at Left Lung base
Heart: reg rate rhythm
Abd: soft/NT/ND
Ext: no c/c/e
Skin: lichen planus changes.
Pertinent Results:
Micro (summary):
Stool cx [**9-3**] and [**2138-9-17**]: Adenovirus
Blood: Adenovirus VL 3900([**9-23**])-> 5400([**10-1**])-> 600([**10-8**])->
<250([**10-9**])
Blood [**2138-9-14**]: MRSA
Sputum [**2138-9-14**]: MRSA and Pseudomonas (Gent and Cipro resistant)
.
Imaging:
CT abdomen [**2138-10-19**]: Large extracapsular liver hematoma with a
large amount of intra-abdominal and intrapelvic hemorrhagic
ascites which is highly concerning for active bleeding given the
patient's coagulopathy and dropping hematocrit status post liver
biopsy.
.
Liver biopsy [**2138-10-16**]: Marked cholestasis with associated
balloon-cell degeneration. Mild lobular mononuclear cell
inflammation and rare apoptotic hepatocytes. Bile ducts and
vascular structures, with no significant findings. No definite
features of graft-versus-host or [**Last Name (un) **]-occlusive disease seen. No
viral cytopathic effect seen.
Extramedullary hematopoiesis. The main findings in this biopsy
are severe cholestasis in the absence of bile duct damage or
bile duct proliferation. The differential diagnosis includes
drug-induced injury. The absence of bile duct proliferation does
not support an extra-hepatic cause/obstruction of cholestasis.
.
UE US [**2138-9-17**]: Small nonocclusive thrombus about Port-A-Cath in
left subclavian vein.
.
Repeat US [**2138-10-14**]: No evidence of intraluminal thrombus within
the left upper extremity venous system.
.
TEE [**2138-9-25**]: No mass/thrombus is seen in the left atrium or left
atrial appendage. Overall left ventricular systolic function is
normal (LVEF>55%). The ascending, transverse and descending
thoracic aorta are normal in diameter and free of
atherosclerotic plaque. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears
structurally normal with mild mitral regurgitation. No mass or
vegetation is seen on the mitral valve. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
.
CT chest with contrast [**2138-9-14**]: 1. Multiple irregular nodules in
the right upper lobe with patchy nodular and linear opacity in
the left lower lobe. Given appearance and the patient's history,
atypical infection such as fungal infections (such as
aspergillosis) are a primary consideration. Bacterial and viral
pneumonias should also be
considered. 2. Heterogeneous hepatic enhancement. Given
patient's history graft versus host disease was most likely.
Brief Hospital Course:
A/P: Patient is a 35 y/o F with GVHD on immunosuppresion now w/
a productive cough, nausea, emesis and acute renal insufficiency
.
TTP/HUS: Ms. [**Known lastname **] was initially admitted to BMT service on
[**2138-9-14**] when she presented with approximately one-month history
of nausea, emesis and worsening productive cough. The patient
was recently admitted to [**Hospital1 18**] [**8-30**] through [**9-10**] with diarrhea
and fever. During that admission her diarrhea was felt to be a
flare of chronic GVHD. She was placed on higher doses of
steroids and was started on antibiotics given travel history.
She improved symptomatically and was discharged home. She is
chronically on Rituxan monthly (last dose 8/3/6) and Prograf.
When she was readmitted to BMT [**2138-9-14**] she was initially felt
to have TTP/HUS-like syndrome and was initiated on
plasmapheresis. She had a total of 7 plasmapheresis treatments
(last [**2138-10-3**]) and improved symptomatically. She was then found
to have disseminated adenovirus infection (isolated from blood
and stool).
.
Transaminitis: Her hospital course was also complicated by MRSA
bacteremia (TEE negative, treated with Vancomycin x 4 weeks),
and PNA (Pseudomonas and MRSA in sputum) treated with Abx. The
patient then was noted to have rising LFTs and direct bilirubin
(total bili peaking at 23.3 with 18.2 direct fraction). She
eventually underwent US guided diagnostic liver biopy on
[**2138-10-16**]. Following her biopsy, the patient was noted to have
decrease in BP (baseline 160-180 systolic to 110-120). She was
otherwise asymptomatic. Her platelet count at the time of liver
biopsy was 45-103. Post-procedure, she was not getting
transfused aggressively with platelets due to concern for
TTP/HUS and her platelets went down as low as 11. On the evening
of [**2138-10-18**] she developed abdominal tenderness and urgent CT
scan of abdomen [**2138-10-19**] showed hemoperitoneum. Hct was 23
post-procedure but she subsequently required 2 units of pRBCs
([**10-16**]) then 2 unitsp RBCs ([**10-18**]) then 1 unit this am ([**10-19**])
and most recent Hct is 21. Surgery was consulted and recommended
conservative management with serial Hct, transfusion support and
close monitoring in the ICU. After her HCT became stable, she
was transferred back to the floor.
.
Diarrhea: Patient has had frequent episodes of diarrhea and
restarted Flagyl on [**9-16**] for explosive diarrhea. C. diff negative
x 2, stool studies negative or pending. Maintained on strict
diet (lactose free, fat free, caffeine free, low residue,
neutropenic). Started prednisone 30mg [**Hospital1 **] on [**9-17**], which ?may
have improved diarrhea. Stopped flagyl on [**9-18**] and started PO
vanco. Adenovirus POSITIVE on [**9-23**], started tapering prednisone
(now at 10mg QD). By discharge, diarrhea has completely
resolved. Etilogy still remained unclear. Colonoscopy was
performed which revealed no evidence of GVHD.
.
#) Productive cough- she is immunosuppressed. Sputum gram
stains: 4+ GPC's in chains, clusters, pairs; 4+ GNR's, <10 polys
(patient neutropenic); culture showed MRSA and Pseudomonas. CT
showed infiltrates in RUL, LLL. Started Vanco and Ceftaz on
[**2138-9-15**]. Blood cultures 2/4 positive for MRSA; however, decided
to leave port in for now unless gets acutely ill. By discharge
and after Abx treatment, her symptoms resolved.
.
#) Thrombus at site of port: U/S on [**9-17**] showed small
non-occlusive thrombus about the site of the port. No other clot
identified. No actions at this time. She was treated for [**4-17**]
weeks of vancomycin for treatment of MRSA, port presumably
infected. Repeat U/S revealed no evidence of thrombus and
vancomycin stopped.
.
#) GVHD- Continue prograf and steroids. Steroids adjusted as
noted below:
- Steroids lowered to 20mg QD on [**2138-9-15**]
- Increased back to 20mg [**Hospital1 **] on [**2138-9-16**]
- Increased to 30mg [**Hospital1 **] on [**2138-9-17**]
- Started CellCept on [**2138-9-22**] (last on CellCept in [**2135**]), D/C'd
on [**9-23**].
- Steroids tapered (because NOT GVHD, Adenovirus positive) to
20mg [**Hospital1 **] on [**9-23**], 10mg [**Hospital1 **] on [**9-26**], 10mg QD on [**9-27**]
.
#) F/E/N. Lyte repletion, IVF. Strict diet as above.
- PICC placed [**9-22**] for TPN
Medications on Admission:
Danazol, Ursodiol, Prograf, Famvir, Prednisone 20 mg po BID,
Protonix 40 mg po QD, Celexa 10mg po QD, Flagyl 500 mg po TID,
Propanol 10 mg po BID, Combivent
Discharge Medications:
1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-13**]
Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: One (1)
Spray Nasal DAILY (Daily).
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-13**]
Drops Ophthalmic PRN (as needed).
4. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
5. Prednisone 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*0*
6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*1*
7. Cephalexin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
8. 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*
9. Line care
Please flush and care for PICC line as per protocol
Discharge Disposition:
Home With Service
Facility:
Home Health [**Location (un) 8117**]
Discharge Diagnosis:
Primary:
AML
adenovirus infection
pneumonia
hepatocellular necrosis
thrombotic throbocytopenic purpura
Secondary:
Discharge Condition:
stable
Discharge Instructions:
You had a viral infection called adenovirus, which may have
resulted in a condition called thrombotic thrombocytopenic
purpura. It may also have caused your diarrhea. In addition, you
had elevated liver function tests caused by a toxin. It is not
known what drug caused your liver dysfunction.
We have made several changes to your medications, and you should
adhere to the prescribed medication list. Please be sure not to
take any new medications without checking with your primary
doctor whether it is safe for your liver. We stopped your
ritalin and Celexa as they may be harmful to your liver. Please
discuss with your primary doctor [**First Name (Titles) 4120**] [**Last Name (Titles) 9457**] these
medications.
You can take no more than 2 grams of Tylenol each day.
Please call you doctor or 911 if you have any fever, chills,
nausea, vomiting, abdominal pain, lightheadedness, shortness of
breath or any other concerning symptoms.
Followup Instructions:
Please return to the [**Hospital Ward Name 1826**] 7 onc outpatient clinic on Tuesday
[**2138-10-28**]. Dr. [**First Name (STitle) 1557**] will see you then.
|
[
"008.62",
"998.12",
"790.7",
"V58.65",
"996.85",
"599.0",
"284.8",
"276.51",
"V09.0",
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"446.6",
"482.1",
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"205.01",
"E947.9",
"079.0",
"482.41",
"211.3",
"251.8",
"584.5",
"401.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"50.11",
"99.14",
"88.72",
"45.25",
"38.93",
"99.04",
"99.05",
"45.42",
"99.71",
"99.07"
] |
icd9pcs
|
[
[
[]
]
] |
9935, 10002
|
4440, 8735
|
336, 392
|
10160, 10169
|
1871, 4417
|
11159, 11320
|
1434, 1530
|
8943, 9912
|
10023, 10139
|
8761, 8920
|
10193, 11136
|
1545, 1852
|
258, 298
|
420, 845
|
867, 1266
|
1282, 1418
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,144
| 147,920
|
15132+15133
|
Discharge summary
|
report+report
|
Admission Date: [**2143-9-2**] Discharge Date: [**2143-9-11**]
Date of Birth: [**2071-2-22**] Sex: M
Service: CARD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
gentleman with diabetes mellitus type 2, hypertension, and
congestive heart failure, who presented to [**Hospital 1474**] Hospital
on [**8-30**], with chest tightness and pressure which
radiated down his arms, diaphoretic and near syncopal
episode. EKG showed sinus tachycardia with non-specific ST
changes, flattening ST in V4 and V6, troponin peaked at 17.4,
CK at 306 and MB at 32.1. Index 10.5. Chest x-ray was
normal. He had an echocardiogram on the [**9-1**] which
showed ejection fraction of 35% with mild diffuse
hypokinesis, akinesis of distal septum and apex, left atrial
enlargement and two plus mitral regurgitation.
He had a cardiac catheterization on the [**9-2**], which
showed 50% ostial left anterior descending stenosis, 80%
proximal stenosis, 70% mid stenosis, left circumflex 80%
stenosis, proximally serial distal lesions 80 to 90%, diffuse
70% obtuse marginal, PDA small stenosis. Right coronary
artery was a non-dominant with total proximal occlusion.
The patient presented to [**Hospital1 188**]. He was comfortable with no complaint. He denied
chest pain, fever, chills, nausea, vomiting, diaphoresis or
discomfort.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Nonsmoker, non-drinker.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Congestive heart failure.
4. Diabetes mellitus type 2.
PAST SURGICAL HISTORY:
1. Bilateral cerebrovascular accident approximately six
years ago.
2. Back surgery in the distant past.
MEDICATIONS:
1. Losartan 40 mg q. day.
2. Prevacid 30 mg q. day.
3. Aspirin 81 mg q. day.
4. Lopressor 25 mg twice a day.
5. Lasix 40 mg q. day.
6. Insulin, Humulin 70/30, 16 units twice a day.
7. Isosorbide mononitrate 30 mg q. day.
8. Atorvastatin 20 mg q. day.
PHYSICAL EXAMINATION: Pleasant, cooperative, in no acute
distress. Vital signs were temperature 99.7 F.; heart rate
87; normal sinus rhythm; blood pressure 118/91; respiratory
rate 18; 95% on room air. Cardiovascular: Regular rate and
rhythm, no murmurs. No carotid bruits. Respiratory: Rales
half way up the lungs posteriorly, no wheezing, no rhonchi.
Abdomen soft, nontender, nondistended, bowel sounds present.
Extremities warm and well perfused. No edema.
LABORATORY: From [**8-31**], white blood cell count 6.7,
hematocrit 34.2, platelets 221. Sodium 135, potassium 4.9,
chloride 104, bicarbonate 31, BUN 31, creatinine 1.1.
Calcium 8.2, magnesium 2.1, phosphorus 2.7, AST 37, ALT 18,
alkaline phosphatase 49, total cholesterol 138, LDL 84, HDL
42.
HOSPITAL COURSE: The patient was admitted to Cardiac Surgery
and was started on heparin. On hospital day number two, the
patient was afebrile, vital signs stable. He had duplex
carotid ultrasound which showed no significant stenosis.
The patient was scheduled for a coronary artery bypass graft,
however, Anesthesia had some concerns about the patient's
pulmonary status, so the operation was postponed. A
Pulmonary consultation was obtained and the patient was
started on Levaquin. Pulmonary recommendation was that the
patient is in a good shape to undergo surgery. His pulmonary
function tests were normal. He should be continued on
Levaquin and Pulmonary Service would follow the patient
postoperatively.
The patient also developed gross hematuria which resolved
after the patient's heparin was stopped. Cardiology was also
consulted and recommended discontinuing the patient's
Losartan preoperatively. They continued him on Lasix for
congestive heart failure.
The patient was taken to the Operating Room on [**9-6**] for
a coronary artery bypass graft times two with a left internal
mammary artery to the left anterior descending, and saphenous
vein graft to obtuse marginal 3 was performed. The operation
went without complications. The patient had pacing wires as
well as mediastinal pleural chest tubes placed
interoperatively and was transferred to the PACU in stable
condition.
Postoperative day number one, the patient was extubated
without complications. He was slowly weaned off his drips
and remained stable. Postoperative day number two, his chest
tube and arterial line were removed without complications.
The patient started ambulating. Pulmonary revisited the
patient and found him to be in great shape respiratory and
with no further intervention from the service.
Postoperative day number three, the patient had an episode of
atrial fibrillation. He responded well to Amiodarone bolus
and was started on p.o. Amiodarone. He was also started on
Lopressor. The patient was transferred to the floor in
stable condition.
Postoperative day number four, the patient's wires were
removed. The patient is doing well, ambulating, working with
Physical Therapy; no active issues or concerns.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q. day.
2. Lasix 20 mg p.o. twice a day times ten days.
3. Potassium Chlamydia 20 mEq p.o. twice a day times ten
days.
4. Lopressor 12.5 mg p.o. twice a day.
5. Amiodarone 400 mg three times a day p.o. times four days,
then 400 mg p.o. twice a day times seven days, then 400 mg
p.o. q. day.
6. Percocet one to two tablets p.o. q. four to six hours
p.r.n.
7. Docusate 100 mg, one tablet p.o. twice a day.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged home.
DISCHARGE INSTRUCTIONS:
1. The patient is discharged home with [**Hospital6 1587**].
2. The patient should follow-up with Dr. [**Last Name (STitle) 70**] in six
weeks for postoperative check.
3. The patient should follow-up with primary care physician
in three to four weeks for blood pressure check.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft.
2. Congestive heart failure.
3. Hypertension.
4. Back pain.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2143-9-10**] 13:54
T: [**2143-9-10**] 12:15
JOB#: [**Job Number **]-5380
Admission Date: [**2143-9-2**] Discharge Date: [**2143-9-11**]
Date of Birth: [**2071-2-22**] Sex: M
Service: CARD [**Doctor First Name 147**]
HISTORY OF PRESENT ILLNESS: The patient is a 73 year old
gentleman with diabetes mellitus type 2, hypertension, and
congestive heart failure, who presented to [**Hospital 1474**] Hospital
on [**8-30**], with chest tightness and pressure which
radiated down his arms, diaphoretic and near syncopal
episode. EKG showed sinus tachycardia with non-specific ST
changes, flattening ST in V4 and V6, troponin peaked at 17.4,
CK at 306 and MB at 32.1. Index 10.5. Chest x-ray was
normal. He had an echocardiogram on the [**9-1**] which
showed ejection fraction of 35% with mild diffuse
hypokinesis, akinesis of distal septum and apex, left atrial
enlargement and two plus mitral regurgitation.
He had a cardiac catheterization on the [**9-2**], which
showed 50% ostial left anterior descending stenosis, 80%
proximal stenosis, 70% mid stenosis, left circumflex 80%
stenosis, proximally serial distal lesions 80 to 90%, diffuse
70% obtuse marginal, PDA small stenosis. Right coronary
artery was a non-dominant with total proximal occlusion.
The patient presented to [**Hospital1 188**]. He was comfortable with no complaint. He denied
chest pain, fever, chills, nausea, vomiting, diaphoresis or
discomfort.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: Nonsmoker, non-drinker.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Hypertension.
3. Congestive heart failure.
4. Diabetes mellitus type 2.
PAST SURGICAL HISTORY:
1. Bilateral cerebrovascular accident approximately six
years ago.
2. Back surgery in the distant past.
MEDICATIONS:
1. Losartan 40 mg q. day.
2. Prevacid 30 mg q. day.
3. Aspirin 81 mg q. day.
4. Lopressor 25 mg twice a day.
5. Lasix 40 mg q. day.
6. Insulin, Humulin 70/30, 16 units twice a day.
7. Isosorbide mononitrate 30 mg q. day.
8. Atorvastatin 20 mg q. day.
PHYSICAL EXAMINATION: Pleasant, cooperative, in no acute
distress. Vital signs were temperature 99.7 F.; heart rate
87; normal sinus rhythm; blood pressure 118/91; respiratory
rate 18; 95% on room air. Cardiovascular: Regular rate and
rhythm, no murmurs. No carotid bruits. Respiratory: Rales
half way up the lungs posteriorly, no wheezing, no rhonchi.
Abdomen soft, nontender, nondistended, bowel sounds present.
Extremities warm and well perfused. No edema.
LABORATORY: From [**8-31**], white blood cell count 6.7,
hematocrit 34.2, platelets 221. Sodium 135, potassium 4.9,
chloride 104, bicarbonate 31, BUN 31, creatinine 1.1.
Calcium 8.2, magnesium 2.1, phosphorus 2.7, AST 37, ALT 18,
alkaline phosphatase 49, total cholesterol 138, LDL 84, HDL
42.
HOSPITAL COURSE: The patient was admitted to Cardiac Surgery
and was started on heparin. On hospital day number two, the
patient was afebrile, vital signs stable. He had duplex
carotid ultrasound which showed no significant stenosis.
The patient was scheduled for a coronary artery bypass graft,
however, Anesthesia had some concerns about the patient's
pulmonary status, so the operation was postponed. A
Pulmonary consultation was obtained and the patient was
started on Levaquin. Pulmonary recommendation was that the
patient is in a good shape to undergo surgery. His pulmonary
function tests were normal. He should be continued on
Levaquin and Pulmonary Service would follow the patient
postoperatively.
The patient also developed gross hematuria which resolved
after the patient's heparin was stopped. Cardiology was also
consulted and recommended discontinuing the patient's
Losartan preoperatively. They continued him on Lasix for
congestive heart failure.
The patient was taken to the Operating Room on [**9-6**] for
a coronary artery bypass graft times two with a left internal
mammary artery to the left anterior descending, and saphenous
vein graft to obtuse marginal 3 was performed. The operation
went without complications. The patient had pacing wires as
well as mediastinal pleural chest tubes placed
interoperatively and was transferred to the PACU in stable
condition.
Postoperative day number one, the patient was extubated
without complications. He was slowly weaned off his drips
and remained stable. Postoperative day number two, his chest
tube and arterial line were removed without complications.
The patient started ambulating. Pulmonary revisited the
patient and found him to be in great shape respiratory and
with no further intervention from the service.
Postoperative day number three, the patient had an episode of
atrial fibrillation. He responded well to Amiodarone bolus
and was started on p.o. Amiodarone. He was also started on
Lopressor. The patient was transferred to the floor in
stable condition.
Postoperative day number four, the patient's wires were
removed. The patient is doing well, ambulating, working with
Physical Therapy; no active issues or concerns.
DISCHARGE MEDICATIONS:
1. Enteric coated aspirin 325 mg p.o. q. day.
2. Lasix 20 mg p.o. twice a day times ten days.
3. Potassium Chlamydia 20 mEq p.o. twice a day times ten
days.
4. Lopressor 12.5 mg p.o. twice a day.
5. Amiodarone 400 mg three times a day p.o. times four days,
then 400 mg p.o. twice a day times seven days, then 400 mg
p.o. q. day.
6. Percocet one to two tablets p.o. q. four to six hours
p.r.n.
7. Docusate 100 mg, one tablet p.o. twice a day.
CONDITION AT DISCHARGE: Good.
DISCHARGE STATUS: The patient is discharged home.
DISCHARGE INSTRUCTIONS:
1. The patient is discharged home with [**Hospital6 1587**].
2. The patient should follow-up with Dr. [**Last Name (STitle) 70**] in six
weeks for postoperative check.
3. The patient should follow-up with primary care physician
in three to four weeks for blood pressure check.
DISCHARGE DIAGNOSES:
1. Coronary artery disease status post coronary artery
bypass graft.
2. Congestive heart failure.
3. Hypertension.
4. Back pain.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**]
Dictated By:[**Last Name (STitle) 7487**]
MEDQUIST36
D: [**2143-9-10**] 13:54
T: [**2143-9-10**] 12:15
JOB#: [**Job Number 44126**]
|
[
"599.7",
"250.00",
"401.9",
"427.31",
"410.71",
"428.0",
"414.01",
"724.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.12",
"39.61",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
12160, 12589
|
11299, 11759
|
9067, 11276
|
11858, 12139
|
7903, 8283
|
8306, 9049
|
11775, 11834
|
6489, 7708
|
7772, 7880
|
7725, 7750
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,231
| 145,056
|
49252
|
Discharge summary
|
report
|
Admission Date: [**2117-12-12**] Discharge Date: [**2117-12-15**]
Date of Birth: [**2043-2-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Codeine / Heparin Agents
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
GI Bleeding Scan
History of Present Illness:
75 yo F with extensive history of GI bleeds due to AVM presents
with melena x 1 week and dizziness x 1. (Hct dropped from
27->16) She was admitted twice in [**10-2**], and once in [**7-2**] and
[**4-1**] for episodes of hematochezia and melena. She has sigmoid
diverticulosis, PVD, barretts esophagitis and diffuse AVM
(stomach -> rectum). Her last colonoscopy and EGD were [**10-8**] and
[**10-22**] respectively. Has afib but not on coumadin. Also has
stable chronic thrombocytopenia. Does not have any pain at this
time. No BRBPR, CP, SOB, V, HA, dysuria, hematemesis. She does
report nausea, and decreased po intake.
In the ED she had an NG tube that was placed and was found to be
negative on lavage. Started on IV protonix and received 1u PRBC
and transferred to the ICU for closer monitoring.
Past Medical History:
Lower GI bleeds: scopes (most recently [**10-2**]) w/AVMs,
diverticulosis
Throbocytopenia (HIT)
MRSA endocardiitis ([**12-31**])
CRI, baseline creat [**4-1**]
CAD s/p MI & CABG '[**15**]
CHF EF >=55% (diastolic)
DM2 on insulin
HTN, hyperlipid
Paroxysmal atrial fibrillation
PUD, Barrett's esoph
Asthma
Hypothyroidism
Osteoarthritis
s/p chole
Social History:
NO EtOH, tobacco, and drugs. Lives with daughter
Family History:
Significant for CAD and DM
Physical Exam:
T 97.5 P 84 BP 153/67 R 17 O2 97% on RA
Gen - NAD, obese, A+O x 3
HEENT - small pupils 2mm minnimally reactive, round, equal
Cor - RRR no m/r/g
Chest - CTA B
Abd - S/NT/ND + BS Rectal guiac + by ED
Ext - w/wp, no c/c/e
Pertinent Results:
Echo ([**12-31**]) - trace AR, [**1-29**] MR, 2 TR, aortic valve veg
Colonoscopy ([**12-31**]) angioectasias in the rectum, ceum, and
transverse colon
EGD ([**2117-6-29**]) - short sigmoid barretts, 2 nonbleeding
angioectasias, cauterized jejunal angioectasias
Colonoscopy ([**6-30**])- cecal polyp->polypectomy, cecal angiotectasia
(thermal tx), grade 1 internal hemorrhoids
EGD - ([**10-8**]) - hiatal hernia, no bleed
Colonoscopy ([**2117-10-8**]) sigmoid diverticula, no bleeding
EGD -([**2117-10-27**]) angio ectasia of distal jejunum, s/p thermal tx
[**2117-12-12**] 03:13PM GLUCOSE-193* UREA N-75* CREAT-3.7* SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
basline CR - ([**4-1**])
[**2117-12-12**] 03:13PM CALCIUM-8.1* PHOSPHATE-3.6 MAGNESIUM-2.1
[**2117-12-12**] 03:13PM WBC-5.0 RBC-1.75* HGB-5.5* HCT-16.5* MCV-95
MCH-31.4 MCHC-33.3 RDW-17.2*
[**2117-12-12**] 03:13PM NEUTS-71.2* LYMPHS-17.7* MONOS-4.8 EOS-6.2*
BASOS-0.1
[**2117-12-12**] 03:33PM HGB-5.8* calcHCT-17
Baseline HCT high 20's low 30's
EKG - Regular 85BPM, RBBB, flipped T, inferiorly and
anteriolaterally, no changes from prior
[**2117-12-12**] 03:13PM PLT COUNT-121*
[**2117-12-12**] 03:13PM NEUTS-71.2* LYMPHS-17.7* MONOS-4.8 EOS-6.2*
BASOS-0.1
Brief Hospital Course:
75 yo female with multiple GI bleeds secondary to AVM presents
with another episode of melena and an hematocrit of 16.
1. GI Bleed - patient presented with melena most likely
secondary to an upper GI source of AVM. She was transfused with
a total of 4u PRBC during her hospital course, and her HCT was
stable between 27.7 and 29.3. During her hospital course, she
did have multiple bowel movements with minimal black stool and
mainly brown stool. The GI team was consulted who felt that
given she has had multiple scopes in the last couple of months,
she most likely would not benefit from another EGD with push
enterscopy or a pill study. Also, the patient was reluctant to
have another EGD. She did have a GI bleeding scan study that
showed no active bleeding at that time. Given that she improved
clinically and was tolerating po well with a stable HCT, and no
bright red blood per rectum, it was decided that it would be
reasonable to send her home with close follow up. VNA was setup
for her HCT to be drawn on Friday morning and faxed over to Dr. [**Name (NI) 103247**] office.
2. Coronary Artery Disease - She was continued on her outpatient
regimen of B-blocker, Lipitor and Lasix. Her Aspirin was held in
the setting of her GI bleed.
3. Hypothyroidism - Continued home dose of Levothyroxine
4. Renal - She has known chronic renal insufficiency, and during
her stay, her Creatinine remained stable at her baseline. Her
Creat was between 3.5-3.8.
5. Diabetes - she was continued on her home regimen of Insulin
70/30 at 30 unit sq q am, and 10 u sq q pm.
6. Heme - she has known HIT and so she was not given any Heparin
products
7. Code - DNR / DNI
Medications on Admission:
[**Doctor First Name 130**] 60mg [**Hospital1 **]
Vit C 500mg qday
insulin 70/30 30 units qam/ 10 unit qpm
levothyroxine 175 mcg
gabapentin 200 [**Hospital1 **]
lipitor 10 mg qday
toporol XL 25mg qday
protonix 40mg qday
lasix 40mg qday
folate 1mg qday
vit B complex
Discharge Medications:
1. Fexofenadine HCl 60 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Levothyroxine Sodium 175 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO HS
(at bedtime).
4. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
6. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Insulin 70/30 70-30 unit/mL Suspension Sig: Thirty (30)
units Subcutaneous q am.
11. Insulin 70/30 70-30 unit/mL Suspension Sig: Ten (10) units
Subcutaneous q hs.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
1. GI bleed
Secondary:
1. Coronary Artery Disease
2. Hypertension
3. Diabetes
4. GERD
5. Chronic Renal Insufficiency
6. Hypothyroidism
Discharge Condition:
Stable
Discharge Instructions:
Please take all your medications as directed.
Please call your Primary Care Physician if you experience any
broght red blood per rectum, shortness of breath,
lightheadedness or dizziness.
Please follow up with Dr. [**Last Name (STitle) 1789**] in [**8-7**] days. VNA nurses will
come and draw your blood on Friday morning and fax results to
Dr. [**Last Name (STitle) 1789**].
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Name Initial (NameIs) **].D., PH.D.[**MD Number(3) **]: [**Hospital6 29**]
MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2118-2-7**] 4:00
|
[
"593.9",
"414.01",
"428.0",
"250.00",
"578.1",
"493.90",
"427.31",
"569.84",
"401.9",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
6166, 6223
|
3179, 4842
|
307, 326
|
6412, 6420
|
1898, 3156
|
6846, 7079
|
1610, 1638
|
5159, 6143
|
6244, 6391
|
4868, 5136
|
6444, 6823
|
1653, 1879
|
260, 269
|
354, 1163
|
1185, 1528
|
1544, 1594
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,202
| 130,595
|
4652
|
Discharge summary
|
report
|
Admission Date: [**2129-1-10**] Discharge Date: [**2129-1-21**]
Date of Birth: [**2059-7-23**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
[**Last Name (un) **]
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
69 yo M w/ PMH CAD s/p LCx stent [**2-1**] admitted to ICU [**1-10**] with
melena and syncope with an HCT (baseline 37 [**1-4**]. He also notes
chronic epigastric pain -> back, occurring daily and lasting 1
hr. He underwent an EGD [**1-10**] which showed ulcers at antrum and
pyloris, some with visible vessels, which were cauterized. HCT
nadired at 25.3 on [**1-10**]; received total of 4 units PRBC (last
[**1-11**]); HCT 35.9 [**11-11**] and pt transferred to the floor. Last
p.m., pt reports he had fleeting mild abdominal pain
(epigastric) after eating, but this resolved. He is currently
pain free. He notes mild lightheadedness and generalized
weakness. No current chest pain, shortness of breath. Pt had one
small black BM yesterday at 6 p.m
Past Medical History:
CAD, S/P MI in [**2117**]
HTN
hypercholesterolemia
Depression
Anxiety
Social History:
46 pack-year tobacco, quit 1 month ago
Family History:
married with 1 son
Physical Exam:
PE: Tc 97.3, Tm 99, bpc 133/70, HR 61, resp 20, 97% RA
Gen: pleasant elderly male, A&OX3, NAD
HEENT: anicteric, mucous membranes moist, neck supple
Cardiac: RRR, S1,S2, no M/R/G
Pulm: CTA bilaterally
Abd: NABS, soft, NT/ND, no masses
Ext: No cyanosis or edema
Neuro: alert
Psych: appropriate
Pertinent Results:
[**2129-1-21**] 07:15AM BLOOD WBC-10.8 RBC-3.91* Hgb-11.9* Hct-35.4*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.4 Plt Ct-309
[**2129-1-9**] 11:50PM BLOOD WBC-11.4* RBC-3.49* Hgb-10.9* Hct-30.6*
MCV-88 MCH-31.2 MCHC-35.6* RDW-14.5 Plt Ct-229
[**2129-1-9**] 11:50PM BLOOD Neuts-68.1 Lymphs-27.0 Monos-4.3 Eos-0.4
Baso-0.2
[**2129-1-19**] 01:00AM BLOOD PT-13.5* PTT-30.8 INR(PT)-1.2*
[**2129-1-19**] 01:00AM BLOOD UreaN-14 Creat-1.2 Na-142 K-3.9 Cl-107
HCO3-26 AnGap-13
[**2129-1-20**] 07:29AM BLOOD CK(CPK)-42
[**2129-1-18**] 07:00AM BLOOD ALT-18 AST-15 AlkPhos-74 Amylase-51
TotBili-0.9
[**2129-1-18**] 07:00AM BLOOD Lipase-35
[**2129-1-20**] 07:29AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-1-20**] 12:30AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-1-19**] 06:35AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-1-11**] 07:40AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-1-12**] 04:06AM BLOOD CK-MB-2 cTropnT-<0.01
[**2129-1-16**] 08:00AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
[**2129-1-13**] 07:20AM BLOOD TotProt-5.1* Calcium-8.2* Phos-3.4 Mg-2.0
Iron-29*
[**2129-1-13**] 07:20AM BLOOD calTIBC-177* VitB12-227* Folate-8.4
Ferritn-387 TRF-136*
[**2129-1-13**] 07:20AM BLOOD PEP-ABNORMAL B IgG-1017 IgA-139 IgM-22*
IFE-MONOCLONAL
[**2129-1-13**] 07:20AM BLOOD TSH-1.2
[**2129-1-17**] 12:39AM BLOOD Hgb-11.6* calcHCT-35
[**2129-1-9**] 11:56PM BLOOD Hgb-11.0* calcHCT-33
GASTRIN
Test Name In Range Out of Range
Reference Range
--------- -------- ------------
---------------
Gastrin (Fasting) 63
0-99 pg/mL
TEST PERFORMED AT:
Quest Diagnostic, [**State 19693**], [**Hospital1 8**], [**Numeric Identifier 19694**]
Complete report on file in the laboratory.
Protein Electrophoresis
ABNORMAL BAND IN GAMMA REGION
SEE IFE FOR IDENTIFICATION
REPRESENTS ROUGHLY 8% (400 MG/DL) OF TOTAL PROTEIN
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
Immunoglobulin G 1017 mg/dL [**Telephone/Fax (1) 763**]
Immunoglobulin A 139 mg/dL 70 - 400
Immunoglobulin M 22* mg/dL 40 - 230
Immunofixation
MONOCLONAL IGG KAPPA DETECTED
POLYCLONAL IGG ALSO PRESENT
INTERPRETED BY [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 19695**], MD
[**2129-1-13**] 07:20AM BLOOD PEP-ABNORMAL B IgG-1017 IgA-139 IgM-22*
IFE-MONOCLONAL
[**2129-1-13**] 07:08PM URINE Hours-RANDOM TotProt-6
[**2129-1-13**] 07:08PM URINE U-PEP-NO PROTEIN
[**2129-1-10**] 4:36 pm SEROLOGY/BLOOD
**FINAL REPORT [**2129-1-12**]**
HELICOBACTER PYLORI ANTIBODY TEST (Final [**2129-1-12**]):
POSITIVE BY EIA.
(Reference Range-Negative).
Cardiology Report ECG Study Date of [**2129-1-19**] 11:18:06 PM
Sinus rhythm. P-R interval 0.12. The QRS axis is approximately
30 degrees. Low
voltage in the limb leads. Diffuse non-specific ST-T wave
changes with
prominent U waves. Compared to the previous tracing no
significant change.
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 0 114 [**Telephone/Fax (2) 19696**] -124
Brief Hospital Course:
Upper GI bleed/acute blood loss anemia: [**1-10**] EGD showed with
small hital hernia, ulcers in antrum and pyloris and duodenal
bulb; he was treated with thermal therapy. HE recieved 4 units
PRBC, last [**1-11**] in the ICU, was hemodynamically stable and sent
to floor. However, due to ongoing [**Last Name (un) 15557**], another EGD was done
that showed improvement and no acute blleding. He will need
repeat EGD in 8 wks to ensure ulcer resolution. PPI [**Hospital1 **] to be
continued along with the antibiotics for H pylori to complete
the Rx.
His B 12 levels wer e low as well. He was given IM B 12 shots
while in house, changed to oral at discharge. Vit B12 levels to
be check ed in 1 month and dosing adjusted.
SPEP was done as an anemia work up and showed an M spike. The
patient should be referred to heme clinic for further
evaluation. UPEP pending. Will defer to primary care provider
for follow up.
The patient had orthostatic hypotension despite no bleeding and
a stable hematocrit. ACE inhibitor was held and the dose of beta
blocker was reduced with good tolerance. ACE I may be started in
clinic if BP tolerates.
EcASA was continued for the CAD. The patient has complete 11
month of plavix since the stent placement. Given the severe GI
bleed, plavix was stopped.
Medications on Admission:
Aspirin 325 daily,
Toprol XL 50 daily,
Lisinopril 5 daily,
Plavix 75 daily,
Lipitor 40 daily
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
3. Amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 3 days.
Disp:*12 Capsule(s)* Refills:*0*
4. Clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 3 days.
Disp:*12 Tablet(s)* Refills:*0*
5. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
8. Vitamin B-12 1,000 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute blood loss anemia
Upper GI bleeding
Orthostatic hypotension
H.Pylori
Vit B12 deficiency
h/o
CAD s/p stent
HTN
CHD
Discharge Condition:
stable
Discharge Instructions:
Return to the hospital if you notice worsening bleeding, chest
pain or any other symptoms of concern to you.
You should make a follow up appointment with your primary doctor
for a blood count check (CBC) and vitamin B12 levels.
Call [**Telephone/Fax (1) 2422**] and reschedule the upper endoscopy appointment
for next 6-8 weeks.
Also it is recommended that you not take plavix, motrin,
ibuprofen or such drugs without consulting your doctor and these
may cause bleeding.
DO not take lisinopril as this may decrease blood pressure. Talk
to you doctor [**First Name (Titles) **] [**Last Name (Titles) 19697**] your blood prssure and restart
lisinopril at that time. The dose of metoprolol has been changed
as below.
Followup Instructions:
Provider: [**Name10 (NameIs) **] WEST,ROOM ONE GI ROOMS Date/Time:[**2129-1-25**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**]
Date/Time:[**2129-1-25**] 9:00
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2129-1-25**] 1:30
Call - [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5522**] to make an appointment in
1 week for blood test (CBC)
|
[
"458.0",
"041.86",
"401.9",
"V45.82",
"531.00",
"272.0",
"414.01",
"285.1",
"266.2",
"532.00",
"300.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.16",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
7079, 7085
|
4715, 6002
|
337, 342
|
7250, 7258
|
1635, 4692
|
8024, 8548
|
1287, 1307
|
6146, 7056
|
7106, 7229
|
6028, 6123
|
7282, 8001
|
1322, 1616
|
276, 299
|
370, 1121
|
1143, 1214
|
1230, 1271
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,422
| 175,585
|
31787
|
Discharge summary
|
report
|
Admission Date: [**2137-4-25**] Discharge Date: [**2137-5-4**]
Date of Birth: [**2087-10-29**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 12174**]
Chief Complaint:
Scrotal Bleeding
Major Surgical or Invasive Procedure:
Paracentesis times 3
History of Present Illness:
49 yo man w h/o etoh cirrhosis, portal hypertension with
refractory ascites s/p recent TIPS placement who presents with
scrotal bleeding. He was discharged yesterday and got home to
find that he had urinary incontinence. Took off underwear and
"scraped" his scrotum. He then described a "squirt of blood"
shooting out of the base of his scrotum approximately 5 feet
away. It was a steady stream and soaked through his white
t-shirt (which he used to clean up the mess). Lasted
approximately 5m. Called his liver team who recommended eval.
ED: VSS. Morphine 10mg for abd pain. Underwent u/s guided para
which was neg for SBP.
Currently, he described constant dull aching abd pain since
discharge. Also describes scrotal discomfort. Reports that he
has had mild bloody discharge from a prior para site for several
days. Otherwise ROS neg for F/C/NS/bloody stools/melena/N/V.
Denies any current scrotal bleeding.
Past Medical History:
-EtOH cirrhosis, end-stage liver disease: EGD showing portal
hypertensive gastropathy, but no h/o acute GI bleeds but
continues blood loss from gastropathy; no h/o SBP; refractory
chylouse ascites s/p TIPS on [**2137-4-12**] without complication or
encepalopathy but hepatic encephalopathy in the past. non
compliance with fluid and salt restriction
- Hyponatremia
- Anemia
- H/o cellulitis
- broad base colon polyp, extending [**3-10**] of colonic
[**Last Name (LF) 74615**], [**First Name3 (LF) **] need to be removed to be enlisted on
transplant list. To be coordinated with Dr. [**Last Name (STitle) **]
Social History:
Lives at home with his mother who suffered from a large MI and
his brother who also has [**Name (NI) 13808**] secondary to EtOH cirrhosis.
Unemployed. Denies EtOH (quit months ago) or tobacco use
currently.
.
Family History:
Brother w substance abuse and ETOH cirrhosis, mother with CAD.
Physical Exam:
VS: 98.8 112/58 HR 82 98% RA
Gen: cachectic appearing, jaundiced, NAD. large edema
Neuro: Pos asterixis, alert to person, place, not month
([**Month (only) **])
HEENT: Scleral icteric, MMM
Cards: RRR II/VI systolic m and LUSB
Lungs: CTAB
Abd: protuberant. shifting dullness. ttp diffusely but no
rebound or guarding. no masses. two sites of drainage: right
lateral spot draining mild amounts of blood. right medial spot
draining chylous ascites fluid.
Scrotum: excoriations at base but no bleeding. unable to palpate
testes [**3-9**] edema
Ext: profound painful edema
rectal: light red OB pos. no melena
Pertinent Results:
[**2137-3-8**] EGD: Granularity and mosaic pattern in the fundus
compatible with portal hypertensive gastropathy
[**2137-3-8**] Colonoscopy: A single flat polyp was found in the
proximal ascending colon. The polyp covered one third of the
colon cicumference. Cold forceps biopsies were performed for
histology at the flat polyp in the proximal ascending colon.
Final Path colon bx: Adenoma
**FINAL REPORT [**2137-5-1**]**
Blood Culture, Routine (Final [**2137-5-1**]):
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
ISOLATED FROM ONE SET ONLY SENSITIVITIES PERFORMED ON
REQUEST..
Anaerobic Bottle Gram Stain (Final [**2137-4-29**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2137-4-29**] 10:30AM.
GRAM POSITIVE COCCI IN CLUSTERS.
Aerobic Bottle Gram Stain (Final [**2137-4-29**]):
GRAM POSITIVE COCCI IN CLUSTERS.
[**5-2**]
The left atrium is moderately dilated. The estimated right
atrial pressure is 10-20mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF 60%) There is no ventricular septal defect. The right
ventricular cavity is dilated with normal 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. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. Trivial mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is borderline pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2137-2-12**], the tricuspid regurgitation is increased.
IMPRESSION: no obvious vegetations seen
---------------
3.27 lenis
FINDINGS: No DVT was demonstrated in either leg.
-------------------
[**5-1**]
IMPRESSION:
1. T12 compression fracture without evidence of retropulsion or
significant spinal canal stenosis. Hyperintensity signal is
identified in the intervertebral disc space at T11 and T12
without evidence of bone edema.
Posterior disc bulge is noted at T10/11 producing mild anterior
thecal sac deformity, without evidence of nerve root
compression.
This is a very limited examination secondary to motion artifact
even after the administration of multiple pain medications,
please consider obtaining a new study under conscious sedation
if clinically warranted.
Bilateral pleural effusion is noted
---------------
[**4-28**] u/s
IMPRESSION:
1. Markedly elevated flow velocities in the mid and distal TIPS,
concerning for intrastent stenosis.
2. Cirrhotic liver.
3. Large volume of ascites
Brief Hospital Course:
49 y/oM with [**Month/Year (2) 13808**]/Cirrhosis secondary to heavy alcohol use and
alcohol addiction, no history of viral hepatitis, portal
hypertension without varices but with hypertensive gastropathy
and significant refractory ascites s/p TIPS, renal impairment,
anemia, admitted with scrotal bleeding, diagnosed with SBP,
transiently in ICU for severe abdominal pain, found to have T12
compression fx, now re-transferred to medicine after
stabilization.
.
# SBP
Diagnosed per ultrasound guided paracentesis with increased
polys. Started on CTX and Vanco. Cont to have abd pain and
intermittent fever but with stable hemodynamics. Completed
course of cefepime, subsequent tap revealed adequate treatment.
Was discharged on prophylactic ciprofloxacin 250mg daily for
life.
.
# Fever/SCN Bacteremia
Staph coagulase negative, likely contaminant, treated with 7
days vancomycin as precaution given his cirrhosis,
immunosuppressed state. Repeat tap had 300 wbc and only 20%
polys. Surveillance cultures all no growth. TTE to workup IE was
negative as were LENI's which were checked given assymetric leg
swelling. Was ruled out for c.diff toxin given abx, negative
times 3. Review of MRI was negative for signs of abscess.
.
# Cirrhosis secondary to EtOH
Has had refractory ascites and also mild encephalopathy. No
history of bleeding though is anemic. Encephalopathy, Cont
lactulose, rifaxamin. Continued MVI and PPI
- Varices: No varices on EGD
- Ascites: therapeutic tap 2 days ago with 3L off, s/p TIPS
placed 3 weeks ago, placed back on lasix 20, aldactone 50 at
discharge
- SBP: completed course abx, cipro daily as ppx
- Coagulopathy- no h/o bleeding
- [**Name (NI) 74616**] unclear
- [**Name (NI) 55362**] on list
.
# T12 Compression fracture
[**Month (only) 116**] be contributing to abdominal pain. No evidence of falls.
Orthospine ordered MRI thoracic spin with STIR, possible
vertebroplasty, seen by Dr. [**Last Name (STitle) 548**], MRI c/w old fracture, no
surgical intervention, signed off, pain control.
.
# Scrotal Bleeding- resolved at discharge
Medications on Admission:
Lactulose 30 TID
MVI
Pantoprazole 40 q24
Folic acid daily
B12 100 daily
Rifax 600 [**Hospital1 **]
Discharge Medications:
1. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
eight (8) hours.
2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Rifaximin 200 mg Tablet Sig: Three (3) Tablet PO twice a day.
6. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
8. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
10. Oxycodone 5 mg Capsule Sig: One (1) Capsule PO every [**5-12**]
hours as needed for pain.
Disp:*20 Capsule(s)* Refills:*0*
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary Diagnosis:
Spontaneous bacterial peritonitis
T12 compression
Scrotal Bleeding
Abdominal Pain
Secondary Diagnosis:
ETOH Cirrhosis
Refractory Ascites
Discharge Condition:
Stable, ambulating well
Discharge Instructions:
You were admitted to the hospital with scrotal bleeding and were
found to have a bacterial infection in your abdomen for which
you completed antibiotics and will now need to take
Ciprofloxacin 250mg 1 tablet daily to prevent recurrence of this
infection. You also had bacteria in your blood which was treated
with antibiotics. You were found to have a T12 compression
fracture which was evaluated by surgery with an MRI, the
fracture did not require any surgical intervention. You had
fluid removed from your abdomen several times and you were
placed back on diuretics (water pills). You
Your new medication list will be printed for you before you
leave.
If you develop fevers, chills, severe abdominal pain or any
worrisome symptoms then call the transplant clinic or go to the
emergency room for evaluation.
Followup Instructions:
Dr. [**Last Name (STitle) 497**] ([**Telephone/Fax (1) 3618**] call his office on Monday to schedule
an appointment in [**3-11**] weeks, transplant coordinator aware
.
[**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 3183**] call on Monday to schedule an
appointment in the
|
[
"276.1",
"572.3",
"608.83",
"E849.7",
"567.23",
"789.59",
"571.2",
"805.2",
"E885.9",
"303.93",
"287.5",
"572.2",
"537.89"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
8946, 9001
|
5744, 7817
|
333, 356
|
9202, 9228
|
2877, 5721
|
10088, 10386
|
2173, 2237
|
7967, 8923
|
9022, 9022
|
7843, 7944
|
9252, 10065
|
2252, 2858
|
277, 295
|
384, 1298
|
9145, 9181
|
9041, 9124
|
1320, 1930
|
1946, 2157
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,729
| 149,861
|
14313
|
Discharge summary
|
report
|
Admission Date: [**2122-3-19**] Discharge Date: [**2122-3-24**]
Date of Birth: [**2042-5-12**] Sex: F
Service: NEUROLOGY
Allergies:
Cortisone / Zestril
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
transfer from [**Hospital1 **] [**Location (un) 620**] with left cerebellar stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname **] is a 79 year old right handed female with a
history of hypertension, hyperlipidemia and atrial flutter s/p
ablation who presented to [**Hospital1 **] [**Location (un) 620**] ED on [**3-18**] with complaints
of nausea, lightheadness and dysarthric speech. Ms. [**Known lastname **] was
in your usual state of health and on the morning of admission,
awoke, performed her usual morning stretching exercises of her
back/knees. Took a shower afterwards and while walking to the
bedroom noticed that she "felt floppy." Her head also began to
fell like it was "a bobble doll" and she need to lay down. Her
tongue began "feeling thick" and she heard some buzzing in her
ears. She had no loss of consciousness and did not feel as if
she
was spinning. She had no headache or visual symptoms at this
time. She did not fell her heart racing or seeming to skip any
beats. Because of the lightheadedness and difficulty speaking,
she went to the [**Hospital1 **]-[**Location (un) 620**] ED on [**3-18**].
On arrival to the ED, she felt nauseous and proceeded to vomit
several times. Any motion seemed to trigger a spell of emesis.
Her blood pressure was markedly elevated to 206/74. She had a
head CT showing old infarctions but nothing acute. She was
treated with zofran and meclizine for the nausea and ativan for
anxiety. She was observed overnight but this AM on awakening
and
attempting to walk to the bathroom with assistance, she felt
very
lightheaded and was unsteady standing. Her heart rate decreased
to the 40's so cardiology was consulted. They were concerned
for
a possible arterial dissection, prompting the MRI/MRA today
which
showed a L SCA cutoff and L cerebellar infarction. Because of
the concern for swelling with cerebellar infarctions, she was
transferred to the [**Hospital1 18**] ICU for further care.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysphagia, vertigo, tinnitus or hearing
difficulty. Does still endorse mild change in her speech,
although this has been improving substantially. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. Gait is unsteady and she
requires assistance even to stand up. Could not ambulate to
bathroom this AM as above.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Intermittent arthralgias and myalgias secondary to
arthritis. Denies rash.
Past Medical History:
-Hypertension
-Hyperlipidemia
-Sciatica
-Osteoarthritis
-bilateral knee replacements
-R shoulder replacement
-multiple lower back surgeries
-atrial flutter s/p ablation 1 year ago
-s/p hysterectomy
Social History:
Lives with her husband. [**Name (NI) **] 9 adult children. Retired
bookepper. Used 1 pack per week of cigarettes but quit 30 years
ago. Alcohol on rare occasions such as [**Holiday **]. No drug use.
Family History:
No family history of stroke. Coronary artery disease in brother
who had angioplasty at age 60. Another brother had a heart
valve replacement.
Physical Exam:
Vitals: T: afebrile P: 64 R: 14 BP: 168/62 SaO2: 94% on RA
General: Awake, cooperative, moderately obese female in NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple.
Pulmonary: Lungs CTA bilaterally.
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: WWP
Skin: no rashes or lesions noted. multiple well healed surgical
scars on anterior knees and lower back.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Able to spell WORLD forwards and backwards.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt. was able
to name both high and low frequency objects. Able to read
without difficulty. Speech was not dysarthric. Able to follow
both midline and appendicular commands. Pt. was able to register
3 objects and recall [**1-22**] at 5 minutes. The pt. had good
knowledge of current events including [**Male First Name (un) **] wedding and [**Location (un) 86**]
Marathon. There was no evidence of apraxia or neglect.
Calculations intact.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI with mild end gaze nystagmus bilaterally.
Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Decreased vibratory sensation in toes (5 seconds
bilateraly). No other deficits to light touch, pinprick, cold
sensation, vibratory sense, proprioception throughout. No
extinction to DSS.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
Mild dysmetria on L FNF and some pass pointing with mirroring on
L. [**Doctor First Name **] decreased on left. L heel-shin with mild ataxia.
-Gait: Able to stand unsupported. Falls backward with any
attempt to take a step. Romberg present.
Pertinent Results:
IMAGING:
Non contrast head MRI ([**3-24**]):
1. Since [**2122-3-19**], there has been slight inferior extension of
the evolving acute infarct in the left superior cerebellum.
2. Faint high T2 signal in the pons, possibly due to chronic
ischemic disease. No acute pontine infarct.
3. Chronic cortical infarcts in the right frontal and left
parietal lobes. Chronic supratentorial white matter infarcts.
.
Non contrast head CT ([**3-22**]): Expected evolution of small
superior left cerebellar hemispheric infarct, without
hemorrhagic conversion or increased mass effect.
.
ECHO ([**3-20**]):
Mild spontaneous echo contrast but no thrombus is present in the
left atrial appendage. The left atrial appendage emptying
velocity is depressed (<0.2m/s). No spontaneous echo contrast or
thrrombus is seen in the body of the left atrium or the body of
the right atrium/right atrial appendage. Right atrial appendage
ejection velocity is good (>20 cm/s). No atrial septal defect is
seen by 2D or color Doppler. Overall left ventricular systolic
function is normal (LVEF>55%). There are simple atheroma in the
aortic arch. There are simple atheroma in the descending
thoracic aorta extending to 42 cm from the incisors. The aortic
valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Moderate (2+) mitral regurgitation is seen. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: Spontaneous echo contrast but no thrombus in left
atrial appendage. Moderate mitral regurgitation.
.
Head CT ([**3-18**]):
Hypodensities within the right frontal lobe and left parietal
lobe with adjacent volume loss in the left parietal region
likely
represent encephalomalacia and gliosis, related to prior
ischemic
events.
.
Brain MRI/MRA ([**3-19**]): L cerebellar infarction with occlusion of
the L SCA.
.
Chest, Abdomen, Pelvis CT/CTA ([**3-19**])
NO EVIDENCE OF PULMONARY EMBOLISM ON LIMITED EVALUATION.
NO AORTIC DISSECTION OR AORTIC ANEURYSM.
ATHEROSCLEROSIS INVOLVING THE ORIGINS OF THE LEFT SUBCLAVIAN
ARTERY, CELIAC ARTERY, SUPERIOR MESENTERIC ARTERY, AND BILATERAL
RENAL ARTERIES. PATENT ORIGINS OF THE VERTEBRAL ARTERIES.
CORONARY ARTERY DISEASE.
SUBCUTANEOUS 12 MM SOFT TISSUE DENSITY ANTERIOR TO THE THYROID
GLAND, POSSIBLY A SEBACEOUS CYST. PLEASE CORRELATE WITH PHYSICAL
EXAM.
EVALUATION OF THE LUNGS IS LIMITED BY RESPIRATORY MOTION.
MILDLY ENLARGED PARATRACHEAL LYMPH NODES.
A 2.4 STONE IN A DISTENDED GALLBLADDER.
.
LABS ON ADMISSION:
WBC-9.1, Hct-41, Plts-260.
Na-136, K-4.1, Cl-102, Bicarb-25, BUN-25, Cr-0.9, Glu-111
.
LABS ON DISCHARGE:
[**2122-3-24**] 05:20AM BLOOD WBC-15.7* RBC-5.00 Hgb-14.7 Hct-44.3
MCV-89 MCH-29.4 MCHC-33.3 RDW-14.0 Plt Ct-261
[**2122-3-24**] 05:20AM BLOOD Neuts-70.1* Lymphs-21.9 Monos-5.1 Eos-2.3
Baso-0.6
[**2122-3-24**] 05:20AM BLOOD PT-24.8* PTT-80.6* INR(PT)-2.3*
[**2122-3-24**] 05:20AM BLOOD Glucose-98 UreaN-29* Creat-1.2* Na-137
K-4.1 Cl-103 HCO3-20* AnGap-18
[**2122-3-24**] 05:20AM BLOOD CK(CPK)-79
[**2122-3-24**] 05:20AM BLOOD CK-MB-2 cTropnT-LESS THAN
[**2122-3-20**] 02:05AM BLOOD %HbA1c-6.3* eAG-134*
[**2122-3-20**] 02:05AM BLOOD Triglyc-135 HDL-58 CHOL/HD-2.9 LDLcalc-86
[**2122-3-20**] 02:05AM BLOOD TSH-0.93
.
MICRO/URINE:
Color Appear Sp [**Last Name (un) **]
[**2122-3-20**] Yellow Clear 1.019
Blood Nitrite Protein Glucose Ketone Bilirub Urobiln
pH Leuks
[**2122-3-20**] MOD NEG 30 NEG NEG NEG NEG
6.0 MOD
RBC WBC Bacteri Yeast Epi
[**2122-3-20**] 51* 30* FEW NONE <1
[**2122-3-20**] URINE CULTURE-ENTEROCOCCUS SP.. >100,000
ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
[**2122-3-20**] MRSA SCREEN-NEGATIVE
Brief Hospital Course:
79 year old right handed female with a history of hypertension,
hyperlipidemia, atrial flutter s/p ablation who initially
presented with nausea, lightheadness and diffuse weakness found
to have L SCA infarct.
Neuro: Initially admitted to neuro ICU for left superior
cerebellar artery stroke on imaging from [**Hospital1 **].
Transferred to floor neurology service on [**3-20**]. Found to have
diplopia, unlikely new large stroke; possible microvascular
infarct not seen on MRI. However, without involvement of CN 7,
this is likely in the course of the 6th nerve or Left lateral
rectus; see results section for repeat MRI read. Etiology likely
emobolic, however TEE showed no evidence of thrombus. IV heparin
started at 13 IU/kg/hr, goal PTT of 50-70; discontinued on
[**2122-3-24**] with INR 2.3 on coumadin 3mg daily. Aspirin 325 mg PO/NG
DAILY for antiplatelet therapy. LDL found to be 86, not at goal,
increased Lipitor from 10 to 40mg daily. Speech and swallow
evaluation in ICU cleared pt for thin liquids and regular
solids. Physical therapy consult recommended home with PT. Pt
will follow-up with her PCP for INR monitoring. Will have
patient follow-up with Dr. [**Last Name (STitle) **] in 6 weeks.
Cardiovascular: Cardiology consulted for arrhythmia, amiodarone
loaded for PAF. Atorvastatin 40mg as above. Coumadin with
heparin bridge as above. Home chlorthalidone continued. HgA1C
found to be 6.3. Pt to follow-up with Dr. [**Last Name (STitle) **] within a
month of discharge.
ID: Pt found to have UTI during admission, started on
nitrofurantoin 100mg [**Hospital1 **] x 3 days on day of discharge.
Medications on Admission:
-chlorthalidone 25mg daily (started 1 month prior to
presentation)
-lovastatin 10mg daily
-losartan 50mg daily
-caltrate daily
-aspirin 81mg daily
-tylenol 1000mg prn
Discharge Medications:
1. lovastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
2. losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
5. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
Disp:*90 Tablet(s)* Refills:*2*
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. nitrofurantoin monohyd/m-cryst 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 6 doses.
Disp:*6 Capsule(s)* Refills:*0*
8. Caltrate 600 600 mg (1,500 mg) Tablet Sig: One (1) Tablet PO
once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 620**] VNA
Discharge Diagnosis:
cerebellar stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname **],
You were admitted for a cerebellar stroke. This was thought to
be
secondary to your atrial fibrillation. You were started on
coumadin
for stroke protection. Your stroke risk factors were checked.
You
should not smoke. Your cholesterol was LDL 86. You were
started on
lipitor. You were checked for blood glucose control with a HgB
A1c.
The level was 6.3. You need to continue your blood pressure
control.
You should continue to eat a low fat healthy diet, and follow up
with
your primary care physician and stroke Neurology.
It was a pleasure taking care of you.
Followup Instructions:
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 8506**] f/u on coumadin Friday [**3-27**] 11
am. Fax: [**Telephone/Fax (1) 8512**]
Cardiology [**Last Name (LF) **], [**First Name3 (LF) **] J Office Phone: ([**Telephone/Fax (1) 20575**]
Office
Location: W/[**Hospital Ward Name **]/4 Department: Medicine Organization: [**Hospital1 18**]
In 1 month time
Neurology with Dr. [**Last Name (STitle) **] in 6 weeks time. Please call
[**Telephone/Fax (1) 2574**] for an apppointment.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
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73,186
| 174,257
|
29755
|
Discharge summary
|
report
|
Admission Date: [**2198-3-14**] Discharge Date: [**2198-3-17**]
Date of Birth: [**2115-5-26**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
Fatigue x 2 weeks
Major Surgical or Invasive Procedure:
Permanent pacemaker placement
History of Present Illness:
82 year old female with hx of bipolar disorder on lithium, HTN,
achalasia, and hypothyroidism presents with fatigue x 2 weeks.
She denies CP/SOB, no fever. She was noted to have bradycardia
during outpatient PT eval and was sent to her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],
for further evaluation. He then sent her to the [**Hospital1 **] [**Location (un) 620**] ED.
Rates ranged from 30s to 50s. She has had similar presentations
in the past, in the setting of lithium toxicity.
.
In the ED, initial vitals were: 97.4, 50, 128/56, 97% on 2L NC.
She was noted once again to have HRs in the 30s, with SBPs in
90s. She was given 1L IVF, 0.5mg atropine with resulting vitals
on transfer of: HR 63, BP 125/69, RR 19, O2 sat 100% 3L.
.
Of note, she was last hospitalized at [**Hospital1 18**] in [**2197-3-25**] with
weakness, bradycardia, and tremors attributed to lithium
toxicity in the setting of acute kidney injury, with episodes of
bradycardia to the 30s. She was put on peripheral dopamine
briefly for hypotension and her bradycardia was generally not
responsive to atropine. She is now followed by Neurology as an
outpatient for carpal tunnel syndrome, neuropathic pain in the
feet (on Lyrica, followed by Pain service), lumbar
radiculopathy, and gait unsteadiness (working with PT).
.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG: none
-PERCUTANEOUS CORONARY INTERVENTIONS: none
-PACING/ICD: none
3. OTHER PAST MEDICAL HISTORY:
Achalasia
Bipolar disorder, on chronic lithium
Hypothyroidism ([**12-27**] Li toxicity)
Gait disorder
Carpal tunnel syndrome
Frequent UTIs and urinary incontinence
s/p cataract removal in left eye
rotator cuff tear
GERD
Social History:
Lives alone. Independent in ADLs.
-Tobacco history: none
-ETOH: none
-Illicit drugs: none
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
On admission:
VS: T=97.4, BP=119/44, HR=58, RR=20, O2 sat=97%
GENERAL: elderly female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT, PERRL, EOMI, sclera anicteric. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Mild sinus
tenderness. No xanthalesma.
NECK: Supple with no JVD, no carotid bruits, no LAD
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: Moderate kyphosis. Resp were unlabored, no accessory
muscle use. Crackles to right middle and lower lung fields, with
mildly decreased BSs at the right base. No wheezes or rhonchi.
ABDOMEN: Soft, NT/ND. No HSM or tenderness.
EXTREMITIES: No c/c. Mild edema over LE bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
NEURO: CN II-XII intact, 5/5 strength in UEs and LEs, intact
sensation to light touch, reflexes and cerebellar testing not
assessed. Mild resting tremor.
On discharge: no changes to exam.
Pertinent Results:
Labs on admission:
[**2198-3-15**] 04:55AM BLOOD WBC-7.4 RBC-3.59* Hgb-11.1* Hct-34.3*
MCV-95 MCH-30.9 MCHC-32.4 RDW-14.0 Plt Ct-341
[**2198-3-15**] 04:55AM BLOOD PT-12.8 PTT-23.7 INR(PT)-1.1
[**2198-3-15**] 04:55AM BLOOD Glucose-94 UreaN-27* Creat-0.8 Na-141
K-4.6 Cl-114* HCO3-22 AnGap-10
[**2198-3-15**] 04:55AM BLOOD ALT-14 AST-18 LD(LDH)-126 CK(CPK)-31
AlkPhos-44 TotBili-0.3
[**2198-3-15**] 04:55AM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.7 Mg-2.1
[**2198-3-16**] 05:24AM BLOOD VitB12-336
[**2198-3-15**] 04:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2198-3-15**] 04:55AM BLOOD TSH-0.21*
[**2198-3-15**] 04:55AM BLOOD Free T4-1.4
Lithium
[**2198-3-15**] 04:55AM BLOOD Lithium-1.2
[**2198-3-16**] 05:24AM BLOOD Lithium-0.8
MICROBIOLOGY:
OTHER STUDIES:
EKGs:
#1 on admission: Sinus bradycardia with A-V conduction delay.
Otherwise, normal tracing. Since the previous tracing of [**2197-4-13**]
low T wave amplitude has improved.
#2: Sinus rhythm with possible S-A nodal block (question type
II). Clinical correlation is suggested. Since the previous
tracing of same date the rhythm as outlined has replaced sinus
bradycardia.
#3: Sinus bradycardia with slight A-V conduction delay.
Otherwise normal tracing. Since the previous tracing of [**2198-3-14**]
possible S-A nodal block is now absent.
IMAGING:
TTE: The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Right ventricular chamber size and free wall
motion are normal. There are focal calcifications in the aortic
arch. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen. The
left ventricular inflow pattern suggests impaired relaxation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
CXR: One view. Comparison with the previous study of [**2197-4-14**].
The lungs remain clear except for streaky density at the lung
bases consistent with
subsegmental atelectasis. The heart and mediastinal structures
are unchanged. The bony thorax is grossly intact. A bipolar
transvenous pacemaker has been inserted on the left with intact
electrodes terminating in the regions of the right atrium and
right ventricular apex.
IMPRESSION: Bibasilar subsegmental atelectasis. Transvenous
pacemaker in
place.
Brief Hospital Course:
82 year old female with hx of bipolar disorder on lithium, HTN,
and hypothyroidism, presents with recurrent episode of
symptomatic bradycardia secondary to lithium toxicity, here for
consideration of pacemaker placement.
.
ACTIVE ISSUES
.
# RHYTHM / Bradycardia [**12-27**] lithium toxicity: She was initially
bradycardic down to 30s along with hypotension down to SBPs of
90s, somewhat responsive to atropine (though noted to have very
little effect in the past). Cardiology described her rhythm as
junctional with ?sinus exit block or atrial escape. Lithium
levels were checked and she was only slightly supratherapeutic
and her PM dose was held prior to repeating a level the
following morning. Her normal home dosing was then restarted.
Her valsartan was held, given her hypotension at the OSH. Given
her need for long-term mood stabilization for bipolar disorder
and recurrent episodes of symptomatic bradycardia, it was felt
that a pacemaker was the most logical next step for her. Also,
chronic lithium therapy can affect sinus node function in the
long-term. Atropine was kept at the bedside prior to her
pacemaker placement. TTE on the morning following admission was
normal. The Electrophysiology team placed a permanent pacemaker
([**Company 1543**] Adapta L ADDRL1, SN: NWE231413H) and she was
discharged on cephalexin for 3 days after 1 dose of IV
vancomycin in house. She will be discharged with close
Electrophysiology follow-up.
.
# Hypothyroidism: Her TSH was recently just below the normal
range at 0.24, indicating relative hyperthyroidism from likely
over-replacement. fT4 was normal at 1.4. Her dose was initially
lowered to 50mcg prior to fT4, but restarted back at 75mcg.
While on lithium and levothyroxine, routine TSH testing should
continue as an outpatient.
.
INACTIVE ISSUES
.
# CORONARIES: There was no evidence of ischemia causing her
bradycardia, without ST changes on EKG. Initial Trop <0.01 and
cardiac enzyme trend was unremarkable. TTE did not show any wall
motion abnormalities.
.
# Achalasia: No recent difficulties with eating. She sees
gastroenterology as an outpatient, but previous motility studies
have been unremarkable.
# Bipolar disorder: On lithium chronically, with episodes of
lithium toxicity in the past, already manifested by thyroid
disease. No recent symptoms, well controlled with mood
stabilizers.
.
# Carpal tunnel syndrome - Previously with wrist splint, now
choosing to undergo surgery for release. Scheduled in about 1
month.
.
TRANSITIONAL ISSUES
.
#. Follow-up: She will follow-up closely with the
Electrophysiology Department as an outpatient.
.
#. Communication: [**Name (NI) 803**] [**Name (NI) 1124**] (HCP, daughter - [**Telephone/Fax (1) 71234**])
Medications on Admission:
Aspirin 81 mg a day
Citracal 950mg [**Hospital1 **]
Claritin 10mg daily PRN allergy symptoms
Detrol 2mg PRN incontinence
Diovan 80mg [**Hospital1 **]
Levothyroxine 75 mcg daily
Lithium 300mg qAM, 150mg qPM
Lorazepam 0.5mg daily PRN anxiety
Lyrica 50 mg TID
Omeprazole 20mg daily
Zonalon cream 5% q6h PRN pain/itching
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Citracal Regular Oral
3. Claritin 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for allergy symptoms.
4. Detrol 2 mg Tablet Sig: One (1) Tablet PO once a day as
needed for incontinence.
5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. lithium carbonate 300 mg Capsule Sig: One (1) Capsule PO QAM
(once a day (in the morning)).
7. lithium carbonate 150 mg Capsule Sig: One (1) Capsule PO QPM
(once a day (in the evening)).
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for anxiety.
9. Lyrica 50 mg Capsule Sig: One (1) Capsule PO three times a
day.
10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Zonalon 5 % Cream Sig: One (1) application Topical q6h () as
needed for itching.
12. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 3 days: start date:[**2198-3-18**]
end date:[**2198-3-20**].
Disp:*9 Capsule(s)* Refills:*0*
13. tramadol 50 mg Tablet Sig: 0.5 to 1 Tablet PO every six (6)
hours as needed for pain for 5 days.
Disp:*20 Tablet(s)* Refills:*0*
14. Outpatient [**Month/Day/Year **] Work
Please have your primary care doctor check your lithium level in
the week after your discharge.
15. valsartan 80 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: bradycardia (sinus exit 2:1 block in setting of chronic
lithium usage), fatigue
Secondary: bipolar disorder, hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 15131**],
You were admitted to the hospital for slow heart rate that is
likely secondary to chronic lithium usage. Since you will need
to remain on lithium, a pacemaker was placed to keep your heart
rate at a good rate. Given that you are fatigued, please visit
your primary care doctor for further evaluation.
You will also need to get your lithium level checked within a
week of discharge. Please have this done at your primary care
doctor's office.
Post-pacemaker placement instructions:
* Avoid any efforts with left arm. Avoid lifting heavy objects.
Avoid raising arm above the level of the shoulder for AT LEAST
ONE MONTH.
* You can wear the shoulder sling for comfort
* Do not drive for at least 4 weeks after the procedure
* Given that you have a pacemaker, you cannot be in magnetic
fields. You cannot have MRI. You cannot go through the regular
security at airports.
* Do not place cell phone in direct contact with pacemaker.
* Please report back to the hospital if you have fever or notice
pus or swelling coming from the pacemaker pocket.
* The steri-stripes under the dressing MUST remain in place. The
dressing can be removed if needed or it becomes bothersome.
* You MUST cover up the wound when taking a shower. DO NOT a
BATH.
Medication changes:
START keflex (an antibiotic) to prevent infection after
pacemaker placement for 3 days. Last dose is on [**2198-3-20**].
START tramadol for pain after your procedure. This medication
may make you constipated, so it is important to take
anti-constipation medicatons such as senna and colace if you are
not able to have consistent bowel movements.
Followup Instructions:
Since it is the weekend, we were unable to schedule all your
appointments. Please follow-up with your primary care doctor
within a week of discharge to check your lithiuim level and your
psychiatrist within 2-3 weeks of discharge
Department: CARDIAC SERVICES
When: THURSDAY [**2198-3-22**] at 1:30 PM
With: DEVICE CLINIC [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: SURGICAL SPECIALTIES
When: THURSDAY [**2198-8-9**] at 10:30 AM
With: [**Name6 (MD) 161**] [**Name8 (MD) 6476**], MD [**Telephone/Fax (1) 2998**]
Building: None [**Location (un) **]
Campus: OFF CAMPUS Best Parking: Parking on Site
|
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|
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75,785
| 115,646
|
39377
|
Discharge summary
|
report
|
Admission Date: [**2113-11-3**] Discharge Date: [**2113-11-8**]
Date of Birth: [**2061-12-3**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 4393**]
Chief Complaint:
tachypnea
Major Surgical or Invasive Procedure:
Therapeutic paracentesis x 2
History of Present Illness:
51-year-old male with past medical history of decompensated
alcoholic cirrhosis still actively drinking complicated by
portal hypertension with ascites and grade II esophageal varices
admitted on [**2113-11-3**] with hyponatremia, new portal vein
thrombosis, atrial fibrillation with RVR. He does have a history
of an uncharacterized gastric mass in the pre-pyloric region
with previous biopsies at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] during an EGD, which were
inadequate. Another biopsy was attempted, but FNA deferred due
to high INR of 1.9. Patient was admitted from [**Hospital Ward Name 1950**] 5 as was
supposed to get scoped yesterday for same etiology but noticed
to have worsening laboratory values/clinical status and sent to
ED.
Of note, the patient's liver disease has been worsening over the
past 6 months to the point where he reuiqired therapeutic
paracentesis (total of three taps with 4.5, 2, and 3.5 L
removed). He also has a history of thoracentesis for effusions
although specific data are not available.
.
During hospital course, diagnostic paracentesis with 60 mL
serous fluid removed. Atrial fibrillation with RVR to 150s was
noted and controlled with dilitazem. Patient was also managed
for hyponatremia and continued management of decompensated
alcoholic cirrhosis with likely vascular component given new
portal vein thrombosis with poor collaterals. Surgery also
consulted in setting of uncharacterized gastric mass.
.
On [**2113-11-5**] in AM, team concerned about increased labor of
breathing and worsened altered MS with concern for airway
protection. CXR showed L sided pleural effusion. ABG indicates
good oxygenation on 2L NC. On exam pt appeared mildly tachypnic.
He is alert and oriented x 3. ABG at time showed no hypoxemia or
hypercarbia. Patient was subsequently transfered to the MICU. On
floor, patient was AAOx2-3 and did not want to discuss his
hospital course. Patient in no respiratory distress.
Past Medical History:
1. Etoh Cirrhosis:
- history of UGIB in [**2111**] at [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] which showed
non-bleeding grade II esophageal varices, portal gastropathy,
gastric mass
- thrombocytopenia
- anemia
2. Alcohol abuse/withdrawal - recently hospitalized at [**Hospital **]
hospital in [**2113-8-25**] and was placed on ativan gtt
3. Atrial fibrillation (long-standing)
4. Folate deficiency
Social History:
Tobacco: smokes 1PPD x "decades"
EtOH: daily 6-pack after work for "many years", and "big bottles
of SoCo" every night, unable to report last use
Illicits: + marijuana (last use last week), denies IV or
intranasal drug use
Family History:
Non-contributory. No GI or liver disease. Father had stroke.
Physical Exam:
Admission Exam
Vitals: T 99.1 HR 100 BP 119/79 HR 88 RR 19 SaO2 94 % on 2 L NC
GENERAL - ill-appearing man in no acute distress
HEENT - NC/AT, EOMI, + scleral icterus, dry MM
NECK - supple, no LAD or thyromegaly, no JVD
LUNGS - CTA bilat, no r/rh/wh
HEART - tachycardic, irreg irreg, no MRG
ABDOMEN - +BS, soft/NT, + large ascites but not tense, + caput
medusae, no palpable masses or HSM, no rebound / guarding
EXTREM - WWP, 2+ BLE edema, 3+ scrotal edema
SKIN - mild jaundice, no rashes or lesions
NEURO - AAOx2-3, asterixis, poor insight
.
Discharge Exam
97.0 126-132/75-77 89-102 20-22 93%RA
GENERAL - Male in no acute distress
HEENT - Normocephalic. Nontraumatic. PERRLA. EOMI. Supple neck.
LUNGS - Bibasilar crackles.
HEART - Irregularly irregular. Not tachycardic.
ABDOMEN - +BS, soft/NT, + large ascites but not tense, + caput
medusae, no palpable masses or HSM, no rebound / guarding
EXTREM - WWP, 2+ BLE edema, 3+ scrotal edema
SKIN - mild jaundice, no rashes or lesions
NEURO - Alert and oriented to person, place and time. Poor
insight.
Pertinent Results:
[**2113-11-3**] 09:31AM BLOOD WBC-12.6* RBC-3.11* Hgb-11.3* Hct-33.1*
MCV-106* MCH-36.4* MCHC-34.3 RDW-14.9 Plt Ct-64*
[**2113-11-5**] 05:10AM BLOOD WBC-6.9 RBC-2.49* Hgb-8.9* Hct-27.4*
MCV-110* MCH-35.8* MCHC-32.6 RDW-15.6* Plt Ct-47*
[**2113-11-8**] 05:10AM BLOOD WBC-9.7 RBC-2.43* Hgb-8.9* Hct-27.1*
MCV-111* MCH-36.6* MCHC-32.8 RDW-15.5 Plt Ct-64*
[**2113-11-3**] 09:31AM BLOOD PT-18.2* PTT-36.7* INR(PT)-1.6*
[**2113-11-6**] 05:54AM BLOOD PT-19.7* PTT-41.3* INR(PT)-1.8*
[**2113-11-8**] 05:10AM BLOOD Plt Ct-64*
[**2113-11-3**] 09:31AM BLOOD UreaN-14 Creat-0.7 Na-122* K-4.8 Cl-91*
HCO3-22 AnGap-14
[**2113-11-8**] 05:10AM BLOOD Glucose-115* UreaN-14 Creat-0.7 Na-133
K-4.0 Cl-99 HCO3-26 AnGap-12
[**2113-11-3**] 09:31AM BLOOD ALT-34 AST-74* AlkPhos-206* Amylase-139*
TotBili-5.7* DirBili-2.3* IndBili-3.4
[**2113-11-5**] 05:10AM BLOOD ALT-23 AST-44* LD(LDH)-265* AlkPhos-158*
TotBili-4.0*
[**2113-11-8**] 05:10AM BLOOD ALT-25 AST-40 LD(LDH)-276* AlkPhos-146*
TotBili-4.1*
[**2113-11-3**] 09:31AM BLOOD Albumin-2.9* Calcium-8.4 Phos-3.4 Mg-1.5*
[**2113-11-7**] 04:45AM BLOOD Albumin-3.7 Calcium-9.2 Phos-3.3 Mg-1.5*
[**2113-11-6**] 05:54AM BLOOD VitB12-1845*
[**2113-11-4**] 02:46AM BLOOD Osmolal-280
[**2113-11-4**] 02:46AM BLOOD HBsAg-NEGATIVE HBsAb-BORDERLINE
HBcAb-NEGATIVE HAV Ab-POSITIVE
[**2113-11-3**] 09:31AM BLOOD AFP-2.4
[**2113-11-4**] 02:46AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2113-11-4**] 02:46AM BLOOD HCV Ab-NEGATIVE
Test Result Reference
Range/Units
HCV AB, RIBA Negative Negative
RUQ US ([**2113-11-3**]): Cirrhotic liver with large volume perihepatic
ascites, and possible thrombosis of the main portal vein.
Differential includes sluggish flow. Limited evaluation.
CXR ([**2113-11-3**]): Subsegmental atelectasis in the left upper lobe,
and patchy opacity in left lung base, also likely representing
atelectasis. Probable small bilateral pleural effusions.
CT Chest with contrast ([**2113-11-4**]):
1. Thrombosis of the portal venous system as described, with
distal reconstition of right anterior and left branches due to
cavernous transformation. However, it is noted that
collateralization to the portal branches appears minimal in
comparison with shunting of portal venous flow to massive
esophageal varices.
2. Cirrhotic-appearing liver without arterially enhancing
lesion.
3. Stigmata of portal hypertension including large
gastroesophageal varices and splenomegaly.
4. Moderate left pleural effusion.
5. Abdominal ascites.
Brief Hospital Course:
51 year old man with alcoholic cirrhosis complicated by portal
hypertension with ascites and esophageal varices admitted for
biopsy of known gastric mass and found to have hyponatremia,
portal vein thrombus, and atrial fibrillation with RVR.
1. Portal vein thrombus: Ultrasound and CT abdomen consistent
with portal vein thrombosis with some collaterals. Transplant
surgery was consulted who suggested no anticoagulation in lieu
of his esophageal varices
2. Hyponatremia: Improved with fluid restriction, discontinuing
lasix/spironolactone and IV albumin 1g/kg daily x 3 days. Once
his hyponatremia resolved, his spironolactone was started at
increased dose of 100 mg po qdaily and lasix was started at
decreased dose of 40 mg po qdaily. His serum sodium remained
within normal range on latter doses of spironolactone and lasix.
3. Atrial fibrillation with RVR on admission: Rate controlled
with diltiazem and nadolol. Likely due to not taking his
regular medications on day of admission. He was not
anticoagulated due to his Grade II nonbleeding esophageal
varices and portal gastropathy.
4. Decompensated alcoholic cirrhosis: Known grade II esophageal
varices and history of upper GI bleeding. Has large ascites and
peripheral edema on admission. He reeceived two paracentesis
(4L and 3L) during his hospital stay with IV albumin (25 g and
25 g respectively). He was encephalopathic during his hospital
stay with negative diagnostic paracentesis, RUQ ultrasound,
blood and urine culture, CXR and toxicology screen. His
encephalopathy improved with lactulose and rifaximin.
5. Gastric mass: Pt has known pre-pyloric gastric mass.
Initially noted on EGD, biopsies reportedly non-diagnostic. EUS
[**8-/2113**] noted findings above, but biopsies not done due to his
elevated INR at the time. Presented for repeat EUS for biopsies
but unable to have this once as his labs returned markedly
abnormal as above.
Was not biopsied as he was not medically thought to be stable.
Will follow up as outpatient.
6. Alcohol abuse with hx of withdrawal. Last drink day prior to
admission. He was given ativen 2 mg po for CIWA > 8 on day of
admission leading to worsening of his encephalopathy and ICU
admission for a day. He was monitored for alcohol withdrawal
with CIWA scale but not given ativan for rest of his admission
stay. He was started on folic acid, thiamine and multivitamin
for nutrition.
Medications on Admission:
Medications on Transfer:
Lorazepam 1-2 mg PO/NG Q4H:PRN CIWA > 8
Albumin 25% (12.5g / 50mL) 37.5 g IV ONCE Duration: 1
Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
Metoclopramide 10 mg PO/NG QIDACHS
CeftriaXONE 1 gm IV Q24H Duration: 4 Days Order date: [**11-4**]
Nadolol 40 mg PO DAILY
Diltiazem 30 mg PO/NG QID
Nicotine Patch 14 mg TD DAILY
FoLIC Acid 1 mg PO/NG DAILY
Pantoprazole 40 mg PO Q12H
Rifaximin 550 mg PO/NG [**Hospital1 **]
Heparin 5000 UNIT SC TID
Thiamine 100 mg PO/NG DAILY
Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheeze
Tolterodine 2 mg PO DAILY
Iron Polysaccharides Complex 150 mg PO DAILY
Vancomycin 1000 mg IV Q 12H
Lactulose 30 mL PO/NG QID
Zinc Sulfate 220 mg PO/NG DAILY
Lactulose Enema 1000 mL PR ONCE Duration
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Sust. Release 24 hr Sig: One
(1) Capsule, Sust. Release 24 hr PO once a day.
2. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
5. tolterodine 1 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. polysaccharide iron complex 150 mg Capsule Sig: One (1)
Capsule PO DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
7. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
11. spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO Q4H (every 4
hours).
Disp:*500 ML(s)* Refills:*2*
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 8300**] VNA and Hospice
Discharge Diagnosis:
Primary Diagnosis
1. Grade I encephalopathy
2. Alcoholic cirrhosis with esophageal varices and ascites
3. Alcohol abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted because you were found to have low sodium
level during your pre-EGD labs. It was thought to be due to
your worsening liver function. Your sodium level improved with
fluid restriction and change in your diuretics. You were noted
to have worsening of your mental status and increase work of
breathing thought to be due to fluid in your lung which led to
admission to the intensive care unit. They aggressively removed
fluid from your body which made your breathing better.
.
It is extremely essential you do not have another alcoholic
beverage.
.
Following medication changes were made to your regimen
INCREASE SPIRONOLACTONE to 100 mg once a day to help with low
sodium level
START RIFAXIMIN 550 mg by mouth twice a day for confusion
START IRON 150 mg by mouth once a day for nutrition
START THIAMINE 100 mg by mouth once a day for nutrition
START FOLATE 1 mg by mouth once a day for nutrition
DECREASE LASIX to 40 mg by mouth once a day to help with your
low sodium level
Followup Instructions:
Name: [**Known firstname **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD
Specialty: Internal Medicine
Address: 161 CORPORATE DR, [**Location (un) **],[**Numeric Identifier 62963**]
Phone: [**Telephone/Fax (1) 87045**]
We are working on a follow up appointment for you with Dr. [**Last Name (STitle) 40563**]
for the beginning of next week. You will be called at home with
the appointment. If you have not heard or have questions, please
call the number above.
Name: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD
Specialty: Gastroenterology
Location: [**Hospital1 18**] LIVER CENTER
Address: [**Doctor First Name **], STE 8E, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 2422**]
We are working on a follow up appointment with Dr. [**Last Name (STitle) **] within
the next 16-30 days. You will be called at home with the
appointment. If you have not heard within 2 business days or
have questions, please call the number above.
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]
|
[
"511.9",
"286.9",
"572.2",
"570",
"571.2",
"427.31",
"287.5",
"452",
"572.3",
"537.9",
"303.91",
"285.9",
"305.1",
"276.1",
"789.59"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
11327, 11398
|
6798, 7664
|
314, 345
|
11562, 11562
|
4196, 6775
|
12764, 13868
|
3048, 3110
|
9994, 11304
|
11419, 11541
|
9228, 9228
|
11745, 12741
|
3125, 4177
|
265, 276
|
373, 2344
|
7678, 9202
|
11577, 11721
|
9253, 9971
|
2366, 2791
|
2807, 3032
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,316
| 188,664
|
20279
|
Discharge summary
|
report
|
Admission Date: [**2128-11-3**] Discharge Date: [**2128-11-8**]
Date of Birth: [**2075-12-31**] Sex: M
Service: CCU
HISTORY OF PRESENT ILLNESS: Patient is a 52-year-old man
with a past medical history significant for diabetes, who
presents after an episode of substernal chest pain. Patient
states that he developed sudden onset of chest pain radiating
to his jaw at 6 p.m. on [**2128-11-2**]. The patient returned
home from work with persistent substernal chest pain. The
following day on [**2128-11-3**], with persistent chest pain, the
patient presented to [**Hospital1 1474**] ED for evaluation at 4:30 p.m.
on [**2128-11-3**]. At this time, an EKG was obtained, which
demonstrated likely inferior infarct with inferior Q waves
and ST segment elevations.
The patient was started on aspirin, Plavix, sublingual
nitroglycerin, and nitroglycerin drip. On this regimen, the
patient had persistent chest pain. In addition, his blood
pressure markedly decreased. The patient was then started on
IV fluids and thrombolytic therapy. Because the patient's
pain also radiated to his back, he underwent a chest CT to
rule out aortic dissection. The chest CT was negative for
aortic dissection. He was then transferred to the [**Hospital1 1444**] for urgent cardiac
catheterization.
Selective coronary angiography demonstrated a right dominant
system with two vessel coronary artery disease. The proximal
RCA was totally occluded. The LAD had a 60% mid vessel
stenosis. Resting hemodynamics demonstrated elevated left
and right sided filling pressures. Mean RA pressure was 23.
Mean wedge pressure was 32 mm Hg. The patient underwent
successful stenting of the RCA. The patient was then
transferred to the CCU team for further management.
PAST MEDICAL HISTORY:
1. Type 2 diabetes mellitus.
2. Right leg varicose veins.
SOCIAL HISTORY: Patient denies significant tobacco, alcohol,
or illicit drug use. He is married and works two jobs.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION:
1. Metformin 1,000 mg b.i.d.
2. Glipizide 10 mg b.i.d.
ALLERGIES: No known drug allergies.
FAMILY HISTORY: [**Name (NI) **] father died of cancer. Patient
states that both he and his father have very low cholesterol.
PHYSICAL EXAMINATION: Afebrile, heart rate 90, blood
pressure 123/72, respiratory rate 16, sating 98% on 2 liters
nasal cannula. HEENT: Sclerae are nonicteric. PERRL.
Neck: Supple, no lymphadenopathy appreciated, jugular venous
pressure at 6 cm. Pulmonary: Clear to auscultation
bilaterally, no wheezes and no crackles on examination.
Cardiac: Normal S1, S2, no murmurs, rubs, or gallops
appreciated on examination. Abdomen: Normal bowel sounds,
soft, nontender, nondistended. Extremities: Trace edema.
Neurologic is alert and oriented times three. Cranial nerves
II through XII intact. No focal deficits.
LABORATORIES: Patient's admission laboratories were notable
for a CK of 2,606 and a troponin-I greater than 50. CBC and
Chem-7 were within normal limits.
On cardiac catheterization, his cardiac output was measured
at 3.34 and his cardiac index was measured at 1.47.
EKG showed that the patient was in sinus rhythm with a rate
in the 90s. He had ST segment elevations in III, II, and
aVF.
HOSPITAL COURSE: Patient was admitted to the CCU team. He
remained hemodynamically stable overnight. The patient
stated that he became chest pain free for the first time
following cardiac catheterization. He did complain of back
pain which he states was at baseline from a prior lower back
injury. An echocardiogram was ordered to evaluate his
cardiac pump function. Although the patient had an elevated
wedge pressure, it was decided to hold diuresis initially
given his likely decrease in right ventricular function.
An EP consult was obtained to evaluate possible need for
defibrillator. With the exception of an episode of
hypotension, the patient remained stable and was transferred
to the floor. He was maintained on aspirin, Plavix, low
dosed Lipitor, metoprolol, and captopril. The patient was
seen by EP consult, who suggested followup echocardiogram in
three months and followup Holter in one month, and a stress
in one month.
In the CCU, the patient was on an insulin drip initially, but
then was switched to Glipizide and metformin as these were
his outpatient medications. The results from the
transthoracic echocardiogram revealed that the patient's left
atrium was mildly dilated. There was moderate global left
ventricular hypokinesis and the left ventricular ejection
fraction was measured at 30%. There was akinesis of the
entire inferior wall and inferior septum.
The patient continued to improve and was able to walk without
difficulty. It was the consensus of the CCU team, that he
was stable to return home with appropriate followup.
However, the patient did spike a temperature to 101 and was
kept overnight for additional observation.
On [**2128-11-9**], the patient was discharged home with followup
with EP service.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: Home.
DISCHARGE DIAGNOSIS: Myocardial infarction.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg q.d.
2. Plavix 75 mg q.d.
3. Glipizide 10 mg q.d.
4. Metformin 1,000 mg q.d.
5. Atorvastatin 5 mg q.d.
6. Lisinopril 20 mg q.d.
7. Metoprolol succinate 50 mg q.d.
Although the patient had a favorable cholesterol profile, he
was started on atorvastatin given that this has been shown to
benefit patients with diabetes in the setting of myocardial
infarction.
[**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**]
Dictated By:[**Name8 (MD) 9719**]
MEDQUIST36
D: [**2128-11-9**] 16:41
T: [**2128-11-10**] 07:00
JOB#: [**Job Number **]
|
[
"414.01",
"998.89",
"458.29",
"780.6",
"250.00",
"454.9",
"E942.4",
"410.41"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"99.20",
"88.56",
"37.23",
"36.01",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
5052, 5087
|
2143, 2255
|
5156, 5820
|
5109, 5133
|
2032, 2126
|
3288, 5030
|
2278, 3270
|
162, 1768
|
1790, 1849
|
1866, 2006
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,065
| 165,066
|
14896
|
Discharge summary
|
report
|
Admission Date: [**2164-1-16**] Discharge Date: [**2164-1-26**]
Date of Birth: [**2085-6-17**] Sex: M
Service: CSU
HISTORY OF PRESENT ILLNESS: This patient was admitted to our
Emergency Room on [**2164-1-16**], complaining of chest pain
since the evening prior. He had a known history of
myocardial infarction with prior left anterior descending
coronary artery stenting in [**2161-9-10**].
Immediate scanning of the patient revealed a type B aortic
dissection with patent vasculature to his SMA and renals. He
was evaluated in the Emergency Room on initial contact.
PAST MEDICAL HISTORY: Coronary artery disease status post
two stents.
Atrial fibrillation.
Hypertension.
Status post myocardial infarction.
Prostate cancer.
ALLERGIES: Penicillin.
PAST SURGICAL HISTORY: Appendectomy in [**2119**].
MEDICATIONS ON ADMISSION: Atenolol, Lipitor, Benicar and
Amiodarone which had been discontinued.
IMAGING: Electrocardiogram showed first degree AV block. CT
scan of the chest showed type B dissection extending into the
right femoral vessels.
PHYSICAL EXAMINATION: Vital signs: Blood pressure on exam
on the right was 160/60, on the left 107/55. White count
10.2, hematocrit 35.2, platelet count 194,000. The patient
was alert and oriented and appropriate. Lungs: Clear
bilaterally. Heart: He had S1 and S2 heart tones with no
murmurs, rubs, or gallops. Abdomen: Soft, nontender, and
nondistended. Extremities: He had positive femoral pulses
bilaterally and positive dorsalis pedis pulses bilaterally.
PLAN: The plan was to get a TEE and see if this was normal,
then no MRI, but if it was abnormal, then get an MRI and MRA
of the chest. An arterial line was started with strict blood
pressure control with Esmolol and Nipride drips.
HOSPITAL COURSE: The patient was admitted to Cardiac Surgery
under Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who examined him and noted lability of
his blood pressure. His CT started at the left subclavian
artery and continued down to his iliac bifurcation into the
right iliac artery. The patient was pain-free at the time of
examination. He was on beta-blockade and Nipride. He was
neurologically intact.
Dr. [**Last Name (STitle) **] agreed with the plan to get a TEE first with tight
blood pressure control and to have Vascular Surgery also
consult on the patient and schedule an MRA approximately two
days hence.
The patient was also seen by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Vascular
Surgery. All recommendations and analysis of the scans were
the same with a type B dissection requiring tight medical
management.
TEE later that day showed normal left ventricular function
with normal valves and no dissection of the ascending aorta,
as well as a normal right ventricle and left ventricle.
This was also seen at the proximal end of the descending
aorta, please refer to the final report dated [**2164-1-16**].
The patient was also seen by Case Management to help plan for
his hospital stay and eventual discharge.
The patient was seen by Vascular Surgery and by Cardiac
Surgery every day. On house-day 1, there were no changes in
his medical condition.
His blood pressure was 100/44 on an Esmolol drip and a
Nipride drip. He remained pain-free. The plan was to switch
him over to p.o. medications.
Serial lactates were also drawn. The patient remained on
Esmolol drip at 200 and a Nipride drip at 0.5 mg/kg/min. The
patient was also started on beta-blockade orally with
Lopressor 25 mg p.o. twice a day. He also had maintained his
peripheral positive dorsalis pedis and femoral pulses
bilaterally.
The patient was also seen by Cardiology when he developed
what appeared to be atrial fibrillation. He was then
diagnosed by EP to be supraventricular tachycardia. He was
examined by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] of EP. He was also given
6 mg bolus of adenosine with no change and then a 12 mg bolus
of adenosine which had terminated the supraventricular
tachycardia and resumed sinus rhythm in the 70s with a
prolonged QT.
She diagnosed AVNRT, but it was responsive to Adenosine. The
patient continued on Esmolol and Labetalol.
The patient remained pain-free. His hematocrit was stable.
He had no abdominal tenderness and continued to make good
urine. It was determined he could be transferred out to the
floor.
The following day, he had no further supraventricular
tachycardia. His blood pressure was 80/50 in his left arm.
He remained in sinus rhythm at 70. He continued to be
monitored tightly with telemetry and remained in the CSRU.
He did receive a single dose of ibutilide for that initial
episode of atrial fibrillation.
On house-day 2, he was weaned off all of his intravenous
drips. Blood pressure was controlled through oral
medications with beta-blocker. He went for his MRA and was
transferred up to the floor.
He was seen again by Case Management. He continued to have
palpable pulses. His blood pressure increased that afternoon
to 130 systolic. Additional Labetalol was ordered and given
with a goal range of 100-120 systolic.
Later that day, the patient did complain of a sharp pain in
the center of his back which prevented him from taking a deep
breath. He also was noted to have a lingering slow nose
bleed. At the time, his blood pressure dropped to 70. The
house-officer was immediately called to evaluate the patient.
Hydralazine and an additional order was given if the blood
pressure rose to greater than 160; his pressure at the time
was 147/70. Later that evening he had a single episode of
supraventricular tachycardia with his heart rate to 130s.
His blood pressure remained stable to 100/70. The patient
was mentating well with good distal pulses. He was
administered intravenous adenosine again. The rhythm broke
and came down to 80s in sinus rhythm. The patient continued
to mentate well and was asymptomatic.
At 2 a.m. on the 8th, the patient again had a reemergence of
his AV nodal reentrant tachycardia to 130s. He was given
additional 6 mg of adenosine with good affect. Heart rate
broke and dropped down to the 80s again. He also complained
of severe urinary retention. A Foley catheter was replaced.
EP continued to follow the patient for his random
tachycardia. Over the next couple of days, his blood
pressure continued to be monitored tightly, as well as his
rhythm issues. The patient remained pain-free.
It was determined that the patient should probably an AV
nodal ablation, and in addition, he had been unable to obtain
his MRA due to his rhythm issues.
On house-day 5, his white count was 6, hematocrit 30,
potassium 4.0, BUN 23, creatinine 0.9. He was on Labetalol
800 three times a day, hydralazine and Losartan 100 mg p.o.
once a day. He had some slight erythema in his left upper
extremity antecubital space. He was alert and oriented. His
examination was otherwise unremarkable.
Flomax was started on the patient for urinary retention.
Warm packs were placed for his left upper extremity
antecubital erythema.
On the 10th, the patient went to the EP Lab for ablation of
this reentry tachycardia pathway with Dr. [**Last Name (STitle) 284**]. The
patient's blood pressure rose slight to 125/50 on house-day
5. Lopressor was added back in addition to his Labetalol and
Losartan with plans to complete the MRA that evening post EP
ablation. The patient was also reevaluated by Physical
Therapy.
On house-day 6, the patient continued to have elevations in
his blood pressure to 162/80. He was in sinus rhythm at 69
at the time. Toprol was increased to 100 p.o. once a day.
Norvasc was added, in addition to his p.r.n. Hydralazine,
Losartan, and Labetalol. Additionally, intravenous fluids
were given as the patient remained NPO.
He was unable to urinate after his MRI, and his Foley was
replaced on the 11th. The patient was also replaced on a
sliding scale for regular Insulin. He was also given Calcium
Carbonate on house-day 8. His Flomax was increased with the
hopes of discontinuing his Foley.
On house-day 8, his blood pressure was 140/78 despite
Norvasc, Lopressor, Losartan, and Labetalol. It was then
determined by the team and Dr. [**Last Name (STitle) **] that most likely this
systolic blood pressure 120/40 was his baseline and was
reasonable control given his age.
His type II dissection continued to be stable, and Vascular
Surgery signed off. On postoperative day 8, his blood
pressure continued to climb to 182/90 and remained in sinus
rhythm at 72. His oxygen saturation was 91 percent on room
air.
He continued to have significant issues with blood pressure
control. Cardiology was reconsulted and also recommended
starting Hydrochlorothiazide 25 mg p.o. twice a day.
Magnesium Citrate was given for complaints of constipation by
the patient.
His Norvasc was switched back to Benicar 20 p.o. daily at the
recommendation of Cardiology, and Toprol, Labetalol,
Hydrochlorothiazide were continued.
MRA performed on the 11th showed his type B aortic dissection
originating in the distal subclavian and extending all the
way down to the right common iliac. It also noted all
mesenteric vessels originated from the true lumen and two
right renal arteries and a single left renal artery all arise
from the true lumen. In addition, there was incidental
notation of several hepatic and multiple bilateral renal
cysts including a 1.2 cm cyst in the uncinate process of the
pancreas. Please refer to the final report dated [**2164-1-21**].
The patient continued to have good urine output and otherwise
was doing well, other than mild depression over his lack of
blood pressure control and having to remain hospitalized.
The patient's blood pressure dropped on the morning of
[**1-25**] after his Labetalol dose to the 70s to 80s
systolic range. The patient complained of dizziness but was
much better at the time of exam with a blood pressure of 105
where he remained in sinus rhythm.
His creatinine remained stable at 1.0. His Labetalol was
decreased to 400 mg three times a day with plans to increase
his Toprol as needed. He was also encouraged to use his
incentive spirometer and cough and deep breath, given his
limited ability to ambulate at the time of blood pressure
issues.
The patient did not complain of any chest pain or abdominal
pain. He was seen again by Vascular Surgery on consult with
plans to try and discharge him if possible if his blood
pressure settled out. On postoperative day 10, he did have
much better blood pressure control with decreased Labetalol
with a blood pressure of 126/79. Dr. [**Last Name (STitle) **] made the
decision that the patient could go home and see his primary
care physician on [**Name9 (PRE) 766**]. He is to be followed by VNA of
[**Hospital1 1474**] and followed by his primary care physician and
cardiologist as soon as he was discharged. He was also given
clearance for discharge home by Vascular Surgery attending
and to have repeat imaging with either CT Surgery or Vascular
Surgery in approximately [**4-16**] mos to follow his dissection.
DISCHARGE INSTRUCTIONS: He was told to follow-up with Dr.
[**Last Name (STitle) 16004**], his primary care physician, [**Telephone/Fax (1) 3183**], on Monday,
[**1-30**], four days postdischarge at 11 a.m. He was
instructed to follow-up with Dr. [**Last Name (STitle) **] in approximately
one week, his cardiologist, and to see Dr. [**Last Name (STitle) **] in
approximately three months for continued monitoring of his
type B dissection.
DISCHARGE DIAGNOSIS: Status post type B aortic dissection.
Hypertension.
Atrial fibrillation/AV nodal reentrant tachycardia with
ablation.
Status post myocardial infarction.
Coronary artery disease status post left anterior descending
coronary artery stenting times two.
Prostate cancer.
DISCHARGE MEDICATIONS: Toprol XL 100 mg p.o. once a day,
Flomax 0.8 mg p.o. once a day, Hydrochlorothiazide 25 mg p.o.
once daily, Amlodipine 10 mg p.o. daily at bed time, Losartan
100 mg p.o. at bed time, Labetalol 400 mg p.o. 3 times a day.
DISPOSITION: The patient was discharged in stable condition
to home on [**2164-1-26**].
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2164-2-29**] 12:13:30
T: [**2164-2-29**] 13:14:02
Job#: [**Job Number 43668**]
|
[
"V45.82",
"414.01",
"V10.46",
"424.0",
"427.31",
"441.00",
"424.1",
"427.89",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.26",
"37.27",
"37.34",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
11908, 12486
|
11616, 11884
|
857, 1077
|
1801, 11152
|
11177, 11594
|
801, 830
|
1100, 1783
|
165, 593
|
616, 777
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,674
| 197,977
|
15711
|
Discharge summary
|
report
|
Admission Date: [**2119-4-24**] Discharge Date: [**2119-4-27**]
Service: NEUROSURGERY
Allergies:
Aspirin / Motrin / Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
elective admission for coiling of Pcom aneurysm
Major Surgical or Invasive Procedure:
Coiling of Pcom aneurysm
History of Present Illness:
From [**3-11**]: 84 yo woman with PMh of LBP, HTn, Gout, Arthirits,
Kidney
stones, Ovarian cyst, dyastolic dysfunction who had an MRI today
showing bilateral PCOM aneurysms. Says that about 2-3 months
ago
she began to note symptoms of vertical diplopia, right
temporal/facial pain and right eye blurring. She has had 3 ESRs
within normal limits and was briefly on prophylacitic steroids
for temporal arteritis until the ESR came back negative. She
was
started on Trileptal 1 week ago for trigeminal neuralgia and
takes 150 [**Hospital1 **] but has not noted any improvement yet.
Her symptoms are mostly constant and have been gradually
worsening. Her neurologist ordered an MRI/A which showed 12mm
PCOM aneurysm right and 5mm PCOM aneurysm left.
Right eye vision changes complicated by recent corrective laser
surgery on right eye which preceded symptoms.
Past Medical History:
PMHx: LBP, HTn, Gout, Arthirits, Kidney stones, Ovarian cyst,
dyastolic dysfunction
Social History:
Social Hx: [**Last Name (un) **]
Family History:
Family Hx: no aneurysms
Physical Exam:
Upon discharge:
Neuro: A&Ox3, tongue midline, face symetric, PERRL. Her exam was
notable for LUE weakness and what appeared as neglect to her
LUE.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date. Attentive.
Language: Speech fluent with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Pertinent Results:
CT [**4-25**]: Status post coiling of right PCOM aneurysm with no
large territorial infarction. There is a hypodense focus in the
right frontal region which was likely present on the prior MRI
but difficult to compare due to differences in technique. This
can be further assessed on a MRI.
CT [**4-25**] Coils are present in the expected location of the right
PCOM
aneurysm, with extensive streak artifact which limits
evaluation. There is no evidence of intracranial hemorrhage,
edema, mass, mass effect, or shift of normally midline
structures. A small hypodense focus in the right frontal lobe is
again noted, and is not significantly changed in appearance from
prior study. Periventricular white matter low attenuation, most
likely represents chronic small vessel ischemic disease. The
ventricles and sulci are age appropriate. Visualized paranasal
sinuses and mastoid air cells are normally aerated. Osseous
structures are unremarkable.
[**4-26**] X-ray L elbow:Unremarkable left elbow.
Moderate-to-severe osteoarthritis of the first CMC joint.
Chondrocalcinosis involving the wrist. It is unclear if a
rounder region of calcification projecting volar to the proximal
carpal row represents marked chondrocalcinosis or the
possibility of an intra-articular or juxta-articular calcified
wrist mass. A gouty tophus could have this appearance, but no
periarticular erosion is identified.
Brief Hospital Course:
85F was admitted to ICU s/p coiling. Neurologically she was
intact however she was found to have LUE weakness and what
appeared as neglect to her LUE. She had a repeat scan which did
show a small hypodensity in the R frontal lobe. This was felt
not to be the underlying cause. She was then transferred to the
floor where she worked with PT and found to be swaying to L
side. She also had extreme L wrist/elbow pain and X-rays were
neg for fx however has h/o gout. She was started on Colchicine
and had relief. She was then discharged home with PT.
Medications on Admission:
Aspirin (ASA, Easprin, Ecotrin, Empirin)
(81 mg every other day (
instructions per Dr. [**Last Name (STitle) **] office))
Diltiazem (Cardizem) (120 mg daily)
Hydrochlorothiazide (Esidrix)(25 mg daily)
Lipitor (Atorvastatin)(10 mg daily)
Lisinopril [Prinivil, Zestril] (5 mg twice daily)
Nexium(40 mg daily)
Other 1 (evista)
Other 2 (lexapro 10 mg daily)
Toprol XL (Metoprolol) (75 mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
3. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO twice a day
for 3 days: Please take for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
12. Outpatient Physical Therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Pcom aneurysm
Discharge Condition:
neurologically stable however has new LUE weakness
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Followup Instructions:
?????? You have an MRA on [**5-25**] at 2P in the [**Hospital Ward Name 517**]
Basement, then you will see Dr. [**First Name (STitle) **] at 2:45 in the [**Hospital **]
Medical Office Building [**Location (un) 470**]. Please call ([**Telephone/Fax (1) 88**] if
you have any questions.
- You were also treated for what appears to be an acute gout
flare up for which you were treated. Please follow-up with your
PCP [**Name Initial (PRE) 176**] 7 days of discharge.
Completed by:[**2119-5-3**]
|
[
"620.2",
"414.01",
"401.9",
"729.89",
"996.1",
"378.51",
"592.0",
"E879.8",
"437.3",
"272.4",
"274.0",
"429.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.41",
"88.48",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
5467, 5473
|
3368, 3917
|
308, 335
|
5531, 5584
|
1951, 3345
|
7620, 8116
|
1405, 1433
|
4357, 5444
|
5494, 5510
|
3943, 4334
|
5608, 6678
|
6704, 7597
|
1448, 1448
|
221, 270
|
1464, 1698
|
363, 1227
|
1713, 1932
|
1249, 1336
|
1352, 1389
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,161
| 101,665
|
28421
|
Discharge summary
|
report
|
Admission Date: [**2146-3-22**] Discharge Date: [**2146-3-24**]
Date of Birth: [**2106-12-1**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Keflex / Ciprofloxacin / Sulfa (Sulfonamides) /
Clarithromycin / Demerol / Red Dye / Haldol
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
fevers, abdominal pain, diarrhea, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 39 year-old male with a history of cerebral palsy,
chronic aspiration, GERD, ? ulcerative colitis who presents with
low grade temps at home, cough, abdominal pain. He is
accompanied by his mother. [**Name (NI) **] had a colonoscopy on [**3-17**] to
evaluate for IBD, with fairly normal appearing bowel but
biopsies are pending. Afterwards, he was constipated, but then
started have very loose stools yesterday and today. He has had
low grade temps, about 100 at home. Also, his mother states his
cough seems to be worse lately. He has also been complaining of
abdominal pain as well. He gets his nutrition via his G-tube at
home. Also of note, he recently completed a course of
azithromycin for a skin boil.
.
In the ED, inital vitals were 101.2, 140, 113/79, 28, 92%RA. He
was given a total of 3L IVFs in the ED with improvement of his
tachycardia. He was also given morphine and zofran in the ED.
Subsequently, his SBP dropped to the 80s and high 70s, and was
not improving with IVFs. He was started on peripheral dopamine.
There were lengthy discussions with the family regarding a
central line, but they did not want one at this time. His CXR
was concerning for a LLL consolidation. He underwent CT
abdomen/pelvis which did not show any specific findings, but did
show some inflammation of the rectum and ? prostatitis. Rectal
exam did not show e/o tenderness of his prostate. He was given
vancomycin, flagyl, and gentamicin in the ED. He has multiple
abx allergies. He was then transferred to the ICU for further
monitoring.
.
ROS: the patient has limited communication at baseline. Denies
pain at this time.
Past Medical History:
-Cerebral Palsy
-Chronic Aspiration
-Gastroesophageal reflux disease
-? Ulcerative Colitis- currently undergoing workup
-Seizure disorder
Social History:
Lives at home with his parents who provide his care. He is
wheelchair bouns and non verbal at baseline. He receives
nutrition through a G-tube, though he can take certain liquid
medications by mouth. He has a personal care assistant at home
who also helps with his care. No tobacco, ETOH or illicit drug
use.
Family History:
Paternal grandfather with multiple [**Month/Year (2) 499**] polyps.
Paternal great grandfather with [**Name2 (NI) 499**] cancer.
Paternal grandmother died of [**Name2 (NI) 499**] cancer in her 30's.
Maternal grandmother with [**Name2 (NI) 499**] cancer.
Brother with polyps of unknown type.
Father "a few adenomas".
Physical Exam:
Vitals: T: BP: HR: RR: O2Sat:
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or
rhinorrhea, MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, no HSM, no masses
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.
Pertinent Results:
Imaging:
CXR: IMPRESSION: Hazy subtle opacity within the left lung base,
which could represent early pneumonia.
.
[**3-21**] CT ABD/PELVIS:
CT PELVIS WITH IV CONTRAST: There is apparent mild rectal
thickening, which may relate to recent instrumentation or be
inflammatory in nature. A slightly edematous appearance of the
prostate and seminal vesicles is again seen, but of unclear
etiology. There is no pelvic or inguinal lymphadenopathy.
Bilateral fat and fluid-containing inguinal hernias are
identified. Osseous structures demonstrate a right convex
curvature of the lumbosacral spine. There are bilateral pars
defects of the L5 vertebral body, without evidence of antero- or
retrolisthesis. There are apparent undescended or high-riding
testicles, for which non-urgent scrotal ultrasound should be
consisdered.
IMPRESSION:
1. No evidence of perforation or abscess.
2. Mild rectal thickening may be inflammatory or post-procedural
in nature.
3. Consider non-urgent scrotal ultrasound.
.
Brief Hospital Course:
This is a 39 year-old male with a history of cerebral palsy,
chronic aspiration, GERD who presents with fevers, cough,
abdominal pain, and diarrhea with persistent hypotension.
.
Plan:
# Hypotension - on initial admit, febrile, tachycardic, and had
leukocytosis. Potential likely sources included LLL pneumonia
with infiltrate on CXR, c.diff given diarrhea and recent abx
exposure. Other possible causes are prostate though no specific
findings on exam. urine clear. no clear reason to suspect
meningitis (no neck stiffness than baseline per mother). GI was
consulted. Family deferred CVL; team discussed risks of
dopamine peripherally. Dopamine was initially given for ~10
hours to maintian MAPs>60. Pt was initially treated for
possible aspiration pna and cdiff with vanco, gentamicin, and
flagyl. On hospital day #2, gentamicin and vancomycin were
discontinued and flaygl was continued as the infiltrates on cxr
were not felt to be the active site of infection. Patient did
not have evidence of c.diff and was discontinued. The patient
clinically improved and was discharged home on loperamide.
.
# Hypotension: as above, thought likely component of
dehydration, medication effect from meds given in the ED and
infection. Pt was treated with IVF and initially with dopamine.
Hemodynamics were stabilized.
.
# Abd pain/gerd: CT scan ruled out acute pathology, suggested
duodenitis. CXR suggested possible chronic aspiration. Pt
remained on his at-home PPI and H2 blocker. He was restarted on
his TFs via G-tube on hospital day #2.
.
# Seizure d/o: continued home phenobarb and diazepam
.
Medications on Admission:
1. Mesalamine DR 1200 mg PO BID
2. Citalopram Hydrobromide 40 mg PO DAILY
3. PHENObarbital 32.4 mg tabs 3 tabs PO HS
4. Diazepam 6 mg PO HS
5. Pantoprazole 40 mg PO Q12H
6. Famotidine 20 mg PO HS
7. Nasonex 1 SPRY NU DAILY
Discharge Medications:
1. Diazepam 2 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO HS (at
bedtime).
2. Phenobarbital 30 mg Tablet [**Month/Year (2) **]: Three (3) Tablet PO HS (at
bedtime).
3. Famotidine 20 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
4. Citalopram 20 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Year (2) **]: One
(1) Tablet, Delayed Release (E.C.) PO every twenty-four(24)
hours.
6. Loperamide 2 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*30 Capsule(s)* Refills:*1*
7. Fluticasone 50 mcg/Actuation Spray, Suspension [**Month/Year (2) **]: One (1)
Spray Nasal DAILY (Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
Diarrhea
Fevers
Hypotension
Cerebral Palsy
GERD
Siezure disorder
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return the ED for high fevers, significantly worsening diarrhea,
profuse vomiting.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2146-4-15**] 8:20
Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**]
Date/Time:[**2146-4-27**] 1:10
Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION
BILLING Date/Time:[**2146-4-27**] 1:30
|
[
"789.00",
"535.60",
"787.91",
"530.81",
"564.1",
"276.51",
"780.60",
"458.0",
"343.0",
"E930.8",
"V46.3",
"V44.1",
"345.90",
"315.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
7334, 7340
|
4681, 6288
|
407, 413
|
7448, 7468
|
3663, 4658
|
7599, 8007
|
2589, 2907
|
6561, 7311
|
7361, 7427
|
6314, 6538
|
7492, 7576
|
2922, 3644
|
327, 369
|
441, 2085
|
2107, 2246
|
2262, 2573
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,542
| 125,260
|
26914
|
Discharge summary
|
report
|
Admission Date: [**2131-3-16**] Discharge Date: [**2131-3-22**]
Date of Birth: [**2051-12-15**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
Anemia, syncope
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
79 yo M with recent biliary stent placement for likely
cholangiocarcinoma, who was brought in to the [**Hospital 1474**] Hospital
ED for feeling weak and his "legs giving ouot" this morning. PT
was doing well while at home and felt weak today. He was
recently d/c from [**Hospital3 **] after a stent placement. Pt denies
any abd pain, LH/dizziness, chest pain, SOB, cough, F/C/N. He
states his stool are slight more blacka nd he had one episode of
vomiting of food. He called a friend who called 911.
.
At [**Hospital1 1474**], he was 96.3, 89, 96/59. Labs notable for co2 of 15,
TB 7.1, AP 254, hct 11.4, WBC 21.5 with 87 % polys, 1 band.
Unclear what therapy was given.
.
Per OSH records: Pt was broguht to ED on [**3-9**] for epistaxis and
noted to be jaundiced with 33 lbs wt loss prior to this
evaluation. TB was 18.9, INR 2, UA with bilirubin; CT scan
showed marked intra adn extrahepatic ductal dilitation in the
prox and common bile duct. A biliary spinchterotomy was
performed , brushing obtained, polyethelene stent was placed.
TBili improved to 11.9 and improvement in jaundice. Unclear
whether pt was notified of diagnosis.
.
At [**Hospital1 18**], VS 96, 57, 90/59, 97 % RA. Exam with guiac + stool. Pt
recieved got CTX/flagyl. Given IVF,started 1 u PRBCS. Culture
drawn. Protonix 40 mg IV given.
.
On admission, pt feels well without complaints.
.
Admitted to MICU for anemia.
Past Medical History:
1. TB as child, spent 7.5 yrs in sanitroium
2. TIA
3. detached retina
4. hypercholesterolemia
Social History:
former machinist, no ETOH for a few years, retired, lives alone,
multiple pets.
Family History:
1. brother-lung cancer
2. brother-CAD
3. sister- cancer, one with breast cancer
Physical Exam:
98.3, 83, 113/47, 20, 100% 4 L NC
thin elderly jaundiced man, o x 3, NAD
sceral icterus, subungual jaundice
thin neck, JVP flat
rrr, nl s1/s2, no m/r/g
cta bilaterally
+BS, no HSM, no mass plapable, no rebound or guarding
trace edema bilaterally
no asterixis
Pertinent Results:
[**2131-3-21**] 05:15AM BLOOD WBC-8.3 RBC-3.15* Hgb-9.8* Hct-29.2*
MCV-93 MCH-31.2 MCHC-33.6 RDW-17.1* Plt Ct-247
[**2131-3-20**] 05:15AM BLOOD WBC-11.4* RBC-3.30* Hgb-10.1* Hct-30.5*
MCV-93 MCH-30.5 MCHC-33.0 RDW-17.6* Plt Ct-261
[**2131-3-16**] 06:01PM BLOOD Hct-17.2*
[**2131-3-16**] 01:45PM BLOOD WBC-23.7* RBC-1.46* Hgb-4.6* Hct-14.4*
MCV-99* MCH-31.5 MCHC-31.9 RDW-21.7* Plt Ct-340
[**2131-3-18**] 05:55AM BLOOD Neuts-84.6* Lymphs-9.8* Monos-4.6 Eos-0.7
Baso-0.3
[**2131-3-16**] 01:45PM BLOOD Neuts-87.8* Bands-0 Lymphs-8.0* Monos-4.1
Eos-0.1 Baso-0.1
[**2131-3-21**] 05:15AM BLOOD Plt Ct-247
[**2131-3-20**] 05:15AM BLOOD Plt Ct-261
[**2131-3-20**] 05:15AM BLOOD PT-13.7* PTT-25.9 INR(PT)-1.2*
[**2131-3-16**] 01:45PM BLOOD Plt Ct-340
[**2131-3-16**] 01:45PM BLOOD PT-15.3* PTT-27.6 INR(PT)-1.4*
[**2131-3-21**] 05:15AM BLOOD Glucose-91 UreaN-19 Creat-1.1 Na-145
K-3.7 Cl-109* HCO3-29 AnGap-11
[**2131-3-20**] 05:15AM BLOOD Glucose-105 UreaN-20 Creat-1.1 Na-145
K-3.9 Cl-111* HCO3-28 AnGap-10
[**2131-3-17**] 04:08AM BLOOD Glucose-120* UreaN-73* Creat-1.4* Na-153*
K-2.7* Cl-120* HCO3-21* AnGap-15
[**2131-3-16**] 01:45PM BLOOD Glucose-199* UreaN-99* Creat-1.8* Na-147*
K-3.4 Cl-110* HCO3-17* AnGap-23*
[**2131-3-21**] 05:15AM BLOOD TotBili-4.1*
[**2131-3-20**] 05:15AM BLOOD ALT-50* AST-30 AlkPhos-519* Amylase-36
TotBili-4.8*
[**2131-3-16**] 01:45PM BLOOD ALT-74* AST-69* AlkPhos-530* TotBili-7.4*
[**2131-3-20**] 05:15AM BLOOD Lipase-25
[**2131-3-16**] 01:45PM BLOOD Lipase-82*
[**2131-3-17**] 04:08AM BLOOD CK-MB-7
[**2131-3-16**] 01:45PM BLOOD cTropnT-<0.01
[**2131-3-16**] 01:45PM BLOOD CK-MB-9
[**2131-3-21**] 05:15AM BLOOD Calcium-7.3* Phos-2.6* Mg-1.7
[**2131-3-20**] 05:15AM BLOOD Calcium-7.3* Phos-2.5* Mg-1.8
[**2131-3-17**] 04:08AM BLOOD Albumin-2.5* Calcium-8.2* Phos-4.1 Mg-1.8
[**2131-3-16**] 01:45PM BLOOD Albumin-2.4* Calcium-7.8* Phos-5.6*
Mg-2.2
[**2131-3-16**] 01:45PM BLOOD Acetone-NEGATIVE
[**2131-3-20**] 11:10AM BLOOD CEA-11*
[**2131-3-17**] 01:02AM BLOOD Lactate-1.7
[**2131-3-16**] 01:58PM BLOOD Lactate-9.6*
[**2131-3-17**] 01:02AM BLOOD freeCa-0.98*
[**2131-3-16**] 01:45PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-5.0 Leuks-NEG
[**2131-3-16**] 1:40 pm BLOOD CULTURE
**FINAL REPORT [**2131-3-22**]**
AEROBIC BOTTLE (Final [**2131-3-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2131-3-20**]):
REPORTED BY PHONE TO [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **] AT 08:57AM ON [**2131-3-17**]
- CC6D.
ESCHERICHIA COLI. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 I
CEFTRIAXONE----------- <=1 S
CEFUROXIME------------ =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
IMIPENEM-------------- <=1 S
LEVOFLOXACIN----------<=0.25 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- 8 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
[**2131-3-16**] 1:45 pm URINE Site: CLEAN CATCH
**FINAL REPORT [**2131-3-18**]**
URINE CULTURE (Final [**2131-3-18**]): NO GROWTH.
[**2131-3-16**] 2:40 pm BLOOD CULTURE
**FINAL REPORT [**2131-3-26**]**
AEROBIC BOTTLE (Final [**2131-3-22**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2131-3-26**]):
PREVOTELLA SPECIES. BETA LACTAMASE NEGATIVE.
[**2131-3-19**] 9:00 pm BLOOD CULTURE
**FINAL REPORT [**2131-3-25**]**
AEROBIC BOTTLE (Final [**2131-3-25**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2131-3-25**]): NO GROWTH.
EGD Friday, [**2131-3-16**]
Impression: Ampulla within large diverticulum. Evidence of
recent sphincterotomy and plastic stent placment. No bleed
apparent.
Recommendations: Remain ICU - transfuse - NPO.
Additional notes: No source of GI bleed noted. No fresh blood
within upper GI tract. Both forward and sideviewing scopes
utilised.
CTA ABD W&W/O C & RECONS [**2131-3-19**] 4:50 PM
CTA ABD W&W/O C & RECONS; CT PELVIS W/CONTRAST
Reason: evaluate for mass
Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
79 year old man with ? of cholangiocarcinoma based on ERCP, ERCP
s/p stent placement
REASON FOR THIS EXAMINATION:
evaluate for mass
CONTRAINDICATIONS for IV CONTRAST: None.
This is a CTA of the abdomen with and without reconstructions.
INDICATION FOR STUDY: Evaluate for possible cholangiocarcinoma
in 79-year-old man with abnormal ERCP study. No prior studies
are available for comparison purposes.
TECHNIQUE: An initial noncontrast enhanced study was performed.
Thereafter, the patient received 150 cc intravenous Optiray and
helical scan was obtained through the abdomen during both the
bolus and nonequilibrium phases. Delayed images obtained at 10
minutes through the upper abdomen. Multiplanar reconstructions
were performed thereafter.
FINDINGS:
Abdomen with contrast. Small bilateral pleural effusions are
present. Bilateral Bochdalek hernias are noted in the posterior
left and right hemithoraces. A large amount of intraperitoneal
free fluid is noted. This does not contain any obvious enhancing
nodules. Bilateral intrahepatic bile duct dilatation is noted
with bilateral pneumobilia. No focal lesions identified within
the liver. Immediately superior to the gallbladder fossa is an
approximately 3 x 3 cm rim calcified mass which might represent
a large gallstone. Several other large gallstones are noted
within the distended gallbladder. Layering of contrast is noted
within the gallbladder presumably relating to recent ERCP. A
biliary stent is noted. In the portahepatus encircling the stent
is ill-defined enhancing soft tissue. This is associated with
several periportal lymph nodes. The adjacent vascular
structures, specifically the portal vein, the superior
mesenteric artery, and the superior mesenteric vein are all
widely patent. This ill-defined soft tissue appears to encircle
but not occlude the common hepatic artery (series 6, image 44)
and this soft tissue extends up and abuts the cystic duct. This
soft tissue also encircles the right hepatic artery and the left
hepatic artery and insinuates itself within the portahepatus. No
discrete masses identified within the pancreatic head where a
large approximately 3 x 3 cm diverticulum is present. The
pancreatic duct is unremarkable. Head, body, and tail of the
pancreas are unremarkable. Spleen is not enlarged. A small
splenule is identified. The adrenal glands are not enlarged. No
solid masses are present in the left or right kidneys. Several
simple cysts are identified in both kidneys. Numerous calcified
mesenteric lymph nodes are identified.
Pelvis with contrast. Large amount of free intrapelvic fluid is
noted encircling the bladder. The prostate gland is enlarged
measuring approximately 5.6 x 4.4 cm. The bladder is
unremarkable. The ureters are well visualized and unremarkable.
Large and small bowel is unremarkable apart from multiple
sigmoid diverticuli.
Bone windows. Degenerative changes are noted in the lower lumbar
spine. A single sclerotic focus is noted in the right iliac bone
which measures approximately 3 x 4 mm in size. No other lytic or
blastic lesions are identified throughout the skeleton.
Multiplanar reconstructions. 3D arterial MIP and volume rendered
images as well as MINIP and venous volume rendered MIP images
were obtained which again confirm the presence of ill-defined
soft tissue encircling a stent within the portahepatus and
encircling the proximal portions of the left and right hepatic
artery.
IMPRESSION:
1. Ill-defined delayed enhancing soft tissue masses within the
portahepatus encircling the common hepatic duct as well as the
proximal left and right hepatic arteries and indistinguishable
from the cystic duct. The features concerning for a
Klatskin-type neoplasm. No hepatic metastases are noted and the
main portal SMV and superior mesenteric arteries are patent.
2. Multiple large gallstones. An additional calcified mass
immediately adjacent to the gallbladder might indeed represent a
large gallstone but it does have an unusual appearance. This is
not concerning for a hepatic neoplasm.
3. Large amount of intraperitoneal and intrapelvic ascitic
fluid. The etiology of this fluid is uncertain but this would be
amenable to a tap for cytologic purposes if indicated.
4. Large duodenal diverticulum.
5. Enlarged prostate gland.
6. Multiple calcified mesenteric nodes.
Brief Hospital Course:
MICU Course: The patient was admitted to the MICU and remained
stable throughout his stay. He was transfused 3 units of pRBCs.
An EGD was performed: no apparent bleed, no fresh blood in upper
tract. His lactate was noted to be 4.2, down from 9.6
approximately 5 hours prior. He was continued on CTX and Flagyl
for a question of sepsis (elevated WBC, elevated lactate, temp
96). He was hemodynamically stable and transferred to the
floor.
On the medical floor:
1. Anemia: thought to be secondary to recent sphincterotomy. He
remained stable without active bleeding.
- PPI QD
.
2. ID: Appeared initially septic on admission to ICU; started on
broad antibiotic coverage. Admission cultures grew E. coli;
surveillance cultures drawn later in his stay showed that he had
cleared his bacteremia. Bacteremia may have been secondary to
recent OSH ERCP and stent.
Plan 2 weeks antibiotics (Levo)
.
4. Elevated Cr: prerenal etiology improved with IVF
.
5. Probable cholangiocarcinoma: per OSH ERCP brushings,
suspicious for adenocarcinoma.
CT shows soft tissue masses within the portahepatus encircling
the common
hepatic duct, as well as the left and right hepatic arteries.
CA [**43**]-9 level still pending
- tried to obtain surgical consult in-house but the appropriate
attending was not available. He will f/u closely in surgery
clinic.
- Seen by Oncology here, they are awaiting surgical input on
whether lesion is resectable.
- he will also f/u with his biliary physician at [**Name9 (PRE) **] to
address his
recent ERCP.
Medications on Admission:
ASA
ocuvite gtt
Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 8 days.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Suspected cholangiocarcinoma
Discharge Condition:
Stable
Discharge Instructions:
You have been diagnosed with suspected cholangiocarcinoma based
on pathology brushings from ERCP and your CT scan. You were
seen by Oncology and Surgery regarding your condition. It is
extremely important that you follow up as directed and take
medications as directed.
Return to the Emergency Room or call your doctor if you develop
episodes of fainting, nausea and vomiting, blood in your stools,
chest pain, shortness of breath, high fevers or any other
concerns.
Followup Instructions:
Follow up with surgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], you have at
appointment Mon [**3-26**] at 9 AM, please call ([**Telephone/Fax (1) 673**]) with
any questions or concerns.
Follow up with Gastroenterology, Dr. [**Last Name (STitle) 56292**], you have an
appointment on [**3-29**] at 10:00AM, arrive at 9:45AM, located
at [**Street Address(2) **] [**Apartment Address(1) 66199**], in [**Hospital1 1474**] at the corner of pearl
and pleasant street, call ([**2131**] with any questions or
concerns.
You have a follow up appointment with Dr. [**Last Name (STitle) **] in internal
medicine, Monday, [**3-30**] at 2:00PM in Westbridgewater, call
([**Telephone/Fax (1) 16005**] with questions or concerns.
Follow up with oncology, Mrs. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6745**] is arranging an
appointment and will call you with an appointment. You may call
([**Telephone/Fax (1) 21188**] with any questions or concerns.
If you decide to have oncologic care closer to [**Hospital1 **], you may
discuss oncologists in your area with your PCP.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
|
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icd9cm
|
[
[
[]
]
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[
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] |
icd9pcs
|
[
[
[]
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13087, 13093
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11173, 12699
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332, 337
|
13166, 13175
|
2365, 6806
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13692, 14937
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1988, 2070
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12765, 13064
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6843, 6928
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13114, 13145
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12725, 12742
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13199, 13669
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2085, 2346
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277, 294
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6957, 11150
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365, 1757
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,901
| 105,202
|
49638+59193+59194
|
Discharge summary
|
report+addendum+addendum
|
Admission Date: [**2189-6-18**] Discharge Date: [**2189-6-26**]
Date of Birth: [**2117-5-7**] Sex: M
Service: [**Hospital Unit Name 196**]
HISTORY OF PRESENT ILLNESS: This is a 72 year old man with a
history of coronary artery disease, status post coronary
artery bypass graft, diabetes mellitus type 2, and end-stage
renal disease secondary to diabetes mellitus, who presents
with 24 to 36 hour history of chest pain, similar to that
which he has had in his past myocardial infarction. On two
days prior to admission, the pain began in his chest
associated with nausea but no shortness of breath or
diaphoresis. The pain continued until the next morning when
it was relieved by Nitroglycerin. The patient went to
dialysis and was pain free during dialysis. The patient was
transferred to [**Hospital1 69**] for
evaluation after hemodialysis.
Prior cardiac catheterization on [**2189-2-20**], had revealed
100% stenosis of the proximal right coronary artery, 60%
stenosis of the left main, 100% stenosis of the proximal left
anterior descending, 100% stenosis of the mid left anterior
descending, 70% stenosis of the first diagonal; 100% stenosis
of the proximal left circumflex; 40% stenosis of the left
internal mammary artery to left anterior descending, obtuse
marginal 1 to left anterior descending. All discrete
lesions. The D1 and left main coronary artery received
percutaneous transluminal coronary angioplasty with stents.
The saphenous vein grafts were known to be totally occluded.
Since then, the patient denies regular anginal chest pain at
home or shortness of breath. The patient does have severe
peripheral neuropathy secondary to his diabetes mellitus as
well.
PAST MEDICAL HISTORY:
1. End-stage renal disease on hemodialysis Tuesday, Thursday
and Saturday.
2, Diabetes mellitus type 2.
3. Peripheral neuropathy.
4. Status post myocardial infarction three years ago.
5. Status post coronary artery bypass graft in [**2184**] with
saphenous vein graft to the left circumflex marginal,
saphenous vein graft to the PDA and left internal mammary
artery to left anterior descending.
6. Status post cholecystectomy in [**2185**].
7. Status post spinal surgery with postoperative
meningitis.
8. History of cholesterol emboli.
9. History of hemorrhoidal bleeding.
PHYSICAL EXAMINATION: On admission, temperature 100.1 F.;
130/60; 85; 18; 98% on room air. The patient was in no acute
distress, appears comfortable, speaks easily. Neck revealed
no jugular venous distention, no carotid bruits and the neck
was supple. Lungs were clear to auscultation bilaterally.
Heart is regular rate and rhythm. III/VI systolic murmur at
the right upper sternal border. Abdomen distended but soft
and nontender. Positive bowel sounds. Extremities without
edema. Right foot with ulceration, gangrenous between the
first and second digits. The left foot has a Charcot
deformity. Pulses were Doppler-able bilaterally.
LABORATORY: White blood cell count of 8.9, hematocrit of
38.9, platelet count of 143, potassium 3.9, chloride 97,
bicarbonate 28, BUN 28, creatinine 4.6 and glucose 164. PT
13.3, PTT 28.0, INR 1.2. CK 116, MB 11, index 9.5, troponin
26.8. PSA 20.2.
Later CK were 89 and 98, troponin 23.6 and 38.9. Liver
function tests showed ALT 12, AST 25, LD 272, alkaline
phosphatase 216, total bilirubin 0.9, albumin 3.9, calcium
8.9, phosphorus 5.0, magnesium 1.8.
HOSPITAL COURSE:
1. Coronary artery disease: The patient had no elevation in
his CK although climbing troponin. He was taken to
catheterization on [**2189-6-19**], and received stents to his D1
and left circumflex. After catheterization, the patient did
well until about 12:30 a.m. on [**6-20**], when he was found to be
dyspneic, diaphoretic and in junctional bradycardia in the
50s, with [**Street Address(2) 93151**] elevation in the inferior leads, with ST
depressions in V5, V6, I and AVL. His blood pressure fell
and shortness of breath increased. The patient was intubated
and Dopamine started.
The patient was taken to the Catheterization Laboratory for a
relook at which time the re-look revealed left anterior
descending and left circumflex 100% occluded, and left main
without evidence of reocclusion. The left internal mammary
artery to left anterior descending was patent but distal left
anterior descending had diminished flow and it was stented at
that time in order to fill the right coronary artery through
collaterals.
An intra-aortic balloon pump and pacemaker were placed at
that time and he was transferred to the Cardiac Care Unit for
hemodynamic monitoring. The following day, the balloon pump
as well as the pacemaker were removed. The patient was
extubated on [**2189-6-22**] and the patient was returned to the
Floor on that day in stable condition. The patient had no
more chest pain throughout the hospital admission.
Pump: The patient had no signs of congestive heart failure
throughout this admission.
Electrophysiology Service: The temporary pacer placed during
the second trip to the Catheterization Laboratory was removed
and the patient remained event free on Telemetry.
2. Renal: The patient was continued on hemodialysis on
Tuesday, Thursday and Saturday.
3. Infectious Disease: The patient developed borderline low
grade fevers and actually did develop a temperature of 102.0
F., while in Cardiac Care Unit. Blood cultures and urine
cultures were taken, all of which revealed no growth.
The culture of his infected toe revealed Group B strep,
moderate growth, probable Enterococcus moderate growth and
Diphtheroids heavy growth. An Infectious Disease
consultation was called which recommended that the patient be
placed on Flagyl 500 mg p.o. q. eight hours and Levaquin 250
mg p.o., four times a day. As for his toe infection,
Podiatry and Vascular were both consulted. Vascular felt
that the patient was not a candidate for any invasive
treatments at this time including amputation. Podiatry
suggested x-ray of his toes to determine if there was any
possibility of osteomyelitis in the toe. The dressings were
changed and Podiatry followed the patient throughout his
admission.
4. Hematologic: The patient's hematocrit hovered around 28
the entire admission, however, fell slightly to 26 at one
point. The patient may receive blood in Dialysis for falling
hematocrit. There was no evidence of any bleed.
5. Neurologic: On [**2189-6-24**], the patient complained of
extreme lower extremity weakness on the right side. Prior to
admission, he has been able to ambulate with a walker and on
that day he stated that he could not move his leg. A
neurologic consultation was called and since the patient also
had an episode of bowel incontinence that morning, there was
a concern for cauda equina syndrome or sciatic nerve
compression, or some L5-S1 lesion. Neurology suggested and
MRI without contrast which was ordered for [**2189-6-25**].
The patient did regain some movement of his right lower
extremity and now is able to lift it and move against
gravity.
6. Diabetes mellitus: The patient was maintained on Lentis
26 units q. h.s. as well as covering sliding scale during the
day.
The patient was discharged in stable condition to [**Hospital3 103798**] in [**Hospital1 8**].
DISCHARGE MEDICATIONS:
1. Neurontin 1500 mg q. day divided as follows: 300 mg p.o.
at breakfast; 600 mg p.o. at 16:00; 600 mg p.o. at 21:00 each
day.
2. Flagyl 500 mg p.o. q. eight hours.
3. Levaquin 250 mg p.o. q.o.d.
4. Compazine 25 mg p.r. q. 12 hours.
5. Lantus 26 units q. h.s.
6. Tums one tablet p.o. three times a day.
7. Aspirin 81 mg p.o. q. day.
8. Protonix 40 mg p.o. q. day.
9. Nephrocaps one capsule p.o. q. day.
10. Lisinopril 5 mg p.o. q. day.
11. Plavix 75 mg p.o. q. day times 30 days.
12. Heparin 5000 units subcutaneously q. 12 hours.
13. Zoloft 50 mg p.o. q. day.
14. Ambien 5 mg p.o. q. h.s.
15. Imdur 30 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient is to follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **].
2. He may possibly get an MRI in the future of his toe in
order to determine the depth of infection, if infection is
worsening.
[**Name6 (MD) **] [**Last Name (NamePattern4) 5467**], M.D. [**MD Number(1) 5468**]
Dictated By:[**Last Name (NamePattern1) 4525**]
MEDQUIST36
D: [**2189-6-25**] 17:45
T: [**2189-6-25**] 18:16
JOB#: [**Job Number 103799**]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 16817**]
Admission Date: [**2189-6-18**] Discharge Date: [**2189-6-26**]
Date of Birth: [**2117-5-7**] Sex: M
Service:
ADDENDUM: This patient had an x-ray of his foot to evaluate
for osteomyelitis on [**2189-6-25**]. The right foot x-ray
revealed an undisplaced fracture of the proximal right first
digit and undisplaced fracture of the medial aspect of the
proximal digit for undermined length. There was no evidence
of osteomyelitis, however, there was some evidence of
osteopenia.
[**Name6 (MD) **] [**Last Name (NamePattern4) 8732**], M.D. [**MD Number(1) 8733**]
Dictated By:[**Last Name (NamePattern1) 1427**]
MEDQUIST36
D: [**2189-6-26**] 09:12
T: [**2189-7-6**] 11:57
JOB#: [**Job Number **]
Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 16817**]
Admission Date: [**2189-6-18**] Discharge Date: [**2189-6-26**]
Date of Birth: [**2117-5-7**] Sex: M
Service:
The patient had an magnetic resonance scan performed on
[**2189-6-26**] prior to discharge. The results arrived following
discharge and they are included in a fax to [**Hospital 16818**]
Hospital and Rehabilitation Center where the patient was
discharged.
The impression of the magnetic resonance scan was
degenerative changes of the lumbosacral spine and there are
postoperative changes. There is a mild spinal canal
narrowing at L4-L5. In the interval since previous
radiographs of L2 compression deformity of L2 has developed.
There is a soft tissue structure in the pelvis which is
incomplete at this time on my examination and might be
further investigated with CT imaging. We asked the attending
physician at the rehabilitation facility at [**Location 16818**] to
please arrange for follow-up chest, abdomen and pelvic CT
concerning the results of this report. It is not possible to
organize a CT scan and we will have Mr. [**Known lastname **] return to [**Hospital1 **]. If the CT scan is not possible, please
contact [**Telephone/Fax (1) 16819**] on Monday, [**2189-6-29**]. This plan has been
discussed with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN at [**Hospital 16818**] [**Hospital **]
Hospital by the covering intern, [**Doctor First Name **] Osh Kinani as well
as Dr. [**Last Name (STitle) 690**].
[**Name6 (MD) **] [**Last Name (NamePattern4) 8732**], M.D. [**MD Number(1) 8733**]
Dictated By:[**Dictator Info **]
MEDQUIST36
D: [**2189-6-27**] 16:27
T: [**2189-7-6**] 18:39
JOB#: [**Job Number **]
|
[
"250.60",
"585",
"410.41",
"414.01",
"707.14",
"250.70",
"357.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"99.20",
"37.23",
"37.61",
"36.06",
"36.01",
"96.04",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
7307, 7937
|
3441, 7284
|
7961, 11151
|
2339, 3424
|
189, 1711
|
1733, 2316
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,119
| 178,970
|
48315
|
Discharge summary
|
report
|
Admission Date: [**2113-9-15**] Discharge Date: [**2113-9-27**]
Date of Birth: [**2032-3-8**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
[**2113-9-15**]
Strangulated right inguinal hernia repair,primary, with
ileocolectomy and lysis of adhesions
[**2113-9-15**]
bedside exploratory laparotomy, Small bowel resection,
discontinuous
[**2113-9-15**]
Left chest tube thoracostomy
[**2113-9-17**]
Exploratory laparotomy, enteroenterostomy and delayed primary
closure.
History of Present Illness:
This patient is a 81 year old male with a h/o CAD, HTN,
right sided inguinal hernia. 1 hour after eating lunch had
midepig/perimb pain, with NBNB emesis. BM this AM - normal,
none since
Past Medical History:
PMH
Hypertension
right inguinal hernia
CAD
depression
vitaligo
PSH
THR
Social History:
Lives alone, supportive family
ETOH none
Tobacco remote
Family History:
non contributory
Physical Exam:
PE: 97.9 85 140/99 16 100% RA
AAOx3 NAD, however did vomit infront of me - chunks of food and
some bile
RRR
CTAB
Mildly firm and distended
R scrotum - large RIH - non-reducible - feels like it contains
bowel, no erythema, moderately tender
no edema, extrem warm
no masses guaiac negative
Pertinent Results:
[**2113-9-14**] 08:50PM WBC-9.4# RBC-4.96 HGB-14.6 HCT-43.6 MCV-88
MCH-29.4 MCHC-33.5 RDW-16.4*
[**2113-9-14**] 08:50PM NEUTS-89.3* LYMPHS-6.7* MONOS-2.3 EOS-1.3
BASOS-0.4
[**2113-9-14**] 08:50PM PLT COUNT-113*
[**2113-9-14**] 08:50PM ALBUMIN-4.4
[**2113-9-14**] 08:50PM ALT(SGPT)-29 AST(SGOT)-33 ALK PHOS-60
[**2113-9-14**] 08:50PM GLUCOSE-173* UREA N-24* CREAT-1.3* SODIUM-139
POTASSIUM-2.9* CHLORIDE-99 TOTAL CO2-21* ANION GAP-22*
[**2113-9-15**] 06:30AM WBC-7.3 RBC-2.01*# HGB-6.0*# HCT-18.2*#
MCV-91 MCH-30.0 MCHC-33.1 RDW-17.0*
[**2113-9-14**] KUB : No radiographic evidence for obstruction. Please
note, given the paucity of bowel gas, dilated loops of
fluid-filled bowel are not excluded. No free air.
[**2113-9-16**] TTE :
Normal biventricular systolic function, small pericardial
effusion with no evidence of tamponade physiology. Moderately
dilated right ventricle
[**2113-9-16**] Head CT : No acute intracranial process.
Brief Hospital Course:
Mr. [**Known lastname 101787**] was evaluated by the Acute Care service in the
Emergency Room and based on exam and xray had an incarcerated
right inguinal hernia and surgery was recommended emergently.
The patient refused and due to the urgent circumstances a
Psychiatric consult was obtained to clarify his competency. In
the meantime his family talked with him and together they
decided surgery was in his best interest. He was taken to the
Operating Room on [**2113-9-15**] and underwent repair of a
strangulated right inguinal hernia with ileocolectomy and lysis
of adhesions. he tolerated the procedure well and returned to
the ICU in stable condition. He remained intubated and sedated.
Soon thereafter he developed elevated bladder pressures, a
decreasing hematocrit and some hypotension requiring bedside
exploratory laparotomy with resection of some necrotic small
bowel with subsequent discontinuity. He was resuscitated with IV
fluids and blood and his lowest hematocrit was 24. He also
developed a left pneumothorax following central line placement
requiring chest tube placement with complete re-expansion of the
lung.
Over the next 48 hours he maintained stable hemodynamics but did
remain intubated and sedated. On [**2113-9-17**] he was taken back to
the Operating Room for a washout, enteroenterostomy and delayed
primary closure. He tolerated that procedure well and again
returned to the ICU in stable condition. He remained intubated
for 3 additional days and eventually was successfully extubated
on [**2113-9-20**]. He underwent vigorous chest PT and incentive
spirometry and remained free of any other pulmonary
complications.
For a short time he was enterally fed however as his bowel
function returned he was able to gradually advance to a regular
diet. He needs cueing and help at this point with feeding and
will gladly take protein supplements. His hematocrit was stable
in the 28 range for days but on [**2113-9-24**] it gradually decreased
and eventually he developed melena without any other symptoms.
On [**2113-9-25**] his hematocrit was 23.6 and he was transfused with 2
units of packed red blood cells. He felt better and his melena
stopped. Subsequent hematocrits were >30. He was having normal
formed bowel movements from that point on. He is still guiac
positive but his stools are formed, brown and his hematocrit
today is 33.
He was evaluated by the Physical Therapy service and found to be
very deconditioned and in need of a short term rehab prior to
his return home. After a complicated course he was discharged
on [**2113-9-27**].
Medications on Admission:
Questran 1 packet [**Hospital1 **]
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
3. cholestyramine-sucrose 4 gram Packet Sig: One (1) Packet PO
BID (2 times a day).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Strangulated right inguinal hernia with bowel obstruction.
Postoperative bleeding and small bowel necrosis
Acute blood loss anemia
Left pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
* You were admitted to the hospital for repair of your
strangulated hernia. Your surgery was complicated by bleeding
which required a second operation with removal of part of your
small bowel. The bowel was not reconnected due to swelling.
You ultimately required a 3rd operation to put the bowel back
together and close the incision.
* Despite a long difficult course , you have recovered well.
* In order to get you back home we are sending you to a short
term rehab so that you may work on Physical Therapy, eat a bit
more and get stronger.
* You need to follow up with the surgeon in [**12-21**] weeks or earlier
if any new symptoms develop.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in [**12-21**] weeks.
Completed by:[**2113-9-27**]
|
[
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icd9cm
|
[
[
[]
]
] |
[
"96.6",
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"45.93",
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"53.00",
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icd9pcs
|
[
[
[]
]
] |
5432, 5531
|
2377, 4971
|
328, 659
|
5724, 5724
|
1400, 2354
|
6579, 6718
|
1058, 1076
|
5057, 5409
|
5552, 5703
|
4997, 5034
|
5907, 6556
|
1091, 1381
|
274, 290
|
687, 874
|
5739, 5883
|
896, 969
|
985, 1042
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,860
| 148,551
|
747
|
Discharge summary
|
report
|
Admission Date: [**2115-11-6**] Discharge Date: [**2115-11-26**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
CyberKnife mapping
History of Present Illness:
Dr. [**Known lastname 5459**] is an 85 year old gentleman with history of COPD on
6L home O2 (FEV1 28% predicted), recurrent DVT on coumadin, and
recently diagnosed LUL NSCLC who is admitted with hypotension.
Today he was scheduled for LUL fiducial electrode placement and
was noted to have relative hypotension with [**Name (NI) 5462**] in the 90's.
.
His primary oncologist noted L > R weakness on examination and
neurology was consulted out of concern for potential stroke.
The patient dates the onset of worsening generalized weakness
and gait instability for the last 2 months, similar to around
the time he was diagnosed with LUL mass.
.
The patient complains of decreased PO intake and DOE, unchanged
from recent baseline. He may have had one episode of dysuria
today but denies urinary frequency. He denies fevers, chills,
headache, chest pain, SOB at rest, abdominal pain, nausea,
vomiting, diarrhea, arthralgias, myalgias, rash. Of note, the
patient was on a prednisone taper for COPD that ended the day
prior to admission.
.
In the ED, VS 97.2 77 81/52 16 94%4L NC. The patient was given
3L NS, solumedrol 125 mg IV x 1, levaquin 750 mg IV x 1,
clindamycin 600 mg IV x 1, vancomycin 1 gm IV x 1, glucagon 2 mg
IV x 1, zofran 4 mg IV x 1, heparin gtt, and was briefly on
dopamine gtt.
Past Medical History:
- Non Small Cell Lung Cancer - diagnosed [**2115-10-22**] via CT guided
biopsy, without known metastases
- Thyroid Papillary (Hurthle Cell) Carcinoma - Diagnosed by FNA
[**2115-10-30**]
- COPD - FEV1 28% predicted; rising home O2 requirements in
recent weeks, 4L normally, now on 6L
- Recurrent DVT - started about four years ago, not in setting
of travel, currently anticoagulated on coumadin.
- Hypertension
- Hyperlipidemia
- Spinal stenosis
.
Past Surgical History:
- Appendectomy in childhood
- s/p bilateral Dupuytren's contracture releases
- Back surgery
- Rotator cuff repair
.
Social History:
Lives alone, professor [**First Name (Titles) **] [**Last Name (Titles) 5463**], still studies medical
imaging. Grew up in Poland. Remote 50 pack year history. No
current ETOH. No illicit of IVDU.
Family History:
No family history of stroke or neurological disease. No lung
Ca, mother passed away from colon ca.
Physical Exam:
Vitals: T: 98.7 P: 85 R: 16 BP: 92/78 SaO2: 94% on 6L NC
General: Awake, very pleasant, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted
in oropharynx
Neck: Supple, no JVD or carotid bruits appreciated. No nuchal
rigidity
Pulmonary: Scattered crackles, more prominent at bases b/l
Cardiac: Distant sounds, RRR, nl S1S2, no M/R/G noted
Abdomen: Soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: No rashes
Neurologic: Alert, oriented x 3. Strength 5/5 RUE/LE, [**4-27**] LUE,
[**2-25**] LLE. Sensation grossly intact.
Pertinent Results:
CXR [**11-6**]: Since prior exam, there has been no significant
interval change. Persistent opacification at the left lung base
may represent pneumonia or atelectasis. The cardiomediastinal
silhouette is stable. There is no pneumothorax. The pulmonary
vasculature is unchanged.
IMPRESSION: No significant interval change.
.
CT Head w/o contrast [**11-7**]: No acute intracranial pathology.
Please note that gadolinium-enhanced MRI is more sensitive for
the detection of intracranial masses.
.
MRI/MRA head
No evidence of metatstasis, masses, mass effect, or hemorrhage.
.
[**2115-11-7**] TTE
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%) Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is mildly dilated. There is mild global right
ventricular free wall hypokinesis. There is abnormal systolic
septal motion/position consistent with right ventricular
pressure overload. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the prior study (images reviewed) of [**2115-10-21**],
there is worsening in right ventricular function with more right
ventricular dilation, increased severity of tricuspid
regurgitation, and increased estimated pulmonary artery systolic
pressure.
.
[**2115-11-15**] UGI Series
Free passage of the thin barium into the stomach without
evidence of obstruction or severe stricture or gross mass.
Evaluation of the mucosal surface is limited. If indicated,
please consider more dedicated study such as endoscopy.
.
[**2115-11-23**] CTA
No central or segmental pulmonary embolism, however,
subsegmental pulmonary emboli cannot be excluded given the
extent of atelectasis/collapse of the lower lobes.
2. Interval increase in the size of the cavitating left upper
lobe neoplasm with new bilateral lung lesions consistent with
disease progression.
3. Invasion of the left second rib by the left upper lobe
neoplasm.
.
[**2115-11-24**] CXR
.
FINDINGS:
Heart and mediastinum are within normal limits. There is no
appreciable change since the prior study. There are multifocal
opacities in left upper lobe as well as bilateral lower lobes.
The left upper lobe lesion is a known cavitary malignancy.
IMPRESSION:
No appreciable change since prior study.
[**2115-11-6**] 07:55PM LACTATE-2.1*
[**2115-11-6**] 06:00PM WBC-14.9* RBC-3.69* HGB-12.1* HCT-34.4*
MCV-93 MCH-32.8* MCHC-35.2* RDW-13.7
[**2115-11-6**] 07:55PM LACTATE-2.1*
[**2115-11-6**] 06:00PM WBC-14.9* RBC-3.69* HGB-12.1* HCT-34.4*
MCV-93 MCH-32.8* MCHC-35.2* RDW-13.7
[**2115-11-6**] 06:00PM PLT COUNT-424
[**2115-11-6**] 02:15PM GLUCOSE-211* UREA N-71* CREAT-1.9* SODIUM-134
POTASSIUM-5.5* CHLORIDE-96 TOTAL CO2-24 ANION GAP-20
[**2115-11-6**] 02:15PM estGFR-Using this
[**2115-11-6**] 02:15PM ALT(SGPT)-56* AST(SGOT)-40 CK(CPK)-21* ALK
PHOS-96 TOT BILI-0.7 DIR BILI-0.3 INDIR BIL-0.4
[**2115-11-6**] 02:15PM CK-MB-2 cTropnT-<0.01
[**2115-11-6**] 02:15PM ALBUMIN-2.9* CALCIUM-8.8 MAGNESIUM-2.8*
[**2115-11-6**] 11:00AM PT-19.2* INR(PT)-1.8*
[**2115-11-6**] 09:20AM PT-19.0* INR(PT)-1.8*
.
LABORATORIES AT DISCHARGE
.
WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2115-11-26**] 06:50AM 18.3* 3.49* 10.6* 32.6* 93 30.4 32.6 13.9
362
.
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2115-11-26**] 06:50AM 93 25* 1.0 135 5.1 100 27
.
INR: 2.8
Brief Hospital Course:
85 y/o male with a h/o COPD on 6L home O2 (FEV1 28% predicted),
recurrent DVT on coumadin, and recently diagnosed LUL NSCLC who
was admitted with hypotension, new AF, and ARF. The patient was
initially admitted to the intensive care unit for hypotension,
which was thought due to a combination of dehydration and
adrenal insufficiency (patient had finished a steroid taper the
day before). After volume expansion and steroids, he was then
transferred to the floor on a steroid taper. He then developed
hypoxia worsening about [**11-16**] and had another brief few days in
the intensive care unit on stress dose steroids for respiratory
monitoring before he was transferred back to the oncology floor.
He has remained afebrile and feeling well on the floor except
for two episodes of obtundation due to the combination of
steroids, trazodone and ambien.
.
1. Dysphagia
Pt had issues with pain on swallowing and a "feeling of food
getting stuck in chest/epigastrium" ongoing for several weeks
which seemed to worsene over the admission. A barium swallow was
performed and there was no evidence of stricture or obstruction.
He had evidence of thrush in his mouth and he was empirically
treated with a course of fluconazole for presumed [**Female First Name (un) **]
esophagitis, especially in view of his recent intake of high
dose steroids. EGD was briefly considered but was then cancelled
when the patient improved on fluconazole. Speech and swallow
evaluated the patient and he had no issues with swallowing and
was deemed not an aspiration risk. He can continue regular diet
as tolerated.
.
2. Newly diagnosed NSCLC
The patient was diagnosed with non-small cell lung cancer on
[**9-/2115**] per cytology. He was being admitted for fiducial
electrode placement and he was found to be hypotensive. He did
have the electrodes placed and underwent CyberKnife mapping. He
wlll follow up after discharge for his CyberKnife therapy.
Radiation Oncology followed up the patient in house and
discussed the treatment options with his daughter [**Name (NI) 5464**], who
agreed fully. He has a schedule for cyberknife prior to leaving
the hospital. CTA performed on [**11-23**] to assess for pulmonary
embolism showed some questionably new lesions on the R lung. The
patient will follow with new scan in [**3-29**] weeks.
.
3. Atrial fibrillation
During the patient's admission for hypotension, he was also
found to be in atrial fibrillation with a rapid ventricular
rate. He is currently rate controlled with BB and CCB with care
to avoid hypotension. Initially he required diltiazem 30 mg four
times a day for rate control, but then his requirements
decreased to 15 mg qid and then 15 mg [**Hospital1 **]. He is also
anticoagulated for his h/o recurrent DVT and atrial
fibrillation. Target INR goal is [**1-26**], and his INR at discharge
is 2.8.
.
4. Thrush
The patient was treated for thrush and presumed [**Female First Name (un) **]
esophagitis with a course of fluconazole x 7 days, course
completed. He was also started on Nystatin therapy and he will
continue this on discharge.
.
5. Weakness
He worked with physical therapy and he will be discharged to
acute rehab. Neurology followed the patient from the beginning
for a history of left sided weakness and found no acute issues.
His weakness was thought due to neuropathy, deconditioning and
poor PO intake. The patient was back to his baseline at the time
of discharge.
.
6. COPD/hypoxia
The patient has a h/o severe COPD with FEV1 28% predicted and on
home O2 (6 liters). The patient was continued on his outpatient
medications included his inhalers. He did have episodes of
hypoxia which was attributed to his NSCLC and severe COPD. He
was treated with high dose steroids during this admission for
COPD exacerbation and he will be maintained on 10 mg of
prednisone daily upon discharge, according to the
recommendations of pulmonary consult. [**10-24**] and 2 he
decompensated briefly requiring NRB mask to maintain his sats. A
CTA was performed which showed no pulmonary embolism. It showed
questionably new nodules on his right chest. required NRB but
for the past 48 hours he has been back to baseline satting low
90s on [**3-28**] L n/c. He has had two ICU stays, one for hypoxia and
one for hypotension. On his second ICU stay, for hypoxia, he was
treated for presumed hospital acquired pneumonia with 3 days of
vancomycin/zosyn, then transitioned to PO levaquin, of which he
has completed a 7 day course during which he has remained
afebrile.
.
7. DVT
The patient has a known h/o DVT on coumadin prior to admission.
He was maintained on anticoagulation for both this and his
atrial fibrillation. His INR has remained therapeutic.
.
8. Hypotension, resolved
This was likely due to volume depletion and atrial fibrillation
resulting in loss of atrial kick. Relative adrenal
insufficiency is also high on the differential given recent
discontinuation of prednisone. Sepsis less likely; patient was
afebrile, leukocytosis was at baseline (patient on steroids).
PE less likely given absence of tachycardia, change in oxygen
requirement, or pleuritic chest pain, although patient has
history of DVT. ACS less likely given lack of acute ST-T
changes on EKG and negative CE. Patient was started on
Solumedrol 125 mg IV x 3 doses, then slow prednisone taper. A
TTE was ordered to assess cardiac function (see above).
.
9. CODE status: a meeting with the medical team and his daughter
[**Name (NI) 5464**] clarified issues of treatment plan. Cyberknife and
radiation therapy. The daughter is very insistent the patient is
absolutely DNR/DNI.
.
10. The patient became acutely obtunded and agitated when
sleeping pills were used. These should be avoided
Medications on Admission:
Advair 500/50 INH [**Hospital1 **]
Atenolol 25mg PO daily
Coumadin 2.5mg daily (stopped [**11-1**] for planned fiducial
placement)
Amlodipine 2.5mg daily
Percocet 5/325 2 tabs Q12 hrs PRN pain
Spiriva daily
Estazolam (prosom) 1mg PO QHS for sleep
Prednisone 5mg daily tapered off the day prior to admission
Discharge Medications:
1. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation 1 puff [**Hospital1 **] ().
2. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once
Daily at 16).
3. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for constipation.
7. Amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Albuterol
Albuterol nebulizer every 4 hours as needed for shortness of
breath.
10. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID
(4 times a day) as needed for Thrush.
11. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
12. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every twelve
(12) hours as needed for pain.
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Diltiazem HCl 30 mg Tablet Sig: 0.5 Tablet PO twice a day.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Primary:
Non-small cell lung cancer
Secondary:
COPD on 6L of home oxygen
Recurrent DVT on coumadin
Thyroid Papillary Cancer
Hypertension
Hyperlipidemia
Discharge Condition:
The patient was discharged hemodynamically stable, afebrile with
appropriate follow up.
Discharge Instructions:
You were admitted to the hospital for electrode placement and
you were found to have low blood pressure and left-sided
weakness. Neurology saw you and did not think that you had a
stroke. You also had some shortness of breath. You were admitted
initially to the intesive care unit and then transferred to the
floor. While on the floor, you can another episode of difficulty
breathing and were transferred again to the intensive care unit.
You were then transferred back to the floor once your breathing
was stable.
Please take all medications as prescribed to you
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2115-12-3**] 10:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5465**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2115-12-3**] 10:30
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 1401**], M.D. Phone:[**Telephone/Fax (1) 2386**]
Date/Time:[**2116-2-4**] 11:20
|
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"V12.51",
"276.51",
"255.41",
"564.09",
"458.8",
"V46.2",
"507.0",
"112.84",
"585.2",
"288.60",
"787.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.27"
] |
icd9pcs
|
[
[
[]
]
] |
14408, 14478
|
6962, 12672
|
275, 296
|
14675, 14765
|
3251, 6939
|
15379, 15810
|
2464, 2566
|
13030, 14385
|
14499, 14654
|
12698, 13007
|
14789, 15356
|
2116, 2234
|
2581, 3232
|
224, 237
|
324, 1624
|
1646, 2093
|
2250, 2448
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,339
| 198,656
|
51481
|
Discharge summary
|
report
|
Admission Date: [**2155-7-25**] Discharge Date: [**2155-8-4**]
Service: MEDICINE
Allergies:
Codeine / Penicillins / Sulfonamides / Iodine; Iodine Containing
/ Citalopram / Celebrex
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
CC: fever, hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. [**Known lastname **] is a [**Age over 90 **] y/o woman with PMH significant for
asthma and recent C diff colitis who presented to the emergency
room earlier today with fever and hypotension. The patient was
discharged on [**2155-6-23**] after being diagnosed with C diff colitis;
she was discharged to finish a 3-week course of PO vancomycin
and flagyl. She completed antibiotics 10 days ago and reports
that at that time, her diarrhea had resolved. Starting about
four days ago, the patient began having loose stools (soft, not
liquid) about 2-3 times per day. This morning, she was febrile
to 104 (per report) and was sent to the emergency room. In the
ER, the patient's temp was 101.3 with initial blood pressure
50/30. With 1800 cc IV fluids, her blood pressure increased to
118/35. However, her subsequent blood pressures were quite
erratic, ranging from 70-132 systolic. She was started on a
dopamine gtt via peripheral IV with some improvement in blood
pressures. She was dosed with IV flagyl X 1 in the ED and
received a total of 4 L NS. For her fever, she received 30 mg IV
toradol X 1. She transiently complained of dyspnea and was given
an albuterol/atrovent neb with improvement.
.
On admission to the [**Hospital Unit Name 153**], the patient says that she feels
relatively well. She denies abdominal pain, nausea, and
vomiting. She reports several episodes of soft stools per day
for the past few days. She denies any respiratory difficulty,
cough, chest pain, blood in her stools, dysuria, or lower
extremity edema. She endorses a decreased appetite for several
weeks and decreased PO intake. Within the last few days, the
patient noticed that her lips were quite swollen; she saw her
PCP who treated her with hydroxyzine for presumed allergic
reaction. Her lips are now much improved per her report.
.
Past Medical History:
Past Medical History:
1. Asthma
2. Hiatal hernia with GERD
3. Irritable bowel syndrome
4. Diverticulosis
5. Diverticulitis with microperforation in [**2151**].
6. Hypertension
7. Paroxysmal SVT (atrial tachycardia)
8. Pseudogout
9. Aortic stenosis
10. Paroxysmal atrial fibrillation
Social History:
Social History: She lives alone, her husband died about 1.5
years ago. She has recently been at [**Hospital **] rehabilitation
facility but had returned home with caregivers coming at night.
She lives in [**Location (un) 55**]; her children live in [**State 33977**] and
[**State **]. Grandchildren live nearby and go to college (BU and
Brown). Had smoked in the past 1 pack per day x10 yrs. Had
previously been a social worker.
Family History:
Family History: mother with lumpectomy
Physical Exam:
PE:
T 98.9 HR 65 BP 112/45 RR 14 O2 sat 100% on 3LNC
Gen: Alert, pleasant elderly female in NAD, speaking in full
sentences
HEENT: Lips dry with evidence of crusting, no sign of
superinfection. PERRL, EOMI. Tongue moist.
Neck: Prominent v waves. JVP at 10 cm. Evidence of radiation of
aortic stenosis murmur.
Chest: Decreased breath sounds at right base. No crackles or
wheezing.
CV: Regular rate and rhythm. Loud, harsh 3/6 systolic murmur
best heard at the LLSB but radiating throughout the precordium.
Abd: Normoactive bowel sounds, soft, nontender to palpation. No
rebound/guarding.
Ext: Trace peripheral edema. DP pulses 2+ bilaterally.
Skin: Other than crusting at lips, no visible rashes.
.
Pertinent Results:
Labs:
Na 133
**K 3.4
Cl 96
Bicarb 27
BUN 20
** Cr 1.3 (baseline is approximately 1.1, was 0.9 on [**7-5**])
Glu 118
.
**WBC 10.3 (**28% Bands, 60% PMNs)
Hg 9.7
**Hct 29.3
Plt 357
.
**Lactate 2.1
.
Micro:
UA [**2155-7-25**] - Trace leuk, occ bacteria, 3-5 WBCs, Neg Nitrite
Urine Cx - pending
Bl Cx x 2 - pending
.
EKG: sinus rhythm at 60, normal axis. PR prolonged (~ 200 ms). T
waves flattened in II, avF. < [**Street Address(2) 4793**] elevation in V3 appears to
be repolarization abnormality.
.
CXR: (prelim) hazy opacity at right lung base concerning for
atelectasis versus pneumonia
Brief Hospital Course:
A/P: Ms. [**Known lastname **] is a [**Age over 90 **] year old female who presents with
hypotension of unclear etiology, likely septic shock.
.
# Hypotension. On admission patient was hypotensive to the 70s
systolic. This was thought to be most likely secondary to
septic shock vs. hypovolemia. Her EKG was unchanaged and she
did not complain of chest pain making cardiogenic shock
unlikely. She received aggressive IVF hydration and peripheral
dopamine for pressure support. She required vasopressor
medications for approximately 24 hours. For the remainder of
her MICU course she was hemodynamically stable.
.
# Sepsis. On presentation the patient had a WBC count of 10.3
with 28% bands and a fever to 101.3 suggesting septic shock as
the etiology for her hyptension. Her only localizing complaint
was diarrhea. She completed a course of antibiotics for c. diff
colitis approximately ten days prior to presentation. On exam
she had no abdominal pain and actually did not have any diarrhea
for hospital days one and two. Her CXR showed a possible
pneumonia vs. atelectasis but on presentation she complained of
no respiratory symptoms. She was started on broad spectrum
antibiotics. Blood, urine and stool cultures were sent. Blood
and urine cultures were negative but stool was positive for c.
diff. Her antibiotics were changed to PO vancomycin and flagyl
with plans to complete a three week course. On discharge, she
had two soft bowel movements daily with resolution of her
diarrhea.
.
# Congestive Heart Failure: Patient noted to be increasingly
short of breath on hospital day 2 with increased pulmonary edema
on CXR. She was started on cautious diuresis as her blood
pressure would tolerate with good effect. Upon discharge, she
was off diuretics and without dyspnea.
.
# Mouth sores: On presentation she was noted to have numerous
small sores on her upper and lower lips thought to be herpes
labialis. The lesions had been present for a number of days so
it was felt that oral acyclovir would not shorten her course.
She was given topical acyclovir and symptomatic therapy.
.
# Atrial Fibrillation: Patient noted to have intermittent atrial
fibrillation throughout her stay. She was started on diltiazem
for rate control and her dose was titrated up to 180mg daily.
She was continued on her home dose of amiodarone. Aspirin was
continued for oral anticoagulation.
.
# Hypertension: Following her initial presentation with
hypertension the patient was noted to be hypertenstive. At home
the patient takes norvasc 2.5 mg and avapro 150 mg for HTN at
home. She was started on norvasc and valsartan 80 mg. On this
regimen she was persistently hypertensive and her atrial
fibrillation was poorly rate controlled. This was switched to
valsartan 80 mg daily and diltiazem 30 mg daily with good blood
pressure and rate control. She subsequently developed
orthostatic hypotension and she was switched to extended release
diltiazem 180mg daily on discharge.
.
# Asthma: Patient received albuterol and ipratroprium inhalers
and was continued on her home dose of azmacort during this
hospitalization with good control of her asthma.
.
# Yeast Infection: Patient noted to have vaginal yeast
infection on presentation. Started on miconazole cream for
treatment and prophylaxis.
.
# Hypothyroidism: She was continued on her home dose of
levothyroxine.
.
# Prophylaxis. She received subcutaneous heparin for DVT
prophylaxis.
.
CODE: DNR/DNI
.
Communication: With patient and son, Dr. [**First Name (STitle) **] [**Known lastname **], ([**Telephone/Fax (1) 106745**] home, ([**Telephone/Fax (1) 106746**] cell, ([**Telephone/Fax (1) 106747**] beeper.
Medications on Admission:
.
Meds:
levothyroxine 50 mcg MWF, 25 mcg TThSaSu
norvasc 2.5 mg daily
amiodarone 200 mg daily
avapro (irbesartan) 150 mg daily
azmacort 2 puffs [**Hospital1 **]
ventolin 1 puff daily
aspirin 81 mg daily
biotin 1000 mcg daily
furosemide 40 mg as needed
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO MWF
(Monday-Wednesday-Friday).
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO TUE,
THURS, SAT, SUN ().
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-19**]
Drops Ophthalmic PRN (as needed).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
5. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
8. Triamcinolone Acetonide 75 mcg/Actuation Aerosol Sig: One (1)
Inhalation three times a day.
9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 2 weeks.
10. Menthol-Cetylpyridinium Cl 2 mg Lozenge Sig: One (1) Lozenge
Mucous membrane PRN (as needed).
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
12. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
Inhalation Q2H (every 2 hours) as needed.
13. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-19**] Sprays Nasal
[**Hospital1 **] (2 times a day) as needed.
14. Benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID
(4 times a day) as needed.
15. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 2 weeks.
16. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily) as needed for atrial
fibrillation.
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
18. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): while inpatient.
19. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day) as needed for arthritis.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
1. Clostridium difficile colitis, recurrent, complicated by
resolved septic shock
2. Hypertension
3. Paroxysmal atrial fibrillation
4. Hypothyroidism
5. Diverticulosis with history of diverticulitis
6. Hiatal hernia
7. GERD
8. Aortic stenosis
Discharge Condition:
Stable and with improving strength
Discharge Instructions:
You will be transferred to an extended care facility for further
rehabilitation. A physician will be following you there until
you are discharged.
Followup Instructions:
1. Please make a follow up appointment with your primary care
physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) 931**] [**Telephone/Fax (1) 3329**] after you are
discharged from rehabilation.
|
[
"493.90",
"553.3",
"038.9",
"427.31",
"401.9",
"112.1",
"428.0",
"424.1",
"244.9",
"008.45",
"995.92",
"562.10",
"530.81",
"785.52",
"054.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.17",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
10208, 10286
|
4342, 8020
|
318, 325
|
10573, 10610
|
3729, 4319
|
10805, 11059
|
2970, 2995
|
8322, 10185
|
10307, 10552
|
8046, 8299
|
10634, 10782
|
3010, 3710
|
256, 280
|
353, 2183
|
2227, 2491
|
2523, 2938
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,348
| 187,256
|
6052
|
Discharge summary
|
report
|
Admission Date: [**2108-12-11**] Discharge Date: [**2108-12-15**]
Date of Birth: [**2027-12-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Atypical Chest Discomfort and abnormal ETT
Major Surgical or Invasive Procedure:
[**2108-12-11**] - Redo Sternotomy with CABGx2 (LIMA->LAD, SVG->OM)
History of Present Illness:
This 80-year-old patient with a history of hypertension,
hyperlipidemia, peripheral vascular disease, and coronary artery
disease has been having atypical chest pain for several years,
and was investigated recently with an abnormal stress test. A
subsequent coronary angiogram showed 60% left mainstem lesion
with further disease in the circumflex, the LAD, and also a
small right coronary artery which was diseased as well. She has
had a previous thymectomy done about 6 months ago through a
sternotomy approach. She has electively opted for reduced
sternotomy and coronary artery bypass grafting.
Past Medical History:
Coronary artery disease
Thymectomy
Paroxysmal atrial fibrillation in past
right carotid endarterectomy
Hypercholesterolemia
HTN
Hypothyroidism
Chronic hyperamylasemia
Arthritis
PVD
Bilateral Illiac Stenting
Osteoporosis
Social History:
Prior tobacco, no ETOH, exposure to chemicals during war- type
unknown
Family History:
7 of her siblings had CABG's in their 60's.
Physical Exam:
Vitals: BP 120/60, HR 74, RR 14, SAT 98% on room air
General: well developed elderly female in no acute distress
HEENT: oropharynx benign, fair dental health
Neck: supple, no JVD, transmitted murmur to carotid noted
Heart: regular rate, normal s1s2
Lungs: clear bilaterally
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, no edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Pertinent Results:
[**2108-12-14**] 06:20AM BLOOD WBC-8.2 RBC-3.32* Hgb-9.7* Hct-28.1*
MCV-85 MCH-29.2 MCHC-34.4 RDW-14.7 Plt Ct-96*
[**2108-12-14**] 06:20AM BLOOD Plt Ct-96*
[**2108-12-14**] 06:20AM BLOOD Glucose-108* UreaN-14 Creat-0.8 Na-139
K-3.9 Cl-103 HCO3-29 AnGap-11
[**2108-12-14**] 06:20AM BLOOD Calcium-8.4 Phos-2.9# Mg-2.0
[**2108-12-12**] CXR
1. Interval removal of chest tubes, with extubation and removal
of NG tube. No evidence of pneumothorax.
2. Persistent retrocardiac opacity, probably atelectasis.
[**2108-12-11**] EKG
Sinus rhythm. Left bundle-branch block. Compared to the previous
tracing
of [**2108-11-27**] no major change.
[**Last Name (NamePattern4) 4125**]ospital Course:
Ms. [**Known lastname 9834**] was admitted to the [**Hospital1 18**] on [**2108-12-11**] for elective
surgical management of her coronary artery disease. She was
taken directly to the operating room where she underwent a
redosternotomy with coronary artery bypass grafting to two
vessels. Postoperativelyy she was taken to the cardiac surgical
intensive care unit for monitoring. On [**Date Range **] day one,
Ms. [**Known lastname 9834**] [**Last Name (Titles) 5058**] neurologically intact and was extubated.
Aspirin and beta blockade were resumed. Her drains were removed
without complication. On [**Last Name (Titles) **] day two, she was
transferred to the cardiac surgical step down unit for further
recovery. She was gently diuresed towards her preoperative
weight. The physical therapy service was consulted for
assistance with her [**Last Name (Titles) **] strength and mobility. Ms.
[**Known lastname 9834**] continued to make steady progress and was discharged home
with a visiting nurse [**First Name (Titles) **] [**Last Name (Titles) **] day 4. She will follow-up
with Dr. [**Last Name (Prefixes) **], her cardiologist and her primary care
physician.
Medications on Admission:
Lopresor
Lipitor
Aspirin
Synthroid
Discharge Medications:
1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 14
days.
Disp:*56 Capsule, Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO every 4-6 hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 14 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary artery disease
Thymectomy
Paroxysmal atrial fibrillation in past
right carotid endarterectomy
Hypercholesterolemia
HTN
Hypothyroidism
Chronic hyperamylasemia
Arthritis
PVD
Bilateral Illiac Stenting
Osteoporosis
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain.
2) Report any fever greater then 100.5.
3) Report any weight gain of greater then 2 pounds in 24 hours
and 5 pounds in 1 week.
4) No lifting greater then 10 pounds for 10 weeks.
5) No driving for 1 month.
[**Last Name (NamePattern4) 2138**]p Instructions:
Follow-up with Dr. [**Last Name (Prefixes) **] in 1 month.
Follow-up with cardiologist in [**11-19**] weeks.
Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 1407**] in 2 weeks.
Call all providers for appointments.
Completed by:[**2108-12-15**]
|
[
"401.9",
"272.4",
"414.01",
"443.9",
"790.5",
"244.9",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"39.61",
"36.11"
] |
icd9pcs
|
[
[
[]
]
] |
5160, 5218
|
324, 394
|
5482, 5489
|
1850, 2485
|
1371, 1416
|
3788, 5137
|
5239, 5461
|
3728, 3765
|
5513, 5813
|
5864, 6155
|
1431, 1831
|
2536, 3702
|
242, 286
|
422, 1023
|
1045, 1266
|
1282, 1355
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,405
| 167,055
|
9258
|
Discharge summary
|
report
|
Admission Date: [**2139-1-6**] Discharge Date: [**2139-2-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
Admission for scheduled initiation of hemodialysis
Major Surgical or Invasive Procedure:
1. Exploration of right upper arm brachiocephalic fistula and
evacuation of hematoma, repair of laceration of the cephalic
vein, [**2139-1-7**].
2. Balloon angioplasty of brachiocephalic fistula stricture,
[**2139-1-20**]
3. PEG tube placement
4. HD Tunnel catheter placement
History of Present Illness:
This is an 87-year-old female with a past medical history
significant for end-stage renal disease, hypertension,
hypothyroidism, and anemia, who lives at a nursing home and was
noted to have decreasing urine output and increasing
BUN/creatinine. The patient is followed by nephrology and had
an AV fistula placed over the last six months in anticipation
for initiation of hemodialysis.
.
History was unable to be obtained from the patient given lack of
communication due to baseline mental retardation. Per her
nursing home records, she had had increasing lethargy and
decreasing urine output.
Past Medical History:
1. Hypertension.
2. Hypothyroidism.
3. Anemia secondary to end-stage renal disease.
4. Chronic renal insufficiency with a baseline creatinine of 4,
status post AV fistula placement complicated by stenosis status
post by angioplasty with only residual stenosis.
5. Ulcerative colitis, status post ileostomy.
6. Morbid obesity.
7. History of MRSA peritoneal infection.
8. Mild mental retardation complicated by poor hearing.
Social History:
The patient lives in [**Hospital **] [**Hospital **] Nursing Home.
Family History:
Noncontributory.
Physical Exam:
VITAL SIGNS: Temperature 98.1, blood pressure 126/72, heart
rate 84, respiratory rate 20, oxygen saturation of 97% on room
air.
GENERAL: She is a well-appearing female, in no acute distress,
not able to answer questions at baseline.
HEENT: Sclerae are anicteric, with no JVD noted.
CHEST: Poor inspiratory effort and unable to assess for rales
or crackles.
CARDIOVASCULAR: Regular rate and rhythm, with a normal S1 and
S2, no pericardial rubs noted.
ABDOMEN: Soft, nontender, ileostomy bag intact.
EXTREMITIES: Strong thrill noted over the right brachial AV
fistula.
NEUROLOGIC: Cannot assess mental status as patient is
uncooperative. She is moving all extremities spontaneously and
responding to painful stimuli. Asterixis cannot be assessed
given lack of cooperation.
Pertinent Results:
[**2139-1-6**] 05:45PM PT-11.8 PTT-26.1 INR(PT)-1.0
[**2139-1-6**] 05:45PM PLT COUNT-176
[**2139-1-6**] 05:45PM NEUTS-86.1* LYMPHS-8.4* MONOS-4.2 EOS-1.0
BASOS-0.3
[**2139-1-6**] 05:45PM WBC-9.3# RBC-4.95 HGB-13.0 HCT-39.9# MCV-81*
MCH-26.3* MCHC-32.6 RDW-19.5*
[**2139-1-6**] 05:45PM CALCIUM-10.2 PHOSPHATE-7.3*# MAGNESIUM-2.7*
[**2139-1-6**] 05:45PM GLUCOSE-106* UREA N-124* CREAT-6.8*#
SODIUM-137 POTASSIUM-7.9* CHLORIDE-102 TOTAL CO2-22 ANION
GAP-21*
[**2139-1-6**] 08:29PM K+-5.9*
[**2139-1-6**] 09:00PM URINE RBC-3* WBC-77* BACTERIA-NONE YEAST-NONE
EPI-<1
[**2139-1-6**] 09:00PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
.
IMAGING:
[**2139-1-6**] CXR: IMPRESSION: Left basilar plate-like atelectasis.
No evidence of pneumonia
.
[**2139-1-8**] ECHO: The left atrium is moderately dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Due to suboptimal technical quality, a
focal wall motion abnormality cannot be fully excluded. 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. Physiologic mitral
regurgitation is seen (within normal limits). There is no
pericardial effusion. IMPRESSION: Normal global left ventricular
systolic function.
.
[**1-16**]: CXR: IMPRESSION: Little change from prior, with
retrocardiac opacity, possibly representing atelectasis,
consolidation, or pleural effusion again noted.
.
[**1-15**]: CT Head
IMPRESSION:
1. Limited examination, however, no evidence of acute
intracranial pathology or hemorrhage. If needed, the scan could
be repeated at no additional cost to the patient or further
evaluation of etiology of altered mental status may be assessed
with MRI.
.
[**1-15**] Venous US
IMPRESSION:
1) Large 7 x 3 x 2 cm hematoma adjacent to the outflow end of
the fistula.
2) Patent fistula with elevated velocities distally, up to 550
cm/s, suggesting outflow stenosis. Further evaluation
angiographically may be warranted.
.
[**1-16**]: RUE ultrasound
FINDINGS: The right subclavian, right axillary, right cephalic,
paired brachial veins, and basilic veins are patent. No DVT is
identified. Again seen is a large hematoma adjacent to the
outflow end of the patient's fistula.
IMPRESSION: No deep venous thrombosis.
.
[**1-20**] Echocardiogram
Conclusions:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Transmitral Doppler and
tissue velocity imaging are consistent with Grade I (mild) LV
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets (?#) are
mildly thickened. An aortic valve vegetation/mass cannot be
excluded. There is no aortic valve stenosis. Mild to moderate
([**11-18**]+) aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. No mass or vegetation is seen on the
mitral valve. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. The main
pulmonary artery is dilated. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2139-1-8**],
the estimated pulmonary artery pressures indicate at least
moderate pulmonary hypertension. Mild-moderate aortic
regurgitation is now seen. No obvious vegetations are seen. If
clinically indicated, a TEE may better assess for vegetations
given suboptimal echo windows.
.
[**1-20**]: AVFistula angioplasty
IMPRESSION:
1. Tight stenosis along the venous aspect of the brachiocephalic
fistula.
2. Balloon angioplasty of the stricture, with resolution of
stenosis.
3. Contained rupture of the fistula during angioplasty, which
was treated by balloon tamponade with resolution
.
Microbiology:
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| STAPHYLOCOCCUS, COAGULASE
NEGATIVE
| |
ERYTHROMYCIN---------- =>8 R =>8 R
GENTAMICIN------------ 1 S 1 S
LEVOFLOXACIN---------- =>8 R =>8 R
OXACILLIN-------------<=0.25 S 0.5 R
PENICILLIN------------ =>0.5 R =>0.5 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=1 S
Brief Hospital Course:
In general, this is an 87-year-old female with a past medical
history of end-stage renal disease, hypertension,
hypothyroidism, and anemia, who lived at a nursing home,
admitted with declining urine output and worsening renal failure
to initiate hemodialysis. Her hospitalization was complicated
by AV fistula laceration and hematoma, status post repair with
subsequent stenosis of her fistula, and repair of the stenosis
complicated by laceration. She had multiple transfers to the
medical intensive care unit and ultimate withdrawal of care by
her family.
.
1. Altered mental status. The etiology of her mental status
change was not entirely clear, but likely multifactorial.
Uremia was felt not to be a contributor as she was having
regular hemodialysis. The patient does have a known history of
mild mental retardation at baseline, and per her [**Month/Day (4) 802**] was noted
to "get like this" during her hospitalizations. However, her
mental status was reported to return to normal on her return to
the nursing home. Initially, all sedating medications and
psychiatric medications were held, including her Risperdal,
Prozac, and fluoxetine. These were subsequently restarted
during her hospitalization. Morphine was held for concern of
contributing to her altered mental status. A CT scan of her
head on [**2139-2-5**] did not reveal any acute processes. Serial
arterial blood gases during hospitalization did not show any
evidence of hypoxemia or hypercarbia. Following her PEA arrest,
she did not regain consciousness and the family ultimately
withdrew care.
.
2. Hypotension. On her first transfer to the medical intensive
care unit for hypotension, the etiology was felt to be secondary
to blood loss after AV fistula laceration. However, her second
episode of hypotension was felt to be of unclear etiology.
Fluid shifts during hemodialysis were felt to be a contributor,
though it should be noted that her fluid balance was maintained
neutral during that session. Her only potential infectious
source was her known coag-negative staph bacteremia, however,
she did not show any evidence of sepsis and had a normal
lactate. She also did not spike any fevers and was noted not to
have a leukocytosis. Her hematocrit remained stable at this
time, making blood loss an unlikely contributor. Her
cosyntropin stim test was also without evidence of adrenal
insufficiency. She did have short requirement for vasopressors
for several hours following the episode, however, was quickly
weaned off. On her third transfer to the medical intensive care
unit following her PEA arrest at hemodialysis, ECG initially
showed a new right bundle branch block that was concerning for a
pulmonary embolus or myocardial ischemia. However, a
transthoracic echocardiogram showed no new wall motion
abnormalities and no signs of right ventricular strain.
Subsequent CT, pulmonary angiogram did not demonstrate any
evidence of pulmonary emboli either.
.
3. End-stage renal disease/hemodialysis. Initiation of
hemodialysis was performed via her AV fistula. However, this
was complicated by laceration of her fistula requiring repair by
transplant surgery in the operating room. She subsequently
developed a tight stenosis in her fistula, which necessitated
repair by interventional radiology with angioplasty. This
repair was again complicated by laceration, but was stabilized
with balloon tamponade. Her hematocrit was monitored
subsequently and noted to be stable. However, she had
persistent swelling and ecchymoses of her right upper extremity.
She subsequently underwent placement of a temporary
hemodialysis catheter and started hemodialysis via this catheter
on a Monday, Wednesday, and Friday schedule. She underwent
several sessions of hemodialysis uneventfully, prior to her PEA
arrest at dialysis on [**2139-1-26**].
.
4. Aspiration pneumonia. The patient developed a fever and was
found to have developed a nosocomial aspiration pneumonia that
was treated with vancomycin and Zosyn for a period of ten days.
Given her continued aspiration, she was maintained n.p.o. and
had tube feeds delivered via a nasogastric tube. However, the
patient self-discontinued her nasogastric tube twice and was
unable to take medications p.o. given her mental status. A PEG
tube was placed and tube feeds delivered via her PEG.
.
5. Atrial fibrillation. The patient was noted to have new
onset atrial fibrillation during this hospitalization with
occasional episodes of rapid ventricular response with
occasional hypotension. She was loaded with amiodarone for
rhythm control with reversion to sinus rhythm. However, in the
setting of losing enteral access, and not receiving amiodarone,
reverted back to atrial fibrillation. Transthoracic
echocardiogram demonstrated normal ejection fraction. Use of
nodal agents including calcium channel blockers and beta
blockade were limiting given her hypotension. Anticoagulation
was not initiated in the setting of her recent hematoma from her
AV fistula.
.
6. Coagulase negative staph bacteremia. Two sets of blood
cultures grew different strains of coagulase negative
staphylococcus. This was felt to most likely represent a
contaminant, and felt unlikely to be the cause of her
hypotension. However, she completed a 12-day course of
vancomycin. Transthoracic echocardiography did not demonstrate
any evidence of valve vegetations. Her tunneled hemodialysis
catheter was left in place, as these positive blood cultures
were not felt to represent bacteremia.
.
7. Hypothyroidism. She has continued on her dose of Synthroid.
This was given intravenously when she did not have enteral
access.
.
8. Anemia. Her baseline hematocrit was noted to be between 29
and 30. Iron studies were consistent with mixed iron deficient
and anemia of chronic disease etiology. Her anemia of chronic
disease was felt to be secondary to end-stage renal disease.
She was continued on iron supplementation and erythropoietin
given at dialysis. She required multiple blood transfusions in
the setting of her AV fistula bleed, as described above.
.
9. Access. She had a right brachial AV fistula, right
subclavian hemodialysis line placed on [**2139-1-8**], and
peripherally inserted central catheter line, and PEG tube.
.
10. FEN. As described above, she was unable to take p.o. in
the setting of decreased alertness. A PEG tube was subsequently
placed on [**2139-1-23**] and tube feeds administered via this PEG.
An H. pylori antibody was sent as recommended by the
gastroenterology consult service.
.
11. Communication was with her [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 2617**], her
healthcare proxy at [**Telephone/Fax (1) 31754**] and [**Telephone/Fax (1) 31755**].
Medications on Admission:
1. Epo 1000 units every Monday, Wednesday, and Friday.
2. Risperdal 0.5 mg q.h.s.
3. Levothyroxine 175 mcg daily.
4. Calcitriol 0.5 mcg every other day.
5. Torsemide 20 mg daily.
6. Bupropion SR 150 mg b.i.d.
7. Metoprolol 25 mg b.i.d.
8. Fluoxetine 10 mg daily.
9. Iron supplementation 325 mg daily.
10. Bicitra 15 mL b.i.d.
11. Cefpodoxime 200 mg daily (started [**2139-1-3**] to complete a
14-day course).
12. Senokot b.i.d.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
1. Right brachiocephalic fistula laceration and repair.
2. End-stage renal disease.
3. Aspiration pneumonia.
4. Atrial fibrillation.
5. Ulcerative colitis, status post ileostomy.
6. Morbid obesity.
Discharge Condition:
Expired
Completed by:[**2139-3-10**]
|
[
"584.9",
"599.0",
"287.5",
"578.9",
"280.0",
"996.73",
"403.91",
"518.5",
"276.51",
"507.0",
"427.31",
"585.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"38.95",
"88.49",
"96.6",
"38.93",
"96.72",
"39.95",
"96.04",
"43.11",
"39.50",
"39.42"
] |
icd9pcs
|
[
[
[]
]
] |
14449, 14464
|
7210, 13959
|
310, 591
|
14705, 14743
|
2604, 7187
|
1770, 1788
|
14485, 14684
|
13985, 14426
|
1803, 2585
|
220, 272
|
619, 1216
|
1238, 1670
|
1686, 1754
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,664
| 109,248
|
7291
|
Discharge summary
|
report
|
Admission Date: [**2151-10-13**] Discharge Date: [**2151-10-15**]
Date of Birth: [**2086-8-10**] Sex: M
Service: MEDICINE
Allergies:
All drug allergies previously recorded have been deleted
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization with balloon angioplasty of a previously
placed drug eluting stent.
History of Present Illness:
65 year old Male with a history of HTN, HL, CAD s/p NSTEMI with
DES placed to LAD in [**2150-1-6**], who presented with chest pain
since 9 am this morning. Patient was driving to doctor's
appointment and experienced diaphoresis, heart burn then left
sided chest discomfort. Per wife patient "passed out" for a
couple of minutes. Patient asked for help at [**Hospital Ward Name 23**] Center and
was consequently sent to ED. Patient denies nausea or shortness
of breath.
.
Of note, patient has been taking ASA consistently, even during
knee surgery and melanoma excision over the past year. He
stopped his plavix in [**Month (only) 956**] per recommendation of his
cardiologist.
.
In ED, initial vitals were 97, HR 78, bp 100/85, rr 18, o2 sat
98% nrb. In ED patient received Plavix 600 mg load, Heparin
bolus, Integrillin bolus and morphine. EKG demonstrated
anterior/lateral STE. Patient was taken to cath lab which
demonstrated in stent thrombus of LAD. Mechanical aspiration,
thrombectomy, and angioplasty were performed. Patient was
hemodynamically stable and admitted to CCU for further
monitoring.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
.
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.
Past Medical History:
1. CARDIAC RISK FACTORS: - Diabetes, + Dyslipidemia, +
Hypertension
2. CARDIAC HISTORY:
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI in [**2150-1-6**] s/p
stent to LAD
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
1. Hodgkin's lymphoma treated in [**2128**] at [**Hospital6 1130**] with radiation therapy to his mediastinum, and
chemotherapy. He is also status post splenectomy during the
staging workup for his disease.
2. R plantar invasive melanoma s/p excision, R femoral sentinel
lymph node biopsy, with split-thickness skin graft on [**2151-10-7**]
3. Coronary artery disease status post non-ST elevation MI
followed by an LAD stent in [**2150-1-6**].
4. Status post left knee surgery in [**2151-5-7**].
5. Status post left shoulder surgery x2 once for a rotator cuff
repair and second time for labral repair.
6. Herniorrhaphy for ventral hernia in [**2142**].
Social History:
He owns and operates an auto/truck body shop
with his son. [**Name (NI) **] is married and lives with his wife of 37 years.
They have 3 children. He is a lifetime nonsmoker. He rarely
drinks alcohol and states he drinks perhaps 1 time per month.
Family History:
His father died at age 55 from complications of
sarcoma. His mother died at age 62 from leukemia. He has a
69-year-old brother who is alive and well. He has no family
history of melanoma.
Physical Exam:
VS: T=36.4 BP=116/64 HR=77 RR=14 O2 sat=95%
GENERAL: 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: JVP not elevated.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Pertinent Results:
[**2151-10-13**] 10:03AM PT-11.5 PTT-22.7 INR(PT)-1.0
[**2151-10-13**] 10:03AM PLT COUNT-396
[**2151-10-13**] 10:03AM NEUTS-66.3 LYMPHS-26.4 MONOS-4.9 EOS-1.8
BASOS-0.5
[**2151-10-13**] 10:03AM WBC-12.8* RBC-4.68 HGB-14.4 HCT-42.2 MCV-90
MCH-30.8 MCHC-34.1 RDW-14.8
[**2151-10-13**] 10:03AM CALCIUM-9.5 PHOSPHATE-3.1 MAGNESIUM-2.3
[**2151-10-13**] 10:03AM CK-MB-3
[**2151-10-13**] 10:03AM cTropnT-<0.01
[**2151-10-13**] 10:03AM CK(CPK)-116
[**2151-10-13**] 10:03AM GLUCOSE-169* UREA N-18 CREAT-1.4* SODIUM-135
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-21* ANION GAP-19
[**2151-10-13**] 06:17PM PLT COUNT-364
[**2151-10-13**] 06:17PM WBC-14.9* RBC-4.32* HGB-13.0* HCT-39.5*
MCV-91 MCH-30.1 MCHC-32.9 RDW-14.5
[**2151-10-13**] 06:17PM CALCIUM-9.0 PHOSPHATE-3.9 MAGNESIUM-2.3
[**2151-10-13**] 06:17PM CK-MB-73* MB INDX-7.4* cTropnT-2.00*
[**2151-10-13**] 06:17PM CK(CPK)-993*
Cardiac Cath [**10-13**]
COMMENTS:
1. Selective coronary angiography of this left dominant system
demonstrated one vessel CAD. The LMCA, LCX and nondominant RCA
was
without significant angiographic disease. The LAD had a 95% in
stent
occlusion with extensive thrombus.
2. Right heart catheterization post-intervention demonstrated
mild
systemic arterial hypotension (95/50 mmHg) with normal pulmonary
arterial pressures (31/14/23 mmHg) and mildly elevated right and
left
sided filling pressures (mean RAP 11 mmHg, RVEDP 13mmHg, mean
PCWP
13mmHg). Cardiac index was preserved at 3.5L/min/m2. Left
ventriculography was deferred.
3. Successful manual and mechanical aspiration thrombectomy and
PTCA
were performed in the mid-LAD. Intravascular ultrasound showed
good
expansion of the prior stent without areas of flow-limiting
stenoses.
Final angiography showed normal flow, no apparent dissection,
and a 10%
residual stenosis. (See PTCA comments.)
FINAL DIAGNOSIS:
1. One vessel coronary artery disease.
2. ST elevation myocardial infarction.
3. Thrombectomy and PTCA of the mid-LAD.
4. Preserved cardiac index.
TTE [**10-14**]
The left atrium is mildly dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). However, there is focal hypokinesis of the
midventricular segment of the anterior septum. 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
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The left ventricular inflow
pattern suggests impaired relaxation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
Compared with the findings of the prior study (images reviewed)
of [**2150-3-10**], left ventricular function remains preserved.
Brief Hospital Course:
65 year old M p/w anterior STEMI found to have re-stent thrombus
of mid LAD.
.
# CORONARIES: Anterior STEMI found to have re-stent thrombus of
mid LAD s/p PTCA. Patient's Metoprolol dose was increased, and
patient was discharged on ASA, simvastatin, Metoprolol,
Valsartan, and Plavix [**Hospital1 **] for 2 months, then daily for life.
Cardiac enzymes peaked at CK 73* CkMB 7.4* Trop 2.00* then
down-trended.
.
# PUMP: Echo from [**2150-3-7**], shows normal EF. TTE [**10-14**] showed
EF 70% with midventricular hypokinesis of anterior septum.
Patient was euvolemic in-house, continued on Metoprolol at
increased dose, as above.
.
# Elevated Cr: Cr 1.4 on admission, improved to 0.9. Most
likely hypoperfusion in the setting of ISRS.
.
# R plantar melanoma s/p excision and LN biopsy: General surgery
consulted in the ED, followed patient during his stay. LN biopsy
negative, communicated to patient by surgery team. Wound
dressing changed, f/u appointment with Dr. [**Last Name (STitle) 519**] as an
outpatient.
.
# s/p splenectomy: Patient prescribed one month of Bactrim
starting [**10-5**] for prostatitis. Continued abx in-house.
Medications on Admission:
Metoprolol XR 25 mg po daily
Nitroglycerin 0.4 mg SL PRN CP
Simvastatin 40 mg po daily
Tamsulosin [Flomax] 0.4 mg po qhs
Trimethoprim-Sulfamethoxazole 800 mg-160 mg Tablet
1 Tablet(s) by mouth [**Hospital1 **] x 30 days [**2151-10-5**]
Valsartan [Diovan] 80 mg po daily
Aspirin 325 mg po daily
Omega-3 Fatty Acids [Fish Oil]
Discharge Medications:
1. Wheelchair Device Sig: One (1) Miscellaneous once a day:
Wheelchair with elevated leg rests.
Disp:*1 device* Refills:*0*
2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
5. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day).
6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*11*
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
8. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: 1-3 tablets
Sublingual every 5 mintues x3 [**Year (4 digits) 4319**] only: call 911 if you still
have chest pain after 3 nitroglycerin tablets.
Discharge Disposition:
Home
Discharge Diagnosis:
ST Elevation Myocardial Infarction
Hypertension
Hyperlipidemia
Plantar melanoma
Discharge Condition:
stable.
Discharge Instructions:
You had a heart attack because the stent clotted off. Your heart
pumping function continues to be normal despite the heart
attack. You will be on Plavix twice daily for 2 months and then
daily therafter. Do not miss [**First Name (Titles) 691**] [**Last Name (Titles) 4319**] or stop taking Plavix
unless your cardiologist tells you to. You should also take a
full 325mg aspirin every day for the rest of your life. You will
need to follow up with Dr. [**Last Name (STitle) **].
.
Medication changes:
1. We increased your Metoprolol Succinate (long acting version)
to 50 mg daily
2. Plavix increased to twice daily for at least two months
3. Increase Simvastatin to 80 mg daily
.
Please call Dr. [**Last Name (STitle) **] if you have any chest pain, trouble
breathing, nausea, fatigue or dizziness, severe headache, dark
stools or any other concerning symptoms.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 519**] on [**2151-10-20**] at 1:45PM in his
clinic. ([**Telephone/Fax (1) 22135**].
Primary Care:
[**Last Name (LF) 10531**],[**First Name3 (LF) **] R. Phone: [**Telephone/Fax (1) 9347**] Date/Time:
Urology:
Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2151-10-30**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8941**], MD Phone:[**Telephone/Fax (1) 4537**]
Date/Time:[**2151-11-30**] 8:15
Cardiology:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/Time: [**2151-11-10**] at
11:40am.
|
[
"V87.41",
"414.01",
"272.4",
"V10.82",
"412",
"V45.82",
"410.11",
"401.9",
"V10.79",
"V45.79"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.20",
"88.56",
"37.22",
"00.66",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
9820, 9826
|
7254, 8394
|
330, 424
|
9950, 9960
|
4332, 6180
|
10870, 11545
|
3269, 3461
|
8771, 9797
|
9847, 9929
|
8420, 8748
|
6197, 7231
|
9984, 10465
|
3476, 4313
|
2185, 2295
|
10485, 10847
|
280, 292
|
452, 2075
|
2326, 2987
|
2097, 2165
|
3003, 3253
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,716
| 100,206
|
12700
|
Discharge summary
|
report
|
Admission Date: [**2115-9-20**] Discharge Date: [**2115-10-16**]
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Ultram / Ether
Attending:[**First Name3 (LF) 7141**]
Chief Complaint:
abdominal pain, transfer from OSH for further care
Major Surgical or Invasive Procedure:
PICC line placement
CT guided abdominal Biopsy
Exploratory laparotomy
Resection of pelvic mass
lymph node dissection
Small bowel resection and anastomosis
Cystectomy
Ileo-conduit placement
Omentopexy
Sigmoidoscopy
11 units blood transfusion and 1 unit FFP transfusion
ICU admission x 2 for hypotension and hemolytic transfusion
reaction.
History of Present Illness:
HPI: Ms [**Known lastname **] presents with her daughter with 3 month
history
of worsening nausea, weight loss and decreased appetite. She was
initially evaluated and admitted to [**Hospital 1474**] hospital [**Date range (1) 39208**]
after she fell on her back after slipping on a wet surface. On
arrival, she was also found to have nausea and abdominal pain at
which time a pelvic mass was discovered on exam. She underwent
CT
evaluation and received IVF and pain meds. Her abdominal and
back
pain improved with vicodin and darvocet. Following her discharge
on [**9-13**], she was informed by her PCP Dr [**Last Name (STitle) 3314**] that this was
likely an ovarian malignancy but that she should undergo
colonoscopic evaluation. She started the prep with Golytely but
felt so awful during this, that she declined to actually undergo
colonoscopy.
.
Patient came to [**Hospital1 18**] for further care. Continues to experience
abdominal pain, confirmed to have a large pelvic mass, 16cm, and
small lesions in liver (cannot characterize) and uncinate
process. Pathology consistent with either GYN primary (ovarian)
vs Renal.
.
Per Med consult, she has a history of angina (but has not had to
use NTG for the past few months). She is able to do all ADLs and
walk around a mall without CP or SOB. Denied any recent RVR
episodes or CHF hospitalizations (maintained on 40mg [**Hospital1 **] of
lasix). Previous cardiac catheterization >2 yrs ago, but no
interventions were done.
No Hx of MI. No DM.
.
Per family, prior to admission had lost some weight w/ decreased
energy. Also, no bowel movement in 10 days. Otherwise ROS neg.
Past Medical History:
CHF (EF 55% on echo several years ago)
Mitral regurgitation
Afib on pacemaker
osteoporosis
hypothyroid
PSH: TAH-BSO (40 years ago for unclear reasons and daughters
were
not entirely sure whether both ovaries were removed at the
time),
pacemaker placement in [**2112**]
Social History:
Remote smoking hx. no etoh. Lives
independent and driving previously. Several children live
nearby.
Family History:
No hx of colon, breast, ovarian CA
Mother had hodgkin's disease
Father had oral cancer with mets.
Physical Exam:
At time of admission:
98.2 75 120/61 16 95%RA
Lying in bed, appears mildly uncomfortable
Gen: A&O x 3. Gait not inspected. Answers questions
appropriately.
HEENT: no thrush, no [**Doctor First Name **]
Breasts: no [**Doctor First Name **], no masses, no nipple discharge or inversion
LUNGS: CTAB
CVS: RRR, no murmurs
Back: tenderness elicited at the level of lumber spine along
bony
processes. No bruising seen.
ABD: moderately distended, tympanic to percussion in RUQ/LUQ,
dull to percussion in RLQ/LLq. Firm, non-mobile mass in lower
quadrants tender to palpation but no rebound or guarding. +BS.
RECTAL: deferred (guaiac neg per ED resident)
BIMANUAL: deferred (pt uncomfortable at the time)
LE: 1+ pitting edema up to mid-calf in LLE. No palpable cord or
tenderness. Ecchymosis along medial aspect of right knee and
shin
mildly tender to palpation. [**4-27**] motor strength with hip and knee
flexion/extension. No limited ROM of kness bilaterally. No
effusion or swelling of knees bilaterally.
Pertinent Results:
STUDIES:
PATHOLOGY: Procedure date Tissue received Report Date
Diagnosed by
[**2115-10-2**] [**2115-10-2**] [**2115-10-10**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/lo??????
Previous biopsies: [**-6/3848**] ABDOMEN BX.
DIAGNOSIS:
Pelvic mass resection:
I. Pelvic mass (A-E):
Epithelioid malignant mesothelioma (see note).
II. Lymph node, left external iliac (F-H):
No malignancy identified (0/2) nodes.
III. Segment of bladder dome (I and Z):
Malignant mesothelioma involving bladder wall and undermining
the mucosa.
The tumor does not appear to arise from bladder mucosa and no
in-situ carcinoma is seen.
IV. Peritoneal tumor (J):
Malignant mesothelioma in adipose tissue.
V. Bladder, vagina, and pelvic mass (K-R, X-Y):
Malignant mesothelioma extending into vagina and bladder walls.
The tumor does not appear to arise from the vaginal or bladder
mucosa and no precursor lesion is seen.
VI. Segment of small bowel (S-T):
Malignant mesothelioma involving serosa of small intestine of
bowel.
The tumor does not arise from the bowel mucosa and no precursor
lesion is seen.
VII. Omentum (U-W):
Malignant mesothelioma.
[**10-11**] CXR:
REASON FOR EXAM: Assess for pleural effusions and pulmonary
edema. Patient S/P surgery.
Comparison is made with prior studies including most recent one
dated [**2115-10-10**].
Cardiomediastinal contour is unchanged. Right transvenous
pacemaker leads terminate in standard position in the right
atrium and right ventricle. There is no CHF. There is minimal
vascular engorgement which is stable. Blunting of the left
lateral costophrenic angle with adjacent lung opacity is
unchanged, due to small pleural effusion with adjacent
atelectasis.
[**10-10**]: LENIs
FINDINGS: Grayscale and color Doppler imaging of the common
femoral, superficial femoral, and popliteal veins were performed
bilaterally. Normal compressibility, flow, waveform, and
augmentation is demonstrated. No intraluminal thrombus is
identified.
IMPRESSION: No evidence of DVT.
[**10-8**] LENIs
RIGHT LOWER EXTREMITY VENOUS ULTRASOUND: [**Doctor Last Name **]-scale and Doppler
son[**Name (NI) 1417**] of the right common femoral, superficial femoral, and
popliteal veins were performed. Normal compressibility,
augmentation, flow, and waveforms were demonstrated. There is no
evidence of intraluminal thrombus.
.
CT [**2115-10-9**]
IMPRESSION:
1. New small bilateral pleural effusion with associated
atelectasis (left greater than right).
2. Small amount of ascites which has slightly increased in size
since the prior study.
3. Pelvic loculated fluid collection that may represent an
organizing postoperative fluid collection/ hematoma.
Alternatively, less likely, this may reflect residual
tumor.There is a 3.7 x 4.2 cm cystic collection in the left
aspect of the pelvis (series 2, image 6 and 7). This collection
has a faint peripheral hyperdense rim that may reflect an
organizing postoperative fluid/hematoma. Although no frank
pocket of gas are seen within the fluid collection, a
superimposed infection cannot be excluded. Alternatively, this
may be related to residual tumor.
4. No evidence of colitis, free air, pneumatosis or bowel
obstruction.
CT Scan Pelvis [**2115-9-19**]
IMPRESSION:
1. Large heterogeneous, lobulated pelvic mass seen, most likely
of gynecological origin. Patient recalls history of TAH/BSO,
however, prior records not available at time of dictation. Less
likely considerations include lymphoma (although very unlikely
given no lymphadenopathy identified elsewhere), or bladder
origin.
2. Marked extrinsic compression of sigmoid colon, without
evidence of obstruction.
3. Right sided hydronephrosis and proximal hydroureter.
4. Small hypoattenuating lesions seen within the liver.
Metastases cannot be excluded.
6. Compression fracture of L1, of [**Last Name (un) 5487**] chronicity.
7. Poorly defined low attenuation lesion in uncinate process of
pancreas, incompletely evaluated on this study. Primary versus
secondary neoplasm suspected.
Brief Hospital Course:
#Pelvic Mass: On [**2115-9-19**] the patient was admitted to [**Hospital 61**] to be evaluated by surgical and gynecological services.
Abdominal CT scan showed - 15.9 x 14.2 x 15.9 cm mass ,
incompletely encasing sigmoid colon. Small amount of oral
contrast seen passing through sigmoid colon. Mild dilation of
colon proximal to mass. Given the involvement of the sigmoid
colon, the patient was admitted to the General Surgery team for
possible surgical resection. On [**9-24**], a CT guided biopsy was
performed which showed features suggestive of an unusual ovarian
adenocarcinoma. The staining pattern suggests clear cell
carcinoma of the ovary, or possibly metastatic endometrial
carcinoma. Adrenal, renal or colonic origin are unlikely.
Mesothelioma is unlikely, but cannot be entirely excluded based
on the available information.
Given the pathology findings, the patient was transferred to the
GYN ONC service for further management.
The patient underwent exploratory laparotomy, pelvic mass
resection and cystectomy with ileoconduit placement by Drs [**First Name8 (NamePattern2) **]
[**Name (STitle) 1022**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**] on [**10-2**]. Please see operative note for
details. The patient was admitted to the ICU postoperatively
given 2 minutes of hypotension during surgery.
#Nutrition/GI:
Preoperatively, a PICC line was placed for TPN given minimal PO
intake. Postoperatively, the patient's TPN was restarted.
TPN was restarted following surgery. Nutrition consult
following. The patient passed flatus and bowel movement
postoperatively; her diet was advanced to regular. TPN continued
until time of discharge due to limited PO intake. The patient
refused TPN at time of discharge.
The patient underwent a sigmoidoscopy which revealed normal 15cm
but unable to advance scope due to insufficient bowel cleansing.
#ID:
The patient was started on Flagyl/Keflex postoperatively for
empiric treatment given extent of surgery.
-Pseudomonas infection: Postoperatively, her WBC was noted to
double from 12 to 25. Peak WBC 39 while in the ICU. Blood
cultures, JP fluid cultures, urine culture from ileo-conduit and
wound culture were obtained. Pan-sensitive pseudomonas returned
in urine, wound and JP drainage. An ID consult recommended IV
and PO vancomycin and Zosyn. A CT scan was performed which
demonstrated a post operative fluid collection vs hemotoma vs.
organizing infection. An interventional radiology consult stated
that the fluid was not-amenable to drainage. As the patient's
WBC improved with IV antibiotic treatment and the patient
remained afebrile, further surgical management was not pursued.
Her antibiotics were narrowed to Zosyn IV. The patient was to
receive PICC line IV treatments for total 14 days following
discharge. Her WBC was normal at time of discharge. A repeat
urine culture pending at time of discharge; but no bacteria
present on urinalysis.
#Respiratory: The patient was extubated on postoperative 2. The
patient remained on room air. A CT scan on [**9-27**] was performed to
evaluate for pulmonary metastasis; this workup was negative.
The patient experienced acute dyspnea on postoperative day 9
during a blood transfusion. She received 2 doses of albuterol
nebulizers; she desaturated to 89% room air. She needed minimal
oxygen support upon her readmission to the ICU. She was
discharged on room air.
#Heme:
The patient's HCT was followed closely. The patient received 9
units of blood during surgery and her initial postoperative stay
to keep her HCT above 25. On postoperative day 9, the patient's
hematocrit was noted to be slowly dropping from 28 -> 26 -> 23.
It was unclear the cause of the hematocrit drop: slow bleeding
from operative site vs hematoma. The patient was transfused [**12-25**]
unit of blood before hemolytic reaction occurred (see below).
This blood transfusion was discontinued immediately. During her
2nd ICU stay, the patient received 2 additional pRBC units that
were screened by the Blood Bank after consultation with the
transfusion fellow. Her postoperative HCT remained stable daily
after the hemolytic reaction (bewlow) at 29-30.
-Hemolytic Reaction: The patient experienced an acute hemolytic
reaction manifested by acute onset of dyspnea on postoperative
day 9. This unit of blood was discontinued immediately. She
received 2 doses of Albuterol nebulizer treatment. She received
25 mg Benadryl, 40 mg Lasix IV and 20 mg proton pump inhibitor.
Due to the patient's acute pulmonary distress and elevated
respiratory rate to 40, a code Blue was called to facilitate any
need for possible intubation. No intubation or cardiac
resuscitation was needed. A transfusion fellow consult was
called stat. A repeat type and screen found a JKA antibody in
the patient's blood. The patient was transferred to the ICU for
further monitoring.
#Cardiac: The patient was noted to be in atrial fibrillation
prior to surgery. The patient was rate controlled prior to
surgery with Metoprolol and Diltiazem in the 80s-90s. She was
followed on telemetry. A medicine consult was called
preoperatively for assessment of her cardiac function. Prior
cardiac evaluation was obtained from her PCP documenting an
ejection fracture of 55% on recent Echo and 65% on recent stress
test.
Following surgery, postoperative cardiac enzymes were negative x
3.
-Hypotension: Occurred intraoperatively for which the patient
was placed on 2 pressors which were weaned off in the ICU. The
patient maintained a MAP of 65 per A-line. All pressors were
discontinued by time of ICU discharge and Metoprolol was
restarted.
-Atrial Fibrillation: The patient was maintained on telemetry
and rate controlled with Metoprolol in the 80s-90s. She was
restarted on her Coumadin when tolerating adequate PO on
postoperative day 11.
.
# Pain: Patient had high level of post-operative pain treated
with morphine PCA which was transitioned to PO due to patient
somnolence. Patient able to wean off pain medications and as of
[**10-9**] required minimal PO medications.
.
# Coagulopathy: INR elevated following surgery to 1.6 attributed
to multiple transfusions intraoperatively. The patient responded
well to one unit of FFP with INR 1.2. INR trended to 1.0
spontaneously prior to discharge. INR followed daily following
restart of Coumadin. INR 1.1 at time of discharge. VNA to follow
INR daily upon discharge.
.
# Hypothyroidism: levothyroxine continued
.
# Prophylaxis: PPI, sc heparin, aspiration precautions,
pneumoboots when patient accepted.
.
# Code: Full, confirmed w/ HCP
#Dispo: Patient discharged on [**10-16**] with VNA services, ostomy
care, and follow up with Urology, INR checks to be followed by
PCP, [**Name10 (NameIs) 39209**] and Thoracic oncology.
Medications on Admission:
coumadin 2-5mg
cardizem 240
atenolol 25
synthroid 150mcg
furosemide 40 qd
Discharge Medications:
1. Simvastatin 40 mg Tablet [**Name10 (NameIs) **]: One (1) Tablet PO DAILY
(Daily).
Disp:*50 Tablet(s)* Refills:*2*
2. Latanoprost 0.005 % Drops [**Name10 (NameIs) **]: One (1) Drop Ophthalmic HS (at
bedtime).
Disp:*qs bottles* Refills:*2*
3. Docusate Sodium 100 mg Capsule [**Name10 (NameIs) **]: One (1) Capsule PO BID (2
times a day) as needed.
Disp:*60 Capsule(s)* Refills:*2*
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
5. Acetaminophen 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q6H (every
6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
6. Salmeterol 50 mcg/Dose Disk with Device [**Last Name (STitle) **]: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
Disp:*60 Disk with Device(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY 10AM ().
Disp:*50 Tablet(s)* Refills:*2*
9. Nystatin 100,000 unit/mL Suspension [**Last Name (STitle) **]: Five (5) ML PO TID
(3 times a day) for 5 days.
Disp:*75 ML(s)* Refills:*0*
10. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1) Intravenous Q8H (every 8 hours) for 5 days.
Disp:*qs piggyback* Refills:*0*
11. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*60 Tablet(s)* Refills:*0*
12. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
13. Xanax 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime.
Disp:*60 Tablet(s)* Refills:*0*
14. Codeine Sulfate 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H
(every 4 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
15. Levothyroxine 150 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*2*
16. picc line care [**Last Name (STitle) **]: One (1) once a day: PICC line care
[**First Name8 (NamePattern2) **] [**Last Name (un) 6438**] protocol .
Disp:*1 1* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Partners [**Name (NI) **] [**Name2 (NI) **]
Discharge Diagnosis:
Primary Diagnosis:
-Peritoneal mesothelioma
-L1 compression fracture
-Acute hemolytic reaction
-Pseudomonas infection
Secondary Diagnoses:
-Afib with pacemaker
-CHF
-COPD
-Osteoporosis
-Hypothyroid
Discharge Condition:
Tolerating some regular diet, afebrile, normal white blood cell
count, ambulating. Pain controlled. Voiding through
ileo-conduit.
Discharge Instructions:
Call Dr. [**First Name (STitle) 1022**] if: shortness of breath, fever > 100.4, abdominal
pain not relieved by medicine, chest pain, redness around
incision that is expanding, drainage from incision, diarrhea,
decreased urine output at your ostomy or concerns about your
ostomy.
No driving after surgery. Please have your daughters/son drive
you.
No heavy lifting for 6 weeks. No tub baths; you may shower. Do
not scrub your incision. Let the water run down over the
incision.
You may take Codeine for pain as prescribed
You may take a stool softener to keep bowels regular.
-Please take Levoquin 500 mg daily (1 tablet).
-Please continue:
-Coumadin 2.5 mg daily. Your Coumadin dosing will be checked by
the visiting nurse and your dose may be adjusted. Dr. [**Last Name (STitle) 3314**]
will follow the dosing.
-Levothyroxine 150 mcg
-Latanoprost eye drops
-Metoprolol 25 mg three times a day
-Nystatin swish/swallow three times a day x 3 days
-Zosyn (IV antibiotic) 5 days three times a day
-Salmeterol inhaler twice a day
-Zocor 1 tablet daily for high cholesterol
-Xanax 1 tablet at night to help sleep
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 7613**], MD Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2115-10-24**] 10:45am
[**Location (un) **] [**Hospital Ward Name 23**] Center
Thoracic Oncology
[**10-29**] 3pm Dr. [**First Name (STitle) **] [**Name (STitle) **]
[**Location (un) **] [**Hospital Ward Name 23**] Building
[**0-0-**]
Dr. [**Last Name (STitle) 365**], Urology
[**11-6**] at 12 noon
[**Hospital1 9384**] (across from [**Hospital3 1810**] next to
[**Company 38877**]) [**Location (un) 448**]
([**Telephone/Fax (1) 6441**]
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,882
| 105,958
|
46479+58919
|
Discharge summary
|
report+addendum
|
Admission Date: [**2173-9-14**] Discharge Date: [**2173-9-17**]
Date of Birth: [**2103-11-27**] Sex: F
Service: SURGERY
Allergies:
A.C.E Inhibitors / Ativan / Ambien
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
malfunctioning hemodialysis fistula
Major Surgical or Invasive Procedure:
- attempted venoplasty and declotting of existing AV fistula
- placement of new left upper extremity AV graft
- placement of new tunneled perm cath for dialysis
History of Present Illness:
69 y/o F w/Right arm fistula placed 9 years ago was transferred
from referring hospital because of inability to undergo
hemodialysis on [**2173-9-13**]. Pt. also had K of 6.1 but denied any
palpitations, confusion, disoritentation, nausea/vomitting,
chest pain, shortness of breath. Pt. did c/o some lower
abdominal pain that resolved prior to arriving at this
institution.
Past Medical History:
multiple drug allergies, ACEI-cough, ativan, confusion w/ ambien
hx delirium in the hospital
hx Dm2
Hx ESRD on HD MWF
hx CAD, CHF, EF 40%
hx CVA
hx DVT
hx hyperhomocystenemia
hx microcytic anemia
hx refractory HTN requiring Hd
hx cervical spondylosis s/p C4-7 fusion
Social History:
She is widowed, lives with her son and daughter.
She ambulates with a cane.
She denies alcohol or tobacco use.
Family History:
CAD/MI
Physical Exam:
Vitals: T 98.8 P 88 BP 106/88 R 20 O2 100ra
Gen: Well developed, well nourished female in no acute distress
CV: RRR, no m/r/g appreciated
Chest: CTAB, no w/c/r appreciated
Abd: soft, non-tender, non-distended, normal active bowel sounds
Ext: wound clean/dry/intact and appropriately tender, +thrill,
no cyanosos/clubbing/edema
Pertinent Results:
[**2173-9-16**] 08:35AM BLOOD WBC-7.1# RBC-3.58* Hgb-11.7* Hct-35.8*
MCV-100* MCH-32.6* MCHC-32.6 RDW-17.5* Plt Ct-229
[**2173-9-14**] 10:00AM BLOOD Neuts-56.4 Lymphs-32.4 Monos-4.3 Eos-5.9*
Baso-0.9
[**2173-9-14**] 10:00AM BLOOD Hypochr-2+ Anisocy-2+ Poiklo-1+
Macrocy-2+
[**2173-9-16**] 08:35AM BLOOD Plt Ct-229
[**2173-9-16**] 08:35AM BLOOD Glucose-107* UreaN-37* Creat-8.5*# Na-142
K-4.6 Cl-101 HCO3-24 AnGap-22*
[**2173-9-14**] 10:00AM BLOOD ALT-11 AST-15 AlkPhos-67 Amylase-135*
TotBili-0.4
[**2173-9-14**] 10:00AM BLOOD Lipase-121*
[**2173-9-16**] 08:35AM BLOOD Calcium-9.7 Phos-4.9* Mg-2.0
[**2173-9-14**] 05:28PM BLOOD K-5.5*
Brief Hospital Course:
69 y/o F was admitted to [**Hospital1 18**] on [**2173-9-14**] for revision vs.
thrombectomy of right arm AV fistula. During the operation the
fistula was not able to be salvaged and a new graft was placed
in the left upper extremitiy. Please see the operative report
for further details. POD 1 Pt. had a tunneled perm cath placed
by interventional radiology so she could continue with dialysis.
This procedure went without difficulty. Pt. successfully
underwent HD later that day. Evening of [**2173-9-15**] pt. blood
pressure dropped to 80/60 and was given a small bolus of 250cc
ns. This blood pressure drop was believed to be secondary to
having 2.5L of fluid taken off during dialysis earlier in the
day. POD [**3-2**] pt. underwent another treatment of hemodialysis -
per renal b/c it had been quite and extended amount of time
between her prior treatments. Pt. tolerated hemodialysis well.
Pt. was afebrile during her stay, pain was controlled on oral
pain medications, and pt was tolerating a regular diet by POD 2
and pt. ready for discharge.
Medications on Admission:
- ASA qday
- plavix 75 qday
- amlodipine 10 qday
- isosorbide mononitrate 30 qday
- lipitor 40 qday
- metoprolol 100 [**Hospital1 **]
- protonix 40 qday
- renagel 800 tid
- sertraline 50 qday
- diovan 160 [**Hospital1 **]
- pyridoxine 50 qday
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6 hours prn as needed for for pain: Do not drive while taking
this medication.
Disp:*30 Tablet(s)* Refills:*0*
2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: -
please take while taking pain medications
- hold for diarrhea.
Disp:*20 Capsule(s)* Refills:*0*
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
5. Valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
10. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
- s/p attempted thrombectomy of existing AV fistula and
placement of new Left upper extrem AV graft
- chronic renal insufficiency
- diabetes mellitis
- s/p myocardial infarction (six years ago)
- peripheral vascular disease
- hypertension
- h/o deep venous thrombosis
- s/p right fem-pedal bipass ([**2173-8-10**])
- congestive heart failure w/EF 40%
- h/o ceberal vascular accident
Discharge Condition:
good
Discharge Instructions:
- Please resume all home medications
vomitting, pain in arm, erythema or purulent drainage from
wound, numbness or tingling in hand/arm, loss of strength in
hand/arm, signigicant swelling, loss of thrill, difficulty with
dialysis, or any other concern.
Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] at the [**Hospital 1326**] clinic.
Please call [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 15170**] at [**Telephone/Fax (1) 7207**] for an appointment.
Name: [**Known lastname **],[**Known firstname 2**] S Unit No: [**Numeric Identifier 15789**]
Admission Date: [**2173-9-14**] Discharge Date: [**2173-9-17**]
Date of Birth: [**2103-11-27**] Sex: F
Service: SURGERY
Allergies:
A.C.E Inhibitors / Ativan / Ambien
Attending:[**First Name3 (LF) 2648**]
Addendum:
this is an addendum from the prior summary because the pt. will
no longer be discharged to home but rather a long term care
facility.
POD 2 after dialysis the pt. had an episode of hyoptension to
80s/50s and she responded to a 250cc bolus with her pressures
raising to 90s/60s. The pt. was also very weak after her second
dialysis treament in two days. The decision was made to keep
the patient in house over night and to have PT evaluate her in
the morning to assess her safety and fall risk. POD3 PT came to
evaluate the patient and strongly recommended that the pt. go to
a rehab facility secondary to her deconditioning(unable to walk
only 20 feet) and instability on her feet. The felt some of her
instability was be related to her recent dialysis treatment,
however, she would greatly benefit from daily physical therapy
treatments and 24 hour care. During the day the patient
remained medically stable, afebrile, and willing to work with
rehab.
Please see previous summary for all other information.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2173-9-17**]
|
[
"428.0",
"250.00",
"996.73",
"403.91",
"414.01",
"458.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"39.95",
"39.42"
] |
icd9pcs
|
[
[
[]
]
] |
7191, 7429
|
2367, 3429
|
331, 494
|
5251, 5258
|
1708, 2344
|
5559, 7168
|
1334, 1342
|
3722, 4722
|
4845, 5230
|
3455, 3699
|
5282, 5536
|
1357, 1689
|
256, 293
|
522, 899
|
921, 1189
|
1205, 1318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,123
| 119,621
|
7940
|
Discharge summary
|
report
|
Admission Date: [**2189-10-13**] Discharge Date: [**2189-10-14**]
Date of Birth: [**2118-11-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine / Fluorescein / IV Dye, Iodine Containing
Contrast Media
Attending:[**First Name3 (LF) 2712**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a 70-year-old man with a complicated medical
history that includes ERSD with cadaveric renal transplant,
coronary artery disease with multiple interventions, sCHF with
ejection fraction of 20%, diabetes, hypertension,
hyperlipidemia, gout, spinal stenosis, atrial fibrillation who
recently underwent amputation of his second right toe, fifth
right ray and debridement of right heel who is presenting with
hypotension. The patient was discovered at his rehab facility
today to have reddening of the sclerae of his right eye. The
patient reports that he had a brief period of double vision in
the morning, but no other visual symptoms. He complains only of
irritation of the right eye at the moment. Because the patient
is anticoagulated, his nurse at the rehab facility was
concerned. An ambulance was called and the patient's [**First Name3 (LF) **]
pressure was discovered to be 70/40.
On appearance on the Emergency Department, the patient continued
to be hypotensive in the 70s and 80s, though mentating well. He
initially refused any central line, but was willing to accept
peripheral pressors, so he was started on norepinephrine. When
that was maximized and his [**First Name3 (LF) **] pressure had still not much
recovered, discussion was initiated and he accepted the
placement of a right IJ, at which point a second pressor,
phenylephrine, was added. He continued to require both pressors
in order to achieve an adequate [**First Name3 (LF) **] pressure.
Past Medical History:
- End-stage renal disease [**1-15**] diabetic nephropathy s/p cadaveric
renal transplant [**2180**],
- Coronary Artery Disease, s/p Non-ST Elevation Myocardial
Infarction, CABG, Multiple PTCA/stents, last being bare metal
stent to SVG-OM2 graft [**2189-8-24**].
- Congestive heart failure -EF 20% on TTE [**2188**]
- Chronic afib on Coumadin
- Hyperparathyroidism
- Diabetes-type II
- Hypertension
- Hyperlipidemia
- Gout
- HSV meningitis in [**2184**]
- Spinal stenosis
- Sciatica chronic back pain and left hip pain
- s/p AV fistula for HD
- Scalp seborrhea
Past Surgical History:
- cadaveric renal transplant [**2180**]
- CABG
- AV fistula for HD
Social History:
Lives in [**Location 2312**] with wife. (Has been in rehab since last
discharge.)
Has not been very active for the past 8 months due to his leg
ulcers.
He has 4 children.
Used to run a yacht charter company.
No smoking.
No significant alcohol use.
Family History:
Father died of MI in early 60s, brother died of MI age 53.
Mother with diabetes.
Physical Exam:
Admission physical exam:
Vitals: T: 97.8, BP: 132/79, P: 95, R: 18, O2: 92% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
hemorrhage in right eye
Neck: supple, no LAD
CV: Regular rate and rhythm, quiet heart sounds, S1, S2,
systolic murmur
Lungs: Clear to auscultation bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present
Ext: Left foot, first toe without nail but no exudate; right
foot, dry gangrene at site of 2nd toe, lateral foot where 5th
ray taken also blackened, but clean, dry, intact. Heel also
blackened but without erythema or exudate.
Neuro: CN III-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation
Pertinent Results:
Admission labs:
[**2189-10-13**] 01:20PM WBC-4.2 RBC-2.93* HGB-9.0* HCT-29.2* MCV-100*
MCH-30.7 MCHC-30.7* RDW-19.9*
[**2189-10-13**] 01:20PM NEUTS-66.0 LYMPHS-21.5 MONOS-9.9 EOS-2.1
BASOS-0.4
[**2189-10-13**] 01:20PM PLT COUNT-117*
[**2189-10-13**] 01:20PM ALBUMIN-2.7*
[**2189-10-13**] 01:20PM cTropnT-0.21*
[**2189-10-13**] 01:20PM LIPASE-8
[**2189-10-13**] 01:20PM ALT(SGPT)-7 AST(SGOT)-24 ALK PHOS-160* TOT
BILI-0.5
[**2189-10-13**] 01:20PM GLUCOSE-85 UREA N-41* CREAT-2.8* SODIUM-134
POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-28 ANION GAP-16
[**2189-10-13**] 01:31PM LACTATE-1.6
[**2189-10-13**] 02:38PM PT-25.6* PTT-39.2* INR(PT)-2.4*
[**2189-10-13**] 03:30PM URINE [**Month/Day/Year 3143**]-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
[**2189-10-13**] 03:30PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
[**2189-10-13**] 03:30PM URINE COLOR-Red APPEAR-Clear SP [**Last Name (un) 155**]-1.012
[**2189-10-13**] 03:30PM URINE HYALINE-12*
[**2189-10-13**] 04:37PM TYPE-[**Last Name (un) **] PO2-58* PCO2-54* PH-7.35 TOTAL
CO2-31* BASE XS-2 COMMENTS-GREEN-TOP
[**2189-10-13**] 07:01PM LACTATE-3.1*
[**2189-10-13**] 07:01PM O2 SAT-67
Imaging:
[**2189-10-13**] CXR:
IMPRESSION:
Left basilar opacity may reflect atelectasis but infection is
not excluded. Small left pleural effusion. Low lung volumes.
CT abdomen and pelvis:
IMPRESSION:
1. There is anasarca, bilateral pleural effusions, and
mild-to-moderate
ascites within the abdomen.
2. Atelectasis/ consolidation is seen at the lung bases,
improved from
previous.
3. Again appreciated is severe diffuse atherosclerosis involving
the aorta and all branch vessels. The native kidneys are
severely atrophic and the right lower quadrant renal transplant
appears unremarkable.
4. Sigmoid diverticulae. There is mottled gas pattern in the
sigmoid colon, favoured to represent air in diverticulae.
Pneumatosis is less likely. Clinical assessment is recommended.
Brief Hospital Course:
The patient is a 70-year-old man with a complicated medical
history that includes ERSD with cadaveric renal transplant,
coronary artery disease with multiple interventions, sCHF with
ejection fraction of 20%, diabetes, hypertension,
hyperlipidemia, gout, spinal stenosis, atrial fibrillation who
recently underwent amputation of his second right toe, fifth
right ray and debridement of right heel who is presenting with
hypotension. The patient's hypotension is of unclear etiology,
but was supected to be secondary to sepsis. He had not been
febrile or had a white count. He has a recent intervention to
his right foot that may be a possible site of infection,
although his wounds currently do not have obvious visual
evidence of infection. His urinalysis has small leuks and few
bacteria (but no pyuria). CXR and CT abdomen not suggestive of
specific He has been on longstanding prednisone. SVO2 not
suggestive of cardiogenic shock. Due to a CVP of around 30, no
additional fluids were provided. The patient was started on
broad-spectrum coverage with vancomycin, levofloxacin, and
aztreonam. (The patient once had an anaphylactic reaction to
penicillins.) He was also placed on [**Month/Day/Year **]-dose steroids.
[**Month/Day/Year **] Surgery was consulted, but intervention would likely
have been a below-the-knee amputation. On [**2189-10-14**] in the early
afternoon, the patient's pressor requirement suddenly increased.
He then developed a wide complex bradyarrhythmia with poor
perfusion and mottling of his appendages. In keeping with his
wishes against aggressive resuscitation, the patient's family
was informed of his grave prognosis. No additional pressor was
added, and the patient expired in the early afternoon of
[**2189-10-14**], likely secondary to a cardiac event caused by the
strain of his likely sepsis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY Start: In am
3. Fentanyl Patch 37 mcg/h TP Q72H
4. Calcitriol 0.25 mcg PO EVERY OTHER DAY
On odd days
5. Calcitriol 0.5 mcg PO EVERY OTHER DAY
On even days
6. Clopidogrel 75 mg PO DAILY Start: In am
7. PredniSONE 5 mg PO DAILY Start: In am
8. Simvastatin 40 mg PO DAILY Start: In am
9. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (MO,WE,FR)
MO, WE, FR
10. Tacrolimus 0.5 mg PO Q12H
11. Torsemide 60 mg PO DAILY
12. traZODONE 25 mg PO HS
13. Warfarin 2 mg PO DAILY16
14. Ciprofloxacin HCl 500 mg PO Q24H
15. MetRONIDAZOLE (FLagyl) 500 mg PO TID
16. Vancomycin 1250 mg IV HD PROTOCOL
17. Oxycodone-Acetaminophen (5mg-325mg) [**12-15**] TAB PO Q4H:PRN pain
18. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
19. Docusate Sodium 100 mg PO BID
20. Lisinopril 2.5 mg PO DAILY
21. Metoprolol Succinate XL 12.5 mg PO DAILY
Hold for SBP < 100, HR < 60.
22. sevelamer CARBONATE 800 mg PO TID W/MEALS
23. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
Patient expired.
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired.
Discharge Condition:
Patient expired.
Discharge Instructions:
Patient expired.
Followup Instructions:
Patient expired.
|
[
"785.52",
"414.00",
"443.9",
"995.92",
"V45.81",
"785.4",
"V49.72",
"707.14",
"V58.61",
"V49.86",
"274.9",
"372.72",
"038.9",
"E878.5",
"250.70",
"V58.67",
"997.69",
"252.00",
"V45.11",
"427.31",
"250.40",
"428.22",
"403.91",
"585.6",
"V45.82",
"996.81",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
8652, 8661
|
5697, 7530
|
353, 359
|
8721, 8739
|
3665, 3665
|
8804, 8823
|
2826, 2908
|
8611, 8629
|
8682, 8700
|
7556, 8588
|
8763, 8781
|
2475, 2543
|
2948, 3646
|
302, 315
|
387, 1868
|
3681, 5674
|
1890, 2452
|
2559, 2810
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,107
| 102,549
|
50019
|
Discharge summary
|
report
|
Admission Date: [**2140-3-28**] Discharge Date: [**2140-4-4**]
Date of Birth: [**2068-10-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 710**]
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
71 year-old M with esophageal Ca s/p recent lap esophagectomy
who presents with altered MS, intubated in ED for MRI to r/o
spinal cord process. History is obtained per chart, as
patient's wife is not reachable by telephone. She had reported
mental status changes and confusion starting yesterday. He also
had worsened abdominal pain. She denied any fever, chills,
diarrhea, or vomiting.
.
Of note, he had his J-tube changed in Dr.[**Name (NI) 1482**] office 2
weeks prior due to obstruction.
.
In the ED surgery was consulted to rule out surgical issues. A
foley was placed with 1 L of urine, with good relief of
abdominal pain. He received morphine 2mg IV x 2 and ativan 2 mg
IV. He also received levoflox 500 mg and flagyl 500 mg for
concern for GI pathology. Out of concern for spinal abscess or
cord compression, he underwent intubation with propofol and
fentanyl. Post-intubation he became bradycardic to 24 but
spontaneously resolved before atropine could be given. He also
vomited peri-intubation. He received 5L NS in total in the ED.
..
On exam he denies abdominal or back pain.
Past Medical History:
Past Medical History:
Esophageal CA
GERD/ Barrett's esophagus
Asthma
Left knee arthritis
Past Surgical History:
Tonsillectomy
Submandibular gland excision
Social History:
Married, works as a dentist; seven drinks per week, non-smoker
Family History:
Father and 2 half sisters with CAD
Physical Exam:
Vitals: T: 99.0 BP: 118/62 P: 79 RR: 14 SaO2: 99% on AC:
500/12/0.60/5
General: Opens eyes to voice, intubated, bites at ETT.
HEENT: NC/AT, PERRL, EOMI, sclera anicteric.
Neck: supple, no JVD, no cervical or supraclavicular LAD.
Pulm: decr breath sounds to left base, otherwise clear
anteriorly.
Cardiac: RRR, nl S1/S2, no M/R/G appreciated
Abdomen: soft, NT/ND, faint BS, no masses or hepatomegaly noted.
J-tube site erythematous, but without frank discharge,
fluctuance. well-healed laparoscopy scars.
Rectal: deferred
Ext: No edema b/t, 2+ DP pulses b/l.
Skin: xerosis, J-tube site as above.
Neurologic:
-mental status: intubated and sedated, but opens eyes to voice
and follows simple commands. in soft restraints
-cranial nerves: II-X grossly intact
-DTRs: [**Name2 (NI) **] Babinskis bilaterally.
Pertinent Results:
[**2140-3-28**] 06:52PM CK(CPK)-100
[**2140-3-28**] 06:52PM CK-MB-NotDone cTropnT-<0.01
[**2140-3-28**] 06:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2140-3-28**] 01:00PM URINE HOURS-RANDOM
[**2140-3-28**] 01:00PM URINE HOURS-RANDOM
[**2140-3-28**] 01:00PM URINE UHOLD-HOLD
[**2140-3-28**] 01:00PM URINE GR HOLD-HOLD
[**2140-3-28**] 01:00PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.027
[**2140-3-28**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
[**2140-3-28**] 09:54AM GLUCOSE-100 LACTATE-1.8 NA+-128* K+-3.9
CL--94* TCO2-25
[**2140-3-28**] 09:54AM HGB-13.5* calcHCT-41
[**2140-3-28**] 09:40AM GLUCOSE-108* UREA N-14 CREAT-0.6 SODIUM-128*
POTASSIUM-4.4 CHLORIDE-91* TOTAL CO2-29 ANION GAP-12
[**2140-3-28**] 09:40AM estGFR-Using this
[**2140-3-28**] 09:40AM ALT(SGPT)-20 AST(SGOT)-22 CK(CPK)-90 ALK
PHOS-148* AMYLASE-46 TOT BILI-0.5
[**2140-3-28**] 09:40AM LIPASE-69*
[**2140-3-28**] 09:40AM CK-MB-NotDone cTropnT-<0.01
[**2140-3-28**] 09:40AM TOT PROT-6.7 CALCIUM-9.4 PHOSPHATE-3.3
MAGNESIUM-2.1
[**2140-3-28**] 09:40AM WBC-7.5 RBC-4.24* HGB-12.6* HCT-36.7* MCV-87
MCH-29.7 MCHC-34.2 RDW-13.8
[**2140-3-28**] 09:40AM NEUTS-75.9* LYMPHS-12.7* MONOS-6.8 EOS-4.5*
BASOS-0.2
[**2140-3-28**] 09:40AM PLT COUNT-469*
[**2140-3-28**] 09:40AM PT-12.1 PTT-38.0* INR(PT)-1.0
Brief Hospital Course:
Assessment and Plan: 71 year-old M s/p recent lap esophagectomy
who presents with altered MS, intubated in ED for MRI to r/o
spinal cord process.
.
* Altered MS: In the emergency room, a Foley catheter was placed
upon arrival which found 1000cc urine. Due to urinary retention
and the patient's delirium and inability to follow commands,
there was concern for cauda equina vs. epidural abscess/mass.
The patient was intubated in the ED and transferred for an
emergent lumbar and sacral MRI. There were no abnormalities
found. The patient was transferred to the ICU intubated for
further management. A Head CT and UA were normal. Mild
hyponatremia was noted. A serum tox screen was negative. The
patient was afebrile with nl white count. Ambien and Celexa were
held. A surgery consult was obtained which determined that the
patient's Jtube site was not infected. The patient was extubated
and transferred to the medicine service on Hospital Day 2. He
was alert and oriented x 2, however he was noted to have slow
verbal response times but was overall alert and able to carry on
shortened conversation.
.
Upon transfer to the floor, the patient was noted to be
delirious. He was speaking Spanish and no longer speaking
English (English is primary language and has never spoken
spanish before according to his wife). A psychiatry and
neurology consult was obtained to which both thought that the
etiology of this language shift was likely acute delirium. The
patient had a 1:1 sitter. Blood cultures from admission returned
negative. A Head MRI was obtained which was negative for masses
or acute event.
.
The patient's delirium improved over time. Neurology felt that
there was no acute neurological issue that could cause this
language shift. Psychiatry believed that this language shift was
likely due to resolving delirium on top of longer-standing
depression and a new conversion disorder. Remeron was started.
.
Psychiatry continued to follow the patient closely; he improved
spontaneously and with the addition of Remeron. The patient was
discharged to home with an outpatient partial psych
hospitalization program set up.
.
* Hyponatremia: The patient was rehydrated in the ED with 5L NS
and the Na did not improve. TSH, cortisol were normal. Serum
osms were noted to be low indicating that there was excessive
ADH secretion. Fluid restriction to 1500cc per day corrected the
patient's hyponatremia. A nutrition consult was obtained and the
patient's tube feeds were changed to Nutren 2.0 for a more
concentrated formula with no free water. He was discharged on
this Nutren 2.0 formula. His sodium remained normal x 3 days at
the end of his hospitalization.
.
* Esophageal Ca s/p esophagectomy
The patient was continued on his Jtube feeds as above and his
outpatient regimen of isoprostol and carafate and prevacid and
lansoprazole. The patient tolerated small amounts of regular
food.
.
* Urinary Retention:
The patient failed two voiding trials; his Flomax was increased
to 0.8 and on the third voiding trial, he was able to void
spontaneously with this new increase in medication. The patient
did not receive any narcotics or any anti-cholinergics.
.
*Prophylaxis: PPI, SC heparin, bowel regimen
Medications on Admission:
misoprostol 100 mcg 4 x daily
Flomax 0.4 mg daily
Carafate 1 gram 4 x daily
Zantac syrup 150 mg [**Hospital1 **]
Prevacid 30 mg [**Hospital1 **]
Senna
Colace
Flovent 110 mcg 2 puffs [**Hospital1 **]
Albuterol p.r.n.
Celexa 40 mg daily
Ambien CR 6.25 mg QHS
Discharge Medications:
1. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
2. Albuterol 90 mcg/Actuation Aerosol [**Hospital1 **]: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
Disp:*1 inhaler* Refills:*0*
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
Disp:*30 * Refills:*2*
4. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 inhaler* Refills:*2*
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR PO BID (2 times a day).
Disp:*60 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
6. Mirtazapine 7.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO daily at
evening.
Disp:*30 Tablet(s)* Refills:*1*
7. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
8. Sucralfate 1 g Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a
day).
Disp:*120 Tablet(s)* Refills:*2*
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Last Name (STitle) **]: Two (2)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
Disp:*60 Capsule, Sust. Release 24 hr(s)* Refills:*2*
10. Zolpidem 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at bedtime)
as needed.
Disp:*40 Tablet(s)* Refills:*0*
11. Misoprostol 100 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDPCHS (4
times a day (after meals and at bedtime)).
Disp:*40 Tablet(s)* Refills:*2*
12. Nutren 2.0 Liquid [**Last Name (STitle) **]: 4.5 cans PO once a day: as
prescribed.
Nutren 2.0 or caloric equivalent in J tube.
Disp:*QS cans* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Delirium
Urinary retention
Possible Conversion Disorder / psychogenic amnesia
.
Secondary Diagnoses:
T2N0 Esophageal cancer; no evidence of metastasis on Head MRI
Asthma
Benign Prostatic Hyperplasia
Depression
Discharge Condition:
Stable; delirium resolved.
Afebrile.
Discharge Instructions:
You presented to the hospital because of confusion. You were
found to have a low sodium level. Your sodium level was
corrected with a new tube feeding formula. You had images of
your brain which did not find anything concerning. You had some
urinary retention which resolved.
.
2pm Tomorrow [**4-5**]:
[**Hospital6 **]
[**Hospital1 **], [**Location (un) 583**]
Floor [**Location (un) **] 6
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 100416**], Licensed Social Worker
[**Telephone/Fax (1) 104433**]
.
Continue with the current tube feedings (will be delivered
tomorrow by [**Last Name (un) 6438**]).
-2.0 calorie formula 4.5 cans per day.
45cc/hour for 24 hours/day
60cc/hour for 18 hours/day
90cc/hour for 12 hours/day
Do not increase beyond 90cc/hour on your pump.
If you feel distention, diarrhea, abdominal pain, decrease the
infusion rate on your pump.
You may continue to eat your regular diet as tolerated.
.
Please call your doctor if: confusion, delirium, fever, chest
pain, shortness of breath, urinary retention or other worrisome
signs.
.
Please keep Jtube site covered with gauze. You may change the
gauze every 2 days. Please apply bacitricin ointment with the
dressing changes. Call physician if increased redness or pus
seen at Jtube site.
.
Please continue your medications as prescribed. Please continue
Remeron at 7.5 mg every night. Your Flomax dose has increased to
0.8 mg. We have discontinued your Celexa.
Medications:
1. Lansoprazole Oral Disintegrating Tab 30 mg by mouth twice a
day
3. Acetaminophen 325-650 mg up to 4g daily
13. Misoprostol 100 mcg by mouth with meals
4. Albuterol [**11-24**] PUFF every 6 hours as needed
Mirtazapine 7.5 mg every night
5. Bacitracin Ointment 1 Application WITH DRESSING CHANGES
Senna 1 TAB by mouth twice a day if needed for bowels
Docusate Sodium 100 mg twice daily please administer by JTube
Fluticasone Propionate 110mcg 2 PUFF inhaler twice a day
Sucralfate 1 gm PO QID
Flomax: Tamsulosin HCl 0.8 mg PO HS
Ambien: Zolpidem Tartrate 5 mg by mouth every night
Followup Instructions:
-Please keep your appointment as described above with [**Hospital 7302**] with Mr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 100416**]
.
-Please call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 17811**] for follow-up appointment.
.
Call Dr.[**Name (NI) 1482**] office on Thursday: [**Telephone/Fax (1) 2981**]
to discuss J-tube removal.
Will have to maintain weight for period of time without Jtube
feedings for 1 week-10 days.
.
Provider: [**Name10 (NameIs) **] INJECTIONS Phone:[**Telephone/Fax (1) 1723**]
Date/Time:[**2140-4-12**] 8:55
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2847**], MD Phone:[**Telephone/Fax (1) 719**]
Date/Time:[**2140-6-6**] 9:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2140-8-19**] 7:30
|
[
"600.01",
"300.12",
"511.9",
"493.90",
"293.0",
"311",
"V44.4",
"276.1",
"715.96",
"300.11",
"V10.03",
"E939.0",
"788.20",
"285.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"57.94",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
9364, 9370
|
4088, 7297
|
336, 342
|
9633, 9672
|
2633, 4065
|
11764, 12653
|
1748, 1784
|
7605, 9341
|
9391, 9480
|
7323, 7582
|
9696, 11741
|
2545, 2614
|
1607, 1651
|
1799, 2417
|
9501, 9612
|
275, 298
|
370, 1470
|
2432, 2528
|
1515, 1583
|
1667, 1732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,663
| 111,630
|
18671
|
Discharge summary
|
report
|
Admission Date: [**2185-9-4**] Discharge Date: [**2185-9-9**]
Date of Birth: [**2124-8-11**] Sex: F
Service: NEUROSURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Subdural hematoma(acute on chronic)
Major Surgical or Invasive Procedure:
[**9-5**]: Left sided craniotomy for subdural collection
History of Present Illness:
61 yo Ethiopian F s/p resection of a R Frontal meningioma on
[**2185-7-29**] by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] who presents directly to the ED
with 3 day history of progressively worsening R sided weakness
and decrease sensation. On [**2185-8-20**] she was diagnosed with a
subsegmental posterior PE and was started on Lovenox 50mg [**Hospital1 **].
Per daughter's translation, pt. noticed sl numbness to RU/L
extremity with weakness and R foot drop. Denies confusion,
[**Hospital1 **] changes, N/V or L sided deficits.
Past Medical History:
1. resection of a planum sphenoidale chordoid meningioma on
[**2185-7-29**]
2. Hypercholesterolemia
3. Pulmonary Emboli
Social History:
from [**Country 4812**] and now lives in the U.S. with her daughter. She
has 7 children.
Family History:
non-contributory
Physical Exam:
On Admission:
PHYSICAL EXAM:
O: T: 98 BP: 110/76 HR:66 R: 16 O2Sats:99%
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, Atraumatic. Pupils: 3, minimally reactive
R, 3-2 L EOMs: Intact
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date with the
English
translation of her daughter.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round, R trace reactive (3) L 3 to 2mm.
Decreased [**Country 12588**] Field R, since tumor resection [**7-28**]
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 to all extremities No abnormal
movements,tremors. Strength full power [**5-24**] to L-Side, but [**4-24**]
RUE/RLE. Slight R pronator drift.
Sensation: Subjective decrease sensation to RUE/RLE.
Toes downgoing bilaterally
On Discharge:
Alert, Oriented to person place and date. Persistent right
[**Month/Day (1) **] field deficit. PERRL(L more brisk than R). Full strength
and sensation in upper extremities(improved from admission).
Full strength and sensation in the lower extremites. Wound is
clean, dry and intact without erythema or exudate.
Pertinent Results:
Labs on Admission:
[**2185-9-4**] 07:00PM BLOOD WBC-4.1 RBC-3.88* Hgb-10.9* Hct-33.2*
MCV-86 MCH-28.1 MCHC-32.8 RDW-13.8 Plt Ct-375#
[**2185-9-4**] 07:00PM BLOOD Neuts-60.7 Lymphs-32.2 Monos-5.9 Eos-0.7
Baso-0.5
[**2185-9-4**] 07:00PM BLOOD PT-12.2 PTT-27.0 INR(PT)-1.0
[**2185-9-4**] 07:00PM BLOOD Glucose-106* UreaN-8 Creat-0.8 Na-142
K-4.6 Cl-107 HCO3-27 AnGap-13
[**2185-9-5**] 04:54AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.3
Labs on Discharge:
[**2185-9-8**] 05:05AM BLOOD WBC-5.5 RBC-3.84* Hgb-10.7* Hct-32.7*
MCV-85 MCH-27.8 MCHC-32.6 RDW-13.5 Plt Ct-297
[**2185-9-8**] 05:05AM BLOOD Plt Ct-297
[**2185-9-6**] 03:02AM BLOOD PT-12.5 PTT-22.2 INR(PT)-1.1
[**2185-9-8**] 05:05AM BLOOD Glucose-104 UreaN-7 Creat-0.7 Na-143
K-4.0 Cl-108 HCO3-27 AnGap-12
[**2185-9-8**] 05:05AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1
Imaging:
Head CT [**9-4**]:
FINDINGS: There are postoperative changes following a right
frontal
craniotomy. There is a predominantly hypodense right frontal and
right
temporal extra- axial collection, which is similar in size from
[**2185-8-20**], and may reflect evolving post-surgical blood products.
External to the dura, there is an additional hypodense
collection, measuring approximately 6mm in maximal dimensions,
which also likely reflects residual post-operative changes and
is not significantly changed. A tiny focus of hyperdensity in
the right frontal lobe likely reflects residual intraparenchymal
hemorrhage as seen on prior studies, decreased from [**2185-7-30**].
However, there is a new left acute-subacute subdural hematoma
overlying the left frontal and parietal convexity with a fluid
level, measuring up to 20 mm in width maximally. The subdural
hematoma extends to overlie the left inferior frontal lobe,
where there is hyperdense hemorrhage, compatible wtih acute
blood products. A new right subdural hemorrhage is also evident
overlying the right convexity near the vertex.
There is associated local mass effect, with sulcal effacement,
effacement of the left frontal [**Doctor Last Name 534**] and a rightward shift of
normally midline structures of approximately 5 mm. No uncal
herniation is appreciated. No major vascular territorial
infarction is identified. A hypodensity in the right basal
ganglia may be chronic. Visualized paranasal sinuses and mastoid
air cells are normally aerated. Osseous structures reveal
craniotomy defect in the right frontal bone.
IMPRESSION:
1. Enlarged left subdural hematoma, with acute-subacute
components,
compatible with interval bleeding from the prior study, with
subsequent
effacement of the frontal [**Doctor Last Name 534**] of the left lateral ventricle and
5 mm
rightward midline shift.
2. New right subdural hematoma overlying the convexity near the
vertex.
3. Evolving hemorrhagic products in the right frontal subdural
space, from
prior surgery.
4. Evolving small focus of intraparenchymal hemorrhage in the
right frontal lobe, decreased from [**2185-7-30**].
Head CT [**9-6**]:
FINDINGS: There has been interval evolution of the left frontal
subdural
hematoma. There is a decreased amount of pneumocephalus. The
collection now measures 12 mm in maximal radial dimension
(2A:13). The previously noted linear hemorrhage at the
evacuation site is less prominent on this
examination. The previously noted left frontoparietal
subarachnoid hemorrhage appears grossly unchanged. The
appearance of the previous right frontal craniotomy is
unchanged. There is a hypodense collection in the right epidural
as well as right subdural spaces consistent with prior surgery.
A previously noted right parietal hematoma is currently
measuring 29 mm in longest diameter versus 11 mm previously
(2A:26). This could represent either a subdural or epidural
hematoma. The ventricles are not enlarged. A hyperdense focus
(2A:15) within the left sylvian fissure is likely due to
layering of blood products in addition to different slice
position on this examination; however, a small new bleed cannot
be completely excluded. The paranasal sinuses and mastoid air
cells are unremarkable. The patient is status post remote right
craniotomy and status post left craniotomy. Otherwise, the
osseous structures are unremarkable.
IMPRESSION:
1. Interval increase in size of right parietal hemorrhage.
2. Interval evolution of left subdural fluid collection.
3. New focus of hyperdensity in the left parietal region may
represent
interval layering of blood, however, new hemorrhage cannot be
fully excluded
Cardiac Echo [**9-7**]:
The left atrium is elongated. The estimated right atrial
pressure is 0-5 mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and regional/global systolic
function (LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). Right ventricular chamber size and free wall
motion are normal. 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 estimated pulmonary artery systolic pressure is normal.
There is an anterior space which most likely represents a fat
pad.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function
Brief Hospital Course:
Patient was admitted to the ICU/neurosurgery service following
vague complaints of right sided weaknes and gait abnormality.
She had been on lovenox for the treatment of a subsegmental
pulmonary embolus that was diagnosed on [**8-20**]. Hematology was
consulted for suggestion as to the reversal of lovenox.
Unfortunatley, there was no reversal [**Doctor Last Name 360**] that could be
recommened, and we were advised to continue to hold the lovenox
as we are doing. It was further suggested to pursue an IVC
filter to further prevent further embolus of clot. She was
taken to the operating room on [**9-5**] for a craniotomy to
decompress the subdural collection. Post-operatively, she was
returned to the ICU for overnight monitoring. The following day
on [**9-6**], an IVC filter was placed, as she would be unable to
continue on her lovenox therapy in the setting of intracranial
hemorrhage. She again tolerated this procedure well and was
transferred out of the ICU to the neurosurgical floor. Since the
decompression of the SDH, her weakness in the right upper
extremity has significantly improved. Her diet was advanced as
tolerated. She was seen and evaluated by PT/OT who determined
that she would be appropriate for disposition to home with 24h
supervision(which her children will provide). She was given
instructions to refrain from ANY anticoagulation until she is
seen in follow up in 4 weeks with Dr. [**Last Name (STitle) **]. She was
discharged to home on [**2185-9-9**]. By the time of discharge. the
patient had regained full strength of her right upper extremity.
Medications on Admission:
1. Lovenox SQ 60mg [**Hospital1 **]
2. Calcium with D Daily
3. Docusate 100 mg Daily
4. Percocet 5/325 mg PO, PRN
5. Zocor 20 mg Daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*30 Capsule(s)* Refills:*0*
2. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain. Tablet(s)
4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QAM (once a day (in the morning)).
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left sided acute on chronic subdural hematoma
Discharge Condition:
Neurologically Stable
Discharge Instructions:
General Instructions
?????? Have a friend/family member check your incision daily for
signs of infection.
?????? Take your pain medicine as prescribed.
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Your wound closure uses dissolvable sutures, you must keep
that area dry for 10 days.
?????? You may shower before this time using a shower cap to cover
your head.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
?????? You have been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.
?????? Clearance to drive and return to work will be addressed at
your post-operative office visit.
?????? Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
?????? Fever greater than or equal to 101?????? F.
Followup Instructions:
Follow-Up Appointment Instructions
??????Please return to the office in [**7-29**] days(from your date of
surgery) for a wound check. This appointment can be made with
the Nurse Practitioner. Please make this appointment by calling
[**Telephone/Fax (1) 1669**]. If you live quite a distance from our office,
please make arrangements for the same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast.
??????You will not need an MRI of the brain.
The following appointment have been included for your
convenience:
Provider: [**First Name8 (NamePattern2) 2053**] [**Last Name (NamePattern1) **] [**Name Initial (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2185-9-9**] 3:45
Provider: [**Name10 (NameIs) 6131**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2185-9-14**]
2:00
Provider: [**Name10 (NameIs) **] FIELD SCREENING Phone:[**Telephone/Fax (1) 253**]
Date/Time:[**2185-9-14**] 2:30
Completed by:[**2185-9-9**]
|
[
"E878.8",
"998.12",
"V58.61",
"429.3",
"427.89",
"272.0",
"415.19",
"V88.01",
"348.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"01.31"
] |
icd9pcs
|
[
[
[]
]
] |
10629, 10635
|
8205, 9794
|
353, 412
|
10725, 10749
|
2892, 2897
|
12355, 13475
|
1257, 1275
|
9980, 10606
|
10656, 10704
|
9820, 9957
|
10773, 12332
|
1319, 1523
|
2560, 2873
|
278, 315
|
3336, 8182
|
440, 990
|
1820, 2546
|
2911, 3317
|
1538, 1804
|
1012, 1134
|
1150, 1241
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,298
| 158,948
|
4492
|
Discharge summary
|
report
|
Admission Date: [**2190-11-26**] Discharge Date: [**2190-12-14**]
Date of Birth: [**2119-4-3**] Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Fall
ALOC
Respiratory Failure
Major Surgical or Invasive Procedure:
Endotracheal Intubation with subsequent extubation
Placement of central venous catheter with subsequent removal
Placement of peripherally inserted central catheter
Bronchoscopy
History of Present Illness:
Mrs. [**Known lastname 19205**] is a 71 yo female with atrial fibrillation on
coumadin/arpirin/plavix, coronary artery disease, and congestive
heart failure who presented to [**Hospital1 **] on [**2190-11-25**]. She tripped
while walking down the stairs and hit her head on a driveway.
Afterwards she had only epistaxis but denied headache or LOC. At
[**Hospital1 **], a head CT showed a subarachnoid hemorrhage so she was
transferred here for neurosurgical evaluation. She was initially
awake, alert and oriented with a normal neuro exam in their ED,
but she developed a left facial droop and UE weakness during the
ambulance ride.
.
In the [**Hospital1 18**] ED, she was intubated upon arrival for airway
protection secondary to worsening mental status and
emesis/bloody secretions. She received proplex, dilantin, FFP,
and platelets in the ED. A repeat head CT here revealed large
bilateral subarachnoid hemorrhages as well as a large
right-sided intraparenchymal hemorrhage. She was admitted to the
MICU as Neurosurgery did not recommend surgical intervention.
.
In the MICU, her INR was reversed (was 2.9 due to being on
coumadin). Another CT scan the morning after admission showed
slight subfalcine herniation. She was started on mannitol. Her
mental status improved where she was intermittently following
commands. Initially, she was placed on vancomycin and
ceftriaxone which were discontinued after 3 days. She was
diuresed in order to maximally wean her from the vent. The
mannitol was tapered. Per neurosurgery, it was okay to restart
coumadin (on [**12-3**]) but this was not done by the MICU team. The
MICU team did discuss anticoagulation with the patient's family
on multiple occasions, including the risks and benefits of
remaining off of the anticoagulation with her known atrial
fibrillation and cardiac dysfunction.
.
Her fingersticks were difficult to control requiring an insulin
drip while in the ICU. Serial head CTs were unchanged. In the
ICU, she became febrile and was placed on vancomycin and
meropenem for an 8 day course. Bronchoscopy revealed diffuse
friable mucosa in both bronchial trees and a small amount of
thin secretions. Lavage of her left upper lobe grew nothing, but
sputum culture did grow MSSA. Blood cultures grew coagulase
negative Staph from 1/4 bottles and were felt to be contaminant.
Her central line was removed and a PICC was placed prior to
coming to the floor.
.
It was difficult to get her therapeutic on Dilantin so she was
changed to keppra. She was extubated on [**12-7**]. Her c-spine was
unable to be cleared clinically as she could not flex or extend
her neck on command. However, the family felt very strongly that
her collar should be removed, so it was. She had a bedside
swallow on [**12-9**] which she failed. However, this was difficult
to interpret as she was not fully alert. She did begin speaking
single words. She was called out to the floor from the ICU on
[**12-11**].
Past Medical History:
1. Type 2 DM, on glyburide as outpt
2. Status post vitreous hemorrhage in right eye and early
retinopathy in both eyes as per the patient's ophthalmologist.
3. CAD status post anterior MI nine years ago, most recent cath
[**6-28**] with 80% mLAD (not stented) and 90% LCx (stented w/DES)
4. Ischemic cardiomyopathy with EF 20% in [**12-28**], status post
biventricular pacer internal defibrillator. 2+MR/TR w/severe PA
HTN
5. Hypertension.
6. Hypothyroidism.
7. Atrial fibrillation.
8. CKD (baseline mid 1's prior to admission)
Social History:
The patient lives with her husband. She previously used tobacco
but quit years ago. She does not drink alcohol.
Family History:
non-contributory
Physical Exam:
T: 98.5 BP: 125/59 P: 60 R: 22 100%4LNC
Wt 101 kg
Gen: awake and alert, not following commands, not speaking
HEENT: PERRL-min 2mm bilat, DHT in place
Lungs: decreased breath sounds at bases anteriorly
CV: RRR, S1/S2, no M/R
Abvd: obese, soft, nontender, nondistended. NABS.
Extrem: 1+ BLE edema. Large ecchymosis and soft tissue swelling
over left knee, no warmth/erythema
Neuro: pupils equal, awake/alert, looks to right side, not
interactive or following commands
Pertinent Results:
Admit Labs
[**2190-11-26**] 12:45AM BLOOD WBC-15.6*# RBC-3.90* Hgb-12.0 Hct-35.8*
MCV-92 MCH-30.7# MCHC-33.4 RDW-16.1* Plt Ct-226
[**2190-11-26**] 12:45AM BLOOD Neuts-86.8* Bands-0 Lymphs-8.9* Monos-2.8
Eos-1.0 Baso-0.5
[**2190-11-26**] 12:45AM BLOOD Glucose-252* UreaN-53* Creat-1.5* Na-140
K-5.1 Cl-109* HCO3-20* AnGap-16
[**2190-11-26**] 12:45AM BLOOD Calcium-8.8 Phos-2.5* Mg-2.5
[**2190-11-26**] 07:08AM BLOOD Type-ART Rates-18/ Tidal V-500 PEEP-5
FiO2-100 pO2-246* pCO2-38 pH-7.45 calTCO2-27 Base XS-3 AADO2-450
REQ O2-75 -ASSIST/CON Intubat-INTUBATED
[**2190-11-26**] 12:45AM BLOOD PT-29.8* PTT-29.5 INR(PT)-3.1*
[**2190-11-26**] 03:15AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.024
[**2190-11-26**] 03:15AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-250 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG.
.
Labs on discharge
* WBC 10.8, Hgb 11, Hct 33.9, Plt 377
* BMP remarkable for K 4.7, bicarb 34 (stable from [**12-13**]), BUN
31, creatinine 1
.
Micro
.
[**11-26**] BCX - no growth
.
[**2190-11-26**] 6:43 pm SPUTUM Source: Endotracheal.
**FINAL REPORT [**2190-11-28**]**
GRAM STAIN (Final [**2190-11-26**]):
>25 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final [**2190-11-28**]):
MODERATE GROWTH OROPHARYNGEAL FLORA.
.
[**2190-11-26**] 6:43 pm URINE
**FINAL REPORT [**2190-11-28**]**
URINE CULTURE (Final [**2190-11-28**]): <10,000 organisms/ml.
.
[**2190-12-1**] 9:42 pm BLOOD CULTURE
AEROBIC BOTTLE (Final [**2190-12-5**]):
[**2190-12-3**] REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **] AT 12:50
AM.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
ISOLATED FROM ONE SET ONLY. SENSITIVITIES PERFORMED ON
REQUEST..
ANAEROBIC BOTTLE (Pending):
.
[**2190-12-1**] 10:16 pm BLOOD CULTURE TLC SUBCLAVIAN.
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
.
[**2190-12-1**] 9:46 pm URINE Site: CATHETER
**FINAL REPORT [**2190-12-2**]**
URINE CULTURE (Final [**2190-12-2**]): NO GROWTH.
.
[**2190-12-1**] 9:47 pm SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2190-12-5**]**
GRAM STAIN (Final [**2190-12-2**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2190-12-5**]):
OROPHARYNGEAL FLORA ABSENT.
STAPH AUREUS COAG +. RARE GROWTH.
PENICILLIN SENSITIVITY AVAILABLE ON REQUEST.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
.
[**2190-12-2**] 11:58 am BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
.
[**2190-12-2**] 11:58 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT [**2190-12-4**]**
GRAM STAIN (Final [**2190-12-2**]):
[**11-17**] PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2190-12-4**]): NO GROWTH.
.
[**2190-12-2**] 3:00 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2190-12-4**]**
GRAM STAIN (Final [**2190-12-2**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2190-12-4**]): NO GROWTH, <1000
CFU/ml.
.
[**2190-12-2**] 9:37 pm BLOOD CULTURE
AEROBIC BOTTLE (Pending):
ANAEROBIC BOTTLE (Pending):
.
[**2190-12-4**] 4:43 pm CATHETER TIP-IV
**FINAL REPORT [**2190-12-6**]**
WOUND CULTURE (Final [**2190-12-6**]): No significant growth.
.
.
.
Imaging
.
[**11-26**] CT Head w/o Contrast
1. There is a large amount of subarachnoid hemorrhage
bilaterally.
Additionally, there is a large focus of intraparenchymal
hemorrhage within the right parietal region.
2. There is an area of low attenuation in the brain parenchyma
eccentric and anterior to the area of hemorrhage. This may
represent edema due to the hematoma itself. Correlate with
history. If the cause of this hemorrhage is unknown, then
further evaluation with an MRI should be considered.
.
[**11-26**] CT Maxillofacial
1. Minimal frontal soft tissue swelling.
2. Dense fluid, likely hemorrhage, is seen within the paranasal
sinuses.
While no definite fractures are identified, an occult fracture
can not be
excluded.
3. There are areas of bilateral subarachnoid and right-sided
intraparenchymal hemorrhage seen, which are better and more
completely evaluated on the dedicated CT scan of the head
performed at the same time.
.
[**11-26**] CT C-spine
No fracture or subluxation is identified. Degenerative changes,
including anterior and posterior marginal osteophyte formation
are noted,
predominantly at the C4-C5 level. There may be mild canal
narrowing at the C4-C5 level, with abutment of the posterior
osteophytes on the anterior contour of the thecal sac. The
remainder of the levels are widely patent. CT provides limited
evaluation of intrathecal contents, however, contour of thecal
sac is within normal limits. Calcification of the left
vertebral artery is noted. There is no prevertebral soft tissue
swelling.
.
[**11-26**] X-ray Left Knee - no fracture.
.
[**11-26**] X-ray Pelvis - no fracture.
.
[**11-26**] f/u CT Head w/o Contrast
No significant change in appearance of extensive subarachnoid
and right
intraparenchymal hemorrhage, but with slight increase in
surrounding edema and leftward subfalcine herniation.
.
[**11-27**] f/u CT Head w/o Contrast
Slight increase in edema surrounding right intraparenchymal
hemorrhage, with increased mass effect and leftward subfalcine
herniation, especially when compared to original study performed
at on [**2190-11-26**]. Again seen is extensive bilateral
subarachnoid hemorrhage.
.
[**11-27**] Left Humerus and Forearm X-rays
Two views of the humerus demonstrate normal bony anatomy. No
fractures identified. Two views of the forearm demonstrate
normal bony
alignment without fracture.
.
[**11-28**] CXR
Bibasilar opacities. Diagnostic considerations again include
pulmonary edema and pneumonia.
.
[**12-1**] CXR
1. Cardiomegaly.
2. Improved left lower lobe atelectasis, pulmonary edema and
right lower lobe consolidation which was most likely due to a
relatively asymmetric edema.
.
[**12-4**] CT Head w/o Contrast
No significant interval change in the large right cerebral
intraparenchymal hemorrhage and extensive subarachnoid
hemorrhage, with a
similar degree of right-to-left subfalcine herniation. Interval
opacification of right mastoid air cells.
.
[**12-6**] PICC placement
Successful placement of a single lumen 4 French PICC via the
right basilic vein. The tip is in the central superior vena
cava. The line is ready for use.
.
[**12-7**] Portable CXR
Dobbhoff tube with its tip likely within the body of the
stomach. Stable appearance of lungs compared to one hour prior.
Right-sided PICC line somewhat withdrawn with its tip likely
within the vicinity of the junction of the right and left
brachiocephalic veins.
.
[**12-7**] Portable CXR
Dobbhoff tube at the thoracoabdominal junction, above the
gastroesophageal junction. No coiling of the tube in the
thoracic portion of the esophagus.
.
[**12-10**] Portable CXR
Worsening pulmonary edema. Dobhoff in the stomach.
Brief Hospital Course:
Mrs. [**Known lastname 19205**] is a 71 year old female with coronary artery disease,
atrial fibrillation on coumadin who presented status post a fall
with bilateral subarachnoid hemorrhages and large right
intraparenchymal bleed initially cared for in the MICU now
extubated and improving on the general medical floor.
.
# Intracranial hemorrhages: On presentation, Mrs. [**Known lastname 19205**] was
evaluated by the neurosurgical team who did not recommend any
surgical interventions. They followed her throughout her MICU
course and signed off when she stabilized. Mrs. [**Known lastname 19205**] neurologic
exam has been slowly improving/stable per notes and our exam on
the floor. She has a dense left hemiplegia including left facial
droop. She actively moves her right side. She can shake her head
yes or no and answers questions appropriately when asked yes/no.
Per her family, she has participated in appropriately bidding on
bridge which they read to her from the newspaper. Her serial
head CT's have also been stable. The patient should continue on
Keppra for seizure prophylaxis. She is to continue to physical
therapy and occupational therapy at the rehabilitation facility
as she will hopefully continue to improve over the course of the
next weeks to months.
- Per their note on [**12-1**], the neurosurgical team believed that
it was okay to restart the patient's coumadin. Having said this,
they did recommend a repeat CT scan when her coumadin level
becomes therapeutic. As per the patient's family, they are
comfortable waiting until after the patient's PEG tube situation
is resolved prior to restarting her coumadin. Both the patient's
husband and daughter [**Name (NI) **] understand that there is risk with
both options: anticoagulation versus no anticoagulation in the
setting of atrial fibrillation with depressed ejection fraction.
They understand that without anticoagulation, the patient is at
risk for embolic stroke due to her atrial fibrillation. However,
on anticoagulation, there is no guarantee that the patient's
intracranial bleed would not progress.
.
# Respiratory failure: The patient was initially intubated due
to aspiration of blood from epistaxis as well as deteriorating
mental status. In the ICU, she had a prolonged wean from the
ventilator due to congestive heart failure, requiring diuresis.
Her course was also complicated by ventilator associated
pneumonia, for which she was treated with approprite antibiotics
during her MICU stay.
- On the floor, the patient was restarted on her prior dose of
lasix due to concern for continued element of congestive heart
failure.
- At the time of discharge, the patient is comfortable on 2 L
nasal cannula. Off of nasal cannula, she desaturated to the
mid-80s.
.
# Atrial fibrillation: The patient is paced. She should continue
on her amiodarone. She is currently not on coumadin. Her family
is comfortable continuing without the coumadin for now until the
issue surrounding her potential need for a PEG tube is resolved.
They understand her risk for embolic stroke while not on
coumadin. They also understand that if restarted on coumadin,
there is a chance that her hemorrhage will progress. This can be
further discussed with the patient and her family as she
recovers from this stroke.
.
# CHF: The patient's ejection fraction is 20% on most recent
echocardiogram which is felt due to ischemic cardiomyopathy.
- The patient was continued on carvedilol and spironolactone.
- She also received PO lasix as above for volume overload.
.
# CAD: The patient was most recently cathed in [**6-28**]. Since her
admission, she has been restarted on aspirin, but her plavix is
still being held secondary to her intracranial hemorrhage.
- The patient should continue her aspirin, atorvastatin, and
carvedilol.
.
# DM: Very difficult to manage in ICU, requiring insulin gtt at
times. Uptitrating NPH and humalog sliding scale - high sugar
220 yesterday.
.
# Hyperlipidemia: The patient should continue her atorvastatin.
.
# Hypothyroidism: The patient should continue her levothyroxine.
.
# CKD: The patient's creatinine is currently 1, which is
improved from baseline.
.
# Anemia: The patient's hemoglobin and hematocrit continue to
improve since her ICU stay. Her anemia in the ICU is likely due
to frequent phlebotomy during her ICU course. She did have one
guaiac positive stool, but has since had guaiac negative stool.
Her guaiac positive stool could be due to Dobhoff placement.
.
# FEN: Ms. [**Known lastname 19205**] [**Last Name (Titles) 19206**] demonstrate a likely metabolic
alkalosis, but her bicarbonate is stable at 34. She did receive
diamox in the ICU for elevated bicarbonate but we did not pursue
this on the floow.
- Her tube feeds are at goal. A PEG tube is on hold for now per
discussion with the patient's family. As the patient's speech
and swallow study was somewhat confounded by her depressed
mental status, her family would like to continue for now with
tube feeds. Should she need a PEG tube at a later date, they
will consider it. They are reluctant to pursue any intervention
at present which may require the patient to be re-intubated. She
should be re-evaluated by speech & swallow in the near future to
gauge any improvement.
.
# Ppx: The patient should remain on SQ heparin until she is able
to get up. She should be on aspiration precautions with the head
of the bed elevated. As she is receiving tube feeds, she does
not have an indication for a PPI. She should receive a bowel
regimen as necessary, but she is having bowel movements.
Medications on Admission:
coumadin 5
aldactone 6.25
asa 81
lasix 20
lipitor 20
synthyroid 125
plavix 75
micronase 1.25 [**Hospital1 **]
cozaar 12.5 [**Hospital1 **]
amiodarone 200
coreg 6.25 [**Hospital1 **]
Discharge Medications:
1. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. 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.
5. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-25**] Sprays Nasal
[**Hospital1 **] (2 times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) U
Injection TID (3 times a day): while patient not ambulatory.
9. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1)
Appl Ophthalmic PRN (as needed).
10. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Losartan 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
12. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY
(Daily).
13. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed: pain/fever. do not exceed 4 g daily.
15. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
16. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
17. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Forty
Five (45) Units Subcutaneous twice a day.
18. INSULIN SLIDING SCALE
Please continue regular insulin on a sliding scale as needed.
See attached sliding scale for details.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Mechanical fall resulting in bilateral subarachnoid hemorrhage
and right intraparenchymal hemorrhage with resultant left
hemiplegia
Secondary:
* Atrial fibrillation
* Diabetes mellitus type 2
* Coronary artery disease
* Ischemic cardiomyopathy with EF 20%
* Hypertension
* Hypothyroidism
* Chronic kidney disease
Discharge Condition:
Hemodynamically stable, afebrile, and comfortable on 2 L nasal
cannula.
Discharge Instructions:
Please take your medications as prescribed.
Please let the doctors at your facility know if you have any of
the following symptoms: fever > 100.5, chills, weakness or
numbness of the right arm or leg, abdominal pain, nausea or
vomiting, or any other concerns.
You should be weighed daily.
Adhere to 2 gm sodium diet
Fluid Restriction: 1.5 L
Followup Instructions:
You will be followed by physicians at the [**Hospital 19207**]
hospital. If you have any issues, you may call Dr. [**Last Name (STitle) 9960**] at
[**0-0-**].
Completed by:[**2190-12-14**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,492
| 124,194
|
27932
|
Discharge summary
|
report
|
Admission Date: [**2119-8-4**] Discharge Date: [**2119-8-25**]
Date of Birth: [**2056-2-12**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Male First Name (un) 5282**]
Chief Complaint:
ABDOMINAL PAIN
Major Surgical or Invasive Procedure:
Hemodialysis
Placement and Removal of a tunneled hemodialysis catheter
Colonscopy with polyp removal
History of Present Illness:
This is a 63 year old Portuguese-speaking man with extensive
history of alcoholic cirrhosis, frequent admissions at [**Hospital1 18**],
now here with right-sided abdominal pain, and increased ascites.
Starting on Wednesday ([**8-2**]) he began having right-sided
abdominal pain. His wife reported that he had increased fatigue,
abdominal pain, abdominal girth, and one episode of non-bloody
emesis. His wife and cousin denied that he had any episodes of
confusion. They explained that he had "pain where they took the
water out" on the right. They explained and he affirmed that he
has been urinating less. I confirmed the essentials of this
history with him during a brief Portuguese interpreter phone
interview.
.
In the emergency department his initial vitals were: 97.9,
111/63, 18, 98% on room air. He was found to be guaiaic
negative; and he had labs notable for lactate 9.1, WBC 21.3, Cr
7.6, Glu 15. With low glucose, a D5 drip was started. With
consideration of ischemic colitis, the ED sent him for CT scan,
ordered without contrast given his renal function; this did not
show any signs of ischemia. Additionally, he received: 4.5 gm IV
zosyn, octreotide 50 mcg IV and octreotide 25 mcg/hr gtt; as
well as 1 amp of calcium gluconate. Liver and kidney services
were consulted in the ED; liver fellow left recs in the ED chart
and renal fellow planned for HD in the unit. A diagnostic
paracentesis was performed in the ED; the liver service
recommended against therapeutic tap for now.
Past Medical History:
Alcoholic cirrhosis known varices
portal vein thrombosis
s/p TIPS
DM
Hypothyroid
Pituitary mass
h/o nephrolithiasis
h/o +PPD
Social History:
Lives w/ wife at home. Independent in ADLs and ambulation.
Smokes [**12-23**] cigars per day. No alcohol for the last 5 months.
[**Month/Day (2) 4273**] IVDU. No ETOH since [**10-29**].
Family History:
Mother deceased, age 50, CVA. Father deceased, age 62, stomach
problems. One brother living and in good health. Two sisters,
both living and in good health
Physical Exam:
97.9, 111/63, 18, 98% on room air
comfortable, continues to moan periodically, [**Year (2 digits) **] abdominal
pain
Neuro: A0x3, asterixis
CV: RRR
LUNG: scattered rales with expiratory wheeze
abd: +ve bs, marked distension ,tense abd, no rebound/no
guarding
EXT: trace edema
Pertinent Results:
[**2119-8-4**] 11:47PM GLUCOSE-99 UREA N-87* CREAT-7.5*
POTASSIUM-6.3*
[**2119-8-4**] 03:42PM LACTATE-9.1*
[**2119-8-4**] 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-8-4**] 02:45PM ALT(SGPT)-28 AST(SGOT)-44* CK(CPK)-40 ALK
PHOS-391* TOT BILI-0.7
[**2119-8-4**] 02:45PM LIPASE-94*
[**2119-8-4**] 02:45PM cTropnT-<0.01
[**2119-8-4**] 02:45PM CK-MB-NotDone
[**2119-8-4**] 02:45PM AMMONIA-66*
[**2119-8-4**] 02:45PM PT-40.6* PTT-39.9* INR(PT)-4.3*
[**2119-8-7**] 04:09AM BLOOD WBC-5.2 RBC-2.79* Hgb-8.7* Hct-25.3*
MCV-91 MCH-31.1 MCHC-34.3 RDW-16.5* Plt Ct-99*
[**2119-8-7**] 04:09AM BLOOD Neuts-79.0* Lymphs-11.9* Monos-6.1
Eos-2.8 Baso-0.2
[**2119-8-7**] 04:09AM BLOOD Plt Ct-99*
[**2119-8-7**] 04:09AM BLOOD Glucose-182* UreaN-38* Creat-4.2* Na-138
K-3.8 Cl-103 HCO3-24 AnGap-15
[**2119-8-7**] 04:09AM BLOOD Phos-2.9 Mg-2.2
[**2119-8-6**] 03:17PM BLOOD Lactate-2.4*
[**2119-8-7**] 04:20AM BLOOD freeCa-1.03*
C.diff negative
Therapeutic tap y/d: gram stain, cx pending, blood cx x2
pending, urine cx showed yeast (10,000-100,000).
Brief Hospital Course:
LIVER CIRRHOSIS, ETOH, w/ encephalopathy Hepatorenal syndrome
worsens prognosis. Could have been precipitated by large volume
tap on prior admission, though pt has tolerated similar (~5L) in
the past. Pt has been on transplant list. MELD on admission =
41. U/S shows some stenosis from TIPS in protal
circulation.Being worked up for liver/renal transplant, f/u
workup with transplant surgery team. Patient was treated for
HRS with improvement. Recieved screening colonoscopy which
identified one polyp (path pending) on day of discharge.
Additionally, patient recieved a 3L therapeutic paracentesis
prior to discharge. Treated with Cipro in hospital and
continued on prophylactic doses on discharge due to possible
history of SBP. Patient will need MRI head to follow-up on
pituitary mass found incidentally on CT.
.
RENAL FAILURE, ACUTE (ACUTE RENAL FAILURE, ARF): Patient
presented w/ ARF that was likely [**1-23**] hepatorenal syndrome, but
perhaps [**1-23**] large volume tap on last admission; vs change in
hemodynamics [**1-23**] infection; vs compartment syndrome from ascites
causing pre-renal picture vs metformin side effect. He was
admitted to the MICU where patient underwent emergent dialysis
for significanly elevated lactate and was started on octreotide
and midodrine. It was felt that his acute renal failure may have
been secondary to HRS related to his recent large volume tap vs
lactic acidosis related to metformin versus infection. He had
abd u/s which confirmed large amt of ascites with persistent
elevated TIPS velocities. He was initially started on levophed
to maintain hemodynamic stability which was discontinued soon
after. In addition, he underwent 5L paracentesis which he also
tolerated well. Given elevated WBC ct and concern for infection
pt started empirically on zosyn. Peritoneal, blood and urine and
stool cultures remain negative to date. He was transfered to the
floor. On the floor patient continued to improve only needing
dialysis on 2 more occasions, last on [**2119-8-11**]. He was continued
on octreotide/midodrine/albumin and his Cr ranged in the 2.8-3.1
range. Due to hypertension and hyperglycemia, octreotide and
midrinone were discontinued, but albumin was continued. Renal
function continued to improve until discharge, with creatinine
of 1.8 on discharge. On the day prior to discharge, Mr.
[**Known lastname 68037**] tunneled HD line was removed without complication.
.
HYPOTENSION Possibly due to decreased venous return due to
abdominal pressure vs infection/sepsis vs hypovolemia due to
fluid sequestration as ascites. Briefly needed levophed early in
ICU course for MAP <60. His hypotension resolved in the MICU. On
transfer to the floor patient had no issues with hypotension.
.
ALTERED MENTAL STATUS (NOT DELIRIUM) Per family report, patient
admitted with intact mental status, however, appeared confused
at times, with mumbling and groaning on. This was thougth to due
to hepatic encephalopathy that could have been caused by
infection, UTI vs SBP, vs acidemia. Infectious work up was
negative. His acidemia resolved after HD. He was re-started on
lactulose and rifaxamin and his MS improved. On the floor
patient remained at baseline MS until [**8-16**] when he [**Month/Year (2) 68038**]
[**Month/Year (2) 68039**]. He was found to be altered aggressive, was given
haldol and restrained. His mental status did not improve despite
continued treatment with lactulose and rifaxamin. He was
transfered to the MICU on [**8-17**]. In the MICU he was treated with
albumin, octreotide, midodrine and [**Month/Year (2) 8005**]. Also, he was
treated empirically with vanc, pip/tazo and then cipro for SBP.
He was also given lactulose enemas and had an NGT placed and
received NG lactulose titrated to bowel movements. With BM his
mental status improved. Paracentesis was performed with 4L of
turbid fluid taken off with a WBC of 125. NGT d/c'ed with
improved mental status. On the floor patient's mental status
remained at baseline on current medications and he was
discharged at baseline.
.
COAGULOPATHY: Patient with known portal vein thrombosis on
chronic coumadin. Presented with supratherapeutic INR >3.0. His
coumadin was held on admission. Once his INR was <2.0 his
coumadin was restarted. His INR became therapeutic 2 days after
restarting coumadin. Coumadin was held on [**8-22**] for 3 days due to
planned tunneled HD catheter removal and colonoscopy. He was
restarted on discharge on 3 mg PO qday to follow-up next week
for INR check.
.
LACTIC ACIDOSIS Most likely [**1-23**] liver failure itself, though
metformin toxicity in setting of new renal failure may also be
responsible. Mesenteric ischemia could be culprit as patient
presented with large moderately tense ascites. Metformin was
discontinued on admission, he underwent a large volume
paracentesis 5.5L in the MICU and was started on HD. On transfer
to the floor the patient's acidosis had resolved and only
received HD on 3 occasions. On [**8-16**] his MS [**First Name (Titles) 68038**] [**Last Name (Titles) 68039**]
and became acidemic with a lactate of 6.4. He received a medium
volume paracentesis (3.5L) as this appeared to be similar to his
presentation. He was transfered to the MICU on [**8-17**]. He was
treated as previously mentioned and his lactate had decreased to
2.8 on [**8-18**].
.
Leukocytosis: No clear source was ever found for the patient's
leukocytosis. Concern for abdominal source but as above this is
not clear after dx tap and CT abd/pelvis. Empiric gram negative
coverage with vanc/zosyn, which he received for a total 7 days
course, his leukocytosis resolved shortly after starting
treatment. He had a second episode of acute increase of his WBC,
this one on [**8-18**] after the episode of AMS for which he had to be
transfered to the MICU. He had been started on cipro on [**8-16**].
Cipro was continued at treatment doses until his leukocytosis
returned to [**Location 213**]. Cipro was continued at SBP prophylactic
doses due to quesitonable history of SBP in the past. He was
discharged on SBP prohpylaxis to be continued indeffinately.
.
DIABETES Patient's oral antihyperglycemics were discontinued as
metformin could have been cause for lactic acidosis. On the
floor patient was consistently hyperglycemic to 200-400s,
despite increasing doses of glargine and ISS. [**Last Name (un) **] was
consulted and the recommended changes made on his ISS and his BG
improved slightly. On [**8-17**] The patient was trasfered to the ICU
for an insulin drip after glucose found to be in the 600s. The
drip was d/c'ed after 24 hours with normalization of gap and
blood glucose. He was continued on glargine and ISS which was
continuously changed by [**Last Name (un) **] while on the floor. Blood sugar
control was variable during admission, however HbA1C was 6.8
when checked. Due to possible lactic acidosis from metformin on
admission, and in consultation with [**Last Name (un) **], Mr. [**Known lastname 16651**] was
sent home on Glargine and HISS after extensive education with
his wife and translator. Plan was for the patient's wife to
check blood sugar and draw up insulin due to his confusion [**1-23**]
liver disease. Appropriate follow-up was coordinated for the
patient's management of diabetes.
Medications on Admission:
[**Month/Day (2) **] 400 mg TID
Levothyroxine 100 mcg DAILY
Calcium Carbonate 500 mg TID
Cholecalciferol 800 unit DAILY
Omeprazole 20 mg DAILY
Glipizide 10 mg DAILY
Lactulose 30-60 MLs PO QID
Metformin 1,000 mg [**Hospital1 **]
Propranolol 40 mg TID
Warfarin 5 mg qHS
Discharge Medications:
1. [**Hospital1 **] 200 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO
three times a day.
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
5. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Lactulose 10 gram/15 mL Syrup Sig: Sixty (60) ML PO QID (4
times a day).
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Insulin Glargine 300 unit/3 mL Insulin Pen Sig: Thirty Six
(36) u Subcutaneous at bedtime.
Disp:*1 pen* Refills:*2*
9. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1)
syringe Miscellaneous four times a day: for use with sliding
scale insulin regimen .
Disp:*1 box* Refills:*2*
10. Alcohol Swabs Pads, Medicated Sig: One (1) swab Topical
four times a day: Cleanse skin prior to insulin injections. .
Disp:*1 box* Refills:*2*
11. Lancets,Ultra Thin Misc Sig: One (1) lancet
Miscellaneous four times a day.
Disp:*1 box* Refills:*2*
12. Blood Sugar Diagnostic Strip Sig: One (1) test strip In
[**Last Name (un) 5153**] four times a day: For testing with sliding scale regimen.
.
Disp:*1 container* Refills:*2*
13. Humalog 100 unit/mL Solution Sig: as dir u Subcutaneous four
times a day: refer to sliding scale for dose.
Disp:*1 bottle* Refills:*2*
14. glucometer Sig: One (1) once.
Disp:*1 glucometer* Refills:*0*
15. Coumadin 3 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
Alcoholic Cirrhosis
Acute Renal Failure
Lactic Acidosis
Hepatic Encephalopathy
Hepatorenal Syndrome
Refractory Ascites
Secondary:
Portal vein thrombosis
Diabetes mellitus
Hypothyroidism
Pituitary mass
Discharge Condition:
Hemodynamically stable, afebrile. Creatinine 1.8
Discharge Instructions:
You were admitted to the hospital for abdominal pain. You were
found to have very abnormal labs and so underwent urgent
dialysis. These abnormal labs were likely related to a
combination of kidney failure from your liver disease and the
metformin you were taking for your diabetes. Your course was
complicated by fluctuating mental status, high blood sugars, and
fluctuating kidney status. You were seen by the [**Last Name (un) **]
endocrinology doctors and started on insulin. You may have had
an abdominal infection so you were given antibiotics and should
continue on the antibiotic (cipro) to prevent any futher
infections.
.
Changes to your medications:
STOP Glipizide
STOP Metformin
Decrease Coumadin to 3 mg by mouth every day
START Ciprofloxacin 500 mg once daily.
START Glargine 36u nightly
START Sliding Scale Insulin as Instructed if eating well. If not
eating well, take [**12-23**] the dose indicated on the sliding scale.
.
Please check your blood sugar should you feel nauseous, sweaty,
confused, or dizzy. If you feel poorly and your blood sugar is
less than 100, drink 6oz of [**Location (un) 2452**] juice and call your doctor.
If your blood sugar is >400, please call your doctor.
.
Please call the liver clinic or return to the emergency room if
you experience fever, chills, nausea, vomiting, abdominal pain,
shortness of breath, chest pain, constipation, diarrhea, bloody
or black bowel movements, confusion, or any other concerning
symptoms.
Followup Instructions:
Please come to the liver clinic on Tuesday, [**8-29**] to
have your blood work checked. Dr [**Last Name (STitle) 497**] will be able to access
the results of the pathology on the colon polyp that was removed
during your colonoscopy when you see him in the clinic.
Please follow up with Dr[**Name (NI) 24775**] [**Name (STitle) **] Practitioner ([**First Name4 (NamePattern1) 553**]
[**Last Name (NamePattern1) 22204**] Burns)on Tuesday, [**8-29**] at 1:00pm. Please discuss
your blood sugars and plan for insulin at that visit.
ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2119-9-1**] 8:00
[**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2119-9-4**] 8:00
[**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2119-9-4**] 9:00
To complete your work up for liver transplant, you will need to
have an MRI with contrast of your brain. This is because you
were noted to have a small, stable lesion in the base of your
brain. CT scans cannot characterize this well so you should have
an MRI. The MRI requires contrast which can be risky to give
with your currently abnormal kidney function.
|
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"276.7",
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"239.7",
"V58.67",
"038.9",
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"305.1",
"288.8",
"571.2",
"276.2",
"401.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"38.95",
"39.95",
"45.42",
"38.91",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
13173, 13231
|
3949, 11225
|
333, 436
|
13486, 13537
|
2801, 3926
|
15051, 16228
|
2329, 2487
|
11545, 13150
|
13252, 13465
|
11251, 11520
|
13561, 14192
|
2503, 2782
|
14221, 15028
|
279, 295
|
464, 1960
|
1982, 2109
|
2125, 2313
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,062
| 129,154
|
45035
|
Discharge summary
|
report
|
Admission Date: [**2112-3-15**] Discharge Date: [**2112-3-19**]
Date of Birth: [**2045-11-30**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 552**]
Chief Complaint:
GI Bleed
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Blood transfusion
History of Present Illness:
66 yo F with metastatic NSCLC s/p cyberknife to brain,
diverticulosos p/w DOE x 1 week and dark stool. NO chest pain,
palpitations, fevers, chills. Has also been taking hydrogen
peroxide diluted in water in order to remove the cancer from her
body.
.
In ED, vitals were 98.3 116 133/45 16 100. Exam was remarkable
for marroon stool that was guaiac positive. HCT was 19, down
from baseline of 36 two weeks ago. Patient was given 2L NS. CXR
stable. EKG sinus tachycardia. HR improved to low 100s with NS.
The first unit of PRBCs was started in the ED and continued on
transport across the street.
.
On arrival to the [**Hospital Unit Name 153**], she reported continued improvement in
her dyspnea. She denied nausea, vomiting, abdominal pain, cough,
fevers, chills. She had a 125cc menanotic stool without bright
red blood per rectum.
Past Medical History:
Chronic back, neck, and hip pain
panic disorder with depressive component
hypertension
lumbar facet arthropathy with radiofrequency treatments
NSCLCA stage IV with known mets to brain/bone s/p cyberknife to
brain mets, currently considering chemotherapy
Diverticulosis
Social History:
Lives in [**Location **] with son. Previously work as a hairdresser. 50
pack year smoking history, occassional social ETOH.
Family History:
Father - NHL
Otherwise non-contributory
Physical Exam:
GENERAL - well-appearing feman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - decrease bs and dullness at right base to midway up, no
r/rh/wh, good air movement, resp unlabored, no accessory muscle
use
HEART - PMI non-displaced, regular, tachy, no MRG, loud S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-5**] throughout, sensation grossly intact throughout, gait
deferred
Brief Hospital Course:
66 yo F w PMHx of metastatic NSCLC presents with symptomatic
acute blood loss anemia
1. Symptomatic acute blood loss anemia - Symptoms
improved/resolved sp prbc transfusion. No futher episodes of
bleeding noted. EGD with candidal esophagitis and stomach ulcers
which likely were cause of her melena. Colonoscopy showed
ulceration in cecum and diverticulosis.
-Avoid NSAIDs, Hydrogen peroxide
-Cont PPI [**Hospital1 **] X6-8weeks
-Repeat EGD in [**5-9**] weeks
-No more visible bleeding per pt
-HCT down trended slightly but essentially remained stable over
2 days without visible bleeding or [**Month (only) **] in bp. Pt was asked to
return to Ed if she noticed anymore melena or
hematochezia/hematemesis
2. DOE - likely [**1-4**] to profound anemia. sx exacerbated by anemia
but continues to note significant DOE. Pt had diagnostic and
therapeutic tap as outpt on [**2-15**] and since then has
reaccumulated her large R pleural effusion. Pt is not needing
oxygen but is significantly symptomatic and would like to have
fluid removed from her lungs.
-Discussed with Onc and Interventional pulm and they will see pt
in clinic in one week and either do pleurodesis or place pleurx
catheter
-pt set up for home oxygen
3. Esophageal candidiasis - likely [**1-4**] to immuonocompromised
state from underlying malignancy and steroid use. Will tx w
diflucan for 14 days
4. Stage IV NSCLC - Diagnosed recently with malignant pleural
effusion, spread to brain including leptomeningeal involvment
and bony mets.
-SP cyberknife therapy to brain
-Currently on dexamethasone [**Last Name (LF) 15123**], [**First Name3 (LF) **] continue. Will also
continue keppra for sz prophylaxis
-Pt recently saw Oncology as oupt and is contemplating pursuing
chemo and has outpt fu with Onc soon
5. Leukocytosis - reason unclear. Pt afebrile w stable vitals.
Will check ua and blood cx. CXR w stable pleural effussions. WBC
downtrending and likely represents a leukemoid reaction
6. Depression - Continue celexa
7. HTN - bp meds held in setting of acute bleed. Pt asked to
resume them at dc
Medications on Admission:
1. Amlodipine 10mg QD
2. Dyazide 37.5/25mg QD
3. Zantac 150mg [**Hospital1 **]
4. Keppra 500mg [**Hospital1 **], end day [**3-18**]
5. Dexamethasone 2mg [**Hospital1 **] until [**3-20**], then 2mg qd until [**3-23**],
then 2mg QOD until [**3-28**]
6. Naproxyn 500mg [**Hospital1 **]
7. Advair 100/50mcg [**Hospital1 **]
8. Fluticasone 50mcg 1 spray Nostril [**Hospital1 **]
9. Celexa 30mg qd
10. Alprozalam 0.25mg [**Hospital1 **] prn
11. Tylenol #3 prn
12. Albuterol inhaler prn
Discharge Medications:
1. Home Oxygen
Home Oxygen at 2 LPM via nasal cannula conserving device for
portability
2. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Puff
Inhalation Q4H (every 4 hours) as needed.
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 12 days.
Disp:*12 Tablet(s)* Refills:*0*
6. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
7. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO twice a day:
until [**3-20**], then 2mg QD until [**3-23**], then 2mg every other day on
[**4-4**], [**3-28**] and then stop.
10. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO
every four (4) hours as needed for pain.
11. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
12. Dyazide 37.5-25 mg Capsule Sig: One (1) Capsule PO once a
day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Acute blood loss anemia likely [**1-4**] bleeding gastric ulcers
Malignant pleural effusion
Stage IV NSCLC
HTN
Discharge Condition:
Good
Discharge Instructions:
You were admitted with shortness of [**Month/Day (2) 1440**] and black stools. You
were noted to have a very low blood count due to bleeding, which
was most likely from gastric ulcers. Please do not take naproxen
or any other NSAIDs or hydrogen peroxide as it can cause the
gastric ulcers. Please take a new medication called protonix
twice a day which will help with healing of these ulcers. You
were also noted to have some changes in your esophagus which is
likely caused by a fungal infection. Please finish the course of
diflucan as you are prescribed.
You have metastatic lung cancer and fluid in your right lung
from it. It is causing your significant shortness of [**Month/Day (2) 1440**]. We
talked to your lung and cancer doctors and they would like to
see you in clinic in a few days to discuss options to remove the
fluid
Please return to Ed for worsening shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**]
black/bloody stools, vomiting of blood, fevers, chills, chest
pain
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**Telephone/Fax (1) 3020**]
Date/Time:[**2112-3-29**] 9:00
Provider: [**First Name8 (NamePattern2) 828**] [**Name11 (NameIs) 829**], MD Phone:[**Telephone/Fax (1) 5072**]
Date/Time:[**2112-3-29**] 10:00
Please call your oncologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**] on MOnday to set
up a clinic appt
|
[
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"198.5",
"162.9",
"569.82",
"311",
"198.3",
"112.84",
"584.9",
"198.4",
"562.10",
"276.52",
"401.9",
"511.81",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.25",
"45.43"
] |
icd9pcs
|
[
[
[]
]
] |
6359, 6416
|
2432, 4507
|
281, 317
|
6571, 6578
|
7628, 8055
|
1630, 1672
|
5038, 6336
|
6437, 6550
|
4533, 5015
|
6602, 7605
|
1687, 2409
|
233, 243
|
345, 1180
|
1202, 1473
|
1489, 1614
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,765
| 155,500
|
12710
|
Discharge summary
|
report
|
Admission Date: [**2152-1-31**] Discharge Date: [**2152-2-6**]
Date of Birth: [**2078-10-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2152-1-31**] - Coronary Artery Bypass Graft X 3 (LIMA > LAD, SVG >
Diag, SVG > OM)
History of Present Illness:
73 y/o gentleman with a history of multiple stents to his right
coronary artery system. Despite multiple percutaneous
interventions, he continues to experience exertional dyspnea. A
recent cardiac cathterization showed severe three vessel disease
including severe left main disease. He now presents for surgical
revascularization.
Past Medical History:
Coronary Artery Disease s/p RCA & PDA stents
Benign Prostatic Hypertrophy
Gastroesophageal reflux disease
Bladder cancer
Cateracts
Psoriasis
Sciatica
s/p Hernia repair
s/p Hemorrhoid surgery
?Hepatitis history
Social History:
+ TOB quit 40 yrs ago
ETOH occasional
Family History:
Brother [**Name (NI) 1291**] in 50's
Physical Exam:
97.3 52 SR 117/57 96% room air sat
GEN: A/O x3 NAD
PULM: CTA B
CV: RRR
ABD: soft,nt,+BS
EXT: trace edema
INC: no drainage, no erythema
Pertinent Results:
[**2152-2-6**] 06:30AM BLOOD Hct-28.6*
[**2152-2-6**] 06:30AM BLOOD PT-17.6* INR(PT)-1.6*
[**2152-2-6**] 06:30AM BLOOD UreaN-29* Creat-1.4* Na-139 K-4.8
[**2152-2-6**] CXR
Persistent, small-moderate, left-sided pleural effusion.
[**2152-2-3**] CT Scan
1. Chest x-ray nodule corresponds to a small exostosis, of no
clinical significance.
2. Fluid filled esophagus and stomach. Clinically correlate.
[**2152-1-31**] ECHO
Pre Bypass: The left atrium is elongated. No atrial septal
defect is seen by 2D or color Doppler. There is severe symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Regional left ventricular wall motion is normal.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the aortic arch and descending
thoracic aorta. The descending thoracic aorta is mildly dilated.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. Trivial mitral regurgitation is seen.
Post bypass: Preseved biventricular function LVEF > 55%. No wall
motion
changes. Aortic contours intact. TR remains mild, MR is trace to
mild.
Remaining exam is unchanged. Results discussed with surgeons at
time of the exam.
Brief Hospital Course:
Mr. [**Known lastname 39224**] was admitted to the [**2152-1-31**] for surgical management
of his coronary artery disease. He was taken to the operating
room where he underwent coronary artery bypass grafting to three
vessels. Please see operative note for detail. Postoperatively
he was taken to the cardiac surgical intensive care unit for
monitoring. On postoperative day one, Mr. [**Known lastname 39224**] [**Last Name (Titles) 5058**]
neurologically intact and was extubated. Plavix, aspirin, a
statin and beta blockade were resumed. He was then transferred
to the cardiac surgical step down unit for monitoring. Mr.
[**Known lastname 39224**] was gently diuresed towards his preoperative weight.
The physical therapy service was consulted for assistance with
his postoperative strength and mobility. His drains and pacing
wires were removed per protocol without complication. As there
was a question of a lung nodule on chest x-ray, a ct scan of his
chest was obtained. This revealed a small exotosis without
clinical significance. He had a brief episode of atrial
fibrillation which converted to normal sinus rhythm with
amiodarone. Coumadin was started for short term anticoagulation.
Mr. [**Known lastname 39224**] was noted to be thrombocytopenic and a heparin
induced thrombocytopenia assay was sent which was negative.
Vitamin C and iron were started for one month for anemia. Mr.
[**Known lastname 39224**] continued to make steady progress and was discharged
home on postoperative day six. He will follow-up with Dr.
[**Last Name (STitle) **], his cardiologist and his primary care physician as an
outpatient. His heart rate was 58 in normal sinus rhythm with a
blood pressure of 107/65. His wounds were clean, dry and intact
and his chest x-ray showed a small left sided pleural effusion
with room air saturations of 96%.
Medications on Admission:
ASA 325', Plavix 75', Imdur 30', Atenolol 12.5', Protonix 40',
Flomax 0.4', Crestor 5'
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. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7
days.
Disp:*28 Capsule, Sustained Release(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. Rosuvastatin 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1)
Capsule, Sust. Release 24HR PO HS (at bedtime).
Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2*
8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*40 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
13. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
CAD
Discharge Condition:
good
Discharge Instructions:
no creams, lotions or powders to any incisions
no lifting > 10# for 10 weeks
may shower, no bathing or swimming for 1 month
Followup Instructions:
with Dr. [**Last Name (STitle) **] in 4 weeks
with Dr. [**Last Name (STitle) **] in [**12-31**] weeks
with Dr. [**Last Name (STitle) 12184**] in [**12-31**] weeks
Completed by:[**2152-3-3**]
|
[
"997.1",
"272.0",
"600.00",
"401.9",
"427.31",
"530.81",
"414.01",
"V45.82",
"V10.51",
"413.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.05",
"99.04",
"99.07",
"36.12",
"89.60",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6365, 6423
|
2715, 4554
|
341, 429
|
6471, 6478
|
1302, 2692
|
6650, 6843
|
1094, 1132
|
4691, 6342
|
6444, 6450
|
4580, 4668
|
6502, 6627
|
1147, 1283
|
282, 303
|
457, 789
|
811, 1022
|
1038, 1078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,515
| 122,217
|
46066
|
Discharge summary
|
report
|
Admission Date: [**2126-7-15**] Discharge Date: [**2126-7-19**]
Date of Birth: [**2054-1-28**] Sex: F
Service: MEDICINE
Allergies:
Epinephrine / Bactrim DS
Attending:[**First Name3 (LF) 2751**]
Chief Complaint:
cough, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72F w/ HTN p/w sudden progressive SOB and orthopnea x 3days. no
cp. no palps. Pt has long hx of labile BP and hyponatremia. 6
weeks ago, pt was switched from HCTZ to Lasix for hyponatremia.
Pt did not tolerate Lasix as she did not like having a dry mouth
while on it and was switched to chlorthalidone. This was stopped
last Wednesday [**7-10**] [**1-24**] low Na. Admits to some b/l pedal edema
that has been improving since decreasing dose of felodipine. Now
complains of muscle pain on inspiration which started today
after exerting herself (climbing into a vehicle). Has been
coughing for past two days, non productive, no hemoptysis. Per
pt, had a temp of 100 this am and had chills. Took Tylenol
before coming to the ED.
ED Course (labs, imaging, interventions, consults):
- Initial Vitals/Trigger: hypoxic to low- to mid-80s on RA
- CXR: bilat fluffy infiltrates but pt reports fever so tx for
PNA
- CAP coverage for ICU admit w/addition of doxy to tx for
potential tularemia given recent [**Hospital3 **] visit
-1L bolus
-azithro and ceftriaxone
Initial VS in the ED were T97.6 HR76 BP 196/85 RR20 satting 94%.
Labs showed WBC of 18.3 with 87.5 PMN's, HCT of 34, plt of 485.
ProBNP was checked and was 4968. Metabolic panel showed sodium
of 130, chloride of 91, and BUN of 22, creatinine of 1.1,
potassium of 4.4 and bicarbonate of 27. ABG showed pH of 7.36
with pCO2 of 47 and pO2 on 74 on NRB. Troponins were negative x
1. Patient was provided with a baby aspirin. CxR was performed
which showed pulmonary edema with basilar opacity and likely
atelectasis. No pneumothorax was noted and heart size appeared
stable. Left and possibly small right effusions were noted. EKG
showed Q waves in III as well as V1-3 with inverted TW in
V1/V2...
Given necessity for NRB, patient was transferred to the ICU for
further care.
On arrival to the MICU, stabilized and saturating low to mid 90s
with NRB. Given zofran for nausea.
Past Medical History:
PMH:
hypertension
pulmonary hypertension
hypothyroidism secondary to thyroidectomy
poor glucose tolerance
chronic lower back pain secondary to osteoarthritis
.
PSH:
vaginal hysterectomy
bilateral salpingo oophorectomy
anterior and posterior colporrhaphy and sacrospinous colpopexy
thyroidectomy
bilateral rotator cuff repairs
Social History:
rare EtOh consumption, no Tobacco use, widowed. lives alone in
[**Location (un) **], retired medical secretary.
Family History:
both parents died of heart disease, brother had esophageal
cancer.
Physical Exam:
ON ADMISSION:
Vitals: T: 97.9 BP: 148/118 P: 78 R:25 O2: 93% NRB 15L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: bilateral crackles, L>R, expiratory wheezes
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact
.
ON DISCHARGE:
VS T 98.7 136/92 HR 96 RR 16 97RA
GEN Appears significantly brighter today. Alert, oriented, no
acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, JVD not able to be assessed [**1-24**] significant neck
mass, no LAD
PULM Good aeration, few bibasilar rales, CTAB no wheezes or
rhonchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no edema, c/c
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
[**2126-7-15**] 01:35PM BLOOD WBC-18.3*# RBC-3.98* Hgb-11.2* Hct-34.0*
MCV-86 MCH-28.2 MCHC-33.0 RDW-13.3 Plt Ct-485*
[**2126-7-15**] 01:35PM BLOOD Neuts-87.5* Lymphs-6.7* Monos-4.2 Eos-1.0
Baso-0.6
[**2126-7-15**] 06:45PM BLOOD PT-10.9 PTT-29.4 INR(PT)-1.0
[**2126-7-15**] 01:35PM BLOOD Glucose-164* UreaN-22* Creat-1.1 Na-130*
K-4.4 Cl-91* HCO3-27 AnGap-16
[**2126-7-15**] 06:45PM BLOOD ALT-14 AST-22 AlkPhos-65 TotBili-0.7
[**2126-7-15**] 01:56PM BLOOD Lactate-1.1
[**2126-7-15**] 01:35PM BLOOD proBNP-4968*
[**2126-7-15**] 06:45PM BLOOD proBNP-8152*
[**2126-7-15**] 01:35PM BLOOD cTropnT-<0.01
[**2126-7-15**] 10:35PM BLOOD cTropnT-0.03*
[**2126-7-16**] 06:18AM BLOOD cTropnT-0.02*
.
DISCHARGE LABS:
[**2126-7-19**] 07:10AM BLOOD WBC-6.6 RBC-3.17* Hgb-8.9* Hct-26.7*
MCV-84 MCH-28.0 MCHC-33.2 RDW-13.1 Plt Ct-374
[**2126-7-19**] 07:10AM BLOOD Glucose-120* UreaN-21* Creat-1.0 Na-135
K-4.1 Cl-96 HCO3-31 AnGap-12
[**2126-7-19**] 07:10AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.8
.
MICRO:
[**2126-7-15**] Blood cultures: no growth to date
[**2126-7-16**] Urine culture: no growth
.
IMAGING:
[**2126-7-15**] CXR: There is pulmonary edema with basilar opacity
likely atelectasis. No pneumothorax. Heart size appears stable.
Left effusion, possibly small right effusion noted.
.
[**2126-7-16**] TTE: The left atrium is mildly dilated. The estimated
right atrial pressure is 5-10 mmHg. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion. There is an anterior space which most likely
represents a prominent fat pad. Compared with the prior study
(images reviewed) of [**2124-5-29**], the estimated pulmonary artery
systolic pressure is now higher. There is now borderline tissue
Doppler/mitral inflow evidence of high left ventricular
diastolic filling pressures.
.
[**2126-7-17**] CT Chest w/o con:
1. Mild residual pulmonary edema can explain the lung opacities
and pleural effusion. Considering the rapid evolution of the
opacities, it is certainly the privileged diagnosis.
Superimposed infection cannot be excluded but is less likely.
2. Left renal lesions, probably cysts, but a son[**Name (NI) **] is
suggested.
Brief Hospital Course:
72 year old woman with a history of HTN and pulmonary HTN who
presents with SOB and hypoxia.
.
# Hypoxia, SOB: CHF versus pneumonia were on differentials.
Pneumonia was considered with pt's history of progressively
worsening cough and shortness of breath with leukocytosis and
subjective fevers. On hospital Day 2, pt was febrile to 101F and
was started on Levaquin. CXR shows pleural effusions but no
lobar consolidations, and given that pt recently stopped
diuretics, it was likely pt was fluid overloaded. This was
supported by pt's elevated BNP. TTE showed moderate mitral
regurgitation and pulmonary hyptertension (stable from prior).
Pt was diuresed with Lasix and given captopril for BP control
but was discontinued after UOP decreased and creatinine
increased. Pt did well with antibiotic and her oxygen
supplementation was weaned. She was discharged on levofloxacin
to complete a 7-day course, as well as furosemide 10mg daily
until she sees her PCP [**Last Name (NamePattern4) **] [**7-25**].
.
# HTN: Pt was on felodipine, atenolol and Losartan as an
outpatient. Pt came in with SBP in 190s and we continued
felodipine and started TID captopril. On hospital day 2 pt
became oliguric and Cr bump to 1.3 and thus stopped captopril.
SBP in 130s and we restarted home atenolol. Once [**Last Name (un) **] resolved,
all home antihypertensive medications were resumed, as well as
furosemide as noted above.
.
# Anxiety: Pt was having multiple anxiety episodes upon
admission and we continued her home diazepam. During these
episodes, pt's BP increased significantly with tachycardia and
had periods of nausea. Pt received valium at night and an ativan
when she was particularly anxious.
# Hyponatremia: Pt's sodium remained low throughout MICU course
and has a history of having diuretics changed due to
hyponatremia. Urine lytes, osm and urea were checked which
showed low Na and osm consistent with dehyradation. Pt was
hydrated and hypoNa resolved.
# Anemia: Pt has h/o of anemia which had been worked up recently
with EGD and colonoscopy. Would recommend outpatient follow-up
given that her Fe was 7 and TIBC was low during admission.
.
# Hypothyroidism: Chronic and stable. We continued Synthroid at
home dose.
.
# Renal lesions: Two renal lesions were seen incidentally on CT.
Recommend that PCP get renal ultrasound to further characterize
and to eval for renal cell carcinoma (considering her iron
deficiency anemia of unclear etiology).
.
# Transitional Issues:
- Needs renal ultrasound
- Anemia workup
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Omeprazole 20 mg PO BID
2. Atenolol 50 mg PO DAILY
3. butalbital-acetaminophen-caff *NF* 50-325-40 mg Oral q4-6 PRN
headache
4. Levothyroxine Sodium 125 mcg PO DAILY 6/7 DAYS OF WEEK
Do not give on Sunday
5. Acyclovir 200 mg PO FIVE TIMES DAILY PRN herpes outbreak
6. Atorvastatin 10 mg PO DAILY
7. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
8. Cyanocobalamin 1000 mcg IM/SC MONTHLY
9. Diazepam 2 mg PO Q8H:PRN anxiety
10. Felodipine 5 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Estrogens Conjugated 0.625 mg PO DAILY
13. Losartan Potassium 100 mg PO DAILY
14. MetFORMIN (Glucophage) 1000 mg PO BID
15. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Diazepam 2 mg PO Q8H:PRN anxiety
4. Estrogens Conjugated 0.625 mg PO DAILY
5. Felodipine 5 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY 6/7 DAYS OF WEEK
Do not give on Sunday
7. Losartan Potassium 100 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Omeprazole 20 mg PO BID
10. Levofloxacin 500 mg PO DAILY Duration: 3 Days
RX *levofloxacin 500 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
11. Acyclovir 200 mg PO FIVE TIMES DAILY PRN herpes outbreak
12. Aspirin 81 mg PO DAILY
13. butalbital-acetaminophen-caff *NF* 50 mg ORAL Q4-6 PRN
headache
14. Calcium Carbonate 500 mg PO QID:PRN dyspepsia
15. Cyanocobalamin 1000 mcg IM/SC MONTHLY
16. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
17. Furosemide 10 mg PO DAILY
To be taken until you see your primary care doctor Dr. [**Last Name (STitle) **]
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: community acquired pneumonia, pulmonary edema
Secondary: hypertension, pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. [**Known lastname 4610**],
.
It was our pleasure caring for you at [**Hospital1 827**]. You were admitted because you have been having
shortness of breath and fevers. The chest x-ray and cat scan
show that you have pneumonia as well as fluid in your lungs
which is likely related to the pneumonia. You also have
pulmonary hypertension which has been a longstanding issue, but
which may be contributing. We are treating you with an
antibiotic called levofloxacin and restarted lasix (a diuretic)
to remove the fluid from your lungs until you see your primary
care doctor and/or cardiologist at which time they may decide to
stop this.
.
You are anemic which is not new, but which is slightly worse
than prior, and you were found to have low iron. Your primary
care doctor will need to do further workup for this.
.
The cat scan showed two lesions in your kidneys which may be
benign cysts, however your primary care doctor will need to do
further workup for this.
.
We made the following changes to your medications:
1. START levofloxacin (an antibiotic) 500mg daily to be taken
through [**2126-7-22**]
2. START furosemide (Lasix) 10mg daily until you see Dr. [**Last Name (STitle) **]
3. START benzonatate (Tessalon perles) as needed for cough
.
Please continue to take all of your home medications as
previously prescribed.
Followup Instructions:
Department: [**Hospital **] MEDICAL GROUP
When: THURSDAY [**2126-7-25**] at 3:00 PM
With: DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2400**] [**Telephone/Fax (1) 133**]
Building: [**Street Address(2) 3375**] ([**Location (un) **], MA) [**Location (un) 858**]
Campus: OFF CAMPUS
Best Parking: On Street Parking
.
We are working on a follow up appointment for your
hospitalization in Cardiology with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. It is
recommended you be seen within 2 weeks of discharge. The office
will contact you at home with an appointment. If you have not
heard within 2 business days please call the office at
[**Telephone/Fax (1) 62**].
.
Department: OPTHALMOLOGY
When: WEDNESDAY [**2126-9-4**] at 3:30 PM [**Telephone/Fax (1) 253**]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: [**Hospital3 1935**] CENTER
When: THURSDAY [**2126-9-5**] at 12:30 PM
With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST
Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"518.0",
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"338.29",
"416.8",
"244.0",
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"280.9",
"428.0",
"276.1",
"486",
"584.9",
"721.3",
"593.9",
"300.00"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
11180, 11186
|
6857, 9312
|
312, 319
|
11333, 11333
|
4063, 4063
|
12842, 14048
|
2783, 2851
|
10183, 11157
|
11207, 11312
|
9403, 10160
|
11484, 12480
|
4783, 6834
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2866, 2866
|
3527, 4044
|
12509, 12819
|
246, 274
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347, 2287
|
4079, 4767
|
2880, 3513
|
11348, 11460
|
9335, 9377
|
2309, 2636
|
2652, 2767
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,125
| 147,262
|
33921
|
Discharge summary
|
report
|
Admission Date: [**2165-6-18**] Discharge Date: [**2165-7-10**]
Date of Birth: [**2137-4-23**] Sex: F
Service: MEDICINE
Allergies:
Azithromycin / Levaquin
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Fever and altered mental status
Major Surgical or Invasive Procedure:
Lumbar puncture, muscle (left deltoid) biopsy, bronchial lavage,
lymph node biopsy, intubation x 2
History of Present Illness:
Ms. [**Known lastname **] is a 28 year old female with a reported history of
"connective tissue disorder" NOS that was diagnosed a number of
years ago for which she was previously maintained on Prednisone
1mg daily as well as Plaquenil. Apparently the patient had
self-discontinued her Plaquenil a couple months ago secondary to
concern for photosensitivity. More recently, approximately 3
weeks ago, the patient started developing symptoms of low grade
fevers and muscle aches in her proximal thighs in associatio
with reported URI symptoms such as pharyngitis and sinus
congestion. Over the last three weeks the patient's symptoms
have progressed with increasing severity of fevers, reaching as
high as 102.0 as well as worsening muscle aches. Given her
symptoms the patient was referred to a Rheumatologist, Dr.
[**Last Name (STitle) 1693**], at [**Hospital1 **].
Per conversation with Dr. [**Last Name (STitle) 1693**] his initial impression was
that the patient had evidence of polymyositis given quad and hip
flexor weakness with elevated aldolase and CPK. Lab work up at
that time was revealing for a negative [**Doctor First Name **] and Rheumatoid Factor
although the patient did have weakly positive DS-DNA, SS-A and
U1-RNP. SS-B, SCL-70 and [**Doctor First Name **]-1 all negative. Given definite
diagnosis was not secured at this time plan was for muscle
biopsy, scheduled to be performed today. Lab work also revealed
a leukocytosis to 15 range with as much as 15% bandemia. The
patient was referred to see Dr. [**First Name (STitle) **], Infectious Disease
physician at [**Name9 (PRE) **]. Etiology of the patient's
symptoms were not apparent although concern for tick-born
illness was raised for which Lyme, Babesia, Ehrlichia titers
were sent, all negative. Blood cultures have remained negative
to date. During this time, the patient received an empiric
course of Azithromycin x 5 days by her PCP which was
discontinued because of the evolution of a maculopapular rash
over her proximal thighs although question has been raised
whether this is related or not that antibiotics course. The
patient additionally received a course of Doxycycline while
serologies for tick-borne illnesses were pending.
Over the last week the patient has had increasing pain in
her legs which affected her quality of life. Given this her
rheumatologist opted to start treatment Friday, 4 days prior to
admission with Prednisone 10mg tid, the patient was actually
taking 45mg daily. Over the last couple of days the patient has
had intermittent "sleepiness" per her mother's report. This
morning the patient was very sleepy and had a fever to 104.0 for
which she presented to [**Hospital1 18**].
.
ED Course: In the ED the patient was reportedly agitated and
speaking only Cantonese (although she does speak fluent
English). Given concern for meningitis the patient received
Vanc, CTX and Acyclovir as well as Dexamethasone after blood
cultures were obtained. LP was not consistent with meningitis
(OP 22). Urine was negative for UTI. Labs were pertinent for
mild transaminitis in setting of CK of 1000 with WBC 21.1 with
17% Bandemia. The patient is now being admitted to medicine for
ongoing management and care.
Past Medical History:
Reported history of Connective Tissue Disorder NOS
Social History:
The patient was born in [**Location (un) 6847**] and lives in [**Location 86**] and is
studying for her MBA at [**Last Name (un) 7700**]. Per ID notes patient lives by
herself (roommate moved out 1 week) without known sick contacts.
She has no pets, traveled to [**State 531**] a few weeks ago. Last
Winter she travelled to [**Location (un) 6847**] and [**Country 14635**] without event. She
is near wooded areas but no known tick and insect exposures.
Tobacco: None
ETOH: None
Illicts: None
Denies high risk behaviors (ie unprotected sexual intercourse,
IV drug use)
Family History:
No history of rheumatoid diseases.
Physical Exam:
(Upon transfer to MICU)
T: 101.F BP: 90/73 HR: 114 RR: 27 SaO2: 97% 15L NRB, Pulsus
6mmHg
Gen: Asian female, intermittently answering questions
appropriately, complaining of being cold. Follows simple
commands.
HEENT: NCAT, EOMI, sclerae anicteric, no conjunctival injection.
+periorbital edema. OP clear with no lesions or exudates, no
buccal or labial sores/ulcers.
Neck: Supple, no LAD, no JVD or meningismus
Chest: Bibasilar crackles, no wheezing
Cor: Tachycardic, nl S1 and S2, no m/r/g
Abd: Soft, NT/ND, hypoactive but positive bowel sounds, no
masses appreciated, no HSM.
Extr: Maculopapular rash over medial and anterior thighs, with
evidence of excoriations. No inguinal adenopathy. Pulses 2+
bilaterally, no LE edema. Nodules on R 2nd and 3rd DIPs.
Neuro: Intermittently cooperative. A&Ox1. CNII-XII intact.
Uncooperative with formal strength testing, but MAEW. Downgoing
toes. DTRs 2+ and symmetric bicep, tricep, patella, ankle jerk.
Pertinent Results:
[**6-18**] HEAD CT WITHOUT IV CONTRAST: Please note, the study is
limited due to patient motion despite repeated attempts.
However, there is no hemorrhage, mass effect, edema, or shift of
normally midline structures. Incidental note is made of a CSF
space between the lateral ventricles likely representing a cavum
velum interpositum, a congenital variant. The [**Doctor Last Name 352**]- white matter
differentiation is preserved. The ventricles and sulci are
normal in size and configuration. The visualized paranasal
sinuses are unremarkable. There is no fracture. IMPRESSION: No
evidence of hemorrhage or edema.
.
[**6-18**] CXR: There is diffuse perivascular haziness seen in both
lungs. No focal infiltrate is seen. The heart size is top
normal. There is no pleural
effusion. IMPRESSION: 1. Mild vascular congestion and edema. 2.
No definite pneumonia. Followup examination after treatment of
edema is recommended.
.
[**6-18**] CT Chest/Abd/pelvis: 1. Abnormal lymph node conglomerate in
the axillary and mediastinal nodal stations. Given history of
presumed connective tissue disease status post treatment,
lymphoproliferative disorder may be considered. 2. Bilateral
lower lobe ground-glass opacity may be related to breathing
artifact versus atelectasis. 3. Small pericardial effusion.
.
[**6-18**] MRI Head: Normal MR head. No evidence to suggest infection,
vasculitis, or cerebritis. Final Attending Comment: 1.There is a
tiny puntate focus of restricted diffusion left frontal lobe ,
may be artifactual versus tiny acute infarct.There is no
associated mass
effect. 2. There is mildly prominent vascular enhancement.
.
[**6-20**] Skin biopsy: 1. Skin, left superior thigh; punch biopsy
(A): Sparse perivascular mononuclear cell infiltrate (see
comment). Multiple tissue levels examined. 2. Skin, left
inferior thigh; punch biopsy (B): Sparse perivascular
mononuclear cell infiltrate (see comment). Multiple tissue
levels examined. Comment: The changes in both biopsies are
similar and minimal. There are very scant dyskeratotic
keratinocytes within the epidermis but other interface changes
are not appreciated. Vascular ectasia is present in the
superficial dermis, with focal red blood cell extravasation.
There is also a sparse perivascular mononuclear cell infiltrate,
focal perifollicular inflammation and very rare foci of acute
inflammatory cells. The appearances are non-specific and are not
diagnostic. In the correct clinical setting they are compatible
with a viral exanthem. Diagnostic changes of a connective tissue
disease, lymphoma or Still's disease are not identified in these
samples. No fungal or bacterial organisms are identified on GMS
or Gram stains, respectively (performed on both biopsies).
.
[**6-20**] Bronchial lavage: NEGATIVE FOR MALIGNANT CELLS.
.
[**6-21**] CXR: There is marked increase in bilateral now confluent
airspace opacities involving the entire lung. Given diffuse
process obscuring bilateral costophrenic angles, underlying
effusions cannot be excluded. No pneumothorax is detected. Lines
and tubes remain in satisfactory position, unchanged.
.
[**6-25**] CXR PORTABLE: The patient is status post removal of the NG
tube and endotracheal tube. The left IJ is in place. The heart
size is mildly enlarged. There is interval increase in bilateral
interstitial markings compatible with mild pulmonary edema. No
pleural effusion or pneumothorax is detected. No focal
consolidation. IMPRESSION: Status post removal of the
endotracheal tube and NG tube with development of mild pulmonary
edema.
.
[**7-5**] CXR AP/Lat: In comparison with the study of [**6-25**], the
cardiac silhouette remains mildly enlarged. The increased
pulmonary venous pressure is less apparent on the current study.
No evidence of acute pneumonia or pleural effusion.
.
[**2165-7-6**] 07:10AM BLOOD WBC-17.1* RBC-3.08* Hgb-9.6* Hct-29.0*
MCV-94 MCH-31.3 MCHC-33.2 RDW-19.1* Plt Ct-517*
[**2165-7-5**] 06:20AM BLOOD WBC-18.0* RBC-3.06* Hgb-9.5* Hct-28.9*
MCV-95 MCH-31.2 MCHC-33.1 RDW-19.6* Plt Ct-496*
[**2165-6-18**] 10:00PM BLOOD WBC-13.9* RBC-3.40* Hgb-10.2* Hct-30.6*
MCV-90 MCH-30.0 MCHC-33.4 RDW-14.3 Plt Ct-357
[**2165-6-18**] 08:00AM BLOOD WBC-21.1* RBC-4.07* Hgb-12.1 Hct-36.7
MCV-90 MCH-29.7 MCHC-33.0 RDW-14.3 Plt Ct-443*
[**2165-7-1**] 06:35AM BLOOD Neuts-84* Bands-2 Lymphs-7* Monos-4 Eos-1
Baso-0 Atyps-0 Metas-0 Myelos-2*
[**2165-6-18**] 08:00AM BLOOD Neuts-80* Bands-17* Lymphs-3* Monos-0
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2165-7-1**] 06:35AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Target-OCCASIONAL
Tear Dr[**Last Name (STitle) **]1+
[**2165-6-18**] 08:00AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-2+
[**2165-7-5**] 06:20AM BLOOD PT-11.8 PTT-23.6 INR(PT)-1.0
[**2165-6-19**] 07:05AM BLOOD ESR-39*
[**2165-6-18**] 10:00PM BLOOD Parst S-NEGATIVE FOR INTRA OR
EXTRACELLULAR FORMS
[**2165-7-6**] 07:10AM BLOOD Glucose-79 UreaN-16 Creat-0.6 Na-139
K-4.2 Cl-103 HCO3-24 AnGap-16
[**2165-6-19**] 07:05AM BLOOD Glucose-95 UreaN-10 Creat-0.6 Na-133
K-4.5 Cl-98 HCO3-25 AnGap-15
[**2165-6-18**] 08:00AM BLOOD Glucose-104 UreaN-10 Creat-0.6 Na-131*
K-4.1 Cl-95* HCO3-26 AnGap-14
[**2165-7-2**] 06:20AM BLOOD CK(CPK)-584*
[**2165-6-27**] 06:25AM BLOOD CK(CPK)-655*
[**2165-6-21**] 05:13PM BLOOD ALT-44* AST-56* LD(LDH)-515* AlkPhos-61
TotBili-0.2
[**2165-6-18**] 08:00AM BLOOD ALT-44* AST-96* LD(LDH)-703*
CK(CPK)-1116* AlkPhos-64 TotBili-0.3
[**2165-6-19**] 10:06PM BLOOD ALT-49* AST-101* LD(LDH)-743*
CK(CPK)-1327* AlkPhos-54 Amylase-46
[**2165-6-20**] 03:49PM BLOOD Lipase-24
[**2165-7-2**] 06:20AM BLOOD CK-MB-7
[**2165-7-6**] 07:10AM BLOOD Calcium-8.7 Phos-5.0* Mg-2.4
[**2165-6-19**] 07:05AM BLOOD TotProt-6.8 Albumin-3.1* Globuln-3.7
Calcium-8.1* Phos-3.8 Mg-2.1
[**2165-6-20**] 03:49PM BLOOD Albumin-2.2* Calcium-6.3* Phos-2.8 Mg-2.3
[**2165-6-20**] 03:49PM BLOOD Cryoglb-NEGATIVE
[**2165-6-19**] 07:05AM BLOOD Ferritn-5120*
[**2165-6-18**] 08:00AM BLOOD VitB12-972* Folate-9.4
[**2165-6-20**] 03:49PM BLOOD Triglyc-249*
[**2165-6-19**] 07:05AM BLOOD TSH-3.1
[**2165-6-18**] 08:00AM BLOOD TSH-1.4
[**2165-6-18**] 08:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2165-6-19**] 07:05AM BLOOD ANCA-NEGATIVE B
[**2165-6-19**] 07:05AM BLOOD [**Doctor First Name **]-POSITIVE Titer-GREATER TH
dsDNA-NEGATIVE
[**2165-6-19**] 07:05AM BLOOD CRP-44.1*
[**2165-7-2**] 06:20AM BLOOD C3-79* C4-11
[**2165-6-20**] 03:49PM BLOOD C3-98 C4-14
[**2165-7-3**] 07:15AM BLOOD HIV Ab-NEGATIVE
[**2165-6-25**] 03:57AM BLOOD Type-ART Temp-37.9 Rates-12/ FiO2-50
pO2-138* pCO2-47* pH-7.48* calTCO2-36* Base XS-10 Intubat-NOT
INTUBA Comment-98.3F
[**2165-6-19**] 08:13PM BLOOD Type-ART pO2-57* pCO2-31* pH-7.47*
calTCO2-23 Base XS-0
[**2165-6-20**] 04:47AM BLOOD Type-ART Temp-38.8 Rates-20/10 Tidal
V-396 PEEP-5 FiO2-100 pO2-145* pCO2-42 pH-7.35 calTCO2-24 Base
XS--2 AADO2-545 REQ O2-88 INTUBATED
[**2165-7-3**] 07:15AM BLOOD ALDOLASE-Test
[**2165-7-2**] 06:20AM BLOOD DNA AUTOANTIBODIES, SS-Test
[**2165-7-2**] 06:20AM BLOOD SM ANTIBODY-Test
[**2165-6-20**] 07:19PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY, IGG-Test
[**2165-6-20**] 07:19PM BLOOD MYCOPLASMA PNEUMONIAE ANTIBODY IGM-Test
[**2165-6-19**] 07:05AM BLOOD SM ANTIBODY-Test
[**2165-7-7**] 04:10PM BLOOD WBC-20.9* RBC-3.17* Hgb-9.8* Hct-29.8*
MCV-94 MCH-31.0 MCHC-32.9 RDW-18.7* Plt Ct-538*
[**2165-7-7**] 04:10PM BLOOD LD(LDH)-369* TotBili-0.4 DirBili-0.1
IndBili-0.3
[**2165-7-7**] 04:10PM BLOOD Hapto-352*
[**2165-7-6**] 07:10AM BLOOD VitB12-587 Folate-8.6
Brief Hospital Course:
28F with h/o of connective tissue disorder NOS maintained on low
dose prednisone and Plaquenil, the latter self-d/c'ed 2-3 months
ago for unclear reasons. She began developing symptoms of fevers
and proximal thigh myalgias with additional symptoms of sore
throat and sinus congestion 3 weeks ago. Her fevers and thigh
pain worsened progressively over the next 2-3 weeks. CK and
aldolase were found to be significantly elevated, and she was
noted to have a leukocytosis to 15 with 15% bandemia. She was
seen by a rheumatologist at NWH, who suspected possible
polymyositis, and scheduled an outpatient muscle biopsy. She was
also seen by an ID specialist, who had concerns of tick-borne
illness. Lyme, babesia, and Ehrlichia titers were negative, and
BCx were negative x 2. She was treated empirically with
Azithromycin x 5 days, which was d/c'ed due to the evolution of
a maculopapular rash on her proximal thighs, though it was
unclear whether the antibiotic was associated with the rash. She
also received doxycycline while tick-borne serologies were
pending. Four days PTA she was started on prednisone 10mg PO
tid, with no improvement. When her leg pain worsened and fever
increased to 104F, she was sent to the ED.
.
In the ED she was found to be agitated and confused, tachycardic
to 120s with BP 100s/60s. Her wbc was 21.1 with 17% bands. and
was initially covered with vanc/CTX/acyclovir/dexamethasone
until LP showed no evidence of bacterial meningitis, at which
point all but acyclovir were d/c'ed. She was noted to have a
mild transaminitis and elevated CK to 1000s. UA negative. CXR,
then subsequent chest CT demonstrated axillary and mediastinal
lymphadenopathy, mild bibasilar ground glass infiltrates c/w
atelectasis, and a small pericardial effusion.
.
On the floor, ID, neurology, and rheumatology teams were
consulted, with work-up continuing. A recommendation was made by
rheumatology to hold on steroids until infectious etiologies
were ruled out. Relevant results include CK 1161, ferritin
higher than [**2157**], ESR 39, CRP 44, LDH 675, ALT 53, AST 108. A
decision was made to electively intubate her for an MRI, due to
concerns about HSV encephalitis or CNS vasculitis. She was
successfully extubated and monitored in the PACU with an
uneventful course, confused but hemodynamically stable and
satting 98% on RA at the time of transfer back to the medicine
floor. About 2 hours later, the patient was noted to complain of
cough and dyspnea. Her vitals were found to be BP 97/58 (recent
baseline 100s/60s), HR 120, RR 28, SaO2 69% RA. She was
combative and attempted to remove O2. On intermittent 3L NC, her
ABG was 7.47/31/57. A CXR demonstrated bilateral infiltrates,
new from the day before. Infiltrates were not perihilar, and
consistent with non-hydrostatic pulmonary edema or [**Year (4 digits) **]. She
experienced cough productive of blood-tinged sputum. Combative
with her NRB, she was 93%, and a decision was made to transfer
to the MICU for further care.
.
She remained intubated in the ICU from HD#2-HD#8, while further
workup by ID, neurology, hematology, and rheumatology occurred.
Skin biopsy and lymph node biopsy were performed without
significant results. Infectious workup continued to be
unrevealing. Please see pertinent results section for specific
studies/lab results. Pt was started on vancomycin and
levo/flagyl for presumed aspiration pneumonia. On HD#8, she was
successfully extubated and transferred to the floor.
.
Please see the following problem list for details regarding pt's
[**Hospital1 **] course:
.
*) Fever: Pt continued to have fevers which responded quickly to
antipyretics. Broad differential included rheumatologic,
infectious, and neoplastic etiologies. No clear evidence of
viral or bacterial infection on cultures. Derm, rheum, ID, and
heme following. Rheum feels is mixed connective tissue disease,
heme does not feel is c/w hemophagocytosis as cell counts
stable. Please see labs for full immunologic workup. Patient
continued on IV methylprednisolone, which was tapered and
eventually was transitioned to prednisone PO 40mg on [**6-27**];
patient remains on this dose at discharge, and prednisone
tapering is to occur with rheumatology as an outpatient. She was
also given a one time dose of Solumedrol 100mg IV on the day
preceding discharge to persistent fever and moreso increasing
arthralgias. At discharge, we strongly felt that the cause of
the fevers was moreso rheumatologic - possibly a lupus-like
syndrome - than infectious. She did complete a prolonged course
of vancomycin, levofloxacin, and flagyl for possible aspiration
pneumonia. All cultures (blood, urine, sputum) were no growth at
final reads. C. difficile toxin neg x2, and HIV Ab and viral
load negative. As fevers were uncomfortable for patient and
persistent, she was started on standing acetaminophen. Standing
ibuprofen was later added to for her arthralgias but of course
also has antyi-pyretic properties. Her fever was well-controlled
with this regimen at discharge.
.
*) Hypoxic resp failure/ARDS: Inciting event unclear but was due
to [**Name (NI) **] (although BAL was bland) vs. rheum etiology as would
think aspiration PNA would not resolve so quickly. Patient had
no evidence of tamponade on echocardiogram, though she was found
to have persistent small amount of fluid surrounding her heart.
Pt was extubated successfully towards the end of her MICU stay
and, on the floor, continued to sat very well on room air. Of
note, patient has persistent crackles, inspiratory > expiratory,
particularly bibasilar. This may be secondary to resolving ARDS
vs. interstitial inflammatory process related to her underlying
rheumatologic condition.
.
*) Encephalopathy: Improved. Neurology following. MRI results
negative for causative agents. Infectious evaluation as above.
Mental status continued to improve.
.
*) Orthostatic hypotension: Possibly secondary to autonomic
dysfunction from deconditioning. Slight concern for adrenal
insufficiency in setting of high doses of IV steroids. BP stable
when supine throughout day. Pt cautioned to rise slowly, always
with assistance. Encouraged PO intake to increase volume. At
discharge, patient with excellent PO intake. She has also been
ambulating very well with nurses and physical therapy.
.
*) Myopathy - Patient presented with considerable muscle
weakness, particularly in her proximal muscles. Neurology
determined through physical examination and EMG that her weakest
muscle was her deltoid. EMG indicated a myopathy, and the
results of a subsequent left deltoid biopsy are still pending.
As above, at discharge, the patient is being continued on
prednisone 40mg/day. Rheumatology to taper beginning at
outpatient visit this week. Further medication therapy will be
dependent on biopsy results.
.
*) Arthralgias - Surprising in light of high dose steroids.
Ibuprofen 600mg TID helps to ease the pain, but patient was
given solumedrol 100mg IV x1 to try to break her pain cycle. She
will be continued on the ibuprofen until see by rheumatology.
.
*) Left vocal cord paralysis - Patient suffered a left vocal
paralysis secondary to intubation. She had a normal swallow
study (ie. no indicaton of aspiration), and is to follow-up with
ENT as outpatient for possible surgery to repair vocal cord. F/u
scheduled for late [**Month (only) 205**], patient will make appointment.
.
*) Tachycardia - Persistent since admission. Asymptomatic. DDx
hypotension (although low BP may be patient's baseline) vs.
myocarditis (small pericardial effusion noted on TTE) vs.
infection vs. anemia vs. acute exacerbation of lupus-like
disease. A clear source was not found, but again the most likely
diagnosis was believed to be rheumatologic. Patient was not
given medication to control heart rate, but given the risk of
tachycardia-induced cardiomyopathy, the use of a low-dose
beta-blocker may be helpful.
.
*) Hypomania [**2-9**] steroid use - Psychiatry evaluated the patient.
Patient with labile mood, and clear concern regarding leaving
the hospital and resuming her normal daily routine. Patient was
reassured on a daily basis, and started on Seroquel for
insomnia, 50mg QHS standing as needed.
.
*) Anemia - Patient at presentation had hct of 36.7. [**Month (only) 116**] have
been [**2-9**] daily blood draws, but will investigate further.
Concern for hemolysis. Retic count highly elevated at 7.2. B12,
folate were found to be normal. LDH was elevated. Anemia was
steady at 36.7 upon discharge.
Medications on Admission:
Prednisone - previously 1mg daily
30mg daily as of [**2165-6-14**]
Claritin PRN
Tylenol PRN
Ibuprofen PRN
.
Allergies: Azithromycin - question if etiology of rash
Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: 1.5 Tablet,
Chewables PO BID (2 times a day).
Disp:*90 Tablet, Chewable(s)* Refills:*2*
2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
3. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
5. Omeprazole 20 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:*0*
6. Outpatient Physical Therapy
Please evaluate and treat for strength and endurance training.
7. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary:
1. Mixed connective tissue disorder vs. lupus-like syndrome
2. Fever of unknown origin
3. Tachycardia
4. Delirium/encephalopathy, now resolved
5. Steroid-induced hypomania
6. Acute lung injury, now resolved
Discharge Condition:
Hemodynamically stable. Ambulatory.
Discharge Instructions:
You were admitted with recurrent fevers, muscle pain, and mental
status changes. You had an extensive workup which included an
MRI requiring intubation, after which you had significant
trouble with breathing and required reintubation. Your doctors
feel that your symptoms were due to your rheumatologic disease.
You were maintained on steroids and NSAIDs and supported
symptomatically through your recovery. You also had a biopsy of
your deltoid muscle to help determine the cause of your
symptoms. You worked with physical therapy and had a signficant
improvement in your strength over the time course of your
admission. You currently have vocal cord paralysis, which is
most likely due to intubation.
Your medication regimen has changed since being in the hospital.
Please review your medications carefully and be sure to take
them as directed.
It is very important to make it to your follow-up appointments
as scheduled.
Please seek immediate medical attention for any of the
following: worsening fever, shortness of breath, changes in
mental status, or for any other concerns.
Followup Instructions:
- ENT
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 39**], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 41**]
Date/Time:[**2165-7-18**] 2:45pm
[**Last Name (NamePattern1) **]. [**Location (un) 895**]
- Rheumatology
Dr. [**First Name (STitle) **] [**Name (STitle) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2165-7-16**]
12:30
- Psychiatry
Please contact your school health care center for psychiatric
follow-up.
- Primary care
Provider: [**Name10 (NameIs) 50967**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2165-7-18**] 2:00
*Your arm sutures will be removed by Dr. [**Last Name (STitle) **]
*He may refer you to [**Company 191**]-Social Work, or Psychiatry.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2165-7-18**]
|
[
"309.28",
"710.8",
"478.30",
"348.30",
"518.81",
"507.0",
"283.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"83.21",
"40.11",
"86.11",
"33.24",
"96.72",
"96.6",
"03.31",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
22404, 22462
|
12925, 21407
|
315, 416
|
22722, 22760
|
5355, 12902
|
23892, 24783
|
4338, 4374
|
21620, 22381
|
22483, 22701
|
21433, 21597
|
22784, 23869
|
4389, 5336
|
244, 277
|
444, 3662
|
3684, 3737
|
3753, 4322
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,971
| 183,031
|
10962
|
Discharge summary
|
report
|
Admission Date: [**2148-7-24**] Discharge Date: [**2148-8-3**]
Date of Birth: [**2085-5-15**] Sex: M
Service:
CHIEF COMPLAINT: Cough and shortness of breath.
HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old man
from [**State 4565**] with a 2-month progressive history of
shortness of breath. Initial radiologic studies showed a
left pleural mass which was biopsied and shown to be an
epithelial type malignant mesothelioma with no evidence of
metastasis. The patient denies exposure to asbestos but does
state that his father was a shipbuilder during World War II
who would have worked with asbestos. The patient had lost 17
pounds in the last two to three weeks.
PAST MEDICAL HISTORY: Coronary artery disease, status post
left anterior descending artery percutaneous transluminal
coronary angioplasty in [**2141**]. No diabetes or other CAs.
PAST SURGICAL HISTORY: Hernia operation.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: [**Last Name (LF) **], [**First Name3 (LF) **].
PHYSICAL EXAMINATION ON ADMISSION: Initial weight was
215 pounds, SaO2 92% on room air. Cardiovascular revealed a
regular rate and rhythm. Abdomen had no masses, soft,
nontender, and nondistended. Extremities had no peripheral
edema.
HOSPITAL COURSE: On [**7-24**] the patient was brought to the
operating room with an initial diagnosis of mesothelioma, and
the patient had a left extra pleural pneumonectomy which he
tolerated well and was transferred to the Surgical Intensive
Care Unit.
On postoperative day one, the patient did well. The
patient's Intensive Care Unit stay was uneventful, and the
patient was transferred to the floor on [**7-27**]. The
patient initially progressed well with ambulation and was
scheduled for discharge home.
On postoperative day eight, the patient was noted to have
orthostatic hypotension with a decrease between 10 to 30
units systolic blood pressure.
On postoperative day nine, the patient continued to have
orthostatic hypotension and was given 150 cc piggyback of
albumin which resulted in no change in his orthostatic
numbers. The highest physical therapy level the patient
achieved during his hospital stay was a stage IV, and at
discharge was roughly a stage III. The patient was
reassessed, and the decision was made to transfer the patient
to rehabilitation to continue with physical therapy.
PHYSICAL EXAMINATION ON DISCHARGE: Temperature 98.4
Fahrenheit, heart rate 67, respiratory rate 20, 97% on room
air, blood pressure 110/70, 70 cc in p.o. and 90 cc out of
urine. Cardiovascular had a regular rate and rhythm.
Respiratory was clear to auscultation with decreased breath
sounds on the left. Abdomen was soft, nontender, and
nondistended, positive bowel sounds. The incision was clean,
dry and intact. Extremities had slight peripheral edema with
swelling.
COMPLICATIONS AND SIGNIFICANT EVENTS: Orthostatic
hypotension.
MEDICATIONS ON DISCHARGE:
1. Lopressor 12.5 mg p.o. b.i.d. (hold for a systolic blood
pressure less than 100).
2. Amiodarone 400 mg p.o. b.i.d. times seven days,
then 400 mg p.o. q.d.
3. Zantac 150 mg p.o. b.i.d.
4. Serax 15 mg p.o. q.h.s. p.r.n.
5. Dulcolax suppository 30 mg p.r.n.
6. Milk of Magnesia 30 cc p.o. q.d. p.r.n.
7. Ibuprofen 800 mg p.o. q.8.h. q.h.s.
CONDITION AT DISCHARGE: Good and stable.
DISCHARGE STATUS: To rehabilitation facility.
DISCHARGE FOLLOWUP: Follow up was to be with Dr. [**Last Name (STitle) 175**] in
one to two weeks.
DISCHARGE DIAGNOSES:
1. Status post left extrapleural pneumonectomy.
2. Metastatic mesothelioma.
[**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**]
Dictated By:[**Last Name (NamePattern1) 33068**]
MEDQUIST36
D: [**2148-8-3**] 09:43
T: [**2148-8-3**] 09:49
JOB#: [**Job Number 35571**]
|
[
"196.1",
"V45.82",
"414.01",
"163.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.22",
"34.59",
"32.5"
] |
icd9pcs
|
[
[
[]
]
] |
3534, 3891
|
2959, 3317
|
990, 1060
|
1296, 2414
|
906, 963
|
3332, 3399
|
2429, 2933
|
148, 180
|
3420, 3513
|
209, 699
|
1075, 1278
|
723, 882
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,922
| 198,138
|
18885
|
Discharge summary
|
report
|
Admission Date: [**2193-11-11**] Discharge Date: [**2193-12-2**]
Date of Birth: [**2141-5-30**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
hyponatremia
Major Surgical or Invasive Procedure:
Tracheal intubation
Central line placement
History of Present Illness:
52 yo m with schizophrenia, HOCM, found at group home face down
in pool of vomit, found to have Na 99 at [**Hospital 46**] Hosp, got
hypertonic saline, corrected to 107 by the time he got to our
ED. Intubated here for airway protection and went to MICU. Na
corrected rapidly with NS and subsequently had difficulty waking
up from sedation. MRI head negative for CPM. EEG negative for
sz. After long course of weaning, he was extubated, but then
re-intubated because of secretions. Was treated with vanc/zosyn
for VAP. Negative cx's thus far (only needs 8 day courrse of
vanc/zysyn, now day #6). Extubated 2 days ago, now on RA.
Hyponatremia thought [**1-17**] psychogenic polydipsia. Became
subsequently hypernatremic, thought to have renal DI due to
lithium that he took in [**2189**]. Renal following. Had worsening
HTN, had required labetolol gtt. Started on
captropril/amlodipine. Uptitrated BB. CT abd found mass c/w
renal cell CA, needs workup (onc has not yet been consulted).
Currently thought to be at baseline mental status. Also has had
12 sec run of Vtach. EP was consulted.
On the floor, the patient was hypertensive to 180 SBP and was
given Hydral IV 10mg x 1.
Past Medical History:
Schizophrenia diagnosed at age 17
Lithium toxicity in [**2189**]
left ventricular outflow obstruction EF >55%
HTN
Social History:
lives in group home, occasional alcohol, (+) tobacco, no
intravenous drug use.
Family History:
per OMR: Schizophrenia, and father died at age
52 [**1-17**] coronary artery disease.
Physical Exam:
Physical Exam:
Vitals: Afebrile HR 80 BP 153/70 RR 20 100%/A/C
Gen: intubated and sedated
HEENT: pupils equal and sluggishly reactive, anicteric sclera
Neck: in C-collar
CV: regular, [**1-21**] harsh systolic murmur at apex
Pulm: CTA-Ant
Abd: Normoactive bowel sounds, soft, ND/NT
Ext: WWP, 2+ DP pulses
Pertinent Results:
[**2193-11-11**] 01:55AM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0
[**2193-11-11**] 01:55AM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2193-11-11**] 01:55AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2193-11-11**] 01:55AM PT-12.2 PTT-27.0 INR(PT)-1.0
[**2193-11-11**] 01:55AM PLT COUNT-129*#
[**2193-11-11**] 01:55AM NEUTS-89.0* BANDS-0 LYMPHS-5.1* MONOS-5.7
EOS-0.1 BASOS-0
[**2193-11-11**] 01:55AM WBC-12.2*# RBC-UNABLE TO HGB-UNABLE TO
HCT-31.0* MCV-UNABLE TO MCH-UNABLE TO MCHC-UNABLE TO
RDW-UNABLE TO
[**2193-11-11**] 01:55AM URINE GR HOLD-HOLD
[**2193-11-11**] 01:55AM URINE HOURS-RANDOM
[**2193-11-11**] 01:55AM URINE HOURS-RANDOM
[**2193-11-11**] 01:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
.
[**11-11**] CT C-spine:
1. Multilevel degenerative change with no fracture identified.
2. Mild overdistention of the endotracheal tube cuff.
3. Bilateral thyroid nodules, when feasible,U/S recommended.
4. Posterior opacity in the right upper lung, possible
aspiration
.
[**11-11**] CT Maxillary sinus:
1. No definite fracture identified.
2. Moderate ethmoid sinus opacification and air-fluid level in
the left maxillary sinus in this intubated patient. An
air-filled level could suggest acute sinusitis. There is no
hyperdensity within the fluid in the left maxillary sinus to
suggest an occult fracture.
.
CT head:
1. No evidence of acute intracranial hemorrhage. No fracture
identified.
2. Moderate ethmoid sinus opacification with air-fluid level in
the left
maxillary sinus likely due to intubation.
.
CT abdomen and pelvis:
1. 4-cm heterogeneous left renal mass, highly suspicious for
renal cell
carcinoma. As this study was performed without IV contrast,
either a
dedicated CT urogram or MRI is recommended to further assess.
2. Trace amount of left perinephric fluid and stranding,
however, no evidence
of significant retroperitoneal or intraperitoneal hematoma.
3. Bibasilar consolidation and small effusions, most likely
relating to
aspiration.
4. Asymmetric enlargement of the left gluteal minimus muscle
with prominent
subcutaneous stranding, consistent with contusion.
5. Very limited study for assessing for any other potential
lesions or
metastases without IV or oral contrast.
.
EEG:
This is a moderately abnormal EEG due to the presence of a
slow and unvarying background, consistent with a moderate
encephalopathy
of toxic, metabolic, and/or anoxic etiology. No evidence of
ongoing
seizures was seen despite the presence of limb jerks as recorded
by the
technologist.
.
MRI: There is no slow diffusion to indicate an acute infarct.
There is
mild sulcal prominence as noted on the prior examination of
[**2190-8-4**]. There is ventricular prominence also. The
ventricles are dilated slightly out of proportion to the size of
the sulci although there are unchanged from the prior exam.
Could this patient have mild communicating hydrocephalus?
There is extensive pansinus opacification. However, the patient
has recently been intubated and these findings could be due to
that procedure. There are no enhancing abnormalities. There is
no midline shift, mass effect or hydrocephalus. There are no
areas of abnormal magnetic susceptibility.
Brief Hospital Course:
52 year old male with hyponatremia, possible aspiration on CT,
intubated for airway protection.
.
# Hyponatremia - From psychogenic polydipsia. patient was
initially given hypertonic saline for short interval. He
subsequently corrected himself rapidly ([**1-17**] requiring large
volumes NS due to hypotension); concern was raised for central
pontine myelinolysis. MRI was negative for this but did show a
question of stable communicating hydrocephalus. Renal was
following. With fluid restriction, patient became hypernatremic,
which was attributed to diabetes insipidus in the context of
past Lithium use. Sodium was monitored closely and fluid
restriction was discontinued. He likely has greater than 4L
free water requirement and should be allowed to drink to thirst
only instituting fluid restriction if Na<130.
.
# Hypotension: briefly after admission Mr. [**Known lastname **] became
tachycardic and hypotensive requiring large volume repletion.
It was likely that his hypotension was [**1-17**] both volume
depletion, sepsis, and hypertrophic obstructive cardiomyopathy.
He was started on levofloxacin and flagyl to cover for
aspiration pneumonia which was switched to vanco/zosyn as below.
As his blood pressure improved with IVF beta blockers were
started to prolong filling time and improve his cardiac output
from his HOCM.
.
# Airway protection - patient intubated, was weaned and
extubated after prolonged wake up phase but was not able to
adequately clear copious secretions and was reintubated.
Treatment for VAP was started with Vanco and Zosyn. He improved
and was again extubated on hospital day 8. He was doing well
subsequently. Given that no gram negative rods were present on
sputum culture or gram stain, a total of 8 days would be
sufficient.
.
# Altered mental status: difficulty to wean of sedation with
intermittent unresponsiveness. EEG ruled out seizure acitvity.
MRI did not show any evidence of stroke or anoxic brain injury.
Neurology was consulted and did not see any neurological
deficit. After extubation the patient was felt to be at his
baseline. He was restarted on all home medications with good
effect. Delirium was monitored on the floor with the help of
psychiatry, and mental status cleared several days prior to
discharge.
.
# Pnuemonia: Mr [**Known lastname **] was treated for aspiration pneumonia
on admission with levofloxacin and flagyl; he later developed
fevers refarctory to this and was changed to vancomycin and
zosyn for empiric VAP. His sputum as grown GPC. He should have
an 8day course of IV abx.
.
# hypertension: later in Mr. [**Known lastname **] course he developed
severe hypertension in the 200/110 range and was started on a
labetalol drip which was eventually weaned and he was changed to
a regimen of amlodipine 100po tid + captopril 25 tid +
amlodipine 10. His SBP was well controlled, and eventually, we
d/c'd the captopril as he was only about 100's systolic with a
rising creatinine. Even with discontinuation of captopril, the
patient's SBP has remained very well controlled in the 120's.
.
# Renal mass: very suspicious for renal cell carcinoma. MRI/MRA
was ordered, but the patient refused several days in a row,
including the day of discharge. It was explained to him that the
findings on the CT scan showed a mass in the kidney and that it
was suspicious for cancer and further, if it's not definitively
diagnosed and treated, that it could spread and he could die.
The patient said he understood this and wanted his doctors [**First Name (Titles) **] [**Name5 (PTitle) 51673**] to handle the work-up as an outpatient. Cardiology has
recommended that this be sorted out prior to any pacemaker/ICD
placement.
.
# V tach: Mr. [**Known lastname **] had an isolated 12 second run of V-tach
on the morning of transfer. He was asymptomatic and it resolved
spontaneously. K was 3.7 which was repleted. EKG showed normal
QT interval. EP was consulted who felt that he was a candidate
for ICD placement in light of his HOCM, however other medical
issues including renal mass as above needed to be evaluated
prior to any intervention, and that he can follow up in their
outpatient clinic.
.
# Renal failure: Mr [**Known lastname **] was admitted with a Cr of 1.1 and
had a Uprot/Cr ratio of 1.2 indicating likely chronic renal
disease. His creatinine has trended up to 2.0, necessitating
discontinuation of ACEI. Could be secondary to the renal mass,
which needs to be further evaluated.
.
# Metabolic Derangements: The patient had several days of
hypercalcemia and hyperkalemia, which was attributed to the
patient focusing on drinking extreme amounts of Ensure and then
Nepro in the setting of his renal failure. After stopping all
supplements, these electrolyte abnormalities resolved.
Medications on Admission:
depakote
haldol
zyprexa
lopressor
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for pain, fever.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
4. Valproic Acid 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours).
5. Haloperidol 10 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
6. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Olanzapine 5 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
8. Olanzapine 5 mg Tablet Sig: Four (4) Tablet PO HS (at
bedtime).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
10. Haloperidol 5 mg IV TID:PRN agitation
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Primary:
1. Hyponatremia.
2. Obtundation.
3. Respiratory Failure.
4. Psychogenic Polydipsia
5. Ventilator-associated Pneumonia
6. ?Diabetes Insipidus
7. Non-Sustained Ventricular Tachycardia
8. Hypercalcemia, Hyperkalemia
9. Anemia of Inflammation.
9. 4-cm left renal mass, highly suspicious for RCC.
Secondary:
1. Hypertrophic Cardiomyopathy.
2. Hypertension.
3. Chronic Kidney Disease Stage III.
4. Proteinuria.
5. Lithium Nephropathy.
6. Schizophrenia
Discharge Condition:
Stable, afebrile, ambulating
Discharge Instructions:
You were admitted for a dangerously low serum sodium level
secondary to your diagnosis of psychogenic polydipsia. During
your admission you were also treated for pneumonia.
.
If you experience shortness of breath, chest pain, confusion,
fevers/chills or seizures please seek medical attention
immediately.
Followup Instructions:
Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **] on Thursday [**2193-12-5**] @10:15am.
.
It was recommended for you to receive MRI/MRA here for
definitive diagnosis, as this mass was very concerning for renal
cell carcinoma, but you have refused this work-up, with the
understanding that if this is cancer, it may spread and even
result in death if not evaluated and treated appropriately. You
have, however, indicated that you would prefer for your
outpatient physicians to handle this work-up. Therefore, you
have been scheduled in the [**Hospital 159**] Clinic at [**Hospital1 18**] on Thursday,
[**2194-1-2**] @3pm with Dr. [**Last Name (STitle) 1263**]. Please call
[**Telephone/Fax (1) 164**], if you need to reschedule this appointment.
.
Please follow up for your psychogenic polydipsia and question of
diabetes insipidus, in the [**Hospital 2793**] Clinic in the [**Hospital Ward Name 23**] Building
at [**Hospital1 69**] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
[**Name8 (MD) **], MD Date/Time: [**2193-12-18**] @ 1:00pm. Phone:[**Telephone/Fax (1) 435**] if
you need to reschedule.
|
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"287.5",
"276.1",
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"305.1",
"276.7",
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"584.9",
"518.81",
"236.91",
"295.90",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.6",
"38.93",
"99.04",
"00.17",
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] |
icd9pcs
|
[
[
[]
]
] |
11289, 11342
|
5607, 7390
|
327, 371
|
11842, 11873
|
2254, 3721
|
12227, 13454
|
1825, 1912
|
10459, 11266
|
11363, 11821
|
10401, 10436
|
11897, 12204
|
1942, 2235
|
275, 289
|
399, 1576
|
3730, 5584
|
7405, 10375
|
1598, 1713
|
1729, 1809
|
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