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21,881
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51938
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Discharge summary
|
report
|
Admission Date: [**2175-8-3**] Discharge Date: [**2175-8-9**]
Date of Birth: [**2118-5-29**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2777**]
Chief Complaint:
This 57 y/o Patient is c/o an new open wound on her right knee
after recent BKA. She has a history of extensive Peripheral
artey disease and sustained a stroke about 5 weeks ago, no
residual deficits. She presented to with new ulcer and redness
over her R
knee. She denies any trauma. To note she had a right ileofemoral
bypass with 8mm ringed PTFE, s/p subsequent revision in [**2-22**]
Major Surgical or Invasive Procedure:
1. Right iliofemoral graft thrombectomy.
2. Iliofemoral bypass graft to profunda femoris artery
bypass graft with PTFE.
History of Present Illness:
This 57 year old F has an extensive history of peripheral ertery
disease. Most recently with right belwo knee amputation. She is
now c/o a new open wound on her right knee. She denies any
trauma. She also denies nausea, emesis or abdominal pain.
Past Medical History:
The patient has had a couple of recent admissions to other
hospitals and suffered a stroke about 5 weeks ago. No residual
deficits.
[**6-25**] s/p right below the knee amputation
[**8-22**] s/p transmetatarsal amputation of right foot
[**2-22**] right ileofemoral bypass with 8mm ringed PTFE, s/p
subsequent revision
Multiple right and left lower extremity percutaneous
interventions/stents, including left external iliac stenting
[**2167**], pta [**2168**], right external iliac, common femoral and
porfunda
femoris thromboendarterectomy, Dacron patch angioplasty 2093
[**1-19**] s/p Left femoral popliteal bypass, left great toe
amputation
Lacunar infarts x 2
hypercholesterolemia
CAD s/p MI, [**2169**] occluded RCA on angiography
Peripheral neuropathy
CHF, EF 25%
DM type I
DKA [**2170**]
Hypothyroidism
Acute renal failure [**12-19**] after peripheral angiography
Cervical spondylosis/nerve entrapment s/p c4-C6 discectomy and
fusion as well as L4-L5 laminectomy
CRF Stage III
Social History:
Lives at home with her 84 year old mother. Does not work.
Patient??????s friend [**Name (NI) **] will bring her to the procedure, 617 328
8137. Previously worked as a researcher at [**Hospital1 18**].
Family History:
Father died at age 50 of an MI
Physical Exam:
VS: 99.0 P:86 BP: 144/80 RR:18 Spo2:96%
General: NAD. A&Ox3.
Pulm: Lungs clear bilaterally. Good excursion. No crackles or
wheezes.
Cardiac: RRR.
Abd: Soft. NT. ND. No palpable masses.
LLE: Palpable popliteal pulse, palpable posterior tibial pulse,
palpable dorsalis pedis pulse. TMA site C/D/I
RLE: palp fem, no palp graft, area of erythema noted on knee,
warm to touch, open wound shallow.
Pertinent Results:
[**2175-8-8**] 06:20AM BLOOD WBC-7.2 RBC-3.38* Hgb-10.2* Hct-30.6*
MCV-91 MCH-30.1 MCHC-33.3 RDW-12.7 Plt Ct-303
[**2175-8-8**] 06:20AM BLOOD Plt Ct-303
[**2175-8-8**] 06:20AM BLOOD Creat-1.4* K-3.6
[**2175-8-3**]
HISTORY: A 57-year-old woman with PNH of stroke, evaluate for
acute CVA.
HEAD CT: Axial imaging was performed through the brain without
IV contrast.
COMPARISON: MRI brain [**2169-5-4**].
FINDINGS: In the medial aspect of the right cerebellar
hemisphere is a region
of hypodensity (2:12), but has not yet reached CSF density and
likely
represents an evolving subacute infarct. There are no areas
suspicious for
acute vascular infarct. Ventricles and sulci display minimal
prominence
likely age- related atrophy. There is no shift of normally
midline
structures. [**Doctor Last Name **]- white matter differentiation remains well
preserved. There
is no edema. The osseous structures appear intact. Paranasal
sinuses,
ethmoid and mastoid air cells are clear, which is an improvement
from [**2169**]
where the maxillary sinuses were partially opacified.
IMPRESSION:
1. Area of hypodensity in the medial aspect of the right
cerebellar
hemisphere, corresponding to the site of subacute infarct. No
regions
concerning for acute vascular territorial infarction. If there
is a
persistent concern, MRI is more sensitive for evaluation.
2. No hemorrhage.
3. Improvement in aeration of the maxillary sinuses.
NOTE ADDED AT ATTENDING REVIEW: The right cerebellar lesion
appears to
represent atrophy, suggesting an old infarct, rather than a
subacute lesion.
[**2175-8-3**] CTA
Final Report
HISTORY: 57-year-old woman with infection of BK [**Doctor Last Name **] bypass
graft. Please
assess infrarenal to right lower extremity stump for arterial
blood flow.
CTA AORTA RUNOFF: Helical imaging was performed from the level
of the kidneys
through or below the level of the right below-knee amputation
prior without IV
contrast. Subsequently, after uneventful administration of
intravenous
contrast, helical imaging was again performed from the level of
the kidneys to
below the level of the right below-knee amputation. Coronal and
sagittal
reformats were prepared. Repeat imaging was performed in the
venous phase.
COMPARISON: CT pelvis from [**2173-8-25**].
FINDINGS: The partially visualized kidneys enhance symmetrically
with small
bilateral hypodensities too small to fully characterize. At the
origin of the
bilateral renal arteries are moderate-severe narrowing with
adjacent calcific
atherosclerotic plaque. There is hypoenhancement of the left
kidney, which is
slightly atrophic compared to the right.Tiny accessory left
renal artery
perfuses the upper pole. Small wedge-shaped peripheral areas of
hypoenhancement are likely infarcts. The hepatic vasculature
appears
conventional and the liver and gallbladder are unremarkable. The
partially
visualized spleen appears unremarkable. Abdominal loops of bowel
are normal in
their appearance.
Approximately 6 cm below the aortic bifurcation on the right is
a bypass graft
which demonstrates complete occlusive thrombus along its entire
length
extending into the right mid thigh. There are small collateral
arterial
vessels which flow into the right proximal thigh (5a:157). Right
popliteal
artery recionstitutes and is patent but diminuitive. Proximal
right AT and PT
are patent but not well assessed. Right peroneal appears
occluded In
addition, there is a bypass graft catheter from the left common
femoral artery
to the left above knee popliteal artery, which demonstrates
normal arterial
flow. The left popliteal artery is patent. The left anterior
tibial artery is
widely patent proximally. The left PT and peroneal arteries are
diminuitive
with significant disease not well assessed on this study.
The bladder, rectum, sigmoid colon and pelvic loops of small and
large bowel
appear normal. The bladder wall is mildly thickened but may be
due to
underdistension of the bladder. The uterus appears atrophic.
Adnexal
structures are not visualized. There is no free air in the
abdomen or pelvis.
BONE WINDOWS: There are no suspicious sclerotic or lytic
lesions. There are
mild degenerative changes of the lower lumbar spine. Patient is
status post
L4/L5 laminectomy.
IMPRESSION:
1. Complete occlusive thrombus along the length of the right
femoral bypass
graft. The left femoral bypass graft demonstrates normal
arterial flow. There
are small collateral arterial vessels which perfuses the right
lower extremity
with reconstitution of a diminutive politeal artery. there may
be occlusion of
the right peroneal artery and there is disease in the proximal
left PT and
peroneal arteries incompletely assessed on this study.
2. Moderate-severe bilateral renal artery stenosis with adjacent
calcific
plaque. Mild left renal atrophy and hypoenhancement indicates
worse stenosis
on the left. Possible small bilateral renal infarcts.
3. Status post L4/L5 laminectomy.
[**2175-8-4**]
HISTORY: Possible prior stroke.
FINDINGS: Calcific plaque involving the internal carotid
arteries
bilaterally. The peak systolic velocities on the right are 186,
145, 128, 108
and 133 cm/sec for the proximal, mid and distal ICA and CCA and
ECA
respectively. Similar values on the left are 73, 119, 77, 71,
and 80 cm/sec.
The ICA to CCA ratio is 1.7 on the right and 1.6 on the left.
There is
antegrade flow involving both vertebral arteries.
IMPRESSION:
1. Approximately 60% right ICA stenosis.
2. Approximately 40% left ICA stenosis.
Brief Hospital Course:
The patient was taken to the operating room on [**2175-8-4**] and
underwent a right iliofemoral graft thrombectomy and an
iliofemoral bypass graft to the profunda femoris artery bypass
graft with PTFE. She was hemodynamically stable throughout the
entire case and continued to be so after awaking from
anesthesia. The patient was taken to the recovery room in
stable condition.
[**8-5**] VSS, no events. Transfered from PACU to VICU. Home
medications reviewed. Diet resumed. Resumed Lasix for STABLE,
CHRONIC DIASTOLIC CHF. Placed on Vanco/Cipro/Flagyl
[**Date range (1) 107524**] VSS, no events. Tolerating diet. Cleared for discharge
to home. IV ABX changed to po ABX on [**8-8**] (Diclox/cipro/flagyl).
Neurology following for recent stroke.
[**8-9**] VSS, no events. Discharged to home on Augmentin. F/U
scheduled with Dr. [**Last Name (STitle) **].
Medications on Admission:
atorvastatin 80', plavix 75', digoxin 250mcg', lasix 60',
ibuprofen 800", insulin pump, levothyroxine 200mcg', lisinopril
5', protonix 40', accuzyme to LLE ulcer daily, ASA 325'
Discharge Medications:
1. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): refills from PCP [**Name9 (PRE) **],[**Name9 (PRE) 275**] [**Name Initial (PRE) **]. [**Telephone/Fax (1) 107525**].
Disp:*30 Tablet(s)* Refills:*0*
8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 2 weeks.
Disp:*42 Tablet(s)* Refills:*0*
12. Insulin pump
Insulin Pump SC (Self Administering Medication)
13. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
DAILY (Daily) as needed for itching.
Disp:*1 1* Refills:*0*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
15. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed for indigestion.
Discharge Disposition:
Home
Discharge Diagnosis:
57F with painful and infected R BKA Stump, had stroke 5 weeks
ago with no residual affects, now s/p ilio-PFA bypass
PMH: [**4-26**] s/p L 4th toe amp and angio, [**6-25**] s/p R BKA, [**8-22**] s/p
transmetatarsal amputation of right foot, [**2-22**] R ileofemoral
bypass with 8mm ringed PTFE, s/p subsequent revision, Mult R and
LLE percutaneous interventions/stents, including L external
iliac stenting, [**2167**], pta [**2168**], R external iliac, CFA and
profunda, femoris thromboendarterectomy, Dacron patch
angioplasty [**2169**] [**1-19**] s/p L femoral popliteal bypass, L great
toe amputation Lacunar infarts x 2, ^chol, CAD s/p MI, [**2169**]
occluded RCA on angiography, Peripheral neuropathy, CHF (EF
25%), IDDM on insulin pump, DKA [**2170**], Hypothyroidism, ARF [**12-19**]
after peripheral angiography, Cervical spondylosis/nerve
entrapment s/p c4-C6 discectomy and fusion as well as L4-L5
laminectomy
Discharge Condition:
stable
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Bypass Surgery Discharge Instructions
What to expect when you go home:
1. It is normal to feel tired, this will last for 4-6 weeks
?????? You should get up out of bed every day and gradually increase
your activity each day
?????? Unless you were told not to bear any weight on operative foot:
you may walk and you may go up and down stairs
?????? Increase your activities as you can tolerate- do not do too
much right away!
2. It is normal to have swelling of the leg you were operated
on:
?????? Elevate your leg above the level of your heart (use [**2-21**]
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:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2175-8-31**] 11:15
Completed by:[**2175-8-9**]
|
[
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"428.0",
"272.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.29"
] |
icd9pcs
|
[
[
[]
]
] |
10892, 10898
|
8329, 9187
|
703, 828
|
11861, 11870
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2815, 3104
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3113, 8306
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1125, 2109
|
2125, 2330
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,017
| 143,180
|
39311
|
Discharge summary
|
report
|
Admission Date: [**2186-9-9**] Discharge Date: [**2186-9-14**]
Service: NEUROLOGY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Cipro
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Fluent aphasia (garbled speech).
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. [**Known lastname **] was unable to provide his own history in the ER
due to his aphasia, hx obtained from his son and
daughter-in-law, who were present in the room.
Mr. [**Known lastname **] is an 85 y/o right handed white man with PMH
significant for hemorrhagic stroke in [**2185-8-23**] (exact
location unclear though son believes possible same location as
current hemorrhage, presented with similar speech deficits at
that time, treated at [**Hospital1 2025**] with subsequent rehab, no residual
deficits aside from possible some decline in memory), diabetes,
hypertension, CAD s/p 2 stents, and hyperlipidemia, who presents
[**2186-9-9**] with speech difficulties that began that morning.
Per son and daughter-in-law at bedside, pt was last seen normal
at approx. 9:30am. At that time, he was walking, talking, and
interacting with people normally. At 10:00am, his grandson went
to speak with him and noticed his speech was different. He was
described as speaking in his normal voice, but non-sensical
sounds were coming out. At times he appeared frustrated as if
with word-finding difficulty. No other symptoms noted at that
time, including headache, dizziness, visual changes, dysphagia,
and facial or extremity weakness.
He was initially brought to [**Hospital **] [**Hospital 1459**] Hospital where a
CT head was performed; this showed a L parietal intraparenchymal
hemorrhage. He was then transferred to [**Hospital1 18**] for evaluation and
management.
Upon arrival here, his symptoms have been stable and unchanged
as per family members, except for 1 incident where he unsure
what to do with the urinal and was found standing up with urinal
in hand.
Neuro ROS: Unable to elicit full Neuro ROS given aphasia, but
patient did deny headache, dizziness, visual changes, dysphagia,
weakness, numbness or tingling. He does have hearing loss at
baseline.
General ROS: Unable to fully obtain given aphasia; per family no
known recent fevers/chills or illnesses.
Past Medical History:
DM, type 2
HTN
CAD, s/p 2 stents
Hyperlipidemia
Hemorrhagic stroke ([**8-/2185**])
Eczema
Basal cell carcinoma of nose s/p excision
Allergic reactions:
1. Penicillin reaction ("severe rxn" of unknown tpye)
2. Sulfa
3. Ciprofloxacin
Social History:
Lives in [**Location 2251**], MA with wife and son. History heavy tobacco
use and alcohol use, but quit both many years ago. Denies
history of drug use. He is ambulatory at home and able to
perform all ADLs.
Family History:
Father had emphysema. No history of stroke or other neurological
illnesses. No history of bleeding, clots, or miscarriages.
Physical Exam:
Vitals:
T 98, BP 125/67 (124-154/61-74), HR 60, RR 18, O2 97% on 2L O2
Physical exam:
General: Elderly male appearing stated age, NAD
HEENT: NC/AT, sclera anicteric, MMM
neck: supple, no carotid bruits
CVS: RRR, S1S2, no murmurs
chest: lungs CTA b/l, good air movement
Abdomen: soft, NT/ND, +BS
Extremities: Warm
Neurological exam:
Mental status: Awake, alert, cooperative. He has been quiet, no
agitation. No confusion Left and Right side. Unable to evaluate
orientation. Difficult to assess for apraxia given component of
receptive aphasia. No evidence of neglect. Motor perseveration
was noted.
Language: He is dysarthric. Fluent speech with normal prosody,
some paraphasic errors, able to understand and sometimes he is
able to answer questions. Unable to read or write. Sometimes he
is able to name objects. Able to repeat sometimes. to follow
some central and appendicular commands.
CN: Pupils equally round and reactive to light, 2-->1 mm b/l,
right visual field cut, EOMI with no nystagmus, blink to threat,
facial sensation intact to light touch, no facial droop, able to
close eyes tightly but when asked to, palate elevation midline,
tongue midline, esternocleidomastoid/trapezius grossly intact
Motor: Normal bulk and tone. No asterixis. No pronator drift. No
tremor.
D B T WE WF FE FF IP Q HS DF PF
L 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
DTR: B T Br P A
L 2 2 2 2 0
R 2 2 2 2 0
Toes downgoing bilaterally. No clonus
Sensory: Generally appears to be intact to light touch and
pinprick. Diminished vibration in toes. No extinguishing to DSS.
Coordination: Finger-nose and FNF intact with no dysmetria.
Gait: Wide based gait with small steps.
Pertinent Results:
[**2186-9-9**] 02:43PM PT-12.1 PTT-25.9 INR(PT)-1.0
[**2186-9-9**] 02:43PM PLT COUNT-281
[**2186-9-9**] 02:43PM NEUTS-65.1 LYMPHS-27.8 MONOS-4.7 EOS-1.7
BASOS-0.7
[**2186-9-9**] 02:43PM WBC-7.8 RBC-4.17* HGB-13.5* HCT-39.4* MCV-95
MCH-32.4* MCHC-34.3 RDW-13.2
[**2186-9-9**] 02:43PM cTropnT-0.02*
[**2186-9-9**] 02:43PM estGFR-Using this
[**2186-9-9**] 02:43PM GLUCOSE-157* UREA N-19 CREAT-1.5* SODIUM-139
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-30 ANION GAP-12
[**2186-9-9**] 05:42PM URINE RBC->50 WBC->50 BACTERIA-MANY YEAST-NONE
EPI-0
[**2186-9-9**] 05:42PM URINE BLOOD-MOD NITRITE-POS PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-MOD
[**2186-9-9**] 05:42PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.013
[**2186-9-9**] 06:24PM LACTATE-1.3
[**2186-9-9**] 06:24PM COMMENTS-GREEN TOP
[**2186-9-9**] 10:30PM CK-MB-4 cTropnT-0.02*
[**2186-9-9**] 10:30PM CK(CPK)-148
EKG: NSR, no ST abnormalities
IMAGING:
CT head (OSH): 3.6x2.2x4 cm left parietal lobe IPH with
surrounding edema, associated with acute SAH in L parietal
region, more superiorly. Old L posterior parietal/occipital lobe
infarct, site of former ICH.
Repeat head CT ([**Hospital1 18**]): L parietal bleed appears slightly larger
w/ surrounding edema, 3mm rightward shift of midline structures,
mass effect on left lateral ventricle.
CXR (OSH): 'no acute process'
CXR ([**2186-9-11**]):
1. Extensive calcified pleural plaques consistent with asbestos
related
pleural disease.
2. No evidence of pneumonia.
Brain MRI does not show any underlying mass of vascular
malformation.
URINE CULTURE (Final [**2186-9-12**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood cultures are pending (no growth on [**9-14**] from cultures from
[**9-9**].
MR head [**9-10**]:
IMPRESSION:
1. MRI head demonstrates a lobar hemorrhage with surrounding
edema and evidence of surrounding superficial siderosis. In
absence of gadolinium-enhanced images, underlying mass cannot be
excluded but the presence of surrounding superficial siderosis
is suggestive of chronic process such as amyloid angiopathy.
2. No evidence of acute infarct.
3. MRA shows no evidence of vascular abnormalities around the
circle of [**Location (un) 431**]. No abnormal vascular structures in the
inferior portion of the hemorrhagic area.
4. If there is persistent concern for underlying mass, MRI with
gadolinium can help if clinically indicated.
Brief Hospital Course:
Mr. [**Known lastname **] is an 85-year-old right-handed gentleman with a
previous medical history significant for left posterior
parieto-occipital hemorrhage in [**2184**], diabetes 2, hypertension,
coronary artery disease status post two stents on aspirin and
hyperlipidemia, who presented with a new sudden onset of speech
difficulties
(normal voice, non sense sounds. His CT shows an
intraparenchymal left
parietal hemorrhage.
Stroke, hemorrhagic
He was admitted to the critical care unit. His transfer to
the unit happened because there was significant mass effect and
his mental status was deteriorating. There was a 3 mm right
[**Hospital1 **] shift at the time. His exam was remarkable for his aphasia
which was both receptive and expressive. His mental status was
depressed given the edema, mass effect. He received an MRI to
assist the etiology of his bleed. The MRI showed a low-grade
hemorrhage with surrounding edema and superficial siderosis.
There was no evidence of an acute infarct. There were no
vascular
abnormalities identified. As far as the MRI was performed
without gadolinium, there was no certainty that this was not a
mass; however, it seems to be the case that the patient has
amyloid angiopathy. Once stabilized, the patient was sent to the
floor. We restarted his aspirin 81 mg once daily and his full
dose metoprolol and losartan.
On [**2186-9-11**] he was improving, able to follow some central and
appendicular commands, dysarthric, able to repeat sometimes, no
left-right side confusion, with motor perseveration and
apparently sensation was intact to light touch. He has right
visual field cut. On his exam he has a typical Wernicke aphasia.
According to the OT/PT evaluation he is able to go to rehab. We
had a family meeting and decided that he is going to rehab, he
is going to continue 7 day-course of antibiotics. He has a
follow-up appointment with Dr [**First Name (STitle) **] in 6 weeks with a new brain
MRI/MRA with and without contrast (along with lab work for
BUN/creatinine less than 30 days prior to MR with contrast). The
MRI/A has been ordered for [**Hospital1 18**] [**Hospital Ward Name 516**] on [**2186-10-30**].
Urinary Tract Infection and Infectious Diseases
For UTI, nitrofurantoin, seven day course will complete on
[**2186-9-17**]. His blood cultures are pending at the time of
discharge (no growth since [**9-9**]). The patient is MRSA positive
on nasal swab.
Diabetes
Diabetes was managed with insulin sliding scale, with glipizide
held while the patient was in the hospital.
Blood Pressure
His BP remained stable throughout the admission.
Code Status
He is DNR/DNI.
Medications on Admission:
Glipizde 5 mg daily
Metoprolol 25 mg [**Hospital1 **]
Simvastatin 20 mg daily
Aspirin 81 mg daily
Losartan 25 mg daily
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: Two (2) Tablet PO BID (2 times a
day) as needed for constipation.
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Losartan 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).
6. Nitrofurantoin (Macrocryst25%) 100 mg Capsule Sig: One (1)
Capsule PO BID (2 times a day) for 3 days.
7. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
8. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
9. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
10. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day:
Patient was on insulin sliding while in hospital and did not
take glipizide - we leave this to the discretion of his
physicians at rehabilitation. .
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Left parietal hemorrhage probably secondary to amyloid
angiopathy. No underlying vascular malformation
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you.
You were admitted for a new onset of speech difficulties (normal
voice, non-sensical sounds). You underwent to a CT scan that
shows an hemorrage in your brain probably secondary to amyloid
angiopathy (amyloid deposits form in the walls of the blood
vessels of the central nervous system that makes vessels more
likely to break and bleed). You also had an MRI of the brain and
blood vessels without contrast with no evidence of mass related
with your hemorrhage. You are going to have a follow-up
appointment with Dr [**First Name (STitle) **] with a new brain MRI/MRA with and
without contrast. Date: [**10-30**] 1:30 pm. [**Hospital Ward Name 23**]
Building Floor 5.
Also you have an urinary tract infection. This is usually
treated with antibiotics and in this case you are going to
complete a 7 day course with Nitrofurantoine.
At this point you are able to go to rehab: [**Hospital 86932**] Hospital-[**Location (un) 246**] [**Numeric Identifier 86933**]
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2186-10-30**] 1:30- with a new brain MRI/MRA with and
without contrast. Date: [**10-30**] 1:30 pm. [**Hospital Ward Name 23**]
Building Floor 5.
You will be called with a time for MRI/MRA prior to this time
(or possibly date). You will also need to have blood drawn prior
to MRA. Blood can be drawn on [**Hospital Ward Name 23**] 8 on the morning of your
MRA or earlier. Please arrive early so that this can be done
prior to your appointment. Arrive 90 minutes before MRA. You
will be called with further details.
- Rehab: [**Hospital6 **] Hospital-[**Location (un) 246**] [**Numeric Identifier 86933**]
|
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icd9cm
|
[
[
[]
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[] |
icd9pcs
|
[
[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,138
| 146,613
|
44363
|
Discharge summary
|
report
|
Admission Date: [**2117-7-27**] Discharge Date: [**2117-8-9**]
Date of Birth: [**2061-4-27**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
pseudoanurysm aortic root
Major Surgical or Invasive Procedure:
[**2117-7-28**] redo sternotomy, resection of pseudoaneursym,
reimplantation of right coronary artery
[**2117-8-4**] mediastinal re-exploration
History of Present Illness:
This 56 year old white male underwent a Bental procedure with a
Bjork-Shiley valve in [**2090**]. He has done well until recently
when he developed dizziness. An echocardiogram was performed
then wheich revealed dilitation of the root. Further workup
included a catheterization which demonstarted a pseudoaneurym of
the aortic root, preserved LV function and a well functioning
prosthetic aortic valve.
He was admitted now for reoperation. Heparin was begun to
bridge the transition from Coumadin.
Past Medical History:
s/p Bental Prcedure with Bjork-Shiley aortic valve replacement
[**2090**]
Hepatitis C- Hyperlipidemia
Hemorrhoids
Benign tremor
Seasonal Allergies
Marfan's syndrome (never tested)
hyperlipidemia
Social History:
Works as a bartender/waiter. Not married, lives in [**Location 6134**],
MA.
-Tobacco history: Smoked for 4 years [**1-10**] ppd, quit at age 17
-ETOH: drinks 2-6 beers per week
-Illicit drugs: none
Family History:
Brother who also "looks Marfanoid" and has dextrocardia but no
genetic testing done.
Father died of a stroke at age 81. Mother is 85, has dementia
and lives in an [**Hospital3 **] facility on [**Hospital3 4298**],
brother has severe resting tremor.
Physical Exam:
Physical Exam:
Pulse: 78 Resp: 18 O2 sat: 97/RA
B/P 122/75
Height: 5'8" Weight: 61.4 kgs
General: no acute distress
Skin: Dry [X] intact [X] midline sternal surgical scar healed,
right groin surgical scar healed
left groin soft, ecchymotic
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X] Healed MSI
Heart: RRR [X] Irregular [] Murmur +mechanical click
Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds
+
[X]
Extremities: Warm [X], well-perfused [X] Edema none Varicosities
none
Neuro: alert and oriented x3 nonfocal
Pulses:
Femoral Right: Left:
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit pulses 2+ (B) Right: no bruit Left: no
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
Date/Time: [**2117-7-28**] at 14:35 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16164**], MD
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present.
Left-to-right shunt across the interatrial septum at rest.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
MITRAL VALVE: Normal mitral valve leaflets.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
PREBYPASS: An aortic disruption near the right coronary cusp was
seen with a echolucent fluid collection consisten with a
pseudoaneurysm. This was seen to communicate with the aortic
root. The mechanical aortic valve prosthesis was seen to
funciton normally with no AI and no AS. The left coronary artery
was easily idendified but the right was not and it was thought
that the right coronary button (ostium) was the location of the
disruption of the aorta. This was found to be the case
intraoperatively
Otherwise the exam was essentially normal. Normal LV systolic
funciton with LVEF> 55%, no segmental wall motion abmormalities.
Normal RV size and function. Normally functioning MV, andn TV.
PV not well seen. No clot in the left atrial appendage. No
dissection seen in the descending Aorta. Normal descending
thoracic aorta A small patent foramen ovale was seen with a
small left-to-right shunt across the interatrial septum . Right
ventricular chamber size and free wall motion are normal. The
mitral valve leaflets are structurally normal, with No MR, no
MS. There is no pericardial effusion.
POSTBYPASS: the right coronary artery button was repaired and no
leak was seen. Not dissection seen after aortic cannula removed.
No segmental wall motioin abnormalities. Normal LVEF. No other
changes.
[**2117-8-9**] 06:20AM BLOOD WBC-7.5 RBC-3.10* Hgb-9.8* Hct-28.2*
MCV-91 MCH-31.5 MCHC-34.7 RDW-14.1 Plt Ct-538*
[**2117-8-8**] 06:45AM BLOOD WBC-6.6 RBC-3.05* Hgb-9.5* Hct-28.1*
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.3 Plt Ct-489*
[**2117-8-9**] 06:20AM BLOOD Glucose-100 UreaN-13 Creat-0.7 Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
[**2117-8-8**] 06:45AM BLOOD UreaN-12 Creat-0.7 Na-138 K-4.6 Cl-104
[**2117-8-7**] 07:10AM BLOOD Glucose-103* UreaN-11 Creat-0.7 Na-138
K-4.5 Cl-102 HCO3-28 AnGap-13
[**2117-8-9**] 06:20AM BLOOD PT-24.4* PTT-69.4* INR(PT)-2.3*
[**2117-8-8**] 06:45AM BLOOD PT-19.0* PTT-31.0 INR(PT)-1.7*
[**2117-8-7**] 11:45PM BLOOD PT-18.0* PTT-30.5 INR(PT)-1.6*
[**2117-8-7**] 07:10AM BLOOD PT-15.9* PTT-26.9 INR(PT)-1.4*
Brief Hospital Course:
Heparin was instituted on admission and on [**7-28**] he went to the
Operating Room where reoperation was performed. There was
contained rupture of the proximal anastomoses and right graft
implant site. Excision of the pseudoaneurysmal sac and
reimplantation of the RCA was performed. Cross clamp time= 60
minutes, Cardiopulmonary Bypass time=69 minutes. Please see
operative report for further details. He tolerated the
procedure well and weaned from bypass on Phenylephrin and
Propofol. He was transferred to CVICU intubated and sedated in
critical but stable condition. He awoke neurologically intact
and was weaned to extubation without incident. On POD #1 beta
blocker, Lasix and Amlodipine were begun for hypertension
control. He remained stable and Coumadin was begun. POD #1 he
was transferred to the step down unit for further monitoring.
Physical Therapy was consulted for evaluation of strength and
mobility. The remainder of his postoperative course was
essentially uneventful. Chest tubes and pacing wires removed
per protocol. Heparin was started for anticoagulation bridge
until he was therapeutic on Coumadin. Right pleural effusion
noted on CT scan [**8-3**]. He was transfused multiple units for
dropping hematocrit, INR reversed and he was taken back to OR on
[**8-4**] for re-exploration and washout. Transferred back to the
CVICU in stable condition. He was extubated within 2 hours of
arrival to CVICU with pain control an issue post operatively.
He was given Dilaudid and Toradol with improved pain control.
His chest tubes were removed again POD2 after reexploration
without incidence. He was restarted on Coumadin and
anticoagulated to INR goal 2.5-3.5. His INR was 2.3 at the time
of discharge. He continued to progress well. He was ambulating
in the halls without difficulty, wound was healing well and he
was tolerating a full po diet with good pain control. He was
cleared for discharge to home on POD 12. All follow up
appointments were advised. First INR check [**8-10**]. Dr. [**First Name (STitle) **]
(PCP who normally follows INR) is on vacation for 1 week with
covering MD unable to follow Coumadin. Therefore VNA instructed
to call cardiac surgery office for Coumadin dosing instructions
until Dr [**First Name (STitle) **] returns from vacation and Coumadin can be
followed by him.
Medications on Admission:
WARFARIN -1 mg Tablet [**3-12**] Tablet(s) by mouth once a day take
with
10 mg tab for total dose of 13 or 14 mg per day
WARFARIN -10 mg Tablet 1 Tablet(s) by mouth once a day take with
1 mg tabs to make 13 or 14 mg per day
CETIRIZINE [ZYRTEC] 10 mg Capsule - 1 Capsule(s) by mouth once a
day
MULTIVITAMIN Tablet - 1 Tablet(s) by mouth daily
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - Dosage uncertain
PHOSPATIDYL COLINE - Dosage uncertain
PSEUDOEPHEDRINE HCL [SUDAFED] - 1 Tablet(s) by mouth once a day
as needed for prn
Plavix - last dose: N/A
Coumadin: last dose 7/14/11-10mg
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for fever or pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) for 2 weeks.
Disp:*28 Tablet(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
8. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): Take
as directed for INR goal 2.5-3.5. Take 7.5 mg on [**8-9**].
Disp:*60 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
pseudoaneurysm of aortic root
s/p Bental/Bjork-Shiley aortic vale replacement [**2090**]
s/p redo sternotomy,resection of pseudoaneurysm, reimplantation
of right coronary artery [**2117-7-28**]
hyperlipidemia
Hepatitis C
benign tremor
?? Marfan's Syndrome
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 Right- healing well, no erythema or drainage.
Edema:.................
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
**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 Tues [**8-17**] at 10:15 AM
Surgeon:Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) on [**8-25**] at 1:00pm in the
[**Hospital **] medical office building [**Hospital Unit Name **]
Cardiologist:Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] [**9-16**] at 3:00 pm
Please call to schedule appointments with:
Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 95123**]-9600) in [**4-13**] weeks
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication mechanical aortic valve
Goal INR 2.5-3.5
First draw day after discharge [**8-10**]
Patient instructed to take Coumadin 7.5 mg on [**8-9**]
Results to phone [**Telephone/Fax (1) 170**] until Dr [**First Name (STitle) **] returns from
vacation
Completed by:[**2117-8-9**]
|
[
"V15.82",
"996.74",
"E878.2",
"511.89",
"V12.09",
"996.1",
"285.9",
"759.82",
"070.54",
"E849.9",
"272.4",
"E849.7",
"V70.7",
"441.01",
"998.11",
"788.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"34.03",
"39.64",
"39.59",
"38.34",
"88.72"
] |
icd9pcs
|
[
[
[]
]
] |
9216, 9267
|
5215, 7545
|
335, 481
|
9567, 9806
|
2531, 5192
|
10646, 11674
|
1466, 1716
|
8176, 9193
|
9288, 9546
|
7571, 8153
|
9830, 10623
|
1747, 2512
|
270, 297
|
509, 1013
|
1035, 1231
|
1247, 1450
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,200
| 119,210
|
42809
|
Discharge summary
|
report
|
Admission Date: [**2136-2-9**] Discharge Date: [**2136-2-27**]
Date of Birth: [**2061-11-11**] Sex: M
Service: EMERGENCY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2565**]
Chief Complaint:
Mesenteric Ischemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known firstname 449**] [**Known lastname 31251**] is a 74 year old male who was transferred from
[**Hospital3 **] for concern of possible bowel ischemia. Mr.
[**Known lastname 31251**] reports he presented to [**Hospital1 **] on [**2136-2-3**] with
bloodydiarrhea and abdominal pain and was admitted overnight and
discharged with antibiotics (flagyl). He returned to their ER
[**2136-2-5**] with worsening abdominal pain and was admitted for
further work up and put on levofloxacin and flagyl. He has
since had increasing abdominal pain which he describes as
intermittent and he describes it as gas pain that is sharp in
nature. He received several abdominal CT's over the next 4 days
that showed progressively worsening edema and thickening of the
bowel wall
but without evidence of free air. He also had leukocytosis to
18K with a left shift; stool cultures were negative as of time
of transfer. He reports he had a colonoscopy about 2-3 years
ago and told everything was OK. He denies having any sick
contacts or family history of GI illness.
Of note, Mr. [**Known lastname 31251**] recently had a CVA 6 weeks ago on [**2135-12-18**]
that presented with left facial droop which has resolved but has
persistent bladder incontinence. He had originally been on
coumdin for history of afib and PE but was switched to pradaxa
since the CVA and begriming about 2-3 weeks ago he reports the
presence of hematuria for which he presented to his PCP but had
not had any interventions. About 1 week ago he stared
experiencing bloody diarrhea as noted above, with accompanied
incontinence to stool for which he presented to [**Hospital3 **].
Past Medical History:
PMH: Afib, dilated cardiomyopathy - resolved, PE s/p cardiac
cath, glucose intolerance, hyperlipidemia, DJD, gout,
hypertension, CVA - [**12-23**] - now with urinary incontinence,
essential tremor
PSH: none
Social History:
Retired Police Officer from [**Location (un) 5110**].
Married, lives with wife.
Non-[**Name2 (NI) 1818**].
Denies alcohol use.
Family History:
Non-contributory
Physical Exam:
PE: T96.2 HR 83 BP 104/68 RR 18 02Sat 95RA
GEN: NAD, AOx3
CV: Irregularly irregular, rate controlled, nl s1 and s2
PULM: CTA b/l, no respiratory distress
ABD: Soft, mildly tender in lower quadrants bilaterally, BS (+),
non-distended, no rebound or guarding. Guiac positive (+)
stools. Good rectal tone. Rash and Stage II ulcer on left
buttock and gluteal cleft.
EXT: No c/c/e, MAE, no gross motor deficit
Brief Hospital Course:
The patient was transferred from [**Hospital3 **] on [**2136-2-9**] for
possible mesenteric ischemia. At time of admission the patient
was made NPO, started on intravenous fluids for resuscitation,
pradaxa was discontinued, heparin gtt was started for
anticoagulation. On HD 2 gastroenterology was consulted. Stool
cultures, blood cultures and urine cultures were sent. A CMV
viral load and C. Diff PCR were sent as recommended by the
gastroenterologists. On HD 2 the patient was started on a trial
of clear liquids which he tolerated. A consult was placed to the
Infectous Disease department. On HD 3 multiple stool cultures
and tests were sent as recommended by ID. The patient had one
episode of rapid heart rate to the 150s. The patient responded
to 5mg IV lopressor. On HD4 the patient was switched to IV
digoxin and IV beta blocker for better rate control of his
atrial fibrillation. An RPR and ANCA were sent as per GI
recommendations. Medicine was consulted for work up for
patient's diarrhea and GI bleeding. Patient's care was
transferred to the medical service on HD 4 and subsequently to
the medical ICU.
.
The patient was transferred to the MICU for closer management of
Atrial fibrillation with RVR.
.
MICU Green Course
.
74 with Afib with rvr, dialated cardiomyopathy, HLD, HTN, s/p
PE, recent stroke who was initially transferred from the medical
floor to the MICU for management of Afib with RVR in the setting
of diarrhea, enteritiss, palpable purpura and petechiae
indicative of possible vasculitis. Subsequently developed
intermittent bowl obstruction which improved at times with NG
tube. Started on steroids [**2136-2-16**] for suspected GI vasculitis.
Decompensated on [**2136-2-19**] with hypoxemic respiratory failure and
septic shock requiring mechanical ventilation and pressors. He
was initially extubated successfully for 4 days before being
intubated again [**2136-2-25**], given recurrent tachypnea and
Hypotensive episode. He then developed 2 large volume upper GI
bleeds requiring 7 units of prbc and then a family meeting took
place. After the family meeting his health care proxy, his wife,
decided to make the patient CMO and he was extubated. The
patient passed away shortly thereafter.
.
#Hypoxemic Respiratory failure: Patient intubated twice during
the admission. Differential included aspiration pneumonitis and
mucous plugging, unlikely to be acute heart failure or pneumonia
given clear CXR. First extubation failed and the patient was
reintubated 4 days later due to persistent tachypnea.Continued
Abx coverage with Vancomycin and Zosyn for presumed HAP given
fevers/sputum cx grew MRSA.
.
#Hypotension- At times during the admission the patient became
hypotensive to SBP to the 70's. He did grow MRSA from 1 blood cx
which was treated with Vancomycin. He recieved multiple fluid
bolus's and at times was breifly on phenylephrine. His BP during
his admission was mostly stable above SBP>120 without any
support
..
# UGIB/SBO: KUB and RUQ consistent with SBO concerning ischemic
colitis or mesenteric ischemia.At time had high NG output,
including cofee ground, bilious output In the differential is
vasculitis, mesenteric emboli from atrial fibrillation, and
atherosclerosis. Continued IV pantoprazole to 80mg
[**Hospital1 **].Appreciated GI and Surgery recs. Lactate was never
significantly elevated
.
# Enteritis: clinically most likely to be same process as in
skin where biopsy shows Medium to small vessel vasculitis. Had
CT abdomen which revealed isolated jejunitis and ileitis.
Autoimmune serologies were negative and Rheumatology recommended
to start steroids for presumed vasculitis.Thought to be most
consistent with LCV vs. HSP-like process. [**Doctor First Name **] and ANCA were
negative. The following tests were negative: dsDNA, ENA ([**Doctor Last Name 1968**],
Ro, La, RNP), cryoglobulins, RF, RPR, SPEP, UPEP, lupus
anticoagulant, anticardiolipin Ab, and RMSF titers.
.
# Rash ?????? Leading diagnosis is vasculitis as above largely based
on skin biopsy. Improved in last 24 hours of life, unclear what
led to improvement, but may have been due to high dose pulsed
steroids.
.
# Afib/RVR: Difficult to control. Worsened RVR with fever spikes
and episodes of hypotension related to the GI bleed. Very
difficult to control during admission with RVR to 140's. Was put
on Esmolol drip and diltiazam drip and continued Digoxin. Cards
recs were appreciated.
# Renal Failure /Hematuria/Proteinuria: may be prerenal
azotemia but will have to balance with risk of pulmonary
edema.Combination of renal contrast and pre renal during
admission which recovered with fluids. In last 3 days of life
Creatinine was trending up in the setting of recent Hypotensive
episode and intubation. Renal recs were appreciated
.
# Elevated Lipase:In the differential was bowel obstruction as
etiology though more likely is pancreatitis, no nausea,
vomiting, some epigastric tenderness, could be pancreatitis
caused by medications, or potential autoimmune . Triglycerides
normal level. Lasix induced pancreatitis was in the
differential.
.
# elevated INR: likely secondary to poor nutritional
status.Reversed to 1.2 with vitamin K.
# Nutrition:Continued TPN.
# Hyperglycemia: Insulin sliding scale continued.
.
# Thrush: resolved with nystatin
.
Death Note:
Mr. [**Known firstname 449**] [**Known lastname 31251**] expired at 810PM on [**2136-2-27**].
Exam:
Pupils fixed and nonreactive to light
No heart sounds
No lung sounds
No response to nail bed pressure
No carotid pulse
Wife, [**Name (NI) **] [**Name (NI) 31251**], notified. Attending of record, Dr. [**Last Name (STitle) **],
and PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 10543**], notified. Autopsy requested by wife.
Pathology [**Name (NI) 653**]. Documentation filed.
Medications on Admission:
primidone 50mg''', allopurinol 100mg', digoxin 0.25mg',
quinapril 10mg', carvedilol 6.25mg'', simvastatin 40mg qpm',
lasix 40mg', ubidecarenone (Co Q 10) 60mg', calcium 500mg'',
MVI', pradaxa 150mg'', calmoseptine ointment, cirpofloxacin
500mg
[**Hospital1 **], probiotics', hyophen
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2136-3-14**]
|
[
"531.40",
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"276.0",
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"577.0",
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"715.90",
"425.4",
"518.81",
"449",
"782.7",
"790.22",
"532.41",
"781.0",
"788.39",
"560.1",
"584.5",
"693.0",
"E947.9",
"276.2",
"790.01",
"V58.61",
"995.92",
"276.3",
"009.0",
"599.71",
"427.31",
"482.42",
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"272.4",
"785.52",
"458.29",
"V58.65",
"518.82",
"792.1",
"530.19"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"38.93",
"45.16",
"96.04",
"96.72",
"99.15",
"45.13",
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
9001, 9010
|
2867, 8667
|
325, 331
|
9061, 9070
|
9126, 9164
|
2402, 2420
|
9031, 9040
|
8693, 8978
|
9094, 9103
|
2435, 2844
|
266, 287
|
359, 2010
|
2032, 2241
|
2257, 2386
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,074
| 160,999
|
10190
|
Discharge summary
|
report
|
Admission Date: [**2173-3-14**] Discharge Date: [**2173-3-24**]
Date of Birth: [**2116-5-19**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Fatigue, Diarrhea, elevated INR
Major Surgical or Invasive Procedure:
none
History of Present Illness:
56 y/o female with PMHx significant for metastatic pancreatic
cancer who presents with elevated INR of 10 and fatigue. Patient
states that initially she has been having diarrhea for the past
5 weeks, non-bloody. Within the last week her diarrhea has
resolved however now she has nausea and vomiting, constipation
and decreased appetite. Her husband at home has also noticed
that her cellulitis at her left buttock region has gotten worse.
She went to [**Hospital3 4298**] ED intially where she was found to
have an INR of 5. She was transferred to our ED where repeat
coags showed a PT 78/PTT 39/INR 10. She did not have any obvious
active bleeding. Patient denies any blood per rectum, coughing
up any blood, or nosebleeds. In the ED patient also found to
have K of 2.3. She was given 1U PRBC, KCL, levofloxacin x1,
vitamin K, 1 unit of FFP and diluadid. She was intially admitted
to the floor, however on arrival to the floor nurses felt she
was too unstable for the floor so transferred her to the ICU
although her VS were stable.
.
In the [**Name (NI) 153**], pt was given FFP with correction of her INR.
However she subsequently developed respiratory distress
secondary to pulmonary edema likely due to volume overload and
required brief intubation. she was diuresed with iv lasix. she
also had bronch with bal. she was also treated for pneumonia
with vanco-zosyn-azithyromycin which was subsequently narrowed
down to levofloxacin alone. pt's respiratory status improved
rapidly and was extubated yesterday. since then she has required
minimal oxygen. she was also noted to have an enterococcus uti
which was sensitive to vanco and she was continued on that. pt
has a history of spinal myoclonus and had mri of spine per neuro
rec. she has not had any further recurrences. she continues to
have some diarrhoe and c diff was sent. Furthermore she had some
pre-renal azotemia for which she was rehydrated with
normalisation of her renal function.
Past Medical History:
Onc Hx: The patient was diagnosed with metastatic nonfunctioning
islet cell cancer of the pancreas in [**2166**] when she presented
with bony mets. She had persistent low back pain after an MVA,
not relieved with chiropractor. She has mets to the liver,
breast, scalp, calvarium, thoracic and lumbar vertebra, s/p XRT
x 2 to the low back and once to the upper back. S/P chemo 5FU,
experimental drug, thalidomide (stopped due to neuropathy), with
Temodar and avastin (two cycles most recently [**2172-4-13**]).
.
PMHx:
-Pancreatic Islet cell cancer- Neuroendocrine with metastasis to
the liver, scalp, calvarium, T/L/S spine, right breast, and left
arm status-post chemotherapy and radiation.
-depression
-low back pain
-history of cauda equina syndrome
-hypothyroidism
-GERD
-Raynaud's syndrome of the feet and peripheral neuropathy [**1-15**]
thalidomide.
-Shingles left T7-8 dermatome
Social History:
The patient lives with husband, 2 kids, she is raising her 4 yo
granddaughter. Former picture [**Last Name (un) 33982**]. No tob/etoh/drugs.
Family History:
Dad died of lung CA and also smoked
Physical Exam:
On tranfer to OMED service:
PE: 98.6 BP 115/74 HR 90/min RR 16 O2Sat 99% 2L
Gen: comfortable at rest, no apparent distress
Heent: PERLAA, oropharynx clear.
Neck: supple, no jvd
Lungs: mild rhonchi bilaterally
Cardiac: rrr, nl s1+s2, SEM [**1-19**]
Abd: soft, non tender, nl bs
Back: Skin irritation on upper back [**1-15**] radiation; circular
erythematous lesion 5x5cm on L buttock cheek resolving.
Ext: no e/c/c
Neuro: alert and oriented x 3
Pertinent Results:
[**2173-3-14**] 07:39PM WBC-4.8 RBC-2.74* HGB-7.9* HCT-23.0* MCV-84
MCH-28.8 MCHC-34.3 RDW-18.5*
[**2173-3-14**] 07:39PM NEUTS-79.8* BANDS-0 LYMPHS-14.5* MONOS-4.8
EOS-0.5 BASOS-0.3
[**2173-3-14**] 07:39PM PLT SMR-VERY LOW PLT COUNT-64*
[**2173-3-14**] 07:39PM PT-78.2* PTT-39.3* INR(PT)-10.2*
[**2173-3-14**] 07:39PM CK-MB-3 cTropnT-0.03* proBNP-3973*
[**2173-3-14**] 07:39PM ALT(SGPT)-15 AST(SGOT)-34 CK(CPK)-133 ALK
PHOS-329* AMYLASE-38 TOT BILI-0.3
[**2173-3-14**] 07:39PM GLUCOSE-120* UREA N-23* CREAT-1.5* SODIUM-139
POTASSIUM-2.3* CHLORIDE-100 TOTAL CO2-26 ANION GAP-15
[**2173-3-14**] 07:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-NEG
[**2173-3-14**] 10:45PM THROMBN-20.9*
[**2173-3-14**] 07:43PM GLUCOSE-112* LACTATE-0.8 K+-2.3*
.
ECG [**3-15**]: Sinus rhythm. Since the previous tracing of [**2173-1-10**] the
rate is somewhat faster. T waves are now flattened to slightly
inverted in leads I, III, aVF and leads V4-V6. The abnormalities
are non-specific.
.
Chest Xray [**3-15**]: IMPRESSION: Interval significant progression of
bilateral mid- and lower lung opacities suggestive of interval
fluid overload or development of ARDS. Aspiration is a less
likely differential consideration.
.
CT abd/pelvis [**3-15**]: IMPRESSION:
.
1. No evidence of retroperitoneal bleed.
.
2. Progression of metastatic disease within the lungs and liver.
Questionable hemmorhagic metastasis noted within the liver may
explain mild Hct drop. Scattered areas of ill- defined patchy
opacities within the lung parenchyma. Differential included
infectious or inflammatory etiologies with areas of hemorrhage
from early metastatic lesions felt unlikely, but not completely
excluded. This can be followed up with subsequent imaging if
change in clinical management will occur.
.
3. Stable appearance of diffuse osseous metastatic disease.
.
MRI C/T/L spine [**3-17**]:
L-spine: Mild interval improvement in the epidural extent and
spinal canal stenosis produced by expansile bony metastases in
the L2 and L3 verterbal bodies since [**2172-12-19**]. The epidural
component of an expansile metastasis in the L5 vertebral body is
also decreased - there is no spinal canal stenosis at this
level.
T-spine: Diffuse osseous metastases are again noted. While no
axial images were acquired, there is epidural disease in the
paracentral regions bilaterally posterior to the T10 vertebral
body, causing mild spinal canal stenosis. Bilateral paracentral
epidural disease posterior to the T11 vertebral body is more
prominent on the right.
C-spine: Interval progression of disease from most recent MR C
spine dated [**2173-5-15**]. Multiple bony metastases have increased in
size and number. There is epidural extension of disease with
mild spinal canal stenosis posterior to C4 and moderate stenosis
posterior to C6. Paraspinal disease cases neural foraminal
narrowing at multiple levels and encases the right verterbal
artery from C3-4.
.
CXR [**3-18**]: IMPRESSION: Improved bilateral diffuse air space
opacity likely representing pulmonary edema. Doubt focal
consolidation.
Brief Hospital Course:
56 y/o female with PMHx of metastatic pancreatic cancer who
presents with fatigue, n/v, and elevated INR admitted to ICU for
close monitoring, transferred to the floor, then returned to the
[**Hospital Unit Name 153**] with mental status changes which resolved with intravenous
hydration, empiric antibiotic coverage.
## Respiratory failure. This was most likely secondary to volume
overload exacerbated by pneumonia. The patient was effectively
diuresed in addition to being treated with broad spectrum
antibiotics eventually tailored appropriately to a single [**Doctor Last Name 360**]
according to culture data.
- has done well since extubation. continued to wean off o2.
- levofloxacin was given for full 10-day course empirically for
pneumonia.
.
## Enterococcus UTI: identified vanc-sensitive Enterococcus in
urine
- completed vanco for a full 7 day course.
.
## Diarrhea:
- c diff pending.
.
## Spinal myoclonus: pt had RLE jerking movements on [**3-15**]. Neuro
was consulted. they had recommended MRI whole spine which was
done. Patient has had recurrence of her muscle spasms overnight
and this morning.
- per [**Last Name (LF) 33983**], [**First Name3 (LF) **] start clonazepam TID, start at 0.5mg and
titrate up to relief of symptoms.
- continue to follow neuro recs.
.
## Elevated INR - thought to be secondary to chronic diarrhea
and poor nutrition.
- trend coags; INR mildly elevated today but much lower than on
admission.
.
## Nausea and Vomiting - Unclear if this is related to
pancreatic cancer as it has been occuring for a few weeks now or
secondary to infection; could also be secondary to opiates
- cont Anzemet, Ativan, Zydis
.
## Anemia - Patient with history anemia outpatient requiring
blood transfusions. No active source of bleeding.
- transfused 2 units prior to discharge with appropriate
response.
.
## Back Pain - Patient with chronic pain from metastatic
pancreatic cancer and on outpatient oxycodone
- continue analgesic therapy
.
## Leg spasm - Will continue outpatient flexeril and Lyrica and
starting clonazepam as above
.
## H/O shingles - cont acyclovir, but we redosed to q8h due to
improving renal function.
.
## Acute renal failure - patient's creat went to 1.5, baseline
0.6-0.9. Most likely secondary to pre-renal azotemia from volume
depletion
- no further diuresis at present.
- monitor fluid status and I/O carefully
.
## Hypothyroidism - Will continue outpatient thyroid replacement
.
## Cellulitis - Will monitor cellulitis on buttock region.
d/c'ed ancef as now on vanc
.
## PPx - pneumoboots, PPI
.
Medications on Admission:
Vit K 5 x1
NS at 90/hour
levothyroxine 25mcg
citalopram 20 qhs
Lyrica *NF* 75 mg Oral qhs
Epo QMWF
vanc 1gm IV q24
levofloxacin finished on [**3-20**]
pantoprozole 40 iv q24
olanzapine 5 [**Hospital1 **]
acyclovir 400 q8
dexamathosone 0.25
Oxycodone SR (OxyconTIN) 240 mg PO QAM hold for sedation
Clonazepam 0.5 mg PO TID
Oxycodone SR (OxyconTIN) 240 mg PO QHS hold for sedation
Oxycodone SR (OxyconTIN) 240mg PO DAILY at 4pm; hold for
sedation
Zosyn 4.5 IV q8
dilaudid - none on [**3-21**]
Cyclobenzaprine HCl 10 mg PO TID:PRN - 1 dose 4/8
morphine 1 dose 4/8
ativan 1mg - 1 dose 4/8
Discharge Medications:
1. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
Disp:*90 Tablet(s)* Refills:*2*
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*0*
4. Pregabalin 75 mg Capsule Sig: One (1) Capsule PO qhs ().
Disp:*30 Capsule(s)* Refills:*2*
5. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Six (6)
Tablet Sustained Release 12 hr PO QAM (once a day (in the
morning)).
Disp:*7 Tablet Sustained Release 12 hr(s)* Refills:*2*
6. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Five (5)
Tablet Sustained Release 12 hr PO DAILY (Daily).
Disp:*7 Tablet Sustained Release 12 hr(s)* Refills:*0*
7. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: Six (6)
Tablet Sustained Release 12 hr PO QHS (once a day (at bedtime)).
Disp:*7 Tablet Sustained Release 12 hr(s)* Refills:*0*
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed.
Disp:*30 Capsule(s)* Refills:*2*
9. Dexamethasone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
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. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*0*
12. Dolasetron 12.5 mg/0.625 mL Solution Sig: One (1)
Intravenous Q8H (every 8 hours) as needed.
13. Zofran 8 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*2*
14. Cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
Disp:*30 day supply* Refills:*0*
16. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) **] Nursing Association
Discharge Diagnosis:
Metastatic Pancreatic Carcinoma
Discharge Condition:
Fair
Discharge Instructions:
Please call your doctor if you experience pain uncontrolled by
your pain medicines or are feeling short of breath. There are a
number of medicines that can help you with your symptoms.
You will have an aid visiting you often who can continue to get
you up from bed and exercise as you are able.
Please take all of your medications as prescribed
Followup Instructions:
[**Name6 (MD) **] your MD as needed for follow up.
|
[
"244.9",
"198.81",
"518.81",
"285.9",
"157.8",
"197.7",
"198.2",
"428.0",
"584.9",
"486",
"599.0",
"198.5",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
12279, 12350
|
7056, 9613
|
307, 314
|
12426, 12433
|
3896, 7033
|
12828, 12882
|
3379, 3416
|
10249, 12256
|
12371, 12405
|
9639, 10226
|
12457, 12805
|
3431, 3877
|
236, 269
|
342, 2293
|
2315, 3204
|
3220, 3363
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
71,660
| 104,812
|
43198
|
Discharge summary
|
report
|
Admission Date: [**2113-11-12**] Discharge Date: [**2113-11-16**]
Date of Birth: [**2073-5-8**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfonamides
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
40-year-old woman with hx of fibromyalgia and past pancreatitis
presented with severe abdominal pain. The pain was primarily
located in the epigastric region, but she was diffusely tender
across her entire abdomen. She had positive nausea.
Past Medical History:
Fibromyalgia,
Sarcoidosis,
Appendectomyy,
Csec x 5,
Polychondritis,
Abdominoplasty
Social History:
lives at home with 5 children
Family History:
non-contributory
Physical Exam:
at time of discharge
Alert and oriented x3
cards: regular rate and rhythm, no murmurs rubs or gallops
auscultated
Pulmonary: lungs clear to auscultation bilaterally
Abdomen: + bowel sounds, soft, mild epigastric tenderness to
deep palpation.
extremities: no clubbing, cyanosis, edema
Pertinent Results:
[**2113-11-12**] 02:20AM PLT COUNT-264
[**2113-11-12**] 02:20AM NEUTS-75.6* LYMPHS-16.7* MONOS-5.6 EOS-1.6
BASOS-0.5
[**2113-11-12**] 02:20AM WBC-9.4 RBC-3.71* HGB-12.2 HCT-33.7* MCV-91
MCH-32.9* MCHC-36.2* RDW-12.8
[**2113-11-12**] 02:20AM ALBUMIN-4.1
[**2113-11-12**] 02:20AM LIPASE-2850*
[**2113-11-12**] 02:20AM ALT(SGPT)-147* AST(SGOT)-212* LD(LDH)-339*
ALK PHOS-145* TOT BILI-0.8
[**2113-11-12**] 02:20AM estGFR-Using this
[**2113-11-12**] 02:20AM GLUCOSE-112* UREA N-9 CREAT-0.7 SODIUM-139
POTASSIUM-3.7 CHLORIDE-104 TOTAL CO2-28 ANION GAP-11
[**2113-11-12**] 03:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-7.0
LEUK-NEG
[**2113-11-12**] 03:50AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2113-11-12**] 03:50AM URINE GR HOLD-HOLD
[**2113-11-12**] 03:50AM URINE HOURS-RANDOM
[**2113-11-12**] 11:55AM PLT COUNT-250
[**2113-11-12**] 11:55AM WBC-5.2 RBC-3.72* HGB-12.1 HCT-33.8* MCV-91
MCH-32.5* MCHC-35.7* RDW-13.2
[**2113-11-12**] 11:55AM CALCIUM-8.6 PHOSPHATE-2.5* MAGNESIUM-1.9
[**2113-11-12**] 11:55AM LIPASE-456*
[**2113-11-12**] 11:55AM ALT(SGPT)-367* AST(SGOT)-432* LD(LDH)-466*
ALK PHOS-178* AMYLASE-357* TOT BILI-1.7*
[**2113-11-12**] 11:55AM GLUCOSE-88 UREA N-5* CREAT-0.7 SODIUM-143
POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-28 ANION GAP-9
Brief Hospital Course:
The patient was admitted to the surgery service for evaluation
and treatment.
The patient was admitted to the ICU for monitoring on the first
day of admission for overnight observation. She recieved IV
hydration and pain medications and was transferred to the floor
the following day.
Neuro: The patient received IV dilaudid with good effect and
adequate pain control. When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout this hospitalization.
GI/GU/FEN:
The patient was made NPO with IVF. The patients diet was
advanced on HD 3 first to sips, then clears, then a low-fat
regular diet. Her pancreatic enzymes trended downward
appropriately. This was tolerated well. The patients
electrolytes were monitored routinely.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required during this stay.
Prophylaxis: The patient was given pneumatic boots and was
encouraged to get up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
Vitamin D
Maalox
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while using narcotics for pain control to
help prevent constipation.
Disp:*60 Capsule(s)* Refills:*0*
2. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours: for nausea. [**Month (only) 116**] cause sedation. Do not operate heavy
machinery or consume alcohol. .
Disp:*15 Tablet(s)* Refills:*0*
3. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every six (6) hours:
Do not operate heavy machinery or consume alcohol or other
sedatives. [**Month (only) 116**] cause drowsiness. .
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Sarcoidosis
Fibromyalgia
Discharge Condition:
tolerating low fat diet
stable
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.
*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
Medications: please resume home medications. Take other
medications as ordered
Diet: it is very important that you maintain a Low-fat diet
between now and your surgery next week (lean meets, vegetables,
and fruits; avoid fried foods, red meats, processed foods). We
will provide you with materials to help guide your food
decisions.
Followup Instructions:
Please call Dr.[**Name (NI) 2829**] office ([**Telephone/Fax (1) 2363**] at noon on
Monday [**11-20**] for instructions if you have not been contact[**Name (NI) **]
regarding your gallbladder surgery on Tuesday.
Completed by:[**2113-11-21**]
|
[
"574.20",
"135",
"729.1",
"733.99",
"577.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
4757, 4763
|
2473, 4067
|
301, 308
|
4855, 4888
|
1086, 2450
|
6151, 6396
|
748, 766
|
4134, 4734
|
4784, 4834
|
4093, 4111
|
4912, 6128
|
781, 1067
|
247, 263
|
336, 579
|
601, 685
|
701, 732
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,478
| 149,096
|
33130+57836
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-2-3**] Discharge Date: [**2174-2-14**]
Service: CARDIOTHORACIC
Allergies:
Protamine Sulfate / Gluten / Milk / Wheat Flour
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
palpitations
Major Surgical or Invasive Procedure:
[**2174-2-3**] cardiac catherization
[**2174-2-8**] Mitral Valve Replacement (25mm [**Company 1543**] mosaic
porcine), MAZE procedure with left atrial appendage ligation
History of Present Illness:
85 year old female with history atrial fibrillation admitted for
dofetilide initation. Has known history of mitral stenosis
based on echocardiogram.
Past Medical History:
Paroxysmal atrial fibrillation
Rheumatic heart disease
Moderate-to-severe mitral stenosis
Hypertension
Hypothyroidism
Glaucoma
Osteoporosis
Social History:
She currently lives alone but has a daughter
Retired
[**Name2 (NI) 1139**] denies
ETOH denies
Family History:
non contributory
Physical Exam:
VS - 97.9, 125/69, 70s, 97% RA
Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with JVP of *** cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by
palpation. No abdominial bruits.
Ext: 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:
[**2174-2-13**] 06:40AM BLOOD WBC-9.0 RBC-3.42* Hgb-10.6* Hct-30.9*
MCV-90 MCH-30.9 MCHC-34.2 RDW-17.0* Plt Ct-204
[**2174-2-3**] 12:40PM BLOOD WBC-6.3 RBC-3.34* Hgb-10.8* Hct-32.6*
MCV-97 MCH-32.3* MCHC-33.1 RDW-15.6* Plt Ct-300
[**2174-2-13**] 06:40AM BLOOD Plt Ct-204
[**2174-2-13**] 06:40AM BLOOD PT-13.8* INR(PT)-1.2*
[**2174-2-3**] 07:50AM BLOOD PT-14.6* INR(PT)-1.3*
[**2174-2-8**] 12:27PM BLOOD Fibrino-83*
[**2174-2-14**] 10:57AM BLOOD K-4.3
[**2174-2-13**] 06:40AM BLOOD Glucose-61* UreaN-18 Creat-0.8 Na-134
K-3.7 Cl-96 HCO3-33* AnGap-9
[**2174-2-3**] 12:40PM BLOOD Glucose-121* UreaN-13 Creat-0.9 Na-139
K-4.7 Cl-104 HCO3-26 AnGap-14
[**2174-2-12**] 09:21AM BLOOD ALT-26 AST-29 AlkPhos-49 Amylase-36
TotBili-1.8*
[**2174-2-14**] 10:57AM BLOOD Mg-2.3
[**2174-2-4**] 06:20AM BLOOD %HbA1c-5.9
[**2174-2-3**] 12:40PM BLOOD TSH-4.2
[**2174-2-12**] 09:21AM BLOOD Cortsol-25.1*
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG FA6A [**2174-2-14**] 9:15 AM
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 77012**]
Reason: f/u effusions/atx
[**Hospital 93**] MEDICAL CONDITION:
85 year old woman with s/p MVR, maze
REASON FOR THIS EXAMINATION:
f/u effusions/atx
Provisional Findings Impression: CHgc MON [**2174-2-14**] 11:50 AM
No significant change in left greater than right pleural
effusions.
Preliminary Report !! PFI !!
No significant change in left greater than right pleural
effusions.
DR. [**First Name4 (NamePattern1) 19115**] [**Last Name (NamePattern1) **]
DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**]
PFI entered: MON [**2174-2-14**] 11:50 AM
[**Known lastname 77013**],[**Known firstname **] [**Age over 90 77014**] F 85 [**2088-7-7**]
Cardiology Report ECG Study Date of [**2174-2-11**] 8:19:40 AM
Atrial pacing. Probable prior inferior infarction. Long QTc
interval.
Compared to the previous tracing of [**2174-2-8**] atrial pacing is now
evident.
Q-T interval is slightly shorter. The other findings are
similar.
Read by: [**Last Name (LF) **],[**First Name3 (LF) **] V.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
84 0 92 420/462 0 20 7
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 77013**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 77015**]TTE (Complete)
Done [**2174-2-11**] at 8:28:05 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) **]
[**Street Address(2) 15115**]
[**Location (un) 15116**], [**Numeric Identifier 15117**] Status: Inpatient DOB: [**2088-7-7**]
Age (years): 85 F Hgt (in): 64
BP (mm Hg): 115/63 Wgt (lb): 130
HR (bpm): 80 BSA (m2): 1.63 m2
Indication: Tamponade.
ICD-9 Codes: 424.0
Test Information
Date/Time: [**2174-2-11**] at 08:28 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD
Test Type: TTE (Complete) Son[**Name (NI) 930**]: Cardiology Fellow
Doppler: Full Doppler and color Doppler Test Location: West Echo
Lab
Contrast: None Tech Quality: Suboptimal
Tape #: 2009W007-0:06 Machine: Vivid [**6-8**]
Echocardiographic Measurements
Results Measurements Normal Range
Left Ventricle - Ejection Fraction: >= 55% >= 55%
Mitral Valve - Peak Velocity: 1.4 m/sec
Mitral Valve - Mean Gradient: 4 mm Hg
TR Gradient (+ RA = PASP): *34 mm Hg <= 25 mm Hg
Findings
This study was compared to the prior study of [**2174-2-3**].
LEFT ATRIUM: Moderate LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA.
LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall
motion abnormality cannot be fully excluded. Overall normal LVEF
(>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
Trace AR.
MITRAL VALVE: Bioprosthetic mitral valve prosthesis (MVR). MVR
well seated, with normal leaflet/disc motion and transvalvular
gradients. Torn mitral chordae. No MR. [Due to acoustic
shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild to
moderate [[**12-3**]+] TR. Mild PA systolic hypertension.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion. No
echocardiographic signs of tamponade.
GENERAL COMMENTS: Suboptimal image quality - poor echo windows.
Left pleural effusion.
Conclusions
The left atrium is moderately dilated. 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. Trace aortic
regurgitation is seen. A bioprosthetic mitral valve prosthesis
is present. The mitral prosthesis appears well seated, with
normal leaflet/disc motion and transvalvular gradients. Torn
mitral chordae are present. No mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] There is mild pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion. There are no echocardiographic signs of
tamponade.
IMPRESSION: No significant pericardial effusion.
Normally-functioning mitral valve bioprosthesis. Preserved
global biventricular systolic function. Mild pulmonary
hypertension.
Compared with the prior study (images reviewed) of [**2174-2-3**],
stenotic mitral valve has been replaced with a bioprosthesis.
Right ventricular function has improved and pulmonary pressures
are lower. The other findings are similar.
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-2-11**] 08:50
Brief Hospital Course:
Underwent cardiac catherization for evaluation prior to starting
dofetilide. She was started on dofetilide and underwent
surgical evaluation for mitral valve stenosis. On [**2-10**] she was
brought to the operating room where she underwent a mitral valve
replacement, MAZE procedure and left atrial appendage ligation.
Please see operative report for surgical details. She received
vancomycin for perioperative antibiotics. She was transferred
to the intensive care unit for hemodynamic montioring. In the
first twenty four hours she was found to have bleeding from the
left ear and ENT was consulted to evaluate. The bleeding
stopped and she was placed on cirpodex for five days per ENT
recommendations. She was also weaned from sedation, awoke
neurologically intact, and was extubated without complications.
She remained in the intensive care unit for monitoring and was
transferred to the floor on post operative day two. Due to
hypotension that required vasoactive medications, hematocrit was
21 and she was transfused, and echocardiogram was performed
which showed no pericardial effusion. She was transferred to
the floor the next day with her hematocrit and blood pressure
stable. She continued to do well and was ready for discharge to
rehab on post operative day six.
Sternal incision healing no erythema no drainage steristrips
intact
Right groin with eccyhmosis area soft no hematoma no bruit
Edema bilateral lower extremity +2 pitting
Weight preoperative 56 kg discharge 61 kg
Coumadin - has been receiving 2.5 mg - INR 1.2, increased to 4
mg [**2-15**] and [**2-16**] with draw [**2-17**]
Medications on Admission:
Toprol-XL 25 mg once daily, Aspirin 81 mg once daily, Coumadin
for therapeutic INR of 2 to 3, Levoxyl 75 mcg once daily, Evista
60 mg once daily, Effexor XR 75 mg once daily
Discharge Medications:
1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Dofetilide 250 mcg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours) for 4 weeks: Please follow up with
[**Last Name (LF) **],[**First Name3 (LF) 275**] in 4 weeks.
Disp:*56 Capsule(s)* Refills:*0*
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a
day.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
8. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
2 weeks. Tablet(s)
10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 2
weeks.
11. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
12. Warfarin 4 mg Tablet Sig: One (1) Tablet PO once a day for 1
days: received 4mg [**2-14**], to receive 4 mg [**2-15**] and lab draw [**2-16**]
for further dosing - goal INR 2-2.5.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Mitral stenosis s/p mitral valve replacement
Paroxysmal atrial fibrillation s/p MAZE and left atrial
appendage ligation
Left ear bleed
Rheumatic heart disease
Hypertension
Hypothyroidism
Glaucoma status post bilateral eye surgery
Osteoporosis
Bladder suspension
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Call ENT Dr [**Last Name (STitle) 77016**] if any further bleeding from left ear
[**Telephone/Fax (1) 2349**]
Followup Instructions:
Please call to schedule all appointments
Dr. [**First Name (STitle) **] in 4 weeks [**Telephone/Fax (1) 170**]
Dr. [**Last Name (STitle) **] in 1 month - [**Hospital **] clinic [**Telephone/Fax (1) 62**]
Dr. [**Last Name (STitle) 17863**] after discharge from rehab [**Telephone/Fax (1) 11376**]
Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] after discharge from rehab [**Telephone/Fax (1) 11767**]
Provider: [**Last Name (NamePattern4) **]. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2174-5-19**] 10:00
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3878**] - ENT [**3-1**] at 1230 [**Location (un) **] -
[**Telephone/Fax (1) 2349**]
Labs: PT/INR for coumadin dosing with goal INR 2-2.5 for atrial
fibrillation and MAZE (mon/wed/fri) until steady dose
Labs: potassium, magnesium, and creatinine twice a week while on
lasix and replete K to greater than 4 and Magnesium greater than
2 due to dofetilide
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2174-2-14**] Name: [**Known lastname 12521**],[**Known firstname 1049**] Unit No: [**Numeric Identifier 12522**]
Admission Date: [**2174-2-3**] Discharge Date: [**2174-2-14**]
Date of Birth: [**2088-7-7**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Protamine Sulfate / Gluten / Milk / Wheat Flour
Attending:[**First Name3 (LF) 265**]
Addendum:
Due to blood pressure was unable to start betablocker but on
dofetilide. Consider restarting toprol XL if blood pressure
tolerates in the next few days at rehab.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 14**] & Rehab Center - [**Hospital1 15**]
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**]
Completed by:[**2174-2-14**]
|
[
"416.8",
"398.90",
"365.9",
"458.29",
"286.9",
"V58.61",
"599.0",
"394.0",
"244.9",
"585.3",
"388.69",
"427.31",
"733.00",
"300.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.23",
"37.23",
"38.93",
"39.61",
"88.56",
"18.11",
"37.36"
] |
icd9pcs
|
[
[
[]
]
] |
13613, 13814
|
7670, 9285
|
272, 444
|
11233, 11240
|
1803, 2859
|
11861, 13590
|
914, 932
|
9509, 10825
|
2899, 2936
|
10948, 11212
|
9311, 9486
|
11264, 11838
|
947, 1784
|
220, 234
|
2968, 7647
|
472, 624
|
646, 787
|
803, 898
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,045
| 141,239
|
49202
|
Discharge summary
|
report
|
Admission Date: [**2144-12-25**] Discharge Date: [**2144-12-29**]
Date of Birth: [**2089-1-20**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1055**]
Chief Complaint:
alcohol overdose
Major Surgical or Invasive Procedure:
endotracheal intubation
History of Present Illness:
55 yo male, h/o alcohol abuse, HTN, TBI (hit as a pedestrian,
with pins in leg at this time), presenting s/p overdose with
alcohol. Pt was apparently found wandering around the street in
[**Location (un) 686**], brought in to hospital by EMS. In the ED, he states
that he took [**1-24**] bottle of atenolol with ?amt Benadryl and vodka
(drinks 1 pint/day alcohol at baseline). He was initially
following commands in the ED, with stable vitals, but his O2
sats dropped to 75%, became cyanotic, and he was intubated for
airway protection/admitted to the MICU for observation. He was
also given 50 mg charcoal in the ED. He was put on CIWA, with
valium as needed, propofol gtt while intubated. Pt was
extubated the next morning, did well, and was transferred for
the floor for further observation. Pt was seen by psych,
reportedly had no current SI's (and was not trying to commit
suicide with overdose), but he does report symptoms of
depression (finanacial, family problems, concerns about his
son). On admission, he also had a sodium of 150 which resolved
after hydration with D5W (presumed hypovolemic hypernatremia [**2-24**]
dehydration).
Pt currently stable, extubated, doing well on transfer to the
floor. He was requesting to leave AMA on transfer to the floor,
still on 1:1 sitter.
Past Medical History:
1. TBI, [**2-24**] being hit as a pedestrian, currently with pins in
knee
2. HTN, on medication
3. Alcohol abuse; no history of psych disease or inpt/outp
treatment
4. ?facial rash/rosacea, on doxy
Meds on Admission:
Atenolol
Benadryl
Doxycycline
ALL: NKDA
Social History:
Drinks 1 pint/day; history of drinking for past 15 years
(longest sobriety 9 mo), history of 5 detoxes, including at
[**Hospital1 **] 1 yr ago
No tobacco/drug use
Cocaine x 1 in remote past
Grad from BC, MA in teaching in Brown, former teacher, currently
unemployed
Divorced [**2130**]
Living in shelters over past 5 yrs
Has 18 yo son living with ex-wife
Family History:
Grandparent with alcoholism
Physical Exam:
VS: 98.6 150/82 70 16 96% RA wt=91.7 kg
Gen: mild distress, no tremor, somewhat disheveled, with beard
HEENT: PERRL, EOMI, OP clear
Neck: no lad, no JVD
Lungs: CTA bilaterally, no w/r/r
CV: RRR, nl S1/S1, no m/r/g
Abd: soft, nt/nd, nabs, no hsm
Extr: trace LE edema, R>L
Neuro/psych: denies SI, stable, requesting to leave
Pertinent Results:
EKG: NSR, LAD, nl intervals, no ST-T-wave changes, no change
from baseline EKG
CXR: low lung volumes, bibasilar atelectasis, NAD
[**2144-12-25**] 06:37PM SODIUM-144
[**2144-12-25**] 06:37PM LD(LDH)-243 CK(CPK)-123
[**2144-12-25**] 06:37PM CK-MB-2 cTropnT-<0.01
[**2144-12-25**] 06:59AM TYPE-ART PO2-138* PCO2-38 PH-7.47* TOTAL
CO2-28 BASE XS-4
[**2144-12-25**] 06:59AM LACTATE-3.6* NA+-147
[**2144-12-25**] 06:10AM GLUCOSE-136* UREA N-20 CREAT-0.8 SODIUM-148*
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-27 ANION GAP-15
[**2144-12-25**] 06:10AM ALT(SGPT)-24 AST(SGOT)-38 CK(CPK)-92 ALK
PHOS-58 TOT BILI-0.4
[**2144-12-25**] 06:10AM CK-MB-NotDone cTropnT-<0.01
[**2144-12-25**] 06:10AM CALCIUM-8.0* PHOSPHATE-2.4* MAGNESIUM-1.9
[**2144-12-25**] 03:20AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2144-12-25**] 12:49AM ASA-NEG ETHANOL-398* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Brief Hospital Course:
A/P: 55 yo male, h/o alcohol abuse, HTN, TBI (pedestrian
accident), who presented after an overdose with EtOH,
?atenolol/benadryl, intubated initially for airway protection,
now extubated, doing well, transferred from MICU (overnight
stay) to floor.
1. Alcohol overdose: pt s/p large amount of alcohol with
benadryl/atenolol, s/p intubation for airway protection and
overnight MICU stay for observation, received charcoal in the
ED, now extubated and doing well. He was maintained on CIWA
scale as well as on standing valium. He required 45 mg valium 1
day post-extubation. He was then put on 10 mg TID and tapered
accordingly. He did not require additional valium as per CIWA,
was stable hemodynamically, with no signs of DT's/autonomic
instability. He was started on MVI/thiamine/folate supplements.
He continued to deny any suicidal ideations and denied that his
overdose was a suicide attempt. As per psych, he has a history
of changing his story/lying, and it was felt that he required
further psychiatric hospitalization. He was screened by BEST and
placed accordingly.
2. Psych: as above, denies any SI/denies current SI. As above,
psych felt he was not being completely truthful about his story.
They recommended placement as per BEST. He was screened and
placed accordingly.
3. Hypernatremia: pt with Na=150 on admission, repleted free
water deficit (D5W) and Na 140 on transfer to the floor. He
likely had hyponatremic hyponatremia which responded to fluid
resuscitation. His hyponatremia remained stable throughout the
rest of his hospitalization.
4. HTN: Initially held BP meds, and Atenolol was restarted on
discharge. His PCP should address with him the possibility of
adding a second bp [**Doctor Last Name 360**] for better control.
5. CAD: cycled enzymes on admission, 2 sets neg, no EKG
changes, atenolol was continued on discharge, and pt with no
more symptoms.
6. Dispo: Pt was stable on discharge. He was discharged to
complete a valium taper. He was discharged/placed as per BEST
on [**Hospital1 **] 4.
Medications on Admission:
Meds on Admission:
Atenolol 50 mg
Benadryl
Doxycycline
ALL: NKDA
Discharge Medications:
1. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
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. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed.
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for 3 days: Please take 5 mg TID on [**12-28**] mg TID on
[**12-29**], 1mg TID on [**12-30**], then stop.
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary diagnosis:
Alcohol overdose requiring intubation
Secondary diagnosis:
Hypertension
Discharge Condition:
Good
Discharge Instructions:
1. Please take all your medications as prescribed. The only
thing we added was a valium taper. You should take 5 mg TID on
[**12-28**] mg TID on [**12-29**], 1mg TID on [**12-30**], and then off. We also
added some vitamin supplements (thiamine, MVI, folate) that you
should take daily
2. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 1-2 weeks
of leaving your facility. Bring this discharge paperwork with
you to the appointment.
3. Please call your PCP if you are experiencing chest pain,
shortness of breath, fevers/chills, or with any other concerns.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], within 1-2 weeks of
leaving your facility. Bring this discharge paperwork with you
to the appointment. At this time, he should continue adding
another [**Doctor Last Name 360**] for blood pressure control to your regimen.
|
[
"E858.1",
"E860.0",
"972.9",
"963.0",
"401.9",
"311",
"414.01",
"782.1",
"980.0",
"434.90",
"V60.0",
"276.1",
"E858.3",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
6579, 6594
|
3700, 5751
|
291, 316
|
6730, 6736
|
2726, 3677
|
7399, 7718
|
2317, 2346
|
5867, 6556
|
6615, 6615
|
5777, 5782
|
6760, 7376
|
2361, 2707
|
235, 253
|
344, 1643
|
6694, 6709
|
6634, 6673
|
5796, 5844
|
1665, 1873
|
1945, 2301
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,850
| 103,237
|
54029
|
Discharge summary
|
report
|
Admission Date: [**2194-5-17**] Discharge Date: [**2194-6-2**]
Date of Birth: [**2152-5-1**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 949**]
Chief Complaint:
Leukocytosis with bandemia.
Major Surgical or Invasive Procedure:
1. Endoscopic esophagogastroduodenoscopy
History of Present Illness:
42 year old woman with EtOH hepatitis on multiple occasions, ?
cirrhosis, depression with multiple suicidal attempts, obesity
s/p Reux-en-Y gastric bypass surgery, [**Last Name (un) **] [**2192**] s/p multiple
abdominal surgeries who was admitted to ET service during ([**5-6**]
- [**5-16**]) for another bout of EtOH hepatitis in setting of
Urosepsis, started on steroids w/ resolution of encephalopathy,
improvement in WBCs/Tbili and discharged to rehab on [**5-16**] w/
elevated WBC and 3 bands thought to be due to steroids (based on
neg. inf. w/up and clinical improvement) who now presents with
right sided abdominal pain (unchanged), encephalopathy and
bandemia from rehab. Of note, on day of discharge, Lactulose had
been held due to frequent BMs and was not restarted.
.
In the interim, no precipitating events were noted. She became
progressively more confused (off lactulose), labs were drawn and
showed a WBC of 15.7K w/ 35% bands. She was sent to the ED for
re-evaluation.
.
In the ED, initial VS: 99.7 110 110/65 18 99%. She was found to
have a WBC of 17, bandemia of 10 (down from 34 from OSH). She
underwent a RUQ U/S which was negative for ascites, portal
thrombosis, or biliary pathology (s/p cholecystectomy). U/A was
initially dirty, but given CTX, then repeat U/A negative. CXR
showed lower lobe atelectasis, so azithromycin was added. She
was given 1g of CFTX, 500mg Azithro, and ? fluconazole 150mg (on
dashboard but not recorded in chart) and lactulose for presumed
hepatic encephalopathy. Liver was notified. Last set of vitals
98, 120/65, 18, 98%RA.
.
On the floor in initial evaluation, her ROS was negative w/
exception of "a severe headache that started yesterday, frontal
in nature, [**6-22**], and she states she's never experienced a
headache like this before. She denies neck stiffness,
photophobia, phonophobia, vomitting, flu/cold symptoms." On the
floor, she underwent an attempt at LP w/o success. Her MS
improved markedly w/ lactulose.
.
On my interview, she was alert, oriented to date, time and place
and was following commands. She recalls not being able to
participate with rehab due to confusion. She c/o of persistent
RUQ pain that was unchanged from prior as well as LLE pain
improved from prior. ROS was otherwise negative.
Past Medical History:
* Anemia of chronic disease
* Depression - two suicide attempts in past (one an overdose),
followed by counselor (unsure location)
* Anxiety
* Recent memory loss/black out spells
* Roux-en-Y gastric bypass
* Small bowel obstruction, lysis of adhesions
* Urinary incontinence
* Open cholecystectomy
* Tubovarian abscess [**2193-6-3**]
* Left hip plate s/p fall as child
* Multiple admissions for EtOH hepatitis.
Social History:
Separated from her husband, lives alone. Does not work. Brother
and boyfriend help her out. Patient denies tobacco and illicits.
Heavy alcohol use, last drink "two days ago" per patient.
Adopting a dog.
Family History:
Mother and father with diabetes mellitus.
Physical Exam:
Upon admission:
VS: 100.1 (100.9Tm) 110/60 112 21 98%RA
GENERAL: Sitting in bed, watching television, pleasant.
Obese, jaundiced (increased).
HEENT: NC/AT, sclerae icteric, MMM, OP clear. No sinus
tenderness.
NECK: Supple, no meningisumus, no JVD.
HEART: RR, no MRG, nl S1-S2.
LUNGS: Poor effort, bilateral crackles.
ABDOMEN: Obese, soft, TTP at RUQ, no rebound/guarding. Guiac
positive stool. SubQ mass of 2.5cm to 3cm in L abdominal wall.
EXTREMITIES: 4+ edema to hips.
SKIN: jaundiced, no rashes or lesions.
NEURO: Awake, A&Ox3, DOWb intact but not MOYb. Naming,
repetition, [**Location (un) 1131**] intact. no apraxia or neglect.
CNs EOMi, no nystagmus, face symmetric, sensation intact to LT
b/l, palate is symmetric as is tongue.
Full strength in UEs b/l. Sensation intact to LT and
proprioception.
Normal tone in LEs and UEs.
RLE w/ [**3-18**] IP/H/TA, full quad., limited by effort.
LLE w/ AG in IP, Quad/Ham,TA, when LLE liften above RLE and let
go to fall, it is abducted and extended by patient temporarily
before falling to bed.
Toes down b/l.
At discharge:
Vital signs: 98.8 98.4 118/76 101 18 97% RA. 117kg
I/O: 240/BR 1300+100/400
General: Overweight, jaundiced woman in no distress.
HEENT: +Scleral icterus.
Neck: Supple, no JVD.
Heart: RRR, normal s1s2, no murmurs.
Lungs: CTAB no w/r/c.
Abdomen: Obese, soft, mild TTP at RUQ, no rebound/guarding.
+hepatosplenomegaly. Multiple abdominal wall nodules.
Extremities: 1+ edema to hips.
Neurological: Oriented x3, moving all extremities.
Pertinent Results:
Labs upon admission:
[**2194-5-17**] 10:50PM URINE COLOR-DkAmb APPEAR-Hazy SP [**Last Name (un) 155**]-1.019
[**2194-5-17**] 10:50PM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-4* PH-5.5 LEUK-NEG
[**2194-5-17**] 10:50PM URINE RBC-<1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1
[**2194-5-17**] 10:50PM URINE GRANULAR-1* HYALINE-10* CELL-14*
[**2194-5-17**] 10:50PM URINE MUCOUS-OCC
[**2194-5-17**] 10:40PM LACTATE-3.2*
[**2194-5-17**] 10:35PM AMMONIA-81*
[**2194-5-17**] 09:50PM URINE HOURS-RANDOM
[**2194-5-17**] 09:50PM URINE UCG-NEGATIVE
[**2194-5-17**] 09:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2194-5-17**] 09:50PM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.019
[**2194-5-17**] 09:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-8* PH-5.5 LEUK-NEG
[**2194-5-17**] 09:50PM URINE RBC-0 WBC-12* BACTERIA-MANY YEAST-NONE
EPI-30
[**2194-5-17**] 09:50PM URINE HYALINE-5*
[**2194-5-17**] 09:50PM URINE MUCOUS-MANY
[**2194-5-17**] 08:45PM GLUCOSE-78 UREA N-10 CREAT-0.5 SODIUM-138
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-29 ANION GAP-16
[**2194-5-17**] 08:45PM ALT(SGPT)-58* AST(SGOT)-147* ALK PHOS-109*
TOT BILI-17.3*
[**2194-5-17**] 08:45PM LIPASE-25
[**2194-5-17**] 08:45PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
[**2194-5-17**] 08:45PM NEUTS-66 BANDS-10* LYMPHS-7* MONOS-14* EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-2*
[**2194-5-17**] 08:45PM PLT COUNT-159
[**2194-5-17**] 08:45PM PT-19.0* PTT-29.7 INR(PT)-1.7*
[**2194-5-16**] 05:58AM GLUCOSE-62* UREA N-9 CREAT-0.5 SODIUM-138
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-31 ANION GAP-12
[**2194-5-16**] 05:58AM ALT(SGPT)-50* AST(SGOT)-137* ALK PHOS-111*
TOT BILI-15.1*
[**2194-5-16**] 05:58AM CALCIUM-8.0* PHOSPHATE-2.1* MAGNESIUM-1.5*
[**2194-5-16**] 05:58AM WBC-15.8* RBC-2.49* HGB-8.3* HCT-25.5*
MCV-103* MCH-33.4* MCHC-32.6 RDW-17.3*
[**2194-5-16**] 05:58AM NEUTS-80* BANDS-3 LYMPHS-10* MONOS-6 EOS-1
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2194-5-16**] 05:58AM HYPOCHROM-1+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL TARGET-OCCASIONAL TEARDROP-OCCASIONAL
[**2194-5-16**] 05:58AM PLT SMR-NORMAL PLT COUNT-163
[**2194-5-16**] 05:58AM PT-18.6* PTT-30.2 INR(PT)-1.7*
Labs at discharge:
CBC: 18.7/7.8/23.9/207 MCV 96
Chem 7: 140/4.2/104/27/14/0.7<86
Chem 10: Ca: 9.6 Mg: 1.7 P: 3.4
ALT: 50 AST: 128 AP: 79 Tbili: 10.4
PT: 22.7 INR: 2.1
Micro:
[**2194-5-25**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-22**] URINE URINE CULTURE-yeast
[**2194-5-21**] MRSA SCREEN MRSA SCREEN-FINAL
[**2194-5-20**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-19**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-19**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-18**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-18**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL
[**2194-5-18**] BLOOD CULTURE Blood Culture, Routine-negative
[**2194-5-17**] URINE URINE CULTURE-negative
Imaging:
[**2194-5-21**] renal u/s: The kidneys are normal in appearance and there
is no evidence of hydronephrosis. The right kidney measures 13
cm and the left kidney measures 13.8 cm. The bladder is
collapsed around a Foley catheter. IMPRESSION: Normal renal
ultrasound study.
[**2194-5-20**] CXR: Aside from mild left basal atelectasis, left lung is
clear. Right lung volume has improved. Mild interstitial
abnormality at the right lung base reflected in bronchial
cuffing is minimal, and probably not sufficient to explain
clinical findings. Heart size is top normal. Pleural effusion is
minimal if any. No pneumothorax.
[**2194-5-18**] CXR: In comparison with the study of [**5-17**], there are lower
lung volumes. Atelectatic changes are again seen at both bases.
In the appropriate clinical setting, the possibility of
supervening pneumonia would have to be considered.
[**2194-5-18**] CT chest/abd/pelvis: intact Roux en Y, subcutaneous soft
tissue mass in abdominal wall 1.6x1.9cm
[**2194-5-17**] RUQ U/S: Echogenic liver again seen, most consistent with
fatty infiltration; advanced liver diseaes including hepatic
fibrosis/cirrhosis can not be excluded on this study. Patent
main portal vein with hepatopetal flow. Status post
cholecystectomy. No free fluid seen.
Brief Hospital Course:
42 year old female with EtOH hepatitis on multiple occasions,
likely cirrhosis, depression with multiple suicidal attempts,
obesity s/p Reux-en-Y gastric bypass surgery, [**Last Name (un) **] [**2192**] s/p
multiple abdominal surgeries who was initially admitted to ET on
[**5-6**] with EtOH hepatitis. Hospital course has been complicated
by gastric ulcer bleed, hypotension with MICU transfer, and
subsequent ATN. She was broadly covered with vanco/meropenem and
bolused IVF. She was previously on steroids but spiked fevers
with bandemia during her last hospitalization, so she was given
a trial of pentoxyfylline. However TB and INR continued to
uptrend for MDF of 80 so prednisone restarted with marked
improvement.
# Alcoholic hepatitis: MDF on admission was 50, and uptrended as
high as 80. Multiple complications including UTI, sepsis,
gastric ulcer bleed and ATN making prognosis worse. TB and INR
uptrending on trial of pentoxyfylline, so prednisone was
restarted at 30mg with taper by 10mg per week. She was
discharged on 20mg of prednisone. She is on a PPI [**Hospital1 **], calcium,
and vitamin D. Her sugars were within normal limits. She was
given supplemental enteral nutrition for goal kcal>[**2182**]/day.
She was set up with SW and outpatient EtOH counseling at [**Hospital1 **]
as an outpatient.
# [**Last Name (un) **]: Patient developed ATN after gastric ulcer bleed with
hypotensive episode. This improved with time. Diuretics were
restarted after the creatinine improved due to a large amount of
lower extremity edema. The creatinine increased on diuretics
likely representing [**Last Name (un) **]. FeUrea was 19%. She responded well to
midodrine, octreotide, and albumin challenge with creatinine
returning to baseline of 0.7 prior to discharge.
# Cirrhosis: Patient with alc hep. No thrombus on imaging, and
no evidence of varices on EGD. She likely has cirrhosis and has
been compensated between episodes of alcoholic hepatitis. She
was given ACE wraps to help with her lower extremity edema. She
was started on rifaximin with lactulose as needed. She will
follow up with liver as an outpatient and will need outpatient
Hep A/B vaccines.
# Acute on chronic blood loss anemia: She developed melena with
a drop in her hematocrit to 17. EGD performed in ICU showed
ulcer at the anastomosis site. The ulcer was clipped.
Otherwise normal EGD to third part of the duodenum. Resumed
clear liquid diet and discontinued PPI gtt/octreotide. Placed
on PPI [**Hospital1 **]. Subsequently, her hematocrit was stable at 24-26,
without signs of hematochezia or melena.
# Leukocytosis: No evidence of bandemia or infection without
fevers. Likely secondary to EtOH hepatitis. WBC stable at 17-21,
even with the addition of steroids.
# Right Upper Quadrant pain: Likely due to inflammation and
swelling within the liver capsule. Treated with oxycodone
5-10mg prn pain.
# Macrocytic Anemia: HCT at baseline. Likely secondary to ETOH
abuse with bone marrow toxicity. The patient is heme positive.
Suspect tachycardia from anemia.
# Hepatic Encephalopathy: Clear by HD#2. Continued lactulose
and rifaxamin.
# Thrombocytopenia: Likely splenic sequestration.
# Depression/Anxiety: Stable, no SI. All of her psychiatric
medications were held as they were on her last discharge. Her
outpatient physicians can consider starting Celexa when her
liver function improves.
Medications on Admission:
- gabapentin 300 mg Capsule q 8hrs
- multivitamin Tablet daily
- folic acid 1 mg Tablet daily
- thiamine HCl 100 mg Tablet daily
- miconazole nitrate 2 % Powder QID
- furosemide 40 mg Tablet DAILY
- spironolactone 50 mg Tablet daily
- oxycodone 5 mg Tablet q 6hrs prn
- cholecalciferol (vitamin D3) 1,000 unit Tablet daily
- docusate sodium 100 mg Tablet [**Hospital1 **]
- ferrous sulfate 325 mg (65 mg iron) Tablet daily
Discharge Medications:
1. multivitamin Tablet Sig: One (1) 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. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain for 10 days.
Disp:*40 Tablet(s)* Refills:*0*
5. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. prednisone 10 mg Tablet Sig: 1-2 Tablets PO once a day for 12
days: Please take 2 tablets daily for the first five days
([**Date range (1) 24549**]), and then take 1 tablet for the next 7 days
(6/25-6/31).
Disp:*17 Tablet(s)* Refills:*0*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary diagnosis: Alcoholic hepatitis, Bleeding gastric ulcer
s/p clipping, Acute tubular necrosis, Acute kidney injury
Secondary diagnosis: Alcohol abuse, Alcohol induced liver
disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Weight at discharge: 116.2kg
Discharge Instructions:
It was a pleasure taking care of you during your stay here at
[**Hospital1 18**].
You were admitted for an elevated white blood cell count which
was secondary to your alcohol induced liver disease known as
alcoholic hepatitis. You were started on steroids with much
improvement in your liver function. You will need to continue
taking these steroids for another 12 days.
During your stay, you had large bloody bowel movements. An
endoscopic evaluation of your stomach revealed a bleeding ulcer.
The blood vessel within this ulcer was clipped and the bleeding
stopped. You were started on a medication called a PPI to help
heal this ulcer and prevent new ulcers.
As a result of this blood loss, your kidneys did not receive
enough blood flow and became dehydrated. This improved over the
course of your stay.
You have a large amount of lower extremity swelling. Diuretics
were tried, but this also dehydrated your kidneys. These water
pills were stopped and your kidney function improved to
baseline. You should continue to use ACE wraps on your legs,
keep your legs elevated, and walk around as much as possible.
The following changes have been made to your medication regimen:
START prednisone (steroid) 20mg for five days, then 10mg for one
week
START rifaximin twice daily for your liver
START pantoprazole twice daily to help heal the ulcer and
prevent rebleeding
START ursodiol twice daily for itching
STOP lasix
STOP spironolactone
Followup Instructions:
Please attend the following appointments:
Department: BIDHC [**Location (un) **]
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP
When: FRIDAY [**2194-6-6**] at 5:00 PM
Address: 545A [**Street Address(1) **], [**Location (un) 538**], [**Numeric Identifier 7023**]
Phone: [**Telephone/Fax (1) 608**]
This appointment is to establish care with [**Doctor First Name **] who has cared
for you in the past. For insurance purposes, please list Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] as your pcp with your insurance company.
Department: LIVER CENTER
When: MONDAY [**2194-6-9**] at 12:50 PM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: LIVER CENTER
When: MONDAY [**2194-6-30**] at 11:30 AM
With: [**Name6 (MD) 1382**] [**Name8 (MD) 1383**], MD [**Telephone/Fax (1) 2422**]
Building: LM [**Hospital Unit Name **] [**Location (un) 858**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
|
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|
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[]
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[
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|
[
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,855
| 112,928
|
53931
|
Discharge summary
|
report
|
Admission Date: [**2139-8-31**] Discharge Date: [**2139-9-8**]
Service: MEDICINE
Allergies:
Feldene / nitroglycerin / Penicillins / piroxicam
Attending:[**First Name3 (LF) 1515**]
Chief Complaint:
severe aortic stenosis, exaccerbation of diastolic heart failure
here for corevalve
Major Surgical or Invasive Procedure:
transcutaneous aortic valve replacement (Corevalve)
permanent pacemaker- [**Company 1543**] Model: SENSIA SESR01
History of Present Illness:
Cardiologist: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD
[**First Name (Titles) **] [**Last Name (Titles) **]: Dr. [**First Name (STitle) **] [**Name (STitle) **], MD
Referring Physician: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 110614**] [**Name (STitle) 110615**]
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].
Reason for admission: severe aortic stenosis, exaccerbation of
diastolic heart failure
Chief Complaint: shortness of breath, chest pressure
HPI: Patient is an 89yo caucasian male with known aortic
stenosis
and CAD s/p CABGx4([**2123**])with postop course complicated by deep
sternal wound infection, occluded SVG graft to RCA s/p bare
metal
stent to RCA ([**2138**]), diabetes, CKD, hypertension and
hyperlipidemia who presented with c/o worsening shortness of
breath and chest pressure. He reports that he feels vague chest
pressure with ambulation or climbing a flight of stairs, if he
continues with the activity, he experiences blurred vision,
urinary incontinence, and confusion.
He was evaluated at [**Hospital1 2025**] for aortic stenosis. Cardiac
surgery
deemed him at extreme risk for surgical aortic valve
replacement. He was also evaluated for the TAVI/[**Doctor Last Name **] [**Last Name (un) 30978**]
valve and was found to have an annulus too large for the device.
He was referred here for aortic valve treatment options. He
again was found to be of prohibitively extreme risk for
conventional surgical AVR.
He was scheduled for elective cardiac cath but cancelled
due
to illness. He was later admitted for shortness of breath and
diaphoresis. He underwent urgent cardiac cath and was found to
have patent grafts and stent.
On [**2139-7-25**] he was againg admitted with chest pain,
exaccerbation of diastolic CHF and NSTEMI. He was transferred to
[**Hospital1 18**] for stabilization and BAV. He was then screened for
Corevalve TAVR after extensive discussion with patient and
family and informed consent was obtained. He met all inclusion
criteria and did not meet exclusion criteria. He now returns for
Corevalve/TAVR. Coumadin was discontinued 4 days prior to
admission.
NYHA Class: III
Past Medical History:
Cath on [**7-31**] showed 2VD, with patent 3 grafts, pulm htn
CAD - s/p CABG x 3 ( [**2123**])- postop deep sternal wound infection
PCI bare metal stent to RCA ([**5-/2138**])
severe aortic stenosis s/p valvuloplasty with [**Location (un) 109**] 0.82cm2
afib on coumadin
hypertension
hyperlipidemia
Type II DM, diet controlled
CKD, basline Cr looks to be 2.5
renal calculi
obesity
GERD
BPH
colon polyps
s/p left cataract surgery
bilateral rotator cuff repair
skin cancer
left inguinal hernia repair
left wrist fracture
[**First Name9 (NamePattern2) **] [**Hospital Ward Name 4675**] cyst
Active Medication list as of [**2139-7-14**]:
Medications - Prescription
AMLODIPINE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth once a day
DOXAZOSIN - (Prescribed by Other Provider) - 2 mg Tablet - 1
Tablet(s) by mouth once a day
GABAPENTIN - (Prescribed by Other Provider) - 100 mg Capsule -
2
Capsule(s) by mouth three times a day
HYDROCODONE-ACETAMINOPHEN - (Prescribed by Other Provider) - 5
mg-500 mg Tablet - 1 Tablet(s) by mouth q4-6 hrs as needed for
prn
METOPROLOL TARTRATE - (Prescribed by Other Provider) - 25 mg
Tablet - 1 Tablet(s) by mouth twice a day
SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet -
0.5 (One half) Tablet(s) by mouth once a day
Medications - OTC
ASCORBIC ACID - (Prescribed by Other Provider) - 500 mg Tablet
Extended Release - 1 Tablet(s) by mouth once a day
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1
Tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) -
1,000 unit Capsule - 1 Capsule(s) by mouth once a day
CYANOCOBALAMIN (VITAMIN B-12) - (Prescribed by Other Provider)
-
1,000 mcg Tablet - 1 Tablet(s) by mouth once a day
--------------- --------------- --------------- ---------------
Allergies:
Penicillin - rash
piroxicam - photosensitivity
bee stings - anaphylaxis
feldene
NTG - syncope
Social History:
Retired worked in contruction company making steel [**Doctor Last Name **].
Married with two children, 4 grandchildren. Lives in single
level home, one flight of stairs to enter in [**Location 110611**].
Family History:
Father deceased age [**Age over 90 **], CHF. Mother deceased age 36, brain
abcess.
Physical Exam:
Pulse: 65
B/P: 110/66
Resp: 18
O2 Sat: 100%
Temp: 97.8
Height: 74 inches Weight: 209 lbs
General: Alert pleasant male seated in chair in NAD at rest.
Skin: color pale pink, skin warm and dry. No lesions.
HEENT: normocephalic, anicteric, conjunctiva pale pink. Good
dentition, oropharynx moist.
Neck: Neck supple, trachea midline, carotid bruit vs. referred
murmer.
Chest: decreased bases bilat. Essentially CTA, no rales/whz.
Anterior chest wall deformity superior portion of sterum.
Irregularly healed sternal scar. Depressed area mid-upper
sternum.
Heart: murmer RSB, radiating.
Abdomen: round, soft, nontender, nondistended, (+)BS
Extremities: Trace lower extremity edema, L>R. Well healed
surgical scars bilateral ankles to mid thighs.
Neuro: alert and oriented, pleasant, gross FROM. Gait slow but
steady.
Pulses: palpable peripheral pulses.
Pertinent Results:
[**2139-8-31**] 01:58PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.012
[**2139-8-31**] 01:58PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-TR
[**2139-8-31**] 10:40AM GLUCOSE-107* UREA N-32* CREAT-2.1* SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-25 ANION GAP-14
[**2139-8-31**] 10:40AM estGFR-Using this
[**2139-8-31**] 10:40AM ALT(SGPT)-13 AST(SGOT)-26 CK(CPK)-41* ALK
PHOS-54 TOT BILI-0.5
[**2139-8-31**] 10:40AM proBNP-[**Numeric Identifier 35706**]*
[**2139-8-31**] 10:40AM ALBUMIN-4.3
[**2139-8-31**] 10:40AM WBC-5.0 RBC-3.62* HGB-11.3* HCT-35.4* MCV-98
MCH-31.1 MCHC-31.9 RDW-17.0*
[**2139-8-31**] 10:40AM PLT COUNT-158
[**2139-8-31**] 10:40AM PT-11.8 PTT-34.0 INR(PT)-1.1
STS SCORE:
Procedure Name Is[**Name (NI) 88959**] [**Name2 (NI) 88960**]
Risk of Mortality 15.261%
Morbidity or Mortality 49.370%
Long Length of Stay 31.219%
Short Length of Stay 5.950%
Permanent Stroke 3.205%
Prolonged Ventilation 39.894%
DSW Infection 0.353%
Renal Failure 29.457%
Reoperation 12.900%
EUROSCORE: 32.11 %
MMSE-2 SCORE:
GRIP STRENGTH TEST: RIGHT: LEFT:
WALK TEST: (Wheelchair dependent? no )
Time in Seconds: 12.2, 11.2
Cardiac Catheterization:([**2139-7-31**])
ASSESSMENT
1. Two vessel coronary artery disease; patent SVG to OMB; patent
SVG to LAD; patent LIMA to the diagonal branch
2. Severe aortic stenosis
3. Successful Balloon valvuloplasty reducing gradient from
55.34 mmHg to 45.32 and aortic valve area increase from 0.69 to
0.82.
4. Elevated right and left heart filling pressures
Echocardiogram: Done [**2139-8-3**] at 9:54:24 AM FINAL
Echocardiographic Measurements
Results Measurements Normal
Range
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1
cm
Left Ventricle - Inferolateral Thickness: *1.4 cm 0.6 - 1.1
cm
Left Ventricle - Diastolic Dimension: 4.5 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 30% >= 55%
Left Ventricle - Stroke Volume: 59 ml/beat
Left Ventricle - Cardiac Output: 3.89 L/min
Left Ventricle - Cardiac Index: *1.80 >=2.0
L/min/M2
Aorta - Sinus Level: 3.4 cm <= 3.6 cm
Aorta - Ascending: *3.6 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *4.8 m/sec <= 2.0
m/sec
Aortic Valve - Peak Gradient: *94 mm Hg < 20 mm
Hg
Aortic Valve - Mean Gradient: 63 mm Hg
Aortic Valve - LVOT VTI: 17
Aortic Valve - LVOT diam: 2.1 cm
Aortic Valve - Valve Area: *0.5 cm2 >= 3.0
cm2
Findings
This study was compared to the prior study of [**2139-7-30**].
LEFT VENTRICLE: Mild symmetric LVH with normal cavity size.
Moderate regional LV systolic dysfunction. Estimated cardiac
index is depressed (<2.0L/min/m2). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size. Moderate global RV free
wall hypokinesis.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in aortic root. Mildly dilated ascending aorta.
AORTIC VALVE: Severely thickened/deformed aortic valve leaflets.
Critical AS (area <0.8cm2). No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP.
Moderate mitral annular calcification. Trivial MR. [Due to
acoustic shadowing, the severity of MR may be significantly
UNDERestimated.]
TRICUSPID VALVE: Tricuspid valve not well visualized.
PULMONIC VALVE/PULMONARY ARTERY: Thickened pulmonic valve
leaflets. Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
Conclusions
There is mild symmetric left ventricular hypertrophy with normal
cavity size. There is moderate regional left ventricular
systolic dysfunction with hypokinesis of the anterior wall,
septum, and apex. The estimated cardiac index is depressed
(<2.0L/min/m2). Right ventricular chamber size is normal with
moderate global free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets are severely thickened
with critical aortic stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing from the aortic valve and MAC, the
severity of mitral regurgitation may be significantly
UNDERestimated.] The pulmonic valve leaflets are thickened.
There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with anterior/septal wall motion
abnormalities and depressed overall left ventricular systolic
function. Moderately depressed right ventricular free wall
systolic function. Critical aortic stenosis. Mildly dilated
ascending aorta.
EKG: Study Date of [**2139-8-19**] 10:36:12 AM
Intervals Axes
Rate PR QRS QT/QTc P QRS T
61 154 96 468/469 10 6 132
CT chest w/o contrast: ([**2139-6-17**] [**First Name8 (NamePattern2) **] [**Hospital3 6783**] hospital)
FINDINGS: A 4mm nodule is noted at the right lung base. A 6mm
nodule is noted at the right posterior costophrenic angle. A
possible 6mm nodule is noted in the right lung base. Increased
markings are present at the [**Doctor Last Name **] bases suggesting atelectasis. No
pleural fluid is seen. The heart is enlarged. Extensive
ahterosclerotic changes are noted. Nomediastinal or hilar
adenopathy is seen.
Scans through the upper abdomen demonstrate no evidence of
an adrenal mass. Left renal atrophy is present. Calcifications
are noted in upper pole calyces suggesting stones. No definite
hydronephrosis is seen. The visualized portion of the right
kidney is unremarkable. The gallbladder is filled with stones.
No
obvious abnormality is seen in the visualized portions of the
liver or spleen.
IMPRESSION: Lung nodules as described.
PFT's: ([**2139-8-3**])
FEV1 2.16L/86%
DLCO 59%
Carotid dopplers: ([**2139-7-7**])
Significant plaqueis not noted, doppler shows mild spectral
broadening compatible with less than 29% stenosis in the
internal
carotid arteries bilaterally and good flow was seen with
colorflow.
Brief Hospital Course:
88yo male with severe symptomatic aortic stenosis, with history
of CAD s/p CABG with postop course complicated by extensive deep
sternal wound infection, occluded SVG graft s/p bare metal stent
to RCA, diabetes, and CKD, repaeat cardiac cath with 2 vessel
CAD/patent grafts,recurrent acute on chronic diastolic heart
failure, recent NSTEMI, and now s/p BAV.
ACUTE ISSUES
#symptomatic severe aortic stenosis - ([**Location (un) 109**] 0.8cm2, mean gradient
63mmmHg: The patient was admitted to the hospital electively for
the procedure on [**8-31**]. He was Plavix loaded at 300mg. A
Corvalve/TAVR was done on [**2139-9-1**]. The patient's beta blocker
and diuretic were held the day of procedure. The patient
developed a hypotensive episode after the procedure to a BP 50
systolic that required epinephrine 300 mcg IV bolus. His
pressure responded to > 200 systolic with improvement in his
wall motion (LVEF = 30%). He developed atrial fibrillation but
remained hemodynamically stable. Echocardiography demonstrated
no evidence of pericardial perforation and no change in his left
or right ventricular function. There was 2+ mitral
regurgitation by echocardiography. An intraaortic balloon pump
was placed from the left femoral artery without complications
for hemodynamic support. The patient was transported to the CCU
in stable condition on norepinephrine and dobutamine. He was
rapidly weaned from both pressors and his balloon pump was
discontinued. He continued to maintain an excellent blood
pressure off pressors and his heart rate did not drop below the
high 50s. His repeat echo on [**9-2**] showed a well-seated
replacement valve with minimal leak. His ejection fraction,
mitral regurgitation, and pulmonary hypertension were unchanged.
On [**2139-9-3**], his transvenous pacing wire was removed and his
femoral sheath was pulled. Later that day, he had several four
second pauses on EKG, during which time he was asymptomatic. On
the evening of the 26th, the patient had two 10 second pauses
separated by an escape beat. During the second pause he became
unresponsive and required chest compressions before regaining
consciousness. Isoproterenol was started at 1mcg/min per
electrophysiology recommendations. He had a pacemaker placed
without complications. He was transferred to the floor and
subsequently discharged.
#Fever: while here patient had a fever of Tm 101 after pacemaker
placed. It was believed this was likely transient bactermeia in
setting of pacemaker being placed. He was treated for a possible
hospital aquired pneumonia bc he had a cough. He was started on
[**9-4**] started on vanc and zosyn which was d/c'don [**9-6**] switched
to levofloxacin for respiratory infection, end date is [**9-10**] so
he will have 2 more days to complete while at rehab.
# CKD: The patient has known chronic kidney disease with a
baseline creatinine of approximately 2.5. His admission
creatinine this hospitalization was 1.9. After his recent
NSTEMI, he suffered contrast nephropathy after catheterization
that brought his creatinine to 3. As such, he received
pre-catheterization hydration to minimize contrast nephropathy.
The patient's creatinine gradually increased to 2.9 and then
trended back down to 2.2 by day of discharge.
# Anemia, thrombocytopenia: The patient's admission Hct 35.5 to
25.5 on [**9-3**], concomitant with a platelet drop from 150
(admission) to 100 ([**9-3**]). Hemolysis labs were done but found
negative. The patient received two units packed red blood cells
given his recent NSTEMI and the desire to avoid a low hematocrit
in a recent post-MI patient. His coags were elevated due to the
heparin and coumadin that he received, but consumptive
coagulopathy (DIC, TTP) were considered extremely unlikely. His
numbers were followed. HIT was considered but the time course,
degree of platelet depression, and absence of known thrombosis
argued against this hypothesis. Platelet counts improved on
their own and were 196 at day of discharge.
#Confusion: The morning following his procedure, Mr. [**Known lastname 52455**] was
initially confused as to the date and which hospital he was in;
this improved the following day. At time of discharge still
slightly confused regarding some details, but was close to or at
home baseline.
#CAD - s/p RCA stent [**2138**], NSTEMI, ccath-Two vessel coronary
artery disease; patent SVG to OMB; patent SVG to LAD; patent
LIMA to the diagonal branch. We continued ASA
held her beta blocker for the Corevalve procedure but restarted
it soon after. We also decreased his statin due to current
antibiotic therapy with erythromycin for lip lesion prescribed
by DMD.
#Atrial arrhythmia: The patient has a known history of atrial
arrhythmia that may be atrial fibrillation with an abnormally
regular ventricular response or atrial flutter. The exact nature
of this was unclear but he has been treated anticoagulated (goal
INR [**3-13**]) and rate controlled with beta blocker. His coumadin was
stopped on [**8-27**] in anticipation of the procedure, after which
his heparin was continued as a bridge to coumadin and resumption
of his pre-hospitalization anticoagulation. He was transitioned
back to warfarin and had an INR of 1.5 at time of discharge.
Since he was also on ASA and Clopidogrel, this was thought
adequate INR to discharge off heparin. He will continue
uptitration of his warfarin as an outpatient and will need INR
checks every 2-3 days until he achieves a stable INR goal of
[**3-13**]. Once INR is > 1.8, his plavix should be discontinued.
CHRONIC ISSUES
# DM type II: The patient was maintained on an insulin sliding
scale while he was in the hospital. His blood sugars were
appropriately controlled.
# Lip lesion: The patient presented with a lip lesion sustained
during a recent dentist visit for which he had briefly received
erythromycin (which was not continued while hospitalized).
TRANSITIONAL ISSUES
# Atrial fibrillation: the patient was bridged back onto
coumadin with a heparin drip while in the hospital although had
not yet achieved therapeutic INR at time of discharge but this
felt okay as he is also on ASA and plavix. He should receive his
INR checks as regularly scheduled and his plavix should be
stopped once his INR > 1.8.
# Aortic stenosis now s/p core valve: should follow up with Dr.
[**Last Name (STitle) **] on an outpatient basis. Plan to discontinue his plavix
once INR > 1.8
# Anemia, thrombocytopenia: Largely resolved. Will need one f/u
CBC as an outpatient.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Gabapentin 200 mg PO TID
4. Ascorbic Acid 500 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Torsemide 20 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Metoprolol Tartrate 25 mg PO BID
9. Warfarin 3 mg PO 3X/WEEK (TU,TH,SA)
10. Warfarin 2 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
Discharge Medications:
1. Warfarin 2 mg PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR)
2. Warfarin 3 mg PO 3X/WEEK (TU,TH,SA)
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Ascorbic Acid 500 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Aspirin 81 mg PO DAILY
9. Gabapentin 200 mg PO Q24H
10. Metoprolol Tartrate 25 mg PO BID
11. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN bad cough, hard
time sleeping
please do not give if somnalant RR<12
12. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
13. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
14. Furosemide 40 mg PO DAILY
15. Acetaminophen 1000 mg PO Q8H:PRN pain/temp > 38.0
16. Bisacodyl 10 mg PR ONCE Duration: 1 Doses
notify NP if no results after 2 hours
17. Guaifenesin [**6-18**] mL PO Q6H:PRN cough
18. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Rehab
Discharge Diagnosis:
-Severe Aortic stenosis s/p Corevalve placement [**2139-9-1**]
-Complete heart block s/p permanent pacemaker placement
[**2139-9-4**]
-CAD - s/p CABG x 3 ( [**2123**])- postop deep sternal wound
infection (EF35%)
-PCI bare metal stent to RCA ([**5-/2138**])
-Hypertension
-Hyperlipidemia
-Type II DM
-Chronic kidney disease
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Groin precautions - no lifting > 10lbs
Discharge Instructions:
Dear Mr. [**Known lastname 52455**],
It was a pleasure caring for you while you were hospitalized at
the [**Hospital1 **]. As you know, you were admitted for
severe symptomatic aortic stenosis and were treated with a
percutaneous transcatheter aortic valve replacement (Corevalve).
Postoperatively, you experienced a very slow heart rate and had
a permanent pacemaker placed without difficulty. Your kidney
function was temporarily impaired (as Dr. [**Last Name (STitle) **] had mentioned
would probably happen), but this improved. Your blood counts
were low (anemia) so you received one unit of red blood cells.
You have continued to progress well and are now ready for
discharge.
Weigh yourself every morning, call Dr. [**Last Name (STitle) **] if weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
INR should be checked regularly and plavix should be stopped
once INR > 1.8
Department: ECHO LAB
When: WEDNESDAY [**2139-10-7**] at 11:00 AM
With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**]
Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 1951**]
Campus: EAST Best Parking: Main Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2139-10-7**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"250.00",
"V45.82",
"426.0",
"424.1",
"585.9",
"427.32",
"V10.83",
"278.00",
"427.5",
"403.90",
"272.4",
"530.81",
"285.9",
"V58.61",
"410.72",
"790.7",
"458.29",
"600.00",
"416.8",
"427.89",
"287.5",
"414.01",
"428.42",
"428.0",
"486",
"V45.81",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.71",
"35.05",
"37.61",
"37.81"
] |
icd9pcs
|
[
[
[]
]
] |
19902, 19950
|
12015, 18508
|
340, 455
|
20318, 20318
|
5863, 11992
|
21379, 22083
|
4895, 4979
|
19017, 19879
|
19971, 20297
|
18534, 18994
|
20539, 21356
|
4994, 5844
|
983, 2704
|
483, 966
|
20333, 20515
|
2726, 4657
|
4673, 4879
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,792
| 144,660
|
16570
|
Discharge summary
|
report
|
Admission Date: [**2158-3-27**] Discharge Date: [**2158-4-2**]
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
[**2158-3-27**] 1. Coronary bypass grafting x3: Reverse saphenous vein
graft from aorta to posterior descending coronary artery;
reverse saphenous vein single graft from aorta to second obtuse
marginal coronary artery; as well as reverse saphenous vein
single graft from aorta to the first diagonal coronary artery.
2. Endoscopic left greater saphenous vein harvesting.
History of Present Illness:
87 year old male with known history of coronary artery disease
s/p catheterization [**9-4**] which has been medically managed,
stable angina x 20 years, hypertension, hyperlipidemia, and
COPD,who reports non-radiating substernal chest tightening x 10
minutes during exertion which was relieved with 1 SL NTG.Shortly
thereafter he resumed walking and experienced a second episode
of chest tightening and took a 2nd SL NTG. Emt was called and he
was taken to [**Hospital1 18**] for further cardiac workup. Positive troponin
along with ECG changes revealed NSTEMI. Cardiac surgery was
consulted for possible revascularization.
Past Medical History:
HTN
Hypercholesterolemia
COPD
SEVERE PTSD- WWII Veteran
Right Facial Nerve Palsy: VERY sensitive about this. He has
trouble eating and often drools. His wife asks that we not
discuss this AT ALL with him, as he becomes very upset and often
cries.
CRI (baseline Cr: ~1.4)
Angina/Sob-25 years ago diagnosed with stress test at the VA
Allergic Rhinitis
Herpes Zoster
Bilateral Cataract Surgery
Left Inguinal Hernia Repair
Right Inguinal Hernia- Not repaired
Colonic Polyps
BPH
Anemia
Tinnitus
Eczema
HOH
GERD
Malaria over 30 years ago while in [**Country 480**]
Social History:
Used to work in hospital administration. He lives with his wife
[**Name (NI) **] in [**Location (un) **] MA. Denies alcohol. Quit smoking cigs. over 20
years ago. Quit smoking pipe in his mid 50s. Denies drugs
Family History:
There is no family history of premature coronary artery disease
or sudden death.
Physical Exam:
Pulse:72 Resp: 20 O2 sat: 98%
B/P Right:96/51 Left:
Height: Weight:
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI []
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]diminished (B)
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x, well-perfused [x] Edema Varicosities:
None
[x]
Neuro: Grossly intact:(R) facial nerve palsy
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: 2+ Left:2+
Carotid Bruit Right: 2+ Left:2+
Pertinent Results:
[**2158-3-30**] 06:05AM BLOOD WBC-9.1 RBC-3.68* Hgb-10.9* Hct-32.4*
MCV-88 MCH-29.7 MCHC-33.7 RDW-14.6 Plt Ct-88*
[**2158-3-27**] 11:29AM BLOOD WBC-11.7* RBC-2.78*# Hgb-8.5*# Hct-24.9*#
MCV-90 MCH-30.5 MCHC-34.0 RDW-13.7 Plt Ct-106*
[**2158-3-28**] 12:49AM BLOOD PT-14.4* PTT-32.0 INR(PT)-1.2*
[**2158-3-27**] 11:29AM BLOOD PT-15.3* PTT-36.4* INR(PT)-1.3*
[**2158-3-30**] 06:05AM BLOOD Glucose-95 UreaN-27* Creat-1.3* Na-139
K-3.7 Cl-100 HCO3-30 AnGap-13
[**2158-3-30**] 06:05AM BLOOD Calcium-8.0* Phos-2.7 Mg-2.2
[**2158-3-27**] 03:50PM BLOOD Mg-3.9*
Cardiology Report ECG Study Date of [**2158-3-27**] 2:10:54 PM
Sinus rhythm with premature beats that may be junctional. Modest
right
ventricular conduction delay pattern may be incomplete right
bundle-branch
block although is non-diagnostic. Low QRS voltage. Diffuse ST-T
wave
abnormalities are non-specific but cannot exclude myocardial
ischemia. Clinical
correlation is suggested. Since the previous tracing of [**2158-3-10**]
ST-T wave
changes are less prominent.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 186 100 422/446 76 67 16
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 47016**] (Complete)
Done [**2158-3-27**] at 9:25:41 AM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name3 (LF) 177**] C.
[**Hospital Unit Name 927**]
[**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2070-9-18**]
Age (years): 87 M Hgt (in): 67
BP (mm Hg): 134/78 Wgt (lb): 136
HR (bpm): 54 BSA (m2): 1.72 m2
Indication: Inraoperative TEE for CABG procedure. Aortic valve
disease. Chest pain. Coronary artery disease. Left ventricular
function. Mitral valve disease. Preoperative assessment. Right
ventricular function.
ICD-9 Codes: 786.05, 786.51, 424.1, 424.0, 424.2
Test Information
Date/Time: [**2158-3-27**] at 09:25 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**],
MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2010AW1-: Machine: aw1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Peak Pulm Vein S: 0.5 m/s
Left Atrium - Peak Pulm Vein D: 0.2 m/s
Left Ventricle - Septal Wall Thickness: *1.2 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Aorta - Annulus: 2.4 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Findings
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal regional LV systolic
function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Simple
atheroma in ascending aorta. Simple atheroma in descending
aorta.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. Mild (1+)
AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild to
moderate ([**1-28**]+) MR.
TRICUSPID VALVE: Mild [1+] TR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
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%). Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the ascending aorta. There are simple atheroma in
the descending thoracic aorta. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis. Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. Mild to moderate
([**1-28**]+) mitral regurgitation is seen. There is no pericardial
effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on
[**2158-3-27**] at 900am.
Post bypass
Patient is in sinus rhythm and receiving an infusion of
phenylephrine. Biventricular systolic function is unchanged.
Mild mitral regurgitation persists. Aorta is intact post
decannulation.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2158-3-30**] 09:47
Brief Hospital Course:
Admitted same day and was brought to the operating room for
coronary artery bypass graft surgery. See operative report for
further details. He received cefazolin for perioperative
antibiotics and was transferred to the intensive care unit for
post operative management. In the first twenty four hours he
was weaned from sedation, awoke at baseline, and was extubated
without complications. He continued to do well and was
transferred to the floor on post operative day one. Physical
therapy worked with him on strength and mobility. He was noted
for left arm erythema, warmth, but no tenderness, area marked
with no increase in size, started on antibiotics. He was ready
for discharge to rehab on post operative day six with oral
antibiotics for left arm with plan for wound check.
Medications on Admission:
Colace 100 mg twice a day
Valium 5 mg bedtime
Fluticasone nasal spray
Lasix 20 mg daily
Combivent inhaler q6h
Isordil 40 mg three times a day
aspirin 325 mg daily
Lipitor 80 mg daily
ranitidine 150 mg daily
metoprolol succinate 100 mg daily
lisinopril 10 mg daily
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: 17 grams
PO DAILY (Daily) as needed for constipation.
7. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-28**] Sprays Nasal
twice a day.
8. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Tablet(s)
9. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day for 7 days: LUE cellulitis.
12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day.
14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 3145**] Nursing Home - [**Location (un) 3146**]
Discharge Diagnosis:
coronary artery disease s/p cabg
Hypertension
Hyperlipidemia
NSTEMI [**2-/2158**]
Chronic obstructive pulmonary disease
Severe post traumatic stress disorder
Right facial nerve palsy
Chronic renal insufficiency (baseline cr ~1.4)
Allergic rhinitis
Herpes Zoster
Colonic polyps
Benign prostatic hypertrophy
Anemia
Tinnitus
Eczema
Gastric esophageal reflux
Malaria over 30 while in [**Country 480**]
Discharge Condition:
alert and oriented x3, facial droop baseline
Ambulating with assistance gait steady
Pain control with ultram
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Surgeon Dr. [**Last Name (STitle) 914**] on [**5-2**] at 1pm [**Telephone/Fax (1) 170**]
Please call to schedule appointments
Primary Care Dr. [**Last Name (STitle) **] after discharge from rehab -
[**Telephone/Fax (1) 1579**]
Cardiologist Dr[**Name (NI) 3733**] after discharge from rehab -
[**Telephone/Fax (1) 62**]
Return to [**Wardname 5010**] for wound check of left arm 1 week following
discharge
Completed by:[**2158-4-2**]
|
[
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"550.90",
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"511.9",
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"272.4",
"411.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.13",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
10400, 10486
|
7944, 8735
|
277, 650
|
10928, 11039
|
2871, 7921
|
11519, 11953
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2130, 2212
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8761, 9027
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227, 239
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678, 1303
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,723
| 173,584
|
11914
|
Discharge summary
|
report
|
Admission Date: [**2132-4-27**] Discharge Date: [**2132-5-1**]
Date of Birth: Sex: F
Service: Neurology
Patient is a [**Age over 90 **]-year-old Russian female found unresponsive on
[**2132-4-26**] and brought to the Emergency Department at the
[**Hospital1 69**]. Subsequent workup showed
large interventricular hemorrhage in all four ventricles and
hydrocephalus and subarachnoid hemorrhages bilaterally.
Patient was deemed to be DNR/DNI, and was initially
transferred to the Neuro/ICU here at the [**Hospital1 346**].
While in the ICU, the patient has been somnolent and unable
to be aroused. Neurosurgical consult was called on the
patient and they did not recommend intervention at family's
request. She developed bilateral pleural effusions in the
ICU from CHF that had been treated with p.o. Lasix, yet
remained persistent. Her blood pressure was controlled with
IV medications, but now that has been D/C'd.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Chest x-ray.
3. Hypertension.
4. Degenerative joint disease.
5. Gastroesophageal reflux disease.
6. Essential tremor.
7. Urinary incontinence.
After extensive discussion and education with the patient's
family and healthcare proxy, it was decided that a non-
aggressive palliative approach would be adopted in directing
care for this patient given the poor prognosis with the
interventricular hemorrhage complicated the goal of the
patient's admission.
PHYSICAL EXAMINATION: Temperature 99.4, blood pressure
142/76, pulse 108, respiratory rate 16, and 98 percent on 35
percent O2 face mask. Physical examination was pertinent for
the following: The patient was an elderly female lying in
bed in modest distress with labored breathing. Decreased
breath sounds on pulmonary exam halfway up both lungs.
Patient's heart rhythm was regular. There was a 3/6 systolic
ejection murmur radiating to the right upper sternal border.
On neurologic examination, on mental status: The patient
grimaces and opens eyes to vigorous sternal rub, but prefers
her eyes closed. On cranial nerve examination, the patient
has dolls intact, corneal intact, and gag reflex intact.
Pupils are surgical bilaterally. Motor examination: The
patient moves right upper extremity to painful stimulus, but
there is no movement in the left upper extremity to painful
stimulus. Patient dorsiflexes both lower extremities to
pain, but does not withdraw. Patient has flexor plantar
responses bilaterally.
LABORATORIES: Patient had CBC, Chem-8, and chest x-rays in a
serial fashion drawn throughout the admission. Chest x-ray
showed static bilateral pleural effusions despite treatment
with Lasix. Follow-up head CT showed blood in all
ventricles, positive atrophy, and questionable hydrocephalus,
which remains unchanged from initial head CT.
Patient had an elevated sodium at 146 and BUN of 31. Patient
also had a troponin of 0.25 on serial cardiac enzymes that
were drawn throughout the admission.
HOSPITAL COURSE: Given the patient's palliative goal,
patient was kept DNR/DNI throughout the admission, and
comfort care was established after the patient was
transferred to the Neurologic floor on [**Hospital Ward Name 121**] 5 from the
Neuro/ICU. Patient was given Lasix for symptomatic relief of
bilateral pleural effusions and aortic stenosis. Patient's
mental status remained static on the Neurology floor. She
was unresponsive to voice and vigorous painful stimulus.
Neurosurgical consult signed off on the case after deeming
that the patient was not a surgical candidate.
On [**2132-4-30**], the patient's daughter decided to make the
patient comfort care only. Morphine drip was started.
Patient's respirations and vital signs were monitored
regularly to assess comfort. Palliative Care consult was
called, which recommended scopolamine patch for secretions,
Tylenol for fever, and Morphine drip.
Patient then expired on [**2132-5-1**]. Family was informed.
Autopsy was accepted.
DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279
Dictated By:[**Doctor Last Name 37530**]
MEDQUIST36
D: [**2132-6-18**] 11:41:44
T: [**2132-6-18**] 12:44:41
Job#: [**Job Number 37531**]
|
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"V10.05",
"430",
"424.1",
"401.9",
"428.0",
"511.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
3007, 4216
|
1484, 1965
|
1981, 2989
|
975, 1461
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,553
| 137,812
|
35240
|
Discharge summary
|
report
|
Admission Date: [**2100-9-17**] Discharge Date: [**2100-9-28**]
Date of Birth: [**2032-1-23**] Sex: M
Service: MEDICINE
Allergies:
Cefazolin / Hydromorphone
Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Acute on chronic fatigue/hypotension/productive cough
Major Surgical or Invasive Procedure:
arterial line placement
History of Present Illness:
68 y/o gentleman with metastatic renal cell cancer to lungs,
acute on chronic fatigue and SOB, presented to ED with abdominal
pain. He has experienced worsening fatigue for many days. His
abdominal pain is crampy in nature and diffuse. Patient has had
chronic dry cough but has experienced clear sputum production
since yesterday. Denies fevers, chills, nausea, vomiting, black
stools or chest pain. He recently stopped Pavluzimab on Tuesday,
to start Sutinib this week.
.
In the emergency department initial vitals were T 98.5, BP
82/40, HR 94, RR 16, 96% in RA. Patient recieved 2 units of PRBC
and 2L NS. His HCT was low at 23.7 (BL 29-30). He was guaic
negative. He also recieved Vancomycin 1 gram IV, Zosyn 4.5 grams
IV and Levaquin 750 mg IV for possible PNA. He also was started
on levophed 0.09 given BP was still in 90s/40s. Patient made a
urine output of 350ml. He was transfered to [**Hospital1 18**] ED for further
evaluation.
.
Review of systems is negative for headache, change in vision,
hearing, focal weakness, numbness, diarrhea. He has chronic
constipation.
.
ONCOLOGIC HISTORY: Mr. [**Known lastname 1557**] is a 68-year-old gentleman who was
in his usual state of health until early [**2099-8-19**] when he
developed dyspnea. CXR revealed a large right-sided pleural
effusion. CT torso on [**2099-8-24**] showed a large right pleural
effusion. It also revealed a 2.3 cm RML nodule and pleural
studding. A 9-cm mixed attenuation mass was seen in the mid
portion of the right kidney, extending laterally into the left
renal vein. There were no focal liver abnormalities and no
adenopathy. Thoracentesis on [**2099-8-24**] drained 1.4 L of bloody
pleural fluid. Cytology was negative. He was seen at [**Hospital1 18**] on
[**2099-9-1**] and was admitted on [**2099-9-5**] for recurrent pleural
effusion. He underwent thoracentesis which was negative for
malignancy and bronchoscopy which revealed no endobronchial
lesions. He returned on [**2099-9-9**] for an elective thoracoscopy,
pleural biopsy, talc pleurodesis, and pleurex catheter
placement. Pathology from the pleural biopsy showed metastatic
poorly differentiated carcinoma with clear cell features. He was
then readmitted on [**2099-9-15**] with a severe drug rash, felt to be
due to dilaudid. His pleurex catheter was removed on [**2099-9-15**].
He underwent laparoscopic nephrectomy on [**2099-9-21**] and pathology
revealed renal cell carcinoma, conventional clear cell type,
grade II, greatest dimension 7.5cm. Tumor extended into
perinephric tissues and renal vein. Margins at Gerota's fascia
were positive for tumor. Papillary adenomas were also seen. No
lymph nodes were sent for review. He initially enrolled in
clinical trial 04-117, with the goal of creating a dendritic
cell + tumor fusion vaccine, but he had radiographic and
clinical signs of disease progression so was taken off trial. He
was admitted for hypercalcemia from [**11-13**] to [**11-15**]. He enrolled
in clinical trial 08-219, comparing pazopanib vs. sunitinib for
locally advanced or metastatic RCC, on [**2099-11-17**] and was
randomized to receive pazopanib. Treatment was held from
[**2100-1-19**] to [**2100-2-2**] for grade 3 elevation in his ALT (grade 2 in
AST). He was restarted at 600mg daily when his LFTs normalized.
His pazopanib was on hold from [**7-9**] thru [**2100-7-28**] because he
needed urgent dental surgery including bone removal. During this
time he had rapid growth of an intramuscular lesion on the right
chest wall.
Past Medical History:
-Metastatic renal cell carcinoma.
-History of recurrent malignant pleural effusion, S/P right
pleurodesis.
-Right chest wall pain as well as dyspnea and worsening disease
in the right lung.
-Hypthyroidism, started on levothyroxine two days ago
-Hypertension
-Severe dermatitis reaction, which was thought secondary to
Ancef prior to his pleuroscopy
Social History:
Married, has 2 daughters one is a nurse at [**Hospital1 **]. Former
smoker, quit 26 years ago. Drinks 1 glass wine/week. Retired
from customer service.
Family History:
No immediate family history of CA, aunt died of gastric CA.
Physical Exam:
GENERAL: Pleasant gentleman, in NAD
HEENT: Normocephalic, atraumatic. Cconjunctival pallor present.
EOMI. MMM. OP clear. Neck Supple.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. I/VI
systolic murmur best at RUSB. JVP 7 cm
LUNGS: Decreased BS at right lower lung field.
ABDOMEN: Soft, NT, ND. No HSM
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis
NEURO: A&Ox3. Appropriate. Preserved sensation throughout. [**3-23**]
strength throughout.
PSYCH: Listens and responds to questions appropriately, pleasant
Pertinent Results:
[**2100-9-16**] 09:35PM HAPTOGLOB-372*
[**2100-9-16**] 09:35PM ALBUMIN-3.0* CALCIUM-11.2* PHOSPHATE-3.3
MAGNESIUM-2.1
[**2100-9-16**] 09:35PM cTropnT-0.01
[**2100-9-16**] 09:35PM CK-MB-NotDone
[**2100-9-16**] 09:35PM ALT(SGPT)-8 AST(SGOT)-13 CK(CPK)-16* ALK
PHOS-57 TOT BILI-0.4
[**2100-9-16**] 09:35PM estGFR-Using this
[**2100-9-16**] 09:35PM GLUCOSE-103 UREA N-23* CREAT-1.5* SODIUM-133
POTASSIUM-5.3* CHLORIDE-101 TOTAL CO2-25 ANION GAP-12
[**2100-9-16**] 09:40PM RET AUT-2.1
[**2100-9-16**] 09:40PM PLT COUNT-412
[**2100-9-16**] 09:40PM NEUTS-77.9* LYMPHS-15.7* MONOS-5.0 EOS-0.8
BASOS-0.5
[**2100-9-16**] 09:40PM WBC-5.4 RBC-2.58* HGB-7.8* HCT-23.7* MCV-92
MCH-30.4 MCHC-33.1 RDW-17.3*
[**2100-9-16**] 09:43PM GLUCOSE-105 LACTATE-1.7 NA+-133* K+-5.0
CL--100 TCO2-24
[**2100-9-17**] 01:46AM URINE RBC-0 WBC-0-2 BACTERIA-OCC YEAST-NONE
EPI-0
[**2100-9-17**] 01:46AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2100-9-17**] 01:46AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]->1.050
[**2100-9-17**] 03:40AM RET AUT-1.7
.
Chest CT:
1. Worsening right lung consolidation since the prior
examination, with
stable appearance of pleural abnormalities. Soft tissue
components of pleural abnormality cannot be differentiated from
pleural fluid without contrast.
2. Slight enlargement of now trace-to-small left pleural
effusion with associated left lower lobe atelectasis.
3. Sift tissue abnormalities of the left chest and upper
abdominal wall as previously noted.
.
Echo:
poor technical quality due to patient's body habitus. Left
ventricular function is probably normal, a focal wall motion
abnormality cannot be fully excluded. The right ventricle is not
well seen but may be dilated and hypokinetic. Moderate pulmonary
artery systolic hypertension.
.
US of RUE, and LE bl neg for DVT.
Brief Hospital Course:
68 y/o gentleman with metastatic renal cell cancer to lungs who
presents with acute on chronic fatigue and SOB admitted to ICU.
.
#. Anemia: Ptaient received 2 units pRBC in the ED for a hct of
23.7. Hemolysis work up was negative, and guaic negative. An
iron panel showed iron deficiency. Pelvic fluid collection was
noted on CT, otherwise there were no obvious sources of
bleeding. Subsequently his hct remained stable between 26-29.
Patient did not require further transfusions throughout hospital
course.
- Please check weekly CBC; transfuse for hct <21
.
#. Hypotension/Sepsis/Pneumonia: The patient was initially
transfered to medical ICU for monitoring. His hypotension was
thought to be secondary to sepsis in the setting of pneumonia.
The differential diagnosis included hemorrhagic shock given the
pelvic fluid collection noted on CT. However, the patient's
hematocrit remained stable. In the ICU the patient initially
required norepinephrine for blood pressure support but was
weaned off of this on [**2100-9-19**]. Otherwise, the patient's blood
presure was supported with IV fluids and by holding his home
antihypertensives. The patient was treated with vancomycin,
Zosyn, and ciprofloxacin given frequent contact with healthcare.
Ciprofloxacin was discontinued on [**2100-9-20**]. Upon transfer to
the floors, patient remained afebrile but was orthostatic and
required IVFs. Vancomycin and zosyn were transitioned to po
levofloxacin to complete a course of antibiotic therapy for
community acquired pneumonia. Patient was found to be iron
defecient and hypothyroid (as stated below). Orthostasis
resolved with fluids on discharge.
- Can restart home antihypertensives if patient becomes
hypertensive
.
#. Acute on chronic renal failure: On admission, the patient's
creatinine was elevated to 1.5 from baseline 1.3. This was
thought to be prerenal and returned to baseline with IVFs.
Creatine on discharge was 1.
.
# Hypercalcemia: In the ICU, patiently initially found to have
elevated Ca, that resolved with IVFs. Calcium again trended up
while on the floors and patient was given iv pamidronate.
Calcium on discharge was 8.8.
.
#. Metastatic renal cell carcinoma: Patient is s/p laparoscopic
nephrectomy on [**2099-9-21**] and pazopanib therapies. On this
admission a Chest CT done was done that showed extensive
neoplastic invasion of the right hemithorax, extending across
the chest wall and into the abdomen overlying the right psoas.
Patient was started on Sutinib and this is to be continued while
in rehab.
- Please continue Sutinib
- Please check weekly CBC
.
#. Hypothyroidism: Prior to admission patient recently started
on levothyroxine. His TSH on this admission was 17. No changes
were made to his home dose of levothyroxine as he had only been
recently started on this medication. Patient was discharged
with plans to follow up with his oncologist.
Medications on Admission:
Fentanyl 50 mcg/hour Patch
Furosemide 20 mg [**Hospital1 **] PRN, has only taken two doses
Levothyroxine 25 mcg daily
Lidocaine-Prilocaine 2.5 %-2.5 % Cream apply 1 hour prior
porta-cath access as directed
Lisinopril 5 mg daily
Lorazepam 1 mg q8h PRN anxiety/nausea
Megestrol 400 mg daily
Methylphenidate 5 mg [**Hospital1 **]
Oxycodone 2.5 - 5 mg by mouth q 2hours as needed for trouble
breathing; pain
Docusate Sodium 100 mg [**Hospital1 **]
Multivitamin daily
Polyethylene Glycol [**Hospital1 **] PRN
Senna 17.2 mg PRN
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
Primary:
Anemia
Pneumonia
Acute on Chronic Renal Failure
Metastatic Renal Cancer
Discharge Condition:
Stable: T 97.8, BP 119/55, O2 96/RA
Discharge Instructions:
You were seen in the hospital for your fatigue. You were found
to have low blood pressure, low hematocrit, and a pneumonia.
While in the emergency room you received blood transfusion. You
were in the ICU, and were treated with iv antibiotics and iv
fluids. You improved with this therapy.
We have made the following changes to your home medications:
1. We have stopped your lisinopril and lasix because your blood
pressure was low, please follow up with your PCP to decide when
to restart these medications
2. Please take levofloxacin to treat your pneumonia until [**9-26**].
3. We have increased your fentanyl patch to 62mcg/hr every 72
hours.
4. We have changed your morning methylphenidate dose from 2.5mg
to 5 mg. You can continue your afternoon dose of 2.5mg.
5. We have started you on an iron supplement.
6. Please continue Sutent; this is the chemotherapy [**Doctor Last Name 360**] you
were started on while in the hospital.
If you should experience fevers >101, lightheadedness, or any
concerning symptoms please contact your PCP or return to the
emergency room.
Followup Instructions:
Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2100-10-1**]
10:30
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on [**2100-10-4**] 9:45am, she
will decide if you should be restarted on lisinopril and lasix.
She will also follow up on your TSH and determine if your
synthroid dose should be changed.
Completed by:[**2100-9-29**]
|
[
"995.92",
"285.9",
"403.90",
"584.9",
"585.9",
"275.42",
"486",
"038.9",
"197.0",
"244.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
10454, 10539
|
6989, 9882
|
340, 365
|
10664, 10702
|
5067, 6966
|
11829, 12258
|
4453, 4514
|
10560, 10643
|
9908, 10431
|
10726, 11062
|
4529, 5048
|
11080, 11806
|
247, 302
|
393, 3895
|
3917, 4268
|
4284, 4437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,718
| 158,007
|
44500
|
Discharge summary
|
report
|
Admission Date: [**2202-12-20**] Discharge Date: [**2203-1-15**]
Date of Birth: [**2162-8-15**] Sex: M
Service: MEDICINE
Allergies:
Betadine / Iodine; Iodine Containing / Compazine / Heparin
Agents
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Witnessed seizure
Major Surgical or Invasive Procedure:
Intubation for MRI
History of Present Illness:
This is a 40 year-old male who is well known to [**Hospital1 18**] with
history of C6 quadraplegia, autonomic dysreflexia, renal
transplant, multiple sacral decubitus ulcers, anemia, chronic
pain, and recurrent UTI with indwelling suprapubic catheter sent
in to ED from [**Hospital3 672**].
.
He was recently admitted for UTI for much of [**11-15**] and was found
unresponsive in bed the morning of admission with associated
hypertension. He was given Narcan with some response. He then
had generalized tonic stiffening and rhythmic movements of the
extremeties. His eye were described as rolled back in the head
and twitching. The event self-resolved after about 2 minutes. He
became somewhat responsive but was still hypertensive to greater
than 200 as is usual with his autonomic crisis. He received
nitropaste with resolution of his unresponsiveness. His
suprapubic catheter had been draining well, urine output had
dropped that morning. He was brought to [**Hospital1 18**] for further
evaluation.
.
In the ED, neurology was consulted for the question of seizure.
They recommended a sleep-deprived EEG and to increase
lamotrigine dose. His blood pressure stabilized and his urine
output picked up.
Past Medical History:
1. Status post motor vehicle accident resulting in C6
quadraplegia and autonomic dysreflexia. His course is also
complicated by sacral decubiti.
2. Status post renal transplant
3. Obesity (260lbs)
4. Depression
5. Anemia
6. Chronic pain
7. Recurrent UTI with indwelling suprapubic catheter
8. History of HIT thrombosing port-a-cath
9. History of anyphylaxis with iodine refractory to pretreatment
with steroids
10. History of cocaine-induced MI '[**88**]
11. Chronic osteomyelitis
12. Status post right BKA
13. Status post diverting colostomy
14. History of adrenal insufficiency
15. Status post splenectomy
16. Asthma
Social History:
He lives at [**Hospital3 672**] rehab, He is a former smoker and
denies alcohol or illicits since cocaine in '[**88**].
Family History:
Non-contributory
Physical Exam:
VS: Tm 101.4 Tc 101.4 HR 102 BP 176/44 RR 18 99% NRB
Gen: Obese, chronically ill-appearing man, with HOB up, towel on
face,
HEENT: Sclerae anicteric, dry mm.
Neck: supple no JVP elevation
CV: tachycardic, nl s1/s2, port-a-cath in plce
Resp: Good air movement, clear anteriorly.
Abd: protruberant, distended, no fluid wave appreciated,
nontender, suprapubic catheter in place, ostomy with green-brown
stool
Extrem: right knee ulceration without erythema or induration,
faint radial pulses palpable
Pertinent Results:
Chemistries:
GLUCOSE-82 UREA N-30 CREAT-1.0 SODIUM-143 POTASSIUM-4.3
CHLORIDE-109 TOTAL CO2-24
CALCIUM-8.2 PHOSPHATE-2.8 MAGNESIUM-1.2
Lactate:1.1
.
Hematology:
WBC-8.6 HGB-8.0 HCT-25.9 PLT COUNT-145
NEUTS-78.4 BANDS-0 LYMPHS-15.5 MONOS-3.5 EOS-2.4 BASOS-0.1
.
Coagulation:
PT-13.4 PTT-26.8 INR(PT)-1.2
.
Urinalysis: large nitrate, moderate leukocyte esterase
Urine culture ([**12-20**]): Pan-sensitive proteus.
.
Serum Toxicology: Negative
.
Imaging:
Chest x-ray ([**12-20**]): Persistent cardiomegaly and small left
pleural effusion. Stable left lower lobe atelectasis/pneumonia.
.
CT Head ([**12-21**]): Suggestion of hypodensity in the left frontal
and temporal lobes. In the setting of seizure, an MR could be
helpful for evaluation and to ascertain whether this appearance
is artifactual related to motion or reflects the presence of an
underlying mass, without mass effect.
.
ECG ([**12-21**]): Sinus rhythm. Normal ECG. Compared to the previous
tracing of [**2202-12-2**] no diagnostic interim change.
.
Renal ultrasound ([**12-21**]): Normal arterial and venous Doppler
waveforms in a transplant kidney with no perinephric fluid
collection. Minimal pelviectasis is present without
hydronephrosis.
.
MRI Head ([**12-24**]): No mass or signal abnormality to reflect fluid
densities seen on CT that were likely artifactual.
.
EEG ([**12-24**]): No evidence of epileptiform changes
Brief Hospital Course:
This is a 40 year-old male found unresponsive followed shortly
by apparent convulsive episode and was found to have urinary
tract infection
.
1. Seizure: The etiology of his seizure is unclear and was
thought it could be secondary to hypertensive encephalopathy,
drug induced/withdrawl, and perhaps underlying infectious
process. Moreover, some hypomagnesemia noted on admission. Per
neurology, underlying seizure disorder is also an option,
although a toxic metabolic cause appeared more likley. An EEG
on [**12-24**] was negative for any epileptiform changes. A head CT on
[**12-21**] revealed hypodensity in the left frontal and temporal
lobes. An MRI of the head showed no mass or signal
abnormalities. His thorazide was stopped as that can lower his
seizure threshold. He remained seizure-free for the duration of
this admission.
.
2. ID: Pt has suprapubic catheter which was likely source of
infection at prior admission. He was continued on tobramycin
until [**12-11**]. Fevers on this admission were concerning for
infections. Blood cultures were negative throughout admission.
Urine cultures grew Proteus from [**12-20**]. Initially, he was on
tobramycin since prior cultures were sensitive only to this
[**Doctor Last Name 360**]. Per ID, the decision was made to discontinue this [**Doctor Last Name 360**].
On [**1-1**], urine culture again grew Proteus again and ID
recommended treating with Ceftriaxone after sensitivities were
confirmed. His urine cleared the day after initializing
treatment. In addition, his suprapubic tube was changed by
Urology and the patient continued to make good urine through the
day of discharge. He completed a 10 day total course of IV
Ceftriaxone.
.
3. Right lower molar pain: Mr. [**Known lastname 11679**] complained of lower
right molar pain on [**1-3**]. Intially, he was to follow-up as an
outpatient. However, his pain worsened. Oral surgery came and
removed a loose fragment of molar #30. His pain resolved.
.
4. Labile Blood pressure: Autonomic dysreflexia: Mr. [**Known lastname 11679**] has
periodic bouts of elevated blood pressure which, in the past,
have resulted in hospital admissions. In general,
antihypertensives and supportive care usually led to decreased
blood pressure. For example, when he had elevated blood pressure
and bladder pain, his suprapubic catheter was readjusted and he
urinated 700cc and felt immediate relief with a decrease in
blood pressure. While the etiology of his elevated blood
pressure in this case wasn't necessarily his underlying
autonomic dysreflexia, any elevation in blood pressure can
trigger similar responses in Mr. [**Known lastname 11679**] including pain,
transient MS changes, shaking, discomfort. Prior to subsequent
admissions for elevated blood pressure, measures should be taken
to control his pain such as giving him an extra dose of pain
medication. On the day of discharge the patient's BP was stable.
.
5. Anemia: Iron deficiency documented; continued iron
supplementation, His hematocrit remained stable throughout this
admission.
.
6. Sacral decubiti/chronic osteomyelitis: Previously followed by
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 1022**] from orthopedics. We continued Zinc,
multivitamin, and wound care throughout admission.
.
7. Status post renal transplant: Continued immunosuppressive
medications (Azathioprine and Prednisone at 10mg). Renal
function normal despite renotoxic meds.
.
8. Chronic pain: He was continued on methadone and dilaudid as
needed throughout admission.
.
9. Spasticity: He was continued on baclofen.
.
10. Depression: He was continued on celexa.
.
11. FEN: regular diet.
.
12. ACCESS: port-a-cath
.
13. CODE: full
.
14. Dispo: He was discharged back to [**Hospital3 672**].
Medications on Admission:
Prednisone 10mg daily (until [**12-21**])
Atrovent
Paxil 10mg qd
Dulcolax 10mg [**Hospital1 **]
Zinc 220mg qd
Senekot
Phenergan 12.5mg q6:prn
Protonix 40mg qd
Nicorette
MVI
Methadone 5mg tid
Lamictal 25mg qd
Humalog sliding scale
Dilaudid 3mg q4h:prn
FA 1mg qd
Feosol 325mg [**Hospital1 **]
Vit D 400u qd
Colace 200mg [**Hospital1 **]
Benadryl 25mg q6:prn
Tums 2500mg tid
Lioresal 20mg tid
Imuran 75mg qd
Tylenol
NS 1L [**Hospital1 **] until [**12-20**]
Discharge Medications:
1. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
3. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Nicotine 2 mg Gum Sig: One (1) Gum Buccal Q1H (every hour) as
needed.
7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
8. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
9. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
12. Cholecalciferol (Vitamin D3) 400 unit 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.
14. Azathioprine 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
15. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
16. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2
times a day) as needed for seborrheic dermatitis.
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed.
19. Magnesium Oxide 400 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
20. DiphenhydrAMINE HCl 50 mg IV Q6H:PRN
21. Promethazine HCl 25 mg IV Q6H:PRN
22. Vitamin D 400 unit Capsule Sig: One (1) Capsule PO once a
day.
23. Atrovent 18 mcg/Actuation Aerosol Sig: One (1) Inhalation
every 4-6 hours as needed for allergy symptoms.
24. Phenergan 12.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
25. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four
times a day as needed for Hyperglycemia: Sliding scale.
26. Lidocaine Viscous 2 % Solution Sig: 1-2 MLs Mucous membrane
TID (3 times a day) as needed: To tooth as needed.
27. Hydromorphone 1 mg/mL Solution Sig: 2-4 mg Injection Q3-4H
(Every 3 to 4 Hours) as needed.
28. Methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Seizure
Autonomic dysreflexia
status post renal transplant
Chronic pain
urinary tract infection
Right lower molar pain
Discharge Condition:
Stable
Discharge Instructions:
Please seek medical attention immediately should you experience
new symptoms including weakness, fainting, seizures, shortness
of breath, shaking, etc.
Take all medications as prescribed.
Follow up as outlined below.
Followup Instructions:
With Outpatient doctor at rehab as needed
In autonomic clinic.
Completed by:[**2203-1-16**]
|
[
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"907.2",
"596.54",
"337.0",
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"V58.65",
"401.0",
"275.2",
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"707.03",
"996.65",
"V55.5",
"E929.0",
"780.39",
"690.10",
"707.8",
"V42.0",
"337.3",
"707.05",
"525.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"23.09",
"59.94",
"96.04"
] |
icd9pcs
|
[
[
[]
]
] |
10980, 11035
|
4365, 8125
|
345, 366
|
11198, 11207
|
2952, 4342
|
11474, 11568
|
2401, 2419
|
8630, 10957
|
11056, 11177
|
8151, 8607
|
11231, 11451
|
2434, 2933
|
288, 307
|
394, 1605
|
1627, 2248
|
2264, 2385
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
54,183
| 150,129
|
54641
|
Discharge summary
|
report
|
Admission Date: [**2165-9-13**] Discharge Date: [**2165-9-27**]
Date of Birth: [**2108-6-4**] Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / Erythromycin Base
Attending:[**First Name3 (LF) 4765**]
Chief Complaint:
Respiratory Failure and Hypotension
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
This is a 57yoM with history of diabetes, hypertension,
psychiatric disorder with paranoid features who initially
presented to OSH with fever and AMS. Of note patient was
recently admitted to [**Hospital 1562**] Hospital earlier this week after
having fall. He was dicharged on [**9-12**] back to his nursing home
during which time he developed fevers to 103 with rigors.
At OSH ED, he was noted to have a large scrotal mass on exam.
Labs there were significant for pancytopenia. He was then
transferred to [**Hospital1 18**] ED for further evaluation. He was given
zosyn prior transfer.
In [**Hospital1 18**] ED, initial VS were: 99.9 103 91/56 22 100% 4LNC. When
he presented, he was hypoxic and altered requiring intubation.
He was sedated with fentanyl and midazolam. He was also
hypotensive and received a total of 4L of fluid. RIJ CVL was
placed and was started on norepinephrine for persistent
hypotension. While in ED he spike to 104.8 and received tylenol.
Initial laboratory data revealed pancytopenia with 6% bandemia,
along with Cr of 1.6, Glucose of 173, troponin of 0.03, Lactate
of 2.2 and bland UA. CXR, CT a/p and CT head were all
unremarkable. Urology was consulted given scrotal findings who
did not feel it was consistent with Fournier's. Scrotal
ultrasound showed hyperechoic mass which could be consistent
with tumor. He received vancomycin, ceftriaxone and acyclovir
given concern for meningitis. LP was completed prior antibiotics
however which showed 1 WBC with no RBCs and elevated protein.
Patient was then admitted to MICU for further management.
On arrival to the MICU, patient was sedated and intubated.
Of note [**Name6 (MD) **] primary NP[**MD Number(3) 10222**]'s office, patient called 1 week
prior to admission and appeared confused, asking for dentist to
visit him in nursing home and having odd requests.
Per [**Hospital1 1501**], on Tuesday sent to hospital. Found on floor,
incontinent of urine. Havign unsteady gait. Waxing and [**Doctor Last Name 688**]
mental status. Difficult patietn to assess because of lots of
complaints. Perseverative.
Past Medical History:
- HTN
- DM
- Obesity
- Psychiatry Disorder NOS - paranoid features
- TIA/"stroke" last fall
- "Memory problems"
Social History:
Lives on [**Location (un) **] on nursing home (somewhere in [**Hospital1 1562**] Care
[**Telephone/Fax (1) 111768**]) as of 03/[**2165**]. Used to be high functioning lawyer.
Independent with ADLs. Very disorganized.
Family History:
Unknown
Physical Exam:
ADMIT EXAM:
Vitals: 99.9 103 91/56 22 100% 4LNC
General: intubated and sedated
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: Coarse breath sounds on inspiration
Abdomen: soft, non-tender, obese, bowel sounds present, no
organomegaly
GU: foley in place, firm mass
Ext: proximal extremities warm, distal extremities cool. +1 left
DP and dopplerable
Skin: erythematous macular rash on flanks, blanchable
Neuro: sedated, pupils sluggish
DISCHARGE EXAM:
Pertinent Results:
IMAGING:
HIDA [**2165-9-15**] -
IMPRESSION: Abnormal hepatobiliary scan. The delayed tracer
uptake into the hepatic parenchyma suggests hepatocellular
dysfunction. The lack of
visualization of the biliary collecting system may be secondary
to biliary
obstruction; however, poor hepatocellular dysfunction can also
cause this
finding.
CHEST CT [**2165-9-14**] -
IMPRESSION:
1. No evidence of pneumonia. Bibasilar subsegmental atelectasis
with small
left greater than right pleural effusions.
2. Tiny pulmonary nodules <4mm as described above.
ECHO [**2165-9-14**] -
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. No masses or vegetations are seen on the aortic valve,
but cannot be fully excluded due to suboptimal image quality.
There is no aortic valve stenosis. No aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. No masses or vegetations are seen on the
mitral valve, but cannot be fully excluded due to suboptimal
image quality. There is no pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (suboptimal-quality study). Symmetric LVH
with normal global and regional biventricular systolic function.
US Gallbladder [**2165-9-13**] -
IMPRESSION: Cholelithiasis with edematous gallbladder wall.
Cholecystitis cannot be excluded. A HIDA scan could be
performed for further characterization. Splenomegaly.
Scrotal US [**2165-9-13**] -
IMPRESSION: Large heterogeneous mass in the left testis
enlarging and
replacing a majority of the normal testicular tissue. These
findings are
suggestive of mass lesion.
CT Abdomen/Pelvis [**2165-9-13**] -
IMPRESSION: No acute intra-abdominal process.
CT Head Without Contrast [**2165-9-13**] -
No acute intracranial hemorrhage, large vascular territory
infarct, shift of midline structures or mass effect is present.
There is an old left cerebellar infarct. The ventricles and
sulci are normal in size and configuration. The visible
paranasal sinuses show anterior ethmoidal secretions.
Secretions are noted in the nasopharynx.
IMPRESSION: No acute intracranial process.
MICRO/PATH:
CSF;SPINAL FLUID FUNGAL CULTURE (Preliminary): NO FUNGUS
ISOLATED.
CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN NOT DETECTED.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED
CMV IgG ANTIBODY (Final [**2165-9-17**]): NEGATIVE FOR CMV IgG ANTIBODY
BY EIA.
RAPID PLASMA REAGIN TEST (Final [**2165-9-16**]): NONREACTIVE.
RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal
Respiratory Flora. GRAM NEGATIVE ROD(S). SPARSE GROWTH.
ADMIT LABS:
[**2165-9-13**] 04:00AM BLOOD WBC-3.6* RBC-4.43* Hgb-13.0* Hct-38.5*
MCV-87 MCH-29.4 MCHC-33.8 RDW-14.0 Plt Ct-96*
[**2165-9-13**] 11:09AM BLOOD WBC-10.3# RBC-4.36* Hgb-13.0* Hct-38.2*
MCV-88 MCH-29.9 MCHC-34.1 RDW-14.2 Plt Ct-93*
[**2165-9-13**] 04:00AM BLOOD Neuts-85* Bands-6* Lymphs-6* Monos-3
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0
[**2165-9-13**] 11:09AM BLOOD Neuts-66 Bands-29* Lymphs-0 Monos-2 Eos-0
Baso-0 Atyps-0 Metas-3* Myelos-0
[**2165-9-13**] 11:09AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
[**2165-9-13**] 04:00AM BLOOD Plt Smr-LOW Plt Ct-96*
[**2165-9-13**] 11:09AM BLOOD PT-14.1* PTT-44.5* INR(PT)-1.3*
[**2165-9-13**] 11:09AM BLOOD Fibrino-417*
[**2165-9-13**] 05:14PM BLOOD FDP-10-40*
[**2165-9-13**] 04:00AM BLOOD Glucose-174* UreaN-35* Creat-1.6* Na-138
K-3.9 Cl-99 HCO3-29 AnGap-14
[**2165-9-13**] 11:09AM BLOOD Glucose-130* UreaN-37* Creat-2.2* Na-140
K-4.7 Cl-104 HCO3-23 AnGap-18
[**2165-9-13**] 05:14PM BLOOD Glucose-85 UreaN-40* Creat-2.6* Na-139
K-4.9 Cl-105 HCO3-23 AnGap-16
[**2165-9-13**] 04:00AM BLOOD ALT-24 AST-36 LD(LDH)-327* CK(CPK)-279
AlkPhos-163* TotBili-2.1*
[**2165-9-13**] 11:09AM BLOOD ALT-26 AST-41* AlkPhos-126 TotBili-3.0*
[**2165-9-13**] 04:00AM BLOOD cTropnT-0.03* proBNP-570*
[**2165-9-13**] 04:00AM BLOOD Lipase-32
[**2165-9-13**] 04:00AM BLOOD Albumin-3.8 Calcium-9.2 Phos-1.6* Mg-1.6
[**2165-9-13**] 11:09AM BLOOD Calcium-7.9* Phos-4.0# Mg-1.3*
UricAcd-8.2*
[**2165-9-13**] 11:09AM BLOOD Ferritn-438*
[**2165-9-13**] 11:09AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
[**2165-9-13**] 05:14PM BLOOD AFP-<1.0
[**2165-9-13**] 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2165-9-13**] 05:49AM BLOOD Type-ART Temp-40.4 Rates-24/ pO2-102
pCO2-52* pH-7.31* calTCO2-27 Base XS-0 Intubat-INTUBATED
Vent-CONTROLLED
[**2165-9-13**] 11:35AM BLOOD Type-MIX pH-7.28* Comment-GREEN TOP
Brief Hospital Course:
57yoM with history of DM, HTN, psychiatric illness who presents
for fevers, new testicular mass and altered mental status found
to be in respiratory failure and hypotension. Infectious work up
was unrevealling but pt was noted to have scrotal mass. He was
taken for orchiectomy with post-operative course complicated by
V fib arrest.
# Cardiac arrest: Pt tolerated orchiectomy well with no
procedural complications, extubated successfully in the PACU.
However, shortly after the procedure, he developed v-fib arrest
with prolonged resuscitation efforts in the PACU and ongoing
shock requiring multiple vasopressors. He was taken to the cath
lab emergently for coronary angiography. Initial angiography
demonstrated 99% thrombotic lesion in the distal RCA with slow
flow beyond that was deemed the culprit lesion. He had
successful PCI of the RCA with BMS but given continued
hemodynamic instability requiring levophed and [**Last Name (LF) 21313**], [**First Name3 (LF) **]
IABP was placed via RFA access. Following the procedure, he
developed sustained VT/VF with degeneration into PEA arrest. He
was treated following ACLS protocol and was started on
epinephrine, norepinephrine, phenylephrine and lidocaine drips,
as well as receiving amiodarone and vasopressin, PRBC x 2,
magnesium and calcium. His family was present for the code. He
regained pulse and was transfered to the CCU, where cooling
protocol was initiatied. He developed bradycardia unresponsive
to dopamine, atropine and transcutaneous pacing, which again
degenerated into PEA arrest. CPR was performed but resuscitative
efforts were unsuccessful. Pt was pronouced at 21:10 on [**2165-9-28**]
with family at bedside. Case was referred to the medical
examiner, who declined the case, but family did request autopsy.
Complete hospital course:
# SIRS: Given leukopenia, tachycardia, and fever, meets criteria
for SIRS but no obvious source of infection to evoke sepsis. He
was initially treated with empiric antbioitic coverage with
vancomycin, levofloxacin, zosyn, and doxycyclin pending
infectious workup. He also required brief blood pressure support
with pressors. Initially there was concern for scrotal source
given testicular enlargement, however exam not c/w Fouriners.
Multiple repeated blood, urine, and CSF cultures were all
negative for infectious soruces. Tick-borne illnesses were
tested and were all negative. He did have one positive sputum
sample with E. coli, but this was a very contaminated sample,
and per ID, was likely not a real pathogen. His empiric
antibiotic coverage was slowly peeled off as his fevers
subsided. There was no source of infection identified despite
extremly extensive workup. No evidence of cardiogenic or
distributive causes for SIRS. His antibiotic course was as
follows: Levofloxacin ([**Date range (1) 111769**]), Vancomycin ([**Date range (1) 111769**]),
Zosyn ([**Date range (1) 111770**]), Ceftriaxone ([**Date range (1) 111771**]), Doxycyclin
([**Date range (1) 111772**]).
# Respiratory Failure: On admission he had respiratory failure
and was unable to protect his airway secondary to altered mental
status. On admission he was briefly intubated while in the ICU.
During this time he was found to have elevated PIP, with normal
plateau pressures. This was found to improve with MDIs.
Following extubation he did not have any additional respiratory
issues. He was maintained on PRN nebs, which he received
occassionally while on the floor.
# Renal Failure: His creatinine was slightly elevated on
admission to 1.6, but with the development of hypotension
creatinine went as high as 2.9. This was likely prerenal in the
setting of hypotension. His renal function improved as his blood
pressures normalized, and his creatinine was at his baseline
upon discharge.
# Fevers: On presentation his fevers were elevated up to 104.8F,
which was concerning for sepsis. As outline above, the entire
infectious workup was negative. He defervesced shortly after
being transferred from the ICU to the floor. Other possible
causes for fever, such as TTP, serotonin syndrome, Still's
disease, or drug fever were investigated. However, there was no
evidence of any of these etiologies.
# Encephaolpathy (acute, metabolic): Patient has a history of
depression, anxiety, and hallucinations per nursing home
records. Additionally, he has a history of psychotic illness of
unknown type, and has been evaluated as an outpaitent by a
neurologist for neurodegenerative decline over the last 5 years.
On admission there was concern for infection, however despite
extensive infectious workup, there was no pathogen identified.
He underwent EEG, per neurology recs, which showed only
encephalopathy, without evidence of epileptiform features or
electrographic seizure. He also underwent MRI of the brain,
which showed atrophy, but no masses or acute changes. Given
testicular mass, there was concern for paraneoplastic causes of
encephalopathy. The decision was made to undergo orchiectomy for
further evaluation of the scrotal mass.
# Pancytopenia/Coagulopathy: Early in his hospital course he was
noted to have these lab findings. This, coupled with fevers,
raised suspicion for possible tick-borne illness. However, these
studies were all engative. There was no evidence of schistocytes
on blood smear, making TTP also unlikey. DIC labs were trended,
but were never concerning for the development of DIC. We
continued to monitor his labs, and he had spontaneous resolution
of pancytopenia/coagulopathy.
# Testicular mass: Per the patient and his wife, he first
noticed this testicular mass approximately 2 years ago. He
reportedly presented to an outside urologist for evaluation, but
it is unclear what the recommnedations were at that time. The
mass is located in the left testis, and is firm, non-tender, and
mobile. Serum beta-HCG, and AFP were negative. LDH was slightly
elevated. Given these findings, there was concern for possible
malignancy. He was seen and evauated by urology, as above, and
underwent orchiectomy. Post operative course complicated by v
fib arrest as above.
# Elevated LFTs: On presentation there was concern for possible
biliary source for sepsis in the setting of fevers and
transaminitis. RUQ US was performed, which showed a small stone
in the neck of the galbladder, along with thickening of the wall
of the galbladder, which was concerning for cholecystitis. HIDA
scan was performed for additional evaluation, which demonstrated
hepatocellular dysfunction vs obstruction. he did not have RUQ
pain, and his LFT's were down-trending.
# Nutrition: Throughout this hospitalization he had very poor
oral intake. He reported decreased appetite and that he did not
like the hospital food. However, when his family brought food
from home, he continued to have poor oral intake. He was
evaluated by nutrition, who recommended a feeding tube, which he
refused. His diet was initially diabetic/consistent carbohydrate
but based on his very poor intake, it was subsequently
broadedned to regular in hopes to encourage him to eat.
# Diabetes: Blood glucose was well controlled on a basal dose of
lantus and a HISS.
# Hypertension: Following extubation he did have elevated blood
pressures. He was started on amlodipine, which was well
tolerated.
# Psychiatric Disorder: He was maintained on his home regimen of
klonapin, cymbalta, seroquel.
Medications on Admission:
Medications HOME: per PCP
[**Name Initial (PRE) **] [**Name Initial (NameIs) 43510**] 600mg
- Pravastatin 20mg daily
- Lantus 100units
- Humulin R (short acting)
- Propranolol 80mg [**Hospital1 **]
- Magnesium Oxide 400mg [**Hospital1 **]
- Metoprolol XL 25mg daily
MEDICATIONS Per Nursing Home:
- Depakote 250mg [**Hospital1 **]
- Klonopin 0.5mg [**Hospital1 **]
- Lasix 20mg daily
- Mag Oxide 400mg daily
- Potassium Cloride 10mEq daily
- Propranolol 80mg [**Hospital1 **] for HTN
- Vitamin D [**Numeric Identifier 1871**] units qFriday
- Zocor 10mg HS
- Cymbalta 60mg daily
- Neurontin 800mg Q6h
- Ultram 50mg prn
- Seroquel 25mg hs
- Lantus 70units HS
- Novolin SS
Discharge Medications:
Pt deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
pt deceased.
Discharge Condition:
Pt deceased.
Discharge Instructions:
pt deceased.
Followup Instructions:
Pt deceased.
Completed by:[**2165-9-30**]
|
[
"V12.54",
"E878.8",
"790.6",
"608.89",
"427.41",
"307.9",
"293.0",
"427.1",
"998.01",
"250.00",
"995.92",
"518.81",
"038.9",
"576.8",
"401.9",
"427.5",
"284.19",
"286.9",
"578.0",
"E888.9",
"458.9",
"300.89",
"414.01",
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] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"00.45",
"96.71",
"00.66",
"62.3",
"38.91",
"99.60",
"00.40",
"36.06",
"37.61",
"96.04",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
16505, 16514
|
8377, 10171
|
347, 359
|
16570, 16584
|
3493, 5936
|
16645, 16688
|
2867, 2876
|
16468, 16482
|
16535, 16549
|
15773, 16445
|
10188, 15747
|
16608, 16622
|
2891, 3457
|
3474, 3474
|
6074, 6296
|
6331, 8354
|
271, 309
|
387, 2480
|
2502, 2616
|
2632, 2851
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,264
| 195,512
|
34343
|
Discharge summary
|
report
|
Admission Date: [**2122-7-22**] Discharge Date: [**2122-7-25**]
Date of Birth: [**2063-11-5**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 492**]
Chief Complaint:
chronic respiratory failure
Major Surgical or Invasive Procedure:
[**2122-7-24**]: Patient had rigid bronch in OR with microdebridement and
APC ablation of granulation tissue in the trachea and
tracheostomy stoma revision/dilatation with trach upgrade to #7
History of Present Illness:
58 year old female with history of COPD, OSA, Pulmonary HTN
admitted to MICU service at [**Hospital1 3278**] for bronchoscopy evaluation.
Patient initially presented to [**Hospital6 **] on
[**2122-2-16**] in Respiratory failure. She was intubated in the ED and
was difficult to wean leading to a trach and PEG being placed
during that admission. She also developed abdominal distention
and was found to have an incarcerated umbilical hernia. She had
part of a colon resected in a colostomy and rectal pouch
performed. During the admission, she became septic and
developed
ATN requiring HD. She was subsequently transferred to [**Hospital3 33538**] for rehabilitation where she was weaned off HD and her
dependence on the Ventilator. Over the past couple of weeks, the
patient noted feeling like something was stuck in her throat as
well as increased difficulty breathing. She was also noted to
have increased yellow and bloody secretions from her trach site.
The patient was subsequently transferred to [**Hospital1 3278**] for
Bronchoscopy to further eval her trach site. After being
evaluated it was found that she had severe TBM and was
transferred to [**Hospital1 18**] for further workup and Y stent placement.
On Admission: tach Portex #6
On vent at night : was tolerating trach collar during the day.
Past Medical History:
COPD
OSA
Pulmonary HTN
systemic HTN
Chronic renal insufficiency
ischemic bowel s/p colectomy
Depression
Social History:
30 pack year former smoker
married, lives with family
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
Temp (F): 98.8
Heart Rate: 94
Blood Pressure: 122/60
Resp Rate: 14
O2 Sat(%):100
Room Air/O2:40
Ht (in):5 2
Wt (lb):273
GENERAL [x] ALL FINDINGS NORMAL
[ ] WN/WD
[x] WD
[x] NAD
[x] AAO
[x] abnormal findings: morbid obesity, trach/PEG/Colostomy
HEENT [x] ALL FINDINGS NORMAL
[ ] NC/AT
[ ] EOMI
[ ] PERRL/A
[ ] Anicteric
[ ] OP/NP mucosa normal
[ ] Tongue midline
[ ] Palate, upper symmetric
[ ] Trachea midline
[ ] Neck supple/NT/without mass
[ ] Thyroid Normal size/contour
[ ] Abnormal findings:
RESPIRATORY [ ] ALL FINDINGS NORMAL
[ ] Clear to auscultation and percussion
[ ] Excursion normal
[ ] No fremitus
[ ] No egophony
[ ] No spine/costovertebral angle tenderness
[x] Abnormal findings: Bilateral Wheeze throughout, mild
rhonchi
CARDIOVASCULAR [x] ALL FINDINGS NORMAL
[x] RRR
[x] No M/R/G
[x] No JVD
[x] Normal peripheral pulses
[ ] PMI normal
[x] No edema
[ ] No abdominal bruit
[ ] No carotid bruit
[ ] Abnormal findings:
GI [] ALL FINDINGS NORMAL
[x] Soft
[x] NT
[x] ND
[ ] No mass/HSM
[ ] No hernia
[x] Abnormal findings: large pannus, PEG, Colostomy
SKIN [x] ALL FINDINGS NORMAL
[ ] No rashes/lesions/ulcers
[ ] No induration/nodules/tightening
[ ] Abnormal findings:
NEURO [x] ALL FINDINGS NORMAL
[ ] Strength intact/symmetric
[ ] Sensation intact/symmetric
[ ] Reflexes normal
[ ] No facial asymmetry
[ ] Cognition intact
[ ] Cranial nerves intact
[ ] Abnormal findings:
PSYCHIATRIC [x] ALL FINDINGS NORMAL
[ ] Normal judgement/insight
[ ] Normal memory
[ ] Normal mood/affect
[ ] Abnormal findings
Pertinent Results:
[**2122-7-22**] 09:53PM TYPE-ART TEMP-37.1 RATES-/22 PEEP-10 O2-40
PO2-126* PCO2-48* PH-7.30* TOTAL CO2-25 BASE XS--2
[**2122-7-22**] 09:43PM GLUCOSE-90 UREA N-43* CREAT-1.8* SODIUM-140
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-22 ANION GAP-13
[**2122-7-22**] 09:43PM ALT(SGPT)-33 AST(SGOT)-22
[**2122-7-22**] 09:43PM CALCIUM-9.4 PHOSPHATE-4.0 MAGNESIUM-2.0
[**2122-7-22**] 09:43PM WBC-7.2 RBC-2.89* HGB-8.1* HCT-26.7* MCV-92
MCH-28.1 MCHC-30.5* RDW-15.8*
[**2122-7-22**] 09:43PM NEUTS-79.8* LYMPHS-12.3* MONOS-3.8 EOS-4.1*
BASOS-0.2
[**2122-7-22**] 09:43PM PLT COUNT-307
[**2122-7-22**] 09:43PM PT-14.2* PTT-25.0 INR(PT)-1.2*
Brief Hospital Course:
58 F transferred from [**Hospital1 3278**] with Severe TBM, OSA for placement
of Y stent by Interventional Pulmonary.
Admitted to SICU and underwent bronch which demonstrated mild
tracheal
stenosis w/ moderate amount of granulation tissue noted at the
site of the stoma. The mid portion of the trachea was noted to
have severe tracheomalacia with greater
than 95% occlusion during exhalation. The distal trachea had
mild tracheomalacia, approximately 65%. The right main stem
bronchus had mild bronchomalacia at about 65%. Bronchus
intermedius was noted to have moderate bronchomalacia estimated
at about 80%. The left main stem bronchus was noted to have
moderate bronchomalacia estimated at approximately 80%
occlusion.
She was taken to the OR on [**2122-7-24**] and underwent rigid [**Last Name (un) 1066**] with
microdebrider to granulation tissue and APC to coaggulate
bleeding. Her tracheostomy stoma was then dilated with a Blue
Rhino and a new tracheostomy, a Portex size #7, was inserted.
She did well post operatively and will be transferred back to
rehab [**2122-7-25**].
Will need to continue PPI [**Hospital1 **] and ranitidine qhs for GERD and
complete 8 days of zosyn for VAP.
She is scheduled for follow up appointment with Dr. [**Last Name (STitle) **] in
Interventional pulmonary in 2 weeks. She is planned to undergo
Rigid Bronch with stoma revision and T-tube placement then.
Medications on Admission:
Lopressor 25 mg PO BID
Miconazole topical 2% qday
Venlafaxine 37.5mg PGT qday
Albuterol MDI one puff q 2hr prn
Ativan 1mg PGT q4h prn
Tylenol 650mg PGT q6H prn fever
Zosyn 3.375 mg IV q8H
Vancomycin 1500mg IV q 48h
Peptomen AF 10cc/hr PGT advanced to goal 55cc/hr
Insulin sliding scale
Zofran 4mg IV q8h
morphine 4mg IV q 4h
Baclomethanone 80 mcg 2 puff [**Hospital1 **]
Combivent 2 puff q 6hours
Fentanyl patch 50 mcg q72H
Reglan 10 mg PGT q6H
Pepcid 40 mg PGT daily AM
Trazadone 50 mg PGT QHS prn agitation
Heparin 5000 U TID
Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) SQ
Injection ASDIR (AS DIRECTED).
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical DAILY
(Daily).
6. Venlafaxine 37.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Neb Inhalation Q6H (every 6 hours) as
needed for wheeze.
8. Acetaminophen 160 mg/5 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain/fever.
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
10. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for agitation.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection Injection TID (3 times a day) as needed for
prophylaxis.
12. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
13. Ranitidine HCl 15 mg/mL Syrup Sig: One [**Age over 90 1230**]y (150)
mg PO HS (at bedtime).
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
15. Metoclopramide 10 mg IV Q6H
16. Protonix 40 mg Susp,Delayed Release for Recon Sig: Forty
(40) mg PO twice a day.
17. Zosyn 3.375 gram Recon Soln Sig: 3.375 mg Intravenous every
six (6) hours for 7 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Tracheobronchomalacia
OSA
Chronic Respiratory Failure
Ventilator Associated PNA
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon or return to the emergency department
if you develop a fever greater than 101.5, chest pain, shortness
of breath, severe abdominal pain, pain unrelieved by your pain
medication, severe nausea or vomiting, severe abdominal
bloating, inability to eat or drink, foul smelling or colorful
drainage from your incisions, redness or swelling around your
incisions, or any other symptoms which are concerning to you.
Followup Instructions:
She is scheduled for follow up appointment with Dr. [**Last Name (STitle) **] in
Interventional pulmonary in 2 weeks. She is planned to undergo
Rigid Bronch with stoma revision and T-tube placement then.
[**Doctor Last Name **] office #: [**Telephone/Fax (1) 3020**]
[**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**Doctor First Name 494**]
|
[
"327.23",
"V55.0",
"519.19",
"428.0",
"707.03",
"786.3",
"519.09",
"403.90",
"E879.8",
"416.8",
"585.9",
"486",
"241.0",
"V44.1",
"425.4",
"496",
"999.9",
"V15.82",
"518.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"96.6",
"31.74",
"33.23",
"31.99",
"33.22",
"97.23"
] |
icd9pcs
|
[
[
[]
]
] |
8247, 8322
|
4674, 6079
|
348, 542
|
8446, 8453
|
4011, 4651
|
8935, 9318
|
2101, 2119
|
6658, 8224
|
8343, 8425
|
6105, 6635
|
8477, 8912
|
2154, 3992
|
281, 310
|
570, 1793
|
1807, 1886
|
1908, 2014
|
2030, 2085
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,460
| 180,006
|
2170
|
Discharge summary
|
report
|
Admission Date: [**2163-2-18**] Discharge Date: [**2163-3-1**]
Date of Birth: [**2114-8-16**] Sex: M
Service: MEDICINE
Allergies:
Codeine / Morphine
Attending:[**First Name3 (LF) 6021**]
Chief Complaint:
non-responsive, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 48 yo M with h/o HIV (CD4 346, VL < 50 [**1-8**]),
Burkitt's lymphoma with CN palsies on chemo/XRT with recent
admission for HIDAC and IT liposomal cytarabine who presents
from rehab with altered mental status and fevers to 103F. He was
recently admitted to the OMED service from [**1-28**] - [**2-17**] for
progressive distal upper extremity weakness and shoulder pain
and was found to have lymphomatous involvement of the brachial
and lumbosacral plexi on MRI. He received IV HIDAC and IT
liposomal cytarabine with some improvement in his pain.
Post-chemo, the pt was noted to be progressively pancytopenic
requiring every other day transfusions of blood products. He was
discharged to rehab on [**2-17**] with filgrastim and prophylactic
levaquin and acyclovir. On [**2-17**] at rehab, pt had T 102F, HR
120-130s, blood cxs sent. This am, T to 103F, HR 150s, BP
122/63, and pt mostly non-verbal (at baseline oriented to self).
He was sent to the ED.
.
In the ED, T 105 (rectal), BP 144/42, HR 156, RR 40, O2 sat 100%
on 4L NC. Labs significant for WBC 1.3 with 0% neutrophils and
bands, Hct 23.9, Plt 40, lactate 3.9. A port CXR showed a
developing retrocardiac opacity. He was given 5 L NS, tylenol 1
gm X 1, vancomycin 1 gm IV X 1, levaquin 750 mg IV X 1, and
cefepime 2 gm IV X 1. After 5L IVFs, the pt's HR decreased to
the 120-130s, RR improved to 18-22, and O2 sat 100% on 2L NC.
SBPs remained stable in 120s. Given relative hemodynamic
stability and plts < 50K, a CVL was not placed in the ED. He was
admitted to the [**Hospital Unit Name 153**] for further care.
.
On arrival to the [**Hospital Unit Name 153**], the pt denies any specific complaints
beyond feeling tired. He denies HA, stiff neck, cough, SOB, CP,
abd pain, n/v/d, dysuria, urinary frequency, or mouth pain. +
chills, did not feel fevers. ROS is otherwise positive for
continued distal extremity weakness, but not worse from prior.
Reports seeing hallucinations, but when asked about them replies
"I see the world in a scientific manner."
Past Medical History:
ONCOLOGIC HISTORY:
Diagnosed in [**2162-10-2**] w/ BM bx [**10-19**]. CODOX and intrathecal
cytarabine started on [**10-21**]. On [**10-22**], MRI demonstrated
progressive CNS disease and he commenced whole brain XRT x 5
fractions of radiation (completed [**10-28**]). He was admitted from
[**12-17**] through [**12-25**] for his second cycle of R-IVAC. He also
received intrathecal liposomal cytarabine on [**2162-12-22**]. During
that admission he reported numbness of his left shoulder as well
as bilateral fingertip numbness, thought to be due to
vincristine-induced peripheral neuropathy, not a central process
(MR [**First Name (Titles) **] [**Last Name (Titles) 11580**]). He has now completed 2 cycles of CODOX
(second given with rituximab) and two cycles of R-IVAC. His
second cycle of R-IVAC was complicated by neutropenic sepsis and
blood cultures grew out both MRSA and Citrobacter. He was
hospitalized from [**Date range (1) 11585**]. During that time he was also
developed C. difficile colitis and bilateral subdural hematomas.
In addition, he has received WBXRT and numerous IT cytarabine
treatments including 3 doses of DepoCyt. Most recently received
HIDAC, IT liposomal cytarabine for lymphomatous involvement of
brachial and lumbosacral plexi.
.
PAST MEDICAL HISTORY:
1. Burkitt's Lymphoma as described above.
2. HIV as above, diagnosed in [**5-/2159**] thought to be contracted
from an MSM contact after which he developed a viral-like
syndrome.
3. Left V1/V2 trigeminal zoster without ocular involvement in
[**6-/2160**]
4. Viral orchitis in left testicle at age 15; testicle is
chronically shrunken, "mushy", and tender, per patient
5. Chronic low back pain from herniated disc noted several yrs
ago
6. Depression/Anxiety
7. HBcAb and HBsAb (+) (HBsAg neg)
8. s/p cholecystectomy in [**2145**]
9. Chronic anisocoria (per patient) with R>L
.
Social History:
He worked for a small company doing computer programming. He
denies tobacco use. Has used marijuana in the past, but denies
IV drug use. He uses occasional alcohol, though none
since his diagnosis.
Family History:
He reports that his father died of an MI in his 50s. His mother
has diabetes. His sister has had zoster
Physical Exam:
T 98.0 BP 110/56 HR 134 RR 24 O2 sat 99% 4L NC
Gen - NAD, speaking in short sentences without SOB, no accessory
muscle use, odd affect, glasses with masking tape over R lens
HEENT - [**Year (4 digits) 2994**] but sluggish, very dry MM, no mucositis
Neck - no LAD palpated, flat JVP
CV - tachycardic, nl s1/s2, no m/r/g appreciated
Lungs - CTA b/l, no r/r/w
Abd - Soft, NT, ND, nomroactive BS,
Ext - PICC without any surrounding erythema, no LE edema, warm
to palpation, + 2 distal pulses b/l, L forearm splint in place
Neuro - AAO X 2 (to self, year "[**2163**]", month "[**Month (only) 404**]", not to
place), unable to lift arms or legs against gravity, no
myoclonus, 1+ DTRs b/l, downgoing toe on left, equivocal on
right
Skin - no rashes or lesions
Pertinent Results:
[**2163-2-18**] 10:55PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2163-2-18**] 10:55PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-TR
[**2163-2-18**] 10:55PM URINE RBC-0-2 WBC-[**4-6**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2163-2-18**] 10:55PM URINE GRANULAR-0-2
[**2163-2-18**] 10:55PM URINE MUCOUS-OCC
[**2163-2-18**] 09:49PM LACTATE-3.9*
[**2163-2-18**] 09:45PM GLUCOSE-147* UREA N-35* CREAT-1.0 SODIUM-135
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-25 ANION GAP-17
[**2163-2-18**] 09:45PM ALT(SGPT)-22 AST(SGOT)-18 ALK PHOS-112
AMYLASE-30 TOT BILI-0.7
[**2163-2-18**] 09:45PM LIPASE-20
[**2163-2-18**] 09:45PM ALBUMIN-3.7 CALCIUM-10.0 PHOSPHATE-2.8
MAGNESIUM-1.7
[**2163-2-18**] 09:45PM WBC-1.3*# RBC-2.77* HGB-8.8* HCT-23.9* MCV-86
MCH-31.7 MCHC-36.7* RDW-14.5
[**2163-2-18**] 09:45PM NEUTS-0 BANDS-0 LYMPHS-90* MONOS-1* EOS-0
BASOS-0 ATYPS-5* METAS-0 MYELOS-0 OTHER-4*
[**2163-2-18**] 09:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
TEARDROP-OCCASIONAL ENVELOP-1+
[**2163-2-18**] 09:45PM PLT COUNT-40*
[**2163-2-18**] 09:45PM PT-15.7* PTT-34.8 INR(PT)-1.4*
[**2163-2-17**] 01:11PM HCT-27.5*
[**2163-2-17**] 01:11PM PLT COUNT-50*
Brief Hospital Course:
48 yo M with HIV, Burkitt's lymphoma s/p chemo, XRT who
presented with neutropenic fever. On [**2-28**] the patient was made
"comfort measures only" and died on [**3-1**].
.
During this hospitalization he had neutropenic fevers and was
treated with vancomycin and cefepime. He had CNS involvement
from his Burkitt's lymphoma and had brain XRT and intrathecal
chemotherpay [**12/2162**] and signficant pain from neuropathy. He
slowly became less responsive and focus of his care was changed
to comfort and he was placed on a morphine drip. He died of
cardiopulmonary arrest with his family at his bedside.
Medications on Admission:
MEDICATIONS: (per d/c summary [**2-17**])
Acetaminophen prn
Heparin 5000 units SQ tid
Docusate 100 mg [**Hospital1 **]
Senna 1 tab qhs
Acyclovir 400 mg po q12h
Lorazepam 0.5 mg po q6h prn
Mirtazapine 15 mg qhs
Ranitidine HCl 150 mg [**Hospital1 **]
Efavirenz 600 mg po daily
Emtricitabine-Tenofovir 200-300 mg tab daily
Calcium Carbonate 500 mg po qid
Zolpidem 5 mg Tablet qhs prn
Fentanyl 25 mcg/hr Patch q72 hr
Pregabalin 300 mg [**Hospital1 **]
Prednisolone Acetate 1 % Drops 1 Drop Ophthalmic QID
Oxycontin 10 mg q12h
Oxycodone 5 mg 0.5-1 Tablet PO q4-6 h prn
Levofloxacin 500 mg po daily (to be continued indefinitely)
Filgrastim 300 mcg/mL Solution Sig 1 Injection Q24H: continue
until ANC is greater than 1000 for two consecutive days.
Duloxetine 30 mg po daily
Dulcolax daily prn
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
deceased
Discharge Condition:
deceased
Discharge Instructions:
deceased
Followup Instructions:
deceased
|
[
"352.9",
"276.8",
"357.6",
"200.20",
"995.91",
"042",
"V09.0",
"E933.1",
"284.1",
"038.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.05",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
8174, 8183
|
6697, 7306
|
300, 306
|
8235, 8245
|
5377, 6674
|
8302, 8313
|
4483, 4588
|
8145, 8151
|
8204, 8214
|
7332, 8122
|
8269, 8279
|
4603, 5358
|
239, 262
|
334, 2363
|
3672, 4250
|
4267, 4467
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,505
| 190,114
|
5102
|
Discharge summary
|
report
|
Admission Date: [**2171-1-10**] Discharge Date: [**2171-1-25**]
Date of Birth: [**2112-11-2**] Sex: F
Service: MEDICINE
Allergies:
Ceftriaxone / Lisinopril / Pneumovax 23
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
Intubation on [**2171-1-10**] and [**2171-1-13**]
History of Present Illness:
58 y/o female with no significant PMH who was admitted to [**Hospital1 18**]
on [**1-10**] with flu like symptoms. In the [**Name (NI) **], pt was treated for a
presumed COPD flare but underwent respiratory decompensation at
that time eventually necessitating intubation for hypercarbic
respiratory failure. Her ABG in the ED was 7.29/47/145. Pt was
treated in the MICU with steroids and azithro. She was extubated
on [**1-13**] but after only 3.5 hours developed tachypnia and
tachycardia requiring reintubation. In further workup, pt's DFA
was negative for flu. A CTA showed severe emphysema and the pt
was continue on steroids and antibiotics. A sputum culture grew
strep pneumonia but the pt did not have an infiltrate on
imaging. On [**1-21**], the pt underwent controlled extubation in the
OR and has been stable from a respiratory standpoint since that
time. Pt failed her speech and swallow eval in the MICU and is
currently receiving tube feeds. On [**1-22**], the pt was called out
to the floor and is being transferred to the APG service at this
time.
Past Medical History:
1. Urinary incontinence
Social History:
Pt is married with two children. She works part time as a travel
[**Doctor Last Name 360**]. Pt has smoked 1 PPD for 40 years. Occasional ETOH. No
drugs.
Family History:
Positive family history of COPD.
Physical Exam:
98.3 99 132/61 18 96% 3L NC
FS: 153
Gen- Resting in bed in NAD. Able to speak in full sentences.
Cardiac- RRR. No m,r,g.
Pulm- Rare end exipiratory wheezes.
Abdomen- Soft. NT. ND. Positive bowel sounds.
Extremities- No c/c/e.
Skin- Diffuse macular, erythematous rash worse on buttock, back,
and legs.
Pertinent Results:
[**2171-1-10**] 04:20PM BLOOD WBC-6.1 RBC-4.48 Hgb-14.0 Hct-43.1 MCV-96
MCH-31.3 MCHC-32.6 RDW-13.3 Plt Ct-278
[**2171-1-10**] 04:20PM BLOOD Neuts-71.2* Lymphs-17.8* Monos-9.8
Eos-0.4 Baso-0.9
[**2171-1-10**] 04:20PM BLOOD Plt Ct-278
[**2171-1-10**] 05:37PM BLOOD PT-12.0 PTT-32.4 INR(PT)-0.9
[**2171-1-10**] 04:20PM BLOOD Glucose-112* UreaN-9 Creat-0.7 Na-142
K-3.9 Cl-101 HCO3-30* AnGap-15
[**2171-1-10**] 04:20PM BLOOD CK(CPK)-332*
[**2171-1-10**] 04:20PM BLOOD CK-MB-16* MB Indx-4.8
[**2171-1-10**] 04:20PM BLOOD cTropnT-<0.01
[**2171-1-11**] 03:04AM BLOOD Calcium-8.3* Phos-2.7 Mg-1.7
[**2171-1-25**] 05:59AM BLOOD WBC-11.0 RBC-3.47* Hgb-11.3* Hct-32.8*
MCV-94 MCH-32.6* MCHC-34.6 RDW-14.0 Plt Ct-426
[**2171-1-24**] 04:17AM BLOOD Neuts-72.5* Lymphs-18.3 Monos-5.0 Eos-4.0
Baso-0.2
[**2171-1-25**] 05:59AM BLOOD Plt Ct-426
[**2171-1-25**] 05:59AM BLOOD Glucose-86 UreaN-23* Creat-0.7 Na-142
K-3.9 Cl-100 HCO3-34* AnGap-12
[**2171-1-25**] 05:59AM BLOOD Calcium-9.6 Phos-4.2 Mg-1.9
CT 100CC NON IONIC CONTRAST ([**2171-1-10**]):
REPORT. A good quality CT pulmonary angiogram was obtained. The
CT pulmonary angiogram is negative for pulmonary embolism. There
is mild prominence of the aortic wall on contrast examination
possibly due to anemia. No other evidence of aortic pathology is
seen. There is some mild calcification of the descending
thoracic aorta. The patient is intubated and the tip of the ET
tube is in good position approximately 4.5 cm above the carina.
A prominent pericardial recess is seen. A few small pretracheal
lymph nodes and hilar lymph nodes are seen. The largest lymph
node identified is in the right hilum and measures 12 mm in
short axis. Probable small goitre is seen.
There is profound centrilobular and panacinar emphysema present,
particularly in the upper zones, typical of cigarette smoking.
Some small paraseptal change is also identified, particularly
peripherally. Some minor bibasilar atelectasis is identified,
but there is no other pulmonary parenchymal abnormality seen.
The visualized portions of the bones appear normal.
CONCLUSION:
1. Profound emphysematous change.
2. Patient intubated.
3. No evidence of pulmonary embolism.
4. Probable mild goiter.
Cardiology Report ECG Study Date of [**2171-1-10**]:
Sinus tachycardia
Significant baseline artifact precludes accute assessment of ST
segment
Nondiagnostic inferolateral ST-T wave changes
Probably no significant change but suggest follow-up tracing
CHEST (PORTABLE AP) ([**2171-1-23**]):
FINDINGS: A single frontal view of the chest is centered over
the mid abdomen. A central venous line overlies the mid SVC. The
NG tube courses well below the diaphragm, although the tip is
not visible for technical reasons. The heart size and
mediastinal contours are stable. The imaged portions of the
lungs appear grossly clear.
IMPRESSION: NG below the diaphragm, tip not visible.
VIDEO OROPHARYNGEAL SWALLOW ([**2171-1-24**]):
VIDEO OROPHARYNGEAL SWALLOW: Fluoroscopic guidance was provided
for the speech pathologist, who administered barium solid and
liquids of various consistencies to the patient.
There is mild impairment of bolus formation, bolus control and
AP tongue movement, with premature spilling of thin liquids.
There is also consistent penetration and occasional aspiration
of thin liquids. Cough was spontaneous, but only partially
effective. Reduced base of tongue retraction resulted in residue
in the valleculae during the entire examination, for all
consistencies. This was reduced when the patient took a one sip
or swallow at a time, swallowed, cough, and swallowed again.
IMPRESSION:
Mild-to-moderate oropharyngeal dysphasia, with aspiration of
thin liquids, and residue in the valleculae for all
consistencies. For more details, please refer to the speech
pathology report of the same date.
Cardiology Report ECHO Study Date of [**2171-1-24**]:
Findings:
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No ASD by 2D or color Doppler.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
systolic function (LVEF>55%). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic root diameter. Normal ascending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Normal PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
PERICARDIUM: No pericardial effusion.
Conclusions:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. There is no
aortic valve stenosis. The mitral valve appears structurally
normal with trivial mitral regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal study.
Brief Hospital Course:
58 y/o female transferred to APG after a prolonged hospital
course for a COPD exacerbation requiring intubation x2. Now much
more stable from a pulmonary standpoint.
1. Respiratory failure- Pt's respiratory failure appears to have
been due to a COPD exacerbation. DFA was negative for flu. No
evidence of a pneumonia. It is very concerning that a lady this
young has such severe emphysema although she does have a long
smoking history. Consider further testing to evaluate as an
outpatient such as an alph-1-antitrypsin. For now, will slowly
taper prednisone over the next week. Continue scheduled inhalers
and PRN nebs. Monitor oxygen status closely and wean oxygen for
saturation equal to or greater than 93%.
2. Type 2 diabetes mellitus- Pt has been newly diagnosed with DM
since admission. Had planned to involve [**Last Name (un) **] and do home
diabetic insulin teaching. However, pt adamently refuses to take
insulin at home. She understands that an insulin regimen would
result in better blood sugar control but refuses to do so.
[**Last Name (LF) **], [**First Name3 (LF) **] plan to DC to home on metformin with close PCP
follow up. For now, continue NPH and RISS. QID FS. [**Doctor First Name **] diet.
Continue low dose ACEi. Obtaining a baseline echo today. Pt will
need an othamology exam on discharge.
3. [**Name (NI) 20972**] Pt with severe, erythematous macular rash on her legs,
buttock, back, abdomen, and legs. Question if it is an allergic
reaction but unusual in appearance. Most likely offending
medicaion would have been an antiotic she received in the MICU.
Will get dermatology consult today. Sarna lotion for comfort at
this time.
4. [**Name (NI) 20973**] Pt failed her speech and swallow evaluation
following extubation. Receiving tube feeds at this time. Speech
and swallow will reevalute today. If she fails again, will place
a Dobhoff tube.
5. [**Name (NI) **] Continue pt on beta blocker and ACEi. Will
monitor closely and adjust medications as needed.
6. FEN- Tube feeds. NPO for now. Agressive electrolyte
replacement.
7. Proph- SC heparin; PPI; bowel regimen
8. Code- Full
9. [**Name (NI) 11053**] Pt currently refusing rehab placement. [**Month (only) 116**] have to go
home with services when medically stable if does not change her
mind.
Medications on Admission:
Medications on Transfer:
1. Albuterol 2 puff Q2H
2. Calcium carbonate 10 ml TID with meals
3. Fluticasone 110 mcg 2 puff [**Hospital1 **]
4. SC heparin TID
5. NPH insulin 14 units QAM and 7 units QPM plus RISS
6. Ipratropium bromide 2 puff Q4H
7. Lanosprazole 30 mg daily
8. Metoprolol 25 mg TID
9. Nicotine 21 mg daily
10. Nystatin cream [**Hospital1 **]
11. Prednisone 30 mg daily
12. Vitamin D 400 units daily
PRNs-
Tylenol
Albuterol nebs
Ipratropium nebs
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H PRN.
Disp:*1 MDI* Refills:*2*
2. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*0*
3. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
Disp:*1 MDI* Refills:*2*
5. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a
day).
Disp:*45 Tablet(s)* Refills:*2*
6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 MDI* Refills:*2*
7. Prednisone 10 mg Tablet Sig: Please see below for taper. mg
PO once a day for 6 days: 30 mg on [**1-26**]; 20 mg on [**1-17**];
10 mg on [**3-20**], and [**1-31**] then you are done with the
prednisone.
Disp:*10 tablets* Refills:*0*
8. Lancets Regular Misc Sig: One (1) lancet Miscell. per
fingerstick as needed: Please use for insulin injections.
Disp:*1 box* Refills:*4*
9. blood glucose test strips
Sig: 1 test strip as needed for each fingerstick
Dispense: 1 box (30 day supply)
Refills: 2
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary diagnosis:
COPD exacerbation
Secondary diagnosis:
Type 2 diabetes mellitys
Dysphagia
Discharge Condition:
Stable. Pt was able to ambulate on the day of discharge with an
oxygen saturation of 94% on room air.
Discharge Instructions:
1. Please keep all follow up appointments.
2. Please take all medications as prescribed.
3. Seek medical attention for fevers, chills, chest pain,
shortness of breath, or other concerns.
4. Please check you blood sugar at least once a day at various
times and record the values. Take this information to your next
appointment with your primary care physician.
5. Please follow all instructions from the speech and swallow
recommendations when eating. A copy of these is included with
your discharge paperwork.
6. While you were in the hospital, it was found that you are
allergic to ceftriaxone. This is in the class of medicines
called cephalosporins. Please let future physicians know this
information. It will be noted in your chart.
Followup Instructions:
1. Please follow up with Dr. [**Last Name (STitle) 20974**] (covering for your
primary care physician) on Tuesday [**1-29**] at 8:30 AM. You then
have an appointment to see your primary care physician [**Last Name (NamePattern4) **].
[**Last Name (STitle) 20975**] on Friday [**3-1**] at 1:30 PM.
2. Please follow up in pulmonary clinic on Friday [**2-15**] at
8:30 AM with Dr. [**Last Name (STitle) **]. His office is located on the [**Location (un) 436**]
of the [**Location (un) 8661**] Clinical Center. Please obtain a referral from
your primary care physician prior to this appointment.
3. You need to have a repeat speech and swallow evaluation in
two to four weeks. If you wish to have it done at [**Hospital1 18**], please
call [**Telephone/Fax (1) 3731**] to schedule an appointment. You could also
have it done at [**Hospital 1474**] hospital or another facility of your
choice. Please call as soon as possible to the facility of your
choice to schedule the appointment.
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
|
[
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"787.2",
"250.00",
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"518.81",
"523.9",
"599.7",
"V15.82",
"486",
"491.21",
"E930.8",
"525.8",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.6",
"31.42",
"96.71",
"96.04",
"38.91",
"96.72",
"97.39"
] |
icd9pcs
|
[
[
[]
]
] |
11319, 11374
|
7300, 9587
|
320, 372
|
11512, 11615
|
2068, 7277
|
12405, 13485
|
1698, 1732
|
10096, 11296
|
11395, 11395
|
9613, 9613
|
11639, 12382
|
1747, 2049
|
260, 282
|
400, 1464
|
11454, 11491
|
11414, 11433
|
9638, 10073
|
1486, 1511
|
1527, 1682
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,982
| 151,966
|
3190
|
Discharge summary
|
report
|
Admission Date: [**2135-6-18**] Discharge Date: [**2135-7-4**]
Date of Birth: [**2069-8-5**] Sex: F
Service: [**Last Name (un) **]
ADMISSION DIAGNOSIS:
1. Small bowel obstruction.
2. Recurrent C. Diff colitis.
3. COPD.
4. Diastolic congestive heart failure.
5. History of pulmonary embolism ([**2134**]).
6. Noninsulin dependent diabetes mellitus.
7. History of cerebrovascular accident.
8. History of pneumonia.
9. Obstructive sleep apnea.
10. Seizure disorder.
11. Hypertension.
12. Hypercholesterolemia.
13. Depression.
14. History of pancreatic mass.
15. Status post exploratory laparotomy/lysis of
adhesions/ventral hernia repair ([**2135-4-23**]).
16. Total abdominal hysterectomy.
17. Right rotator cuff repair.
18. Placement of J-tube and removal.
19. Status post laminectomy.
20. Status post inferior vena cava filter.
DISCHARGE DIAGNOSIS:
1. Jejunal closed loop obstruction - status post exploratory
laparotomy with lysis of adhesions.
2. Malnutrition.
3. Acute renal insufficiency.
4. Urinary tract infection (Klebsiella)
5. Postoperative iliaus.
6. Remainder of discharge diagnosis as above.
ADMISSION HISTORY AND PHYSICAL: Mrs. [**Known firstname 14980**] [**Known lastname **] is a 65-
year-old female with an extensive past medical history as
noted above who in [**2135-4-11**] underwent exploratory
laparotomy with lysis of adhesions and a ventral hernia
repair which was complicated postoperatively by hematoma
though the patient was eventually stabilized and subsequently
discharged to rehabilitation where she had been prior to
presenting on [**2135-6-18**] with complaints of persistent abdominal
pain, nausea, distension and fever of 101 with notably over
two liters of nasogastric output when the nasogastric tube
was placed at the rehabilitation facility. When she was
initially seen in the emergency department at [**Hospital1 346**] she was febrile to a temperature of
101.8, tachycardiac at 115, pressure 127/79, respiratory rate
was 26, she is sating 96% on room air. On gross examination
she had a baseline right sided upper and lower extremity
tremor, was otherwise alert and oriented, somewhat
diaphoretic. Her sclera were anicteric. She had no cervical
adenopathy. Cardiac examination was notable for a
tachycardia which was a regular rhythm, otherwise her lungs
were clear bilaterally. Her abdomen was slightly distended
with mild pain in the left mid to low abdomen with pressure
but no calf tenderness otherwise, she had no peripheral edema
and rectal examination was guaiac negative. In terms of
admission labs and imaging studies. The patient's admission
white count was 10.8 with and admission BUN and creatinine of
35 and 2.6. Her admission KUB showed no evidence of free
air. CT scan showed only pass of oral contrast to the distal
duodenum where there was an abrupt cut off consistent with a
closed loop obstruction.
HOSPITAL COURSE: The patient was admitted to the intensive
care unit and aggressively hydrated for her acute renal
failure. Given her obstruction it was felt that the patient
needed surgery but the patient during the initial course of
the admission refused any sort of operative procedure and was
therefore monitored with close serial abdominal exams. She
was monitored closely with serial abdominal exams and
otherwise treated with antibiotics, nasogastric suction and
aggressive hydration. By hospital two, after extensive
discussion with the patient and family the patient agreed to
undergo surgery for this closed loop obstruction
intraoperatively. The patient underwent an exploratory
laparotomy intraoperatively and extensive lysis of adhesions
was performed and closed loop obstruction was taken down.
The patient tolerated the procedure and there was no
excessive intraoperative blood loss. She remained intubated
postoperatively and was taken to the Intensive care unit.
In terms of her hospital course from a neurologic standpoint,
the patient essentially had no issues and had excellent pain
control with narcotics. She had no recurrence of her prior
history of seizures and Carbezepine was restarted prior to
discharge.
From a respiratory standpoint the patient was initially in
the intensive care unit for respiratory support while she
remained intubated. She was extubated by postop day two and
essentially did fairly well with minimal supplemental O2 and
p.o. Prednisone for chronic obstructive pulmonary disease was
restarted. Her O2 requirement decreased.
From a cardiac standpoint the patient also did fairly well.
There was no evidence of acute cardiac event during the
course of her hospitalization. She did have mild episodes of
congestive failure which were treated with aggressive
diuresis. Otherwise her blood pressure was controlled with
beta-blockade with Lopressor and by the time she was ready
for discharge her Diovan had been restarted along with her
Clonidine.
From a gastrointestinal perspective, as noted the patient was
NPO for sometime postoperatively and upon initial attempts at
restarting her diet the patient did not tolerate this. Was
felt to have somewhat of a postoperative ileus but this had
resolved by five days prior to discharge at which time the
patient was tolerating a regular diet and otherwise having
bowel movements and passing flatus.
From a fluid standpoint the patient was notably volume
overloaded initially during her early postoperative course,
during the resuscitation phase and subsequently with fluid
shifts intravenous Lasix was needed to diurese her
appropriately. Prior to discharge she had been diuresed
close to her baseline level by looking at daily weights. The
patient's nutrition status of utmost concern given her
prolonged stay at the rehabilitation facility and prolonged
delay of nutrition in the postoperative period. Therefore,
she was started on total parenteral nutrition in the
perioperative and postoperative period. We were able to wean
the total parenteral nutrition on the day prior to discharge
to rehabilitation as the patient had excellent oral intake
with regular diet with nutritional supplementation. From a
renal standpoint the patient initially came in with acute
renal dysfunction with a BUN and creatinine of 35 and 2.6.
Her creatinine went as high as 2.7 but with aggressive
hydration and maintenance of hematocrit around 30 the
patient's renal dysfunction resolved and her creatinine
returned down to 1.0 during the late course of her
hospitalization. During the final days of her
hospitalization we began to see a slight increase in her
creatinine up to a maximum of 1.5, it was felt that this was
secondary to a slight bit of dehydration along with possible
side effects of the antibiotics that she had been on which
were discontinued and prior to discharge her BUN and
creatinine were trending down and otherwise she had excellent
urine output.
From a hematologic standpoint, the patient did require
occasional transfusions of packed red blood cells in the
perioperative period in order to maintain hematocrit of at or
near 30 but her hematocrit had been stable for over 7 days
prior to discharge. In terms of patient's ID issues, her
blood cultures remained negative throughout her
hospitalization but notably she had significant urinary tract
infection with Klebsiella pneumonia which was essentially pan
resistant to most antibiotics except for Meropenum,
Nitrofurantoin and Zosyn. After discussion with the
Infectious Disease Services felt that this should be
untreated for a short course for which the patient was placed
on Zosyn for eight days. This subsequent surveillance
urinalysis did not evidence any urinary tract infection. As
noted surveillance blood cultures did not evidence any sort
of infection and the patient's empiric Levofloxacin and
Flagyl were discontinued during the mid-point of her
hospitalization. Otherwise there was no evidence of any
pneumonia during the course of the patient's hospitalization
and the wound did not evidence any infection.
As noted above on the gastrointestinal section, the final
week of the patient's hospitalization was essentially around
nutritional support and resolution of disposition issues with
physical therapy. It is felt that as these issues had
resolved, the patient was up ambulating with physical
therapy, otherwise is eating an excellent diet and had
excellent control with p.o. pain medication that she could be
discharged to rehabilitation in fair condition.
Prior to discharge her white count was 11.8, this had been
trending down. Hematocrit was stable at 34 otherwise.
Platelet count was 661. Urinalysis did not evidence any
infection. BUN and creatinine were 37 and 1.4. This was
also trending down .
MEDICATIONS:
1. Albuterol 90 mcg inhaler one to two puffs every 4 hours as
needed.
2. Imitropium 18 mcg inhaler two puffs every four to six
hours as needed.
3. Protonix 40 mg p.o. q day.
4. Prednisone 2.5 mg p.o. q day.
5. Chronic obstructive pulmonary disease.
6. Percocet 5/325 take one tablet very 4 to 6 hours as needed
for pain.
7. Lopressor 100 mg p.o. twice a day.
8. Clonidine 0.2 mg p.o. twice a day.
9. Valsartan 80 mg p.o. q day.
10. Insulin sliding scale.
11. Oxcarbazepine 600 mg p.o. twice a day.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 14981**]
Dictated By:[**Doctor Last Name 3763**]
MEDQUIST36
D: [**2135-7-4**] 09:44:37
T: [**2135-7-4**] 11:48:15
Job#: [**Job Number 14982**]
|
[
"560.1",
"263.9",
"041.3",
"584.9",
"560.81",
"E878.6",
"599.0",
"997.4",
"276.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15",
"89.64",
"54.4",
"99.04",
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] |
icd9pcs
|
[
[
[]
]
] |
930, 2955
|
2973, 9552
|
173, 909
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,865
| 100,215
|
36907
|
Discharge summary
|
report
|
Admission Date: [**2193-5-3**] Discharge Date: [**2193-5-15**]
Date of Birth: [**2145-4-30**] Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending:[**First Name3 (LF) 898**]
Chief Complaint:
Seizure and fever
Major Surgical or Invasive Procedure:
Intubation
Right internal jugular central venous line
Arterial Line
History of Present Illness:
This is a 48 year old male with mental retardation, history of
seizure disorder (unknown etiology, absence type, last [**12-6**]) who
came to medical attention after having a generalized seizure at
his group home. After his seizure he was taken to OSH, where
VS 103.4, HR 119, BP 68/32 resolving to 102/67 without
intervention, RR 24, O2 Sat 94% on 1.5 L nasal cannula. He was
lethargic with diffuse "maculopapular blanching" rash. He was
also noted to be in acute kidney injury with Cr 2.1 with a WBC
count of 8.3 (with 20% bands). INR was 3.6 (pt on chronic
warfarin for history of DVT *2) and UA, CXR, and CT head were
without acute process. He received ceftriaxone 2gm, gentamicin
120mg, and fosphenytoin 1000 mg. As he had what appeared
consistent with a drug rash and was recently started on
treatment for cellulitis with TMP/Sulf he was also presumptively
treated for anyphylactic shock with IM epineprhine, IVF,
methylprednisolone, diphenhydramine, and famotidine. He was
then started on dopamine gtt and transferred to [**Hospital1 18**] for
further management.
Upon arrival to [**Hospital1 18**], VS: T 98.9, P 112, BP 126/44, RR 21, O2
92% on 100% non-rebreather mask. He was quickly weaned off
dopamine. At that point exam was notable for
delirium/agitation, diffuse erythematous macular rash, edema,
and oral mucosal irritation on the tongue and hard palate with
conjunctival injection. He received 2-3L LR for hypotension
with CVP in ~14-17 range. Because he was persistently agitated
he received 2mg lorazepam and 2 mg haloperidol with resulting
sedation then progressive hypoxia requiring intubation.
REVIEW OF SYSTEMS: Unobtainable as patient initially
unresponsive and then without enough mental status to report.
His mother denied any changes in bowel or bladder habits, known
fevers or chills prior to the day of presentation, complaints of
chest pain, labored breathing, or other complaints.
Past Medical History:
-Seizure Disorder (last seizure [**12-6**])
-Deep Vein Thromboses *2 without history of pulmonary embolism
-Lower extremity cellulitis (started on TMP-Sulfa [**Date range (1) 83313**])
-Mental Retardation
-Obsessive Compulsive Disorder
-Hypothyroidism
-Urosepsis with hospitalization at [**Hospital3 **] in [**2191**].
Social History:
He lives at a group home. No known smoking, alcohol, drugs.
Family History:
Non-contributory
Physical Exam:
Vitals: T 98.9, P 112, BP 126/44, RR 21, O2 Sat 92%NRB -> 88%RA.
General: agitated, delerious, non-communicative.
HEENT: oropharynx with dark, ?ulceration on hard palate, trauma
over toungue.
Neck: supple, no LAD
Lungs: roncherous bilaterally (airway sounds) anteriorly.
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses.
Skin: diffuse, confluent, erythematous macules over arms, legs,
abdomen, lower extremities, sparing palms, and soles.
+blanching.
Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-9.8 RBC-4.05* Hgb-11.8* Hct-36.3* MCV-90 RDW-14.3 Plt
Ct-146*
---Neuts-93.0* Lymphs-4.1 Monos-2.6 Eos-0.3 Baso-0.1
PT-47.3* PTT-38.8* INR(PT)-5.3*
Na 143, K 4.5, Cl 110*, HCO3 22, BUN 16, Cr 1.5*, Glu 196*
ALT-34 AST-38 LD(LDH)-245 CK(CPK)-1116* AlkPhos-102 TotBili-0.5
Albumin-3.2* Calcium-6.9* Phos-3.7 Mg-1.2* UricAcd-9.0*
Serum Tox: ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG Color-Yellow
Appear-Clear Sp [**Last Name (un) **]-1.007 Eos-NEGATIVE
--Tox bnzodzp-POS barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
On Discharge:
WBC 5.2, Hb 11.1, Hct 32.5, Plt 459*
PT 45.1, PTT 42, INR 4.8
na 144, K 3.7, Cl 108, HCO3 30, BUN 7, Cr 0.5, Glu 95
Ca 9.2, Mg 2.3, P 3.5
Other Studies:
CEREBROSPINAL FLUID (CSF) WBC-13 RBC-373* Polys-7 Lymphs-57
Monos-0 Macroph-36 TotProt-97* Glucose-74 (HSV PCR Negative for
HSV 1 and 2)
MICROBIOLOGY
=============
All cultures no growth to date
OTHER RESULTS
==============
ECG [**2193-5-3**]:
Sinus tachycardia. RSR' pattern in lead V1. Reverse anterior R
wave
progression. Clinical correlation is suggested. Non-specific T
wave changes.
Chest Radiograph [**2193-5-3**]:
FINDINGS: Lung volumes are low and there is elevation of the
right
hemidiaphragm. There are bilateral infiltrates throughout both
lungs central greater than peripheral, it is difficult to assess
the cardiac and mediastinal silhouettes secondary to the low
lung volumes and overlying infiltrates. There is a left
subclavian line with tip in the SVC.
EEG [**2193-5-7**]:
IMPRESSION: This is an abnormal portable EEG due to the slow and
disorganized background. This abnormality is suggestive of a
widespread
encephalopathy of medication, metabolic disturbance, or
infection
etiology. Of note is the sinus tachycardia. There were no
lateralized
or epileptiform features seen.
Chest Radiograph [**2193-5-10**]:
IMPRESSION: AP chest compared to [**5-8**]:
Consolidation in the perihilar right lung and infrahilar left
lung has
improved consistent with resolving pneumonia. There is no good
evidence for
edema. Heart size is top normal, mediastinal vasculature hard to
assess,
pulmonary vessels are minimally engorged. No pneumothorax or
pleural effusion.
Trasnthoracic Echocardiogram [**2193-5-14**]:
Conclusions
The left atrium is normal in size. The interatrial septum is not
well visualized (suboptimal views). Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). The right
ventricular cavity is borderline dilated with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve leaflets are mildly thickened. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
Brief Hospital Course:
48 year old male with past medical history of mental
retardation, seizure disorder and DVT* 2 who presented with a
seizure and mental status changes and was found to have seizure.
1)Meningitis: The patient presented with a seizure, a fever to
103.4, and altered mental status. He was unable to answer
questions about localizing symptoms. Meningitis was initially
suspected due to skin rash, though this was more maculopapular
than petechial in nature. On the first day of his
hospitalization he received vancomycin/ceftriaxone/and
acyclovir, which would be appropriate empiric treatment of a
non-specified meningitis/encephalitis. Unfortunately, due to
difficulties with obtaining an LP, this was not performed until
hospital day three and showed pleiocytosis and increased protein
but was ultimately culture negative. Ultimately, this was
thought most consistent with partially treated bacterial
meningitis. Therefore, the patient was treated with
vancomycin/ceftriaxone with resolution of his fevers and
improvement of his mental status to baseline without further
seizures. Acyclovir was stopped when HSV PCR returned negative.
The patient will ultimately need to complete fourteen days of
antibiotic therapy for meningitis.
2) Seizure: The patient has a previous history of seizures and
has been on phenytoin. His previous seizures have not been
grand mal, but this appears to have been the type that occurred
on the day of presentation. The likely precipitant of this
seizure was the patient's infection and fever, though phenytoin
level was also a bit low. Initially, he was maintained on IV
phenytoin then fospheynytoin but then transitioned back to his
outpatient PO regimen as mental status resolved. He never
showed signs of further seizure activity and EEG obtained to
rule out further seizure activity was not consistent with
persistent epileptiform activity.
3) ? Allergic Reaction/Respiratory Failure: The patient had a
presentation of rash, hypotension, and per report swelling of
the throat and tongue. This could be consistent with acute
allergic reaction and the TMP/Sulfa he had been given for
cellulitis is certainly a potential causative [**Doctor Last Name 360**]. Still, it
seems unlikely he would react suddenly and this remarkably to
TMP/Sulfa after he had been receiving it for a full day.
Nevertheless, he was treated appropriately for an anaphylactic
reaction with epinephrine, histamine blocker, and steroids and
recovered.
4) Respiratory failure: As stated before it is difficult to tell
if the patient actually had anaphylactic shock leading to airway
compromise and respiratory failure. Other possible etiologies
would include pulmonary edema given need for vigorous fluid
resuscitation soon after presentation and oversedation in the
emergency departments. Ultimately, the patient was weaned off
supplementary oxygen without event.
5) Altered mental status: Per the patient's mother at baseline
he has the mental status of a small child with minimal verbal
communication skills but he follows commands and interacts
appropriately. The patient was initially extremely somonolent
and then minimally responsive raising concern for non-convulsive
status epilepticus. EEG was more consistent with
encephalopathy, however, and the patient's mental status
eventually resolved to baseline with treatment of his underlying
condition and maximization of other variables. Likely this was
due to toxic-metabolic delirium in the context of severe
infection.
6) History of DVT: The patient has a history of two DVT's and
thus is presumably on lifelong anticoagulation. His INR was
initially supratherapeutic so further anticoagulation was held
then he was transitioned to low molecular weight heparin for
systemic anticoagulation while he was NPO. Once he was eating,
warfarin was restarted and LMWH was stopped after 24 hours of
therapeutic INR on coumadin.
7) Non sustained ventricular tachycardia: On the morning of
[**2193-5-13**] the patient had two brief runs of NSVT that broke
without further management. This was discussed with EP who
thought barring signs of structural heart disease that this
likely had no prognostic significance and was likely simply a
response to acute illness. The patient had an echocardiogram
that was within normal limits and he had no further episodes of
VT. Of note this also happened while he was being phenytoin
loaded, which may have contributed to arrythmia.
8) FEN: The patient initially required tube feeds due to altered
mental status and lack of inclination to eat. He self
discontinued his dobhoff unfortunately and due to a desire to
spare another invasive process if possible he was observed and
thankfully had cleared enough to tolerate PO in around forty
eight hours. After that he tolerated a full diet with out
incident.
He tolerated a full diet prior to discharge. All vital signs
were stable and he was afebrile>72 hours. The patient was full
code.
Medications on Admission:
- atenolol 25mg po qdaily
- neurontin 600mg po tid
- risperdal 0.5mg po qdaily + qhs
- ativan prn
- dilantin 200mg po bid
- levothyroxine 250 mcg po qdaily
- warfarin 4.5 mg po qdaily
- buspirone 30 mg po qdaily
- ranitidine 150mg po qdaily
- sertraline 250-mg po qdaily
- clonidine 0.1mg po bid
- tylenol
- keopectate
- peridex oral rinse
- robitussin
- mvi
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Neurontin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO twice a day:
once daily and once QHS.
4. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for anxiety.
5. Phenytoin 100 mg/4 mL Suspension Sig: Two Hundred (200) mg PO
twice a day.
6. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO once a
day.
7. Buspirone 30 mg Tablet Sig: One (1) Tablet PO once a day.
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. Sertraline 100 mg Tablet Sig: 2.5 Tablets PO once a day.
10. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Ceftriaxone in Dextrose,Iso-os 2 gram/50 mL Piggyback Sig:
Two (2) gm Intravenous Q12H (every 12 hours) for 2 days:
Continue two more days after discharge. through [**2193-5-17**].
12. Vancomycin 1,000 mg Recon Soln Sig: 1000 (1000) mg
Intravenous every eight (8) hours for 2 days: Continue for two
more days after discharge. Through [**2193-5-17**].
13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for temp>101 or pain.
14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: hold for loose stools.
15. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
16. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Please start on [**2193-5-16**]. Please note that the patient's
previous home dose was 4.5 mg daily. His dose is decreased for
INR [**1-1**] for prophylaxis of DVT.
18. Outpatient Lab Work
coumadin PRN to goal INR is [**1-1**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital
Discharge Diagnosis:
Primary Diagnoses
-Meningitis
-Seizure disorder
-History of DVT
-Acute Kidney Injury
Secondary Diagnoses:
-Hypothyroidism
Discharge Condition:
Good, mentating at baseline, afebrile
Discharge Instructions:
You were admitted because you had an infection that precipitated
a seizure. We treated you for this infection with antibiotics
and you improved.
Your medications have have been changed. You will have to
continue your antibiotics for 2 more days after discharge (for a
total of 14 days of therapy). Otherwise your medications have
not been changed.
Please see your doctor or come in to your local emergency
department if you have fevers, chills, night sweats, chest pain,
shortness of breath, inability to tolerate food or drink, or any
other concerning changes in your health.
Followup Instructions:
You are being discharged to a facility to complete your
recovery. After you are discharged you should schedule follow
up appointments with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] as well as your
neurologist and other providers.
|
[
"375.15",
"300.3",
"682.6",
"276.3",
"244.9",
"284.1",
"584.5",
"V58.61",
"785.52",
"693.0",
"286.9",
"518.81",
"758.0",
"047.9",
"293.0",
"345.90",
"995.0",
"995.92",
"372.73",
"E944.4",
"707.15",
"038.9",
"319",
"V12.51",
"783.40",
"427.89",
"E931.0",
"737.30"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31",
"96.71",
"96.6",
"38.91",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13746, 13820
|
6547, 9445
|
284, 353
|
13987, 14027
|
3412, 4128
|
14657, 14917
|
2746, 2764
|
11916, 13723
|
13841, 13927
|
11533, 11893
|
14051, 14634
|
2779, 3393
|
13948, 13966
|
4142, 6524
|
2032, 2310
|
227, 246
|
381, 2013
|
9460, 11507
|
2332, 2653
|
2669, 2730
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,285
| 189,873
|
14012
|
Discharge summary
|
report
|
Admission Date: [**2195-9-14**] Discharge Date: [**2195-9-25**]
Service: CARDIOTHORACIC
Allergies:
Cortisone
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
3 vessel CAD
Major Surgical or Invasive Procedure:
CABG x 3(SVG->LAD, SVG->RCA, SVG->OM)
History of Present Illness:
84 year old female w/ CAD, PAF, CRI, and labile hypertension
admitted for catheterization on [**2195-9-14**].
Patient is s/p acute IMI in [**2195-4-5**] at which time she underwent
a cardiac cath which showed severe 3VD. LAD had 96% ostial
stenosis, with 60% mid-vessel stenosis, and diffuse disease of 2
main diagonal branches. LCx had 90% bifurcation stenosis, and
diffuse disease of the 2 main OM branches. Her RCA had 100%
mid-vessel stenosis with collaterals distally. She receievd 2
Cyphere DES in the proximal to mid RCA, with subsequent
angiography showing 10% residual stenosis. Over the next few
months, she had intermittent symptoms of angina and shortness of
breath. She underwent ETT-MIBI in [**2195-8-6**], which revealed
a reversible mild lateral wall defect. Her ETT was limited to 4
minutes due to SOB.
Since her stress test, she continued to have intermittent chest
pain, occuring at rest and exacerbated by lying on left side.
She also reports generalized fatigue, and shortness of breath
with mild exertion.
Past Medical History:
1) HTN
2) New AF as of last week: Incidentally discovered during
pre-op w/u for finger surgery, tachycardic. Treated with rate
control (diltiazem) and anticoagulation. Has since converted
back to SR. Coumadin being held at OSH in aniticipation of
cath.
3) Rheumatic fever
4) Diptheria as a child
5) Left inguinal hernia repair
6) CRI
7) Bladder polyps
8) Cataracts
9) Dementia
10) Glaucoma.
Social History:
Remote smoking history in [**2169**]. Very occasional alcohol use.
Lives alone. Two daughters who are her health care proxies.
Family History:
Mother with CAD, details unclear.
Physical Exam:
Gen: thin, elderly female, in NAD
HEENT:EOMI, O/P clear, MMM
Neck: soft & supple, no LAD, no JVD
Lungs: decreased bibas BS, crackles bil 1/3 up
CV: RRR, no m/r/g
Abd: soft, NT, ND. NABS
Ext: W&D, no edema. pulses dopplerable
Neuro: A&Ox3, grossly intact
Pertinent Results:
[**2195-9-14**] CREAT-1.8
[**2195-9-18**] Creat-1.7
[**2195-9-19**] Creat-2.0
[**2195-9-22**] Creat-1.9
[**2195-9-22**] INR(PT)-1.6
Brief Hospital Course:
The patient was admitted [**2195-9-14**] for cardiac catheterization,
which showed significant disease with progression of the left
main lesion - she had 60% stenosis of LMCA, LAD had 80% ostial
lesion then 70% mid-vessel stenosis, D1 with 60% origin, D2 with
50%, LCX with 70% in OM1, and RCA with 70% ostial lesion, with
patent stents distally. Given the progression of disease,
decision made to not intervene and refer for CABG. Of note, pt
quite hypertensive this morning upon arrival to cath lab. In
addition to being given all of her htn meds, she also was
started on a nitro gtt, which was continued through the
procedure. She had some CP, which resolved with control of her
BP. She was also pre-hydrated given her arrival creatinine of
1.8
Following cath, she was maintained on the nitro gtt for
hypertention and transferred to CCU from CMI service for
management of hypertensive urgency and chest pain.
Patient then underwent an uncomplicated CABG x 3
(SVG->LAD,SVG->RCA,SVG->OM) on [**2195-9-16**]. Please see OP report
for details. Post-operatively she remained in the CSRU for close
management.
She was extubated by post op day one, and transferred to the
step down unit by post op day 6. She did have some post op a fib
for which she was placed on amiodarone and coumadin. Her
creatinine remained at her baseline of 1.8-1.9. Her leg incision
continued to drain moderate amounts of serous fluid. She as
placed on levofloxacin for minimal erythema surrounding the Left
knee incision. She was ready for dischrge on post op day eight
and a rehab bed became available on post op day 9.
Medications on Admission:
MEDS (home): plavix 75 mg QD, aspirin 81 mg QD, metoprolol 50 mg
[**Hospital1 **], lisinopril 10mg QD, isosorbide 10 mg TID
.
MEDS (transfer): tylenol 650 mg PO Q4H:PRN, Lorazepam 0.5-1 mg
PO Q4-6H:PRN, Acetylcysteine 20% 600 mg PO BID, metoprolol 75 mg
PO TID, maalox 30 ml PO QID:PRN, Aspirin 325 mg PO,
Nitroglycerin 0.05 mcg/kg/min IV DRIP, plavix 75 mg PO DAILY,
potassium Sliding Scale, pravastatin 40 mg PO DAILY, isosorbide
dinitrate 10 mg PO TID, ambien 5 mg PO HS:PRN
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day:
Take 2 once a day for 7 days, then take only 1 once a day
ongoing.
6. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: &
check INR [**9-28**] and PRN.
Disp:*30 Tablet(s)* Refills:*0*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
Discharge Disposition:
Extended Care
Facility:
Highgate Manor
Discharge Diagnosis:
CAD s/p CABG x 3
CRI (creatine 1.9)
Atrial Fibrillation
HTN
Glaucoma
Discharge Condition:
good
Discharge Instructions:
Shower, wash incision with soap and water and pat dry, no baths.
No lotions, creams, or powder to incision.
Call with fever >101.5, redness or drainage from incision, or
weight gain >2 pounds in 1 day or 5 lbs in 1 week.
No heavy lifting >10 lbs.
No driving.
Followup Instructions:
Please follow-up with Dr [**Last Name (STitle) **] in 4 weeks, call to schedule an
appoinment.
Please follow-up with Dr [**Last Name (STitle) **] in 2 weeks, call for an appt.
Completed by:[**2195-9-25**]
|
[
"414.01",
"411.1",
"427.31",
"428.0",
"412",
"401.9",
"585.9",
"V58.61"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.13",
"37.22",
"88.55",
"88.52"
] |
icd9pcs
|
[
[
[]
]
] |
5519, 5560
|
2402, 4001
|
238, 278
|
5673, 5680
|
2246, 2379
|
5987, 6194
|
1920, 1955
|
4530, 5496
|
5581, 5652
|
4027, 4507
|
5704, 5964
|
1971, 2227
|
184, 200
|
306, 1338
|
1360, 1757
|
1773, 1904
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,594
| 134,171
|
15698
|
Discharge summary
|
report
|
Admission Date: [**2200-7-25**] Discharge Date: [**2200-7-29**]
Date of Birth: [**2169-1-6**] Sex: F
Service: MEDICINE CCU
HISTORY OF PRESENT ILLNESS: The patient is a 31-year-old
female with past medical history of pulmonary embolism and
pulmonary hypertension status post thromboendarterectomy at
UCSD three weeks ago, who had been started on Coumadin prior
to her discharge, who for the past week had been complaining
of increasing shortness of breath with exertion and at rest,
and substernal chest pain x1 week. The morning of admission
she had complained of orthopnea, no PND, so she went to the
Pulmonary Clinic, where Dr. [**First Name (STitle) **] had a CT of the chest
done, which showed that she had a pericardial effusion.
She was sent to the Emergency Room. An echocardiogram done
in the Emergency Room showed a 3-4 cm circumferential
pericardial effusion with right atrial and right ventricular
collapse. The patient was sent to the Catheterization
Laboratory for pericardial centesis after having been given a
unit of fresh-frozen plasma. No vitamin K was given
secondary to the patient's anticoagulation needs. 850 cc of
fluid were drained. The patient's hemodynamics and symptoms
improved.
REVIEW OF SYSTEMS: The patient had chest pain, dyspnea on
exertion, orthopnea, shortness of breath, presyncope, no PND,
no edema, no palpitations, or syncope.
PAST MEDICAL HISTORY:
1. She had a pulmonary embolus which was diagnosed in [**2199-9-17**] in the distal left main with extension to the upper
and lower bronchi and right main bronchi.
2. Pulmonary hypertension. She had been starting on Coumadin
in [**3-20**]. Status post thromboendarterectomy at UCSD.
4. Placental abruption.
5. Postpartum thyroiditis.
6. IVC filter in place.
MEDICATIONS ON ADMISSION:
1. Coumadin 10 mg [**Month (only) 766**], Wednesday, Friday, 15 mg Tuesdays,
Thursdays, Saturdays, Sundays.
2. Tylenol #3 prn.
3. Tylenol PM prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: She is married. She has no history of
tobacco use, social alcohol use.
FAMILY HISTORY: Her mother had a pulmonary embolus. Her
father had a DVT. She has an aunt with lupus.
EXAM ON ADMISSION: Vital signs in the Emergency Room: 97.2,
121/74, heart rate of 99, respiratory rate of 18, and sats
100% on room air. In general, she was alert and oriented
times three, a thin white female in no apparent distress.
HEENT: Pupils are equal, round, and reactive to light and
accommodation. Extraocular movements are intact. Mucous
membranes moist, oropharynx clear. Cardiovascular: Regular,
rate, and rhythm, normal S1, S2. She had a three-component
friction rub, no murmurs. She had jugular venous distention
to 9 cm. Respiratory: Clear to auscultation bilaterally.
Abdomen is soft, nontender, nondistended, bowel sounds
present. Extremities: No clubbing, cyanosis, or edema. Her
pulses were 2+ bilaterally. Groin: She had
postcatheterization left femoral A-V sheath.
LABORATORIES ON ADMISSION: White count was 10, hematocrit
was 33.7, platelets of 502. Her complete blood count within
normal limits. Her INR was 4.2. Her LFTs were within normal
limits. Hypercoagulable workup in the past had been
negative.
STUDIES IN THE EMERGENCY ROOM: CTA of the chest showed no
pulmonary embolus, large pericardial effusion. The last
echocardiogram in [**5-20**] showed an ejection fraction of 55%
with right ventricular hypertrophy.
The transthoracic echocardiogram on the day of admission
showed a 3-4 cm circumferential pericardial effusion with RA
and RV collapse, and respiratory variations consistent with
tamponade.
ELECTROCARDIOGRAM: Normal sinus rhythm, heart rate of 100,
it was normal voltage. She had T-wave inversions in V3 to V5
which were old and questionable pulsus alternans.
The patient was admitted to the CCU after having gone to the
Catheterization Laboratory, where they drained 850 cc of
bloody fluid.
HOSPITAL COURSE BY SYSTEMS: Cardiovascularly: The patient's
drain was left in place. The plan was not to discontinue the
drain until the output had fallen to almost 0, but with the
plan of restarting the Coumadin prior to pulling the drains
to make sure that no further accumulation of fluid would
happen. Her hematocrit after the drain was placed were
checked q3h until they stabilized. Even though the patient's
hematocrit dropped to 33 to 27, she was not transfused as she
was a healthy female with no coronary artery disease.
On the evening of admission, followup chest x-ray showed
pneumopericardium. Thoracic Surgery was consulted. They
felt that this was not significant. It was probably likely
due to having drain the pericardial effusion, and her
pericardium having been stiff from being expanded for so
long. Thus, no action was taken. She was hemodynamically
stable. Of note, the pericardial drain significant amounts
of fluid and air were drained from the patient and the
pneumopericardium had resolved as of the 9th.
The patient on the 9th, had drained 875 cc of fluid. Her
pain was being controlled.
Pulmonary wise: She was being weaned off oxygen. She had
been on 3 liters of oxygen prior to going to pericardial
drainage. Her Coumadin had been held as her INR was 4.0 on
admission. Echocardiogram done on the 9th showed an ejection
fraction of 55%.
On the 10th, the pericardial drain drained 150 cc. Her
Coumadin was restarted that evening and Heparin was started
as well as the patient's INR had become subtherapeutic. Her
pain was still being controlled.
On the 11th, the patient had a small nosebleed likely due to
the oxygen. She was given humidified air to breathe. Her
sats had remained stable throughout. The pericardial drain
was discontinued on the 11th as it had put out less than a
half a cc in 24 hours.
On the 12th, the patient had been stable overnight. Her INR
was 2.5, and her pain has been controlled. As she had no
other acute needs, she was discharged home.
DISCHARGE INSTRUCTIONS: If she experiences any chest pain,
felt short of breath, or increasing fatigue, to please [**Name6 (MD) 138**]
her M.D. or go to the Emergency Room. She is being
discharged on Coumadin 10 mg tablet to be taken every
evening. Her Coumadin level was currently therapeutic. She
needs to have her INR level checked by her PCP later that
week.
FINAL DIAGNOSES:
1. Pericardial effusion.
2. History of pulmonary embolism status post
thromboendarterectomy.
3. History of pulmonary hypertension.
4. Hypomagnesemia which was repleted.
RECOMMENDED FOLLOWUP: She was to followup with Dr. [**First Name (STitle) **]
on [**Last Name (LF) 766**], [**8-4**] at 1:45 pm. She was to have a
follow-up echocardiogram, [**First Name3 (LF) 766**], [**8-11**] at 11 am. She
was to followup with Dr. [**Last Name (STitle) 911**] on [**9-29**] at 11:30 am.
MAJOR SURGICAL OR INVASIVE PROCEDURES: Cardiac
catheterization, repair of pericardial effusion drainage.
DISCHARGE CONDITION: Stable.
POST-DISCHARGE MEDICATIONS:
1. Ibuprofen 600 mg take one q8h prn for seven days.
2. Coumadin 10 mg po q hs at bedtime. This would be dosed by
her primary care physician.
[**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **], M.D. [**MD Number(2) 2139**]
Dictated By:[**Name8 (MD) 8736**]
MEDQUIST36
D: [**2200-7-31**] 19:07
T: [**2200-8-3**] 09:53
JOB#: [**Job Number 45251**]
cc:[**Last Name (NamePattern4) 45252**]
|
[
"416.0",
"423.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0"
] |
icd9pcs
|
[
[
[]
]
] |
6964, 6978
|
2094, 2188
|
7001, 7445
|
1802, 1987
|
5994, 6337
|
3975, 5969
|
6354, 6942
|
1253, 1394
|
169, 1233
|
3015, 3946
|
1416, 1776
|
2004, 2077
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,909
| 175,314
|
9644
|
Discharge summary
|
report
|
Admission Date: [**2141-8-20**] Discharge Date: [**2141-9-1**]
Date of Birth: [**2072-1-5**] Sex: F
Service: SURGERY
Allergies:
Prednisone / Erythromycin / Sulfa (Sulfonamides) / Fosamax
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Colicky abdominal pain.
Major Surgical or Invasive Procedure:
Exploratory laparotomy, biopsy of mesenteric nodules x2,
resection of ischemic ileum and primary anastomosis, biopsy of
pancreatic mass.
History of Present Illness:
Ms. [**Known lastname 32636**] was transferred from [**Hospital3 7571**]to [**Hospital1 18**] on
[**2141-8-20**]. She has been having 2-3 weeks of abdominal pain after
eating. Her pain worsened the evening of [**2141-8-19**]. A CT scan
obtained at [**Hospital3 7571**]was concerning for ischemia small
bowel and a pancreatic mid body mass. The patient was
transferred to [**Hospital1 18**].
Past Medical History:
SVT
Hypercholesterolemia
Peptic ulcer disease
Atrial fibrillation
H/O XRT for bronchitis at age 2, now with chronic wound on back
Social History:
She denies alcohol abuse. She has a 30 pack year history of
smoking, but quit in [**2134**].
Family History:
Non-contributory
Physical Exam:
Temp 98.6 HR 113 BP 126/45 RR 15 O2 sat 97% on RA
Gen: obviously in pain
CV: regular rhythm, tachy
Pulm: clear bilaterally. Large open wound on mid back with
chronic XRT changes surrounding it. No infected.
Abd: diffuse abdominal tenderness, rigid with guarding and
rebound. Distended. No masses palpable.
Pertinent Results:
Pathology
DIAGNOSIS:
1. Mesenteric node (A):
Fibroadipose tissue with metastatic moderately differentiated
adenocarcinoma; see note #1. No definite lymph node seen.
2. Mesenteric nodule (B):
Fibroadipose tissue, no malignancy identified.
3. Proximal and mild ileum (C-L):
Small bowel with mucosal and transmural hemorrhagic infarction.
Margins are viable.
4. Distal ileum (M-O):
Small bowel with mucosal ischemia present at one of two margins.
5. Pancreatic mass biopsy (P):
Moderately differentiated adenocarcinoma; see note #2.
Note #1: There is no unequivocal carcinoma present on the
original frozen sections.
Note #2: The tumor and the metastasis represented in specimens 1
and 5 are positive for cytokeratin 7; negative stains include
CK20, ER, PR, mammoglobin, and GCDFP. These findings suggest
pancreaticobiliary origin. However, other primary sites cannot
be completely excluded.
Echocardiogram
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). There is a mild (20mmHg peak) resting
left ventricular outflow tract obstruction. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets appear structurally normal with good leaflet excursion.
There is no valvular aortic stenosis. The increased transaortic
gradient is likely related to high cardiac output. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
[**2141-8-20**] 08:50AM BLOOD WBC-28.1*# RBC-4.52 Hgb-14.6 Hct-42.4#
MCV-94 MCH-32.2* MCHC-34.3 RDW-13.7 Plt Ct-258
[**2141-8-31**] 05:30AM BLOOD WBC-14.2* RBC-2.80* Hgb-8.8* Hct-26.5*
MCV-95 MCH-31.5 MCHC-33.4 RDW-16.5* Plt Ct-343
[**2141-8-20**] 08:50AM BLOOD Glucose-242* UreaN-20 Creat-1.1 Na-141
K-4.2 Cl-106 HCO3-16* AnGap-23*
[**2141-8-31**] 05:30AM BLOOD Glucose-121* UreaN-29* Creat-0.6 Na-138
K-3.7 Cl-105 HCO3-26 AnGap-11
[**2141-8-20**] 08:41AM BLOOD Lactate-8.9*
[**2141-8-29**] 08:03PM BLOOD Lactate-1.1
Brief Hospital Course:
Ms. [**Known lastname 32636**] was transferred to [**Hospital1 18**] from [**Hospital3 7571**]hospital
after a CT obtained there was concerning for ischemic small
intestine. Her lactic acid was 8.9 on admission. After fluid
resusitation, she was immediately taken to the operating room
for an exploratory laparotomy where she was found to have
infarcted small bowel. This section of small bowel was resected
and a primary anastomosis was performed. Two mesenteric nodule
were biopsied as well as the pancreatic mid body mass.
Pathology ultimately revealed metastatic pancreatic carcinoma.
Neurological: She is alert and oriented and her mental status
appears to be back to baseline.
Cardiovascular: On POD1 she became hypotensive and required
pressors, which were quickly weaned. She also went into atrial
fibrillation with a rapid ventricular response, which required a
diltiazem drip. Her rate was well controlled on diltiazem and
she converted back to a normal sinus rhythm. She was
transitioned to IV then PO Lopressor.
Respiratory: She was extubated on POD1 but remained very
tenuous. She has increased work of breathing and was requiring
an increased oxygen concentration to maintain normal
saturations. Her respiratory status slowly improved with
aggressive diuresis. She was weaned over one week to nasal
canula and eventually weaned to room air.
Gastrointestinal: Her infarcted small bowel was removed and a
primary anastomosis was performed. Her lactic acid normalized
on POD1. She remained NPO for a number of days
post-operatively. Her bowel function returned and she was
slowly advanced to a regular diet. She did require 3 days of
TPN for nutritional support before she was switched to a PO
diet.
Skin: She has a chronic back wound secondary to radiation
therapy received as a child. This wound requires daily dressing
changes with Aquacel AG.
Heme: She was started on anticoagulation due to the unknown
etiology of her small bowel ischemia. It is suspect that this
was caused by a hypercoagulable state from her malignancy. She
and her husband have been given Lovenox teaching, so they can
administer this medication themselves.
Medications on Admission:
Albuterol
Atenolol 25mg [**Hospital1 **]
Metformin
Reglan
Omeprazole
Discharge Medications:
1. Enoxaparin 100 mg/mL Syringe Sig: One (1) 100mg/ml syringe
Subcutaneous Q12H (every 12 hours): Empty 10ml out of syringe
before injecting. .
Disp:*60 100mg/ml syringe* Refills:*2*
2. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72 hr(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Nahoba VNA
Discharge Diagnosis:
Infarcted ileum, now status post small bowel resection with
primary anastomosis. Metastatic pancreatic carcinoma.
Discharge Condition:
Good
Discharge Instructions:
Please call your surgeon if you develop chest pain, shortness of
breath, fever greater than 101.5, foul smelling or colorful
drainage from your incisions, redness or swelling, severe
abdominal pain or distention, persistent nausea or vomiting,
inability to eat or drink, or any other symptoms which are
concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: No heavy lifting of items [**11-20**] pounds until the
follow up
appointment with your doctor.
Medications: Resume your home medications. You should take a
stool softener, Colace 100 mg twice daily as needed for
constipation. Take Motrin as needed for pain.
Followup Instructions:
Follow up with your scheduled appointments after discharge.
Follow up with Dr. [**Last Name (STitle) **] in [**2-7**] weeks. Call her office at
([**Telephone/Fax (1) 15665**] to schedule your appointment.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
|
[
"564.00",
"E879.2",
"567.9",
"557.0",
"453.8",
"799.02",
"272.0",
"909.2",
"707.8",
"792.1",
"276.4",
"427.31",
"157.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.23",
"52.12",
"45.61",
"99.15",
"93.90",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6569, 6610
|
3824, 5999
|
348, 487
|
6769, 6776
|
1553, 3801
|
7621, 7971
|
1190, 1208
|
6118, 6546
|
6631, 6748
|
6025, 6095
|
6800, 7598
|
1223, 1534
|
285, 310
|
515, 910
|
932, 1063
|
1079, 1174
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
25,329
| 120,386
|
49957
|
Discharge summary
|
report
|
Admission Date: [**2121-9-29**] Discharge Date: [**2121-10-17**]
Date of Birth: [**2079-7-20**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
left sided pain
Major Surgical or Invasive Procedure:
picc line placement
debridement of right foot ulcer in OR
History of Present Illness:
42 yo man with DM I, ESRD on HD, CHF, HTN, chronic L sided pain
with multiple admissions for the same complaints with no
identified physical etiology, who presents for acute worsening
of the the same L sided pain for 1 day. Pt was recently
hospitalized at [**Hospital1 **] and discharged for [**2121-8-16**] with left flank
pain, nausea and vomiting. He has had multiple workups in the
past including CT, MRI, and renal ultrasound all without clear
etiology. A CT scan was repeated today and was again normal.
.
Pt now presents with left sided flank pain, nausea, vomiting for
one day. The pain is similar to other admissions. Denies fever,
CP, SOB. Unable to tolerate POs [**3-20**] pain. Pain controlled with
morphine.
Pt does report that he missed his last dialysis due on Sat, [**9-27**] [**3-20**] to fatigue. Last dialysis [**9-25**].
.
In the [**Name (NI) **], pt found to have k+ of 7.9 with peaked t waves on
ECG. Pt received kayexalate, insulin with dex and calcium
gluconate. K dropped to 7.4. Renal was consulted and did
emergent HD with plans for full HD in the AM. Plan if for the
patient to go from the ED to HD, and then to the MICU for close
monitoring overnight.
Past Medical History:
1. DM type I x 17 years
2. End stage renal disease- dialyzed T, Th, Sat at [**Location (un) **]
Dialysis.
3. Hypertension, poorly controlled
4. Right foot operation - bone excision
5. Right foot ulcer
6. Depression, h/o prior SA and psych hospitalizations.
7. Esophagitis on EGD [**10-21**] H.Pylori negative
8. History of L flank pain as above
Social History:
Lives with his mother in subsidized housing. 4 children in FL.
No smoking, etoh, drugs
Family History:
Diabetes in multiple relatives
Physical Exam:
VS T 97.5 P 78 BP 178/80 RR 17
GENERAL: hispanic man sitting up in bed, vomiting
HEENT: PERRLA, EOMI, OP clear, MMM
NECK: supple
CARDIOVASCULAR: RRR, S1, S2, + S4, no m/r/g
LUNGS: coarse breath sounds BL
ABDOMEN: soft, distended, tympanic, tender to deep palpation L >
R, no HSM
EXTREMITIES: no edema, muscle wasting in hands BL
NEURO: alert, oriented, CN [**Month/Year (2) 20691**] [**Month/Year (2) 5235**]
Pertinent Results:
[**2121-9-29**] 06:21PM GLUCOSE-207* UREA N-81* CREAT-14.3*#
SODIUM-134 POTASSIUM-7.8* CHLORIDE-100 TOTAL CO2-16* ANION
GAP-26*
[**2121-9-29**] 06:21PM AST(SGOT)-15 ALK PHOS-87 AMYLASE-39 TOT
BILI-0.5
[**2121-9-29**] 06:21PM LIPASE-25
[**2121-9-29**] 06:21PM ALBUMIN-4.0 CALCIUM-7.9* PHOSPHATE-9.3*
MAGNESIUM-2.5
[**2121-9-29**] 10:38PM LACTATE-0.8 K+-7.4*
[**2121-9-29**] 10:38PM TYPE-ART PO2-95 PCO2-32* PH-7.36 TOTAL
CO2-19* BASE XS--6
.
Abd CT:
CT ABDOMEN WITHOUT AND WITH IV CONTRAST: There are small
bilateral pleural effusions with associated dependent
atelectasis. There are few focal areas of patchy opacities
bilaterally, which may represent atypical focal atelectasis,
however, focal areas of infiltrate cannot be excluded.
The liver, gallbladder, pancreas, spleen, adrenal glands,
kidneys are unremarkable. There is no evidence of stones or
hydronephrosis. The small and large bowel are within normal
limits. There are no pathologically enlarged lymph nodes within
the mesentery or retroperitoneum. There is no free fluid or free
air.
CT PELVIS WITHOUT AND WITH IV CONTRAST: The distal ureters and
urinary bladder are unremarkable. The prostate, rectum, sigmoid
colon are within normal limits. There is no pelvic
lymphadenopathy.
.
Ultrasound: Normal abdominal ultrasound study.
.
Stress: No ischemic symptoms/EKG changes. Nuclear report sent
separately. : Mild, fixed myocardial perfusion defect in the
inferior wall. No
reversible myocardial perfusion defects. Normal left ventricular
cavity size.
Inferior wall hypokinesis with calculated LVEF 40%.
.
CT head [**10-11**]
There is no intracranial hemorrhage, mass effect, shift of the
normally midline structures, or major vascular territorial
infarct. The [**Doctor Last Name 352**]- white matter differentiation is preserved.
There is a cavum septum pellucidum. There is no hydrocephalus.
The osseous structures are unremarkable. The paranasal sinuses
and mastoid air cells are well aerated.
CT neck [**10-11**]
The osseous structures are unremarkable. The visualized lung
apices are unremarkable. There is a small pretracheal lymph node
[**10-13**] foot ulcer
Compared with [**2120-10-13**], old fracture deformities of the second,
third and fourth distal metatarsals are noted. There is now
focal bony resorption and poor definition of the lateral cortex
of the head of the third metatarsal, as well as the lateral
corner of the base of the third proximal phalanx, worrisome for
osteomyelitis. Please correlate with the location of the
patient's plantar ulcer
Foot xray after debridement:
Interval resection bone around 35d MTP joint. Residual
osteomyelitis this area cannot be excluded
Discharge labs:
wbc 7.0 hgb 10.3 hct 32.6 plt 211
140 104 7
----------< 94
3.9 27 0.6
Micro:
wound Cx: MSSA and GBS sensitive to naficillin
Brief Hospital Course:
A/P:42 yo man with DM I, ESRD on HD, CHF, HTN, chronic L sided
pain admitted with L sided pain, hyperkalemia requiring urgent
dialysis.
.
.#Osteomyiltis of 3rd metatarsal-this was likely the cause of
his fevers and leukocytosis. The patient was taken to the OR and
underwent debridement. His wound cx grew out MSSA and GBS
sensitive to naficillin and he was started on this and should
continue for 4 weeks. He has a picc line in place. After
debridement and starting the patient on naficillin, the white
count normalized and he was afebrile and overall felt much
better. He has an appointment with podiatry in one week and
should have the wound covered with dry sterile gauze to be
changed daily.
.
# Depression: Pt has a hx of severe depression causing need for
hospitalizations. After extensive work-up of his abdominal
pain, it is likely that there is a strong component of
somatization and depression contributing. Psychiatry was
consulted and they recommended starting celexa 20mg qd to help
with the depression. Initially, they were not recommending
inpatient stay but towards the end of his hospitalization, he
started stating that he "did not want to go on anymore" and
"could not deal with the pain anymore." He was started on
remeron and placed on a 1:1 sitter. At the end of
hospitalization, patient did not require 1:1 sitter and denied
any suicidal ideation. Inpatient psychiatry was deemed
unecessary. He should be followed by his PCP.
.
# Abdominal Pain: CT of abdomen was done initially in the ER and
was negative for any etiology of his pain. Pt's workup has
included abd u/s which ruled out renal vein thrombosis, negative
MRI of abdomen and multiple negative abdominal CTs. Later in
his hospitalization, he complained of sharp RUQ pain and a stat
ultrasound was done which ruled out acute cholecystitis. His
abdominal pain migrated between his left flank, RLQ and RUQ. He
never had any peritoneal signs or acute abdomen and as above,
all his studies were negative. Psych was consulted and both
medicine and psych agreed that most of his pain was somatic.
.
# Atypical Chest Pain: Pt complained of chest pain during
dialysis. Cardiology was consulted and they recommended a PMIBI
although their suspicion for cardiac chest pain was low. PMIBI
was done and showed LVEF of 40%, inferior wall hypokinesis and a
fixed perfusion defect in inferior wall. The patient was already
on lisinopril and metoprolol. We started him on ASA 81 mg. His
lipid profile showed an LDL of 73 and given his history of
noncompliance with new medications, we decided not to start a
statin.
.
# Hyperkalemia/ESRD: Patient missed dialysis and thus came in
with hyperkalemia. This corrected after HD x 1. He was
followed by renal and dialyzed T, Th, Sa. He was continued on
Calcium Acetate 667 mg PO TID W/MEALS, Calcium Carbonate 500 mg
PO TID.
.
# DMI: Pt was continued on insulin 70/30 15 units in AM, 10 in
PM with RISS to cover otherwise.
.
# Hypertension: Pt was continued on lisinopril, metoprolol and
nifedipine. Lisinopril and metoprolol were titrated up because
patient had poor bp control.
.
Medications on Admission:
1. Calcium Acetate 667 mg PO TID W/MEALS
2. Metoclopramide 5mg Tablet PO QIDACHS
3. Glycopyrrolate 1 mg PO BID
4. Calcium Carbonate 500 mg PO TID
5. Lisinopril 20 mg PO DAILY
6. Metoprolol Succinate 200 mg Sustained Release 24HR PO once a
day
7. Nifedipine 60 mg Tablet Sustained Release PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Simethicone 80 mg Chewable PO QID PRN
10. Oxycodone 5 mg PO Q4-6H PRN
11. insulin
insulin 70/30 15 units in the morning and 10 units at night
Discharge Medications:
1. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
2. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO four times a day as needed.
9. Insulin NPH-Regular Human Rec 100 unit/mL (70-30) Cartridge
Sig: as directed units Subcutaneous twice a day: 15U qam , 10U
qpm.
10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
13. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
15. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) grams
Intravenous Q6H (every 6 hours) for 4 weeks.
Disp:*qs qs* Refills:*0*
17. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
18. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
Disp:*30 Tablet(s)* Refills:*2*
19. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: Three
(3) Tablet Sustained Release 24HR PO once a day.
Disp:*90 Tablet Sustained Release 24HR(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Manor
Discharge Diagnosis:
Primary Diagnosis:
1. Hyperkalemia [**3-20**] missed dialysis
2. ESRD on dialysis
3. Chronic left sided abdominal pain
4. Osteomyelitis of right foot
Secondary Diagnosis:
1. Hypertension
2. Diabetes type I
3. Right foot ulcer
Discharge Condition:
good, potassium within normal limits, afebrile, hemodynamically
stable.
Discharge Instructions:
You had an elevation in your potassium because you missed your
dialysis. It is very important that you go to every [**Month/Day (2) 1988**]
dialysis to avoid this happening again.
We have increased your Lisinopril and metoprolol to better
control your blood pressure. We also added aspirin for heart
disease. Please take all your medication as directed.
Please call your PCP or go to the ER if you experience any of
the following symptoms: chest pain, shortness of breath,
dizziness, fevers, chills, abdominal pain associated with
nausea, vomiting or diarrhea.
Please follow-up with all your outpatient appointments including
podiatry.
Followup Instructions:
We have made you a follow-up appointment with Dr. [**Last Name (STitle) **] on
[**10-22**] at 2:45p. If you would like to change this
appointment, please call [**Telephone/Fax (1) 65441**].
.
We have made a podiatry follow-up appointment for you with Dr.
[**Last Name (STitle) **]. Your appointment is on [**10-28**] at 11:20 am. The
office is in the [**Hospital Ward Name 121**] Building on [**Location (un) 10043**].
|
[
"789.09",
"428.0",
"296.20",
"V45.1",
"357.2",
"280.9",
"276.7",
"362.01",
"306.9",
"250.81",
"250.61",
"403.01",
"786.59",
"250.51",
"V15.81",
"585.6",
"731.8",
"707.15",
"730.27"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"77.88",
"77.68"
] |
icd9pcs
|
[
[
[]
]
] |
11067, 11120
|
5409, 8517
|
331, 391
|
11391, 11465
|
2569, 5243
|
12153, 12576
|
2092, 2124
|
9040, 11044
|
11141, 11141
|
8543, 9017
|
11489, 12130
|
5259, 5386
|
2139, 2550
|
276, 293
|
419, 1602
|
11313, 11370
|
11160, 11292
|
1624, 1971
|
1987, 2076
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,215
| 125,626
|
38749
|
Discharge summary
|
report
|
Admission Date: [**2175-3-15**] Discharge Date: [**2175-3-29**]
Date of Birth: [**2097-12-13**] Sex: M
Service: MEDICINE
Allergies:
Ambien
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
VTach Storm
Major Surgical or Invasive Procedure:
Electrophysiology Study, Ablation [**2175-3-16**]
History of Present Illness:
Mr. [**Known lastname 131**] is a 77M with PMH of severe cardiomyopathy with EF 15%
with [**Company 1543**] BiV ICD, Concerto 2 CRT-D D274TRK pacemaker and
hx of VTach storm, transferred from [**Hospital3 3583**] for
recurrent VTach. He is followed by Dr. [**Last Name (STitle) **] at [**Hospital1 18**] for
cardiomyopathy and [**Hospital1 **]-V pacing. Patient noticed last week a few
intermittent episodes of lightheadedness and palpitations,
followed by ICD firing. ICD fired 2 times en route to the
nearest OSH ED, 3 times at [**Hospital3 **] where he was
hospitalized for one week, and 2 more times on the morning of
transfer. Patient denies chest pain/pressure or shortness of
breath associated with these episodes. He denies any other
symptoms, and has not felt more fatigued lately.
Patient's cardiac hx began with a MI in [**2146**] and another in
[**2153**]. He has been followed by Dr. [**Last Name (STitle) 86069**] at [**Hospital1 **] for over 15
years since having an AICD placed. In Fall [**2174**], patient had VT
ablation for recurreent episodes of VT. He was discharged on a
maintenance dose of 400mg amiodarone, which has been tapered
down to 200mg in [**2174-11-29**] due to gait instability.
At the OSH, he was loaded with IV amiodarone x 2, and his rhythm
stabilized until morning of transfer when he was shocked 2 more
times from his ICD. He was maintained on amiodarone and
mexilitine. His SBP was chronically in the 80s-90s and he was
asymptomatic.
.
On review of systems, he endorses recent constipation, but no
blood or change in the color of his stools. He denies any prior
history of stroke, TIA, deep venous thrombosis, pulmonary
embolism, bleeding at the time of surgery, myalgias, joint
pains, cough, hemoptysis, black stools or red stools. He denies
recent fevers, chills or rigors. He denies exertional buttock or
calf pain. All of the other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema.
Past Medical History:
1. CARDIAC RISK FACTORS: +hypertension, +hyperlipidemia
2. CARDIAC HISTORY:
-ischemic cardiomyopathy with EF 15%.
-Coronary artery disease status post occluded RCA and MI x 2.
-History of recurrent VT and VT storm status post BiV ICD
upgrade in [**2173**].
3. OTHER PAST MEDICAL HISTORY:
- hx of prostate cancer
Social History:
He is married. He lives on [**Location (un) **] and also
spends part of the year in [**State 108**]. He is a former smoker and
quit five years ago, but used to smoke extensively prior to
that.
History of former alcohol abuse and has stopped in [**2162**].
- Tobacco history: 130pack-year smoking hx
- ETOH: none
- Illicit drugs: none
Family History:
- Father died of heart disease.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T=96.5 BP=94/62 HR=76 RR=18 O2 sat=95(RA)
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. oropharynx clear
NECK: Supple with JVP of 10 cm.
CARDIAC: RRR, normal S1, S2. No m/r/g. faint S3
LUNGS: bibasilar wheezes, no crackles
ABDOMEN: normoactive bowel sounds, soft, NTND.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: left arm bruising and skin breakdown
NEURO: AAOx3, CNII-XII intact, upper and lower extremity
strength grossly intact
PULSES:
Right: DP 2+ PT 2+
Left: DP 2+ PT 2+
PHYSICAL EXAM ON DISCHARGE:
VS: tc 97 BP 99-104/62-72 rr 18 93-99% on RA
Wt: 77.8<--78.2
HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no
lymphadenopathy, b/l neck hematomas resolving, JVP non elevated
CHEST: CTABL, faint crackles BB, clear somewhat with cough.
CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or
gallops
ABD: soft, non-tender, non-distended, BS normoactive. no
rebound/guarding.
EXT: 2+ DPs, PTs, no pedal edema. right groin hematoma
resolving
NEURO: 5/5 strength in U/L extremities.
PSYCH: Appropriate, normal affect.
Skin: left arm abcess healing well, no tenderness or erythema,
scant yellow drainage. Small area of eschar at outer margin.
Pertinent Results:
Labs on Admission:
[**2175-3-15**] 03:15PM BLOOD WBC-5.4 RBC-3.77* Hgb-13.3* Hct-37.5*
MCV-100* MCH-35.3* MCHC-35.5* RDW-13.3 Plt Ct-102*
[**2175-3-17**] 05:47AM BLOOD Neuts-83.2* Lymphs-8.6* Monos-6.0 Eos-1.2
Baso-1.1
[**2175-3-15**] 03:15PM BLOOD PT-38.1* PTT-36.4 INR(PT)-3.7*
[**2175-3-15**] 03:15PM BLOOD Glucose-112* UreaN-32* Creat-1.2 Na-133
K-5.5* Cl-99 HCO3-29 AnGap-11
[**2175-3-15**] 03:15PM BLOOD Calcium-8.1* Phos-2.7 Mg-2.2
Micro:
[**2175-3-15**] 6:42 pm SWAB Source: l lower arm abcess.
**FINAL REPORT [**2175-3-17**]**
WOUND CULTURE (Final [**2175-3-17**]): NO GROWTH.
CXR [**3-18**]:
IMPRESSION:
Left-sided pacemaker with multiple leads is unchanged. Right
subclavian PICC line has its tip in the proximal SVC. The heart
remains markedly enlarged which may represent cardiomegaly,
although a pericardial effusion should also be considered. There
is elevation of the left hemidiaphragm with some adjacent
airspace opacity which may represent partial lower lobe
atelectasis with associated pleural effusion. Overall, this does
not appear to be significantly changed. No pulmonary edema.
Right lung is grossly clear.
Brief Hospital Course:
Primary Reason for Hospitalization:
77M with PMH of severe cardiomyopathy with EF 15% with [**Company 1543**]
BiV ICD, Concerto 2 CRT-D D274TRK pacemaker and hx of VTach
storm, now s/p EP ablation and transferred back to CCU for
multiple runs of NSVT.
Active Diagnoses:
# VTach storm: Patient experienced VTach storm during week of
hospitalization, was shocked total of 7 times prior to transfer.
Patient has a history of prior VTach storm, s/p EP ablation and
BiV pacing. Receive amiodarone load and gtt, all amiodarone
stopped on [**3-17**]. He was also started on Procainamide which has
now been discontinued per EP recs. He has been doing well but
has had numerous runs of NSVT necessitating start amiodarone gtt
and then lidocaine gtt on morning of [**3-17**], likely due to a few
remaining non-ablated VT focuses. Procedure itself was
uncomplicated. Lidocaine was DC??????d, and in the evening, patient
had more runs of NSVT. NSVT persisted, roughly 3 episodes/day,
but patient asymptomatic and EP aware. Per EP, patient will
likely continue to experience some NSVT. Patient was called out
to the floor on [**3-20**], but in the early AM of [**3-21**], developed
escalating episodes of NSVT, with one series of 8 episodes of
15-25 beat runs within 3 minutes, the last two runs of which he
was ATP??????d. After consulting EP, patient was bolused IV
lidocaine, transferred back to CCU, started on lidocaine drip.
Lidocaine drip has now been DC??????d in effort to aid clearance of
all antiarrythmics, and mexilitine has been increased to 150mg
TID in the interim. After patient experienced further persistent
runs of VTach, a decision was made to initiate him on quinidine
during this hospital stay. Patient was discharged on Quinidine
amd Mexilitine. Amiodarone was DISCONTINUED. He will follow-up
with his outpatient electrophysiologist to further titrate these
medications as amiodarone washes out of his system.
# Bleeding/Bruising. Patient??????s INR was not entirely reversed
for procedure. Received 3mg VitK total and one unit FFP prior
to procedure. Patient had bleeding from right EJ site, left
forearm I and D site, and right groin catheterization site. He
was transfused 1 unit of pRBC prophylactically for continued
bleeding. HCT is now trending down mildly. Bruises resolved well
during hospitalization, and he was restarted on anticoagulation,
maintaining INR [**3-3**].
# CHF: Most recent EF 20%. Diuresis was held on admission as
patient was not felt to be volume overloaded and blood pressure
was on the softer side (100s/70s). He received IV lasix
post-ablation procedure because he had received 1.5L fluid
during procedure. He appeared clinically euvolemic afterward
and was restarted on home Lasix PO 80 qAM 40 qPM. Cr bumped to
this diuresis, so he was backed down to furosemide 80mg daily
only. He was also continued on spironolactone, carvedilol 3.125
[**Hospital1 **], ASA 81, atorvastatin 20. He was anticoagulated for low EF
and afib and continued on anticoagulation, as outlined above.
# Cellulitis: Patient has an area of erythema, fluctuance and
possible pus on left forearm in area where he had previous PIV.
Was I and D??????d by surgery. Wound culture no growth, final. PICC
in place. He was treated with a 7 day course of vancomycin.
Dressing changes (wet to dry) were performed daily. Wound was
dry, pink and healing well at the time of discharge.
#Hypotension ?????? Patient was transiently hypotensive after coming
back from ablation and on dopamine. Quickly weaned off and SBP
remained in 100s-130s throughout remainder of hospital course.
Patient will reinitiate midodrine upon discharge.
Chronic Diagnoses:
# Afib: Patient has underlying afib but is [**Hospital1 **]-V paced. He was
anticoagulated.
# HLD: Patient continued home simvastatin 10
Transitional Issues:
Patient will follow-up with outpatient electrophysiologist to
further titrate antiarrhythmic medications. he had an appt with
Dr [**Last Name (STitle) **] on the day of dc. He was dc/ed to home with
services inclduing home telemonitoring, med teaching, SW, PT
etc.
Medications on Admission:
amiodarone 400 mg once a day
carvedilol 3.125 mg twice a day,
Lasix 80 mg in the morning and 40 mg at night,
mexiletine 150 mg twice a day,
midodrine 10 mg three times a day,
omeprazole 40 mg once a day,
potassium chloride 20 mEq once a day,
simvastatin 40 mg once a day,
spironolactone 25 mg once a day,
aspirin 81 mg once a day,
warfarin as directed to keep therapeutic INR -> 3 mg 5x/week,
1.5 mg Tues and Sat
Discharge Medications:
1. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
2. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. mexiletine 150 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
4. midodrine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 PM.
10. quinidine gluconate 324 mg Tablet Extended Release Sig: 0.5
Tablet Extended Release PO Q12H (every 12 hours).
Disp:*30 Tablet Extended Release(s)* Refills:*2*
11. Outpatient Lab Work
Please have your BMP and INR checked on Friday [**3-31**] and faxed
to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 86070**]
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Ventricular tachycardia
systolic heart failure
biventricular ICD
coronary artery disease (MI x2)
Hypertension
Dyslipidemia
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:
It was a pleasure caring for you during your hospitalization at
[**Hospital1 69**].
You were admitted to the hospital with ventricular tachycardia
(VT) which resulted in your ICD firing several times. You were
given several intravenous medications and had an ablation
procedure to help keep you in sinus rhythm.
Medication changes:
STOP your Amiodarone
STOP your potassium chloride
CHANGE your Lasix to 40mg daily
CHANGE your Simvastatin to Atorvastatin 20mg daily
CHANGE your Mexiletine to 150mg three times daily
START Quinidine 162mg daily
CHANGE your Coumadin to 1.5mg daily
Otherwise, continue your medications as previously prescribed
For your heart failure diagnosis: Weigh yourself every morning,
[**Name8 (MD) 138**] MD if weight goes up more than 3 lbs in 3 days or 5 lbs in
2 days, follow a low salt diet and restrict your fluid intake to
1500ml/ day.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2175-3-29**] 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: CARDIAC SERVICES
When: WEDNESDAY [**2175-3-29**] at 2:20 PM
With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], 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
Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **]
[**Last Name (NamePattern4) 4094**]: INTERNAL MEDICINE
Address: [**Street Address(2) 86071**], [**Location (un) **],[**Numeric Identifier 58635**]
Phone: [**Telephone/Fax (1) 41197**]
Appointment: WEDNESDAY [**4-5**] AT 3PM
|
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24,129
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10071
|
Discharge summary
|
report
|
Admission Date: [**2113-11-1**] Discharge Date: [**2113-11-12**]
Date of Birth: [**2063-4-17**] Sex: F
Service: MEDICINE
Allergies:
Sulfonamides / Zithromax / Floxin / Penicillins / Demerol /
Morphine Sulfate / Dilaudid / Bactrim
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
Requesting pain medications
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
50 y/o F with MMP including h/o gastric bypass, DVT/PE s/p IVC
filter [**11-23**], SLE on chronic prednisone, hypothyroidism, chronic
hypoventilation with PCO2 60s, adrenal insufficiency presents to
ED today for request of pain meds. Pt was recently admitted to
[**Hospital 4199**] hospital from [**Date range (1) 33651**] after presenting with
unresponsiveness and respiratory failure requiring intubation.
Per d/c summary from [**Name (NI) 4199**], pt was admitted with resp failure,
intubated, admitted to the ICU, and then quickly extubated. She
was treated for COPD with IV antibiotics, IV solumedrol, and
nebulizer treatments. The pt had attributed her respiratory
failure to seroquel and thus, seroquel was discontinued. The
patient was discharged on only Klonapin 0.5 PO BID, and per d/c
summary, was strongly recommended not to have extra pain and
anti-anxiety medications pescribed since they have caused
significant lethargy and loss of respiratory drive. During her
hospital stay, pt was found to have a UTI on [**10-21**] (d/c summary
does not state what she was treated with), resp cx with +MRSA
(unclear if this was treated or thought to be colonized), blood
cxs NGTD. Pt was also placed on steroid taper of Prednisone 20
mg to continue for one week and then plan was to taper to 10 mg
daily (unclear when IV solumedrol was d/ced at OSH, ?[**10-27**]).
.
Pt presents to ED today for request of pain and anxiety
medications for abdominal pain and anxiety. Pt reports that her
doctor took all of her pain medications and that she has been
having "wicked" pain since then with increased anxiety. Pt also
reports throat pain/soreness after recent intubation and
extubations. Denies fevers/chills, headache, chest pain,
shortness of breath, abd pain, dysuria, no change in BMs, no LE
swelling. Of note, pt has been having continual oozing from G
tube site which has been out for last 2 months per last note
from GI.
.
In [**Last Name (LF) **], [**First Name3 (LF) **] staff had discussion with PCP [**Last Name (NamePattern4) **]: chronic pain issues
and after discussion with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 6431**] as well as NH physician
[**Last Name (NamePattern4) **]. [**Last Name (STitle) **], it was decided that pt could be re-started on Klonapin
0.5 mg [**Hospital1 **] as well as Methadone 5 mg TID. Labs in ED were drawn
and found to have Na of 127 (baseline 133-136 on last d/c,
although has been as low as 127) and K of 5.7, repeat 5.8. EKG
with NSR at 96 bpm and +peaked T waves. Pt was given 10 units
regular insulin IV +1 amp D50, Kayexylate 30 gm PO, Ca gluconate
2 gm IV x 1, also hydrated with 1 L NS. Also given Klonapin 0.5
mg PO and Methadone 5 mg PO, tums. Repeat EKG at 6 pm with
still peaked T waves. Pt was then admitted to medicine service
for further treatment of hyperkalemia.
Past Medical History:
1. S/p gastric bypass in [**2099**] for weight loss, very complicated
course including chronic malnutrition s/p J-tube
2. DVT/PE [**10-23**] IVC filter placed on [**2111-11-23**].
3. SLE with dermatologic involvement, treated with low dose
chronic prednisone for several yrs. s/p biopsy.
4. Hypothyroidism, treated with levothyroxine.
5. Hypoventilation syndrome with CO2 in 60s s/p multiple
intubations/ICU stays
6. Osteoporosis
7. Barretts esophagus and esophageal stricture.
8. Peripheral neuropathy.
9. H/O tachycardia, ? MAT
10. Anxiety and depression.
11. Chronic malnutrition s/p J- tube
12. h/o thigh hematomas while on coumadin therapy X 2 occassions
(right and left)
13. orthostatic hypotension
14. Migraine headache
15. Asthma
16. Adrenal Insufficiency
17. Small left frontal cortical bleed and frontal scalp hematoma
s/p [**2111**]8. Status post cholecystectomy
[**27**]. History of seizures
Social History:
75 pack year smoking history and quit few months ago.
She denies any alcohol consumption.
She lives in a nursing home at the [**Location (un) 29393**] in [**Location (un) 2251**].
Family History:
Father died on MI, had diabetes; mother died of MI
Physical Exam:
T 98.7 BP 130/90 P 103 P18 Sat 99%RA wt 97 lbs
Gen: A+O x 3, cachectic female, lying comfortably, NAD
HEENT: PERRL, EOMI, OP clear with MMM
Neck: supple, NT, no LAD
Pulm: CTA bilat
CV: reg rhythm, tachy, no m/r/g
Abd: s/nt/nd +BS; G tube slightly oozing (pt states chronic) and
mild erythema around site (also been present >1 month per pt)
[**Name (NI) **]: thin, no edema, no CT, +2 DP bilat; R heel: small abrasion
with eschar, no erythema, no tenderness
Neuro: CN 2-12 intact, DTRs 2+throughout
Pertinent Results:
[**2113-11-1**] 02:35PM WBC-10.4# RBC-3.88* HGB-13.0 HCT-42.0
MCV-108* MCH-33.5* MCHC-31.0 RDW-14.2
[**2113-11-1**] 02:35PM NEUTS-92.9* BANDS-0 LYMPHS-4.3* MONOS-2.1
EOS-0.5 BASOS-0.1
[**2113-11-1**] 02:35PM PLT SMR-HIGH PLT COUNT-506*#
[**2113-11-1**] 02:35PM GLUCOSE-105 UREA N-11 CREAT-0.5 SODIUM-127*
POTASSIUM-5.8* CHLORIDE-85* TOTAL CO2-32 ANION GAP-16
[**2113-11-1**] 02:40PM K+-5.7*
U/A:
[**2113-11-1**] 02:35PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2113-11-1**] 02:35PM URINE BLOOD-TR NITRITE-POS PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
CXR:no infiltrate; dilated bowel in LUQ but seen on prev CXR
Brief Hospital Course:
A/P: 50 y/o female with MMP including chronic pain, COPD s/p
recent intubation for ?hypercarbic respiratory failure
attributed to benzo/narcotic use, SLE on chronic prednisone,
remote h/o adrenal insufficiency, depression/anxiety, h/o DVT/PE
with IVC filter presenting with hyperkalemia, EKG changes,
hyponatremia. The patient was initially admitted to the medical
service who, in discussion with the ED and the patient's PCP,
[**Name10 (NameIs) **] the patient on Methadone 5 TID and Klonopin 0.5. The
patient recieved a total of methadone 10 and klonopin 0.5 when
she had a respiratory arrest with a max PCO2 of 132. She was
emergently intubated and sent to the MICU. There, she was
slightly hypotensiove requiring a small amount of dopamine. She
was weaned off the vent, and transfred to the floor on no
narcotics or benzos.
.
Hypercarbic respiratory failure: She has a baseline hypercarbia
secondary to likely COPD (although past PFT's unrevealing with
poor effort) with extensive smoking history, but also has
diagnosis of hypoventilation sydrome. She had an acute on
chronic exacerbation of this hypercarbic respiratory failure,
most likely secondary to hypoventilation, as she had normal A-a
gradient and clinical syndrome of decreased level of
consciousness and bradypnea in the setting of re-initiating her
methadone and clonopin. She will follow up in pulmonary clinic
to have a outpainett sleep study since she may have central
sleep apnea. She was also started on BiPap overnight at 8/5 and
tolerated it well. Recommend to avoid ALL BENZOS AND PAIN MEDS!!
Hyperkalemia on admission: unclear etiology; no K sparing
medications. No renal insufficency. Possibly adrenal
insufficiency in her clinical context. She was given
insulin/d50/calcium/kayexalate in ED for K of 5.8 and peaked T
waves. Her
potassium is now normal. She recevied stress dose steroids in
the MICU and then was changed to her standing prednisone 20mg po
qd.
Methicillin Resistent Staph Epi Bacteremia: Unclear where the
source is from. Blood cultures positive for MRSE on [**11-4**]. She
was started on Vancomycin. ESR is only 3 so unlikely
endocarditis or osteomyelitis. TTE negative for vegetetations.
Vancomycin iv per PICC line x 14 day course started on [**11-4**].
EColi Urinary Tract Infection. Sensitive to bactrim, but patient
is allergic. Treated with Macrobid x 7 days.
Chronic Abdominal pain and anxiety: Psychiatry saw the patient
for anxiety. We held all narcotics and benzodiazepines given the
recent intubation. Started her on seroquel and titrated up as
this allievates some of her anxiety. She was started on standing
APAP, lidocaine patches and Ibuprofen with some relief of her
pain. She understands that she may never be pain-free as
narcotics are not an option given her intubations in the past.
SLE, chronic steroids/immunosuppression: Recieved stress dose
steroids in the MICU and then was dropped to Prednisone 20mg
qday
Fluids/Electrolytes/Nutrition - She is very malnurouished after
a gastric bypass.
[**Last Name (un) 1372**]-jejunal tube placed underfouroscopic guidance. She was
started on tube feeds. B12 injection was given as patient has
been deficient in the past and currently macrocytic. Plan is for
her to follow up with Dr. [**Last Name (STitle) **] of surgery and Dr. [**Last Name (STitle) 12590**] of
GI to plan for percutaneous J tube once her bacteremia has
resolved.
Hyponatermia. Was planning to discharge her on [**11-10**] but then
her am Na returned at 125. She was somewhat volume depleted and
so she was started on NS x 1.5L. There was also concern that
this could be SiADH and so her celexa was held. Urine lytes show
Na 15, which shows dilute urine, which is NOT c/w with siADH.
Most likely due to volume depletion. On day of discharge Na was
...
Code: Full Code
Access: Single lumen PICC
Dispo: To rehabiliation for iv antibiotics
Medications on Admission:
1. Albuterol IH 2 puffs qid
2. Levoxyl 75 mcg PO daily
3. Plaquenil 200 mg daily
4. Prednisone 20 mg daily x 1 week (?beg [**10-31**]), then taper to
10 mg daily
(previously on 7.5 mg QMWF alternating with 9.5 mg
QTues/Thurs/Sat per last d/c summary [**8-25**])
5. Klonopin 0.5 mg [**Hospital1 **]
6. Neurontin 600 mg TID
7. Protonix 40 mg daily
8. Tylenol 650 mg q4hr prn
9. MOM 30 cc PO daily prn
10. Mylanta 30 cc PO q4hr prn
11. Albuterol nebs q4hr prn
12. ?Sorionate 25 mg daily
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
2. Levothyroxine Sodium 75 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO DAILY (Daily) as needed.
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
8. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Lidocaine HCl 2 % Solution Sig: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed for sore throat.
12. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig:
Two (2) Spray Nasal [**Hospital1 **] (2 times a day).
13. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours).
15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
17. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO PRN (as
needed).
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
Four (4) Adhesive Patch, Medicated Topical QD ().
19. Quetiapine 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day) as needed for anxiety.
20. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea
21. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g
Intravenous Q 12H (Every 12 Hours) for 7 days.
22. Vitamin B12-Vitamin B1 100-1 mg/mL Solution Sig: One (1) mL
Intramuscular once a month.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Methicillin-Resistent Staph Epi Bacteremia
EColi UTI
Hypercarbic respiratory failure
Malnutrition
Hyperkalemia, Resolved
Discharge Condition:
Good
Discharge Instructions:
Follow up as below
Followup Instructions:
Please call Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Surgeon), M.D.([**Telephone/Fax (1) 2363**]
for an appointment within the next month for a consultation
regarding your feeding tube.
Call Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] (Gastroenterology)([**Telephone/Fax (1) 8892**] for an
appointment to follow up in [**1-22**] weeks after discharge
Call Dr. [**First Name (STitle) **] [**Name (STitle) **] (Pulmonary) at ([**Telephone/Fax (1) 513**] for an
appointment in [**1-22**] weeks after discharge
Call your primary care doctor [**First Name (Titles) 33652**] [**Last Name (Titles) **] for an appointment [**1-22**]
weeks after discharge [**Telephone/Fax (1) 33653**].
Provider: [**First Name11 (Name Pattern1) 2890**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**]
Date/Time:[**2113-11-24**] 11:00
Provider: [**First Name4 (NamePattern1) 8990**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2113-12-18**]
1:30
|
[
"276.1",
"518.84",
"244.9",
"790.7",
"041.19",
"493.20",
"E939.4",
"276.52",
"V45.3",
"255.4",
"263.9",
"V58.65",
"710.0",
"733.00",
"599.0",
"276.7",
"E935.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.04",
"00.17",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
12170, 12240
|
5737, 7325
|
386, 399
|
12405, 12412
|
5021, 5714
|
12479, 13572
|
4430, 4482
|
10155, 12147
|
12261, 12384
|
9646, 10132
|
12436, 12456
|
4497, 5002
|
319, 348
|
427, 3288
|
7339, 9620
|
3310, 4216
|
4232, 4414
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,898
| 143,326
|
17323
|
Discharge summary
|
report
|
Admission Date: [**2160-2-13**] Discharge Date: [**2160-2-29**]
Date of Birth: [**2096-4-23**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Nsaids / Rapamune
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
increasing dyspnea
Major Surgical or Invasive Procedure:
VATS with wedge biopsy
History of Present Illness:
63yo M s/p OLT ([**5-11**]) for HepC cirrhosis/HCC on
immunosuppression, s/p tracheostomy for subglottic stenosis
([**7-11**]), recurrent pna who comes to the ED from [**Hospital 48496**] rehab with c/o increasing dyspnea x 1 month and
multiple pulmonary nodules seen on CT 5d ago. Associated
pleuritic substernal CP, fatigue, thicker trach secretions, and
night sweats (?chronic). Denies fever/chills. +100lb weight
loss over 1 year. Denies history of exposure to TB, travel
outside of the country, IVDU, imprisonment. His CT was done at
an OSH, but reportedly showed multiple 7-10mm nodules not
previously seen (last CT chest in OMR [**4-11**]). Recently d/c from
[**Hospital1 18**] on [**2160-1-22**] for pneumonia, empirically treated with
vanc/ceftaz.
.
In the ED, he was afebrile with baseline O2 requirement. He
received vanc 1g IV and ceftaz 2g IV.
.
He currently states he feels fine. His dyspnea is improved. He
denies CP, chills, abdominal pain, N/V.
Past Medical History:
1. OLT: [**5-11**], for HCV/EtOH cirrhosis and HCC, on rapamycin and
Cellcept, c/b wound infection, followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]
2. tracheostomy: x2, [**8-11**] for chronic vent dependency,
subglottic stenosis, tracheomalacia
3. DM2
4. OSA/Pickwickian syndrome
5. COPD
6. Diastolic dysfunction
7. CKD
8. Bipolar d/o
9. HTN
10. H/o VRE, MRSA, C. diff, and resistant Pseudomonas infections
11. Hiatal hernia
12. Pulmonary hypertension
Social History:
Quit tobacco 8 years ago. Quit alcohol 17 years prior to
admission. Denies any recreational drugs.
Family History:
NC
Physical Exam:
vitals- T 97.8, HR 62, BP 145/60, RR 16, O2sat 100% 40%trach
mask
General- chronically ill-appearing man lying in bed, NAD, mask
to trach, awake and alert, difficulty speaking with trach
HEENT- sclerae anicteric and noninjected, OP clear without
evidence of thrush, moist MM
Neck- trach site appears mildly erythematous, no discharge
Lungs- upper airway secretions, decreased breath sounds and
dullness to percussion 1/3 up b/l (L>R)
Heart- RRR, normal S1/S2, no murmur/rub/gallop
Abd- soft, NT, ND, NABS, large surgical scar, no hepatomegaly
Ext- 1+ LE edema to mid-calf, RLE with 5x5cm area of erythema
and warmth on the lateral aspect of the lower R calf
Skin- erythematous blanching papular (2mm papules) rash over the
neck/chest/upper arms, not pruritic, no excoriations, no facial
rash, no involvement of palms and soles
Pertinent Results:
[**2160-2-13**] 01:00PM WBC-5.7 RBC-3.87* HGB-10.8* HCT-32.3* MCV-84
MCH-27.9 MCHC-33.4 RDW-15.2
[**2160-2-13**] 01:00PM NEUTS-84.1* LYMPHS-8.5* MONOS-4.2 EOS-1.7
BASOS-1.4
[**2160-2-13**] 01:00PM PLT SMR-LOW PLT COUNT-90*
[**2160-2-13**] 01:00PM PT-12.2 PTT-24.1 INR(PT)-1.0
[**2160-2-13**] 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2160-2-13**] 01:00PM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE
EPI-<1
[**2160-2-13**] 01:00PM CK(CPK)-33*
[**2160-2-13**] 01:00PM cTropnT-0.05*
[**2160-2-13**] 01:00PM CK-MB-NotDone
[**2160-2-13**] 01:00PM GLUCOSE-128* UREA N-31* CREAT-1.6* SODIUM-142
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-36* ANION GAP-9
[**2160-2-13**] 03:10PM ALT(SGPT)-23 AST(SGOT)-22 ALK PHOS-173*
AMYLASE-87 TOT BILI-0.2
[**2160-2-13**] 03:10PM LIPASE-25
[**2160-2-13**] 09:46PM CK(CPK)-35*
[**2160-2-13**] 09:46PM CK-MB-NotDone cTropnT-0.05*
.
CXR: Stable small bilateral pleural effusions. Stable elevation
of
left hemidiaphragm. No evidence for pneumonia or overt CHF.
.
ECG: NSR at 63bpm, RBBB, TWI in III, Twave flattening in F, no
new changes from prior study in [**2160-1-17**]
.
CT chest [**2-26**] -
IMPRESSION:
1. Mild congestive heart failure with cardiomegaly and small
bilateral pleural effusion.
2. Tiny loculated hydropneumothorax in the medial portion of the
right hemithorax.
3. Increased consolidation in both lower lobes, probably
explained by the combination of atelectasis and BOOP.
4. Increased elevation of the left hemidiaphragm.
5. Mild subcutaneous emphysema in the right chest wall.
6. Status post right VATS procedure.
.
[**2-19**] Lung biopsy.
1. Right lung, lower lobe, wedge biopsy (A-P):
Patchy organizing pneumonitis
No malignancy identified
2. Right lung, middle lobe, wedge biopsy (Q-V):
Patchy organizing pneumonitis
No malignancy identified.
* There is a peribronchiolar chronic inflammatory infiltrate
with focal alveolar collapse and intra-alveolar macrophages and
fibroblastic proliferation. Acute inflammation is limited to
bronchioles. Findings are non-specific.
.
[**2-29**] - Video Swallow eval:
IMPRESSION: Penetration of the vocal cords during swallowing of
both thin and nectar thick liquids. No frank aspiration during
this study.
.
CXR [**2160-2-26**]. Elevation of the left hemidiaphragm is chronic and
left lower lobe atelectasis currently present is intermittent.
Small bilateral pleural effusions are stable on the left but
increased on the right following some improvement in transient
interstitial pulmonary edema. Cardiomegaly with particular left
atrial enlargement is longstanding. Tip of the tracheostomy tube
abuts the lateral wall of the trachea and should be evaluated
clinically. Tip of the left PIC line projects over the margin of
the upper superior vena cava. Dr. [**Last Name (STitle) 15264**] and I discussed these
findings by telephone at the time of dictation
.
LABS from day of DISCHARGE [**2160-2-29**]:
FK506: 4.3
CHEM 7:
141 | 107 | 31
--------------<97
4.2 | 26 | 2.3
.
Ca: 8.3 Mg: 1.9 P: 4.2
CBC: WBC 4.6 Hct 26 Plt 188
PT: 13.0 INR: 1.1
Brief Hospital Course:
Pt is a a 63yo M s/p OLT ([**5-11**]) for HepC cirrhosis/HCC on
immunosuppression, s/p tracheostomy for subglottic stenosis
([**7-11**]), recurrent pna admitted from [**Hospital3 **] rehab
for increasing dyspnea x 1 month, found to have multiple
pulmonary nodules but no PE seen on CTA. These nodules were not
previously seen (last CT chest at [**Hospital1 18**] [**4-11**]). Of note, recently
d/c from [**Hospital1 18**] on [**2160-1-22**] for pneumonia, empirically treated
with vanc/ceftaz for unclear duration.
.
## Respiratory Failure - On this admission, patient was
re-started on vanco, ceftaz, and levo for nosocomial PNA.
Infectious disease was consulted for possible
infectious/inflammatory etiology. Urine legionella, CMV, serum
cryptococcal antigen, and 3 AFB smears were negative. Bronch was
attempted by IP on [**2-15**] but was unsuccessful due to small trach.
Thoracics were consulted for VATS, and the patient underwent
VATS with BAL and wedge biopsies of right lower lobe and middle
lobes on [**2-18**]. Chest tubes placed to suction postoperatively.
[**Name (NI) 4452**], pt received 1 mg midazolam and intraoperatively 340 mg
Propofol, 125 mcg Fentanyl, 12 mg Vecuronium. Also received 14
mg of morphine (last given at 10:45 pm), Ceftaz, Vancomycin,
Hydrocort 100 mg IV, Neostigmine, and glycopyrrolate. EBL was
50 cc and intraoperatively, received 300 cc LR. In OR, pt had
ABG of 7.30/68/125. [**Name (NI) **], pt initially placed on
100% trach mask and sent to PACU. Follow up ABG was 7.08/94/154
and pt was somnolent. He was briefly placed on CMV for 30
minutes then CPAP PS 10/5. Repeat ABG was 7.10/71/104. He was
transferred to ICU for further ventilatory management.
.
Patient likely developed acute on chronic respiratory
acidosis. The acute respiratory acidosis was thought to be
secondary to narcotics/sedatives causing hypoventilation as well
as exposure to 100% FIO2 leading to decreased respiratory drive
and causing more shunt lung physiology given his chronic
obstructive lung disease and Pickwickian syndrome. He was
initially placed on ventilator and then eventually weaned off to
trach mask. He required very frequent pulmonary toileting due to
copious amount of sputum production which was thought to be
secondary to his pulmonary nodules vs infection. The pathology
result of the pulmonary nodule biopsy returned as bronchiolitis
obliteran pneumonitis. Liver transplant consultants thought that
Sirolimus was likely the culprit for the cause of BOOP and
discontinued sirolimus on [**2-21**] and increased Cellcept to 1000mg
[**Hospital1 **] and continued prenisone 5mg daily. They did not feel
necessary to start high dose prednisone for BOOP and felt that
pt would recover with discontinuation of sirolimus. In addition,
BAL and tissue culture from the VATS came back positive for
pseudomonas, GNR, and Coag positive Staph. These organisms
could very well have been colonized however after discussion
with ID, patient was continued on vanco and ceftaz to finish a
10 day course on [**2160-2-23**]. The chest tube was placed during VATS
procedure was managed by thoracis and initially planeed on
removing the chest tube on [**2160-2-23**] or [**2160-2-24**]. Patient was
tolerating trach mask ok and was transferred to the medical
floor. On the floor he was continued on ceftaz/vanco for 10
days as above. FK506 was started on [**2-24**] and increased cellcept
to 1 gm [**Hospital1 **]. He continued to have copious yellow/white thick
secretioning requiring suctioning every few hrs initially.
Chest tubes were discontinued on [**2-26**]. Chest CT was done on
[**2-28**]. On AM [**2-27**] patient was noted to be more lethargic. He
was also requiring frequent suctioning, nebs. ABG was near his
baseline however given nursing concern he was transferred back
to Medical ICU. He was placed on CPAP/PS briefly and tolerated
well and was changed over to trach mask. Plan is for trach
collar during the day and BIPAP 8/5 at night.
.
# Renal Insufficienty - Post operatively patient was noted to be
in oliguric renal failure. REnal was consulted. He had acute
on chronic renal insufficiency. Urine lytes were sent were
consistent with pre-renal vs. ATN. The creatinine and urine
output improved with aggressive IV fluids.
.
# OLT - Liver followed the patient in the unit and discontinued
sirolimus and increased Cellcept as above. Tacrolimus started
[**2160-2-26**] along with mycophenolate, and prednisone. Continue
Tacrolimus 2mg [**Hospital1 **].
.
# DM II - Glucose control maintained with Sliding scale
insulin.
.
# Anemia - Microcytic. Hct stable during this admission.
Hyperplastic polyp on [**7-10**] colonoscopy. Received 1U PRBC on
[**2-25**]. Iron studies suggest anemia of chronic disease, iron
normal. Epogen was continued.
.
# Hypertension - Continued on metoprolol and amlodipine.
Started hydral.
.
# RUE swelling - noted to have RUE swelling. Ultrasound was
done which showed no evidence of DVT.
.
# Nutrition - He was started on po diet once he tolerated
trach mask. Speech and swallow were consulted for Passy Muir
Valve Evaluation, but pt was thought not to be safe to use it
due to his tracheal stenosis. Video swallow was performed on
[**2-29**] by speech and swallow who recommended that he can take
Regular diet with thin liquids. Soup and cereals should be
avoided however.
.
# Ppx: Maintained on SC heparin + pneumaboots. PPI. Bowel
regimen.
.
# Code status: FULL CODE. HCP is [**Last Name (LF) 802**], [**Name (NI) **] [**Name (NI) 48497**]
([**Telephone/Fax (1) 48498**], ([**Telephone/Fax (1) 48499**] (cell).
Medications on Admission:
Sirolimus 4mg qd
Cellcept 500mg [**Hospital1 **]
Prednisone 5mg qd
Flovent 110mcg 4puffs [**Hospital1 **]
Atrovent prn
Lansoprazole 30mg qd
Risperidone 2mg qhs
Celexa 10mg qd
Epogen 5000U qMWF
Lorazepam 0.5mg [**Hospital1 **]
NPH
Amlodipine 10mg qd
SC heparin
Nystatin 5mL qid
Discharge Medications:
1. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One
(1) Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection
QMOWEFR (Monday -Wednesday-Friday).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Risperidone 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day).
10. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
11. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
12. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
Two (2) Inhalation [**Hospital1 **] (2 times a day).
13. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
14. Insulin sliding scale
Fingerstick QACHS
Insulin SC Fixed Dose Orders
Breakfast - NPH 5 units;
Bedtime - NPH 2 Units
+ humumlog insulin sliding scale
15. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
17. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
18. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN
(as needed).
19. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4)
Puff Inhalation Q4H (every 4 hours).
20. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff
Inhalation Q4H (every 4 hours) as needed.
21. Lasix 40 mg Tablet Sig: One (1) Tablet PO qAM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Respiratory failure
Bronchiogenic obliterans pneumonitis
Acute on chronic renal failure
Anemia
Hypertension
Diabetes type 2
Discharge Condition:
Stable
Discharge Instructions:
Please continue to administer medications as directed.
If patient as has fever, chills, increased shortness of breath
please seek further medical care.
Followup Instructions:
Please call [**Telephone/Fax (1) 673**], Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] to setup an
appointment in [**12-10**] weeks.
.
Please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**] [**Telephone/Fax (1) 45347**] in
[**12-10**] weeks after discharge from rehab.
Completed by:[**2160-2-29**]
|
[
"585.9",
"518.81",
"496",
"707.09",
"250.00",
"486",
"272.0",
"516.8",
"584.9",
"276.2",
"V42.7",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"32.29",
"34.21",
"38.93",
"33.24",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13775, 13850
|
6002, 11624
|
311, 335
|
14018, 14027
|
2845, 5979
|
14229, 14635
|
1979, 1983
|
11951, 13752
|
13871, 13997
|
11650, 11928
|
14051, 14206
|
1998, 2826
|
253, 273
|
363, 1335
|
1357, 1847
|
1863, 1963
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,358
| 173,197
|
18206
|
Discharge summary
|
report
|
Admission Date: [**2169-8-18**] Discharge Date: [**2169-8-24**]
Date of Birth: [**2117-12-28**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 301**]
Chief Complaint:
51 year old male who presented to outside hospital on [**2169-8-17**]
with R sided abdominal and flank pain. Patient transfered to
[**Hospital1 18**] on [**2169-8-18**], went to OR for question of gastric
perforation/sepsis.
Major Surgical or Invasive Procedure:
S/P Exploratory Laparotomy, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], Closure of perforated
duodenal ulcer, repair of incisional hernia.
History of Present Illness:
The patient is a 51-year-old gentleman status post gastric
bypass by Dr. [**Last Name (STitle) **] 3 years ago. He lost approximately 100 pounds
with a 75 pound regain. He has
recently had severe knee pain and has been taking excessive and
extreme doses of NSAIDs by his own report. He presented to
[**Hospital 1474**] Hospital with severe abdominal pain. [**Hospital1 1474**] notified
us in the morning of admission about patient.
We welcomed transfer, however, he did not arrive until late in
the evening evening and was emergently and urgently taken to the
operating room within approximately an hour.
Past Medical History:
Hypertension,
Diabetes Mellitus,
Depression,
Degenerative joint disease
Dyslipedemia
asthma/bronchitis
Chronic back pain
Osteoarthritis
Obesity
Gerd
Hepatitis A
Social History:
Ex nurse, works in real estate now. Married.
Physical Exam:
Per Dr. [**Last Name (STitle) 4467**] on [**2169-8-18**]
VS HR 133, BP 111/62 94% on 4 liters
Patient complaining of severe abdominal pain
lungs: Clear to auscultation bilaterally
Heart: Sinus tach, RRR
Pertinent Results:
[**2169-8-18**] 11:59PM GLUCOSE-163* UREA N-27* CREAT-1.3* SODIUM-139
POTASSIUM-5.2* CHLORIDE-109* TOTAL CO2-20* ANION GAP-15
[**2169-8-18**] 11:59PM CALCIUM-8.4 PHOSPHATE-3.1 MAGNESIUM-1.3*
[**2169-8-18**] 11:59PM WBC-15.9* RBC-4.78 HGB-15.3 HCT-43.7 MCV-91
MCH-31.9 MCHC-34.9 RDW-14.6
[**2169-8-18**] 11:59PM NEUTS-56 BANDS-31* LYMPHS-8* MONOS-3 EOS-0
BASOS-0 ATYPS-0 METAS-1* MYELOS-1*
[**2169-8-18**] 11:59PM PT-18.4* PTT-36.3* INR(PT)-1.7*
Brief Hospital Course:
This is a 51 year old male transferred from [**Hospital 1474**] Hospital on
[**2169-8-18**] with R sided abdominal and flank pain. Taken emergently
into the operating room where they found a perforated duodenal
ulcer, incisional hernia and 2 liters of purulent drainage
aspirated from abdomen. Intraoperatively, patient required large
amounts of fluid and pressors to maintain blood pressure.
Postoperatively he was sent to the intensive care unit where he
was weaned off his pressors as well as ventilatory support.
[**2169-8-21**] - He was transfered to the regular floor. Remains npo on
Iv fluids.
[**2169-8-22**] - Out of bed, Central line discontinued. Foley
discontinued started on sips. Physical therapy has seen and
cleared for discharge without home PT.
[**2169-8-23**] Started back on home medication regimen. Out of bed and
ambulating. Dressing changes to abdomen taught to wife. [**Name (NI) **]
signs stable, afebrile. Progressed to stage 3 diet.
[**2169-8-24**] On stage 4 diet, ambulating, abdominal wound clean and
dry. Vs stable afebrile. Discharge to home today with wife who
is [**Name8 (MD) **] RN doing dressing changes will follow-up with Dr. [**Last Name (STitle) **]
and primary care provider.
.
Upon discharge, the patient is afebrile with all vitals stable,
tolerating stage IV diet, ambulating well, and with pain
controlled on po pain medication.
Medications on Admission:
Atenolol
Cardura
Elavil
lisinopril
Prozac
Simvastatin
voltaren
xanax
motrin
Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. Doxazosin 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
10. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Perforated duodenal ulcer
Discharge Condition:
stable
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the emergency department if you develop a fever greater than
101.5, chest pain, shortness of breath, severe abdominal pain,
pain unrelieved by your pain medication, severe nausea or
vomiting, severe abdominal bloating, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness
or swelling around your incisions, or any other symptoms which
are concerning to you.
.
Please do wet to dry dressing changes on your abdominal wound
twice daily. Continue with your stage IV diet until your follow
up appointment. Use the abdominal binders provided at all
times.
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10486**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2169-9-29**] 1:30
Please return to Dr. [**Last Name (STitle) 15645**] office ([**Telephone/Fax (1) 2723**]) on Friday
[**9-1**].
|
[
"V85.4",
"038.9",
"560.81",
"311",
"278.01",
"V45.86",
"493.90",
"532.10",
"250.00",
"995.93",
"530.81",
"272.4",
"401.9",
"E935.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"53.51",
"44.42",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4730, 4736
|
2260, 3640
|
496, 660
|
4806, 4815
|
1781, 2237
|
5516, 5784
|
3766, 4707
|
4757, 4785
|
3666, 3743
|
4863, 5493
|
1556, 1762
|
232, 458
|
688, 1294
|
1316, 1479
|
1495, 1541
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
67,054
| 194,604
|
10130
|
Discharge summary
|
report
|
Admission Date: [**2162-1-15**] Discharge Date: [**2162-1-20**]
Date of Birth: [**2099-8-4**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
coronary artery disease
Major Surgical or Invasive Procedure:
[**2162-1-15**] Coronary artery bypass graft x 3(LIMA-LAD,SVG-dg,SVG-OM)
History of Present Illness:
This is a 62 year old male with known coronary disease. Bypass
surgery was recommended but he wanted to try angioplasty.
Catheterization on [**12-23**] showed left main disease with mild distal
taper, a large anterior descending vessel with a large mid
vessel aneurysm and a 90% stenosis prior to and distal to the
aneurysm,first diagonal mild ostial lesion,90% circumflex
stenosis at OM and widely patent RCA stents. Because of the LAD
aneurysm additional stenting was not a good option and he was
referred for surgery.
Past Medical History:
coronary artery disease
Myocardial infarction in [**2161-10-22**]
s/p RCA stent [**2150**] and RCA bare metal stents x [**2161-10-23**]
Dyslipidemia
Hypertension
Hypothyroidism
Asthma
s/p Tonsillectomy
Social History:
Race: Caucasian
Lives with: Wife
Occupation: Electrical Engineer
Cigarettes: Never
ETOH: Rate
Illicit drug use: Denies
Family History:
Mother died at age 86, s/p CABG.
Father died at age 89, s/p AVR/CABG.
Brother had PCI/stenting in his early 60's.
Physical Exam:
Pulse: 59 Resp: 16 O2 sat: 98% room air
B/P Right: 124/75 Left: 113/75
General: WDWN male in no acute distress
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur - none
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x]
Edema: None
Varicosities: None
Neuro: Alert and oriented. CN 2-12 grossly intact. 5/5 strength
in all extremities with FROM.
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: None
Pertinent Results:
[**2162-1-15**] Echo: PRE-CPB: The left atrium is mildly dilated. A
patent foramen ovale is present. A left-to-right shunt across
the interatrial septum is seen at rest. Left ventricular wall
thicknesses are normal. Overall left ventricular systolic
function is normal (LVEF>55%). The right ventricular cavity is
mildly dilated with normal free wall contractility. 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 leaflets are structurally normal. Trace to mild mitral
regurgitation is seen.
POST-CPB: The patient is in sinus rhythm. The patient is on no
inotropes. Biventricular function is unchanged. Mitral
regurgitation is unchanged. The aorta is intact
post-decannulation.
.
[**2162-1-18**] 10:30AM BLOOD WBC-9.3 RBC-2.75* Hgb-9.0* Hct-26.2*
MCV-95 MCH-32.7* MCHC-34.3 RDW-13.1 Plt Ct-134*
[**2162-1-18**] 10:30AM BLOOD Plt Ct-134*
[**2162-1-18**] 04:20AM BLOOD Mg-2.4
[**2162-1-20**] 04:50AM BLOOD Hct-24.8*
[**2162-1-19**] 05:35AM BLOOD WBC-7.8 RBC-2.57* Hgb-8.4* Hct-24.8*
MCV-97 MCH-32.8* MCHC-33.9 RDW-13.3 Plt Ct-160
[**2162-1-17**] 06:20AM BLOOD WBC-12.1* RBC-2.84* Hgb-9.4* Hct-27.2*
MCV-96 MCH-33.0* MCHC-34.4 RDW-13.2 Plt Ct-129*
[**2162-1-20**] 04:50AM BLOOD Glucose-97 UreaN-16 Creat-0.9 Na-137
K-4.1 Cl-100 HCO3-29 AnGap-12
[**2162-1-19**] 05:35AM BLOOD UreaN-15 Creat-0.8 Na-138 K-4.8 Cl-102
[**2162-1-15**] 03:49PM BLOOD UreaN-16 Creat-0.8 Na-139 K-4.0 Cl-110*
HCO3-22 AnGap-11
Brief Hospital Course:
Mr. [**Known lastname 33852**] was a same day admit and on [**1-15**] was brought to the
Operating Room where he underwent coronary artery bypass graft
x 3 (LIMA, Diag and OM). Please see operative note for further
surgical details.
Following surgery he was transferred to the CVICU for invasive
monitoring in stable condition on no gtts Several hours later he
was weaned from sedation, awoke neurologically intact and
extubated. On post-op day one he was started on beta-blockers
and diuretics and gently diuresed towards his pre-op weight.
Later that day he was transferred to the step-down floor for
further care.
Chest tubes and epicardial pacing wires were removed per
protocol. On POD #3 he went into rapid atrail fibrillation and
was started on IV amiodarone with conversion to sinus rhythm.
he was transitioned to oral Amiodarone and remained in a regular
sinus rhythm. He worked with physical therapy for strength and
mobility.
On [**12/2078**] he was discharged home with appropriate follow up
appointments and medications.
Medications on Admission:
Albuterol Sulfate 2puffs QID prn
**Aspirin 325mg daily
**Effient 10mg daily
Foradil Aerolizer 1 puff twice dailuy
Levoxyl 88mcg daily
Lisinopril 5mg daily
Metoprolol 25mg daily
Nitro SL prn - does not use
Pravastatin 40mg daily
Discharge Medications:
1. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
2. flu vaccine [**2160**] (36 mos+)(PF) 45 mcg (15 mcg x 3)/0.5 mL
Syringe Sig: One (1) ML Intramuscular NOW X1 (Now Times One
Dose).
3. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for PAIN.
5. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
7. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. amiodarone 200 mg Tablet Sig: as directed Tablet PO BID (2
times a day): two (2) tablets twice daily for two weeks, then
0ne (1) tablet twice daily for two weeks, then one tablet daily
untily directed otherwise.
Disp:*100 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Coronary artery disease
s/p Coronary artery bypass graft x 3
Myocardial infarction in [**2161-10-22**]
s/p RCA stent [**2150**] and RCA bare metal stents x [**2161-10-23**]
Dyslipidemia
Hypertension
Hypothyroidism
Asthma
s/p Tonsillectomy
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating with steady gait
Incisional pain managed with Percocet
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema: none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming until cleared by surgeon. Look at
your incisions daily for redness or drainage
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Followup Instructions:
You are scheduled for the following appointments
Surgeon: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 170**]) [**2162-2-17**] at 2:15pm
Cardiologist: Dr. [**Last Name (STitle) **] on [**2-9**] at 10:45 am
Wound check on [**1-26**]//12 at 10:30am in [**Hospital Unit Name **], [**Last Name (un) 6752**] Office
Building
Please call to schedule appointments with:
Primary Care Dr. [**Last Name (STitle) 17025**] ([**Telephone/Fax (1) 6699**]) in [**2-25**] 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:[**2162-1-20**]
|
[
"414.11",
"401.9",
"V45.82",
"410.92",
"413.9",
"427.31",
"244.9",
"272.4",
"414.01",
"493.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
6356, 6411
|
3744, 4784
|
333, 408
|
6694, 6915
|
2173, 3721
|
7838, 8501
|
1340, 1455
|
5062, 6333
|
6432, 6673
|
4810, 5039
|
6939, 7815
|
1470, 2154
|
270, 295
|
436, 962
|
984, 1188
|
1204, 1324
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,041
| 177,648
|
33526
|
Discharge summary
|
report
|
Admission Date: [**2137-6-4**] Discharge Date: [**2137-6-7**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2745**]
Chief Complaint:
Bradycardia
Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y.o. Polish speaking male with h/o paroxysmal afib, Diastolic
HF, several falls and recent [**Hospital1 18**] admissions [**Date range (1) 77733**] after
fall with left humerus fx and on [**4-4**] for decreased
appetite and increased fatigue thought to be due to diastolic
heart failure. During his most recent admission cardiology was
consulted and the recommended event montor to eval for arhythmia
as a possible cause of falls, but pt refused. They also
recommended holding off on coumadin for treatement of Afib, and
using only aspirin given multiple falls. Per report, patient was
more lethargic at his NH today and was responsive only to
painful stimuli, he was found to by bradycardic to the 40s and
hypotensive with SBPs in the 80s. He received atropine 1 mg in
the field with increase in his HR to 60s and was brought to the
ED.
.
In the ED, initial vitals were T: 96.8 HR:55 BP:90/38 RR:18
O2Sat:100% on NRB. Patient received 9 L of NS with UOP of about
100 cc and no response in his BP. He then developed abdominal
distention and underwent a CT abdomen, which revealed evidence
of volume overload. CXR showed a resolving right-sided pleural
effusion. He had 1 episode of bradycardia to the 30s and
received atropine 0.5 mg. He was admitted for further
management of bradycardia and hypotension.
Past Medical History:
Diastolic heart failure
2+ MR, 3+ TR
Afib
Left humerus fracture [**2137-3-15**]
Recurrent falls
Social History:
Origially from Poland. Worked as a chemistry teacher. Came to US
after the war. was living independently prior to last admission.
Ambulated with cane. Has supportive son [**Name (NI) **] who is HCP. [**Name (NI) **]
would visit with him 5 days/week but had increasing concern for
his safety at home. Wife lives in a NH secondary to stroke. Also
has a daughter who is not really involved. Has remote h/o
tobacco >40 yrs and denies etoh. He deferred to his son
regarding code status who confirms that his father does not want
life-prolonging measures and prefers to focus on quality.
Confirms DNR status.
Previously wore hearing aids, but has not worn for years. Also
has old broken glasses that he no longer wears.
Family History:
NC
Physical Exam:
Skin warm and dry, NAD. Frail, cachetic male. Alert, engaging,
but unable to communicate as he cannot hear the interpretor on
the phone
HEENT: MMM dry, no teeth
Pulm: decreased breath sounds at bases bilaterally R>L
CV: distant heart sounds, [**Last Name (un) 3526**], [**Last Name (un) 3526**], no murmur
Abd: distended but soft, +BS, non-tender
EXT: 1+ DP pulses, no edema
Neuro: awake, movinf all 4 extremiti
Pertinent Results:
[**2137-6-4**] 05:31PM WBC-7.6 RBC-3.77* HGB-11.3* HCT-34.7* MCV-92
MCH-30.0 MCHC-32.6 RDW-14.1
[**2137-6-4**] 05:31PM NEUTS-80.1* LYMPHS-15.1* MONOS-3.8 EOS-0.9
BASOS-0.2
[**2137-6-4**] 05:31PM PLT COUNT-227
[**2137-6-4**] 05:27PM GLUCOSE-120* UREA N-29* CREAT-1.6* SODIUM-136
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
[**2137-6-4**] 05:27PM CK(CPK)-20*
[**2137-6-4**] 05:27PM cTropnT-<0.01
[**2137-6-4**] 05:27PM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-2.2
[**2137-6-4**] 05:27PM PT-13.0 PTT-29.6 INR(PT)-1.1
[**2137-6-4**] 11:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR
[**2137-6-4**] 11:15PM URINE RBC-21-50* WBC-[**2-20**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2137-6-4**] 11:15PM URINE HYALINE-0-2
[**2137-6-4**] 11:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2137-6-5**] 03:22AM BLOOD PT-13.5* PTT-29.1 INR(PT)-1.2*
[**2137-6-5**] 03:22AM BLOOD CK(CPK)-33*
[**2137-6-5**] 03:22AM BLOOD CK-MB-3 cTropnT-0.01
.
[**6-4**] CT ABD and Pelvis - prelim read Stranding in the mesentery
is likley related to fluid overload, without
evidence of large abscess or hemorrhage.
Brief Hospital Course:
Assessment/Plan: [**Age over 90 **] y.o. male with h/o syncope with falls, afib,
recent humerus fx is s/p pna with known large right pleural
effusion,
presents with lethargy and weakness found to be bradycardic and
hypotensive
.
# Bradycardia: Unclear etiology as not on BB, CCB or digoxin.
Unclear if patient's bradycardia and hypotension were trully
related. Was in slow atrial fibrillation on admission.. Likely
age-related sclerotic conduction system disease. Evaluated by EP
per family wishes, no role for ICD.
# Hypotension: No focal infectious etiology. Perhaps volume
depletion secondary to diarrhea.
# ARF: Likely pre-renal in etiology given recent diarrhea versus
ATN given hypotension.
Resolved.
# Diarrhea: Unclear etiology. He had loose stools on his last
admission as well that were attributed to narcotic withdrawl and
antibiotics and chronic stool softner use. Of note, he was also
on amoxicillin at the nursing home for unclear reasons.
.
# Diastolic CHF: Patient has received 9 L IVF. No LE edema, but
does have pleural effusion and abdominal edema.
Patient restarted on home lasix day prior to d/c, satting well
on RA on d/c.
.
# Pleural effusion: He has had a loculated pleural effusion in
setting of recent pna, possible parapneuomnic effusion vs
transudate from right heart failure. No fevers, no elevtaed WBC
to suggest active infection.
-Patient continued on home diuresis.
.
# Afib: actually in slow afib. not anticoagulated secondary to
patients wishes.
- continue ASA
.
# h/o Humerus fx: tylenol PRN
.
# FEN: regular heart healthy diet, nectar thickened liquids
.
# ACCESS: PIVs
.
# PPX: SC heparin, fall precautions, aspiration precautions
.
# Code Status: DNR/DNI, no CVL, no invasive procedures, however
patient's son did want evaluation by EP for question of
pacemaker placement.
# Contact: HCP [**Name (NI) **] [**Name (NI) 77734**] [**Telephone/Fax (1) 77735**]
.
Medications on Admission:
.
CURRENT MEDICATIONS: (per nursing home list)
1. Aspirin 325 mg Po Qday
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
3. Docusate Sodium 100 mg PO BID
4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
5. Lasix 20 mg PO once a day.
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO BID
7. MOM PRN
8. [**Name2 (NI) 77736**] 875 mg PO BID ([**Date range (1) 77737**])
9. Dulcolax PRN
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO daily
(): mix with 8 ounces of water.
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
4. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
5. Vitamin D-3 400 unit Tablet Sig: Two (2) Tablet PO once a
day.
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
On [**Location (un) **] - [**Location (un) **]
Discharge Diagnosis:
Bradycardia
Hypotension
Acute Renal Failure
Diastolic Heart Failure Acute
Delirium
Discharge Condition:
Vital Signs Stable
Discharge Instructions:
Return if having difficulty breathing, fevers, chills (pending
final CMO decision by family).
Followup Instructions:
Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2137-6-11**] 8:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2137-6-11**] 8:40
Pt's family to schedule f/u appt with PCP.
|
[
"584.9",
"458.9",
"787.91",
"428.33",
"V15.82",
"427.31",
"424.0",
"276.51",
"V54.11",
"397.0",
"780.09",
"V66.7",
"427.89",
"789.59",
"428.0",
"V15.88"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7074, 7147
|
4181, 6089
|
284, 290
|
7273, 7293
|
2967, 4158
|
7435, 7745
|
2516, 2520
|
6566, 7051
|
7168, 7252
|
6115, 6117
|
7317, 7412
|
2535, 2948
|
221, 246
|
6139, 6543
|
318, 1647
|
1669, 1767
|
1783, 2500
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
3,705
| 159,174
|
801
|
Discharge summary
|
report
|
Admission Date: [**2149-7-30**] Discharge Date: [**2149-8-5**]
Date of Birth: [**2087-11-13**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Confusion & agitation
Major Surgical or Invasive Procedure:
Endotracheal intubation
Central venous line & arterial line placement
EEG
History of Present Illness:
61yo male with HBV cirrhosis complicated by portal HTN,
gastric varicies, and s/p TIPS who was transferred to [**Hospital1 18**] from
outside facility for confusion & agitation. He was also noted
to be jaundiced with asterixis. Pt had also sustained a fall
with facial trauma several weeks ago.
In the ED, he desaturated to 80% on 6L/NC and was found to
have EKG evidence of an acute anterior MI. He was intubated for
airway protection & seen by cardiology. He had an emergent ECHO
which demonstrated an EF of 40-50%. He was felt to be too high
risk for anticoagulation or catheterization, and was treated
medically with beta-blocker, aspirin, and plavix. He also
received a chest CTA to evaluate a widened mediastinum & LLL
consolidation prior to transfer to MICU.
Past Medical History:
HBV with cirrhosis
Portal hypertension
Gastric varicies
s/p TIPS [**1-/2149**]
Hepatic encephalopathy
HPV
Gastroparesis
Diverticulosis s/p partial colectomy
s/p cholecystectomy
Hypothyroidism
Liver hemangioma s/p radiofreq-ablation
s/p R knee surgery
Social History:
Lives with partner.
Worked as a volunteer @ VFW.
Family History:
Father deceased - liver disease.
Mother alive.
[**Name2 (NI) **] siblings.
Physical Exam:
VS - 98.2, 104, 119/78, 15, 100% on vent:
AC/100%/VT-500/PEEP-8/RR-12
Gen - sedated/intubated, jaundiced male
HEENT - icteric, PERRL, large L periorbital/maxillary bruise,
stiches above eyebrow, moist mucous membranes
Neck - supple, no LAD
CV - RRR, no m/r/g
Lungs - CTA bilat, no wheezes/rhonchi/crackles, diminished L
base
Abd - soft, NT/ND, +BS, no dullness, guiac neg
Ext - no edema
Neuro - sedated
Pertinent Results:
[**2149-7-30**] 07:25PM GLUCOSE-102 UREA N-19 CREAT-0.5 SODIUM-130*
POTASSIUM-5.3* CHLORIDE-98 TOTAL CO2-25 ANION GAP-12
[**2149-7-30**] 07:25PM ALT(SGPT)-72* AST(SGOT)-87* CK(CPK)-45 ALK
PHOS-184* AMYLASE-18 TOT BILI-10.8*
[**2149-7-30**] 07:25PM LIPASE-10
[**2149-7-30**] 08:22PM LACTATE-2.2*
[**2149-7-30**] 07:25PM cTropnT-0.02*
[**2149-7-30**] 07:25PM CK-MB-NotDone
[**2149-7-30**] 07:25PM ALBUMIN-2.1* CALCIUM-9.6 PHOSPHATE-3.2
MAGNESIUM-1.7
[**2149-7-30**] 07:25PM AMMONIA-73*
[**2149-7-30**] 07:25PM WBC-4.4# RBC-3.55* HGB-13.0* HCT-37.7*
MCV-106* MCH-36.8* MCHC-34.6 RDW-17.6*
[**2149-7-30**] 07:25PM NEUTS-78.5* BANDS-0 LYMPHS-11.4* MONOS-8.8
EOS-1.1 BASOS-0.3
[**2149-7-30**] 07:25PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-3+ MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2149-7-30**] 07:25PM PLT SMR-LOW PLT COUNT-125*#
[**2149-7-30**] 07:25PM PT-19.2* PTT-44.0* INR(PT)-2.3
[**2149-7-30**] 08:22PM TYPE-ART PO2-296* PCO2-47* PH-7.41 TOTAL
CO2-31* BASE XS-4
[**2149-7-30**] 07:25PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.028
[**2149-7-30**] 07:25PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-8* PH-6.5 LEUK-NEG
[**2149-7-30**] 07:25PM URINE RBC-[**2-14**]* WBC-[**2-14**] BACTERIA-OCC YEAST-NONE
EPI-0-2
[**2149-7-30**] 7:25 pm URINE CULTURE (Final [**2149-8-2**]):
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML..
[**2149-7-30**] 9:10 pm BLOOD CULTURE x 2
AEROBIC BOTTLE (Final [**2149-8-5**]): NO GROWTH.
ANAEROBIC BOTTLE (Final [**2149-8-5**]): NO GROWTH.
[**2149-7-31**] 12:38 am SPUTUM CULTURE (Final [**2149-8-2**]):
STAPH AUREUS COAG + (MSSA)
[**2149-7-30**] ECHO - The left ventricular cavity size is normal.
There is mild regional left ventricular systolic dysfunction
(ejection fraction 50%). The distal anterior septum and a
portion of the apex appear hypokinetic. The right ventricular
size and function appear normal.
[**2149-8-1**] ECHO - The left atrium is mildly dilated. Left
ventricular wall thickness, cavity size, and systolic function
are normal (LVEF>55%). Regional left ventricular wall motion is
normal. There are complex (>4mm) atheroma in the descending
thoracic aorta. There is no evidence of endocarditis. Compared
with the findings of the prior report (tape unavailable for
review) of [**2149-7-30**], there has been no significant change.
[**2149-7-30**] CXR - Left lower lobe collapse/consolidation.
[**2149-7-30**] Chest CT - Left lower lobe consolidation and patchy
opacities seen in the remaining left lung consistent with
infectious process. No aortic dissection.
[**2149-7-30**] Abd CT - Cirrhotic liver with TIPS stent. Splenomegaly.
New enhancing nodular foci within the right lobe of the liver
at the dome and surrounding the previous site of RF ablation,
most compatible with local multifocal recurrence.
[**2149-7-30**] Head CT - No intracranial hemorrhage or mass effect.
[**2149-7-31**] TIPS U/S - Reduced overall rate of flow through the
tips compared with
previous exam, at which time flow was approximately 80-85 cm per
second. Flow
across the TIPS is now uniformly approximately 40-45 cm per
second.
Brief Hospital Course:
Mr. [**Known lastname 5715**] was admitted via the ED on [**2149-7-30**] following
presentation with mental status changes & subsequent respiratory
failure. He was intubated & transferred to MICU upon admission.
In addition to his end-stage liver failure & hepatic
encephalopathy, he was also found to have a LLL pneumonia & a
new ST-elvation MI. He was not a candidate for cardiac cath or
anticoagulation, so his MI was treated medically with
beta-blocker/asa & initially plavix, which was later stopped.
He remained intubated & mechanically ventilated while his
pneumonia was treated with antibiotics (cipro/vanco). Pt
discovered to also have enterococcus/staph UTI sensitive to
current antibiotics. Neurology consulted on [**8-4**] for question
of seizure like activity with rhythmic eye & arm movements -
clinically diagnosed with status epilepticus, bedside EEG with
delta slowing, low amplitude waves. Based on his poor progress
and poor prognosis, following a discussion [**2149-8-5**] with the
patient's mother & partner, the focus of care was shifted to
comfort measures only (based on previously expressed wishes),
the patient was eventually extubated, and expired at 17:40 PM on
[**2149-8-5**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5716**].
Medications on Admission:
Levothyroxine
Adefavir
Protonix
Aldactone
Iron
Lactulose
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
Left lower lobe pneumonia
Respiratory failure s/p intubation
Coagulopathy
Hyponatremia
Acute myocardial infarction
Seizure - status epilepticus
Hepatitis B with cirrhosis
Portal hypertension s/p TIPS [**1-/2149**]
Gastric varicies
Hepatic encephalopathy
Hypothyroidism
Discharge Condition:
Deceased
Discharge Instructions:
N/A
Followup Instructions:
N/A
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
[
"482.41",
"507.0",
"572.2",
"599.0",
"570",
"286.7",
"518.81",
"038.9",
"410.11"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"96.6",
"88.72",
"96.72",
"96.04",
"99.04",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6762, 6771
|
5337, 6627
|
294, 369
|
7084, 7094
|
2045, 5314
|
7146, 7278
|
1531, 1607
|
6734, 6739
|
6792, 7063
|
6653, 6711
|
7118, 7123
|
1622, 2026
|
233, 256
|
399, 1175
|
1197, 1449
|
1465, 1515
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,723
| 147,134
|
43758
|
Discharge summary
|
report
|
Admission Date: [**2192-9-5**] Discharge Date: [**2192-9-7**]
Date of Birth: [**2127-5-7**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hemoptysis, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
65-year-old M with metastatic pancreatic cancer status post
disease progression after two cycles of gemcitabine and 2 cycles
of capecitabine and oxaliplatin, recently initiated on 3rd line
chemotherapy with taxotere on [**2192-8-31**] who presented to the ED
with lethargy, and abdominal pain and had 2 episodes of
hematemesis during evaluation. Per his wife and daughter, he had
severe N/V [**8-31**] following chemo which resolved with antiemetics.
He has complained of odynophagia, markedly decreased PO intake,
fatigue and retching vs belching over the last week. He has also
been intermittently confused over the last week with worse
confusion today and increasing somnolence since approximately
7pm. He is on a fentanyl patch which was recently uptitrated and
percocet which he last took at noon today.
In the ED, initial VS were: HR 118, BP 127/91, RR 24, Sat 98%
RA.He had two episodes of dark emesis with clots around 4pm
that patient told his daughter "tasted like blood." He was given
PPI bolus and gtt and GI was consulted. His blood pressure
remained stable with HR to 110's which has been his baseline
heart rate over the last several months. Labs were notable for
new bilirubin elevation 1.5-->4.1 in the past 5 days,
leukopenia, thrombocytopenia, elevated INR, elevated AP, and
increased transaminases. RUQ US showed biliary dilitation
concerning for obstruction from known pancreatic mass. He has
never had dedicated upper endoscopy in the past. No history of H
pylori or ulcers. Last EUS in [**4-/2192**] showed pancreatic tumor
invading into D1.
On arrival to the MICU, patient's VS 97.7 HR 122 134/89 RR 15
95% RA.
Past Medical History:
Metastatic pancreatic ca
COPD
History of OSA
Uvelectomy
Tonsilectomy and repair of deviated septum
Social History:
- hx 50 pack year smoking - quit in [**2191-12-18**], hx [**1-20**]
drinks/day, quit in [**12/2191**], retired toll collector at [**Location (un) 26358**]
- Last colonoscopy about 10yrs ago: normal
Family History:
- Son with melanoma, no family hx of pancreatic cancer,
pancreatitis
Physical Exam:
Admission Physical Exam:
Vitals: 97.7 HR 122 134/89 RR 15 95%
General: somnolent, opens eyes to voice, not following commands
HEENT: Sclera anicteric, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, +crackles left vase
Abdomen: hypoactive bowel sounds, +distended, + tenderness to
palpation and guarding bilateral lower quadrants, no rebound
GU: foley in place
Ext: Warm, well perfused, 2+ pulses, 2+ pitting edema bilateral
lower extremities to ankles
Neuro: face symmetric, not following commands, 2+ reflexes
bilaterally, moves all 4 extremities spontaneously
Discharge Physical Exam: EXPIRED
Pertinent Results:
[**2192-9-5**] 02:20PM PT-17.2* PTT-46.4* INR(PT)-1.6*
[**2192-9-5**] 02:20PM PLT SMR-LOW PLT COUNT-106*#
[**2192-9-5**] 02:20PM NEUTS-87* BANDS-1 LYMPHS-6* MONOS-0 EOS-0
BASOS-0 ATYPS-1* METAS-1* MYELOS-4*
[**2192-9-5**] 02:20PM WBC-2.0*# RBC-3.83* HGB-12.1* HCT-37.8*
MCV-99* MCH-31.6 MCHC-32.0 RDW-16.1*
[**2192-9-5**] 02:20PM ALBUMIN-3.0*
[**2192-9-5**] 02:20PM ALT(SGPT)-44* AST(SGOT)-74* ALK PHOS-282* TOT
BILI-4.1*
[**2192-9-5**] 02:20PM GLUCOSE-144* UREA N-30* CREAT-0.5 SODIUM-134
POTASSIUM-4.8 CHLORIDE-95* TOTAL CO2-33* ANION GAP-11
[**2192-9-5**] 02:27PM LACTATE-3.3*
[**2192-9-5**] 03:10PM URINE RBC-5* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-1
[**2192-9-5**] 03:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-4* PH-5.5
LEUK-NEG
[**2192-9-5**] 09:52PM CALCIUM-8.2* PHOSPHATE-2.2*# MAGNESIUM-2.0
[**2192-9-5**] 09:52PM CK-MB-2 cTropnT-<0.01
[**2192-9-5**] 09:52PM ALT(SGPT)-41* AST(SGOT)-71* CK(CPK)-43* ALK
PHOS-269* TOT BILI-4.5* DIR BILI-3.5* INDIR BIL-1.0
[**2192-9-5**] 10:16PM LACTATE-2.5*
[**2192-9-5**] 10:44PM TYPE-ART TEMP-36.5 RATES-/22 PO2-67* PCO2-39
PH-7.47* TOTAL CO2-29 BASE XS-4 INTUBATED-NOT INTUBA
Imaging:
Abdominal Ultrasound [**2192-9-5**]:
FINDINGS: The liver demonstrates a heterogeneous echotexture,
compatible with known metastatic lesions. Mild intrahepatic
biliary dilatation is present. The portal vein is patent with
directionally appropriate flow. The gallbladder is nondistended,
shows no wall edema, and there is no son[**Name (NI) 493**] [**Name2 (NI) 515**] sign.
A tiny amount of pericholecystic ascites is present. The CBD is
prominent measuring 9 mm in caliber. The pancreas could not be
evaluated due to overlying bowel gas. IMPRESSION: Extra- and
intra-hepatic biliary dilatation as described above, in a
patient with pancreatic head mass concerning for obstruction due
to the pancreatic mass.
CXR PA+lateral [**9-5**]:
FINDINGS: Again is seen a left-sided Port-A-Cath with its tip in
the mid SVC. The heart size is within normal limits. The
mediastinal contours are within normal limits. The hilar
contours are prominent but likely within normal limits. The
lungs are clear of consolidation or edema. There is no pleural
effusion or pneumothorax. No subdiaphragmatic free air is
present. Mild degenerative changes are seen at the lower
thoracic spine, primarily in the form of small anterior
osteophytes. IMPRESSION: No acute cardiopulmonary abnormality.
CT head [**2192-9-6**]: IMPRESSION: 1. Limited study due to motion
artifact. No definite hemorrhage or mass effect. 2. Punctate
7mm hyperdensity in the right cerebellum may represent a
granuloma or other infectious etiology. MR with contrast can be
considered for further evaluation.
CTA chest/abdomen: IMPRESSION: 1. No PE or acute aortic
syndrome.
2. Emphysema. 3. Fluid within the esophagus placing the
patient at increased risk of aspiration. 4.
Perihepatic/perisplenic ascites and heterogeneous liver
compatible with metastases.
Brief Hospital Course:
65M with metastatic pancreatic cancer with known duodenal mass
who presented with abodminal pain and hematemesis with altered
mental status and was originally admitted to the [**Hospital 332**] medical
ICU. On arrival the patient was noted to be altered.RUQ
ultrasound showed ductal dilatation and elevated alk phos with
tenderness on exam was concerning for possible cholangitis as
the source of a neutropenic sepsis. Discussions with his family
regarding the level of aggressiveness of his care were discussed
and it was felt that although he may temporarily benefit from an
ERCP if it was cholangitis it was also very possible that given
his comorbidities and current state may not be able to be
extubated and the family decided not to pursue this and instead
to make hte patient CMO. He was orginally covered with IV zosyn
which was stopped when the goals of care were changed. The
patient's oncologist was involved in these discussions and
palliative care was consulted and assisted in helping with
making the patient comfortable. On [**2192-9-7**] at 9:08pm the
patient lost his pulse and was declared dead. His family was at
the bedside at the time and declined an autopsy.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Albuterol Inhaler 1 PUFF IH DAILY
2. Fentanyl Patch 50 mcg/h TP Q72H
3. Advair Diskus (100/50) 1 INH IH Frequency is Unknown
4. Lorazepam 1 mg PO Q8H:PRN anxiety, nausea, insomnia
5. Omeprazole 20 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Oxycodone-Acetaminophen (5mg-325mg) [**12-19**] TAB PO Q4H:PRN pain
8. Prochlorperazine 10 mg PO Q8H:PRN nausea
9. Sertraline 25 mg PO DAILY
10. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis
Metastatic pancreatic cancer
Discharge Condition:
expired
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"197.4",
"496",
"196.2",
"038.9",
"V87.41",
"338.3",
"V49.86",
"576.8",
"V66.7",
"780.97",
"V15.82",
"157.0",
"578.0",
"197.7",
"288.00",
"305.03",
"197.6",
"789.07",
"327.23",
"576.1",
"995.92"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8044, 8053
|
6245, 7433
|
342, 348
|
8132, 8278
|
3186, 6222
|
2372, 2443
|
8012, 8021
|
8074, 8111
|
7459, 7989
|
2483, 3132
|
269, 304
|
376, 2017
|
2039, 2140
|
2156, 2356
|
3158, 3167
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,079
| 194,586
|
44659+58746
|
Discharge summary
|
report+addendum
|
Admission Date: [**2145-10-19**] Discharge Date: [**2145-10-22**]
Service:
Briefly, this is an 81-year-old male who has had a prior
history of coronary artery disease, status post coronary
artery bypass graft in the past who is also known to have
severe aortic stenosis, moderate ventricular dysfunction,
congestive heart failure, peripheral vascular disease status
post right carotid endarterectomy, hypertension, atrial
fibrillation and insulin dependent diabetes mellitus who
presented with dyspnea on exertion. He was found to have
severe aortic stenosis with a calculated area of 0.6 and a
gradient of 40.
The patient was taken to the Operating Room on [**2145-10-19**] where
a pericardial AVR was performed. The patient was transferred
postoperatively to the CSRU where he recovered. The patient
was transferred postoperatively and was slowly weaned from
his ventilator. He did well with the wean and was able to be
extubated on the end of postoperative day #1. The patient's
pressors were weaned and the blood pressure tolerated well.
The patient's permanent pacemaker was set at DDD at 80 and
tolerated well. Foley was kept in place at that time. On
the 19th, it was removed in the evening. His chest tubes
were also removed at that time and his external pericardial
pacing wires pulled on the 19th after being transferred to
the floor.
Physical therapy was consulted to begin working with him to
improve his ambulation and his endurance. They felt that he
was capable of moving around, however he was significantly
weak and needed a lot of guidance. At that time, it was
decided that the patient would benefit most from
rehabilitation placement. The patient did well in aggressive
pulmonary toilet and continued diuresis was continued. The
patient was screened for rehabilitation on [**2145-10-22**] and is
awaiting rehabilitation placement at this time.
DISCHARGE MEDICATIONS:
1. Amiodarone 200 mg po qd
2. Lipitor 10 mg po qd
3. Percocet 1 to 2 tablets po q4h prn
4. Regular insulin sliding scale
5. Enteric coated aspirin 325 po qd
6. Zantac 150 po bid
7. Colace 100 mg po bid
8. KCL 20 milliequivalents po bid
9. Lasix 20 mg po bid
Th[**Last Name (STitle) 1050**] is discharged to a rehabilitation in stable
condition. He is instructed to follow up in one to two weeks
with his primary care physician, [**Name10 (NameIs) **] two to four weeks with
cardiology with his cardiologist and follow up with Dr. [**Last Name (Prefixes) 411**] in four weeks. The patient is discharged to
rehabilitation in stable condition.
DISCHARGE DIAGNOSES:
1. Coronary artery disease, status post coronary artery
bypass graft
2. Severe AS, status post AVR
3. Systolic dysfunction with congestive heart failure
4. Arrhythmia status post pacemaker placement
5. Diabetes mellitus
6. Hypertension
The patient was discharged in stable condition.
Please see addendum for any clarifications in medications as
well as exact discharge date.
[**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**]
Dictated By:[**First Name (STitle) **]
MEDQUIST36
D: [**2145-10-22**] 09:50
T: [**2145-10-22**] 09:57
JOB#: [**Job Number 95580**]
Name: [**Known lastname 15153**], [**Known firstname **] Unit No: [**Numeric Identifier 15154**]
Admission Date: [**2145-10-19**] Discharge Date: [**2145-10-25**]
Date of Birth: [**2064-3-15**] Sex: M
Service:
Patient is discharged to rehab facility on [**2145-10-25**].
Discharge medications include amiodarone 200 mg po q day,
Lipitor 10 mg po q day, Percocet 1-2 tablets po q4 hours prn,
regular insulin sliding scale, EC-ASA 325 po q day, Zantac
150 mg po bid, Colace 100 mg po bid, [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq po bid,
and Lasix 20 mg po bid.
The patient's discharging diagnoses include coronary artery
disease status post coronary artery bypass graft, severe
stenosis, status post aortic valve replacement with
pericardial valve, moderate systolic ventricular dysfunction,
congestive heart failure.
Th[**Last Name (STitle) 1293**] is discharged to rehabilitation facility in
stable condition. Instructed to followup in four weeks with
Dr. [**Last Name (Prefixes) **] and to followup with his primary care
physician [**Last Name (NamePattern4) **] [**2-3**] weeks and his cardiologist in four weeks.
The patient is discharged in stable condition.
[**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 681**]
Dictated By:[**First Name (STitle) 1589**]
MEDQUIST36
D: [**2145-10-24**] 14:47
T: [**2145-11-1**] 05:46
JOB#: [**Job Number 15155**]
|
[
"424.1",
"250.00",
"414.00",
"443.9",
"401.9",
"427.31",
"V45.81",
"428.0",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2587, 4728
|
1912, 2566
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
45,835
| 100,337
|
3322+55457
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-12-17**] Discharge Date: [**2174-12-29**]
Date of Birth: [**2095-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
coronary artery bypass grafts (LIMA-LAD, SVG-OM1,
SVG-OM2,SVG-DG) [**12-21**]
left heart cathaterization and coronary angiography
History of Present Illness:
This is a 79 year-old male with a history of hypertension,
hyperlipidemia, PVD, malignant melanoma and non-hodgkins
lymphoma who presents for evaluation of chest pain. The pain has
felt squeezing in nature, does not radiate, is not associated
with other symtpoms and has been episodic for the past 5 days.
It typically had resolved quickly but when it did not resolve
last night after several minutes he came to the hospital. No
nausea, diaphoresis, or shortness of breath. There is no history
of exertional dyspnea, PND, orthopnea, presyncope, syncope, or
palpitations.
In the ED his EKG was WNL but cardiac enzymes were positive and
this was felt to be a NSTEMI. A head CT ruled out brain
metastasis and the patient was started on a heparin infusion,
aspirin 325, metoprolol 25mg. He was admitted for cardiac
catheterization.
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
h/o Stage IIIB melanoma
h/o B-cell non-Hodgkinds lymphoma
History of basal cell carcinoma.
benign prostatic hypertrophy.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He is a retired
schoolteacher and administrator. He has been married for more
than 50 years. He has two children and five grandchildren.
.
Family History:
Family history significant for father who had heart disease and
possible anemia. Mother died of heart disease. He has a brother
who is healthy, sister died from complications of obesity,
likely
heart disease. His children are healthy. He has one grandchild
with celiac disease.
Physical Exam:
Discharge:
Awake and alert. Has advanced to soft diet as directed by
speech pathology evaluation.
Lungs- clear
Cor: NSR at 80.
Extremeties- warm, without edema
Wounds- clean and dry. Stable sternum (PT does rarely complain
of clicking, but it is lateral to sternum)
122/65. Wt 99kg (v.100 preop)
Pertinent Results:
[**Hospital1 18**] ECHOCARDIOGRAPHY REPORT
[**Known lastname 15423**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 15424**] (Complete)
Done [**2174-12-21**] at 1:52:25 PM FINAL
Referring Physician [**Name9 (PRE) **] Information
[**Name9 (PRE) **], [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **].
[**Last Name (NamePattern1) **] Information
Date/Time: [**2174-12-21**] at 13:52 Interpret MD: [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD
Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Last Name (NamePattern5) 9958**], MD
Doppler: Full Doppler and color Doppler Test Location:
Anesthesia West OR cardiac
Contrast: None Tech Quality: Adequate
Tape #: 2008AW33-: Machine:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.6 cm <= 4.0 cm
Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: *1.6 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: >= 45% >= 55%
Aorta - Annulus: 2.1 cm <= 3.0 cm
Aorta - Sinus Level: 3.2 cm <= 3.6 cm
Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm
Aorta - Ascending: 2.8 cm <= 3.4 cm
Aorta - Arch: *3.2 cm <= 3.0 cm
Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm
Aortic Valve - Peak Velocity: 1.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: 15 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Aortic Valve - Valve Area: *1.3 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No ASD by 2D or
color Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Moderate symmetric LVH. Normal LV
cavity size. Mild regional LV systolic dysfunction.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal diameter of aorta at the sinus, ascending and arch
levels. Normal descending aorta diameter. Simple atheroma in
descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Moderately thickened
aortic valve leaflets. Mild AS (AoVA 1.2-1.9cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+)
MR.
TRICUSPID VALVE: Physiologic TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: No pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE-BYPASS: The left atrium is mildly dilated. No atrial septal
defect is seen by 2D or color Doppler. There is moderate
symmetric left ventricular hypertrophy. The left ventricular
cavity size is normal. There is mild regional left ventricular
systolic dysfunction with hypokinesis of the inferior and
inferiolateral walls. EF is approximately 50%. Right ventricular
chamber size and free wall motion are normal. There are simple
atheroma in the descending thoracic aorta. There are three
aortic valve leaflets. The aortic valve leaflets are moderately
thickened. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
POST-BYPASS:
Left and right ventricular function is preserved. The aorta is
intact. The remainder of the examination is unchanged.
Dr.[**Last Name (STitle) 914**] was notified of the results in person at the time of
the study.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 15425**] [**Name8 (MD) 15426**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2174-12-22**] 15:02
FInal Report
STUDY: Carotid series complete.
FINDINGS: Duplex evaluation was performed of bilateral carotid
arteries.
There is mild plaque seen in the proximal ICAs bilaterally.
On the right, peak velocities are 90, 90, and 123 cm/sec in the
ICA, CCA, and ECA respectively. This is consistent with less
than 40% stenosis.
On the left, peak velocities are 104, 101, and 83 cm/sec in the
ICA, CCA, andECA respectively. This is consistent with less than
40% stenosis.
There is antegrade vertebral flow bilaterally.
IMPRESSION: Bilateral less than 40% carotid stenosis.
Brief Hospital Course:
This 79 year old male presented to the emergency room with a
complaint of chest pain. His EKG showed no acute changes but his
cardiac bio markers were elevated. He was admitted and
diagnostic cardiac catheterization showed severe coronary artery
disease. Cardiac surgery was consulted for evaluation for
revascularization.
He was brought to the operating room on [**2174-12-21**] and underwent
4-vessel CABG. Please see operative note for full details. The
surgery was uncomplicated and he weaned from bypass on
neosynephrine. He was transferred to the cardiac surgical ICU
post-operatively for invasive hemodynamic monitoring. He was
extubated on POD 1. He required intravenous nitroglycerine for
several days to control his blood pressure.
He was gently diuresed towards his pre-operative weight and was
transferred to the step-down floor on POD 5. He failed speech
and swallow on POD 5 and had a video-swallow study on POD 6 he
was able to take a ground solids/thin liquids diet. This was
tolerated and advanced to soft on [**12-28**].
He remained stable and was ready for transfer to rehabilitation
for further recovery prior to return home. Discharge
instructions, medications and follow up instructions were
outlined with the transfer information.
Medications on Admission:
Lipitor 10mg po daily
Terazosin 5mg po daily
Diovan 160mg daily
Atenolol 50 mg po daily
Aspiring 81mg po daiily
Discharge Medications:
1. Influen Tr-Split [**2174**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed. Tablet(s)
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
12. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
13. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
16. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED): 120-160-2units SQ
161-200-4units SQ
201-240-6units SQ
241-280-8units SQ.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass graft
benign prostatic hypertrophy
noninsulin dependent diabetes mellitus
hyperlipidemia
h/o B cell nonHodgkins Lymphoma
peripheral vascular disease
hypertension
h/o melanoma
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**])
Dr. [**Last Name (STitle) 131**] in 1 week ([**Telephone/Fax (1) 133**])
Dr. [**Last Name (STitle) 1016**] in 2 weeks
please call for appointments
Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse
([**Telephone/Fax (1) 3071**])
Completed by:[**2174-12-28**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 2438**]
Admission Date: [**2174-12-17**] Discharge Date: [**2174-12-29**]
Date of Birth: [**2095-2-8**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
On the morning of planned discharge [**12-28**] he had sinus
bradycardia to the 40s. he was assymptomatic with BP 120s.
Electrophysiology service consultation was obtained and their
recommendation was to continue low dose beta blockade and let
his rate occassionally fall. He was discharged on the 20th.
Chief Complaint:
bradycardia
Major Surgical or Invasive Procedure:
coronary artery bypass grafts (LIMA-LAD, SVG-OM1,
SVG-OM2,SVG-DG) [**12-21**]
left heart cathaterization and coronary angiography
History of Present Illness:
see prior summary
Past Medical History:
Diabetes
Dyslipidemia
Hypertension
h/o Stage IIIB melanoma
h/o B-cell non-Hodgkinds lymphoma
History of basal cell carcinoma.
benign prostatic hypertrophy.
Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. He is a retired
schoolteacher and administrator. He has been married for more
than 50 years. He has two children and five grandchildren.
.
Family History:
Family history significant for father who had heart disease and
possible anemia. Mother died of heart disease. He has a brother
who is healthy, sister died from complications of obesity,
likely
heart disease. His children are healthy. He has one grandchild
with celiac disease.
Physical Exam:
see summary
Pertinent Results:
see summary
Brief Hospital Course:
see discharge
Medications on Admission:
see discharge summary
Discharge Medications:
1. Influen Tr-Split [**2174**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One
(1) ML Intramuscular ASDIR (AS DIRECTED).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day). Capsule(s)
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed. Tablet(s)
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed.
9. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation QID (4 times a day).
11. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
15. Insulin Regular Human 100 unit/mL Solution Sig: see sliding
scale Injection ASDIR (AS DIRECTED): 120-160-2units SQ
161-200-4units SQ
201-240-6units SQ
241-280-8units SQ.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
Discharge Diagnosis:
coronary artery disease
s/p coronary artery bypass graft
benign prostatic hypertrophy
noninsulin dependent diabetes mellitus
hyperlipidemia
h/o B cell nonHodgkins Lymphoma
peripheral vascular disease
hypertension
h/o melanoma
Discharge Condition:
Good
Discharge Instructions:
Please shower daily including washing incisions, no baths or
swimming
Monitor wounds for infection - redness, drainage, or increased
pain
Report any fever greater than 101
Report any weight gain of greater than 2 pounds in 24 hours or 5
pounds in a week
No creams, lotions, powders, or ointments to incisions
No driving for approximately one month
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 1477**]
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 1477**])
Dr. [**Last Name (STitle) **] in 1 week ([**Telephone/Fax (1) 1154**])
Dr. [**Last Name (STitle) 2439**] in 2 weeks
please call for appointments
Wound check appointment [**Hospital Ward Name **] 2 as instructed by nurse
([**Telephone/Fax (1) 2440**])
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2174-12-29**]
|
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|
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12313, 12563
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,816
| 137,693
|
8475
|
Discharge summary
|
report
|
Admission Date: [**2202-3-22**] Discharge Date: [**2202-4-23**]
Date of Birth: [**2134-2-11**] Sex: M
Service: MEDICINE
Allergies:
Demerol
Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transfer from [**Hospital3 **] after respiratory failure and
STEMI
Major Surgical or Invasive Procedure:
Cardiac catheterization
Placement of an intra-aortic balloon pump
History of Present Illness:
Mr. [**Known lastname **] is a 68 yo male with h/o CAD s/p CABG in [**2196**] with
LIMA to LAD, SVG to OM, SVG to RCA and subsequent
catheterization x2 in [**12/2197**] revealing both SVG grafts down and
receieved stents to LCX, CABG c/b opsteomyelitis with open
wound, OM3, OM4 and RCA, ischemic cardiomyopathy with EF of 35%,
IDDM, COPD and [**Hospital 2091**] transferred from [**Hospital3 2783**] after
respiratory failure and STEMI. He was originally admitted to
[**Hospital3 2783**] in the end of [**Month (only) 404**] for a LLE cellulitis
which was treated with linezolid because of concern of rash with
oxacillin. He was discharged on [**3-18**], but was readmitted on
[**3-19**] after being seen in his PCP's office with severe LLE pain
as he was discharged without narcotics given his history of
narcotic abuse. The wound appeared unchanged and was only
tender in the immediate area of the wound. A pain consult was
obtained given his history of respiratory arrest after receving
morphine the past and he was started on 25 mcg fentanyl patch
and dilaudid 2 mg po Q 4-6H PRN pain. He was admitted to the
medical floor for pain control. Over the course of the past 2
days he was noted to be somnolent and confused, and his dilaudid
was discontinued. He was found to have urinary retention and a
foley was placed. He became increasingly delerious as he had in
the past on narcotics. He was found unresponsive in his room at
11pm with "white froth in his mouth." He was intubated and sent
to the ICU with hypercarbic and hypoxic respiratory failure.
CXR, per report, revealed cardiomegaly and likely aspiration
pneumonitis. He was started on zosyn and vancomycin. EKG
revealed ST elevations in the inferior leads. CE's were obtained
and Trop 0.28->3.32->3.32->5.45. Cardiology was consulted and
patient was started on dopamine gtt, heparin gtt, asa and prn
atropine. Dopamine was attempted to be weaned off but he became
hypotensive and with SBP in 60s and HRs in 30s with high degree
AV block and was restarted on the dopamine drip. He was
transferred to [**Hospital1 18**] for further management.
.
Of note, he recently had a pharmacologic stress test on [**2202-3-6**]
at [**Hospital **] [**Hospital 1459**] Hospital which revealed reported inferior
reversible ischemia evidence of ischemia (final report not
available in records), but after discussion with the patient and
his wife, it was decided that he would not undergo cardiac
catheterization given the risk of renal failure, and per the
discharge summary he had also had a long discussion with his
cardiologist who also thought medical management was the best
option and his lopressor was titrated up to a total of 200 mg
daily, zocor was increased to 80 mg and ACE-I was added to his
regimen.
.
Could not obtain ROS given patient intubated and sedated.
Past Medical History:
1. Left circumflex stent in 3/[**2194**].
2. Catheterization in [**10-5**] with three vessel disease.
3. Status post coronary artery bypass graft x 3 as above.
4. s/p catheterization x2 [**12-6**]- with stent to native right
coronary artery with an occluded saphenous vein grafts and
subsequent catheterization with stents to LCX, OM3 and OM4 .
5. Insulin dependent diabetes mellitus.
6. CRI with a baseline creatinine of 1.8.
7. Hypothyroidism
8. COPD
9. ? PE in [**2196**] per d/c summary in [**2199**]
10. History of ETOH.
11. Pancreatitis.
12. s/p CABG [**11-4**] complicated by osteomyelitis of the sternum.
The patient had a left hemisternectomy in [**2197-1-1**] due
to
infection. Sternal debridement rectus flap and bilateral
pectoralis flaps. Still has open wound since surgery.
13. History of lens transplant in right eye secondary to
cataract.
14. Left hand hematoma [**2199**]
15. Right BKA c/b sepsis in [**2201**]
16. Bilateral carotid stenosis
17. Positive stress test in [**2202-3-4**], but no cath because of fear
of worsening renal failure
18. Lymphoma s/p radiation
19. Left LE cellulitis
20. History of stroke with left hand weakness [**2201**]
21. ? MRSA infection versus colonization
Social History:
He lives with his wife. They have 4 children and 18
grandchildren. Ex-smoker, quit 6 months ago. Has 150 pack-year
smoking history. Prior EtOH use. History of addiction to
narcotics.
Family History:
F: died at 63 of MI
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: T 99.4, BP 105/61 , HR 104, O2 97 % on AC TV 600/18/5/0.4
breathing at a rate of 22
Gen: Middle aged male intubated and sedated.
HEENT: Sclera anicteric. Right pupil slightly reactive but
surgical, left reactive to light. Conjunctiva were pink, ET tube
in place
Neck: Large neck, could not appreciate JVD.
CV: Visible beating of heart under pectoral flap, sternum
absent, tachycardic, RR, normal S1, S2. No murmurs appreciated.
Chest: sternum absent. Few scattered rhonchi bilaterally.
Abd: Obese, soft, mildly distended, No HSM or tenderness. No
abdominal bruits. Open 5 cm x 2 cm wound C/D/I with dressing,
no drainage
Ext: right BKA, warm, diffuse, patchy erythematous rash on RLE.
Right groin line in place. Healing eschar on lateral aspect of
LLE 4cmx2cm with slight surrounding erythema
Skin: dry, flaking erythematous rash on scrotum.
Pulses:
Right: Carotid 2+ without bruit
Left: Carotid 2+ without bruit; 1+ DP, 2+PT
Pertinent Results:
ADMISSION LABS:
[**2202-3-22**] 08:04PM BLOOD WBC-25.6*# RBC-3.34* Hgb-10.2* Hct-31.7*
MCV-95 MCH-30.6 MCHC-32.3 RDW-15.2 Plt Ct-400
[**2202-3-22**] 08:04PM BLOOD Neuts-88.5* Bands-0 Lymphs-5.5* Monos-4.8
Eos-0.1 Baso-0.2
[**2202-3-22**] 08:04PM BLOOD PT-19.0* PTT-150* INR(PT)-1.8*
[**2202-3-22**] 08:04PM BLOOD Glucose-252* UreaN-40* Creat-3.1*# Na-137
K-4.8 Cl-106 HCO3-20* AnGap-16
[**2202-3-22**] 08:04PM BLOOD ALT-137* AST-323* LD(LDH)-601*
CK(CPK)-1591* AlkPhos-186* TotBili-0.6
[**2202-3-22**] 08:04PM BLOOD Albumin-3.1* Calcium-8.3* Phos-3.8 Mg-2.2
[**2202-3-24**] 04:57PM BLOOD freeCa-1.06*
CARDIAC ENZYMES:
[**2202-3-22**] 08:04PM BLOOD CK-MB-213* MB Indx-13.4* cTropnT-3.18*
[**2202-3-23**] 05:14AM BLOOD CK-MB-238* MB Indx-14.4* cTropnT-4.38*
[**2202-3-23**] 12:29PM BLOOD CK-MB-191* MB Indx-16.2* cTropnT-3.75*
[**2202-3-24**] 04:46AM BLOOD CK-MB-94* MB Indx-12.2* cTropnT-3.97*
[**2202-3-24**] 04:37PM BLOOD CK-MB-65* MB Indx-10.6*
[**2202-4-21**] 04:57AM BLOOD WBC-21.8*# RBC-3.39* Hgb-10.2* Hct-32.4*
MCV-96 MCH-30.0 MCHC-31.4 RDW-15.8* Plt Ct-533*
[**2202-4-15**] 06:40AM BLOOD Neuts-68.1 Lymphs-19.9 Monos-7.1 Eos-4.5*
Baso-0.4
[**2202-4-21**] 04:57AM BLOOD Plt Ct-533*
[**2202-4-21**] 04:57AM BLOOD Glucose-150* UreaN-34* Creat-1.4* Na-148*
K-4.6 Cl-111* HCO3-25 AnGap-17
[**2202-4-10**] 05:33AM BLOOD ALT-55* AST-87* LD(LDH)-256* AlkPhos-143*
TotBili-0.6
[**2202-4-21**] 04:57AM BLOOD Calcium-10.5* Phos-3.7 Mg-1.9
[**2202-4-13**] 06:45AM BLOOD calTIBC-280 Ferritn-206 TRF-215
[**2202-3-30**] 04:48AM BLOOD VitB12-1204* Folate-16.8
[**2202-4-1**] 01:56PM BLOOD Ammonia-13
[**2202-4-11**] 06:02AM BLOOD TSH-2.1
[**2202-4-11**] 06:02AM BLOOD Free T4-1.6
[**2202-4-12**] 02:38PM BLOOD PTH-126*
[**2202-4-5**] 06:38PM BLOOD Cortsol-16.4
[**2202-4-15**] 06:08PM BLOOD ANCA-NEGATIVE B
[**2202-4-15**] 06:08PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2202-4-15**] 06:08PM BLOOD RheuFac-39*
[**2202-4-14**] 05:20PM BLOOD CRP-9.1*
[**2202-4-7**] 1:00 pm CSF;SPINAL FLUID TUBE 3.
GRAM STAIN (Final [**2202-4-7**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2202-4-10**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): No Virus isolated so far.
[**2202-4-6**] 3:30 pm Influenza A/B by DFA
Source: Nasopharyngeal aspirate.
**FINAL REPORT [**2202-4-7**]**
DIRECT INFLUENZA A ANTIGEN TEST (Final [**2202-4-7**]):
Negative for Influenza A viral antigen.
DIRECT INFLUENZA B ANTIGEN TEST (Final [**2202-4-7**]):
NEGATIVE FOR INFLUENZA B VIRAL ANTIGEN.
[**2202-4-8**] 3:22 pm STOOL CONSISTENCY: FORMED Source:
Stool.
**FINAL REPORT [**2202-4-9**]**
CLOSTRIDIUM DIFFICILE TOXIN ASSAY (Final [**2202-4-9**]):
FECES NEGATIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
[**2202-4-14**] 6:49 pm BLOOD CULTURE
**FINAL REPORT [**2202-4-20**]**
Blood Culture, Routine (Final [**2202-4-20**]): NO GROWTH.
[**2202-4-10**] 3:35 pm CATHETER TIP-IV Source: right IJ.
**FINAL REPORT [**2202-4-12**]**
WOUND CULTURE (Final [**2202-4-12**]): No significant growth.
[**2202-3-30**] 11:28 pm URINE Source: Catheter.
**FINAL REPORT [**2202-4-1**]**
URINE CULTURE (Final [**2202-4-1**]): NO GROWTH.
RADIOLOGY Final Report
IN-111 WHITE BLOOD CELL STUDY [**2202-4-20**]
IN-111 WHITE BLOOD CELL STUDY
Reason: CAD S/P CABG STEMI MENTAL STATUS CHANGE ? OCCULT
INFECTION
RADIOPHARMECEUTICAL DATA:
480.0 uCi In-111 WBCs ([**2202-4-20**]);
HISTORY: Patient with coronary artery disease post STEMI with
mental status change. Assess for occult infection.
INTERPRETATION: Following the injection of autologous white
blood cells labeledwith In-111, images of the whole body were
obtained at 24 hours.
These images show physiologic distribution of labelled white
cells in the liver,spleen, and bone marrow. There are no
abnormal foci of tracer to suggest occult infection. Note is
made of a right below the knee amputation.
IMPRESSION: No evidence of occult infection. Normal WBC study.
CXR:FINDINGS: As compared to the previous examination, the
nasogastric tube has been removed. There is unchanged evidence
of mild pulmonary edema. No evidence of focal parenchymal
opacity suggestive of pneumonia, no pleural effusions. The size
and the shape of the cardiac silhouette is unchanged.
IMPRESSION: Status post removal of the nasogastric tube,
unchanged. Mild cardiomegaly with mild signs of pulmonary edema,
no pleural effusions, no parenchymal opacities
CT chest/abd/pelvis:1. Compared to the prior exam from [**2199-3-19**], the lungs show progressive emphysema. Note is made of
several small pulmonary nodules/nodular opacity within the left
lower lobe, which is not clearly present on prior exam from [**2196**]
and given emphysema, 12 month follow up is recommended. Small
bilateral pleural effusions and adjacent dependent atelectasis
is identified. A small amount of debris seen dependently in
central airways.
2. Parenchymal calcifications within the pancreas consistent
with chronic pancreatitis.
3. Stable cortical scarring and atrophy involving the upper pole
of the left kidney, unchanged.
4. Mild bladder wall thickening, which may be secondary to
underdistension, however, cystitis cannot be excluded and
therefore recommend correlation with UA.
5. Balloon of Foley catheter is inflated within the prosthetic
urethra and tip appears to project within the vas deferens. This
was discussed with clinical team at time of interpretation.
MRI AND MRA BRAIN AND NECK: There is no signal abnormality on
diffusion series to suggest acute ischemia. There is evidence of
chronic infarction in the subcortical right frontal, right
temporal, and right occipital regions. There is possible chronic
infarct in the left occipital lobe. Only one anterior cerebral
artery is visualized. There is mild irregular flow signal in the
right carotid artery with no evidence of high-grade stenosis.
There is no evidence of hemorrhage, edema, or mass effect.
IMPRESSION:
1. No evidence of acute ischemia.
2. Chronic infarcs in frontal, temporal, and occipital lobes
Card Cath:
1. Selective coronary angiography of this right-dominant system
demonstrated severe three native vessel disease. The RCA and LAD
were
occluded proximally. The LCX had 70% proximal stenosis, the OM1
had 90%
origin stenosis, and the OM2 was occluded with stent thrombosis
and
likely ISR.
2. Artefrial conduit angiography revealed patent LIMA-LAD. The
SVG-OM
and SVG-RCA were known occluded and were not assessed.
3. Limited resting hemodynamic assessment of this intubated
patient
initially revealed normal systemic arterial pressure (113/70
mmHg) and
moderately elevated pulmonary arterial pressure (52/31 mmHg).
The
filling pressures were elevated with a mean PCWP of 28 mmHg. The
cardiac
output and index were preserved at 4.71 l/min and 2.3 l/min.
4. Successful PTCA of the OM1 ostium with a 2.0 and the a 3.0
balloon.
Final angiography revealed a 30% residual stenosis at the
ostium, no
dissection and TIMI III flow.
5. Successful stenting of the proximal LCX with a 3.5 x 12 mm
Vision
BMS. After stent deployment the patient became hypotensive
requiring
IABP placement and pressors. Final angiography revealed no
residual
stenosis, no dissection and TIMI III flow. (See PTCA comments)
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease with patent LIMA-LAD.
2. Successful PTCA of the OM1.
3. Successful stenting of the proximal LCX.
4. Hypotensive episode requiring IABP and pressors.
Brief Hospital Course:
# Respiratory failure: Initially the patient suffered a
respiratory arrest at an OSH, likely due to narcotics. The
patient was intubated during this time. He also suffered an
inferior ST elevation MI complicating his course (see below for
more details). His ICU course was further complicated by an
aspiration pneumonia, treated with a full course of vancomycin,
cefepime and flagyll with improvement. His respiratory status
continued to improve and he was extubated successfully after
approximately 2 weeks of intubation. He has been stable mostly
on room air (with intermittent O2 reuirement during sleep) since
extubation with no further signs of respiratory distress.
.
# STEMI: The patient was diagnosed with an inferior STEMI
requiring PTCA of OM1 ostium and bare metal stent to proximal
left circumflex artery, complicated initially by profound
hypotension, bradycardia, and hypoxia during the catheterization
requiring intra-aortic ballon pump placement. His hypotension
and bradycardia spontaneously resolved and did not recur. He was
begun on maximum medical management of his coronary artery
disease, including maximum dose lisinopril, metoprolol, aspirin,
plavix, and lipitor. He will follow up with his outpatient
cardiologist for further management.
.
# Leukocytosis: After treatment of his initial aspiration
pneumonia and resolution of the associated leukocytosis, the
patient again developed a leukocytosis of unknown origin. The
patient remained afebrile but was having diarrhea after broad
spectrum antibiotics. However C.difficile was negative x3.
Nonetheless, he was treated with a 14 day course of flagyll for
presumptive c.difficile infection. However, this did not resolve
his leukocytosis. A c.difficile cytotoxin B is still pending at
the time of this writing. Multiple sets of blood cultures off
antibiotics were negative as well as urine and sputum cultures.
A lumbar puncture was performed which revealed no signs of
infection and grew nothing on culture. A contrast CT scan of the
chest, abdomen, and pelvis revealed no signs of occult infection
including abscesses or colitis. He did have yeast colonization
of his urine but fungal blood cultures were negative. However,
he was then treated for oral thrush with a 7 day course of
fluconazole with improvement in the thrush but no improvement in
his leukocytosis. Hematology/oncology was consulted and felt
that this leukocytosis, and its associated thrombocytosis, was
reactive. In discussion with his PCP, [**Name10 (NameIs) **] lymphoma history was
clarified and appeared to be in remission after radiation in
[**2186**] and confirmed by yearly CT scans. Thus, it was felt to not
be contributing to his current leukocytosis. A tagged white
blood cell scan showed no localizing source of infection.
.
#Thrush: Finished fluconazole for 7 day course, ending [**4-19**]
.
# MS changes: After extubation the patient had persistent mental
status changes. Intitially he was unresponsive but very agitated
with associated hypertension and tachycardia. This was initially
thought to be consistent with a withdrawal state and treated
with valium. This resolved his agitation but his
unresponsiveness remained. He received no more sedating
medications for 10 days. He was well outside the window for
further withdrawal states. Slowly he slightly improved, becoming
more awake and localizing to voice. However, he still did not
respond to commands or exhibit purposeful movement. Neurology
was consulted. An MRI showed only signs of older strokes and an
EEG showed only diffuse slowing, consistent with an
encephalopathy. He had a normal urinanalysis and culture, normal
LFTs with a normal ammonia level. Neurology felt his condition
was likely a toxic metabolic encephalopathy, related to the same
process causing his leukocytosis. However, they could not rule
out some level of anoxic brain injury, likely suffered during
his initial arrest and subsequent hypotension, not seen on MRI.
They could not prognisticate on his chance of recovery although
he was showing signs of recovery before discharge with some
return of coherent speech and response to commands.
.
# Sinus Tachycardia: The patient remained persistently in sinus
tachycardia, with rates of 90-110s. This was from an unclear
cause. TSH and free T4 were normal, he was afebrile, not anemic
and not hypovolemic. It was suspected that his tachycardia may
be from pain that he cannot tell us about. Thus he was begun on
standing tylenol, a low dose fentanyl patch, and lyrica for pain
control.
.
# Hypernatremia: The patient initially exhibited some
hypernatremia, as high as 150 which was resolved by increasing
free water boluses in his tube feeds. Na on d/c was 145. pls
continue free water boluses and monitor Na.
# Pump: A post procedure echo showed EF 40% with
inferior/lateral akinesis. However, the patient remained
euvolemic with no signs of volume overload without the need for
standing Lasix. He was continued on an increased dose of
lisinopril and metoprolol.
.
# Hypertension: Continued on increased doses of metoprolol and
lisinopril
.
# Acute on CKD: Last creatinine per records was 1.8. Patient was
briefly elevated post cath but returned to below baseline
creatinine at 1.4 before discharge.
.
# Abdominal wound: Secondary to rectus muscle flap to cover
sternal removal wound. Healing by secondary intention. Not
draining, and does not appear infected. Wound care consulted and
appropriate care taken.
.
# R BKA erythema: Appeared to be due to fungal infection.
Treated with topical antifungal for 14 day course.
.
# DM: Monitor fingersticks, currently well controlled on 50
units of lantus and Humalog ISS
.
# COPD: Albuterol and atrovent inhalers PRN
.
# Hypothyroidism: Continued levothyroxine with good results
.
# FEN: PEG in place, tolerating tube feeds at goal
.
# Prophylaxis: heparin SC TID, PPI, mouth care
.
# Access/Lines: L arm PICC, single lumen
.
# Code: Full, confirmed with wife and HCP
.
# Communication: Wife, [**Name (NI) **] [**Name (NI) **] Home [**Telephone/Fax (1) 29850**], cell
[**Telephone/Fax (1) 29851**]
Medications on Admission:
MEDICATIONS ON TRANSFER:
Aspirin 81 mg Po qday
Hydrocortisone 1% cream
Miconazole powder
RISS
Nystatin cream
heparin gtt
propofol drip
Dopamine drip 5 mcg per kg
Levohyroxine 150 mcg po qday
Omeprazole 20 mg po qday
Combivent inhaler
Zosyn 2.25 g Q6H (? if dose given)
Atropine PRN
HOME MEDICATIONS (per dischareg summary):
Lisinopril 10 mg po qday
Lopressor 50 mg po TID
Remeron 30 mg Po qhs
Prilosec 20 mh Po qday
Lyrica 50 mg po TID
Zocor 80 mg po qday
ASA 325 mg po qday
Lantus 50 units QHS, ISS
Doxazosin 2 mg Po qday
Levothyroxine 150 mcg qday
Citalopram 40 mg Po qday
Imdur 60 mg po qday
Lasix 40 mg Po qday
Discharge Medications:
1. Senna 8.6 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Aspirin 325 mg Tablet [**Telephone/Fax (1) **]: One (1) Tablet PO DAILY (Daily).
3. Levothyroxine 50 mcg Tablet [**Telephone/Fax (1) **]: Three (3) Tablet PO DAILY
(Daily).
4. Miconazole Nitrate 2 % Powder [**Telephone/Fax (1) **]: One (1) Appl Topical TID
(3 times a day) as needed.
5. Miconazole Nitrate 2 % Cream [**Telephone/Fax (1) **]: One (1) Appl Topical [**Hospital1 **] (2
times a day).
6. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1)
Injection TID (3 times a day).
7. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One Hundred (100) mg
PO BID (2 times a day) as needed.
8. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO TID
(3 times a day).
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
11. Lisinopril 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day.
12. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: 1000 (1000) mg PO Q
8H (Every 8 Hours).
13. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Last Name (STitle) **]:
One (1) Inhalation Q6H (every 6 hours) as needed.
14. Atorvastatin 80 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
15. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Fifty (50) units
Subcutaneous at bedtime.
16. Fentanyl 12 mcg/hr Patch 72 hr [**Last Name (STitle) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
17. Pregabalin 75 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID (2
times a day).
18. Mirtazapine 30 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO HS (at
bedtime).
19. Clopidogrel 75 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: Two
(2) ML Intravenous DAILY (Daily) as needed.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Inferior ST elevation myocardial infarction s/p bare metal stent
to left circumflex and OM1
Hypertension
Diabetes Type 2
Chronic Kidney Disease
Encephalopathy of unclear origin
Persistent Leukocytosis
Discharge Condition:
All vital signs stable, afebrile, mental status improving.
Discharge Instructions:
You were admitted after a cardiac arrest and heart attack. This
was alleviated by stents to two of your arteries. You also have
persistently decreased mental status, likely from your cardiac
arrest. This may slowly improve over time. You were unable to
pass a swallowing test safely so a tube was placed into your
stomach to provide nutrition and medications. This will need to
retested at a later date.
Please take all your medications as prescribed and attend all
follow up appointments.
Please return to the emergency room if you experience chest
pain, shortness of breath, fevers, chills, nausea, vomitting or
any other symptom that concerns you.
Followup Instructions:
Please call Dr.[**Name (NI) 29852**] office at [**Telephone/Fax (1) 29849**] to schedule a
follow up appointment.
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67,675
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37608
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Discharge summary
|
report
|
Admission Date: [**2183-10-7**] Discharge Date: [**2183-10-10**]
Date of Birth: [**2131-9-29**] Sex: M
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: 52yM w/ HTN and diet controlled hypercholesterolemia p/w
onset this am of left sided weakness found to be due to right
thalamic bleed at OSH. Pt woke up in USOH around 6am today. At
7:30 he took some vitamin w/ water and extended his head. After
flexing back to neutral he felt transient dizziness. He then
noted his left side including face arm and leg felt weak. He
then drove his son to college and noted more weakness to the
point he couldn't lift his left arm to use the turn signal. On
arrival home, he was unable to get out of the car and his wife
called 911.
He was taken to [**Hospital6 **] where his blood sugar
was 151 and BP 250/161. He was treated with 20mg of labetalol
x2
with improvement to 180/116. He was found to have a 2.5cm right
thalamic hemorrhage and was transferred to [**Hospital1 18**]. During or
before transfer (unclear which) he was started on a labetalol
drip. On arrival to [**Hospital1 18**] his BP was 103/58 and dipped as low
as
85/60. He remained alert and oriented throughout.
He notes slurred speech and numbness of the entire left side.
He
has not yet taken his BP meds today as he usually waits and
takes
them when he eats. He notes difficulty coughing up phlegm since
onset.
He does not currently have a PCP. [**Name10 (NameIs) **] clinic where he was
previously prescribed the meds keeps refilling them he says. He
has noted that his BP has been drifting up recently when he
checks it at the grocery or pharmacy (as high as SBP 220).
ROS:
Gen: No fevers/chills/sweats, CP, SOB, palpitations, N/V, URI,
cough, abd pain, dysuria, rash, travel
Neurological: No deficits noted in: memory, personality,
vision, hearing, language/speech, swallowing, coordination,
writing, walking, bowel/bladder function.
No history of stroke, HA, seizures. No weakness, no sensory
loss, no neck pain.
Past Medical History:
- HTN
- psoriasis
- bilateral knee reconstruction surgery
Social History:
Patient lives with his wife. [**Name (NI) **] is currently unemployed and
worked as a corporate lawyer. [**Name (NI) **] has a son in the National
Guard in boot camp currently, a son who is a sophomore in
college, and a daughter who is a senior in high school. No h/o
tobacco use. Drinks "a few" glasses of wine in 2 weeks. No
illicit drug use in MANY years. He has been under more stress
than usual.
Family History:
Brother with TIAs in 50s, father w/ hemorrhagic stroke at 47.
Maternal aunt with cerebral aneurysm found post mortem. Strong
family history of hypertension in both parents and brother.
Brother also had triple CABG and type II diabetes.
Physical Exam:
VS: T 98 HR 70 BP 138/88 RR 18 Sat 97%RA
PE:
HEENT AT/NC, MMM no lesions
Neck Supple, no bruits
Chest CTA B
CVS RRR,
ABD obese, soft, NTND, + BS
SKIN
NEUROLOGICAL
MS:
General: alert, appropriately interactive, normal affect
Orientation: oriented to person, place, date, situation
Attention: full??????months of year backwards except skipped [**Month (only) 958**]
Speech/[**Doctor Last Name **]: fluent w/o paraphasic errors; simple and complex
command-following w/o L/R confusion. Repetition, naming intact
Memory: [**4-1**] after 5 minutes
CN:
II,III: VFFTC, pupils 3-2 mm bilaterally to light, unable to
view optic discs as pt could not keep eyes open and fixed
III,IV,V: EOM full with right end gaze nystagmus that did not
extinguish, slight left ptosis. Normal pursuits
V: sensation intact to LT/PP
VII: Left facial droop
VIII: hears finger rub bilaterally
IX,X: voice normal, palate elevates symmetrically
[**Doctor First Name 81**]: SCM/trapezeii [**6-3**] bilaterally
XII: tongue protrudes midline without atrophy or fasciculation
Motor:
Normal bulk and tone; no tremor, rigidity, or bradykinesia.
Delt [**Hospital1 **] Tri WE FE Grip IO
C5 C6 C7 C6 C7 C8/T1 T1
L 1 4 4 4 3 [**4-2**]* 3
R 5 5 5 5 5 5 5
* [**5-4**] 4th and 5th finger flexors [**4-3**] 2nd and 3rd digit flexion
IP Quad Hamst DF [**Last Name (un) 938**] PF
L2 L3 L4-S1 L4 L5 S1/S2
5 5 5 5 5 5
4- 5- 4 5- 5- 5
Reflex:
[**Hospital1 **] Bra Pat An Plantar
C5 C6 L4 S1 CST
L 2 2 2 2 Extensor
R 1 1 1 1 Flexor
Sensation: LT, temp intact throughout. Vibration intact.
Romberg deferred.
Coordination: Finger-nose-finger limited by weakness,
heel-to-shin movements intact but again limited.
Gait: deferred
Pertinent Results:
ADMISSION LABS
[**2183-10-7**] 12:25PM
PT-12.4 PTT-23.6 INR(PT)-1.0
PLT COUNT-229
NEUTS-81.1* LYMPHS-14.6* MONOS-2.9 EOS-1.2 BASOS-0.2
WBC-11.1* RBC-4.43* HGB-12.7* HCT-37.9* MCV-86 MCH-28.7
MCHC-33.6 RDW-14.9
GLUCOSE-141* UREA N-31* CREAT-1.9* SODIUM-140 POTASSIUM-3.6
CHLORIDE-102 TOTAL CO2-28 ANION GAP-14
ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
LIPID PROFILE
TRIGLYCER-186* HDL CHOL-33 CHOL/HDL-6.2 LDL(CALC)-134*
[**2183-10-7**] 12:25PM CHOLEST-204*
%HbA1c-5.3
CARDIAC BIOMARKERS
[**2183-10-7**] 12:25PM cTropnT-0.02* CK(CPK)-65
[**2183-10-7**] 11:50PM cTropnT-0.03* CK-MB-4
[**2183-10-8**] 08:40AM cTropnT-0.02* CK(CPK)-75
[**2183-10-7**] 03:30PM URINE
BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG
COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
CT HEAD W/O CONTRAST Study Date of [**2183-10-7**] 12:27 PM
IMPRESSION: 2.2 x 2.1 cm right thalamic bleed with surrounding
area of edema and 3 mm leftward shift of midline structures.
Small amount of layering blood within the right occipital [**Doctor Last Name 534**]
indicates intraventricular extension. Hemorrhage has remained
stable in size since the prior study.
CT HEAD W/O CONTRAST Study Date of [**2183-10-8**] 7:53 AM
IMPRESSION:
Stable appearance of right thalamic hemorrhage with surrounding
edema and
minimal shift of the midline structures, since the the recent
study dated at 9:37, on [**2183-10-7**].
DISCHARGE LABS
[**2183-10-10**] 04:55AM BLOOD WBC-11.2* RBC-4.14* Hgb-12.0* Hct-36.1*
MCV-87 MCH-29.0 MCHC-33.2 RDW-15.3 Plt Ct-182
[**2183-10-7**] 12:25PM BLOOD Neuts-81.1* Lymphs-14.6* Monos-2.9
Eos-1.2 Baso-0.2
[**2183-10-10**] 04:55AM BLOOD Plt Ct-182
[**2183-10-10**] 04:55AM BLOOD Glucose-89 UreaN-24* Creat-1.9* Na-139
K-3.7 Cl-105 HCO3-25 AnGap-13
[**2183-10-9**] 04:45AM BLOOD ALT-16 AST-24 LD(LDH)-263* AlkPhos-43
TotBili-0.4
[**2183-10-10**] 04:55AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.3
[**2183-10-7**] 12:25PM BLOOD %HbA1c-5.3
[**2183-10-7**] 12:25PM BLOOD Triglyc-186* HDL-33 CHOL/HD-6.2
LDLcalc-134*
[**2183-10-7**] 12:25PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
Mr. [**Known lastname 84385**] is a 52 year old left handed man with a history
of hypertension and hypercholesterolemia who presented with
left sided weakness secondary to poorly controlled hypertension,
found to be due to a right thalamic bleed.
# NEURO: The patient was transferred here from [**Hospital3 1280**]
Hospital for further management of his intraparanchymal
hemorrhage. This was suspected to be secondary to poorly
controlled hypertension. He was initially admitted to the ICU
for blood pressure managment and close neurologic evaluation.
His exam improved over his initial hospital course, with
increased strength and use of his left leg. Repeat CT scans
demonstrated a stable hemorrhage. The appearance of bilateral
lacunar infarcts was also noted. He was cleared by speech and
swallow and evaluated by physical therapy who recommended
inpatient rehab.
# Hypertension: Mr. [**Known lastname 84386**] blood pressure on
presentation to [**Hospital3 1280**] was documented as 250/161. While
at [**Hospital1 18**], blood pressure was initially maintained on a labetalol
drip. He was transitioned over to oral therapy and is currently
on amlodipine, labetalol and captopril. His medications should
continue to be adjusted to maintain an SBP<140.
# Renal Failure: Creatinine on arrival was 1.9 and did not
improve with fluids. The patient denied any history of renal
disfunction. His home medications of lisinopril and HCTZ where
held. It was suspected that this was secondary to poorly
controlled hypertension.
# Hypercholesterolemia: Total cholesterol was 204, with an LDL
of 134 and TG 186. Statin therapy was initiated.
# Social: Mr. [**Known lastname 84385**] stated that he was unemployed at the
moment and did not have health insurance. His wife also
expressed significant concern over his apathetic approach to his
health. Social work was consulted.
Medications on Admission:
- hctz 50mg daily
- lisinopril 40mg po daily
- amlodipine 10mg daily
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) 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. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a
day) as needed for psoriasis flare.
4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Labetalol 100 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
6. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Captopril 12.5 mg Tablet Sig: Three (3) Tablet PO Q8H (every
8 hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Right thalamic hemorrhagic stroke
Secondary: Hypertension
Discharge Condition:
Left sided weakness, lower extremity greater than upper
extremity. No sensory deficits noted.
Discharge Instructions:
You were admitted with left sided weakness. You were found to
have a hemorrhage in your right thalamus. This was likely due
to having poorly controlled blood pressure. You were started on
a new blood pressure regimen, and will need to make sure that
this remains well controlled.
If you have worsening weakness, numbness, headache, or other
concerning symptoms, please return to the nearest ED for further
evaluation.
Followup Instructions:
Please call [**Telephone/Fax (1) 2574**] to arrange a follow-up Neurology
appointment in [**5-5**] weeks.
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]
|
[
"431",
"403.90",
"728.87",
"696.1",
"584.9",
"272.0",
"V15.81",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
9675, 9745
|
7011, 8907
|
336, 342
|
9856, 9952
|
4809, 6988
|
10421, 10621
|
2745, 2983
|
9027, 9652
|
9766, 9835
|
8933, 9004
|
9976, 10398
|
2998, 4790
|
277, 298
|
370, 2223
|
2245, 2305
|
2321, 2729
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
15,090
| 167,338
|
53096
|
Discharge summary
|
report
|
Admission Date: [**2156-9-1**] Discharge Date: [**2156-9-7**]
Date of Birth: [**2082-9-2**] Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5755**]
Chief Complaint:
babesiosis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mrs. [**Known lastname **] is a formerly healthy 73 F with a PMHx of dormant SLE
who presented to [**Hospital6 2561**] [**2156-8-30**] with few days'
history of fatigue, profound sleepiness, slurred speech and
fever. She lives in [**Hospital1 6687**], and gives a history of working
outside at home in the yard and being too busy to check herself
for ticks about a week ago, although she is uncertain of the
time. On [**8-30**] she was driving through [**State 350**] to a wedding
in upstate [**State 531**] when a concerned motorist who had been
following her felt that she had been driving erratically and
called police. She was then adviced to take a taxi to her
friend's house. She was noted to have slurred speech and "not
herself".
She was then brought to [**Hospital3 **] and was found to have
temperature of 102.6. Initial lab show WBC 6.8 Hct 29.1,
pletelet 76, nml PT and PTT. Patient received ASA and CTX in the
ED. She was intially thought to have lupus flare, and remained
intermittently somnolent and confused. ESR 83 and CRP350. Blood
smear on [**2156-8-31**] show >50% babesia. Patient received 2 doses of
azithromycin and was then started on clindamycin and quinine on
[**2156-9-1**]. Head CT showed subcortical disease bifrontally and MRI
head was negative.
She had a spurious Hct drop from 29.1 to 15.1, now 28.9 post 2u
PRBC transfusion. Platelets dropped from 76 to 40s with normal
coags and Cr 1.3 improving to 0.8. She was also found to have
rising LFTs and high LDH. She was transferred to [**Hospital1 18**] [**Hospital Unit Name 153**] [**9-1**]
in anticipation of possible exchange transfusion given her
parasite burden.
.
ROS: denies sick contacts. Otherwise, she denies chest pain,
shortness of breath, cough, abdominal pain, nausea/vomiting,
urinary complaints, heache, dizziness. She does have diarrhea
but claims that it is chronic.
Past Medical History:
systemic lupus not on immunosuppresion, no flare for >10 years
pernicious anemia
celiac sprue w/ chronic loose stool
hypertension
appendectomy
[**7-6**] ORIF of olecranon fracture(by Dr. [**Last Name (STitle) 284**]
abnormal LFTs from ?liver disease:liver bx in 97, us in
[**2154**]-neg.
mild aortic stenosis, recently diagnosed by echo [**6-5**], EF 75%
osteopenia
Social History:
Widowed, 2 children, lives in [**Hospital1 6687**].Former [**Male First Name (un) **] of [**Location (un) 11269**]
School, retired [**2144**]. Occasional alcohol use up to [**3-5**] drinks
daily.
Family History:
deferred
Physical Exam:
PHYSICAL EXAMINATION:
T100.3 P77 BP93/37 R28 97% on RA
Gen- lethargic, conversant initially but fall asleep later on in
exam
HEENT- anicteric, PERRLA, EOMI, dry mucous membrane, neck
supple, no cervical LAD
CV- rrr, 2/6 SEM in aortic area
RESP- CTAB
ABDOMEN- soft, nontender, nondistended, nml bowel sounds
EXT- no edema, strong pedal pulses bilaterally
SKIN- no rashes
NEURO- A+O to self, CNII-XII intact, move all 4 symmetrically
Pertinent Results:
[**2156-9-1**] 02:49PM GLUCOSE-122* UREA N-25* CREAT-0.6 SODIUM-131*
POTASSIUM-3.9 TOTAL CO2-24
[**2156-9-1**] 02:49PM ALT(SGPT)-37 AST(SGOT)-108* LD(LDH)-1100*
CK(CPK)-183* ALK PHOS-163* TOT BILI-1.9*
[**2156-9-1**] 02:49PM CK-MB-3 cTropnT-<0.01
[**2156-9-1**] 02:49PM ALBUMIN-2.4* CALCIUM-7.3* PHOSPHATE-1.5*
MAGNESIUM-2.2
[**2156-9-1**] 02:49PM WBC-5.0 RBC-3.19* HGB-10.1* HCT-28.5*# MCV-90
MCH-31.6 MCHC-35.3* RDW-16.4*
[**2156-9-1**] 02:49PM NEUTS-68 BANDS-12* LYMPHS-12* MONOS-3 EOS-0
BASOS-0 ATYPS-5* METAS-0 MYELOS-0
[**2156-9-1**] 02:49PM PLT SMR-VERY LOW PLT COUNT-57*# LPLT-1+
[**2156-9-1**] 02:49PM PT-12.2 PTT-27.7 INR(PT)-1.0
[**2156-9-1**] 02:49PM FIBRINOGE-796*
[**2156-9-1**] 02:49PM PARST SMR-POSITIV
[**2156-9-1**] 02:49PM RET AUT-1.6
.
c diff negative [**9-6**], [**9-5**], [**9-4**], [**9-1**]
[**Last Name (un) **] cx [**9-1**]: negative
bld cx [**9-1**]: negative
Lyme serology: pending (Quest)
Ehrlichia: pending
.
EKG: NSR nl axis no ST/TW changes
.
CXR [**9-1**]: Mediastinal widening is new in the interval and
may be due to lymphadenopathy. Low lung volumes are present.
Heart is normal size. Pulmonary vascularity is normal. Lungs
are clear
.
CT CHEST WITHOUT AND WITH IV CONTRAST: There are no
pathologically enlarged lymph nodes within the mediastinum,
hila, or axilla. There are small bilateral pleural effusions
with associated dependent atelectasis. There are no focal
nodular opacities or areas of consolidation. There is no
evidence of pneumothorax.
Limited views of the upper abdomen demonstrate no obvious
abnormalities within the upper abdominal organs.
CTA CHEST: There is no evidence of filling defects within the
pulmonary arterial vasculature. No evidence of pulmonary
embolism. No evidence of aortic dissection or aneurysmal
dilatation. There are a few calcifications seen within the
aortic arch and descending aorta.
BONES: No suspicious lytic or sclerotic bony lesions.
IMPRESSION:
1. No evidence of pulmonary embolism, aortic dissection, or
mediastinal lymphadenopathy.
2. No evidence of pneumonia.
Brief Hospital Course:
# Babesiosis: Patient was admitted to the [**Hospital Unit Name 153**] for initial
admission for possible exchange transfusion given her extreme
parasite burden, however this was not necessary. She was
monitored in the ICU and required intermittent boluses overnight
on hospital day #1 for sbp 80s. ID was consulted and suggested
coverage with quinine and clindamycin, in addition to
doxycycline for possible concurrent Lyme or Ehrlichia. Repeat
parasite smears trended down to 0.2% from > 50% at OSH, however,
patient's platelets continued to drop and she complained of
hearing loss concerning for possible cinchonism due to quinine.
She was thus switched to azithromycin and atovaqoune (through
[**9-13**]) and continued on the doxycycline (through [**9-21**]).
.
# Hemolytic anemia: Likely due to babesiosis. Ferritin was >
[**2150**]. Folate and B12 were within normal limits. Patient's
baseline hct was 38.5 in [**Month (only) 205**]. She was admitted to the OSH with
a hematocrit of 20. She received a total of 4 U PRBC over the
course of her admission and her hematocrit on the day of
discharge was 32.5. She was guiac negative during her hospital
stay.
.
# Thrombocytopenia: Likely due to babesiosis. Fibrinogen was
normal. Platelets on day of discharge were up to 116.
.
# CHF: Developed in setting of IVF resuscitation. On transfer
to the floor, patient was requiring 2 L supplemental O2 but this
resolved with autodiuresis. CTA on transfer to the floor given
abnormal CXR in the ICU showed only mild CHF.
.
# Hyponatremia: Likely was due to hypovolemia. Returned to
[**Location 213**] with IVFs.
.
# Transaminitis: Patient has baseline elevated AST, likely due
to alcohol use. Ultrasound from '[**54**] normal. Hepatitis
serologies were repeated this admission and were negative for
hep A and C antibody and showed borderline immune status to
hepatitis B without evidence of past infection.
.
# Diarrhea: Patient had diarrhea during her hospital admission
which she stated was typical of her celiac sprue. She normally
manages her symptoms with imodium. C diff was negative x 4 and
patient was restarted on her imodium with good control of her
symptoms.
.
# Lupus: Asymptomatic without medications
.
# Hypertension: BP meds initially held in the setting of
hypotension on admission. Her blood pressure stabilized and her
BB and ACEI were restarted. She will follow-up with her primary
care doctor as an outpatient to consider restarting her
diuretic.
.
# Osteopenia: Patient was continued on calcium and fosamax and
started on vitamin D.
.
# Celiac sprue: Continued on B12. Started on folate and vitamin
D supplementation. Imodium prn. Gluten-free diet.
.
# Recent ORIF for olecranon fx: Patient was scheduled for
follow-up with Dr. [**First Name (STitle) 4304**] [**Name (STitle) 284**].
.
# Dispo: PT was consulted and felt patient was safe for
discharge to home
Medications on Admission:
MEDICATION at home
ALENDRONATE 70MG
ATENOLOL 25 MG QD
FLONASE
HYDROCHLOROTHIAZIDE 25 mg
LIDEX 0.05 %--apply to affected area twice a day
METROGEL 0.75%--Aplly twice a day to face for rash
OPTICROM 4%--1-2 drops each eye twice a day
PRILOSEC 20 mg
UNIVASC 15 mg [**Hospital1 **]
VITAMIN B-12 1000MCG QD
.
MEDICATION ON TRANSFER:
folic acid 1mg po QD
MVI
azithromycin 250 QD(d1=[**2156-9-1**], started w/500mg load, d/c's [**9-1**])
atovaqoune 750mg [**Hospital1 **](d1=[**2156-9-1**]); d/c [**9-1**]
clindamycin 1200mg IV Q12(d1= [**9-1**])
quinine 520mg Q8H(d1= [**9-1**])
ativan prn
thiamine injection QD
protonix
ECASA 325
Discharge Medications:
1. Outpatient Lab Work
CBC w/ diff, sodium, glucose, BUN, creat, ALT, AST, alk phos, t
bili to be drawn at your follow-up with Dr. [**Last Name (STitle) **] on [**9-16**], [**2156**]
2. Atovaquone 750 mg/5 mL Suspension Sig: Seven [**Age over 90 1230**]y
(750) mg PO BID (2 times a day) for 7 days.
Disp:*[**Numeric Identifier **] mg* Refills:*0*
3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 7 days.
Disp:*14 Capsule(s)* Refills:*0*
4. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours) for 15 days.
Disp:*30 Capsule(s)* Refills:*0*
5. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
6. Alendronate 70 mg Tablet Sig: One (1) Tablet PO QMON (every
Monday).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO TID (3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet Sig: One (1) Tablet PO three
times a day.
9. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
12. Loperamide 2 mg Capsule Sig: [**2-2**] Capsules PO QID (4 times a
day) as needed for diarrhea: Start with 2 tablets following your
first loose stool, followed by additional 1 tablet as needed,
max 6 tablets perday.
13. Univasc 15 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
primary: babesiosis
secondary: hemolytic anemia, thrombocytopenia, celiac sprue,
hypertension, osteopenia, transaminitis
Discharge Condition:
good - afebrile, cbc stable, afebrile
Discharge Instructions:
Please call your primary care doctor or go to the emergency room
if you experience temperature > 101, confusion/sleepiness,
abdominal pain or cramping, vomiting, or other concerning
symptoms.
Medication changes:
1. Please be sure to take your calcium 2 hours after your
antibiotics, as the 2 medications interact.
2. Please do not restart your hydrochlorothiazide until you see
Dr. [**Last Name (STitle) **]
3. Please start taking vitamin D and folate, as prescribed.
4. Please take the antibiotics, as prescribed, until they are
gone.
Followup Instructions:
Dr. [**Last Name (STitle) 13336**] office will be in contact with you regarding an
appointment to be scheduled for [**9-16**] to have your blood
counts and electrolytes rechecked. If you do not hear from his
office by Friday, please call to determine your appointment
time. Phone: [**Telephone/Fax (1) 250**]
Please follow-up with Dr. [**Last Name (STitle) 284**] on [**9-16**] at 9:00 AM.
[**Street Address(2) 1126**], [**Location (un) **], MA. Phone: ([**Telephone/Fax (1) 109381**]
|
[
"424.1",
"283.19",
"287.5",
"710.0",
"088.82",
"428.0",
"733.90",
"401.9",
"276.51",
"276.1",
"579.0"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
10473, 10479
|
5376, 8282
|
280, 287
|
10644, 10684
|
3278, 5353
|
11269, 11760
|
2800, 2810
|
8959, 10450
|
10500, 10623
|
8308, 8936
|
10708, 10901
|
2825, 2825
|
2847, 3259
|
10921, 11246
|
230, 242
|
315, 2182
|
2204, 2571
|
2587, 2784
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,975
| 173,986
|
8824
|
Discharge summary
|
report
|
Admission Date: [**2108-10-16**] Discharge Date: [**2108-10-21**]
Date of Birth: [**2036-8-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfonamides / Amlodipine / Percocet
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
HD
History of Present Illness:
The pt is a 72M w/ Type 2 DM, ESRD on HD, referred by
nephrologist for shortness of breath, likely from fluid
overload. For the last 4 days he has been feeling more short of
breath that has improved with dialysis. He also had one day of
dysuria. Otherwise he has had no other symptomatic complaints
including no nausea, vomiting, or diarrhea, no chest pain, no
fever or chills. Reports chronic cough productive of a teaspoon
of sputum, whitish-green tinged color which has been stable.
.
In the ED Vitals were t 98.8 Hr 126 (went to 70-80s) BP 104/54,
then went to SBPs in 80s, 91 % RA. While in the ED, he was
given a dose of vancomycin 1g x 1, levofloxacin 500 mg x1 and 1
g tylenol, lasix 40 IV.
Past Medical History:
1)CAD s/p CABG [**2102**]
2)PVD: s/p fem-[**Doctor Last Name **] bypass in [**12-29**] for cluadication, non-healing
ulcer on [**2-26**] s/p atherectomy of L SFA popliteal tbioperoneal
trunk with angioplasty x 2. Pt had recent right first toe
amputation and left TMA on [**2107-3-24**].
3)Paroxysmal atrial fibrillation
4)Type II DM: followed by [**Last Name (un) **]
5)Hyperlipidemia
6)Chronic bronchiectasis
7)EF 35%
p-MIBI [**2108-2-27**]: Mild-moderate anterior-lateral and apical
reversible defect. 2. Mild global hypokinesis and septal
akinesis. 3. Ejection fraction is 35%.
8)BPH
9)Anemia of chronic illness
10)CRI on daily peritoneal dialysis
.
PAST SURGICAL HISTORY:
1) s/p angioplasties of the left common femoral, superficial
femoral, tibioperoneal trunk in ([**2106-11-24**])
2) left CEA ([**2102**] at [**Hospital1 2025**])
3) CABG (LIMA to the LAD and saphenous vein graft to the
obtuse marginal 1 and the ramus intermedius - [**2103-9-24**])
4) s/p cholecystectomy with exploratory lap with repair of
liver lacerations ([**2105-11-23**])
5) PD catheter placement in ([**2106-9-24**])
6) right eye cataract with intraocular lens, right
eye vitrectomy
7) right common femoral artery to posterior
tibial bypass graft with in situ saphenous vein in [**Month (only) 404**] of
[**2106**].
Social History:
Significant for the absence of current tobacco use although he
is a former smoker. Reports smoking 2PPD X 40 yrs, quit 30 yrs
ago. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Family History:
Father with DM type 2
Two sisters and one brother--all well
Physical Exam:
BP 134/72 HR 88 RR 18 T98.7 O2Sat 94% on RA
Gen: AAO X 3, elderly gentleman
HEENT: EOMI, PERRL, sclera anicteric, MMM
Neck: supple, JVP of 5 cm.
Pulm: coarse rhonchi b/l with crackles at R base, increased
expiratory phase
Cor: RRR, normal S1S2, no rubs, murmurs, clicks or gallops.
Abd: soft, NT, ND, normoactive BS
Ext: no pallor, cyanosis, clubbing, trace edema with
erythematous and warm LE b/l up to mid lower leg.
Skin: stasis dermatitis of LE
Pulses: 2+ r DP, 1+ l DP
Pertinent Results:
[**2108-10-16**] 05:28PM WBC-9.3 RBC-3.36* HGB-11.4* HCT-35.1*
MCV-104* MCH-34.0* MCHC-32.5 RDW-15.8*
[**2108-10-16**] 05:28PM PLT COUNT-474*
[**2108-10-16**] 05:28PM PT-15.7* PTT-43.9* INR(PT)-1.4*
[**2108-10-16**] 05:28PM CALCIUM-7.9*
[**2108-10-16**] 05:28PM CK-MB-NotDone cTropnT-2.33*
[**2108-10-16**] 05:28PM UREA N-16 CREAT-1.7* SODIUM-138 POTASSIUM-4.3
CHLORIDE-100 TOTAL CO2-33* ANION GAP-9
[**2108-10-16**] 05:30PM GLUCOSE-98 LACTATE-1.8 K+-3.9
EKG: NSR with mild elevation of ST segments onf V2, V3.
Otherwise unchanged from prior.
.
CXR: Again seen is evidence of CHF and bilateral pleural
effusions. New opacity in the left upper lung, possibly
represents early pneumonia versus asymmetric edema.
.
Chest CT [**10-17**] - Multifocal consolidation and peribronchial
infiltration is present in all lobes. The largest region of
abnormality is the apical and posterior portions of the left
upper lobe, but smaller abnormalities are present in the
superior
segment of the left lower lobe and at the base of the right
lower lobe is also mild septal thickening throughout the lungs.
The lingula is largely collapsed distal to what appears to be
impacted bronchi. Small-to-moderate bilateral pleural effusion
is nonhemorrhagic, layering posteriorly having developed
between [**9-25**] and 15. There is extensive central lymph node
enlargement ranging up to 20 mm in the right lower paratracheal
and 18 mm in diameter in the pretracheal stations of the
mediastinum with many smaller lymph nodes distributed and there
is no bronchial obstruction by lymph node or compromise
of any other vital structures. Atherosclerotic calcification in
the aorta and native coronary arteries is severe. There is no
pericardial effusion. This examination is not designed for
subdiaphragmatic evaluation except to note the absence of
ascites.
.
CT scan corroborates the well-documented pattern in this patient
of current episodes of pulmonary edema and pleural effusions
also accompanied by mass-like consolidation. Findings of
extensive central lymph node enlargement are difficult correlate
with those of plain radiographs, but are not necessarily new.
Differential diagnosis of the multifocal pulmonary abnormality
includes current pneumonia, drug reaction, or pulmonary
hemorrhage.
.
Past cardiology studies:
.
[**2108-2-27**] Persantine MIBI: IMPRESSION: 1. Mild-moderate
anterior-lateral and apical reversible defect. 2. Mild global
hypokinesis and septal akinesis. 3. Ejection fraction is 35%.
.
Cath [**2106-12-22**]:
R dominant system
LMCA: 60% occluded
LAD: widely patent LIMA to LAD. SVG to RI 80% ostial
LCX: patent SVG to OM. LCX 80% prox.
RCA: proximally occluded, filled by collaterals from LIMA/SVG
.
Cath [**2108-3-28**]
1. Selective coronary angiography in this right dominant
circulation demonstrated severe native vessel coronary artery
disease. The LMCA was diffusely diseased with 60% distal
stenosis. The LAD was totally occluded in the proximal segement.
The distal LAD had mild disease and was supplied by the LIMA
graft. The LCx had severe diffuse disease. The OM and Ramus were
totally occluded at their origins, but filled via an SVG.
2. Saphenous vein angiography demonstrated widely patent SVG to
OM and SVG to Ramus. The Ramus was totally occluded after the
touchdown point and filled via collaterals from the grafted OM.
3. Arterial conduit arteriography demonstrated a widely patent
LIMA to LAD.
4. Opening pressure in the central aorta was moderately
elevated.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA to LAD.
3. Patent SVG to OM.
4. Patent SVG to Ramus, but total occlusion after touchdown
point.
.
TTE [**10-17**] - 1. The left atrium is moderately dilated. The left
atrium is elongated.
2. Left ventricular wall thicknesses are normal. There is
asymmetric left ventricular hypertrophy. There is no asymmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Overall left ventricular systolic function is normal
(LVEF>55%). Tissue velocity imaging E/e' is elevated (>15)
suggesting increased left ventricular filling pressure
(PCWP>18mmHg).
3. Right ventricular chamber size is normal. Right ventricular
systolic function is normal.
4.The aortic valve leaflets are mildly thickened. No aortic
regurgitation is seen.
5.The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen.
6.There is a trivial/physiologic pericardial effusion.
7. There is a large pleural effusion present.
Brief Hospital Course:
1) Shortness of breath: Likely due to fluid overload [**1-26**]
paroxysmal a-fib c RVR given prior history of paroxysmal a-fib
with RVR. Unfortunately, pt is not aware when he is in a-fib.
Differential also included fluid overload [**1-26**] ESRD; however pt
did not miss HD session prior to admission. CXR findings with
possible element of PNA, however pt did not have leukocytosis,
fever, and productive cough. Given dose of levaquin while in ED
which was not continued on the floor. Sputum culture was
significant only for sparse OP flora. Evaluated by renal and
given daily HD during hospital course with subsequent improval
in pt's shortness of breath. CT chest performed given question
of diagnosis of chronic bronchietasis. CT significant for
multifocal consolidation and infiltrates with lingula largely
collaspsed distal to what appears to be impacted bronchi which
supports diagnosis of chronic bronchiectasis.
.
2) ESRD - Followed by renal consult and had HD qd during
hospital course with subsequent resolution in pt's shortness of
breath. On Nephrocaps.
.
3) Troponin elevation: Recent troponin elevation during last
admission felt to be from demand ischemia while in rapid afib in
the setting of ESRD. During hospital course had troponin peak to
2.33. Likely still demand ischemia as patient did not have any
signs of CP or cardiac dysfunction. EKG without new ischemic
changes. Given that the patient has recent troponin leak,
elevated troponins may be persistent due to poor renal function.
Cardiology made aware of troponin leak and agreed that it was
[**1-26**] rate related demand ischemia. Continued on aspirin,
metoprolol, lisinopril, and statin.
.
4) CHF- TTE on [**10-17**] significant for nl LVEF but with elevated
LV filling pressures. Fluid removed via HD. Stressed importance
of fluid and salt restriction to pt. Continued beta-blocker,
ACE-I.
.
5) Paroxysmal afib - Continued on amiodarone, metoprolol, and
digoxin. Dig level checked and was therapeutic. Pt remained in
NSR during hospital course with HR in 70-80s. Warfarin was also
continued.
.
6) Hypotension - Was transiently hypotensive with SBPs in 80s
while in ED, and was admitted to MICU where low BPs resolved
without intervention. Remained normotensive during remaining
hospital course.
.
7) DM2 - Continued outpt regimen of NPH 16 U qam and 8 U qhs,
RISS with good effect.
.
8) LE cellulitis- Was treated as outpatient with augmentin [**1-27**]
weeks ago per pt. On admission, PE significant for continued
b/l LE cellulitis. Was treated with Augmentin post-HD during
hospital course X 5. By discharge, exam was underwhelming for
active LE cellulitis and pt was not discharged on further
antibiotics.
.
9) Hypothyroidism - Synthroid continued.
.
10) Code - DNR, DNI per patient
Medications on Admission:
(Per last d/c, per patient he is not taking all of these but
can't remember what he isn't taking )
-- atorvastatin 10mg po qd
-- ASA 81mg po qd
-- levothyroxine 100mcg po qd
-- vitamin E 400U po qd
-- B complex-Vitamin C-Folic acid 1mg po qd
-- folic acid 1mg po qd
-- sevelamer 800mg po tid
-- amiodarone 200mg po qd
-- digoxin 125mcg po qod
-- NPH 16U qam, 8U qpm
-- mirtazapine 15mg po qodhs
-- tamsulosin 0.4mg p qhs
-- warfarin 1mg po qhs
-- hydromorphone 4mg po q8h prn
-- metoprolol 150mg po qd
-- lisinopril 1.25mg po qd
Discharge Medications:
1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*2*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Sevelamer 400 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
Disp:*180 Tablet(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
7. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. 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*
9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
12. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
Disp:*15 Tablet(s)* Refills:*2*
13. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO bid as
needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
14. Lisinopril 5 mg Tablet Sig: 0.25 Tablet PO DAILY (Daily).
Disp:*10 Tablet(s)* Refills:*2*
15. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: 1.5
Tablet Sustained Release 24HRs PO once a day.
Disp:*45 Tablet Sustained Release 24HR(s)* Refills:*2*
16. Atrovent 18 mcg/Actuation Aerosol Sig: 2-3 puffs Inhalation
every 6-8 hours as needed for shortness of breath or wheezing.
Disp:*qs inhalers* Refills:*3*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Fluid Overload [**1-26**] CHF, paroxysmal a-fib c RVR
Lower Extremity Cellulitis
Secondary Diagnoses:
Discharge Condition:
stable
Discharge Instructions:
Please call your physician or return to the emergency room if
you experience any of the following: chest pain, increased
shortness of breath, fevers, chills, night sweats, increased
lower extremity pain and warmth.
It is very important that you continue to keep all of your
outpatient dialysis sessions. It is also very important that you
continue fluid restriction and adhere to a low sodium diet when
you are at home.
Followup Instructions:
Please follow up with your primary care physician [**Name Initial (PRE) 176**] 1 week
of discharge.
You have an appointment to see Dr. [**Last Name (STitle) **], a cardiologist, on
118 at 3:40 pm. Please report to [**Hospital Ward Name 23**] Building, [**Location (un) 436**].
[**Telephone/Fax (1) 4022**].
Please follow up with Dr. [**First Name (STitle) 805**] at hemodialysis.
Completed by:[**2108-10-21**]
|
[
"428.0",
"427.31",
"250.00",
"585.6",
"244.9",
"682.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
12989, 12995
|
7761, 10533
|
301, 305
|
13161, 13170
|
3215, 6721
|
13639, 14053
|
2643, 2705
|
11112, 12966
|
13016, 13117
|
10559, 11089
|
6738, 7738
|
13194, 13616
|
1736, 2360
|
2720, 3196
|
13140, 13140
|
258, 263
|
333, 1037
|
1059, 1713
|
2376, 2627
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,325
| 130,500
|
5026
|
Discharge summary
|
report
|
Admission Date: [**2147-8-16**] Discharge Date: [**2147-8-25**]
Date of Birth: [**2065-3-3**] Sex: M
Service: MEDICINE
Allergies:
Minoxidil
Attending:[**First Name3 (LF) 2279**]
Chief Complaint:
dizziness,falls
Major Surgical or Invasive Procedure:
Frontal and parietal burr holes.
History of Present Illness:
Mr. [**Name13 (STitle) 2093**] is an 82 yo M with h/o ITP and IDDM c/b autonomic
postural hypotension, recently admitted for 7mm acute traumatic
SDH after fall, now transferred from OSH for acute on chronic
SDH with 7mm midline shift.
Patient was recently admitted from [**Date range (1) 20779**]/12 for acute
traumatic SDH after fall at home with headstrike and worsening
nausea, vomiting, headache and ataxia at home. Head CT in [**Hospital1 18**]
ED showed an acute 9mm right cerebral SDH and possible 2mm SDH
along left inferior frontal lobe. He was admitted to neurology
service and followed by neurosurgery. He was medically managed
with BP control, Keppra seizure prophylaxis and also received
one platelet transfusion given ITP. His neuro exam during
hospitalization was notable for upper extremity weakness (4+/5
strength D/T/IO, +left pronator drift) in an upper motor neuron
pattern. Course was complicated by orthostatic hypotension to a
nadir of SBP 45 due to his autonomic neuropathy, so his Losartan
was stopped and TEDs started. He was discharged home with
outpatient neuro and neurosurgery follow-ups.
Since discharge from the hospital, patient complains of
recurrent dizziness and numerous resultant falls (never with
headstrike). Today he became dizzy and fell onto his rear end,
did not strike head. C/O left arm tingling after fall which has
improved. No LOC, ataxia, vision changes, weakness at time. He
presented to OSH ED, where head CT reportedly showed new SDH
with 7mm midline
shift. He was then transported to [**Hospital1 18**] ED for further workup
and management of this issue.
On arrival to the ED, vitals were 97.5, 84, 164/78, 18 100% RA.
Pt supine in C-collar, AAOx3, speech fluent and comprehension
intact. Complained of mild right temporal headache (unchanged
since initial SDH on [**7-21**]) and mild left arm tingling which was
improving. Denied weakness, numbness, diplopia, blurred vision,
dizziness, room spinning, nausea/vomiting, chest pain, dyspnea.
OSH labs notable for platelets 64 (coags WNL), so patient
received 1 bag platelets in [**Hospital1 18**] ED.
Past Medical History:
-Acute 9mm right SDH ([**2147-7-19**]), medically managed
-DM type 2 with nephropathy, retinopathy, peripheral and
autonomic neuropathy with orthostatic hypotension
-hypertension, calcification of the aortic valvular ring with
trifasicular block and left atrial abnormality on EKG,
pacemaker,
-idiopathic thrombocytopenic purpura
-s/p complete right knee arthroplasty
-BPH s/p TURP
-adult onset macular degneration
Social History:
married
Family History:
non-contributory
Physical Exam:
O: 97.5, 84, 164/78, 18 100% RA.
Gen: elderly M in NAD, AAOx3
HEENT: Pupils: 2mm, reactive BL EOMs intact
Neck: in C-collar
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.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2 to 1.5
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. Fine tremor in BUEs
(low
amplitude, high frequency), unchanged from prior. Strength full
power [**6-17**] throughout. No pronator drift.
Sensation: Intact to light touch and propioception bilaterally.
Reflexes: Deferred
Toes downgoing bilaterally
Coordination: +past pointing bilaterally
PHYSICAL EXAM UPON DISCHARGE:
Pertinent Results:
Admission labs:
[**2147-8-16**] 05:00PM BLOOD WBC-7.6 RBC-3.96*# Hgb-11.4* Hct-35.2*
MCV-89 MCH-28.8 MCHC-32.3 RDW-14.6 Plt Ct-74*
[**2147-8-16**] 05:00PM BLOOD Neuts-64.0 Lymphs-30.1 Monos-4.3 Eos-1.4
Baso-0.3
[**2147-8-16**] 07:15PM BLOOD PT-11.2 PTT-31.1 INR(PT)-1.0
[**2147-8-16**] 05:00PM BLOOD Plt Smr-VERY LOW Plt Ct-74*
[**2147-8-20**] 06:33AM BLOOD Ret Aut-1.6
[**2147-8-16**] 05:00PM BLOOD Glucose-53* UreaN-33* Creat-1.1 Na-141
K-3.9 Cl-104 HCO3-27 AnGap-14
[**2147-8-19**] 10:59PM BLOOD ALT-15 AST-33 LD(LDH)-201 AlkPhos-85
TotBili-0.4
[**2147-8-17**] 05:09AM BLOOD Calcium-8.2* Phos-3.0 Mg-2.2
[**2147-8-19**] 10:59PM BLOOD calTIBC-179* Ferritn-383 TRF-138*
[**2147-8-20**] 06:33AM BLOOD Cortsol-17.7
[**2147-8-19**] 04:57PM BLOOD Lactate-1.7
Discharge labs:
[**2147-8-23**] 05:30AM BLOOD WBC-8.1 RBC-3.10* Hgb-8.9* Hct-27.2*
MCV-88 MCH-28.7 MCHC-32.7 RDW-14.5 Plt Ct-59*
[**2147-8-23**] 05:30AM BLOOD Plt Ct-59*
[**2147-8-23**] 05:30AM BLOOD PT-13.0* PTT-26.6 INR(PT)-1.2*
[**2147-8-23**] 05:30AM BLOOD Glucose-213* UreaN-25* Creat-0.9 Na-137
K-3.7 Cl-104 HCO3-27 AnGap-10
[**2147-8-23**] 05:30AM BLOOD Mg-1.8
Studies:
[**8-16**] CXR: IMPRESSION: No evidence of acute cardiopulmonary
abnormality.
[**8-17**] Echo:Mild symmetric LVH with normal global and regional
biventricular systolic function. Mild mitral regurgitation.
LVEF>55%
[**8-17**] NCHCT:Minimal interval increase in right subdural mixed
density
hemorrhage since [**2147-8-16**] with 11 mm leftward shift of normally
midline
structures. Suggestion of early left ventricular entrapment
[**8-17**] Post operative head CT: Interval subdural hematoma
evacuation and drain placement, with improvement in degree of
mass effect. There is no acute intracranial hemorrhage.
[**2147-8-18**] head CT:
Interval decrease in degree of pneumocephalus overlying the
right cerebral
hemisphere with persistent small right subdural collection.
Decreased mass
effect. No new hemorrhage.
[**2147-8-19**] head CT: No significant interval change in size of right
subdural
collection or degree of pneumocephalus. Unchanged mass effect.
No new
hemorrhage.
Micro:
[**2147-8-20**] URINE URINE CULTURE- no growth
[**2147-8-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2147-8-20**] BLOOD CULTURE Blood Culture, Routine-PENDING
[**2147-8-19**] URINE URINE CULTURE-FINAL - no growth
[**2147-8-17**] MRSA SCREEN MRSA SCREEN-FINAL - no growth
[**2147-8-16**] MRSA SCREEN MRSA SCREEN-FINAL - no growth
Brief Hospital Course:
Dr. [**Known lastname 20773**] is an 82 year old man with a history of ITP and IDDM
complicated by autonomic postural hypotension, recently admitted
for 7mm acute traumatic SDH after fall, was transferred from OSH
for acute on chronic SDH with 7mm midline shift s/p right burr
hole drainage by [**Hospital1 18**] neurosurgery. Post-op course complicated
by hypotension and hypoglycemia being transferred to medicine
for further management.
# Subdural hematoma: Acute on chronic. Patient is now s/p right
burr hole by neurosurgery. Pt was admitted to the Neurosurgery
service, ICU for close neurological observation. He was started
on Keppra for seizure prophylaxsis, and blood pressure was kept
<140 systolic. Platelets were only 64K so he was given a unit.
On [**8-17**] it was noted that the patient had developed a facial
droop. A CT was performed which revealed slightly increased
hemorrhage and increased MLS. He was pre-opped for the OR and
consent was obtained from his wife. [**Name (NI) **] went to the OR and
underwent burr hole drainage. Surgery was without complication.
He was transferred back to the ICU and then successfully
extubated. Post op head CT revealed improvement in mass effect
with no acute hemorrhage. His JP drain was placed to thumb
suction. On post operative exam, he had some L sided weakness,
but otherwise stable. On [**8-18**], his L sided weakness was
improved. He was full motor and improvement of his L facial
droop was seen. His JP put out 60cc for 24 hours and 30cc for 8
hours overnight. JP was removed and patient was transferred to
the floor with tele. On [**8-19**], patient was seen to be stable in
the AM. Speech and swallow determined he was safe to have a diet
of thin liquids and regular solids. In the afternoon, patient
was more confused on exam, a repeat head CT was done which
showed no changes from previous scan. PT evaluated patient and
determined that he was not safe to ambulate.
# Glycemic control: Patient had difficult to control blood
sugars while in the hospital. He was initially hypoglycemic in
the setting of poor PO intake on admission. Insulin regimen was
held and patient gradually restarted normal diet. Once resuming
normal diet, blood sugars were very high in the 300-400 range
and we slowly titrated back his insulin to his home regimen.
Endocrinologists from [**Last Name (un) **] were consulted to help manage his
blood glucose levels and he was discharged on a stable regimen
close to his home doses.
# Labile blood pressures: Baseline autonomic dysfunction and
hypertension from holding BP meds. Initially severely
orthostatic with symptoms, likely the cause of his fall (see
below). Orthostasis improved with fluids and abdominal binder.
Initially his anti-hypertensives were held due to severe
orthostasis, which caused him to become slightly hypertensive
later in his hospital course (see below). His orthostasis
improved with hydration, increased PO intake, and abdominal
binder. Physical therapy was consulted to assess his safety
while walking and felt he would benefit from additional
rehabilitation at an extended care facility.
#HTN: Lisinopril, metoprolol, and furosemide were held initially
given hypotension and labile blood pressures (above). As he was
fluid resuscitated and resumed normal diet, his blood pressures
steadily increased over his hospitalization and his home
anti-hypertensives were titrated back to home doses. We
continued to hold his furosemide on discharge. This should be
added back while at his extended care facility as his blood
pressure tolerates.
# Falls: Patient had falls at home, which lead to current SDH.
This is likely in the setting of orthostatic hypotension
(above). Patient was placed on fall precautions and was seen by
cardiology and pacemaker was interrogated, which revealed no
malignant rhythm near the time of the fall. They did find
evidence of AVNRT, however which was broken to sinus rhythm with
carotid massage (see below).
# Tachycardia: Likely AVNRT per cardiology. Patient had two
episodes of tachycardia to 140-150 with symptoms of
lightheadedness, palpitations, shortness of breath. He remained
neurologically intact and did not have chest pain during these
episodes. These episodes occured in the setting of holding his
home metoprolol given his severe orthostasis and volume
depletion (above). These episodes were responsive to carotid
massage by cardiology which broke the rhythm immediately to
sinus rhythm in the 70s-80s. Upon resuming home metoprolol, he
did not have any additional episodes of AVNRT.
#ITP: platelets currently stable at approx 50-100 no signs of
bleeding. This was trended throughout his hospital course.
#Anemia: Hct is stable at approx 30-35. No signs of bleeding
throughout his hospitalization. He was maintained on an active
type and screen.
# Transitional issues:
- Will need neurosurgery follow up in [**8-22**] days post hospital
discharge for wound check. Please see discharge planning
instructions.
- Will need PCP follow up
Medications on Admission:
1. quinapril 20 mg Tablet Sig: Two (2) Tablet PO Qpm.
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for edema, SOB.
3. pravastatin 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
5. insulin detemir 100 unit/mL Solution Sig: Fourteen (14) units
Subcutaneous twice a day.
6. PreserVision Oral
7. Novolog 100 unit/mL Solution Sig: [**5-21**] units Subcutaneous ac.
8. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. Levemir *NF* (insulin detemir) 100 unit/mL Subcutaneous [**Hospital1 **]
14 units [**Hospital1 **]
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. NovoLOG *NF* (insulin aspart) 100 unit/mL Subcutaneous DAILY
4-8 units
5. PreserVision *NF* (vit C-vit
E-copper-ZnOx-lutein;<br>vitamins A,C,E-zinc-copper) 226-200-5
mg-unit-mg Oral daily
6. quinapril *NF* 40 mg Oral daily
Hold for SBP < 100
7. Pravastatin 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**]
([**Hospital3 1122**] Center)
Discharge Diagnosis:
Right sided acute on chronic SDH
Midline shift
Altred mental status
facial droop
Orthostatic hypotension
Hypoglycemia
Tachycardia (AVNRT)
Discharge Condition:
Patient has baseline labile blood pressures with orthostatic
hypotension. He does better with abdominal binder, but still
requires assistance to walk. Has been asymptomatic even after
restarting his home antihypertensives.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Dr. [**Known lastname 20773**],
You were admitted to the hospital after a fall resulting in a
bleed in your brain (subdural hematoma) and had surgery to place
burr holes in your skull to relieve the pressure in your head.
You also had issues with your blood sugars and blood pressure
while you were in the hospital and you should follow up with
your PCP and cardiologist when you are discharged from the
extended care faciltiy.
Please take your medications as directed in the medication
section of this discharge paperwork.
Please follow the instructions below from your surgeons:
?????? Have a friend or family member check the wound for signs of
infection such as redness or drainage daily.
?????? Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
?????? Exercise should be limited to walking; no lifting >10lbs,
straining, or excessive bending.
?????? Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
?????? DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
?????? 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.
?????? Do not drive until your follow up appointment.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
?????? New onset of tremors or seizures.
?????? Any confusion, lethargy or change in mental status.
?????? Any numbness, tingling, weakness in your extremities.
?????? Pain or headache that is continually increasing, or not
relieved by pain medication.
?????? New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
Follow-Up Appointment Instructions
***Please discuss with the staff at the facility a follow up
appointment with your endocrinologist once you are ready for
discharge:
Name: [**Last Name (LF) 10088**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Last Name (un) **] DIABETES CENTER
Address: ONE [**Last Name (un) **] PLACE, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3402**]
??????Please call Paresa at ([**Telephone/Fax (1) 4676**] to schedule an appointment
with one of the Physician Assistant or [**Name9 (PRE) **] Practitioner in
[**8-22**] days from the time of surgery for suture/staple removal.
*** You may have them removed at your rehab facility as well.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury
(TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any
problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**].
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]
Completed by:[**2147-8-27**]
|
[
"287.31",
"852.21",
"250.62",
"V15.88",
"285.9",
"250.52",
"427.32",
"V43.65",
"458.0",
"337.1",
"362.01",
"E885.9",
"401.9",
"V58.67",
"293.0",
"250.82",
"V53.31",
"276.51",
"427.89",
"780.4",
"342.90",
"348.4",
"250.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.24"
] |
icd9pcs
|
[
[
[]
]
] |
12795, 12931
|
6666, 11504
|
285, 320
|
13113, 13338
|
4174, 4174
|
15456, 16829
|
2936, 2954
|
12318, 12772
|
12952, 13092
|
11720, 12295
|
13521, 15433
|
4947, 5768
|
2969, 3196
|
230, 247
|
4155, 4155
|
348, 2456
|
3333, 4124
|
6152, 6643
|
4190, 4931
|
13353, 13497
|
11527, 11694
|
2478, 2895
|
2911, 2920
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,958
| 160,910
|
45020
|
Discharge summary
|
report
|
Admission Date: [**2130-9-17**] Discharge Date: [**2130-9-22**]
Service: MEDICINE
Allergies:
Penicillins / Terbutaline / Egg/Pro / Atenolol / Nifedipine /
Tetracyclines / Heparin Agents
Attending:[**First Name3 (LF) 45**]
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
Cath?
History of Present Illness:
80 F who presented from home with sudden onset of weakness and
dizziness and tremors last night. No LOC. almost fainted. No CP,
slight SOB and abd pain. +N/no vomiting. No D/back pain. States
she has had an "awful cold" for 1 week. Mild HA 2 days ago, none
now. No neck pain. Fevers. +cough, non productive. Denies any
changed in vision. Similar admission in [**Month (only) 216**], thought to be
[**12-21**] infection and hypoglycemia. BG 218. BM QOD. also with some
diaphroesis at that time.
.
In the ED, 102.7-->99.5, 105, 197/81, 16, 99 % RA.
Vanco/bactrim given (PCN all) for meningitis. Decadron 10 mg as
well (unclear why). LP done which did not suggest infection.
.
Initially, thought was to d/c home if LP negative however
attending uncomfortable as pt appears dry, WBC, with fever.
.
Admitted for fever.
Past Medical History:
1. Coronary artery disease; status post myocardial
infarction in [**2102**] (silent). cath [**4-21**]: 2-vessel
disease, stent in the LCx and angioplasty of OM1, EF=19%.
2. Congestive heart failure (reported EF 20%, but more recent
echo states ?30% with difficult visualization).
3. flash pulmonary edema
4. recent UTI (dx'ed [**2130-5-22**]) on levofloxacin
5. s/p fall [**3-23**] without trauma in setting of lasix increase
6. PVD: s/p R fem-[**Doctor Last Name **] and L fem-DP bypass grafts. s/p R 5 toe
amputation and L one toe amputation.
7. DM2
8. HTN
9. Heparin-induced thrombocytopenia.
10. DJD/osteoarthritis B knees
11. s/p both hip fx, shoulder fx and ?proximal humerus fx (pt
denies).
12. R foot cellulitis.
13. (COPD - pt denies).
14. appendectomy.
15. cholecystectomy.
16. hysterectomy.
17. R eye cataract surgery [**4-23**]
18. anemia - baseline Hct 30-33
19. ARF - baseline Cr 1.1
Social History:
The patient lives at home with her sister. She has a VNA qweek
that helps to draw up her insulin. She is able to complete daily
ADLs. She walks with a cane. She denies tobacco and alcohol use.
Family History:
twin sister died last year of colon cancer. otherwise
unremarkable
Physical Exam:
On Admission:
Temp 98.5
BP 140/86
Pulse 68
Resp 18
O2 sat 99% RA
Gen - Alert, no acute distress, sleeping but arousable
HEENT - post surgical pupil, extraocular motions intact,
anicteric, mucous membranes dry
Neck - hard to assess as pt with lip trmeor, no cervical
lymphadenopathy
Chest - Clear to auscultation bilaterally
CV - Normal S1/S2, RRR, [**12-25**] SE murmur across precordium, no
rubs, or gallops
Abd - Soft, nontender, nondistended, with normoactive bowel
sounds
Back - No costovertebral angle tendernes
Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally
Neuro - Alert and oriented x 3, cranial nerves [**12-31**] intact,
upper and lower extremity strength 5/5 bilaterally, sensation
grossly intact
Skin - No rash
Pertinent Results:
[**2130-9-16**] 06:45PM BLOOD WBC-18.8*# RBC-4.33# Hgb-13.6# Hct-38.9
MCV-90 MCH-31.4 MCHC-34.9 RDW-13.1 Plt Ct-153
[**2130-9-16**] 06:45PM BLOOD Neuts-93.9* Bands-0 Lymphs-3.7*
Monos-1.8* Eos-0.5 Baso-0.1
[**2130-9-16**] 06:45PM BLOOD Glucose-204* UreaN-33* Creat-1.2* Na-140
K-4.6 Cl-100 HCO3-28 AnGap-17
[**2130-9-16**] 06:45PM BLOOD ALT-14 AST-20 LD(LDH)-249 CK(CPK)-77
AlkPhos-113 Amylase-50 TotBili-0.6
[**2130-9-16**] 06:45PM BLOOD CK-MB-4 cTropnT-0.01
[**2130-9-16**] 06:45PM BLOOD Albumin-4.1 Calcium-9.6 Phos-2.5* Mg-1.7
[**2130-9-16**] 07:03PM BLOOD Glucose-207* Lactate-2.1* K-4.7
*
[**2130-9-17**] 07:55PM BLOOD Lactate-1.8
[**2130-9-17**] 11:20AM BLOOD WBC-15.8* RBC-3.71* Hgb-11.4* Hct-33.9*
MCV-91 MCH-30.9 MCHC-33.8 RDW-13.3 Plt Ct-119*
[**2130-9-17**] 05:10PM BLOOD Hct-31.3*
[**2130-9-17**] 05:10PM BLOOD PT-13.3 PTT-26.9 INR(PT)-1.2
[**2130-9-17**] 11:20AM BLOOD Glucose-469* UreaN-35* Creat-1.4* Na-138
K-4.1 Cl-101 HCO3-24 AnGap-17
[**2130-9-17**] 07:41PM BLOOD Glucose-269* UreaN-34* Creat-1.3* Na-139
K-4.1 Cl-103 HCO3-24 AnGap-16
[**2130-9-17**] 11:20AM BLOOD CK(CPK)-161*
[**2130-9-17**] 03:15PM BLOOD CK(CPK)-143*
[**2130-9-17**] 09:30PM BLOOD CK(CPK)-119
[**2130-9-17**] 11:20AM BLOOD CK-MB-17* MB Indx-10.6* cTropnT-0.39*
[**2130-9-17**] 03:15PM BLOOD CK-MB-13* MB Indx-9.1* cTropnT-0.35*
[**2130-9-17**] 09:30PM BLOOD CK-MB-10 MB Indx-8.4* cTropnT-0.34*
[**2130-9-17**] 11:20AM BLOOD Calcium-8.2* Phos-3.7 Mg-1.8
[**2130-9-17**] 07:41PM BLOOD Calcium-8.4 Phos-2.8 Mg-2.7*
*
[**2130-9-18**] 08:50AM BLOOD WBC-13.2* RBC-3.64* Hgb-11.2* Hct-32.3*
MCV-89 MCH-30.8 MCHC-34.7 RDW-13.1 Plt Ct-130*
[**2130-9-18**] 08:50AM BLOOD Neuts-91.1* Bands-0 Lymphs-6.6* Monos-2.0
Eos-0.3 Baso-0
[**2130-9-18**] 08:50AM BLOOD PT-19.6* PTT-74.4* INR(PT)-2.7
[**2130-9-18**] 08:50AM BLOOD Glucose-115* UreaN-31* Creat-1.2* Na-141
K-4.4 Cl-110* HCO3-23 AnGap-12
[**2130-9-18**] 08:50AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.3
.
.
[**2130-9-18**]: CXR: IMPRESSION: Upper zone redistribution. Prominence
of hila, which may relate to underlying pulmonary hypertension.
Peribronchial cuffing, unchanged. No definite infiltrate.
.
[**9-16**]: Blood Cultures: positive for GPC in pairs and chains in
[**1-20**] bottles
.
[**9-16**]: LP:
ANALYSIS WBC RBC Polys Lymphs Monos
[**2126-9-17**] 1* 92 45 45
Total protein: 67
Glucose: 102
.
[**2130-9-22**]: TEE:
No spontaneous echo contrast is seen in the body of the left
atrium. No atrial septal defect is seen by 2D or color Doppler.
There is severe regional left ventricular systolic dysfunction.
There are complex (>4mm) atheroma in the aortic arch. There are
simple atheroma in the descending thoracic aorta. There are
three aortic valve leaflets. The aortic valve leaflets are
moderately thickened. There are filamentous strands on the
aortic leaflets consistent with Lambl's excresences (normal
variant) as well as a focal calcification on the left coronary
cusp - no definite vegitation seen. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. No mass or
vegetation is seen on the mitral valve. There is a small
pericardial effusion. The absence of a vegetation by 2D
echocardiography does not exclude endocarditis if clinically
suggested.
.
CXR:
IMPRESSION: AP chest compared to [**9-19**]:
Pulmonary edema has largely cleared. A mild degree of residual
edema or atelectasis persists at the lung bases and there may be
a small right pleural effusion. The heart is top normal size and
unchanged. Slight rightward displacement of the trachea at the
thoracic inlet is longstanding, most likely due to an enlarged
left lobe of the thyroid gland
.
[**2130-9-16**]:
HEAD CT WITHOUT IV CONTRAST: No intra- or extra-axial
hemorrhage, mass effect, or shift of midline structures is
demonstrated. Differentiation of [**Doctor Last Name 352**] and white matter is
preserved. The sulci, ventricles, and basal cisterns are all
within normal limits. Polypoid mucosal thickening versus a
retention cyst is seen within the left maxillary sinus.
Remaining visualized paranasal sinuses and mastoid air cells are
clear. Calcification of the internal carotid arteries and
vertebral arteries bilaterally are again noted.
IMPRESSION: Stable appearance of the brain parenchyma without
evidence of intracranial hemorrhage or mass effect.
.
Brief Hospital Course:
80 F with multiple medical problems, including CAD, CHF, PVD,
DM2, who presented with a near syncopal episode, fever, elevated
WBC, some nausea today with poor PO intake who was found to have
GPC bacteremia and NSTEMI on [**9-17**].
.
#Fever:
Unclear source. Elevated WBC with left shift suggesting
infection. viral infection possible (?influenza, although veyr
atypical story without myalgias); CAP (dry, no doesnt show on
CXR), occult bacteremia. Viral Cx (including influenza)
negative.
-UA and LP were negative in ED
-[**12-21**] postive for GPC in pairs and clusters - IDd as Coag
negative Staphlococcus -> started on Vancomycin 1g q 24 -
renally dosed -> then switched to Levofloxacin to one day since
this bacteria was sensitive to levoquin. However, on [**2130-9-21**], an
ID consult recommended that this bacteria was probably not Staph
Epi since its sensitivity spectrum was not typical for Staph
Epidermidis. And thus, convering with Levofloxacin was not
optimal coverage. Hence, it was recommended that the patient
undergo 4 weeks of treatment for this with IV Vancomycin and
undergo a TEE. The TEE was not suggestive of endocarditis or
vegetations. The patient will be followed up by Dr. [**First Name (STitle) 2505**] in the
[**Hospital **] clinic at [**Hospital1 18**] and he will arrange for patient's follow up.
Please check weekly CBC with diff, BUN and Cr and Vancomycin
troughs. Please fax to [**Telephone/Fax (1) 1419**].
.
- Newly diagnosed NSTEMI
- Cardiology aware and she was placed on bivalirudin and pre
cath hydration - in expectation of cath on [**2130-9-18**].
- had Plymorphic VTach, NSVT x 3 other episodes - all
aymptomatic - no EKG changes, except for once incident of PVC
- CEs stabilized (i.e. not rising)
- On [**2130-9-18**] - Pt had been getting pre-cath hydration and was
more than 1L positive over the past day. Pt had been afebrile x
2 days but had begun having large amounts of diarrhea over the
past 12 hours. Guaiac positive. She developed respiratory
distress and was not able to maintain O2 saturations. She is
DNR/DNI and was brought to the CCU for BiPap and possible
diuresis. CXR showed diffuse whitening of the R lung and
enlarged heart border without obvious cephalization of vessels.
In the unit, she was diuresed heavily until being transferred
back to the medical floor.
- at this time there is no plan for a cath as the impression is
that these events were secondary to demand from her infection.
Can consider outpatient stress workup - however, likely
situation was that patient had demand ischemia and risks would
outweigh benefits of any intervention.
.
#Nausea/tremor/LH: near syncope: likely secondary to infectious
sources. Patient febrile on arrival.
.
#CHF: dry by exam. Titrated to keep even/net negative to prevent
further occurrences of pleural effusions.
-cont digoxin. Monitored dig levels
.
#DM2: cont outpt regimen, SS insulin, NPH at home regimen
.
#FEN: [**Doctor First Name **], Lasix 20mg PO.
.
#Ppx: no heparin as HIT, PPI, bowel, pneumboots
.
#Code: Full
.
# Patient was educated on necessity of the antibiotic regimen
prescribed for her bacteremia. Since the TEE was not suggestive
of endocarditis/vegetations, patient will be treted for 4 weeks;
however, this will be further elucidated by Dr. [**First Name (STitle) 2505**] whom the
patient will follow up with in the [**Hospital **] clinic at [**Hospital1 18**]. The
patient was given a PICC line for the administration of
Vancomycin.
Medications on Admission:
ASPIRIN 325MG qd
ATORVASTATIN CALCIUM 10MG qd
AZELASTINE HCL 137 mcg/SPRAY--[**11-20**] squirts in each nostril up to
twice a day as needed for nasal congestion
CLOPIDOGREL BISULFATE 75MG qd
DIGOXIN 125MCG qd
FUROSEMIDE 60 mg qd
ISOSORBIDE MONONITRATE 30MG qd
LISINOPRIL 20MG qd
METOPROLOL SUCCINATE 50MG-- qd
MULTIVITAMINS
NPH (HUMAN) 20 units qam, 13 units qpm
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
6. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Ketorolac Tromethamine 0.5 % Drops Sig: One (1) drop
Ophthalmic nightly ().
12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1)
Intravenous Q 24H (Every 24 Hours) for 27 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 599**] of [**Location (un) 55**]
Discharge Diagnosis:
1. NSTEMI
2. Coagulase Negative Staph Bacteremia
Discharge Condition:
AAOx3
Ambulating
In good spirits, and conversant
Afebrile and hemodynamically stable
Discharge Instructions:
Weigh yourself every morning, call your doctor if your weight >
3 lbs.
*
Adhere to 2 gm sodium diet.
*
Please call your doctor if you start to de
Followup Instructions:
You have the following prescheduled appointments:
1. Provider: [**First Name8 (NamePattern2) 5257**] [**Last Name (NamePattern1) 5258**], [**Name12 (NameIs) 280**] Date/Time:[**2130-9-27**] 12:00
2. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1849**], M.D. Date/Time:[**2130-10-24**] 1:40
3. Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Date/Time:[**2130-10-25**] 11:00
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Doctor First Name 63**]
Completed by:[**2130-9-22**]
|
[
"V58.67",
"584.9",
"428.0",
"443.9",
"790.7",
"578.1",
"401.9",
"287.4",
"276.51",
"518.82",
"041.19",
"707.14",
"410.71",
"E934.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"93.90",
"88.72",
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12528, 12600
|
7490, 10958
|
308, 315
|
12693, 12780
|
3153, 7467
|
12974, 13580
|
2308, 2376
|
11371, 12505
|
12621, 12672
|
10984, 11348
|
12804, 12951
|
2391, 2391
|
259, 270
|
343, 1159
|
2405, 3134
|
1181, 2080
|
2096, 2292
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,637
| 110,835
|
17523
|
Discharge summary
|
report
|
Admission Date: [**2146-3-29**] Discharge Date: [**2146-4-2**]
Date of Birth: [**2084-9-15**] Sex: F
Service: CCU
HISTORY OF PRESENT ILLNESS: This is a 61 year old female
with no significant past medical history. Her coronary
artery disease risk factors included age and tobacco use.
The patient was in her usual state of health until the
morning of admission when she started to experience a left
arm pain while at rest. The arm pain progressed to a
substernal chest pain similar to a "brick on her chest", and
was associated with shortness of breath. She denied any
nausea, vomiting, neck pain or back pain.
She subsequently activated Emergency Medical Services and was
brought to the [**Location (un) 620**] Emergency Room. While there, she was
found to have inferior ST segment elevations on an EKG. She
was given an aspirin and started on Nitroglycerin drip,
heparin bolus, along with a drip, Integrilin bolus with drip
and Lopressor 5 mg intravenously times two. After the
Nitroglycerin drip was started, her blood pressure dropped to
70 systolic and remained there for approximately 15 minutes.
Her pressure responded to a two liter intravenous fluid bolus
and the Nitroglycerin drip was discontinued. She was then
transferred to the [**Hospital1 69**] for
cardiac catheterization.
In the catheterization laboratory, she was found to have a
chronically occluded right coronary artery lesion of
approximately 90% and acutely occluded 90% proximal left
circumflex, which was stented with a 3.5 millimeter by 15
millimeter Zeta stent. Her wedge pressures were found to be
elevated at approximately 22 and she subsequently received 20
mg of intravenous Lasix to which she diuresed over 2.5 liters
with a reduction in her wedge to 16. She was then
transferred to the Coronary Care Unit in stable condition.
PAST MEDICAL HISTORY: Appendectomy 20 years ago.
ALLERGIES: Penicillin which gives her hives.
MEDICATIONS UPON ADMISSION: None.
FAMILY HISTORY: Mother with coronary artery disease in her
70s; sister with angina symptoms in her sixties.
SOCIAL HISTORY: The patient is a current tobacco user with
approximately 40 pack years.
PHYSICAL EXAMINATION: Physical examination showed a
temperature of 98.9 F.; heart rate of 75; blood pressure
107/58; 02 saturations were 100% at room air. In general,
this is an elderly female in no apparent distress. Her
pupils were equally round and reactive to light. Her
extraocular movements were intact. Her oropharynx was clear.
She showed no jugular venous distention or carotid bruits.
She had a normal carotid upstroke. Her lungs were clear to
auscultation bilaterally. Her heart was a regular rate and
rhythm with a normal S1, S2. There was no murmur,
regurgitation or gallop appreciated. Her abdomen was soft,
obese, nontender, nondistended, with normoactive bowel
sounds. Her extremities were without cyanosis, clubbing or
edema. She had plus two dorsalis pedis pulses. Her
neurological examination showed her alert and oriented times
three with no focal abnormalities.
LABORATORY: Upon admission, showed a white blood cell count
of 16.8, a hematocrit of 38.0 and a platelet count of 269.
Her Chem-7 showed a sodium of 140, potassium of 3.6, a
chloride of 109, bicarbonate of 24, BUN of 12, creatinine
0.5, glucose of 118.
Her PT was 12.8, PTT 40.1, INR was 1.1. Her liver function
tests were normal. Her magnesium was 1.6, calcium 7.7,
phosphate 3.0.
EKG post intervention showed a normal sinus rhythm at 75
beats per minute with a normal axis and normal intervals.
She had an isolated Q wave in lead III. She had [**12-30**]
millimeter to [**Street Address(2) 2914**] depression in leads V2 and V3.
Chest x-ray showed no acute cardiopulmonary process.
HOSPITAL COURSE: This is a 61 year old female with a history
of tobacco use who was admitted from an outside hospital with
an acute inferior ST elevation myocardial infarction. She
was immediately taken to the cardiac catheterization
laboratory and was found to have two vessel coronary artery
disease with the right coronary artery with a 90% lesion and
an acutely occluded 90% proximal left circumflex artery.
The left circumflex lesion was successfully stented and the
patient was transferred to the Coronary Care Unit for further
observation.
PROBLEM LIST:
1. CARDIAC: The patient was admitted to Coronary Care Unit.
She was placed on Telemetry and her cardiac enzymes were
cycled. Her peak CK was 3,745 with a CK MB of 654 for an MB
index of 17.5. She was placed on aspirin, Plavix, an ACE
inhibitor and a beta blocker. She was also placed on a G23B
inhibitor for 18 hours following the catheterization.
Her lipid panel was checked which showed a total cholesterol
of 192 with an LDL of 123. She had normal liver function
tests and was started up on a lipid lowering [**Doctor Last Name 360**].
An echocardiogram showed there was a mild symmetrical left
ventricular hypertrophy with a normal cavity size. There was
a moderate regional left ventricular systolic dysfunction
with a focal near akinesis of the basal two-thirds of the
inferior and inferolateral wall. The remaining segments
contracted well. The right ventricular chamber size and free
wall motion were normal. The aortic valve leaflets were
structurally normal with good leaflet excursion. No aortic
regurgitation was seen. The mitral valve leaflets were
mildly thickened. Mild plus one mitral regurgitation was
seen. The pulmonary artery systolic pressure could not be
estimated. There was no pericardial effusion. The ejection
fraction was estimated to be about 35%.
On the third day of her admission, the patient was taken back
to the Cardiac Catheterization Laboratory for further
intervention on the right coronary artery lesion. This
lesion was successfully stented without any complications and
the patient was returned to the floor.
While on the floor, the patient remained hemodynamically
stable and her ACE inhibitor and beta blocker were gradually
titrated up. Her electrolytes were repleted as needed.
DISCHARGE DIAGNOSES:
1. Two vessel coronary artery disease status post a stent
placement in the left circumflex and the right coronary
artery.
2. Tobacco use.
DISCHARGE STATUS: The patient was discharged home.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q. day.
2. Plavix 75 mg p.o. q. day.
The patient was instructed to take the aspirin and the Plavix
unless specifically instructed by her Cardiologist. She was
explained the importance of these medications given her
recent coronary interventions.
3. Metoprolol XL 25 mg p.o. q. day.
4. Captopril 12.5 mg p.o. three times a day.
5. Atorvastatin 20 mg p.o. q. day.
DISCHARGE INSTRUCTIONS:
1. The patient was instructed of the importance of
discontinuing smoking.
2. She was also told to return to the Emergency Room if she
develops any further chest pain, shortness of breath, jaw
pain, back pain or any other cardiac symptoms.
3. She was scheduled a follow-up appointment with Dr. [**First Name4 (NamePattern1) 122**]
[**Last Name (NamePattern1) **].
4. She was also told to follow-up with her primary care
physician.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**]
Dictated By:[**Name8 (MD) 6284**]
MEDQUIST36
D: [**2146-6-17**] 16:24
T: [**2146-6-25**] 19:20
JOB#: [**Job Number 48909**]
|
[
"410.31",
"V15.82",
"414.01",
"429.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"88.56",
"36.06",
"37.22",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
1994, 2087
|
6098, 6293
|
6316, 6708
|
3786, 4319
|
6732, 7429
|
2202, 3768
|
161, 1840
|
4333, 6077
|
1969, 1976
|
1864, 1954
|
2105, 2178
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,973
| 193,773
|
13415
|
Discharge summary
|
report
|
Admission Date: [**2179-3-29**] Discharge Date: [**2179-4-14**]
Service: CARD [**Doctor First Name 147**]
CHIEF COMPLAINT: Coronary artery disease.
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 78 year old man
with a history of coronary artery disease, congestive heart
failure, with ejection fraction of 25%, hypertension, and
hypercholesterolemia, who presented to an outside hospital on
[**2179-3-25**], after sudden onset of shortness of breath and
chest pressure while walking. His cardiac enzymes were
slightly elevated while in the hospital and he was also
diagnosed with congestive heart failure. An echocardiogram
revealed an ejection fraction of 20% with global hypokinesis.
He was transferred then to [**Hospital1 188**] for cardiac catheterization.
PAST MEDICAL HISTORY:
1. Coronary artery disease: Status post inferior myocardial
infarction ten years ago.
2. Congestive heart failure, with ejection fraction of 25%.
3. Hypertension.
4. Hypercholesterolemia.
5. Status post tonsillectomy 50 years ago.
ALLERGIES: None known.
OUTPATIENT MEDICATIONS:
1. Bumex 2 mg p.o. q. day.
2. Celexa 20 mg q. day.
3. Zestril 10 mg q. day.
4. Atenolol 50 mg twice a day.
5. Lipitor 10 mg q. day.
6. Vitamin E.
7. Aspirin 81 mg q. day.
8. Nitroglycerin patch 0.2 mg q. a.m.; off q. p.m.
HOSPITAL COURSE: The patient was admitted to the Cardiac
Medicine Service and underwent a catheterization which
revealed severe left main and three-vessel coronary artery
disease with a severely depressed ejection fraction of 24%.
On [**2179-3-30**], he underwent a coronary artery bypass graft
times three, with left internal mammary artery to left
anterior descending, saphenous vein graft to obtuse marginal,
saphenous vein graft to PDA. He was transferred to the
Cardiac Care Unit postoperatively. He had an intra-aortic
balloon pump at the time and was on pressors. The
vasopressors were slowly weaned off over the next couple of
days. He was extubated on postoperative day one.
On postoperative day two, his intra-aortic balloon pump was
weaned and discontinued. On postoperative day three, he was
noted to have an expiratory wheeze while lying down which
would disappear when he sat up. He was treated with
Albuterol MDI. He continued to have episodic shortness of
breath with wheezing and tachycardia, which mainly would
resolve with Albuterol nebulizers. A chest x-ray was done
which showed bilateral lower lobe atelectasis. The patient
had chest physiotherapy at this point.
On [**2179-4-2**], a Pulmonary consultation was obtained for the
episodes of shortness of breath and wheezing. The Pulmonary
consult suspected and upper airway pathology which could
become audible during the rapid breathing phase of
[**Last Name (un) 6055**]-[**Doctor Last Name **] respiration. They recommended an ENT
evaluation, steroids, plus/minus racemic epinephrine.
An ENT consultation was obtained was obtained at that time
and a fiberoptic examination showed a normal nasopharynx,
hypopharynx and larynx with no granulation tissue or edema,
normal vocal cord appearance and mobility. The impression
was that he had normal vocal cords and a wide open glottis
and they suggested evaluating for dynamic upper airway
obstruction below the level of the vocal cords. Over the
next few days, he continued to have episodes of audible
expiratory wheeze. He was also slightly confused at this
point.
On [**2179-4-4**], he underwent a bronchoscopy which showed a
normal oropharynx, normal larynx, no endobronchial lesions,
mild dynamic clots at the level of the main stem. He
continued to be treated with Metered-Dose Inhalers and
racemic epinephrine.
A Cardiology consultation was also obtained and they
recommended to continue diuresis and give bronchodilators.
On [**4-7**], the patient had an episode of rigors accompanied
by hypertension, tachycardia and mottled lower extremities
and expiratory wheezes bilaterally. The patient was treated
with two doses of Benadryl intravenously. The episode
resolved after 25 minutes. He had a CT scan of his torso
which was negative. Blood cultures were sent and he was
started on Levofloxacin.
On [**4-8**], he was transferred out of the Coronary Care Unit.
At this point, neurologically, he was having episodes of
agitation and confusion. This was treated with Haldol.
Over the next few days, his pulmonary status gradually
improved; the wheezing episodes decreased. His confusion
started dissolving. On [**2179-4-2**], he was transferred out to
the Regular Floor. On [**2179-4-13**], postoperative day 14, his
condition was stable. Neurologically, he was oriented and
appropriately responsive. His pacing wires were
discontinued. Rehabilitation Screening was started as it was
felt that he was stable enough to go to rehabilitation at
this point.
MEDICATIONS ON DISCHARGE:
1. Captopril 37.5 mg three times a day.
2. Protonix 40 mg p.o. q. day.
3. Albuterol one to two puffs q. four to six hours p.r.n.
4. Haldol 2 mg p.o. q. eight hours p.r.n.
5. Lopressor 12.5 mg p.o. twice a day.
6. Lasix 20 mg q. day times one week.
7. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq q. day times one week.
8. Colace 100 mg p.o. twice a day.
9. Enteric coated aspirin 325 mg p.o. q. day.
10. Carvedilol 3.125 mg twice a day.
11. Celexa 20 mg q. day.
12. Ciprofloxacin 500 mg q. 12 hours times one week.
13. Tylenol 650 mg p.o. q. four to six hours p.r.n.
CONDITION AT DISCHARGE: Stable.
DISPOSITION: Discharge to Rehabilitation facility.
DISCHARGE INSTRUCTIONS:
1. Follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks.
2. Follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], in two
weeks.
3. Suggestion is also made to the primary care physician to
test for urinary metabolites for a pheochromocytoma.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 2209**]
MEDQUIST36
D: [**2179-4-14**] 10:34
T: [**2179-4-14**] 11:00
JOB#: [**Job Number 2589**]
|
[
"492.8",
"410.41",
"998.2",
"428.0",
"997.3",
"425.4",
"414.01",
"518.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"36.12",
"38.93",
"88.56",
"88.53",
"37.23",
"36.15"
] |
icd9pcs
|
[
[
[]
]
] |
4872, 5494
|
1351, 4846
|
5597, 6177
|
1102, 1333
|
5510, 5573
|
136, 162
|
191, 792
|
814, 1078
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
27,426
| 197,980
|
52293
|
Discharge summary
|
report
|
Admission Date: [**2134-4-16**] Discharge Date: [**2134-4-21**]
Date of Birth: [**2052-10-9**] Sex: M
Service: MEDICINE
Allergies:
Iodine; Iodine Containing / Casodex
Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
Blood in the stool/fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a 81 y/o M with h/o CAD, CHF 35%, HTN, CRI, metastatic
prostate cancer who was recently initiated on chemotherapy
Taxotere/pamidronate [**2134-4-8**] who presents with 2 syncopal
episodes and bright blood per rectum
.
He reports that 2 days ago, went to the bathroom, had some
diarrhea and on his way back fainted. he felt as it was going to
happen. No palapitations, chest pain or lightheadenss with the
episopde. Then last night, increase amount of diarrhea, spent >1
hours in the bathroom and on his way back, he fainted with LOC
per his report. He recovered himself and got to his bed. He did
notice blood in the toilet paper after his long episode of
diarrhea.
He denied nausea, vomit, abominal pain, hematemesis.
Of note he has been controling his pain with naproxen,
ibuprofen, aspirin and tylenol. Per OMR note, daughter called
case manager concern for him being depressed and taken a lot of
Ibuprofen "15 pills".
.
Of note, he wasn feeling well since chemotherapy.. Not taking a
lot of food. He also had weight loss for the alst year [**56**]
pounds.
In the ED, T 96.9, Hr 79, Bp 92/66, RR 16,. He received protonix
40 mg IV, morphine IV x2. He refused to get a foley catheter.
.
Currently patient feels ok with no complaints.
Past Medical History:
#. CAD s/p CABG in [**2113**] and multiple caths
-PCI: stents to distal LAD and lPL in 8/99, stents to proximal
LCx and OM2 in [**2-20**] and PTCA of OM2 on [**2128-7-16**].
-patent LIMA to LAD, SVG to LPL as of cath in [**2133-3-19**]
-The SVGs to D1 and OM, and occluded SVG to RCA, as well as the
native RCA are known to be occluded.
#. Chronic Systolic CHF EF 35% ([**8-/2133**])
#. metastatic Prostate Ca followed by Dr. [**Last Name (STitle) **]
#. Chronic Renal Insufficiency, Baseline Cr 1.2-1.5
#. HTN - x 20 years, pt reports excellent BP control at home
#. Gout
#. P-Afib/Aflutter (ablation [**2132-1-10**])
#. Glaucoma --blind in Right eye
#. Depression/anxiety
.
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]
OUTPATIENT CARDIOLOGIST: Dr [**Last Name (STitle) 120**]
.
All: Iodine containing contrast, casodex
Social History:
Lives with his [**Last Name (un) 108115**], very independent, drives and does his
bills. Pt is a retired mechanic. He recently lost his wife from
dementia this summer. He denies any EtOH over last 10 years.
Smoked from 19-25 while in the service. None since.
Family History:
2 brothers with CAD. No family history of sudden death.
esophageal Ca in his son, who died 5 years ago; daughter well.
Physical Exam:
Vitals: T: 98.9 P:75 R:16 BP:99/48 SaO2:97% RA
General: Awake, alert, NAD.
HEENT: dry oral mucose, no JVD. R eye opaque- glaucoma
Neck: supple, no JVD
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, soft diastolic murmur RUSB
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: no edema. 2 toe left foot tender to palpation, mild
erythema. no secretion.
Rectal exam: ED: BRB in the vault. No external hemorroids.
Skin: scoriation lower extremities. + skin pigmentation in the
lower back.
Pertinent Results:
[**2134-4-16**] MRI Lspine:
1. Findings indicative of bony metastatic disease with
predominant involvement of the sacrum.
2. Sacral involvement is in the midline and on the left side
with involvement of the left S2 and S3 foramina which could
result in irritation of left S2 and S3 nerve roots.
3. Severe left foraminal stenosis at L4-5 level due to disc
protrusion which could result in irritation of left L4 nerve
root.
4. Multilevel degenerative changes with mild-to-moderate spinal
stenosis at L2-3 and mild spinal stenosis at L3-4 and L4-5
levels.
5. Retroperitoneal and pelvic lymphadenopathy.
.
[**2134-4-16**] Hip Xray: Unchanged appearance of subtle lucent lesion
in left proximal femoral diaphysis consistent with metastasis.
No evidence of pathologic fracture. No other foci suspicious for
metastasis identified in the pelvis or imaged portion of left
femur and knee.
.
[**2134-4-16**] Head CT: No evidence of acute intracranial hemorrhage or
fracture
.
[**2134-4-16**] Chest Xray: No acute cardiopulmonary disease.
.
[**2134-4-17**] MRI HEAD: Moderate changes of small vessel disease. No
enhancing brain lesions are identified. No acute infarct is
noted. Chronic lacune left thalamus.
.
[**2134-4-19**] Right foot xray: No fracture or osteolysis involving
the second digit.
.
[**2134-4-20**] Echocardiogram: The left atrium is elongated. The right
atrium is markedly dilated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is
10-20mmHg. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is mild to
moderate global left ventricular hypokinesis (LVEF = 30 %). No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with moderate global free
wall hypokinesis. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild to moderate ([**1-20**]+) mitral regurgitation is seen.
The left ventricular inflow pattern suggests a restrictive
filling abnormality, with elevated left atrial pressure. The
tricuspid valve leaflets are mildly thickened. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
Compared with the report of the prior study (images unavailable
for review) of [**2133-8-24**], LVH is now present. The overall LVEF is
probably similar. The degree of mitral regurgitation is slightly
less.
.
LABS ON DISCHARGE:
[**2134-4-21**] 07:20AM BLOOD WBC-5.6 RBC-3.81* Hgb-10.0* Hct-29.9*
MCV-78* MCH-26.2* MCHC-33.4 RDW-18.2* Plt Ct-201
[**2134-4-21**] 07:20AM BLOOD Glucose-89 UreaN-10 Creat-0.9 Na-139
K-4.2 Cl-109* HCO3-23 AnGap-11
[**2134-4-16**] 12:15PM BLOOD cTropnT-0.26*
[**2134-4-16**] 08:37PM BLOOD CK-MB-2 cTropnT-0.21*
[**2134-4-17**] 04:01AM BLOOD CK-MB-4 cTropnT-0.14*
[**2134-4-18**] 12:50AM BLOOD CK-MB-4 cTropnT-0.16*
[**2134-4-19**] 09:00AM BLOOD CK-MB-4 cTropnT-0.11*
[**2134-4-16**] 12:15PM BLOOD CK(CPK)-37*
[**2134-4-16**] 08:37PM BLOOD CK(CPK)-40
[**2134-4-17**] 04:01AM BLOOD CK(CPK)-37*
[**2134-4-19**] 09:00AM BLOOD CK(CPK)-51
Brief Hospital Course:
Mr. [**Known lastname 108116**] is an 81 y/o M with h/o CAD, CHF (EF 35%), HTN,
CRI, metastatic prostate cancer who was recently initiated on
chemotherapy Taxotere/pamindronate [**2134-4-8**] who presents with 2
syncopal episodes and bright blood per rectum.
.
1)BRBPR- He was initially admitted to the ICU due to concern for
brisk GI bleed given syncope. His HCT on admission was 31 and
he was transfused 1 unit PRBC. He was evaluated by GI service
who felt that bleeding was most likely due to irritation and
proctitis in the setting of recent chemotherapy in combination
with ASA/PLAVIX/NSAID use making him more susceptible to
bleeding. His hematocrit remained stable throughout the
remainder of his admission and he did not require any furhter
transfusions. He did not have colonoscopy or endoscopy during
admission given that he had a troponin leak vs old NSTEMI and
was felt to be at high risk for the procedure and his HCT was
stable with no significant bleeding during his admission. He
was advised to avoid NSAIDS, but continue aspirin and plavix
given his cardiac risk.
2)Syncope: most likely related to orthostasis/hypovolemia in the
setting of recent chemotherapy and poor oral intake. Cardiac
arrhythmia/infarction also possible but less likely to be the
cause. He had no events on telemetry during his admission. His
troponin was elevated but his echocardiogram did not show any
change compared with prior. GI bleed also possible but less
likely to be the cause of his syncope as HCT was relatively
stable and >30. He improved with 1 unit PRBC and IV fluids.
3) Back/leg pain: Most likely due to metastatic disease to the
spine. Evidence of foraminal narrowing which per report could
cause L4 irritation. Pain well controlled on morphine on
admission. He was also started on gabapentin which was titrated
up during admission. He will be continued on chemo as may cause
regression of mets/improvement of pain, otherwise XRT may be
considered in the future for symptom management.
4)Chronic systolic heart failure/CAD: He has significant h/o MI
and cardiac disease with troponin elevation on admission which
could be old NSTEMI vs. demand ischemia in setting of volume
depletion and syncope given poor po intake. He had an
echocardiogram which did not show any significant change
compared with prior, EF still 30%. He was continued on asa,
plavix and low dose metoprolol. His dose of metoprolol was
decreased to 25mg [**Hospital1 **] and was not increased on discharge. His
lisinopril was restarted prior to discharge. His Imdur and his
HCTZ/spironolactone were held given that he has been having poor
po intake and was somewhat dehydrated.
5) Acute on Chronic kidney disease - He had acute renal failure
on admission likely due to poor po intake since recent chemo,
which resolved with IVF and was better than baseline CR of ~1.3
by the time of discharge. Home dose lisinopril 20mg daily was
resumed prior to discharge.
6)Metastatic prostate ca: s/p dose of Taxotere about 1 week ago,
now with WBC trending down. Recent ANC -> GRAN 1040. He was
continued on symptom management for pain/nausea. He will follow
up with Dr. [**Last Name (STitle) **] in clinic.
7)Left 2nd Toe pain - He was evaluated by podiatry for left
second toe pain and slight erythema. He had xray with no
evidence of fracture or osteomyelitis. Possibly due to his
gout. He was given short course of colchicine and allopurinol
restarted. Pain improved prior to discharge and no evidence of
infection.
8)Code status: FULL
Medications on Admission:
Allopurinol 200 qd
Plavix 75 [**Doctor First Name **]
Lasix 40 daily
Dronabinol 5mg [**Hospital1 **]
Lisinopril 20 mg qd
Metoprolol 75 [**Hospital1 **]
Imdur 30 qd
HCTZ- spironolactone 25/.25 [**1-20**] tab qam
simvastatin 80 daily
Multivitamin QOD
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day.
2. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24
hours).
Disp:*30 Tablet(s)* Refills:*2*
8. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
10. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal QD () as
needed.
Disp:*qs * Refills:*0*
11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-20**] Sprays Nasal
QID (4 times a day) as needed for Nasal Dryness.
12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
13. Dronabinol 5 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary Diagnoses:
-Rectal Bleeding
-Troponin leak vs NSTEMI
-metastatic Prostate Ca followed by Dr. [**Last Name (STitle) **]
Secondary Diagnoses:
-CAD s/p CABG in [**2113**] and multiple caths
-PCI: stents to distal LAD and lPL in 8/99, stents to proximal
LCx and OM2 in [**2-20**] and PTCA of OM2 on [**2128-7-16**].
-patent LIMA to LAD, SVG to LPL as of cath in [**2133-3-19**]
-The SVGs to D1 and OM, and occluded SVG to RCA, as well as the
native RCA are known to be occluded.
- [**2133-11-19**]. Successful PTCA of the OM1 and SVG to the PL
lesions. -Chronic Systolic CHF EF 35% ([**8-/2133**])
-Chronic Renal Insufficiency, Baseline Cr 1.5-1.6
-HTN - x 20 years, pt reports excellent BP control at home
-Gout
-P-Afib/Aflutter (ablation [**2132-1-10**])
-Glaucoma -blind in Right eye
-Depression/anxiety
Discharge Condition:
fair
Discharge Instructions:
You were admitted after you fainted and had blood in your stool.
It is most likely that you lost consciousness due to your poor
appetite and dehydration related to your recent chemotherapy.
Your rectal bleeding is most likely due to inflammation of the
lower part of your colon and rectum associated with your
chemotherapy. You were transfused 1 bag of blood. You
continued to have evidence of bleeding in your stool but your
blood count was stable and you did not require any additional
transfusions. You also had evidence of a small amount of damage
to your heart muscle that may have happened when you fainted.
You had a heart ultrasound which didn't show any change compared
with prior.
You also had an xray of your toe to evaluate the cause of your
toe pain. There was no evidence of fracture or infection of the
bone.
Medications:
-Your imdur and hydrochlorothiazide/spironolactone were held
during your admission and were NOT restarted on your discharge.
You should not restart these medicines as your blood pressure is
good without them. Please follow up with your doctor regarding
when to restart these medicines.
-Your metoprolol was decreased to 25mg twice daily. Your doctor
can increase the dose as tolerated when your blood pressure
increases and you are eating and drinking normally.
Please follow up as below.
Please call your doctor or return to the hospital if you
experience any concerning symptoms including increased blood in
your stool, light headedness, fainting, chest pain, shortness of
breath, fever, inability to eat and drink, fever or any other
concerning symptoms.
Followup Instructions:
You have the following appoinments scheduled to follow up:
1. Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-4-29**] 9:00
2. Provider: [**First Name11 (Name Pattern1) 2946**] [**Last Name (NamePattern4) 3217**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2134-4-29**] 9:00
[**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]
|
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icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
11849, 11906
|
6926, 10462
|
320, 327
|
12765, 12772
|
3469, 4366
|
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|
2760, 2880
|
10762, 11826
|
11927, 12055
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10488, 10739
|
12796, 14403
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2895, 3450
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12076, 12744
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14486, 14915
|
257, 282
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6269, 6903
|
355, 1601
|
4375, 6249
|
1623, 2467
|
2483, 2744
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,448
| 124,343
|
37688
|
Discharge summary
|
report
|
Admission Date: [**2140-9-14**] Discharge Date: [**2140-10-13**]
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
88yo F fell early [**9-14**] found late in the day by her son. She
normally lives alone and is self sufficient. After fall, she has
a humerus/radius fracture, C-spine fractures, 4cm facial
laceration, and 6cm scalp laceration.
Major Surgical or Invasive Procedure:
[**2140-9-15**]:
1. Posterior cervical laminectomy C5, C6.
2. Posterior cervical laminotomy C7.
3. Posterior cervical laminotomy C4.
4. Posterior cervical arthrodesis C4 to C7.
5. Posterior cervical instrumentation C4-C7.
6. Open reduction of fracture.
7. Placement of cranial tongs for fracture reduction.
8. Application of local autograft and allograft for fusion.
[**2140-9-15**]:
1. Closed treatment left proximal humerus fracture with
manipulation.
2. Closed treatment left distal radius fracture with
manipulation.
[**2140-9-28**]:
1. Percutaneous tracheostomy.
2. Bronchoscopy with bronchoalveolar lavage.
3. Percutaneous endoscopic gastrostomy.
History of Present Illness:
88yo F fell early [**9-14**] found late in the day by her son. She
normally lives alone and is self sufficient. After fall, she has
a humerus/radius fracture, C-spine fractures, 4cm facial
laceration, and 6cm scalp laceration.
Brief Hospital Course:
The patient was brought in after sustaining a fall at home. She
was brought to [**Hospital1 18**] and imaging studies revealed comminuted,
impacted and angulated left humeral surgical neck fracture with
large amount of surrounding soft tissue hematoma and fracture
through the left distal radius, with dorsal displacement and
overriding of the major distal fracture fragment. She also
sustained spinous process fracture at C5, and at C6. There was
evidence of ligamentous injury of the cervix. The patient was
taken to the OR by the orthopedic spine service and underwent
C4-C7 laminectomy and fusion - please refer to operative note
for more details. After this operation, her L arm fractures were
addressed in the same setting.
She was also noted to have a T2 fracture for which she was
fitted with a SOMA brace. She is to wear this when out of bed.
Post-operatively, she remained ventilated and was recovered in
the surgical ICU. She had pulmonary congestion and RLL
consolidation on CXR which prompted starting levofloxacin on
[**2140-9-17**] for pneumonia. These were changed to vancomycin and
cefepime on [**2140-9-19**], after her ventilatory status and fever
curve did not improve. She completed a course of vancomycin and
cefepime for pneumonia on [**2140-10-5**].
She continued to be ventilator-dependent and was tenuous,
oscillating between pulmonary congestion and contraction
alkylosis. She ultimately became euvolemic. On [**2140-9-28**], due to
continued ventilator dependence and tube feed dependence, she
underwent tracheostomy and feeding gastrostomy placement.
On [**2140-10-7**], she again had copious thick respiratory secretions,
her WBC was high at 13.2, she was again requiring full
ventilatory support and she had a consolidation in the RLL. She
was restarted on vancomycin, cefepime and cipro for ongoing
pneumonia. She finished this course on [**2140-10-12**] and has remained
very well with reassuring respiratory status and CXRs. She has
diarrhea with a flexiseal in place, but had 3 negative tests for
C. difficile. This is improving.
She worked with physical therapy and was out of bed to chair
during her stay. She has no limitations of weight-bearing on the
lower extremities or right upper extremity. Her left arm is
non-weight-bearing.
At discharge on [**2140-10-13**], she is tolerating goal tube feeds
without issue. She is on and off trach collar, going back to
pressure-support ventilation when she tires. She is alert and
communicative with a Passey-Muir valve when she is able to be on
trach collar. Her pain is well under control.
Medications on Admission:
Unknown
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
units Injection TID (3 times a day).
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. Acetaminophen 160 mg/5 mL Solution Sig: [**1-22**] PO Q4H (every 4
hours) as needed for pain.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for groin yeast.
7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML
Mucous membrane [**Hospital1 **] (2 times a day).
9. Metoprolol Tartrate 50 mg Tablet Sig: 1 [**1-22**] Tablet PO TID (3
times a day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6
hours) as needed for wheeze.
12. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
13. Haloperidol 0.25-0.5 mg IV BID:PRN agitation
14. HydrALAzine 10 mg IV Q6H:PRN SBP>170
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]
Discharge Diagnosis:
Cervical spine fracture with ligamentous injury
Left humeral neck fracture
Left distal radius fracture
Ventilator associated pneumonia
Ventilator dependence
Tube feed dependence
Blood loss anemia
Pulmonary congestion
Congestive heart failure
Thoracic spine fracture
Discharge Condition:
Ventilator-dependent, tube feed dependent, hemodynamically
stable
Discharge Instructions:
You had spine surgery of the neck. You may wear a cervical
collar for comfort, but it is not necessary to wear at all
times.
You may shower - pat wounds dry afterward. No swimming or
soaking
in a tub for 4 weeks after your surgery.
Come to the Emergency Room if you
have:
* fever above 101.5F
* nausea, vomiting or diarrhea that doesn't stop
* chest pain or pressure
* opening up or drainage from your wound
* any other concerning symptoms
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 1228**] Follow-up appointment
should be in 1 month
Completed by:[**2140-10-13**]
|
[
"790.7",
"873.20",
"997.31",
"806.09",
"518.81",
"802.0",
"813.42",
"511.9",
"788.5",
"276.8",
"873.0",
"E880.9",
"263.9",
"401.1",
"787.91",
"870.8",
"428.0",
"041.19",
"812.01",
"805.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.02",
"86.59",
"38.93",
"33.24",
"03.09",
"81.03",
"31.1",
"81.62",
"34.91",
"96.56",
"08.81",
"02.94",
"96.72",
"96.04",
"21.81",
"79.01",
"93.41",
"43.11",
"96.6",
"33.21",
"03.53"
] |
icd9pcs
|
[
[
[]
]
] |
5339, 5418
|
1434, 4018
|
489, 1154
|
5728, 5795
|
6286, 6478
|
4076, 5316
|
5439, 5707
|
4044, 4053
|
5819, 6263
|
222, 451
|
1182, 1411
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,499
| 127,862
|
24255
|
Discharge summary
|
report
|
Admission Date: [**2199-6-27**] Discharge Date: [**2199-7-18**]
Date of Birth: [**2149-8-24**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p mva
Major Surgical or Invasive Procedure:
[**6-27**]:
1. Irrigation and debridement of left grade 1 open
supracondylar femur fracture.
2. Closed reduction and application of external fixator, left
supracondylar femur fracture and left Schatzker VI tibial
plateau fracture
[**6-28**]:
1. Irrigation and debridement of open femur fracture, staged.
2. Open reduction and internal fixation of left distal femur
fracture, complex.
3. Open reduction and internal fixation of left proximal
tibia fracture, Schatzker 6.
4. Four compartment fasciotomies of left lower extremity.
5. Removal of external fixator.
[**6-30**]:
closure of lateral fasciotomies
[**7-1**]:
closure of fasciotomies
[**7-2**]:
I+D and closure of fasciotomies
History of Present Illness:
49yo M s/p MVC who was restrained driver of small automobile vs.
SUV at high speed. Prolonged extraction with GCS 15 and SBP in
70s at the scene. Pt responded to IVF and SBP improved to 110s.
Initially worked up at [**Hospital **] Hospital and then transferred to
[**Hospital1 18**] for further management. Primary and secondary survey on
arrival showed patient to have deformed Left lower
extremity->externally rotated and shortened with apparent open
distal femur fracture.
Past Medical History:
hypertension
sleep apnea
Social History:
occasional cigars
occasional Etoh
Family History:
denies
Physical Exam:
GCS 15 alert and oriented x3 T98.8 HR 105 BP 120/80 O2100%on RA
CV: tachy, no murmurs
Chest: positive seatbelt sign, no chest wall deformity
Abdomen: obese, soft, nontender, +lower quadrant abrasions
bilaterally
Rectal: guaiac negative, good tone
Back: no tenderness, no obvious injuries
Left Lower extremity: externally rotated and shortened, deformed
left distal thigh and knee
vascular:
Rad [**Last Name (un) 1035**] Carotid Fem [**Doctor Last Name **] DP PT
L 2+ 2+ 2+ 2+ 0 biphasic 2+
R 2+ 2+ 2+ 2+ 2+ biphasic 2+
Left Lower extremity: cap refill 2sec, cool
Right Lower extremity: cap refill 2 sec, cool
ABI's
Right DP 150/150=1.0 PT 200/150=1.33
left DP 150/150=1.0 PT 170/150=1.13
Pertinent Results:
[**6-27**]
1. CT of left lower extremity: Comminuted femoral and tibial
plateau fractures. Minimally displaced fibular fracture
2. TWO VIEWS OF THE LEFT KNEE, ONE VIEW OF THE LEFT HIP, AND ONE
VIEW OF THE LEFT ANKLE: There is a fracture through the left
proximal femur at the level of the greater trochanter. There is
a comminuted fracture through the distal femur as well as the
tibia extending to the articular surface. There is a fracture of
the proximal fibula with medial displacement of the distal
fragment and angulation. There are limited views of the distal
tibia and fibula, so a lateral malleolar fracture cannot be
excluded.
3. CT of Chest/abd/pelvis: No evidence of solid or hollow organ
injury, Proximal left femoral shaft fracture.
4.TIB/FIB (AP & LAT) LEFT PORT [**2199-6-27**] 6:30 PM
TRAUMA #2 (AP CXR & PELVIS POR; TIB/FIB (AP & LAT) LEFT PORT
a. Apparent mediastinal widening, possibly technical in nature,
correlation with the CT chest of the same day is recommended.
b. Left intertrochanteric femoral fracture.
c. Comminuted fracture of the left proximal tibia.
d. Fracture of the left proximal fibula.
5. CT cspine:No fracture identified. Normal vertebral alignment.
Left neck soft tissue edema.
6. CT Head:White and [**Doctor Last Name 352**] matter differentiation is preserved.
No intracranial masses, no hemorrhages are seen. Midline
structures are normal in position. Ventricles and subarachnoid
spaces are normal. Brain stem and cerebellum are also normal.
No bony fractures are seen. Small left maxillary mucous
retention cyst is present. Mild mucosal thickening is seen
involving the right maxillary sinus and minimally involving the
left frontoethmoidal recess and left frontal air cell.
Cardiology Report ECHO Study Date of [**2199-7-3**]
Conclusions:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The inferior vena cava is dilated
(>2.5 cm). 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 60%). No masses or thrombi are seen in
the left ventricle. There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic regurgitation.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is no
pericardial effusion
[**2199-6-27**] 06:21PM BLOOD WBC-21.1* RBC-3.86* Hgb-11.2* Hct-32.2*
MCV-83 MCH-28.9 MCHC-34.7 RDW-12.7 Plt Ct-182
[**2199-6-28**] 09:16PM BLOOD Hct-23.7*
[**2199-6-29**] 02:36AM BLOOD WBC-10.7 RBC-2.95* Hgb-8.5* Hct-24.0*
MCV-81* MCH-28.7 MCHC-35.4* RDW-13.5 Plt Ct-112*
[**2199-6-30**] 04:17AM BLOOD Hct-23.8*
[**2199-6-30**] 12:18PM BLOOD Hct-23.6*
[**2199-7-1**] 08:35AM BLOOD WBC-11.9* RBC-2.83* Hgb-8.2* Hct-24.1*
MCV-85 MCH-29.1 MCHC-34.2 RDW-14.1 Plt Ct-174#
[**2199-7-2**] 03:49AM BLOOD WBC-8.4 RBC-2.52* Hgb-7.5* Hct-21.4*
MCV-85 MCH-29.6 MCHC-34.8 RDW-14.0 Plt Ct-209
[**2199-7-2**] 06:25PM BLOOD WBC-8.9 RBC-2.52* Hgb-7.2* Hct-21.8*
MCV-87 MCH-28.4 MCHC-32.8 RDW-13.8 Plt Ct-248
[**2199-7-3**] 10:30AM BLOOD Hct-24.3*
[**2199-7-4**] 02:48AM BLOOD WBC-11.2* RBC-3.09* Hgb-9.0* Hct-26.7*
MCV-86 MCH-29.2 MCHC-33.9 RDW-14.2 Plt Ct-359
[**2199-7-6**] 03:54AM BLOOD WBC-8.2 RBC-2.72* Hgb-7.9* Hct-23.9*
MCV-88 MCH-29.2 MCHC-33.2 RDW-14.1 Plt Ct-370
[**2199-7-8**] 02:13AM BLOOD WBC-10.1 RBC-2.94* Hgb-8.3* Hct-26.1*
MCV-89 MCH-28.3 MCHC-31.9 RDW-14.0 Plt Ct-453*
[**2199-7-10**] 02:26AM BLOOD WBC-10.0 RBC-2.74* Hgb-7.9* Hct-24.2*
MCV-89 MCH-28.6 MCHC-32.4 RDW-14.5 Plt Ct-496*
[**2199-7-13**] 05:20AM BLOOD WBC-12.5* RBC-3.00* Hgb-8.5* Hct-27.0*
MCV-90 MCH-28.5 MCHC-31.7 RDW-14.9 Plt Ct-684*
[**2199-7-15**] 04:37AM BLOOD WBC-9.9 RBC-3.16* Hgb-8.9* Hct-28.1*
MCV-89 MCH-28.2 MCHC-31.7 RDW-14.7 Plt Ct-575*
[**2199-6-27**] 06:21PM BLOOD PT-13.9* PTT-21.0* INR(PT)-1.3
[**2199-6-30**] 03:04AM BLOOD PT-14.7* PTT-28.4 INR(PT)-1.4
[**2199-7-11**] 02:07AM BLOOD PT-13.1 PTT-21.5* INR(PT)-1.1
[**2199-7-12**] 12:53AM BLOOD PT-13.1 PTT-21.1* INR(PT)-1.1
[**2199-6-28**] 04:24AM BLOOD Glucose-165* UreaN-14 Creat-0.8 Na-138
K-4.6 Cl-107 HCO3-21* AnGap-15
[**2199-6-30**] 03:04AM BLOOD Glucose-116* UreaN-13 Creat-0.8 Na-134
K-4.2 Cl-102 HCO3-26 AnGap-10
[**2199-7-4**] 02:45AM BLOOD Glucose-139* UreaN-27* Creat-0.8 Na-140
K-4.3 Cl-101 HCO3-29 AnGap-14
[**2199-7-6**] 03:54AM BLOOD Glucose-128* UreaN-31* Creat-0.9 Na-142
K-4.3 Cl-104 HCO3-32* AnGap-10
[**2199-7-12**] 12:53AM BLOOD Glucose-103 UreaN-22* Creat-0.7 Na-144
K-4.4 Cl-108 HCO3-27 AnGap-13
[**2199-7-18**] 07:50AM BLOOD Glucose-108* UreaN-11 Creat-0.7 Na-140
K-3.9 Cl-102 HCO3-30* AnGap-12
[**2199-7-2**] 06:25PM BLOOD CK-MB-15* MB Indx-0.3 cTropnT-0.85*
[**2199-7-3**] 02:08AM BLOOD CK-MB-24* MB Indx-0.6 cTropnT-1.21*
[**2199-7-3**] 10:51AM BLOOD CK-MB-12* MB Indx-0.3 cTropnT-0.69*
[**2199-7-3**] 10:18PM BLOOD CK-MB-5 cTropnT-0.62*
[**2199-7-4**] 02:45AM BLOOD CK-MB-4 cTropnT-0.60*
[**2199-7-16**] 12:15PM BLOOD CK-MB-5 cTropnT-0.06*
Brief Hospital Course:
49 y/o s/p MVC in small car vs SUV head-on collision. Pt
restrained driver. The patient was initially evaluated in the ED
by the trauma team. Initial evaluation notable for the
following injuries: left intertrochanteric fracture and
comminuted distal femur and proximal tibia/fibula fractures.
Given the extent of his injuries, both the vascular and
orthopedic surgery services were consulted. Vascular surgery
decided not to do an angiogram given the patient's intact
vascular exam and ABI's of L=1.13 and R=1.33. On HD 1, the
patient was taken to the OR for stabilization of his orthopedic
injuries. He had irrigation and debridement of a left grade 1
open supracondylar femur fracture. Closed reduction and
application of external fixator, left supracondylar femur
fracture and left Schatzker VI tibial plateau fracture. Open
reduction and internal fixation of left intertrochanteric hip
fracture.
Patient taken to OR for:
1. Irrigation and debridement of left grade 1 open
supracondylar femur fracture.
2. Closed reduction and application of external fixator, left
supracondylar femur fracture and left Schatzker VI tibial
plateau fracture
Post operatively the patient was kept intubated. Secondary to
difficult airway patient remained intubated overnight in
preparation for OR next day.
POD 1 ([**6-28**]): Patient taken to OR for:
1. Irrigation and debridement of open femur fracture, staged.
2. Open reduction and internal fixation of left distal femur
fracture, complex.
3. Open reduction and internal fixation of left proximal
tibia fracture, Schatzker 6.
4. Four compartment fasciotomies of left lower extremity.
5. Removal of external fixator.
Patient remained intubated postoperatively.
POD 3 ([**6-30**]): Patient was taken to OR for closure of lateral
fasciotomies. Patient remained intubated postoperatively.
POD 4 ([**7-1**]): Pt taken to OR for further closure of fasciotomy.
Patient had poor oxygenation in AM which improved during course
of the day. Patient was transfused one unit PRBC.
POD 5 ([**7-2**]): Pt taken for I+D and closure of fasciotomy.
Intraoperatively, pt received 1mg of Levophed accidentally
instead of Lopressor. BP transiently increased to 274/151 for
about 3 minutes; controlled with Esmolol and Nitroglycerin. An
EKG
showed biphasic T-waves V4-V6, I, and aVL. Cardiac enzymes with
initial troponin at 0.85. Cardiology consulted and recommended
following enzymes, which could represent a troponin leak from
the trauma, and echo and fluids. No further events overnight
POD 6 ([**7-3**]): Echo without evidence of acute injury. Troponin
increased to 1.21 but began to trend downward. Pt with Hct to
24, and was transfused 1U PRBC. Pt required continued
ventilatory support. Pt febrile to 102.4 and cultures sent.
POD 7 ([**7-4**]): Meeting with pt's family with Anesthesia and
social work to address medication error in the OR. The error and
the immediate measures to correct were explained in detail to
the family.
POD 8 ([**7-5**]): Sputum culture with evidence of GNR and pt started
on Levofloxacin. Continued vent wean.
POD 9 ([**7-6**]): continued slow vent wean. Levo d/c'd when culture
with growth of contaminants.
POD 10 ([**7-7**]): Continued vent wean
POD 11 ([**7-8**]): Bronchoscopy for pulmonary toilet, with
bronchial washings sent for
culture. Neuro consulted and assessment detailing patient
neurologically intact.
POD 12 ([**7-9**]): Bronchial washings without growth. LFT's
elevated, however abdomen benign
POD 13 ([**7-10**]): Continued wean, hepatology consulted and
recommended monitoring LFTs and hepatitis panel, [**Doctor First Name **]. Hep panel
and [**Doctor First Name **] negative.
POD 14 ([**7-11**]): Pulmonary consult prior to extubation, recommend
Lasix to facilitate extubation. Lasix started and patient
extubated and placed on 100% face tent.
POD 15 ([**7-12**]): continued Lasix for diuresis, PT/OT consulted and
speech/swallow eval demonstrating ability to tolerate PO with
assistance. Pt continued diuresis with Lasix, respiratory status
improving. Transferred to the floor. Episode of desat overnight,
shovel mask returned O2 sat to 100% and nebs given. Pt stable.
POD 16 ([**7-13**]): Continued PT/OT. LFTs trending down. CXR with
continued atelectasis and effusions, continued diuresis.
POD 17 ([**7-14**]): Pt with continued episodes of desaturations and
febrile to 101.6. Cultures sent. Diuresis continued, Levaquin
begun for continued consolidation on CXR.
POD 18 ([**7-15**]): Pt O2 saturation improving. Culture results
negative. Cards/Pulm called for final recs, will increase
Atenolol to 50 [**Hospital1 **] and continue diuresis. No follow-up required.
POD 19 ([**7-16**]): CXR with improving consolidation/effusions.
Continued levo, lasix.
POD 20 ([**7-17**]): Continued PT/OT, advancing CPM. Tolerating regular
diet without assistance. Pt started on Kefzol for increased
redness around the incision.
POD 21 ([**7-18**]): Pt much improved respiratory status with O2 sats
95% on RA. Pt doing well with PT/OT. After discussion with
family, pt to be d/c'd to [**Hospital 38**] rehab in stable condition
with Keflex for 7d and Levo until [**7-24**].
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation
Q4-6H (every 4 to 6 hours) as needed for wheezes.
2. Enoxaparin Sodium 40 mg/0.4mL Syringe Sig: One (1)
Subcutaneous DAILY (Daily) for 4 weeks.
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 6 days.
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Please continue until pt tolerating room air and O2 sat
>95% with ambulation.
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed.
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
8. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours) as needed.
9. Albuterol Sulfate 0.083 % Solution Sig: [**2-10**] puff Inhalation
Q6H (every 6 hours) as needed.
10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
1. Grade 1 open left supracondylar femur fracture.
2. Left Schatzker VI tibial plateau fracture.
3. Left intertrochanteric hip fracture.
Discharge Condition:
Stable
Discharge Instructions:
1. Please monitor for the following: fever, chills, nausea,
vomiting, inability to tolerate food/drink. If any of these
occur, please contact your physician [**Name Initial (PRE) 61540**].
Followup Instructions:
Please call Dr. [**Last Name (STitle) 10538**] office for follow up appointment in 2
weeks.
([**Telephone/Fax (1) 2007**]
Completed by:[**2199-7-18**]
|
[
"997.3",
"507.0",
"E819.0",
"820.21",
"821.33",
"823.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"79.36",
"78.65",
"79.06",
"79.65",
"96.72",
"78.67",
"96.6",
"33.24",
"79.35",
"38.91",
"83.14",
"78.15",
"86.59",
"86.22",
"79.05",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
14014, 14111
|
7748, 12899
|
321, 1005
|
14292, 14300
|
2437, 3665
|
14539, 14692
|
1629, 1637
|
12922, 13991
|
14132, 14271
|
14324, 14516
|
1652, 2418
|
274, 283
|
1033, 1514
|
3673, 7725
|
1536, 1562
|
1578, 1613
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,400
| 128,800
|
23192
|
Discharge summary
|
report
|
Admission Date: [**2194-12-30**] Discharge Date: [**2195-1-6**]
Date of Birth: [**2124-10-8**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 3984**]
Chief Complaint:
Left shoulder pain
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Bronchoscopy
History of Present Illness:
Mr. [**Known lastname 4509**] is a 70M with hx of metastatic prostate cancer with
known metastases to the lung and thoracic/lumbar spine with
progression on multiple lines of prior therapy who presents with
left shoulder pain. Patient reports that he was attempting to
elevate himself from his wheelchair on the day of admission when
he felt a "[**Doctor Last Name **]" in his L shoulder. He developed worsening pain
in this region and an obvious deformity over his clavicle.
The patient also endorses worsening shortness of breath with
exertion over the past 2-3 days. He states that previously he
was able to walk throughout his home without significant
breathing difficulty, though has not been able to do so
recently. He is short of breath with telephone conversations and
minimal movement. He denies any associated cough, sputum
production, fevers/chills, chest pain, palpitations. He does
endorse increased leg swelling and [**1-12**] lbs weight gain.
With respect to his end-stage prostate cancer, the patient
recently discontinued treatment with XL184 ([**Hospital1 4601**] clinical
trial) on [**2194-12-11**] due to extreme fatigue. He has remained
transfusion dependent, receiving 2U PRBCs on a weekly basis over
the past two weeks. Most recently, patient received 2 units of
PRBCs for HCT 21.9 on [**12-23**]. Recent oncology notes document a
recent improvement in energy level since discontinuing XL184,
attributed to participation with physical therapy, transfusions,
and an increased dose of steroids (dexamethasone 4 mg [**Hospital1 **]). The
patient is aware of his end-stage status, and has expressed
interest in hospice care per heme-onc notes.
In the ED inital vitals were, 97.8 78 95/58 18 88% ra. CXR
revealed evidence of multifocal PNA vs interstitial edema
(prelim report). X-Ray of his clavicle revealed a fracture. Labs
were significant for lactate 2.5, HCT 17.8, plt 20, and INR 1.2.
He was given vancomycin X 1 and piperacillin/tazobactam X 1. VS
on transfer were: 77 104/57 27 100% on 4 liters. He was
transferred with 18G PIV X 2.
On arrival to the MICU, VS: afebrile 85 101/60 19 92%4L NC. He
has no acute complaints.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
Hypercholesterolemia
Metastatic prostate ca
Hypothyroidism
hx of diverticulosis
.
PSH: prostatectomy, L cataract, L knee arthroscopy
.
Onc hx:(as per recent d/c summary)
- [**2187-11-23**] prostate biopsy which demonstrated with prostate
cancer demonstrated in [**8-22**] cores, [**Doctor Last Name **] 3+3
- [**2188-1-7**] prostatectomy was performed with surgical pathology
revealing a [**Doctor Last Name **] pattern of 3+4 was noted, one left pelvic
lymph node was removed, without malignancy identified. The
seminal vesicles were without malignancy. Margins were
negative, and perineural invasion was noted.
- [**2190-3-10**] PSA 0.2
- [**2190-11-9**] PSA 0.6
- [**2191-6-18**] PSA 6.8
- [**2191-7-6**] CT demonstrated pulmonary nodules within the
visualized lung bases, new from [**2187-12-10**].
- [**2191-8-3**] VATS resection of nodule - pathology from
demonstrated metastatic adenocarcinoma, consistent with
metastasis from a prostatic origin based on immunostains that
demonstrated tumor being positive for PSA and cytokeratin
cocktail. They were negative for cytokeratin 7, 20, PSAP and
TTF-1 with satisfactory controls.
- [**2191-8-11**] started Lupron therapy
- [**2194-6-5**] Casodex added to Lupron
- [**9-19**] rising PSA, started on KHAD trial
- [**2193-9-3**] ketoconazole stopped
- [**2193-10-31**] started DES
- [**2193-12-11**] bronchoscopy with endobronchial ultrasound-guided
transbronchial needle aspiration of station 7 and 4R and
biopsies of mucosal irregularity at carina and proximal left
main.
- [**2193-12-11**] positive for malignant cells, immunoreactive for PSA,
PSAP and keratin AE1/AE3, CAM 5.2
- [**Date range (3) 59642**] Taxotere x 3 cycles
- [**Date range (3) 59643**] cabazitaxel x 3 cycles
- [**Date range (3) 59644**] abiraterone
- [**2194-8-21**] cycle 4 Taxotere
- [**2194-9-25**] clinical trial of [**Doctor Last Name 360**] XL-184 ([**Hospital1 4601**] protocol
09-432).
- [**2194-12-11**] withdrew from clinical trial XL-184 [**2-12**] fatigue
Social History:
The patient is married with a 11 year old daughter, is
semi-retired, works in finance, has hx of tobacco use (20 pack
years, but quit 20 yrs ago), drinks a [**Doctor Last Name 6654**] per night, denies
illicits.
Family History:
His mother had a history of hypertension, she died at the age of
88, father with a history of ulcer, and prostate cancer, though
he refused treatment. Mr. [**Known lastname 4509**] reports his father died of old
age at the age of 97. He denies any known history of cancer in
the family otherwise.
Physical Exam:
Admission exam:
Vitals: Afebrile 85 101/60 19 92%4L NC.
General: Alert, oriented, no acute distress, speaks in [**2-13**] word
phrases
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP 8 cm
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no m/r/g
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: left arm in sling, bony deformity over left clavicle,
neurovascularly intact distally, 1+ LE edema b/l
Discharge exam:
expired
Pertinent Results:
Admission Labs:
[**2194-12-29**] 11:00PM BLOOD WBC-7.1 RBC-2.06* Hgb-6.0* Hct-17.8*
MCV-87 MCH-29.2 MCHC-33.7 RDW-20.8* Plt Ct-20*
[**2194-12-29**] 11:00PM BLOOD Neuts-57 Bands-3 Lymphs-25 Monos-8 Eos-1
Baso-0 Atyps-0 Metas-3* Myelos-3* NRBC-18*
[**2194-12-29**] 11:00PM BLOOD PT-12.6* PTT-23.5* INR(PT)-1.2*
[**2194-12-30**] 08:19AM BLOOD Fibrino-391#
[**2194-12-29**] 11:00PM BLOOD Glucose-116* UreaN-40* Creat-0.9 Na-138
K-4.5 Cl-103 HCO3-23 AnGap-17
[**2194-12-30**] 08:19AM BLOOD LD(LDH)-2456*
[**2194-12-29**] 11:00PM BLOOD proBNP-1001*
[**2194-12-30**] 07:43PM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1
[**2194-12-30**] 08:19AM BLOOD Hapto-<5*
[**2194-12-30**] 12:42AM BLOOD Lactate-2.5*
[**2194-12-30**] 07:05AM BLOOD Lactate-0.9
[**2194-12-30**] 07:05AM BLOOD Type-ART pO2-64* pCO2-32* pH-7.49*
calTCO2-25 Base XS-1 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**]
Microbiology:
Viral swab
Bronch culture
blood culture
Imaging:
CXR [**2194-12-29**]:
1. Displaced left clavicular fracture, as described above. No
pneumothorax.
2. Mild interstitial pulmonary edema.
L. clavicle xray [**2194-12-29**]:
IMPRESSION: Displaced distal left clavicular fracture in patient
with diffuse osteoblastic metastases. No evidence of
pneumothorax.
CT chest w/ contrast [**2194-12-30**]:
IMPRESSION: As compared to the previous CT examination from
[**2194-11-11**], there are newly appeared bilateral multifocal diffuse
parenchymal opacities. The morphology of these opacities
suggests multifocal pneumonia. The morphology is neither typical
for pulmonary edema nor for metastatic disease. No pleural
effusions. No other relevant change as compared to the previous
examination with regard to size and distribution of visible
lymph nodes and the appearance of the heart and the large
mediastinal vessels.
Diffuse metastatic bone disease that is, overall, stable, with
the exception of a newly evident displaced left clavicular
fracture.
Brief Hospital Course:
Mr. [**Known lastname 4509**] is a 70 y/o M with hx of metastatic prostate cancer
with known mets to the lung and extensive involvement of his
thoracic and lumbar spine who presents with left clavicle
fracture and hypoxemia.
# Hypoxemia/multifocal pneumona: CXR showed diffuse bilateral
infiltrates. Patient was treated for potential infectious
pneumonia. Bronchoscopy showed evidence of diffuse alveolar
hemorrhage. Patient was placed on high dose steroids which did
not improve respiratory status. It was determined that there
were no further interventions that would help patient, and focus
should be on comfort. Patient was placed on morphine drip to
help with dyspnea. He expired at 20:45 on [**2195-1-6**].
# Left clavicle fracture: Likely pathologic fracture in setting
of osseus involvement of disease. No evidence of neurovascular
compromise distal to fracture. Arm maintained in appropriate
sling device. Pain control with oxycontin + oxycodone home
dose.
# Anemia/Thrombocytopenia: Due to DIC as patient with diffuse
alveolar hemorrhage. Transfused for hematocrit <21 and
platelets <50. When patient's breathing became significantly
worse, he was made comfortable and blood draws/transfusions were
discontinued.
# Metastatic prostate cancer: End-stage metastatic disease with
bone marrow involvement. Recently discontinued clinical trial.
# Goals of care discussion: Patient intially full code on
admission. Family meeting held at bedside with patient, his
wife [**Name (NI) 11705**], Oncology Attending Dr. [**Last Name (STitle) **] and Oncology Fellow
[**First Name4 (NamePattern1) 636**] [**Last Name (NamePattern1) 11309**] on [**12-30**] regarding goals of care. Decision was made
by patient, Mr. [**Known firstname 449**] [**Known lastname 4509**] to change his code status from FULL
to DNR/DNI with request for no heroic efforts to be made in the
setting of cardio/pulmonary distress. Palliative care consulted
to help with pain and dyspnea control. When patient's breathing
became too severe, he was started on morphine drip and made
comfort measures only through discussion with his wife, HCP.
# Hypothyroidism: Continued home dose levothyroxine until
patient made comfort measures only.
Patient expired at 20:45 on [**2195-1-6**].
Medications on Admission:
DEXAMETHASONE - 4 mg Tablet [**Hospital1 **] (8 am, noon)
LEUPROLIDE - 7.5 mg Syringe - monthly
LEVOTHYROXINE - 100 mcg daily
LORAZEPAM - 0.5-1 mg q8H prn insomnia, anxiety
OMEPRAZOLE - 40 mg daily
OXYCODONE - 5-10 mg q3hr prn pain
OXYCONTIN - 10 mg q 8hr
ASPIRIN - 81 mg daily
IBUPROFEN
Discharge Medications:
expired
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]
|
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icd9cm
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[
[
[]
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[
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icd9pcs
|
[
[
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10706, 10715
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8063, 10335
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343, 357
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10766, 10775
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6105, 6105
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6077, 6086
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2557, 2928
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385, 2538
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6121, 8040
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2950, 4947
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4963, 5177
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21,162
| 140,069
|
19094
|
Discharge summary
|
report
|
Admission Date: [**2116-10-17**] Discharge Date: [**2116-10-30**]
Date of Birth: [**2067-1-16**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: This is a 49 year old man, well
known to hepatobiliary service, after a recent admission to
[**Hospital1 69**] during which he was
treated for multiple liver abscesses. Please refer to the
previously dictated discharge summary from [**2116-10-12**].
Mr. [**Known lastname 52114**] is being transferred on [**2116-10-17**] from his
rehabilitation facility with achy right upper quadrant pain
for one day and a fever to 103. The pain is similar but more
mild than the pain he felt on his initial presentation. He
has a normal appetite. He denies nausea, vomiting,
constipation, diarrhea or urinary symptoms. There were no
precipitating or palliative factors for this pain and there
was no radiation to his back, groin or chest. He also
complains of a gassy right upper quadrant pain, times three
or four days, which is aggravated by eating. He currently
does not have this pain. He also reports that his
[**Location (un) 1661**]-[**Location (un) 1662**] drain, with which he was discharged on the
previous admission, had increased output two days prior to
admission, which was bilious but resolved prior to admission.
He denies shortness of breath, chest pain, chills, fevers or
change in his stool habit.
His prior medical history includes hypertension,
diverticulosis and knee surgery and the recent medical
history with the liver abscesses.
SOCIAL HISTORY: He has a 20 pack year smoking history. He
has a history of ethanol abuse, four to five beers a night.
He has been staying previously at [**Hospital6 6296**]
Center. He is married as well.
ALLERGIES: No known drug allergies.
MEDICATIONS:
Medications at [**Hospital3 245**] include Metoprolol 25 mg p.o.
twice a day.
Dilaudid prn.
Lasix 40 mg p.o. twice a day.
Fluconazole 200 mg q. day.
Levaquin 500 mg q. day.
Flagyl 500 mg three times a day.
Protonic 40 mg q. day.
Pepcid Q three times a day.
Albuterol and Atrovent inhalers.
PHYSICAL EXAMINATION: On physical examination, the patient
was febrile with a temperature of 103.5; tachycardiac at 117;
blood pressure was 146/81; respiratory rate 18. His oxygen
saturation was 93% on room air and 96% on two liters of nasal
cannula. His physical examination was notable for
tachycardia as well as tenderness to palpation on the right
side of his abdomen. The [**Location (un) 1661**]-[**Location (un) 1662**] drain in his left side
had a light green output. He is guaiac negative.
LABORATORY DATA: Values were significant for a leukocytosis
of 19.6 with 85% neutrophils. Hematocrit was 31.9; platelets
were 634. Coagulation studies revealed PT of 14.5; PTT was
23.5; INR was 1.4. Sodium was 132; potassium of 4.5;
chloride 95; bicarbonate 35; BUN 11; creatinine .8. Glucose
109. Liver function tests were within normal limits and
urinalysis was negative.
CAT scan on admission showed the following results: Large
complex fluid collection in the right mid abdomen, extending
across the abscess. Stable appearance of three hypodense
hepatic lesions. Stable subphrenic fluid collection. Left
rectus sheath hematoma. Persistent bilateral pleural
effusions with atelectasis.
HOSPITAL COURSE: The patient was admitted to the
hepatobiliary surgery service and was brought that evening to
CAT scan for CT guided drainage of the large complex fluid
collection in the mid abdomen. The patient underwent CT
guided drainage the night of admission and this fluid was
sent for culture. It eventually put out two strains of E.
coli and two strains of Vancomycin resistant enterococcus.
That night, he was stable overnight. He defervesced but, on
the next day, he was tachycardiac and febrile and had
enlarging erythema along his right flank. Repeat CAT scan
revealed that the pigtail drain that was initially placed on
[**10-17**] had actually pulled superficially and now had
the tip lying in the subcutaneous soft tissue. In addition,
there was some air collection, suggestive of an infection of
the subcutaneous tissue. A new drain was placed and the
patient was monitored this time in the Intensive Care Unit.
Overnight, the patient's erythema along the right flank
slowly spread towards the upper thigh and groin area. On
[**10-19**], it was decided that the patient had a serious
subcutaneous infection and he was taken to the operating room
for emergent incision and debridement of this subcutaneous
infection. After proper consent was obtained, the patient
was taken to the operating room by Dr. [**Last Name (STitle) 468**] and Dr. [**Last Name (STitle) 52115**]
and a large amount of pus was removed from the subcutaneous
tissues. In addition, the intra-abdominal abscess that had
originally been drained on [**10-17**] was drained
intraoperatively. Notably, the fascial layers were intact
and alive, rule out necrotizing fasciitis. For the specific
details of this surgery, please refer to the previously
dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 468**] of [**10-19**].
In addition, wound cultures sent during this operation
subsequently grew out Methicillin resistant Staph aureus as
well as Vancomycin resistant enterococcus. Postoperatively,
the patient was returned to the Intensive Care Unit in an
intubated but stable condition. He quickly deverfesced and
was relatively stable. Over the next few days, he was kept
in check with Primaxin, with intravenous antibiotics,
including Primaxin, Nasalide and Fluconazole. He remained
intubated while dressing changes were performed twice a day
and he tolerated these dressing changes well and tolerated
the intubation well.
On [**10-22**], postoperative day number three, the
patient was extubated and on postoperative day number five,
[**10-24**], the patient was transferred to the floor. On
the floor, the patient's pain was controlled with oral
Percocet. During dressing changes, he received intravenous
Morphine, which controlled his pain well. His pulmonary
status was stable and he was on intermittent nasal cannula.
Gastrointestinal: The patient's diet was slowly advanced to
a regular diet, which he tolerated without nausea, vomiting
or abdominal pain. Physical therapy evaluated him and it was
determined that he should return to rehabilitation. On
[**10-28**], the patient had a PICC line placed for long
term intravenous antibiotic treatment. Also on [**10-28**], a VAC drain was placed to assist with the healing
process of the patient's abdominal wound.
On physical examination, on the 26th, the patient is afebrile
with stable vital signs. His urine output is good. He is
tolerating a p.o. diet. General appearance: He is alert and
oriented and appears well. CV: Regular rate and rhythm, no
murmurs, rubs or gallops. Lungs: Clear to auscultation
bilaterally save for some bibasilar wheezes. Abdomen: Obese
with four surgical scars from this admission; one large
transverse one in the periumbilical region and three smaller
ones, two in the right flank and one in the inguinal region.
The large one is packed with a VAC sponge and the three
smaller ones are packed with gauze currently. All four are
overlain with a common hermetic seal. He also has a vertical
midline abdominal wound that is enclosed by secondary
intention. His extremities are warm and well perfused, with
no cyanosis, clubbing or edema. In addition, on extremity
examination, he has a right antecubital PICC line in place.
Therefore, he is being discharged back to [**Location (un) 38**] House
Rehabilitation Center on [**10-30**] in good condition.
DISCHARGE DIAGNOSES:
Liver abscesses.
Abdominal wall infection.
Intra-abdominal infection.
Rectus sheath hematoma.
Chronic blood loss anemia, requiring multiple blood
transfusions.
Hypocoagulability, requiring free frozen plasma.
Pleural effusions.
VRE infection.
Methicillin resistant Staphylococcus aureus infection.
Postoperative atelectasis.
Hypovolemia, requiring fluid resuscitation.
Hypokalemia.
Hypomagnesemia.
Postoperative atelectasis.
Diverticulosis.
The patient's discharge medications are as follows:
Fluconazole 400 mg p.o. q. day.
Nasalide 600 mg p.o. q. 12 hours.
Metoprolol 75 mg p.o. twice a day.
Combivent inhaler q. four hours.
Heparin 500 units subcutaneous q. 8 hours.
Protonic 80 mg q. day.
Ceftriaxone two grams intravenous q. day.
Percocet one to two tablets q. four to six hours prn for
pain.
Morphine prn VAC change.
Lidocaine prn VAC change.
The patient has a follow-up with Dr. [**Last Name (STitle) 8697**] of infectious
disease on [**11-19**]. He also has a follow-up appointment
with Dr. [**Last Name (STitle) 468**] on [**11-16**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Last Name (NamePattern1) 30555**]
MEDQUIST36
D: [**2116-10-29**] 08:41
T: [**2116-10-29**] 19:56
JOB#: [**Job Number 52116**]
cc:[**Last Name (NamePattern1) 52117**]
|
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icd9cm
|
[
[
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icd9pcs
|
[
[
[]
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7675, 9026
|
3284, 7654
|
2084, 3266
|
162, 1512
|
1528, 2061
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,638
| 199,698
|
32539+57810
|
Discharge summary
|
report+addendum
|
Admission Date: [**2194-2-7**] Discharge Date: [**2194-3-4**]
Date of Birth: [**2138-6-4**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1430**]
Chief Complaint:
Thoracic wound drainage and hyponatremia
Major Surgical or Invasive Procedure:
- Debridement and evacuation of wound infection
- latissimus and trapezius flap
- removal of porticath
History of Present Illness:
55 y/o M with PMH of renal cell CA metastatic to T-spine s/p
recent T1-T12 fusion on [**2194-1-28**] on decadron taper presented from
[**Hospital 38**] Rehab with increased serosanguinous drainage from
wound per rehab team and low grade temp of 100.1. Per the
patient, he has been feeling well and denies fever, chills,
increased back pain. He does have bilateral tingling/numbness in
his lower extremities, but able to move his feet/legs. He was
found to have renal cell CA in [**2190**] s/p nephrectomy, then found
to have extradural mass at T5 in [**6-21**] with kyphotic collapse at
T10 when presented with leg weakness with numbness/difficulty
walking. He is s/p recent admission between [**Date range (1) 75880**]
for thoracic instrumented fusion T1-12 on [**2194-1-28**] by Dr. [**Last Name (STitle) 548**]
and was only at his rehab for 2 days when the staff noted
increased serosanguinous drainage from site, without purulence,
odor, but increased WBC.
In the ED, his initial vitals were: T98.1, BP 120/67, HR 107, RR
20, 98% on RA. He was given ativan 1mg IV x 1, dilaudid 4mg PO x
1. Neurosurgery was consulted in the ED and did not suspect
wound infection so did not recommend any antibiotics but
recommended CT imaging of T-spine. Labs drawn significant for
hyponatremia with Na 126, hyperkalemia K 5.5, and WBC 19.2
(around his recent baseline) with 9 bands. Ulytes showed FeNa<1
and UNa 102. He was given IV decadron 10mg x 1 and admitted to
medicine for workup of hyponatremia, tachycardia with
neurosurgery following.
On the floor, the patient denies any back pain, increased
numbness or tingling of his legs, or subjective fever, chills,
dysuria, or diarrhea. He notes increased urination recently and
currently is thirsty.
Past Medical History:
rheumatoid arthritis x 20 years
renal ca s/p nephrectomy
metastatic spine disease s/p thoracic instrumented fusion T1-12
on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at
T10
h/o IVDA
Social History:
Lives with a friend and his wife; tobacco 2 ppd x 30-40 years
but notes has not smoked for the last 2 weeks; recovering
alcoholic but no ETOH recently; history of drug abuse, but none
for last two years, on Methadone.
Family History:
Family History: father deceased at 63 yo of heart disease.
Physical Exam:
VS - T97.9, BP 114/72, HR 108, RR 20, 96% on RA
General: lying in bed, in NAD
HEENT: NCAT, dry mucous membranes
Neck: supple, no carotid bruits, no LAD
Pulmonary: CTA bilaterally, no w/c/r
Cardiac: tachycardia, regular rate and rhythm, with no m/r/g
Abdomen: +BS soft, nontender, mildly distended,
Extremities: radial deviation of MCP joints of both hands,
slight tremor.
Back: + flowing serosanguinous drainage from wound draining 4
wound covers and chucks in 4 hours. No tenderness to palpation
to paraspinal area. staples intact.
NEURO - awake, A&Ox3, able to name hospital, spell his last name
forwards and backwards. Mildly inattentive. Eyelids heavy. CNs
II-XII grossly intact, slight weakness of right orbicularis. [**4-19**]
strength of right LE, 5/5 strength of LLE. Sensation to light
touch intact. Reflexes 1+
Pertinent Results:
Ct spine [**2-8**]
1. Post-operative changes in the thoracic region with
improvement in thoracic kyphosis since the following surgery and
stabilization. At T5 level, no evidence of compression of the
thecal sac is visualized on the current study with persistent
lytic abnormality in the left pedicle of L5 and involving the
articular processes.
2. Fluid collection at the upper end of the laminectomy at
C7-T1 level with small air bubbles without enhancement in the
surrounding soft tissues could be a post-operative fluid
collection. However, clinical correlation recommended as
infection cannot be excluded entirely on the CT appearances.
Brief Hospital Course:
55 yo M with metastatic renal CA to T spine s/p T1-T12 fusion,
with non-healing wound complicated by MSSA, s/p latissimus and
trapezius flap on [**2194-2-20**].
.
Pt presented with fever, elevated WBC, ESR and CRP, increasing
drainage from surcial wound and signs of infection in C7-T1 area
on CT. Thoracic wound was debrided on [**2194-2-9**] and [**2194-2-14**].
Wound cx showed MSSA and pt was started on nafcillin. Blood
cultures remained negative, and ECHO showed no vegetations on
TTE. Pt had portacath removed to ensure not nidus of infection.
On [**2194-2-20**] wound was repaired with latissimus and trapezius flap
and pt transfered to plastic surgery. Pt followed usual post-op
course with adequate healing of spinal wound. Nafcillin to be
continued for 6 weeks at 2 gm q4hr.
.
#. Hyponatremia - Pt with previous history of hyponatremia, and
is at risk of SIADH given cancer and SSRI use. Improved with
fluid restriction. Nephrology followed throught pt stay
.
# HAP - Pt febrile with RLL infiltrate on CXR on [**2-26**]. Pt
started on Levofloxacin to treat HAP continued for 10 days. ID
was consulted and followed throughout stay.
.
# Thrombocytopenia - Platelet drop greater than 50% with current
nadir of 58. HIT positive, but OD equivocal, 0.7. Serotonin
release assay negative. Therefore negative for HIT. Platelets
subsequently improved through hospitalization
.
#. Altered mental status - AAOx3. No change in mental status. No
masses/mets/bleed on CT head.
Medications on Admission:
Bacitracin ointment
Celexa 20 mg PO DAILY
Cyclobenzaprine 10mg PO BID
Dexamethasone 1mg Q12h (down from PO Q8h x 2 days)
Docusate 100mg [**Hospital1 **]
SC heparin
RISS
Methadone 30 mg PO QHS, 60 mg PO Q 6 AM AND Q 6 PM
Metoprolol Tartrate 12.5 mg PO BID
MVI
Senna 2tabs [**Hospital1 **]
Tylenol 1000mg Q6hr prn
Dulcolax 10mg PR QD prn
Dilaudid 2-4mg PO Q3h prn pain
Sorbitol
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Methadone 10 mg Tablet Sig: Three (3) Tablet PO QHS (once a
day (at bedtime)).
4. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
5. Sorbitol 70 % Solution Sig: Thirty (30) ML Miscellaneous
DAILY (Daily) as needed for constipation.
6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
7. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO qAM ().
8. Hydromorphone 4 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
10. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
12. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
14. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
15. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
17. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
19. Methadone 10 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)) as needed for pain.
20. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO NOON (At Noon) as needed for pain.
21. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY16 (Once Daily at 16) as needed for pain.
22. Ondansetron 4 mg IV Q8H:PRN
23. Nafcillin 2 gm IV Q4H
Please administer in NS
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]
Discharge Diagnosis:
PRIMARY:
- Post-operative wound dehiscense c/b MSSA infection.
- MSSA bacteremia
- Aortic valve Lambl's excresences vs. vegetation
- Thrombocytopenia NOS (NOT HIT).
- Anemia of inflammation
- Hyponatremia secondary to SIADH
SECONDARY:
- Transpedicular resection of the T5 renal cell metastasis.
- T9 vertebrectomy for pathologic fracture.
- Posterior instrumentation segmental T1-T12
- Right lower extremity weakness secondary to cord compression
- Metastatic renal cell carcinoma s/p left nephrectomy, XRT.
- Hepatitis C
- Prior IVDA
- ETOH abuse
Discharge Condition:
Good
Discharge Instructions:
Please return to the hospital if
- you experience fevers greater then 101.4, chills, or other
signs of infection.
- you experience chest pain, shortness of breath, redness,
swelling, or purulent discharge from the incision site.
- you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Restart taking all your regular medications.
Continue to take your antibiotics as prescribed
-Please do not shower until your follow-up visit.
.
Please keep track of JP drain output for your follow-up visit
Followup Instructions:
Please have LFT's, CBC with diff, bun and creatine drawn weekly
and ESR and CRP drawn ever other week. Please fax weekly
results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at ([**Telephone/Fax (1) 1353**].
Follow up with Dr. [**Last Name (STitle) 7443**] in [**Hospital **] clinic on [**3-31**] at 11:30 am
Follow up with plastic surgery - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] next tuesday.
Please call to make an appointment.
Follow up with Dr. [**Last Name (STitle) 548**] from neurosurgery in 2 weeks. Please
call to make an appointment
Name: [**Known lastname 1799**],[**Known firstname 63**] Unit No: [**Numeric Identifier 12405**]
Admission Date: [**2194-2-7**] Discharge Date: [**2194-3-4**]
Date of Birth: [**2138-6-4**] Sex: M
Service: PLASTIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3341**]
Addendum:
Pt remained in hospital 1 additional day to ensure
rehabilitation facility could administer nafcillin as directed.
During additional night pt had increased pain. CPS recommended
increasing evening dose of methadone as well as dilaudid dose.
Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical
DAILY (Daily).
4. Sorbitol 70 % Solution Sig: Thirty (30) ML Miscellaneous
DAILY (Daily) as needed for constipation.
5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed.
6. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO qAM ().
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
8. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
9. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day).
12. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily).
14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
15. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 5 days.
17. Methadone 10 mg Tablet Sig: Four (4) Tablet PO QAM (once a
day (in the morning)) as needed for pain.
18. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO NOON (At Noon) as needed for pain.
19. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO DAILY16 (Once Daily at 16) as needed for pain.
20. Ondansetron 4 mg IV Q8H:PRN
21. Nafcillin 2 gm IV Q4H
Please administer in NS
22. Methadone 10 mg Tablet Sig: Five (5) Tablet PO QHS (once a
day (at bedtime)).
23. Hydromorphone 4 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3
hours) as needed for pain.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]
Discharge Diagnosis:
PRIMARY:
- Post-operative wound dehiscense c/b MSSA infection.
- MSSA bacteremia
- Aortic valve Lambl's excresences vs. vegetation
- Thrombocytopenia NOS (NOT HIT).
- Anemia of inflammation
- Hyponatremia secondary to SIADH
SECONDARY:
- Transpedicular resection of the T5 renal cell metastasis.
- T9 vertebrectomy for pathologic fracture.
- Posterior instrumentation segmental T1-T12
- Right lower extremity weakness secondary to cord compression
- Metastatic renal cell carcinoma s/p left nephrectomy, XRT.
- Hepatitis C
- Prior IVDA
- ETOH abuse
Discharge Instructions:
Please return to the hospital if
- you experience fevers greater then 101.4, chills, or other
signs of infection.
- you experience chest pain, shortness of breath, redness,
swelling, or purulent discharge from the incision site.
- you experience worsening pain or any other concerning
symptoms.
Certain pain medications may have side effects such as
drowsiness. Do not operate heavy machinery while on these
medications.
Certain pain medications such as percocet or codeine can cause
constipation. If needed you can take a stool softner such as
Colace (one capsule) or gentle laxative (such as Milk of
Magnesia) once per day.
Restart taking all your regular medications.
Continue to take your antibiotics as prescribed
-Please do not shower until your follow-up visit.
.
Please keep track of JP drain output for your follow-up visit
Followup Instructions:
Please have LFT's, CBC with diff, bun and creatine drawn weekly
and ESR and CRP drawn ever other week. Please fax weekly
results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at ([**Telephone/Fax (1) 3790**].
Follow up with Dr. [**Last Name (STitle) **] in [**Hospital **] clinic on [**3-31**] at 11:30 am
Follow up with plastic surgery - Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 735**] next tuesday.
Please call to make an appointment.
Follow up with Dr. [**Last Name (STitle) 752**] from neurosurgery in 2 weeks. Please
call to make an appointment
[**First Name11 (Name Pattern1) 389**] [**Last Name (NamePattern4) 3342**] MD [**MD Number(1) 3343**]
Completed by:[**2194-3-4**]
|
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"041.11",
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"714.0",
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"V10.52",
"998.59",
"287.5",
"730.08",
"486",
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icd9cm
|
[
[
[]
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] |
[
"83.82",
"86.59",
"86.05",
"38.93",
"03.02",
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icd9pcs
|
[
[
[]
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13009, 13104
|
4295, 5779
|
352, 457
|
8877, 8884
|
3625, 4272
|
14560, 15324
|
2724, 2769
|
11027, 12986
|
13125, 13676
|
5805, 6182
|
13700, 14537
|
2784, 3606
|
272, 314
|
485, 2230
|
2252, 2457
|
2473, 2692
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,824
| 197,069
|
18250
|
Discharge summary
|
report
|
Admission Date: [**2132-10-21**] Discharge Date: [**2132-11-1**]
Date of Birth: [**2063-2-3**] Sex: M
Service: Thoracic Surgery
HISTORY: Patient is a 69 year old male with metastatic colon
cancer, diagnosed two years ago, who was transferred from
[**Hospital 1562**] Hospital. Patient was thought to have lung
metastasis, however, patient was never biopsied and was
receiving serial CT scans. Patient has undergone a colon
resection with removal of the primary tumor and has since
received chemotherapy. Patient also received radiation
therapy to the cervical spine in [**2132-8-15**].
Consequently, patient developed radiation esophagitis and
sinusitis and has symptoms of fevers, coughing, and pain in
the right chest. Patient was also coughing a green purulent
sputum and was initially treated with p.o. Levaquin with
partial resolution of these symptoms. Patient was undergoing
MRI of the spine and was found to have a right-sided
pneumonia incidentally. Patient continued on his antibiotic
treatment with Levaquin and a follow-up chest x-ray
subsequently showed a right-sided effusion which was
confirmed on a follow-up CAT scan. Subsequently patient has
undergone a thoracentesis of the right thorax with drainage
of 600 cc of pus. Patient reports occasional chills,
occasional shortness of breath, but denies any chest pain.
Patient admits to hemoptysis and reports a significant weight
loss.
MEDICAL HISTORY: Significant for metastatic colon cancer as
per above. Consequent radiation esophagitis and sinusitis
and suspected right post-obstructive pneumonia. Patient also
had a history of coronary artery disease, status post
coronary artery bypass graft in [**2127**]. Patient also has a
history of hypertension.
PAST SURGICAL HISTORY: Coronary artery bypass graft five
years ago at [**Hospital3 **] and also colon resection of
primary tumor.
MEDICATIONS AT HOME:
1. Betapace 120 mg p.o. twice a day.
2. Cozaar 50 mg p.o. once daily.
3. Oxycodone 5 mg one to two tablets p.o. q four hours.
ALLERGIES: PATIENT DENIES ANY ALLERGIES TO MEDICATIONS.
SOCIAL HISTORY: Significant for smoking, however, patient
has quit smoking since [**2091**]. There is no history of lung
cancer in the family.
PHYSICAL EXAMINATION ON ADMISSION: Patient was afebrile at
98.7, heart rate of 98, blood pressure 142/80, and
respiratory rate of 18, and satting 95 percent on room air.
GENERAL: Patient was a thin, cachectic looking male in no
apparent distress.
HEENT: Showed pupils are equally round and reactive to light
and accommodation. Extraocular movements intact. There were
no lymph nodes still palpable in the neck.
RESPIRATORY: Shows decreased breath sounds on the right
lower one-half of the lungs with dullness to percussion as
well.
CARDIOVASCULAR: Regular rate and rhythm, S1, S2, no murmurs
appreciated.
ABDOMEN: Good bowel sounds, soft, nontender, nondistended.
There is a well healed scar from the colon resection.
EXTREMITIES; No clubbing, edema, or cyanosis.
NEUROLOGIC: Shows grossly intact cranial nerves II-XII and
no gross motor or sensory deficits.
LABORATORY VALUES ON ADMISSION: A white count of 14.1,
hematocrit 28.3, platelets 337, PT/PTT 14.0 and 28.4 with an
INR of 1.3. Sodium 132, potassium 3.8, chloride 100, CO2 23,
BUN 12, creatinine 0.6, glucose 132, magnesium 1.8, AST 57,
ALT 15, alkaline phosphatase 308, total bilirubin 1.0.
Patient underwent a CT scan of the chest on admission which
showed a large right hydropneumothorax with gas, atelectasis
in the right lower lobe with multiple pulmonary nodules
bilaterally. These findings were most consistent with
metastatic disease. Patient was also noted to have liver
metastases and metastatic foci in the thorax at the spine.
HOSPITAL COURSE: Patient was taken to the Operating Room on
[**2132-10-22**] for his right-sided empyema and hydropneumothorax
and patient underwent a flexible bronchoscopy, right-sided
video assisted thoracoscopy, and partial decortication and
evacuation of the empyema. Patient also underwent a rigid
bronchoscopy with near total removal of endobronchial tumor
obstructing the right lower lobe. Please see the Operative
Report for further details. It should be noted that a full,
complete removal of the endobronchial lesion obstructing the
right lower lobe could not be achieved secondary to bleeding
in the areas that were resected and made free of the
endobronchial tumor. Patient underwent another bronchoscopy
on [**2132-10-23**] by Internal Pulmonary Service as per request of
Dr. [**Last Name (STitle) 952**]. Patient still had portions of the endobronchial
tumor of the right lower lobe and a bronchopulmonary fistula
was also noted. In the postoperative period patient was
observed in the CSRU being closely monitored. Patient was
noted to have air leak in the right-sided chest tube and
given the findings in the bronchoscopy done on [**2132-10-23**] the
air leak was expected.
By postoperative day three patient was doing well in the CSRU
and was transferred to the floor. Patient continued to do
well on the floor. Patient was noted to have positive I's
and O's since his transfer out of the CSRU and given the
interventions that he had gone through patient was further
diuresed with IV Lasix.
By postoperative day seven patient's air leak has decreased
and patient was given a trial of Water-seal with a follow-up
chest x-ray, PA and lateral. Despite the persistent air leak
patient's right lung stayed relatively inflated and one chest
tube out of a total of three was carefully taken out on
postoperative day nine. Again, a repeat chest x-ray done
showed no change in the expansion of the right lung and
patient underwent removal of a second chest tube without any
difficulty.
By postoperative day ten patient remained with one chest
tube, in the right thorax, and plans were made to convert the
chest tube and empyema tube with a Heimlich valve. However,
in the overnight period between postoperative day nine and
ten, patient accidentally removed the third and the final
chest tube for the right thorax, however, a new chest tube
could be placed into the same insertion site without any
difficulty. The new chest tube was converted to a empyema
tube by attachment of a Heimlich valve and a leg drainage
bag. Patient again underwent a chest x-ray to verify that
his lungs were remaining expanded and after a satisfactory
finding on the chest x-ray patient was discharged on
postoperative day ten.
DISCHARGE DIAGNOSES:
1. Metastatic colorectal cancer with endobronchial
metastasis.
2. Hypertension.
DISCHARGE MEDICATIONS:
1. Percocet 5/325 mg one to two tablet p.o. q 4-6 hours
p.r.n. pain.
2. Colace 100 mg p.o. twice a day while taking Prevacid.
3. Betapace 40 mg p.o. twice a day. Please note that this
is a significantly lower dose than patient's usual home dose
of 120 mg p.o. twice a day. Patient was deliberately kept on
a lower dose of Betapace due to his blood pressure in the
ranges of 100's/60's.
4. Lasix 20 mg p.o. twice a day for five days.
5. Levaquin 500 mg p.o. q 24.
6. Iron polysaccharide 150 mg p.o. twice a day.
7. Vitamin-C 500 mg p.o. once daily.
FOLLOW-UP: Patient is to follow-up with Dr. [**Last Name (STitle) 952**] in his
office Thursday, [**2132-11-6**] with a chest x-ray, PA and
lateral to be done on the morning of [**2132-11-8**] prior
to seeing Dr. [**Last Name (STitle) 952**] in the office. Patient is also to
follow-up with his internist and his cardiologist in one to
two weeks regarding his Betapace dose and restarting his
Cozaar.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**]
Dictated By:[**Last Name (NamePattern1) 10201**]
MEDQUIST36
D: [**2132-11-13**] 22:59
T: [**2132-11-14**] 04:15
JOB#: [**Job Number 50368**]
|
[
"197.2",
"510.0",
"511.8",
"414.00",
"198.5",
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"197.0",
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] |
icd9cm
|
[
[
[]
]
] |
[
"32.01",
"34.04",
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] |
icd9pcs
|
[
[
[]
]
] |
6514, 6597
|
6620, 7867
|
3777, 6493
|
1911, 2099
|
1782, 1890
|
3148, 3759
|
2116, 2266
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,522
| 111,204
|
21839
|
Discharge summary
|
report
|
Admission Date: [**2131-9-28**] Discharge Date: [**2131-10-9**]
Date of Birth: [**2087-10-15**] Sex: F
Service: MED
Allergies:
Codeine
Attending:[**First Name3 (LF) 5644**]
Chief Complaint:
Dyspnea and cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
43 year old obese woman with history of smoking (20 pack year),
asthma, bronchitis with multiple admissions since [**2130-9-18**]
for asthma flares. She has required hospitalization and steroids
in the past, but no intubations. She has been on Prednisone 20
mg PO for the past year. On [**9-28**], she presented with one day of
wheezing and cough, peak flows of 120 mL (baseline 250-300 mL).
In the ED, she was unresponsive to nebulizers, heliox, oral
prednisone and was hypoxemic to 87% on 6L NC. She was admitted
to the [**Hospital Unit Name 153**] for nebs q1hr, IV steroids and continuous
monitoring. Empiric CPAP at night was started in [**Hospital Unit Name 153**]. Of note,
pt was seen by Dermatology for rash x 2weeks and a biopsy was
negative for mites. She was discharged from the [**Hospital Unit Name 153**] with
improved oxygenation and ventilation with decreased frequency of
nebs to q3 hour.
ROS: Gained 60 pounds since [**9-21**] (when started steroids).
Endorses fatigue. No rhinorrhea, fever, chills. No N/V or
diarrhea. No chest pain, PND or palpitations. 2 pillow
orthopnea. Denies daytime sleepiness. Frequent bloody stools
with abdominal pain (missed several colonoscopy appointments
because of fatigue).
Past Medical History:
Asthma
Recurrent HAs
Hyperlipidemia
Depression
Obesity
Bronchitis
GERD/hiatal hernia
Anxiety
Rectal bleeding
Social History:
Lives adjacent to a pet store. Noticed that rash developed after
moving into new apartment. Has a dog and is going through
divorce. Lives with 13 and 27 yo sons. 1ppd x 2yrs after
quitting for 11yrs. No EtOH or IVDU.
Family History:
No IBD or early CAD.
Mom – died ovarian CA at 63
Dad- died of ?brain CA at 27
Physical Exam:
Vitals T 97 P 74 BP 114/54 Resp 22
O2 97% on 5L NC
Gen A+Ox3.Slight resp distress. Not toxic.
HEENT No JVD. OP clear w/o exudates. No LAD. EOMI.
Neck Thyroid difficult to assess, but no discrete nodules
palpated. No carotid bruits.
Thorax Diffuse I & E wheezes throughout both lungs. Coarse
rhonchi throughout.
CV Distant heart sounds. NSR. No m/r/g.
Abd Obese. Normoactive BS. No tenderness. No ascites,
masses.
Skin Diffuse macular rash with varying sized lesions on abdomen,
arms and quadriceps.
Ext 1+ pitting edema. Warm. Radial and PT 2+ bilaterally. DP 1+
bilat.
Neuro CN II-XII intact. Strength 5/5 in UE & LE. Sensation to
touch intact. Babinski-upgoing toes bilat.
Pertinent Results:
[**2131-9-28**] 08:06PM TYPE-ART PO2-115* PCO2-46* PH-7.37 TOTAL
CO2-28 BASE XS-1
[**2131-9-28**] 08:06PM O2 SAT-97
[**2131-9-28**] 11:15AM WBC-12.4* RBC-4.64 HGB-12.7 HCT-38.3 MCV-83
MCH-27.5 MCHC-33.3 RDW-15.7*
[**2131-9-28**] 11:15AM NEUTS-82* BANDS-1 LYMPHS-12* MONOS-3 EOS-2
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2131-9-28**] 11:15AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-OCCASIONAL OVALOCYT-1+
STIPPLED-OCCASIONAL
[**2131-9-28**] 11:15AM PLT COUNT-303
CXRs:
([**2131-9-28**]) - IMPRESSION: No evidence of an acute cardiopulmonary
abnormality.
([**2131-9-30**]) - IMPRESSION: There is no evidence of active disease
in the lungs or heart. No significant changes since the prior
study.
([**2131-10-1**]) - IMPRESSION: Improving left heart failure.
Sputum Culture ([**2131-9-30**]): GRAM STAIN - <10 PMNs and >10
epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): MULTIPLE
ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA.
CXR:
[**10-3**] Bilateral lungs are clear. No evidence of active lung
disease. There is minimal plate-like atelectasis in the left
lower lobe (prelim report)
[**10-1**] Cephalization of pulmonary vasculature persists, although
improved since the last exam.
[**9-30**] No cardiomegaly. The lungs are clear of an active
congestion or infiltration. No evidence of pleural effusion or
pneumothorax.
Abdominal Skin Biopsy ([**2131-9-30**]): The presence of acanthosis and
subepidermal fibrin is most consistentwith irritation or trauma
to the site (as would be seen with excoriations). The typical
histologic findings of dermatitis herpetiformis or pemphigus
foliaceous are not seen.
Axillary biopsy ([**2131-10-6**]): Right upper arm. Dermal
hypersensitivity reaction
Note: Sections show an unremarkable epidermis. The dermis
demonstrates a superficial and deep perivascular lymphocytic
infiltrate with eosinophils. The findings are consistent with a
dermal hypersensitivity reaction, such as to an arthropod
assault.
Brief Hospital Course:
43 year old obese woman with history of asthma, 20 pack year
smoking, bronchitis with multiple admissions since [**9-21**] for
asthma flares requiring hospitalization and steroids. Her
hospital course is discussed by problem.
1) Asthma-
On transfer to the medical floor, she was placed on q3:prn nebs
with albuterol and ipratropium. She also received combivent q4
standing, prednisone 60 mg PO, serevent, flovent and singulair.
During her hospital course, she tolerated the weaning frequency
of neb treatment to q3-q4:prn, as well as a decrease in her O2
requirement from an initial 5 L/ min to room air. During this
transition from O2 via nasal cannula to room air, her O2
saturation was between 92-97%. Also, her daily peak flows
gradually increased to 250-300, which is at the patient's
baseline. Notably, the patient's O2 on ambulation was 97% on
her discharge date. Smoking cessation was encouraged during her
hospital stay. She was sent home on Wellbutrin and a nicotine
patch.
2) Rash - Patient reported rash on torso, upper thigh and arms
was pruritic and developed when she moved into her apartment,
which is adjacent to a pet store. She was given clobetasol,
benadryl and hydroxyzine with some relief. Initial biopsy
demonstrated nonspecific inflammation (see results sections).
After her discharge, it was noted that the rebiopsy of new
axillary lesion demonstrated many eosinophil consistent with
arthropod infestation.
3) Obstructive sleep apnea (OSA)
Patient complained of difficulty sleep and apneic episodes. She
noted a decreased in her symptomatology once she started using
CPAP. Patient's obesity, reported symptoms and improvement on
empiric CPAP was thought to be suggestive of OSA. Patient will
follow up with sleep lab for a sleep study.
4) Bronchitis
Patient completed 5 day course on empiric Levaquin for atypical
coverage and a cough characterized by scant white/yellow sputum.
5)Metabolic alkalosis-
Patient's HCO3 was persistently 34 fro a few days, and then
decreased to 29 on her discharge date. This elevated HCO3 was
thought to be due to large consumption of Diet Pepsi (>6 jugs 24
oz/day).
6) Leukocytosis
WBC count between 19 and 25. This was thought to be due to
steroids(chronically on prednisone 20 for over a year, and now
on prednisone 60 mg PO). However, because patient was on
steroids, it was not felt that she would mount a febrile
response if infected, thus, to rule out an infection cultures
were sent. Urine cultures and analysis were negative. Blood
cultures pending upon discharge.
7) Diabetes mellitus
Patient was managed on insulin sliding scale and glucose was
checked qid.
8) Anxiety
Celexa and Klonopin were continued, per outpatient regimen.
9) GERD-
Patient complained of emesis while asleep. CT scan demonstrated
a large hiatal hernia, which was thought to contribute to her
symptoms of GERD and worsening asthma from aspiration. She was
started on a proton pump inhibitor. Also, an appointment with
Dr. [**Last Name (STitle) 57300**] from General Surgery was scheduled for the
patient.
Patient was stable upon discharge to home. She has transferred
all of her medical care to the [**Hospital1 18**].
Medications on Admission:
Transfer Meds:
Ipratropium Bromide MDI 2 PUFF IH QID
Ipratropium Bromide Neb [**1-19**] NEB IH Q3H
Albuterol Neb Soln [**1-19**] NEB IH Q3H
Albuterol 2 PUFF IH Q6H
Albuterol Neb Soln 15 NEB IH EVERY TWO HOURS
Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
Methylprednisolone Na Succ 125 mg IV Q8H
Montelukast Sodium 10 mg PO QD
Guaifenesin-Dextromethorphan 5 ml PO Q6H:PRN
Diphenhydramine HCl 25 mg PO Q6H:PRN
Levofloxacin 500 mg PO Q24H Duration: 5 Days (d1=[**2131-10-2**])
Atorvastatin 10 mg PO QD
Clonazepam 1 mg PO BID
Citalopram Hydrobromide 60 mg PO
Nicotine 14 mg TD QD
Pantoprazole 40 mg PO Q24H
Calcium Carbonate 500 mg PO TID W/MEALS
Vitamin D 400 UNIT PO QD
Sarna Lotion 1 Appl TP QID:PRN
Clobetasol Propionate 0.05% Ointment 1 Appl TP [**Hospital1 **]
Heparin 5000 UNIT SC TID
Insulin SC (per Insulin Flowsheet)
Acetaminophen 325-650 mg PO Q4-6H:PRN
Discharge Medications:
1. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal QD (once a day).
Disp:*30 Patch 24HR(s)* Refills:*2*
2. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO once a day
for 3 days: Stop on [**10-11**].
Disp:*9 Tablet(s)* Refills:*0*
3. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: Start [**10-12**]; stop [**10-17**].
Disp:*6 Tablet(s)* Refills:*0*
4. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day for
6 days: Start [**10-18**]; stop [**10-23**].
Disp:*12 Tablet(s)* Refills:*0*
5. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day
for 6 days: start [**10-24**]; stop [**10-29**].
Disp:*18 Tablet(s)* Refills:*0*
6. Prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for
6 days: start [**10-30**]; stop [**11-4**].
Disp:*6 Tablet(s)* Refills:*0*
7. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day:
start [**11-5**] and continue every day.
Disp:*30 Tablet(s)* Refills:*2*
8. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning))
for 1 days.
Disp:*1 Tablet Sustained Release(s)* Refills:*0*
9. Wellbutrin XL 300 mg Tablet Sustained Release 24HR Sig: One
(1) Tablet Sustained Release 24HR PO once a day.
Disp:*21 Tablet Sustained Release 24HR(s)* Refills:*2*
10. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*42 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*21 Tablet(s)* Refills:*2*
12. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD
(once a day).
Disp:*21 Tablet(s)* Refills:*2*
13. Fluticasone Propionate 220 mcg/Actuation Aerosol Sig: 4
puffs Inhalation twice a day.
Disp:*3 * Refills:*2*
14. Citalopram Hydrobromide 20 mg Tablet Sig: Three (3) Tablet
PO QD (once a day).
Disp:*63 Tablet(s)* Refills:*2*
15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation
Q3-4H () as needed for shortness of breath or wheezing.
Disp:*3 units* Refills:*0*
16. Albuterol Sulfate 5 mg/mL Nebu Soln Sig: [**1-19**] Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
Disp:*21 amps* Refills:*0*
17. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One
(1) Disk with Device Inhalation Q12H (every 12 hours).
Disp:*42 Disk with Device(s)* Refills:*2*
18. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed for itching.
Disp:*100 Tablet(s)* Refills:*0*
19. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO
Q6H (every 6 hours) as needed for itching.
Disp:*100 Capsule(s)* Refills:*0*
20. Clobetasol Propionate 0.05 % Ointment Sig: One (1) Appl
Topical [**Hospital1 **] (2 times a day) as needed for itching: Avoid on
face. .
Disp:*2 tube* Refills:*0*
21. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*2 tube* Refills:*0*
22. Spacer
Please obtain spacer at pharmacy.
Discharge Disposition:
Home
Discharge Diagnosis:
Asthma
Obstructive sleep apnea
Obesity
Rash
Hypoxemia
Hypoventilation
Metabolic alkalosis
Bronchitis
Hyperlipidemia
Gastroesophageal reflux disese
Anxiety
Depression
Discharge Condition:
Stable
Discharge Instructions:
* Call your primary care physician if you develop chest pain,
worsening shortness of breath, lightheadedness or any other
concerning symptoms.
* Take all medications as prescribed.
* Follow up with all appointments.
* Taper prednisone slowly to 10 mg/day over one month. Started
50 mg PO on [**2131-10-10**]. Will take 50 mg PO for 6 days, and then
take 40 mg PO for 6 days, etc.
* Per Dermatology, please request that PCP check tissue
transglutaminase (TTG) for celiac sprue.
* Remind PCP to call insurance company to request a reclining
chair.
* Speak with PCP about home environment evaluation.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2131-10-18**] 2:00
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Where: [**Hospital6 29**] NEUROLOGY
Phone:[**Telephone/Fax (1) 6856**] Date/Time:[**2131-10-12**] 11:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 41726**] ASSOCIATES Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2131-10-22**] 2:30
Provider: [**First Name11 (Name Pattern1) 306**] [**Last Name (NamePattern4) 7907**], MD Where: [**Hospital6 29**]
DERMATOLOGY Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2131-11-19**] 11:00
Completed by:[**2131-10-10**]
|
[
"276.3",
"782.1",
"493.91",
"305.1",
"490",
"780.57",
"519.8",
"134.8",
"278.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"86.11",
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11867, 11873
|
4749, 7921
|
282, 288
|
12083, 12091
|
2727, 4726
|
12744, 13568
|
1926, 2011
|
8839, 11844
|
11894, 12062
|
7947, 8816
|
12115, 12721
|
2026, 2708
|
225, 244
|
316, 1544
|
1566, 1676
|
1692, 1910
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,114
| 164,691
|
9405
|
Discharge summary
|
report
|
Admission Date: [**2160-12-4**] Discharge Date: [**2160-12-26**]
Date of Birth: [**2101-6-28**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Severe chest and back pain with fever and leukocytosis
Major Surgical or Invasive Procedure:
[**2160-12-4**] - Cardiac Catheterization. Placement of IABP
[**2160-12-18**] - CABGx3 (left internal mammary artery graft to the
left
anterior descending and reversed saphenous vein graft to the
marginal branch and the posterior descending branch.
[**2160-12-23**] - Placement of an IABP
[**2160-12-26**] - Exploratory Laparotomy
History of Present Illness:
This is a 59 yo male with a past medical history significant for
diabetes, hypertension, question of sarcoidosis who presented to
the Emergency Department with fever, chills, and back pain.
Patient states that he has had the back pain for months but now
the pain is more localized to his midline. The patient states
that he has had diarrhea for the last couple of weeks but in
combination with constipation. Pt denies any dyspnea,
diaphoresis, melena, hematuria, dysuria.
In emergency department, Mr. [**Known lastname 32118**] was febrile to 102.9. He was
initially worked up for aortic dissection and had a CT of the
chest and abdomen. An EKG was done after he returned from CT
and he was found to have ST elevations, .5-1mm in I, AVL and 2
mm in V2. He was urgently taken to the cath lab where he was
found to have a 90% ostial lesion of the left anterior
descending artery, 50% stenosed circumflex artery and an 80%
stenosed right coronary artery. Hemodynamics showed a cardiac
output of 5.76, an index of 2.44 and a sytemic vascular
resistance (SVR) of 444. No intervention was made as patient's
left anterior descending artery lesion was near the circumflex
and there was concern for blocking left coronary ciculation as
patient was left side dominant. An intra-aortic balloon pump was
placed and Mr. [**Known lastname 32118**] was transferred to the floor for
stabilization with antibiotics for infection, and potential
evaluation for surgical revascualrization when stable. Upon
leaving the cath lab, he became hypotensive. He was started on
low dose dopamine but then he became tachycardic so pt was
switched to neo-synephrine with good relief. Upon arriving to
the floor the patient had a white cell count of 25. He was
started on empiric coverage of vanomycin, levofloxacim and
flagyl. The white cell began trending up from 23.4 on admission
-> 26.5 -> 36.8 -> 46.1. Later Linezolid was added when it was
found that he had a history of methicillin resistent staph aurea
(MRSA) and vancomycin resistent enterococcus (VRE) from past
wound infections. Pt [**Name (NI) **] on the floor trended upwards from 259
-> [**Numeric Identifier 32119**] -> 3352. Cardiology fellow called about possibility of
taking patient to cath lab in light of continued ischemia. It
was deemed that due to pt anatomy, he was not a candidate for
peructaneous intervention.
When Mr. [**Known lastname 32118**] initially came to the floor his blood gas (ABG)
was 7.34/28/94 with a lactate of 1.4. He was found to have a
non-anion gap metabolic acidosis. He was on a nonrebreather and
then transitioned to CPAP. A 3AM gas showed 7.25/47/131 w/
lactate of 2.1. He seemed to be tiring and anesthesia was
called to intubate Mr. [**Known lastname 32118**]. Chest x-ray showed bilateral
patchy infiltrate. He was transitioned to low volume to mimize
barotrauma for suspected acute respiratory distress syndrome.
Other issues included a rising creatinine of 2.3 (baseline
1.5-1.8)on [**12-5**] and a question of vertebral osteomyelitis. ID
consult was obtained and the abx recommendations were followed.
He also developed hyperkalemia and was seen by renal service
for ARF. Pt. also had a small GI bleed with NGT coffee grounds
emesis on heparin. IABP was removed [**12-6**] and treatment
continued for LLE cellulitis. He also continued lasix duresis
with periodic neosynephrine support. He was extubated on [**12-8**].
Referred to Dr. [**Last Name (STitle) **] of CT surgery. He recommended infectious
issues be competely resolved before CABG and a myocardial
viability study. Patient contnued to have episodes of diarrhea.
He continued his courses of vanco and zosyn.CABG was scheduled
but then postponed for a rising creatinine again (2.2). Dr.
[**Last Name (STitle) **] reviewed the high risk status of his surgery with the
patient (10-15% mortality). CABG performed on [**2160-12-18**] by Dr.
[**Last Name (STitle) **] with a LIMA to LAD, SVG to OM and SVG to PDA. He was
transferred to the CSRU on epinephrine, levophed, milrinone and
insulin drips.He was extubated on [**12-20**]. Pressor wean was begun
and epinephrine and levophed were off later in the day. Pt.
remained on lidocaine, milrinone, and neosynephrine drips.
Chest tubes were removed. Creatinine was 2.9 on [**12-20**]. He had an
episode of VT and had cardioversion on [**12-21**]. He was also
transfused and started on a natrecor drip. Swan was exchanged to
a triple lumen catheter on [**12-21**]. EP was consulted for recurrent
VT. Amiodarone drip was started. He also had episodes of rapid
AFib. On [**12-22**] , he had a vfib arrest and was shocked x 4. Cath
was considered but his creatinine was at 3.0 at the time and
cardiology felt it best to monitor him closely. Ischemia was not
suspected given the large area of his anterolateral
infarction.The following day it was 3.2. He continued to receive
SQ heparin for his mobility status. He remained on amio,
natrecor, and lidocaine drips and continued with zosyn. He was
diuresed with lasix drip for volume overload. On the afternoon
of [**12-23**], the pt. was reintubated for respiratory distress. He
went to the cath lab for IABP and swan placement. Heparin was
switched to IV dosing. Milrinone and neo drips were restarted.
On [**12-24**] , a Quinton cath was placed in the left femoral vein to
allow for the institution of CVVHD. He remained sedated with
propofol. TEE was performed on [**12-24**] which revealed severely
depressed LV function with EF 20-25%.A small pericardial
effusion was noted and there were multiple wall motion
abnormalities including anterolateral akinesis. On [**12-25**], he had
a run of Afib, torsades and a 23 beat run of VT with poor
perfusion and severe hypotension. He was cardioverted and then
paced. He had 4+ BLE edema. Right DP pulse was not dopplerable
at this time, and toes were cyanotic, but warm. IABP was pulled
at 4:30AM by cardiology for the compromised circulation in that
leg.
He remained somewhat hypotensive at this time (SBP 70-80's).
Vascular surgery was called when the pulse did not return in
this foot. He continued to be severely acidotic with base excess
of minus 4 to minus 16. There was slight improvement in his
doppler signal, but ischemia with ?thrombus was considered.
Platelet count was 69K at that time with an INR of 2.3. At this
time, there was concern for his bowel circulation given his
acidosis that was not responding to therapy.
The patient remained critically ill and ischemic mesentery was
suspected by the transplant service. Mr. [**Known lastname 32118**] was seen and
evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of general surgery. He had
requested correction of the coagulopathy and additional LFTs in
preparation for emergency exploratory laparotomy. The patient
was taken to the OR on the morning of [**12-26**] and had an emergency
lap by Dr. [**First Name (STitle) **]. During the attempted bowel resection for
mesenteric ischemia, the patient suffered VTach and a VFib
arrest that did not respond to multiple shocks, CPR, and ACLS
protocol meds. He was pronounced expired at 10:24 AM by Dr.
[**First Name (STitle) **] of transplant surgery.
Past Medical History:
Charcot foot - VRE/MRSA past infecftions
Hypertension
hyperlipidemia
Diabetes Mellitus
questionable sarcoidosis
morbid obesity
Social History:
Smokes cigars 1-2 per day. Denies alcohol use. Works for local
sports radio show.
Family History:
non-contributory
Physical Exam:
ED Vitals - Temp 102.9 BP 60/palp HR 110 RR 24 O2 sat 97% on
NRB
Gen: ill appearing
HEENT: Pupils eaqual and reactive, oropharynx clear
Resp: clear
CV: distant heart sounds, no murmur, gallop or rub
ABD: obese, nontender, guaiac (-)
Back: no costovertebral tenderness
Ext: no cyanosis, clubbing or edema, Left Charcot foot deformity
w/ bulging at Left ankle, no drainage, warmth, or erythema
Neuro: alert, appropriate, moving all four extremities
Pertinent Results:
Initial CXR - no acute cardiopulmonary disease
ECG - ST elevations .5-1 mm in I, AVL, 2 mm in V2
Cath - 90% ostial lesion of the left anterior descending artery,
50% circumflex artery, and an 80% right coronary artery.
[**12-4**] Echo - EF 40-45%, nl LV cavity size, possible hypokinesis
at apex, RV free wall motion preserved
[**2158-10-19**] Echo - LVEF 35-40%, mild LVH, moderate systolic
dysfunction, sever hypokinesis of basal system.
CT chest/abdomen - 1) severe coronary artery calcification 2)
mediastinal lymphadenopathy unchanged from prior 3)left sided
exophytic renal cysts, probable hyperdense cysts within mid pole
of right kidney.
LABS; (Admission/Discharge)
[**2160-12-4**] 03:00PM WBC-23.4*# RBC-4.43* HGB-13.0*# HCT-36.8*
MCV-83 MCH-29.4# MCHC-35.3* RDW-15.5
[**2160-12-4**] 03:00PM cTropnT-0.03*
[**2160-12-4**] 03:00PM CK(CPK)-81
[**2160-12-4**] 03:00PM GLUCOSE-217* UREA N-82* CREAT-1.5* SODIUM-138
POTASSIUM-5.7* CHLORIDE-104 TOTAL CO2-23 ANION GAP-17
[**2160-12-4**] 03:44PM LACTATE-2.5*
[**2160-12-4**] 05:43PM WBC-26.5* RBC-3.99* HGB-11.8* HCT-33.7*
MCV-85 MCH-29.6 MCHC-35.0 RDW-15.7*
[**2160-12-4**] 05:43PM ALT(SGPT)-22 AST(SGOT)-34 CK(CPK)-259* ALK
PHOS-65 AMYLASE-59 TOT BILI-0.3
[**2160-12-4**] 08:25PM CK-MB-169* MB INDX-9.5* cTropnT-2.87*
[**2160-12-4**] 08:25PM GLUCOSE-262* UREA N-79* CREAT-1.6* SODIUM-138
POTASSIUM-5.2* CHLORIDE-108 TOTAL CO2-17* ANION GAP-18
[**2160-12-4**] 08:25PM WBC-36.8* RBC-4.12* HGB-11.9* HCT-34.8*
MCV-85 MCH-28.9 MCHC-34.1 RDW-15.7*
[**2160-12-26**] 02:44AM BLOOD WBC-33.7* RBC-3.71* Hgb-11.1* Hct-34.0*
MCV-92 MCH-29.8 MCHC-32.5 RDW-16.8* Plt Ct-69*
[**2160-12-26**] 06:30AM BLOOD Plt Smr-VERY LOW Plt Ct-50*
[**2160-12-26**] 06:30AM BLOOD PT-23.4* PTT-150* INR(PT)-3.4
[**2160-12-26**] 02:44AM BLOOD UreaN-43* Creat-2.7* Na-132* Cl-89*
HCO3-12*
[**2160-12-26**] 07:46AM BLOOD ALT-3820* AST-8175* LD(LDH)-9610*
AlkPhos-168* TotBili-4.0*
[**2160-12-26**] 10:00AM BLOOD Glucose-79 Lactate-23.0* Na-132* K-5.1
Cl-90*
[**2161-12-5**] X-ray
Marked arthropathy consistent with the given history of Charcot
foot, worse since the prior studies. Infection can have a
similar appearance and clinical correlation is requested.
[**2161-12-5**] ECHO
Conclusions:
1 The left atrium is dilated.
2. The left ventricular cavity is mildly dilated. There is
moderate global left ventricular hypokinesis, apical akinesis
and some preservation of basal wall motion. Overall left
ventricular systolic function is moderately depressed. No masses
or thrombi are seen in the left ventricle with and without
contrast.
3. The aortic valve leaflets (3) are mildly thickened.
4. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
[**2160-12-15**] ECHO
1. Technically difficult study.
2.Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. Overall left ventricular
systolic function is severely depressed. Resting regional wall
motion abnormalities include apical and lateral wall akinesis.
3. The number of aortic valve leaflets cannot be determined. The
aortic valve is not well seen. No AI seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen
4.There is no pericardial effusion
[**2160-12-23**] ECHO
Left ventricular systolic function appears depressed, probably
severely, in technically suboptimal views. The anterior septum
appears akinetic, there may be septal hypokinesis and there is
hypokinesis elsewhere. There is a small pericardial effusion.
There are no echocardiographic signs of tamponade. Compared to
the prior study of [**2160-12-15**], the pericardial effusion is now
larger (a trivial effusion was previously present)
[**2160-12-24**] ECHO
The left atrium is mildly dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. The left ventricular cavity is mildly dilated. The LV
systolic function is severely depressed (EF 25%). The best
preserved segments are the basal inferior and basal
inferolateral segments. The anterior wall and the septum are
severely hypokinetic/akinetic, the anterolateral wall is
hypokinetic and the apex is akinetic/hypokinetic. No LV aneurysm
is seen. Right ventricular chamber size and free wall motion are
normal. Intraaortic balloon pump is noted in the descending
thoracic aorta. Simple aortic plaque is noted in the aortic
arch. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion. Trace aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. There is a small pericardial effusion.
[**2160-12-10**] MRI FOOT
Small crescentic area of nonspecific enhancement immediately
abutting the distal edge of the fibula with associated signal
abnormality on the T1- weighted images. The differential
includes both reactive tissue (eg granulation tissue, fibrosis,
synovium) and infectious phlegmon. No focal fluid collection is
identified. There is no marrow edema to suggest osteomyelitis. A
small area immediately around the hardware is obscured by metal
artifact but much of the remainder of the heel and foot is
well-seen.
[**2160-12-23**] Cardiac Catheterization
1. Severe systolic and diastolic ventricular dysfunction.
2. Severe primary pulmonary hypertension.
3. Placement of IABP
Brief Hospital Course:
Mr. [**Known lastname 32118**] was admitted to the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1675**] [**Last Name (NamePattern1) **] Medical
Center on [**2161-12-4**] for further management of his chest pain. He
was taken to the cardiac catheterization lab where he was found
to have severe three vessels coronary disease. As his left
anterior descending artery was markedly calcified with a short
left main, intervention was declined given the risk of jailing
the circumflex artery which was his dominant vessel. An
intra-aortic balloon pump was placed. Heparin, integrillin and
aspirin were started for anticoagulation. Mr. [**Known lastname 32118**] became
hypotensive after his catheterization and pressors were started.
He subsequently became acidotic and required intubation in the
cardiac care unit. Given his leukocytosis, sepsis was suspected
and vancomycin, flagyl and linezolid were started. Given his
charcot foot, the podiatry service was consulted.
Medications on Admission:
KCL
Furosemide 80 po bid
Allopurinol 100 mg po daily
Diovan HCT 160/25 po daily
Atenolol 50 mg po bid
Folic acid 1 mg po qd
Norvasc 10 mg po qd
Lipitor 40 po qd
SL nitroglycerin
Discharge Medications:
none
Discharge Disposition:
Expired
Facility:
[**Hospital1 18**]
Discharge Diagnosis:
s/p coronary artery bypass grafting x3
acute myocardial infarction
severe acidosis with mesenteric ischemia
acute renal failure
s/p intraaortic ballon pump removal with ischemia of leg
LLE cellulitis
leukocytosis
Discharge Condition:
expired in OR
Completed by:[**2161-4-17**]
|
[
"410.01",
"444.0",
"995.92",
"785.51",
"535.01",
"785.52",
"250.60",
"427.31",
"996.72",
"278.01",
"272.0",
"444.22",
"250.70",
"041.11",
"427.5",
"557.0",
"682.6",
"730.17",
"414.01",
"428.43",
"V09.0",
"997.1",
"038.9",
"416.8",
"584.5",
"V49.75",
"401.9",
"440.23",
"713.5",
"518.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56",
"88.72",
"37.61",
"89.68",
"39.61",
"99.62",
"36.12",
"00.13",
"96.04",
"89.64",
"39.95",
"00.14",
"00.17",
"36.15",
"54.11"
] |
icd9pcs
|
[
[
[]
]
] |
15386, 15425
|
14145, 15129
|
377, 709
|
15682, 15726
|
8703, 14122
|
8198, 8216
|
15357, 15363
|
15446, 15661
|
15155, 15334
|
8231, 8684
|
283, 339
|
737, 7932
|
7954, 8083
|
8099, 8182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,246
| 112,249
|
34759
|
Discharge summary
|
report
|
Admission Date: [**2133-6-6**] Discharge Date: [**2133-6-19**]
Date of Birth: [**2078-2-6**] Sex: F
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2569**]
Chief Complaint:
Paraesthesia, right visual impairment and right eye pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
55 [**Name Initial (MD) **] IV RN who works at the [**Hospital1 2025**] was transfered from the
[**Hospital 27217**] Hospital with a right brainstem hemorrhage. Her
symptoms
started around 19:45 h while she was having dinner with her
husband, and she described the following sequence of events:
Symptoms started with left face and hand tingling and a right
retro-orbital pain. Her husband noted that her speech was
slurred and the left side of face was droopy. The paramedics
took her BP and the systolic at the scene was
greater than 260 mmHg.
Past Medical History:
She has not seen a PCP in years, and was not aware or any
medical problems
Social History:
Lives with husband. Non-[**Name2 (NI) 1818**], nil alcohol
Family History:
Mother had HTN controlled on medications.
Father died of a stroke in his 50s
Physical Exam:
Vitals: Apyrexial, BP 182/92, HR 74, RR 20, O2 sats 97% on air
General: Sleepy but rousable, high BMI
HEENT: no meningismus, moist mucosal membranes
CVS: systolic murmur in the aortic area with no radiation to the
carotids
Resp: Lungs clear to auscultation B/L
GI: Soft, non-tender, normal BS
Neurological Examination
Mental status: Sleepy but cooperative with exam. Oriented to
person, place, and date. Able to spell "world" backwards.
Speech is fluent with normal comprehension and repetition.
Naming
intact. Dysarthria. Registers [**1-26**], recalls [**1-26**] in 5 minutes.
No
right left confusion. No evidence of apraxia or neglect.
Cranial Nerves:
Pupils equally round and reactive to light, 2 mm bilaterally.
Visual fields are full to confrontation. right eye deviated
inwards with several beats of lateral nystagmus. Sensation
intact
V1-V3 diminished to pinprick, cold and soft touch on the left
hand side of the face. Facial movement asymmetric, slight left
facial droop. Palate elevation symmetric. Trapezius power
normal ([**3-30**]) bilaterally. Tongue protrudes to the left due to
the
weakness of the facial muscles.
Upper & Lower limb examination
Motor:
Normal bulk bilaterally. Tone normal. No observed clonus or
tremor
No pronator drift
[**Doctor First Name **] Tri [**Hospital1 **] WF WE FE FF IP H Q DF PF TE TF
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
Sensation: Intact to light touch, pinprick, vibration and
proprioception throughout. No extinction to DSS
Reflexes:
+2 and symmetric throughout.
Plantars equivocal
Coordination: finger-nose-finger normal, heel to shin normal
Pertinent Results:
[**2133-6-14**] 02:08AM BLOOD WBC-9.8 RBC-4.60 Hgb-13.7 Hct-40.7 MCV-89
MCH-29.8 MCHC-33.7 RDW-13.8 Plt Ct-249
[**2133-6-13**] 03:10AM BLOOD WBC-9.6 RBC-4.27 Hgb-12.9 Hct-38.6 MCV-90
MCH-30.2 MCHC-33.5 RDW-13.6 Plt Ct-256
[**2133-6-12**] 01:53AM BLOOD WBC-9.3 RBC-4.00* Hgb-12.5 Hct-36.5
MCV-91 MCH-31.3 MCHC-34.3 RDW-13.8 Plt Ct-253
[**2133-6-11**] 02:05AM BLOOD WBC-9.3 RBC-4.14* Hgb-12.4 Hct-38.4
MCV-93 MCH-29.9 MCHC-32.2 RDW-13.9 Plt Ct-260
[**2133-6-10**] 01:50AM BLOOD WBC-10.0 RBC-4.21 Hgb-12.7 Hct-38.3
MCV-91 MCH-30.2 MCHC-33.2 RDW-14.1 Plt Ct-236
[**2133-6-9**] 02:47AM BLOOD WBC-12.5* RBC-4.62 Hgb-13.9 Hct-41.6
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.1 Plt Ct-214
[**2133-6-8**] 12:22AM BLOOD WBC-16.5*# RBC-4.78 Hgb-14.5 Hct-42.9
MCV-90 MCH-30.3 MCHC-33.7 RDW-14.3 Plt Ct-259
[**2133-6-7**] 01:50AM BLOOD WBC-10.4 RBC-4.66 Hgb-13.8 Hct-42.0
MCV-90 MCH-29.6 MCHC-32.9 RDW-14.2 Plt Ct-235
[**2133-6-6**] 07:00AM BLOOD WBC-8.5 RBC-4.71 Hgb-14.2 Hct-41.0 MCV-87
MCH-30.1 MCHC-34.5 RDW-14.1 Plt Ct-259
[**2133-6-5**] 10:40PM BLOOD WBC-12.0* RBC-4.80 Hgb-14.4 Hct-41.8
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.1 Plt Ct-235
[**2133-6-6**] 07:00AM BLOOD Neuts-89.4* Lymphs-7.0* Monos-3.1 Eos-0.2
Baso-0.4
[**2133-6-5**] 10:40PM BLOOD Neuts-90.5* Lymphs-6.5* Monos-2.2 Eos-0.4
Baso-0.3
[**2133-6-14**] 02:08AM BLOOD Plt Ct-249
[**2133-6-13**] 03:10AM BLOOD Plt Ct-256
[**2133-6-12**] 01:53AM BLOOD Plt Ct-253
[**2133-6-11**] 02:05AM BLOOD Plt Ct-260
[**2133-6-10**] 01:50AM BLOOD Plt Ct-236
[**2133-6-9**] 02:47AM BLOOD Plt Ct-214
[**2133-6-8**] 12:22AM BLOOD Plt Ct-259
[**2133-6-7**] 01:50AM BLOOD Plt Ct-235
[**2133-6-6**] 07:00AM BLOOD Plt Ct-259
[**2133-6-6**] 07:00AM BLOOD PT-13.9* PTT-22.4 INR(PT)-1.2*
[**2133-6-5**] 10:40PM BLOOD Plt Ct-235
[**2133-6-5**] 10:40PM BLOOD PT-13.7* PTT-21.9* INR(PT)-1.2*
[**2133-6-15**] 09:30AM BLOOD Glucose-170* UreaN-30* Creat-1.3* Na-143
K-3.7 Cl-103 HCO3-30 AnGap-14
[**2133-6-14**] 02:08AM BLOOD Glucose-128* UreaN-30* Creat-1.2* Na-143
K-4.0 Cl-104 HCO3-30 AnGap-13
[**2133-6-13**] 03:10AM BLOOD Glucose-115* UreaN-26* Creat-1.0 Na-144
K-3.4 Cl-106 HCO3-27 AnGap-14
[**2133-6-12**] 01:53AM BLOOD Glucose-128* UreaN-27* Creat-0.9 Na-145
K-4.2 Cl-110* HCO3-27 AnGap-12
[**2133-6-11**] 02:05AM BLOOD Glucose-137* UreaN-26* Creat-1.0 Na-148*
K-3.9 Cl-111* HCO3-29 AnGap-12
[**2133-6-10**] 01:50AM BLOOD Glucose-144* UreaN-30* Creat-1.0 Na-150*
K-3.5 Cl-111* HCO3-32 AnGap-11
[**2133-6-8**] 12:22AM BLOOD Glucose-143* UreaN-20 Creat-0.9 Na-145
K-3.9 Cl-109* HCO3-28 AnGap-12
[**2133-6-7**] 01:50AM BLOOD Glucose-135* UreaN-23* Creat-1.1 Na-143
K-4.0 Cl-107 HCO3-28 AnGap-12
[**2133-6-6**] 07:00AM BLOOD Glucose-160* UreaN-20 Creat-1.1 Na-144
K-4.1 Cl-104 HCO3-29 AnGap-15
[**2133-6-5**] 10:40PM BLOOD Glucose-185* UreaN-18 Creat-1.0 Na-144
K-3.7 Cl-105 HCO3-29 AnGap-14
[**2133-6-11**] 02:05AM BLOOD ALT-14 AST-15 LD(LDH)-244 AlkPhos-39
TotBili-2.5*
[**2133-6-10**] 01:50AM BLOOD ALT-17 AST-18 LD(LDH)-254* AlkPhos-45
TotBili-3.8*
[**2133-6-8**] 08:00PM BLOOD ALT-18 AST-16 LD(LDH)-303* AlkPhos-52
Amylase-15 TotBili-4.2* DirBili-0.5* IndBili-3.7
[**2133-6-6**] 05:59PM BLOOD CK(CPK)-134
[**2133-6-6**] 07:00AM BLOOD ALT-32 AST-21 CK(CPK)-176* AlkPhos-60
TotBili-1.6*
[**2133-6-5**] 10:40PM BLOOD ALT-37 AST-26 TotBili-1.7*
[**2133-6-8**] 08:00PM BLOOD Lipase-16
[**2133-6-6**] 07:00AM BLOOD CK-MB-5 cTropnT-<0.01
[**2133-6-5**] 10:40PM BLOOD cTropnT-0.01
[**2133-6-6**] 05:59PM BLOOD CK-MB-5
[**2133-6-5**] 10:40PM BLOOD CK-MB-6
[**2133-6-15**] 09:30AM BLOOD Calcium-9.5 Phos-3.7 Mg-2.1
[**2133-6-14**] 02:08AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.1
[**2133-6-13**] 03:10AM BLOOD Calcium-9.2 Phos-4.4 Mg-2.1
[**2133-6-12**] 01:53AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.2
[**2133-6-11**] 02:05AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.2
[**2133-6-10**] 01:50AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.3
[**2133-6-9**] 02:47AM BLOOD Calcium-9.7 Phos-3.8 Mg-2.4
[**2133-6-8**] 12:22AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
[**2133-6-7**] 01:50AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.2 Cholest-219*
[**2133-6-6**] 07:00AM BLOOD Calcium-9.4 Phos-4.8* Mg-2.0 Cholest-225*
[**2133-6-5**] 10:40PM BLOOD Calcium-9.3
[**2133-6-7**] 02:25AM BLOOD %HbA1c-5.6
[**2133-6-7**] 01:50AM BLOOD Triglyc-127 HDL-43 CHOL/HD-5.1
LDLcalc-151*
[**2133-6-6**] 07:00AM BLOOD Triglyc-75 HDL-53 CHOL/HD-4.2
LDLcalc-157*
[**2133-6-8**] 12:22AM BLOOD TSH-0.86
[**2133-6-7**] 01:50AM BLOOD TSH-0.98
[**2133-6-6**] 07:00AM BLOOD TSH-1.3
[**2133-6-11**] 06:28AM BLOOD Vanco-19.9
[**2133-6-10**] 06:19AM BLOOD Vanco-17.0
[**2133-6-6**] 07:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2133-6-14**] 05:39AM BLOOD Type-ART pO2-114* pCO2-49* pH-7.43
calTCO2-34* Base XS-7
[**2133-6-13**] 03:10AM BLOOD Type-ART pO2-113* pCO2-43 pH-7.46*
calTCO2-32* Base XS-6
[**2133-6-12**] 02:38AM BLOOD Type-ART pO2-121* pCO2-44 pH-7.44
calTCO2-31* Base XS-5
[**2133-6-11**] 02:22AM BLOOD Type-ART pO2-98 pCO2-44 pH-7.49*
calTCO2-34* Base XS-9
[**2133-6-10**] 02:06AM BLOOD Type-ART pO2-88 pCO2-51* pH-7.43
calTCO2-35* Base XS-7
[**2133-6-9**] 03:10AM BLOOD Type-ART Temp-35.9 PEEP-5 FiO2-40 pO2-91
pCO2-51* pH-7.44 calTCO2-36* Base XS-8 Intubat-INTUBATED
Vent-SPONTANEOU
[**2133-6-8**] 07:46PM BLOOD Type-ART Temp-38.3 PEEP-5 pO2-105
pCO2-48* pH-7.41 calTCO2-31* Base XS-4 Intubat-INTUBATED
Vent-SPONTANEOU
[**2133-6-8**] 04:54PM BLOOD Type-ART Temp-38.3 PEEP-5 pO2-99 pCO2-48*
pH-7.41 calTCO2-31* Base XS-4 Intubat-INTUBATED Vent-SPONTANEOU
[**2133-6-8**] 12:45AM BLOOD Type-ART Temp-37.6 pO2-115* pCO2-46*
pH-7.39 calTCO2-29 Base XS-2
[**2133-6-9**] 03:10AM BLOOD Lactate-0.9 K-4.2
[**2133-6-8**] 04:54PM BLOOD Lactate-1.1 K-3.5
[**2133-6-8**] 12:45AM BLOOD Lactate-1.0
[**2133-6-12**] 02:38AM BLOOD O2 Sat-98
[**2133-6-11**] 02:22AM BLOOD O2 Sat-96
[**2133-6-10**] 02:06AM BLOOD O2 Sat-97
[**2133-6-13**] 03:10AM BLOOD freeCa-1.17
[**2133-6-11**] 02:22AM BLOOD freeCa-1.19
[**2133-6-10**] 02:06AM BLOOD freeCa-1.17
[**2133-6-9**] 03:10AM BLOOD freeCa-1.22
[**2133-6-8**] 07:46PM BLOOD freeCa-1.11*
[**2133-6-8**] 12:45AM BLOOD freeCa-1.22
Brief Hospital Course:
This 55 yo F was admitted with a right brainstem bleed, thought
to be secondary to extreme hypertension. No AVM or cavernoma was
appreciated on MRI/MRA. Pt was initially treated in the ICU,
where she developed a LLL PNA, treated with Augmentin and
Flagyl. She also developed jaundice to propofol and was sedated
instead with versed. She initally failed swallow eval and had an
NG tube which remained until [**2133-6-15**] when she pulled it out,
however, susbequent repeat swallow eval suggested she could
tolerate oral nutrition.
Pt's BP originally controlled with labetalol gtt, but then
placed on oral regimen of labetalol, lisinopril, and HCTZ.
Systolic BP's are running 130-180, and titration of her BP meds
is ongoing.
Symptomatically, she showed significant improvement, becoming
drowsy with improved HA and nausea. Eye movements continued to
improve, although on discharge she still has some dysconjugate
gaze, giving her what appears as a partial one-and-a-half
syndrome. Her vertigo is also significantly improved, however,
she still experiences dizziness on standing and has trouble
taking more than a few steps without feeling like she is going
to fall. She is continuing to work with PT/OT, and was
discharged to rehab facility on [**2133-6-19**]
Medications on Admission:
ASA prn HA
Discharge Medications:
1. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-26**]
Drops Ophthalmic PRN (as needed).
2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO TID (3 times a day) for 1 weeks: last dose [**2133-6-21**].
5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 1 weeks: last dose [**2133-6-21**].
6. Labetalol 100 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
7. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg
Injection Q8H (every 8 hours) as needed.
8. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Ten (10) mg
Intravenous Q6H (every 6 hours) as needed for SBP>180.
9. Hydralazine 20 mg/mL Solution Sig: Ten (10) mg Injection Q4H
(every 4 hours) as needed for SBP > 160.
10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed: prn pain or fever.
12. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Medical Center - [**Hospital1 3597**]
Discharge Diagnosis:
pontine hemorrhage
hypertension
Discharge Condition:
stable
Discharge Instructions:
You have had a stroke in your brainstem. We think that this was
most likely secondary to uncontrolled hypertension so
controlling your blood pressure is going to be very important.
You may also need to have repeat imaging of your brain in the
future to ensure that there is not a cavernous angioma
underlying the bleed. Follow up with your appointments as
below.
Followup Instructions:
Neurologist: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 2574**]
Date/Time:[**2133-7-21**] 1:30 [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] [**Location (un) **]
Please call ([**Telephone/Fax (1) 1300**] to get a PCP at [**Hospital 18**] [**Hospital **], unless you would like to get a PCP [**Name Initial (PRE) 79638**]. This
will be extremely important in managing your blood pressure.
[**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]
Completed by:[**2133-6-19**]
|
[
"782.4",
"507.0",
"276.0",
"431",
"276.3",
"780.4",
"486",
"401.0",
"276.9",
"E938.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.93",
"96.04",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
11447, 11527
|
8978, 10239
|
372, 378
|
11603, 11611
|
2925, 8955
|
12024, 12611
|
1143, 1221
|
10300, 11424
|
11548, 11582
|
10265, 10277
|
11635, 12001
|
1236, 1554
|
275, 334
|
406, 953
|
1894, 2906
|
1569, 1878
|
975, 1051
|
1067, 1127
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,279
| 137,556
|
50695
|
Discharge summary
|
report
|
Admission Date: [**2113-8-8**] Discharge Date: [**2113-8-12**]
Date of Birth: [**2047-10-10**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Hepatic sepsis
Major Surgical or Invasive Procedure:
IR drainage of hepatic abscess
History of Present Illness:
65yo M with CAD, stroke, DM presented to [**Hospital3 4107**] with 2
wk h/o fevers, chills, malaise. Temps up to 101 that would go
away for several days, then on Monday was acutely worse with
high fevers and rigors, went to ER, there found to be hypotense
and febrile 102.8, tachy 158. Given 3L IVF's and Neo, started on
Vanc, Ceftriaxone, Flagyl. CXR, UA negative. Poor UOP improved
with IVF's.
.
CT non-con at [**Hospital1 **] for increased LFTS (AlkP 278, bili 1.8) and
increased WBCs 19.2 --> showed 4x7cm hypodense lesions, ?
abscess, no GB dz, no stones --> confirmed by RUQ U/S. [**4-15**] +BCx
growing GNR's --> pan sensitive Ecoli. ID saw and rec'd
Ceftriaxone, but continued on Vanc, Zosyn, Flagyl in [**Hospital1 **] ICU.
Prior to Tx to [**Hospital1 18**], pt was on Neo 20 (down from 45) with MAPs
75, hr 60, and PICC line.
.
In [**Hospital1 18**] ICU, Neo turned off and MAPs stayed in 60's. Pt covered
with Zosyn to cover GN's, pseudomonas and anaerobes, was pan
Cx'd. Surgery and IR consulted for drainage. Trop's mild
elevated. ABG 7.36/88/34. Lactate 2.0. Repeat LFTs --> ALT/AST
41/49, AlkP 148. Pt hemodynamically stabilized and was
transferred to the floor for further management.
Past Medical History:
Diabetes
R paritotemporal CVA with left-sided arm residual weakness,
sustained [**5-/2113**]
CAD with MI and stents in [**2102**]
Chronic low-back pain s.p multple back surgeries
GERD
Social History:
Retierd plumber, Denies significant EtOH, Smokes [**1-13**] ppd x 56
years, Independent ADLs, Denies IVDU
Family History:
Two brothers with MI
Physical Exam:
Vitals: T:35.6 BP:96/56 P:70 R: 18 O2: 97%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Crackles bilaterally, loudest at base; no wheezing;
decreased breath sounds in upper lung fields
CV: distant heart sounds, but regular rate and rhythm, normal S1
+ S2, no murmurs, rubs, gallops
Abdomen: obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, + hepatomegaly, no
splenomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: 5/5 strength bilaterally, grossly normal CN 3-12
Pertinent Results:
Labs, summarized:
WBC's on admission 23.6 that trended down to 12.1 by d/c.
H/H stable, admission 10.4/32.3, d/c 11.0/32.4
Plts stable, by d/c 291
.
Chems were stable through admission, was not in acute renal
failure on admission --> BUN/Cr 24/1.0 admission, by d/c 16/0.9
.
LFTs on admit alt/ast 41/49, trended down to 36/36 by d/c.
LDH admit 218
CK's 41, 33, 30
AlkP 148 admission, by d/c 189
Tbili 1.2 --> 0.6
.
Negative cardiac enzymes x3
.
Entamoeba histolytica Ab pending
.
UA significant for RBC's 21-50. Neg nitrites, trace leuks, many
bacteria, WBC [**3-16**]. 30 protein, 15 ketones
.
BCx negative x2 by d/c, UCx <10,000,
Gstain with 3+ PMN's, 2+ GNR's, 2+ GPR's
GRAM STAIN (Final [**2113-8-9**]):
REPORTED BY PHONE TO [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 105472**] @ 6:10A [**2113-8-9**].
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final [**2113-8-13**]):
ESCHERICHIA COLI. MODERATE GROWTH.
CITROBACTER FREUNDII COMPLEX. SPARSE GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| CITROBACTER FREUNDII
COMPLEX
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 I
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CEFUROXIME------------ 4 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN---------- =>128 R <=4 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Preliminary):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum.
ANAEROBIC GRAM NEGATIVE ROD(S). MODERATE GROWTH.
OF TWO COLONIAL MORPHOLOGIES.
.
IMAGING:
[**2113-8-8**] EKG
Sinus bradycardia. Low voltage. RSR' pattern in lead V2. Q-T
interval
prolongation. No previous tracing available for comparison.
Read by: [**Last Name (LF) **],[**First Name3 (LF) 900**] A.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
57 162 86 [**Telephone/Fax (2) 105473**] 77
[**2113-8-8**] CXR
Portable AP chest is compared to same day radiograph from 12:15
p.m. A right
PICC tip projects over the mid SVC in good position. Widening of
the vascular
pedicle, pulmonary vascular cephalization, and mild bilateral
perihilar haze
is compatible with mild fluid overload. The lungs are clear
without focal
consolidation. There is no pneumothorax or appreciable pleural
effusion.
IMPRESSION:
1. Right PICC tip projects over the mid SVC.
2. Mild fluid overload.
[**2113-8-9**] US guided abscess drain
FINDINGS: Targeted ultrasound reveals an 8.5 cm hypoechoic
lesion within the
superior portion of the anterior right hepatic segment with
increased through
transmission suspicious for abscess. Incidental note is made of
a
homogeneously hyperechoic 1.1 cm lesion in the posterior right
hepatic lobe
consistent with a hemangioma. There is some gallbladder wall
thickening.
This is likely due to patient's low albumin.
Brief Hospital Course:
1. Septic shock from hepatic abscess: In the ICU, initial ABG:
7.59 / 22 / 67 and 7.43 / 26 / 104. LFTs: alk phos 278, bili
1.8. WBC 19.2. Poor UOP improved with IVF and pt weaned off
neo. LFT elevation prompted CT abdomen with oral but not IV
contrast, showed abscess. CT abdomen: 7 x 4 cm hypodense lesion
?abscess. BCx from ER grew GNRs [**4-15**]. GI thought likely abscess.
Ultrasound confirmed 7x4 cm collection concerning for abscess or
phlegnom. IR aspiration got 2cc sent fot GS and culture, placed
drain. Vanc, flagyl and zosyn started in the ICU.
.
Abscess continued to drain o/n. No persistent signs of sepsis
after drainage.
.
Pt hemodynamically stablized, transferred to floor where he was
continued on IV Vanc and Zosyn. No acute issues while on floor,
vitals were stable. By the time of discharge the pt's Cx's had
come back and pt was switched to PO Levofloxacin. Pt will follow
up with [**Hospital **] clinic, who will call him to make an appointment. The
pt will also be called by CT radiology to follow up managment of
the drain that was placed.
.
No source of infection was found, including negative CXR, no
other source in abdomen on CT from OSH, UCx negative. Will need
outpt colonscopy.
.
2. Hypotension: Resolved with IVF at OSH and ABx
.
3. CAD s/p stents: Negative cardiac enzymes x3 and ST changes on
EKG. Lisinopril was held due to normal blood pressures while on
the floor and will need to be reassessed in the outpt setting.
Lipitor was held due to increased LFT's also need outpt
assessment. The pt reported no chest pain during admission, no
acute cardiac issues.
.
4. s/p CVA: ASA was continued. No acute neurologic issues.
.
5. DM: Home metformin was held and bs's controlled with sliding
scale insulin. No acute issues.
Medications on Admission:
Metformin 1 tab daily
Aspirin 81 mg daily
Lisinopril and lipitor, but had not been taking.
Formerly on prilosec
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
Primary diagnosis:
1. Septic shock from hepatic abscess
.
Secondary diagnoses:
1. CAD s/p stents in [**2102**]
2. CVA in [**5-/2113**]
3. DM2
Discharge Condition:
By the time of discharge the pt had vital signs, was taking oral
food and liquids, was ambulating, was not in pain, and was set
up with an antibiotic regimen to treat his infection.
Discharge Instructions:
You were admitted to [**Hospital1 18**] with a bacterial infection of your
blood causing low blood pressures. You were admitted to the ICU,
where you were started on IV antibiotics and your blood pressure
was monitored. You had a CT that showed abscesses in your liver.
When you were stable enough, you were brought out of the ICU
onto the regular wards were we continued to give you IV
antibiotics. The abscess in your liver was drained.
.
While you were in the hospital, the Metformin you were taking at
home was stopped, but the Aspirin was continued. We did not
continue the Lipitor or Lisinopril that you said you had not
been taking. On discharge, you should continue to take Aspirin.
You will also need to continue a ........... week course of
.............
You should follow up with your primary care physician to assess
whether you need to restart Lipitor, Lisinopril, and Metformin.
.
Please return to the hospital if you experience: fevers, chills,
or night sweats, yellowing of your skin or eyes, problems with
bleeding or excessive bruising on your skin, white stools, or
very dark urine, or any other concerns.
Followup Instructions:
You will need to have follow-up arranged with the infectious
disease clinic. You will be contact[**Name (NI) **] with an appointment date
and time. If you do not hear from someone by Tuesday, [**8-15**],
please call the infectious disease clinic at [**Telephone/Fax (1) 3395**] to
have an appointment scheduled.
.
You will also need an appointment with CT radioliogy for
management of your drain. Someone will call you with information
about a scheduled appointment. Please call ([**Telephone/Fax (1) 6713**] if you
do not hear from them by [**2113-8-15**] and let them know that Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] performed your procedure on [**2113-8-9**].
.
Please also follow up with your primary care physician
[**Name9 (PRE) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 2-3 weeks of discharge by calling:
[**Telephone/Fax (1) **]
.
You will need an outpt colonoscopy as you are due for your
screening. Your primary care doctor can discuss setting this up
for you. You should also discuss the medication changes
described above with your primary care doctor.
Completed by:[**2113-8-13**]
|
[
"530.81",
"250.00",
"338.29",
"438.89",
"995.92",
"412",
"414.01",
"038.42",
"724.2",
"785.52",
"729.89",
"584.9",
"572.0",
"305.1",
"V45.82"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.91"
] |
icd9pcs
|
[
[
[]
]
] |
8661, 8710
|
6576, 8340
|
329, 361
|
8896, 9080
|
2634, 5068
|
10253, 11415
|
1940, 1962
|
8502, 8638
|
8731, 8731
|
8366, 8479
|
9104, 10230
|
1977, 2615
|
8810, 8875
|
275, 291
|
389, 1592
|
8750, 8789
|
5107, 6553
|
1614, 1800
|
1816, 1924
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
75,668
| 157,090
|
21768
|
Discharge summary
|
report
|
Admission Date: [**2123-1-4**] Discharge Date: [**2123-1-7**]
Date of Birth: [**2075-1-31**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. [**Known lastname **] is a 47-year-old man with type 1 diabetes,
hyperlipidemia, ESRD on HD ([**1-11**] DM), p/w 3 days of N/V/D, but
denied melena, BRBPR, or hematemesis. Did have pink tinge to
emesis 1 day prior to admission. He also c/o fever x 2 days, dry
cough x 1 week. No sick contacts. [**Name (NI) **] a left AV fisula and a
left HD tunnelled catheter. Admits to poor po intake, malaise,
but denies CP, SOB, palpitations. Mild abd pain.
.
In the ED, initial VS: T 101, 112, 182/92, 24, 96%ra. Blood and
urine sent for culture, and pt given tylenol. He had mild abd
tenderness, so CT abd performed which was negative for acute
process. ECG was unchanged from prior. Was mildly tachypneic
which resolved after IVFs (appears to have received 1L). He had
a negative U/A and b/l pleural effusions on CXR, ? b/l
infiltrate vs atelectasis. Given Vanco/zosyn to cover broadly
and for pulm source. While in ED, he had 300cc of coffee ground
emesis, which cleared with NG lavage. GI was called and
recommended IV protonix which was given. He had serial Hct which
dropped from 31-->26. Two PIVs established. Admitted to MICU for
concern for sepsis and UGIB. VS prior to transfer: HR 90s,
180/87, 21, 99% ra.
.
In the MICU, hct dropped from 30 to 26 in the setting of IVF.
Received vanc/zosyn to cover broadly for fever of unknown
source. No further bleeding. He was called out to floor, and EGD
was complicated by vagal episode (bradycardia and hypotension)
and procedure was discontinued. He then had a second presyncopal
episode with elevated troponin with TWI noted on EKG and was
sent back to the ICU. TTE showed newly dpressed EF 30% with no
focal wall motion abnormality. Cards consulted and recommended
work-up for cardiomyopathy. Last HD yesterday in the setting of
hyperkalemia (K 6). Abx discontinued with no further fevers.
Viral screen pending.
Past Medical History:
# Insulin-dependent diabetes for 20 years: HgA1c 9.4% on [**2122-6-3**]
# Hypertension
# Hyperlipidemia with markedly elevated TGs
# CKD (mid 2s [**1-16**] to [**3-14**] most recently)
# Pancreatitis; pancreas divisum
# Obesity
# Hyperuricemia
# GERD
Social History:
Patient is married with five children. Patient with disability
due to poor vision from diabetic retinopathy. Wife works at
[**Hospital1 4601**]. Denies tobacco. Rare ETOH.
Family History:
Mother and father with diabetes, no coronary disease, no colon
cancer, no prostate cancer.
Physical Exam:
vs: T 97, BP 149/74, HR 92, RR 30, 90%ra
gen: appears ill but not toxic
heent: moist mucous membranes, perrl
lungs: bibasilar crackles, expiratory wheezes
heart: RRR, nl S1S2, no m/r/g
abd: +BS, soft, nd/nt
ext: trace edema, 2+ DP pulses
neuro: AAO, no focal defecit
Pertinent Results:
[**2123-1-4**] 12:40AM WBC-6.0 RBC-3.40* HGB-10.6* HCT-31.8* MCV-93
MCH-31.3 MCHC-33.5 RDW-14.5
[**2123-1-4**] 12:40AM PLT COUNT-234
[**2123-1-4**] 12:26AM LACTATE-2.2*
[**2123-1-4**] 12:40AM GLUCOSE-238* UREA N-52* CREAT-8.7*#
SODIUM-139 POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-24 ANION GAP-19
[**2123-1-4**] 12:40AM ALT(SGPT)-39 AST(SGOT)-64* CK(CPK)-285* ALK
PHOS-63 TOT BILI-0.4
[**2123-1-4**] 12:40AM LIPASE-20
[**2123-1-4**] 12:40AM cTropnT-0.13*
[**2123-1-4**] 07:45PM HCT-30.4*
.
[**2123-1-4**] - TTE: Conclusions
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. There is mild global left ventricular
hypokinesis (LVEF = 40 %). The right ventricular cavity is
mildly dilated with moderate global free wall hypokinesis. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
.
[**2123-1-4**] - CXR - FINDINGS: Left subclavian double lumen central
venous dialysis catheter with tip overlying the proximal right
atrium. Moderate bilateral effusions noted. Increased
interstitial markings in the lower lungs bilaterally consistent
with mild interstitial edema. Heart is at the upper limits of
normal in size. No focal consolidation or pneumothorax within
the visualized portion of the lungs.
.
[**2123-1-4**] - CT abdomen/pelvis - IMPRESSION:
1. Moderate-to-large bilateral pleural effusions, right greater
than left.
2. No other CT findings to explain patient's abdominal pain.
.
Test Result Reference
Range/Units
Hereditary Hemochromatosis, PCR, DNA Mutation
[**Numeric Identifier 57191**] NEGATIVE
INTERPRETATION: DNA TESTING INDICATES THAT THIS
INDIVIDUAL IS NEGATIVE FOR THE C282Y AND H63D MUTATIONS
IN THE HFE GENE. THIS NEGATIVE RESULT SIGNIFICANTLY
REDUCES THE LIKELIHOOD OF HEREDITARY HEMOCHROMATOSIS
(HH) IN THIS INDIVIDUAL. HOWEVER, IT DOES NOT RULE OUT
THE PRESENCE OF OTHER MUTATIONS WITHIN THE HFE GENE OR
A DIAGNOSIS OF HH. THE RISK OF THIS INDIVIDUAL
CARRYING A HFE MUTATION OTHER THAN THOSE TESTED IN THIS
ASSAY DEPENDS GREATLY ON FAMILY AND CLINICAL HISTORY AS
WELL AS ETHNICITY. THIS ASSAY DOES NOT TEST FOR OTHER
PRIMARY OR SECONDARY IRON OVERLOAD DISORDERS.
.
CHAGAS'DISEASE PANEL
Test Result Reference
Range/Units
TRYPANOSOMA CRUZI IGG >=1:256 (H) <1:16
TRYPANOSOMA CRUZI IGM <1:20 <1:20
INTERPRETATION PAST INFECTION
THE SERODIAGNOSIS OF CHAGAS' DISEASE OR AMERICAN
TRYPANOSOMIASIS BY IFA IS HIGHLY SENSITIVE AND SPECIFIC,
ALTHOUGH CROSS-REACTIONS [**Month (only) **] OCCUR WITH LEISHMANIASIS. AN
ANTI-T. CRUZI IGM (> OR = 1:20) RESPONSE IS OBSERVED IN
ACUTE DISEASE PRIOR TO AN IGG SEROCONVERSION. IN CHRONIC
CHAGAS' DISEASE IGG LEVELS ARE USUALLY DETECTED AT LEVELS
GREATER THAN OR EQUAL TO 1:64.
Brief Hospital Course:
47 y.o. man with DM2, ESRD on HD, dCHF, presents with N/V/D,
fever, and coffe ground emesis, new cardiomyopathy.
.
CARDIOMYOPATHY: Patient with progressive dyspnea over the past
year and interval decline in EF. He had a history of exposure
to a Chagas endemic country and was found to be Chagas IgG
positive, IgM negative, concerning for Chagas cardiomyopathy.
However, the pattern of heart disease was somewhat inconsistant,
and he may have other causes for cardiomyopathy. Of note, his
Ferritin was > [**2113**] and his Fe/TIBC ratio was 65%, suggestive of
hemachromatosis. However, genotyping showed him to be negative
for the common mutations in this disorder. Further differential
includes ischemic, ideopathic, infectious, or ESRD-associated.
No family history or history of toxin exposure. ESR 46, [**Doctor First Name **]
1:40, TSH 3, HIV negative. Patient was continued on maximum
dose [**Last Name (un) **] and his beta blocker was uptitrated slightly.
Torsemide was restarted.
- Would recommend initiation of antitrypanosomal treatment.
These results came back after discharge and were communicated to
patient's primary care physician.
[**Name Initial (NameIs) **] Outpatient cardiology follow up scheduled
- Continue carful volume control at HD
- Would consider cardiac MRI and stress MIBI to differentiate
etiologies of cardiomyopathy.
.
UPPER GI BLEED: Coffee ground emesis most likely from upper GI
source. Most likely [**Doctor First Name 329**] [**Doctor Last Name **] tear vs. PUD. EGD was deferred
in the setting of hypotension. Patient refused transfusion in
ICU, and Hct improved without intervention. Hematemesis
resolved.
- Continue on [**Hospital1 **] PPI for one month.
.
FEVERS, NAUSEA, VOMITING, DIARRHEA: Patient presented with
somewhat atypical flu symptoms of unclear duration. He was
found to be Influenza positive. He was initially treated with
antibiotics (Vanc/levo), but these were stopped. He was
discharged on droplet precautions to end 8 days after symptom
onset.
.
WHEEZING: [**Month (only) 116**] be cardiac asthma vs. undiagnosed mild
intermittant asthma. He was started on albuterol.
- Reccomend outpatient PFTs
.
END-STAGE RENAL DISEASE: Pt receives HD on MWF, and was
contunued on a regular schedule.
.
ANEMIA : B/L Hct in low to mid 30s. Serial Hct stabilized.
Patient refused blood transfusion
.
DIABETES: Insulin dependent. BG > 300 upon admission. Per OMR
takes 45 units of 70/30 in AM and 40 in PM, but per patient he
only takes 15-20 units. He was started on 20 units NPH [**Hospital1 **] with
plan to give 1/2 dose while NPO. He was discharged on 20 units
of 70/30 twice daily.
- continue to monitor and titrate blood sugars PRN
.
HYPERTENSION: On BB, [**Last Name (un) **].
.
HYPERLIPIDEMIA: pravastatin/tricor.
Medications on Admission:
Acetaminophen 325-650 mg PO Q6H:PRN
Avapro *NF* 300 mg Oral qd
Calcium Acetate 667 mg PO TID W/MEALS
Docusate Sodium 100 mg PO BID:PRN
Doxazosin 4 mg PO BID
Insulin 70/30: 20 units QAM, 20 units QPM
Metoprolol Succinate XL 100 mg PO DAILY
Nephrocaps 1 CAP PO DAILY
Pravastatin 40 mg PO DAILY
Senna 1 TAB PO BID:PRN
Torsemide 20 mg PO DAILY
Tricor *NF* 145 mg Oral Daily
Fluoxetine 10mg po daily
Sensipar 30mg po daily
Omeprazole 20mg po daily
Fluticasone nasal spray, 1 spray in nostrils daily
Discharge Medications:
1. Proventil HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-11**]
Inhalation every four (4) hours as needed for shortness of
breath or wheezing.
Disp:*2 inhaler* Refills:*0*
2. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: Twenty (20) Subcutaneous twice a day.
3. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5
Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*2*
4. Irbesartan 300 mg Tablet Sig: One (1) Tablet PO daily ().
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain, fever.
8. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO twice a day.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day) for 30
days: Take this medication twice daily for 30 days, then resume
taking once daily.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
11. Torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Nephrocaps 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily).
15. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO once a day.
16. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Nasal once a day.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
Primary:
INFLUENZA
CARDIOMYOPATHY
new diagnosis of SYSTOLIC CONGESTIVE HEART FAILURE
UPPER GI BLEED
END-STAGE RENAL DISEASE
Secondary:
ANEMIA
DIABETES
HYPERTENSION
HYPERLIPIDEMIA
GERD
Discharge Condition:
Stable, ambulating, Hct stable
Discharge Instructions:
You were admitted for fevers, muscle aches, and chills after
hemodialysis. These symptoms were caused by the influenza
virus. It will take seven days for this virus to run its
course. In the meantime, you should take tylenol as needed for
aches and pains. You should wear a mask for seven days from
symptom onset to prevent transmission to others.
We also did studies that showed your heart to be functioning
poorly. This condition is called cardiomyopathy or heart
failure. Given this condition, you should be careful to avoid
excess salt in your diet and continue to weigh yourself daily.
You should continue your Avapro and metoprolol to treat this
condition. We initiated some tests to look for treatable causes
of your cardiomyopathy. You should follow up with your PCP for
further testing for this.
Please resume your regular dialysis tomorrow.
Followup Instructions:
Please follow up with your PCP. [**Name10 (NameIs) **] have an appointment
scheduled with [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD, phone:[**Telephone/Fax (1) 250**]
date/time:[**2123-2-2**] 12:00.
You should also follow up with cadidiology. You have an
appointment scheduled with [**Name6 (MD) **] [**Last Name (NamePattern4) **], MD
Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2123-2-24**] 1:00
Completed by:[**2123-1-16**]
|
[
"428.0",
"276.7",
"250.40",
"425.4",
"530.81",
"578.9",
"403.91",
"285.1",
"428.21",
"487.1",
"585.6",
"V64.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11426, 11483
|
6423, 9200
|
328, 335
|
11711, 11744
|
3101, 6400
|
12653, 13121
|
2705, 2798
|
9745, 11403
|
11504, 11690
|
9226, 9722
|
11768, 12630
|
2813, 3082
|
273, 290
|
363, 2224
|
2246, 2499
|
2515, 2689
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,340
| 102,567
|
33271
|
Discharge summary
|
report
|
Admission Date: [**2188-9-25**] Discharge Date: [**2188-10-2**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2145**]
Chief Complaint:
sent from living facility for delusions
Major Surgical or Invasive Procedure:
none
History of Present Illness:
89 yo man with CAD, prostate ca s/p suprapubic catheter placed
[**11/2187**], and anemia, presents from nursing home with 2 days of
delusional thinking. Per the patient, one of the nurses accused
him of calling her a bad name, and out of anger she was trying
to give him harmful medicaitons. He reports that he was "lucky
to have survived." Rest home records indicate that the patient
was referring to a man named "shadow" who was trying to poison
him. Records also indicate that the patient was caught with an
empty bottle of Kahlua recently.
.
Of note he was sent to [**Hospital 882**] Hospital on [**2188-9-19**] for
hypotension (BP 86/50s), vomiting, and diaphoreseis, but had
negative workup and sent home.
.
In the ED, vs= T 98, BP 115/59, HR 72, RR 15, 97%ra. He was
noted to have moderate leuks on UA, so infectious cause of
delirium/psychosis was thought to be likely. He was given Cipro.
Also, he had troponin of 0.05 with new TWI in V2-V6, but no
chest pain. He was given Aspirin 325 and Metoprolol 50mg (home
dose). CXR negative for acute process. Admitted for UTI and
ROMI.
.
ROS: Denies recent fevers or chills, nausea or vomiting, chest
pain or shortness of breath. Does report pelvic pain, is unsure
how long it has been going on.
Past Medical History:
CAD
Hyperlipidemia
Osteoporosis
Restless Leg Syndrome
Glaucoma
Prostate cancer s/p prostatectomy
COPD
Anemia
Urinary Incontinence s/p suprapubic tube placement in [**11-18**]
Fall with resultant rib fractures (x4) [**7-/2188**]
Focal outpouching of the infrarenal aorta (radiographic
diagnosis)
Delirium on previous hospital admissions, most recently [**7-/2188**],
resolved
Calcification in the wall of the gallbladder
Intra and extrahepatic biliary ductal dilation
Multiple 3-4 mm right upper [**Year (4 digits) 3630**] pulmonary nodules
Sigmoid diverticulosis
Social History:
Lives at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] House Rest Home [**Street Address(1) 77252**]. Formerly
was a salesman for motels and gift shops. Divorced, with one son
and two grandchildren in [**Name (NI) 620**]. Denies any smoking history.
Denies alcohol although was found with small bottle of Kaluha at
his NH.
Family History:
Noncontributory.
Physical Exam:
VS: T 98, BP 187/77, P 65, Resp 16, O2Sat 100% RA
GEN: NAD, conversant
HEENT: PERRL, mucus membranes moist, no elevated JVP
LUNGS: No increased WOB, lungs CTAB
HEART: RRR, early systolic murmur
ABDOMEN: soft, nontender, nondistended. suprapubic catheter in
place, erythema ~1 cm surrounding, also opaque white discharge
from site, tender when probed
BACK: No CVA tenderness.
EXTREMITIES: No edema, strong distal pulses
NEURO: alert and oriented x 3 but with persistent paranoid
delusions, [**6-16**] upper and lower extremity strength
Pertinent Results:
Admission Labs:
.
[**2188-9-25**] 06:30PM GLUCOSE-105 UREA N-40* CREAT-1.1 SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-25 ANION GAP-14
[**2188-9-25**] 07:20PM WBC-6.5 RBC-3.53* HGB-10.1* HCT-30.4* MCV-86
MCH-28.6 MCHC-33.2 RDW-14.3
[**2188-9-25**] 07:20PM NEUTS-67.8 LYMPHS-22.0 MONOS-4.6 EOS-4.8*
BASOS-0.7
.
Cardiac Enzymes:
.
[**2188-9-25**] 06:30PM CK-MB-9
[**2188-9-25**] 06:30PM cTropnT-0.05*
[**2188-9-26**] 02:30AM BLOOD CK-MB-8 cTropnT-0.05*
[**2188-9-26**] 10:50AM BLOOD CK-MB-8 cTropnT-0.04*
.
Urine
[**2188-9-25**] 07:05PM URINE RBC-[**7-22**]* WBC-[**4-16**] Bacteri-MOD Yeast-NONE
Epi-0-2
.
Other
[**2188-9-27**] 06:22PM BLOOD TSH-4.6*
.
[**2188-9-25**] EKG:
Sinus rhythm. Left anterior fascicular block. Consider left
ventricular
hypertrophy by voltage in leads I and III. Early R wave
progression.
ST segment elevation in leads V1-V2 with T wave inversion in
leads V2-V6.
Other ST-T wave abnormalities. Since the previous tracing of
[**2188-7-19**]
ST-T wave abnormalities are new. However, ST segment elevations
were seen in leads V1-V2 on prior tracings. Clinical correlation
is suggested.
QTc 445.
[**2188-9-28**] EKG: QTc 487
[**2188-9-29**] EKG: QTc 466
.
[**2188-9-29**] TTE:
The left atrium is normal in size. There is mild
(non-obstructive) focal hypertrophy of the basal septum. The
left ventricular cavity size is normal. Overall left ventricular
systolic function is normal (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) are mildly thickened. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The left ventricular inflow pattern suggests impaired
relaxation. There is no pericardial effusion.
Brief Hospital Course:
89 y.o. man with h/o CAD, suprapubic catheter, here with likely
catheter infection and new ischemic EKG changes.
.
Pelvic pain: On presentation, the patient complained of new pain
at the site of his suprapubic catheter. He later complained of
penile and perineal pain. UA showed bacteria and WBC. He was
persistenly afebrile, with no elevated WBC count, and no CVA
tenderness. He was treated with ciprofloxacin. Urology was
consulted. They changed the suprapubic catheter and commented
that the bacteria represented normal colonizers of a bladder
with an indwelling catheter and were unlikely to be pathologic
and did not require treatment beyond 24 hours past the time of
catheter change. Ciprofloxacin was discontinued accordingly. A
PSA was sent for routine post-prostatectomy screening and was
found to be undetectable.
.
CAD: EKG showed ischemic changes new from previous tracing
06/[**2188**]. Troponins were mildly positive at .05. Records from
[**Hospital 882**] hospital were obtained, showing that EKG at the current
admission was unchanged from an ED visit there [**2188-9-19**] when the
patient was noted to be hypotensive. The most likely cause of
the EKG changes was deduced to be an ischemic event around the
time of that ED visit. Given the patient's multiple medical
comorbidities and the fact that he was asymptomatic, no stress
test was performed. Troponins were flat. Medical management of
CAD was optimized, including continuation of ACEI, BB, increase
of statin (LDL 136) and addition of ASA.
.
Pulseless arrest and ICU course: Pt was transfered to the MICU
after being found unresponsive and pulseless on the floor. On
the day of transfer, the pt was expressing increasing
frustration with his care and wanted to go home. He packed up
his belongings as if to go home, but his primary team was able
to convince him to stay. Due to his agitation, he received an
extra dose of 2.5mg Zydis Zyprexa (he takes 2.5mg at bedtime
nightly). About 1.5 hours later, a CODE BLUE was called when the
pt was found unresponsive by his RN. The primary team was first
to respond, and noted that he was pulseless, diaphoretic, and
hypoxic on arrival. Compressions were initiated, and the pt
immediately responded. CPR was stopped, and evaluation revealed
normal laboratories from the morning, FSBS 171, and ECG with new
QTc prolongation compared to admission. The patient was treated
with Magnesium 2g, and was transferred to the ICU for closer
monitoring of his QTc. The most likely cause of the arrest was
thought to be long-QT-induced arrhythmia secondary to the
combination of ciprofloxacin and olanzapine, although there was
no telemetry documentation of any abnormal rhythm.
.
On arrival to the ICU, the pt was significantly agitated. He was
responding to voice, but unable to speak coherently. Labs were
drawn and he was settled in, after which he complained of vague
mild abdominal "soreness" that had resolved. ROS was otherwise
negative at the time. KUB was unremarkable.
.
He recovered quickly and was returned to the floor in stable
condition. He was monitored on telemetry for the remainder of
his stay without further events.
.
Hypertension: The patient was initially hypertensive to the
180's with HR 50-70. His home blood pressure medications were
restarted, but he continued to be hypertensive. Amlodipine was
added to his outpatient regimen, with good control.
.
Dementia: The patient was initially alert, oriented, coherent,
and calm with a fixed delusion regarding a nursing staff member
at his living facility. He later became agitated and confused
and required redirection and zyprexa. After the pulseless
arrest in the ICU, he was initially incoherent and
uncooperative. No further antipsychotic medications were
administered. On transition back to the general medical [**Hospital1 **],
he continued to be intermittently agitated, often threatening to
leave the hospital, often confused about the place and time, and
requiring frequent redirection. Antipsychotic medications were
avoided. Head CT from prior admission was notable for evidence
of microvascular ischemia, prominent ventricles, and a single
focus of likely chronic blood product in the L frontal [**Hospital1 3630**].
TSH was slightly elevated. Electrolytes and B12 were WNL. The
psychiatry consult service saw the patient and advised that a
further dementia workup including formal neuropsychiatric
testing, laboratory testing, and consideration of head MRI be
pursued after his mental status had returned to baseline several
months after his hospital stay.
.
Glaucoma: Outpatient eye drops were continued.
.
Anemia: Hct remained at baseline 27-30. Iron studies were
consistent with iron deficiency (iron 40 mg, TIBC 348). Iron
supplementation was begun.
Medications on Admission:
Metoprolol 50 po BID
HCTZ 25mg po Daily
Prilosec 20mg po Daily
Vit B12 1000mcg tablet daily
Lisinopril 20 mg daily
Ocuvite 1 tablet daily
Nabumentone 500mg po BID
Simvastatin 20 mg daily
Brimonidine 0.2% eye drops, 1 drop both eyes TID
Travoprost 0.004%, 1 drop both eyes [**Hospital1 **]
Vitamin C 500mg po Daily
Actonel 35mg po QWeek (Wednesday)
Colace 100 mg [**Hospital1 **]
Senna 2 tablet [**Name (NI) **]
MOM 30cc po [**Name (NI) **]
Hemorrhoidal supp, 1 pr prn
Lidocaine ointment, apply to penis prn
Capcacin cream to both knees prn
Zyprexa 2.5mg po [**Name (NI) **]
Lidocaine patch to R flank, 12 hours on, 12 hours off PRN
Acetaminophen 1000mg q8h
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
primary: urinary tract infection, delirium
secondary: coronary artery disease, osteoporosis, glaucoma,
prostate cancer
Discharge Condition:
stable, with dementia and fixed delusions
Discharge Instructions:
You were admitted to the hospital because you were confused and
had pain in your urinary tract. Your catheter was changed and
you were treated with antibiotics.
The following medications were added:
Amlodipine 5 mg daily
Aspirin 81 mg daily
The following medications were changed:
Simvastatin was increased to 40 mg daily
The following medications were stopped:
Zyprexa was stopped.
Please do not take Zyprexa.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) 161**] [**Name11 (NameIs) 162**] [**Name8 (MD) 163**], MD Phone:[**Telephone/Fax (1) 921**]
Date/Time:[**2188-10-6**] 4:00
Primary care as per [**Hospital 671**] [**Hospital 4094**] Hospital.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]
Completed by:[**2188-10-2**]
|
[
"496",
"414.01",
"297.1",
"293.0",
"294.8",
"280.9",
"427.5",
"333.94",
"584.9",
"733.00",
"401.9",
"272.4",
"599.0",
"426.82",
"V10.46",
"788.30",
"365.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.60",
"57.95"
] |
icd9pcs
|
[
[
[]
]
] |
10451, 10506
|
4962, 9743
|
302, 308
|
10670, 10714
|
3137, 3137
|
11179, 11535
|
2548, 2566
|
10527, 10649
|
9769, 10428
|
10739, 11156
|
2581, 3118
|
3474, 4939
|
223, 264
|
336, 1585
|
3153, 3457
|
1607, 2172
|
2188, 2532
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,123
| 135,204
|
7938
|
Discharge summary
|
report
|
Admission Date: [**2188-8-24**] Discharge Date: [**2188-8-27**]
Date of Birth: [**2118-11-28**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Iodine / Fluorescein
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Chief Complaint: Vomiting and generalized weakness
Major Surgical or Invasive Procedure:
Endotracheal intubation ([**2188-8-24**])
History of Present Illness:
69yoM with complicated medical history including ESRD s/p renal
transplant [**2180**] on Tacro and Prednisone, h/o MI s/p multiple
stents and CABG, DM, chronic afib on Coumadin, presenting on
[**2188-8-24**] with profuse vomiting x 1 night and generalized weakness
x few days, found to be hypoxic in the ED, initially transferred
to the MICU for mechanical ventilatory support/intubation and
suspicion of aspiration pneumonitis. Pt extubated on [**2188-8-25**]
and now transferred to the floor.
.
Per pt and his wife, he was in his usual state of health until
last Tuesday (one wks ago), when he tripped on a tree root while
clearing brush in the garden, and had an unwitnessed fall
without apparent loss of consciousness. Pt and his wife doubt
he hit his head, and pt denies any period of confusion,
tongue-biting, or lightheadedness before or after his fall. He
was able to drive afterward without difficulty. Around this
time he restarted gabapentin, and on Thursday pt told his wife
he felt like he had the flu, with general malaise and fatigue.
The next day he felt "shaky," weak, and unstable on his feet.
Per pt, he had similar symptoms when he was last on gabapentin.
Pt denied fevers or chills. He denied seizure-like activity,
changes in vision, headache, language difficulties, or
asymmetric weakness. On Saturday pt went to his daughter's
engagement party, where he ate mostly chicken and potatoes. That
night, pt began vomiting profuse amounts of food-like material,
non-bloody, that started while he was sleeping on his back. Per
wife, pt appeared very weak after this episode and had trouble
standing up, so she called 911. Of note, pt has been
noncompliant with his tacrolimus for the past 3 doses as he ran
out of his medications, and he may have taken double his usual
dose of Tacrolimus the evening before presentation. Pt denies
any associated symptoms of cough, chest pain, diarrhea,
abdominal pain, or dysuria.
.
In the ED, he was found to be hypoxic in the 60s on room air,
and was placed on a NRB with PO2 in the mid 80s. He was
subsequently intubated without difficulty. Initial CXR showed
b/l opacities, and CT torso confirmed these findings without
additional processes. CT head was ordered for the history of
unwitnessed fall and was negative. The patient was initially
started on Vancomycin 1gm, Cefepime 2gm, and Levofloxacin 750mg
IV. Labs were significant for K+ 5.3 without EKG abnormalities,
lactate 3.7, and Cr 2.7.
.
In the MICU, pt appeared volume overloaded on exam and CXR, with
BNP [**Numeric Identifier 28490**], so he was kept on lasix. His gabapentin was
discontinued. Valsartan was held pending Cre normalization. Pt
was noted to have myoclonic jerks in his upper extremities while
sleeping and awake the first night in MICU. Pt was extubated on
[**2188-8-25**], and he started taking PO. Tacrolimus was increased to
1mg PO Q12h per transplant rec's. His Hct dropped from 34.3 on
admission to 26.7, but appeared stable. Cardiac enzymes were
negative x3. CXR showed interval improvement, so Cefepime was
stopped on [**2188-8-26**]. Warfarin was restarted that day at 1/2
dose.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, abdominal pain, diarrhea, constipation,
BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- End-stage renal disease [**1-16**] diabetic nephropathy s/p cadaveric
renal transplant [**2180**], complicated by CMV and delayed graft
function on Tacrolimus and Prednisone followed by Dr. [**Last Name (STitle) **]
- Coronary Artery Disease, s/p Non-ST Elevation Myocardial
Infarction
-- s/p atherectomy LAD in [**2176**], s/p Cypher DES to mid LAD
[**6-/2180**], s/p Taxus DES for ISR in [**5-/2181**], s/p POBA for ISR
[**1-/2186**], s/p CABG
- Congestive heart failure -EF 40-45% on TTE [**2186**]
- 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 in the past
- Scalp seborrhea
Social History:
No smoking. No significant alcohol use. Owns a travel company,
semi-retired yacht charter organizer, lives in [**Location 2312**] with
wife, married, 4 children.
Family History:
Father died of MI in early 60s, brother died of MI age 53.
Mother with diabetes.
Physical Exam:
EXAM ON ADMISSION:
VS: T 97.0, BP 118/51, P 58, R 18, O2 sat 98% RA, FSG 272
GENERAL: Well-appearing man in NAD, comfortable, appropriate.
HEENT: NC/AT, pinpoint pupils, EOMI, sclerae anicteric, MMM, OP
clear.
NECK: Supple, no thyromegaly, no LAD.
LUNGS: Expiratory crackles most prominent at bilateral lung
bases, no wheezes or stridor.
HEART: RRR, no MRG, nl S1-S2. Fistula thrill heard prominently
throughout precordium.
ABDOMEN: Soft/NT/ND, no masses, no rebound/guarding, no tympany.
EXTREMITIES: WWP, 1+ peripheral pulses, 3+ pitting edema to
mid-lower legs bilaterally.
SKIN: R hand and lower leg bruises.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-17**] throughout, sensation grossly intact throughout, DTRs 1+ and
symmetric, toes equivocal. No myoclonus
EXAM ON DISCHARGE:
Same as above, except edema improved to 2+ to ankles bilaterally
Pertinent Results:
LABS ON ADMISSION:
[**2188-8-24**] 06:00AM BLOOD WBC-15.7*# RBC-3.82* Hgb-11.3* Hct-34.3*
MCV-90 MCH-29.5 MCHC-33.0 RDW-17.1* Plt Ct-163
[**2188-8-24**] 06:00AM BLOOD Neuts-79.8* Lymphs-15.9* Monos-2.8
Eos-1.3 Baso-0.3
[**2188-8-24**] 06:00AM BLOOD PT-16.4* PTT-25.3 INR(PT)-1.4*
[**2188-8-24**] 06:00AM BLOOD Glucose-264* UreaN-111* Creat-2.7* Na-136
K-5.4* Cl-99 HCO3-24 AnGap-18
[**2188-8-24**] 06:00AM BLOOD ALT-51* AST-51* CK(CPK)-81 AlkPhos-112
[**2188-8-24**] 06:00AM BLOOD Lipase-58
[**2188-8-24**] 06:00AM BLOOD CK-MB-5 cTropnT-0.12*
[**2188-8-24**] 06:00AM BLOOD Albumin-3.9 Calcium-10.1 Phos-4.5 Mg-2.0
[**2188-8-24**] 07:24AM BLOOD tacroFK-3.1*
[**2188-8-24**] 06:05AM BLOOD Glucose-256* Lactate-3.7* K-5.3*
[**2188-8-24**] 06:05AM BLOOD Hgb-11.3* calcHCT-34 O2 Sat-61 COHgb-3
MetHgb-0
[**2188-8-24**] 08:41PM BLOOD freeCa-1.21
[**2188-8-24**] 08:41PM BLOOD Type-ART pO2-175* pCO2-35 pH-7.44
calTCO2-25 Base XS-0
[**2188-8-24**] 08:41PM BLOOD Lactate-0.8
.
[**2188-8-24**] 06:25AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010
[**2188-8-24**] 06:25AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
[**2188-8-24**] 06:25AM URINE RBC-7* WBC-15* Bacteri-NONE Yeast-NONE
Epi-0
[**2188-8-24**] 06:25AM URINE CastHy-6*
[**2188-8-24**] 06:25AM URINE Mucous-RARE
.
MICROBIOLOGY
[**2188-8-25**] 10:42 am URINE Legionella Urinary Antigen (Final
[**2188-8-26**]):
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
[**2188-8-24**] 1:50 pm MRSA SCREEN Source: Nasal swab. No MRSA
isolated.
[**2188-8-24**] 1:46 pm SPUTUM Site: ENDOTRACHEAL
GRAM STAIN (Final [**2188-8-24**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Final [**2188-8-27**]):
RARE GROWTH Commensal Respiratory Flora.
[**2188-8-24**] 6:25 am Blood Culture, Routine (Pending):
[**2188-8-24**] 6:25 am URINE CULTURE (Final [**2188-8-26**]):
GRAM POSITIVE BACTERIA. ~9000/ML. SUGGESTING
STAPHYLOCOCCI.
.
EKG
[**2188-8-24**]:
Normal sinus rhythm. Left axis deviation. Intra-atrial
conduction defect.
Anterolateral ST-T wave changes of uncertain significance.
Compared to the
previous tracing of of [**2187-9-11**] the anterolateral ST-T wave
changes are much
less marked.
Rate PR QRS QT/QTc P QRS T
78 142 106 364/395 85 -35 125
.
[**2188-8-25**]:
Baseline artifact. Sinus bradycardia. Intra-atrial conduction
delay. Mild
ST-T wave abnormalities previously described are unchanged from
prior tracing.
Rate PR QRS QT/QTc P QRS T
57 164 114 510/[**Medical Record Number 28491**] 180
IMAGING:
.
CT Chest/Abdomen/Pelvis ([**8-24**]):
CHEST: There is extensive consolidation of the bilateral lower
lobes,
markedly progressed when compared with [**2188-4-17**] consistent with
pneumonia or
aspiration. Calcified nodule within the right middle lobe (2;
33) is noted. The patient is intubated, the endotracheal tube
tip is approximately 3.7 cm from the carina. There is marked
calcification of the aortic arch and of the coronary arteries.
Cardiomegaly is present. There is no pericardial effusion. No
pleural effusion is seen. Note is made of gynecomastia.
ABDOMEN: Evaluation of abdominal viscera is limited by lack of
intravenous
contrast. There is no intrahepatic biliary ductal dilatation.
The spleen
contains vascular calcifications, unchanged. The adrenals are
normal
bilaterally. The pancreas is unremarkable. Calcified gallstones
are seen
within the gallbladder, also unchanged compared with prior.
There is no
evidence of acute cholecystitis. The kidneys are atrophic
bilaterally and
calcified. There is a transplanted kidney in the right lower
quadrant which is grossly unremarkable. There is no surrounding
stranding or fluid
collection. An NG tube is present within the stomach. Loops of
small bowel are normal in caliber. The aorta is calcified along
its entire course, but is normal in caliber. There is no
retroperitoneal lymphadenopathy. There is no intraperitoneal
free fluid or free air.
PELVIS: The bladder contains a Foley catheter and is otherwise
normal
appearing. The prostate is normal in appearance, seminal
vesicles are
calcified. The rectosigmoid is notable for numerous diverticula,
but there is no evidence of acute diverticulitis. The appendix
is normal.
BONE WINDOWS: The lumbar spinal alignment is maintained. There
is no
fracture. Disc calcification is seen at T11-12. There is
multilevel disc
degenerative change. No displaced rib fractures are seen.
Deformity in the
posterior left ribs might be the result of prior fractures.
Incidental note is made of an exostosis from the left twelfth
rib.
IMPRESSION:
1. No acute intra-abdominal process identified on this study.
2. Bilateral lower lobe pneumonia.
3. Marked vascular calcification.
4. Gallstones without evidence of acute cholecystitis.
.
CT Head ([**8-24**]):
FINDINGS: There is no acute intracranial hemorrhage, edema or
mass effect. Ventricles and sulci are mildly prominent due to
age-appropriate cerebral atrophy. There is no fracture. Vascular
calcifications are again seen in the scalp. There is mild
mucosal thickening of the ethmoid air cells.
IMPRESSION: No evidence of an acute intracranial injury.
.
Chest xray [**2188-8-24**]: 6 am
FINDINGS: Single portable chest radiograph excluding left lung
base from view
demonstrates endotracheal tube with tip positioned 5 cm above
the carina. The
nasogastric tube is seen coursing out of view with tip position
not evaluated.
Diffuse multifocal patchy opacities and Kerley B lines are
identified
throughout both lungs in presence of enlarged cardiac silhouette
and small
left pleural effusion. No air bronchograms present. Mediastinal
and hilar
contours are unremarkable. Sternotomy sutures are midline and
intact.
IMPRESSION:
1. Endotracheal tube well positioned.
2. Nasogastric tube passing out of view.
3. Multifocal opacifications in setting of cardiomegaly and left
pleural
effusion indicative of pulmonary edema.
.
Chest xray [**2188-8-24**]: 6 pm
IMPRESSION: AP chest compared to [**2188-8-24**] at 6:10 a.m.:
Pulmonary edema has improved since [**8-24**]; residual
consolidation as
show on yesterday's Torso CT is probably widespread aspiration
pneumonia. The
CT did not show cavities or bronchiectasis. Severe cardiomegaly
persists.
Pleural effusions, if any, are small. ET tube and left internal
jugular line
are in standard placements and a nasogastric tube loops in the
stomach ending
in the fundus. No pneumothorax.
.
Chest xray [**2188-8-25**]:
REASON FOR EXAMINATION: Evaluation of the patient after
extubation.
Portable AP chest radiograph was reviewed in comparison to
[**2188-8-24**].
There is interval improvement in widespread parenchymal
consolidations, most
likely consistent with resolution of aspiration versus rapid
improvement of
pneumonia, although it can be another possibility. The left
internal jugular
line tip is at the level of mid low SVC. Severe cardiomegaly is
present and
unchanged. No appreciable pleural effusion is noted.
.
Chest xray [**2188-8-26**]:
COMPARISON: Multiple prior examinations, most recent dated
[**2188-8-25**].
FINDINGS: Mild pulmonary edema appears similar to minimally
increased on this
examination. A small amount of fluid is seen within the right
minor fissure.
There is some retrocardiac atelectasis. No significant pleural
effusion is
identified. No pneumothorax. Cardiomegaly appears unchanged.
There are
calcifications of the aortic arch. Median sternotomy wires and
mediastinal
clips appear unchanged. A left-sided internal jugular venous
catheter reaches
the mid SVC.
.
NOTABLE LABS ON DISCHARGE:
[**2188-8-27**] 07:50AM BLOOD WBC-6.5 RBC-3.26* Hgb-9.4* Hct-29.1*
MCV-89 MCH-28.9 MCHC-32.3 RDW-17.0* Plt Ct-107*
[**2188-8-27**] 07:50AM BLOOD PT-16.5* PTT-25.1 INR(PT)-1.5*
[**2188-8-25**] 05:22AM BLOOD Ret Aut-2.4
[**2188-8-27**] 07:50AM BLOOD Glucose-136* UreaN-81* Creat-2.0* Na-137
K-5.4* Cl-105 HCO3-23 AnGap-14
[**2188-8-25**] 02:32AM BLOOD CK-MB-3 cTropnT-0.15* proBNP-[**Numeric Identifier 28490**]*
[**2188-8-26**] 04:31AM BLOOD CK-MB-3 cTropnT-0.10*
[**2188-8-25**] 02:32AM BLOOD Hapto-112
[**2188-8-25**] 04:03PM BLOOD [**Doctor First Name **]-NEGATIVE
[**2188-8-27**] 07:50AM BLOOD tacroFK-10.8
Brief Hospital Course:
69yoM with ESRD s/p renal transplant [**2180**] on Tacro and
Prednisone, h/o MI s/p multiple stents and CABG, DM, chronic
afib on [**Hospital 28492**] transferred from MICU for aspiration
pneumonitis complicated by volume overload, and generalized
weakness associated with gabapentin use.
.
ACTIVE ISSUES:
#. Aspiration pneumonitis: Patient had a history of emesis,
likely associated with acute food poisoning/viral gastritis that
has since self-resolved, with evidence of lung consolidation on
CT chest. He was intubated for hypoxia in the ED. He was
started on vancomycin, cefepime, and levofloxacin for broad
spectrum coverage on admission ([**2188-8-24**]). Given pt's rapid
improvement and low clinical suspicion for aspiration pneumonia
(active lifestyle, afebrile, and no history of dysphagia), his
presentation was more consistent with aspiration pneumonitis.
Serial chest x-rays showed interval improvements in parenchymal
consolidations. He was extubated on [**2188-8-25**], and started taking
PO without difficulty. Cefepime and vancomycin was stopped on
[**2188-8-26**], and levofloxacin was stopped on [**2188-8-27**]. Urine
Legionella Ag was negative, endotracheal sputum gram stain and
cultures from admission showed >25 polys and <10 epithelial
cells per field with 1+ yeast, and grew rare commensal
respiratory flora. Blood cultures remain pending but have shown
no growth to date. After extubation, pt remained afebrile and
asymptomatic for the remainder of hospital course, and was
feeling back to baseline on discharge.
.
# Acute on chronic systolic CHF: On admission pt also appeared
to be volume overloaded. CXR and chest CT showed mild to
moderate pulmonary edema. BNP was elevated at [**Numeric Identifier 28490**], and he had
signs of pitting edema (per MICU notes, pt was 25 lbs over dry
weight). He was maintained on home dose Lasix with gentle goal
negative diuresis. He was continued on Metoprolol. Valsartan
was held given high Cre on admission (see below). Pt improved
clinically, with decreased edema on discharge. Renal consult
recommended to continue holding valsartan since his SBPs were
100s-110s, and recommended PCP to restart valsartan once his
SBPs have stabilized to baseline. Renal also recommended pt to
be discharged on home lasix regimen (20 mg PO BID), with
instructions to double his morning lasix dose (to 40 mg) as
needed for pedal edema.
.
# Anemia: Pt's hematocrit dropped from 34 on admission (baseline
31-35) to 25-27 on [**2188-8-25**] and was stable ever since (29 on
discharge). There were no apparent sources of bleeding
throughout hospital course, and pt endorsed only dry clots of
blood in his sputum (no blood in stool or urine). Hemolysis labs
were negative. Pt remained asymptomatic, and it is possible his
Hct changes were from hemodilution due to profound fluid shifts.
Reticulocyte index was <2% suggesting an additional chronic
hypoproliferative component. Given his concurrent renal
failure, there was some concern for vasculitis like Wegener??????s or
Goodpasture??????s disease, but ESR was 25 and [**Doctor First Name **] was negative,
making suspicion lower. We recommend continued monitoring of
Hct.
.
# Thrombocytopenia: Pt's platelet count on admission was 163
(baseline 150s-200s), and dropped to 119 on [**2188-8-25**] (107 on
discharge), in parallel with Hct changes above. This is likely
due to hemodilution as above, but we recommend continued
monitoring.
.
#. s/p kidney transplant: Transplant in [**2180**], on tacrolimus and
prednisone but pt may have missed his last 3 tacrolimus doses
prior to admission because he ran out of his medications. His
tacrolimus level was low at 3.1 on admission, and his dosing was
adjusted per Renal Transplant recommendations, to 1 mg [**Hospital1 **] for
1-2 days. His last tacrolimus level prior to discharge was 10.8,
so renal recommended decreasing his dose back down to his home
regimen (0.5 mg [**Hospital1 **]). His home prednisone was continued, as
well as home batrim three times weekly for prophylaxis.
.
#. Acute renal failure: The patient initially presented with
acute on chronic renail failure with Cre 2.7 on presentation.
This was likely due to poor perfusion from heart failure
exacerbation, and Cre improved to baseline of 1.9-2.0 with
gentle Lasix diuresis.
.
# Generalized weakness/myoclonus: Pt noted to have myoclonic
jerks in the MICU that appeared to have resolved on transfer to
medicine. His history suggests this may be related to recent
medication changes, such as skipped tacrolimus doses on
admission, or recently restarted gabapentin doses (per pt, both
these medication changes have been associated with myoclonic
episodes in the past). Gabapentin was held throughout hospital
course, and he no longer had any evidence of myoclonus after
transfer to Medicine. Physical therapy was consulted and
cleared patient for discharge to home (ambulation with a
walker). Pt reported feeling back to baseline on discharge.
.
#) Hyperkalemia: On admission pt's K was 5.4, normalizing to 4.8
one day later, but increased back to 5.4 on discharge. He was
clinically asymptomatic throughout hospital course, without
evidence of EKG changes. No interventions were made. We
recommend continued follow-up of potassium, especially in light
of ongoing renal issues.
.
INACTIVE ISSUES:
#. Afib: Patient has history of chronic afib on Coumadin, which
was initially held because of concern for dropping Hct. His INR
on admission was 1.4. Coumadin was re-started at 1.5 mg daily
when his hct remained stable on [**2188-8-26**]. His INR rose to 2.2
but was 1.5 on discharge, so his warfarin was increased to 3 mg
daily. We recommend continued INR check-ups and follow-up on
warfarin dosing. Of note, his HR was stable in 50s-70s without
evidence of Afib on telemetry x 24 hrs prior to discharge.
.
#. Coronary Artery Disease: Patient with history of NSTEMI in
the past, s/p atherectomy of the LAD [**2176**], DES to mid-LAD, ISRS
[**2180**] s/p DES to mid-LAD, ISRS s/p POBA [**2185**], s/p CABG. His EKGs
throughout hospital course were unchanged from baseline, and his
cardiac enzymes were negative x3. His home aspirin, metoprolol,
were continued. Valsartan was held as above. Simvastatin was
initially held but re-started when initial mild transaminitis
normalized.
.
#. Diabetes: Continued insulin in-house with sliding scale.
.
#. Hypertension: Continued home Metoprolol and lasix. Valsartan
was held per above.
.
#. Hyperparathyroidism: Continued Calcitriol, alendronate per
home regimen.
.
#. Hyperlipidemia: Held home statins initially given elevated
LFTs but was restarted on Simvastatin when LFTs improved.
.
#. Gout: Continued home Allopurinol.
.
#. Chronic back and left hip pain: History of sciatica and
spinal stenosis. Held Gabapentin as above, managed with home
Oxycodone, Fentanyl patch.
.
TRANSITIONAL ISSUES:
***Voice message left with pt's wife [**Doctor First Name **] for him to report
on Friday [**2188-8-29**] for INR check. Please follow-up INR and modify
pt's warfarin regimen accordingly.
***Voice message left with pt's wife [**Doctor First Name **] for him to report
on Friday [**2188-8-29**] for CBC check. Please follow-up pt's Hct and
platelets, and workup causes of anemia and thrombocytopenia if
indicated.
***Please recheck blood pressure and consider re-starting
valsartan for pt's heart failure.
***Please continue to monitor pt's electrolytes (in particular,
potassium and Cre).
Medications on Admission:
ALENDRONATE 70 mg qweekly
ALLOPURINOL 100 mg daily
CALCITRIOL 0.25 mcg - one Capsule on odd days, 2 capsules on
even days.
FENTANYL 25 mcg/hour Patch q72 hr
FLUOCINONIDE 0.05 % Solution - apply to scalp at bedtime
FUROSEMIDE 20 mg [**Hospital1 **]
GABAPENTIN 300 mg tid (take one a day during first week)
METOPROLOL SUCCINATE 50 mg Tablet Extended Release daily
MOM[**Name (NI) **] 0.1 % Solution to scalp every other night
OXYCODONE 5 mg tid prn back pain
PREDNISONE 5 mg daily per Dr. [**First Name (STitle) **] rheumatology
SEVELAMER CARBONATE 800 mg qmeal
SIMVASTATIN 40 mg daily
SULFAMETHOXAZOLE-TRIMETHOPRIM 80-400 mg 3 times weekly
TACROLIMUS 0.5 mg [**Hospital1 **]
VALSARTAN 40 mg po qam
WARFARIN as directed daily
ASPIRIN 81 mg daily and prn
DOCUSATE 100 mg daily prn
INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution -
subcutaneously per sliding scale as needed
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day as needed for constipation.
2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day): Please take on ODD days.
3. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO EVERY
OTHER DAY (Every Other Day): Please take on EVEN days.
4. fluocinonide 0.05 % Ointment Sig: One (1) Appl Topical QHS
(once a day (at bedtime)).
5. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,SA).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Humulin R 100 unit/mL Solution Sig: Sliding scale Injection
four times a day: Inject subcutaneously per sliding scale as
needed.
11. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
12. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
15. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
16. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week.
17. mom[**Name (NI) 6474**] 0.1 % Lotion Sig: One (1) application Topical
every other day: Apply to scalp every other night.
18. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H
(every 12 hours).
Disp:*60 Capsule(s)* Refills:*0*
19. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at
4 PM.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
#) Aspiration pneumonitis
#) Congestive heart failure (ejection fraction 40%).
.
SECONDARY:
#) End stage renal failure with kidney transplant
#) Chronic atrial fibrillation
#) Coronary artery disease
#) Hypertension
#) Hyperlipidemia
#) Gout
#) Diabetes Mellitus
#) Hyperparathyroidism
#) Spinal stenosis
#) Sciatica
#) Seborrhea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. [**Known lastname **]:
.
It was a pleasure taking care of you. You were admitted after
you aspirated vomit into your lungs, which caused shortness of
breath and poor oxygen circulation, requiring intubation. You
received antibiotics to protect against infection, and lasix to
remove excess fluid from your body. Your chest X-rays showed
significant improvement since admission.
.
The following medications were STOPPED:
- Gabapentin 300 mg by mouth three times daily
- Valsartan 40 mg by mouth every morning
.
The following medications were CHANGED:
- Warfarin 3 mg by mouth daily, with further dosing adjusted
according your blood (INR) levels
.
Please weigh yourself every morning. If you think your feet are
still swollen over the next few days, you may double your
morning dose of furosemide (take furosemide 40 mg by mouth in
the morning, and 20 mg by mouth in the evening) for 1-3 days,
then go back to your regular dose of furosemide 20 mg by mouth
twice a day. If your weight goes up more than 3 lbs, please
call your primary care doctor.
.
Please take all your other medications as directed. Please
attend all your follow-up appointments as scheduled.
Followup Instructions:
Provider (Primary care): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD. [**Telephone/Fax (1) 250**],
Date/Time: [**2188-9-1**], 3:00 pm
Provider (Dermatology): [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], M.D. Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2188-9-9**] 1:45
Provider (Renal): [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Phone:[**Telephone/Fax (1) 721**]
Date/Time:[**2188-9-24**] 11:00
Provider (Cardiology): [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2188-12-10**] 10:20
Completed by:[**2188-8-27**]
|
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32,119
| 126,540
|
1049
|
Discharge summary
|
report
|
Admission Date: [**2167-4-11**] Discharge Date: [**2167-4-19**]
Date of Birth: [**2124-2-10**] Sex: M
Service: MEDICINE
Allergies:
Compazine
Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Leg cramps
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
43 yo M with history of rhabdomyolysis related to mitochondrial
d/o comes w/ cramping in legs. Pt reports he's been feeling
somewhat unwell since 2 days ago when he nausea after eating
chicken panini from [**Company **]. However, his symptom resolved
by the end of the day. No diarrhea/abdominal pain/fevers or
chills. Yesterday, he was moving boxes because he's moving to a
different apt and felt tired and took a nap. After taking a nap,
he woke up with calf muscle cramping and checked urine myoglobin
at home which was positive. He then came to the ED. Otherwise,
he denies any chest pain, sob, cough, diarrhea, abdominal pain,
or constipation. He reports some HA and nasal congestion but no
vision changes, stiff neck, neck pain or rhinorrhea.
.
In the Emergency Department, his CK was noted to be in 50,000s
and received 1L NS. 1L of bicarb was started. Initially, for
close monitor of urine output hourly and 'lytes in the setting
of aggressive IVF, there was a consideration for MICU admission.
However, MICU attending did not feel that he warranted MICU
admission, thus floor admission was decided. However, from the
[**Name (NI) **], pt went to MICU. Upon arrival to MICU, pt's VS was 98.3,
144/90, 102, 11, 99% on RA. Upon hearing that pt's moving again
to CC7 again, pt became upset and tachycardic to 120-130s and
hypertensive to 182/105. Currently, pt's BP 144/98, HR 94, 16,
sat 98% on RA. Pt had uop of 500cc of tea-colored urine while in
MICU. While in MICU, pt finished 1L bicarb and received 2 L of
NS. 4th NS is running currently. Pt is refusing foley.
Past Medical History:
1. Mitochondrial myopathy with recurrent rhabdomyolysis; this
myopathy is secondary to a cytochrome c-oxidase mutation; in the
past, his rhabdomyolysis has been precipitated by exercise, warm
weather, dehydration, viral and sinus infections. He is followed
by Dr. [**Last Name (STitle) **] in Neurology. The pt's case has been studied
and published in the journal NEUROLOGY [**2158**];55:644??????649.
2. Obstructive sleep apnea.
3. Recurrent sinusitis.
Social History:
Software engineer, lives in [**Hospital1 **]. Not married. No tob, occ
EtOH.
Family History:
There is no family history of mitochondrial or neuromuscular
disease. His parents are both alive and well. Factor V Leiden.
Physical Exam:
VS T 98.3 BP 144/98, HR 94, 16, sat 98% on RA
GEN: well-appearing male, NAD
HEENT: PERRL, EOMI, MMM. OP clear.
NECK: supple
Lungs: CTAB.
CV: RRR, No MRG.
Abd: S/NT/ND.
Extr: No c/c/e.
Neuro: CNs II-XII intact. Strength was [**3-23**] bilaterally in both
upper and lower extremities. No tremor or asterixis.
Pertinent Results:
ADMISSION LABS:
===============
137 99 19
-----|-----|-----< 108
3.9 25 1.0
Ca 8.7 Phos 2.5 Mg 2.1
CK 51,291
UA: BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG; RBC-0-2 WBC-0-2
BACTERIA-FEW YEAST-NONE EPI-<1
PERTINENT LABS DURING HOSPITALIZATION:
======================================
CK peaked at 55,950 then decreased to 1484 upon discharge
WBC trend: 9.8 - 9.8 - 12.2 - 14.7 - 11.2 - 11.3 - 12.1 - 9.7
[**4-13**] D-dimer: 304
[**4-17**] ESR: 58
[**4-17**] CRP: 97.3
MICROBIOLOGY:
=============
[**4-13**] UCx: negative
[**4-13**] BCx: negative
[**4-14**] BCx x 2: negative
[**2167-4-15**] 4:09 pm CSF;SPINAL FLUID Source: LP.
**FINAL REPORT [**2167-4-18**]**
GRAM STAIN (Final [**2167-4-15**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2167-4-18**]): NO GROWTH.
[**4-16**] UCx: negative
[**4-17**] BCx x 2: negative
[**4-18**] Lyme: negative
STUDIES:
========
CHEST (PORTABLE AP) [**2167-4-13**]
FINDINGS: In comparison with the study of [**2161-7-2**], there are
lower lung volumes, but no evidence of acute pneumonia or
vascular congestion.
EKG [**2167-4-13**]
Sinus rhythm. Diffuse non-specific ST-T wave changes. Compared
to the
previous tracing of [**2158-3-31**] the rate is increased and there are
non-specific ST-T wave changes. Otherwise, no diagnostic interim
change
EKG [**2167-4-14**]
Sinus rhythm
Inferior T wave changes are nonspecific
Since previous tracing of [**2167-4-13**], no significant change
CHEST (PORTABLE AP) [**2167-4-15**]
FINDINGS: In comparison with study of [**4-13**], there is some
increasing prominence of interstitial markings that are less
well defined, consistent with the clinical concern of some
volume overload. No acute focal pneumonia.
CHEST (PA & LAT) [**2167-4-16**]
FINDINGS: In comparison with the study of [**4-15**], the degree of
pulmonary vascular congestion has substantially decreased. There
is still some increased opacification at the bases, which on
lateral views seen to represent bilateral pleural effusions.
Atelectatic change is seen at the bases. The upper lungs are
free of acute pneumonia.
CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2167-4-17**] 1:47 PM
There are several scattered ground-glass opacities in both
lungs, predominantly in a bronchovascular distribution. There
are bibasal effusions with atelectasis in the lower lobes. There
are scattered mediastinal lymph nodes with the largest measuring
14 x 12 mm in a subcarinal location.
There is no aortic dissection or pulmonary embolism. The
coronary arteries arise from the normal expected anatomical
location.
The visualized liver and spleen appear unremarkable.
MUSCULOSKELETAL:
There are no worrisome bone lesions.
CONCLUSION:
1. No pulmonary embolism or aortic dissection. The coronary
arteries arise from the normal expected anatomical location.
2. Multifocal ground-glass opacities predominantly in a
bronchovascular distribution. There is a wide differential for
this appearance, including but not limited to infection,
aspiration or pulmonary hemorrhage.
UNILAT UP EXT VEINS US LEFT [**2167-4-17**]
IMPRESSION: Acute short segment distal basilic vein clot, just
superior to the antecubital fossa, corresponding to the palpable
abnormality.
THYROID U.S. [**2167-4-17**] 2:06 PM
The right lobe measures 4.9 x 1.6 x 1.5 cm and left lobe
measures 4.4 x 1.6 x 1.3 cm. Both lobes demonstrate normal
echogenicity and vascularity. There are no discrete nodules. No
cervical lymphadenopathy.
IMPRESSION: Normal thyroid ultrasound.
EKG [**2167-4-17**]
Sinus tachycardia. Diffuse non-specific ST-T wave changes.
Compared to the previous tracing of [**2167-4-14**] the rate has
increased and there is inferolateral ST-T wave flattening.
Otherwise, no diagnostic interim change.
Brief Hospital Course:
Mr. [**Known lastname 6852**] is a 43-year-old man with a history of
rhabdomyolysis due to mitochondrial myopathy presenting with
muscle pain and myoglobin in the urine due to rhabdomyolysis.
#) Rhabdomyolysis: The patient presented with muscle aches and
home urine test that showed myoglobin. He was treated with
aggressive hydration with NS at 1L/hour, which was then
decreased as he started to increase po intake. While on IV
fluids, his urine output was monitored to keep UOP>200 cc/hour.
His CKs trended down. Electrolytes were monitored, especially
his renal function for signs of renal involvement. He was also
monitored for hyperkalemia (due to release of cellular K) and
metabolic acidosis (due to release of cellular phosphate and
sulfate) but none of these occurred.
#) Chest Pain: On [**4-13**], the pt reported that he has had chest
pain in past episodes of rhabdomyolysis, and again, he had mild
chest pain. CK-MB and troponin were checked and were flat. EKG
showed only nonspecific TW flattening. Therefore, there was
little concern for myocardial ischemia. More likely that this
was [**12-20**] muscle pain in the chest wall. Other concern was for PE
because he also had sinus tachycardia. However, he was
oxygenating well, and D-Dimer was found to be normal making PE
much less likely. He reports that during past admissions he has
became tachycardic for unclear reasons.
#) Sinus Tachycardia: Unclear etiology, as described above, much
less likely to be due to PE due to normal saturation and nml
D-Dimer. He has some pain, which may be underlying the
tachycardia, though unclear. Please also see below.
#) Shortness of Breath: During hospitalization, he did have an
episode of shortness of breath and continued tachycardia, and he
also continued to spike fevers for a few days. A CTA was
obtained to rule out pulmonary embolism, which it did. His
shortness of breath was likely due to volume overload from
aggressive IVF hydration, which was also seen on CTA. This
resolved as IVFs were decreased. A follow up CT chest should be
performed in [**11-19**] months.
#) Abdominal Pain: The patient complained of LLQ abdominal pain
while hospitalized. This pain had been occurring for about 2
months prior to hospitalization. There was no rebound or
guarding on exam. A CT of the abdomen was ordered, but the
patient refused due to the oral contrast. His abdominal pain
improved, and due to its chronicity, it was felt that he could
follow up with his PCP for this chronic issue.
#) Basilic Vein Clot: The patient developed a L basilic vein
clot towards the end of his hospitalization. Anticoagulation
was initiated with Lovenox bridge to coumadin. He will need to
be anticoagulated for 3 months. His goal INR is [**12-21**]. He was
set up with lab checks. Of important note, the patient has a
family history of Factor V Leiden. He will need further workup
of this history.
#) Fevers of Unknown Origin: Hospitalization was complicated by
fevers. The patient began to spike temperatures of 101-102.
All urine cultures and blood cultures were negative to date.
Lyme negative. CXR negative for infiltrates. CTA showed some
ground glass opacities. LP negative. Thyroid U/S showed no
cervical lymphadenopathy. ID was consulted, and he was followed
clinically. Pt did endorse several weeks of lymphadenopathy and
fevers as outpatient that had once been treated with a Z-pak.
He also had a leukocytosis that then resolved upon discharge.
#) Headache: Pt c/o headache in setting of fever and
nausea/vomiting. LP performed that was negative. Headache
resolved s/p LP.
#) L upper extremity cellulitis: After clot developed (which was
after fevers were occurring), pt had cellulitis overlying it.
Pt was started on IV vancomycin, which was switched to Keflex
and Bactrim per ID. The patient discharged with instructions to
take 7 days of these medications, see his PCP, [**Name10 (NameIs) **] should it not
have improved, to take an extra 7 days of Keflex/Bactrim.
#) Anemia: likely [**12-20**] hemodilution from large volume IVF.
However, pt reports that at outside hospital he was also found
to have a low hct. Iron studies were checked, and are not c/w
Iron def anemia, nevertheless pt reports that his PCP scheduled
[**Name9 (PRE) 3782**] colonoscopy for him prior to admission.
Medications on Admission:
None.
Discharge Medications:
1. Enoxaparin 80 mg/0.8 mL Syringe Sig: Eighty (80) Enoxaparin
(Subcutaneous) 80 mg Subcutaneous Q12H (every 12 hours).
Disp:*20 80 mg/0.8 mL Syringe* Refills:*0*
2. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
4. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
Disp:*30 Tablet(s)* Refills:*2*
5. Bactrim DS 160-800 mg Tablet Sig: Two (2) Tablet PO twice a
day for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
6. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6)
hours for 7 days.
Disp:*28 Capsule(s)* Refills:*0*
7. Outpatient Lab Work
Have blood work for INR checked on Tuesday [**4-21**], and faxed to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6853**] office.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Rhabdomyolysis
Fevers
R arm basilic vein thrombus
Cellulitis
Discharge Condition:
CK trending down, muscle aches improved, cellulitis improved,
ambulating.
Discharge Instructions:
You were admitted with rhabdomyolysis. This occured because of
your mitochondiral disorder. You were treated with large
volumes of IV fluids to help protect your kidneys. Your kidney
function remained good throughout your stay. Your
hospitalization was complicated by fevers of unknown origin. A
CT scan was done of your lungs which showed that you had some
fluid in your lungs, most likely due to the IV fluids and no
pneumonia. You will need a repeat CT Chest in [**11-19**] months to
make sure the changes have ressolved. The Infectious Disease
doctors were involved in your care for your fevers. Also, you
had a clot in one of your veins in your left arm, which we
started anticoagulation for with both Lovenox and Coumadin. You
will need to be on anticoagulation for 3 months. You told us
that there is a clotting disorder in your family, and this can
be worked up in you with blood tests as an outpatient. Lastly,
the the area on your left arm appeared infected (cellulitis), so
you were started on an IV antibiotic, which was changed to
antibiotics that you can take by mouth. If you are still having
redness in your arm after 7 days of antibiotics, call your
primary care physician [**Name Initial (PRE) **] 7 more days of antibiotics. Your
blood pressures were elevated in the hospital and you have been
given prescriptions for anti-hypertensives.
.
Please keep your follow up appointments as written below.
.
Please take all your medications as prescribed. You have been
started on metoprolol and amlodipine for elevated blood
pressures. You have been started on coumadin and lovenox for
anticoagulation.
.
You will need to follow up your INR levels to make sure you are
getting adequately anti-coagulated for your clot. Your PCP
should follow these levels and change your dose accordingly.
.
If you have any symptoms of worsening muscle aches, pains, dark
urine, or any other concerning symptoms you should call your
doctor or go to the ER immediately.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 3393**]) in
the next 1 week. You should have blood work done for an INR on
Tuesday [**4-21**], and this should be faxed to Dr.[**Name (NI) 6854**] office.
.
Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. Phone:[**Telephone/Fax (1) 6856**]
Date/Time:[**2167-5-14**] 9:30
[**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
Completed by:[**2167-4-21**]
|
[
"784.0",
"728.88",
"E879.8",
"473.9",
"288.61",
"275.41",
"427.89",
"451.82",
"359.89",
"789.04",
"758.9",
"285.9",
"327.23",
"999.31",
"786.52",
"338.29",
"276.6",
"785.6",
"780.6",
"277.87"
] |
icd9cm
|
[
[
[]
]
] |
[
"03.31"
] |
icd9pcs
|
[
[
[]
]
] |
12140, 12146
|
6872, 11195
|
280, 298
|
12270, 12346
|
2957, 2957
|
14370, 14958
|
2489, 2614
|
11251, 12117
|
12167, 12167
|
11221, 11228
|
12370, 14347
|
2629, 2938
|
230, 242
|
326, 1901
|
2973, 6849
|
12186, 12249
|
1923, 2378
|
2394, 2473
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,276
| 164,837
|
34687
|
Discharge summary
|
report
|
Admission Date: [**2111-7-18**] Discharge Date: [**2111-8-3**]
Date of Birth: [**2084-7-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Necrotizing fasciitis
Major Surgical or Invasive Procedure:
1. Radical debridement of soft tissues of left lower abdominal
wall, groin, thigh and perineum ([**2111-7-18**])
2. Debridement and primary closure, with drains, of necrotizing
fasciitis of the perineum ([**2111-7-31**])
History of Present Illness:
Pt is 27 yo man with DM, morbid obesity, recurrent groin
"boils", who presented to OSH with L groin boil, and fever. Per
chart, pt developed L groin boil 5 days prior to presentation,
had small amt drainage 2 days prior to presentation, developed
fever and L groin swelling/redness on [**7-17**], went to PCP office,
found [**Name Initial (PRE) **]/glucose > 400. OSH ER T 102, exam notable for "severe
erythema of L groin, L hemiscrotum, L medial thigh with pain on
palpation." WBC 15.2 (86N, 11L), CT showed gas in L
groin/scrotum, extending to fem sheath & inguinal canal. Pt
transferred to [**Hospital1 18**] for emergent management of suspected
necrotizing fasciitis.
Past Medical History:
DM2
HTN
Morbid obesity
Hx boils in B groin, spontaneous rupture
Social History:
Tob: Yes
EtOH: Denies
IVDU: Unknown
Family History:
Noncontributory
Physical Exam:
Physical exam on initial evaluation
General: Diaphoretic, flushed
Tm 102 (at OSH), Tc 97, HR 110, BP 151/68, RR 18, O2Sat 98% on
RA
Lungs: CTA B/L
Heart: Tachycardic
Abdom: +BS, soft, obese
Extrem:
R groin: Well healed pits, scabs
L groin: severe erythema/cellulitis, scrotum 2cm boil, +
crepitus, - perineal involvement
LE: no edema
Pertinent Results:
[**2111-7-18**] 03:37AM BLOOD WBC-12.9* RBC-3.91* Hgb-11.2* Hct-32.9*
MCV-84 MCH-28.6 MCHC-33.9 RDW-13.5 Plt Ct-201
[**2111-7-19**] 01:12AM BLOOD WBC-9.7 RBC-3.32* Hgb-9.7* Hct-27.8*
MCV-84 MCH-29.2 MCHC-34.9 RDW-13.5 Plt Ct-222
[**2111-7-20**] 02:16AM BLOOD WBC-7.6 RBC-2.96* Hgb-8.7* Hct-25.0*
MCV-84 MCH-29.4 MCHC-34.8 RDW-13.5 Plt Ct-260
[**2111-7-21**] 02:11AM BLOOD WBC-8.2 RBC-3.13* Hgb-8.8* Hct-26.7*
MCV-85 MCH-28.1 MCHC-33.0 RDW-13.6 Plt Ct-282
[**2111-7-22**] 02:22AM BLOOD WBC-10.9 RBC-3.03* Hgb-8.6* Hct-25.8*
MCV-85 MCH-28.3 MCHC-33.3 RDW-13.6 Plt Ct-352
[**2111-7-23**] 01:54AM BLOOD WBC-11.0 RBC-3.08* Hgb-8.7* Hct-26.2*
MCV-85 MCH-28.1 MCHC-33.0 RDW-13.8 Plt Ct-376
[**2111-7-24**] 01:58AM BLOOD WBC-11.7* RBC-3.13* Hgb-8.9* Hct-26.7*
MCV-85 MCH-28.6 MCHC-33.5 RDW-13.6 Plt Ct-417
[**2111-7-25**] 02:35AM BLOOD WBC-14.3* RBC-3.29* Hgb-9.6* Hct-28.2*
MCV-86 MCH-29.0 MCHC-33.9 RDW-13.9 Plt Ct-509*
[**2111-7-26**] 03:27AM BLOOD WBC-15.7* RBC-3.48* Hgb-10.1* Hct-29.3*
MCV-84 MCH-29.0 MCHC-34.6 RDW-13.9 Plt Ct-599*
[**2111-7-27**] 12:40AM BLOOD WBC-19.3* RBC-3.45* Hgb-9.9* Hct-28.8*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.0 Plt Ct-620*
[**2111-7-28**] 03:58AM BLOOD WBC-17.7* RBC-3.55* Hgb-10.0* Hct-29.4*
MCV-83 MCH-28.1 MCHC-33.9 RDW-14.0 Plt Ct-610*
[**2111-7-29**] 05:30AM BLOOD WBC-17.9* RBC-3.66* Hgb-10.2* Hct-30.6*
MCV-84 MCH-27.9 MCHC-33.3 RDW-14.1 Plt Ct-648*
[**2111-7-30**] 05:45AM BLOOD WBC-13.3* RBC-3.54* Hgb-10.1* Hct-29.6*
MCV-84 MCH-28.6 MCHC-34.2 RDW-14.1 Plt Ct-689*
[**2111-7-31**] 05:45AM BLOOD WBC-11.1* RBC-3.50* Hgb-10.0* Hct-29.2*
MCV-83 MCH-28.6 MCHC-34.3 RDW-14.2 Plt Ct-679*
[**2111-8-1**] 06:10AM BLOOD WBC-9.9 RBC-3.46* Hgb-9.8* Hct-28.8*
MCV-83 MCH-28.4 MCHC-34.1 RDW-14.1 Plt Ct-680*
[**2111-8-2**] 06:20AM BLOOD WBC-8.5 RBC-3.37* Hgb-9.6* Hct-28.2*
MCV-84 MCH-28.6 MCHC-34.2 RDW-14.3 Plt Ct-649*
[**2111-7-18**] 12:36AM BLOOD PT-15.3* PTT-22.6 INR(PT)-1.3*
[**2111-7-18**] 03:37AM BLOOD PT-16.1* PTT-22.6 INR(PT)-1.4*
[**2111-7-19**] 01:12AM BLOOD PT-14.8* PTT-23.2 INR(PT)-1.3*
[**2111-7-19**] 01:12AM BLOOD Plt Ct-222
[**2111-7-20**] 02:16AM BLOOD PT-14.0* PTT-22.2 INR(PT)-1.2*
[**2111-7-20**] 02:16AM BLOOD Plt Ct-260
[**2111-7-21**] 02:11AM BLOOD PT-14.3* PTT-22.0 INR(PT)-1.2*
[**2111-7-21**] 02:11AM BLOOD Plt Ct-282
[**2111-7-22**] 02:22AM BLOOD PT-13.8* INR(PT)-1.2*
[**2111-7-22**] 02:22AM BLOOD Plt Ct-352
[**2111-7-23**] 01:54AM BLOOD Plt Ct-376
[**2111-7-23**] 03:08AM BLOOD PT-13.8* PTT-21.8* INR(PT)-1.2*
[**2111-7-24**] 01:58AM BLOOD Plt Ct-417
[**2111-7-25**] 02:35AM BLOOD PT-13.8* PTT-21.1* INR(PT)-1.2*
[**2111-7-25**] 02:35AM BLOOD Plt Ct-509*
[**2111-7-26**] 03:27AM BLOOD Plt Ct-599*
[**2111-7-27**] 12:40AM BLOOD Plt Ct-620*
[**2111-7-28**] 03:58AM BLOOD Plt Ct-610*
[**2111-7-29**] 05:30AM BLOOD Plt Ct-648*
[**2111-7-30**] 05:45AM BLOOD PT-13.8* INR(PT)-1.2*
[**2111-7-30**] 05:45AM BLOOD Plt Ct-689*
[**2111-7-31**] 05:45AM BLOOD Plt Ct-679*
[**2111-8-1**] 06:10AM BLOOD Plt Ct-680*
[**2111-8-2**] 06:20AM BLOOD Plt Ct-649*
[**2111-7-18**] 12:36AM BLOOD Glucose-414* UreaN-12 Creat-1.0 Na-135
K-4.1 Cl-98 HCO3-20* AnGap-21*
[**2111-7-18**] 03:37AM BLOOD Glucose-251* UreaN-12 Creat-0.9 Na-138
K-3.6 Cl-104 HCO3-24 AnGap-14
[**2111-7-19**] 01:12AM BLOOD Glucose-201* UreaN-13 Creat-0.9 Na-136
K-3.3 Cl-103 HCO3-25 AnGap-11
[**2111-7-20**] 02:16AM BLOOD Glucose-144* UreaN-17 Creat-1.0 Na-137
K-3.7 Cl-105 HCO3-26 AnGap-10
[**2111-7-21**] 02:11AM BLOOD Glucose-146* UreaN-15 Creat-0.8 Na-138
K-4.0 Cl-104 HCO3-26 AnGap-12
[**2111-7-21**] 06:09PM BLOOD Glucose-92 UreaN-15 Creat-0.8 Na-140
K-4.0 Cl-104 HCO3-28 AnGap-12
[**2111-7-22**] 02:22AM BLOOD Glucose-96 UreaN-14 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-28 AnGap-13
[**2111-7-23**] 01:54AM BLOOD Glucose-107* UreaN-14 Creat-0.9 Na-137
K-4.3 Cl-99 HCO3-29 AnGap-13
[**2111-7-24**] 01:58AM BLOOD Glucose-134* UreaN-17 Creat-0.8 Na-139
K-4.3 Cl-101 HCO3-30 AnGap-12
[**2111-7-24**] 06:30PM BLOOD Glucose-158* UreaN-19 Creat-0.9 Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
[**2111-7-25**] 02:35AM BLOOD Glucose-180* UreaN-20 Creat-1.0 Na-138
K-4.4 Cl-103 HCO3-27 AnGap-12
[**2111-7-25**] 04:46PM BLOOD Na-136 K-4.7
[**2111-7-26**] 03:27AM BLOOD Glucose-196* UreaN-23* Creat-0.8 Na-136
K-4.4 Cl-104 HCO3-22 AnGap-14
[**2111-7-27**] 12:40AM BLOOD Glucose-123* UreaN-23* Creat-0.9 Na-136
K-4.4 Cl-102 HCO3-25 AnGap-13
[**2111-7-28**] 03:58AM BLOOD Glucose-80 UreaN-21* Creat-0.9 Na-139
K-3.8 Cl-103 HCO3-25 AnGap-15
[**2111-7-29**] 05:30AM BLOOD Glucose-112* UreaN-19 Creat-0.9 Na-138
K-4.2 Cl-103 HCO3-24 AnGap-15
[**2111-7-30**] 05:45AM BLOOD Glucose-74 UreaN-15 Creat-0.8 Na-139
K-4.2 Cl-104 HCO3-26 AnGap-13
[**2111-7-31**] 05:45AM BLOOD Glucose-85 UreaN-14 Creat-0.8 Na-139
K-4.8 Cl-103 HCO3-28 AnGap-13
[**2111-7-19**] 06:20PM BLOOD Vanco-8.7*
[**2111-7-21**] 06:21AM BLOOD Vanco-19.5
[**2111-7-22**] 06:23AM BLOOD Vanco-18.6
[**2111-7-27**] 08:33AM BLOOD Vanco-22.2*
[**2111-7-18**] 02:48AM BLOOD Type-ART pO2-154* pCO2-38 pH-7.38
calTCO2-23 Base XS--1 Intubat-INTUBATED
[**2111-7-18**] 03:49AM BLOOD Type-ART pO2-239* pCO2-55* pH-7.26*
calTCO2-26 Base XS--2 Intubat-INTUBATED
[**2111-7-18**] 06:14AM BLOOD Type-ART Temp-36.1 Rates-14/4 Tidal V-550
PEEP-10 FiO2-100 pO2-248* pCO2-39 pH-7.34* calTCO2-22 Base XS--4
AADO2-443 REQ O2-74 -ASSIST/CON Intubat-INTUBATED
[**2111-7-18**] 08:12AM BLOOD Type-ART pO2-166* pCO2-48* pH-7.32*
calTCO2-26 Base XS--1
[**2111-7-18**] 06:23PM BLOOD Type-ART pO2-244* pCO2-36 pH-7.43
calTCO2-25 Base XS-0
[**2111-7-18**] 10:30PM BLOOD Type-ART pO2-138* pCO2-40 pH-7.39
calTCO2-25 Base XS-0
[**2111-7-19**] 06:25PM BLOOD Type-ART pO2-103 pCO2-40 pH-7.39
calTCO2-25 Base XS-0
[**2111-7-20**] 02:28AM BLOOD Type-ART pO2-171* pCO2-46* pH-7.39
calTCO2-29 Base XS-2
[**2111-7-20**] 06:39AM BLOOD Type-ART pO2-166* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
[**2111-7-20**] 04:21PM BLOOD Type-ART pO2-94 pCO2-44 pH-7.39
calTCO2-28 Base XS-0
[**2111-7-20**] 06:53PM BLOOD Type-ART pO2-153* pCO2-37 pH-7.41
calTCO2-24 Base XS-0
[**2111-7-20**] 09:24PM BLOOD Type-ART pO2-153* pCO2-39 pH-7.40
calTCO2-25 Base XS-0
[**2111-7-21**] 02:19AM BLOOD Type-ART pO2-135* pCO2-42 pH-7.42
calTCO2-28 Base XS-3
[**2111-7-21**] 06:20AM BLOOD Type-ART pO2-120* pCO2-44 pH-7.42
calTCO2-30 Base XS-4
[**2111-7-21**] 12:24PM BLOOD Type-ART pO2-67* pCO2-36 pH-7.44
calTCO2-25 Base XS-0
[**2111-7-21**] 12:53PM BLOOD Type-ART pO2-83* pCO2-35 pH-7.42
calTCO2-23 Base XS-0
[**2111-7-21**] 07:23PM BLOOD Type-ART pO2-91 pCO2-40 pH-7.45
calTCO2-29 Base XS-3
[**2111-7-22**] 02:45AM BLOOD Type-ART pO2-92 pCO2-45 pH-7.45
calTCO2-32* Base XS-6
[**2111-7-22**] 06:38AM BLOOD Type-ART pO2-88 pCO2-45 pH-7.47*
calTCO2-34* Base XS-7
[**2111-7-22**] 05:45PM BLOOD Type-ART pO2-62* pCO2-45 pH-7.46*
calTCO2-33* Base XS-6
[**2111-7-22**] 07:20PM BLOOD Type-ART pO2-72* pCO2-43 pH-7.47*
calTCO2-32* Base XS-6
[**2111-7-22**] 10:15PM BLOOD Type-ART pO2-153* pCO2-40 pH-7.46*
calTCO2-29 Base XS-5
[**2111-7-24**] 02:11AM BLOOD Type-ART pO2-101 pCO2-42 pH-7.46*
calTCO2-31* Base XS-5
[**2111-7-24**] 10:07AM BLOOD Type-ART Temp-37.4 Rates-/22 Tidal V-550
PEEP-20 FiO2-60 O2 Flow-11 pO2-92 pCO2-46* pH-7.45 calTCO2-33*
Base XS-6 Intubat-INTUBATED Vent-SPONTANEOU
[**2111-7-24**] 12:06PM BLOOD Type-ART Temp-37.0 Rates-/21 Tidal V-595
PEEP-20 FiO2-60 O2 Flow-13.1 pO2-102 pCO2-46* pH-7.46*
calTCO2-34* Base XS-7 Intubat-INTUBATED Vent-SPONTANEOU
Comment-PS 10CM
[**2111-7-24**] 02:58PM BLOOD Type-ART Temp-37.0 Rates-/21 Tidal V-618
PEEP-20 FiO2-60 O2 Flow-13.4 pO2-136* pCO2-44 pH-7.44
calTCO2-31* Base XS-5 Intubat-INTUBATED Vent-SPONTANEOU
[**2111-7-24**] 06:37PM BLOOD Type-ART Temp-37.1 pO2-174* pCO2-40
pH-7.44 calTCO2-28 Base XS-3 Intubat-INTUBATED
[**2111-7-25**] 02:49AM BLOOD Type-ART pO2-132* pCO2-40 pH-7.43
calTCO2-27 Base XS-2
[**2111-7-25**] 04:57PM BLOOD Type-ART Temp-36.9 Rates-/19 Tidal V-650
PEEP-18 FiO2-30 pO2-142* pCO2-36 pH-7.40 calTCO2-23 Base XS--1
Intubat-INTUBATED Vent-SPONTANEOU
[**2111-7-26**] 03:48AM BLOOD Type-ART pO2-103 pCO2-39 pH-7.39
calTCO2-24 Base XS-0
[**2111-7-26**] 05:01PM BLOOD Type-ART pO2-91 pCO2-26* pH-7.42
calTCO2-17* Base XS--5
[**2111-7-26**] 05:37PM BLOOD Type-ART pO2-121* pCO2-32* pH-7.44
calTCO2-22 Base XS-0
[**2111-7-26**] 09:45PM BLOOD Type-ART Temp-37.1 PEEP-12 pO2-107*
pCO2-32* pH-7.43 calTCO2-22 Base XS--1 Intubat-INTUBATED
Vent-SPONTANEOU
[**2111-7-18**] 05:44AM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-100 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2111-7-23**] 10:35AM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2111-7-27**] 11:28AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2111-7-18**] 2:45 am TISSUE Site: GROIN RIGHT.
**FINAL REPORT [**2111-7-24**]**
GRAM STAIN (Final [**2111-7-18**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final [**2111-7-24**]):
REPORTED BY PHONE TO [**Doctor First Name **] [**Doctor Last Name **]@ 3:30 PM ON[**2111-7-19**].
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
ADDITIONAL WORK-UP PER DR [**Last Name (STitle) **] ([**Numeric Identifier 79536**]).
THIS IS A CORRECTED REPORT ([**2111-7-23**]).
REPORTED BY PHONE TO DR [**Last Name (STitle) **] ([**Numeric Identifier 79536**]) [**2111-7-23**] AT 2:55PM.
ENTEROCOCCUS SP.. HEAVY GROWTH.
BETA STREPTOCOCCUS GROUP B. HEAVY GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
VIRIDANS STREPTOCOCCI. HEAVY GROWTH.
PREVIOUSLY REPORTED AS PROBABLE ENTEROCOCCUS ([**2111-7-21**]).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ <=1 S
ANAEROBIC CULTURE (Final [**2111-7-22**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
[**2111-7-18**] 1:50 am SWAB Site: GROIN LEFT.
**FINAL REPORT [**2111-7-22**]**
GRAM STAIN (Final [**2111-7-18**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2111-7-22**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
BETA STREPTOCOCCUS GROUP B. HEAVY GROWTH.
ANAEROBIC CULTURE (Final [**2111-7-22**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
Pathology Examination
SPECIMEN SUBMITTED: left groin tissue.
Procedure date Tissue received Report Date Diagnosed
by
[**2111-7-18**] [**2111-7-18**] [**2111-7-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 14739**]/axg
DIAGNOSIS:
Left groin tissue:
Soft tissue with extensive necrosis and purulent exudate
consistent with necrotizing fasciitis.
Clinical: Necrotizing fascitis left groin.
Gross: The specimen is received fresh in one container marked
with the patient's name, "[**Known lastname 79537**], [**Known firstname **] J", the medical record
number and "left groin tissue". It consists of one fragmented
piece of skin and attached subcutaneous tissue measuring 22 x 15
x 5 cm. Multiple surgical incisions have already been made to
the specimen. The subcutaneous tissue has a brown color with
copious amounts of purulent exudate. The specimen is
represented in A-C.
[**2111-7-18**] 5:44 am URINE Site: CATHETER Source: Catheter.
**FINAL REPORT [**2111-7-19**]**
URINE CULTURE (Final [**2111-7-19**]): NO GROWTH.
[**2111-7-18**] 11:31 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT [**2111-7-24**]**
Blood Culture, Routine (Final [**2111-7-24**]): NO GROWTH.
[**2111-7-22**] 2:22 am SPUTUM Source: Endotracheal.
**FINAL REPORT [**2111-7-24**]**
GRAM STAIN (Final [**2111-7-22**]):
>25 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2111-7-24**]): NO GROWTH.
[**2111-7-22**] 1:47 pm BRONCHOALVEOLAR LAVAGE
**FINAL REPORT [**2111-7-24**]**
GRAM STAIN (Final [**2111-7-22**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2111-7-24**]): NO GROWTH, <1000
CFU/ml.
[**2111-7-22**] 1:47 pm BRONCHOALVEOLAR LAVAGE RIGHT.
**FINAL REPORT [**2111-7-24**]**
GRAM STAIN (Final [**2111-7-22**]):
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final [**2111-7-24**]): NO GROWTH, <1000
CFU/ml.
[**2111-7-23**] 10:27 am STOOL CONSISTENCY: SOFT Source:
Stool.
**FINAL REPORT [**2111-7-23**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2111-7-23**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
[**2111-7-27**] 1:26 pm CATHETER TIP-IV Source: right sc triple
lumen.
**FINAL REPORT [**2111-7-29**]**
WOUND CULTURE (Final [**2111-7-29**]): No significant growth.
Brief Hospital Course:
[**Known firstname **] [**Known lastname 79537**] is a 27-year-old gentleman with poorly-controlled
type II diabetes and morbid obesity who was referred to [**Hospital1 1535**] for treatment and management of
suspected necrotizing soft tissue infection of left abdominal
wall, groin, thigh and perineum. During his admission, he
underwent 1) radical debridement of soft tissues of left lower
abdominal wall, groin, thigh and perineum ([**2111-7-18**]); and
subsequently 2) debridement and primary closure, with drains, of
necrotizing fasciitis of the perineum ([**2111-7-31**]).
Postoperatively, he was admitted to the ICU for supportive
management. The patient was transferred to the surgical floor on
[**2111-7-28**] when stable.
ID: Post-operatively, the Infectious Disease service was
consulted. The patient was started on broad-spectrum IV
antibiotics (Vancomycin, Clindamycin and
Piperacillin-Tazobactam). The antibiotic regimen was tailored
based on tissue culture results and per the recommendations of
the infectious disease service. The patient was eventually
discharged home on a 7 day course of PO metronidazole. At the
time of discharge, the patient was afebrile and the WBC count
was within normal limits.
Pulmonary: Post-operatively, the patient was maintained on
mechanical ventilation. The post-op course was complicated by a
collapsed right upper lung lobe found on
post-op chest x-ray. Repositioning of the endotracheal tube and
repeat imaging showed improved aeration of the right upper lobe.
On [**2111-7-22**], the patient underwent a bronchoscopy for episodes
of oxygen desaturation and increased respiratory secretions.
Sputum and bronchoalveolar cultures were negative. The patient
was weaned from mechanical ventilation on [**2111-7-27**].
CV: The patient's volume status was monitored closely in the ICU
with a central line and an arterial line. Resuscitative fluid
was given as needed. When, necessary a norepinephrine drip was
used to support the patient's blood pressure. Vital signs were
routinely monitored as per ICU and floor protocol.
Neuro: Post-operatively, the patient received propofol and
benzodiazepines for sedation as needed in the ICU. Pain was
adequately controlled with fentanyl and dilaudid IV with good
effect. When tolerating oral intake, the patient was
transitioned to oral pain medications.
GI/GU: The patient was given gastric ulcer prophylaxis. His diet
was advanced when appropriate, which was tolerated well. The
patient was also started on a bowel regimen to encourage bowel
movement. Cultures for C. difficile toxin were negative. The
foley was removed prior to transfer from the ICU to the surgical
floor. Intake and output were closely monitored.
Skin: After initial operative debridement, the patient's groin
wound was treated with wet-to-dry dressings. Wound care was
transitioned to VAC dressings. The wound was eventually closed
with large vertical mattress sutures approximately over a
suction drainage. The patient was discharged with the drain in
place. He was given written and verbal instructions regarding
proper drain and wound care. In addition, during admission, a
stage 2 decubitis ulcer was found by nursing. It resolved with
proper wound care.
Endocrine: The patient's blood sugar levels were closely
monitored throughout the admission. The patient's diabetes
medication regimen was tailored based on [**Last Name (un) **] Diabetes consult
recommendations. An IV insulin drip was used to control blood
sugar levels when a subcutaneous insulin sliding scale was
inadequate.
DVT Prophylaxis: The patient received subcutaneous heparin
during this stay, and was encouraged to get up and ambulate as
early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, voiding
without assistance, and pain was well controlled on PO
medications.
Medications on Admission:
Per admission note:
Linisopril
Metformin
Insulin
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day).
Disp:*QSF QSF* Refills:*2*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
3. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous four times a day.
Disp:*qs * Refills:*2*
5. Insulin Glargine 100 unit/mL Solution Sig: Fifty (50) units
Subcutaneous once a day.
Disp:*QS * Refills:*2*
6. Insulin Syringe [**12-3**] mL 29 x [**12-3**] Syringe Sig: One (1)
Miscellaneous four times a day.
Disp:*150 syringes* Refills:*2*
7. Lancets Misc Sig: One (1) Miscellaneous four times a
day.
Disp:*150 * Refills:*2*
8. One Touch Ultra 2 Kit Sig: One (1) Miscellaneous four
times a day.
Disp:*1 * Refills:*2*
9. onetouch blood glucose testing strip Sig: One (1) four
times a day.
Disp:*150 * Refills:*2*
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for 3 weeks.
Disp:*60 Tablet(s)* Refills:*0*
11. Colace 100 mg Capsule Sig: One (1) Capsule PO once a day as
needed for constipation for 4 weeks.
Disp:*30 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing fasciitis of the groin/scrotum
Discharge Condition:
Stable, tolerating PO intake, pain controlled
Discharge Instructions:
General:
Please continue to change your groin dressings at home as you
did in the hospital. You may continue to use the Miconazole
powder for moisture in the groin. You should continue to take
your antibiotic for 7 days.
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.
JP Drain Care:
-Please look at the site every day for signs of infection
(increased redness, swelling, odor, yellow or bloody discharge,
fever).
-Maintain the bulb deflated to provide adequate suction.
-Note color, consistency, and amount of fluid in drain. Call
doctor if amount increases significantly or changes in
character.
-Be sure to empty the drain frequently.
-You may shower, wash area gently with warm, soapy water.
-Maintain the site clean, dry, and intact.
-Avoid swimming, baths, hot tubs-do not submerge yourself in
water.
-Keep drain attached safely to body to prevent pulling
Followup Instructions:
Please follow-up in the Trauma Clinic with Dr. [**Last Name (STitle) **] in 1 week.
You will need to call ([**Telephone/Fax (1) 22750**] to schedule an
appointment.
Please follow-up in the [**Hospital **] [**Hospital 982**] Clinic in 2 weeks. You
will need to call ([**Telephone/Fax (1) 4847**] to schedule an appointment.
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71,130
| 143,966
|
38099+38100
|
Discharge summary
|
report+report
|
Admission Date: [**2193-6-20**] Discharge Date: [**2193-7-10**]
Date of Birth: [**2170-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5810**]
Chief Complaint:
agitation
Major Surgical or Invasive Procedure:
MICU intubation/sedation for MRI (agitation)
History of Present Illness:
23 YO M with bipolar disorder and recent admission for traumatic
subdural and subarachnoid hematomas as well as multiple
traumatic orthopaedic fractures ([**5-30**]) now presenting with
increasing agitation and insomnia from rehab. The patient was
transferred to [**Hospital1 **] 1-2 weeks ago. Since the accident, the
patient has had alot of frontal behavior. His agitation has
progressed and [**Hospital1 **] is unable to care for him further. He
was given 10-15 mg IM haldol and transferred to the ED.
.
In the ED, initial vs were not obtained as he was agitated,
punching and fighting with the staff. Patient was given haldol 5
IV with minimal effect then switched to geodon 10 * 3 with good
effect. Exam was otherwise unremarkable. CT head showed an
increase in SDH and contusion size. Given that he sounded
rhoncorous on exam, a CXR was done and was without acute
cardiopulm change. Neurosurg and trauma surgery were consulted
and both felt that the patient was stable and inappropriate for
their services so the patient was admitted to the MICU for
continued monitoring of his agitation. VS prior to transfer: 100
129/75 16 100%RA.
Past Medical History:
Right subdural hematoma, a small right subarachnoid hematoma,
left calvarium fracture, left sphenoid fracture, left mandibular
fossa fracture, multiple left rib fractures, and a left clavicle
fracture with small PTX all managed conservatively after
unhelmeted motorcycle accident. Admission complicated by PEG
tube [**6-7**].
GERD
Bipolar
Social History:
HS grad, works as mechanic. Lives with parents, has
girlfriend.
Substance use: intermittent alcohol use, sometimes excessive
but
not daily; regular marijuana use.
Family History:
Depression in mother and others on mother's side of family
Physical Exam:
General: pacing the room, anxious-appearing, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly, G-tube in
place without surrounding erythema or signs of infection
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Labs on Admission:
[**2193-6-20**] 05:00PM BLOOD WBC-9.5 RBC-3.70* Hgb-11.6* Hct-32.9*
MCV-89 MCH-31.4 MCHC-35.3* RDW-13.3 Plt Ct-515*
[**2193-6-20**] 05:00PM BLOOD Neuts-64.6 Lymphs-24.6 Monos-7.1 Eos-2.8
Baso-0.8
[**2193-6-21**] 03:45AM BLOOD PT-13.6* PTT-26.9 INR(PT)-1.2*
[**2193-6-20**] 05:00PM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-137
K-6.2* Cl-100 HCO3-27 AnGap-16
[**2193-6-21**] 03:45AM BLOOD ALT-22 AST-21 CK(CPK)-129 AlkPhos-356*
TotBili-0.5
[**2193-6-21**] 03:45AM BLOOD Albumin-3.3* Calcium-8.8 Phos-5.0* Mg-2.0
[**2193-6-21**] 03:45AM BLOOD Albumin-3.3* Calcium-8.8 Phos-5.0* Mg-2.0
[**2193-6-22**] 02:46AM BLOOD calTIBC-202* VitB12-722 Ferritn-200
TRF-155*
[**2193-6-24**] 05:35AM BLOOD Triglyc-126
[**2193-6-21**] 03:45AM BLOOD TSH-1.0
[**2193-6-23**] 10:33AM BLOOD CRP-92.4*
[**2193-6-23**] 10:33AM BLOOD HIV Ab-NEGATIVE
.
Labs on Discharge:
[**2193-7-8**] 03:25PM BLOOD WBC-9.0 RBC-4.39* Hgb-13.2* Hct-40.8
MCV-93 MCH-30.1 MCHC-32.4 RDW-15.9* Plt Ct-431
[**2193-7-8**] 03:25PM BLOOD Plt Ct-431
Micro:
[**2193-6-21**]: RPR negative
[**2193-6-22**] sputum: oral flora
[**2193-6-22**]: urine negative
[**2193-6-22**]: blood cultures NGTD
[**2193-6-23**]: BAL with coag + staph
.
MR [**Name13 (STitle) 430**] [**6-21**]:
1.Right frontal, temporal, and parietal subdural hematoma.
Apparently unchanged since the prior studies. High signal
intensity is demonstrated in the left opercular region on the
FLAIR sequence, likely related with brain edema and contusions
with possible hemorrhagic transformation and underlying
subarachnoid hemorrhage with moderate restricted diffusion.
2. Multiple foci of magnetic susceptibility are noted adjacent
to the subdural collection and also in the left cerebral
hemisphere as described above, likely consistent with
microhemorrhages, possible slow flow is demonstrated in the
right insular region, possibly related with brain edema.
3. Unchanged left temporal bone fracture with opacities in the
left mastoid
air cells. Minimal mucosal thickening is noted on the left
sphenoid sinus.
There is also mucosal thickening and fluid in the left petrous
apex, related with the previously described left temporal bone
fracture.
CT abd/pelvis [**6-23**]:
1. Left lower lobe consolidation concerning for pneumonia,
particularly as
there is only mild to moderate volume loss, with associated
small left pleural effusion. Clinical correlation suggested.
2. Small pericardial effusion layering dependently, posteriorly.
3. Interval callus formation surrounding the multiple left-sided
rib
fractures and left scapular fracture.
CT Head w/o contrast [**7-2**]:
1. Significant region of hypodensity in the right
temporoparietal region,
concerning for acute/subacute infarction, new in appearance from
examination of [**2193-6-20**]; evolving (non-hemorrhagic)
contusion is an additional diagnostic consideration.
2. Stable right subdural hygroma with stable degree of gyral
effacement and
leftward shift of the midline structures.
3. Hypodensity in the right frontal lobe, compatible with
continued evolution of contusion.
4. Complex left calvarial and central skull base fractures,
better-
characterized on the CTA of [**2193-5-30**].
TTE [**6-22**]: Normal study. No valvular pathology or pathologic flow
identified. No pericardial effusion
Brief Hospital Course:
Mr. [**Known lastname **] is a 23 year old man with a history of bipolar
disorder and traumatic brain injury who presented from [**Hospital **]
Hospital with agitation and insomnia. Initially admitted on
[**2193-6-20**] to the micu for increased nursing needs and intubation
for MRI, then transferred to the floor. He was eventually
discharged to [**Hospital6 979**] -
[**Location (un) 246**] on [**2193-7-10**]
.
# Agitation: On the floor he would occasionally be aggressive
to nurses and family. This was difficult to control, but
eventually was controlled with haldol which was titrated down to
2.5mg qhs before discharge, with neurology recommendations to
continue for 2 more nights post-discharge and eventually switch
to seroquel. Pt was also started on depakote 500 mg po bid,
citalopram 20mg daily, and trazodone 50mg qhs for sleep per
neurology recs. The last week in-house he slept well with no
behavior issues. His Trazadone was eventually decreased to 25mg
QHS with continued good response. He will be following up with
the Neurology Cognitive behavioral clinic at [**Hospital1 18**].
.
#[**Name (NI) 19278**] pt developed fevers in the MICU. Neurology recommended
evaluation for HSV encephalitis. He was intubated for MRI
which did not show evidence of temporal lobe enhancement or
evidence of HSV. He was not able to undergo LP due to concerns
for mildline shift on head imaging. He was started on Acyclovir
800mg IV q8H for empiric treatment of HSV enecephalitis, which
was transitioned to PO, and he completed a 10 day course.
While intubated in the MICU, he underwent bronchoscopy which
showed 1000 colonies of coag + staph aureus. He was started on
Vancomycin. He was extubated on [**2193-6-24**]. He had no other
respiratory symptoms and no cough. His vancomycin was stopped
on [**2193-6-27**].
.
#Tremor: Pt had a noticable tremor of the body and arms, which
was worse while he was awake. He was started on Propranolol
20mg PO TID per neurology recommendations, which was increased
to 40 mg po TID once he got to the floor. His tremor remained
but was stable throughout the remainder of admission, and he was
instructed to continue his propranolol at 40mg TID after
discharge.
.
# Gait abnormaloty: Of note, on [**7-2**] it was noticed that his
posture was different while walking. He leaning backward, and
there was a concern for a change in his neuro-status. Head CT
was obtained which showed an infarct in his right
parieto-occipital lobe, in addition to evolution of his
contusion in the right frontal lobe. It was thought that the
infarct was not acute, as he likely would not have showed up on
the CT had it been acute. Neurology felt that there was likely
more of a behavioral component to his posturing as opposed to a
neurological change. He will be following up w/ an outpt head CT
with neurosurgery
.
#Nutrition: He was started on tube feeds through a PEG briefly
in the MICU, but this caused him to have diarrhea. Tube feeds
were held. Once he was transferred to the floor, tube feeds were
then restarted on [**7-2**]. He has tolerated the feeds well, and was
instructed to continue this.
.
#HTN: His blood pressures began running high beginning around
[**7-1**]. Possibly [**1-1**] agitation. We started him on amlodipine 5mg
daily on [**7-2**] and his pressures responded well. He was
discharged on this regimen.
.
# Cardiac: He was noted to have mild ST segment elevation and PR
segment depression on ECG. His cardiac enzymes were negative.
He underwent TTE to evaluate for pericarditis which was normal.
His ECG was monitored and was unchanged.
.
#Dispo: Patient was eventually discharged to outpatient rehab
at [**Hospital6 979**] - [**Location (un) 246**]
Medications on Admission:
Heparin (Porcine) 5,000 unit/mL TID
Olanzapine 10 qhs
Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Ciprofloxacin 0.3 % Drops Sig: Three (3) Drop Ophthalmic [**Hospital1 **]
Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID
Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
Haloperidol 2.5 mg IV Q8H:PRN agitation
Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H
Discharge Medications:
1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Acetaminophen 650 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for fever or pain.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
6. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane
TID (3 times a day) as needed for for skin breakdown.
7. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Propranolol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
11. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for Constipation.
12. Carbamide Peroxide 6.5 % Drops Sig: 5-10 Drops Otic [**Hospital1 **] (2
times a day) for 4 days.
13. Haloperidol 1 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime).
(this may be switched to Seroquel 100mg by mouth at bedtime
after 2 nights from discharge)
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 979**] - [**Location (un) 246**]
Discharge Diagnosis:
Agitation
Insomnia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. [**Known lastname **],
You were admitted to the hospital from your rehab because of
increased agitation and difficulty sleeping. During the
admission you were initially admitted to the ICU for close
observation, and once you were stable, you were transferred to
the general medical floor. After adjusting your medications,
your agitation and sleep improved. You did quite well over the
past week, and we feel that you are medically clear to return to
rehab.
Please continue to take your medications as prescribed. We
recommend that you continue Haldol 2.5 mg by mouth at bed time
for the next 3 nights. After that, we recommending switching to
seroquel 100mg by mouth nightly and stopping haldol.
We have added or changed the following medications during your
hospital stay which should be continued at rehab:
-Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
-Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4
times a day) as needed for rash.
-Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID
(3 times a day) as needed for for skin breakdown.
-Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO BID (2 times a day).
-Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
-Propranolol 40 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
-Haloperidol 5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
Followup Instructions:
Department: Neurology-Cognitive behavioral clinic
[**2193-8-22**]
Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 1703**]
Department: RADIOLOGY
When: THURSDAY [**2193-7-25**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2193-7-25**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Admission Date: [**2193-7-16**] Discharge Date: [**2193-7-22**]
Date of Birth: [**2170-4-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3574**]
Chief Complaint:
CC:[**CC Contact Info 85031**]
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 23 year old man with h/o bipolar d/o, s/p MVA with
resultant TBI, subdural and subarachnoid hematomas, multiple
fractures, who re-presents from rehab with increased agitation.
Traumatic brain injury was due to a motorcycle accident [**2193-5-30**],
with resultant deficits from this injury. This is his second
readmission from rehab due to increased agitation; will need
placement at a facility that can manage pt agitation. The
patient was noted to be increasingly agitated and had aggressive
behavior, correlated with trouble with insomnia. He received
multiple medications and required 5 people to restrain him prior
to transfer back to the ED.
.
In the ED initial VS were T 99.4 P 105 BP 136/77 RR 16 O2sat
100%RA. The patient was combatant with the ED staff. Over the
course of the last day, he has received Haldol 25mg and Ativan
8mg. He was evaluated by Psych and Neuro. EKG was done today
prior to transfer and showed no QTc prolongation. He was
admitted to medicine to further care.
.
The patient was confused on his first trip up to the floor - he
wandered down the [**Doctor Last Name **] and was eventually taken back down to the
ED. He calmed down and fell asleep, so he was transferred back
to the floor. He remains very sleepy and initially did not
waking up to cooperate with an exam for nightfloat. This AM pt
again wandering the halls looking for mother, mostly cooperative
and redirectable.
.
ROS:
unable to assess
Past Medical History:
s/p MVA with TBI -->Right subdural hematoma, a small right
subarachnoid hematoma, left calvarium fracture, left sphenoid
fracture, left mandibular fossa fracture, multiple left rib
fractures, and a left claviclefracture with small PTX all
managed conservatively after unhelmeted motorcycle accident.
Admission complicated by PEG tube [**6-7**].
GERD
Bipolar/depression
Social History:
HS grad, works as mechanic. Lives with parents, has
girlfriend.
Substance use: intermittent alcohol use, sometimes excessive
but
not daily; regular marijuana use.
Was at [**Hospital6 **] for about a week prior to this
admission. Previously lived at home with his parents prior to
his accident. Was actively smoking and drinking.
Family History:
Depression in mother and others on mother's side of family
Mom with ovarian ca, depression, anxiety. Dad with HLD
Physical Exam:
Physical exam on day of admission:
VS: T 96.8 P 82 BP 106/60 RR 20 O2sat 98%RA
Gen: awake, wandering the halls, NAD, no complaints of pain, pt
not always able to comply with exam due to traumatic brain
injury
CV: RRR S1 S2 no R/G/M
Pulm: CTAB, no rhonchi rales or wheezes
Abd: Gtube and binder in place, +BS, soft NTND
Ext: no edema, pulses 2+ bilaterally
Neuro: unable to fully assess, pt ambulating, talking, not
always making sense but looking for mother, not currently
agitated
.
Pertinent Results:
[**2193-7-16**] 07:50PM GLUCOSE-108* UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
[**2193-7-16**] 07:50PM ALT(SGPT)-112* AST(SGOT)-45* LD(LDH)-179 ALK
PHOS-193* TOT BILI-0.3
[**2193-7-16**] 07:50PM LIPASE-100*
[**2193-7-16**] 07:50PM VALPROATE-47*
[**2193-7-16**] 07:50PM WBC-10.5 RBC-4.18* HGB-12.7* HCT-37.2* MCV-89
MCH-30.4 MCHC-34.2 RDW-15.2
[**2193-7-16**] 07:50PM NEUTS-71.2* LYMPHS-20.0 MONOS-6.7 EOS-1.7
BASOS-0.4
[**2193-7-16**] 07:50PM PLT COUNT-254
[**2193-7-16**] 07:50PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2193-7-16**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2193-7-16**] 07:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
Evolving left frontal and temporo-occipital nonhemorrhagic
contusions.
Stable 1-cm right subdural hygroma.
Complex left calvarial and skull base fractures, better
described on CTA from [**2193-5-30**].
...
[**2193-7-20**] 10:15AM BLOOD WBC-5.5 RBC-4.00* Hgb-12.0* Hct-36.1*
MCV-90 MCH-30.1 MCHC-33.3 RDW-14.9 Plt Ct-246
[**2193-7-19**] 06:00AM BLOOD WBC-6.4 RBC-4.05* Hgb-12.1* Hct-36.5*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.9 Plt Ct-225
[**2193-7-18**] 05:45AM BLOOD WBC-7.4 RBC-4.42* Hgb-13.2* Hct-40.1
MCV-91 MCH-29.8 MCHC-32.8 RDW-15.2 Plt Ct-248
[**2193-7-16**] 07:50PM BLOOD WBC-10.5 RBC-4.18* Hgb-12.7* Hct-37.2*
MCV-89 MCH-30.4 MCHC-34.2 RDW-15.2 Plt Ct-254
[**2193-7-16**] 07:50PM BLOOD Neuts-71.2* Lymphs-20.0 Monos-6.7 Eos-1.7
Baso-0.4
[**2193-7-20**] 10:15AM BLOOD Plt Ct-246
[**2193-7-19**] 06:00AM BLOOD Plt Ct-225
[**2193-7-18**] 05:45AM BLOOD Plt Ct-248
[**2193-7-16**] 07:50PM BLOOD Plt Ct-254
[**2193-7-20**] 10:15AM BLOOD Glucose-90 UreaN-10 Creat-0.5 Na-142
K-3.9 Cl-105 HCO3-27 AnGap-14
[**2193-7-19**] 06:00AM BLOOD Glucose-88 UreaN-12 Creat-0.6 Na-141
K-4.0 Cl-103 HCO3-30 AnGap-12
[**2193-7-18**] 05:45AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-142
K-4.4 Cl-104 HCO3-30 AnGap-12
[**2193-7-16**] 07:50PM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-140
K-3.8 Cl-103 HCO3-25 AnGap-16
[**2193-7-20**] 10:15AM BLOOD ALT-97* AST-57* AlkPhos-187* TotBili-0.4
[**2193-7-19**] 06:00AM BLOOD ALT-91* AST-55* AlkPhos-190* TotBili-0.4
[**2193-7-18**] 05:45AM BLOOD ALT-85* AST-42* LD(LDH)-153 CK(CPK)-404*
AlkPhos-187* TotBili-0.6
[**2193-7-16**] 07:50PM BLOOD ALT-112* AST-45* LD(LDH)-179 AlkPhos-193*
TotBili-0.3
[**2193-7-20**] 10:15AM BLOOD Lipase-54
[**2193-7-19**] 06:00AM BLOOD Lipase-37
[**2193-7-18**] 05:45AM BLOOD Lipase-40
[**2193-7-16**] 07:50PM BLOOD Lipase-100*
[**2193-7-20**] 10:15AM BLOOD Calcium-9.3 Phos-3.5 Mg-1.9
[**2193-7-19**] 06:00AM BLOOD Calcium-9.4 Phos-3.8# Mg-2.0
[**2193-7-18**] 05:45AM BLOOD Albumin-4.0 Calcium-9.8 Phos-5.4* Mg-2.2
[**2193-7-16**] 07:50PM BLOOD Valproa-47*
[**2193-7-16**] 07:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
ECG Study Date of [**2193-7-17**] 1:57:02 AM
Marked baseline artifact. Tall voltage in the lateral precordial
leads. J point elevation in leads V4-V6. Within the constraints
of the baseline artifact, compared to the previous tracing of
[**2193-6-25**] there is probably no diagnostic interim change. This
tracing is probably within normal limits for a patient of this
age.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
116 106 90 312/410 51 67 44
.
ECG Study Date of [**2193-7-17**] 9:42:50 PM
Sinus rhythm. J point elevation with early repolarization in
precordial leads may be a normal variant. PR segment depression
is also present. Consider acute pericardial disease. Compared to
the previous tracing of [**2193-7-17**] baseline artifact in prior
tracing precludes definitive comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
93 144 84 350/407 32 46 47
.
CT HEAD W/O CONTRAST Study Date of [**2193-7-17**] 2:13 AM
FINDINGS: Previously visualized right frontal (2:20) and
temporo-occipital (2:14) hypodensities appear less prominent
since prior examination, consistent with evolving nonhemorrhagic
contusions. There is no new hemorrhage, edema, or infarct. A
chronic right subdural hematoma, now close to CSF in attenuation
(17-18 [**Doctor Last Name **]) is stable, measuring up to 1 cm in maximum thickness,
with stable 3-mm leftward shift of the normally midline
structures. The ventricles and sulci are normal in size and
morphology. The basal cisterns are widely patent, without
evidence of uncal or transtentorial herniation. Again noted is
a complex left calvarial fracture involving the left sphenoid
and temporal bones and extending into the skull base, better
characterized on CTA from [**2193-5-30**]. Hemorrhagic opacification of
multiple right mastoid air cells persists. There is mucosal
thickening of multiple ethmoid air cells, and a mucus-retention
cyst in the right sphenoid sinus.
IMPRESSION:
1. Evolving left frontal and temporo-occipital nonhemorrhagic
contusions.
2. Stable chronic right subdural hematoma, now of virtual-CSF
attenuation.
3. Complex left calvarial and skull base fractures, better
described on CTA from [**2193-5-30**], with opacification of the left
mastoid air cells and middle ear cavity, as before.
Brief Hospital Course:
Pt is a 23 year old man with h/o bipolar d/o, s/p MVA with
resultant TBI, subdural and subarachnoid hematomas, multiple
fractures, who re-presents from rehab with increased agitation.
Traumatic brain injury was due to a motorcycle accident [**2193-5-30**],
with resultant deficits from this injury. This is his second
readmission from rehab due to increased agitation; will need
placement at a facility that can manage pt agitation. The
patient was noted to be increasingly agitated and had aggressive
behavior, correlated with trouble with insomnia. He received
multiple medications and required 5 people to restrain him prior
to transfer back to the ED.
.
In the ED initial VS were T 99.4 P 105 BP 136/77 RR 16 O2sat
100%RA. The patient was combatant with the ED staff. Over the
course of the last day, he has received Haldol 25mg and Ativan
8mg. He was evaluated by Psych and Neuro. EKG was done today
prior to transfer and showed no QTc prolongation. He was
admitted to medicine to further care but had to return to ED b/c
of further significant agitation. In the morning pt agitation
had resolved.
.
Neurology was consulted to titrate medication. While this
titration was underway, the pt again had several nights with
agitation in the evening. Pt was generally ok during the day
especial with parents present (pt parents stayed overnight with
pt after the first night with moderate improvement in
agitation). During the day pt would roam the floor w/sitter or
family member and was very friendly and ate ice cream
frequently, generally cooperative and easily redirectable.
However, at night pt became increasingly restless and less
directable, wandering into other pt's rooms. This would result
in confrontation which would significantly distress pt who would
react by hitting and becoming agitated (e.g. several nurses were
hit, a picture [**Last Name (un) **] was smashed, security had to be called,
etc). Family felt that pt's agitation was worsened by unfamilar
environment and the boundaries imposed on his need to roam b/c
of pt safety issues. Per neurology recommendations, medications
were titrated up to the follow:
-Seroquel (Quetiapine Fumarate) 200 mg daily to be given at8PM;
with insturction to please give at *8pm*, two hours prior to
giving trazadone.
- Seroquel (Quetiapine Fumarate) 50 mg three times per day with
a morning, mid day and afternoon dose.
- For anxiety or agitation, pt was prescribed additional doses
of Seroquel (Quetiapine) 25 mg Tablets, 1-2 Tablets every [**3-5**]
hours as needed for anxiety/agitation
- traZODONE 150 mg at night at 10pm; with instructions to be
given 2hrs after seroquel 200mg dose in evening at 10pm.
- For trouble sleeping after the initial dose of 150mg of
trazodone, pt was prescribed an additional traZODONE 25-50 mg at
night as needed for insomnia.
- Melatonin 3mg each evening at the same time as the evening
dose of trazadone of 150mg.
- BusPIRone 20 mg three times a day
- Benztropine Mesylate 1 mg DAILY
- Propranolol 60 mg three times daily
- Clonazepam 1 mg at night at the same time as taking the 200mg
dose of Seroquel at 8pm
- Haldol was stopped
- Citalopram was stopped
- Valproic acid was stopped
- Olanzapine was stopped
.
Family meeting was held to discuss plans for discharge and
rehab. Family preferred discharge home to familiar environment
rather than rehab with the plan for pt to participate in day
program for pt's with traumatic brain injury.
.
Pt had mild elevation in LFTs but this was believed to be
related to medications. Pt did not have any acute medical issue
while in the hospital.
.
Pt was full code during this admission and was discharge home
under the care of his parents.
.
Medications on Admission:
Propranolol 50mg PO TID
Quetiapine 100mg PO qhs, 25-50mg PO q3h prn agitation
Ranitidine 150mg Po q12h
Trazodone 100mg PO qhs, 25mg PO prn
Valproic acid 250mg PO QID
Tylenol 650mg PO q4h prn pain
Miconazole QID prn rash
Olanzapine 2.5mg IM q4h prn
Amlodipine 5mg PO daily
Benztropine 1mg PO qAM
Buspirone 20mg PO TID
Citalopram 20mg PO BID
Colace 100mg PO BID
Nicotine 7mg TD daily
Olanzapine 2.5mg PO qhs
Senna 2tabs [**Hospital1 **] prn constipation
Discharge Medications:
1. Outpatient Occupational Therapy
diagnosis: traumatic brain injury
Please evaluate and treat for cognitive retraining.
2. Outpatient Speech/Swallowing Therapy
diagnosis: traumatic brain injury
Please evaluate and treat for cognitive retraining.
3. Outpatient Physical Therapy
diagnosis: traumatic brain injury
Please evaluate and treat for cognitive retraining.
4. [**Location (un) **] Bed
diagnosis: traumatic brain injury
Patient is danger to self and others and is at risk for
elopement.
5. Propranolol 40 mg Tablet Sig: 1.5 Tablets PO TID (3 times a
day).
Disp:*135 Tablet(s)* Refills:*2*
6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for rash.
9. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Benztropine 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
11. Buspirone 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day).
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
14. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
15. Quetiapine 50 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
Disp:*90 Tablet(s)* Refills:*2*
16. Quetiapine 200 mg Tablet Sig: One (1) Tablet PO at bedtime:
give 2 hours before bedtime.
Disp:*30 Tablet(s)* Refills:*2*
17. Trazodone 150 mg Tablet Sig: One (1) Tablet PO at bedtime:
at bedtime.
Disp:*30 Tablet(s)* Refills:*2*
18. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)): 2 hours before bedtime with seroquel.
Disp:*30 Tablet(s)* Refills:*2*
19. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*90 Tablet(s)* Refills:*1*
20. Quetiapine 25 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed for anxiety/agitation.
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Last Name (LF) 486**], [**First Name3 (LF) 487**]
Discharge Diagnosis:
Primary:
Agitation related to traumatic brain injury and altered sleep
wake cycle
Insomnia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent but requires a sitter
due to wandering.
Discharge Instructions:
You were admitted to the hospital from the rehabilitation
facility because you were increasingly agitated. It was felt
that this was in part related to difficulty sleeping in
combination with unfamiliar surroundings in the setting of your
recent brain injury from which you are recovering. While in the
hospital we worked on titrating your medications so that you
would be able to sleep more normally and not be agitated during
the day or evening.
.
The following changes were made to your medications:
- Please START taking Seroquel (Quetiapine Fumarate) 200 mg
daily to be given at8PM; please give at *8pm*, two hours prior
to giving trazadone.
- Please START taking Seroquel (Quetiapine Fumarate) 50 mg three
times per day with a morning, mid day and afternoon dose.
- If you are feeling anxious or agitated, you can take
additional doses of Seroquel (Quetiapine) 25 mg Tablets, [**12-1**]
Tablets every 4-6 hours as needed for anxiety/agitation
- Please START taking traZODONE 150 mg at night at 10pm; please
give 2hrs after seroquel 200mg dose in evening at 10pm.
- If you have trouble sleeping after the initial dose of 150mg
of trazodone, you may take an additional traZODONE 25-50 mg at
night as needed for insomnia.
- Please START taking melatonin 3mg each evening at the same
time as your evening dose of trazadone of 150mg. Melatonin can
be obtained at your local drugstord (e.g. CVS or [**Company 4916**], etc)
- Please START taking BusPIRone 20 mg three times a day
- Please START taking Benztropine Mesylate 1 mg DAILY
- Please START taking Propranolol 60 mg three times daily
- Please START taking Clonazepam 1 mg at night at the same time
as taking the 200mg dose of Seroquel at 8pm
- Please STOP taking Haldol.
- Please STOP taking Citalopram,
- Please STOP taking Valproic acid
- Please STOP takeing Olanzapine.
- If you continue to smoke cigarrettes, please STOP using the
nictotine patches (these should only be used if you are STOP
smoking)
- Please CONTINUE taking Amlodipine 5 mg DAILY
- Please CONTINUE taking Ranitidine 150 mg PO/NG [**Hospital1 **]
- Please continue to take all of your other home medications as
prescribed.
Please be sure to take all medication as prescribed. It is
especially important to take the seroquel, trazadone and
melatonin at the prescribed times for the evening doses to help
you sleep and restore your sleep cycle.
.
Please be sure to keep all follow-up appointments with your PCP
and neurologist and other health care providers.
.
It was a pleasure taking care of you and we wish you a speedy
recovery.
Followup Instructions:
Please be sure to keep all follow-up appointments with your PCP
and neurologist and other health care providers.
.
Department: RADIOLOGY
When: THURSDAY [**2193-7-25**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 327**]
Building: CC CLINICAL CENTER [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: NEUROSURGERY
When: THURSDAY [**2193-7-25**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: COGNITIVE NEUROLOGY UNIT
When: THURSDAY [**2193-8-22**] at 2:00 PM
With: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 1690**]
Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **]
Campus: EAST Best Parking: Main Garage
Completed by:[**2193-7-31**]
|
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17,149
| 183,984
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4147
|
Discharge summary
|
report
|
Admission Date: [**2154-10-10**] Discharge Date: [**2154-10-20**]
Date of Birth: [**2097-9-7**] Sex: M
Service: MEDICINE
Allergies:
Plavix / Simvastatin / Tape / Hydrochlorothiazide / Eptifibatide
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
chest pain, angina, shortness of breath
Major Surgical or Invasive Procedure:
Intubated, Extubated
History of Present Illness:
57yo gentleman with h/o CAD s/p 2 MIs, renal transplant [**5-/2154**]
for Wegener's granulomatosis, HTN, dyslipidemia, and paroxysmal
AFib p/w accelerating angina. He c/o pain in his jaw, which then
moves to his throat and then the middle of his chest; feels like
pressure. Symptoms are provoked by activity and associated with
dyspnea. Patient states that symptoms began a few months ago and
have been worsening in the sense that they come on with less
stimulus (now just with walking across the room) and only
resolve with nitro. He also reports feeling exhausted. He has
had a cough productive of large amounts of white sputum x 1
week. +sinus congestion, which he reports feeling like it is
dripping down the back of his throat and collecting in his
lungs. He also notes subjective fevers at home and nausea with
episode of non-bloody emesis in the ED. He has had diarrhea
about 5 times a day, "like minestrone soup." He denies sore
throat, abdominal pain, or dysuria, and he only gets headaches
when he takes the nitroglycerin. Of note, he does endorse PND
and orthopnea as well as ankle edema. He reports 10 pounds of
weight gain in the last week.
.
In the ED, his VS were 100.7, Tmax 102 89 120/68 18 97% RA. He
was given ASA 325mg and Tylenol 650mg as well as Metoprolol 5mg
IV. Levaquin 750mg po was administered at 16:00 for concern of
pneumonia. EKG showed ST depression in V4-V6 as well as I and
aVL and upsloping ST elevation in V1 and V2. Troponin was 0.27
(last Trop 0.04 in [**10-22**]). Patient was evaluated by the
cardiology fellow, and a heparin gtt was ordered, but not
started per nursing notes. Patient was also seen by transplant
nephrology fellow.
Past Medical History:
-Paroxysmal Atrial fibrillation, not on coumadin
-ESRD s/p living donor (sister) renal transplant in [**5-/2154**]
-CAD:
- s/p acute MI [**2143**] with Palmaz LAD and RCA stents
- s/p rotablation and hepacoat stent to the D1 in [**6-/2149**],
treated with brachytherapy for instent restenosis in [**10/2149**]
- s/p Taxus stent in RPL in [**10/2151**]
- s/p two Cypher stents placed in the RCA [**10/2152**]
- cath in [**7-23**] with 60-70% ostial stenosis of LAD, moderate
diffuse disease of LCx, 60% proximal of RCA with in stent
restenosis with a 70% in the PL branch Taxus stent(for latest
cath, see pertinent results)
-Denies h/o DM; however, sugars have been elevated in past
-Chronic angina
-Hypertension
-Hypercholesterolemia
-Wegener's granulomatosis (renal/pulmonary involvement)
diagnosed [**2143**] s/p cytoxan/prednisone x 1y initially, ANCA neg.
since (chronic proteinuria); now s/p renal transplant in [**5-/2154**]
-Idiopathic pericarditis [**2150**]
-GERD
-Anxiety, endorses dysthymic symptoms but not depression
-Gout
-Umbilical hernia repair
-Restless leg syndrome
.
OUTPATIENT CARDIOLOGIST: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Nephrologist: Dr. [**Last Name (STitle) 1366**]
Transplant Nephrologist: [**Doctor First Name **] [**Doctor Last Name **]
PCP: [**First Name8 (NamePattern2) 3788**] [**Last Name (NamePattern1) **]
.
Allergies:
Plavix--rash
Simvastatin--myalgia
Tape--rash
HCTZ--unkown reaction
Social History:
Social history is significant for the absence of current tobacco
use; quit 25 years ago. There is no history of alcohol abuse; he
endorses rare EtOH. No illicit drugs. Married with 3 children,
lives w/ wife and youngest daughter.
Family History:
There is no family history of premature coronary artery disease
or sudden death. Mother had CVA at 46. Sister with scleroderma
and another sister with [**Name (NI) 18109**].
Physical Exam:
VS - 99.7 131/78 91 20 96% RA 175 pounds
Gen: Pale-appearing middle aged male in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, with some pallor but no cyanosis of the oral mucosa. No
xanthalesma.
Neck: Supple. JVP of 5cm.
CV: PMI located in 5th intercostal space, midclavicular line.
RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4.
Chest: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. +Crackles, L>R with
good air entry b/l.
Abd: Soft, NT, mildly distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Somewhat diaphoretic.
.
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:
LABORATORY DATA:
CK 198 Troponin 0.27
CK-MB 4
Hct 25
Cr 2.3
.
EKG demonstrated NSR with old Q wave in V3 but new ST
depressions in V5-V6 and I, aVL as well as ST elevations in V1
and V2 as compared with prior dated [**2154-7-25**].
.
CXR [**10-10**]:
TWO VIEWS OF THE CHEST: There are slight increased patchy
opacities in the right lower lobe, which is seen to project
posteriorly on the lateral view. This may represent an
early/developing pneumonia. The left lung is clear. The aorta is
tortuous. Small Kerley B lines suggest mild interstitial edema.
The bony thorax is normal.
IMPRESSION:
1. Possible early/developing right lower lobe pneumonia.
2. Mild interstitial edema.
.
Echo [**10-11**]:
The left atrium and right atrium is moderately dilated. A
left-to-right shunt across the interatrial septum is seen at
rest c/w a small secundum atrial septal defect.Left ventricular
wall thicknesses and cavity size are normal. There is moderate
regional left ventricular systolic dysfunction with focal
hypokinesis of the basal half of the inferior and inferolateral
walls and distal lateral and anterior walls. The remaining
segments contract normally (LVEF = 35 %). No masses or thrombi
are seen in the left ventricle. Right ventricular chamber size
and free wall motion are normal. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are
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.
IMPRESSION: Regional left ventricular systolic dysfunction c/w
CAD. Moderate mitral regurgitation most likely due to papillary
muscle dysfunction. Secundum type atrial septal defect. Mild
pulmonary artery systolic hyertension.
Compared with the prior study (images reviewed) of [**2152-10-31**],
regional left ventricular systolic dysfunction is more extensive
(now involving the basal inferior and inferolateral walls), the
severity of mitral regurgitation has increased, and pulmonary
artery systolic hypertension is now identified. The secundum
type atrial septal defect is now better defined.
.
PORTABLE ABDOMINAL ULTRASOUND ([**10-13**])
FINDINGS: Limited grayscale images of the abdomen do not detect
ascites and limited views of the liver suggest normal
echotexture.
IMPRESSION: No ascites.
.
CXR [**10-13**]:
Increased airspace disease is evident by progressive increasing
density of the bilateral consolidations, the left now clearly
expressing itself as such. There is a subtle motion degradation
though lateral costophrenic sulci are still reasonably
delineated. Heart size is enlarged.
IMPRESSION: Worsening airspace disease bilaterally for which
bilateral
pneumonias most fitting.
.
ABDOMINAL FILM ON [**2154-10-13**]
INDICATION: Abdominal distention, increased dyspnea and
difficulty breathing.
A single view of the abdomen shows nonspecific non-obstructed
bowel gas
pattern with predominantly gas-filled large bowel visualized.
The appearance is quite similar to a remote prior abdominal film
from [**2154-5-21**]. On the current study, there are surgical
clips overlying the sacrum and there is no evidence for
pneumatosis. No ascites
.
CXR [**10-13**]:
Increased airspace disease is evident by progressive increasing
density of the bilateral consolidations, the left now clearly
expressing itself as such. There is a subtle motion degradation
though lateral costophrenic sulci are still reasonably
delineated. Heart size is enlarged.
IMPRESSION: Worsening airspace disease bilaterally for which
bilateral
pneumonias most fitting.
.
Echo [**10-15**]:
The left atrium is elongated. The right atrium is moderately
dilated. There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity size is normal. There is moderate
regional left ventricular systolic dysfunction with
inferior/inferolateral and apical hypokinesis with mild
hypokinesis elsewhere. Right ventricular chamber size and free
wall motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
Agitated saline contrast study is suggestive of intracardiac
shunt with Valsalva release consistent with the presence of a
patent foramen ovale (or ASD).
Compared with the prior study (images reviewed) of [**2154-10-11**],
ventricular function appears similar.
Brief Hospital Course:
[**Hospital 1516**] Hospital course:
Admitted to [**Hospital Unit Name 196**] with NSTEMI with positive enzymes, (peak trop
0.54, CK 298, CK-MB 6), and EKG with inferolateral 1-2mm ST
depressions, 1mm ST depressions in aVL and 1mm STE in aVR (has
baseline 1-2mm STE in V1, V2). Had TTE here after admission on
[**10-11**] confirming the EF of 35% as well as focal HK of basal
inferior and inferolateral walls and distal lateral and anterior
walls. Was started on heparin gtt, integrillin gtt the latter of
which was d/c'd on the day of transfer to the CCU. Was treated
with abx for PNA, and pulm also had plan for bronch/IBAL [**10-14**]
but course was complicated by intermittent hypotension and hct
drop to 25 for which he was transfused 3 units of prbc's and 1L
of NS. After receiving the blood transfusion pt started to
experience acute SOB this am at around 2:30am. Patient was
given furosemide 40mg IV with urine output of 700cc in 2 hours.
He was also given morphine 1mg IV x 4, and lorazepam 0.5mg IV x
1. No associated fevers with transfusion, although he did spike
to 101.3 the day prior. He does have perihilar consolidation
and hemoptysis and was followed by pulmonary and ENT surgery who
at this point recommended no steroids since they did not beleive
this to be Wegener's flare. He was also followed by renal team
for worsening acute renal failure that was though to be
pre-renal in etiology.
.
[**Hospital **] Hospital course:
.
# PNA
Pt arrived to the CCU in respiratory distress with RR of 40, ABG
7.44/18/56/13; BiPAP was tried but pt was eventually intubated
since the CCu teamed feared he was becoming fatigued. Pt was
found to have bilateral pulmonary infiltrates, R>L, and hypoxia
in the setting of a pneumonia and hemoptysis starting after
integrillin. DAH was suspected. Pulm bronched pt showing
minimal blood and hemoptysis resolved quickly after intergrillin
had been stopped. ANCA was negative making Wegener's very
unlikely. The thinking was that pulm hemorrhage was [**1-18**]
inflammation due to PNA. Pt was afebrile, without a cough, off
oxygen ambulating well with good O2 sats on disccharge.
.
# CHF with EF 35%
Pt also arrived fluid overloaded and in acute on chronic
systolic heart failure after the transfusions. He was given IV
lasix over the next couple of days with great results. 2 days
into the stay in the CCU pt started autodiuresing, for a total
of about 6L for the duration of the CCU stay. Repeat echo on
[**10-15**] was unchaged from [**10-11**].
.
# CAD s/p mulitple stents
Pt likely had a minor NSTEMI on admission and definitely had
interval inferolateral wall motion abnormalities from prior to
admission. The decision was made to continue to [**Hospital 18110**]
medical management and do a stress MIBI as an outpatient for
risk startification since this all happened in the setting of an
acute illness. Patients creatinine was also >2 presenting
another argument to hold off on doing a cath. Plan was for f/u
with cards in [**12-18**] weeks which was communicated with pt.
.
# Atrial Fibrillation
On the evening of extubation ([**10-15**]) pt entered afib with a
ventricular resonse rate of 100-120s. Lopressor 5mg IV x3 and
diltiazem was both tried but unsucessful. Therefore,
cardioversion was performed with pt returning into sinus rhyhtm.
Pt stayed in sinus for the remainder of hosp stay until d/c.
.
# Metabolic acidosis/diarrhea/hypokalemia
Pt had an anion gap of 22 when arriving to the floor, likely [**1-18**]
uremia. The AG corrected failry quickly, however pt still had
an acidosis with a low bicarb since he continued to have
diarrhea with 3-5 loose stools per day. Pt was therefore given
bicarb per renal recommendation with good effect. The cause of
the diarrhea was not found in hosp and was negative for c.diff
x4, O+P, shigella, salm, legionella among other things. Immodium
was prescibed with some effect and mycophenolate preparation was
changed since the different preparations have different GI side
effects. Hypokamlemia to 2.4 was repleted agressively. Pt was
given 20mg daily of K to take at home and to eat banana's,
especially if diarrhea continued. Pt was instructed to follow
up closely with his PCP to have potassium checked on [**10-22**] and
[**10-25**].
.
# Wegener's disease
Patient is s/p 6 match donor transplant in [**2154-5-17**] with
basline Cr 1.8-2.1 since [**Month (only) 205**]. Meds were renally dosed, bactrim
for PCP [**Name9 (PRE) 5**] while on immunosupression, lisinopril was held due
to raised creatinine. sirolimus and cellcept initially
continued sirolimus level was normal/elevated, then sirolimus
was d/c'd due to concern over pulm toxicity. Renal recommended
stopping sirolimus and starting tacrolimus once the sirolimus
was <5. Tacrolimus was in therpeutic range at the time of d/c.
.
# Anemia to 25 with recent baseline hct 25-30
As mentioned above was given 3-4 units of prbc's prior to CCU
transfer. Blood counts in the CCU improved with hct in 32-33
range and no further transfusions were needed. Pt was guaiac
negative and no other source of bleeding was identified other
than the DAH.
.
Pancytopenia of unknown origin
Anemia as above. Also with platelets to high 90s but stable.
White count intially low to 2.7 during the acute illness then
recovered to normal range. Perhaps a medication effect,
although bone marrow biopsy may be indicated if persists and
other causes are ruled out as an outpt.
.
Medications on Admission:
(confirmed with patient and wife at time of admission)
Amlodipine 10mg daily
Actos 15mg daily
Ambien 5mg po QHS PRN sleep
ASA EC 325mg daily
Bactrim SS 1 tab daily
Cellcept 1000mg [**Hospital1 **]
Colace 100mg po daily
Ferrous Sulfate 325mg daily--not taking
Labetalol 900mg po BID
Lipitor 10mg daily
Lisinopril 5mg po BID
Nitroglycerin 1-2 tablets 0.4mg SL prn chest pain
Nitroglycerin 0.4 mg/hr TD patch daily with 6 hour patch-free
interval at night
Protonix 20mg daily
Sirolimus (Rapamune) 3mg daily
Ropinirole (Requip) 3mg [**Hospital1 **] for restless leg
Zoloft 50mg po QAM
Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
8. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
9. Labetalol 200 mg Tablet Sig: Five (5) Tablet PO BID (2 times
a day).
Disp:*300 Tablet(s)* Refills:*2*
10. Mycophenolate Sodium 180 mg Tablet, Delayed Release (E.C.)
Sig: Four (4) Tablet, Delayed Release (E.C.) PO BID (2 times a
day).
Disp:*240 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
11. Ropinirole 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times
a day).
12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day: take if experience chest pain. may take
on tab q5 minutes for a total of three doses. if chest pain
persists please call 911.
Disp:*120 tabs* Refills:*2*
14. Protonix 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
15. Diphenoxylate-Atropine 2.5-0.025 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) as needed for diarrhea for 3 days:
Disp:*20 Tablet(s)* Refills:*0*
16. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
Disp:*120 Capsule(s)* Refills:*2*
17. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO twice a day.
Disp:*120 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2*
18. Sodium Bicarbonate 650 mg Tablet Sig: Two (2) Tablet PO
three times a day.
Disp:*180 Tablet(s)* Refills:*2*
19. Outpatient Lab Work
Chem-10 and Tacrolimus level on [**2154-10-22**] and again on [**2154-10-25**]
Discharge Disposition:
Home
Discharge Diagnosis:
Pneumonia
NSTEMI
Atrial fibrillation
Diffuse alveolar hemorrhage due to pneumonia and anticoagulaion
Acute on chronic systolic heart failure
Acute on chronic renal failure
Discharge Condition:
Stable
Discharge Instructions:
STEMI d/c summ:
You were admitted to [**Hospital1 18**] with a pneumonia, Acute on chronic
systolic heart failure, Acute on chronic renal failure, atrial
fibrillation, Diffuse alveolar hemorrhage due to pneumonia and
anticoagulaion and a small non-ST elevation myocardial
infarction.
Please take your previous medications as prescribed with the
following changes:
- please stop taking sirolimus
- please stop taking the nitroglycerin patch unless stable
angina
- please increase labetalol to 1000mg twice daily (from 900mg)
- please start taking myfortic instead of cellcept
- please start taking amlodopine 5mg instead of 10mg
- please do not take your evening dose of Prograf on [**2154-10-20**]
and restart in the AM at 2 mg twice daily on [**2154-10-21**]
If you develop chest pain, jaw pain, or chest pressure with pain
radiating into arm, or if you for any reason become concerned
about your medical condition please call 911 or present to
nearest ED.
- We also gave you Nitroglycerin tablets to take if you
experience chest pain, please call 911 or your doctor if chest
pain recurs even if it dissapears with nitroglycerine
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6353**], LPN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2154-10-22**]
2:00
Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 11082**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2154-10-29**] 11:10
Provider [**Name9 (PRE) **] [**Last Name (NamePattern4) 6559**], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2154-12-24**] 3:40
|
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70,380
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53884+59557
|
Discharge summary
|
report+addendum
|
Admission Date: [**2174-4-28**] Discharge Date: [**2174-5-10**]
Date of Birth: [**2101-10-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5606**]
Chief Complaint:
Hyperglycemia
Major Surgical or Invasive Procedure:
Splenic abscess drainage
History of Present Illness:
Ms [**Known lastname **] is a 72 year old female with a history of insulin
dependent DM2, and left breast cancer s/p lumpectomy and XRT in
[**2168**] who presents with poorly controlled blood sugars. She was
first started on insulin in [**Month (only) **] when she was admitted to
[**Hospital **] Hospital with a urinary tract infection. She was treated
with antibiotics and discharged home after several days. She
again presented with a UTI in [**Month (only) 547**] to [**Hospital **] hospital. During
her most recent hospitalization at [**Location (un) **] she developed
urosepsis and pyelonephritis and was treated in the ICU. During
both admissions she was hyperglycemic and there was significant
difficulty controlling her sugars. She was discharged one week
ago from [**Hospital **] Hospital on a novolog sliding scale and
glargine 70 units QHS. After discharge she reports that her
fingersticks have been between 300 and 500. She has been feeling
increasingly fatigued and is not satisfied with her current
regiment. She decided to come into [**Hospital1 18**] for further management,
and for "better doctors." She reports good compliance with her
medications, and has been on a diabetic diet. She has lost her
appetite and has not eaten very much during the last week. Other
than her fatigue and loss of appetite, she denies any other
symptoms including fevers/chills, nausea, vomiting, chest pain
or SOB.
At [**Hospital1 18**] ED, initial vital signs were 98.8 82 122/61 18 100%RA.
Exam was unremarkable. Labs were notable for WBC 16 (N80), Hct
37.6, Na 125, Cl 86, Cr 0.9, glucose 518, lactate 2.1, AP 266,
UA w 8WBC, no bacteria. CXR was unremarkable. EKG was
unremarkable. Patient was given 1g CTX IV for presumed UTI, 2L
normal saline. Repeat FS was 398. Vital signs prior to transfer
were 98.8 78 125/58 18 100%RA. Access was 18g PIVx1.
Overnight, patient was hemodynamically stable without any issues
on the floor. She denies any chest pain, SOB, dysuria,
hematuria. She reports some loose stool but this is consistent
with her baseline and denies any melena. Denies any fevers,
chills, night sweats, headache, abdominal pain, nausea or
vomiting.
Past Medical History:
MEDICAL & SURGICAL HISTORY:
- Insulin Dependent DM (started on insulin [**1-/2174**])
- L breast Ca s/p lumpectomy and XRT in [**2168**], no chemotherapy
- s/p R knee replacement
- PVD s/p L fem-[**Doctor Last Name **] bypass, occasional edema of L lower
extremity
- HTN
- HLD
Social History:
Lives in [**Location **] w Husband. Retired. Independent of ADLs, walks
w use of cane. Former tobacco smoker, 30pkyrs but quit 23 years
ago, Social EtOH, denies illicits.
Family History:
She has a cousin with DM
Physical Exam:
Exam on Admission
VS: 98.6 142/78 86 18 96%RA FS 419 on admission, 392 this
morning 72kg
GENERAL: NAD, alert, orientated, comfortable
HEENT: PERRL, EOMI, MMM
NECK: Supple, no JVD, no cervical LAD
HEART: RRR, no murmurs, rubs or gallops, normal S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement
ABDOMEN: Soft/NT/ND, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP, 1+ DP/PT pulses equal bilaterally, no cyanosis
clubbing or edema
SKIN: No rashes/lesions
NEURO: A&Ox3, moving all extremities
Exam on Discharge
VS: 98.3 124/76 75 20 97% Ra
JP drained 50cc yeasterday, today drained 40cc, bulb had just
been changed so unable to assess fluid color/turbidity
GENERAL: NAD, alert, orientated, comfortable
HEENT: PERRL, EOMI, MMM
NECK: Supple, no JVD, no cervical LAD
HEART: RRR, no murmurs, rubs or gallops, normal S1-S2.
LUNGS: CTA bilat, no ronchi/rales/wheezes, good air movement
ABDOMEN: Soft/NT/ND, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: WWP, 1+ DP/PT pulses equal bilaterally, no cyanosis
clubbing or edema
SKIN: No rashes/lesions
NEURO: A&Ox3, moving all extremities
TUBES/LINES/DRAIN: Drainage site appears clean, dry and intact
Pertinent Results:
[**2174-5-10**] 04:42AM BLOOD WBC-11.8* RBC-3.68* Hgb-10.3* Hct-33.2*
MCV-90 MCH-28.0 MCHC-31.1 RDW-14.8 Plt Ct-494*
[**2174-5-9**] 04:31AM BLOOD WBC-12.0* RBC-3.53* Hgb-10.1* Hct-32.0*
MCV-91 MCH-28.5 MCHC-31.4 RDW-14.7 Plt Ct-461*
[**2174-5-8**] 06:30AM BLOOD WBC-12.1* RBC-3.74* Hgb-10.6* Hct-34.2*
MCV-91 MCH-28.4 MCHC-31.1 RDW-14.8 Plt Ct-431
[**2174-5-7**] 05:43AM BLOOD WBC-12.5* RBC-3.67* Hgb-10.4* Hct-33.1*
MCV-90 MCH-28.4 MCHC-31.4 RDW-14.4 Plt Ct-410
[**2174-5-3**] 06:25AM BLOOD WBC-27.9*# RBC-3.36* Hgb-9.7* Hct-30.3*
MCV-90 MCH-28.9 MCHC-32.0 RDW-14.0 Plt Ct-293
[**2174-4-29**] 06:40AM BLOOD WBC-14.2* RBC-4.01* Hgb-11.7* Hct-36.6
MCV-92 MCH-29.3 MCHC-32.0 RDW-14.0 Plt Ct-410
[**2174-4-28**] 06:25PM BLOOD WBC-16.0* RBC-4.19* Hgb-12.2 Hct-37.6
MCV-90 MCH-29.1 MCHC-32.5 RDW-13.6 Plt Ct-453*
[**2174-4-28**] 06:25PM BLOOD Neuts-80* Bands-2 Lymphs-10* Monos-6
Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-1*
[**2174-5-10**] 04:42AM BLOOD Plt Ct-494*
[**2174-5-9**] 04:31AM BLOOD Plt Ct-461*
[**2174-5-8**] 06:30AM BLOOD Plt Ct-431
[**2174-5-3**] 08:35AM BLOOD PT-14.6* PTT-27.8 INR(PT)-1.4*
[**2174-4-29**] 06:40AM BLOOD Plt Ct-410
[**2174-4-28**] 06:25PM BLOOD Plt Ct-453*
[**2174-5-10**] 04:42AM BLOOD Glucose-158* UreaN-14 Creat-0.6 Na-135
K-4.5 Cl-100 HCO3-25 AnGap-15
[**2174-5-9**] 04:31AM BLOOD Glucose-112* UreaN-15 Creat-0.6 Na-135
K-4.2 Cl-101 HCO3-24 AnGap-14
[**2174-5-8**] 06:30AM BLOOD Glucose-117* UreaN-10 Creat-0.7 Na-136
K-4.4 Cl-102 HCO3-25 AnGap-13
[**2174-4-29**] 06:40AM BLOOD Glucose-403* UreaN-13 Creat-0.7 Na-130*
K-4.0 Cl-96 HCO3-23 AnGap-15
[**2174-4-29**] 12:36AM BLOOD Glucose-367* UreaN-12 Creat-0.7 Na-128*
K-4.0 Cl-95* HCO3-21* AnGap-16
[**2174-4-28**] 06:25PM BLOOD Glucose-518* UreaN-13 Creat-0.9 Na-125*
K-4.0 Cl-86* HCO3-25 AnGap-18
[**2174-5-10**] 04:42AM BLOOD ALT-24 AST-13 AlkPhos-289* TotBili-0.3
[**2174-5-9**] 04:31AM BLOOD ALT-34 AST-18 AlkPhos-328* TotBili-0.3
[**2174-5-8**] 06:30AM BLOOD ALT-40 AST-20 AlkPhos-348* TotBili-0.3
[**2174-5-5**] 06:18AM BLOOD ALT-103* AST-54* AlkPhos-477* TotBili-0.2
[**2174-5-3**] 06:25AM BLOOD ALT-149* AST-293* AlkPhos-555*
TotBili-0.5
[**2174-4-28**] 06:25PM BLOOD ALT-32 AST-23 CK(CPK)-14* AlkPhos-266*
TotBili-0.6
[**2174-5-2**] 06:30AM BLOOD Lipase-13
[**2174-4-29**] 12:36AM BLOOD GGT-83*
[**2174-5-10**] 04:42AM BLOOD Calcium-8.9 Phos-3.1 Mg-1.7
[**2174-5-9**] 04:31AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.7
[**2174-5-8**] 06:30AM BLOOD Calcium-8.5 Phos-3.3 Mg-1.7
[**2174-4-29**] 12:36AM BLOOD Calcium-8.7 Phos-2.1* Mg-1.5*
[**2174-4-29**] 12:50PM BLOOD %HbA1c-11.6* eAG-286*
[**2174-5-1**] 07:35AM BLOOD TSH-2.9
[**2174-5-8**] 06:30AM BLOOD Cortsol-24.0*
Brief Hospital Course:
72yo F PMHx DM2 w recent initiation of insulin 2 mo ago, recent
hospitalization for pyelonephritis presenting w poorly
controlled fingersticks, hyperglycemia found to have UTI,
bacteremia and splenic abscess.
.
#E. Coli bacteremi/Sepsis/splenic abscess ?????? Patient was
transferred to the MICU for hemodynamic instability. She was
found to be septic with positive blood cultures for E. Coli and
found to have large 13 cm splenic abscess on imaging. Patient
underwent CT guided drainage of the abscess and a JP drain was
placed. Her antibiotics were broadened to meropenem given
mutli-drug resistant E. coli. Final culture data showed E coli.
Her sepsis resolved given improvement in SBPs with IVF. Last
blood culture was positive on [**2174-5-2**]. ID was consulted to help
with management of antibiotic choice and course of meropenem
while in the hospital with transition to ertapenem 1gm Q24H to
end on [**2174-6-3**]. She was transferred back to the medical
floor and remained hemodynamically stable. She underwent a TTE
which was within normal limits and showed no evidence of
endocarditis. JP drain site was clean, dry and intact. IR
recommended the drain be flushed with 5-10cc saline Q8H and
remain in place until the daily net drainage is less than 15cc
per day (subtracting the flushes), at which time she will need a
repeat CT. If there is no fluid collection, the drain may be
removed by the primary care physician with no further need for
follow up.
.
# Hyperglycemia - Patient has a history of poorly controlled DM
with prior non-compliance with her oral regimen. She was
recently started on insulin and presented with one week of
elevated blood sugars likely in the setting of her splenic
abscess. She was seen by [**Last Name (un) **] diabetes consult who recommended
her sliding scale insulin regimen be increased and her evening
glargine decreased. She was started on metformin once her anion
gap completly normalized. She will be discharged on metformin
and a new insulin scale. She was also given a nutrition consult
to help with her outpatient DM management.
.
# UTI - Patient was found to have multi resistent E. coli in her
urine likely secondary to her splenic abscess. We treated her
with meropenem as above which was changed to Ertepenem for ease
of admninistration (once daily dosing) to treat her bacteremia
and abscess.
.
# Hyponatremia - Patient was found to have a sodium of 125 on
admission which corrected to 135 and therefore was thought to
have been from pseudohyponatremia. We continued to monitor her
sodium which returned to [**Location 213**] at discharge.
.
# Elevated Alk Phos - Patient had an elevated alk phos to 266 on
admission that trended to 411, with ALT and AST of 86. RUQ exam
was unremarkable. She has a remote history of breast cancer so
we were initialy concerned about relapse with [**Last Name (un) 2043**] metastasis.
GGT was obtained which was also elevated suggesting that alk
phos was hepatic in origin. AP downtrended during her
hospitalization. CT did not show any liver pathology.
.
# HTN: Well controlled on home medications. We held atenolol due
to her hypotension in the setting of sepsis. We recommend
restarting on discharge.
.
# HLD: Statin held given elevated LFTs. She may consider
restarting this in the future.
.
# Hypothyroidism: Continued her home dose of levothyroxine
.
# PVD: Continued on home ASA
.
# Enlarged endometrial stripe: Found on imaging as incidental
finding. At this time we recommend outpatient evaluation with a
vaginal ultrasound. The patient is aware and will make a
gynecological appointment through her PCP.
.
# Pancreatic cyst: Found on imaging as incidental finding. At
this time we recommend outpatien evaluation with a MRCP. The
patient is aware of the pancreatic cyst and will schedule MRCP
through her PCP.
.
# Transition: Please arrange MRCP and transvaginal ultrasound as
an outpatient. In regards to the JP drain, monitor daily output
until the net output is less than 10-15cc per day. At that point
please reimage with a CT and insure there is no fluid remaining.
If CT shows complete resolution of the abscess, the drain may be
removed with no further follow up. Continue IV antibiotics until
[**6-3**] with ertapenem 1gm Q24H. Check CBC with diff, BMP, LFTs
each week after discharge and fax the results to the [**Hospital **] clinic
at [**Telephone/Fax (1) 1419**]. A follow up appointment with ID is arranged for
[**5-27**].
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Enalapril Maleate 20 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Lipitor 40 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Glargine 70 Units Bedtime
7. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Furosemide 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Senna 1 TAB PO BID:PRN constipation
8. Polyethylene Glycol 17 g PO DAILY:PRN constpiation
hold for loose stools
9. ertapenem *NF* 1 gram Injection daily Reason for Ordering:
Transitioning from Meropenam
Start [**2174-5-9**]
10. Glargine 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 931**] House Nursing & Rehabilitation Center - [**Location (un) 932**]
Discharge Diagnosis:
Splenic Abscess
Hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with high blood sugars and
were found to have a splenic abscess. We had trouble controlling
your blood pressure since the infection had spread to your blood
and transfered you to the intensive care unit for close
monitoring. Radiology drained the abscess and placed a JP drain
which will continue to drain fluids. Once stable, we transfered
you back to the floor. You were started on an antibiotic called
Miropenem while at the hospital. We will send you to your rehab
center on a similar antibiotic called ertapenem and will need
this antibiotic until [**6-3**]. Please have your rehab center or
your primary care physician check CBC with differential, BMP,
LFTs each week and fax the results to the [**Hospital **] clinic at
[**Telephone/Fax (1) 1419**]. You will need to have the nursing home monitor the
JP output. Once the output is less than 10-15ml per day,
schedule an appointment with your primary care physician. [**Name10 (NameIs) 357**]
get a CT exam the morning prior to the visit to verify complete
resolution. Your PCP can remove the JP drain at that time.
We also recommend stopping your atorvastatin since this can
contribute to abnormal liver function tests. Please have your
liver tests checked by your primary care physician at your next
appointment.
You had high blood sugar levels. This is likely due to your
infection. We monitored your blood sugar and other electrolytes
frequently throughout the day. We consulted the [**Last Name (un) **] Diabetes
service and they recommended a new insulin plan which you will
go home on. We will review your new insulin regiment in detail
before you leave. [**Last Name (un) **] also recommended starting Metformin, an
oral medication you should take twice a day that can help with
the management of diabetes. You will need to follow up with your
primary care physician for further management of your diabetes.
We also consulted the nutrition service and hope that they
provided some education about diet that will help with your
future sugar control.
Your CT exam had two findings that you will need to follow up as
an outpatient. The CT showed a thickened endometrial stripe and
you will need to get a transvaginal ultrasound. Please have your
PCP arrange an appointment with your gynecologist. The CT also
showed a pancreatic cyst and you will require a MRCP for further
evaluation.
Medicaion Changes
START Metformin
START Ertapenem
STOP Atorvastatin
It was a pleasure taking care of you during your hospital stay.
Followup Instructions:
Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Date: Thursday [**2174-5-12**] at 1:30pm
Address: [**State 8536**] [**Apartment Address(1) 8537**], [**Location (un) **],[**Numeric Identifier 8538**]
Phone: [**Telephone/Fax (1) 58624**]
Fax: [**Telephone/Fax (1) 83917**]
[**Last Name (un) **] Diabetes Center
Wednesday [**2174-5-11**] at 8:30am
Phone: [**Telephone/Fax (1) 25521**]
Infectious Disease Clinic at [**Hospital1 18**]
Dr. [**Last Name (STitle) 7443**] on [**2174-5-27**] at 10:00am
Phone: [**Telephone/Fax (1) 457**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13125**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2174-6-17**] 10:30
Name: [**Known lastname 18105**],[**Known firstname 1013**] Unit No: [**Numeric Identifier 18106**]
Admission Date: [**2174-4-28**] Discharge Date: [**2174-5-10**]
Date of Birth: [**2101-10-20**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 12576**]
Addendum:
To clarify - this patient had hypotension due to septic shock
during this hospitalization.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 2332**] House Nursing & Rehabilitation Center - [**Location (un) 2333**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 12580**] MD [**MD Number(2) 12581**]
Completed by:[**2174-7-14**]
|
[
"V15.82",
"599.0",
"038.42",
"401.1",
"443.9",
"790.5",
"244.9",
"577.2",
"995.92",
"428.22",
"289.59",
"428.0",
"785.52",
"272.4",
"250.02",
"V10.3",
"V58.67",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.1",
"38.97",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
16436, 16711
|
6959, 11399
|
319, 346
|
12499, 12499
|
4290, 6936
|
15193, 16413
|
3046, 3073
|
11786, 12288
|
12446, 12478
|
11425, 11763
|
12650, 15170
|
3088, 4271
|
266, 281
|
374, 2541
|
12514, 12626
|
2563, 2841
|
2857, 3030
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,666
| 105,336
|
44237+58693
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-3-31**] Discharge Date: [**2106-4-6**]
Date of Birth: [**2026-7-5**] Sex: M
Service: NEUROLOGY
Allergies:
Tetanus Toxoid / Penicillins / [**Year (4 digits) 13401**]
Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
R sided hemiparesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
79yo RH M who was last known well at his nursing home around
noon-ish, when he ate lunch. He then had the abrupt onset of
right facial droop and right arm weakness and has been unable to
speak since. By report, he was hypoxic in the 70s and
hypotensive; on arrival, bp was 90s/50s and he was placed on a
NRB.
He was recently discharged on coumadin, since he has an aortic
valve. His NH documentation shows last INR on [**3-29**] of 1.5. He
has
been treated recently for C Diff, with last day of flagyl due
tomorrow.
Past Medical History:
- Seizure disorder on dilantin; unclear etiology
- Rheumatic heart disease, s/p MVR ~[**2087**]
- CAD, s/p CABG
- AS s/p AVR
- HTN
- Dyslipidemia
- Spinal stenosis
- Status post C1-C5 Anterior fusion [**2097**]
- Status post L2-5 Decompressive surgery [**2097**]
- Status post C2-4 Posterior fusion [**2102**]
- OA s/p left knee arthroplasty in [**2097**]
- Neuropathy
- B12 deficiency
- Hospitalized at [**Hospital1 18**] [**7-22**] for food aspiration and esophageal
impaction, aspiration PNA, and dilation of esophageal ring
- BPH s/p TURP
- Chronic bilateral carpal tunnel syndrome
Social History:
Lived at home w/ wife but currently at [**Hospital1 **] for rehab. No hx of
tobacco, EtOH or drug abuse. However,most recently in nursing
home.
Family History:
No family history of seizures
Physical Exam:
PE
VS 99.6 89/50-150s/60s after fluid bolus 12 100%
Gen Awake, cooperative, NAD
HEENT NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck Supple, no carotid bruits appreciated. No nuchal rigidity
Lungs CTA bilaterally
CV RRR, nl S1S2, no M/R/G noted
Abd soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted
Ext No C/C/E b/l
Skin no rashes or lesions noted
NEURO
MS Eyes closed, rouses to verbal stimuli. Does not follow
commands or speak. Drowsy.
CN
CN I: not tested
CN II: No blink to threat on the right. Pupils 3->2 b/l. CN III,
IV, VI: Eyes deviated to the left, full EOM to oculocephalics
CN V: b/l corneals
CN VII: R facial droop
CN VIII: opens eyes to voice
CN IX, X: palate rises symmetrically, but choking on saliva
CN [**Doctor First Name 81**]: unable to assess
CN XII: unable to assess
Motor
R arm flaccid. Moves left arm purposefully to pain. The right
externally rotates to noxious stimuli. b/l triple flexion in the
legs
Sensory grimaces to noxious stimuli throughout
Reflexes
Br [**Hospital1 **] Tri Pat Ach Toes
L 2 2 2 1 0 up
R 0 0 0 1 0 up
Coordination unable to assess
Gait deferred
CODE STROKE SCALE:
Neurologic (NIHSS): 22
1a. LOC: 2
1b. LOC questions: 2
1c. LOC commands: 2
2. Best gaze: 2
3. Visual: 2
4. Facial Palsy: 3
5a. Left arm: No drift (0)
5b. Right arm: 4
6a. Left leg: No drift (0)
6b. Right leg: no drift (0)
7. Limb ataxia: x
8. Sensory: no sensory loss bilaterally (0)
9. Language: 3
10. Dysarthria: 2
11. Extinction/inattention: None (0)
Pertinent Results:
CT BRAIN PERFUSION [**2106-3-31**] 5:30 PM
CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS
1. Extensive acute MCA territory infarction extending
posteriorly into the occipital pole, with mass effect on left
lateral ventricle. No hemorrhage or herniation.
2. Saddle embolus at the left M1-M2 bifurcation with poor
filling of both superior and inferior M2 divisions. No PCA
filling defect seen.
3. Underlying ventriculomegaly out of proportion to sulcal and
fissural prominence.
4. Fluid in the sphenoid sinuses, more on the left.
5. Massive OPLL at C2-3 level causing narrowing of spinal canal
above the level of C3-4 laminectomy.
6. Small right pleural effusion.
Brief Hospital Course:
His LOC rapidly deteriorated after CT & he was intubated. He
was not a candidate for t-[**MD Number(3) 6360**] the large size of the
infarct, nor endovascular intervention given the absence of
large vessel occlusion and MTT/CBV mismatch on CTP indicating
lack of a salvageable tissue. His infarct was most likely
cardioembolic secondary to Afib and subtherapeutic INR.
The patient was admitted to the SICU, under the care of
neurology. Over the following days, he developed several
complications. His R foot and lower leg became ischemic. He
developed a fulminent sepsis, despite broad spectrum empiric
antibiotic therapy, requiring pressures and aggressive fluid
rescusitation. There was significant peripheral edema as a
consequence of third spacing. His respiratory drive decreased
and required more pressure support from the ventilator. The C
diff infection was insufficiently controlled, he continued to
have diarrhea with HCO3- and Na+ loss, despite Vancomycin and
Flagyl. He had a prolonged episode of Ventricular Tachycardia
with hypotension on the eve of [**2106-4-5**], spontaneous
reconversion, started on Amiodarone.
Neurologically he slowly declined, only grimacing weekly to pain
on the L, not withdrawing his left arm or leg anymore. The
prognosis of his dense L MCA stroke was very poor with respect
to quality of life and meaningful recovery - and the family
decided to withdraw care and focus on comfort. He died 4 hours
later. Family was notified. No autopsy.
Medications on Admission:
Coumadin 1mg daily
Dulcolax, fleet enema, colace
Seroquel 50mg qhs
Flagyl 500mg TID (last due [**4-1**])
Tamsulosin
Lipitor 20
Senna
Dilantin 100mg TID
Prilosec
Discharge Medications:
None - patient deceased.
Discharge Disposition:
Expired
Discharge Diagnosis:
Large left middle cerebral artery infarct
Discharge Condition:
Deceased
Discharge Instructions:
None.
[**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
Completed by:[**2106-4-6**] Name: [**Known lastname **],[**Known firstname **] J. Unit No: [**Numeric Identifier 14994**]
Admission Date: [**2106-3-31**] Discharge Date: [**2106-4-6**]
Date of Birth: [**2026-7-5**] Sex: M
Service: NEUROLOGY
Allergies:
Tetanus Toxoid / Penicillins / Keppra
Attending:[**First Name3 (LF) 1886**]
Addendum:
Patient also had a stage I pressure ulcer on the coccyx. It was
treated with barrier cream, turning and repositioning and use of
a gaymar overlay.
Discharge Disposition:
Expired
[**Name6 (MD) **] [**Last Name (NamePattern4) 1887**] MD, [**MD Number(3) 1888**]
Completed by:[**2106-5-13**]
|
[
"401.9",
"354.0",
"995.92",
"434.11",
"272.4",
"038.9",
"V43.3",
"V45.81",
"518.81",
"600.00",
"V58.61",
"427.1",
"345.90",
"008.45",
"348.4",
"276.1",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"88.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
6559, 6708
|
4001, 5485
|
338, 344
|
5840, 5850
|
3308, 3978
|
1680, 1711
|
5697, 5723
|
5776, 5819
|
5511, 5674
|
5874, 6536
|
1726, 3289
|
279, 300
|
372, 890
|
912, 1501
|
1517, 1664
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,465
| 194,574
|
5806
|
Discharge summary
|
report
|
Admission Date: [**2124-4-9**] Discharge Date: [**2124-4-12**]
Date of Birth: [**2050-8-26**] Sex: M
Service: MEDICINE
Allergies:
Methyldopa / Shellfish
Attending:[**First Name3 (LF) 1042**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
None
History of Present Illness:
73 y/o M with multiple medical problems including CAD s/p CABG,
DM, ESRD on HD, CHF, AF c/b stroke on coumadin, CVA, and
paraplegia who presented to [**Hospital6 4620**] from
[**Hospital1 **] today after being found lethargic, and in respiratory
distress with an RR in the 30s. At the OSH he was found in
severe respiratory distress with "agonal breathing" [**Name8 (MD) **] MD
report. Apparently this was severe enough to warrant the
physician to recommend [**Name9 (PRE) 3225**] measures to the family. An ABG showed
a respiratory acidosis, and the patient was placed on a NRB. A
CXR showed a LLL PNA in the setting of transient hypotension
(SBP as low as 57) requiring levophed, and a new leukocytosis.
He was given 1 gram of vancomycin.
He was recently discharged from the [**Hospital1 18**] on [**2124-4-4**]. He was
admitted on [**3-2**] for an AV fistula repair complicated by LLL
collapse and effusion s/p bronchoscopy. He was also started on a
course for hospital acquired/aspiration PNA with cefepime anf
flagyl. He was found to have a stage IV sacral decubitus ulcer
which was treated with a wound-vac assisted closure with
enzymatic debridement in consultation with plastic surgery who
did not want to perform an OR debridement. XR did not show OM.
He had a speech and swallow eval which he failed and was started
on tube feeds. He was dx with depression/adj. disorder and start
on citalopram. He was discharged to [**Hospital **] rehab for completion
of IV abx.
Past Medical History:
CAD s/p CABG '[**20**] - Coronary bypass graft x3, left internal
mammary artery to left anterior ascending artery, saphenous vein
graft to 2nd obtuse marginal branch, saphenous vein graft to
posterior descending coronary artery.
CHF EF 42% on PMIMI from [**10-6**]
DM II
Hyperlipidemia
HTN
CKD V due to diabetic nephropathy on HD since [**3-/2122**]
moderate pulm HTN
AF on coumadin, history of stroke (by report) with mild residual
R-sided weakness
PVD s/p L SFA to PT bypass for nonhealing ulcer
tachy-brady s/p PM '[**16**]
C4-C5 spinal cord injury after fall at home in [**10-6**]
s/p R BKA in [**11-5**] for right foot ulcer
Social History:
He currently lives at rehab facility. He used to work as real
estate broker.
He smoked [**1-2**] ppd for 10 years, quit 30 yrs ago. He denies
current ethanol use but history of heavy use, no history of
IVDA.
Family History:
Father with CAD, mother with HTN and DM
Physical Exam:
VS: T 96.9' BP 100/32; HR ; RR
GEN: Chronically ill-appearing gentleman wearing shovel mask,
responding to questions appropriately
HEENT:
LUNGS: Crackles at base bilaterally with decreased breath sounds
on R. Occ rhonchi
HEART:
ABD:
EXT:
NEU:
Pertinent Results:
[**2124-4-9**] 06:58PM WBC-16.5* RBC-2.40* HGB-7.0* HCT-23.6*
MCV-99* MCH-29.4 MCHC-29.8* RDW-21.9*
[**2124-4-9**] 06:58PM PLT COUNT-360
[**2124-4-9**] 06:58PM PLT COUNT-360
[**2124-4-9**] 06:58PM PT-38.6* PTT-44.6* INR(PT)-4.2*
[**2124-4-9**] 06:58PM GLUCOSE-51* UREA N-69* CREAT-2.8* SODIUM-137
POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-24 ANION GAP-15
===========
CHEST (PORTABLE AP) [**2124-4-9**] 10:20 AM
CHEST (PORTABLE AP)
Reason: assess lung status
[**Hospital 93**] MEDICAL CONDITION:
73 year old man with respiratory failure and aspiration event
REASON FOR THIS EXAMINATION:
assess lung status
PORTABLE CHEST OF [**2124-4-9**]
COMPARISON: [**2124-4-3**].
INDICATION: Respiratory failure and aspiration event.
Left pleural effusion has decreased in size with residual
moderate effusion and adjacent atelectasis remaining. New patchy
and linear right infrahilar opacities have developed, and may be
due to clinically suspected acute aspiration. Cardiomediastinal
contours and indwelling devices appear unchanged.
==========
ECG (5/11/8)
Regular ventricular pacing with probable underlying atrial
fibrillation.
Compared to the previous tracing ventricular pacing is new.
Brief Hospital Course:
The patient was transferred from the outside hospital to the
MICU for further observation. His septic shock was treated with
aggressive normal saline IVF boluses, and broadening of his
antibiotic regimen to meropenem, metronidazole, and vancomycin.
He continued to receive his hemodialysis. His tube feeds were
resumed without incident. He received local, aggressive care of
his decubitus ulcers. He was transferred back to rehabilitation
to complete his antibiotic regimen for his aspiration pneumonia
and continue wound care and medical care.
Medications on Admission:
Flagyl 500 q12 until [**4-14**]
Cefepime 1g q24 until [**4-14**]
Lantus 16 units qPM
ISS
Lisinopril 5mg qday
Metoprolol tartrate 25mg [**Hospital1 **]
Simvastatin 40mg daily
ASA 81mg qday
Coumadin 6mg daily (last dose)
Citalopram 5mg daily
Carbamazepine 100mg chewable daily
Epoetin alfa [**Numeric Identifier 389**] units with HD
Docusate sodium 50mg/5mL 100mg daily
Senna syrup 5mL qday
Bisacodyl prn
Lactulose prn
Lansoprazole solutab 30mg daily
Heparin SC
Folic Acid 1mg daily
Pyridoxine 50mg daily
Cyanocobalmin 500mcg daily
Ascorbic acid 500mg daily
Accuzyme 30gm topical [**Hospital1 **]
Oxycodone IR 5mg daily
Acetaminophen 160mg/5mL q4H prn
Guaifenesin prn
Discharge Medications:
1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization [**Hospital1 **]:
[**12-1**] neb Inhalation Q6H (every 6 hours) as needed.
2. Papain-Urea 830,000-10 unit/g-% Ointment [**Month/Day (2) **]: One (1) Appl
Topical DAILY (Daily).
3. Guaifenesin 100 mg/5 mL Syrup [**Month/Day (2) **]: Fifteen (15) ML PO Q6H
(every 6 hours).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Month/Day (2) **]: One (1) Cap
PO DAILY (Daily).
5. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (2) **]: Five (5) mL PO BID (2
times a day).
6. Cyanocobalamin 100 mcg Tablet [**Month/Day (2) **]: 0.5 Tablet PO DAILY
(Daily).
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
8. Carbamazepine 100 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO BID (2 times a day).
9. Pyridoxine 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
10. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID
(2 times a day).
12. Ascorbic Acid 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Simvastatin 10 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily).
14. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Last Name (STitle) **]:
Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10
days.
15. Meropenem 500 mg Recon Soln [**Last Name (STitle) **]: Five Hundred (500) mg
Intravenous Q24H (every 24 hours) for 10 days: Give after
hemodialysis.
16. Vancomycin in Dextrose 1 gram/200 mL Piggyback [**Last Name (STitle) **]: 1000
(1000) mg Intravenous Q48H (every 48 hours) for 10 days: Give
during hemodialysis.
17. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
18. Lantus 100 unit/mL Solution [**Last Name (STitle) **]: Sixteen (16) units
Subcutaneous once a day.
19. Insulin sliding scale
Check fingerstick glucose four times daily. Glucose < 70 mg/dL:
give juice and contact physician on call, 71-150: observe,
151-200: 1 unit lispro insulin SQ, 201-250: 3 units, 251-300: 5
units, 301-350: 7 units, 351-400: 9 units, >400: call physician
on call
20. Outpatient Lab Work
Please check CBC with differential, PT/INR, comprehensive
metabolic panel, phosphorus, magnesium, random vancomycin level,
and blood culture once a week.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
1. Aspiration pneumonia
2. Atrial fibrillation with history of stroke with residual
deficits
3. Coronary artery disease h/o CABG
4. Chronic systolic congestive heart failure
5. Type 2 diabetes mellitus uncontrolled with complications
6. ESRD with associated hyperparathyroidism and anemia
7. Stage 4 decubitus ulcers
8. Cervical vertebral fracture with quadriparesis
9. Hyperlipidemia
10. Tachy/brady syndrome
11. Moderate pulmonary hypertension, secondary
12. History of multiple aspiration events
Discharge Condition:
Guarded
Discharge Instructions:
Please contact the physician on call at your facility if you
develop fevers, sweats, chills, difficulty breathing, confusion,
or worsening skin ulcers.
Followup Instructions:
Provider: [**Name10 (NameIs) **] SURGERY CLINIC Phone:[**Telephone/Fax (1) 4652**]
Date/Time:[**2124-4-21**] 1:00
Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB)
Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2124-8-31**] 1:00
Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2124-8-31**] 1:45
|
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icd9cm
|
[
[
[]
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[
"39.95",
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icd9pcs
|
[
[
[]
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8064, 8139
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3628, 4226
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338, 1816
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2485, 2697
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,612
| 104,002
|
41249
|
Discharge summary
|
report
|
Admission Date: [**2108-4-1**] Discharge Date: [**2108-4-8**]
Date of Birth: [**2086-11-6**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1390**]
Chief Complaint:
S/P gunshot wound to chest and abdomen
Major Surgical or Invasive Procedure:
[**2108-4-2**]
Exploratory laparotomy, repair of diaphragm,
small bowel resection, primary small bowel anastomosis,
gastric repair x2, chest tube placement, hepatorrhaphy
History of Present Illness:
Patient is a 21 yo male hx of s/p nephrectomy and thoracotomy
from previous gunshot wound transferred from [**Hospital3 **].
Patient with gunshot wound to the left chest and abdomen which
was believed to have been caused by a .22 caliber projectile.
Patient found to have left lung injury, left diaphragm injury,
multiple small-bowel enterotomies, two gastric enterotomies,
injury to the left lobe of the liver, injury to the transverse
colon mesentery and retroperitoneum. He was immediately brought
to the OR and underwent an exploratory laparotomy, repair of
diaphragm, small bowel resection, primary small bowel
anastomosis, gastric repair x2, chest tube placement,
hepatorrhaphy.
Past Medical History:
PMH:
PSH: Trauma ex-lap, L nephrectomy
Social History:
Lives with his mother, works as landscaper, + tobacco, + ETOH, -
drugs
Family History:
non contributory
Physical Exam:
98.9 97.9 76 120/70 18 97%RA
AOx3, Ambulating without assistance
RRR
CTAB
Abdomen soft, non tender
Wound open, with moist to dry packing. <1cm margin of erythema
but no over induration indicative of cellulitis
no pedal edema
Pertinent Results:
[**2108-4-1**] 08:50AM WBC-11.6* RBC-4.87 HGB-14.3 HCT-40.6 MCV-83
MCH-29.4 MCHC-35.3* RDW-13.5
[**2108-4-1**] 08:50AM PLT COUNT-356
[**2108-4-1**] 08:50AM PT-13.1 PTT-26.9 INR(PT)-1.1
[**2108-4-1**] 09:01AM GLUCOSE-103 LACTATE-2.7* NA+-141 K+-4.2
CL--105
[**2108-4-1**] 11:39AM GLUCOSE-116* UREA N-9 CREAT-0.6 SODIUM-140
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
[**2108-4-1**] CXR :
The endotracheal tube tip is 5 cm above the carina. NG tube tip
is
in the stomach. There is a left chest tube. No pneumothorax is
identified.
There is a small right effusion. The heart size is mildly
enlarged and there is some increased retrocardiac opacity in the
region of the chest tube, but otherwise no infiltrate.
Brief Hospital Course:
Mr. [**Known lastname **] was transferred directly from Med Flight to the
Operating Room with evidence of hemoperitoneum. He underwent an
exploratory laparotomy with small bowel resection, with repair
of gastrotomy. He was transferred to the PACU and then to the
ICU for recovery. He was put on IV cipro/flagyl and kept NPO/IVF
with an NGT. He had a dilaudid PCA for pain control. He had a
chest tube in place for his left sided pneumothorax.
On [**4-2**], he was transferred to the floor, kept on the IV
cipro/flagyl, NPO/IVF, and an NGT and foley, and a chest tube to
suction.
On [**4-3**], his foley was d/ced and his chest tube put to
waterseal. His CXR four hours later showed increase in his
pneumothorax and his chest tube was put back to suction. His
diet was advanced to sips
On [**4-4**], he was advanced to clears and switched to PO
medications. His CT was put back to waterseal and a chest xray
showed that there was no pneumothorax and his CT was d/ced.
On [**4-5**] he was advanced to a regular diet and his IVF were
d/ced. He failed to take adequate PO and received a 500 cc
crystaloid bolus as well as zofran for his nausea. He was made
NPO.
On [**4-6**] his wound became indurated and erythematous. The wound
was probed with a q-tip and was intact so it was left closed and
ancef started.
On [**4-7**], the wound had not improved so it was opened and wet to
dry dressings were initiated. He continued to get zofran doses
to help control his nausea. Pantoprazole was started [**Hospital1 **]. His
diet was advaned first tosips and then to clears.
On [**4-8**], he was put on PO meds, and advanced to a regular diet
before being discharged with PO pantoprazole, and close follow
up with the [**Hospital 2536**] clinic.
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*
Discharge Disposition:
Home
Discharge Diagnosis:
S/P Gunshot wound to the left chest and
abdomen
1. Left lung injury
2. Left diaphragm injury
3. Multiple small-bowel enterotomies
4. Two gastric enterotomies
5. Injury to the left lobe of the liver
6. injury to the transverse colon, mesentery and
retroperitoneum.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You should continue to change your abdominal wound dressings as
you were taught in the hospital. With sterile saline and sterile
gauze, lightly moisten the gauze and pack it inside your
abdominal wound. Then cover with an abdominal pad. You can
gently cleanse the wound with commercial wound cleaner as taught
to you by your nurse. Change your dressings twice daily. Please
call the clinic if you have any trouble with your wound
dressings or have any questions.
* You were admitted to the hospital after your gunshot wound
with multiple internal injuries requiring surgery for repair.
* You are doing better now with minimal pain, active bowel
function and a stable blood count.
* Continue to eat a regular diet and stay well hydrated.
*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 [**6-26**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks.
|
[
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icd9cm
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[
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[
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icd9pcs
|
[
[
[]
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4439, 4445
|
2437, 4180
|
341, 514
|
4753, 4753
|
1685, 2414
|
7126, 7227
|
1397, 1415
|
4235, 4416
|
4466, 4732
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4206, 4212
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4904, 7103
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1430, 1666
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262, 303
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542, 1230
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4768, 4880
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1252, 1293
|
1309, 1381
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,569
| 183,424
|
8172
|
Discharge summary
|
report
|
Admission Date: [**2176-9-22**] Discharge Date: [**2176-10-1**]
Date of Birth: [**2116-12-12**] Sex: M
Service: MEDICINE
Allergies:
Tylenol / Potassium
Attending:[**First Name3 (LF) 2698**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
Cardiac catheterization
History of Present Illness:
59 yo male DM2, HTN, MI in [**2166**], s/p PTCA w/ stenting, systolic
CHF (EF of 20%), CRI (baseline Cr 2.3), subarachnoid hemorrhage
secondary to cerebral aneurysm s/p aneurysm clipping in [**2163**],
PVD s/p left axillofemoral bypass on [**2175-4-3**] w/ recent
revision, presented to OSH with 3 weeks of headache in the
setting on uncontolled HTN, and progressive SOB. Today around
lunchtime developed n/v, became hypotensive to 50/p after
getting BP meds, Lisinopril and Imdur discontinued, BP responded
to IVF boluses. He had been started on coumadin for unclear
reasons. Pt. had several NSVT runs of [**7-10**] beats. CEs negative
x1 at OSH. He had an echo which showed EF 15% down from previous
20%. Pt. transferred to [**Hospital1 18**] for management of VTach episodes
by EP and possible cardiac catheterization.
.
.
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:
Dyslipidemia
Hypertension
Coronary artery disease
s/p myocardial infarction in [**2166**], s/p percutaneous
coronary intervention
systolic congestive heart failure (EF 15%). Has been
hospitalized for exacerbations x3 w/admission to hospital in
D.R. several months ago requiring intubation.
bilateral renal artery stenosis s/p right renal artery stent
s/p subarachnoid hemorrhage secondary to cerebral aneurysm
s/p aneurysm clipping in [**2163**]
PVD s/p left axillofemoral bypass graft, [**2175**]. Removal of graft
after seroma formation. Fem-fem graft placed.
Social History:
The patient is a former smoker, greater than
30 pack years. Is not smoking at present. He drinks
socially. Denies drug use. He has been disabled for 8 years.
Formerly worked in a fabric factory. He is divorced, but
lives with his previous spouse.
Family History:
non-contributory
Physical Exam:
VS: T= 96.7 BP= 11/67 HR= 75 RR= 18 O2 sat= 99RA
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP at level of clavicle.
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: DP 2+ PT 2+
Left: DP 2+ PT 2+
Pertinent Results:
[**2176-9-22**] 09:50PM BLOOD WBC-7.2 RBC-3.54* Hgb-11.0* Hct-33.1*
MCV-94 MCH-31.1 MCHC-33.2 RDW-14.3 Plt Ct-347#
[**2176-9-22**] 09:50PM BLOOD PT-13.9* PTT-28.3 INR(PT)-1.2*
[**2176-9-22**] 09:50PM BLOOD Glucose-116* UreaN-75* Creat-3.4*# Na-133
K-3.4 Cl-96 HCO3-24 AnGap-16
[**2176-9-23**] 09:20AM BLOOD ALT-10 AST-16
[**2176-9-22**] 09:50PM BLOOD CK(CPK)-61
[**2176-9-22**] 09:50PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2176-9-22**] 09:50PM BLOOD Calcium-8.9 Phos-6.4*# Mg-2.3
[**2176-9-23**] 09:20AM BLOOD Calcium-9.2 Phos-4.7*# Mg-2.5 Cholest-PND
[**2176-9-23**] 09:20AM BLOOD %HbA1c-5.9
[**2176-9-24**] 03:20AM BLOOD Glucose-114* UreaN-73* Creat-2.9* Na-137
K-4.0 Cl-105 HCO3-22 AnGap-14
[**2176-9-22**] Chest XRAY
HISTORY: Acute exacerbation of CHF, question pulmonary edema.
IMPRESSION: PA and lateral chest compared to [**2176-1-13**]:
Moderate cardiomegaly has increased. There is a suggestion of
minimal
interstitial pulmonary edema accompanying a new small left
pleural effusion. Pulmonary vasculature is not particularly
engorged. There is no focal pulmonary abnormality
[**2176-9-27**] Renal Ultrasound CONCLUSION: Small atrophic right
kidney, particularly in the upper pole abnormal intraparenchymal
waveforms, but no evidence of increased velocities at the level
of the aorta and right renal artery stent. Normal waveforms both
in the proximal left renal artery near the stent and in the more
peripheral intraparenchymal renal arteries on the left side.
[**2176-9-29**] 04:50AM BLOOD WBC-11.4* RBC-2.92* Hgb-8.9* Hct-27.0*
MCV-93 MCH-30.6 MCHC-33.1 RDW-14.2 Plt Ct-289
[**2176-9-26**] 03:48PM BLOOD Glucose-139* UreaN-58* Creat-2.5* Na-137
K-4.6 Cl-104 HCO3-21* AnGap-17
[**2176-9-27**] 02:24AM BLOOD Glucose-126* UreaN-58* Creat-2.4* Na-137
K-4.2 Cl-101 HCO3-20* AnGap-20
[**2176-9-28**] 06:34AM BLOOD Glucose-116* UreaN-54* Creat-3.0* Na-133
K-4.2 Cl-96 HCO3-25 AnGap-16
[**2176-9-29**] 04:50AM BLOOD Glucose-137* UreaN-50* Creat-3.3* Na-134
K-4.3 Cl-94* HCO3-27 AnGap-17
[**2176-9-23**] 09:20AM BLOOD %HbA1c-5.9
[**2176-9-23**] 09:20AM BLOOD Triglyc-222* HDL-30 CHOL/HD-8.6
LDLcalc-183*
[**2176-9-29**] 10:18AM BLOOD Type-[**Last Name (un) **] pH-7.46* Comment-GREEN TOP
[**2176-9-26**] 03:56PM BLOOD Lactate-1.0
[**2176-9-27**] 02:39AM BLOOD Lactate-1.0
[**2176-9-29**] 10:18AM BLOOD Lactate-1.9
Discharge labs:
[**2176-10-1**] 06:25AM BLOOD WBC-9.3 RBC-2.80* Hgb-8.5* Hct-25.9*
MCV-92 MCH-30.4 MCHC-32.9 RDW-14.5 Plt Ct-313
[**2176-10-1**] 06:25AM BLOOD Glucose-108* UreaN-47* Creat-3.2* Na-134
K-3.7 Cl-95* HCO3-27 AnGap-16
[**2176-10-1**] 06:25AM BLOOD Calcium-8.6 Phos-4.5 Mg-2.6
CXR: [**2176-9-30**]
TECHNIQUE: Portable AP upright chest radiograph.
COMPARISON: Portable AP radiograph from [**2176-9-25**].
FINDINGS: Slightly improved mild interstitial pulmonary edema.
Unchanged
mild cardiomegaly. Mediastinum and hila are normal. There is no
pleural
pathology.
IMPRESSION: Slightly improved mild interstitial pulmonary edema.
Brief Hospital Course:
Patient is a 59 year old man with a history of CHF (EF 15%). He
presented for transfer from an OSH in acute on chronic renal
failure. After improvement of his creatinine, he underwent
cardiac catheterization on [**9-26**]. Following the procedure he was
observed in the CCU out of concern for embolization causing
mesenteric ischemia. Following the catheterization his
creatinine steadily increased.
.
# CAD: Patient has a history of CAD s/p stenting. We continued
him on aspirin, plavix, and beta-blocker. His lipid panel was:
chol 257 trigl 222 HDL 30 LDL 183. We started him on low dose
pravastatin because of previous intolerance to lipitor (leg
muscle pain). He tolerated it well. He underwent cardiac
catheterization on [**9-26**]. It showed the one vessel CAD and
elevated Left sided filling pressures.
.
.
# CHF - Patient had an EF of 15% on recent echo with severe
global left ventricular hypokinesis. We held his ACE inhibitor
in the setting of his acute renal failure and report of previous
hyperkalemia on an ACE inhibitor (with worsening renal
function). He was discharged on 40mg of lasix PO daily, which
was his original dose prior to admission to the OSH.
.
# HTN - The patient had a hypotensive episode at the OSH after
receiving BP meds. He was initially given carvedilol 6.25 mg [**Hospital1 **]
which was uptitrated to 25 mg [**Hospital1 **]. He was started on hydralazine
for better control post-cath. he was also started on Imdur 30mg
daily as well.
.
# Acute on chronic renal failure: Patient presented with low
urine output and increasing creatinine. We did not diuresis him
any further, but allowed him to eat and drink. His creatinine
slowly improved over time. After cath, his creatinine again
rose. It was stable between 3.1-3.3 post cath. The patient was
set up with an outpatient nephrology appointment.
.
# Diabetes: The patient's chart noted a history of diabetes.
However, he denied ever being told this. His A1C was 5.9%. He
did not require regular fingersticks.
.
PROPHYLAXIS: Patient received subcutaneous heparin.
.
Medications on Admission:
Medications at the OSH:
warfarin 5mg daily
spironolactone 25mg QAM
Carvedilol 12.5mg [**Hospital1 **]
furosemide 100mg Qam
Imdur 30mg daily
plavix 75mg daily
ASA 81mg daily
Colace 100mg [**Hospital1 **]
Zofran 4mg Q8
Ambien 10mg QHS
Heparin SC TID
Discharge Medications:
1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*2*
6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Systolic Heart Failure
Secondary Diagnosis:
Coronary Artery Disease
Renal failure
Discharge Condition:
Patient was breathing on room air. hemodynamically stable.
Discharge Instructions:
You were transferred to [**Hospital1 69**] to
manage your heart failure. When you arrived, your kidneys were
not working properly. Over time your kidneys began to improve.
We performed a procedure called a cardiac catheterization. This
looked at the blood vessels in your heart. This showed that you
had one artery that had mild narrowing. The stents that you had
placed previously were functioning well. However, it also
showed that you continue to have severe heart failure, for which
it is important for you to take your medications as prescribed
and follow up closely with your doctors.
.
Concerning your kidneys, it was likely because of a too high
dose of lasix that their function decreased. Your kidney
function was stable when you were discharged. We have made an
appointment for you to see the kidney doctors as [**Name5 (PTitle) **] outpatient.
That appointment is below.
Please weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 1500 mL
We changed some of your medications.
We stopped your felodipine.
We stopped your digoxin.
We started you on carvedilol 25 mg twice a day.
We started you on hydralazine 10 mg every eight hours.
We started you on pravastatin 10 mg daily.
We started you on isosorbide dinitrate 30mg daily.
Your lasix dose was unchanged at 40mg daily.
Please call your physician or go to the emergency department if
you have an increase in shortness of breath, chest pain, fever,
chills, bleeding, a decrease in the amount of urine you produce,
or any symptom you are concerned about.
Followup Instructions:
Please follow up at the appointments listed below.
The following appointments have been scheduled for:
Patient: [**Known firstname 24039**] [**Known lastname 2427**]
[**Medical Record Number 29064**]37or DOB
Appointment #1
MD: Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) 29065**]
Specialty: PCP
Date and time: [**Last Name (LF) 766**], [**10-14**] at 12:00PM
Location: [**Location (un) 29066**], [**Hospital1 487**] [**Numeric Identifier 29067**]
Phone number: [**Telephone/Fax (1) 29068**]
Special instructions if applicable:
Appointment #2
MD: Dr. [**First Name8 (NamePattern2) 29069**] [**Name (STitle) 29070**]
Specialty: Cardiology
Date and time: Tuesday, [**10-8**] at 1:30PM
Location: [**Apartment Address(1) 29071**], [**Hospital1 487**], [**Numeric Identifier 29072**]
Phone number: ([**Telephone/Fax (1) 29073**]
Special instructions if applicable:
Appointment #3
MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Electrophysiology
Date and time: Wednesday, [**11-20**] at 9:00AM
Location: DIDMC [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) **]
Phone number: [**Telephone/Fax (1) 62**]
Special instructions if applicable:
Appointment #4
MD: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1366**]
Specialty: Nephrology
Date and time: Thursday, [**10-3**] at 2:00PM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**], [**Hospital Ward Name 23**] Bldg [**Location (un) **]
Phone number: [**Telephone/Fax (1) 721**]
Special instructions if applicable:
Completed by:[**2176-10-2**]
|
[
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"V45.82",
"585.9",
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"276.1",
"250.00",
"427.1",
"425.4",
"784.7",
"997.71",
"412",
"E879.0",
"424.0",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.23",
"88.56"
] |
icd9pcs
|
[
[
[]
]
] |
9250, 9256
|
6051, 8110
|
301, 326
|
9402, 9464
|
3064, 5384
|
11102, 12758
|
2223, 2241
|
8408, 9227
|
9277, 9277
|
8136, 8385
|
9488, 11079
|
5401, 6028
|
2256, 3045
|
242, 263
|
354, 1357
|
9341, 9381
|
9296, 9320
|
1379, 1943
|
1959, 2207
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
6,953
| 114,360
|
10161
|
Discharge summary
|
report
|
Admission Date: [**2160-1-22**] Discharge Date: [**2160-1-30**]
Date of Birth: [**2112-11-21**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 47 year old
gentleman, with a history of HIV, hypertension,
cardiomyopathy, alcohol abuse, fatty liver, with frequent
admissions for early alcohol withdraw, characterized by
tremulousness and sinus tachycardia. He frequently leaves
the hospital against medical advice. He was admitted to the
SICU on [**2160-1-22**] after an episode of binge drinking,
complicated by loss of consciousness and falling. The patient
had a picture consistent with rhabdomyolysis on admission
with CK peaking at 3577 and lactic acidosis with bicarbonate
of 10 and molar gap of 30, secondary to dehydration and
alcohol use. The patient's blood alcohol level on admission
was 417. The patient had an admission CAT scan of his head
which was negative.
The patient was initially put on CIWA scale. Initially, he
was empirically treated with Vancomycin and Ceftriaxone.
Antibiotics were stopped and there was no evidence of sepsis.
The patient had a CAT scan of the abdomen and chest, which
was only sufficient for fatty liver. On admission, the
patient was tachycardia to 130's with sinus tachycardia
secondary to early alcohol withdraw. The patient was started
on Ativan drip and electrolytes were aggressively repleted.
During the SICU stay, the patient had an episode of paranoid
agitation. Psychiatry was consulted and on [**2160-1-24**], the
patient was given Haldol and standing Valium. The patient
was seen by psychiatry again and was shown to have the
capacity to make his own medical incisions and leave against
medical advice if he so wished.
Over the course of the Intensive Care Unit stay, the
patient's lactate, CK trended down. The patient had a
transient episode of thrombocytopenia, secondary to liver
dysfunction in a setting of alcohol use. The patient's
weights were trending back up. The patient was
hemodynamically stable and tolerating regular diet. The
patient declined inpatient psychiatric admission.
PAST MEDICAL HISTORY:
1. HIV, diagnosed in [**2135**]. The patient is a presumed non
progressor.
2. Hypertension.
3. Cardiomyopathy, presumed secondary to alcohol use.
Ejection fraction of 30% on [**6-14**].
4. History of rheumatic heart disease.
5. Generalized anxiety disorder.
6. Macrocytic anemia.
7. Status post cholecystectomy.
8. Fatty liver [**11-14**].
9. Alcoholism.
10. Frequent admissions for early signs of alcohol withdraw.
ALLERGIES: No known drug allergies.
MEDICATIONS AS AN OUTPATIENT:
Risperidone 1 mg p.o. q. day.
Effexor XR 150 mg p.o. q. day.
Propanolol 80 mg p.o. twice a day.
Klonopin 1 mg p.o. three times a day.
Zestril 10 mg p.o. q. day.
Hydrochlorothiazide 25 mg p.o. q. day.
Multi-vitamin one q. day.
Thiamine 100 mg p.o. q. day.
Folate 1 mg p.o. q. day.
Protonic 40 mg p.o. q. day.
MEDICATIONS ON TRANSFER FROM THE INTENSIVE CARE UNIT:
[**Unit Number **]. Trazodone 50 mg p.o. q h.s.
2. Risperidone 10 mg p.o. q. day.
3. Effexor XR 150 mg p.o. q. day.
4. Nicotine patch.
5. Propanolol 40 mg p.o. q. day.
6. Protonic 40 mg p.o. q. day.
7. Klonopin 1 mg p.o. three times a day.
8. Valium 5 mg intravenous every one to two hours prn for
CIWA scale.
9. Tylenol prn.
10. Percocet one to two tablets p.o. every four to six hours
prn.
11. Haldol prn.
12. Imodium 2 mg p.o. four times a day prn.
SOCIAL HISTORY: Lives in [**Hospital3 **] for HIV patient's.
Positive alcohol use since a young age. Frequent history of
binge drinking. Tobacco 70 pack year smoking history.
PHYSICAL EXAMINATION: T maximum of 100; T current of 98.0
pulse 95 to 113; blood pressure 94 to 150 over 59 to 96; 99%
on room air. General: Comfortable in bed, in no apparent
distress. HEAD, EYES, EARS, NOSE AND THROAT: Moist mucous
membranes. Cranial nerves intact. Neck: No
lymphadenopathy. Pulmonary: Clear to auscultation
bilaterally. Cardiovascular: Regular rate and rhythm,
normal S1 and S2, no murmurs, rubs or gallops. Abdomen:
Positive bowel sounds, soft, nontender, nondistended.
Extremities: No cyanosis, clubbing or edema. Right groin
hematoma which is stable. No asterixis. Mild intention
trauma. Neurologically intact. No focal signs.
LABORATORY DATA: On admission to the hospital on [**2160-1-22**],
white count was 6.5; hematocrit of 39.2; platelets 140; MCV
49. Chemistry 10 revealed a sodium of 137; potassium of 4.1;
chloride of 90; bicarbonate 20; BUN 8; creatinine 0.8;
glucose 138. Anion gap of 27. CK 35, 77. Troponin less
than .01. Amylase 160; lipase 43; ALT 199; AST 496; alkaline
phosphatase 235. Total bilirubin of 0.8. INR of 1.0.
Calcium 8.4. Phosphorus of 5.3. Magnesium of 1.5. Serum
osmolarity 385. Alcohol level 417. Otherwise, serum
toxicology screen was negative.
Abdominal CT revealed no intraperitoneal or pelvic visceral
injury. Positive fatty infiltration of liver with
hepatomegaly. Chest x-ray revealed no infiltrates, effusions
or congestive heart failure.
Electrocardiogram revealed narrow complex tachycardia; no ST
T wave changes.
Arterial blood gases 7.33, 27, 88. Urine toxicology positive
for benzos.
Laboratory on transfer from Surgical Intensive Care Unit on
[**2160-1-27**] revealed white count of 5.8; hematocrit of 30.3;
platelets 130. INR of 1.5. Sodium of 135; potassium of 4.6;
chloride of 102; bicarbonate 26; BUN 6; creatinine 0.6;
glucose 86. Calcium 8.6. Phosphorus of 4.2. Magnesium of
1.8. ALT 65; AST 76; LDH 279. Alkaline phosphatase 164.
Total bilirubin of 0.8. Amylase of 117. Lipase 85. Albumin
3.2.
HOSPITAL COURSE: 1. Alcohol withdraw. As mentioned above,
the patient was intermittently on Ativan drip. The patient
did not go into delirium tremens and was hemodynamically
stable after Intensive Care Unit course. On transfer to
general medical floor, the patient's CIWA was between 0 and
1. The patient has not required any further Valium. Issues
around alcohol cessation were discussed extensively with the
patient. The patient states that he strongly opposes
alcoholic anonymous meetings; however, he is agreeable to
join Smart Program and will follow through as an outpatient.
The patient was continued on multi-vitamin, folate, thiamine
and B-12. He was able to ambulate with physical therapy.
The patient refused inpatient physical therapy during this
admission.
2. Lactic acidosis, secondary to alcohol use/dehydration.
This resolved with aggressive fluid resuscitation. The
patient was able to take regular p.o. on the day of
discharge.
3. Rhabdomyolysis. The patient's CK's were trending down.
The patient's renal function remained intact.
4. Alcoholic hepatitis. The patient's liver function tests
were monitored and the patient's transaminase trended down to
patient's baseline levels. The patient has known fatty liver
secondary to alcoholic hepatitis. The patient was once again
instructed on dangers of constantly using alcohol. He was
explained about the problems with liver and pancreas
dysfunction.
5. Diarrhea. The patient's stool studies were sent and were
negative. The patient was empirically started on Pancrease
three times a day before meals with resolution of diarrhea.
Therefore, his diarrhea was presumed to be secondary to
pancreatic insufficiency due to chronic alcoholic
pancreatitis.
6. Thrombocytopenia. Secondary to liver disease. Platelets
were at baseline. On discharge, there was no evidence of
bleeding. The patient had negative heparin dependent
antibodies that were sent in the Intensive Care Unit.
7. Cardiomyopathy: Presumed secondary to alcohol use. The
patient was started on Lisinopril and Propanolol that was
increased to the outpatient dose of 80 mg twice a day. The
patient's Hydrochlorothiazide is to be started as an
outpatient since the patient's systolic blood pressure was
between 100 and 120 on the day of discharge.
DISCHARGE CONDITION: Stable.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES;
1. Alcoholism.
2. Alcohol withdraw.
3. Lactic acidosis.
4. Rhabdomyolysis.
5. Thrombocytopenia.
6. Diarrhea secondary to pancreatic insufficiency.
7. Chronic pancreatitis.
8. Cardiomyopathy.
DISCHARGE MEDICATIONS:
The following changes to the outpatient medications were
made:
1. The patient is to take Pancrease one capsule p.o. three
times a day with meals for pancreatic insufficiency.
2. The patient is to take Lisinopril 10 mg p.o. q. day.
3. The patient was instructed not to take
Hydrochlorothiazide until seen as an outpatient by Dr.
[**First Name (STitle) 4702**].
FOLLOW-UP PLANS:
1. The patient is to follow-up with Dr. [**First Name (STitle) 4702**] within the
next week after discharge.
2. The patient is to attend SMART recovery meetings.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4704**], M.D. [**MD Number(1) 4705**]
Dictated By:[**Name8 (MD) 4937**]
MEDQUIST36
D: [**2160-1-30**] 10:54
T: [**2160-1-30**] 12:01
JOB#: [**Job Number 33915**]
|
[
"291.0",
"728.89",
"V08",
"401.9",
"303.91",
"276.5",
"425.5",
"276.2",
"287.5"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7951, 8210
|
8233, 8598
|
5644, 7929
|
3635, 5626
|
8615, 9048
|
157, 2091
|
2113, 3434
|
3451, 3612
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,047
| 122,500
|
30416
|
Discharge summary
|
report
|
Admission Date: [**2114-4-19**] Discharge Date: [**2114-4-29**]
Date of Birth: [**2060-10-4**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Abdominal Pain s/p laparoscopic cholecystectomy
Major Surgical or Invasive Procedure:
Roux-En-Y Hepaticojejunosotmy to Intrahepatic Biliary Confuence
Drainage of Intraabdominal Abscesses
Thrombectomy of Small Hepatic Artery
Fluroscopic Cholangiography
Biliary Stent Placement
History of Present Illness:
This is a 53 year old female s/p Lap CCY ([**4-16**]) at an OSH
complicated by a CBD injury.
She presents with diffuse abdominal pain. She denies fever or
chills.
Imaging from OSH:
[**2114-4-18**] HIDA: + bile leak
[**4-18**] ERCP: primary bile duct injury, unable to get any contrast
past distal CBD
Past Medical History:
GERD, ?CBD stone/cholelithiasis, MVP (w/ prophylaxis)
PSHx: Lap CCY ([**4-16**]), Csection, ERCP x2
Social History:
+ smoking history
Physical Exam:
VS: 97.1, 108, 168/80, 32, 95% 2L
Gen: A+O x 3, very uncomfortable.
HEENT: WNL, anicteric
Resp: bibasilar crackles
CV: tachy, no murmurs/gallops
Abd: tender on palpation, decreased bowel sounds, positive
guarding, firm to right side. Lap sites C/D/I with steri strips
in place.
Ext: no edema noted
Brief Hospital Course:
She was admitted on [**2114-4-19**] from an OSH s/p a lap CCY
complicated by a bile leak.
Abd: She was diffusely tender
A CT scan was done on [**4-19**] and there was successful placement of
8 French pigtail catheter into a subhepatic pocket of fluid.
Samples were sent for Gram stain and culture and analysis as
requested. Approximately 250 cc of bilious fluid was drained.
Post-procedure tachycardia to 150-160 was noted.
.
GI: She was NPO with IVF.
ID: She was started in Zosyn empirically. Blood and fluid
cultures were done and were negative.
CV: She was admitted to the ICU for post procedure, symptomatic
PSVT. Cardiology was consulted. EKG revealed sinus tachycardia
withal rate of 110bpm. She was ordered for beta blockers. The
tachycardia resolved. An ECHO was done pre-operatively and was
showed no abnormalities.
Pain: She was ordered for Dilaudid for pain control.
.
.
She went to the OR for Bile Duct Reconstruction on [**2114-4-20**].
Post-operatively she was in the ICU
Pain: She had a Dilaudid PCA and had good pain control. She was
transitioned to PO pain meds once tolerating a diet.
.
GI/Abd: She was NPO with IVF and a NGT. The NGT was self D/C'd
on POD 1. Her abdomen was soft and appropriately tender. She had
a JP drain in place and T-tube with a scant amount of bile.
She was started on clears on POD 4 and advanced to a regular
diet on POD 5. She was tolerating a diet.
She continued to have a rising WBC which peaked at 32,000.
Clinically she looked fine, but a CT was done to look for an
abscess. CT on [**4-26**] showed large multilobulated pelvic fluid
collection in pouch of [**Location (un) **] with thin enhancing rim. This was
subsequently drained.
A tube Cholangiogram was performed on [**4-27**], POD 7 and showed the
surgically placed tube is in the jejunal loop. No evidence of
leakage of contrast and no opacification of anastomosis or
intrahepatic duct.
Her incision had a 2cm open area of incision on right side. She
will continue with wet to dry dressing changes.
The anterior JP drain was D/C'd on POD 8 and her staples were
removed. The biliary drain was capped and will remain in place
until follow-up.
.
Resp: She was requiring O2 for low O2 saturation. She was a
former smoker and was diminished with crakles at the bases. She
was requiring good pulmonary hygeine for congestion. She was
coughing up thick white/yellow sputum. She was on a O2 face
mask.
She was transferred to the floor on [**4-24**]. Once on the floor, she
had much better O2 sats and was on nasal canula, with sats 95%.
.
CV: No ectopy noted post-operatively.
.
Renal: She received IV Lasix for the bibasillary crackles and
volume overload. she responded well and had brisk diuresis.
.
ID: She continued on IV Zosyn for 7 days.
Medications on Admission:
Prilosec
Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain: please take
colace while taking percocet to prevent constipation.
Disp:*30 Tablet(s)* Refills:*0*
2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*30 Tablet(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): please take colace while taking percocet to
prevent constipation.
Disp:*60 Capsule(s)* Refills:*2*
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain. Tablet(s)
5. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 3 days.
Disp:*1 Tablet(s)* Refills:*0*
6. Outpatient Lab Work
CBC, please send results to Dr. [**Last Name (STitle) 468**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] Hospice and VNA
Discharge Diagnosis:
Biliary Injury s/p Laparoscopic Cholecystectomy
Discharge Condition:
Good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
.
Please resume all of your regular medications and take any new
meds as ordered.
.
Continue to ambulate several times per day.
Keep T-tube (percutaneous biliary drain) capped for three weeks.
Please take fluconazole for a total of 3 days (last dose 3/26).
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**3-10**] weeks. Call ([**Telephone/Fax (1) 27730**] to schedule an appointment.
Completed by:[**2114-4-30**]
|
[
"424.0",
"444.89",
"997.1",
"276.6",
"567.81",
"530.81",
"998.59",
"E878.6",
"427.1",
"998.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"87.51",
"54.91",
"38.06",
"51.37",
"51.43",
"38.93",
"87.54",
"70.12"
] |
icd9pcs
|
[
[
[]
]
] |
5024, 5086
|
1380, 4133
|
361, 553
|
5178, 5185
|
5630, 5801
|
4192, 5001
|
5107, 5157
|
4159, 4169
|
5209, 5607
|
1058, 1357
|
274, 323
|
581, 884
|
906, 1008
|
1024, 1043
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,265
| 146,235
|
10788
|
Discharge summary
|
report
|
Admission Date: [**2104-11-12**] Discharge Date: [**2104-11-17**]
Date of Birth: [**2065-12-27**] Sex: M
Service: MICU
CHIEF COMPLAINT: Shortness of breath.
HISTORY OF PRESENT ILLNESS: A 38-year-old Hispanic male with
human immunodeficiency virus, and hepatitis C, and a history
of asthma who presents with a 3-day history of increasing
shortness of breath. He denies cough, fever, chills,
hemoptysis, hematemesis, melena, bright red blood per rectum,
or dysuria. He does not increasing abdominal girth during
this time period and associated discomfort. He has tried
meter-dosed inhalers with little relief. He denies recent
intravenous drug abuse or alcohol abuse, stating that the
last use of either was four to five months ago. He has not
had any viral illnesses lately.
PAST MEDICAL HISTORY:
1. Human immunodeficiency virus/acquired immunodeficiency
syndrome; CD4 count 46 in [**2104-10-9**], viral 106.
2. Neuropathy.
3. Immune reconstitution syndrome.
4. Asthma.
5. Schizophrenia.
6. Depression.
7. Hepatitis C with cirrhosis.
8. Diabetes mellitus.
MEDICATIONS ON ADMISSION: Risperdal 1 mg p.o. b.i.d.,
Atovaquone 1500 mg p.o. q.d., Kaletra 2 tablets p.o. b.i.d.,
Agenerase 600 mg p.o. b.i.d., Neurontin 800 mg p.o. t.i.d.,
Remeron 15 mg p.o. q.h.s., Cogentin 1 mg p.o. b.i.d.,
Serevent 2 puffs b.i.d., NPH insulin 24 units q.a.m. and
12 units q.p.m., BuSpar 15 mg p.o. t.i.d., Flovent 4 puffs
t.i.d., azithromycin 1200 mg p.o. every week, Nicotine patch,
Fluconazole 100 mg p.o. q.d., Celexa 20 mg p.o. q.d.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: A one pack per day smoker. Two cases of
beer per week. Intravenous drug abuse; last heroine use
three months ago. Three children. Lives in an acquired
immunodeficiency syndrome group house.
PHYSICAL EXAMINATION ON PRESENTATION: On admission
temperature was 96.4, pulse 88, blood pressure of 132/64,
oxygen saturation 100% on room air and 98% on ambulation. In
general, lethargic. Head, ears, nose, eyes and throat
revealed the right eye deviated to the right. Chest had fine
crackles on the left. Heart had a regular rate and rhythm.
A 2/6 systolic murmur at the apex. The abdomen was
distended, dull flanks, nontender. Extremities revealed no
edema. Neurologically, positive for asterixis.
LABORATORY DATA ON PRESENTATION: On admission white blood
cell count was 12.2, hemoglobin 12.9, hematocrit 36.7,
platelets 120. Differential of 88% neutrophils, 6.3%
lymphocytes. PT 14.5, PTT 37.8, INR of 1.5. Chem-7 revealed
sodium of 115, potassium 5.3, chloride 86, bicarbonate 19,
blood urea nitrogen 24, creatinine 0.9, glucose of 115. ALT
of 161, AST 232, alkaline phosphatase 179, total
bilirubin 3.3, albumin 2.7. Serum toxicology screen was
negative.
RADIOLOGY/IMAGING: Chest CT revealed diffuse infiltrates,
left greater than right, of unclear etiology.
HOSPITAL COURSE: Given the patient's very poor prognosis
with acquired immunodeficiency syndrome and cirrhosis, he
elected to make himself do not resuscitate/do not intubate.
1. INFECTIOUS DISEASE: It was unclear what the source of
his respiratory, if any, was. He was started on levofloxacin
as well as empiric antibiotics for Pneumocystis carinii
pneumonia coverage. He had sputum tested for acid-fast
bacillus. Two sputum samples were negative for acid-fast
bacillus by smear and also by culture at the time of death.
He received a bronchoscopy, and the lavage fluid was negative
for Pneumocystis carinii pneumonia.
2. GASTROINTESTINAL: He has a history of gastrointestinal
bleeding for esophageal varices, and was therefore started on
Protonix for prophylaxis as well as Octreotide for
prophylaxis.
3. CARDIOVASCULAR: He was profoundly hyponatremic
throughout the entire hospital stay. This was felt due both
to syndrome of inappropriate secretion of antidiuretic
hormone and also to cirrhosis. He was fluid restricted and
given albumin, as well as 3% normal saline in attempts to
increase his intravascular fluid and correct his
hyponatremia, but the hyponatremia did not resolve, and he
was persistently in the 110 range to 115 range for his
sodium.
4. PULMONARY: He continued to complain of frequency
coughing requiring nebulizer treatments every two hours.
On the morning of [**2104-11-17**], he was noted to become
bradycardic/systolic and then asystolic on his cardiac
monitor. Time of death was [**2104-11-17**] at 9 o'clock
a.m.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Name8 (MD) 4123**]
MEDQUIST36
D: [**2104-11-17**] 10:08
T: [**2104-11-20**] 11:09
JOB#: [**Job Number 35236**]
|
[
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"295.90",
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"789.5",
"276.1",
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icd9cm
|
[
[
[]
]
] |
[
"33.23",
"96.56",
"54.91"
] |
icd9pcs
|
[
[
[]
]
] |
1117, 1590
|
2904, 4707
|
154, 176
|
205, 800
|
822, 1090
|
1607, 2886
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,111
| 168,493
|
15853
|
Discharge summary
|
report
|
Admission Date: [**2100-9-24**] Discharge Date: [**2100-10-11**]
Date of Birth: [**2081-10-10**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is an 18 year old
male involved in a high speed motor vehicle crash/rollover
approximately 100 miles per hour who was unrestrained who had
a prolonged extrication with significant intrusion into the
car. There was positive loss of consciousness. The patient
was intubated in the field and initially brought to [**Hospital6 23267**]. Computerized tomography scan at an outside
hospital showed subdural hematoma and a pneumothorax. He was
brought to [**Hospital6 256**] via
[**Location (un) **].
PAST MEDICAL HISTORY: None.
PAST SURGICAL HISTORY: None.
MEDICATIONS ON ADMISSION: None.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: The patient's temperature is 38.2,
pulse 109, blood pressure 120/50, 100% intubated and
paralyzed. The patient had multiple scalp lacerations that
were stable. A right frontotemporal area laceration with 2
cm laceration superior to the nose bridge. Pupils were 2.5
to 2 mm bilaterally. The face was stable. The neck was in a
cervical collar. Trachea was midline. There was no
crepitus. Chest was stable. The lung sounds were coarse
bilaterally. Heart was regular rate and rhythm. Abdomen was
soft, nontender, nondistended. There was no ecchymosis. The
pelvis was stable. Rectal had decreased stone, was guaiac
positive. Back had no stepoffs, no deformities. Extremities
had no deformities and were warm with distal pulses, 2+
femoral, popliteal, dorsalis pedis and posterior tibial
bilaterally. Neurologically he was intubated and paralyzed.
LABORATORY DATA: Laboratory examination included a white
count of 38, hematocrit of 43, PT 13.9, PTT 29.3, INR 1.3,
platelets 228. Urinalysis had 3 to 5 red blood cells, 0 to 2
white blood cells, sodium is 133, potassium 3.9, chloride 99,
bicarbonate 22, BUN 9, creatinine 0.8, glucose 124, amylase
44, toxicology screen negative. Serum-wise and urine screen
showed positive benzodiazepines. Gas upon entry was 7.37,
41, 158, 25, -1.
Radiologic studies - Chest x-ray showed right pneumothorax,
pelvic AP showed no fractures, dislocations. Head
computerized tomography scan showed right lateral ventricle
interventricular hemorrhage, intraparenchymal hemorrhage with
multiple foci bilaterally. Cervical spine computerized
tomography scan showed a C1 ring fracture. Chest
computerized tomography scan showed a right pneumothorax and
left lower lobe contusion. Abdomen and pelvis computerized
tomography scan were negative.
HOSPITAL COURSE: The patient was evaluated in the Trauma
Bay, was stabilized and was transferred to the Surgical
Intensive Care Unit. There he was evaluated by Neurosurgery
and a communible was placed for intracranial pressure
monitoring. The patient was maintained on sedation and
remained intubated. The patient remained hemodynamically
stable through his initial course. Blood pressure control
was maintained to continue cerebral perfusion and avoid
hypotension. The patient had a repeat head computerized
tomography scan which on hospital day #2 showed no increase
in the intraparenchymal or intraventricular hemorrhages. The
patient was maintained in the cervical collar for the C1 ring
fracture. The patient had additional imaging on hospital day
#2 for TLS spine computerized tomography scans which showed
no fractures or dislocations. The patient's subsequent
laboratory results demonstrated a coagulopathy with INR of 2.
The patient was corrected with 4 units of FFP. On hospital
day #3 the patient had an electroencephalogram done which
showed moderate to severe encephalopathy secondary to toxic
metabolic or noncircular injuries, but no seizure activity.
The patient's sedation was slowly weaned and the patient
demonstrated movement of all four extremities. Movement was
not purposeful and the patient did not respond to any
commands. On hospital day #4 the communible was discontinued
after the patient's intracranial pressures remained stable.
The patient also had a temperature spike. Sputum was sent
which showed a gram stain of gram negative rods. The patient
was started on Levaquin. Cultures remained negative. The
patient had also been started on advancing tube feeds as
well. On hospital day #6 the patient's chest tube was
discontinued. The patient continued to remain on ventilatory
support producing thick amounts of sputum. The patient's
support was weaned as tolerated. The decision was made
secondary to the continued depression of his mental status,
the patient received pertracheostomy and percutaneous
gastrostomy tube. This was done on hospital day #7 without
incident. The patient was able to wean off of the ventilator
support to trach collar. The patient on hospital day #8
spike to 39.8. Blood cultures and sputum revealed
Methicillin-resistant Staphylococcus aureus. The patient was
started on Vancomycin for a 10 day course. Once the
antibiotics were started the patient defervesced and further
cultures have remained negative. On hospital day #14 the
patient remaining stable with decreased amounts of secretions
was transferred to the floor. The patient had continued tube
feeds at goal, started on Heparin t.i.d. for neurosurgery for
deep vein thrombosis prophylaxis. The patient has received
multiple lower extremity ultrasound studies for deep vein
thrombosis which have all been negative. The patient's most
recent x-ray on [**2100-10-5**] showed no evidence of any
pneumonia but continued to have some atelectasis in the right
base. The patient had a repeat magnetic resonance imaging
scan on the floor which revealed a 5 by 9 mm intraparenchymal
hemorrhage of the left upper lobe, and resolution of other
bleeding.
The patient's mental status has remained stable. The patient
does not follow commands and will open eyes and withdraw to
painful stimuli. The patient does show purposeful movement in
attempting to remove percutaneous endoscopic gastrostomy
tube. The patient has not demonstrated any evidence of
comprehension or speech when spoken to. The patient's
strength remains [**4-18**] bilaterally throughout. The patient has
completed a course of Vancomycin for Methicillin-resistant
Staphylococcus aureus pneumonia. The patient is stable and
ready for discharge to rehabilitation.
DISCHARGE DIAGNOSIS:
1. Status post motor vehicle accident with the following
injuries.
2. Intraparenchymal hemorrhage
3. C1 cervical spine fracture
4. Methicillin-resistant Staphylococcus aureus pneumonia
MEDICATIONS ON DISCHARGE:
1. Heparin 5000 units subcutaneous q. 12
2. Colace 100 mg per gastrostomy tube b.i.d.
3. Artificial tears 1 to 2 drops both eyes, prn
4. Dulcolax 10 mg p.r. prn q.d.
5. Pro-Mod with fiber 105 cc/hr via percutaneous endoscopic
gastrostomy tube, trach care
6. Phenytoin 100 mg per gastrostomy tube q. 8 hours
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: The patient will follow up with Neurosurgery in
one week for discharge, should call for an appointment. The
patient should follow up with the Trauma Clinic in two weeks.
ADDENDUM: The patient upon entering the outside hospital was
witnessed to have a tonoclonic seizure lasting eight minutes.
The patient was treated with Valium and was placed on
Dilantin in the hospital. The patient remained on Dilantin
and will do so until follow up with Neurosurgery in the dose
listed on the previous dictation summary.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2213**], M.D. [**MD Number(1) 2214**]
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2100-10-10**] 18:36
T: [**2100-10-10**] 17:47
JOB#: [**Job Number 45563**]
|
[
"853.05",
"560.1",
"V09.0",
"806.00",
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"E816.0",
"780.39",
"518.0",
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icd9cm
|
[
[
[]
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] |
[
"43.11",
"08.81",
"38.93",
"96.6",
"96.72",
"01.18",
"31.1",
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icd9pcs
|
[
[
[]
]
] |
6414, 6604
|
6630, 6944
|
761, 806
|
2638, 6393
|
727, 734
|
6990, 7784
|
829, 2620
|
162, 673
|
696, 703
|
6969, 6978
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,016
| 173,218
|
27252
|
Discharge summary
|
report
|
Admission Date: [**2166-4-22**] Discharge Date: [**2166-5-13**]
Date of Birth: [**2120-11-12**] Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 6743**]
Chief Complaint:
Acute renal failure, pelvic mass
Major Surgical or Invasive Procedure:
Hysterectomy
Bilateral salpingoophorectomy
lymph node dissection
History of Present Illness:
45 y.o. G0 transferred from [**Hospital3 **] to [**Hospital1 18**] on [**2166-4-22**] for
evaluation of large pelvic masses. The pt had MMY for
symptomatic fibroids in [**1-12**], then began having irregular menses
with intermenstrual bleeding and abdominal cramping. Abdominal
U/S in PA from [**2165-12-4**] showed enlarged uterus, multiple
fibroids, ovaries both normal. On [**2166-2-28**], MRI showed bilateral
solid and cystic masses in the adnexa, endometrial thickening to
18mm, and multiple fibroids. The pt states that she was told
these may be "degenerating fibroids", and that she should have
follow-up imaging in a month. She subsequently had an U/S
[**2166-3-27**], which again showed complex bilateral adnexal masses,
enlarged compared to previous imaging and endometrial stripe of
21 mm. Another MRI was also performed on [**2166-4-10**], which again
showed adnexal masses, thickened endometrium, enlarged uterus,
small amount of pelvic ascites, as well as bony lesions in the
right ileum, and L4-L5 vertebral bodies. The pt has never had an
endometrial biopsy.
The pt has switched physicians several times in the past several
months and in the interim, has had increasing abdominal
distention, diffuse abdominal discomfort/pain. After receiving
contrast for a CT scan [**2166-4-18**], she began having significant
n/v. For the past few days, she has also noticed significantly
decreased urine output, constipation without flatus. She has
gained weight from baseline 114 to 138 lbs today. No
fevers/chills.
The pt was seen on day of admission at [**Hospital3 **] with pain,
requiring morphine
PCA. Labs at that time were significant for Cr 3.0 (up from 1.6
on [**4-19**]); she also had low urine output, 125-200 cc per 8 hr
shifts. A renal U/S was performed, which showed bilateral
hydronephrosis, bilateral echogenic kidneys. The pt also had a
CXR which was normal except for small bilateral effusions, and a
bone scan, which was negative. The pt was then transferred to
[**Hospital1 18**] for gyn onc evaluation.
Past Medical History:
PMH: none
PGynHx:
- No abnormal paps, last pap 3/06
- No abnormal mammos, last mammogram [**1-13**]
- Irregular menses as above for past year
- No h/o STD's, not sexually active
PSH: MMY, bunion removal
Social History:
Social:
- No tobacco/EtOH/Drugs
- Lives in [**State 5887**], here in [**Location (un) 86**] alone. Does not want
family present.
-Works as inspector for dept of agriculture.
Family History:
Maternal grandfather w/[**Name2 (NI) 499**] cancer
Physical Exam:
Admission PE:
VS: 99.6 105 18 118/70 98%RA
Cachetic; pt anxious and easily irritable
RRR
CTAB, decreased breath sounds at bases bilaterally
No vertebral tenderness. Some CVA tenderness bilaterally
Abd tensely distended, + fluid wave, very soft/infrequent bowel
sounds, diffusely tender to palpation, no rebound/guarding.
Large masses palpable abdominally
LE 1+ pitting edema
Pelvic deferred
Pertinent Results:
BLOOD
-Hct: Intra-op HCT 23.0, s/p 2 units PRBCs->Hct 26.0, 2 more
units [**4-29**] (total 4)-> [**5-1**] Hct 31 (stable); Hct continued to
rise, last Hct on this admission was 36.6 on [**5-11**]
-WBC on admission 25.8, decreased gradually to pre-op (on HD#7)
of 19.2; post-op contined to decrease gradually, normalized on
HD#10
CHEMISTRIES
-Cr on admission 3.2, declined gradually, returned to wnl at 1.1
on HD#8 and continued to decline; last Cr on [**5-11**] was 0.6
-BUN on admission 35, rose to high of 43 on HD#[**3-12**], then
declined steadily, normalized on HD#9 at 17
-pt was hyponatremic () on HD#s [**12-15**], then normalized on HD#9 and
remained normal therafter (127-130)
CA-125 on admission 669
UA and UCx performed on [**4-23**] were negative
Brief Hospital Course:
Pt was admitted on [**4-22**] with ARF, bilateral pelvic masses. On
[**4-28**] (HD#7) but had hysterectomy, bilateral salpingoophorectomy
and lymph node dissection for what was ultimately staged as IIIA
endometrial cancer. Please see operative report for details of
procedures. Issues during hospitalization,
1)Vaginal discharge/Ascites: pt reported drainage of clear fluid
from vagina. Dye placed into bladder did not drain per vagina,
suggesting that fluid was not coming from a vesicovaginal
fistula. [**5-7**] pelvic MRI suggested probable communication
between anterior vagina & peritoneal cavity, allowing ascitic
fluid to drain per vagina. On [**5-8**], therapeutic paracentesis
removed 3.5L of ascites. At time of discharge, pt was still
having drainage of ascitic fluid per vagina and was advised that
it would improve after she began chemotherapy.
2)Heme: Intra-op HCT 23.0, s/p 2 units PRBCs->Hct 26.0, 2 more
units [**4-29**] (total 4)
-> [**5-1**] Hct 31 (stable); Hct continued to rise, last Hct on this
admission was 36.6 on [**5-11**]
3) Decreased O2 sats HD#4: there was a question of possible PE -
VQ scan intermediate risk, LE dopplers negative. HD#6 MRV
negative for IVC thrombosis. Repeat LE dopplers HD#11 neg. SQ
Hep TID and venodynes were used for prophylaxis
4) Renal failure: resolved slowly; Cr on admission 3.2, declined
gradually, returned to wnl at 1.1 on HD#8 and continued to
decline; last Cr on [**5-11**] was 0.6
5) FEN: on admission, pt was hyponatremic and hyperkalemic, with
a metabolic acidosis. This resolved gradually - as described
above, Cr returned to wnl on HD#8 and continued to decline, last
Cr on [**5-11**] was 0.6; pt was hyponatremic on HD#s [**12-15**], then
normalized on HD#9 and remained normal therafter. Pt was
hyperkalemic on HD#4 (5.2) and #8 (5.3) but otherwise K wnl,
normal EKGs. Pt also experienced bilateral LE edema, which was
treated with lasix.
6) CV: Hypotension postop in ICU, BP stable therafter; EKG WNL
7) Anxiety: SW consult - pt paranoid and anxious. Pt was treated
with ativan prn
Patient was found to be stable for discharge on HD#22 on [**2166-5-13**]
and was discharged to a hotel.
Medications on Admission:
None
Discharge Medications:
1. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical
QID (4 times a day) as needed.
Disp:*qs 1* Refills:*2*
2. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed.
Disp:*30 Capsule(s)* Refills:*2*
3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*30 Suppository(s)* Refills:*2*
4. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Stage IIIA Endometrial cancer
Acute renal failure - resolved
Discharge Condition:
stable
Discharge Instructions:
Pelvic Rest for 6 weeks
No heavy lifting for 6 weeks
Call for fever>101
No driving while taking narcotics
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 5777**] Call to schedule
appointment
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 6753**]
|
[
"560.9",
"182.0",
"300.00",
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"276.1",
"623.5",
"518.5",
"584.9",
"458.29",
"198.6"
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icd9cm
|
[
[
[]
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] |
[
"68.6",
"40.3",
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"54.4",
"99.04",
"40.54",
"48.23",
"65.61"
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icd9pcs
|
[
[
[]
]
] |
7240, 7298
|
4171, 6341
|
325, 392
|
7403, 7412
|
3383, 4148
|
7566, 7807
|
2899, 2951
|
6396, 7217
|
7319, 7382
|
6367, 6373
|
7436, 7543
|
2966, 3364
|
253, 287
|
420, 2463
|
2485, 2690
|
2706, 2883
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,129
| 154,842
|
15716
|
Discharge summary
|
report
|
Admission Date: [**2178-2-16**] Discharge Date: [**2178-2-18**]
Service: CCU
CHIEF COMPLAINT: Increasing dyspnea on exertion.
HISTORY OF THE PRESENT ILLNESS: The patient is an
82-year-old man with a known history of three vessel coronary
artery disease that has been managed medically since [**2175**].
In [**11-5**], the patient underwent a cardiac evaluation as part
of routine preoperative screening prior to a laminectomy
scheduled for his history of symptomatic spinal stenosis.
During this evaluation, the patient had a negative P MIBI but
had a catheterization that again showed three vessel coronary
artery disease without ulcerations or critical nonactive
lesions. The patient was cleared for surgery with the plan
for future further cardiac interventions.
Since the time of the surgery, the patient has noted
continued progression of his chronic DOE (present for
approximately three years) such that he can only ambulate a
half a flight of stairs without experiencing dyspnea. He
was, therefore, referred to the [**Hospital1 18**] for semielective
cardiac catheterizations with plans for PCI to the LAD and
either the LCX or RCA.
The patient underwent PTCA and stenting of the proximal and
distal LAD on the morning of admission and subsequently was
found to have a small perforation of the LAD distal to the
second stent. The remainder of the procedure was, therefore,
aborted, and the patient was sent to the CCU for overnight
monitoring.
Of note, the patient had 6/10 chest pain while in the
Catheterization Laboratory Recovery Suite without EKG
changes.
PAST MEDICAL HISTORY:
1. Coronary artery disease (catheterization in [**2177-11-21**]:
70% LAD at bifurcation, 70-80% small dLAD, 70-80% LCX, 70%
mRCA; negative pMIBI [**2177-11-18**] with EF 61%).
2. BPH.
3. TIA.
4. Spinal stenosis status post surgery on L3-5.
5. Colectomy secondary to obstruction.
ALLERGIES: The patient has no known drug allergies.
ADMISSION MEDICATIONS:
1. Aspirin 81 mg p.o. q.d.
2. Simvastatin 20 mg p.o. q.d.
3. Rabeprazole 40 mg p.o. q.d.
4. Finasteride 5 mg p.o. q.d.
5. Multivitamin one tablet p.o. q.d.
6. Metoprolol XL 12.5 mg p.o. q.d.
7. Isosorbide mononitrate 30 mg p.o. q.d.
SOCIAL HISTORY: The patient is married. He lives at home
with his wife.
PHYSICAL EXAMINATION ON ADMISSION: The patient's temperature
was 97.8 degrees, heart rate 59-77, blood pressure
117-179/62-85, respiratory rate 17-22, oxygen saturation 96%,
and CVP 5-7 mmHg. The patient was asleep, easily arousable,
in no acute distress. He had mild anisocoria with equally
reactive pupils bilaterally. MMM, OP clear. His heart was
with a regular rate and rhythm, and there were normal S1 and
S2 heart sounds. His lungs were clear to auscultation
bilaterally at the midaxillary lines. His abdomen was
benign. He had 2+ dorsalis pedis pulses bilaterally, and no
peripheral edema.
LABORATORY DATA: On the initial laboratory evaluation, his
platelets were 196,000, potassium 3.9, CK 136 with MB of 22
and an index of 16.2. His precatheterization CBC
demonstrated a white count of 8.3, hematocrit 38.5, platelets
201,000. His initial chemistries revealed a sodium of 138,
potassium 5.3, chloride 104, bicarbonate 25, BUN 23,
creatinine 1.0, glucose 92.
Cardiac catheterization demonstrated a right dominant system,
normal LMCA, proximal 80% LAD lesion with distal 80% focal
lesion, nondominant LCX with mild diffuse disease, dominant
RCA with proximal 80% tubular and long lesions; the procedure
was complicated by distal (LAD) myocardial perforation
without evidence of pericardial communication.
Post catheterization echocardiogram demonstrated mildly
depressed left ventricular systolic function, resting
regional wall motion abnormalities apparently including mid
and basal inferior and septal hypokinesis, and no pericardial
effusion.
A post catheterization EKG demonstrated normal sinus rhythm
at 62 beats per minute, normal axis, 1-2 mm upsloping ST
segments in leads V2 through V4 without significant change
from baseline, no other ST segment changes, no T wave
inversions, and Q waves in lead III.
HOSPITAL COURSE: Following his arrival to the CCU, the
patient's blood pressure was controlled with a nitroglycerin
drip.
On hospital day number two, he returned to the
Catheterization Laboratory for repeat cardiac
catheterization. This study demonstrated a right dominant
system, normal LMCA, patent LAD stents without evidence of
coronary or myocardial perforation, TIMI I flow through the
S1, a nondominant LCX vessel without lesions, and a dominant
RCA vessel with midsegment tubular 80% lesion and a serial
60% lesion. The RCA was, therefore, stented with a final
residual of approximately 10% with normal flow.
Following this procedure, the patient was hemodynamically
stable.
Of note, the patient had several episodes of chest pain and
shortness of breath following his catheterizations, during
each of these episodes, there were no EKG changes and the
patient's symptoms resolved either spontaneously or with 1 mg
of IV morphine. At the time of discharge, he was
symptom-free and hemodynamically stable.
Also of note, the patient ruled in for a NST EMI by cardiac
enzymes following the first catheterization. His peak CK
value was 494 with an associated MB fraction of 73. At the
time of discharge, his CK had decreased to 196.
The patient was also seen by the Department of Physical
Therapy, who agreed with the plan for continued home physical
therapy; the patient had been previously receiving physical
therapy at home prior to his admission to the hospital.
DISCHARGE CONDITION: Good.
DISCHARGE PLACEMENT: To home.
DISCHARGE DIAGNOSIS:
1. Cardiac catheterization with percutaneous transluminal
coronary angioplasty and stenting to the left anterior
descending artery times two complicated by a distal (LAD)
myocardial perforation without pericardial communication.
2. Cardiac catheterization with percutaneous transluminal
coronary angioplasty and stenting of the right coronary
artery.
3. NST EMI.
4. Hypertension.
DISCHARGE MEDICATIONS:
1. Clopidogrel 75 mg p.o. q.d. for life.
2. Enteric coated aspirin 325 mg p.o. q.d.
3. Isosorbide mononitrate 30 mg p.o. q.d.
4. Metoprolol XL 12.5 mg p.o. q.d.
5. Simvastatin 20 mg p.o. q.d.
6. Finasteride 5 mg p.o. q.d.
7. Rabeprazole 40 mg q.d.
8. Multivitamin one tablet p.o. q.d.
FOLLOW-UP: The patient was instructed to phone his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 33474**], at [**Telephone/Fax (1) 45283**] to
arrange for a follow-up appointment within four to six weeks.
He was also instructed to telephone Dr. [**First Name (STitle) **] in the
Department of Cardiology to arrange for a follow-up
appointment with him within four to six weeks.
[**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**]
Dictated By:[**Name8 (MD) 2507**]
MEDQUIST36
D: [**2178-2-18**] 04:32
T: [**2178-2-21**] 08:36
JOB#: [**Job Number 45284**]
|
[
"414.01",
"998.2",
"997.1",
"E878.8",
"410.91",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.01",
"37.22",
"88.52",
"99.20",
"36.06",
"88.55"
] |
icd9pcs
|
[
[
[]
]
] |
5629, 5668
|
6097, 7122
|
5689, 6074
|
4143, 5607
|
1972, 2213
|
105, 1588
|
2324, 4125
|
1610, 1949
|
2230, 2309
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,454
| 166,126
|
30500
|
Discharge summary
|
report
|
Admission Date: [**2155-3-31**] Discharge Date: [**2155-4-8**]
Date of Birth: [**2095-4-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Erythromycin Base
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2155-3-31**] Aortic Valve Replacement(25mm CE Pericardial Valve)
[**2155-4-3**] Cardioversion
History of Present Illness:
This is a 59 year old male with known bicuspid aortic valve who
presents with severe shortness of breath associated with cough
and hemoptysis. A SPECT Sestamibi ETT showed poor functional
capacity, limited by fatigue with hypotension at peak exercise.
Nuclear imaging showed global hypokinesis with inferior and
apical hypokinesis. Echocardiography revealed preserved LV
function and severe aortic stenosis of a bicuspid aortic
valve(mean 45 mmHg, [**Location (un) 109**] of 0.7cm2). Subsequent coronary
angiography showed no significant coronary artery disease in a
right dominant circulation. Based upon the above, he was
referred for cardiac surgical intervention. Of note, during a
previous preoperative workup, he was noted to have severe
stenosis of his right internal cartoid artery for which he
underwent successful carotid stent placment on [**2155-3-14**] by Dr.
[**Last Name (STitle) **]. He had been on Plavix since that time.
Past Medical History:
Aortic Stenosis, Bicuspid Aortic Valve - s/p AVR
Congestive Heart Failure
Hypertension
Hyperlipidemia
History of MI
Carotid Disease - recent right carotid stent [**2155-3-14**]
Depression
Pulmonary Nodules
Tonsillectomy
Social History:
Married
Tobacco [**12-3**] ppd x 25yrs
ETOH 3 drinks/day
Family History:
Sister with murmur
Physical Exam:
Vitals: BP 137/73, HR 94, RR 18, SAT 94% on room air
General: well developed male in no acute distress
HEENT: oropharynx benign,
Neck: supple, no JVD,
Heart: regular rate, normal s1s2, 3/6 systolic ejection murmur
radiating to carotid bilaterally
Lungs: bibasilar crackles
Abdomen: soft, nontender, normoactive bowel sounds
Ext: warm, [**12-3**]+ edema, no varicosities
Pulses: 2+ distally
Neuro: nonfocal
Discharge
Vitals 97.4, SR 71, RR 18 RA sat 98%, 118/50
Neuro a/o x3 non focal
Pulm CTA bilat
Cardiac RRR no M/R/G
Abd soft, NT, ND +BS
Ext warm pulses palpable
Sternal inc healing no erythema/drainage sternum stable
Pertinent Results:
[**2155-4-8**] 06:45AM BLOOD WBC-5.8 RBC-2.77* Hgb-8.9* Hct-25.6*
MCV-92 MCH-32.2* MCHC-34.9 RDW-14.3 Plt Ct-194
[**2155-3-31**] 10:41AM BLOOD WBC-10.7# RBC-2.40*# Hgb-7.9*# Hct-22.8*#
MCV-95 MCH-32.9* MCHC-34.8 RDW-14.1 Plt Ct-124*
[**2155-4-8**] 12:40PM BLOOD PT-18.8* INR(PT)-1.8*
[**2155-4-8**] 06:45AM BLOOD Plt Ct-194
[**2155-3-31**] 10:41AM BLOOD PT-14.5* PTT-34.2 INR(PT)-1.3*
[**2155-3-31**] 10:41AM BLOOD Plt Ct-124*
[**2155-3-31**] 10:41AM BLOOD Fibrino-168
[**2155-4-8**] 06:45AM BLOOD K-4.6
[**2155-4-7**] 07:05AM BLOOD Glucose-126* UreaN-10 Creat-1.1 Na-141
K-5.2* Cl-102 HCO3-35* AnGap-9
[**2155-4-1**] 02:57AM BLOOD UreaN-20 Creat-1.0 Na-139 Cl-107 HCO3-27
[**2155-3-31**] 11:42AM BLOOD UreaN-21* Creat-0.8 Cl-111* HCO3-28
[**2155-4-7**] 07:05AM BLOOD Calcium-8.6 Phos-4.8* Mg-2.5
[**2155-4-3**] 06:50AM BLOOD TSH-5.8*
RADIOLOGY Final Report
CHEST (PA & LAT) [**2155-4-7**] 11:10 AM
CHEST (PA & LAT)
Reason: r/o inf, eff
[**Hospital 93**] MEDICAL CONDITION:
59 year old man with AS
REASON FOR THIS EXAMINATION:
r/o inf, eff
INDICATION: 59-year-old man with a history of aortic stenosis
status post replacement.
COMPARISON: [**4-1**] and [**2155-3-10**].
FRONTAL AND LATERAL CHEST: Patient is status post median
sternotomy, with a prosthetic aortic valve in place. There are
small bilateral pleural effusions with associated lower lobe
atelectasis. The inspiration is improved compared to the prior
study. The cardiac and mediastinal contours still appear
prominent compared to preoperative studies, but are stable or
improved compared to the prior study of [**4-1**], given differences
in technique. Pulmonary vascularity does not appear engorged.
There are clips in the anterior superior mediastinum, unchanged.
IMPRESSION:
1. Small bilateral pleural effusions and lower lobe atelectasis.
2. Expected post-operative appearance to cardiac and mediastinal
contours.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name (STitle) 15097**] L. [**Doctor Last Name **]
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5785**]
Approved: MON [**2155-4-7**] 12:56 PM
Cardiology Report ECG Study Date of [**2155-4-3**] 12:58:02 PM
Sinus rhythm. Left axis deviation. Right bundle-branch block
with left anterior
fascicular block. Diffuse non-specific ST-T wave changes with
minimal
ST segment elevaetion in tyhe inferior leads. Clinical
correlation is
suggested.
TRACING #2
Read by: [**Last Name (LF) 2194**],[**First Name3 (LF) **] H.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
74 182 136 [**Telephone/Fax (2) 72449**] -50 117
([**-6/2377**])
RADIOLOGY Final Report
PORTABLE ABDOMEN [**2155-4-3**] 7:18 AM
PORTABLE ABDOMEN
Reason: evaluate for ileus
[**Hospital 93**] MEDICAL CONDITION:
59 year old man s/p AVR
REASON FOR THIS EXAMINATION:
evaluate for ileus
CLINICAL HISTORY: 59-year-old male status post aortic valve
replacement. Evaluate for ileus.
COMPARISON: None.
FINDINGS: Single supine abdominal radiograph demonstrates
air-filled loops of large and small bowel. No intra-abdominal
free air is identified.
IMPRESSION: Findings compatible with ileus.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 7410**]
DR. [**First Name (STitle) 15744**] N. [**Doctor Last Name 1447**]
Approved: [**Doctor First Name **] [**2155-4-3**] 2:56 PM
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for AVR, bicuspid AV with stenosis
Height: (in) 68
Weight (lb): 182
BSA (m2): 1.97 m2
BP (mm Hg): 123/68
HR (bpm): 72
Status: Inpatient
Date/Time: [**2155-3-31**] at 09:04
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW5-:
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.5 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.0 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.3 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *5.7 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 4.2 cm
Left Ventricle - Fractional Shortening: *0.26 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 55% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: *3.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.6 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.2 cm (nl <= 2.5 cm)
Aortic Valve - Peak Velocity: *4.2 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 72 mm Hg
Aortic Valve - Mean Gradient: 62 mm Hg
Aortic Valve - LVOT Peak Vel: 0.77 m/sec
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT Diam: 2.2 cm
Aortic Valve - Valve Area: *0.6 cm2 (nl >= 3.0 cm2)
INTERPRETATION:
Findings:
LEFT ATRIUM: Mild LA enlargement.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. Normal
interatrial septum. No
ASD by 2D or color Doppler.
LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size.
Normal regional LV
systolic function. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Focal
calcifications in
aortic root. Normal ascending aorta diameter. Focal
calcifications in
ascending aorta. Normal aortic arch diameter. Simple atheroma in
aortic arch.
Normal descending aorta diameter. Simple atheroma in descending
aorta.
AORTIC VALVE: Bicuspid aortic valve. Moderately thickened aortic
valve
leaflets. Severe AS (AoVA <0.8cm2). Trace AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular
calcification. No MS. Trivial MR.
TRICUSPID VALVE: Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify
I was present in compliance with HCFA regulations. No TEE
related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Results
were personally
post-bypass
data
Conclusions:
PRE-BYPASS:
1. The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or
color Doppler.
2. There is mild symmetric left ventricular hypertrophy. The
left ventricular
cavity size is normal. Regional left ventricular wall motion is
normal.
Overall left ventricular systolic function is normal (LVEF>55%).
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 is bicuspid. The aortic valve leaflets are
moderately
thickened. There is severe aortic valve stenosis (area <0.8cm2).
Trace aortic
regurgitation is seen.
6. The mitral valve leaflets are mildly thickened. Trivial
mitral
regurgitation is seen.
POST-BYPASS:
1.Preserved biventricular systolic function.
2. There is a well seated, well functioning bioprosthesis in the
aortic
position. No AI is visualized.
3. Study otherwise unchanged from prebypass
Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD on [**2155-4-7**] 14:23.
[**Location (un) **] PHYSICIAN:
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 72450**],[**Known firstname **] W [**2095-4-25**] 59 Male [**Numeric Identifier 72451**] [**Numeric Identifier 72452**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (Prefixes) 413**]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: AORTIC VALVE (1 JAR).
Procedure date Tissue received Report Date Diagnosed
by
[**2155-3-31**] [**2155-3-31**] [**2155-4-3**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/vf
DIAGNOSIS:
Aortic valve:
Cardial valve with nodular calcification and myxoid change.
Clinical: Aortic stenosis.
Gross:
The specimen is received fresh labeled with "[**Known firstname **] [**Known lastname **]" and
the medical record number and "aortic valve" and consists of
multiple tan white to yellow fibrotic soft tissue fragments with
calcifications and areas of hemorrhage present grossly
consistent with valvular structure. It is serially sectioned and
submitted in A after decalcification.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted and underwent an aortic valve
replacement by Dr. [**Last Name (STitle) 1290**]. For surgical details, please see
seperate dictated operative note. Following the operation, he
was brought to the CSRU invasive monitoring. Within 24 hours, he
awoke neurologically intact and was extubated without incident.
He maintained stable hemodynamics and transferred to the SDU on
postoperative day one. He went on to experience atrial flutter
which was initially treated with intravenous Amiodarone and
Heparin. The EP service was consulted and performed successful
cardioversion on [**4-3**]. He transitioned to oral Amiodarone.
Postoperative course was also notable for a right arm phlebitis
for which he was started on a course of Keflex. He continued to
do well and was ready for discharge home with services post
operative day 8.
Medications on Admission:
Atorvastatin 20 qd, Sertraline 100 qd, Aspirin 81 qd, Plavix 75
qd, Bimatoprost eye gtts
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. Sertraline 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
4. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) as needed for phlebitis for 2 days.
Disp:*8 Capsule(s)* Refills:*0*
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
6. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
8. 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*
9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
11. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
12. Warfarin 3 mg Tablet Sig: goal INR 2-2.5 Tablets PO once a
day.
Disp:*60 Tablet(s)* Refills:*0*
13. Warfarin 1 mg Tablet Sig: goal INR 2-2.5 Tablets PO once a
day.
Disp:*60 Tablet(s)* Refills:*0*
14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 7 days.
Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
16. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day): 400mg twice a day until [**4-10**] then decrease to 400mg once
a day until [**4-17**] then decrease to 200mg once a day.
Disp:*60 Tablet(s)* Refills:*0*
17. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
18. coumadin
Please take 6mg of coumadin [**4-9**] and have blood drawn [**4-10**] for
further dosing
19. Outpatient [**Name (NI) **] Work
PT/INR as needed
first draw [**4-10**]
Results to coumadin clinic [**Hospital1 **] heart center
#[**Telephone/Fax (2) 6256**]
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA
Discharge Diagnosis:
Aortic Stenosis, Bicuspid Aortic Valve - s/p AVR
Postoperative Atrial Flutter
Postoperative Right Arm Phlebitis
Congestive Heart Failure
Hypertension
Hyperlipidemia
History of MI
Carotid Disease - recent right carotid stent [**2155-3-14**]
Depression
Pulmonary Nodules
Discharge Condition:
Good
Discharge Instructions:
Patient may shower, no baths. No creams, lotions or ointments to
incisions. No driving for at least one month. No lifting more
than 10 lbs for at least 10 weeks from the date of surgery.
Monitor wounds for signs of infection. Please call with any
concerns or questions.
Followup Instructions:
Cardiac surgeon, Dr. [**Last Name (STitle) 1290**] in [**3-6**] weeks, call for appt.
[**Telephone/Fax (1) 170**]
Local PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 37063**] in [**1-4**] weeks - call for appt. [**Telephone/Fax (1) 37064**]
Local cardiologist, Dr. [**Last Name (STitle) 6254**] in [**1-4**] weeks - call for appt.
Follow up with vascular surgery as previously directed
*****
PT/INR for coumadin dosing first draw [**4-10**] for atrial
fibrillation with goal INR 2.0-2.5 results to [**Hospital 197**] clinic
[**Hospital1 **] Heart Center # 1-[**Telephone/Fax (1) 6256**]
Completed by:[**2155-4-8**]
|
[
"401.9",
"433.10",
"E878.2",
"997.4",
"412",
"426.53",
"428.0",
"518.0",
"560.1",
"999.2",
"518.89",
"E849.7",
"427.32",
"451.82",
"424.1",
"997.3",
"997.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"35.21",
"88.72",
"99.61"
] |
icd9pcs
|
[
[
[]
]
] |
14202, 14253
|
10827, 11691
|
303, 402
|
14566, 14573
|
2383, 3330
|
14891, 15522
|
1704, 1724
|
11830, 14179
|
5189, 5213
|
14274, 14545
|
11717, 11807
|
14597, 14868
|
5844, 9628
|
1739, 2364
|
244, 265
|
5242, 5818
|
430, 1370
|
9662, 10804
|
1392, 1613
|
1629, 1688
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,186
| 139,286
|
47873
|
Discharge summary
|
report
|
Admission Date: [**2157-7-8**] Discharge Date: [**2157-7-20**]
Date of Birth: [**2097-8-21**] Sex: M
Service: MEDICINE
Allergies:
Ativan
Attending:[**First Name3 (LF) 3283**]
Chief Complaint:
hypotension during dialysis
Major Surgical or Invasive Procedure:
ICU monitoring
History of Present Illness:
Mr. [**Known lastname **] is a 59M with ESRD on HD, MSSA endocarditis, and hip
arthroplasty complicated by polymicrobial infection
(Enterobacter, K. oxytoca, VRE) with recent washout presenting
with altered mental status and hypotension.
The patient has a very long and complicated medical course over
the last six months. As summarized by recent admission note, in
[**2156-11-10**] he developed high grade MSSA bacteremia in the
context of a left septic wrist infection. Despite tratment with
6 weeks of cefazoline during HD he sustained significant
valvular damage and plans were made for him to undergo a
surgical intervention. Unfortunately, while this was being
proceeded toward he sustained a fractured right hip
necessitating a hemiarthroplasty on [**2157-1-11**]. He developed
ischemic bowel in the post operative period and underwent
repeated exploratory laparotomies ultimately resulting in a
sub-total colectomy and ileostomy. His prosthetic hip became
dislocated and he underwent revision hemiarthroplasty in mid
[**2157-1-10**] complicatd by an infected hematoma of the hip with
cultures growing Enterobacter cloacae and Klebsiella oxytoca
initially followed by VRE. This required removal of hardware
and ultimately removal of his antibiotic impregnated spacer on
[**2157-2-22**]. His most recent TEE in [**Month (only) 956**] revealed persistence
of a posterior mitral valve leaflet vegetation/abscess which had
progressed in size in comparison with the echocardiogram
completed in [**2156-12-11**]. Associated with this lesion is
severe mitral regurgitation and moderate aortic valvular
regurgitation.
He was admitted to [**Hospital1 112**] on [**5-11**] for valve repair (Dr [**Last Name (STitle) 1537**]
([**Telephone/Fax (1) 101020**]) but was found to be too malnourished. His G/J
tube was repositioned as it was in his esopahgus. He had been
on daptomycin/ciprofloxacin for suppression of his joint
infection, but these antibiotics were stopped during this
admission. He remained afebrile with sterile blood cultures and
was eventually discharged with plan for readmission for cardiac
surgery though this was once again postponed. The patient was
again recently hospitalized from [**6-2**] to [**6-17**] after presented
with left hip wound incisional wound pain. Bone and synovial
tissue cultures isolated vancomycin-sensitive enterococcus The
patient was started on 4 weeks of ciprofloxacin and 6 weeks of
daptomycin with day 1 being [**2157-6-16**]. Orthopedics washed out his
wound twice and placed a VAC to assist with healing. 1 day prior
to discharge his wound was closed after washout with only a
hemovac drain in place. The Hemovac was removed without
difficulty [**6-23**] in follow up with Dr. [**Last Name (STitle) **]. There was some
slight serous drainage from the wound, but overall things
appeared to be healing appropriately.
On the day of presentation, the patient was sent from [**Hospital1 **]
after he developed slurred speech and confusion after HD. Per
report, fluid was removed during the session and he was
transiently hypoxic to 90% on RA. The patient complained of
nausea, dizzines, bilateral eye pain and 5-6 days of HA. He
denies any chest pain, shortness of breath, or palpitations. He
denied fevers/chills, [**Last Name (un) 2043**] pain, or LOC.
In the emergency department, initial vitals were 97.2 90 74/30
14 100%. He was given vancomycin 1g and gentamicin 60mg and 1.5
L of NS. With blood pressuress remaining in the 70s, he was
started on norepinephrine then admitted to the MICU for further
management.
Past Medical History:
++ Post-strep glomerulonpehritis
- LUE AV fistula, [**2135**]; surgical repairs [**2153**]
- renal transplant [**2137**], failed
- transplant nephrectomy, [**2145**]
- ESRD on HD
-----
[Admission [**Date range (2) 101021**]]
++ L wrist infective arthritis
- Left wrist incision and drainage [**2156-12-10**]
- MSSA on Cx [**12-10**], [**12-19**]
- s/p Cefazolin x6 weeks
++ Endocarditis
- BCx [**Date range (1) 31005**] MSSA; BCx [**Date range (1) 101022**] neg
- TEE [**12-22**] = No valvular vegetations; mod-severe eccentric MR
- TTE [**1-5**] = mobile bright post MV veg, old > new?
- TTE [**1-19**], [**2-2**] = no veg seen
++ Right hip fracture
- Right hip hemiarthroplasty, [**2157-1-11**]
- Revision right hemiarthroplasty, femoral component, [**2157-1-26**]
- septic hematoma; I&D, evacuation of hematoma, [**2157-2-3**]
- infective arthritis; removal R hip, abx spacer, VAC, [**2157-2-18**]
- I&D hematoma + abscess, VAC, [**2157-2-22**]
- Cx [**12-18**], [**1-4**], [**1-26**] = NEG
- Cx/tissue [**2-3**] = K.oxytoca, E.cloacae
- Cx [**2-18**] = VRE (linez-[**Last Name (un) 36**])
- s/p >8 weeks daptomycin, ciprofloxacin
++ Ischemic colitis/ileitis
- ex lap, subtotal colectomy, terminal ileectomy, [**2157-1-13**]
- repeat OR [**2157-1-14**]
- g-tube, ileocolonic [**Last Name (un) 1236**], diverting loop ileostomy, [**2157-1-15**]
- d/c with ant abd wound vac (Cx = B.fragilis)
-----
++ Hypertension
++ Coronary artery disease (unspecified)
++ prior diastolic heart failure
++ Pneumonia, multiple (unknown etiology)
++ Pulmonary nodules, stable
++ Hyperparathyroidism
++ ? Amyloid lesions of wrist and metacarpals
+ Right endoscopic carpal tunnel release, [**2-/2155**]
+ Right trigger thumb release, [**2-/2155**]
+ Ring finger flexor tenosynovectomy, [**2-/2155**]
+ Left carpal tunnel release, [**12/2155**]
+ left index, long and ring finger trigger releases, [**12/2155**]
+ Right ring finger closed reduction percut pinning, [**2-/2156**]
Social History:
Owner of a clothing store in [**Location (un) 4398**]. Patient has been
hospitalized/in rehab since [**2156-12-10**]. Prior to this, he lived in
[**Location (un) **] with his mother and brother. [**Name (NI) **] current tobacco and
alcohol use but notes intermittent tobacco use in the past (~3
pack-years). Denies illicit drug use. HIV negative [**2156-12-27**]
Family History:
Positive for cancer (father-prostate), [**Name (NI) 2481**] (mother).
Father deceased. Brother has fibromyalgia. Daughter in good
health.
Physical Exam:
Vitals - T: 96.5 BP: 108/50 HR: 70 RR: 18 02 sat: 100 on 2L
General: pleasant chronically ill appearing man in NAD
HEENT: NC, AT, PERRL, OP clear without exudates/lesions
Neck: JVP at 7cm, supple
Lungs: CTA B anteriorly
Heart: irregularly irregular rhythm, harsh 4/6 systolic murmur
radiating to apex with a thrill palpable across the precordium,
[**2-14**] early peaking diastolic murmur
Abdomen: NT, ND, soft, RLQ ostomy with liquid and solid stool
present, LUQ PEG tube intact, no erythema at entry site, well
healed surgical car
Extremities:
* L forearm HD fistula intact
* RUE PICC line dressed, nontender
* Well healed left hip wound with no drainage
R leg externally rotated. No other joint with effusions.
* No splinter hemmorages, janeway' lesion, or osler nodes
* right femoral line in place
Neuro: A&Ox3, motor and sensory grossly intact
Skin: no rash
Pertinent Results:
LABORATORY RESULTS
===================
On Presentation:
WBC-8.7 RBC-3.88* Hgb-12.9*# Hct-38.0* MCV-98 RDW-22.0* Plt
Ct-122*
--- Neuts-62.8 Lymphs-24.5 Monos-3.6 Eos-8.8* Baso-0.5
PT-14.4* PTT-27.6 INR(PT)-1.3*
Glucose-103 UreaN-27* Creat-3.1*# Na-134 K-3.7 Cl-94* HCO3-25
AnGap-19
Mg-1.7
On Discharge:
WBC-7.1 RBC-3.41* Hgb-11.4* Hct-34.8* MCV-102* RDW-21.6* Plt
Ct-121*
Glucose-96 UreaN-77* Creat-6.8*# Na-133 K-5.3* Cl-97 HCO3-23
AnGap-18
Calcium-10.0 Phos-3.3 Mg-2.2
Other Studies:
VitB12-459
PTH-675*
MICROBIOLOGY
==============
Blood Cultures 5/29/09*3: No growth
Blood Cultures 5/31/09*2: No growth
C diff toxin assay [**2157-7-8**] and [**2157-7-18**]: Negative for toxin A or
BHBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE
RADIOLOGY AND OTHER STUDIES
=============================
ECG [**2157-7-8**]:
Atrial fibrillation with rapid ventricular response and periods
of regular
rhythm raising the possibility of intermittent accelerated
junctional rhythm. Left axis deviation. Intraventricular
conduction delay. Non-specific ST-T wave abnormalities. Compared
to the previous tracing of [**2157-6-13**] ventricular ectopy is no
longer seen.
CT head w/o Contrast [**2157-7-8**]:
IMPRESSION: No acute intracranial pathology. Stable
periventricular white
matter hypodensities.
Chest Radiograph [**2157-7-8**]:
IMPRESSION: Persistent diffuse increased interstitial markings
with ill-
defined nodular opacities, slightly improved since prior.
Findings may
represent a component of mild interstitial pulmonary edema.
Transthoracic Echocardiogram [**2157-7-9**]:
Conclusions
The atria are moderately dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (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 diameters of aorta at
the sinus, ascending and arch levels are normal. There are three
moderately thickened aortic valve leaflets. There is a somewhat
heterogeneous, nonmobile echodensity on the noncoronary aaortic
valve cusp, most consistent with a healed vegetation (cine loop
#47). No aortic valve abscess seen. Moderate (2+) aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is an echodense nonmobile mass on the posterior
mitral leaflet, most consistent with a healed vegetation (given
the patient's history). No mitral valve abscess is seen. An
eccentric, anteriorly-directed jet of moderate to severe (3+)
mitral regurgitation is seen, hugging the interatrial septum.
The pulmonary artery systolic pressure could not be determined.
No vegetation/mass is seen on the pulmonic valve. There is no
pericardial effusion.
IMPRESSION: No mobile vegetations seen on this transthoracic
study. Multiple valvular abnormalities as described above.
Preserved global and regional biventricular systolic function.
Compared with the prior study (images reviewed) of [**2157-3-23**],
findings are similar.
Left Fingers Radiograph 2 views [**2157-7-15**]:
IMPRESSION: No evidence of acute fracture
Radiograph of Left Wrist [**2157-7-15**]:
FINDINGS:
There is a large amount of soft tissue swelling surrounding the
carpus. There is widening of the scapholunate interval. There is
proximal migration of the capitate. There is narrowing of the
radiocarpal joint with degenerative changes of the first CMC and
triscaphe joint. The bones are extremely osteopenic. There are
erosive changes throughout the carpal bones. These findings
could be seen with CPPD or osteomyelitis given history of
washout with osteomyelitis on prior report. There is a large
mass arising at the distal radial aspect of the wrist, which on
MRI appeared to represent possible amyloid deposit. There are
calcifications adjacent to it.
Brief Hospital Course:
59 year old male with a complicated recent medical history,
including ESRD on HD, MSSA endocarditis with active vegetations
and severe MV dysfunction, hip arthroplasty c/b polymicrobial
infection (Enterobacter, K. oxytoca, VRE) and VRE osteomyeltitis
being transferred out of the MICU after being admitted for
altered mental status and hypotension which have resolved.
# Hypotension: Most likely secondary to fluid shift during HD
given recent poor PO intake. However on admission was also
concerned about bacteremia from HD or line, or sepsis as the
patient has known endocarditis and osteomyelitis and not on
antibiotics on admission. The patient did not demonstrate
source of localizing symptom for sepsis, remained afebrile,
without leukocytosis. ESR and CRP were elevated likely secondary
to chronic osteomyelitis and endocarditis. He had a CXR with no
infiltrates, his hip appears to have healed well, and has liquid
stool at baseline. Cipro and dapto were restarted per ID
recommendations to cover for these sources with known history of
recent enterococcus in hip on [**2157-6-17**]. The plan is to continue
these medications until the patient undergoes valve replacement
therapy. During the hospitalization, the patient was initially
admitted to the MICU for hypotension, which resolved on less
than 24 hours of norepinephrine and fluid resuscitation. The
patient was called out to the floor and monitored for 48 hours
without event. The patient tolerated dialysis well the
following Monday. Antihypertensives were initially held, but
then metoprolol 12.5mg [**Hospital1 **] was restarted for cardioprotection
given history of CAD. The patient had a femoral line in the
MICU, which was pulled on arrival to the floor. The blood
cultures did not return positive, thus the patient's PICC line
remained in place.
# Altered Mental Status: Likely secondary to hypoperfusion given
hypotensive episode. NCHCT was negative for acute process. Did
not develop subsequent episodes during admission.
# Aortic and Mitral Valve Endocarditis: TTE showed healed
vegetations on both mitral and aortic valves with moderate to
severe mitral regurgitation and moderate aortic regurgitation,
but no sign of abscess. The patient is scheduled to have MVR at
[**Hospital1 112**] in the next few weeks after his nutritional status improves.
He will be contact[**Name (NI) **] by Dr. [**Last Name (STitle) 1537**] to schedule the surgery.
Continued ciprofloxacin and daptomycin, with follow up in the [**Hospital **]
clinic with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] in the next month.
# Left Wrist Pain: Reported chronic mild pain and swelling of
left wrist over past 2-3 weeks. X-Ray of his wrist revealed
soft tissue swelling, osteopenia, and degenerative changes.
Given his chronic presentation, lack of fevers, and good
mobility on exam, it was thought that his wrist was not septic.
His pain may be a result of either degenerative joint disease or
calcium pyrophosphate deposition disease. He was advised to
wear a volar resting splint, and to contact the [**Name2 (NI) **] clinic at
[**Hospital1 18**] at [**Telephone/Fax (1) 3009**] if he developed worsening symptoms or if
he has further questions. He was given ibuprofen for his pain
to bet taken for three days. He has a follow-up appointment
with the [**Hospital1 18**] hand clinic.
# Hip fracture and h/o Osteomyelitis of the wrist and hip:
Patient likely has low bone density from ESRD and prolonged
immobility. Started on Vitamin D supplementation in addition to
calcium carbonate to prevent further bone resorption.
# ESRD: Continued on MWF HD schedule. His sevelamer was stopped
for hypophosphatemia but he was continued on calcium carbonate.
His diet was liberalized to full in order to promote nutrition
as this is currently the greatest obstacle to him obtaining his
surgery.
# Anemia: Hct at baseline. Continued epo at HD. Continued
folate and iron supplementation. As MCV elevated, checked Vit
B12 level which is still pending.
# Diahrrea: Chronic. C diff toxin negative. Restart loperamide
as indicated as an outpatient.
# GERD: continued on PPI
# AF: Initially held the metoprolol, but then restarted as blood
pressures well controlled. Patient not anticoagulated in
preparation for pending valve surgery.
# Hypercalcemia: The patient developed hypercalcemia and was
started on cinacalcet. His calcium dose was decreased from 500
mg multiple times/day to once a day.
# FEN: IVF, no salt added diet, novasource renal tube feeds
# PPX: Hep SC TID
# Code: FULL
# Comm: [**Name (NI) 101023**]
Medications on Admission:
1. Metamucil 1.7 g Wafer PO twice a day: With meals
2. Loperamide 2 mg Capsule PO TID as needed: Max 16mg daily for
stools >1200mL daily.
3. Acetaminophen 325-650 mg PO every six hours
4. Metoprolol Tartrate 25 mg Tablet QID
5. Amlodipine 2.5 mg PO DAILY
6. Miconazole Nitrate 2 % Powder [**Hospital1 **]
7. Calcium Carbonate 500 mg (1,250 mg) [**Hospital1 **]
8. Epoetin Alfa 10,000 unit/mL Solution Sig: ASDIR Injection
ASDIR (AS DIRECTED): Per Hemodialysis guidelines.
9. B Complex-Vitamin C-Folic Acid 1 mg Capsule PO DAILY (Daily).
10. Ferrous Sulfate 325 mg [**Hospital1 **]
11. Omeprazole 20 mg Capsule PO DAILY
12. Folic Acid 1 mg PO DAILY
13. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
16. Camphor-Menthol 0.5-0.5 % Lotion QID (4 times a day) as
needed.
17. Sevelamer HCl 800 mg PO TID W/MEALS
19. Ipratropium Bromide 2 Puffs [**Hospital1 **]
20. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: Apply to hip.
*** 21. Ciprofloxacin 500 mg PO Q24H last dose due6/4/09, but
stopped [**7-1**].)
*** 22. Daptomycin 500 mg Recon Soln Sig: One (1) Recon Soln
Intravenous Q48H for 2 weeks: Last was due [**2157-7-28**], but stopped
[**7-1**].)
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for affected areas.
3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours): Please continue until the patient undergoes
valve replacement surgery.
6. 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.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: Hold for SBP < 90, HR< 50.
10. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day).
12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO DAILY (Daily).
13. Metamucil 1.7 g Wafer Sig: One (1) wafer PO twice a day.
14. Loperamide 2 mg Capsule Sig: One (1) Capsule PO three times
a day as needed for diarrhea.
15. B Complex-C-Zn-Folic Acid 1 mg Tablet Sig: One (1) Tablet PO
once a day.
16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
puffs Inhalation twice a day.
17. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day for 3 days.
18. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 1230**]y (350)
mg Intravenous q48h.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] center
Discharge Diagnosis:
Primary Diagnosis:
Fluid Shift during hemodialysis
Secondary Diagnoses:
Post-strep glomerulonephritis, end stage kidney disease on
hemodialysis
Left wrist infective arthritis
Endocarditis
Right hip fracture
Ischemic colitis/ileitis
Hypertension
Coronary artery disease (unspecified)
Prior diastolic heart failure
Pneumonia, multiple (unknown etiology)
Pulmonary nodules, stable
Hyperparathyroidism
Amyloid lesions of wrist and metacarpals
Discharge Condition:
The patient was hemodynamically stable and afebrile prior to
discharge.
Discharge Instructions:
You were admitted to [**Hospital1 18**] for evaluation of low blood pressure
and confusion during dialysis. You were determined to have had
too much fluid removed during dialysis. You were also restarted
on your antibiotics in anticipation for your valve surgery.
In addition, your left wrist was evaluated for septic arthritis
vs CPPD and was felt not to be infected. You likely have an
inflammatory condition called CPPD or pseudogout. This should
improve with antiinflmmatory medicaitons. You may use ibuprofen
the next three days for this. You were also given a splint to
wear. Please wear this splint until you follow-up with the hand
clinic.
Medication Changes:
START Ciprofloxacin, please continue until you undergo valve
replacement surgery.
START Daptomycin, please continue until you undergo valve
replacement surgery.
START Simethicone for gas
START Cinacalcet for high calcium
Decrease metoprolol to 12.5mg twice a day, can be increased if
your heart rate is too fast
STOP Amlodipine
STOP Hydromorphone and Lidocaine unless needed
DECREASE Calcium Carbonate dosing
.
If you experience chest pain, fevers, shortness of breath, or
any other concerning symptoms please seek medical attention.
Please call your doctor if your left wrist becomes more painful,
or more swollen.
Followup Instructions:
You will be contact[**Name (NI) **] to schedule an appointment with Dr. [**Last Name (STitle) 1537**]
for the valve replacement surgery.
Please keep the following appointments:
-[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2157-7-25**] 9:00
-[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2157-7-28**]
07:50
-[**Month/Day/Year **] XRAY/HAND CLINIC (SCC 2) Phone:[**Telephone/Fax (1) 1228**]
Date/Time:[**2157-8-2**] 7:40
|
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"285.9",
"275.3",
"396.9",
"428.0",
"424.90",
"263.9",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.10",
"38.91",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
19026, 19080
|
11218, 13059
|
294, 311
|
19564, 19638
|
7333, 7622
|
20979, 21560
|
6291, 6430
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17252, 19003
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15865, 17229
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19662, 20319
|
6445, 7314
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19174, 19543
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7636, 11195
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20339, 20956
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227, 256
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339, 3910
|
19120, 19153
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13074, 15839
|
3932, 5894
|
5910, 6275
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,063
| 178,961
|
802
|
Discharge summary
|
report
|
Admission Date: [**2114-3-26**] Discharge Date: [**2114-4-19**]
Date of Birth: [**2037-3-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
constipation w/ inability to void- developed chest pain in ER
Major Surgical or Invasive Procedure:
[**2114-4-2**] urgent CABG x2 (LIMA to LAD, SVG to PDA)
[**2114-4-11**] PEG
[**2114-4-16**] Trach
History of Present Illness:
76M h/o Diabetes, HTN, hypercholesterolemia, h/o CVA, elevated
PSA, on warfarin arrives with 5 days of inability to void and
7day h/o constipation. Poor historian with reported poor follow
up history in chart and unclear about what meds he takes at
home. Tried suppositories and laxatives without effect initially
but then states that he had small BM yesterday at home. Last
colonoscopy was over 10 yrs ago per pt. Arrived in ED because he
states Dr. [**Last Name (STitle) 5717**] was not in office - he mainly arrives with c/o
urinary retention. Of note, it appears that he was on flomax in
past and has been referred to urology for w/u with elevated PSA
around 6, but he states he is no longer taking this med. He also
failed to f/u with urology for prostate bx. Denies abd pain,
n/v, or any other sx.
In ED, vitals were 98.8, 57, 124/61, 16, 97% RA. KUB consistant
with constipation, no stool in rectum. Foley was placed and
urine relieved. Given enema with another small BM, pt states
that now his bowels are relieved. Labs notable for Cr 1.5
(baseline 1.1), Na slightly elevated to 146 c/w dehydration. On
transfer from ED to floor, pt was comfortable, without pain, and
only concerned for urinary retention.
During the course of his hospitalization, he experienced chest
pain and shortness of breath. His pain was reported to radiate
from to his throat and resolved with sublingual nitroglycerin
and oxygen administration. ECG demonstrated LBBB with ST
depressions in II and AVF which resolved. CE Tn 0.02 -> 0.08 ->
0.14. CK 174 -> 178 -> 138. Cardiac cath deferred until INR
decreased from 3.3. He was clopidogrel loaded with 300mg.
Cardiac cath demonstrated severe 3 vessel CAD with single
remaining vessel with 90% left main supplying LAD and
collateralized RCA. PCI deferred for surgical evaluation.
On arrival to the CCU the patient is resting comfortably. He
currently denies shortness of breath, lower extremity edema, PND
or orthopnea. He denies palpitations, lightheadedness, dizziness
or syncope. All other review of systems were negative.
Cardiac cath done [**3-29**] with 3VD and referred for surgery.
Past Medical History:
HTN;
hypercholesterolemia;
type 2 DM since [**2095**], insulin-requiring
prior TIA [**2096**];
L MCA CVA with expressive aphasia [**7-/2104**];
seizure disorder;
chronic warfarin anticoagulation;
? RHM
Social History:
[**1-27**] ppd x 20 yrs
no etoh. Lives at home with wife. Retired school Spanish
teacher.
Family History:
Noncontributory
Physical Exam:
66" 74.8 kg
VS - Temp 98.1, BP 146/64, HR 88, R 22, O2-sat 92% 2L
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - Warm well profused, 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
[**5-30**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait
.
CCU admission exam:
VS: T 97.7, HR 59, BP 145/60, RR 16, O2 100% RA.
General: well-appearing in NAD
Neck: no carotid bruits, flat JVP
CV: RRR, nl S1/S2, no MRG
Resp: CTAB, no W/R/R
Abd: soft, NT/ND, NABS
Ext: no edema, 2+ PT/DP
Neuro: A&Ox3, speech spontaneous with mild expressive aphasia
Pertinent Results:
[**2114-3-26**] 11:39AM BLOOD WBC-10.6 RBC-4.46* Hgb-13.5* Hct-40.3
MCV-90 MCH-30.2 MCHC-33.4 RDW-13.7 Plt Ct-176
[**2114-3-26**] 11:39AM BLOOD PT-35.2* PTT-30.0 INR(PT)-3.6*
[**2114-3-26**] 11:39AM BLOOD Glucose-84 UreaN-33* Creat-1.5* Na-146*
K-4.1 Cl-105 HCO3-31 AnGap-14
[**2114-3-28**] 01:10PM BLOOD CK(CPK)-126
[**2114-3-28**] 05:46AM BLOOD CK(CPK)-138
[**2114-3-27**] 07:15PM BLOOD CK(CPK)-178
[**2114-3-27**] 10:06AM BLOOD ALT-18 AST-26 LD(LDH)-163 CK(CPK)-174
AlkPhos-58 TotBili-0.7
[**2114-3-28**] 01:10PM BLOOD CK-MB-5 cTropnT-0.11*
[**2114-3-28**] 05:46AM BLOOD CK-MB-6 cTropnT-0.14*
[**2114-3-27**] 07:15PM BLOOD CK-MB-7 cTropnT-0.08*
[**2114-3-27**] 10:06AM BLOOD CK-MB-5 cTropnT-0.02*
[**2114-3-26**] 11:39AM BLOOD PSA-10.9*
COMPARISON: [**2109-10-11**].
FINDINGS: Evaluation is limited due to diffuse bowel gas. Within
these
limitations, the liver shows no focal or textural abnormalities.
There are
gallstones, but no evidence of acute cholecystitis. Incidental
note is made
of several tiny probable cholesterol polyps. Pancreas is
completely obscured
by bowel gas. Spleen is not well visualized. The right kidney
measures 11.4
cm, left kidney measures 13.8 cm. Though partially obscured by
bowel gas,
neither kidney shows evidence of stone or solid mass. Abdominal
aorta is
obscured by bowel gas. Main portal vein is patent, with
appropriate antegrade
flow.
IMPRESSION: Limited exam due to diffuse bowel gas.
Cholelithiasis, without
evidence of cholecystitis.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5718**]
DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: WED [**2114-3-28**] 9:28 AM
Conclusions
PRE-BYPASS:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler.
Right ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the descending thoracic
aorta. There are complex (mobile) atheroma in the descending
aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen.
There is no pericardial effusion.
Dr. [**First Name (STitle) **] was notified in person of the results on [**Known lastname 5719**]
before surgical incision
POST-BYPASS:
Patient is AV paced and receiving an infusion of epinephrine and
milrinone. LVEF = 35%. RV function is normal.
Mild mitral regurgitation present. Aorta is intact post
decannulation. Dr [**Last Name (STitle) **] aware of post bypass findings.
I certify that I was present for this procedure in compliance
with HCFA regulations.
Electronically signed by [**Name6 (MD) 3892**] [**Name8 (MD) 3893**], MD, Interpreting
physician [**Last Name (NamePattern4) **] [**2114-4-3**] 16:03
[**2114-4-19**] 02:22AM BLOOD WBC-9.1 RBC-2.96* Hgb-8.6* Hct-26.3*
MCV-89 MCH-28.9 MCHC-32.6 RDW-15.1 Plt Ct-224
[**2114-3-26**] 11:39AM BLOOD WBC-10.6 RBC-4.46* Hgb-13.5* Hct-40.3
MCV-90 MCH-30.2 MCHC-33.4 RDW-13.7 Plt Ct-176
[**2114-4-19**] 02:22AM BLOOD PT-14.5* PTT-63.3* INR(PT)-1.3*
[**2114-3-26**] 11:39AM BLOOD PT-35.2* PTT-30.0 INR(PT)-3.6*
[**2114-4-19**] 02:22AM BLOOD Glucose-105* UreaN-62* Creat-1.8* Na-136
K-5.0 Cl-100 HCO3-29 AnGap-12
[**2114-3-26**] 11:39AM BLOOD Glucose-84 UreaN-33* Creat-1.5* Na-146*
K-4.1 Cl-105 HCO3-31 AnGap-14
[**2114-4-16**] 02:58AM BLOOD ALT-52* AST-48* LD(LDH)-371* AlkPhos-84
Amylase-36 TotBili-0.3
[**2114-3-27**] 10:06AM BLOOD ALT-18 AST-26 LD(LDH)-163 CK(CPK)-174
AlkPhos-58 TotBili-0.7
Brief Hospital Course:
Mr. [**Known lastname 5719**] was admitted to the [**Hospital1 18**] on [**2114-3-26**] for further
management of his non-ST-elevation myocardial infarction. He was
taken to the cardiac catheterization lab and found severe three
vessel disease. Given the severity of his disease, the cardiac
surgical service was [**Date Range 4221**] and he was worked-up in the usual
preoperative manner. The urology service was [**Date Range 4221**] as he had
recent progression of his voiding difficulty over last week. He
was on flomax in the past and seen by urology for irregularly
nodular prostate concerning for cancer, but he never followed-up
for biopsy. He had an elevated PSA 6.7 in [**2112-6-26**] and now 10.9
although may be falsely elevated due to urinary retention and
foley placement. It was recommended that his foley in and
followup in clinic for further evaluation. Flomax was resumed.
On [**2114-4-1**] Mr. [**Known lastname 5719**] was subsequently transferred to the CCU
where he had chest pain, initially controlled on nitro drip and
subsequently developed angina refractory to nitroglycerin and
morphine.
The cardiac surgical service was called and he went emergently
to the operating room where he underwent coronary artery bypass
grafting to two vessels on [**2114-4-2**]. Please see operative note for
details. Postoperatively he was taken to the intensive care unit
for monitoring. On postoperative day one, diminished right arm
and bilateral leg movement was noted. The neurology service was
[**Date Range 4221**] and a CT scan was performed which showed No acute
intracranial hemorrhage or edema but sequelae of remote left MCA
territory infarct was noted. Aspirin and statin were recommended
and started along with betablockade and diuresis. An MRI was
performed that showed wide spread cortical areas of restricted
diffusion involving all lobes, and more extensive cortical and
subcortical areas of restricted diffusion within the left
occipital lobe and bilateral cerebellar hemispheres, are
compatible with laminar necrosis and acute embolic disease.
Heparin was started with bridge to coumadin. The vascular
surgery service was [**Date Range 4221**] for ischemic fingers and
recommended topical nitrates and to continue heparin for likely
microemolic events. He was extubated on POD#2 but required
re-intubation due to impaired gag and inability to clear
secretions. He was started on broad spectrum IV antibiotics for
GNR in sputum and +U/A. Chest tubes and pacing wires were
removed per protocol on POD#3. The general surgery service was
[**Date Range 4221**] for placement of a PEG feeding tube for long term
nutrition. PICC line was placed under floroscopy w/ tip in upper
SVC on [**2114-4-8**]. He developed atrial fibrillation which was
treated w/ betablocker and amio- he is now in SR. On [**2114-4-11**]
percutaneous endoscopic gastrostomy tube placement was
performed. As he continued to have Respiratory failure on
mechanical ventilation with questionable aspiration pneumonia
requiring almost daily bronchosocopy for secretion management,
the thoracic surgery service was [**Date Range 4221**] for placement of a
tracheostomy. This was performed on [**2114-4-16**] along with rigid
bronchoscopy, flexible bronchoscopy and therapeutic aspiration
of tracheobronchial tree. On [**2114-4-15**] Mr. [**Known lastname 5719**] suffered a
respiratory arrest from presumed mucous plugging. He was
successfully resusitated. During the course of his
hopsitalization Mr. [**Known lastname 5719**] developed an unstageable pressure
ulcer on his coccyx maesuring 4x4 cm for which the wound care
nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**]. A Mepilex sacral border dressing was
applied. Neurologically he remains able to move upper
extremities but has no lower extremity function. He continued to
work with physical therapy and occupational therapy. He is
currently tolerating trach mask for greater than 24hrs.
Antibiotics were stopped on [**2114-4-17**] after subsequent negative
culture data. Vancomycin was initiated [**4-19**] for a 7 day course
prophylactically for his right lower extremity incision site
which appears mildly erythematous. On [**4-19**] per Dr.[**Last Name (STitle) **],
Mr. [**Known lastname 5719**] was cleared for discharge to rehabilitation. All
follow up appointments were advised.
Medications on Admission:
OUTPATIENT MEDICATIONS:
NPH insulin 6 units [**Hospital1 **]
regular insulin 6 units [**Hospital1 **] ( did not use sliding scale or do BG
checks)
Aspirin 325 mg PO/NG DAILY
Atenolol 25 mg PO/NG DAILY
Atorvastatin 40 mg PO/NG DAILY
Aluminum-Magnesium Hydrox.-Simethicone prn
Lactulose 30 mL PO/NG TID
Omeprazole 40 mg PO DAILY
Senna 1 TAB PO/NG [**Hospital1 **]
Tamsulosin 0.4 mg PO HS
Docusate Sodium 100 mg PO BID
.
MEDICATIONS ON TRANSFER:
Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
Insulin SC (per Insulin Flowsheet)
Lactulose 30 mL PO/NG TID
Acetaminophen 650 mg PO/NG Q6H
Lisinopril 20 mg PO/NG DAILY
Aluminum-Magnesium Hydrox.-Simethicone 15-30 mL PO/NG QID:PRN
Nitroglycerin SL 0.3 mg SL PRN CP
Aspirin 325 mg PO/NG DAILY
Omeprazole 40 mg PO DAILY
Atorvastatin 80 mg PO/NG DAILY
Atenolol 25 mg PO/NG DAILY
Senna 1 TAB PO/NG [**Hospital1 **]
Bisacodyl 10 mg PO DAILY
Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
Docusate Sodium 100 mg PO BID
Tamsulosin 0.4 mg PO HS
.
ALLERGIES: NKDA
.
Discharge Medications:
1. Acetaminophen 650 mg/20.3 mL Solution [**Hospital1 **]: One (1) Solution
PO Q4H (every 4 hours) as needed for temperature >38.0.
2. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Ten (10) mls PO BID (2
times a day).
4. Magnesium Hydroxide 400 mg/5 mL Suspension [**Hospital1 **]: Thirty (30)
ML PO DAILY (Daily) as needed for constipation.
5. Atorvastatin 80 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr [**Hospital1 **]: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]:
2-4 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
8. Bisacodyl 10 mg Suppository [**Hospital1 **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
9. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2
times a day).
11. Metoclopramide 5 mg/mL Solution [**Last Name (STitle) **]: One (1) Injection Q6H
(every 6 hours) as needed for nausea/vomiting.
12. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DAILY
(Daily): 400mg x 7days then decrease to 200mg daily ongoing.
13. Warfarin 1 mg Tablet [**Last Name (STitle) **]: as directed for afib Tablet PO
once a day: based on INR for afib- INR goal 2-2.5.
14. picc line care
Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
15. Warfarin 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO ONCE (Once) for
1 doses. Tablet(s)
16. Vancomycin 1000 mg IV Q 24H
x 7 days->DC after dose on [**2114-4-28**]
17. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution [**Year (4 digits) **]: One (1) Intravenous continuous as needed for
AFib: 1800 units/hour to be adjusted for PTT goal 50-70, INR
goal>2.0.
18. Insulin Regular Human 300 unit/3 mL Insulin Pen [**Year (4 digits) **]: One (1)
Subcutaneous every six (6) hours: **As per Sliding Scale.
19. Insulin Glargine 100 unit/mL Cartridge [**Year (4 digits) **]: One (1)
Subcutaneous twice a day: 30 units Q AM/ 15 units Q PM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] Hsopital
Discharge Diagnosis:
CAD s/p urgent CABG x2
NSTEMI
BPH
IDDM
hypercholesterolemia
Left MCA CVA [**7-/2104**]
Acute postoperative stroke
expressive aphasia
prior TIA [**2096**]
seizure disorder
? RHM
Respiratory arrest/Respiratory failure
Discharge Condition:
stable
alert, lethargic-grimaces to pain -unable to determine extent of
orientation further due to impaired communication
transfers via [**Doctor Last Name **].
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 lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name4 (NamePattern1) **] [**5-7**] @ 1:00 PM [**Telephone/Fax (1) 170**]
Primary Care /cardiologist Dr. [**Last Name (STitle) 5717**] in [**1-27**] weeks or upon
discharge [**Hospital 5720**] rehab.
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2114-4-19**]
|
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icd9cm
|
[
[
[]
]
] |
[
"36.11",
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icd9pcs
|
[
[
[]
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] |
15801, 15853
|
7961, 12311
|
382, 482
|
16113, 16276
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4113, 7938
|
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|
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|
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|
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|
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|
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|
281, 344
|
510, 2633
|
12780, 13344
|
2655, 2858
|
2874, 2965
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,998
| 139,768
|
5258
|
Discharge summary
|
report
|
Admission Date: [**2143-8-17**] Discharge Date: [**2143-9-5**]
Date of Birth: [**2099-11-30**] Sex: F
Service: MEDICINE
Allergies:
E-Mycin / Sulfonamides / Ultram / Levofloxacin / Bactrim /
Cefepime
Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Brief HPI: Ms. [**Known lastname **] is 43 yo F with HIV (CD4 193, VL > 100k
[**6-8**]) on HAART, chronic abdominal pain thought to be [**3-7**] to
either chronic pancreatitis or chronic nonobstructive
nephrolithiasis, admitted to the [**Hospital Ward Name 516**] on [**2143-8-17**] with
worsening of abdominal pain. The day before admission, the pain
radiated from right to left flank and was worse than usual. It
was also associated with nausea/vomiting and inability to take
POs so she came to the hospital.
.
In terms of her abdominal pain, she was seen by the pain service
and her medications were changed and titrated for better
control.
.
~On [**8-24**], a UA was sent and was notable for numerous wbcs and
moderate bacteria so she was started on cefpodoxime. She then
became intermittently hypotensive so linezolid and macrodantin
were briefly added. BCx from [**2061-8-23**] and Legionella remained
negative.
.
There were concerns of adrenal insufficiency, so endocrine was
consulted. She was started on a 5 day trial of prednisone
(through [**8-26**]) with minimal improvement in blood pressures. She
started spiking high temperature>100 on [**8-26**]. Repeat [**Last Name (un) 104**] stim
[**8-28**] was normal so she was not restarted on steroids. Her urine
cx from [**8-26**] grew out GNR so she was kept on cefpodoxime.
.
She fell on [**8-29**] and there was a question of her pupils being
unresponsive so she had a stat head CT which was negative for a
bleed. She also had a CTA which was negative for PE, but notable
for a patchy ground-glass opacity ??RLL pneumonia. Her pain
medications were decreased for concerns of oversedation causing
the fall.
.
Throughout [**8-29**], she became increasingly hypotensive with SBPs
80-90s. At first she responded to IVF boluses but on the night
of [**8-29**] her SBP remained in the 70s despite 1.5L IVF bolus so
she was transferred to the ICU. Her HCT that am was also noted
to be down to 23 from 27. On recheck that pm it was stable.
.
In the ICU, her BP improved with 1L NS bolus. Her HCT on [**8-30**] am
was found to be 17 so she was transfused 1 U PRBC with increase
to 28. She was intermittently nauseaus but felt better with
phenergan. Her UCX from [**8-26**] was found to be consistent with
ESBL ENTEROBACTERIACEAE (per ID) so she was changed from
cefpoxime to meropenem. She remained HD stable so she was
transferred to the floor.
.
She currently denies fevers, chills, sweats. She denies nausea,
vomiting, diarrhea (none in 2days). She reports her right
flank/abdominal pain is [**3-15**] on her current medications. She
denies dysuria/hematuria/urgency. She denies
melena/hematochezia. She denies chest pain/ palpitations/
shortness of breath/ cough/ wheezing. Her lightheadedness is
improved.
# Hypotension: resolved with IVFs, pt appears euvolemic on exam,
was most likely sepsis from UTI Treatment for the UTI was
chaanged to levofloxacin by ID. However, the patient developed a
rash to levofloxacin. Eventually, the patient was started of
once daily gentamicin. She will complete a one 14 day coourse.
at discharge, she has 7 more days of gentamicin left.
# chronic abdominal pain: workup negative so far except for b/l
nonobstructing nephrolithiasis. Towards the end of her
hospitalization - she again developed acute abdominal pain. Labs
revealed elevated lipase bu CT showed no evidence of
pancreatitis. The pain resolved with oral analgesics.
.
# fevers - improved on abx; most likely due to GNR UTI.
Antibiotics as above.
# HCT drop - original drop for 27-23 could be dilutional, the 17
is most likely a spurious value as it is impossible to increase
11 points from 1 U PRBC (esp in setting of also getting volume
from NS); hemolysis labs negative
# thrombocytopenia - DIC labs negative, Platelet remained stable
at discharge.
.
# HIV- HAART continued
.
# Hyperlipidemia- Gemfibrozil continued
.
# Peripheral sensory neuropathy- neurontin continued
.
Past Medical History:
1) HIV/AIDS. Last CD4 count in [**2143-6-3**], 193 with VL>100,000.
Opportunistic infections: PCP/MAC/culture + for HSV type 1,
multiple outbreaks, on chronic acyclovir suppression, no recent
outbreaks, disseminated Mycobacterium avium complex- + blood and
bone marrow cultures 12/94, suppression discontinued with
recovery of CD4 count in [**March 2138**]. Had been on atovaquone but
recently d/c'd.
2) Chronic pansinusitis and chronic otitis media, underwent
several sinus surgeries and bilateral myringotomies- [**2132**],
Resection of L ethmoid mucocele [**2138-9-15**].
3) Bacterial pneumonias [**11/2130**], [**4-4**]
4) [**Female First Name (un) 564**] vaginitis- several outbreaks.
5) Vaginitis, ?BV
6) Pancreatitis - [**2-8**] peak lipase ([**2143-2-14**]) 850; CT c/w
pancreatitis w/o necrosis/pseudocyts on [**2-11**]. [**3-7**] Dapsone vs
HAART.
7)H/o Chronic abdominal pain - even in the past, lipase noted to
be elevated to 411, RUQ u/s done showing no biliary pathology,
MRCP done [**12-8**] showing normal pancreas/pancreatic duct. Lipase
to 250 on d/c in [**12-8**]. Major workup in Spring [**2139**] including
abd CT, EGD that was unrevealing (EGD on [**2139-6-26**] that revealed
mild GE junction erythema with an unremarkable biopsy.)
8) C. diff colitis
9) Bilateral nephrolithiasis (innumerable small bilateral
stones)- likely due to IDV therapy. Episode of gross hematuria
in [**Month (only) 116**]-[**2137-7-4**]. Underwent cystoscopy by Dr. [**Last Name (STitle) 21493**] that
revealed urethritis.
10) Recurrent UTI/ Pyelonephritis - [**6-/2139**]- E.coli x 2 strains
Tx
with levofloxacin.
11)Proximal Renal Tubular dysfunction- due to adefovir in 6/99-
developed RTA, inc. creat(peaked at 2.1), hypokalemia,
hypophosphatemia. Creat improved to 1.0-1.3 since.
12) Hyperlipidemia related to ART, primarily triglycerides,
responded well to fenofibrate.
13) Iron-deficiency anemia, [**2132**] and [**2139**].
14) Pancytopenia, required erythropoetin in the past.
15) s/p Appendectomy
16) Cervical dysplasia. LEEP cone biopsy [**2131**].
17) Peripheral sensory neuropathy- likely related to prior
anti-retroviral therapy.
18) Right leg weakness- attributed to CNS lesions seen on [**2133**]
MRI
thought to be due to old vascular events
Social History:
Patient lives alone in [**Hospital1 1474**], never married, has a daughter
who is involved, has a brother and a sister who she is not close
to. Father is alive but not involved. Patient acquired HIV
through sexual contact. Denies any tobacco, no etoh, no IVDU.
Patient has high school education, 1 year of college. Not
employed. Has SSI.
No significant travel; no pets. Not sexually active. Lives
alone. Has alert pendant that she uses at home due to fear of
falling. Has a 21 yo daughter and a 10 months old grandson who
she is fairly close to.
Family History:
brother MI @ 50s, Father had CVA in 70s, has HTN, CAD. Mother
passed away from melanoma. No DM
Physical Exam:
98.4 138/92 78 20 99 on RA
Gen - A+Ox3, lying in bed in no distress, appears comfortable
HEENT - OP clear
Neck - supple, no LAD
Cor - RRR no murmur
Chest - CTAB
Abd - mild tend to palp in RUQ and umbilical region, soft,
nondistended, +BS
Ext - thin, wasted, +2 DP, no edema
.
Pertinent Results:
[**2143-8-17**] 04:15PM GLUCOSE-82 UREA N-22* CREAT-1.2* SODIUM-138
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-18* ANION GAP-18
[**2143-8-17**] 04:15PM ALT(SGPT)-20 AST(SGOT)-38 ALK PHOS-74
AMYLASE-63 TOT BILI-0.8
[**2143-8-17**] 04:15PM LIPASE-105*
[**2143-8-17**] 04:15PM ALBUMIN-4.9* CALCIUM-9.8 PHOSPHATE-4.2
MAGNESIUM-2.2
[**2143-8-17**] 04:15PM WBC-3.5* RBC-3.44* HGB-11.7* HCT-32.9* MCV-96
MCH-34.0* MCHC-35.6* RDW-16.3*
[**2143-8-17**] 04:15PM NEUTS-56.1 LYMPHS-37.9 MONOS-5.3 EOS-0.3
BASOS-0.3
[**2143-8-17**] 04:15PM ANISOCYT-1+ POIKILOCY-1+ MACROCYT-1+
[**2143-8-17**] 04:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.015
[**2143-8-17**] 04:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-6.0 LEUK-SM
[**2143-8-17**] 04:15PM URINE RBC-[**7-13**]* WBC-[**4-7**] BACTERIA-FEW
YEAST-NONE EPI-0-2
[**2143-8-13**] CT Abd/Pel
1. No change in bilateral nonobstructive nephrolithiasis.
Symmetry and multiplicity of calcifications is suggestive of a
possible hypercalcemic state. Clinical correlation is
recommended.
2. No change in multiple small round hypodensities of the
kidneys which are too small to characterize, likely simple
cysts.
3. Unchanged size and position of left lower pelvis calcific
density, likely vascular.
.
[**2143-8-10**] Renal US
No hydronephrosis. Bilateral nonobstructing stones.
.
[**2143-8-4**] RUQ US
No evidence of cholelithiasis or cholecystitis.
.
[**12/2142**] MRCP
1. Normal appearance of the pancreas, without MR findings of
pancreatitis. Normal caliber of the pancreatic duct. No
peripancreatic fluid collections are seen.
2. No gallstones. No intra or extrahepatic biliary ductal
dilatation.
3. Slightly atrophic appearance of both kidneys.
.
[**7-9**] EGD - gastritis
.
[**6-8**] EGD - gastritis
.
[**6-8**] C-Scope - normal
[**2143-9-4**] 05:00PM BLOOD WBC-2.4* RBC-3.62* Hgb-11.0* Hct-33.5*
MCV-92 MCH-30.4 MCHC-32.9 RDW-16.8* Plt Ct-134*
[**2143-9-3**] 12:00PM BLOOD WBC-2.4* RBC-3.65* Hgb-11.4* Hct-33.4*
MCV-91 MCH-31.3 MCHC-34.3 RDW-17.2* Plt Ct-128*
[**2143-9-2**] 06:35AM BLOOD WBC-1.7* RBC-3.61* Hgb-11.1* Hct-32.7*
MCV-91 MCH-30.8 MCHC-33.9 RDW-17.2* Plt Ct-131*
[**2143-9-1**] 06:40AM BLOOD WBC-1.9* RBC-3.20* Hgb-9.9* Hct-29.0*
MCV-91 MCH-30.9 MCHC-34.1 RDW-17.2* Plt Ct-128*
[**2143-8-31**] 06:15AM BLOOD WBC-2.4* RBC-3.38* Hgb-10.4* Hct-30.5*
MCV-90 MCH-30.7 MCHC-34.0 RDW-17.3* Plt Ct-116*
[**2143-8-30**] 05:25PM BLOOD WBC-2.6*# RBC-3.27*# Hgb-10.2*# Hct-29.9*
MCV-92# MCH-31.0 MCHC-33.9 RDW-17.3* Plt Ct-115*
[**2143-8-30**] 10:25AM BLOOD Hct-28.0*#
[**2143-8-30**] 01:47AM BLOOD WBC-1.6* RBC-1.74*# Hgb-5.6*# Hct-17.3*
MCV-99* MCH-32.1* MCHC-32.4 RDW-16.0* Plt Ct-108*
[**2143-8-29**] 04:20PM BLOOD Hct-22.1*
[**2143-8-29**] 06:05AM BLOOD WBC-2.6* RBC-2.43* Hgb-7.9* Hct-23.3*
MCV-96 MCH-32.5* MCHC-33.9 RDW-16.1* Plt Ct-142*
[**2143-9-2**] 06:35AM BLOOD Glucose-83 UreaN-6 Creat-0.7 Na-139 K-3.7
Cl-103 HCO3-26 AnGap-14
[**2143-9-1**] 06:40AM BLOOD Glucose-87 UreaN-4* Creat-0.6 Na-141
K-3.4 Cl-111* HCO3-21* AnGap-12
[**2143-8-30**] 01:47AM BLOOD Glucose-57* UreaN-5* Creat-0.6 Na-146*
K-2.4* Cl-125* HCO3-13* AnGap-10
[**2143-8-29**] 06:05AM BLOOD Glucose-96 UreaN-8 Creat-1.2* Na-140
K-3.8 Cl-109* HCO3-23 AnGap-12
[**2143-8-26**] 12:50PM BLOOD Glucose-86 UreaN-17 Creat-1.3* Na-144
K-3.7 Cl-110* HCO3-23 AnGap-15
[**2143-8-17**] 04:15PM BLOOD Glucose-82 UreaN-22* Creat-1.2* Na-138
K-4.4 Cl-106 HCO3-18* AnGap-18
[**2143-8-17**] 04:15PM BLOOD Glucose-82 UreaN-22* Creat-1.2* Na-138
K-4.4 Cl-106 HCO3-18* AnGap-18
[**2143-9-4**] 05:00PM BLOOD ALT-19 AST-37 LD(LDH)-199 AlkPhos-58
Amylase-91 TotBili-1.1
[**2143-9-3**] 12:00PM BLOOD ALT-21 AST-36 LD(LDH)-208 AlkPhos-59
Amylase-101* TotBili-1.0
[**2143-8-30**] 03:48AM BLOOD ALT-13 AST-26 LD(LDH)-134 CK(CPK)-153*
AlkPhos-45 Amylase-55 TotBili-0.5
[**2143-8-29**] 06:05AM BLOOD ALT-15 AST-24 LD(LDH)-128 AlkPhos-53
Amylase-72 TotBili-0.5
[**2143-8-17**] 04:15PM BLOOD ALT-20 AST-38 AlkPhos-74 Amylase-63
TotBili-0.8
[**2143-8-19**] 06:25AM BLOOD ALT-14 AST-23 LD(LDH)-123 AlkPhos-56
Amylase-39 TotBili-0.6
[**2143-9-4**] 05:00PM BLOOD Lipase-269*
[**2143-9-3**] 12:00PM BLOOD Lipase-394*
[**2143-8-30**] 03:48AM BLOOD Lipase-192*
[**2143-8-29**] 06:05AM BLOOD Lipase-224*
[**2143-8-20**] 06:40AM BLOOD Triglyc-282*
Rib Xray:
A marker has been placed over the right lower rib cage. In this
region, no definite displaced fractures are identified. There is
no focal lytic or blastic lesions. The cardiac silhouette and
mediastinum are within normal limits. Lungs are clear. No focal
consolidation, pleural effusions are seen.
STUDY: CT of the abdomen and pelvis with and without intravenous
contrast.
TECHNIQUE: Axial CT images from the lung bases to the pubic
symphysis were obtained after administration of intravenous
contrast. Coronally and sagittally reformatted images were
displayed in 5 mm slice thickness.
COMPARISON: CT dated [**2143-8-13**].
CLINICAL HISTORY: 43-year-old woman with HIV, _____ gastric
pain, history of chronic pancreatitis and elevated lipase. Acute
pancreatitis.
FINDINGS: There is a small right pleural effusion and adjacent
focal, linear atelectasis. The liver is normal, without focal
lesions. The gallbladder is decompressed, but appears normal. No
intra- or extra-hepatic biliary ductal dilatation. The pancreas
is normal in appearance. Spleen and adrenal glands are normal.
The kidneys again demonstrate multiple small calcific densities,
essentially unchanged from prior study. Multiple hypoattenuating
lesions in both kidneys are stable and too small to
characterize.
CT OF THE PELVIS: The urinary bladder, uterus, and adnexa are
unremarkable. The cecum is patulous, fluid filled, but is
otherwise normal. There are shotty mesenteric and
retroperitoneal lymph nodes, unchanged compared to [**2143-7-8**]. No
pelvic free fluid.
IMPRESSION:
1. No imaging findings to correlate with reported acute
pancreatitis.
2. Small right pleural effusion and adjacent atelectasis.
3. Stable bilateral renal calcifications.
NON-CONTRAST HEAD CT SCAN
HISTORY: HIV and AIDS, presents with lethargy and non-reactive
pupils, but otherwise intact cranial nerves. Fell this morning,
but no head trauma. Rule out intracranial hemorrhage.
TECHNIQUE: Non-contrast head CT scan.
COMPARISON STUDY: MR scan of [**2141-6-24**].
FINDINGS: A few of the scans are degraded by metal artifacts
arising from earrings, which the patient declined to remove.
There is no sign of an intracranial hemorrhage, mass effect, or
shift of normally midline structures. There is a somewhat
irregularly marginated 5-mm zone of low density within the genu
of the left internal capsule, which was also seen on the prior
MR study of [**2141-6-24**]. The lesion most likely represents a
chronic lacunar infarct. Similarly, a 1-cm area of fluid signal
intensity is seen along the lateral aspect of the left
cerebellar hemisphere and also was visualized on the prior MR
study noted above. A focal chronic infarction is the most likely
diagnosis in this locale, as well. Interestingly, the signal
abnormalities noted on the prior MR study in the medial aspect
of the right cerebellar hemisphere are seen as a low density
region on the present CT, along with punctate calcifications.
The combination of findings raises the possibility of prior
inflammatory disease, as opposed to additional areas of chronic
infarction. There is mild mucosal thickening within the sphenoid
sinus, more evident within the right sphenoid air cell. No other
overt intra- or extra- cranial abnormality is discerned.
CONCLUSION: No intracranial hemorrhage. Please see above report
for additional findings.
CTA CHEST W&W/O C &RECONS
Reason: r/o PE
[**Hospital 93**] MEDICAL CONDITION:
43 year old woman with HIV/AIDS p/w SOB, hypoxia, hypotension
with clear CXR.
REASON FOR THIS EXAMINATION:
r/o PE
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 42-year-old female with HIV/AIDS presenting with
shortness of breath and hypoxia. Rule out pulmonary embolus.
COMPARISONS: Comparison is made to [**2139-4-7**].
TECHNIQUE: Initially a non-contrast CT scan of the chest was
obtained. This was followed by contrast-enhanced CT scan of the
chest in the pulmonary artery phase.
FINDINGS: The pulmonary artery is in the upper limits of normal
size. There are no filling defects to suggest pulmonary
embolism. The aorta is within normal limits without evidence of
aortic dissection.
There are multiple small mediastinal lymph nodes. However, they
do not meet CT criteria for pathology. For example, a
prevascular lymph node (image 3, 109) measures 4 mm. A
precarinal lymph node (image 3/101) measures 6 mm.
There is also a right hilar lymph node which measures 18 x 11 mm
(image 3, 85). The heart, pericardium and great vessels are
unremarkable.
When examining the lung fields, there are bilateral smooth
septal thickening which could represent edema versus an atypical
infectious process. There is a more patchy opacity and
ground-glass opacity in the right lower lobe which could
represent early pneumonia versus atypical infection. There is
again noted a scar in the right lower lobe, which is unchanged
when compared to prior study. No pulmonary nodules or masses are
seen.
Limited images of the upper abdomen without IV contrast
demonstrate no calcifications within the kidneys bilaterally,
most which are new or enlarged when compared to the prior study.
No new enlarged when compared to the prior study and likely
represent renal stones. The largest one in the left side
measures 6 mm. The largest one on the right side measures 6 mm.
There is no evidence of hydronephrosis in these images.
BONE WINDOWS: There are no suspicious lytic or blastic lesions.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Smooth bilateral interlobular septal thickening could
represent atypical infection versus pulmonary edema. Clinical
correlation is recommended. More patchy ground-glass opacity in
the right lower lobe could represent early pneumonia.
3. Multiple nonobstructing renal stones as was described above.
Brief Hospital Course:
43 yo F with HIV and chronic abdominal pain who presents with
worsening abdominal pain.
.
# Abdominal/Flank Pain - Patient has had extensive work up
without definite etiology found. Could be gastritis as seen on
EGD or chronic pancreatitis with burned out panc. Also could be
renal colic from stones although recent US demonstrated no
hydro. Patient is scheduled for outpatient MR abdomen. However
on exam patient's pain is mild at most. She is walking around
room, speaking on phone and able to tolerate abd exam with deep
palpation.
She had an episode of acute epigastric pain during the
hospitalization, found then to have an elevated lipase and
amylase - CT abdomen done did not show any acute pancreatitis.
Howvere, she responded to bowel rest and IVfluids and later
tolerated oral diet well. She was eating regular diet at
discharge.
The abdominal pathology was treated with IV antibiotics -
Patient will be discharged on once daily gentamicin dose. A PICC
line was placed for access.
I had a discussion with her ID attending regarding the etiology
of the panceatitis - if it is realted to the HAART. However, ID
team was of the opinion that this was probably not the case as
the patient had been on the medications for a long time.
#Rash: the patient developed a rash - macular, pruritic to
levofloxacin. The rash however, did not expand more than about
5cm area on the upper abdomen. Levofloxacin was stopped for the
above reason and changed to gentamicin.
# HIV - HAART, acyclovir were continued.
.
# Hyperlipidemia - Gemfibrizol was continued.
.
# Anemia - at baseline. Probably multifactorial.
Medications on Admission:
Ferrous sulfate 325mg qday
B12 100mcg qday
Acyclovir 400mg [**Hospital1 **]
Loperimide 2mg qid
Clonezapam 1mg qhs
Lopinavir-Ritonavir 200-50 3 tabs [**Hospital1 **]
Epzicom 600-300 qday
Fosamprenavir 1400mg [**Hospital1 **]
Gemfibrozil 600mg qday
phenergan prn
prilosec 20mg qday
Carafate
percocet prn
Discharge Medications:
1. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Loperamide 2 mg Capsule Sig: One (1) Capsule PO TID (3 times
a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
4. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day
(at bedtime)) as needed.
5. Lopinavir-Ritonavir 200-50 mg Tablet Sig: One (1) Tablet PO
BID (2 times a day).
6. Fosamprenavir 700 mg Tablet Sig: Two (2) Tablet PO Q12H
(every 12 hours).
7. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
10. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed.
12. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
15. Naproxen 250 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8
hours) as needed for pain.
16. Gentamicin Sulfate (PF) 100 mg/10 mL Solution Sig: One (1)
240 mg Intravenous once a day for 7 days.
Disp:*7 * Refills:*0*
17. Heparin Lock Flush 100 unit/mL Solution Sig: One (1) 2 ml
Intravenous once a day for 7 days: Follow the critical care
protocol for flush.
Disp:*7 * Refills:*0*
18. Outpatient Lab Work
Patient to get the following labs checked 1 week after
discharge:
Gentamicin trough level
CBC
Serum creatinine
Dr [**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **] ([**Numeric Identifier 21494**]) or Dr [**First Name (STitle) 2505**] ([**Numeric Identifier 21495**])will follow-up in
clinic. The patient has appointment
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 1474**] VNA
Discharge Diagnosis:
Primary:
1) Abdominal Pain, NOS
Secondary
2) HIV
3) Nephrolithiasis
4) ? UTI vs possible interstitial cystitis
5) Mild pancreatitis
Discharge Condition:
Good
Discharge Instructions:
1. Keep your appointments as instructed and mentioned in the
discharge summary.
2. Make an appointment with your primary provider in the next 10
days.
3. Continue to take the medications that you were taking prior
to your hospitalization (unless otherwise indicated)
4. Arrangements will be made to provide the gentamicin at home
to complete the course.
5. Return to the emergency room or call you primary doctor if
you notice leakage, bleeding, pain, redness, rash at the site of
the catheter or experience fever or chills.
6. Please get labwork done as indicated.
Followup Instructions:
Provider: [**Name10 (NameIs) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2143-9-11**]
10:00
Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12647**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 1803**]
Date/Time:[**2144-1-21**] 11:30
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 4340**], MD Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2143-9-18**] 10:30
|
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"789.04",
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"272.4",
"592.0",
"E888.9",
"042",
"287.30",
"799.02",
"E930.8",
"693.0",
"922.1",
"458.0",
"577.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
21636, 21691
|
17716, 19333
|
343, 350
|
21868, 21875
|
7592, 15321
|
22494, 22917
|
7179, 7276
|
19686, 21613
|
15358, 15436
|
21712, 21847
|
19359, 19663
|
21899, 22471
|
7291, 7573
|
289, 305
|
15465, 17693
|
378, 4316
|
4338, 6599
|
6615, 7163
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,613
| 162,881
|
31701
|
Discharge summary
|
report
|
Admission Date: [**2171-11-2**] Discharge Date: [**2171-11-11**]
Date of Birth: [**2150-1-30**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
status/post high speed motor vehicle crash
Major Surgical or Invasive Procedure:
Open reduction/Internal fixation of Right Clavicle with plates
and screws
History of Present Illness:
21 year old female status/post high speed motor vehicle crash
into guardrail after falling asleep. She was unrestrained but an
airbag did deploy. No loss of conciousness, ambulatory with a
[**Location (un) 2611**] Coma Scale=15 at the scene. Transferred by med flight
from [**Hospital3 **],sedatated/intubated for transfer due to
hypotension and shortness of breath. Right chest tube was placed
at [**Hospital3 **].
Past Medical History:
anxiety
restless legs syndrome
Social History:
works as a landscaper
Family History:
Noncontributory
Physical Exam:
Physical Exam:
T: [**Age over 90 **] F HR: 128 BP: 129/85 RR: 20 O2 sat 100 % intubated
Gen: sedated and intubated
HEENT: +Endotracheal tube,normocephalic, atraumatic, anicteric,
neck supple, no
masses
Heart: regular rate and rhythm, without murmurs, rubs, or
gallops
Lungs: decrease breath sounds bilaterally (right greater than
left),+ rhonchi diffusely on right, Right sided chest tube in
place
Abdomen: soft, nondistended, +bowel sounds
Extremities:abrasion left thigh, pulses: 1+ dorsalis pedis/1+
posterior tibial/1+ femoral/2+ radial, no deformities, no
ecchymoses
Neuro: CNII-XII grossly intact
Spine: No step offs, erythema on lower back
Pertinent Results:
[**2171-11-2**] 03:49AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2171-11-2**] 03:49AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2171-11-2**] 03:52AM GLUCOSE-165* LACTATE-2.6* NA+-140 K+-3.7
CL--110 TCO2-21
[**2171-11-2**] 04:50AM WBC-16.0* RBC-2.74* HGB-8.3* HCT-23.9* MCV-87
MCH-30.2 MCHC-34.7 RDW-12.6
[**2171-11-2**] 06:30AM PT-15.6* PTT-35.8* INR(PT)-1.4*
[**2171-11-2**] 06:30AM CALCIUM-5.3* PHOSPHATE-2.5* MAGNESIUM-1.2*
[**2171-11-2**] 06:30AM LIPASE-20
[**2171-11-2**] 06:30AM ALT(SGPT)-387* AST(SGOT)-495* ALK PHOS-36*
AMYLASE-17 TOT BILI-0.3
[**2171-11-2**] 06:49AM LACTATE-2.7*
[**2171-11-2**] 07:36AM HCT-25.3*
[**2171-11-2**] 07:58AM TYPE-ART TEMP-35.9 RATES-19/ TIDAL VOL-550
PEEP-5 O2-40 PO2-116* PCO2-31* PH-7.37 TOTAL CO2-19* BASE XS--5
-ASSIST/CON INTUBATED-INTUBATED
[**2171-11-2**] 12:48PM TYPE-ART TEMP-37.7 RATES-19/ TIDAL VOL-550
PEEP-5 O2-40 PO2-118* PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2
-ASSIST/CON INTUBATED-INTUBATED
[**2171-11-2**] 08:12PM HCT-27.6*
Radiology
[**11-2**] MRA neck (F): No dissection/occlusion carotid/vertebral a.
[**11-2**] MR Cervical spine (F): No ligamentous injury, no fracture
[**11-2**] CT head (F): negative
[**11-2**] CT Cervical spine (F):No fracture
[**11-2**] CT Chest/Abdomen/Pelvis (F):
Right & Left pneumothoraces (R>L)
Right 1st, 5th, 6th, 7th, 10th, 11th Rib fractures
Right midshaft clavicle (100%displaced)
R scapula (coracoid process) fracture
Right Liver lobe laceration (extending >or=6-7cm into parenchyma
eith right hepatic vein near largest laceration,no active
extravasation)
Right L3, L4, L5 tranverse process fractures
Large contusion Right upper lobe & contusion vs. aspiration
right lower lobe
Extensive Subcutaneous air Right chest wall
Large hemoperitoneum in pelvis
[**11-9**] Right shoulder X-rays:mid-distal Right clavicle fracture
with 2.3cm fragment overlap & 2 cm inferiorly displaced distal
fragment
Microbiology:
[**11-2**] MRSA screen: negative
[**11-2**] Blood Culture: Beta strep group C
[**11-2**] Urine Culture (F): negative
[**11-2**] Sputum Culture: Beta strep, not group A
Brief Hospital Course:
Upon being transferred to the Emergecy Department at [**Hospital1 18**], the
patient was kept intubated due to the unknown nature of her
injuries. A focused abdominal son[**Name (NI) **] for trauma was negative.
CT scans of the head, cervical spine, and torso were performed.
Two units of packed red blood cells were transfused due to her
hematocrit=23.9.Patient was admitted to the trauma surgery
intesive care unit. The acute pain service was consulted to
achieve optimum pain control. Tube feeds were given throught her
oral/gastric tube. She was extubated on [**11-5**]. Neurosurgery
examined the patient and determined that the C2 fracture
initially seen on CT scan was not actually a fracture, and
determined that her nondisplaced lumbar fractures were
nonoperative. The Orthopedic team examined the patient's right
clavicle and scapula fractures, and patient was given a sling
for her right arm, and decided they would delay surgical
fixation of the clavicle fracture until the patient was more
stable. She was transferred to the [**Hospital3 **] floor on
[**11-9**]. On [**11-10**], the patient was taken to the operating room for
an open reduction/internal fixation of her right clavicle with a
plate and screws by Dr [**Last Name (STitle) 2719**]. There were no complications
during her hospital stay and she was discharged from the
hospital on [**11-11**] with instructions to follow up in 2 weeks with
Dr. [**Last Name (STitle) 2719**] (Orthopedics) and with the Trauma Clinic.
Medications on Admission:
ativan
Discharge Medications:
1. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours) for 7 days.
Disp:*7 Capsule(s)* Refills:*0*
2. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours) for 30 days.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 30 days.
Disp:*60 Capsule(s)* Refills:*0*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4h PRN as needed for pain for 30 days.
Disp:*25 Tablet(s)* Refills:*0*
5. Hospital Bed for home
Discharge Disposition:
Home
Discharge Diagnosis:
1. R 1st, 5th, 6th, 7th, 10th, 11th Rib fractures
3. Right midshaft clavicle (100%displaced) &
4. scapula (coracoid process) fracture
5. Liver Laceration
5. Right nondisplaced L3, L4, L5 tranverse process fractures
Discharge Condition:
Good
Good
Discharge Instructions:
Please continue wearing your sling for 48 hours after you leave
the hospital.
Please apply your cooling shoulder brace to your right shoulder
for 15-20 minutes 3 times per day for the 1st week. After that,
you may continue to use it for comfort
Please leave the dressings over your incisions on for 48 hours
No tub baths or swimming. You may shower, but try and keep your
dressings dry. If there is clear drainage from your incisions
after 48 hours, cover with a dry dressing. Leave white strips
above your incisions in place, allow them to fall off on their
own.
Please call your doctor or go to the emergency room if you
develop chest pain, shortness of breath, fever greater than
101.5, foul smelling or colorful drainage from your incisions,
redness or swelling, severe abdominal pain or
distention,persistent nausea or vomiting, inability to eat or
drink, or any othersymptoms which are concerning to you.
No tub baths or swimming. You may shower. If there is clear
drainage from your incisions, cover with a dry dressing. Leave
white strips above your incisions in place, allow them to fall
off on their own.
Activity: Please No weight bearing on your right upper extremity
until your follow up appointment with Dr. [**Last Name (STitle) 2719**] in 2 weeks.
Medications: Resume your home medications. You should take a
stool softener,
Colace 100 mg twice daily as needed for constipation. You will
be given pain
medication which may make you drowsy. No driving while taking
pain medicine.
Followup Instructions:
Follow up with Dr [**Last Name (STitle) 2719**] in 2 weeks. Call his office at ([**Telephone/Fax (1) 15940**] for an appointment.
Follow up at the Trauma Clinic in 2 weeks. Call ([**Telephone/Fax (1) 376**]
to make an appointment
Completed by:[**2171-11-11**]
|
[
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"E815.0",
"805.4",
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"285.1",
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] |
icd9cm
|
[
[
[]
]
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[
"96.6",
"79.39",
"96.71",
"79.09"
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icd9pcs
|
[
[
[]
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6034, 6040
|
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|
358, 434
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6299, 6312
|
1691, 3866
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276, 320
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,819
| 147,411
|
3426
|
Discharge summary
|
report
|
Admission Date: [**2190-9-29**] Discharge Date: [**2190-10-13**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 15519**]
Chief Complaint:
Elevated blood sugars, respiratory failure
Major Surgical or Invasive Procedure:
central venous catheter placement
History of Present Illness:
84 M russian speaking, h/o CAD, NIDDM, HTN, CKD (baseline cre
~1.3), h/o recurrent aspiration PNA, who presents from home,
after his family noted elevated blood sugars. history obtained
from son, who states pt was feeling well until 3-4d ago, when he
noted increasing LH/dizziness, drowsiness, and a feeling of
"fog" attributed to recent increases in his neurontin dose (for
LE pain [**2-12**] spinal stenosis, dose increased from 100mg tid to
300mg tid then 600mg in AM, 300mg [**Hospital1 **]).
On the morning of admission, son noted that pt had increasing
urinary frequency, which pt stated had been going on for [**2-13**]
weeks. FSBS was 500s, and son activated EMS. Pt had apparently
not been checking FSBS or taking his glypizide x 2-3 weeks.
ROS per son negative for f/c/ns/cp/n/v/abd pain/melena,
hematuria, hemetemesis, rash, joint pains, weight loss.
In ED VS= 99.1 109 140/111 87%RA. pt was coughing, afebrile. Per
report, O2 requirement increased, and pt would not tolerate
CPAP. SBPs intially dropped to 80s/30s prior to intubation,
however recovered with 2-3L IVF. Post intubation, SBPs initially
stable, hwowever then dropped again to 71/49, felt partially [**2-12**]
sedation, unresponsive to IVF (1L more), and pt started on
levophed gtt with improvement in MAPs to >60. L IJ TLC placed,
initial CVPs 7-9. CXR interpreted as RLL PNA. EKG= ?sinus tachy,
lad, lvh, no BBB, STE, or STD. CK (1089, MB 13), troponin (0.07)
elevated. Pt given levoquin 750 x 1. blood sugars in 500s.
lactate 2.5->1.5, AG acidosis=16, K=5.3. decadron for ?sepsis.
UA sent, +ketones.
Past Medical History:
- CAD s/p RCA and LAD stenting [**2186**].
- dCHF (EF>55% [**2188**], E/A 0.8).
- PVD - s/p R ICA stent ([**2186**]) with a stable moderate left
internal carotid artery stenosis.
- CKD (baseline cre = 1.2-1.3)
- DM2
- HTN
- hyperlipidemia
- GERD
- h/o radiation to the larynx in the Soviet [**Hospital1 1281**] in the [**2153**]
for presumed laryngeal cancer. No further details available.
- h/o aspiration pneumonia.
- h/o gastrojejunostomy tube; status post aspiration pna
(removed) x 1 [**1-12**] yrs to reduce need for oral feeds and prevent
recurrent pneumonia. Tube fell out and was not replaced in
[**2190**] as he had been eating gradually more food and a
trial of oral feeding was chosen. The cause of the aspiration
pneumonia was thought to be disordered swallowing s/p XRT to his
larynx yrs ago in the USSR.
- h/o syncopal episode [**2185**] s/p Holter [**11/2185**]= sinus brady.
- h/o abnormal stress test in [**1-12**]. +CP and a positive stress
test showing a moderate sized inferior wall reversible defect
and was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] who advised cardiac
catheterization at that time.
- spinal stenosis - s/p ? recent spinal injection.
- h/o recurrent bronchitis - with restrictive defect on PFTs
[**6-16**].
- h/o falls.
Social History:
40 yrs x 1 ppd tobbacco, denies alcohol, IVDU. lives with wife
in [**Name2 (NI) **] (elderly living), former mechanic. at baseline
performs own adls.
Family History:
40 yrs x 1 ppd tobbacco, denies alcohol, IVDU. lives with wife
in [**Name2 (NI) **] (elderly living), former mechanic. at baseline
performs own adls.
Physical Exam:
On Admission to the ICU:
VS: 96.0 74 122/50 24 100% AC 600*14 PEEP 5 60%
GEN: NAD
HEENT: PERRLA, EOMI, sclera anicteric, MMM, no LAD, no carotid
bruits. No JVD.
CV: regular, nl s1, s2, no m/r/g.
PULM: coarse breath sounds at both bases and anteeriorly, no
r/r/w.
ABD: soft, NT, ND, + BS, no HSM.
EXT: warm, 2+ dp/radial pulses BL.
NEURO: intubated, sedated, withdraws to pain
Pertinent Results:
[**2190-9-29**]
CXR
2. Multiple pulmonary nodules combined with reticular opacity.
Given the absence of this finding on the chest CT from [**Month (only) **]
[**2189**], this might represent infectious process or non-infection
lung inflammation. Precise characterization with chest CT will
be recommended.
[**2190-9-30**] TTE - Normal biventricular function. Normal left
ventricular diastolic function. No significant valvular
abnormality seen.
[**2190-10-12**]: LE dopplers: No evidence of DVT.
.
Sputum Cx [**9-29**]
SPARSE GROWTH OROPHARYNGEAL FLORA.
STREPTOCOCCUS PNEUMONIAE. SPARSE GROWTH.
PRESUMPTIVE RESISTANCE NOT CONFIRMED BY MIC. REFER TO
MIC RESULTS.
CEFTRIAXONE AND Penicillin Sensitivity testing
performed by Etest.
ERYTHROMYCIN , SULFA X TRIMETH , TETRACYCLINE AND
VANCOMYCIN
sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints are
<=0.5 ug/ml (S), 1.0 ug/ml (I), and >= 2.0 ug/ml (R).
.
[**2190-9-29**] 05:30PM BLOOD WBC-12.8*# RBC-5.07 Hgb-15.8# Hct-49.1#
MCV-97 MCH-31.2 MCHC-32.2 RDW-13.9 Plt Ct-346
[**2190-9-29**] 05:30PM BLOOD Neuts-89.2* Lymphs-6.8* Monos-3.3 Eos-0.2
Baso-0.6
[**2190-9-29**] 05:30PM BLOOD Glucose-558* UreaN-71* Creat-2.0* Na-145
K-5.3* Cl-103 HCO3-26 AnGap-21*
[**2190-9-29**] 05:30PM BLOOD CK(CPK)-1089*
[**2190-9-29**] 05:30PM BLOOD CK-MB-13* MB Indx-1.2
[**2190-9-29**] 05:30PM BLOOD cTropnT-0.07*
[**2190-9-30**] 02:08AM BLOOD %HbA1c-12.4*
[**2190-10-1**] 04:29AM BLOOD TSH-0.087*
[**2190-10-13**] 06:00AM BLOOD WBC-8.3 RBC-3.11* Hgb-9.6* Hct-29.3*
MCV-94 MCH-30.8 MCHC-32.7 RDW-14.2 Plt Ct-342
Brief Hospital Course:
84 M h/o CAD, PVD, HTN, CKD who presented to ED with DKA and was
intubated for concern for hypoxia and agitation.
.
Hospital course is as outlined below per problem:
.
# Hypoxia - The patient was brought to the ED because of
hyperglycemia, without prior complaint of SOB per his son. [**Name (NI) **]
was found to have an O2 sat of 87%RA. His respiratory status
continued to deteriorate on CPAP and non-rebreather so he was
intubated in the ED. A left IJ was placed and he was started on
levophed for hypotension (MAP 65). He received a dose of
levofloxacin 750mg. Initial ABG obtained after intubation
showed appropriate oxygenation (7.23/40/242 on 60% AC 600x14,
PEEP 5). He was ruled out for MI. He was felt to have a PNA
and was switched to ceftriaxone because of concern over a
prolonged QTc. He was also started on vancomycin to broaden
coverage, but this was stopped on HD#4. Sputum cultures
eventually grew step pneumo. He was extubated on HD#3 without
difficulty. During his ICU course, he continued to have mild
episodes of respiratory distress thought secondary to mucous
plugging. He responded well to aggressive chest PT. Given his
history of aspiration PNA's, it was felt that the patient would
benefit from a PEG, but the patient continuously declined. The
patient and his family were both made aware that he will
continue to be at risk for further aspiration events. He
completed a 10 day course of ceftriaxone on [**2190-10-9**]. He was
transferred to the floor where physical therapy evaluated him.
Incentive spirometry was initiated. He still required
occasional oxygen by nasal cannula overnight due to periodic
desaturations while supine.
.
# Hypotension - The patient was normotensive on admission to ED,
but became hypotensive around the time of intubation. The
etiology was most likely [**2-12**] dehydration from DKA that was
exacerbated by sedation at time of intubation. SBPs improved
with decreased sedation, the patient require pressors into HD#2
(initially on levaphed, which was switched to dopamine as it was
felt it might be contributing to sinus bradycardia below) but he
was then weaned off and maintained his pressures throughout the
rest of his ICU course. His home BP medications were restarted
when his pressures stabalized.
.
# Ischemia: In the ED, there was some initial concern for ACS
given an elevated troponin to 0.07, but serial enzymes were
negative. The original enzyme leak was felt likely to demand
ischemia from tachycardia and hypotension. He was originally
started on a heparin drip, but this was discontinued when the
enzymes were negative. He was maintained on ASA/plavix but beta
blocker was deferred given his history of bradycardia. During
his course in the ICU, the patient continued to complain of left
sided chest pain and multiple sets of enzymes were negative and
EKG's remained unchanged. The patient reports that this pain
has been ongoing for >1 month. He was started on a GI cocktail
and ice packs were used on his chest as the discomfort was
superfical.
.
# Rythym: pt initially nsr, however he subsequently developed
sinus bradycardia into 20-30s with accompanying drop in a-line
SBPs (from 100s to 80s). pt not on BB at baseline (apparently
h/o sinus bradycardia and syncopal episode, followed by dr.
[**Last Name (STitle) **]). EP consult was obtained given signficant drop in
SBPs with bradycardia, who felt bradycardia due to acute
illness/intubation. The patient remained bradycardia after
extubation to 50s, though SBPs stable. His episodes of
bradycardia were always asympotomatic and brief.
.
#DM: The patient presented to ED because of FSBS 500s, +ketone
in urine, +AG, c/w DKA. In the ICU, FSBS improved dramatically
with 10U regular insulin, to 100s, but started on insulin gtt,
and FSBS up to 300s. His insulin gtt was continued x24h, his
gap closed overnight, and pt was transitioned to NPH an HISS.
On the floor he was initiated on metformin 500 mg [**Hospital1 **]. Further
titration of dose was deferred until at least several days on
therapy.
.
# ARF - baseline creatinine 1.2-1.3, up to 2.0 on admission,
felt [**2-12**] dehydration from DKA, and rapidly improved with
aggressive IVF hydration (total 11L given over initial 24 hrs).
The patient continud to make urine throughout MICU stay, and
creatinine was at baseline by HD#2.
.
# Hyperthyroid - given h/o neck radiation and bradycardia, TSH
was obtained (0.087), which was felt suggestive of
hyperthyroidism, though difficult to assess in the setting of
acute illness. T4, T3 uptake, and TBG were obtained, and breif
curbside with endocrine suggestive that T3 uptake (more
appropriate indicator in acute illness) and TSH both being low
suggested TSH was likely abnormal because of acute illness.
plan was for outpt f/u of TSH.
.
#Guiac + Stool
No gross melena or hematochezia, however found to have heme +
stool. Without prior colonoscopy on record will likely need
age-appropriate screening in future. Hematocrit remained stable
during hospitalization.
.
#FEN
Regarding the patient's diet, he understands that he is at
chronic risk of aspiration given his laryngeal dysfunction. We
recommend that the patient continue a dysphagia diet; however,
given his tendency toward dehydration when drinking
pre-thickened liquids only, we also recommend the patient
initiate full liquids as well. The patient is at increased risk
of aspiration with this diet, however without liberalizing his
PO intake he is unlikely to sustain adequate PO's to prevent
renal failure and otherwise decompensation.
.
In summary, the patient was admitted to the MICU with severe
aspiration pneumonia. He was treated w/ ceftriaxone x 10 days.
Home glyburide was discontinued and metformin was started. Also
discontinued were the following: lasix, neurontin, and flovent.
Medications on Admission:
aspirin 325mg po qdaily
plavix 75mg po qdaily
simvastatin 10mg po qam
lasix 20mg po qam
glipizide 10mg po qam
combivent 103-18 2 puffs QID prn
flovent 220 2puffs [**Hospital1 **]
cozaar 25mg po qdaily
flovent 220mcg 2 inhaleatoins [**Hospital1 **]
neurontin 300mg po tid
naprosyn 500mg po qdaily prn (not taking)
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff
Inhalation Q6H (every 6 hours).
5. Losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times
a day).
7. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed).
8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
puff Inhalation Q4H (every 4 hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) **]
Discharge Diagnosis:
Primary: aspiration pneumonia, streptococcus pneumonia
Secondary: Diabetes milletus, coronary artery disease, HTN,
presumed laryngeal cancer w/ chronic aspiration
Discharge Condition:
stable
Discharge Instructions:
You were admitted to the hospital with a severe lung infection
caused by aspiration (inhalation of food and mouth secretions).
You were in the medical intensive care unit for a prolonged time
period in which you recieved intravenous antibiotics and other
medications to help sustain your blood pressure.
.
You were started on a new medication called metformin. We
STOPPED (Discontinued) the following medications: glipizide,
flovent, neurontin, naprosyn.
.
Please return to the emergency room or call your doctor if you
have the following: shortness of breath, fevers, chills, worse
coughing, blood with coughing.
Followup Instructions:
Please make an appointment with Dr. [**First Name (STitle) **] in [**1-12**] weeks.
.
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**]
Date/Time:[**2190-11-22**] 9:30
Provider: [**Name10 (NameIs) 900**] [**Name8 (MD) 901**], M.D. Phone:[**Telephone/Fax (1) 902**]
Date/Time:[**2191-2-8**] 10:20
Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2191-5-31**]
2:00
|
[
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icd9cm
|
[
[
[]
]
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[
"38.93",
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icd9pcs
|
[
[
[]
]
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12831, 12901
|
5786, 11610
|
307, 343
|
13108, 13117
|
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|
3460, 3612
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371, 1953
|
1975, 3276
|
3292, 3444
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,925
| 129,020
|
1307
|
Discharge summary
|
report
|
Admission Date: [**2164-2-24**] Discharge Date: [**2164-2-25**]
Date of Birth: [**2093-11-3**] Sex: F
Service: MEDICINE
Allergies:
No Drug Allergy Information on File
Attending:[**Last Name (NamePattern1) 495**]
Chief Complaint:
Cardiogenic Shock
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
This is a 70 year-old woman with scleroderma and EtOH abuse who
was brought to [**Hospital1 18**]-[**Location (un) 620**] today from home by EMS with
complaint of one month of poor PO intake, fatigue, and malaise.
She had been bedridden for months and reportedly had not eaten
in 1 month. She was reportedly hypotensive with SBP 60s on
presentation to the ED at [**Location (un) 620**]. She was sent for a CT head
and abdomen, and when lying flat she apparently started vomiting
coffee ground material and then arrested (CT scan not
completed). She was given CPR, epi x3, atropine x1, HCO3 x2
amps, and pulse returned with sinus rhythm, but hypotensive. She
was intubated and NGT was placed which returned bright red
blood. Hct initially was 18 and Cr 4.4. She was given 4U PRBC
and 6L IVF. DDAVP was given. RSC line was placed, and she was
started on dopamine. She given doses of vanco, zosyn, and
decadron. She was transferred to [**Hospital1 18**] for further management.
.
On arrival to the ED here, VS: T 88 degrees, BP 128/64 (on
dopa), HR 94, RR 20.
ETT was at 25cm, decreased BS on L were noted, CXR confirmed R
mainstem intubation, so ETT pulled back. NGT from OSH noted to
be coiled in the esophagus, so new OGT was placed with frank
blood and clots initially which cleared with NS and then bright
red blood recurred. FAST exam showed free fluid in the abdomen.
CT scan showed bilateral infiltrates, diffuse colitis, ascites,
fatty liver. Surgery was consulted and felt there is no acute
surgical issue. She was given 4 more L NS, calcium and magnesium
repletion, octreotide gtt, and 2U FFP in the ED. She has
remained on dopamine for hypotension.
Past Medical History:
scleroderma
[**Last Name (un) 8061**]
EtOH abuse
hypothyroidism
GERD
iron deficiency anemia
GERD
Social History:
Per sister, patient lives at home and is bed/wheelchair bound.
Her husband is demented and cannot be left alone so is now with
family (unclear whether he was living with patient at home). Not
clear how much help was available at home. Per sister, patient
has a long history of alcohol use. Recently as she has been
homebound she reportedly sips alcohol all day long (unclear
amounts).
Family History:
Unknown
Physical Exam:
T: 32.4 BP: 111/64 P: 88 RR: 26 O2 sats: 100% [on pressors]
Vent: AC at 450/16, PEEP 5, 100% FiO2
Gen: Intubated, sedated. Bair hugger in place.
HEENT: Pupils nonreactive, mild icterus. Dried blood around
mouth. Lacerations under tongue. ETT and OGT in place.
Neck: RSC in place.
CV: RRR, no m/r/g
Resp: Coarse and rhoncherous breath sounds diffusely
bilaterally. No wheezes.
Abd: Minimal BS. Mildly firm, distended.
Ext: 2+ DP pulses b/l.
Neuro: Not responsive to commands or noxious stimuli. Pupils
nonreactive. Neg corneals. Neg gag. Babinskis equivocal.
Skin: Diffuse macular erythematous rash and extensive skin
sloughing. Stage I decubitus ulcers on L ear, b/l hips.
Pertinent Results:
[**2164-2-24**] 07:00PM BLOOD WBC-11.7* RBC-3.62* Hgb-10.9* Hct-32.9*
MCV-91 MCH-30.1 MCHC-33.1 RDW-18.9* Plt Ct-79*
[**2164-2-24**] 09:15PM BLOOD Neuts-75.1* Bands-0 Lymphs-23.2
Monos-0.9* Eos-0.7 Baso-0.1
[**2164-2-25**] 12:02PM BLOOD PT-21.4* PTT-43.8* INR(PT)-2.0*
[**2164-2-24**] 07:00PM BLOOD PT-114.6* PTT-95.7* INR(PT)-15.7*
[**2164-2-24**] 09:15PM BLOOD Glucose-245* UreaN-18 Creat-2.5* Na-140
K-3.0* Cl-106 HCO3-10* AnGap-27*
[**2164-2-24**] 07:00PM BLOOD ALT-62* AST-112* LD(LDH)-748*
AlkPhos-142* Amylase-76 TotBili-3.4*
[**2164-2-25**] 12:30AM BLOOD ALT-60* AST-103* LD(LDH)-715*
CK(CPK)-447* AlkPhos-144* TotBili-4.2* DirBili-2.9* IndBili-1.3
[**2164-2-24**] 07:00PM BLOOD cTropnT-0.03*
[**2164-2-24**] 07:00PM BLOOD CK-MB-40*
[**2164-2-25**] 12:30AM BLOOD CK-MB-33* MB Indx-7.4* cTropnT-0.05*
[**2164-2-25**] 12:30AM BLOOD TSH-2.6
[**2164-2-25**] 04:12AM BLOOD Cortsol-37.3*
[**2164-2-24**] 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2164-2-24**] 07:16PM BLOOD Glucose-192* Lactate-8.8* Na-136 K-3.4*
Cl-113* calHCO3-12*
[**2164-2-24**] 09:26PM BLOOD Glucose-222* Lactate-8.8* Na-135 K-2.9*
Cl-110
[**2164-2-25**] 12:37AM BLOOD Glucose-209* Lactate-9.9* K-4.1
[**2164-2-25**] 04:20AM BLOOD Lactate-10.8* K-4.0
[**2164-2-25**] 06:57AM BLOOD Lactate-11.0* K-4.0
HEAD CT:
1. No evidence of acute intracranial hemorrhage.
2. Air-fluid levels within the paranasal sinuses which most
likely are related to intubation.
CHEST/ABDOMEN/PELVIX:
1. ETT tip at orifice of right mainstem bronchus. The ETT has
already been repositioned since the CT scan.
2. NG tube curls up in the esophagus.
3. Massive bilateral consolidations which could be related to
aspiration.
4. Bilateral small pleural effusions.
5. Bowel wall thickening of ascending and descending colon and
small abdominopelvic ascites. Primary considerations would be an
infectious process such as C. difficile colitis. Inflammatory or
ischemic causes are other considerations, although ischemia
appears less likely given the distribution.
6. Compression fractures of L2 and L3 vertebral bodies which are
age indeterminate.
7. Right subvlavian line terminates in left brachiocephalic vein
and repositioning is recommended.
EGD:
Impression: Posterior oropharyngeal laceration
Extensive blood clot in the esophagus
Old blood in the duodenum
Erythema and congestion in the whole stomach compatible with
portal hypertensive gastropathy
[**Doctor First Name **]-[**Doctor Last Name **] tear
Old blood in the stomach
Otherwise normal EGD to second part of the duodenum
Recommendations: Double dose PPI IV
Do not replace NGT/OGT
Brief Hospital Course:
MUTLIFACTORIAL SHOCK:
Ms. [**Known lastname 467**] likely presented with GI illness with poor po intake
and suspected nausea/vomiting given [**Doctor First Name 329**]-[**Doctor Last Name **] tear, which
led to large GI bleed contributing to hypotension. She likely
aspirated at [**Hospital1 **] when she arrested in the CT scanner,
leading to cardiogenic shock. Sepsis was also included in the
initial differential given that she had bandemia on [**Location (un) 8062**]
CBC, suspicious for pulmonary or GI source, given colitis seen
on abdominal CT. She was supported fully with dopamine and
vasopressin, in addition to volume and blood, FFP, and
cryoprecipitate.
For possible sepsis, she was treated with broad spectrum
antibiotics initially in the ED.
A discussion of prognosis was had with the medical intensive
care unit team and the patient's sister, [**Name (NI) **] [**Name (NI) **], who was
listed as next of [**Doctor First Name **]. The decision was made to make the patient
comfort measures only, and vasopressors and mechanical
ventilation were withdrawn, and the patient expired, within 24
hours of admission.
RESPIRATORY FAILURE:
She was mechanically ventilated for respiratory failure until
CMO decision.
She had bilateral consolidations consistent with aspiration.
GI BLEED:
Upper endoscopy revealed old blood and clot in the esophagus,
stomach, and duodenum, as well as [**Doctor First Name **]-[**Doctor Last Name **] tear that was
likely the initial culprit of the GI bleed. She also had a
laceration on her soft palate. ENT examined but it was no longer
bleeding. She was treated with IV PPI [**Hospital1 **].
ACUTE RENAL FAILURE:
Recent baseline in CCC of 0.8, up to 2.5 on admission here.
Likely related to hypovolemia from blood loss (pre-renal), plus
Acute Kidney Injury from hypotension. Cr has improved from
initial OSH labs, but still minimal UOP.
METABOLIC ACIDOSIS:
Anion gap acidosis with markedly elevated lactate s/p cardiac
arrest in the setting of hypotension. Also concern for bowel
ischemia, although CT read more consistent with infectious
colitis. POssible contribution from renal failure as well.
ALCOHOL USE:
The patient had history of strong alcohol use. She was treated
with thiamine and vitamins.
Medications on Admission:
Unknown. (?protonix, folate per OSH record; multivitamins,
Protonix, levothyroxine, lorazepam, and Tylenol per [**2161**] OMR
note)
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary
Cardiac Arrest, within 24 hours of interhospital transfer
Cardiogenic Shock
Upper GI Bleed due to [**Doctor First Name 329**]-[**Doctor Last Name **] tear
Aspiration Pneumonia
Acute Renal Failure
Secondary:
Scleroderma
Gastroesophageal Reflux Disorder
Alcohol Abuse
Iron Deficiency Anemia.
Discharge Condition:
Expired
|
[
"530.7",
"244.9",
"710.1",
"530.81",
"995.92",
"707.04",
"038.9",
"518.81",
"584.9",
"537.89",
"571.2",
"785.51",
"507.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"45.13",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8390, 8399
|
5927, 8179
|
321, 326
|
8742, 8752
|
3272, 4590
|
2553, 2562
|
8361, 8367
|
8420, 8721
|
8205, 8338
|
2577, 3253
|
264, 283
|
354, 2014
|
4599, 5904
|
2036, 2135
|
2151, 2537
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
49,082
| 142,680
|
41799
|
Discharge summary
|
report
|
Admission Date: [**2190-10-8**] Discharge Date: [**2190-10-11**]
Date of Birth: [**2110-7-19**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
- Intubation [**2190-10-8**]
- Central Venous Line and Arterial Line Placement [**2190-10-8**]
History of Present Illness:
80yo Chinese-speaking F PMHx dCHF (LVEF of 72% [**5-/2190**]) on home
O2, CAD s/p Xience DES to RCA ([**5-/2189**]), AS s/p AVR, DM, PAD,
HTN, HLD, OSA on bipap at home, cerebrovascular disease s/p
right carotid endarterectomy in [**3-/2190**], pAF who presented to the
ED w worsening shortness of breath and altered mental status,
now s/p intubation and CVL placement in the ED. Ms. [**Known lastname **] was
recently admitted to [**Hospital1 2025**] [**6-3**]-/[**6-10**] for dCHF exacerbation in
addmition to severe OSA and again from [**Date range (1) 20550**] for afib which
converted spontaneously. In the weeks prior to her admission,
she saw her outpatient cardiologist Dr. [**Last Name (STitle) **] and reported
increased SOB and worsening [**Location (un) **]; her home lasix dosing was
increased from 40mg PO BID to 60mg PO BID with interval
improvement in her swelling and breathing. For uncertain
reasons, she then returned to her baseline lasix dosing, and
subsequently re-developed worsening symptoms. On the day of
admission, her family became concerned regarding her symptom
progression and planned to take her to [**Hospital1 2025**] for a scheduled
admission (discussed with Dr. [**Last Name (STitle) **] that day). On the drive
over, she became acutely more short of breath, lethargic. Her
son diverted to [**Hospital1 18**], where he flagged down EMS, who
transported her to the ED.
.
Initial vital signs in the ED HR 88 BP 160/30 RR 12 78% on NRB.
Patient was not following commands, and given concern for airway
protection, underwent rapid sequence intubation w
etomidate/succinyl choline. She had a CVL placed and was
transiently on a levophed drip for brief episode of hypotension
attributed to propofol. She received ASA 600 PR, nitro drip,
100mg IV lasix. EKG did not demonstrate ischemic changes. She
was admitted to CCU for further management of fluid status.
.
On arrival to the CCU, she is intubated and sedated. Her
daughters (all of which are supposedly [**Name (NI) 18133**]) and son were
present and confirmed the above history. Per their report, she
has not had any recent illnesses, fevers, chills, cough, sputum
production, chest pain, numbness, weakness/tingling,
orthopnea/PND.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: dCHF LVEF 72%, RVSP of 50mmhg, RA
dilatation, PA dilatation, and RVH.
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: S/p DES (xience) to RCA
in [**5-/2189**]
- PACING/ICD: None
- S/p carotid endarterectomy in [**3-/2190**]
3. OTHER PAST MEDICAL HISTORY:
- CKD
- LVH
- NIDDM
- Hypothyroidism. [**Doctor Last Name 933**] s/p radioiodine
- Glaucoma
- Hypercholesterolemia
- Gout
- Hypercalcemia
- PAD - high grade focal right ICA stenosis with 30mmhg on
angiogram [**5-30**]. S/p r CEA on [**2190-3-26**]; as well as severe PAD of
the R and L LE's in the aorto-iliac, femoral, and popoliteal
segments as well as the digits
- pAfib thought to be peri-operative previously on coumadin
Social History:
She lives with her family including children who are very
supportive.
- Tobacco history: Remote hx of smoking, unclear how long
- ETOH: Denies
- Illicit drugs: Denies
- Exercise: Denies
- ADL's: ?
Family History:
-Father MI in his 60's, had CABG
-Son with MI in his 40's, had CABG
-Daughter MI age 49, s/p PCI
Physical Exam:
ADMISSION
VS: T96.3, 49, 125/42(62), 15, 100% on Assist Control
GENERAL: Sedated, intubated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, hard to appreciate JVP given habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Systolic ejection murmur loudest at
bases, crescendo decrescendo in quality, III/VI. No thrills,
lifts. No S3 or S4 appreciated.
LUNGS: Lung sounds symmetrical bilaterally. Moderate upper
airway sounds with faint crackles anteriorly
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema to knees in b/l extremities
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+
DISCHARGE
VS: T101 HR67 BP122/47 96% on Assist Control
GENERAL: Sedated, intubated.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple, hard to appreciate JVP given habitus.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Systolic ejection murmur loudest at
bases, crescendo decrescendo in quality, III/VI. No thrills,
lifts. No S3 or S4 appreciated.
LUNGS: Lung sounds symmetrical bilaterally. Moderate upper
airway sounds with faint crackles anteriorly
ABDOMEN: Soft, obese, NTND. No HSM or tenderness.
EXTREMITIES: 1+ edema to knees in b/l extremities
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:
[**2190-10-8**] CXR
Pulmonary edema with moderate right and tiny left pleural
effusion. Top
normal heart size.
[**2190-10-10**] CT Chest w/o Contrast
1. Large right, moderate left simple pleural effusion with
subsegmental
atelectasis of the bilateral lower and right middle lobes.
2. Prominence of the pulmonary arteries, consistent with
pulmonary
hypertension. There is no focal consolidation to suggest the
diagnosis of
pneumonia, nor evidence for ARDS.
Blood Counts
[**2190-10-8**] 03:05PM BLOOD WBC-8.8 RBC-3.85* Hgb-10.4* Hct-33.9*
MCV-88 MCH-27.1 MCHC-30.8* RDW-14.7 Plt Ct-190
[**2190-10-10**] 02:58AM BLOOD WBC-7.5 RBC-3.44* Hgb-9.3* Hct-29.6*
MCV-86 MCH-27.1 MCHC-31.5 RDW-15.2 Plt Ct-173
[**2190-10-11**] 05:10AM BLOOD WBC-11.4* RBC-3.60* Hgb-9.6* Hct-30.7*
MCV-85 MCH-26.6* MCHC-31.1 RDW-15.3 Plt Ct-159
Chemistry
[**2190-10-8**] 03:05PM BLOOD Glucose-283* UreaN-65* Creat-1.5* Na-138
K-4.9 Cl-93* HCO3-34* AnGap-16
[**2190-10-9**] 05:22AM BLOOD Glucose-66* UreaN-61* Creat-1.4* Na-143
K-4.0 Cl-100 HCO3-34* AnGap-13
[**2190-10-11**] 05:10AM BLOOD Glucose-143* UreaN-53* Creat-2.1* Na-141
K-4.0 Cl-97 HCO3-36* AnGap-12
Cardiac
[**2190-10-8**] 03:05PM BLOOD cTropnT-<0.01
[**2190-10-8**] 11:19PM BLOOD CK-MB-3 cTropnT-0.02*
[**2190-10-9**] 05:22AM BLOOD CK-MB-2 cTropnT-0.02*
Brief Hospital Course:
HOSPITAL COURSE SUMMARY
This is an 80yo Chinese-speaking female with a PMHx of dCHF, CAD
s/p DES to RCA AVR, OSA on bipap at home, pAF who presented with
hypoxia and altered mental status requiring intubation, now
status-post diuresis of 5L, remaining intubated, with family
requesting transfer to [**Hospital1 2025**].
.
# Hypoxic Respiratory Failure / Acute Diastolic CHF: Pt w
history of dCHF presenting w profound hypoxia requiring
intubation, w signs of volume overload on admission exam,
imaging, labs; etiology of acute failure exacerbation is
uncertain as no signs of ischemia by EKG or cardiac enzymes;
patient was diuresed with IV lasix drip w improvement in
respiratory status, but remaining w ventilator requirements.
Hospital day 2, patient spiked fever to 101.3 and was started on
respiratory coverage with cefepime/vancomycin/azithro. Imaging
demonstrated large R and moderate L plueral effusions,
suggesting additional restrictive component to respiratory
failure. Patient was evaluated with bedside ultrasound of
pleural fluid prior to transfer, which did not demonstrate
significant tapable fluid. Patient was transferred to [**Hospital1 2025**] for
further management.
.
# Rhythm: Patient w history of Afib (not anticoagulated),
admitted in sinus bradycardia (her baseline) but converted to
afib on hospital day 2. Loaded with 18hrs IV amiodarone, then
transitioned to PO amio 400mg [**Hospital1 **]. Anticoagulated with IV
heparin drip.
.
# CAD: h/o RCA stent ([**5-/2189**]), but w/o ischemic changes by EKG,
enzymes. Continued ASA, pravastatin. Metoprolol held secondary
to bradycardia when in sinus.
.
# HTN: Held home losartan, amlodipine given borderline
hypotension
.
# NIDDM: On glipizide at home, held on admission and managed
with humalog sliding scale.
.
INACTIVE
# Hypothyroidism: Continued on home levothyroxine.
.
# Glaucoma: Continued Cosopt, lumigan
.
# Nutritional Supplementation: Continued calcium/vitaminD.
.
TRANSITIONAL ISSUES (for transfer to [**Hospital1 2025**])
1. Transfer - Family requested transfer of care to [**Hospital1 2025**], where
she has received most of her longitudinal and acute care in the
past. Case discussed with Dr. [**First Name11 (Name Pattern1) 698**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] of [**Hospital1 2025**] Cardiology
([**Telephone/Fax (1) 90785**]) who agrees with decision for transfer.
2. Access - RIJ, L radial artery line, foley
3. Sedation - Propofol drip
4. Vent Setting - Assist Control, Vt 400, PEEP 5, Fi02 30%
5. Prophylaxis - IV heparin, PO lansoprazole, PO senna/colace
6. Code Status - Full (confirmed)
Medications on Admission:
- ASA 325mg PO daily
- Calcium acetate daily
- Cosopt 1 drop OU [**Hospital1 **]
- Glipizide 5mg PO daily
- Lasix 60mg PO BID
- Levothyroxine 125mcg PO daily
- Losartan 25mg PO daily
- Lumigan 1 drop OU QPM
- Amlodipine 10mg PO daily
- Pravachol 40mg PO QPM
- Toprol XL 50mg PO daily
- Vitamin D 400unit PO QAM
Discharge Medications:
1. aspirin 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily).
2. dorzolamide-timolol 2-0.5 % Drops Ophthalmic
3. furosemide 10 mg/mL Solution [**Hospital1 **]: 5-20mg/hr Injection
INFUSION (continuous infusion): titrate to UOP 200cc/hr.
4. levothyroxine 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
5. latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at
bedtime).
6. pravastatin 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day.
7. cholecalciferol (vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
8. amiodarone 200 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
9. Vancomycin 1000 mg IV Q 24H
10. CefePIME 2 g IV Q24H
11. Azithromycin 250 mg IV Q24H Start: In am
12. propofol 10 mg/mL Emulsion [**Hospital1 **]: 5-20mcg/kg/min Intravenous
TITRATE TO RASS (Titrate to RASS).
13. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
14. chlorhexidine gluconate 0.12 % Mouthwash [**Last Name (STitle) **]: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day).
15. senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
16. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
17. Insulin Sliding Scale
Humalog sliding scale
18. IV heparin drip
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY
Acute on Chronic Diastolic Heart Failure
Discharge Condition:
Intubated
Lethargic but arousable
Most recent vital signs:
Discharge Instructions:
Ms [**Known lastname **]--
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted with shortness of breath and
confusion. Your oxygen levels were very low, most likely a
result of your heart failure. You were intubated to help you
breath, and started on medications to help remove fluid from
your body. You also developed fevers and were started on
treatment for a pnuemonia. At the request of your family, you
are now being transferred to [**Hospital6 1129**] for
further care.
Please see the discharge summary for further details of this
admission, or contact [**Hospital1 69**]
Cardiac Care Unit at [**Telephone/Fax (1) 65432**].
Followup Instructions:
TRANSFER TO [**Hospital6 **]
Completed by:[**2190-10-12**]
|
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icd9cm
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
18,614
| 136,514
|
22207
|
Discharge summary
|
report
|
Admission Date: [**2155-1-27**] [**Year/Month/Day **] Date: [**2155-2-11**]
Service: MEDICINE
Allergies:
Penicillins / Iodine; Iodine Containing / Sulfa (Sulfonamides) /
Buspar / Haldol / Levaquin / Sulfamethoxazole/Trimethoprim /
Trazodone / Percocet
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
transferred from [**Hospital1 **] with hypoxemia
Major Surgical or Invasive Procedure:
bronchoscopy (x4)
Y stent placement by interventional pulmonology ([**2155-1-30**])
right thoracentesis ([**2155-1-29**])
History of Present Illness:
85yoW with h/o metastatic thyroid cancer s/p thyroidectomy and
tracheostomy c/b tracheomalacia, also with h/o asthma and
Guillain-[**Location (un) **], discharged from [**Hospital1 18**] [**2155-1-13**] after admission on
[**2155-1-8**] for trach revision, transferred now from [**Hospital1 **] with
hypoxemia.
.
Patient's history dates back to when she was initially admitted
to [**Hospital 11485**] Med Center [**2154-11-6**] after reaction to antibiotics
and required mechanical ventilation. She was transferred to
[**Hospital1 **] [**2154-12-17**] for trach readjustment. She was transferred
from [**Hospital1 **] to [**Hospital 8**] Hospital [**2154-12-19**] where she remained
until transfer to [**Hospital1 18**] [**2155-1-8**]. She was brought to [**Hospital 8**]
Hospital [**2154-12-19**] for intermittent hypoxic respiratory failure
and hypotension due to tracheal obstruction by trach tube with
positional changes. At that time she was volume overloaded and
diagnosed with MRSA pneumonia. She is s/p trach x8yrs
complicated by tracheomalacia. While at [**Hospital1 8**] she was tried
on [**Last Name (un) 295**] 6.5 and Shiley 6.0, but these resulted in air leakage
and subjective distress. She also tried 7.0 talk trach, but she
did not tolerate that either. Hospital course was complicated
by MRSA pneumonia, treated with 14days combination Vancomycin
and Linezolid. She was also treated for E.coli UTI and Staph
epi bacteremia. Speech and swallow study at [**Hospital 8**] Hospital
demonstrated aspiration of all consistencies, and she was fed
via dobhoff tube. She and her family decline PEG placement. At
[**Hospital1 18**] she underwent bedside bronchoscopy and trach change with
placement of an adjustment 11.5cm [**Last Name (un) 295**] was placed. Hospital
course then was complicated by hypotension after attept to
increase diltiazem dose from 15 to 30mg, and recurrent trach
obstruction requiring repeat bronchoscopy. She was diuresed for
volume overload as well.
.
She was transferred from [**Hospital1 **] today after oxygen
desaturations with positional change and inability to bag. On
arrival to ED T 100.6R HR 100 BP 154/83 RR 14 98% ventilated.
She received doses of vancomycin and cefepime in the ED for
pneumonia given h/o MRSA and pseudomonas.
Past Medical History:
Metastatic follicular thyroid cancer s/p thyroidectomy, XRT and
radioactive iodine treatment - mets to lung
Cataracts
h/o DCIS breast ca s/p right mastectomy
Afib
Ulcerative colitis
h/o bilateral DVT s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] filter
Mitral regurg
Critical aortic stenosis
h/o MRSA pneumonia
Asthma
h/o Guillaine-[**Location (un) **]
Hypertension
EF 25-30%
Ocular migraines
Prior stroke
Social History:
Originally from NY. Lives in [**Location 22201**], MA, and was previously
ventilator dependent at night.
No history of smoking, no history of drinking
Family History:
History of lung and ovarian cancer
Physical Exam:
T 97.5 HR 105 BP 82/65 RR 14 99% Wt 65kg
AC Tv 450 RR 14 FiO2 100% PEEP 10
GEN: withdrawn, responding to questions with minimal head nod
HEENT: PERRL, anicteric, OP clear but poor visualization, dry
MM
Neck: supple, trach, no cervical or supraclavicular LAD
CV: irreg irreg, tachycardic, palpable heave, PMI nondisplaced,
II/VI SEM at LLSB and apex
Resp: coarse with rales bilaterally
Abd: +BS, soft, diffusely ttp, no rebounding/guarding, ND
Ext: BLE with 1+ edema, 1+ BDPs
Back: stage I sacral erythematous skin wound
Pertinent Results:
Admission Labs:
[**2155-1-27**] 09:23PM PTT-96.1*
[**2155-1-27**] 09:23PM VoidSpec-NO LABEL O
[**2155-1-27**] 05:54PM HCT-26.5*
[**2155-1-27**] 05:54PM RET AUT-1.9
[**2155-1-27**] 10:31AM TYPE-ART PO2-93 PCO2-59* PH-7.49* TOTAL
CO2-46* BASE XS-18
[**2155-1-27**] 10:31AM O2 SAT-97
[**2155-1-27**] 05:24AM GLUCOSE-120* UREA N-25* CREAT-0.5 SODIUM-140
POTASSIUM-4.1 CHLORIDE-94* TOTAL CO2-41* ANION GAP-9
[**2155-1-27**] 05:24AM CALCIUM-8.7 PHOSPHATE-3.6 MAGNESIUM-2.2
IRON-20*
[**2155-1-27**] 05:24AM calTIBC-247* FERRITIN-228* TRF-190*
[**2155-1-27**] 05:24AM WBC-15.9* RBC-3.17* HGB-9.1* HCT-27.5* MCV-87
MCH-28.6 MCHC-32.9 RDW-16.9*
[**2155-1-27**] 05:24AM PLT COUNT-375
[**2155-1-27**] 05:24AM PT-17.8* PTT-36.5* INR(PT)-1.7*
[**2155-1-27**] 01:28AM LACTATE-1.5
[**2155-1-27**] 01:28AM LACTATE-1.5
[**2155-1-27**] 01:15AM GLUCOSE-160* UREA N-25* CREAT-0.5 SODIUM-143
POTASSIUM-4.8 CHLORIDE-94* TOTAL CO2-43* ANION GAP-11
[**2155-1-27**] 01:15AM estGFR-Using this
[**2155-1-27**] 01:15AM DIGOXIN-1.0
[**2155-1-27**] 01:15AM URINE HOURS-RANDOM
[**2155-1-27**] 01:15AM URINE UHOLD-HOLD
[**2155-1-27**] 01:15AM WBC-18.3*# RBC-3.54*# HGB-10.2*# HCT-31.4*
MCV-89 MCH-28.7 MCHC-32.4 RDW-16.9*
[**2155-1-27**] 01:15AM NEUTS-86.9* BANDS-0 LYMPHS-7.6* MONOS-3.6
EOS-1.2 BASOS-0.7
[**2155-1-27**] 01:15AM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-OCCASIONAL
OVALOCYT-OCCASIONAL STIPPLED-OCCASIONAL ENVELOP-OCCASIONAL
[**2155-1-27**] 01:15AM PLT COUNT-483*
[**2155-1-27**] 01:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016
[**2155-1-27**] 01:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-MOD
[**2155-1-27**] 01:15AM URINE RBC-0 WBC-[**11-11**]* BACTERIA-FEW YEAST-MOD
EPI-0-2
[**2155-1-27**] 01:15AM URINE MUCOUS-FEW
.
[**2155-1-27**] Chest CT:
Improved pulmonary edema. Interval increase in bilateral pleural
effusions. Progression of scores of thyroid metastases to the
lungs. Pulmonary hypertension. Moderate calcification in the
aortic valve is of unknown hemodynamic significance. Extensive
coronary calcifications. Chronic right lower lobe and partial
left lower lobe collapse. Secretions in the trachea above the
cuff and in the left lower bronchus. Worsening mediastinal
lymphadenopathy.
.
PLEURAL FLUID [**2155-1-30**]
WBC 283; RBC 150; Polys 8; Lymphs 38
Glucose 94; LDH 146; Albumin 2.1
pH 7.50
Negative for malignant cells
.
[**2155-1-27**] TTE: The left atrium is dilated. There is symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are moderately thickened.
The aortic valve is not well seen. There is mild to moderate
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a fat pad.
.
[**2155-2-3**] CXR: Tracheostomy tube is in standard midline position
within the trachea. With the patient's neck in a flexed
position, the distal tip is approximately 2 cm above the carina.
Feeding tube continues to terminate below the diaphragm. Heart
size is normal and unchanged. Multiple diffuse pulmonary nodules
are present throughout both lungs with a dominant mass in the
right hilum. Moderate sized pleural effusions are present
bilaterally. A superimposed acute parenchymal process, likely
pulmonary edema, shows some interval improvement since [**2-1**], [**2154**].
.
LUE DOPPLER [**2155-2-6**]
Nonocclusive thrombus extending from basilic vein proximal to
PICC, extending to the proximal subclavian vein. Recommend
short-term followup to evaluate for presence of gas bubbles
within the thrombus.
.
LUE DOPPLER [**2155-2-7**]
1. Almost occlusive thrombus in the basilic vein.
2. Significantly decreased number of echogenic areas, likely
representing gas bubbles related to the manipulation.
3.The subclavian vein appears patent
.
CXR [**2155-2-8**]
A PICC line is present. The tip of the PICC line lies in the
region of the right subclavian/SVC junction. It may or may not
lie immediately within the proximalmost SVC. No pneumothorax is
detected. Extensive pulmonary findings are unchanged, including
a prominent right hilar mass and innumerable metastatic nodules
throughout both lungs. Tracheostomy tube noted.
Brief Hospital Course:
.
85 yo female with h/o mets, thyroid cancer s/p tracheostomy c/b
tracheomalacia, with recent treatment for pneumonia and CHF,
transferred here with hypoxia.
.
# Hypoxia - At rehab, the patient had oxygen desaturations that
occurred with position changes due to tracheomalacia and
collapse around the trach. CT chest was significant for
pulmonary edema/collapse of RLL (chronic) and LLL. CXR w/
consolidation at LLL. Bronch/BAL on [**2155-1-27**] noted thick
secretions and severe tracheomalacia. BAL grew pseudomonas and
serratia, pan-sensitive, specifically sensitive to meropenem.
14 day course of meropenem is planned. The patient was initially
also on vancomycin, but this was discontinued as there was no
evidence of gram + infection. Thoracentesis on [**2155-1-29**] drained
1.5L of serous, transudative fluid. Gram stain and culture of
pleural fluid were negative. Interventional pulmonology took
the patient to the OR on [**2155-1-30**] a Y stent in the
trachea. On [**2155-1-31**] she desatted again and on bronch by IP was
found to still have a lot of secretions. Trach was replaced
with a larger trach (size 8 [**Last Name (un) 295**]) to attempt to fix cuff leak.
On [**2155-2-1**] she was noted to have high PIPs on the vent (as high
as 53) and was bronched again. The trach tube was found to be
no longer overlapping the Y-stent, and redundant airway tissue
was occluding the trach. The trach was pulled back and secured
in place w/ cuff. On [**2-3**] she was noted to again be hypoxic and
was bronched again. It was determined that the trach should be
kept at the 12cm position to ensure overlap with the stent.
Lasix was restarted at a low dose on [**2-3**] and then increased to
her home dose to try to improve fluid status and respiratory
status. She is currently diuresing well on Lasix 80mg PO BID.
The interventional pulmonary service has noted that there are no
further airway interventions available to this patient, and have
determined that her airway is stable for transfer to rehab.
.
# UTI - The patient was diagnosed with a pseudomonas UTI,
sensitive to Meropenem which was started [**2155-1-29**] and is planned
for 14 day course.
.
# LEFT UPPER EXT DVT: The patient was found to have asymmetric
left upper extremity swelling. An ultrasound was done showing
an almost occlusive thrombus in the left basilic vein. She was
initially started on a heparin gtt, then transitioned to
coumadin. Stools were guaiac faintly positive, but brown,
thought to be secondary to her inflammatory bowel disease. Hct
was stable. Heparin gtt discontinued after INR was found to be
2.0.
.
# Afib - Rate controlled on diltiazem and digoxin. The patient
is on coumadin at home and was initially on a heparin gtt.
Coumadin was restarted and heparin stopped after INR found to be
2.0.
.
# CHF - EF 55%, mild AS on TTE here; likely volume down on
admission, so boluses of IV fluid were given for poor urine
output initially. Eventually when patient stabilized, her home
lasix was restarted to attempt to improve fluid and respiratory
status. The patient is not on an ACE or BB for unclear reasons.
.
# AS - h/o ?critical AS at OSH, but TTE here shows only mild AS.
.
# Anemia - Hct trended down from 31->25. Then stabilized after
1U PRBC on [**2-2**] with appropriate hct increase. Stools guiac
positive on heparin gtt, which was d/c'd, hct now stable.
.
# HTN - Continued diltiazem.
.
# h/o DVT - [**Location (un) 260**] filter in place. Is anticoagulated with
warfarin as outpatient. Anticoagulation managed as above
(under afib).
.
# Sacral pressure wound - stage I ulcer. Continued vitamins,
Zinc, vitamin C. Wound care with duoderm.
.
# UC - continued mesalamine
.
# Hypothyroid - continued levothyroxine
.
# FEN - on TF's via Dobhoff. Family refuses PEG tube.
.
# Access - left PICC
.
# PPx - PPI, coumadin, bowel regimen, elevate HOB, Peredex
mouthcare
.
# Communication - patient and her daughter
.
# Full Code - confirmed with patient's daughter and patient
[**2155-2-3**]
.
# Dispo - stable for transfer to rehab.
.
Medications on Admission:
Albuterol/Ipratropium 4puffs Q4hr
Vitamin C 500mg [**Hospital1 **]
Calcium carbonate 1250mg [**Hospital1 **]
Chlorhexidine 0.12% [**Hospital1 **]
Digoxin 0.125mg daily
Diltiazem 30mg QID
Erythromycin 250mg [**Hospital1 **]
Fluticasone 110mcg INH [**Hospital1 **]
Lasix 80mg daily
Insuin regular scale
Levothyroxine 175mg daily
Mesalamine 1000mg PR TID
Reglan 10mg TID
Miconazole TP QID
MVI daily
Naphazoline/Pheniramine 1gtt OU [**Hospital1 **]
Protonix 40mg daily
Senna 10mL [**Hospital1 **]
Simethicone 80mg QID
Zelnorm 6mg [**Hospital1 **]
Zenaderm ointment daily
Vitamin D 400units daily
Warfarin 2mg daily
Zinc 220mg [**Hospital1 **]
[**Hospital1 **] Medications:
1. Ascorbic Acid 90 mg/mL Drops [**Hospital1 **]: Five Hundred (500) [**Hospital1 **] PO
BID (2 times a day).
2. Calcium Carbonate 1,250 mg/5 mL(500 mg) Suspension [**Hospital1 **]: Ten
(10) ML PO BID (2 times a day).
3. Chlorhexidine Gluconate 0.12 % Mouthwash [**Hospital1 **]: Fifteen (15) ML
Mucous membrane [**Hospital1 **] (2 times a day).
4. Digoxin 125 mcg Tablet [**Hospital1 **]: 0.125 mg PO DAILY (Daily).
5. Erythromycin 250 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
6. Insulin Regular Human 100 unit/mL Solution [**Hospital1 **]: As directed
units Injection ASDIR (AS DIRECTED).
7. Levothyroxine 175 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
8. Metoclopramide 5 mg/5 mL Solution [**Hospital1 **]: Ten (10) mg PO TID (3
times a day).
9. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID
(4 times a day).
10. Naphazoline-Pheniramine 0.025-0.3 % Drops [**Hospital1 **]: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
11. Senna 8.8 mg/5 mL Syrup [**Hospital1 **]: Two (2) Tablet PO BID (2 times
a day).
12. Simethicone 80 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for indigestion.
13. Tegaserod Hydrogen Maleate 6 mg Tablet [**Hospital1 **]: One (1) Tablet
PO daily ().
14. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: One (1)
Tablet PO DAILY (Daily).
15. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily).
16. Mesalamine 1,000 mg Suppository [**Hospital1 **]: Five Hundred (500)
Suppository Rectal TID (3 times a day).
17. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol [**Hospital1 **]: Six
(6) Puff Inhalation Q4H (every 4 hours).
18. Lidocaine HCl 1 % Solution [**Hospital1 **]: Five (5) ML Injection Q1-2H
() as needed for cough.
19. Warfarin 2 mg Tablet [**Hospital1 **]: One (1) Tablet PO HS (at bedtime).
20. Diltiazem HCl 30 mg Tablet [**Hospital1 **]: One (1) Tablet PO QID (4
times a day).
21. Guaifenesin 100 mg/5 mL Syrup [**Hospital1 **]: Forty (40) ML PO TID (3
times a day) as needed for y-stent management: total daily dose
should be 2400mg per day .
22. Lorazepam 0.5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every 4
to 6 hours) as needed for nausea, anxiety.
23. Acetaminophen 160 mg/5 mL Solution [**Hospital1 **]: 325-650 mg PO Q4-6H
(every 4 to 6 hours) as needed.
24. Therapeutic Multivitamin Liquid [**Hospital1 **]: One (1) Cap PO
DAILY (Daily).
25. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Six (6) Puff
Inhalation [**Hospital1 **] (2 times a day).
26. Ranitidine HCl 15 mg/mL Syrup [**Hospital1 **]: One [**Age over 90 1230**]y (150)
mg PO BID (2 times a day).
27. Lidocaine HCl 2 % Solution [**Age over 90 **]: Twenty (20) ML Mucous
membrane TID (3 times a day) as needed.
28. Furosemide 80 mg Tablet [**Age over 90 **]: One (1) Tablet PO BID (2 times
a day).
[**Age over 90 **] Disposition:
Extended Care
Facility:
[**Location (un) 32674**]
[**Location (un) **] Diagnosis:
1) Respiratory Failure
2) Pneumonia
3) Upper extremity DVT
4) Urinary Tract Infection
5) Congestive Heart Failure
6) Atrial Fibrillation
7) Tracheomalacia
[**Location (un) **] Condition:
Stable
[**Location (un) **] Instructions:
Continue all medications as prescribed. Please follow up with
your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] to rehab.
Followup Instructions:
Please follow with the doctors at rehab. When discharged from
rehab, you should follow up with your primary care doctor.
|
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icd9cm
|
[
[
[]
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[
"33.23",
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"33.24",
"96.05",
"96.6",
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icd9pcs
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[
[
[]
]
] |
8822, 12885
|
414, 537
|
4096, 4096
|
17073, 17198
|
3492, 3528
|
12911, 13552
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3543, 4077
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16665, 16822
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326, 376
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16854, 16863
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13582, 16633
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16898, 17050
|
565, 2857
|
4112, 8799
|
2879, 3306
|
3322, 3476
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,890
| 150,647
|
12169
|
Discharge summary
|
report
|
Admission Date: [**2151-2-15**] Discharge Date: [**2151-2-19**]
Date of Birth: [**2082-2-14**] Sex: F
Service: BLUE SURGERY
CHIEF COMPLAINT: Mrs. [**Known lastname 38105**] was evaluated in the office
by Dr. [**Last Name (STitle) **] as a consultation for the possible surgical
treatment of a presumed gallbladder carcinoma.
HISTORY OF PRESENT ILLNESS: She is a 68-year-old white
On work up on [**1-4**], she had elevated liver function
tests which were an AST of 80, ALT of 106, alkaline
phosphatase of 517, total bilirubin of 2.6 and a direct
bilirubin of 1.4. She underwent a CT scan of the abdomen
which demonstrated intrahepatic biliary ductal dilatation and
an irregular heterogeneous mass in the region of the
gallbladder fossa. There was a question of some invasion
subsequently demonstrated a stricture of the common hepatic
duct just above the cystic duct that was 1 cm in length. A
wall stent was placed and then she followed up in the office
for possible surgical treatment. Apparently she had some
mild pruritus, but this had improved since her wall stent
placement. She denies any fevers, chills, nausea, vomiting,
diarrhea, constipation or recent weight loss.
PAST MEDICAL HISTORY:
1. Hypertension
2. Coronary artery disease (cardiac catheter [**2150-9-8**]
revealed right coronary artery disease and inferior wall
hypokinesia. Stress test showed anterior wall perfusion
defect.)
3. History of shingles
4. Left Bell's palsy
5. Congestive heart failure with ejection fraction of
approximately 50%
6. History of benign colonic polyps
7. Diverticulosis
8. Hypercholesterolemia
PAST SURGICAL HISTORY:
1. Partial hysterectomy in [**2143**]
2. Cataract surgery in [**2147**]
ADMISSION MEDICATIONS:
1. Dicyclomine 20 mg po tid
2. Hydroxyzine 25 mg po q8h
3. Zyrtec 10 mg po qd
4. Ambien 10 mg po qd
5. Lasix 40 mg po qd
6. Atacand 16 mg po qd
7. Baby aspirin 325 mg po qd
ALLERGIES: She has no known drug allergies.
SOCIAL HISTORY: She denies the use of alcohol and smoking.
She is currently, employed, widowed and has no children.
FAMILY HISTORY: Mother who died of metastatic colon
carcinoma.
PHYSICAL EXAM:
VITAL SIGNS: The patient is afebrile. Pulse of 72, blood
pressure of 130/70, respirations 22, weight 218.8 pounds.
GENERAL: She appears to be an obese female in no acute
distress.
SKIN: She has mild excoriations on her skin. No palmar
erythema or spider angiomas.
HEAD, EARS, EYES, NOSE AND THROAT: She has no scleral
icterus. Oropharynx is clear. Neck has no lymphadenopathy
or thyromegaly. Carotids are 2+ and 4+ without bruit.
LUNGS: Clear to auscultation and percussion.
CARDIAC: Normal S1 and S2 with no S3, S4 or murmurs. She
has regular rate and rhythm.
ABDOMEN: Obese, normal bowel sounds, no masses or
tenderness.
EXTREMITIES: She has no peripheral edema.
NEUROLOGIC: Grossly intact without asterixis.
ADMISSION LABORATORIES: Hemoglobin of 14.4, hematocrit of
43.8, white blood count of 7.2, platelets of 227. Sodium of
140, potassium 4.8, chloride 106, bicarbonate 22, glucose of
83, BUN of 30, creatinine of 1.1. ALT of 50, AST of 42,
alkaline phosphatase of 447, GGT of 83, total bilirubin 0.9,
albumin 3.9. PT 14.1, INR of 1.4, PTT of 27.9, AFP of 2.5,
CEA of 2.8.
IMAGING: CT of the abdomen as a result of a gallbladder
tumor extending into the hepatic segments of 5 and 6.
Gallbladder is contiguous with duodenum although there is no
bowel obstruction. There is no evidence of metastatic
disease. Echocardiogram done on [**2150-9-9**] showed an
ejection fraction of 50% with mild mitral regurgitation and
hypokinesis of basal inferior wall.
HOSPITAL COURSE: The patient was brought to [**Hospital6 1760**] and on the day of admission
she underwent a cholecystectomy with resection of the
gallbladder fossa and portal lymph node dissection. She
tolerated this procedure well, received 4800 cc of
crystalloid fluid, had an estimated blood loss of 200 cc and
a urine output of 600 cc during the case. She was
transferred to the PACU in stable condition and extubated.
On the first postoperative day, she spent the night in the
Intensive Care Unit for close monitoring where she remained
hemodynamically stable. Her respiratory status remained
stable as well with O2 saturations in the high 90s%. She
remained comfortable with an epidural in place. She did
complain of some mild incisional tenderness. She was then
transferred to the floor on postoperative day #2 where she
remained stable for the remainder of her recovery.
Neurologically, the epidural was discontinued on
postoperative day #2 secondary to the fact that she continued
to have incisional pain. She was switched to intravenous
morphine and now her pain has been well controlled. She has
remained alert and oriented throughout her stay and
neurologically intact.
Her cardiovascular status has remained stable. She has
remained in regular rate and rhythm and had stable blood
pressures. She was restarted on her preoperative hypotensive
medications, including Atacand, atenolol on postoperative day
#2. Her respiratory status has remained stable. She has
been using incentive spirometry, has been out of bed and
ambulating and her O2 saturations have remained high on room
air.
Gastrointestinal wise, the patient was started on clears on
postoperative day #1 which she tolerated and was advanced to
a low sodium diet. On postoperative day #2, she received a
bowel regimen including suppositories. Her liver function
tests on postoperative day #1 were elevated and she had some
pruritus on the first postoperative day, but the liver
function tests had appropriately decreased during her
hospital stay. Her latest set of liver function tests are an
ALT of 130, AST of 44, alkaline phosphatase of 274 and total
bilirubin of 0.5.
Genitourinary remained stable. Her Foley was discontinued
once the epidural was removed and she is being able to void
without any problems.
Her hematological status has been stable, as well. Her
hematocrit has remained stable from 32 to 35. She has been
on prophylactic heparin and Venodynes for deep venous
thrombosis prophylaxis.
Her wounds remained clean, dry and intact. Her JP bulb has
been draining serosanguinous fluid approximately 50 to 80 per
shift. There is no erythema. Her abdomen remained soft and
nontender.
DISPOSITION: The patient has been having physical therapy as
an inpatient, would benefit from rehabilitation since the
patient lives alone. The patient, from a clinical
standpoint, is stable and is now ready for discharge to
rehabilitation.
Pathology is still pending from the surgical specimen.
DISCHARGE DIAGNOSES:
1. Status post open cholecystectomy, gallbladder fossa
resection and portal lymph node dissection for presumed
gallbladder cancer.
2. Hypertension
3. Hypercholesterolemia
4. Congestive heart failure
5. Bell's palsy
6. Shingles
DISCHARGE MEDICATIONS:
1. Dicyclomine 20 mg po tid
2. Hydroxyzine 25 mg po q 8
3. Zyrtec 10 mg po qd
4. Ambien 10 mg po qd
5. Lasix 40 mg po qd
6. Atacand 16 mg po qd
7. Baby aspirin 325 mg po qd
8. Actigall 300 mg po qid
9. Oxycodone 5 to 10 mg po q 4 to 6 hours prn
DISCHARGE CONDITION: Stable
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] in the
office in approximately one week.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], M.D.,Ph.D. 02-366
Dictated By:[**Last Name (NamePattern1) 3835**]
MEDQUIST36
D: [**2151-2-19**] 08:03
T: [**2151-2-19**] 08:25
JOB#: [**Job Number 38106**]
|
[
"698.9",
"424.0",
"401.9",
"414.01",
"197.7",
"272.0",
"156.8",
"428.0",
"574.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"51.22",
"40.29"
] |
icd9pcs
|
[
[
[]
]
] |
7208, 7216
|
2111, 2159
|
6674, 6908
|
6931, 7186
|
3673, 6653
|
1749, 1976
|
1651, 1726
|
2174, 3655
|
7228, 7598
|
162, 347
|
376, 1204
|
1226, 1628
|
1993, 2094
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,427
| 197,209
|
46253
|
Discharge summary
|
report
|
Admission Date: [**2186-12-27**] Discharge Date: [**2187-1-1**]
Date of Birth: [**2131-10-29**] Sex: M
Service: MEDICINE
Allergies:
Keflex
Attending:[**First Name3 (LF) 398**]
Chief Complaint:
Hemoptysis
Major Surgical or Invasive Procedure:
Placement of central venous line
Endotracheal intubation
Placement of hemodialysis catheter
Hemodialysis
Placement of arterial line for blood pressure monitoring
History of Present Illness:
All based on OSH records (parts of OSH records unclear). [**Name2 (NI) **]
hospital records, the patient developed erythema and swelling of
his right medical thigh around [**2186-12-18**]. (recently treated with
clindamycin for LE cellulitis. Followed by Dr [**Last Name (STitle) 98330**] at
[**Hospital3 2358**] for chronic open sores on LE's.) He began feeling
worse on [**12-21**] and was brought to [**Hospital6 **]. He
was given a dose of vancomycin and the plan was to go back to
prison on a course of vancomycin. Of note, on [**12-22**], the patient
became hypotensive to 86/42 and was treated with a NS blous.
BP's remained in the 70's to 80's on [**11-25**].
.
The patient was referred to [**Hospital6 33836**] on [**12-23**]
for worsening medial proximal thigh ulcer. He was continued on
vanocomycin and started on tigecycline and was transferred back
to prison that same day.
.
On [**2186-12-24**], the patient reported the sudden onset of left arm
weakness/numbness. He had decreased ROM of LUE. LLE was normal.
Denied HA at that time. + SOB (oxygenating 95% on 2L thoughtout
that day). He was seen by neurology who felt he had an embolic
stroke [**1-26**] to a fib (subtherapeutic INR) and was started on
coumadin and lovenox 100mcg [**Hospital1 **] (? dosing frequency) on [**2186-12-25**].
.
Renal was consulted at the OSH on [**2186-12-25**] for worsening renal
function/hyponatremia/hyperkalemia. They felt his issues were
likely related to intravascular volume depletion. It remains
unclear what his CRI is from (? prior renal injury from SBE, HCV
related?, HTN). At that time they had held his bumex and
spironalactone and continued him on IV NS.
.
Per OSH records the patient was "doing well" on the medicine
floor until the morning of [**12-27**] when he had an episode of
"massive hemoptysis" and respiratory distress. He was intubated
and transfered to the ICU. His original ABG was 7.17/47/77.
Frank blood and clots (>100cc) came from his ETT tube. He was
transfered 2 units of PRBC and FFP. He had a bronch at the OSH
which showed no definite acute bleeding. Transfer to [**Hospital1 18**] was
then arranged.
.
On [**Location (un) **], the patient was reportedly hypotensive and was
started on a dopamine drip. He was given 1 unit PRBC enroute [**1-26**]
hypotension.
Past Medical History:
Recurrent cellulitis of right leg
Cardiomyopathy
Chronic lymphedema
h/o MRSA
HTN
A Fib
CRI - ? baseline around 1.5
GERD
previous endocarditis with tricuspid valve - TV valvotomy [**2166**],
porcine valve [**2174**]
Hepatitis C
Chronic Hyponatremia
Social History:
Serving a 7 year sentence for drugs. Expected to be released
next year. In protective custody.
Family History:
NC
Physical Exam:
T 97.6 BP 96-102/43-51 P 95-97 RR 17-31 O2 94-97%
Vent setting 700 x 20 x 20 FIO2 of 100%
vbg 7.15/56/45
propofol at 10
Gen: obese, intubated, sedated
HEENT: pupils 1mm minimally reactive to light, film on cornea
intubated, cannot evaluate jvp
Lungs: coarse breath sounds anteriorly, no wheezes/crackles
Heart: irregulary irreg, no murmurs appreciated
Abd: obese, distended, hypoactive bowel sounds
Ext: Lower extremeties with marked venous stasis changes b/l,
[**12-26**]+ pitting edema until knee. Ulceration on right shin with
granulation tissue, small area of ulceration on left shin. Area
of erythema and warmth on the right inner thigh to groin. Upper
extremities with no pitting edema.
Neuro: mental status unable to be assessed as sedated
Pertinent Results:
Admission labs:
[**2186-12-27**] 10:17AM BLOOD WBC-33.6* RBC-4.79 Hgb-14.7 Hct-44.1
MCV-92 MCH-30.6 MCHC-33.2 RDW-19.2* Plt Ct-203
[**2186-12-27**] 10:17AM BLOOD Neuts-80* Bands-11* Lymphs-2* Monos-5
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0
[**2186-12-27**] 10:17AM BLOOD PT-15.7* PTT-37.5* INR(PT)-1.4*
[**2186-12-27**] 10:17AM BLOOD Fibrino-445* D-Dimer-3412*
[**2186-12-27**] 10:17AM BLOOD FDP-10-40
[**2186-12-27**] 10:17AM BLOOD Glucose-114* UreaN-105* Creat-4.9*
Na-125* K-6.0* Cl-90* HCO3-17* AnGap-24*
[**2186-12-27**] 10:17AM BLOOD ALT-16 AST-18 LD(LDH)-217 AlkPhos-152*
Amylase-52 TotBili-3.8* DirBili-2.5* IndBili-1.3
[**2186-12-27**] 10:17AM BLOOD Lipase-30
[**2186-12-27**] 05:29PM BLOOD proBNP-6104*
[**2186-12-27**] 10:17AM BLOOD Albumin-3.1* Calcium-8.5 Phos-10.9*
Mg-3.0*
[**2186-12-28**] 11:20AM BLOOD Cryoglb-NO CRYOGLO
[**2186-12-27**] 10:17AM BLOOD Cortsol-48.4*
[**2186-12-27**] 05:07PM BLOOD Cortsol-51.0*
[**2186-12-27**] 05:29PM BLOOD Cortsol-52.1*
[**2186-12-27**] 04:32PM BLOOD ANCA-NEGATIVE
[**2186-12-27**] 04:32PM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **]
[**2186-12-27**] 04:32PM BLOOD PEP-POLYCLONAL IgG-2721* IgA-484*
IgM-462* IFE-NO MONOCLO
[**2186-12-27**] 05:07PM BLOOD C3-90 C4-16
[**2186-12-27**] 10:32AM BLOOD Type-MIX Temp-36.4 Rates-16/ Tidal V-700
PEEP-15 FiO2-100 pO2-45* pCO2-56* pH-7.15* calTCO2-21 Base XS--9
AADO2-636 REQ O2-100 -ASSIST/CON Intubat-INTUBATED
[**2186-12-27**] 08:55PM BLOOD Type-ART Temp-36.6 pO2-120* pCO2-38
pH-7.22* calTCO2-16* Base XS--11 Intubat-INTUBATED
[**2186-12-27**] 10:32AM BLOOD Lactate-2.3*
[**2186-12-27**] 09:12PM BLOOD ANTI-GBM <3 (NEG)
.
Labs from day of death:
[**2187-1-1**] 02:55AM BLOOD WBC-31.7* RBC-4.37* Hgb-13.4* Hct-38.7*
MCV-89 MCH-30.6 MCHC-34.6 RDW-19.7* Plt Ct-150
[**2187-1-1**] 02:55AM BLOOD PT-16.2* PTT-61.5* INR(PT)-1.5*
[**2187-1-1**] 12:46PM BLOOD Glucose-165* UreaN-74* Creat-3.8* Na-127*
K-5.2* Cl-90* HCO3-22 AnGap-20
[**2187-1-1**] 02:55AM BLOOD ALT-12 AST-17 AlkPhos-110 Amylase-81
TotBili-2.6*
[**2187-1-1**] 02:55AM BLOOD Lipase-56
[**2187-1-1**] 12:46PM BLOOD Calcium-8.7 Phos-6.1* Mg-2.7*
[**2187-1-1**] 12:49PM BLOOD Type-ART Temp-36.1 Rates-16/ Tidal V-700
PEEP-8 FiO2-80 pO2-97 pCO2-42 pH-7.36 calTCO2-25 Base XS--1
AADO2-451 REQ O2-75 -ASSIST/CON
.
Urine
[**2186-12-27**] 10:29AM URINE Color-Amber Appear-SlCldy Sp [**Last Name (un) **]-1.015
[**2186-12-27**] 10:29AM URINE Blood-SM Nitrite-NEG Protein-500
Glucose-TR Ketone-NEG Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG
[**2186-12-27**] 10:29AM URINE CastHy-4*
[**2186-12-29**] 11:46AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2186-12-29**] 11:46AM URINE Blood-LG Nitrite-POS Protein->300
Glucose-250 Ketone-15 Bilirub-SM Urobiln-2* pH-6.0 Leuks-LG
[**2186-12-29**] 11:46AM URINE RBC->50 WBC-21-50* Bacteri-MANY
Yeast-NONE Epi-0
[**2186-12-29**] 11:46AM URINE Hours-RANDOM Creat-91 Na-60 TotProt-2090
Prot/Cr-23.0*
.
Microbiology:
Blood cultures from [**12-27**], [**12-29**], [**12-30**], [**12-31**] no growth at time
of demise
Bronchial washings [**12-27**] no growth, cytology negative for
malignancy
Urine cultures 01/03, [**12-29**]: No growth
ASO: Positive at titer of 200-400
Respiratory virus screen: Negative
Leg ulcer wound culture [**12-29**]: GNR at time of death, ultimately
speciated to pseudomonas aeriginosa, pan sensitive
Sputum culture [**12-30**]: No growth at time of death, ultimately
grew acenetobacter baumanii, sensitive only to tobramycin and
imipenem.
Catheter tip culture [**12-31**]: No growth
.
Imaging
[**12-27**] CXR:
The ET tube tip is 2 cm above the carina. The NG tube
terminates in the
stomach. The right subclavian line tip terminates in the upper
SVC. The
heart size is mildly enlarged. There is severe calcification of
mitral
annulus. Bilateral pleural effusion is small. There is no
evidence of
congestive heart failure.
.
[**12-27**] head CT:
1) No acute intracranial hemorrhage or mass effect.
2) Bifrontal and biparietal subcortical white matter
hypodensities most likely relate to chronic micro-ischemic
disease, however, if there is high suspicion of acute stroke,
MRI would be more sensitive in further assessment.
3) Extensive sinus disease as above, with air-fluid levels in
the sphenoid sinuses and right maxillary sinus. This may relate
to intubation, however, acute infectious sinusitis must also be
considered, with the given history of "sepsis."
.
[**12-27**] CT Torso:
1. No evidence of bowel obstruction.
2. Markedly enlarged right atrium with enlargement of the IVC,
right common iliac vein, and right external iliac veins, likely
secondary to right-sided heart failure. There is calcification
within the
region of the right atrial appendage as well as along the right
lateral aspect of the SVC suggestive of thrombus.
3. Lymphadenopathy along with the right common iliac and
external iliac
chains which may be secondary to heart failure however,
infectious,
inflammatory, or neoplastic causes are also in the differential
and clinical correlation and correlation with patient's history
is recommended as well as comparison with outside CT scans.
4. Bilateral inguinal hernias.
5. Ascites, cirrhosis, splenomegaly consistent with portal
hypertension.
6. Cholelithiasis.
.
[**12-27**] Renal U/S:
Limited evaluation. No hydronephrosis.
.
[**12-28**] TTE:
The right atrium is markedly dilated. The estimated right atrial
pressure is >20 mmHg. Left ventricular wall thicknesses are
normal. The left ventricular cavity is unusually small. Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Left ventricular systolic function is
hyperdynamic (EF>75%). The right ventricular cavity is dilated.
Right ventricular systolic function appears depressed. The
aortic valve is not well seen. The mitral valve leaflets are
mildly thickened. A bioprosthetic tricuspid valve is present.
The gradients are higher than expected for this
type of prosthesis. There is no pericardial effusion.
Impression: mild tricuspid bioprosthetic stenosis with massively
enlarged right atrium; no definite mass seen in right atrium but
study technically suboptimal (Definity used as contrast [**Doctor Last Name 360**])
.
[**12-28**] LENIs:
Limited examination. Right mid and distal superficial femoral
vein not visualized. No deep venous thrombosis otherwise seen
within the
remaining veins of the lower extremities.
.
[**12-30**] RUQ U/S:
Cholelithiasis without overt evidence of acute cholecystitis on
this limited study.
.
[**12-31**] Torso and Lower Extremity CT:
1. Skin thickening of the right lower extremity approximately
10 cm cephalad to the knee joint, along the posteromedial aspect
of the distal femur, with associated subcutaneous edema, fluid
adjacent to the deep fascia and subcutaneous air, compatible
with necrotizing fasciitis.
2. Right heart failure.
3. Portal hypertension.
5. Cholelithiasis.
.
Brief Hospital Course:
55 yo M with h/o A fib/cardiomyopathy/chronic venous stasis
being treated for cellulitis of RLE who presented from OSH with
hemoptysis.
1) Hemoptysis: Bronchoscopy was performed which did not
demonstrate a local focus for bleeding. Continued to have bloody
secretions from ETT over the first 48 hours of stay, which
resolved and did not recur. Hct was stable. Most likely etiology
was continued lovenox use at OSH in the setting of worsening
renal failure and decreased renal clearance, combined with
overall volume overloaded state and CHF.
.
2) Sepsis: Arrived with leukocytosis, left-shift, hypotension on
double pressors. No evidence of pneumonia on CXR or UTI on
urinalysis. Most likely source on initial evaluation was from
chronic leg ulcers that had arisen from chronic venous stasis
changes. Differential diagnosis included sinusitis, seen on head
CT, and endocarditis, given h/o prosthetic TV. His BP was
maintained on levophed and vasopressin for MAP>60. Had initially
high cortisol with inadequate response to cosyntropin, and was
started on stress-dose steroids. His blood, sputum, and urine
were cultured, which yielded no initial results. Post-mortem,
sputum from [**12-31**] grew acenetobacter sensitive only to imipenem
and tobramicin. Surgery consulted due to concerns about leg
ulcers, and primary team was advised that there was no acute
need for surgical intervention, and recommended ACE bandage
wraps for severe venous stasis changes. Leg ulcer was sent for
culture that, after patient's death, grew pan-sensitive
pseudomonas. Due to continuing concern over legs as originating
site of sepsis, thigh CT was performed, which confirmed R thigh
fascial thickening and tissue stranding, with focal subcutaneous
emphysema and possible fluid tracking along deep fascia,
consistent with necrotizing fasciitis. Surgery was reconsulted,
who advised that the surgical procedure, should the family wish
to pursue this, was amputation of the right leg, which the
patient would be unlikely to survive given continued need for
hemodynamic support with pressors. Family meeting was held with
patient's mother and lawyer, who agreed to focus care on comfort
measures. Code status was changed to DNR/DNI, all invasive
measures were stopped, and the patient died at 8pm on [**1-1**].
Family and medical examiner were notified.
.
3) Acute renal failure: On presentation, Mr. [**Known lastname 98331**] was also in
severe oliguric acute renal failure which required hemodialysis.
A quinton catheter was placed for CVVHD. Initial BUN/Cr 105/4.9,
with K 6.0 and phos 10.9. CVVHD was done due to sepsis and
pressor requirement. Aluminum hydroxide was used for
hyperphosphatemia. SPEP, cryoglobulins, ANCA, [**Doctor First Name **] negative. ASO
did return positive at titer of 200-400, suggesting possible
diagnosis of post-streptococcal glomerulonephritis, with initial
strep infection originating with leg infection. Renal team
followed throughout stay. By day of patient's death, BUN/Cr was
74/3.8, with improving electrolytes. CVVHD was discontinued when
patient switched to comfort measures.
.
4) Possible IVC and RA thrombus: Initial torso CT suggested
chronic, calcified RAA and SVC thrombus. TTE showed no evidence
of thrombus, but was suboptimal study. LENIs negative for lower
extremity thrombus. Given initial presentation of hemoptysis, PE
was considered in ddx, though less likely given continued
anticoagulation at OSH for Afib. Due to renal failure, pt could
not had CTA done, and due to body habitus and concomittant
volume overload, V/Q scan would not be adequate. Was
prophylactically anticoagulated on heparin gtt during stay, with
no bleeding problems. Discontinued when patient switched to
comfort care.
.
Medications on Admission:
Bumex 1mg QD
Colace 200 [**Hospital1 **]
Senakot 2 tabs QHS
Coumadin 1mg QD
ASA 81 mg QD
Verapamil 240mg QD
Protonix
CaCO3
Lovenox
Calcitriol
Magnesium oxide 400 QD
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Sepsis, necrotizing fasciitis, leg ulcerations
Discharge Condition:
Deceased
Discharge Instructions:
None
Followup Instructions:
None
|
[
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icd9cm
|
[
[
[]
]
] |
[
"38.93",
"00.17",
"38.91",
"33.24",
"38.95",
"39.95",
"96.04",
"96.72"
] |
icd9pcs
|
[
[
[]
]
] |
14872, 14881
|
10897, 14627
|
278, 441
|
14971, 14981
|
3953, 3953
|
15034, 15041
|
3166, 3170
|
14843, 14849
|
14902, 14950
|
14653, 14820
|
15005, 15011
|
3185, 3934
|
228, 240
|
470, 2766
|
7860, 10874
|
3969, 7851
|
2788, 3038
|
3054, 3150
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
11,098
| 168,252
|
49073
|
Discharge summary
|
report
|
Admission Date: [**2174-1-11**] Discharge Date: [**2174-1-17**]
Date of Birth: [**2110-1-10**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Hydrocodone
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain with progressive kyphosis
Major Surgical or Invasive Procedure:
T3-S1 posterior fusion
L2 vertebrectomy
History of Present Illness:
Ms. [**Known lastname 1968**] is a 64 yo female who has undergone a previous
thoracolumbar fusion for scoliosis and kyphosis. Unfortunately,
she has fractured her instrumentation and is progressively
settling into more kyphosis. She presents for surgical
intervention.
Past Medical History:
gastric bypass
bilateral hip replacements
scoliosis fusion
chronic renal insufficiency
Social History:
Denies
Family History:
N/C
Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
Kyphosis at thoracolumbar junction
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles
Pertinent Results:
[**2174-1-17**] 01:00AM BLOOD WBC-5.0 RBC-3.25* Hgb-9.4* Hct-28.7*
MCV-88 MCH-28.9 MCHC-32.7 RDW-14.9 Plt Ct-99*
[**2174-1-16**] 10:10AM BLOOD WBC-5.1 RBC-3.16* Hgb-9.4* Hct-28.5*
MCV-90 MCH-29.8 MCHC-33.1 RDW-14.8 Plt Ct-89*
[**2174-1-16**] 07:50AM BLOOD WBC-5.0 RBC-3.14* Hgb-9.5* Hct-28.4*
MCV-90 MCH-30.2 MCHC-33.4 RDW-15.0 Plt Ct-84*
[**2174-1-15**] 06:44AM BLOOD WBC-4.7 RBC-2.87* Hgb-8.3* Hct-25.3*
MCV-88 MCH-28.8 MCHC-32.6 RDW-15.1 Plt Ct-108*
[**2174-1-14**] 10:03PM BLOOD WBC-4.2 RBC-3.21* Hgb-9.3* Hct-28.1*
MCV-88 MCH-28.9 MCHC-33.0 RDW-15.1 Plt Ct-83*
[**2174-1-17**] 01:00AM BLOOD Glucose-99 UreaN-17 Creat-1.2* Na-144
K-3.6 Cl-108 HCO3-28 AnGap-12
[**2174-1-16**] 07:50AM BLOOD Glucose-109* UreaN-17 Creat-1.2* Na-146*
K-3.8 Cl-109* HCO3-30 AnGap-11
[**2174-1-14**] 01:31PM BLOOD Glucose-180* UreaN-16 Creat-1.2* Na-144
K-3.9 Cl-112* HCO3-26 AnGap-10
[**2174-1-17**] 01:00AM BLOOD Calcium-8.1* Phos-2.6* Mg-1.8
[**2174-1-15**] 04:15AM BLOOD Calcium-7.7* Phos-2.8 Mg-1.8
Brief Hospital Course:
Ms. [**Known lastname 1968**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2173-1-11**] and taken to the Operating Room for an L2
vertebrectomy and L1-L3 fusion through an anterior approach.
Please refer to the dictated operative note for further details.
The surgery was without complication and the patient was
transferred to the PACU in a stable condition. TEDs/pnemoboots
were used for postoperative DVT prophylaxis. Intravenous
antibiotics were given per standard protocol. Initial postop
pain was controlled with a PCA. On HD#4 ([**2173-1-14**]) she returned
to the operating room for a scheduled T3-S1 decompression with
PSIF as part of a staged 2-part procedure. Please refer to the
dictated operative note for further details. The second surgery
was also without complication and the patient was transferred to
the PACU in a stable condition. Postoperative HCT was low and
she was transfused PRBCs. She was placed in the SICU for
neuromonitoring after her large blood loss. She was kept NPO
until bowel function returned then diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Foley will be left in place until it
can be discontinued at rehab. She was fitted with a TLSO brace
for out of bed. Physical therapy was consulted for mobilization
OOB to ambulate. Hospital course was otherwise unremarkable. On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
gabapentin
paroxitine
buproprion
diazepam
valium
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 weeks.
2. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Paroxetine HCl 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO BID (2 times a day).
5. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasms.
6. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
7. Oxycodone 5 mg Capsule Sig: [**12-18**] Capsules PO Q4H (every 4
hours) as needed for pain.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 86**] Center - [**Location (un) 2312**]
Discharge Diagnosis:
Kyphosis and failed instrumentation
Post-op blood loss anemia
Post-op fever
Discharge Condition:
Good
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
when you are walking. You may take it off when sitting in a
chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Activity: Out of bed w/ assist
TLSO for ambulation; may be out of bed to chair without.
Treatment Frequency:
Please continue to change the dressing daily with dry, sterile
gauze.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 363**] in 10 days. Call [**Telephone/Fax (1) **]
for an appointment.
Completed by:[**2174-1-17**]
|
[
"E878.1",
"403.90",
"780.62",
"738.5",
"300.4",
"285.1",
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"V43.64",
"737.19",
"V45.4",
"996.49",
"327.23",
"585.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.38",
"81.35",
"81.64",
"81.36",
"84.52",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
4771, 4854
|
2389, 3921
|
312, 353
|
4973, 4979
|
1379, 2366
|
7164, 7312
|
804, 809
|
4020, 4748
|
4875, 4952
|
3947, 3997
|
5003, 5109
|
824, 1360
|
6959, 7049
|
5145, 5338
|
237, 274
|
5374, 5829
|
5841, 6941
|
381, 653
|
7070, 7141
|
675, 763
|
779, 788
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,825
| 102,838
|
33749
|
Discharge summary
|
report
|
Admission Date: [**2187-2-21**] Discharge Date: [**2187-2-24**]
Date of Birth: [**2122-9-1**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
DOE
Major Surgical or Invasive Procedure:
MI MVRepair on [**2187-2-21**]
History of Present Illness:
DOE found to have severe mitral regirgitation, flail leaflet.
Past Medical History:
Ulcerative colitis
HTN
s/p c-section X2
s/p hand surgery
Social History:
married, lives w/husband
works as OR nurse
no tobacco or ETOH use
Family History:
non contributory
Physical Exam:
unremarkable pre-op
Pertinent Results:
[**2187-2-22**] 01:44AM BLOOD WBC-10.7# RBC-3.34* Hgb-11.1* Hct-32.2*
MCV-96 MCH-33.4* MCHC-34.7 RDW-15.0 Plt Ct-136*
[**2187-2-22**] 01:44AM BLOOD PT-12.4 PTT-30.8 INR(PT)-1.0
[**2187-2-22**] 01:44AM BLOOD Glucose-160* UreaN-10 Creat-0.6 Na-136
Cl-106 HCO3-24
LEFT ATRIUM: Dilated LA. No spontaneous echo contrast or
thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins
identified and enter the left atrium.
RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is
seen in the RA and extending into the RV. No ASD by 2D or color
Doppler.
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness and cavity
size. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Focal calcifications in aortic root. Simple atheroma in
ascending aorta. Simple atheroma in aortic arch. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS.
No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Partial
mitral leaflet flail. Mild mitral annular calcification.
Eccentric MR jet. Moderate to severe (3+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen.
Physiologic (normal) PR.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. The patient was under general anesthesia throughout
the procedure. No TEE related complications. The patient appears
to be in sinus rhythm. Results were personally reviewed with the
MD caring for the patient.
Conclusions
PRE CPB The left atrium is dilated. No spontaneous echo contrast
or thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
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 ascending aorta.
There are simple atheroma in the aortic arch. There are simple
atheroma in the descending thoracic aorta. 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 a flail P2 segment of
the posterior mitral leaflet, resulting in an eccentric,
anteriorly directed jet of moderate to severe (3+) mitral
regurgitation. Dr. [**Last Name (STitle) **] was notified in person of the results
in the operating room at the time of the study.
POST CPB Normal biventricular systolic function. A mitral valve
annuloplasty ring is seen in situ. It is well seated. The mitral
valve is status-post repair. No mitral regurgitation is seen.
The mean pressure across the mitral valve is 4 mm Hg. The mitral
valve area is about 2.2 cm2. No other changes from pre-CPB
study.
Brief Hospital Course:
Admitted day of surgery, taken to OR. Underwent minimally
invasive mitral valve repair (please see operative note for
details of procedure). Post-op she went to the ICU in stable
condition. She was noted to have had a small apical
pneumothorax. The pneumothorax remained unchanged with the tube
off suction, so it was removed on POD # 2. She progressed well
with ambulation, and has remained hemodynamically stable & is
ready for discharge to home on POD # 3.
Medications on Admission:
Atenolol 25"
Diovan 80"
HCTZ 25'
KCl 20'
Asacol 400"
Zantac 75"
Fosamax 35 weekly
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
5 days.
Disp:*5 Tablet(s)* Refills:*0*
2. 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*
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. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Three
(3) Tablet, Delayed Release (E.C.) PO BID (2 times a day).
Disp:*180 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 4 weeks: then may take prn .
Disp:*90 Tablet(s)* Refills:*1*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] homecare
Discharge Diagnosis:
Mitral regurgitation.
HTN
Ulcerative colitis.
Discharge Condition:
good
Discharge Instructions:
[**Month (only) 116**] shower, no creams, lotion or powders to any incisions.
Followup Instructions:
with Dr. [**First Name (STitle) 39190**] in [**2-4**] weeks
with Dr. [**Last Name (STitle) 8098**] in [**2-4**] weeks
with Dr. [**Last Name (STitle) **] in [**4-7**] weeks
Completed by:[**2187-2-24**]
|
[
"556.9",
"424.0",
"512.1",
"401.9",
"E878.8",
"733.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.12",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5486, 5542
|
3793, 4259
|
324, 357
|
5632, 5639
|
700, 3770
|
5766, 5969
|
627, 645
|
4391, 5463
|
5563, 5611
|
4285, 4368
|
5663, 5743
|
660, 681
|
281, 286
|
385, 448
|
470, 528
|
544, 611
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,324
| 168,481
|
29758
|
Discharge summary
|
report
|
Admission Date: [**2125-2-2**] Discharge Date: [**2125-2-4**]
Date of Birth: [**2044-1-6**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 458**]
Chief Complaint:
transfer from [**Hospital3 4107**] with STEMI
Major Surgical or Invasive Procedure:
cardiac cath on [**2125-2-2**]: bare metal stent placed in the RCA
History of Present Illness:
Mr. [**Name13 (STitle) **] iw a 81 yo gentleman with no known cardiac history
who was in his usual state of health until this morning when he
was walking briskly outside and began feeling 5/10 l-sided,
substernal chest pain. He ignored the pain because he thought
his heart was healthy and proceded to sit down with friends for
a cup of tea without any change in his symptoms. He endorsed
some associated nausea and diaphoresis but denied shortness of
breath. Later in the morning while he was standing up talking
with friends he began feeling lightheaded (no associated
palpitations), he sat down, and then slumped onto the ground. He
denied any LOC or hitting his head. His friends then called EMS
and he was taken to [**Hospital3 4107**].
At [**Hospital3 4107**] he was found to have and EKG with STE in
leads II, III, aVF, with ST depression in leads I, aVL, V1, and
V2. His vitals at that point were 138/90, HR 65, RR 16, 100% 2L
n/c. He was given aspirin, integrillin, morphine and SL NTG
which relieved his chest pain. He was then transferred to [**Hospital1 18**]
for urgent cardiac catheterization.
.
His cardiac cath showed
LMCA: no dz
LAD 70% after D2, 70-80% distal; large D2
LCX: mid 30%
RCA: 99% mid thrombus
.
Ballon inflation was complicated by bradycardia and hypotension
to 60-70 systolic; this reversed with atropine, dopamine, and
stent placement. He had a bare metal stent placed in the RCA
with slow flow that responded to TNG, nitroprusside, and
adenosine.
.
On the floor he is feeling well and is chest-pain free with no
SOB, nausea, or diaphoresis. His only complaint is recent
constipation.
.
Upon further questioning he thinks he has been having
intermittent chest pain for at least 1 month and possibly for
longer but has ignored it. He does not know if this is
exertional and does not recall any associated LH or SOB. He does
report an incident 1 month ago where he became light headed (no
chest pain) which prompted [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5871**] hospital ED visit where he
reportedly had a negative w/u; although he was started on
atenolol at this time.
.
Routinely he is very physically active and frequents Irish
dances with his wife and is able to "dance all night" without
getting SOB or fatigued.
Past Medical History:
?pituitary tumor? s/p surgery [**28**] yrs ago; is screened with q3 yr
MRIs
hypothyroid
GERD
s/p CCY
PFO s/p repair
Social History:
Irish, emmigrated to US in [**2058**]'s; retired electrician. smoked
20yrs 1.5ppd; quit 25 yrs ago. occasional EtOH
Family History:
son who had RCA thrombosis in 40's s/p stent
Physical Exam:
AF, BP 138/90, HR 65, RR 16, 100% 2L n/c
Gen: well-appearing elderly man, appears younger than stated age
Skin: pink, rosacea
CV: RRR no m/r/g, decreased heart sounds
Pulm: clear anteriorly (pt flat s/p cath)
Abd: s/nd/nt +BS, tympanic, no HSM
Extremities: cool feet, 1+ B dp pulses; no edema; +
onychomycosis
Pertinent Results:
[**2125-2-2**] CXR:
IMPRESSION: No evidence of congestive heart failure or pulmonary
edema. No pleural effusion.
.
[**2125-2-2**] CATH:
COMMENTS: 1. Selective coronary angiography of this right
dominant
system revealed multi-vessel disease. The LMCA had no
significant
disease. The LAD had a 70% mid-vessel lesion just after a large
D2 and
and a 70-80% distal lesion. The LCX had a mild 30% lesion mid
vessel.
The RCA had diffuse disease proximally and a 99% thrombotic
occlusion
mid vessel.
2. Resting hemodynamics at the end of the case revealed a normal
mean
PCPW of 12mmHg and a normal cardiac index of 3.2 l/min/m2.
3. Left ventriculography was not performed.
4. Successful PCI of a totally occluded RCA using overlapping
bare metal
stents (3.0x18mm mid - 3.5x24mm proximally).
.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Normal cardiac index and filling pressures.
3. Successful bare metal stenting of the proximal to mid RCA.
Brief Hospital Course:
A/P: 81 yo presenting with infero-posterior STEMI from acute RCA
thrombosis.
.
1) Cardiac:
#) Ischemia: Inferior/posterior STEMI resulting from acute RCA
thrombosis; s/p BMS. Also with evidence of significant LAD
disease.
- received Integrellin x 6 hrs
- ASA
- plavix for at least 1 month
- start statin
- peak CK 1778
- will start conservative beta-blockade
.
#) Pump: Unknown baseline. Pt not currently exhibiting signs of
L heart failure. EF >55 % on ECHO.
.
#) Rhythm: pt s/p bradycardia during PCI responsive to atropine
and dopamine. No further significant bradycardiac episodes even
during initiation of beta blockade.
- continue metoprolol
.
2) GERD: continue PPI
.
3) Hypothyroid: continue synthroid
4) PPX: PPI, SQ heparin.
.
4) Code: presumed full
Medications on Admission:
synthroid 88
atenolol
meclizine
ASA
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Toprol XL 25 mg Tablet Sustained Release 24HR Sig: One (1)
Tablet Sustained Release 24HR PO once a day.
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for
indigestion.
Disp:*120 Tablet, Chewable(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Inferior myocardial infarction s/p successful stenting of the
Right Coronary Artery
Discharge Condition:
Stable
Discharge Instructions:
Take all medications as prescribed.
Followup Instructions:
1. Call your PCP and arrange an appointment for within two weeks
of when you leave the hospital.
2. Call Dr.[**Name (NI) 71235**] (electrophysiologist/cardiologist) office
at: ([**Telephone/Fax (1) 5862**] to arrange the next available appointment.
3. Call Echocardiography at: ([**Telephone/Fax (1) 19380**] to arrange an
outpatient echocardiogram prior to be done several days before
your appointment with Dr. [**Last Name (STitle) **], above, if able.
|
[
"530.81",
"414.01",
"244.9",
"410.31",
"458.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"99.20",
"00.66",
"00.45",
"37.23",
"00.40",
"36.06"
] |
icd9pcs
|
[
[
[]
]
] |
6375, 6381
|
4388, 5150
|
357, 426
|
6509, 6518
|
3409, 4196
|
6602, 7062
|
3015, 3062
|
5237, 6352
|
6402, 6488
|
5176, 5214
|
4213, 4365
|
6542, 6579
|
3077, 3390
|
272, 319
|
454, 2725
|
2747, 2865
|
2881, 2999
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,897
| 150,531
|
30709
|
Discharge summary
|
report
|
Admission Date: [**2191-6-11**] Discharge Date: [**2191-7-14**]
Date of Birth: [**2142-1-2**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
[**2191-6-28**] Placement of Right Subclavian Tunnelled Dialysis Catheter
[**2191-6-23**] Placement of PICC Line, Left Upper Extremity
[**2191-6-20**] Mitral Valve Replacement utilizing a 33mm St. [**Male First Name (un) 923**]
Mechanical Valve
[**2191-6-17**] Cardiac Catheterization with Placement of Intra-aortic
balloon pump placement
[**2191-6-16**] Placement of a 14.5-French, 20-cm long, double-lumen
dialysis catheter via the right internal jugular vein.
[**2191-7-7**] teeth extraction
History of Present Illness:
This is a 49 year old male with history of severe mitral regurg
originally presented to OSH w/ 3 months of constitutional
symptoms including "leg heaviness" and 5 days of N/V/anorexia.
He was dx w/ mitral valve endocarditis, BCX growing Strep
viridans, and was treated w/ a dose of levofloxacin. Initial
labs demonstrated acute renal failure w/ hyperkalemia and HCT 18
requiring PRBC transfusion. He was concurrently diagnosed with
bladder outlet obstruction after foley catheter placement was
attempted and failed multiple times. This prompted his transfer
to [**Hospital1 18**] for further care including Urology consultation. ROS on
admission: Admits to dry cough and SOB X 1 day. He denies
headache, sinus tenderness, rhinorrhea or congestion. Denied
chest pain or tightness, palpitations. Denied diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No blood in his stool. No dysuria or blood in
his urine. Denied arthralgias or myalgias. No history of TB
exposure. Admits to HIV negative in the past.
Past Medical History:
MV Endocarditis with Mitral Regurgitation, Renal Failure,
Pulmonary Hypertension, Anemia
Social History:
Lifetime nonsmoker/drinker, no recreation drugs. He lives with
parents, and employed as a drywaller. Had to quit work in
[**Month (only) 404**] secondary to Leg heaviness. Has 2 children: 12 and 17.
Family History:
Parents and children healthy, 3 siblings , 1 brother died of
unknown cancer at 41 treated at [**Hospital1 **].
Physical Exam:
Admission:
Vitals: T: 95.3 P: 115 BP: 126/6 R: 29 SaO2: 100% on 4L
General: Awake, alert, appears anxious, shivering.
HEENT: NC/AT, PERRL, EOMI without nystagmus, ? scleral icterus
noted, dry MM, no lesions noted in OP
Neck: supple, no JVD appreciated
Pulmonary: Lungs CTA bilaterally anteriorly
Cardiac: RRR, III/VI systolic murmur in LLSB radiating to axilla
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: 2+ radial, DP and PT pulses b/l; bilat ankle edema
Lymphatics: No cervical, supraclavicular lymphadenopathy noted.
Skin: no rashes or lesions noted.
Neurologic:
-mental status: Alert, oriented x 3 but per nursing had to ask
in which hospital he was. Initially told me that he did not
have any medical problems (did not include severe MR).
-cranial nerves: II-XII intact
Discharge:
VS T 98.7 HR 61 SR BP 124/71 RR 18 O2sat 97% RA
Gen: NAD
Neuro: A&Ox3, nonfocal exam
Pulm: CTA-B
CV: RRR S1-S2 w/sharp click. Sternum stable, incision healing
well
Ext: warm, trace edema bilat. Rt side Quinton catheter, Lft PICC
line
Pertinent Results:
[**2191-6-11**] 01:55AM BLOOD WBC-17.6* RBC-2.70* Hgb-7.2* Hct-22.3*
MCV-83 MCH-26.5* MCHC-32.1 RDW-19.7* Plt Ct-275
[**2191-6-11**] 01:55AM BLOOD Neuts-94.2* Bands-0 Lymphs-4.4*
Monos-1.3* Eos-0 Baso-0.1
[**2191-6-11**] 01:55AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-OCCASIONAL Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL
[**2191-6-11**] 01:55AM BLOOD Glucose-138* UreaN-135* Creat-10.0*
Na-141 K-6.0* Cl-103 HCO3-12* AnGap-32*
[**2191-6-11**] 01:55AM BLOOD ALT-596* AST-511* LD(LDH)-494* CK(CPK)-79
AlkPhos-103 Amylase-127* TotBili-0.8
[**2191-6-11**] 01:55AM BLOOD Lipase-72*
[**2191-6-11**] 01:55AM BLOOD CK-MB-NotDone cTropnT-2.49*
[**2191-6-11**] 01:55AM BLOOD TotProt-7.6 Albumin-2.7* Globuln-4.9*
Calcium-8.3* Phos-9.6* Mg-2.4 Iron-PND
[**2191-6-11**] 03:02AM BLOOD Lactate-5.1* Na-140 K-5.8*
[**2191-7-14**] 06:50AM BLOOD Hct-29.0*
[**2191-7-12**] 05:54AM BLOOD WBC-5.5 RBC-3.58* Hgb-10.1* Hct-29.1*
MCV-81* MCH-28.1 MCHC-34.7 RDW-17.3* Plt Ct-333
[**2191-7-14**] 06:50AM BLOOD PT-26.5* PTT-45.6* INR(PT)-2.7*
[**2191-7-13**] 12:30PM BLOOD PT-25.5* PTT-53.7* INR(PT)-2.6*
[**2191-7-14**] 06:50AM BLOOD Glucose-74 UreaN-33* Creat-4.8* Na-140
K-4.0 Cl-102 HCO3-29 AnGap-13
[**2191-7-4**] 08:00AM BLOOD ALT-12 AST-20 LD(LDH)-302* AlkPhos-99
Amylase-235* TotBili-0.2
RADIOLOGY Final Report
CHEST (PA & LAT) [**2191-7-11**] 9:09 AM
CHEST (PA & LAT)
Reason: evaluate effusion
[**Hospital 93**] MEDICAL CONDITION:
49 year old man with s/p mVR, endocarditis
REASON FOR THIS EXAMINATION:
evaluate effusion
INDICATIONS: 49-year-old man with endocarditis status post
mitral valve repair. Evaluate effusion.
CHEST, PA AND LATERAL: Comparison is made to [**2191-7-5**]. A double
lumen right internal jugular venous catheter again terminates in
the superior vena cava. A left-sided PICC line is also
unchanged, terminating in the SVC. The patient is status post
sternotomy and mitral valve replacement. There is persistent
elevation of the left hemidiaphragm with a stable effusion and
atelectasis. There is no pneumothorax.
IMPRESSION:
Stable small left-sided pleural effusion and elevation of left
hemidiaphragm.
The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 72753**] Report ECHO Study Date of
[**2191-6-20**]
ECHO
PRELIMINARY REPORT
PATIENT/TEST INFORMATION:
Indication: Intra-op TEE for MVR
Height: (in) 75
Weight (lb): 200
BSA (m2): 2.20 m2
BP (mm Hg): 105/82
HR (bpm): 106
Status: Inpatient
Date/Time: [**2191-6-20**] at 09:17
Test: TEE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2007AW209-9:4
Test Location: Anesthesia West OR cardiac
Technical Quality: Adequate
REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) 1112**] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: *5.3 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 5.0 cm (nl <= 5.2 cm)
Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm)
Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: *8.0 cm (nl <= 5.6 cm)
Left Ventricle - Systolic Dimension: 6.5 cm
Left Ventricle - Fractional Shortening: *0.19 (nl >= 0.29)
Left Ventricle - Ejection Fraction: 35% (nl >=55%)
Aorta - Valve Level: 3.2 cm (nl <= 3.6 cm)
Aorta - Ascending: 2.5 cm (nl <= 3.4 cm)
Aorta - Arch: 2.0 cm (nl <= 3.0 cm)
Aorta - Descending Thoracic: 2.0 cm (nl <= 2.5 cm)
Aortic Valve - LVOT Diam: 2.5 cm
INTERPRETATION:
Findings:
LEFT ATRIUM: Moderate LA enlargement. No spontaneous echo
contrast in the body of the LA. No spontaneous echo contrast is
seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness. Severely dilated LV
cavity.
Moderately depressed LVEF. [Intrinsic LV systolic function
likely depressed given the severity of valvular regurgitation.]
RIGHT VENTRICLE: Mildly dilated RV cavity. Moderate global RV
free wall
hypokinesis. Abnormal systolic septal motion/position consistent
with RV
pressure overload.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta
diameter. Normal aortic arch diameter. Normal descending aorta
diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. No
AS. No AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS.
[**Name13 (STitle) 650**] (4+) MR.
TRICUSPID VALVE: Mild to moderate [[**1-25**]+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR.
PERICARDIUM: Trivial/physiologic pericardial effusion.
GENERAL COMMENTS: A TEE was performed in the location listed
above. I certify I was present in compliance with HCFA
regulations. No TEE related
complications. The patient was under general anesthesia
throughout the
procedure. The patient appears to be in sinus rhythm. Resting
tachycardia
for the
patient. Bilateral pleural effusions. See Conclusions for
post-bypass data The post-bypass study was performed while the
patient was receiving vasoactive infusions (see Conclusions for
listing of medications).
Conclusions:
PRE-BYPASS:
1. The left atrium is moderately dilated. No spontaneous echo
contrast is seen in the body of the left atrium. No spontaneous
echo contrast is seen in the left atrial appendage. No Flow
across the Interatrial septum is seen. A hypoechoic area is seen
in the IAS.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is moderately depressed.
3. The right ventricular cavity is mildly dilated. There is
moderate global right ventricular free wall hypokinesis. There
is abnormal systolic septal
motion/position consistent with right ventricular pressure
overload.
4. The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic regurgitation. 5. The
mitral valve leaflets are mildly thickened. Severe (4+) mitral
regurgitation is seen. Bileaflet flail is seen, with a
echogenicity consistent with subvalvular apparatus/vegetation
attached to the anterior leaflet.
6. There is a trivial/physiologic pericardial effusion.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including epinephrine,
norepinephrine and phenylephrine.
1. A well-seated mechanical bileaflet valve is seen in the
mitral position with normal leaflet motion and gradients.
Trivial (normal for prosthesis) mitral regurgitation is seen,
consistent with washing jets.
2. LV function is slightly improved, RV function is
moderate-severely
depressed. Systolic flattening of the septum is still seen.
3. No flow across the inter-atrial septum is detected.
4. Aorta is intact post decannulation
5. Other findings are unchanged.
[**Location (un) **] PHYSICIAN:
[**2191-7-11**] 06:25AM BLOOD Lipase-93*
Brief Hospital Course:
Mr. [**Known lastname **] was admitted with Strep viridans mitral valve
endocarditis, severe mitral regurgitation, cardiogenic shock,
acute renal failure, and severe anemia.
1)MITRAL VALVE ENDOCARDITIS: Initial blood cultures remained
positive for Streptococcus. Intravenous antibiotics(Vancomycin
and Ceftriaxone) were given per ID recommendations.
Echocardiogram was notable for partial anterior leaflet flail
with a highly mobile, large (1.8 x 0.8cm) echogenic "mass"
attached to the left atrial side of the anterior mitral leaflet
c/w a vegetation. A very small vegetation on the posterior
leaflet was also suggested. No abscess was seen and torn mitral
chordae were present. There was severe (4+) mitral
regurgitation. There was also moderate [2+] tricuspid
regurgitation. A Head CT scan and back MRI revealed no evidence
of septic emboli. He underwent cardiac catheterization which
revealed clean coronary arteries. Given markedly depressed right
ventricular function and severely depressed cardiac indeces, he
required placment of an IABP along with Dopamine for hemodynamic
support. He eventually underwent a mitral valve replacement on
[**6-20**]. Within 24 hours, he awoke neurologically intact and
was extubated. On postoperative day one, the IABP was weaned and
removed without complication. Inotropic support was weaned
without difficulty. From a cardaic standpoint, he maintained
stable hemodyanmics and remained in a normal sinus rhythm. He
remained on intravenous antibiotics per ID recommendations, and
a PICC line was eventually placed for long term antibiotics
until [**7-29**]. He remained afebrile.
2)ACUTE RENAL FAILURE: Followed closely by the renal service and
started on dialysis. Also followed by Urology for urinary
retention. Etiology of his renal failure was most likely from
septic emboli with immune mediated glomerulonephritis associated
with strep-viridans bacteremia, possible contribution from ATN
given relative hypotension at presentation. Unlikely to be
post-obstructive etiology given only 750cc urine drained after
supra-pubic tube placement. Given his urinary retention, he most
likely has an uretheral stricture or other bladder outlet
obstruction. Postoperatively, he remained dialysis dependent. A
tunnelled catheter was placed on [**6-28**] without complication.
His supra-pubic tube was eventually removed on [**7-1**]. Voiding
trial done.
3)ANEMIA: Diagnosed with normocytic anemia with no signs of iron
deficiency or hemolysis. Most likely from chronic inflammation
in setting of SBE, though HCT 18% on presentation was alarming.
MR L spine and skeletal survey to evaluate for malignancy were
negative. Started on Epogen and was transfused with packed red
blood cells to maintain hematocrit over 25%. Hematology/oncology
was consulted. Postoperatively, he remained anemic and continued
to require PRBC with hemodialysis.
4)HEPARIN INDUCED THROMBOCYTOPENIA: Diagnosed in the postop
period, initially required intravenous anticoagulation with
Argatroban. He was slowly transitioned to Warfarin. Warfarin was
dosed for a goal INR around 3.0.
Determined to require infected teeth extraction by Dr. [**Last Name (STitle) 2866**]
to be done this admission. Underwent this procedure on [**7-7**]
while coumadin held. Coumadin restarted while on argatroban and
cleared for discharge on [**7-14**]
Coumadin INR to be followed by Dr [**Last Name (STitle) 3003**]/[**Hospital3 **] Clinic. First
blood draw to be done [**7-16**]. Antibiotics via PICC line until [**7-29**].
Pt. is to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11382**] in the [**Hospital **] clinic.
Medications on Admission:
Aleve prn
Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 2 g/50 mL Piggyback Sig: Two
(2) gm Intravenous Q24H (every 24 hours): last dose 7/6.
Disp:*qs qs* Refills:*0*
2. PICC line
PICC line care per NEHT protocol
please remove after last dose 7/6
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
as needed.
Disp:*50 Tablet(s)* Refills:*0*
6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*2*
7. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
8. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*
9. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
11. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15)
ML Mucous membrane [**Hospital1 **] (2 times a day) for 1 weeks.
Disp:*210 ML(s)* Refills:*0*
12. Warfarin 5 mg Tablet Sig: as directed Tablet PO once a day:
take 10 mg [**7-14**] and [**7-15**] then as directed by Dr [**Last Name (STitle) 3003**].
Target INR 2.5-3.5.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Mitral Valve Endocarditis, Mitral Regurgitation - s/p MVR
Cardiogenic Shock
Acute Renal Failure
Pulmonary Hypertension
Anemia
Heparin-Induced Thrombocytopenia
infected teeth
Discharge Condition:
Stable
Discharge Instructions:
Patient should shower daily, no baths. No creams, lotions or
ointments to incisions. No driving for at least one month. No
lifting more than 10 lbs for at least 10 weeks from the date of
surgery. Monitor wounds for signs of infection. Please call
cardiac surgeon if start to experience fevers, sternal drainage
and/or wound erythema.
Target INR 2.5-3.5
Followup Instructions:
DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital **] CLINIC ([**Telephone/Fax (1) 457**]APPT [**2191-7-8**] @
11:00
DR. [**First Name4 (NamePattern1) 1112**] [**Last Name (NamePattern1) **], SURGEON IN [**4-28**] WEEKS - CALL FOR APPT
DR. [**Last Name (STitle) 72754**], CARDIOLOGIST - CALL FOR APPT
DR. [**Last Name (STitle) **], PRIMARY CARE PHYSICIAN [**Name Initial (PRE) **] [**Name10 (NameIs) **] FOR APPT [**Telephone/Fax (1) 14916**]
Completed by:[**2191-7-14**]
|
[
"424.0",
"428.20",
"428.0",
"E934.2",
"584.9",
"599.0",
"421.0",
"285.1",
"788.20",
"416.0",
"785.51",
"585.6",
"287.4",
"041.09",
"521.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.95",
"35.24",
"38.93",
"39.61",
"37.23",
"88.56",
"39.95",
"37.61",
"23.19"
] |
icd9pcs
|
[
[
[]
]
] |
15773, 15824
|
10442, 14093
|
300, 798
|
16041, 16050
|
3439, 4845
|
16452, 16959
|
2214, 2327
|
14153, 15750
|
4882, 4925
|
15845, 16020
|
14119, 14130
|
16074, 16429
|
5946, 10342
|
3156, 3420
|
2342, 2960
|
241, 262
|
4954, 5920
|
826, 1867
|
10376, 10419
|
2975, 3139
|
1889, 1980
|
1996, 2198
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,179
| 112,413
|
45581
|
Discharge summary
|
report
|
Admission Date: [**2165-8-26**] Discharge Date: [**2165-9-3**]
Date of Birth: [**2085-11-14**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Chest Pain, abnormal Stress
Major Surgical or Invasive Procedure:
[**2165-8-28**] Cardiac Cath
[**2165-8-29**] Intra-aortic balloon pump insertion
[**2165-8-29**] Coronary bypass grafting x 3 on intra-aortic balloon
pump, urgent, with left internal mammary artery left anterior
descending coronary; reverse saphenous vein single graft from
aorta to first diagonal coronary artery; reverse saphenous vein
single graft from aorta to posterior descending coronary artery
History of Present Illness:
79 year old male with history of Hypertension, Diabetes (on
insulin), Hyperlipidemia, reports acute Shortness of breath on
exertion while down on [**Hospital3 **]. He woke up the next morning
with tightness across the middle of his chest, without
radiation, that lasted minutes and then resolved. He denies a
history of angina or SOB but has noticed an increase in fatigue
and lower extremity edema. Mr.[**Known lastname **] went to his PCP, [**Name10 (NameIs) 1023**] did an
EKG and found normal sinus rhythm at 60 beats per minute,
prolonged PR interval of 248 consistent with first-degree AV
block, a right bundle-branch block and T-wave inversions
primarily in leads III, T-wave flattening in aVF, T-wave
inversions in V1 through V3 (not markedly changed from his prior
EKG in [**2164-2-7**]). He was referred to the ED. In the ED he
had 3 negative sets of CE, and was ordered for stress test given
his ECG. MIBI grossly abnormal= 4 [**Last Name (LF) 1364**], [**First Name3 (LF) **] depressions, 1mm ST
elevation, also had nuclear-- moderate reversible inferolateral
wall with an inappropriate BP drop. Patient was sent to cath lab
which revealed mutivessel coronary artery disease with
significant Left Main stenosis. Dr.[**Last Name (STitle) 914**] was consulted for
coronary revascularization.
Past Medical History:
Hypertension
Type 2 diabetes mellitus
Prostate cancer
Spinal stenosis for which he received steroid injections
Gout
Past Surgical History: s/p Left Knee
Social History:
-Tobacco history: Denies any tobacco use
-ETOH: Denies alcohol
-Illicit drugs: None
Family History:
Father who passed away from MI at 60, otherwise noncontributory.
Physical Exam:
Pulse:SB-53 Resp: 16 O2 sat: 94% R/A
B/P Right:147/61 Left:
Height: Weight:
General:A&Ox3
Skin: Dry [x] intact []
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM x[]
Chest: Lungs clear bilaterally [CTA]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
None [x]
Neuro: Grossly intact
Pulses:
Femoral Right: Left:
DP Right:2+ Left:2+
PT [**Name (NI) 167**]: Left:
Radial Right: Left:
Carotid Bruit :none Right: 2+ Left:2+
Pertinent Results:
[**2165-8-28**] Cardiac Cath: 1. Coronary angiography in this right
dominant system demonstrated three vessel disease. The LMCA was
calcified and had a 90% distal stenosis, which extended into the
LAD, resulting in a 80% proximal stenosis. The Ramus intermedius
had an 80% stenosis surrounded by aneurysmal dilatation. The LCx
had a 90% stenosis at its origin. The OM2 was occluded. The RCA
had a 70% distal stenosis. 2. Limited resting hemodynamics
revealed mild systemic hypertension with an SBP of 143 mmHg and
DBP 68 mmHg.
[**2165-8-29**] Echo: PRE-BYPASS: The left atrium is moderately dilated.
No spontaneous echo contrast is seen in the left atrial
appendage. 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%). Right ventricular
chamber size and free wall motion are normal. The descending
thoracic aorta is mildly dilated. There are three aortic valve
leaflets. The aortic valve leaflets (3) are mildly thickened. No
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no pericardial effusion. POST-BYPASS: For the post-bypass study,
the patient was receiving vasoactive infusions including
phenylephrine and was being A paced. 1. Biventricular function
is normal 2. Aortic contours appear intact post decannulation.
3. Other findings are unchanged
[**2165-8-29**] Carotid U/S: Right ICA stenosis <40%. Left ICA stenosis
<40%.
[**2165-9-3**] 03:04AM BLOOD WBC-6.7 RBC-3.15* Hgb-10.3* Hct-29.2*
MCV-93 MCH-32.6* MCHC-35.2* RDW-16.2* Plt Ct-165#
[**2165-8-26**] 03:50PM BLOOD WBC-5.3 RBC-3.53* Hgb-12.1* Hct-34.1*
MCV-97 MCH-34.2* MCHC-35.4* RDW-14.3 Plt Ct-155
[**2165-8-30**] 04:45AM BLOOD PT-13.4 PTT-29.2 INR(PT)-1.1
[**2165-8-26**] 03:50PM BLOOD PT-13.5* PTT-27.5 INR(PT)-1.2*
[**2165-9-3**] 03:04AM BLOOD Glucose-99 UreaN-41* Creat-1.7* Na-140
K-3.7 Cl-100 HCO3-30 AnGap-14
[**2165-8-26**] 03:50PM BLOOD Glucose-111* UreaN-32* Creat-1.5* Na-137
K-4.1 Cl-102 HCO3-24 AnGap-15
Brief Hospital Course:
On [**8-28**], during the night after his cardiac cath, Mr.[**Known lastname **]
developed recurrent chest pain and ECG changes:*- new ST
depressions in V2 - V4 which resolved when his chest pressure
was relieved with SL Nitro and morphine. He was transferred to
the CCU where he had an intra-aortic balloon pump placed as a
bridge to surgery. On [**2165-8-29**], he was taken urgently to the
operating room where he underwent coronary artery bypass graft x
3(Left internal Mammary artery grafted to Left anterior
Descending/Saphenous vein grafted to Ramus/Posterior Descending
Artery).Cross Clamp time= 51 minutes.Cardiopulmonary Bypass
Time= 70 minutes. Please see Dr[**Last Name (STitle) 5305**] operative report for
further details. Mr.[**Known lastname **] [**Last Name (Titles) 8337**] the procedure well and was
transferred in critical but stable condition to the CVICU. The
Intraortic balloon pump was removed on post-op day one. POD#2 he
was weaned from sedation, awoke neurologically intact and
extubated. Of note, his rhythm went into atrial fibrillation,
treated medically optimizing Beta-Blocker, and it converted to
sinus rhythm. All lines and drains were discontinued in a timely
fashion. Mr.[**Known lastname **] continued to progress and was transferred to
the telemetry floor for further care. Physical therapy
consulted and evaluated him for strength and mobility. The
remainder of his postoperative course was essentially
uneventful. He was cleared by Dr.[**Last Name (STitle) 914**] for discharge to rehab
on POD# 5, where he will have therapy to increase strength,
enduranance, and activities of daily living. All follow up
appointments were advised.
Medications on Admission:
Atenolol 50mg daily, Hydrochlorothiazide 12.5mg daily, Lantus
80-100 units daily, Humalog 30 units three times a day,
Lisinoprol 80mg daily, Flomax 0.4mg daily, Aspirin 81mg daily,
Multivitamin daily, Omego 3 fatty acids
Discharge Medications:
1. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
2. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours).
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for temp.
10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. Insulin Lispro 100 unit/mL Solution Sig: One (1)
Subcutaneous As directed.
12. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q6H
(every 6 hours) as needed for constipation.
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]
Discharge Diagnosis:
Coronary Artery Disease s/p Coronary Artery Bypass Graft x 3
Hypertension
Type 2 diabetes mellitus
Prostate cancer
Spinal stenosis for which he received steroid injections
Past Surgical History: s/p Left Knee
Discharge Condition:
Good
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks from date of
surgery.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
[**Hospital Ward Name 121**] 6 in 2 weeks for wound check
Dr. [**Last Name (STitle) 914**] in 4 weeks, [**Telephone/Fax (1) **], please call for an
appointment
Dr. [**First Name (STitle) 216**] in [**2-8**] weeks
Cardiologist in [**3-12**] weeks
Completed by:[**2165-9-3**]
|
[
"V10.46",
"V58.67",
"788.41",
"410.91",
"414.01",
"E878.2",
"426.52",
"403.10",
"427.31",
"600.01",
"278.00",
"724.00",
"285.9",
"250.00",
"274.9",
"585.9",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.56",
"39.61",
"36.15",
"37.22",
"36.12",
"37.61"
] |
icd9pcs
|
[
[
[]
]
] |
8439, 8523
|
5217, 6893
|
348, 751
|
8775, 8781
|
3086, 5194
|
9579, 9855
|
2380, 2447
|
7164, 8416
|
8544, 8716
|
6919, 7141
|
8805, 9556
|
8739, 8754
|
2462, 3067
|
281, 310
|
779, 2084
|
2106, 2222
|
2276, 2364
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,050
| 176,773
|
49277
|
Discharge summary
|
report
|
Admission Date: [**2122-2-28**] Discharge Date: [**2122-3-3**]
Service: Medicine
HISTORY OF PRESENT ILLNESS: The patient is an 81-year-old
man with a history of coronary artery disease, status post
coronary artery bypass graft in [**2102**], with an ejection
fraction of 20%, history of lower gastrointestinal bleed, now
with multiple episodes of bright red blood per rectum. Most
recently admitted in [**2121-9-21**] with a lower
gastrointestinal bleed. A colonoscopy at that time revealed
multiple nonbleeding diverticula. He was transfused 4 units
of packed red blood cells and treated with fresh frozen
plasma at that time. He has been doing well until 10 a.m. on
the morning of admission when he began to have loose bloody
bowel movements. He states that he had approximately one
bowel movement an hour since [**30**] a.m. In the emergency
department he had 300 cc of bloody bowel movements with
clots. He was otherwise without complaints. He denies chest
pain, dizziness, orthostasis or abdominal pain. The patient
has been taking Plavix and aspirin. He refuses NG lavage.
PAST MEDICAL HISTORY:
1. Coronary artery disease, status post coronary artery
bypass graft in [**2102**], status post myocardial infarction in
[**2119**], when he had a thrombus in saphenous vein graft to D1.
2. Prostate cancer.
3. History of gastrointestinal bleed in [**2113**] with
diverticulosis, also in [**2121-9-21**]. Colonoscopy in
[**2121-9-21**] showed multiple nonbleeding diverticula.
4. Congestive heart failure with an ejection fraction
of 25% in [**2120-5-21**] by echocardiogram.
5. Neural endocrine tumor, status post pancreatectomy and
splenectomy in [**2117**].
6. Status post hernia repair.
7. Status post cholecystectomy.
8. Hypertension.
9. Buerger's disease.
10. Cerebrovascular accident in [**2119**].
11. Diabetes mellitus.
MEDICATIONS ON ADMISSION: Aspirin 162 mg p.o. q.d.,
Plavix 75 mg p.o. q.d., Lopressor 25 mg p.o. b.i.d.,
digoxin 0.25 mg p.o. q.d., Lasix 40 mg p.o. four times a
week, Zocor 40 mg p.o. q.d., folate 1 mg p.o. q.d.,
vitamin B12 1 tablet p.o. q.d., Betoptic 1 drop both eyes
b.i.d., lisinopril 30 mg p.o. q.d., Glucovance 5/500.
ALLERGIES: RELAFEN which causes bleeding. PROCAINAMIDE.
SOCIAL HISTORY: The patient is a retired pharmacist. No
alcohol. No tobacco.
FAMILY HISTORY: Noncontributory.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.1, heart
rate 75, blood pressure 155/93, breathing comfortably on room
air. Generally, a pleasant man in no apparent distress.
HEENT revealed the patient had cataracts. Extraocular
muscles were intact. No icterus. No jugular venous
distention. Lungs revealed dry rales at the bases
bilaterally. Heart had a regular rate and rhythm, 2/6
systolic ejection murmur at the apex. Abdomen revealed
well-healed scars, hyperactive bowel sounds, nontender, and
distended. Extremities had no edema, 2+ dorsalis pedis
pulses and posterior tibialis pulses bilaterally.
Neurologically, alert and oriented times three. Strength was
[**4-25**] throughout. Rectal examination revealed bright red blood
per rectum.
LABORATORY ON ADMISSION: White blood cell count 15.7,
hematocrit 40 (which dropped to 35 in the emergency
department with hydration), platelets 290. Differential
revealed 69 neutrophils, 21 lymphocytes, 7 monocytes.
INR 1.1, PTT 27.9. Sodium 141, potassium 4, chloride 105,
bicarbonate 23, BUN 27, creatinine 0.9, glucose 87.
Electrocardiogram showed normal sinus rhythm at a rate of 70.
Normal axis. Q waves in V1 and V3. No change from
electrocardiogram on [**2121-10-12**].
ASSESSMENT: The patient is an 81-year-old male with
significant cardiac disease and recurrent gastrointestinal
bleeding, now with bright red blood per rectum.
HOSPITAL COURSE:
1. GASTROINTESTINAL: The patient was admitted to the
medical intensive care unit for close observation. The
patient had a tagged red blood cell scan which showed
evidence of bleeding in the sigmoid colon. The patient was
transfused 2 units of packed red blood cells to establish a
stable hematocrit of 38 to 39 until the day of discharge.
The patient was seen by interventional radiology for proposed
intervention to embolize the bleeding artery; however, the
patient's bleeding stopped spontaneously, and the patient
refused any further interventions.
The patient continued to have dark brown stools which were
extremely OB positive; however, his hematocrit remained
stable. He refused any further workup of this at this time
unless he became unstable. He was to have his blood drawn
two days post admission to be faxed over to Dr. [**Last Name (STitle) 12167**] who
was covering for his primary doctor, Dr. [**Last Name (STitle) **]. Also, he
will call Dr. [**Last Name (STitle) 1940**] who is his primary gastroenterologist
if there were any problems. The patient's cardiologist, Dr.
[**First Name8 (NamePattern2) **] [**Known lastname **], was also notified, and he agreed that at this
time it was prudent to withhold the patient's aspirin and
Plavix.
2. DIABETES MELLITUS: The patient's Glucophage was held
while in the hospital but will be restarted upon discharge.
DISCHARGE STATUS: To home.
CONDITION AT DISCHARGE: Good.
MEDICATIONS ON DISCHARGE:
1. Multivitamin 1 tablet p.o. q.d.
2. Vitamin B12.
3. Nitroglycerin 0.4 mg sublingual every five minutes
p.r.n.
4. Prilosec 20 mg p.o. b.i.d.
5. Betoptic 2.5% 1 drop both eyes b.i.d.
6. Lopressor 25 mg p.o. b.i.d.
7. Digoxin 0.25 mg p.o. q.d.
8. Lasix 40 mg p.o. four times a week.
9. Lisinopril 30 mg p.o. q.d.
10. Zocor 40 mg p.o. q.d.
11. Folate 1 mg p.o. q.d.
12. Glucovance 5/500 p.o. q.d.
FOLLOWUP: The patient should have his hematocrit and
hemoglobin drawn on [**2122-3-5**], and results faxed to
Dr. [**Last Name (STitle) 12167**]. The patient should have followup with Dr. [**Last Name (STitle) **]
and Dr. [**Last Name (STitle) 12167**] per his office, and follow up with
Dr. [**Last Name (STitle) 1940**] per his office, and Dr. [**Known lastname **] per his office.
DISCHARGE DIAGNOSES:
1. Lower gastrointestinal bleed, resolved spontaneously.
2. Diabetes mellitus.
3. Coronary artery disease.
[**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**]
Dictated By:[**Name8 (MD) 24585**]
MEDQUIST36
D: [**2122-3-3**] 16:38
T: [**2122-3-4**] 07:48
JOB#: [**Job Number 103285**]
cc:[**Known lastname 103286**]
|
[
"402.91",
"V10.46",
"562.12",
"V45.81",
"250.00",
"414.8",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2360, 2399
|
6117, 6554
|
5278, 6096
|
1901, 2261
|
3800, 5228
|
5244, 5251
|
120, 1102
|
3163, 3782
|
1125, 1874
|
2278, 2342
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
22,260
| 104,270
|
6164
|
Discharge summary
|
report
|
Admission Date: [**2193-12-15**] Discharge Date: [**2193-12-28**]
Date of Birth: [**2116-11-22**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamides) / Haldol
Attending:[**First Name3 (LF) 5438**]
Chief Complaint:
Acute renal failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 24071**] is a 77y.o. man who presents from [**Hospital 24072**] with acute renal failure. He was admitted there on
[**11-14**] after acute hospitalization for encephalopathy of unknown
origin, concern for NMS (though ruled out by neurology), and
failure to wean of mechanical ventilation. He had originally
presented at that time with agitation, disorientation and
admitted to psych. He received Haldol and developed "movements"
throughout his body. Subsequent course is unknown at this time.
His course over the last month at NE Specialty is also not
known.
However, over the last week he has developed renal failure.
According to lab results from rehab, his Cr was 2.7 on [**12-7**].3 on [**12-8**] on [**12-11**], and 3.3 today. BUN has been
consistently over 100. There is no notation of events,
treatments that occurred during this time. At rehab today, he
was started on dopamine at 2, but this was stopped on his
arrival to ED here. His BP at rehab today was also 80/48.
In the ED here, pt received treatment for his hyperkalemia with
CaGluc, Insulin, Bicarb, and kayexalate.
Past Medical History:
1. CAD: s/p IMI, s/p 3v CABG ('[**79**]), s/p cath in '[**92**] with LMCA
stent and POBA of LAD.
2. Cardiomyopathy, Ischemic: TTE in [**2-9**] showed EF 40%, 2+ MR.
3. HTN
4. Hypercholesterolemia
5. PVD: extensive with occl right SFA, LCI, LCF.
6. COPD with bullous emphysema
7. Chronic respiratory failure: recent vent settings were AC
500 x 14 O2 0.5 PEEP 5 with last ABG today of 7.26/43/57/85%.
8. Recent MRSA, stenotrophomonas, pseudomonas in sputum, ?
treated.
Social History:
Married. Now resides at rehab.
Former cigarette smoker (? amount).
No h/o EtOH abuse or IVDA.
Family History:
Unable to obtain.
Physical Exam:
VS>>
.
GEN>> turns head to voice but does not follow commands, tongue
writhing movements, in NAD
HEENT>> NCAT. Pupils 1mm equal and min reactive to light. OP
with thrush with MMM.
NECK>> Right subclavian site C/D/I. JVP not appreciated due to
pt's mouth movements.
Lungs>> coarse BS b/l but clear o/w
CV>> RRR, nml S1S2, m/r/g not appreciated due to loud BS
ABD>> PEG in place and site C/D/I. Soft, NT, ND, na BS.
EXT>> 3+ pitting edema of b/l UE. 1+ pitting edema of b/l LE.
+ sacral edema.
NEURO>> does not follow commands but orients to face (baseline
per NH).
..
Pertinent Results:
[**2193-12-15**] 07:51PM WBC-12.0* RBC-2.98*# HGB-9.2*# HCT-27.7*#
MCV-93
NEUTS-89* BANDS-2 LYMPHS-2* MONOS-4 EOS-0 BASOS-0 ATYPS-0
PLT COUNT-210
..
[**2193-12-15**] 07:51PM PT-13.5* PTT-26.4 INR(PT)-1.2
..
[**2193-12-15**] 07:51PM GLUCOSE-87 UREA N-158* CREAT-3.7*# SODIUM-135
POTASSIUM-6.8* CHLORIDE-99 TOTAL CO2-18* ANION GAP-18
..
[**2193-12-15**] 07:51PM CK(CPK)-134
[**2193-12-15**] 07:51PM cTropnT-0.14*
[**2193-12-15**] 07:51PM CK-MB-6
..
[**2193-12-15**] 07:51PM URINE COLOR-Amber APPEAR-Hazy SP [**Last Name (un) 155**]-1.015
BLOOD-LG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG
BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-MOD
RBC-[**10-27**]* WBC-[**5-17**]* BACTERIA-MOD YEAST-OCC EPI-0-2 TRANS
EPI-[**2-9**]
.
[**2193-12-15**] 07:51PM URINE UREA N-380 CREAT-114 SODIUM-18
POTASSIUM-24 CHLORIDE-30 TOT PROT-182 PROT/CREA-1.6*
..
[**2193-12-15**] 07:51PM CALCIUM-6.9* PHOSPHATE-12.8*# MAGNESIUM-2.5
..
..
CXR: mild instertial edema with confluent opacities in both
lung bases
..
ECG: Sinus brady at 45 bpm. IVCD (old). nml axis. diffuse
pseudonormalization of T waves. No acute ST changes.
.
MR C/T/L spine - IMPRESSION:
No abnormal enhancing lesions noted to suggest epidural abscess.
If symptoms persist, a followup MRI may be performed in one to
two weeks with a small field of view in the area of interest.
.
EMG -
IMPRESSION:
Abnormal study. There is electrophysiologic evidence for a
severe,
generalized, polyneuropathy which is predominantly axonal in
nature. In this clinical context, this finding is consistent
with a diagnosis of critical illness polyneuropathy. A
superimposed myopathic process, although difficult to exclude
with certainty, does not appear to be present.
.
EEG - Abnormal portable EEG due to the disorganized and slowed
background with occasional bursts of generalized slowing. These
findings indicate a moderate encephalopathy affecting both
cortical and
subcortical structures. Medications, metabolic disturbances, and
infection are among the most common causes. There was no
prominent
focal abnormality although encephalopathies may obscure focal
findings.
There were no epileptiform features
Brief Hospital Course:
77 y.o. man with h/o extensive CAD, ischemic cardiomyopathy,
PVD, ill-defined nervous system insult, now ventilator-dependent
presenting with acute renal failure that has been waxing and
[**Doctor Last Name 688**] 1 week prior to admission. Renal service was consulted
who belived that the pt likely was intravascularly dry but total
body overloaded. They recommended diuresing pt with lasix and
diuril, there was no improvement in renal function. Pt
underwent hemodialysis X 3 days with no improvement in mental
status. Neurology was also following who recommended several
studies including mri, emg, eeg. All tests were inconclusive
and pt likely had critical care neuropathy. His respiratory
status was not clear as to why pt was vent dependent. After
several days in the hospital and not much improvement in
clinical status family meeting was done, where the family
decided to change the code status to comfort measures only. He
was taken of the ventilator and expired few hours later.
Medications on Admission:
Depakote 500mg qhs
Heparin SC 5000U tid
Epogen 20000U SC weekly
Duoneb q6h
Prednisone 10mg daily
Colace 100mg [**Hospital1 **]
Norvasc 10mg daily
Labetalol 600mg [**Hospital1 **]
Valium 2.5mg qhs
Nitropaste 1 inch q6h
Nystatin
Zoloft 25mg daily
MVI
Iron sulfate 325mg [**Hospital1 **]
Ranitidine 150mg daily
Lasix 80mg IV x 1 on [**12-14**]
Dopamine gtt 2mcg/kg/min started [**12-14**]
SSRI
Discharge Medications:
none
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 **] Hospital - [**Location (un) 701**]
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
expired
Followup Instructions:
expired
Completed by:[**2194-1-6**]
|
[
"275.3",
"782.3",
"530.81",
"285.9",
"276.7",
"428.0",
"276.2",
"344.00",
"V45.81",
"272.0",
"348.30",
"414.8",
"401.9",
"599.0",
"296.80",
"492.0",
"443.9",
"V44.1",
"388.69",
"584.9",
"V44.0",
"518.83",
"V46.11",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"96.72",
"38.95",
"99.04",
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6383, 6461
|
4913, 5912
|
327, 333
|
6512, 6521
|
2729, 4890
|
6577, 6614
|
2100, 2119
|
6354, 6360
|
6482, 6491
|
5938, 6331
|
6545, 6554
|
2134, 2710
|
268, 289
|
361, 1476
|
1498, 1971
|
1987, 2084
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
69,169
| 143,710
|
42372
|
Discharge summary
|
report
|
Admission Date: [**2132-1-9**] Discharge Date: [**2132-1-26**]
Date of Birth: [**2090-1-15**] Sex: M
Service: MEDICINE
Allergies:
Heparin Agents
Attending:[**First Name3 (LF) 1363**]
Chief Complaint:
transfer from OSH for further oncologic workup
Major Surgical or Invasive Procedure:
resection of cerebellar lesion
peg tube placement
History of Present Illness:
42 y/o male with a 30+ pk year smoking history who was
transferred from [**Hospital6 3105**] and admitted to the
thoracic surgery service on [**2132-1-9**] for evaluation of a 3-4 cm
mass at the GE junction.
.
He first noted symptoms in late [**2131-11-6**] including
mid-epigastric pain, heartburn, dysphagia and weight loss. He
established care with a Gastroenterologist, Dr. [**Last Name (STitle) 21448**] affiliated
with [**Hospital6 3105**] (LGH) and was treated for H.
pylori. His symptoms however progressed and in [**Month (only) 1096**] he
started having nausea/vomiting initially only to solids and then
with liquids. The vomiting was essentially immediate upon
eating. During this time he also developed heavy sweats during
the day and night. He estimates he has lost 15-25
lbs over the last months. Due to severe pain and inability to
tolerate PO, he presented to the ED at LGH and was admitted for
dehydration and further work-up.
.
CT abd/pelvis [**2132-1-7**] revealed a 3.8 X 5.0 cm soft tissue mass at
GE junction as well as diffuse soft tissue deposits and adrenal
nodules. The following day, [**2132-1-8**] he underwent EGD and biopsy
of the mass from OSH reports low grade adenocarcinoma. He was
transferred to [**Hospital1 18**] on [**2132-1-9**].
Past Medical History:
PAST MEDICAL HISTORY:
- metastatic cancer, as above
- R knee arthroplasty ([**2122**])
Social History:
Born and raised in the area. Works as a bus driver for [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) **]. Lives with his girlfriend [**Name (NI) **]. [**Name2 (NI) **] children. Notes that
his HCP is his brother and the alternate is his sister-in-law;
believes he gave documentation to the primary team. + Tobacco
30 pk yrs, quit 6 weeks ago, + ETOH [**1-8**]
times/wk, no IVDA
Family History:
Father - Deceased from an MI in his 80s.
Mother - Deceased of unknown causes in her 60s, unexpected
death.
Brother - testicular cancer
Not aware of any other history of malignancy in his family.
Physical Exam:
Vitals - T 98.6 HR 90 BP 110/73 RR 18 O2 97%RA
GENERAL: NAD, well appearing
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: Patient with midline incision posterior occipital area
c/d/i, orpharynx wnl, multiple palpab lymph nodes that are hard
in the neck bilaterally, large supraclavicular nodule slightly
erythematous, indurated and nontender to the touch
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, G tube without erythmea
or surrounding excoriation
M/S: moving all extremities well, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, mild ptosis on L side no visual field
defects noted, finger to nose and heel to shin normal
bilaterally, no difficulty with rapid alternating movements,
strength 5/5 in upper and lower extremities, DTR's [**2-9**] in b/l
biceps, [**2-9**] b/l patellar, babinskis negative, no sensation
abnormalities detected, gait deffered
Pertinent Results:
ADMIT LABS:
[**2132-1-9**] 05:00PM BLOOD WBC-19.7* RBC-4.87 Hgb-14.5 Hct-43.3
MCV-89 MCH-29.8 MCHC-33.6 RDW-11.4 Plt Ct-270
[**2132-1-9**] 05:00PM BLOOD ALT-12 AST-12 AlkPhos-61 TotBili-0.7
[**2132-1-9**] 05:00PM BLOOD Triglyc-174*
[**2132-1-9**] 05:00PM BLOOD calTIBC-191* Ferritn-339 TRF-147*
.
IMAGING/STUDIES:
PET SCAN [**2132-1-11**]:
IMPRESSION: Remarkably extensive focal FDG-avid lesions,
predominantly in the musculature throughout the head, neck, and
torso, but note should be made of FDG-avid lesions in the brain,
bilateral adrenals, bone, and peritoneum. Differential diagnosis
includes melanoma, atypical lymphoma, and other aggressive
neoplastic disease. Extensive granulomatous disease may also be
considered. Biopsy of nodules or the esophagus would be helpful
for a more definitive diagnosis.
.
MRI HEAD W/O CONTRAST [**2132-1-13**]:
FINDINGS:
There is a hemorrhagic mass measuring 2.2 x 2.4 cm in the right
cerebellum with a small satellite nodule adjacent to it,
compatible with
metastatic disease. Another lesion is seen in the left inferior
cerebellum
measuring 8.3 mm. There is edema surrounding the lesion with
mass effect on the fourth ventricle which is partially effaced.
No hydrocephalus is present at this time supratentorially.
.
IMPRESSION:
Cerebellar metastatic lesions as detailed, with mass effect on
the fourth
ventricle which is partially effaced. No evidence for acute
hydrocephalus at this time.
.
R GLUTEAL BIOPSY PATHOLOGY:
Soft tissue, right gluteus, biopsy (A):
.
Poorly differentiated carcinoma, see note.
.
Note: The carcinoma is positive for cytokeratin cocktail, CK7,
and [**Last Name (un) **]-31. It is negative for CK20, TTF-1, PSA, PSAP and
S-100. Although this immunoprofile is non-specific, it is
compatible with tumors of upper gastrointestinal or
pancreatobiliary origin.
.
CXR [**2132-1-17**]:
IMPRESSION: Stable appearance of superior mediastinal mass, no
cardiac
enlargement, no pulmonary congestion, and no acute pulmonary
infiltrates on this preoperative chest examination
.
CEREBELLAR TUMOR BIOPSY:
. Specimen labeled "right cerebellar tumor" (including frozen
section and smear preparation" (A-B):
METASTATIC ADENOCARCINOMA, SEE NOTE.
2. Specimen labeled "right cerebellar tumor" (C-D):
METASTATIC ADENOCARCINOMA, SEE NOTE.
NOTE:
The sections show an adenocarcinoma composed of columnar cells
with hyperchromatic nuclei, prominent nucleoli and moderate
degree of nuclear pleomorphism arranged in villous to solid
architecture involving cerebellar parenchyma. Some of the cells
display intracellular mucin. By immunohistochemistry, the
lesional cells stain positively for Cam5.2, CK7, CK20 (focal)
and CDX2 (block C). PAS and PAS/D stains highlights
intracellular accumulation of glycogen in scattered cells.
Overall, the morphologic and immunohistochemical characteristics
are consistent with a metastatic adenocarcinoma of
gastrointestinal origin. Note is made of patient's history of
esophageal/gastric adenocarcinoma. Slides will be referred to GI
pathology for consultation and an addendum will be issues.
.
MRI HEAD [**2132-1-18**]:
IMPRESSION: Cerebellar metastatic lesions involving both
cerebellar
hemispheres, right greater than left side as described above,
unchanged from prior study. This study was performed for
surgical planning.
.
CT HEAD [**2132-1-18**]:
IMPRESSION: No evidence of large hemorrhage.
.
MRI HEAD W/O CONTRAST [**2132-1-19**]:
IMPRESSION: Since the previous study, patient has undergone
resection of
right-sided cerebellar lesion. Blood products and edema are
seen. No change in the mass effect on the fourth ventricle noted
or evidence of hydrocephalus seen. No acute infarct.
.
CXR [**2132-1-22**]:
PA and lateral upright chest radiographs were reviewed in
comparison to
[**2132-1-17**].
.
The right upper mediastinal stripe thickening is consistent with
known
lymphadenopathy as well as right hilar involvement. Heart size
is stable.
There is new opacity in the left mid lower lung, worrisome for
developing
infectious process in this location, most likely in the lingula.
The rest of the lungs are unchanged. There is no appreciable
right pleural effusion but small left pleural effusion is seen
and might reflect parapneumonic fluid.
.
TISSUE PATHOLOGY FROM GE JUNCTION MASS SENT FROM [**Hospital1 **] FOR REVIEW:
Gastroesophageal junction, biopsy (2 consult slides labeled
S12-43, procedure date [**2132-1-8**], [**Hospital6 3105**],
[**Hospital1 487**], MA): Adenocarcinoma, moderately differentiated, at
least intramucosal; no submucosal tissue present for evaluation.
.
BARIUM ESOPHAGRAM [**2132-1-25**]
Distal esophageal stricture with holdup of the passage of
contrast; however, this is patent to both thin and thick barium
with some delay, with the residual contrast cleared by drinking
water.
.
The patient could not manage the pharyngeal phase of swallowing
a tablet
therefore assessment of transition of a 13-mm tablet through the
stricture
could not be made.
.
DISCHARGE LABS:
[**2132-1-26**] 08:10AM BLOOD WBC-39.9* RBC-3.71* Hgb-11.9* Hct-34.2*
MCV-92 MCH-32.1* MCHC-34.8 RDW-13.7 Plt Ct-114*
[**2132-1-26**] 08:10AM BLOOD Glucose-99 UreaN-28* Creat-1.0 Na-130*
K-4.7 Cl-98 HCO3-25 AnGap-12
[**2132-1-26**] 08:10AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.3
Brief Hospital Course:
42 y/o male transferred from LGH for evaluation of a 3.8 x 5.0
cm mass at the GE junction, s/p OSH EGD and biopsy of the mass
with report of low grade adenocarcinoma, with diffusely
metastatic disease on PET including musculature, bones, lungs,
cardiac, adrenal as well as CNS metastases, now s/p posterior
craniotomy for resection R cerebellar mass, transferred to OMED
for consideration of XRT and/or chemotherapy for poorly
differentiated tumor of upper gastrointestinal origin.
.
BRIEF HISTORY PRIOR TO TRANSFER TO OMED:
42 y/o male with a 30+ pk year smoking history who was
transferred from [**Hospital6 3105**] and admitted to the
thoracic surgery service on [**2132-1-9**] for evaluation of a 3-4 cm
mass at the GE junction.
.
He first noted symptoms in late [**2131-11-6**] including
mid-epigastric pain, heartburn, dysphagia and weight loss. He
established care with a Gastroenterologist, Dr. [**Last Name (STitle) 21448**] affiliated
with [**Hospital6 3105**] (LGH) and was treated for H.
pylori. His symptoms however progressed and in [**Month (only) 1096**] he
started having nausea/vomiting initially only to solids and then
with liquids. The vomiting was essentially immediate upon
eating. During this time he also developed heavy sweats during
the day and night. He estimates he has lost 15-25 lbs over the
last months. Due to severe pain and inability to tolerate PO, he
presented to the ED at LGH and was admitted for dehydration and
further work-up.
.
CT abd/pelvis [**2132-1-7**] revealed a 3.8 X 5.0 cm soft tissue mass at
GE junction as well as diffuse soft tissue deposits and adrenal
nodules. The following day, [**2132-1-8**] he underwent EGD and biopsy
of the mass from OSH reports low grade adenocarcinoma. He was
transferred to [**Hospital1 18**] on [**2132-1-9**].
.
A PEG was placed [**2132-1-11**] due to ongoing inability to tolerate PO.
A PET CT on [**2132-1-11**] showed extensive, diffuse FDG-avid lesions,
predominantly in the musculature throughout the head, neck, and
torso but also in the bone and brain. Overall, he is felt to
have widely metastatic disease, including musculature, bones,
lungs, cardiac, adrenal as well as CNS metastases (notable for
partial effacement of the 4th ventricle). Patient had
ultrasound-guided right gluteal intra-muscular nodule biopsy on
[**2132-1-14**]. This returned as positive for metastatic
adenocarcinoma. On [**1-18**], pt underwent posterior craniotomy for
resection R cerebellar mass, as there was partial effacement of
the 4th ventricle with mass effect. He was extubated immediately
post-op. Radiation oncology was consulted for WBXRT or
Cyberknife as well.
.
Per discussion with neurosurgery, patient was cleared for
radiation to the brain as of POD 5 (currently POD #5) based on
results of post-op MRI and CT head. Patient had his
dexamethasone tapered down to 2mg [**Hospital1 **].
===========
#Esophageal v Gastric Cancer with known metastasis including to
the brain: History as above, patient had several biopsies
consistent with adenocarcinoma of gastric origin. Radiation
Oncology was consulted regarding treatment options, and will be
seeing the patient on an outpatient basis for further
evaluation. Patient also has been setup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**]
as well to be primary oncologist. While on the floor he was on a
clear liquid diet which was slowly advanced. He was able to
tolerate PO and take his pills, an esophogram study was
performed which did show backing up of contrast in the esophagus
but it was able to pass through. Patient was moved to soft
dysphagia diet and tolerated this well. In addition to this,
nutrition was consulted and patient was placed on 6 cans of
isosource per day through his PEG tube. Patient's biopsy results
from mass at LGH was requested and sent here for further review
to assist with onc treatment and planning.
.
#Brain Metastasis: S/p Cerebellar resection [**1-18**]. Repeat MRI/CT
did not show hydrocephalus, c/w with postop changes, no
hemorrhage. He was continued on decadron 2mg [**Hospital1 **]. He will follow
up with rad/onc as an outpatient. His cerebellar biopsy was
consistent with metastatic adenocarcinoma.
.
#Leukocytosis: Patient with WBC in the 40's on presentation to
OMED, trending upwards since admission. While he is on steroids,
he has been on a taper which is less likely causing this,
patient could also have stress response to recent surgery but is
still trending upwards. Afebrile, no respiratory symptoms, GU
symptoms. Patient had an infectious workup, no growth on blood
or urine cultures. CXR PA and lateral was obtained which did
show concern for L lingula infiltrate, but as the patient
clinically did not demonstrate signs of PNA we opted not to
start a course of antibiotics.
.
#Thrombocytopenia: Patient with downward trending platelets
since admission from 200's now to low 100's with eventual nadir
in low 100's. Patient was given heparin subq starting [**1-11**], which
was stopped prior to surgery on [**1-18**]. Concern for HIT, 4T score
is 5 which is intermediate risk. A HIT AB test was sent and was
positive, with and Optical Density of 2.606. Heparin was added
to his allergy list. Patient will be on fondoparinux for a total
of 3 weeks, d1=[**1-23**].
.
TRANSITIONAL ISSUES:
1) Follow up with Dr. [**Last Name (STitle) 1852**] and Rad/Onc for further chemo/tx
planning
2) Patient is full code, and very adamant about pursing therapy
Medications on Admission:
- Nicotine patch
- Protonix 40 mg PO bid
Discharge Medications:
1. fondaparinux 7.5 mg/0.6 mL Syringe Sig: One (1) Subcutaneous
DAILY (Daily): Start date was in hospital on [**1-23**].
Continue to take until last day [**2-13**].
Disp:*19 injections* Refills:*0*
2. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for Pain: can be crushed and put through peg
tube.
Disp:*60 Tablet(s)* Refills:*0*
4. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*25 Patch 72 hr(s)* Refills:*0*
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
Disp:*280 ml* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: Two (2) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*200 Tablet(s)* Refills:*0*
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*0*
8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
10. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
Disp:*56 Tablet(s)* Refills:*0*
11. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*56 Tablet(s)* Refills:*0*
12. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
Disp:*42 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
All Care VNA
Discharge Diagnosis:
Primary Diagnosis: Gastrointestinal Adenocarcinoma with
metastasis to teh brain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 31385**],
It was a pleasure taking care of you at [**Hospital1 18**]. After your
transfer from [**Hospital6 3105**] we were able to work up
your esophageal/stomach mass. The biopsy was shown to be a
cancer, with metastasis to your brain. You had a brain biopsy
and the biopsy was consistent with the cancer in your esophagus.
You tolerated the brain surgery well. A PEG tube was placed for
feeding and your diet was advanced to a soft mechanical diet
with thin liquids along with your tube feeds. You have follow up
scheduled below with Dr. [**Last Name (STitle) 1852**] and with the Rad/Onc team for
further evaluation and treatment.
MEDICATION CHANGES:
START Fondaparinux 7.5mg5 mg/0.6 mL Syringe take one syringe and
inject daily, last day is [**2132-2-13**]
START Acetaminophen (tylenol) 325mg tablet take 1-2 tablets
every 6 hours as needed for pain
START fentanyl patch 75mcg/hr, apply to the same spot that was
used during the hospitalization, change patch every 72 hours'
START Docusate 50mg/5ml take up to 100mg/10ml two times a day
for softening the stool
START hydromporphone (dilaudid) 2mg tablet take up to 2 tablets
every 3 hours as needed for pain
START Senna 8.6 mg take 1 tablet by mouth two times daily as
needed for constipation
START Bisacodyl 5mg tablet take one tablet up to two times daily
as needed for constipation
START dexamethasone 2mg tablet take one tablet by mouth every 12
hours
START Zofran 4mg tablet take one tablet every 8 hours as needed
for nausea
Be aware that you are being prescribed a narcotic medication
(hydromorphone). This medicaion may cause drowsiness, do not
operate machinery or drive while taking this medication. Also,
it may cause constipation, so be sure to use your stool softener
and laxative medications as needed.
We wish you all the best!
Followup Instructions:
You have a schedule appointment with Dr. [**Last Name (STitle) 3929**] in Radiation
Oncology:
Time: [**2-6**] at 1:30 P.M.
Location: [**Hospital1 69**] - [**Hospital Ward Name 516**],
[**Location (un) **], [**Hospital Ward Name 332**] Baseement
Phone: [**Telephone/Fax (1) 9710**]
Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2132-2-8**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 1368**]
|
[
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"198.5",
"285.22",
"348.5",
"197.0",
"786.8",
"338.3",
"263.9",
"431",
"289.84",
"198.89",
"280.9",
"150.4",
"305.1",
"530.3",
"787.91",
"198.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"01.59",
"43.11",
"86.11",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
16043, 16086
|
8785, 14068
|
321, 373
|
16210, 16210
|
3488, 8470
|
18214, 18917
|
2210, 2407
|
14340, 16020
|
16107, 16107
|
14274, 14317
|
16361, 17025
|
8486, 8762
|
2422, 3469
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14089, 14248
|
17045, 18191
|
235, 283
|
401, 1672
|
16126, 16189
|
16225, 16337
|
1716, 1782
|
1798, 2194
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,475
| 126,668
|
9889
|
Discharge summary
|
report
|
Admission Date: [**2156-3-29**] Discharge Date: [**2156-4-7**]
Date of Birth: [**2087-10-6**] Sex: F
Service: SURGERY
Allergies:
Penicillins / Amoxicillin
Attending:[**First Name3 (LF) 371**]
Chief Complaint:
mental status changes, hypercalcemia, small bowel obstruction
Major Surgical or Invasive Procedure:
exploratory laparotomy with lysis of adhesions
History of Present Illness:
68yF transferred from [**Hospital 1474**] Hospital after being found to
have slurred speech and confusion over past three days. At OSH,
patient found to be in respiratory failure, intubated. Ca++ 14
at OSH, INR 7. KUB demonstrated moderately dilated small bowel.
NGT placed with 2000cc black tarry fluid expressed.
Past Medical History:
-CAD s/p CABG x 2
-PVD s/p fem-[**Doctor Last Name **] bypass [**2145**]
-CVA
Social History:
-+tobacco 1ppd
-no EtOH
-Lives with husband
Family History:
NK
Physical Exam:
Gen elderly, thin, NAD
Heent perrl, eomi, nares patent, oropharynx without
erythema/exudate
Neck supple no masses
CV rrr, no m/r/g
Resp CTA bilaterally
Abd soft NTND with midline incision intact small opening
draining serosang fluid
Ext no LE edema
Neuro answers appropriately, aao x 3
Pertinent Results:
[**2156-4-6**] 04:03AM BLOOD WBC-12.6* RBC-2.64* Hgb-8.4* Hct-24.9*
MCV-94 MCH-32.0 MCHC-34.0 RDW-14.4 Plt Ct-160
[**2156-4-5**] 03:28AM BLOOD WBC-12.3* RBC-2.75* Hgb-8.9* Hct-25.9*
MCV-94 MCH-32.2* MCHC-34.2 RDW-13.7 Plt Ct-166
[**2156-4-4**] 01:12PM BLOOD WBC-11.1* RBC-2.93* Hgb-9.7* Hct-27.8*
MCV-95 MCH-33.3* MCHC-35.0 RDW-13.7 Plt Ct-154
[**2156-4-6**] 04:03AM BLOOD Plt Ct-160
[**2156-4-6**] 04:03AM BLOOD PT-14.3* PTT-63.9* INR(PT)-1.3*
[**2156-4-5**] 03:28AM BLOOD Plt Ct-166
[**2156-4-6**] 04:03AM BLOOD Glucose-86 UreaN-13 Creat-0.6 Na-137
K-3.7 Cl-109* HCO3-21* AnGap-11
[**2156-4-5**] 01:04PM BLOOD Glucose-136* UreaN-13 Creat-0.6 Na-136
K-3.4 Cl-107 HCO3-16* AnGap-16
[**2156-4-4**] 07:15AM BLOOD Glucose-97 UreaN-10 Creat-0.7 Na-140
K-3.2* Cl-108 HCO3-21* AnGap-14
[**2156-4-6**] 04:03AM BLOOD Calcium-7.4* Phos-2.3* Mg-2.3
[**2156-4-5**] 01:04PM BLOOD Calcium-7.5* Phos-2.0* Mg-1.6
[**2156-4-4**] 07:15AM BLOOD Albumin-2.8* Calcium-7.8* Phos-2.1*
Mg-1.6
[**2156-3-30**] 10:37AM BLOOD Calcium-11.1* Phos-0.7* Mg-2.2
[**2156-3-29**] 04:46PM BLOOD Calcium-10.4* Phos-1.1* Mg-2.0
[**2156-3-29**] 12:45PM BLOOD TotProt-4.6* Calcium-11.3* Phos-2.3*
Mg-1.5*
[**2156-3-29**] 08:00AM BLOOD Albumin-2.7* Calcium-12.9* Phos-2.8
Mg-1.5* Iron-34
[**2156-3-29**] 04:15AM BLOOD Albumin-3.8 Calcium-16.6* Phos-3.0 Mg-1.7
[**2156-3-31**] 02:25AM BLOOD TSH-0.99
Brief Hospital Course:
Patient admitted to the medical service intubated. She was
started on broad spectrum antibiotics and stabilized with fluid
resuscitation and supportive care. A general surgery and
endocrinology consult were obtained for her hypercalcemia and
presumed SBO, respectively. She was taken to the operating room
for an exlap with lysis of adhesions and was transferred
intubated to the PACU. She was transferred to the surgical ICU
and cardiology was consulted postoperatively due to prolonged QT
interval and T wave inversions noted on her postop EKG. Her
cardiac enzymes were negative for ischemia and she was stable
overnight. She was maintained on parenteral nutrition
immediately postop. She was extubated POD2 and remained afebrile
and stable. She continued to be followed by endocrinology and
her hypercalcemia slowly resolved with iv fluids and pamidronate
treatment. POD4 she regained bowel function and was started on a
liquid diet which she tolerated. She continued to do well and
was restarted on her home medications and transferred to the
floor. Her diet was advanced to a regular low residue diet. She
did have an episode of emesis on POD5, however, and an NGT was
placed revealing a large amount of gastric output. She remained
NPO with an NGT placed for approximately 2 days where she
tolerated an NGT clamping trial and her NGT was d/c'ed without
complication. Her diet was again advanced which she tolerated
without difficulty. Endocrinology requested a torso CT scan to
r/o malignancy as a cause of the patient's hypercalcemia which
was negative. At the time of discharge, no clear cause of the
patient's initial hypercalcemia was found. She continued to do
well. Her abdominal wound was opened on POD8 revealing brown
sanguinous fluid which was lightly packed. She remained afebrile
and was discharged on POD9 in good condition to rehab.
Endocrinology recommended treatment with Ca++ and vit D upon
discharge. She was instructed to follow up with Dr. [**Last Name (STitle) **].
Medications on Admission:
calcium 600'', asa 81', calcitonin 200IU', coumadin [**3-20**]',
atenolol 50'', difluoxetine 4', oxycodone 40', namenda 5''
Discharge Medications:
1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Memantine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Trazodone 50 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
Disp:*90 Tablet(s)* Refills:*2*
6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*30 Tablet(s)* Refills:*2*
8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
Disp:*60 Tablet, Chewable(s)* Refills:*2*
9. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
hypercalcemia
small bowel obstruction
Discharge Condition:
good
Discharge Instructions:
-please come to the emergency room if you have fever >101.4F,
nausea or vomiting, persistent redness or oozing from your
surgical incision, dizziness or weakness or shortness of breath.
-no lifting anything heavier than a telephone book for three
weeks
-you may shower normally but no tub bathing or swimming for six
weeks
-do not drive while taking pain medications
-keep your incision clean and dry, the bandage strips on your
abdominal wound will fall off on their own, do not remove them
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**2-20**] weeks. Call
[**Telephone/Fax (1) 1864**] for an appointment.
Please make an appointment with the dermatology clinic for your
abdominal lesion. Call [**Telephone/Fax (1) 1971**] for an appointment.
|
[
"518.81",
"560.1",
"426.82",
"276.3",
"V49.84",
"577.0",
"V45.81",
"486",
"275.42",
"V58.61",
"560.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15",
"99.07",
"96.04",
"96.08",
"54.59",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
6209, 6281
|
2626, 4620
|
345, 394
|
6363, 6370
|
1242, 2603
|
6910, 7177
|
917, 921
|
4794, 6186
|
6302, 6342
|
4646, 4771
|
6394, 6887
|
936, 1223
|
244, 307
|
422, 738
|
760, 840
|
856, 901
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
72,660
| 102,713
|
41417
|
Discharge summary
|
report
|
Admission Date: [**2188-3-10**] Discharge Date: [**2188-3-10**]
Date of Birth: [**2167-1-5**] Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending:[**First Name3 (LF) 3556**]
Chief Complaint:
Illicit drug overdose
Major Surgical or Invasive Procedure:
Left and right anterior tibial IO line placement, intubation
History of Present Illness:
21 year old man with a history of drug abuse who apparently
ingested approximately 300mg of what he thought was ecstacy and
was later found to be wandering around shoeless in a local
neightborhood, diaphoretic. He was brought in by ambulance and
only hx he gave was that he was taking suboxone at home and that
his name was [**Male First Name (un) **].
Past Medical History:
Patient did not give background or identifying information.
Social History:
Tox screen + for benzos, barbituates, cocaine, and amphetamines
Otherwise unknown, patient did not disclose.
Family History:
Patient did not disclose.
Physical Exam:
On ICU admission:
Vitals: T:97.5 BP:146/73 P:98 R:10 100% on 500 x 16 PEEP 5 fio2
100%
General: woke up mildly on transfer
HEENT: Sclera anicteric, MMM, pupils equal and reactive
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally anteriorly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +bs, soft, non-tender, non-distended, no rebound
tenderness or guarding
GU: foley
Ext: warm, dry, well perfused, 2+ pulses, no clubbing, cyanosis
or edema
On Discharge:
Vitals T: 98.4 BP 112/46 P: 93 RR:16 Sat 100% on RA
Gen: relaxed in bed, conversant
HEENT: Sclera anicteric, MMM, pupils equal and reactive
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally anteriorly
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: +bs, soft, non-tender, non-distended, no rebound
tenderness or guarding
GU: no foley
Ext: warm, dry, well perfused, 2+ pulses, no clubbing, cyanosis
or edema
Pertinent Results:
On Admission:
[**2188-3-9**] 11:20PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-POS amphetmn-POS mthdone-NEG
[**2188-3-9**] 09:17PM GLUCOSE-100 UREA N-16 CREAT-1.4* SODIUM-143
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-26 ANION GAP-20
[**2188-3-9**] 09:17PM ALT(SGPT)-24 AST(SGOT)-29 LD(LDH)-307*
CK(CPK)-253 ALK PHOS-94 TOT BILI-0.4
[**2188-3-9**] 09:17PM LIPASE-14
[**2188-3-9**] 09:17PM ALBUMIN-5.4* CALCIUM-10.6* PHOSPHATE-4.0
MAGNESIUM-2.0
[**2188-3-9**] 09:17PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-3-9**] 09:17PM WBC-12.8* RBC-5.48 HGB-14.7 HCT-43.5 MCV-79*
MCH-26.9* MCHC-33.9 RDW-12.9
[**2188-3-9**] 09:17PM NEUTS-78.7* LYMPHS-16.9* MONOS-3.4 EOS-0.4
BASOS-0.6
[**2188-3-9**] 09:17PM PT-11.7 PTT-20.5* INR(PT)-1.0
On Discharge:
[**2188-3-10**] 06:48AM GLUCOSE-82 UREA N-15 CREAT-0.8 SODIUM-142
POTASSIUM-4.0 CHLORIDE-111* TOTAL CO2-24 ANION GAP-11
[**2188-3-10**] 06:48AM CALCIUM-7.5* PHOSPHATE-3.5 MAGNESIUM-1.9
[**2188-3-10**] 06:48AM CK(CPK)-1479*
Imaging:
CT HEAD W/O CONTRAST Study Date of [**2188-3-10**] 12:05 AM
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass
effect, or
infarction. The [**Doctor Last Name 352**]-white matter differentiation is preserved,
and the
ventricles and sulci are normal in configuration. No fracture is
seen. The
middle ear cavities, mastoid air cells and included views of the
paranasal
sinuses are clear.
IMPRESSION: Normal study.
CHEST (PORTABLE AP) Study Date of [**2188-3-10**] 12:05 AM
FINDINGS: In comparison with the study of [**3-9**], the tip of the
endotracheal
tube lies approximately 4.6 cm above the carina. The nasogastric
tube loops in the upper stomach, then extends to the distal
stomach.
There is mild indistinctness of pulmonary vessels, raising the
possibility of some overhydration. No acute focal pneumonia.
Brief Hospital Course:
Vitals on arrival to the ED were 100.8 HR 150 153/112 RR16 98%
RA. He received ativan 4mg IV after 1 IVs were placed. He then
pulled out the 2 IVs. He then received ativan 10mg IM. A right
IO was attempted but was not in properly and a left IO was
placed. In the emergency room was very agitated, altered, and
diaphoretic. His exam was notable for mydriasis, tachycardia,
hyperthermia and hyperreflexia with lower extremity clonus. He
was intubated in the emergency room for airway protection.
Etomidate 30mg IV, succinylcholine 150mg IV, and propofol gtt
were given through IO. ET was initiall high and then replaced.
Then 2 peripheral 18 gauge IVs were placed. He was later given
vecuronium 10mg IV x1 because he was biting on the tube. His
sweatiness improved. CT head non contrast was done to look for
cerebral edema and was negative for an acute intracranial
process. Labs were notable for WBC 12.8 with 78% neutraphils.
Lactate of 3.2 (got 4L IVF). UA was neg. ARF with creatinine of
1.4 (made good urine). Urine tox + for benzos, barbituates,
cocaine, and amphetamines. Neg for opiates. Toxicology was
consulted, who felt that this was a sympathomimetic and
serotonergic toxidrome with likely co-ingestion of LSD and
ecstasy, possibly along with other amphetamines. EKG showed
sinus tachycardia. Tmax in ED 101.4. Vitals prior to transfer
were T98.3 101 133/70 12 100% on 500 x 16 PEEP 5 fio2 100%. ABG
was 7.35/74/455.
Patient was transferred to ICU and remained stable overnight. He
was extubated the following morning without event. His CK
trended up to a peak of 1789. He was observed over the course of
that day. He requested to be discharged as soon as possible and
refused to provide identifying information or family contacts.
Psychiatry was consulted to evaluate his safety for discharge
and felt he was not suicidal. The patient was felt to have full
decision making capacity. Outpatient psychiatric follow-up was
arranged and the patient was discharged following a re-check of
his serum CK. He was volume resuscitated with approximately 7L
of IV fluids.
Medications on Admission:
Patient refused to provide identifying information.
Discharge Medications:
No changes to patients medications
Discharge Disposition:
Home
Discharge Diagnosis:
Polysubstance Overdose
Sympathomimetic and Serotonergic Toxidrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital after overdosing on multiple
drugs including ecstasy, LSD, and amphetamines. A breathing
tube had to be placed in the Emergency Department, and you were
admitted to the Intensive Care Unit. A special line similar to
an IV also had to be placed into the bone of your left leg. The
breathing tube was removed the next day. Imaging of your head
did not show any evidence of trauma or bleeding in the brain.
Your continued abuse of drugs is extremely dangerous and could
easily result in death or permanent injury. You should seek
help with your drug abuse problem, and many resources are
available for this.
None of your home medications were changed during your stay.
You should continue taking them as previously prescribed.
You should follow up with your Primary Care Provider within one
week of discharge. Please call to schedule an appointment.
Followup Instructions:
You should follow up with your PCP within one week of discharge.
Please call to schedule an appointment as soon as possible.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]
Completed by:[**2188-3-11**]
|
[
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icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6128, 6134
|
3888, 5967
|
307, 369
|
6244, 6244
|
1992, 1992
|
7310, 7596
|
977, 1004
|
6069, 6105
|
6155, 6223
|
5993, 6046
|
6395, 7287
|
1019, 1507
|
2797, 3865
|
246, 269
|
397, 751
|
2007, 2782
|
6259, 6371
|
773, 834
|
850, 961
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
40,775
| 132,572
|
9182
|
Discharge summary
|
report
|
Admission Date: [**2184-9-9**] Discharge Date: [**2184-9-15**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
arterial line
Pacemaker Placement
History of Present Illness:
Mrs. [**Known lastname **] is a 88yo F with history of follicular lymphoma
(treated by Dr. [**First Name (STitle) **], atrial fibrillation, aortic stenosis and
history of CVA in [**2179**] who started cycle 4 of of R-CVP chemo
yesterday. This was uneventful and she denied fevers, chills,
sweats, diarrhea and emesis. She developed shortness of breath
and substernal chest pressure this morning after awakening and
having a bowel movement at 4:30am. The chest pain did not
radiate to the neck/arms/back, not pleuritic, no
nausea/vomiting/diarrhea or epigastric pain. She did not cough
or have a fever and denies any sick contacts. There was no
unilateral leg swelling or pain. By the time EMS arrived, she
reported resolution of her symptoms except continued weakness.
.
In the ED, initial vs were: 98.4, 80, 127/55, 16, 98% 2L.
Patient was given a full dose of aspirin and later developed
hypotension to SBP 80s, but developed no new symptoms. She
received 1500 cc of IVF through two large bore peripheral IVs
and was placed on neo for pressure support. She had a CXR which
showed persistent small right pleural effusion with right lower
lobe atelectasis and mediastinal lymphadenopathy. CTA did not
show any evidence of pulmonary embolism. Initial EKG was sinus
and unremarkable but a second EKG in setting of hypotension
showed atrial flutter/fibrillation with a stable rate. No ST
changes. At time of transfer, vitals were 75, 110/50 at 0.8
mcg/kg/min, 100% on RA. The patient is DNR/DNI.
.
On the floor, the pt was placed on a heart monitor which showed
pauses. The patient's eyes rolled back and her eyelids sagged
during the pauses. The family reports that they have seen pauses
before when using the patient's home BP cuff.
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:
[**Hospital Unit Name 153**] Admission Exam
Vitals: T: 98.7 BP: 131/45 P: 74 R: 18 O2: 100% on 2L NC
General: Alert, oriented, anxious, but in no acute distress.
kyphotic.
HEENT: PERLA, Sclera anicteric, oropharynx clear
Neck: supple, JVP not elevated, no cervical LAD
Lungs: nearly absent breath sounds bilaterally in the rear, but
up to a higher level on the right.
CV: Irregular rate, normal S1 + S2, with a mid systolic murmur
[**2-14**], not late peaking, no paradoxical splitting.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no cyanosis or pedal edema
Discharge Exam
Vitals: Tm 97.3, Tc96.8, 110s-130s/60s-70s, 60s-100s, 24, 98/RA
General: Portuguese speaking elderly female who is currently
alert and oriented times 3 and in NAD.
HEENT: PERRLA, sclera anicteric, oropharynx clear
Neck: supple
Lungs: Decreased breath sounds on the right, otherwise clear to
auscultation bilaterally.
Chest: Hematoma soft, superficial tracking across chest.
CV: Irregular rate, normal S1 + S2, with a [**2-14**] mid systolic late
peaking murmur
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, no cyanosis or pedal edema
Pertinent Results:
ADMISSION LABS
[**2184-9-9**] 05:23PM LACTATE-1.3
[**2184-9-9**] 05:16PM CK(CPK)-22*
[**2184-9-9**] 05:16PM CK-MB-2 cTropnT-<0.01
[**2184-9-9**] 10:25AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011
[**2184-9-9**] 10:25AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2184-9-9**] 08:00AM GLUCOSE-102* UREA N-25* CREAT-1.0 SODIUM-142
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-27 ANION GAP-13
[**2184-9-9**] 08:00AM CK(CPK)-31
[**2184-9-9**] 08:00AM cTropnT-0.02*
[**2184-9-9**] 08:00AM CK-MB-3 cTropnT-<0.01 proBNP-3083*
[**2184-9-9**] 08:00AM CALCIUM-8.4 PHOSPHATE-3.9 MAGNESIUM-2.0
[**2184-9-9**] 08:00AM TSH-1.9
[**2184-9-9**] 08:00AM FREE T4-1.3
[**2184-9-9**] 08:00AM WBC-5.7# RBC-3.14* HGB-10.9* HCT-34.0*
MCV-108* MCH-34.7* MCHC-32.0 RDW-17.1*
[**2184-9-9**] 08:00AM NEUTS-92.5* LYMPHS-3.5* MONOS-2.1 EOS-0.9
BASOS-0.9
[**2184-9-9**] 08:00AM PLT COUNT-103*
[**2184-9-9**] 08:00AM PT-12.4 PTT-27.3 INR(PT)-1.0
[**2184-9-8**] 11:05AM GLUCOSE-95
[**2184-9-8**] 11:05AM UREA N-26* CREAT-0.9 SODIUM-141 POTASSIUM-4.6
CHLORIDE-105 TOTAL CO2-30 ANION GAP-11
[**2184-9-8**] 11:05AM estGFR-Using this
[**2184-9-8**] 11:05AM ALT(SGPT)-7 AST(SGOT)-16 LD(LDH)-182 ALK
PHOS-109* TOT BILI-0.3
[**2184-9-8**] 11:05AM ALBUMIN-3.7 CALCIUM-8.7 PHOSPHATE-4.7*
MAGNESIUM-2.1
[**2184-9-8**] 11:05AM WBC-3.7*# RBC-3.00* HGB-10.2* HCT-32.1*
MCV-107* MCH-34.1* MCHC-31.9 RDW-17.0*
[**2184-9-8**] 11:05AM NEUTS-76.5* LYMPHS-16.3* MONOS-5.7 EOS-0.8
BASOS-0.7
[**2184-9-8**] 11:05AM PLT COUNT-109*
ECHOCARDIOGRAM [**9-10**]
The left atrium is moderately dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is normal
(LVEF>55%). The estimated cardiac index is normal
(>=2.5L/min/m2). The right ventricular cavity is mildly dilated
with borderline normal free wall function. The aortic arch is
mildly dilated. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area <0.8cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is borderline pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Critical aortic stenosis.
Mild mitral and aortic regurgitation. Mild symmetric left
ventricular hypertrophy with preserved global left ventricular
systolic function. Right ventricular dilation/dysfunction. Mild
pulmonary hypertension.
CTA [**9-9**]
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Diffuse smooth septal thickening is most consistent with
hydrostatic edema in the setting of effusions and anarsarca.
3. Enlarging moderately large right pleural effusion and new
small left
pleural effusion.
4. Mediastinal lymphadenopathy, stable since [**2184-8-12**].
CXR [**9-14**]
IMPRESSION:
1. Persistent right pleural effusion, unchanged in size with
increased
associated right lower lobe atelectasis.
2. Leads appropriately placed in apex of the right ventricle as
well as
within the right atrium.
Brief Hospital Course:
Ms. [**Known lastname **] is an 88 year old female with history of follicular
lymphoma, atrial fibrillation, aortic stenosis and history of
CVA in [**2179**] who started cycle 4 of R-CVP chemo 20 hours before
presenting to ED with SOB and substernal CP after a bowel
movement. She was admitted to the ICU on a phenylephrine drip
for hypotension that developed in the ED.
.
# Hypotension: This may be cardiogenic, or secondary to volume
depletion or infection. ECHO showed critical AS which likely
contributed. CXR is not typical of left ventricular failure,
but the patient's fluctuating heart rate with pauses may be
leading to drops in cardiac output. The elevated BNP is of
little use in the context of chronic aortic stenosis. The
patient was bolused 500cc NS and phenylephrine d/c'ed. Since
then her pauses have been much less frequent and her BP more
stable. Art line was inserted for BP monitoring and was removed
prior to transfer. UA was suggestive of UTI so pt was started
on Ciprofloxacin PO 500 mg [**Hospital1 **], urine cx showed E. coli so 3 day
course of abx was completed. In light of the pt's pauses on
tele, cardiology c/s (EP) was called, and the pt was ultimately
transferred to the EP service for pacemaker placement on [**2184-9-13**]
(see below). Her BP was stable for floor transfer and remained
normotensive on the floor. Her Metoprolol was decreased to 12.5
mg PO BID.
.
# Arrhythmia: Pauses in Heart rate and Afib - likely due to sick
sinus syndrome that is not new. Her sick sinus syndrome and poor
volume status together may have dropped her cardiac output
leading to SOB and low BP while in ICU. Evaluated by cardiology
and a pacemaker was placed on [**2184-9-13**]. The pacer was
interrogated on [**9-14**] without incidence. As for the pt's Afib,
as her Metop dose was decreased to 12.5 mg PO BID, and in the
setting of this decreased dose, her afib went into RVR. As per
EP, she was started on an amiodarone load to be finished after
discharge. Briefly, she is to get 200 mg of Amiodarone TID x 7
days, and then 400 mg PO daily x 3 weeks, and finally 200 mg PO
daily afterward. Of note, a hematoma formed on the pt's chest
after PPM placement, likely [**1-13**] her thrombocytopenia after
chemo. Her Hct remained stable, and Ms. [**Known lastname **] was treated with
pain medication. Of note, the pt's risk of stroke from Afib is
quite high given her h/o stroke. A calculated CHADS2 score
would recommend anticoagulation, however when the pt was on
cardiology, we contact[**Name (NI) **] her Oncologist who recommended against
all anticoagulation/antiplatelet agents. We would recommend
starting the pt on anticoagulation at a later date if it is
deemed safe to do so by her Oncologist. We continued her low
dose BB at 12.5 mg PO BID of metoprolol tartrate.
.
# Agitation/delerium: Particularly at night. Pt often agitated
in the few days after chemo according to children. Zyprexa was
given PRN at night for agitation, and soft mitts were used for
restraints for one instance of attempting to pull her lines.
Agitation improved and she was able to sleep through the night.
.
# Episode of Chest pain: [**Month (only) 116**] represent an episode of unstable
angina in a pt with a strong family history of CAD, but more
likely caused by decreased cardiac output secondary to the
patient's sick sinus syndrome and hypovolemia. MI, PE ruled out.
trops and CTA neg. Chest pain did not return after transfer to
the floor.
.
# Follicular lymphoma: She just received a dose of R-CVP chemo
prior to admission and was continued on her scheduled prednisone
and zofran. In addition, she was started on neupogen daily by
the BMT team to increase her WBC. She was not neutropenic after
her chemotherapy, but in the setting of her sick sinus syndrome
and need for pacemaker placement, she was placed on neupogen in
order to increase her counts and lower her infection risk. She
will continue to be followed by her primary outpatient
oncologist, Dr. [**First Name (STitle) **], who will determine her future course as
far as further cycles of R-CVP.
.
# Anemia: Pt's Hct was noted to have dropped after the procedure
and in light of the hematoma. Multiple causes are possible,
although most likely is a combination of chemotherapy (nadir
when Hct was 22-23) as well as slight [**First Name (STitle) **] loss from the PPM
placement and the hematoma. When the pt was on the cardiology
team, her BMT attending was asked regarding this and she was
transfused 2 units pRBCs on the day prior to discharge and her
hematocrit rose appropriately to 26.2.
.
# Persistent right pleural effusion and smaller left pleural
effusion. These are present on CT chest of 1 month ago. Most
likely secondary to the patient's lymphoma, they are probably
not large enough to cause respiratory distress or hemodynamic
comprimise. Did not tap or drain these this admission.
# Hypothyroidism: continued her home synthroid.
.
# Seziures s/p CVA: continued home dilantin.
Medications on Admission:
Zyprexa 10 mg qHS PRN agitation
Senna 8.6 mg Cap 2 at bedtime
Acetaminophen 500 mg q6 PRN pain
Omeprazole 20 mg daily
Prednisone 60 mg daily until [**9-11**], then taper
Metoprolol Tartrate 75 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **] PRN
Levothyroxine 88 mcg daily
Dilantin Extended 200 mg qOD alternating with 300mg
Gabapentin 200 mg qHS
Acyclovir 400 mg [**Hospital1 **]
Ondansetron HCl 8 mg daily x 2 days after chemo, then [**Hospital1 **] PRN
Discharge Medications:
1. senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Zyprexa Zydis 10 mg Tablet, Rapid Dissolve Sig: One (1)
Tablet, Rapid Dissolve PO at bedtime as needed for insomnia.
6. docusate sodium 100 mg Tablet Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
8. acyclovir 400 mg Tablet Sig: One (1) Tablet PO twice a day.
9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day): x 7 days (last day should be [**2184-9-20**]).
10. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day
for 3 weeks: To be started on [**2184-9-21**] until [**2184-10-11**].
11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day:
starting [**2184-10-12**].
12. Zofran 8 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for nausea.
13. phenytoin sodium extended 200 mg Capsule Sig: One (1)
Capsule PO 3 times a week: On M, W, Fr.
14. phenytoin sodium extended 300 mg Capsule Sig: One (1)
Capsule PO 4 times a week: Tu, Th, [**Last Name (LF) **], [**First Name3 (LF) **].
15. filgrastim 300 mcg/mL Solution Sig: One (1) ml Injection
Q24H (every 24 hours).
16. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) as needed for post pacemaker for 2 days: started on
[**9-14**] with one dose. Needs to be continued until [**9-16**] (for two
doses on that day).
17. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
18. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
19. Outpatient Lab Work
Please check a CBC with diff and ANC on Friday, [**9-17**] and
fax the results to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Telephone/Fax (1) 30658**].
20. Calcium 500 500 mg (1,250 mg) Tablet, Chewable Sig: One (1)
Tablet, Chewable PO three times a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 15967**] Facility - [**Hospital1 8**]
Discharge Diagnosis:
Sick Sinus Syndrome s/p Pacemaker placement
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
It was a pleasure taking care of you during your
hospitalization. You were admitted to [**Hospital1 18**] with chest pain and
low [**Hospital1 **] pressure. You were first admitted to the ICU because
of these issues, and a medication was used to keep your [**Hospital1 **]
pressure normal. Then, since you had just started cycle four of
your chemotherapy, you were admitted to the Bone Marrow
Transplant Unit. Since the cause of your low [**Hospital1 **] pressure and
chest pain was thought to be because of your arrhythmia
(abnormal pattern of heart beats), you were transferred to the
Cardiology service for a pacemaker to be placed. This was done
on [**2184-9-13**], and you were discharged on [**2184-9-15**] to a
rehabilitation facility.
PLEASE MAKE THE FOLLOWING CHANGES TO YOUR MEDICATIONS
1) CHANGE your METOPROLOL to 12.5 mg twice daily
2) START taking AMIODARONE 200 mg by mouth three times a day for
6 more days, then 400 mg by mouth daily for 3 weeks, then 200 mg
by mouth daily
3) START taking Vitamin D 800 units daily
4) START taking Calcium Carbonate 500 mg three times a day
5) START taking Cephalexin 500 mg by mouth every 8 hours for 4
more doses.
PLEASE FOLLOW UP WITH YOUR PHYSICIANS AS YOU SEE BELOW
Followup Instructions:
Please follow-up with all of your outpatient medical
appointments listed below:
1. Department: CARDIAC SERVICES
When: WEDNESDAY [**2184-9-22**] at 10:00 AM
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
2. Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2184-9-22**] at 12:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3919**], RNC [**Telephone/Fax (1) 3241**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
3. Department: HEMATOLOGY/BMT
When: WEDNESDAY [**2184-9-22**] at 12:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], MD [**Telephone/Fax (1) 3237**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
4. Name: [**Last Name (LF) **],[**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 3947**].
Location: [**Name2 (NI) **] FAMILY HEALTH [**Last Name (NamePattern1) 31551**]Address: [**Street Address(2) 31552**] [**Hospital1 8**] MA
Phone: [**Telephone/Fax (1) 31553**]
Appointment: Wednesday [**2184-9-22**] 6:00pm
5. Department: CARDIAC SERVICES
When: MONDAY [**2184-10-18**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 539**] [**Last Name (NamePattern4) 13861**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
6. Department: CARDIAC SERVICES
When: MONDAY [**2184-10-18**] at 11:40 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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icd9cm
|
[
[
[]
]
] |
[
"37.72",
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icd9pcs
|
[
[
[]
]
] |
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|
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|
281, 316
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|
5807, 6511
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
32,074
| 105,598
|
50122
|
Discharge summary
|
report
|
Admission Date: [**2196-8-5**] Discharge Date: [**2196-8-8**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Bright red blood per rectum
Major Surgical or Invasive Procedure:
Upper endoscopy with one clip placed on bleeding blood vessel at
the base of an ulcer in the stomach.
History of Present Illness:
This is a [**Age over 90 **] year old male, holocaust survivor with history of
CAD with 3VD s/p multiple PCIs with stenting to LAD and LMCA,
HTN, DM II, RAS, PVD who presents to [**Hospital1 18**] ED from home after
large episode of melena along with coffee ground emesis.
Patient reports that he was at home when he had a notable large
black stool which was loose. Patient then had an episode of
nausea and coffee ground emesis. EMS was called and found
patient with SBP in 70s. Patient also had coffee ground emesis
on floor surrounding him. Patient was brought to the [**Hospital1 18**] for
further evaluation.
In the ED: Temp 97.2, BP 70/p, HR 60, RR 16, 95% RA. GI was
consulted and patient received Protonix 80mg IV followed by gtt
8mg /hr. Given 1uPRBC. Insulin Reg 10u x 1, 2mg IV Morphine,
Calcium Gluconate and d50. Patient also complaining of chest
pain and received NTG SL x 3 with resolution of pain. ECG done
which showed anterolateral ST depressions
On arrival to the floor, patient continued to complain of [**6-30**]
chest pain which was his typical angina. Patient reports
baseline angina when walking up his stairs at home. He takes
NTG with relief. He denies any current N/V, palpitations,
diaphoresis or radiating pain.
Past Medical History:
CAD: [**5-26**]
Three vessel coronary artery disease.
Bilateral renal artery stenosis.
Diabetes
hypertension
hyperlipidemia
carotid artery disease- [**2193-3-12**] u/s: 50% [**Country **], 50-60% [**Doctor First Name 3098**],
External carotid artery stenosis > 50% on the left.
[**2182**] Left Carotid Endarterectomy
CRI
Social History:
Social History: Patient is married. His wife requires a lot of
care at home for which they have [**Name Initial (MD) **] visiting NP at least weekly
and visiting nurses as needed. His son is from out of town. The
patient is a survivor of the Holocaust. 7 p-y h/o tobb quit
[**2157**], has 2 sons, one is dentist. No EtOH.
Family History:
(?) [**Name (NI) 41900**] [**Name (NI) **] unclear
Physical Exam:
Tmax: 35.6 ??????C (96 ??????F)
Tcurrent: 35.6 ??????C (96 ??????F)
HR: 72 (72 - 81) bpm
BP: 109/30(51) {109/30(51) - 136/67(73)} mmHg
RR: 17 (13 - 24) insp/min
SpO2: 100%
Heart rhythm: SR (Sinus Rhythm)
Height: 64 Inch
Gen: NAD, lying comfortably in bed
HEENT: anicteric sclerare, EOMI, PERRLA, +arcus senilus
Neck: no LAD
CVS: +S1/S2, +II/VI SEM RUSB, RRR
ABD: +BS, NT/ND, no guarding, no hepatomegaly
EXT: no peripheral edema, +2 distal pulses
Neuro: AAOx3, CN II-XII intact
Pertinent Results:
.
[**2196-8-5**] 11:53PM BLOOD CK-MB-NotDone cTropnT-0.01
[**2196-8-6**] 05:12AM BLOOD CK-MB-10 MB Indx-9.9* cTropnT-0.08*
[**2196-8-6**] 05:12AM BLOOD cTropnT-0.12*
[**2196-8-6**] 11:12AM BLOOD CK-MB-12* MB Indx-10.4* cTropnT-0.16*
[**2196-8-6**] 09:22PM BLOOD CK-MB-NotDone cTropnT-0.22*
[**2196-8-7**] 08:50AM BLOOD CK-MB-NotDone cTropnT-0.18*
[**2196-8-7**] 03:55PM BLOOD CK-MB-7 cTropnT-0.16*
.
[**2196-8-5**] 09:00PM BLOOD WBC-5.1 RBC-3.02* Hgb-9.9* Hct-29.9*
MCV-99* MCH-32.7* MCHC-33.1 RDW-14.7 Plt Ct-127*
[**2196-8-6**] 01:10AM BLOOD Hct-26.9*
[**2196-8-6**] 05:12AM BLOOD WBC-3.8* RBC-3.19* Hgb-10.5* Hct-30.0*
MCV-94 MCH-32.8* MCHC-34.9 RDW-16.9* Plt Ct-69*
[**2196-8-6**] 09:22PM BLOOD Hct-28.7* Plt Ct-49*
[**2196-8-7**] 08:50AM BLOOD WBC-3.2* RBC-3.61* Hgb-11.6* Hct-33.3*
MCV-92 MCH-32.3* MCHC-35.0 RDW-16.6* Plt Ct-63*
[**2196-8-8**] 02:21AM BLOOD WBC-2.2* RBC-3.44* Hgb-10.5* Hct-31.4*
MCV-91 MCH-30.4 MCHC-33.4 RDW-16.0* Plt Ct-45*
.
[**2196-8-8**] 02:21AM BLOOD Glucose-180* UreaN-18 Creat-1.1 Na-142
K-3.9 Cl-109* HCO3-29 AnGap-8
[**2196-8-8**] 02:21AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.0
Brief Hospital Course:
# GI Bleed: GI was consulted and did an EGD which showed 2
antral ulcers, one with a bleeding vessel. The vessel was
clipped with one clip and bleeding was stopped. Patient was kept
on [**Hospital1 **] PPI and D/C'd on this as well. There were no further
episodes of bleeding per rectum, hematemesis, or melena.
Patient's plavix and ASA were held initially. After consulting
with his cardiologist the plavix was d/c'd and patient was
re-started on ASA.
# Chest Pain: In setting of anemia and tachycardia, patient had
recurrent episodes of chest pain throughout his stay with
troponins peaking at 0.22 and increasing CKs without ever
reaching an abnl level. At some points the pain was likened to
his normal angina and at others the patient felt it was [**1-23**] his
Right shoulder pain from a previous fracture. Patient's ekg
showed lateral ST depressions in V2-V6 unchanged whether patient
had pain or not. This was responsive to morphine and nitro
paste. Patient was discharged with nitro and tylenol with codein
for the pain which is how he manages it at home.
# DMII ?????? Patient with history of DM. Kept on RISS while on
floor.
# PVD ?????? held ASA, Plavix as above. restarted ASA on d/c.
# HTN ?????? held antihypertenisives at first given hypotension
associated with UGIB. Patient was discharged on all of his home
meds as BP had come up after transfusions and EGD.
# Hyperkalemia ?????? Patient with hyperkalemia on arrival, possible
[**1-23**] ACEi and hypovolemia. Received Kayexalate x 1. Further K
levels were WNL.
# ARF ?????? Cr of 1.9 on admission, likely in setting of hypovolemia
from UGIB, improved on arrival to ICU after IVF boluses PRN and
transfusions.
#. Nutrition: Patient was initally kept NPO for the EGD. Diet
was then advanced to diabetic diet which patient tolerated well.
Medications on Admission:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
10. Plavix 75mg PO daily
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous twice a day.
Discharge Medications:
1. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. Atenolol 25 mg Tablet Sig: Three (3) Tablet PO once a day.
3. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day.
6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO
Q4H (every 4 hours) as needed.
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*120 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
12. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension
Sig: Eighteen (18) units Subcutaneous twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1.Upper GI bleed
2.Angina
Secondary Diagnosis:
1. CAD
2. Diabetes Mellitus
3. Hypertension
Discharge Condition:
Bleeding resolved. Stable.
Discharge Instructions:
You were admitted for a bleed in your stomach from an ulcer. A
clip has been placed on the ulcer to stop the bleeding. We have
discontinued your plavix as it can contribute to bleeding. You
should no longer take this medication. We have started you on
omeprazole for your stomach ulcers. You should take this
medication twice per day as prescribed.
You have had an ultrasound of your heart to assess how well it
is functioning. Your PCP should review the record at your
upcoming appointment.
Please take the rest of your medications as prescribed.
You should follow-up with your primary care physician on the
date and time scheduled below.
Please call your PCP or come to the ED if you develop any chest
pain, shortness of breath, dizziness, light-headedness, bright
red blood in your stool or black tarry stools.
Followup Instructions:
Please call your doctor of come to the ED if you have
light-headedness, dizziness, chest pain, shortness of breath,
abdominal pain, bright red blood per rectum, dark or tarry
stools, or blood in your vomitus.
Completed by:[**2196-8-8**]
|
[
"584.9",
"414.01",
"413.9",
"531.40",
"V45.82",
"285.9",
"250.00",
"276.7",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"44.43"
] |
icd9pcs
|
[
[
[]
]
] |
8075, 8081
|
4102, 5925
|
288, 392
|
8236, 8265
|
2967, 4079
|
9131, 9369
|
2386, 2438
|
6937, 8052
|
8102, 8102
|
5951, 6914
|
8289, 9108
|
2453, 2948
|
221, 250
|
420, 1684
|
8169, 8215
|
8121, 8148
|
1706, 2029
|
2061, 2370
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,275
| 177,258
|
12205
|
Discharge summary
|
report
|
Admission Date: [**2173-3-30**] Discharge Date: [**2173-4-5**]
Date of Birth: [**2138-1-19**] Sex: F
Service: CARDIOTHORACIC SURGERY
HISTORY OF PRESENT ILLNESS: The patient is a 35 year-old
female with a past medical history significant for previous
myocardial infarction, known coronary artery disease and a
previous stent to the right coronary artery who presents as a
transfer for acute myocardial ischemia and cardiac
catheterization.
PAST MEDICAL HISTORY: Coronary artery disease, previous
myocardial infarction, previous stent, arthritis, carpal
tunnel syndrome.
ALLERGIES: No known drug allergies.
MEDICATIONS ON ADMISSION: Aspirin, Atenolol, Lipitor,
Calcitrel, magnesium and calcium supplements.
HOSPITAL COURSE: The patient was transferred to our facility
and admitted to the Medical Service where she underwent a
cardiac catheterization, which revealed a right dominant
system with significant obstruction of two vessels and left
main disease. The left main had a 60% osteal lesion, left
anterior descending coronary artery had a 60% mid vessel
stenosis and the left circumflex had minimal luminal
irregularities throughout its course and was otherwise
normal. Right coronary artery 60% stenosis of his proximal
stent and 90% mid vessel stenosis. Ejection fraction of
approximately 60%. Based on these findings a stat
Cardiothoracic Surgery consult was obtained and the patient
was deemed appropriate for surgery. On [**2173-4-2**] she was
taken to the Operating Room where she underwent a coronary
artery bypass graft times three. The patient's grafts were
left internal mammary coronary artery to left anterior
descending coronary artery, saphenous vein to posterior
descending coronary artery, and left radial to the obtuse
marginal. The patient tolerated this procedure well without
complications.
Postoperatively, she was transferred to the Cardiothoracic
Intensive Care Unit where she was maintained on intravenous
drips. She was extubated and did well in this immediate
period. She had an air leak on her chest tube, which was
left in for two additional days. The remainder of her
Intensive Care Unit course was uneventful and she was
transferred to the floor off drips still with her chest
tubes. By postoperative day four the patient's air leak was
resolved. Chest x-ray demonstrated no pneumothorax and her
chest tube was removed. She continued to do well working
with physical therapy and tolerating a regular diet and on
postoperative day five will be discharged home.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: To home.
DISCHARGE MEDICATIONS: Metoprolol 12.5 mg po b.i.d., Lasix
20 mg po q day, K-Ciel 20 milliequivalents po q day, ASA 325
mg po q.d., Zantac 150 mg po b.i.d., Colace 100 mg po b.i.d.,
Plavix 75 mg po q day, Imdur 60 mg po q day, and Dilaudid 2
mg po q 4 to 6 hours prn for pain.
The patient will follow up with her primary care physician
and with CT Surgery in two to four weeks.
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**]
Dictated By:[**Last Name (NamePattern1) 22409**]
MEDQUIST36
D: [**2173-4-5**] 08:17
T: [**2173-4-5**] 08:42
JOB#: [**Job Number 38175**]
|
[
"414.01",
"412",
"V45.82",
"V15.82",
"272.0",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"37.22",
"36.12",
"88.57",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
2624, 3264
|
659, 734
|
752, 2537
|
183, 462
|
485, 632
|
2562, 2600
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
2,051
| 184,088
|
30569+57704
|
Discharge summary
|
report+addendum
|
Admission Date: [**2169-2-21**] Discharge Date: [**2169-2-25**]
Date of Birth: [**2119-10-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
melana
Major Surgical or Invasive Procedure:
EGD
Left subclavian access line
History of Present Illness:
49 y.o. male with PMHx of DM, HTN, CAD, s/p MI and arthritis,
who presents with a GIB. Patient reports "not feeling well",
specifically complaining of diaphoresis, lightheadedness and
chest pain 2 days ago. Given his cardiac history, EMS was
notified and upon arrival, he had an episode of coffee-ground
emesis, approximately 700 ccs. He was then rushed to [**Hospital1 **] in [**Location (un) 47**]. During his admission at
[**Location (un) 47**], he had an EGD which showed a large clot in the
fundus and a shatzki's ring. The leading differential was a
gastric ulcer from ASA/Plavix use, though no ulcer was seen on
imaging. The patient reportedly also experienced black, tarry
stools during his hospitalization. He received a total of 9 [**Location 72557**] before transfer to [**Hospital1 18**] for further evaluation. Patient
denies a history of GIB, has no history of family GI-related
cancers and has one year before his recommended screening
colonscopy.
.
Upon arrival to [**Hospital1 18**], the patient experienced an episode of
BRRPR with approximately 800 ccs. His vitals were significant
for low, but stable BP and tachycardia to the 120s. He was
urgently seen by surgery and GI with plans for bedside EGD.
Past Medical History:
DM
HTN
CAD s/p MI in [**2165**] with stent in OM (per wife)
Arthritis, s/p b/l total knee replacement in [**2166**] and [**2167**]
Social History:
Infrequent alcohol use, former tobacco user, 2pk/day, quit two
years ago, no illicit drug use.
Family History:
Father with "liver disease, not alcohol-related" s/p liver
transplant
Otherwise, no history of GI-related diseases/cancers
Physical Exam:
Vitals: T - 99.4, BP - 116/77, HR - 121, RR - 23, O2 - 98% 3 L
NC
General: Lethargic, but arousable, NAD
HEENT: NC/AT; PERRLA, EOMI, pale conjunctiva; OP clear,
nonerthematous, dry, pale mucous membranes
Neck: Supple, No LAD
Chest/CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB
Abd: Soft, NT, ND, + BS
Rectal: Bright red blood per rectum, no melena
Ext: No c/c/e
Skin: No stigmata of liver disease, no ecchymoses, no petichiae
Brief Hospital Course:
Mr. [**Known lastname 9840**] is a 49 year old male with a past medical history of
DM, HTN, CAD s/p MI and arthritis, but no liver/GI disease who
presented with hematemesis and BRBPR. He was found to have a
Dieulafoy lesion that was cauterized during a brief ICU stay.
.
1. GIB: Differential is mostly concerned with gastritis from
ASA/Plavix, NSAIDs as well as diverticulosis/ lower GI polyps,
explaining BRBRP. Patient has received multiple units of PRBCs
with minimal to no increase in Hct. GI performed EGD which
demonstrated Dieulafoy lesion vs. mucosal tear with a visible
vessel at cardiac/GEJ which was injected w/ epi and cauterized
w/ successful hemostasis. Post EGD, continued to have Hct drop;
repeat EGD was negative for resumed bleed; CT abd/pelvis was
obtained and was negative for bleed. Hct subsequently stablized.
Received total of 8 U PRBCs, 2 units FFP, platelets and
cryoglobulin. He was given a pantoprazole gtt and then switched
to [**Hospital1 **] when stable. His aspirin and plavix were held in the
setting of his acute bleed. Will need to follow up with GI as
outpatient for EGD to further evaluate the Dieulafoy lesion.
.
2. CAD: s/p MI in [**2165**] with stent. Patient is outside of window
for mandatory daily Plavix. Currently without chest pain. His
aspirin and plavix are being held; should discuss with
cardiology and GI when it would be safe to restart these agents.
His cardiac enzymes were cycled for concern of demand ischemia
and were negative. He was continued on atorvostatin. He was
started on a BB for cardioprotection upon discharge.
.
3. HTN: His antihypertensives were held. A BB was started for
HTN and also for cardioprotection. He should follow up with his
PCP on the management of his HTN.
.
4. DM: On Glipizide as an outpatient. Monitored here with finger
sticks and insulin SS with good control of blood sugars in the
mid 100 range. Glipizide was restarted upon discharge.
.
5. Thrombocytopenia: Plt were stable around 80-100. Unclear
etiology. No splenomegaly on exam and CT. Possibly due to recent
ASA, Plavix. Pt not receiving any heparin products anymore.
Further workup as outpatient recommended.
.
6. Arthritis: s/p b/o Knee replacements. Was on tramadol and
trileptal (? neuropathic component) as outpt. Tripletal has been
discontinued. Patient without significant pain off this
medication. Pain control with prn Tramadol and Tylenol. Follow
up with his PCP [**Name Initial (PRE) 3675**].
.
7. Code status: FULL
Medications on Admission:
Tramadol 50 mg TID PRN
Trileptal 150 mg TID PRN
Lipitor 40 mg QD
Aspirin 325 mg QD
Lotrel 5/10 mg QD
Clopidogrel 75 mg QD
Glipizide 2.5 mg QD
HCTZ 25 mg QD
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. 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*
3. GlipiZIDE 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO DAILY (Daily).
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Dieulafoy lesion
2. severe upper GI bleed with hemorrhagic shock
3. Diabetes mellitus type II, uncontrolled with complications
4. Hypertension
.
Secondary Diagnosis:
1. CAD s/p MI with stenting
2. Arthritis s/p knee replacements b/l
Discharge Condition:
Afebrile, hemodynamically stable with no further evidence of
bleeding. Ambulating and tolerating a regular diabetic, cardiac
diet.
Discharge Instructions:
You have suffered from upper and lower gastrointestinal
bleeding. You have received blood products and were briefly
intubated. An ulcer in your stomach has been cauterized which
stopped the bleeding. We have started you on a medication,
Protonix, to help protect your stomach, you will need to take
this medication twice a day. We have also started you on a low
dose beta-blocker for your cardiac health, and have stopped your
other blood pressure medications. In addition we have stopped
your aspirin and Plavix. Please refrain from taking these
medications until you have discussed this with your PCP. [**Name10 (NameIs) **]
all other medications as instructed.
.
Please call your primary doctor or return to the ED with fever,
chills, chest pain, shortness of breath, nausea/vomiting,
spontaneous bleeding or any other concerning symptoms.
.
Please keep you follow up appointments as below.
Followup Instructions:
Please follow up with your primary care doctor in [**11-22**] weeks from
now.
.
It is recommended that you have another endoscopy or EGD in
approximately 4-6 weeks. Call ([**Telephone/Fax (1) 2233**] to schedule an
appointment. In addition, it is recommended that you have a
colonoscopy. You may schedule this through the same number
listed above.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Name: [**Known lastname 12088**],[**Known firstname 12089**] Unit No: [**Numeric Identifier 12090**]
Admission Date: [**2169-2-21**] Discharge Date: [**2169-2-25**]
Date of Birth: [**2119-10-19**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1472**]
Addendum:
.
Pertinent Results:
[**2169-2-21**] 12:48AM WBC-11.4* RBC-2.69* HGB-8.4* HCT-23.8* MCV-88
MCH-31.1 MCHC-35.2* RDW-14.2
[**2169-2-21**] 12:48AM PLT COUNT-157
[**2169-2-21**] 12:48AM PT-15.3* PTT-31.2 INR(PT)-1.4*
[**2169-2-21**] 12:48AM FIBRINOGE-124*
[**2169-2-21**] 12:48AM ALT(SGPT)-13 AST(SGOT)-15 CK(CPK)-82
AMYLASE-19 TOT BILI-0.3
[**2169-2-21**] 12:48AM LIPASE-17
[**2169-2-21**] 12:48AM GLUCOSE-154* UREA N-31* CREAT-0.9 SODIUM-147*
POTASSIUM-3.8 CHLORIDE-116* TOTAL CO2-23 ANION GAP-12
[**2169-2-21**] 12:48AM CALCIUM-6.3* PHOSPHATE-3.1 MAGNESIUM-1.5*
[**2169-2-21**] 04:53AM PLT COUNT-139*
[**2169-2-21**] 04:53AM HCT-23.1*
[**2169-2-21**] 09:05AM HCT-22.7*
[**2169-2-21**] 02:17PM HCT-24.4*
[**2169-2-21**] 10:05PM HCT-26.8*
.
EGD: Blood in the stomach body and fundus Dieulafoy lesion in
the cardia (injection, thermal therapy) Normal mucosa in the
whole esophagus Otherwise normal EGD to second part of the
duodenum.
.
Repeat EGD: Cauterized ulcer in the gastroesophageal junction
Recommendations: No blood in the stomach or duodenum. Check for
other sources of hct drop. Rule out retroperitoneal bleed,
hemolysis.
If passes more stool/melena, consider bleeding scan/angio.
.
Imaging:
[**2169-2-21**] CXR: The lungs are unremarkable. The heart size and
mediastinum are normal.
.
[**2169-2-21**] CT ABD/PELVIS:
1) No evidence of retroperitoneal hematoma.
2) Otherwise, very limited study without IV or oral contrast.
3) Left lower lobe consolidation with air bronchograms,
suspicious for pneumonia.
4) Irregular defect in the right iliac bone, possibly a bone
graft harvest site; please correlate with patient history.
.
[**2169-2-21**] HEAD CT:
There is no hemorrhage, mass, shift of normally midline
structures or hydrocephalus. No major vascular territorial
infarct is apparent. The [**Doctor Last Name **]-white matter differentiation is
preserved. A large mucus- retention cyst is seen within the
right maxillary sinus as well as a smaller one within the left,
with adjacent mucosal thickening. Air-fluid levels are present
within the sphenoid sinus as well as mucosal thickening within
the ethmoid sinus, which given presence of dependent fluid
within the nasopharynx, is likely related to intubation. Mastoid
air cells remain normally aerated. No osseous abnormalities are
identified.
.
Discharge Disposition:
Home
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1473**]
Completed by:[**2169-2-27**]
|
[
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"280.0",
"E934.8",
"250.00",
"V43.65",
"412",
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icd9cm
|
[
[
[]
]
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[
"99.05",
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icd9pcs
|
[
[
[]
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] |
10257, 10414
|
2482, 4960
|
322, 355
|
5948, 6082
|
7921, 9575
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7030, 7902
|
1888, 2013
|
5167, 5620
|
5670, 5670
|
4986, 5144
|
6106, 7007
|
2028, 2459
|
276, 284
|
383, 1605
|
5858, 5927
|
9584, 10234
|
5689, 5837
|
1627, 1760
|
1776, 1872
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,845
| 198,772
|
2040
|
Discharge summary
|
report
|
Admission Date: [**2163-5-1**] Discharge Date: [**2163-5-5**]
Service: MED
HISTORY OF PRESENT ILLNESS: An 85-year-old female with
osteoporosis and legally blind who fell while walking with
family in a mall. She had no precipitating symptoms, no head
trauma or seizure activity but did lose consciousness for
approximately 2 minutes. After the syncopal episode, she
felt lightheaded and had a headache; 30 minutes later, she
had a second syncopal episode. The patient became
progressively agitated and confused over the next few hours.
The patient was in [**Country 6607**] and refused to go to the emergency
room. They drove down from [**Country 6607**] to [**Hospital1 18**] Emergency
Department for evaluation. On arrival to the emergency
department, her vital signs were stable, but she quickly
became hypoxic and hypotensive requiring intubation and
pressors. A head CT showed an old right occipital infarct,
and she had a negative CTA and negative lumbar puncture. The
patient had an elevated lactate, and also there was no clear
source of infection. She was started on antibiotics. She
was admitted to the intensive care unit.
PAST MEDICAL HISTORY: Legally blind.
Osteoporosis.
Right occipital stroke in [**2160**].
PAST SURGICAL HISTORY: Femoral hernia repair.
MEDICATIONS:
1. Aspirin.
2. Fosamax.
FAMILY HISTORY: Liver cancer.
SOCIAL HISTORY: She lives at home with her daughter. [**Name (NI) **]
tobacco or alcohol use. The patient walks with a cane at
baseline.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: On arrival to the ICU, temperature
98.6 degrees, pulse 100, respiratory rate 18, blood pressure
97/51, saturation 100 percent. General, intubated, elderly
thin female, sedated. HEENT, pupils 3 mm and sluggishly
reactive. Neck, no JVD, no carotid bruits. Pulmonary, clear
to auscultation anteriorly. Cardiovascular, tachycardia,
regular rhythm, and no murmurs. Abdomen, soft, nontender,
nondistended, normoactive bowel sounds. Extremities, no
clubbing, cyanosis, or edema; warm, 2 plus dorsalis pedis
pulses bilaterally. Skin, no stigmata of endocarditis
noticed.
LABORATORY DATA: Significant labs at the time of ICU
admission, white count 7.5, 0 bands, bicarbonate 17, anion
gap 10, negative UA, troponin 0.07, CPK 84, albumin 2.9, ABG
7.21/39/442, lactate 5.2.
RADIOGRAPHIC STUDIES: EKG, normal sinus rhythm at 100 beats
per minute with normal axis and intervals; [**Street Address(2) 5366**]
depressions in V5, V6, and I, new biphasic T-wave in V4
through V6 and I. A right upper quadrant ultrasound showed
positive intrahepatic ductal dilatation with mild gallbladder
wall thickening. Chest x-ray showed no cardiopulmonary
process with some apical scarring. CT of her head without
contrast showed no hemorrhage, but an old right posterior
infarct with chronic small-vessel ischemic changes and a
possible 1.8 cm aneurysm in her ICA. A CTA showed no
pulmonary emboli with small pleural effusions bilaterally,
right greater than left, questionable ascites with some fluid
around the pancreas. An x-ray of her right hand showed no
fracture. Hip x-ray showed no fracture. Echocardiogram
showed an ejection fraction greater than 55 percent with
dilated right ventricle and some hypokinesis without any
evidence of pericardial effusion.
HOSPITAL COURSE: An 85-year-old female who is status post
syncope times 2, admitted with hypotension and hypoxia,
requiring intubation, pressors, and antibiotics that
completely resolved within 2 days.
Infectious disease. Although the patient appeared septic
upon presentation with an elevated lactate and hypotension,
there was no clear evidence of infection. Blood pressure
improved and the patient was weaned off pressors after 1
night. There have been no source or other evidence of
infection. Therefore, antibiotics were discontinued. The
patient did have multiple episodes of diarrhea but she was C.
difficile negative.
Hypoxia. Again, there was no clear etiology of the patient's
hypoxia. She was extubated without difficulty and remained
on room air for the rest of her hospitalization.
Syncope. The patient was kept on telemetry. However, there
was no evidence of arrhythmia. A CT of her head showed no
change and lumbar puncture was negative. She had normal
carotid ultrasounds. An echocardiogram showed small right
ventricular hypokinesis and dilation with tricuspid
regurgitation. The patient was recommended to have an
outpatient MRA/MRI to evaluate questionable aneurysm seen on
CT scan.
Abnormal right upper quadrant ultrasound. The patient had
mild transaminase with ductal dilatation and gallbladder wall
thickening on right upper quadrant ultrasound. The patient's
LFTs trended downwards. The patient was recommended to have
an outpatient MRCP to evaluate for stones in her common bile
duct.
DISPOSITION: The patient was discharged to home with
services.
CONDITION ON DISCHARGE: Alert and oriented, full affect,
presently walking with a cane and assistance, blood pressure
and oxygen saturation are normal.
DISCHARGE DIAGNOSES: Syncope of unknown etiology.
Hypotension.
Respiratory failure requiring intubation.
Transaminitis.
History of cerebrovascular accident.
Osteoporosis.
Blindness.
FOLLOW-UP: Recommended to follow up with her PCP within the
next 1 to 2 weeks.
PLAN: We recommend outpatient MRI to evaluate questionable
injuries as seen on the CT scan as well as an outpatient MRCP
for elevated transaminitis and dilatation and thickening of
the gallbladder.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg once a day.
2. Multivitamin 1 capsule p.o. q.d.
3. Fosamax 35 mg 1 tablet p.o. q.d.
[**First Name11 (Name Pattern1) 122**] [**Last Name (NamePattern1) 11159**], [**MD Number(1) 11160**]
Dictated By:[**Last Name (NamePattern1) 2022**]
MEDQUIST36
D: [**2163-6-28**] 09:57:28
T: [**2163-6-28**] 14:51:25
Job#: [**Job Number 11161**]
|
[
"780.2",
"733.00",
"369.4",
"787.91",
"276.2",
"790.4",
"458.9",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"03.31",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
1353, 1368
|
5097, 5546
|
5569, 5949
|
3342, 4921
|
1273, 1336
|
1570, 3324
|
116, 1156
|
1179, 1249
|
1385, 1547
|
4946, 5075
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,128
| 121,318
|
52712
|
Discharge summary
|
report
|
Admission Date: [**2132-2-20**] Discharge Date: [**2132-2-27**]
Date of Birth: [**2085-8-31**] Sex: F
Service: MEDICINE
Allergies:
Haldol / Flagyl
Attending:[**First Name3 (LF) 2763**]
Chief Complaint:
hypotension, tachycardia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
46 year old female with a PMH of transverse myelitis (T7) with
subsequent paraplegia, multiple dependent ulcers (including
stage IV decubitus ulcer), left heel ulcer osteomyelitis s/p
treatment in [**2130**], and now left foot osteomyelitis in the
setting of infected hardware who presents with hypotension and
tachycardia concerning for sepsis. She has undergone debridement
as recently as 1.5 weeks ago at [**Hospital1 112**] and has been treated with 6
weeks of treatment with vanc and cipro for treatment of MRSA and
pseudomonas, and subsequently was transitioned to cipro/bactrim;
she has a history of non compliance with her medications, but
reports she has been taking these. She presented to [**Hospital **] [**Hospital 4898**]
clinic today feeling tired and not herself. Denied fevers,
chills, cough, but notes weight loss, loss of appetite,
weakness, diarrhea. Vital signs at that time were T 96.5, BP
70/50 (manual), HR 147, O2 100% RA. She was brought to the ED
for management of sepsis and possible left foot amputation vs.
debridement.
.
In the ED, initial vs were: T98.7 P 146 BP 119/49 R 16 O2 sat
99% on RA. RIJ was placed and CVP was 1. Patient was given [**Last Name (un) 2830**]
and vanc. Blood cultures were sent. Labs were notable for a
lactate of 6.2 which improved to 2.0 with aggressive fluid
resuscitation. EKG was within normal limits. Also had plain
films of her left foot and a CXR (with no focal findings) before
she was sent up to the floor. Urology was consulted and placed a
foley given patient's dilated urethral meatus and chronic
neurogenic bladder/incontience. She was receiving liters 5 and 6
when she arrived in the MICU.
.
On the floor, patient was shaking and reported feeling cool.
Denied pain- no abdominal or chest pain. Has chronic pain of
sacral and foot ulcers. Has been feeling weak and out of it for
the past month. Denies nausea, vomiting, but has had non bloody
diarrhea for the past month. Poor PO intake. Denies dysurea, but
does not urine color has been off for a month.
.
Review of systems: Per HPI
Past Medical History:
-chronic right ischial and bilateral foot ulcers
-Sacral osteomyelitis s/p 6wks of meropenem and vancomycin [**7-25**]
-Ankle osteomyelitis s/p 6wks meropenem and vancomycin
[**Date range (1) 108746**]
-Paraplegia due to transverse myelitis at T7
-Neurogenic bladder
-Multiple complications from pressure wounds
-Chronic schizophrenia and delusional paranoia, as of 6 months
ago was deemed competant and no longer has guardian
-Depression with suicidal ideation, treated at [**Hospital1 **]
Social History:
Lives with 24 hour personal care assistant. Has a sister and two
brothers who live in the area. Is a Jehovah's Witness and does
not want to be transfused with any blood products. Previously
with guardian, but has been deemed competant by court in mid
[**2131**] and so now makes her own decisions. Sister was former
guardian. Smoked up to 1 pack every few days for 10 years and
now smokes 5 cigarettes per day. EtOH occasionally at social
occasions. Illicit drugs: has tested positive for cocaine in the
past, denies current use.
Family History:
NC
Physical Exam:
On Admission:
Vitals: T: 96.1 BP: 104/54 P: 133 R: 22 O2: 100% on RA
General: Alert, oriented, tremulous
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, RIJ in place, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: large, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Left foot with deep ulceration in medial and heel aspect,
gangrenous aspect visible, with active discharge. Right foot
with more superficial ulcertion of heel. Legs atrophic in
appearance. Warm, dry scaly skin; no edema.
Back: Grade IV sacral decubitus ulcer extending anteriorly with
exposure of underlying muscles and tissues; no obvious pustular
exudate or signs of infection
Neuro: alert and oriented. strength grossly intact in upper
extremities; unable to move b/l lower extremities; sensation to
pressure, pain intact, but not light touch; CN II-XII tested and
grossly intact.
On Discharge:
Vitals: T: 97.9 BP: 89/40 P: 133 R: 22 O2: 100% on RA
General: Alert, oriented, appropriate
HEENT: Sclera anicteric, MMM, oropharynx clear, PERRL
Neck: supple, RIJ in place, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: large, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: Foley in place
Ext: Left foot with deep ulceration in medial and heel aspect,
gangrenous aspect visible, with active discharge. Right foot
with more superficial ulcertion of heel. [**1-20**]+ lower extremity
edema b/l. Warm.
Back: Grade IV sacral decubitus ulcer extending anteriorly with
exposure of underlying muscles and tissues; no obvious pustular
exudate or signs of infection
Neuro: alert and oriented. strength grossly intact in upper
extremities; unable to move b/l lower extremities; sensation to
pressure, pain intact, but not light touch; CN II-XII tested and
grossly intact.
Pertinent Results:
ADMISSION LABS:
[**2132-2-20**] 06:20PM WBC-15.8* RBC-3.59* HGB-7.5* HCT-25.8*
MCV-72* MCH-20.9* MCHC-29.0* RDW-21.1*
[**2132-2-20**] 06:20PM NEUTS-86.6* LYMPHS-10.2* MONOS-2.8 EOS-0.1
BASOS-0.2
[**2132-2-20**] 06:20PM PLT COUNT-525*
[**2132-2-20**] 06:20PM PT-16.2* PTT-71.6* INR(PT)-1.4*
[**2132-2-20**] 03:07PM GLUCOSE-153* LACTATE-6.2* NA+-130* K+-7.4*
CL--106 TCO2-14*
[**2132-2-20**] 06:20PM ALBUMIN-1.6*
[**2132-2-20**] 06:20PM ALT(SGPT)-7 AST(SGOT)-16 ALK PHOS-122* TOT
BILI-0.3
[**2132-2-20**] 06:29PM LACTATE-2.0
Pertinent Labs:
[**2132-2-21**] 02:43AM BLOOD FDP-0-10
[**2132-2-21**] 02:43AM BLOOD Fibrino-320#
[**2132-2-23**] 03:40AM BLOOD cTropnT-<0.01
[**2132-2-21**] 02:43AM BLOOD Hapto-149
[**2132-2-24**] 02:57AM BLOOD TSH-2.1
[**2132-2-24**] 03:36PM BLOOD Cortsol-7.9
[**2132-2-24**] 05:52PM BLOOD Cortsol-17.0
[**2132-2-26**] 02:52AM BLOOD Vanco-18.1
MICRO:
2/2 Blood cultures x3 - No Growth.
[**2132-2-21**] 5:22 pm SWAB Source: Left heel wound.
**FINAL REPORT [**2132-2-25**]**
GRAM STAIN (Final [**2132-2-21**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final [**2132-2-25**]):
Due to mixed bacterial types (>=3) an abbreviated workup
is
performed; P.aeruginosa, S.aureus and beta strep. are
reported if
present. Susceptibility will be performed on P.aeruginosa
and
S.aureus if sparse growth or greater..
Work-up of organism(s) listed below discontinued (excepted
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
PROTEUS MIRABILIS. SPARSE GROWTH. PRESUMPTIVE
IDENTIFICATION.
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
sensitivity testing performed by Microscan.
MEROPENEM IS SENSITIVE AT <=1 MCG/ML.
AMIKACIN IS SENSITIVE AT <=4 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| PSEUDOMONAS AERUGINOSA
| |
AMIKACIN-------------- S
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S 16 I
CEFTAZIDIME----------- <=1 S 16 I
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R =>2 R
GENTAMICIN------------ <=1 S =>8 R
MEROPENEM------------- 0.5 S S
PIPERACILLIN/TAZO----- <=4 S 16 S
TOBRAMYCIN------------ <=1 S =>8 R
TRIMETHOPRIM/SULFA---- =>16 R
[**2132-2-22**] 4:23 am URINE Site: CATHETER
**FINAL REPORT [**2132-2-23**]**
URINE CULTURE (Final [**2132-2-23**]):
YEAST. ~9000/ML.
[**2132-2-26**] BLOOD CULTURE- NGTD (PENDING ON DISCHARGE)
STUDIES:
[**2132-2-20**] EKG: Sinus tachycardia. Generalized low voltages are
non-specific but clinical correlation is suggested. Since the
previous tracing of [**2131-11-6**] sinus tachycardia rate is faster.
[**2132-2-20**] CXR: No focal opacity to suggest pneumonia is seen. No
pleural
effusion, pulmonary edema, or pneumothorax is present. The heart
size is
normal. Dextroscoliosis of the lower thoracolumbar spine is
unchanged. The
pleural surface contours are normal. Previously seen venous
catheters have
been removed.
IMPRESSION: No evidence of acute cardiopulmonary process.
[**2132-2-20**] FOOT AP/LAT/OBL: 1. Extensive lateral, plantar and medial
foot ulceration. 2. Findings concerning for development of
osteomyelitis at the base of the fourth and fifth metatarsals
[**2132-2-23**] ECHO: The left atrium is normal in size. Left ventricular
wall thickness, cavity size, and global systolic function are
normal (LVEF>55%). Due to suboptimal technical quality, a focal
wall motion abnormality cannot be fully excluded. The aortic
valve leaflets (?#) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Preserved global left
ventricular systolic function. Right ventricle not
well-visualized.
[**2132-2-24**] MRI LEFT FOOT:
1. Multiple areas of skin ulceration, over the medial, lateral,
and plantar foot, extending near to the bone in several areas,
with edema and enhancement seen within the lateral cuboid, and
base of the fifth metatarsal, and also within the navicular
bone, concerning for osteomyelitis.
2. Findings most consistent with neuropathic osteoarthropathy
within the
midfoot. Changes within the calcaneus could be postoperative
and/or sequelae of prior infection.
3. Diffuse soft tissue edema, and edema within the plantar
musculature.
[**2132-2-25**] MRI PELVIS: 1. Markedly abnormal study showing a large
deep right gluteal decubitus ulcer extending to the right iliac
bone, as before. Chronic osteomyelitis in the right ilium with
acute on chronic osteomyelitis and small fluid collection in the
posterior right ilium adjacent to the SI joint and small
collection about the superior right ilium.
2. Asymmetric amount of fluid in right sacroiliac joint, may be
reactive in the setting of acute osteomyelitis, presence of
infection is not excluded.
3. Decubitus ulcer extends to the perineum and in close
proximity to the
urethra with persistent foci of air and marked enhancement in
the perineal
region.
4. Status post Girdlestone procedure versus extensive
destruction of the
right hip from infection, correlation with past surgical history
is advised.
5. Marked muscle atrophy and edema about the pelvic girdle.
6. Left parasympyseal abnormality may be due to reactive changes
versus acute osteomyelitis.
DISCHARGE LABS:
141 119 3
------------ <89
3.5 19 0.2
Ca: 7.1 Mg: 2.2 P: 2.6
MCV 72
6.2
7.7> <268
20.6
Repeat hematocrit: 23.7
Brief Hospital Course:
46 year old female with a history of transverse myelitis (T7)
with subsequent paraplegia, multiple dependent ulcers (including
stage IV decubitus ulcer), left heel ulcer osteomyelitis s/p
treatment in [**2130**], and now recurrent left foot osteomyelitis who
presents with hypotension and tachycardia concerning for sepsis.
.
# Osteomyelitis of left foot and pelvis: Patient was empirically
started on vancomycin and meropenem given previous culture
sensitivitis for treatment of her osteomyelitis. A wound swab of
her left heel was done which grew out proteus and pseudomonas on
culture (see above for sensitivities). She was continued on her
her vancomycin and meropenem per infectious disease
recommendations. She underwent MRI of both her left foot on [**2-23**]
showing multifocal osteo and her pelvis also showing chronic
osteo of the R ilium. Given the multifocal and significant
disease burden, debridement and amputation were tabled during
this admission and therapy with antibiotics alone was pursued.
Patient will need to follow up with outpatient infectious
disease specialists for further management as well as with her
outpatient orthopedic surgeon to discuss possible future left
below knee amputation. Vancomycin level should be checked the
evening of arrival to rehab with dosing adjusted for a goal
trough of 15 to 20. Dosing prior to discharge with achievement
of this level was 1.25 g daily. She will coninue Vanc and [**Last Name (un) **]
for 6 weeks with an end date of [**4-2**].
.
# Tachycardia/hypotension: Initially there was high concern for
sepsis given her pressures in the 70s and tachycardia in the
130s. She was fluid resuscitated with some initial response
which tapered off, and then was started on levophed. Even on
levophed, MAPs were in the 50s to 60s. The levophed was tapered
off and patient remained with similar pressures. It appears the
patient's baseline blood pressures are in the 80s-90s, and her
heart rate on numerous inpatient and outpatient visits has been
consistently in the 120s to 130s. Septic physiology was felt to
be less concerning given patient's decent urine output and
appropriate mentation. EKG showed sinus tachycardia
consistently. Differential for the patient's strange
hemodynamics include neurogenic causes given her transverse
myelitis as volume repletion, pressors, and treatment of her
infection had little effect on her heart rate and blood
pressure. The possibility of PE was considered but was felt
unlikely given the patient's pristine oxygen saturations on room
air, lack of dyspnea and baseline paraplegia as well as the
chronic nature of her hemodynamics. She was given enoxaparin for
DVT prophylaxis. An ECHO showed preserved global ventricular
function without effusion. We would not be alarmed when her
heart rates and blood pressures continue to trend in the
120s-130s and 80s-90s persistently as this is her baseline.
Concern for decompensation would be heightened if her mental
status were to deteriorate or urine output were to fall. We also
noticed that anxiety and pain were at times contributors and
recommend continuing her lorazepam and morphine as needed.
# Anemia- Patient with baseline hematocrit around 25 (microcytic
anemia). She remained close to this baseline during
hospitalization with an occasional dip to 20. On the morning of
discharge hematocrit was 20- on recheck it was 23.7. She
remained at her hemodynamic baseline without signs of bleeding.
Hemolysis and DIC labs negative. Continued her home iron
supplements. Of note, patient is not a candidate for blood
transfusions given her religious views (Jehovah??????s witness).
.
# Diarrhea- Patient reported diarrhea for 1 month. However
during her hospitalization she had no episodes of diarrhea and
actually did not stool for several days. Eventually with a
loosely formed BM with lactulose. Given no abdominal pain and no
diarrhea during hospitalization, concern for C. diff was low.
Recommend monitoring stools since patient is at risk given her
long term antibiotics.
.
# Psychotic disorder- Patient with a history of chronic
schizophrenia (paranoid and disorganized features) currently
stable. She was seen by psychiatry who felt she was currently
competent to make decisions. She was continued on her home
zyprexa 5 mg PO qHS and home ativan. She also received her home
dose of risperdal 50 mg IM on [**2-25**]. She will need to receive her
next dose on [**3-10**] (medicine is written for every two weeks).
.
# Neurogenic bladder- Chronic Foley use leading to wide open
patulous urethral meatus, requiring Foley to be blown up 30 cc.
Seen by urology in the ED and Foley catheter placed. She was
given ditropan (is on vesicare at home) and foley was left in
place. Urine output was hard to track as patient leaks around
catheter, but she appeared to be putting out good urine.
.
# Sacral decubitus ulcer- Stage IV, extensive ulcer with deep
involvement extending from posterior to anterior surfaces. Did
not appear infected on superficial examination, though clearly
with underlying infection given MRI findings. She was seen by
wound care who recommended dressing changes as above. She was
also seen be Dr. [**Last Name (STitle) **], a plastic surgeon, who felt there was
no acute indication for debridement, but felt that she would
benefit from outpatient follow up and consideration of a skin
flap. She will need to follow up at the scheduled appointment.
As per wound care recsp atient should not sit up in her
wheelchair.
On DC needs to pursue wheelchair repair and seating eval. The
wound care clinic may be able to help with this.
.
# Nutrition- Laboratory results suggest significant nutritional
deficiencies with albumin of 1.6 and elevated coags. She was
given a regular diet with ensure supplements.
.
# HCP: Aunt [**Name (NI) **] [**Name (NI) 108749**]: [**Telephone/Fax (1) 108750**]
.
# Code: DNI, ok to resuscitate (discussed with patient and
sister)
Medications on Admission:
Bactrim 1 DS [**Hospital1 **]
Ciprofloxacin 500mg [**Hospital1 **]
vesicare 5 mg PO daily
lorazepam 0.5 mg PO QID PRN
risperdal consta 15 mg/3l IM q2 weeks; (last dose 1/24 ->
recently changed from 37.5 mg)
zyprexa 5 mg qHS (last filled in [**Month (only) **])
zinc sulfate 220 mg daily
ferrous sulfate 325 mg daily
colace 100 mg PO daily
senna
vitamin C 500
vitamin E 400
multivitamin
bisacodyl 10 mg PR PRN
Oxybutynin 15 qam
Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for anxiety.
4. olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for bladder spasms.
6. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day). Tablet(s)
7. risperidone microspheres 50 mg/2 mL Syringe Sig: One (1)
Syringe Intramuscular Q2W (MO): Last Dose 2/7.
8. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
9. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
reflux/indigestion.
10. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q
24H (Every 24 Hours).
11. meropenem 1 gram Recon Soln Sig: One (1) Intravenous every
eight (8) hours for 8 weeks: Start [**2132-2-20**]
End [**2132-4-2**].
12. vancomycin 500 mg Recon Soln Sig: 2.5 Recon Solns
Intravenous Q 24H (Every 24 Hours) for 8 weeks: Start [**2132-2-20**]
End [**2132-4-2**].
13. Vesicare 5 mg Tablet Sig: One (1) Tablet PO once a day.
14. zinc sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO
once a day.
15. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO once a day.
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
17. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day.
18. vitamin E 400 unit Capsule Sig: One (1) Capsule PO once a
day.
19. multivitamin Capsule Sig: One (1) Capsule PO once a day.
20. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*36 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis
Osteomyleitis
Hypotension
Tachycardia
Secondary
Stage IV Sacral Decubitus Ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted to the ICU because you had low blood pressures
and a fast heart rate which were concerning for infection. You
had multiple tests, including MRI's of your foot and back which
showed a possible bone infection. You will complete an 8 week
course of IV antibiotics.
It appears that your blood pressure typically runs low. You
tolerate these low blood pressure well therefore it does not
require treatment.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 11705**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 **] PLASTIC SURGERY, PC
Address: [**Street Address(2) **], [**Apartment Address(1) 1427**], [**Location (un) **],[**Numeric Identifier 1415**]
Phone: [**Telephone/Fax (1) 1416**]
Appointment: Wednesday [**3-5**] at 9:30AM
Department: INFECTIOUS DISEASE
When: THURSDAY [**2132-3-13**] at 2:30 PM
With: [**Doctor First Name 1412**] [**Name Initial (MD) **] [**Name8 (MD) 1413**], M.D. [**Telephone/Fax (1) 457**]
Building: LM [**Hospital Unit Name **] [**Hospital 1422**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Name: [**Last Name (LF) 1005**], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], PHD
Location: [**Hospital1 **]
DEPT OF ORTHOPEDICS
Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 1228**]
**We are working on a follow up appointment with Dr. [**Last Name (STitle) 1005**]
within 1-2 weeks. You will be called with the appointment. If
you have not heard from the office within 2 days or have any
questions, please call the number above.
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**]
|
[
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"707.14",
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"038.9",
"730.17",
"326",
"344.1",
"V15.81",
"041.7",
"730.07",
"311",
"295.32",
"785.52",
"707.04",
"041.6",
"785.4",
"V12.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
20106, 20205
|
11811, 17738
|
301, 308
|
20348, 20348
|
5634, 5634
|
20928, 22288
|
3471, 3475
|
18216, 20083
|
20226, 20327
|
17764, 18193
|
20483, 20905
|
11664, 11788
|
3490, 3490
|
4574, 5615
|
2382, 2392
|
237, 263
|
336, 2363
|
5650, 6174
|
3504, 4560
|
20363, 20459
|
6190, 11647
|
2414, 2908
|
2924, 3455
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,978
| 102,829
|
44384
|
Discharge summary
|
report
|
Admission Date: [**2179-10-31**] Discharge Date: [**2179-11-12**]
Date of Birth: [**2128-2-5**] Sex: M
Service: MEDICINE
Allergies:
Latex
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Low urine output
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a 51 year-old M w/ a h/o MS, quadraparesis, HTN,
[**First Name3 (LF) 12382**] lung disease, chronic constipation and SBOs s/p
ileostomy, multiple UTIs (also s/p suprapubic tube) presents
with SBO and UTI. Of note he was just recently discharged from
the [**Hospital1 18**] on [**10-28**] for an admission for a UTI (negative cultures)
treated with cipro, shingles treated w/ acyclovir and SBO
evaluated by surgery but managed conservatively. He returns
today as his home health aide had noticed his decreased urine
output, 75cc overnight when he usually has about 1 liter
overnight. His ostomy output has been high. The patient himself
was not sure if he has had a change in his ostomy output or
suprapubic output.
.
Over the past two weeks he has had mild earaches, a sorethroat
as well as some rhinorrhea. He has not noticed any watery /
itchy eyes, any visual changes, or any new neurologic symptoms.
He denies any abdominal pain and has not subjectively noticed
any change in abdominal distention. He denies any pain in
regards to his zoster (now or when diagnosed). Denies CP, has
an occasional cough that is not worsening. Of note, his sister
reports he does not report pain unless it is extreme.
.
In the ED, he was noted to be severely dehydrated on exam. His
BP nadir was 79/43 and HR peak was 97. T 99 (he usually "runs
low"), new ARF 1.4 up from 0.6. Rec'd levo / flagyl / vanc.
Seen by Surgery who state the SBO is not high grade and he is
losing fluid from ileostomy. NGT placed. Rec'd 6L of fluids.
VS prior to transport were: HR 72 BP 112/79 100% 4L NC
(initially sating well on RA but may have aspirated w/ NGT
plcmt- desat to 92% w/ coughing and SOB).
Past Medical History:
-MS
[**Name13 (STitle) 95154**], LE weaker than UE
-HTN
-[**Name13 (STitle) **] lung disease
-obstructive sleep apnea, on nocturnal BiPAP (IPAP 16, EPAP 14)
-Severe gastroparesis
-Chronic constipation s/p colectomy with ileostomy
-Recurrent UTIs with suprapubic cath (changed monthly)
-Hyponatremia
-Appendectomy
-Left axillary lumpectomy
Social History:
Lives at home with parents and sister; has home health aid. No
alcohol. Quit smoking in [**2159**], with a 10-year tobacco history.
Family History:
Non-contributory
Physical Exam:
Vitals: T: 95.5 BP: 132/68 HR: 77 RR: 12 O2Sat: 98-100% on
RA
GEN: Well-appearing, well-nourished, no acute distress
HEENT: PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM,
OP Clear
NECK: JVP 7-8cm, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, 1/6 SEM @ USB w/o radiation
PULM: Lungs L base rales
ABD: distended, BS hypoactive, mild LLQ tenderness. No rebound
or guarding. Suprapubic site looks c/d/i. Ileostomy pink w/
bilious watery output.
EXT: No C/C/E, no palpable cords.
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
intact. + rotatory nystagmus. UE: [**6-7**] stregnth in grip, bicep,
triceps, deltoid, and trapezius. LE - [**Month/Day (1) 5348**] inability to
move lower extremities. significant bilateral clonus in lower
extremities. Reflexes 2+ UE bilat symmetrical, LE 3+ bilat
symmetrical.
Pertinent Results:
On Admission:
[**2179-10-31**] 10:25AM WBC-15.7*# RBC-3.71* HGB-11.2* HCT-33.4*
MCV-90 MCH-30.3 MCHC-33.6 RDW-14.7
[**2179-10-31**] 10:25AM NEUTS-83.9* LYMPHS-8.9* MONOS-6.1 EOS-1.0
BASOS-0.1
[**2179-10-31**] 10:25AM PLT COUNT-524*#
[**2179-10-31**] 10:25AM GLUCOSE-116* UREA N-15 CREAT-1.4* SODIUM-128*
POTASSIUM-5.1 CHLORIDE-94* TOTAL CO2-23 ANION GAP-16
[**2179-10-31**] 12:05PM URINE RBC-[**4-7**]* WBC->50 BACTERIA-MANY
YEAST-MANY EPI-0-2
[**2179-10-31**] 12:05PM URINE MUCOUS-MOD
[**2179-10-31**] 10:35AM LACTATE-2.4* K+-4.8
[**2179-10-31**] 12:05PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
[**2179-10-31**] 12:05PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.010
[**2179-10-31**] 08:26PM URINE HOURS-RANDOM CREAT-105 SODIUM-55
[**2179-10-31**] 09:03PM LACTATE-0.9
Brief Hospital Course:
#. Partial small bowel obstruction: Within past 6 months he has
had several admits with partial obstruction. Presented with
considerable ileostomy output and hypotension. KUB and CT
abdomen consistent with partial obstruction. Surgery was
consulted and felt either partial SBO or unchanged from prior
admission given the amount of ostomy output. Recommended to
watch for cessation of output or signs of peritonitis, as these
would be indications of worsening and surgery would be
considered. At that time, there was no indication for surgery.
An NG tube was placed for gut decompression, and the patient was
kept NPO and given IVF. We attempted to match ostomy output with
IV fluids. Per Surgery recommendations, we consulted GI to
consider placement of G tube, given the frequency of these
episodes. Consideration was given to opening this tube for
decompression if he becomes obstructed again. He was evaluated
by GI on [**2180-11-1**], and they felt that G tube would not be
appropriate in the setting of an acute partial obstruction, and
we would re-address if this is something the family would want
in the future. If so, they recommended that IR may be more
appropriate for placement given his aspiration risks.
.
The possibility of undiagnosed Crohn's disease accounting for
distal small bowel strictures, which in turn have been
contributing to SBOs, was raised and discussed at length. If
confirmed, GI would recommend a trial of empiric steroids. The
GI team also contact[**Name (NI) **] Pathology to re-cut tissue from frozen
sections of colon, resected during prior surgeries, to look for
evidence of IBD. Of significant concern was that if Mr. [**Known lastname 26173**]
does have Crohn's, starting him on steroids would be
challenging. The risks could outweigh the benefits, and it
would be unlikely that steroids would reverse the small bowel
strictures already present. In addition, we would need to
involve his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], and his neurologist, Dr. [**Last Name (STitle) 95158**],
in the discussion. We would also need to readdress his
overall goals of care, as his family has been considering
hospice care.
.
Given his prolonged NPO status, he was started on TPN. Mr.
[**Known lastname 95159**] obstruction gradually improved with NGT to suction, and
it was clamped on [**2179-11-8**]. His ostomy output increased and it
was decided to proceed with small bowel MR enterography to look
for evidence of bowel wall inflammation or strictures to support
the diagnosis of possible IBD. There was no evidence of this.
We concluded his recurrent SBOs are most likely secondary to
worsening multiple sclerosis. He continued to improve
clinically, and his NGT was removed on [**11-11**]. The following day
he had a swallowing evalution, which showed no evidence of
aspiration, and he was started on a regular diet. His family was
eager to take him home to gradually advance his diet there. TPN
was discontinued.
.
# UTI: No fevers on admission but he had leukocytosis and
hypotension, likely due to hypovolemia, as well as elevated
lactate. Prior pathogens have included Pseudomonas, with a MIC
of 9 for cefepime and zosyn, and MRSA. He was initially
empirically started on vancomycin and ceftazidime. Urine culture
grew few gram negatives (likely contaminant) and yeast. As his
leukocytosis and hypotension improved, and given the above urine
culture, ceftazidime was discontinued.
.
# Hypotension: This was attributed to hypovolemic shock, and
initially also possibly due to sepsis. This improved with IVF
resuscitation. In addition, given his initial hyponatremia and
hyperkalemia, a.m. cortisol was checked and found to be normal.
.
# Acute renal failure: On admission. FeNa 0.6% indicating likely
prerenal etiology. Resolved with administration of IVF.
.
# OSA: Desatting to 60s without BiPap. Needs to be on BiPap at
night. Has machine at home.
.
# Anemia: Hematocrit 27.8 on [**2179-11-2**], down from 33.4 at
admission. Was likely hemoconcentrated on admission given
dehydration. No evidence of acute blood loss. Hematocrit was
monitored daily, and he was maintained on his daily folic acid.
.
# Hypertension: Restarted on lisinopril per home regimen on
[**2179-11-2**]. Dose titrated up to 10 mg/day on [**11-10**] as patient was
persistently hypertensive.
.
# Multiple sclerosis: Methotrexate weekly given IM. Dose
confirmed with Neurologist.
.
#Goals of care: Patient lives with his supportive family, with
his mother as his primary caretaker along with his sister who
lives nearby. They are very devoted to him and recognize that
his disease is quite advanced. Discussions were held between
the patient's mother and sister and the attending, Dr. [**Last Name (STitle) **],
who also spoke with the patient's PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**]. They wish
to take Mr. [**Known lastname 26173**] home as soon as possible. They have a hospice
program that is ready to accept him into their care when they
are ready and know how to activate this benefit when they feel
it is time.
Medications on Admission:
Gabapentin 300 mg po q6hrs
Folic Acid 1 mg po daily
Metoclopramide 10 mg po qid AC and HS
Erythromycin 250 mg po q6hrs
Modafinil 200 mg po bid
Memantine 10 mg Tablet po bid
Lisinopril 5 mg po daily
Methotrexate Sodium 15mg (6x2.5mg tablets) po q week on sundays
Acyclovir 800 mg po q8hrs, end date [**2179-10-31**]
Ciprofloxacin 250 mg po q12hrs x 3 days, last day [**2179-10-31**]
Prilosec
Guaifenesin 600 mg po bid
Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q6HRS ().
2. Memantine 5 mg Tablet Sig: Two (2) Tablet PO bid ().
3. Modafinil 100 mg Tablet Sig: Two (2) Tablet PO bid ().
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Methotrexate Sodium 15 mg Tablet Sig: One (1) Tablet PO once
a week: on Sundays.
7. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO four times
a day: QAC and QHS.
8. Erythromycin 250 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO twice a day.
Discharge Disposition:
Home With Service
Facility:
Gentiva
Discharge Diagnosis:
-- small bowel obstruction
-- chronic constipation s/p colectomy with ileostomy
-- multiple sclerosis
-- hypertension
-- [**Month/Day/Year 12382**] lung disease
-- obstructive sleep apnea on nocturnal CPAP
Discharge Condition:
Clinically stable, tolerating a regular diet.
Discharge Instructions:
You were admitted with recurrent small bowel obstruction. You
were treated with bowel rest and decompression via nasogastric
tube. You were followed closely by the GI consult team, and an
MRI enterogram did not show any evidence of inflammatory bowel
disease. After your obstruction improved, we clamped and
eventually removed your NG tube. You did well with a swallowing
evaluation and can eat and drink whatever you'd like when you go
home.
Followup Instructions:
Please contact your [**Name (NI) 6435**] office (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 665**]) if you would
like an appointment.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
Completed by:[**2179-11-17**]
|
[
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"340",
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"518.89",
"536.3",
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"785.59",
"564.09",
"276.6",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10729, 10767
|
4375, 9472
|
283, 289
|
11017, 11065
|
3481, 3481
|
11556, 11855
|
2540, 2558
|
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10788, 10996
|
9498, 9916
|
11089, 11533
|
2573, 3462
|
227, 245
|
317, 2011
|
3496, 4352
|
2033, 2374
|
2390, 2524
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,998
| 102,433
|
25823
|
Discharge summary
|
report
|
Admission Date: [**2170-5-29**] Discharge Date: [**2170-6-11**]
Date of Birth: [**2128-3-18**] Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin
Attending:[**First Name3 (LF) 3705**]
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
42 y.o. female smoker with COPD, HTN, sleep apnea, CHF, and
HTN, on home O2, transferred from OSH for "possible open lung
biopsy." Patient was initially admitted to [**Hospital 882**] Hospital on
[**5-26**] with DOE, SaO2 of 67%, low-grade fevers to 100.1, and
palpitations [**1-18**] anxiety after three days of medication
non-compliance. Patient is not able to give any reason for her
non-compliance. She denies chest pain, dysuria, lower extremity
swelling or pain, or any rashes. She does report that she had a
bout of diarrhea, vomiting, and nausea lasting approximately
three weeks which ended suddenly this past Friday. She has had
a normal formed BM x 1 since then, and denies any abdominal
pain, melana, BRBPR, hemetemesis, or hematochezia. She saw her
PCP who put her on the BRAT diet but did not recommend any
further work-up. She denies any recent travel, sick contacts,
or changes in her routine.
.
At the OSH pt became hypoxic on the floor, unable to maintain
her sats even on 100% by NRB so she was transferred to the ICU.
She was started on BiPAP with significant improvement in her
oxygenation and treated with solumedrol 80 mg IV. She was found
to have a RLL infiltrate concerning for PNA and she was started
on Levaquin. She had a chest CT with significant new findings
as described below and was transferred to [**Hospital1 18**] for further
work-up and management.
Past Medical History:
Asthma: h/o multiple hospitalizations and intubations x1
([**2167-12-17**]) - no prednisone x 8 months [**1-18**] ?allergy, has been
getting solumedrol without difficulty
HTN
pulmonary HTN
tobacco use
sleep apnea
CHF
anxiety attacks w/palpitations
allergic rhinitis
Hypothyroidism
HTN
endometriosis, s/p hysterectomy 97
BPD/Depression
GERD
Migraines
DJD
morbid obesity
chronic lower back pain - on narcotics
osteoporosis
h/o elevated right heart pressures on angiogram performed
in [**2168-8-17**] for suspicious stress test. Clean Cs
.
Past surgical Hx:
cholecystectomy
foot surgery
shoulder surgery
s/p two c-sections
Social History:
She smokes 1.5 PPD x 25 years. Husband also smokes. No
alcohol, no IVDU. Homemaker on disability. She has three
children (22, 20, 14.) No environmental exposures.
Family History:
Father has diabetes with coronary artery disease, angina, and
hypertension. Mother, history of breast cancer and ultimately
died of lung cancer at age 61. She has a brother and fraternal
twin sister who are healthy.
Physical Exam:
VS: 83 111/64 33 95% on 15L by NRB
Gen: middle-aged obese woman in NAD
HEENT: EOMI, OP thick yellow-brown coating on tongue
Chest: coarse breath sounds throughout, harsh crackles, wheezes,
squeaks, gurgles
CVS: RRR, no m/r/g, JVD flat
Abd: soft, NT, ND, + BS, no HSM, erythema beneath pannus
Extrem: no c/c/e, + 2 DP pulses
Neuro: alert, oriented, CN II - XII grossly intact
Pertinent Results:
Relevant labs (OSH)Ddimer: 1.6
WBC: 20, left-shift
ABG (6L by NC) 7.36/51/53
ECG: SR, rate 113, normal axis & intervals, no acute ST changes
.
Relevant imaging (OSH)
CXR: no cardiomegaly, + bilateral honeycomb appearance c/w
interstitial lung disease, + RLL infiltrate, cannot rule out LLL
infiltrate
.
Chest CT ([**5-26**]): no evidence of PE; mediastinal and hilar LAD;
relatively diffuse confluent alveolar opacities throughout the
lungs BL, new since previous CT of [**4-24**]
.
Pathology review of consult slides from [**Hospital3 **] Hospital from
date wedge resection [**11-20**]: RUL with hemorrhagic infarct and RLL
with focal, acute organizing pneumonitis
Brief Hospital Course:
A/P: 42 y.o. woman with [**Hospital 2182**] transferred from OSH for unclear
reasons after presenting with COPD exacerbation in the setting
of medication non-compliance and possible PNA.
.
#Respiratory Distress/COPD: Patient was transferred from the
[**Hospital1 1562**] ICU directly to the [**Hospital Unit Name 153**]. The differential was wide.
She is not neutropenic but her chest CT is most consistent with
an infection, especially given the acute onset. Infectious
etiologies include viral (RSV, parainfluenza, influenza,
adenovirus), bacterial (mycoplasma), and less likely fungal.
Also on the differential are allergic bronchopulmonary
aspergillosis and less common interstitial pneumonias such as
acute eosinophilic pneumonia; however, preliminary CT read by
[**Hospital1 18**] radiologists seemed to indicate an alveolar process.
Studies were sent: legionella antigen (negative),
mycoplasma titer (pending), IgE level ([**2169**], high), nasal swab
for viral cx (pending), HIV (pending), and DFA for influenza
(negative.) Patient was unable to produce a specimin for sputum
culture. She was continued on Levofloxacin for likely atypical
versus viral pneumonia and treated with her usual home
medications including atrovent, singulair, and xopinex, which
was subsequently changed to albuterol without ill effect. She
was treated with steroids at the OSH, and these were continued,
initially as 80 mg solumedrol Q8H, which was then transitioned
to medrol, and the plan is to do a long, slow medrol taper over
the course of about 1 month. She remained stable on 100% by
non-rebreather and she was started on BiPap at night, which she
tolerated reasonably well. This was started to decrease her
work of breathing and because she has known sleep apnea and has
only been waiting for insurance approval before beginning home
BiPap. Her respiratory status continued to improve with
treatment and patient now has stable oxygen saturations on 4L by
NC. After review of her case at pulmonary conference it was
decided that a biopsy after several weeks on steroids would be
non-diagnostic, therefore the decision was to keep her on a slow
steroid taper and if she recurrs biopsy her at that time. She
will go home on 2 weeks of 48 mg medrol, and taper by 6 mg every
week for a total of 7 more weeks of steroids. She will follow up
with her regular pulmonologist, Dr. [**Last Name (STitle) 47851**], of [**Hospital 1562**]
hospital, and arrange to have PFTs in [**Month (only) 205**]. She will then follow
up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] here at [**Hospital1 **] [**2170-7-3**] in clinic. If she
develops recurrent disease/symptoms she will likely need a
biopsy at that time.
.
#HTN: Currently normotensive; held cardizem while an inpatient,
and was never hypertensive. Follow up with PCP regarding
restarting this medication.
.
#Elevated blood glucose: Does not currently carry a diagnosis of
diabetes but had some notably high sugars at OSH; HgA1C was 5.7.
While in [**Hospital Unit Name 153**], patient was covered with a regular insulin
sliding scale. She was sent home on a sliding scale regular
insulin. She likely will not need this when she comes off
steroids.
.
#Anxiety: cont ativan TID PRN
.
#BPD/Depression: stable, cont abilify, effexor, lamictal
.
#Hypothyroidism: stable
- cont levothyroxine
.
#Migraines: stable, cont imitrex PRN
.
#lower back pain: stable; cont ultram
.
#FEN: Cardiac diet; replete lytes PRN
.
#PPX: Heparin SQ TID, PPI, pneumoboots
.
#ACCESS: PIV
.
#COMM: patient; husband
.
#CODE: FULL - confirmed with patient.
.
#DISPO: ICU
Medications on Admission:
Meds at Home:
Aciphex 20 QD
Lasix 80 PO QD
Zyflo 600 TID
Abilify 5 QD
Imitrex injection 6 mg p.r.n.
Loratidine 10 QHS
Singulair 10 mg h.s.
Effexor XR 112 mg p.o. QD
Lamictal 150 mg QD
Levoxyl 100 mcg QD
Potassium 10 mEQ QD
Actonel 35 Q Sunday
Oxycodone 10 mg Q6H
Ativan 1 mg t.i.d.
Xolair 375 Q 2 weeks
Atrovent QID and Q2H PRN sob
Xopenex QID
oxygen 3 liters h.s. and p.r.n. (about [**1-19**] x per day)
.
Meds on Xfer:
Aciphex 20 QD
Lasix 80 PO QD
Zyflo 600 TID
Abilify 5 QD
Imitrex injection 6 mg p.r.n.
Loratidine 10 QHS
Singulair 10 mg h.s.
Effexor XR 112 mg p.o. QD
Lamictal 150 mg QD
Levoxyl 100 mcg QD
Potassium 10 mEQ QD
Actonel 35 Q Sunday
Oxycodone 10 mg Q6H
Ativan 1 mg t.i.d.
Xolair 375 Q 2 weeks
Atrovent QID and Q2H PRN sob
Xopenex QID
oxygen 2 liters h.s. and p.r.n.
Discharge Medications:
1. One Touch UltraSoft Lancets Misc Sig: qs 1 month Miscell.
four times a day: Please give lancets qs 1 month.
Disp:*qs 1 month* Refills:*3*
2. One Touch Ultra Test Strip Sig: One (1) strip Miscell.
four times a day: qs 1 month.
Disp:*qs 1 month* Refills:*3*
3. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale
sliding scale Injection four times a day.
Disp:*qs 1 month* Refills:*3*
4. Aripiprazole 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
5. 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*
6. Sumatriptan Succinate 6 mg/0.5 mL Solution Sig: Six (6) mg
Subcutaneous X1 (ONE TIME) as needed for migraines.
7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
Disp:*30 Tablet(s)* Refills:*2*
9. Lamotrigine 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily).
10. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Risedronate 35 mg Tablet Sig: One (1) Tablet PO Q sunday ().
12. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours as needed for shortness of breath
or wheezing.
Disp:*qs 1 month* Refills:*3*
14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
16. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
Disp:*qs 1 month* Refills:*2*
17. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR
Transdermal DAILY (Daily).
Disp:*qs 1 month* Refills:*0*
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
Disp:*qs 2 weeks* Refills:*0*
19. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed.
Disp:*qs 2 weeks* Refills:*3*
20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q4H (every 4 hours): Can also take prn q2h as needed.
Disp:*qs 1 month* Refills:*2*
21. Venlafaxine 37.5 mg Capsule, Sust. Release 24HR Sig: Three
(3) Capsule, Sust. Release 24HR PO DAILY (Daily).
22. Methylprednisolone 8 mg Tablet Sig: Six (6) Tablet PO DAILY
(Daily) for 7 weeks: Take 6 tabs daily for the next 2 weeks,
then take 5 tabs daily for 1 week, then take 4 tabs daily for
one week, then take 3 tabs daily for one week, then take 2 tabs
daily for one week, then 1 tab daily for one week, then stop.
Disp:*189 tablets* Refills:*0*
23. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO 3X/WEEK (MO,WE,FR).
Disp:*90 Tablet(s)* Refills:*2*
24. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
25. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
26. CALCIUM 500+D 500-400 mg-unit Tablet, Chewable Sig: One (1)
Tablet, Chewable PO twice a day: Please take at least 3 hours
apart from your levothyroxine.
Disp:*60 Tablet, Chewable(s)* Refills:*2*
27. Insulin Syringe [**12-18**] mL 29 x [**12-18**] Syringe Sig: One (1)
syringe Miscell. four times a day.
Disp:*qs 1 month* Refills:*3*
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
Interstitial Lung Disease NOS
Chronic Obstructive Lung Disease
Asthma
Pneumonia
Discharge Condition:
stable, satting well on 4L NC
Discharge Instructions:
Please continue using your oxygen at 4-5L NC continuous. Please
continue your solumedrol dose for another 2 weeks at the current
dose and begin to taper by one pill each subsequent week. If you
feel that your breathing worsens while tapering this please call
your PCP or Dr. [**Last Name (STitle) **]. Follow up with your pulmonologist and
PCP. [**Name10 (NameIs) 357**] also weigh yourself daily and call your PCP if you
gain more than 3 lbs. Please also quit smoking.
Followup Instructions:
1. Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], your new
pulmonologist, on [**8-3**] at 11:30 am, please arrive at 11:10
for your breathing tests before your appointment. Located in
[**Last Name (un) 469**] Building [**Location (un) 436**]. You can call [**Telephone/Fax (1) 612**] if you
have questions/concerns.
2. Please follow up with your PCP in the next week.
3. Please also follow up with your regular pulmonologist, Dr.
[**Last Name (STitle) 47851**], and arrange to have pulmonary function tests done with
him in [**Month (only) 205**]. Please bring the results of these to your visit
with Dr. [**Last Name (STitle) **].
|
[
"799.02",
"305.1",
"518.81",
"296.7",
"790.6",
"327.23",
"493.22",
"515",
"428.0",
"300.4",
"V15.81",
"486",
"401.9",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"93.90"
] |
icd9pcs
|
[
[
[]
]
] |
11745, 11806
|
3892, 7509
|
286, 293
|
11930, 11962
|
3200, 3869
|
12481, 13164
|
2569, 2789
|
8343, 11722
|
11827, 11909
|
7535, 8320
|
11986, 12458
|
2804, 3181
|
243, 248
|
321, 1719
|
1741, 2367
|
2383, 2553
|
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