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3,081
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14656
|
Discharge summary
|
report
|
Admission Date: [**2131-7-25**] Discharge Date: [**2131-7-30**]
Date of Birth: [**2086-7-8**] Sex: F
Service: GYNECOLOGY
HISTORY OF PRESENT ILLNESS: The patient is a 45 year-old
gravida 5 para 1, last menstrual period [**2131-7-11**] who
presented with severe dysmenorrhea and dysfunctional uterine
bleeding. The patient had known uterine fibroids. She
complained of irregular bleeding and endometrial biopsy,
however, was not possible given her discomfort. The most
recent ultrasound revealed a multifibroid uterus with the
largest fibroid posterior and measuring 3 cm. The
endometrial stripe was 8 mm and homogenous. The right ovary
was normal with two small clear cysts. The patient desired
definitive therapy for her dysmenorrhea.
PAST OB HISTORY: C section for twins.
PAST GYN HISTORY: Last menstrual period [**2131-7-11**], menorrhagia
and dysmenorrhea, unable to do endometrial biopsy due to
patient discomfort. Status post tubal ligation. No history
of sexually transmitted disease. Last pap [**2131-6-15**] normal.
Last mammogram [**2131-2-7**] abnormal with a 3 by 4 mm right benign
appearing density. Follow up scheduled in [**7-27**].
PAST MEDICAL HISTORY: History of multiple pneumonias most
recently in [**2131-5-26**], status post pelvic fracture
following a fall on 11/[**2129**]. The patient was hospitalized
times two weeks, rehab times one week. The patient still has
arthritis and limited mobility. The patient was also
hospitalized for a coma after a beating in [**2111**].
PAST SURGICAL HISTORY: C section times one, bilateral tubal
ligation. Status post left salpingo-oophorectomy.
MEDICATIONS: Celexa and Trazodone.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: History of smoking two packs per day,
history of alcohol abuse in the past. Normal liver function
tests [**4-25**]. History of domestic violence.
PHYSICAL EXAMINATION: Vital signs stable. Heart regular
rate and rhythm. Lungs clear bilaterally. Neck no
lymphadenopathy. Breast normal breast examination. No
masses. Abdomen soft, nontender, nondistended. No masses.
Pelvic, normal external genitalia. Cervix normal appearing.
Uterus anteverted, nontender, irregular contour and mobile.
No adnexal masses or tenderness. Extremities no clubbing,
cyanosis or edema.
ASSESSMENT: The patient is a 45 year-old gravida 5 para 1
with complaints of fibroids, dysmenorrhea and dysfunctional
uterine bleeding who desired surgical treatment. The patient
was admitted for a total abdominal hysterectomy on [**2131-7-25**].
HOSPITAL COURSE: 1. Gyn: On [**2131-7-25**] the patient underwent
a total abdominal hysterectomy. The patient was noted to
have a small uterus with a 3 cm posterior fibroid, absent
left tube and ovary, normal right ovary with small
hemorrhagic cyst. There were a few adhesions of the omentum
to the uterus. Estimated blood loss was 100 cc. There were
on complications. Please see operative note for details.
Following the surgery the patient had no complications from a
gyn perspective. Her incision was clean, dry and intact.
2. Pulmonary: On postoperative day number two the patient
was noted to have a decreased oxygen saturation of 69% on
room air, which increased to 86% on nonrebreather. Her lungs
were noted to have bilateral coarse crackles. She had an
arterial blood gas, which revealed a pH of 7.36, PO2 of 55
and PCO2 of 52. She had a chest x-ray, which showed diffuse
opacities consistent with congestive heart failure. Given
the patient's oxygen status she was transferred to the MICU.
There she was placed on a 100% nonrebreather. She underwent
a CT angiogram, which was negative for pulmonary embolus,
however, revealed diffuse alveolar and interstitial
infiltrates. The differential diagnosis at this time was a
diffuse atypical pneumonia versus congestive heart failure
versus other underlying process. She was maintained on the
O2. A repeat arterial blood gas revealed a pH of 7.39, PO2
of 72 and PCO2 of 50. She received multiple doses of
intravenous Lasix to which she had a good diuresis. She was
also started on antibiotics (see below). The pulmonary
service considered performing a lung biopsy, however, it was
decided that this would be performed after the patient was
stabilized. The patient was also seen by thoracic surgery
who recommended follow up lung biopsy when stabilized. The
patient was gradually weaned off the O2 and her oxygen
saturation improved. She was stable for transfer to the
regular floor on postoperative day number four. On the
regular floor her oxygen saturation was 91% on room air with
improvement to 96% on room air after incentive spirometry.
Her bilateral crackles had also resolved.
3. Infectious disease: The patient was seen by the ID
Service who thought that she could potentially have an
atypical pneumonia. She was initially started on intravenous
Levo, Vancomycin and Flagyl. The patient had multiple tests
sent including HIV, Legionella, cryptococcal antigen,
immunoglobulin studies and sputum cultures. She was noted to
have some thrush in her mouth and was started on Mycelex. On
postoperative day number three the Vancomycin and Flagyl were
discontinued and she was switched to just po Levaquin. Her
white blood cell count was elevated at 21.8 with 8 bands.
Follow up white blood cell count came down to 13. The
patient remained afebrile throughout the course of
hospitalization. She was discharged to home on Levaquin for
ten days.
4. Cardiovascular: The patient was thought to have an
element of mild congestive heart failure. She received Lasix
diuresis to which there was noted to be clinical improvement.
She underwent an echocardiogram, which revealed mild
pulmonary hypertension with an ejection fraction of greater
then 55%. The patient remained stable from that standpoint.
5. [**Last Name (STitle) 43161**]hylaxis: The patient was maintained on subcutaneous
heparin until she was ambulatory. She was also maintained on
Protonix for gastrointestinal prophylaxis. The patient was
discharged to home on postoperative day number five. She was
to follow up as an outpatient with Dr. [**Last Name (Prefixes) 14004**] as well
as her primary care physician and the pulmonary specialist
for possible lung biopsy.
DISCHARGE STATUS: Stable.
DISCHARGE DIAGNOSES:
1. Status post total abdominal hysterectomy.
2. Status post respiratory failure with MICU transfer.
3. Congestive heart failure versus atypical pneumonia versus
chronic lung process.
DISCHARGE MEDICATIONS: Percocet, Motrin and Levofloxacin
times ten days.
[**Location (un) 680**] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 43162**]
Dictated By:[**Name8 (MD) 21942**]
MEDQUIST36
D: [**2131-7-30**] 10:34
T: [**2131-8-6**] 11:46
JOB#: [**Job Number 43163**]
|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,763
| 162,187
|
13850
|
Discharge summary
|
report
|
Admission Date: [**2141-6-28**] Discharge Date: [**2141-6-30**]
Date of Birth: [**2065-11-29**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Melena
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
75F CAD s/p RCA stent in [**2136**], ESRD on PD, DM, here w/ melena X
2 days. USOH until two days prior to admission, began to feel
lightheaded and weak in the morning, then had bought of melena
in evening - thought initially due to diarrhea or something she
ate, but no one else in family had this issue, and no other sick
contacts. On next day, had mild nausea, but no vomiting, abd
pain, or BRBPR. Continued having melena, and reported this to
her PD nurse, who suggested that pt report to ED. On day of
admission, did have anorexia and did not eat anything. Of note,
had not had "normal" hemoglobin when dialysis labs were drawn on
first day of melena.
In ED, was noted to have Hct of 22, down from 31.5, was thought
to be complaining of chest pain, but in discussion with patient
in Mandarin, she states that she has been feeling anorexic, and
as such has felt some mild abdominal discomfort from not eating
for the last 24 hours. Her previous anginal equivalent in [**2136**]
was throat discomfort similar to throat dryness. Per discussion
w/ Dr. [**Name (NI) 17976**], pt's cardiologist, has not had any active angina,
negative stress in [**2139**], and no recent interventions since [**2136**].
NG lavage in ED negative.
Otherwise, denies F/C, preceding abd pain, chest pain, SOB,
orthopnea, DOE, joint pain, use of NSAIDS, recent med changes,
ulcers. Does have history of chronic dysphagia, previously
worked up ~[**2136**] by EGD and CScope which were negative. Denies
palpitations or irregular heart rhythm.
Past Medical History:
- ESRD on peritoneal dialysis
- Hypertension (L is significantly lower than R)
- Hyperlipidemia
- CAD s/p RCA stent [**2136**]- Dr [**Hospital1 41564**]
- - - - [**2139**] P MIBI neg, EF preserved, last seen [**2141-3-15**], no
active disease
- End Stage Renal Disease
- Anemia [**2-16**] ESRD
- Proteinuria
- DM w/ renal and eye manifestations
- Carotid stenosis - Rt carotid > Lt; Rt CEA [**8-18**]; [**Hospital1 112**]
- Lt subclavian artery stenosis
- Hypothyroidism - Diagnosed [**12-16**]
- Hyperparathyroidism, secondary
Social History:
Lives with daughter. Moved to US from [**Country 5142**] in [**2105**], denies
alcohol or tobacco use.
Family History:
NC
Physical Exam:
VS 84 125/62 14 100%RA
GENERAL: NAD, lying in bed, pale.
HEENT: Anicteric, PERRL, EOMI, dry MM.
NECK: no JVD, Supple, Bilat loud carotid bruits, R>L
CARDIOVASCULAR: S1, S2, reg, no MRG.
LUNGS: CTAB
ABDOMEN: Mildly distended, soft, NT, ND, no HJR, active bowel
sounds.
EXTREMITIES: Warm, no CCE
NEURO: A/Ox3
Rectal - per ED, melena, no clots or bright blood.
Pertinent Results:
EGD:
Impression: Ulcer in the gastroesophageal junction
Salmon colored in the gastroesophageal junction compatible with
barrett's esophagus (biopsy)
Erosions in the stomach body
Erythema, congestion and erosion in the antrum compatible with
gastritis (biopsy)
Otherwise normal EGD to second part of the duodenum
Recommendations: Follow-up biopsy results
Continue [**Hospital1 **] PPI therapy for 1 month
Repeat EGD in 1 month to assess for resolution of esophageal
ulcer.
Can advance diet
.
[**2141-6-28**] 07:55PM GLUCOSE-124* UREA N-132* CREAT-3.6*
SODIUM-139 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16
[**2141-6-28**] 07:55PM WBC-11.9* RBC-3.74*# HGB-11.7*# HCT-32.4*#
MCV-87 MCH-31.4 MCHC-36.2* RDW-15.1
.
Esophagus and Stomach Bx:
A. Gastroesophageal junction:
1. Squamous epithelium, no diagnostic abnormalities recognized.
2. Cardiac type gastric mucosa, scant.
3. No intestinal metaplasia identified.
B. Stomach, antrum:
Changes suggestive of chemical gastropathy.
Brief Hospital Course:
75F CAD, DM, ESRD, here w/ GI bleed.
<BR>
* GI Bleed: Transfused 4u PRBC, was hemodynamic stable,
post-transfusion, hct was stable in the 40s. EGD showed likely
barretts esophagus (bx taken), erosions in stomach body, and a
linear erosion on the antrum (bx taken). Advised by GI to stay
on PPI, repeat EGD in 1 months, advance diet. Patient continued
to have melena, but this was to be expected. Hct remained
stable and patient was d/c'd home. Tollerating POs and
ambulating prior to d/c.
.
* CAD: Stable,s he has had no recent interventions, and will
continue baby ASA (while on PPI) and statin. Antihypertensives
were initially held, but re-started after EGD. BP was difficult
to controll and monitor given her known subclavian stenosis.
EKG in ED difficult to interpret given changes in voltage
between EKGs in limb leads, esp in absence of symptoms. MICU
team did speak to patient's cardiologist who states patient has
not had any problems in the past year. Cardiac enzymes were
negative. Patient can follow up as outpatient with her
cardiologist.
.
* UTI: Patient had some dysuria with Foley Cath in place. UA
was obtained and she was started on a short course of
antibiotics. Foley was removed.
.
* ESRD: Continued per renal consult recommendations. Started on
Potassium repletion that should be followed as outpatient.
.
* DM: Lantus 13U in AM. Half dose when NPO, SSHI.
.
* Communication: Son [**Name (NI) **], who is HCP: [**Telephone/Fax (1) 41565**] (cell), [**Telephone/Fax (1) 41566**] (home)
Medications on Admission:
Medications:
Levoxyl 50mcg once a day
Lantus 13U AM
Novolog 4 AM 4 Lunch 0-3PM
Rocaltrol 0.5mcg 1 time per day
Furosemide 40mg or as directed.
Procrit 4000 U/ml
Labetalol Hcl 400mg twice a day
Procardia Xl 60mg
Isosorbide Dinitrate 40mg twice a day
Folic Acid 0.4mg QID
Aspirin 81mg once a day
Multivitamin once a day
Lipitor 40mg once a day
Iron 325(65)mg [**Hospital1 **]
Sof-gel Efa twice a day,3 caps
Cozaar 50mg
Omega 3 fatty acid 3000 [**Hospital1 **]
Discharge Medications:
1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
5. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO QID (4 times a day) as needed.
6. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO DAILY (Daily).
9. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
10. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*
11. 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*
12. Potassium Chloride 20 mEq Packet Sig: One (1) packet PO
DAILY (Daily).
Disp:*30 packet* Refills:*2*
13. Aspir-81 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastroesophageal Ulcer
Barretts Esophagus
ESRD on PD
Hypertension
Discharge Condition:
Hct stable. Biopsy results pending. Taking good PO and
ambulating
Discharge Instructions:
Continue PD as directed. You will need to follow up in one
month for another endoscopy. See the appointment below. Also
follow up with your primary care doctor. You have 2 new
medications. Protonix twice a day for acid. Also Potassium
daily. You have biopsy results that are pending You can take a
baby aspirin daily.
Followup Instructions:
1. Endoscopy [**2147-8-5**]:30pm, Dr. [**Last Name (STitle) **]: Provider: [**Name10 (NameIs) **]
WEST,ROOM FOUR GI ROOMS Date/Time:[**2141-8-4**] 12:30
2. Please follow up with your primary care doctor and check on
the results of your gastric and esophageal biopsy that were done
during your procedure.
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
|
[
"585.6",
"250.50",
"403.91",
"V45.82",
"244.9",
"414.01",
"250.40",
"272.4",
"362.01",
"531.40",
"285.1",
"413.9",
"599.0",
"588.81",
"285.21",
"530.85"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"45.16",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7289, 7295
|
3992, 5517
|
322, 327
|
7405, 7475
|
2968, 3969
|
7848, 8279
|
2570, 2574
|
6026, 7266
|
7316, 7384
|
5543, 6003
|
7499, 7825
|
2589, 2949
|
276, 284
|
355, 1880
|
1902, 2433
|
2449, 2554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
5,100
| 138,747
|
47941+59043
|
Discharge summary
|
report+addendum
|
Admission Date: [**2156-2-6**] Discharge Date: [**2156-2-9**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1070**]
Chief Complaint:
transfer from OSH for GI bleed work up
Major Surgical or Invasive Procedure:
EGD with Push Enteroscopy
Colonoscopy
Capsule endoscopy
History of Present Illness:
82 F c CAD, DM2, HTN who was in USOH until [**1-29**] when she
developed BRBPR for 1st time. It was associated with abdominal
cramping and emesis of dark blood. She did not have
lightheadedness, or syncope. She went to [**Hospital3 4107**] and
admitted from [**Date range (1) 94282**] with an initial Hct of 32.1. There
she had extensive w/u for GI bleed including negative EGD and
colonoscopy showing non-bleeding diverticulae. Bleeding scan
and SBFT were also negative. Her hct dropped to 26.4 but never
hemodynamically unstable. She was ultimately transfused to Hct
of 40 on discharge [**2-3**].
She was discharged on ASA and had similar episode of BRBPR and
represented to [**Hospital1 **] with hct 25.1 without hemodynamic
collapse. She was transfused to Hct of 33 and transfered to
[**Hospital1 18**] for capsule endoscopy.
On arrival to [**Hospital1 18**] she started go-lytely prep. Shortly
thereafter she experienced 3 episodes of BRBPR. Per nurse, 1st
bloody stool was bright red and roughly 100-150 cc. Subsequent
stools were flushed. Pt denied lightheadedness, abd pain,
rectal pain, chest pain, shortness of breath. She is not sure
if she has take her anti-hypertensive meds on the day of
admission.
Past Medical History:
PMH
1. DM2
2. CAD
-s/p MI [**37**]'
-s/p angioplasty
3. HTN
4. Cataract
5. hyperlipidemia
All: nkda
Social History:
no tobacco/EtOH/drug use
Family History:
father with diabetes
Physical Exam:
PE 95.7 164/72 80 (laying flat) 16 100%RA; 148/62 92
(sitting)
Gen: nad, aox3, pleasant and comfortable
heent: mmm
neck: radiation of murmur bilaterally in neck
cv: rrr; 3/6 SEM @ RUSB
pulm: cta b/l
abd: nt, nd, +bs
ext: no edema, warm
rectal: deferred. known OB +
Pertinent Results:
[**2156-2-6**] 09:59PM BLOOD Hct-30.1*
[**2156-2-6**] 09:00PM BLOOD Hct-29.6*
[**2156-2-6**] 08:18PM BLOOD Hct-29.6*
[**2156-2-6**] 05:10PM BLOOD WBC-8.8 RBC-4.03* Hgb-12.5 Hct-35.5*
MCV-88 MCH-31.1 MCHC-35.3* RDW-14.0 Plt Ct-219
[**2156-2-7**] 12:54AM BLOOD Plt Ct-207
[**2156-2-6**] 09:59PM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-142
K-3.7 Cl-107 HCO3-25 AnGap-14
.
EGD with push enteroscopy ([**2156-2-7**]):
An outpouching was found in the distal duodenum or proximal
jejunum that may represent a diverticulum. There was no evidence
of blood or obvious AVMs in the visualized small bowel but
visualization was limited by peristalsis and patient tolerance.
There was no blood or evidence of bleeding in stomach.
Otherwise normal egd to mid jejunum
.
COLONOSCOPY ([**2156-2-7**]):
There was no evidence of blood found in colon or visualized
portion of terminal ileum. Do to suboptimal quality of prep AVMs
may have been missed. Diverticulosis of the sigmoid colon.
Otherwise normal colonoscopy to terminal ileum.
.
CAPSULE ENDOSCOPY ([**2156-2-8**]): results pending
Brief Hospital Course:
GI bleeding: On admission, the patient transferred to the MICU
for ongoing bleeding. She was monitored closely overnight. Her
HCT was checked each four hours and remained between 29-31. She
was not orthostatic the AM after transfer to the MICU. She did
not require transfusion. Her antihypertensives were held. She
continued to have some blood per rectum with the GoLytly prep.
The following afternoon an endoscopy and colonoscopy were
performed. No source of bleeding was found. The findings were
a proximal jejeunal diverticula with no bleeding and multiple
sigmoid and descending colon diverticuli. The plan was for a
capsule endoscopy the following day. Given her stable Hct and
hemodynamic status, she was transferred to the floor.
After admission to the floor, her Hct remained stable. She was
transfused one unit of PRBC's for a slightly low hematocrit of
28. After transfusion, her Hct remained stable above 30 for the
remainder of her hospital course. On [**2156-2-8**], a capsule
endoscopy was performed. Results were pending at the time of
discharge. The patient was instructed to call for the results
of this test the week following discharge. The patient was
restarted on her antihypertensives prior to discharge, but was
told not to continue taking her aspirin to prevent further
bleeding. She will follow up with her primary care physician
following discharge.
Medications on Admission:
Meds on transfer
1. Go lytely prep
2. atorvastatin 40mg'
3. insulin ssi
4. protonix 40 IV'
5. lopressor 12.5 mg PO BID
6. eye drops
Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
4. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop
Ophthalmic [**Hospital1 **] (2 times a day).
5. Metoprolol Tartrate 25 mg Tablet Sig: Two (2) Tablet PO BID
(2 times a day).
6. Cardizem 120 mg Tablet Sig: One (1) Tablet PO once a day.
7. 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*
8. Actos 45 mg Tablet Sig: One (1) Tablet PO once a day.
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
Discharge Condition:
Stable, improved from the time of admission
Discharge Instructions:
Please call your doctor or return to the ER if you experience
blood in your stool, black stool, chest pain, difficulty
breathing, or dizziness. Take your medications as prescribed.
You should stop taking aspirin.
Followup Instructions:
Please call your primary care doctor (Dr. [**Last Name (STitle) 4469**] [**Telephone/Fax (1) 4475**])
for an appointment after discharge.
Please call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 4971**] next week for the results
of your capsule endoscopy.
Name: [**Known lastname 4476**],[**Known firstname 16238**] Unit No: [**Numeric Identifier 16239**]
Admission Date: [**2156-2-6**] Discharge Date: [**2156-2-9**]
Date of Birth: [**2073-7-22**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14946**]
Addendum:
Blood Loss Anemia: patients gastrointestinal bleed caused a
blood loss anemia. Please see above for addtional details.
Discharge Disposition:
Home
Discharge Diagnosis:
Gastrointestinal bleeding
Blood Loss Anemia
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 14947**] MD [**MD Number(2) 14948**]
Completed by:[**2156-3-14**]
|
[
"401.9",
"412",
"V45.82",
"280.0",
"414.01",
"V58.67",
"272.4",
"578.9",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
6759, 6765
|
3219, 4616
|
299, 357
|
5654, 5700
|
2126, 3196
|
5962, 6736
|
1801, 1823
|
4798, 5555
|
6786, 6991
|
4642, 4775
|
5724, 5939
|
1838, 2107
|
221, 261
|
385, 1618
|
1640, 1743
|
1759, 1785
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,911
| 148,438
|
11346
|
Discharge summary
|
report
|
Admission Date: [**2150-1-16**] Discharge Date: [**2150-1-21**]
Date of Birth: [**2085-9-29**] Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
fevers, multiple liver masses
Major Surgical or Invasive Procedure:
liver biopsy [**2150-1-19**]
History of Present Illness:
64M with a history of DM and HTN presents with a fever to
103.1 today. He states he has been having fevers intermittently
over the past 3 weeks. They have been as high as 102.9 at home.
Initially he and his wife attributed the fevers to his wife's
illness 3 weeks ago. She states she had a "flu-like" illness
that consisted of fevers, which resolved in 3 days. His fevers
started soon after hers had resolved. They come intermittently,
generally every 2-3 days. He went to his PCP to have this
evaluated an a CT scan was performed, which showed multiple
hypodensities within his liver. He was scheduled to see Dr.
[**Last Name (STitle) **] in clinic but when his fever went to 103 he was advised to
come to the Emergency Room for evaluation. His only complaints
are of these fevers and some occasional nausea. He denies
chills, emesis, abdominal pain, diarrhea, melena, dysuria, cough
or sputum production. He denies any change in his bowel or
bladder habits. He has no recent sick contacts or exposures.
He
had a colonoscopy 5 years ago and this was normal. He does
report a 25lb weight loss over the past 10 months but he
attributes this to dietary changes to help with diabetes
control.
.
Review of systems: All 10 systems reviewed and negative except
as
noted above in the HPI.
Past Medical History:
PMH: HTN, DM, irritable bowel disease, cervical neck
degeneration, chronic renal insufficiency, colonoscopy 5 years
ago that was reportedly normal
.
PSH: lap chole
.
Social History:
Nonsmoker, occasional ETOH. He is retired. Daughter is
a PACU nurse here at [**Hospital1 18**].
Family History:
Father with a history of throat cancer
Physical Exam:
103.1, 134, 114/75, 22, 99% on room air
Gen: no distress, diaphoretic, alert and oriented x 3
HEENT: PERLA, EOMI, anicteric
Neck: no lymphadenopathy
Chest: tachycardic, no murmur, lungs clear bilaterally
Abdomen: soft, nontender, nondistended
Rectal: normal tone, guaiac negative, no masses
Ext: no edema, palpalble pulses
Msk: no axillary or inguinal lymphadenopathy
.
Labs:
- WBC 9.6, Hct 37.2, Plt 244, neutrophils 81, lymphs 11
- INR 1.2
- Na 131, K 4.8, Cl 98, HCO3 21, BUN 17, crea 1.6, glu 160
- ALT 81, AST 109, AP 172, TB 0.9
- Lipase 64
- Urinalysis negative
.
Imaging:
- CT torso:
1. Innumerable hypodensities scattered throughout the liver,
which are incompletely characterized. The differential diagnosis
includes diffuse hepatic metastases. However, infection may have
a similar appearance in some unusual cases such as neutropenic
infection but there is no indication of abscess formation or
biliary dilatation. The cause of likely malignant.
2. Mild splenomegaly.
3. Mild non-specific inflammatory stranding within the porta
hepatis, with prominent periportal and peripancreatic lymph
nodes.
4. Enlarged mediastinal and pericardial lymph nodes.
.
Pertinent Results:
[**2150-1-20**] 05:45AM BLOOD WBC-6.7 RBC-3.57* Hgb-9.3* Hct-30.5*
MCV-85 MCH-26.1* MCHC-30.6* RDW-14.6 Plt Ct-132*
[**2150-1-19**] 05:30AM BLOOD PT-15.8* PTT-40.1* INR(PT)-1.4*
[**2150-1-20**] 05:45AM BLOOD Glucose-135* UreaN-16 Creat-1.4* Na-135
K-4.4 Cl-102 HCO3-25 AnGap-12
[**2150-1-20**] 05:45AM BLOOD ALT-76* AST-74* AlkPhos-128 TotBili-0.8
[**2150-1-20**] 05:45AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0
[**2150-1-17**] 03:30AM BLOOD CEA-<1.0 AFP-1.4
[**2150-1-17**] 03:30AM BLOOD CA [**58**]-9 -7
Brief Hospital Course:
He was admitted to the SICU from the ED with fever of 103 and
tachycardic to
130 which was treated with 2L of IVF. Heart rate decreased.
Mucomyst and IV bicarb were given for renal protection for a
repeat CT [**1-16**] demonstrating innumerable hypodensities scattered
throughout the liver, which are incompletely characterized, mild
splenomegaly, mild non-specific inflammatory stranding within
the porta hepatis, with prominent periportal and peripancreatic
lymph nodes and enlarged mediastinal and pericardial lymph
nodes.
He was pan cultured and broad spectrum antibiotics
(cipro/flagyl/vanco)were begun. He continued to spike
temperatures to as high as 103. Repeat cultures were done. These
were negative to date. Tumor markers: CEA, AFP, CA [**58**]-9 were
sent. CEA was <1.0, afp was 1.4, ca [**58**]-9 was 7. ID was consulted
and recommended liver biopsy for path and micro which was done
on [**1-19**] that had positive cytology for malignant cells. Final
diagnosis was to be reported on the core biopsy after
immunohistochemical studies. Micro workup on the liver tissue
was negative for bacterial, fungal and AFB. PPD was negative.
TTE was negative for vegetations, Toxoplasma IgG/IgM was
negative, ebv IGG was positive with IgM negative. CMV was
pending.
He was treated with tylenol when febrile for comfort. He
experienced intermittent RUQ pain rated as a [**4-6**]. PO dilaudid
was given with improved pain control. Antibiotics were stopped
on [**1-20**]. WBC remained in the 6-7 range. He was ambulatory and
was tolerating a regular diet. Vital signs were stable and he
remained in a sinus rhythm.
Dr. [**Last Name (STitle) **] discussed the preliminary liver biopsy results with
the patient and his wife. [**Name (NI) 36354**] intervention was not an
option and he was discharged home to await final pathology
report that would guide Oncology follow up.
Medications on Admission:
januvia 50mg daily, dicyclomine 10mg [**Hospital1 **], diovan 80mg
daily, aspirin 81mg daily, benefiber 3 tablets daily, [**Doctor First Name 130**]
180mg daily
Discharge Medications:
1. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
2. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
5. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. Januvia 50 mg Tablet Sig: One (1) Tablet PO once a day.
8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO as needed
every 4 hours: no more than 4 grams per day.
Discharge Disposition:
Home
Discharge Diagnosis:
Fevers
Liver lesions, awaiting biopsy results
Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - Independent
Discharge Instructions:
Please call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if you experience
any of the warning signs listed below
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**]
Date/Time:[**2150-1-29**] 10:20
Dr. [**Last Name (STitle) **] will call you [**1-22**] with pathology results
[**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**], RN coordinator [**Telephone/Fax (1) 17195**] will call to schedule
Oncology follow up appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2150-1-22**]
|
[
"427.89",
"783.21",
"585.9",
"780.61",
"721.0",
"564.1",
"789.01",
"250.00",
"155.2",
"403.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"50.11"
] |
icd9pcs
|
[
[
[]
]
] |
6514, 6520
|
3762, 5640
|
321, 352
|
6610, 6610
|
3238, 3739
|
6910, 7489
|
1999, 2039
|
5851, 6491
|
6541, 6589
|
5666, 5828
|
6758, 6887
|
2054, 3219
|
1604, 1677
|
251, 283
|
380, 1585
|
6625, 6734
|
1699, 1867
|
1883, 1983
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,632
| 170,086
|
41640
|
Discharge summary
|
report
|
Admission Date: [**2161-9-21**] Discharge Date: [**2161-9-24**]
Date of Birth: [**2100-8-18**] Sex: F
Service: NEUROSURGERY
Allergies:
lisinopril / [**Doctor First Name **] / Mucinex
Attending:[**First Name3 (LF) 78**]
Chief Complaint:
3-4 Days of constant headache
Major Surgical or Invasive Procedure:
[**2161-9-22**] LEFT ICA ANEURYSM STENT ASSISTED COILING
History of Present Illness:
History of the Present Illness: This is a 61yo W with a history
of HTN, depression and insomnia who presents to the ED as a
transfer from an OSH for possible aneurysm work up. The patient
was in her USOH until approximately 3 days ago when she was
watching TV and started to experience headache. This occurred
suddenly, and she went from having no headache to severe
headache
very quickly. This is described as a pounding headache ([**8-31**])
that is localized bifrontally and bitemporally with radiation
down the midline to her occiput. Tylenol extra strength pills
have helped partially and mostly help her sleep, but she keeps
waking up with worse pain. She went to an OSH today and had a
NCHCT which showed a 11mm left ICA aneurysm that has apparently
described on a head CT done one year previously but the patient
had no idea about this. She had the CT done in the context of
possible sinusitis. She states that she experienced headache
like
this one month ago which lasted for one day and then subsided.
She denies any problems with visual disturbances, nausea, neck
stiffness, vomiting, chest pain, shortness of breath, difficulty
walking, asymmetric weakness or numbness, dysphagia or
dysarthria.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Past Medical History:
- HTN
- MDD
- Insomnia
Social History:
Social History: Not obtained
Family History:
Family History: Not obtained
Physical Exam:
Physical Exam:
Vitals: 98.2, 78, 110/71, 18, 98%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities:warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward
without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic
errors.
Pt. was able to name both high and low frequency objects. Able
to read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt. was able to
register 3 objects and recall [**1-22**] at 5 minutes. The pt. had
good
knowledge of current events. There was no evidence of apraxia
or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV and VI: EOM are intact and full, no nystagmus
V: Facial sensation intact to light touch.
VII: No facial droop, no ptosis, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L 5 5 5 5 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: No deficits to light touch throughout
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response: down
-Coordination/Gait: not tested
On Discharge:
A&Ox3
PERRL
EOMs intact
Face symmetrical
tongue midline
Motor: full
no pronator drift
Pertinent Results:
[**2161-9-21**] CT head and Neck IMPRESSION:
1. Lobulated aneurysm of the distal supraclinoid left internal
carotid artery, just at the bifurcation, measuring 1.1 cc x 1
trv x 1.03 ap cm. The aneurysm contains a smaller lobulated
portion extending medially and measuring 0.6 x 0.4 cm. The
aneurysm neck measures 0.5 cm.
2. No evidence of acute hemorrhage.
[**2161-9-22**] PORTABLE UPRIGHT CHEST XRAY:
There is a new left IJ central line, terminating in the upper
SVC. There is no evidence of pneumothorax. The lungs remain
clear, without focal
consolidation concerning for pneumonia. There is no pleural
effusion. Hilar and cardiomediastinal contours are stable, with
no pulmonary vascular congestion or pulmonary edema. The aortic
contour is tortuous. There is no acute osseous abnormality
identified.
Angiogram: stent assisted coiling of L ICA aneurysm
Brief Hospital Course:
Pt was admitted to the NICU after ED CT imaging revealed left
ICA aneurysm. She was neurologically stable and remained so
overnight. She was brought to the angio suite the following day
for a stent assisted coiling of the aneurysm. Stent assisted
coiling was done without complications. Patient was started on a
heparin gtt and sent to ICU. On examination, patient remained
neurologically intact. On [**9-23**], patient was transferred to the
floor with tele for ectopy. She was eating and voiding
appropriately and was discharged home on [**9-24**].
Medications on Admission:
Ambien (dose?)
Wellbutrin (dose?)
Centrum MVI
BP med (?, dose?)
Discharge Medications:
1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze / cough .
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 30 days.
Disp:*28 Tablet(s)* Refills:*0*
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*100 Tablet(s)* Refills:*2*
4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 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
Discharge Diagnosis:
LEFT ICA ANEURYSM
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Angiogram with Embolization and/or Stent placement
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily.
?????? Take Plavix (Clopidogrel) 75mg once daily.
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort.
What activities you can and cannot do:
?????? When you go home, you may walk and go up and down stairs.
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal).
?????? After 1 week, you may resume sexual activity.
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate.
?????? No driving until you are no longer taking pain medications
What to report to office:
?????? Changes in vision (loss of vision, blurring, double vision,
half vision)
?????? Slurring of speech or difficulty finding correct words to use
?????? Severe headache or worsening headache not controlled by pain
medication
?????? A sudden change in the ability to move or use your arm or leg
or the ability to feel your arm or leg
?????? Trouble swallowing, breathing, or talking
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
Followup Instructions:
*SUDDEN, SEVERE BLEEDING OR SWELLING
(Groin puncture site)
Lie down, keep leg straight and have someone apply firm pressure
to area for 10 minutes. If bleeding stops, call our office. If
bleeding does not stop, call 911 for transfer to closest
Emergency Room!
Follow up with Dr. [**First Name (STitle) **] in 1 month with an MRI/MRA. This
appointment can be scheduled by having the patient call
[**Telephone/Fax (1) 1669**]
Completed by:[**2161-9-24**]
|
[
"V16.8",
"V17.49",
"V14.8",
"305.93",
"401.9",
"296.20",
"437.3",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.91",
"38.93",
"88.41",
"88.49",
"39.72"
] |
icd9pcs
|
[
[
[]
]
] |
6695, 6701
|
5193, 5748
|
340, 399
|
6763, 6763
|
4312, 5170
|
8665, 9120
|
2112, 2127
|
5863, 6672
|
6722, 6742
|
5774, 5840
|
6914, 7984
|
8010, 8642
|
3200, 4192
|
2157, 2568
|
4206, 4293
|
271, 302
|
427, 1960
|
6778, 6890
|
2004, 2030
|
2063, 2079
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,736
| 169,922
|
24369
|
Discharge summary
|
report
|
Admission Date: [**2102-8-29**] Discharge Date: [**2102-8-31**]
Date of Birth: [**2028-3-30**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
bile [**First Name3 (LF) 3564**] s/p CCY
Major Surgical or Invasive Procedure:
ERCP [**2102-8-30**]
PICC placement [**2102-8-30**]
History of Present Illness:
74M with PMH of Afib on Coumadin, ICD for sustained VT and
syncope, alcoholic cardiomyopathy (EF 20-25%), GERD, prostate ca
s/p XRT, previous DVT/PE, colectomy for perforated
diverticulitis with reversal, presented to OSH with abdominal
pain, found to have cholecystitis secondary to cholelithiasis,
now s/p open CCY complicated by bile [**Month/Day/Year 3564**]. Patient received
pre-operative cardiac clearance for surgery at OSH given
complicated cardiac hx. Post-operatively, JP drain found to
contain bile, which was concerning for bile [**Last Name (LF) 3564**], [**First Name3 (LF) **] HIDA was
obtained and showed bile [**First Name3 (LF) 3564**]. Patient remained hemodynamically
stable and afebrile, no leukocytosis (WBC 11), normal Tbili 1.1,
TnT 0.013. He was transferred to [**Hospital1 18**] for ERCP and endoscopic
correction of bile [**Hospital1 3564**].
.
On the floor, initial vs were: HR95 BP126/99 R19 O2sat 96(2L).
He is comfortable, but somnolent and has difficulty answer
questions regarding his past medical history and recent events
of surgery and hospitalization. He endoses RUQ pain,
nonradiating, and unchanged from before his surgery. He denies
nausea/vomiting, changes to bowel movement (chronically
constipated for past decade). Denies SOB, but endorses chest
pain (not pressure) that is substernal that radiates bilaterally
across chest. Also has esophageal pain on swallowing that he
says is chronic for past decade.
Past Medical History:
- Atrial fibrillation on Coumadin
- Diabetes mellitus type II, non-insulin dependent
- Hypertension
- Alcoholic cardiomyopathy (EF 20-25%)
- Asbestosis
- Erectile dysfunction s/p penile prosthesis
- Prostate cancer s/p prostatectomy and XRT
- Ventral hernia repair w/ Duomesh [**3-/2098**]
- Colectomy w/ colostomy x2 and reversal x2 (per patient
report)for diverticulitis
- ICD placement
Social History:
Former smoker, quit 20 yrs ago, 60py history. Former EtOH
abuse. Social drinker near, has not drank in [**2099**]. Lives with
wife and children. Retired, formerly worked in construction,
carpentry, painting.
Family History:
heart disease, DM
Physical Exam:
Physical Exam on Admission:
Vitals: T 98.2 HR 95 BP 126/99 R 19 O2sat 96(2L)
General: somnolent, oriented, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles [**1-17**] way up lungs
CV: Regular rate and rhythm, frequent skipped beats, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: no BS, large abdominal incision that is dressed and
covered by abd binder, diffusely tender to mild palpation
Ext: warm, well perfused, no edema
.
Discharge Physical Exam:
Vitals: T 97.6 HR 78 BP 129/68 R20 O2sat 98(2L)
General: More alert, oriented, no acute distress
HEENT: Sclera anicteric, moist mucous membranes, oropharynx
clear
Neck: supple, JVP not elevated, no LAD
Lungs: bibasilar crackles [**1-17**] way up lungs
CV: Regular rate and rhythm, frequent skipped beats, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: no BS, large abdominal incision that is dressed and
covered by abd binder, diffusely tender to mild palpation
Ext: warm, well perfused, no edema
Pertinent Results:
Labs on Admission:
[**2102-8-29**] 09:48PM WBC-11.9*# RBC-4.18* HGB-13.7* HCT-39.9*
MCV-96# MCH-32.9*# MCHC-34.4 RDW-13.2
[**2102-8-29**] 09:48PM NEUTS-75.6* LYMPHS-12.4* MONOS-10.7 EOS-0.9
BASOS-0.5
[**2102-8-29**] 09:48PM ALBUMIN-3.4* CALCIUM-8.2* PHOSPHATE-3.0
MAGNESIUM-2.1
[**2102-8-29**] 09:48PM LIPASE-10
[**2102-8-29**] 09:48PM ALT(SGPT)-14 AST(SGOT)-29 LD(LDH)-412*
CK(CPK)-128 ALK PHOS-70 AMYLASE-16 TOT BILI-1.4
[**2102-8-29**] 09:48PM GLUCOSE-90 UREA N-12 CREAT-0.8 SODIUM-140
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-21* ANION GAP-18
.
Pertinent Labs:
[**2102-8-30**] 08:52AM BLOOD WBC-10.6 RBC-3.86* Hgb-12.3* Hct-36.9*
MCV-96 MCH-31.8 MCHC-33.2 RDW-13.1 Plt Ct-185
[**2102-8-30**] 08:52AM BLOOD PT-14.5* PTT-34.3 INR(PT)-1.3*
[**2102-8-30**] 08:52AM BLOOD Glucose-105* UreaN-16 Creat-1.0 Na-140
K-4.3 Cl-106 HCO3-25 AnGap-13
[**2102-8-29**] 09:48PM BLOOD CK-MB-2 cTropnT-0.02*
[**2102-8-30**] 08:52AM BLOOD CK-MB-2 cTropnT-0.02*
[**2102-8-30**] 08:52AM BLOOD Digoxin-2.0
[**2102-8-30**] 10:22AM BLOOD Type-[**Last Name (un) **] pO2-39* pCO2-59* pH-7.32*
calTCO2-32* Base XS-1
[**2102-8-30**] 10:22AM BLOOD Lactate-1.1
[**2102-8-30**] 10:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.021
[**2102-8-30**] 10:20AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2102-8-30**] 10:20AM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-0
[**2102-8-30**] 10:20AM URINE CastHy-16*
[**2102-8-30**] 10:20AM URINE Mucous-RARE
.
Microbiology:
Blood cx [**8-30**]: pending
Urine cx [**8-30**]: pending
JP drain contents [**8-30**]: pending
.
Imaging:
CXR ([**8-29**]): FINDINGS: Exam is limited by failure to include the
extreme periphery of the left mid and lower lung on the
radiograph. This could be repeated at no additional charge to
the patient. An ICD remains in place, with interval placement of
a second lead within the right ventricle since the prior
radiograph. Heart remains enlarged, but there is no evidence of
acute congestive heart failure. Extensive bilateral calcified
pleural plaques are present, with possible element of underlying
interstitial lung disease bilaterally in the mid and lower
lungs. This is difficult to assess on a portable radiograph, and
could be more fully assessed with a standard PA and lateral
chest x-ray. Note is also made of a 9-mm diameter lucent lesion
in the proximal shaft of the right humerus, also difficult to
evaluate on a portable chest radiograph. Standard radiographs of
the right humerus are recommended for further evaluation when
the patient's condition allows, in order to assess for the
possibility of myeloma or metastatic disease at this site.
.
ERCP report:
Impression:
Successful vannulation of bile duct (cannulation)
Mild biliary dilation
No clear site of bile [**Month/Year (2) 3564**] identified.
Can not rule out segmental exclusion
Successful sphincterotomy was performed
8 cm by 10FR cotton [**Doctor Last Name **] stent was placed
Otherwise normal ercp to third part of the duodenum
Recommendations:
Return to floor
NPO overnight with aggressive IV hydration with LR at 200 cc/hr.
If no abdominal pain in the AM, advance diet to clear liquids
and then advance as tolerated.
No aspirin, plavix, NSAIDS, coumadin for 5 days
Repeat ERCP in 8 weeks for stent removal
If bile [**Doctor Last Name 3564**] persists, consider CT and PTC to rule out a
possible excluded segment.
Discharge Labs:
[**2102-8-31**] 02:50AM BLOOD WBC-7.9 RBC-3.62* Hgb-11.7* Hct-34.5*
MCV-95 MCH-32.3* MCHC-34.0 RDW-12.8 Plt Ct-200
[**2102-8-31**] 02:50AM BLOOD Glucose-121* UreaN-18 Creat-1.0 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
[**2102-8-31**] 02:50AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.2
Brief Hospital Course:
74M with PMH of Afib on Coumadin, ICD placement for sustained VT
and syncope, alcoholic cardiomyopathy (EF 20-25%), GERD,
prostate ca s/p XRT, previous DVT/PE, colectomy for perforated
diverticulitis with reversal, presented to OSH with abdominal
pain, found to have cholecystitis secondary to cholelithiasis,
now s/p open CCY complicated by bile [**Month/Day/Year 3564**]. He transferred to
this hospital for ERCP, with planned return to the OSH.
# Bile [**Month/Day/Year **] s/p CCY: Patient was found posteratively to have
bile-colored fluid in JP drain, and bile [**Month/Day/Year 3564**] was confirmed by
HIDA scan. Planned ERCP the day after transfer for endoscopic
repair. He was kept NPO overnight for ERCP. Although he was
not febrile or have a leukocytosis, on the morning of HD1,
blood, urine, and JP drain cultures were obtained, and he was
empirically started on vancomycin and Zosyn. Vancomycin was
stopped after 1 day, but Zosyn was continued until discharge and
should be continued until the cultures return negative. He was
not given narcotics for pain control to allow his mental status
to improve (unknown how much narcotics he had received at OSH),
and he did not complain of pain, so did not receive any pain
medication in his post-operative state. ERCP was performed on
[**8-30**]. ERCP found biliary dilation, no evidence of bile
[**Month (only) 3564**]. Spinterotomy was performed and a stent was placed, which
will need to be removed in 8 weeks. Can consider further
evaluation in future with MRCP or CT Abd if continued [**Month (only) 3564**] is
suspected.
# Chest Pain: On admission, patient endorsed substernal chest
pain (not pressure) radiating bilaterally across chest with no
exacerbating or alleviating factors. Patient says he had been
experiencing this pain for "the past 10 years." Story not very
concerning for ACS, but patient has complex cardiac hx and is
s/p ICD placement, so troponins were cycled and returned
negative. EKG was not suggestive of ischemia, and chest xray
suggested pulmonary edema, but not significantly changed from
prior. Patient had bibasilar crackles on admission indicative of
pulmonary edema and is requiring oxygen by nasal cannula. He
was not diuresed as he also appeared dry on exam and was given
gentle fluid boluses the next morning to normalize his blood
pressure in the setting of several days of being NPO.
# Afib: Per patient's outpatient cardiologist, he is on coumadin
5mg daily, INR goal [**2-16**]. This was held for his procedure, but
restarted on POD1 at the outside hospital. His INR on transfer
was 1.3. He was continued on metoprolol, digoxin and amiodarone
per his home regimen for rate control. He was monitored on
telemetry and his HR remained in the 70s-90s throughout
hospitalization.
#Hypotension: Patient's blood pressure on admission was
120s/80s, but trended down on the morning after admission to
80s/40s, which responded to gentle fluid boluses. Patient has
been NPO for many days due to surgery and then awaiting ERCP,
and he appeared dry on exam (dry mucous membrane, dry skin
turgor, no JVD despite CHF). However, he was found to also have
pulmonary edema due to low EF. His UOP ranged from 20-70cc/hr.
The patient was again hypotensive the morning after ERCP
(morning of HD2), but this was thought to be medication effect
as he had just received valsartan and amiodarone. He was
encouraged to take in fluids PO and his blood pressure
normalized by the end of the day.
# Somnolence: On admission, patient was very somnolent and
intermittently dozing off during conversation, had trouble
relaying events of presentation, surgery, and hospitalization.
Narcotics were withheld overnight and mental status improved by
day after admission, as evidenced by patiet's concern that he
was in the ICU. He did not experience pain after ERCP and was
given tylenol prn, which he asked for once. His mental status
was markedly improved by the morning after ERCP.
Transitional Issues:
- Found to have a possible lesion in right humerus on a chest
xray and was recommended to get a dedicated right humerus to
better evaluate this lesion as an outpatient.
- Patient was told not take coumadin or aspirin for for 5 days.
This means start taking these medications again on [**9-4**].
- Patient needs repeat ERCP in 8 weeks from now for stent
removal. The ERCP service will call patient to set up an
appointment.
- He will need to follow-up on JP drain, blood, urine cxs that
are still pending here and need to be followed-up by the
inpatient team at [**Hospital3 **] (where the patient is being
transferred) or patient's outpatient Primary Care Physician
Medications on Admission:
Home Medications (per OSH surgery intake form, may not be
complete):
Coumadin
Lasix
Metoprolol
Clonidine
Lisinopril
Oxycontin
.
Home medications per family:
Carvedilol 25mg qd
Digoxin 0.25mg qd
Diovan 80 mg qd
Glyburide 5mg qam
Metformin 500mg qam
Pantoprozole 40mg qd
Singulair 10mg qhs
Amiodarone 200mg qam
Aspirin 81mg qd
Valsartan 80mg qd
.
Medications on transfer:
Hydromorphone 0.75mg IV q4h prn pain
Ondansetron 4mg IV q6h prn nausea
Heparin SC
Warfarin 5mg po daiy
ASA 81 po daily
Furosemide 40mg po daily
Metoprolol 50mg po daily
Glyburide 5mg po daily
Metformin 500mg po qhs
Digoxin 0.25mg po daily
Valsartan 80mg po daily
Fluticasone /Salmeterol INH [**Hospital1 **]
Montelukast 10mg PO qhs
Nitro SL q6min prn chest pain
Amiodarone 200mg PO daily
Carvedilol 25mg PO q24h
Omeprazole PO 20mg daily
Oxycodone 5mg/APAP 325mg PO q6h prn pain
Morphine 100mg PO q8h prn pain
Albuterol 2.5mg - IPRATROP 3mL INH qid
ISS
.
Allergies: NKDA
Discharge Medications:
1. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
Please begin taking this again on [**9-4**].
Disp:*30 Tablet(s)* Refills:*2*
2. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily): Please begin to take again on [**9-4**].
7. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
9. montelukast 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Puff Inhalation Q6H (every 6 hours) as needed for
shortness of breath or wheezing.
13. valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
14. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1)
Injection Q8H (every 8 hours) as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 10353**]
Discharge Diagnosis:
Biliary Dilation s/p Open Cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Known lastname 61723**],
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted to us for ERCP after you were
suspected of having bile [**Hospital1 3564**] after gallbladder surgery at
[**Hospital3 **]. While here, we started you on antibiotics for
a potential infection from your bile [**Hospital3 3564**]. The ERCP found mild
biliary dilation, no clear site of bile [**Hospital3 3564**] identified. They
could not rule out segmental exclusion and sphincerotomy
performed. Your blood pressure was at times low during your
hospital stay, so we gave you some fluid by IV when you were not
allowed to eat/drink prior to the ERCP and then encouraged your
to eat/drink after the procedure to keep yourself hydrated. You
were not given narcotic pain medications before you were very
somnolent when you were transferred and did not complain of
pain. Your mental status improved upon transfer back to [**Hospital1 392**].
Please note the following items that are important to follow up
on:
- You were found to have a possible lesion in your right humerus
on a chest xray and we recommend a dedicated right humerus to
better evaluate this lesion.
- Since you just had a sphincterotomy, you should not take
coumadin or aspirin for for 5 days. This means you can start
taking these medications again on [**9-4**].
- You will need a repeat ERCP in 8 weeks from now for stent
removal. The ERCP service will call you to set up an
appointment.
- You have JP drain, blood, urine cxs that are still pending
here and need to be followed-up by your outpatient Primary Care
Physician
Followup Instructions:
- Please follow-up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 122**]
[**Last Name (NamePattern1) **] in 2 weeks following this hospitalization by calling him at
[**Telephone/Fax (1) 45859**] to schedule an appointment.
- Please follow-up with ERCP in 8 weeks to remove your biliary
stent from this ERCP procedure.
Completed by:[**2102-8-31**]
|
[
"V15.3",
"V10.46",
"576.8",
"530.81",
"401.9",
"V12.51",
"458.8",
"250.00",
"425.5",
"514",
"427.31",
"501",
"V45.02",
"780.09"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"51.87"
] |
icd9pcs
|
[
[
[]
]
] |
14627, 14675
|
7398, 11374
|
346, 399
|
14761, 14761
|
3653, 3658
|
16547, 16945
|
2541, 2561
|
13054, 14604
|
14696, 14740
|
12089, 12434
|
14912, 16524
|
7101, 7375
|
2576, 2590
|
11395, 12063
|
265, 308
|
427, 1887
|
3672, 4210
|
14776, 14888
|
4226, 7085
|
12459, 13031
|
1909, 2299
|
2315, 2525
|
3131, 3634
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
51,258
| 129,821
|
51227
|
Discharge summary
|
report
|
Admission Date: [**2119-10-30**] Discharge Date: [**2119-11-6**]
Date of Birth: [**2061-6-6**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Fatigue, dyspnea on exertion and lightheadedness.
Major Surgical or Invasive Procedure:
[**2119-10-31**] - aortic valve replacement, coronary artery bypass
grafts x2(LIMA>LAD,SVG>RCA)
[**2119-10-30**] - Left and right heart catheterization, coronary
angiogram left ventriculogram
History of Present Illness:
This 58 year old white male with known aortic stenosis is
followed with serial echocardiograms. Most recently these
revealed an aortic valve area of 0.7cm2, a bicuspid valve and
LVEF of 30%. She was referred for surgical evaluation after
recent new onset heart failure.
Past Medical History:
Hypertension
Noninsulin dependent diabetes mellitus
Aortic Stenosis/Aortic Insufficiency
Mitral Regurgitation
Gastroesophageal Reflux Disease
degenerative joint disease
tonsillectomy
Social History:
Occupation: disabled
Last Dental Exam: last year clearance in chart
Lives alone
Race:Caucasian
Tobacco:none
ETOH:2 beers per week
Enrolled in any clinical/research study? no
Family History:
Mother died of MI at 59; father died of CVA at 53
Physical Exam:
Admission:
Pulse:91 Resp: 20 O2 sat: 100% RA
B/P Right: 108/63 Left: 104/65
Height: 68" Weight: 175 lbs
General:NAD; slow to process and answer questions
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable;teeth
in poor repair
Neck: Supple [x] Full ROM [x]no JVD
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur 4/6 SEm radiates throughout
precordium to carotids
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
no HSM/CVA tenderness
Extremities: Warm [x], well-perfused [x] Edema - none
Varicosities: None [x]chronic mild venous stasis brawniness
above
ankles bil.
Neuro: Grossly intact;MAE [**4-18**] strengths;nonfocal exam; has mild
cognitive deficits
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: NP Left: NP
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid: murmur radiates to both carotids
Pertinent Results:
[**2119-10-31**] ECHO
PREBYPASS
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. There is severe global
left ventricular hypokinesis (LVEF = 20-25 %). The right
ventricular cavity is mildly dilated with moderate impairment
with focal hypokinesis of the apical free wall. The ascending
aorta is moderately dilated. The descending thoracic aorta is
mildly dilated. There are simple atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is severe
aortic valve stenosis (valve area 0.8-1.0cm2). Moderate to
severe (3+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen.
POSTBYPASS
The patient is receiving dobutamine at 7ucg/kg/min.
RV systolic function is improved. There is now mild RV
hypokinesis with minimal focality. LV systolic function is
marginally improved, LVEF ~25%. There is a well seated, well
fumctioning bioprosthesis in the aortic position. There is a
mild perivalvular leak. TR is now mild (1+). The remaining study
is otherwise unchanged from prebypass.
[**2119-11-5**] 06:00AM BLOOD WBC-10.0 RBC-3.42* Hgb-8.7* Hct-26.8*
MCV-78* MCH-25.3* MCHC-32.4 RDW-16.0* Plt Ct-345
[**2119-11-3**] 07:00AM BLOOD WBC-16.0* RBC-3.71* Hgb-9.1* Hct-29.8*
MCV-80* MCH-24.6* MCHC-30.6* RDW-15.6* Plt Ct-281
[**2119-11-5**] 06:00AM BLOOD Glucose-166* UreaN-26* Creat-1.1 Na-139
K-3.5 Cl-98 HCO3-33* AnGap-12
[**2119-11-4**] 06:45PM BLOOD UreaN-31* Creat-1.1 K-3.7
[**2119-10-31**] 05:41PM BLOOD Type-ART pO2-72* pCO2-45 pH-7.37
calTCO2-27 Base XS-0
[**2119-10-30**] 12:30PM BLOOD %HbA1c-7.6*
Brief Hospital Course:
Mr. [**Known lastname 79441**] was admitted to the [**Hospital1 18**] on [**2119-10-30**] for a cardiac
catheterization in anticipation of his aortic valve surgery. His
cardiac catheterization revealed three vessel coronary artery
disease. Mr. [**Known lastname 79441**] was worked-up in the usual preoperative
manner and was ready for surgery.
On [**2119-10-31**] he was taken to the Operating Room where he
underwent coronary artery bypass grafting to two vessels and an
aortic valve replacement using a tissue prosthesis. (Please see
operative note for details.) He weaned from bypass on
Dobutamine,Propofol and Neosynephrine in stable condition.
Postoperatively he was taken to the intensive care unit for
monitoring.
Over the next 24 hours he had awoke neurologically intact and
was extubated. Pressors were weaned off and he remained stable.
Beta blockade and aspirin were resumed. On postoperative day
one, he was transferred to the step down unit for further
recovery. He was gently diuresed towards his preoperative
weight. The physical therapy service was consulted for
assistance with his postoperative strength and mobility.
Oxygenation remained low and a CXR revealed what appeared to be
a large left effusion. A left lung thoracentesis was performed
on [**11-4**] yielding 500 mL of serosanguinous fluid. A repeat CXR
demonstrated an elevated left diaphragm with atelectasis and
resolution of the effusion. His oxygenation improved and he
felt better.
He was discharged to a rehabilitation facility for further
recovery prior to going home. He will continue on diuretics for
a week as he remained above his preoperative weight.
Arrangements were made for follow up with his cardiology,
medical and surgical providers.
Medications on Admission:
Furosemide 20mg daily, citalopram 20mg daily, glipizide 5mg
daily, metformin 1000mg daily, omeprazole 20mg daily,
simvastatin 80mg daily, diphenoxylate-atropine 25prn-prn
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
8. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
10. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q4H (every 4 hours).
11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7
days.
15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7
days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital 4316**] Rehab and skilled nursing
Discharge Diagnosis:
coronary aretery disease
s/p coronary artery bypass
acute systolic heart failure
Hypertension
Non insulin dependent Diabetes Mellitus
Aortic Stenosis/Aortic Insufficiency
Mitral Regurgitation
Gastroesophageal Reflux Disease
degenerative joint disease
Discharge Condition:
Good
Discharge Instructions:
Monitor wounds for signs of infection. These include redness,
drainage or increased pain.
Report any fever greater then 100.5.
Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1
week.
No lotions, creams or powders to incision.
Shower daily,gently pat the wound dry.
No bathing or swimming for 1 month.
Take all medications as directed.
No driving for 1 month or while taking narcotics..
.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 170**])
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2903**] in [**1-17**] weeks. ([**Telephone/Fax (1) 2205**])
Dr. [**Last Name (STitle) **] in 2 weeks ([**Telephone/Fax (1) 62**])
Please call for appointments
Completed by:[**2119-11-6**]
|
[
"511.9",
"V45.89",
"401.9",
"428.23",
"E878.1",
"424.1",
"416.8",
"285.9",
"288.60",
"715.36",
"424.0",
"746.4",
"533.90",
"530.81",
"250.00",
"428.0",
"997.39",
"E878.2",
"414.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.64",
"35.21",
"88.72",
"34.91",
"36.11",
"88.56",
"39.61",
"36.15",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
7435, 7507
|
4090, 5829
|
371, 565
|
7802, 7809
|
2311, 4067
|
8259, 8587
|
1280, 1332
|
6051, 7412
|
7528, 7781
|
5855, 6028
|
7833, 8236
|
1347, 2292
|
282, 333
|
593, 865
|
887, 1072
|
1088, 1264
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,976
| 122,601
|
10358
|
Discharge summary
|
report
|
Admission Date: [**2196-11-5**] Discharge Date: [**2197-1-2**]
Date of Birth: [**2126-2-12**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 14964**]
Chief Complaint:
70 year old white male s/p recent hospitalization who presented
to the ED after a fall.
Major Surgical or Invasive Procedure:
CABGx3(SVG->LAD, OM, PDA)/Aortic dissection repair [**2197-11-10**]
PEG
History of Present Illness:
This 70 year old white male was discharged from [**Hospital1 18**] 6 days
prior to admission after having and impacted CBD stone which was
extracted via ERCP. He was scheduled to have a CCY on [**2196-11-11**],
but presented to the ED with increased weakness and a fall.
Past Medical History:
alcohol abuse
Pancreatitis
hepatitis
Anemia
Thrombocytopenia
Gastrointestinal bleed
Hypertension
History of Deep venous thrombosis
Renal tubular acidosis type 4
history of ketoacidosis
Tonsillectomy
Social History:
Alcohol,approximately 2 drinks a day. Quit smoking 25 years
ago. retired salesman, lives with wife
Family History:
mother and father died in their 80s of an unknown cancer
Physical Exam:
Thin, elderly white male in NAD who smells of ETOH
AVSS
HEENT: NC/AT, PERLA, EOMI, oropharynx benign
Neck: Supple, From, no lymphadenopathy or thyromegaly, carotids
2+= bilat. without bruits.
Lungs: Clear to A+P
CV: RRR without R/G/M
Abd.: + BS, soft, nontender, without masses or
hepatosplenomegaly
Ext: without C/C/E
Neuro: A+Ox3, intermittently confused.
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2196-12-26**] 06:30AM 7.5 4.31* 13.0* 38.4* 89 30.1 33.8 14.8
146*
BASIC COAGULATION (PT, PTT, PLT, INR) PT Plt Ct INR(PT)
[**2196-12-26**] 06:30AM 146*
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2196-12-24**] 05:15AM 118* 34* 0.7 137 4.2 102 28 11
Brief Hospital Course:
The patient was admitted on [**2196-11-5**] for ROMI as he had new
diffuse TW inversions in V1-V6. He stated that he had had an
episode of CP in the past which had awoken him from sleep. He
underwent cardiac cath on [**2197-11-10**] which revealed: 90%LAD
lesion, 90% mid RCA lesion, 50% LCX lesion, and a 55% LVEF. His
RCA was dissected and it tracked up into the ascending aorta.
Dr. [**Last Name (STitle) 70**] was consulted and on [**2197-11-10**] the pt. underwent a
CABGx3 (SVG->LAD, OM, and PDA)/Ascending Aortic replacement w/ a
26 mm gelweave graft. Cross clamp time was 113 mins, total
bypass time was 142 mins, and circ. arrest was 11 mins. He was
transferred to the CSRU on Epi, Levo, Nitro, and Propofol. He
had low cardiac output on the postop night and remained sedated
and intubated. He had a large right pneumothorax on POD#1 and a
chest tube was inserted. He was extubated on POD#3 and required
aggressive respiratory therapy. He was off all of his drips and
progressing. He had intermittent confusion and aggitation, and
was noted to be coughing while eating. He was profoundly
aspirating on his swallowing evaluation and had a nasogastric
feeding tube placed. He also had bilat. thoracentesis for large
effusions.
On POD#10 he coded and was reintubated and shocked out of VT.
He remained intubated for several days requiring aggressive
respiratory therapy and having somewhat marginal hemodynamics.
He was also diagnosed with a DVT of his R brachiocephalic vein,
and had E. coli bacteremia which were appropriately treated.
On POD#17 he was hypotensive and had been having episodes of
bradycardia. Cardiology evaluated him and he had a small,
loculated, pericardial effusion which did not need to be tapped.
He had a temporary pacing wire placed. His hemodynamics
responded well to this and he had a permanent pacer placed on
POD#21.
On POD #25 he was extubated and he slowly progressed.
He had multiple swallowing evaluations and eventually had a PEG
placed by GI. He was transferred to the floor on POD #34. He
was progressing and ready to go to rehab when he had an episode
on severe hypoglycemeia and was transferred back to the CSRU.
This resolved and he was transferred back to the floor. He grew
out Morexella Cataralis in his sputum on [**12-23**] and was started on
Levaquin.
He had a repeat video swallow eval. which was improved from
previous study. He was started on nectar thick liquids and
pureed diet (supervised only), and his tube feeds were changed
to cycle from 8 pm until 6 am.
On [**12-30**], he complained of right foot pain, an x-ray was obtained
which was negative. His pain improved with ibuprofen.
Medications on Admission:
Colchicine 0.6 mg PO daily
Lipitor 20 mg PO daily
Zoloft 50 mg PO daily
Protonix 40 mg PO daily
Ditropan 5 mg PO BID
Discharge Medications:
1. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2
times a day).
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal TID (3
times a day).
4. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One
(1) Capsule, Sust. Release 24HR PO HS (at bedtime).
5. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
7. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
9. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Ascorbic Acid 100 mg/mL Drops Sig: One (1) PO BID (2 times
a day).
11. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY
(Daily).
12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): INR goal 2-2.5. Tablet(s)
15. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 7 days.
16. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: One
(1) PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] health care center
Discharge Diagnosis:
CAD
Type A aortic disection
s/p repair of type A aortic disection/CABG
post atrial fibrillation
post op heart block
s/p permanent pacer insertion
prolonged intubation
post op dysphagia/aspiration
h/o impaceted CBD stone-s/p sphincterotomy/ERCP
HTN
h/o DVT
post op RUE DVT
h/o EtOH abuse
h/o GIB
Discharge Condition:
Good.
Discharge Instructions:
Follow medications on discharge instructions.
PEG care per protocol.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] when you are discharged from
rehab.
Make an appointment with Dr. [**Last Name (STitle) 70**] for 6 weeks.
Make appointment with Dr. [**Last Name (STitle) 284**] (cardiology/EPS) ([**Telephone/Fax (1) 5425**] upon discharge from rehab.
Completed by:[**2197-1-2**]
|
[
"441.01",
"998.2",
"518.5",
"251.2",
"512.1",
"414.01",
"427.81",
"E888.9",
"780.79",
"401.9",
"453.8",
"511.9",
"790.7",
"284.8",
"294.8",
"507.0",
"291.0",
"427.31",
"303.00",
"423.0",
"041.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"99.62",
"37.22",
"36.06",
"34.04",
"38.45",
"35.39",
"96.04",
"37.83",
"88.72",
"37.78",
"37.23",
"36.13",
"88.56",
"36.01",
"43.11",
"88.42",
"96.6",
"89.64",
"34.91",
"37.72"
] |
icd9pcs
|
[
[
[]
]
] |
6157, 6223
|
1981, 4645
|
409, 483
|
6562, 6569
|
1590, 1958
|
6768, 7088
|
1139, 1197
|
4812, 6134
|
6244, 6541
|
4671, 4789
|
6593, 6744
|
1212, 1571
|
282, 371
|
511, 784
|
806, 1006
|
1022, 1123
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,769
| 193,014
|
3837
|
Discharge summary
|
report
|
Admission Date: [**2150-12-28**] Discharge Date: [**2151-1-12**]
Date of Birth: [**2084-12-10**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
66 [**Female First Name (un) **] old white male with 3 episodes of chest pain over past 3
days.
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2150-12-29**]
Redo CABG x 4 (LIMA->LAD, SVG->PDA, OM, Diag)[**2151-1-4**]
Reexploration for bleeding [**2151-1-4**]
History of Present Illness:
66 y.o. male h/o CABG x3 '[**38**], stent x4 [**Date range (1) 17231**],
hyperlipidemia, HTN, OA, presents with 3 recent episodes of CP
over 3 days (x2/last 12hrs). First episode occured 2 days ago
while patient was shoveling snow. Sudden onset, 5 minutes,
[**4-22**], diffuse sternal discomfort "smoky feeling in my lungs."
Resolved quickly with rest. 2nd episode 4 am, awoken from
sleep. Same description, lasting 5-10 minutes, patient was
diaphoretic. Able to fall back asleep after taking 2 tums.
Last, most recent episode, occured at work when patient was
lifting a toilet bowl. Same description, increase in
diaphoresis, lasting 10 minues, relieved with rest after 2
minutes. spontaneosly resolved with rest 5-10 minutes long.
Pain was never radiating, it was identical to his previous
anginal chest pain, denied any associated nausea/vomiting,
SOB/palps. After speaking with his PCP instructed to come to
[**Hospital1 18**] ED. Currently patient is assymptomatic: no
CP/SOB/Palps/diaphoresis/N/V.
Past Medical History:
Caths x 4 [**12-16**], with OM and Diag stents
CABG '[**38**] ( RIMA -> LAD, SVG -> D1, PDA)
hyperlipidemia,
HTN
GERD
OA
Anemia
Polymyalgia rheumatica
Social History:
Lives with wife.
denies EtOH, +tob - quit 30 yrs ago, 60 pack yrs.
Family History:
?arteriosclerosis 78->death, brother AMI@62, HTN, dyslipidemia
in siblings.
Physical Exam:
Vitals: 129/62 P:56 RR: 14 99% RA
HEENT: MMM, no JVD, no carotid bruits
CV: rrr nl S1, S2, distant heart sounds
Lungs: CTAB/l no w/r/r
Abd: + BS SNT/ND, no masses
Ext: no femoral bruits, +1 DP, femoral pulses, no edema, no
rashes.
Neuro: nonfocal
Pertinent Results:
Hematology
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2151-1-12**] 06:26AM 6.5 3.66* 11.2* 32.7* 90 30.5 34.1 14.2
337#
BASIC COAGULATION Plt Ct
[**2151-1-12**] 06:26AM 337#
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2151-1-12**] 06:26AM 88 22* 1.0 132* 4.5 100 25 12
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
[**2151-1-12**] 06:26AM 7.7* 3.8 2.1
Brief Hospital Course:
The patient was admitted on [**2150-12-28**] and was started on heparin
and integrillin. He underwent cardiac cath [**2150-12-29**] which
revealed: 50% LMCA lesion, 100% occlusion of LAD, 40% LCX, 100%
occlusion of RCA, 90% instent restenosis in the Diag graft, 90%
mid graft lesion of the RCA, and 100% occlusion of the RIMA,
with a 50% LVEF. Dr. [**Last Name (STitle) **] was consulted and on [**2151-1-4**] he
underwent a Redo CABG x 4 with LIMA->LAD, SVG->PDA, OM, Diag).
He had increased chest tube output and was reexplored that
evening. He continued to bleed and had a right chest tube
placed and then had to return to the OR the next morning and had
a right thorocotomy performed by Dr. [**Last Name (STitle) **]. He had evactuation
of hematoma and a wedge resection of the right middle lobe of
the lung. He stabilized and then went into rapid afib/flutter.
He converted with amiodorone and then was aggressively diuresed
and continued to progress.
He was extubated on POD#3 and had all of his chest tubes d/c'd
by POD#4. On POD#4 he was transferred to the floor and his
epicardial pacing wires were d/c'd on POD#5. He was discharged
to home in stable condition on POD#8.
Medications on Admission:
Toprol XL 50, Lipitor 20 mg, Plavix 75. ASA 81, Lisinopril 10.
Allopurinol 300, Prilosec 20,
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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
3. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO twice a
day for 7 days: Take 400 mg once per day for 7 days after [**Hospital1 **]
dose finished, then take 200 mg PO qd after 400 mg dose
finished.
Disp:*60 Tablet(s)* Refills:*0*
4. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig:
One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed: Take with food.
Disp:*120 Tablet(s)* Refills:*0*
6. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
7. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO once a day for 10 days.
Disp:*40 Capsule, Sustained Release(s)* Refills:*0*
8. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Non ST elevation myocardial infarction
Coronary artery disease
s/p CABG
Hyperlipidemia
Hypertension
GERD
Discharge Condition:
Good
Discharge Instructions:
Follow medications on discharge instructions.
You may not drive for 4 weeks.
You may not lift more than 10 lbs. for 3 months.
You should shower, let water flow over wounds, pat dry with a
towel.
Followup Instructions:
Make an appointment with Dr. [**Last Name (STitle) **] for 1-2 weeks.
Make an appointment with Dr. [**Last Name (STitle) **] for 4 weeks.
Completed by:[**2151-1-12**]
|
[
"274.9",
"998.0",
"V17.3",
"725",
"998.11",
"511.8",
"414.02",
"530.81",
"996.72",
"414.01",
"410.71",
"401.9",
"427.31",
"285.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"99.62",
"00.17",
"99.04",
"88.72",
"36.15",
"37.22",
"88.56",
"99.20",
"88.57",
"36.13",
"88.53",
"34.03",
"32.29",
"39.61",
"99.05"
] |
icd9pcs
|
[
[
[]
]
] |
5381, 5439
|
2699, 3886
|
419, 562
|
5588, 5594
|
2238, 2676
|
5838, 6007
|
1877, 1954
|
4030, 5358
|
5460, 5567
|
3912, 4007
|
5618, 5815
|
1969, 2219
|
284, 381
|
590, 1602
|
1624, 1777
|
1793, 1861
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,055
| 153,824
|
140
|
Discharge summary
|
report
|
Admission Date: [**2113-7-25**] Discharge Date: [**2113-7-31**]
Date of Birth: [**2030-11-26**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
Acute mental status change
Major Surgical or Invasive Procedure:
Embolectomy [**2113-7-27**]
History of Present Illness:
Pt's a 82 yo F with h/o HTN, h/o of prox a-fib, (not on
coumadin), mood disorder on depakote (has had since CVA 4 yrs
prior), with prior L inferior division MCA infarct now
presenting with altered mental status. Pt basically at baseline
AA0x2, has been reclusive living alone with mood disorder since
her stroke - but has family heavily involved in her care -
including ex-husband who visits daily. Pt basically has been at
her baseline (which is described as more aggressive - usually
asking her family to leave within 10-15minutes of being around
her), but then 3-4 days ago noted being more lethargic - less
aggressive but without any other notable complaints per
ex-husband who saw pt then (no report of CP, F/C, HA, SOB as
best assessed). Family getting concerned - were thinking would
be needing more higher level care placement as pt generally
weaker (no focal weaknesses) - but Sunday started appearing at
baseline again. Pt was seen Monday early and was doing well
(has called ex-husband roughly around 2pm and noted again at her
baseline) - however when home aide came by apartment today in
the morning - pt did not respond to door - found lethargic with
emesis/stool/urine around her. No further information able to
be obtained related to any events preceding to the evident n/v,
bowel/stool incontinance.
<br>
Pt denies any cp, ha symptoms - can not elaborate further - was
sent to ED - noted aggitated, +echolalia described in ED and
from home aide initially - all consistant per family with her
prior CVA 4 yrs prior. CT head without sig changes - however
noted poor quality due to aggitation - neurology consulted.
Noted trop elevated 1.12 - cardiology called - stated will not
cath at present but for full medical treatment. Pt had been put
in restraints in ED with foley placed - pt was subsequently
severely aggitated. On arrival to floor - pt much calmer - not
in restraints - family at bedside.
<br>
In [**Name (NI) **] pt treated with hep gtt, ASA/Plavix (though pt refused to
take), IV metoprolol (due to declining po meds), and vanc
1g/ceftriaxone 1g - for emperic treatment with leukocytosis (d/w
ED resident - they stated just emperic tx with leukocytosis -
were not aiming towards meningitis at time or any focal
infection).
<br>
ROS: pt unable to appropriately respond to full questions.
Past Medical History:
-HTN
-prox atrial fibrillation
-mood disorder - on depakote
-CVA 4yrs prior as above
frequent UTIs reported in past
anxiety
h/o HSV I around mouth, s/p valtrex
right cataract surgery
Social History:
lives alone, divorced, though ex-husband visits daily, 2
children, no tob/etoh/drugs. Russian speaking. Since stroke, pt
more reclusive with h/o of mood disorder, but family very
involved with care - pt lives by herself - but gets assistance
from family for all IDLS, and for help with food preparation,
bathing - pt able to go to restroom and does take medications by
herself (as arranged in pill box by family).
<br>
Pt does not have officially assigned HCP - however 2 daughters
collectively have been making decisions on her care since her
stroke 4 yrs prior.
NOK: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1484**] Cell) [**Telephone/Fax (1) 1485**], [**First Name5 (NamePattern1) **] [**Known lastname 1486**] [**Telephone/Fax (1) 1487**]
(cell), [**Telephone/Fax (1) 1488**] (work). Ex-Husband (but also highly
involved in daily care of patient - [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1484**] [**Telephone/Fax (1) 1489**].
Family History:
HTN, no seizures or strokes
Physical Exam:
Discharge Vitals: 97.1 150/88 (generally SBP 100-120) 81 18
97RA
Gen: Elderly female, NAD.
HEENT: PERRL, EOMI. No scleral icterus. No conjunctival
injection. Mucous membranes moist. No oral ulcers.
Neck: Supple, no JVP
Lungs: CTA bilaterally anteriorly, no wheezes, rales, rhonchi.
Normal respiratory effort.
CV: irreg irreg, no murmurs, rubs, gallops.
Abdomen: soft, NT, ND, NABS
Extremities: L arm with significant post-surgical eccymosis,
without hematoma or bleeding. Ecchymosis stable, with gradual
dilutional spread.
Neurological: CN2-12 grossly intact. No focal defecits.
Pertinent Results:
[**2113-7-25**] 04:46PM LACTATE-2.8*
[**2113-7-25**] 01:18PM GLUCOSE-170* LACTATE-4.8*
[**2113-7-25**] 01:15PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.017
[**2113-7-25**] 01:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2113-7-25**] 01:15PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2113-7-25**] 01:15PM URINE GRANULAR-<1 HYALINE-<1
[**2113-7-25**] 01:15PM URINE MUCOUS-FEW
[**2113-7-25**] 01:10PM GLUCOSE-175* UREA N-20 CREAT-0.8 SODIUM-139
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-25 ANION GAP-21*
[**2113-7-25**] 01:10PM ALT(SGPT)-34 AST(SGOT)-132* CK(CPK)-6902* ALK
PHOS-61 TOT BILI-1.2
[**2113-7-25**] 01:10PM LIPASE-12
[**2113-7-25**] 01:10PM cTropnT-1.12*
[**2113-7-25**] 01:10PM CK-MB-237* MB INDX-3.4
[**2113-7-25**] 01:10PM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-3.3
MAGNESIUM-2.0
[**2113-7-25**] 01:10PM WBC-15.4* RBC-5.10 HGB-15.7 HCT-45.9 MCV-90#
MCH-30.8# MCHC-34.2 RDW-13.0
[**2113-7-25**] 01:10PM NEUTS-87.8* LYMPHS-7.0* MONOS-4.5 EOS-0.6
BASOS-0.2
[**2113-7-25**] 01:10PM PLT COUNT-196
[**2113-7-25**] 01:10PM PT-12.5 PTT-21.9* INR(PT)-1.1
<br>
Discharge labs:
[**2113-7-31**] 09:25AM BLOOD WBC-7.9 RBC-4.07* Hgb-12.5 Hct-36.7
MCV-90 MCH-30.8 MCHC-34.1 RDW-13.5 Plt Ct-272
[**2113-7-31**] 09:25AM BLOOD Glucose-270* UreaN-11 Creat-0.7 Na-142
K-4.3 Cl-106 HCO3-32 AnGap-8
[**2113-7-31**] 09:25AM BLOOD Calcium-9.8 Phos-3.1 Mg-2.1
[**2113-7-28**] 01:19AM BLOOD VitB12-181*
[**2113-7-28**] 01:19AM BLOOD TSH-2.1
[**2113-7-29**] 06:55AM BLOOD Valproa-19*
[**2113-7-30**] 07:10PM BLOOD PT-18.9* PTT-150* INR(PT)-1.7*
[**2113-7-31**] 02:00AM BLOOD PT-16.4* PTT-26.0 INR(PT)-1.5*
[**2113-7-31**] 09:25AM BLOOD PT-19.6* PTT->150 INR(PT)-1.8*
[**2113-7-31**] 10:35AM BLOOD PT-21.3* PTT->150* INR(PT)-2.0*
[**2113-7-25**] 01:10PM BLOOD ALT-34 AST-132* CK(CPK)-6902* AlkPhos-61
TotBili-1.2
[**2113-7-26**] 06:30AM BLOOD CK(CPK)-4823*
[**2113-7-29**] 08:10PM BLOOD CK(CPK)-1455*
[**2113-7-25**] 01:10PM BLOOD cTropnT-1.12*
[**2113-7-30**] 03:25AM BLOOD CK-MB-12* cTropnT-0.45*
[**2113-7-30**] 11:58AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009
[**2113-7-30**] 11:58AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
.
Blood cultures: neg x 2
Urine culture: negative x1, pending x 1
RPR negative
<br>
CXR: IMPRESSION:
1. Enlargement of the cardiac silhouette, without evidence of
pulmonary edema and without change compared to [**2109**], suggesting
possible cardiomyopathy.
2. Slight increased, now moderate-sized hiatal hernia.
<br>
[**7-25**] EKG compared to 05' EKG - nsr, new TWI in avL, +min st dep
v4-6 - otherwise no other acute st/tw changes.
<br>
Non-contrast Head CT:
IMPRESSION: No acute hemorrhage or obvious major acute area of
infarction.
If acute infarction is of clinical concern, MR has improved
sensitivity in comparison to non-contrast head CT.
Chronic infarct in left MCA distribution.
<br>
Cardiac Echo:
Conclusions
The left atrium is dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is
moderate regional left ventricular systolic dysfunction with
akinesis of the mid to distal anterior septum, anterior wall and
apex. A left ventricular mass/thrombus cannot be excluded. Right
ventricular chamber size and free wall motion are normal. There
is no aortic valve stenosis. Mild (1+) aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Trivial mitral regurgitation is seen.
There is no pericardial effusion.
IMPRESSION: Focal LV systolic dysfunction consistent with LAD
infarction. Mild aortic regurgitation.
<br>
[**7-26**] CXR: The patient's radiograph currently demonstrates new
bilateral perihilar opacities consistent with interval
development of pulmonary edema. There are bilateral pleural
effusions also developed in the meantime interval, most likely
small to moderate. There is no pneumothorax and there is no
change in the cardiomediastinal silhouette.
.
LLE LENI: Preliminary Report !! WET READ !! No DVT LLE.
Brief Hospital Course:
82 yo F with h/o HTN, h/o of prox a-fib, (not on coumadin), mood
disorder on depakote (has had since CVA 4 yrs prior), with prior
L inferior division MCA infarct now presenting with altered
mental status with troponin elevation.
<br>
# AMS/NSTEMI: Patient began to have mental status changes [**4-5**]
days prior to admission, then was found on the floor with
emesis/stool/urine around her. In ED, had altered MS with new
inferolateral ST depressions and T-wave inversions in aVL on
ECG, elevated troponin and no acute changes on CT Head.
Neurology was consulted for possible metabolic encephalopathy,
either due to effect of medications (on depakote at home) or
infection (T to 100.4 and leucocytosis). Her family declined a
lumbar puncture. ACS protocol was initiated with IV heparin and
betablockers, while patient refused PO medications. The family
chose not to undergo catheterization, opting for more
conservative medical management.
The morning of [**2113-7-26**] the patient was noted to be in atrial
fibrillation with rapid ventricular response with decreased
urine output and new pulmonary edema on CXR. Echocardiogram
that day showed akinesis of the mid to distal anterior septum,
anterior wall and apex. Diuresis was undertaken. Then at 1700,
the patient's left hand was noted to become cold, blue and
painful. Vascular surgery was consulted, the patient was
transferred to the CCU. She was also started on a high dose
statin and a small dose of an ACE inhibitor. Neurology
recommended that she have a non-emergent MRI head to r/o embolic
stroke not visualized on head CT, however family declined as it
would not likely change management.
<br>
# Anticoagulation: Patient has multiple indications for being
maintained on anticoagulation, and at the time of discharge, pt
is currently on a heparin drip while bridging to therapeutic
INR. Considering thromboembolism to her arm requiring
embolectomy, her atrial fibrillation, and her history of strokes
in the past, I recommend overlapping her heparin drip with a
therapeutic INR x 48 hours. Please note that at the time of
discharge, her INR measured 2, however this is likely
OVERestimated, as her PTT at the time was >150, and at that
level of anticoagulation can falsely elevate the INR. I
recommend obtaining a repeat INR upon admission. Please titrate
coumadin dosing prn for goal INR [**3-7**].
<br>
# Left hand ischemia: Patient was noted [**7-26**] to have a palpable
brachial pulse and absent radial pulse on the left side. Most
probably cause was felt to be an arterial clot in the setting of
atrial fibrillation. The patient had already been started on a
heparin drip for ACS and this was continued. The vascular
surgery team was consulted regarding the limb ischemia and
embolectomy was felt to be indicated as she continued to have
cyanosis of her left hand despite being on the heparin drip.
She had a successful embolectomy on [**7-27**] of the left brachial
artery under local anesthesia. Her post-op course was
complicated by a large 8cm hematoma at the entry site in the
left arm, which was followed closely by vascular surgery, as no
urgent need for hematoma evacuation was indicated overnight.
Given a stable hematocrit, the patient was continued on IV
Heparin for anticoagulation for her recent NSTEMI as well as her
history of Afib.
<br>
# Atrial Fib - Patient has a history of paroxysmal a-fib, but
was not on coumadin due to a high risk of falls. She was found
to be in atrial fibrillation with RVR the morning of [**7-26**], but
since has been adequately rate controlled with metoprolol.
Given her recent embolic event to her left arm, she was started
on coumadin with a heparin bridge. To avoid an excessive
bleeding risk, her Plavix was discontinued(patient was started
on aspirin and plavix after an MCA CVA apprx 3 years ago) and
her Aspirin dose was reduced to 81mg daily.
<br>
# Mood disorder: Patient has had behavioral problems since a CVA
three years ago. After admission her mental status apparently
returned to baseline. She was continued on home doses of
Depakote, Paxil and Zyprexa. Restraints and foley catheter were
avoided.
<br>
# Pulmonary edema - patient was diuresed with IV Lasix. She is
incontinent and did not have a foley catheter, making it
difficult to measure her fluid balance, but she appeared to be
euvolemic and breathing comfortably at the time of discharge.
<br>
# HTN - Patient was adequately controlled with metoprolol and
lisinopril.
<br>
Prophylaxis - patient maintained on famotidine and SQ heparin.
<br>
NOK: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1484**] (Cell) [**Telephone/Fax (1) 1485**], [**First Name5 (NamePattern1) **] [**Known lastname 1486**]
[**Telephone/Fax (1) 1487**] (cell), [**Telephone/Fax (1) 1488**] (work). Ex-Husband (but also
highly involved in daily care of patient - [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 1484**]
[**Telephone/Fax (1) 1489**].
Code: FULL
DISPO: pt discharged to [**Hospital 100**] Rehab LTAC
Medications on Admission:
Confirmed with family [**7-25**]:
Aspirin 81 mg po q day
Lisinopril 10 mg po q day
Depakote 250 mg po BID
metoprolol 25 mg po BID
zyprexa 5 mg po q day
Paxil 10 mg po q am
Vitamin C 500 mg po BID
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. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
9. Heparin (Porcine) in D5W 25,000 unit/250 mL Parenteral
Solution Sig: per protocol units Intravenous contin: Please
continue heparin gtt until INR [**3-7**] for 48 hours.
10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
11. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) mL
Injection DAILY (Daily) for 4 days.
12. Valproic Acid (as Sodium salt) 250 mg/5 mL Syrup Sig: Two
[**Age over 90 1230**]y (250) mg PO Q12H (every 12 hours).
13. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day): hold for loose stools.
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H
(every 4 hours) as needed for pain or fever.
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
-Altered mental status
-Non ST-elevation myocardial infarction
-Left arm ischemia
-B12 deficiency.
Discharge Condition:
Good
Discharge Instructions:
You were admitted with altered metntal status. You ruled in for
a heart attack but the decision was made to pursue conservative
management. Your heart went into a rapid rate and a blood clot
traveled to your left arm causeing a blockage. You were taken to
the OR for removal of the clot. You were put on a heparin drip
and will need to be on long term anticoagulation with coumadin
to prevent further blood clots. You were also noted to have low
B12 level which can contribute to altered mental status and you
being given b12 supplementation
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction:
Followup Instructions:
Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1490**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2113-8-9**] 3:15
[**Hospital **] Medical Office Building; [**Location (un) 442**].
|
[
"300.00",
"427.32",
"266.2",
"428.21",
"276.8",
"410.71",
"401.9",
"276.50",
"296.90",
"444.21",
"427.31",
"998.12",
"V12.54",
"E878.8",
"553.3",
"443.9",
"788.30",
"V58.61",
"348.31",
"428.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.03"
] |
icd9pcs
|
[
[
[]
]
] |
15554, 15620
|
8791, 13823
|
343, 373
|
15763, 15770
|
4607, 5793
|
16480, 16690
|
3944, 3974
|
14070, 15531
|
15641, 15742
|
13849, 14047
|
15794, 16457
|
5810, 7387
|
3989, 4588
|
277, 305
|
401, 2728
|
7396, 8768
|
2750, 2934
|
2950, 3928
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,139
| 127,618
|
33353
|
Discharge summary
|
report
|
Admission Date: [**2130-7-16**] Discharge Date: [**2130-7-20**]
Date of Birth: [**2051-1-3**] Sex: F
Service: MEDICINE
Allergies:
Heparin Agents / Succinylcholine
Attending:[**First Name3 (LF) 13541**]
Chief Complaint:
Chief complaint:Initially presented to OSH ([**First Name8 (NamePattern2) **] [**Doctor First Name **]) with
generalized weakness and chest pain after HD.
MICU admit for:OSH transfer for respiratory distress
Major Surgical or Invasive Procedure:
PICC line placement.
History of Present Illness:
79F with complicated PMH including ESRD on HD 3x/week, CAD, DM,
h/o c. diff. Of note pt was hospitalized at [**Hospital1 18**] last in
[**2130-1-24**] with complicated ICU course with multiple severe
infections (including pseudomonas VAP, CMV viremia and VRE
bactermia), respiratory failure requiring intubation and
eventual tracheostomy and PEG placement. Pt was formerly a
resident of [**Doctor Last Name **] NH, presented from there after HD to St.
[**Hospital **] hospital with complaint of 1 week of generalized weakness
and 1 day of chest pain. At the OSH she was dound to be in AF
with RVR. Ruled out for MI with serial enzymes. Was found to
have a UTI which was treated initially with renally dosed
levaquin. On CXR had evolving LLL infiltrate with pleural
effusion. Per their records she had recently completed a course
of bactrim for an abdominal cellulitis/rash and had been
completing a course of vancomycin for a MRSA infection at her HD
catheter site. She was treated with flagyl prophylactically
while on other abx given hx of c. diff. Had 1/4 bottles blood
cultures + for GPCs, given linezolid x 1 d until cx resulted
CNS, considered contaminant. Was started on zosyn for LLL
infiltrate. Urine cultures resulted as e. coli resistant to
levaquin and zosyn, sensitive to 3rd gen cephalosporins.
Pulmonary service consulted, recommended continuing flagyl,
discontinuing levaquin and zosyn and starting ceftriaxone. On
[**7-15**] while at HD pt had an episode of bradycardia and
hypotension, after which her digoxin was held and metoprolol
dose was decreased. Her PNA coverage was broadened to imipenem
to cover for pseudomonas in setting of worsening CXR. In early
am of [**7-16**] pt had acute respiratory distress with desat to
30-50%, was suctioned, placed transiently on bipap (which she
did not tolerate), CXR showed interval L lung whiteout. Bronch
was offered but refused by the family, pt remained firmly DNI.
On repeat suctioning, large mucous plug extracted and pt recoved
with 02 sats ~100% on NRB. Pt's family requested tx to [**Hospital1 18**] for
continued care.
.
On arrival to [**Hospital1 18**] ICU pt appeared comfortable, VSS, sating
well on NC. Denied pain, stated she was not SOB and that her
breathing was back to baseline. Son stated that she would
occasionally have substernal CP during dialysis that radiated to
her back. Currently denies CP.
Past Medical History:
-Hypertension
-Hyperlipidemia
-CAD - s/p MI [**6-28**], s/p stents x 3 @ [**Hospital1 **], nl EF in [**1-28**]
-Hypothyroid
-RA
-Gout
-ESRD
-Anemia [**12-24**] CKD - on epo
-DM2 - on insulin
-Asthma - not on home o2
-Pseudocholinesterase insufficiency
-H/o HITT ([**2127**] [**Hospital1 2025**])
-H/o hemoptysis on heparin ([**2127**] [**Hospital1 2025**])
-H/o UGIB on heparin ([**2127**] [**Hospital1 2025**])
-H/o respiratory failure [**2-/2130**] with pseudomonas VAP, VRE
bactermia and CMV viremia, necessitating trach and peg, both
subsequently removed
Social History:
Lived in [**Doctor Last Name **] NH. Sons live close by are joint HCPs. [**Name (NI) **]
[**Name2 (NI) **]/ETOH/drugs. Portugese speaking.
Family History:
non contributory
Physical Exam:
Vitals: T: 95.6 BP: 118/52 P:87 R: 21 SaO2: 96% 3L NC
General: Awake, responding to commands and questions, appears
comfortable.
HEENT: alopecia. MM dry
Neck: supple, thick, no JVP appreciated, healed trach site
Pulmonary: decreased L base.
Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated
Abdomen: soft, NT, ND, normoactive bowel sounds, no masses or
organomegaly noted. Several small healing erythematous scabs.
well healed PEG site.
Extremities: trace non-pitting edema b/l
Skin: no rashes or lesions noted.
Neurologic: Alert, oriented to [**Location (un) **], cannot say name of place
but "I know I have been here before.", moving all extremities,
no facial asymmetry, responds to questions through translator.
Pertinent Results:
CBC:
[**2130-7-19**] WBC-9.3 RBC-4.41 Hgb-11.5* Hct-35.8* Plt Ct-191
.
Chemistry:
[**2130-7-19**] Glucose-94 UreaN-12 Creat-2.0 Na-136 K-4.1 Cl-101
HCO3-27 AnGap-12
[**2130-7-19**] Calcium-8.5 Phos-3.0 Mg-1.9
.
Vanc level:
[**2130-7-16**] Vanco-2.2*
CXR: [**2130-7-19**]: Since prior study, there has been no relevant
change in bilateral left greater than right effusions as well as
retrocardiac opacity. The right PICC and dialysis catheter are
in unchanged positions. There is no pulmonary edema.
.
CXR: [**2130-7-17**]: As compared to the previous radiograph, there is
no relevant change. The position of the left-sided central
venous access line is unchanged. Also unchanged is the size of
the cardiac silhouette and the left-sided parenchymal
consolidation with air bronchograms. There is no evidence of
newly occurred focal parenchymal opacities
Brief Hospital Course:
1. LLL pneumonia: At [**Hospital1 18**], she was briefly observed in the ICU,
where she did well and was transferred to the floor 24 hours
later. She had no oxygen requirement, although repeat chest
imaging did demonstrate a left retrocardiac opacity. Repeated
sputum cultures were unrevealing, and blood cultures all
remained negative. She
essentially completed 7 days of various antimicrobial agents for
pneumonia coverage.
2. E. coli lower UTI: She was placed on Meropenem to cover for
her resistant E. coli UTI (ESBL qualities, although still noted
as sensitive to third generation cephalosporins), and will
complete a 7-day course of therapy (last day on [**7-22**]).
3. History of C. difficile colitis: Flagyl PO was continued,
with the plan to continue therapy at least 7 days beyond
completion of the above Meropenem course given her history of C.
difficile colitis.
4. Possible recent line infection: She was continued on
Vancomycin for a period of time, discontinued on [**7-19**] given no
clear evidence of MRSA infection. Repeated blood cultures
remained negative.
5. ESRD on HD: She was followed by the renal service during her
hospitalization, and underwent dialysis three times weekly
(Tu/Th/Sat).
6. Atrial fibrillation: Rate controlled with beta blockade
therapy, which was titrated. Digoxin was NOT restarted. We will
defer the decision to initiate
anticoagulation to you, since her outside physicians elected not
to start it, and I see in her records that she has a prior
history of GI bleeding.
Her other problems remains relatively stable in the hospital.
Medications: Meropenem was continued with a plan for a 7 day
course. Flagyl was started as patient on multiple antibiotics
and having some diarrhea. Flagyl course for ten days.
Metoprolol 25 mg [**Hospital1 **]. Can be titrated up to heart rate of 65 as
long as pressure tolerates.
Medications on Admission:
(on transfer)
Guaifenesin
ISS/Glargine 10 [**Hospital1 **]
Ipratropium nebs
Albuterol nebs
Levothyroxine 125mcg daily
loratadine 10mg daily
metoprolol 25mg [**Hospital1 **]
Metronidazole 500mg IV TID
Paroxetine 20mg daily
Senna
Sevelamer 800mg TIDAC
Imipenem/cilastatin 250mg Q12
Mucomyst nebs
Asa 81mg daily
dulcolax
docusate
duloxetine 30mg QHS
lorazepam 0.5mg Q6
esomeprazole 40mg daily
.
(meds at NH)
Digoxin 0.125mg Q 48
Colace
Duloxetine
Lantus/novolog SS
Albuterol
Lactulose
levothyroxine
ativan
metoprolol
warfarin
sevelamer
senna
bisacodyl
ipratropium
oxycodone
prevacid
acetylcysteine
paxil
nepro
loratadine
bactrim
Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a
day) as needed.
3. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO BID (2
times a day).
4. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) Inhalation
Q6H (every 6 hours).
5. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Hospital1 **]: One (1) Inhalation Q2H (every 2 hours) as
needed for SOB, wheeze.
6. Levothyroxine 125 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY
(Daily).
7. Fexofenadine 60 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times
a day).
8. Sevelamer HCl 800 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
9. Aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Acetaminophen 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H
(every 6 hours) as needed.
11. Duloxetine 30 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Metronidazole 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3
times a day) for 14 days: To be completed on [**2130-7-30**].
14. Meropenem 500 mg Recon Soln [**Date Range **]: One (1) Intravenous every
twelve (12) hours for 4 days: For 7 day course to be completed
on [**7-23**].
15. Metoprolol Tartrate 25 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Extended Care
Facility:
Greater [**Hospital 5503**] health center
Discharge Diagnosis:
Urinary tract infection
Pneumonia
Atrial fibrillation
End-stage renal disease on hemodialysis
History of C. difficile colitis
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to St. [**Hospital **] hospital for weakness and chest
pain on dialysis. You were found to have a rapid and irregular
heart beat. Medication was given to slow your heart down. You
were also found to have a urinary tract infection as well as a
pneumonia (infection of the lung). You were started on
antibiotics for these infections. Your lungs were suctioned and
a large mucous plug was removed. You were then transfered to
[**Hospital1 18**].
.
At [**Hospital1 18**] you were intially admitted to the intensive care unit.
You did well and were able to be transfered to a general medical
floor. Your shortness of breath improved and your chest pain
resolved. A PICC line was placed for your antibiotics.
.
Medications: Meropenum IV. The rest of your home medications
were continued.
Followup Instructions:
With PCP
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 13546**]
|
[
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"285.21",
"403.91",
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"250.00",
"412",
"E912",
"585.6",
"599.0",
"289.89",
"041.4",
"V45.1",
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"008.45",
"414.01",
"493.90",
"V09.91",
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] |
icd9cm
|
[
[
[]
]
] |
[
"39.95",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
9632, 9700
|
5352, 7223
|
502, 525
|
9869, 9878
|
4474, 5329
|
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|
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|
7900, 9609
|
9721, 9848
|
7249, 7877
|
9902, 10713
|
3724, 4455
|
270, 464
|
553, 2936
|
2958, 3519
|
3535, 3675
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
28,499
| 188,396
|
46906
|
Discharge summary
|
report
|
Admission Date: [**2150-4-7**] Discharge Date: [**2150-4-13**]
Date of Birth: [**2092-3-20**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1283**]
Chief Complaint:
asymptomatic/past avr now followed by serial echos, now with
worsening stenosis/gradients
Major Surgical or Invasive Procedure:
AVR(#23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra)[**4-7**]
History of Present Illness:
57yoM s/p AVR/CABG in '[**40**] followed by echo now presents with
worsening stenosis
Past Medical History:
AS s/p AVR(tissue), CAD s/p CABG(SVG-OM), HTN, ^chol, GERD,
Schizophrenia, Depression, Tonsillectomy
Social History:
Lives alone. Does not work.
Remote tobbacco- quit 30 years ago
Rare ETOH
Family History:
noncontributory
Physical Exam:
Admission:
VS HR 76 BP Rt104/60 Lft 100/64 RR 12 Ht 5'8" Wt 195lbs
Gen NAD
Neuro A&Ox3 MAE, nonfocal exam
Pulm CTA bilat
CV RRR 4/6 SEM
Abdm soft, NT/+BS
Ext warm, well perfused. No edema. Rt LE incision mid thigh to
ankle-clean. No varicosities
Palpable pulses throughout
Discharge:
VS
Pertinent Results:
[**2150-4-12**] 05:35AM BLOOD
WBC-10.8 RBC-3.49* Hgb-10.6* Hct-29.7* MCV-85 MCH-30.3
MCHC-35.5* RDW-14.3 Plt Ct-342
[**2150-4-8**] 01:18PM
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
[**2150-4-8**] 10:44 am URINE Source: Catheter.
URINE CULTURE (Final [**2150-4-9**]): NO GROWTH.
[**2150-4-12**] 05:35AM BLOOD
Glucose-112* UreaN-17 Creat-0.9 Na-138 K-4.2 Cl-105 HCO3-24
AnGap-13
[**2150-4-11**] 2:57 PM
CHEST (PA & LAT)
Cardiomediastinal contours are stable in the post-operative
period. Bibasilar atelectatic changes have nearly resolved.
Calcified granuloma is incidentally noted within the right mid
lung. No definite pleural effusions are evident, and there is no
evidence of pneumothorax. Right hemidiaphragm remains mildly
elevated.
IMPRESSION: Resolving bibasilar atelectasis
[**2150-4-10**] 10:39 AM
FEMORAL VASCULAR US RIGHT; FEMORAL VASCULAR US RIGHT PORT
FINDINGS: Sagittal and transverse son[**Name (NI) 493**] analysis of the
right groin demonstrate a 5 x 5 x 2 cm hematoma in the
subcutaneous tissues. There are small branch vessels around the
hematoma but there is no evidence of pseudoaneurysm or fistula
formation. Doppler analysis of the common femoral artery and
vein shows normal waveforms.
IMPRESSION: Right groin hematoma with no evidence of
pseudoaneurysm or fistula formation.
Brief Hospital Course:
Mr [**Known lastname 1313**] was a direct admission to the operating room on [**4-7**].
At that time he had an AVR, please see OR report for details. In
summary he had an AVR with #23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Supra valve, his bypass
time was 98 minutes with a crossclaamp time of 68 minutes. He
did well in the immediate post-op period, and he was extubated
on the day of surgery. On POD1 he remained hemodynamically
stable and was transferred to the floors for continued care.
Once on the floors he had an uneventful post-op course. His
chest tubes and Epicardial wires were removed on POD 3 His
activity level was advanced medicationsd tittrated and on POD 5
it was decided he was ready for discharge home with visiting
nurses.
Medications on Admission:
Lipitor 40'
Digoxin 0.25'
Depakote 250'
Lisinopril 2.5'
Lopressor 50"
ASA 81'
Clozapine 200'Omepprazole 20'
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. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day. Capsule, Delayed
Release(E.C.)(s)
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
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. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Clozapine 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
9. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days.
Disp:*7 Tablet(s)* Refills:*0*
11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for
7 days.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
12. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. Divalproex 250 mg Tablet Sustained Release 24 hr Sig: One
(1) Tablet Sustained Release 24 hr PO HS (at bedtime).
14. Clozapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
15. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
16. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO bid ().
17. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed: prn.
Disp:*30 Tablet(s)* Refills:*0*
18. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
19. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
20. [**Last Name (un) 1724**]
lipitor 40', digoxin .25', depakote 250', lisinopril 25',
lopressor 50'', asa 81', clozapine 200', omeprazole 20'.
Discharge Disposition:
Home With Service
Facility:
[**Hospital1 **] VNA, [**Hospital1 1559**]
Discharge Diagnosis:
s/p redo sternotomy AVR(#23 [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] Epic Supra)[**4-7**]
Discharge Condition:
stable
Discharge Instructions:
Keep wounds clean and dry. OK to shower, no bathing or swimming.
Take all medications as prescribed.
Call for any fever, redness or drainage from wounds.
Followup Instructions:
[**Hospital 409**] clinic in 2 weeks
Dr [**Last Name (STitle) **] in 4 weeks
Dr [**First Name (STitle) 1726**] or [**Doctor Last Name 99504**] in [**3-17**] weeks
Completed by:[**2150-4-12**]
|
[
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"295.70",
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] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"35.21",
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icd9pcs
|
[
[
[]
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5962, 6035
|
2670, 3441
|
410, 506
|
6193, 6202
|
1198, 2647
|
6404, 6598
|
851, 868
|
3599, 5939
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6056, 6172
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3467, 3576
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6226, 6381
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883, 1179
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281, 372
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534, 621
|
643, 745
|
761, 835
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,948
| 115,432
|
54066
|
Discharge summary
|
report
|
Admission Date: [**2172-9-22**] Discharge Date: [**2172-10-13**]
Date of Birth: [**2093-3-7**] Sex: M
Service: MEDICINE
Allergies:
Insulin,Beef
Attending:[**First Name3 (LF) 2736**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
Intubation, Artic Sun cooling protocol, hemodialysis
History of Present Illness:
Patient is a 79 year-old Russian male with a past medical
history significant for multivessel CAD s/p MI '[**45**], s/p OM PCI
to LCX '[**60**], s/p BMS to D1 of LAD '[**66**] with stable exertional
angina, atrial fibrillation on coumadin, diastolic heart
failure, PVD, hypertension, hyperlipidemia, DM2, long history of
medication non-compliance presented with CHF exacerbation,
elevated INR, now transferred to CCU due to asymptommatic
hypotension during diuresis.
.
Per patient, had N/V/Diarrhea 3 days ago reported to be
self-resolving. After resolution, noted worsening LE edema,
orthopnea, fatigue and decreased PO intake. No PO intake since
illness. On day of admission, he was so weak that he crawled to
phone to be brought to ED. In the ED was found to have slow
atrial fibrillation, unchanged EKG. CXR with e/o of pulmonary
edema and right sided pleural effusion. INR was 19. Due to
back bruise, CT scan done which was negative for RP bleed.
However, did note moderate pericardial effusion. Echo with no
tamponade physiology. Recieved 10 mg Vitamin K to reverse INR,
Lasix 80 mg IV with 75 cc UOP and admitted to the floor.
.
Overnight, he was placed on lasix gtt with subsequent
hypotension this morning. Urine output total 261 cc in 12
hours. Lasix gtt was discotninued and blood pressures improved
to mid-90's, however, no urine output. Blood pressure slowly
declined to mid-80's off the lasix gtt and now transferred to
CCU.
.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, constipation, BRBPR, melena, hematochezia,
dysuria.
.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope
or presyncope.
Past Medical History:
-- Multivessel CAD - s/p MI '[**45**], s/p OM PCI to LCX '[**60**], s/p BMS
to D1 of LAD '[**66**]; stable exertional angina, rare with climbing
hills, stairs;
MIBI ETT in [**2166**] - anignal symptoms with no ischemic changes,
52% predicted max HR
-- Chronic AF - on warfarin
-- Diastolic HF - orthopnea, paroxysmal nocturnal dyspnea,
exertional dyspnea; Echo in [**2166**] - mild MR, normal EF; normal
spirometry testing in [**2168**]
-- PVD - calf claudication bilaterally
-- Hypertension - normally 161-170/80 mmHg at home
-- Dyslipidemia - most recent cholesterol 98, LDL 46
-- Diabetes. Most recent A1c was 7.7
-- Proteinuria
-- Chronic anemia
-- BPH
-- H/o TB.
-- Medication noncompliance.
-- asthma
-- DVT [**2170**] while on coumadin
Social History:
Retired electrician, widowed, has no children, lives alone in
[**Location (un) 86**]. He quit smoking many years ago and does not drink
alcohol nor use other drugs. He has had occupational lead
exposure.
Family History:
[**Name (NI) **] CA - father
Physical Exam:
Admission physical exam:
VS: T= Afebrile BP= 108/61 HR= 51 RR= 18 O2 sat= 92% pulsus
[**8-5**]
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: left eye conjunctiva injected, [**Last Name (un) **], MMM (but lips appear
dry).
NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of *** cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+
.
Discharge physical exam
deceased
Pertinent Results:
Admission labs:
[**2172-9-22**] 02:30PM BLOOD WBC-5.0 RBC-3.07* Hgb-9.1* Hct-27.9*
MCV-91 MCH-29.7 MCHC-32.7 RDW-16.9* Plt Ct-321
[**2172-9-22**] 02:30PM BLOOD Neuts-81.7* Lymphs-13.0* Monos-4.0
Eos-0.9 Baso-0.4
[**2172-9-22**] 02:30PM BLOOD PT-150* PTT-71.6* INR(PT)-19.2*
[**2172-9-29**] 10:55AM BLOOD Fibrino-481*
[**2172-9-28**] 12:50PM BLOOD Thrombn-14.8*
[**2172-9-22**] 02:30PM BLOOD Glucose-360* UreaN-83* Creat-2.5* Na-139
K-4.2 Cl-101 HCO3-27 AnGap-15
[**2172-9-22**] 02:30PM BLOOD ALT-7 AST-13 AlkPhos-173* TotBili-2.1*
[**2172-10-2**] 06:00AM BLOOD ALT-184* AST-383* AlkPhos-129
TotBili-3.5*
[**2172-9-22**] 02:30PM BLOOD Lipase-35
[**2172-9-22**] 02:30PM BLOOD CK-MB-3 proBNP-4878*
[**2172-9-22**] 02:30PM BLOOD cTropnT-0.13*
[**2172-9-22**] 05:05PM BLOOD cTropnT-0.13*
[**2172-9-23**] 12:00PM BLOOD CK-MB-4 cTropnT-0.12*
[**2172-9-30**] 07:20AM BLOOD CK-MB-9 proBNP-7367*
[**2172-9-30**] 11:37PM BLOOD CK-MB-15* MB Indx-1.8 cTropnT-0.15*
[**2172-9-22**] 02:30PM BLOOD Albumin-3.1* Calcium-9.3 Phos-4.6* Mg-2.5
[**2172-9-29**] 07:30AM BLOOD TotProt-6.0* Calcium-8.5 Phos-6.1*#
Mg-2.5
[**2172-10-3**] 06:03AM BLOOD Hapto-93
[**2172-9-29**] 10:55AM BLOOD D-Dimer-<150
[**2172-9-23**] 12:00PM BLOOD TSH-3.3
[**2172-10-4**] 06:22AM BLOOD Cortsol-15.4
[**2172-9-30**] 11:43PM BLOOD Lactate-10.8* K-4.9
.
[**2172-9-30**] 11:37PM BLOOD WBC-8.3 RBC-2.66* Hgb-7.8* Hct-25.2*
MCV-95 MCH-29.3 MCHC-31.0 RDW-17.3* Plt Ct-285
[**2172-10-4**] 06:22AM BLOOD PT-17.0* PTT-44.0* INR(PT)-1.5*
[**2172-10-3**] 06:03AM BLOOD Ret Aut-3.5*
[**2172-10-1**] 11:48AM BLOOD Glucose-256* UreaN-94* Creat-5.0* Na-140
K-4.5 Cl-101 HCO3-14* AnGap-30*
[**2172-10-4**] 05:25PM BLOOD Glucose-125* UreaN-87* Creat-4.8* Na-139
K-3.8 Cl-105 HCO3-14* AnGap-24*
[**2172-10-4**] 06:22AM BLOOD ALT-102* AST-184* TotBili-7.9*
[**2172-10-4**] 06:43AM BLOOD Glucose-110* Lactate-1.6
[**2172-9-23**] 06:59AM URINE Hours-RANDOM UreaN-241 Creat-73 Na-82
K-37 Cl-80
[**2172-9-24**] 08:00AM URINE Blood-LG Nitrite-POS Protein-300
Glucose-NEG Ketone-TR Bilirub-MOD Urobiln-1 pH-5.5 Leuks-LG
[**2172-9-24**] 08:00AM URINE RBC->182* WBC-151* Bacteri-MANY
Yeast-NONE Epi-0
[**2172-9-24**] 08:00AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]-1.020
[**2172-9-30**] 11:00PM ASCITES WBC-250* RBC-[**Numeric Identifier **]* Polys-18*
Lymphs-12* Monos-0 Mesothe-5* Macroph-65*
[**2172-9-30**] 11:00PM ASCITES TotPro-3.3 Glucose-167 LD(LDH)-185
Amylase-20 Albumin-1.8
[**2172-9-30**] 11:00PM PERICARDIAL FLUID WBC-5000* RBC-[**Numeric Identifier 110831**]*
Polys-7* Lymphs-83* Monos-5* Macro-5*
[**2172-9-30**] 11:00PM PERICARDIAL FLUID TotProt-4.8 Glucose-144
LD(LDH)-2680 Amylase-16 Albumin-2.2
[**2172-9-30**] 11:00PM PERICARDIAL FLUID ADENOSINE DEAMINASE,
FLUID-PND
.
DISCHARGE LABS: N/A
.
MICROBIOLOGY
[**2172-9-22**] Urine Cx: SKIN AND/OR GENITAL CONTAMINATION.
[**2172-9-23**] MRSA screen: No MRSA isolated.
[**2172-9-24**] Urine Cx: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000
ORGANISMS/ML.
ENTEROCOCCUS SP.
| STAPHYLOCOCCUS,
COAGULASE NEGATIVE
| |
AMPICILLIN------------ <=2 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- =>16 R 8 I
VANCOMYCIN------------ 1 S 1 S
[**2172-9-30**] ASCITES
GRAM STAIN (Final [**2172-10-1**]): NO POLYMORPHONUCLEAR LEUKOCYTES
SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2172-10-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2172-10-1**]): NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2172-9-30**] PERICARDIAL FLUID
GRAM STAIN (Final [**2172-10-1**]): 1+ POLYMORPHONUCLEAR LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2172-10-4**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
ACID FAST SMEAR (Final [**2172-10-1**]): NO ACID FAST BACILLI SEEN ON
CONCENTRATED SMEAR.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST CULTURE (Preliminary):
[**2172-9-30**] PERICARDIAL FLUID CULTURE: pending
[**2172-9-30**] ASCITIC FLUID CULTURE: pending
.
IMAGING:
- [**2172-9-22**] ECHO: FOCUSED STUDY: Due to suboptimal technical
quality, a focal wall motion abnormality cannot be fully
excluded. Overall left ventricular systolic function is low
normal (LVEF 50-55%). The right ventricular cavity is mildly
dilated with normal free wall contractility. The aortic valve
leaflets are mildly thickened (?#). Trace aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. Mild to
moderate ([**12-29**]+) mitral regurgitation is seen. There is a small
to moderate sized pericardial effusion. The effusion appears
circumferential. No right atrial diastolic collapse is seen. No
echocardiographic evidence of tamponade physiology. Compared
with the findings of the prior study (images reviewed) of
[**2171-11-6**], the pericardial effusion is new. Left ventricular
function appears less vigorous. The severity of mitral
regurgitation is increased.
.
[**2172-9-22**] CHEST (PORTABLE AP): Portable semi-upright chest
radiograph demonstrates an interval increase in right basilar
opacity, which likely represents a component of pleural
effusion. Superimposed atelectasis and/or consolidation is not
excluded. The heart size is moderately enlarged. The mediastinal
contours are notable only for calcification of the aortic arch.
The pulmonary vasculature is within normal limits.
.
[**2172-9-22**] CT ABD & PELVIS W/O CONTRAST:
LUNG BASES: Granulomata are seen within the lungs bilaterally.
There is a
large right and small left pleural effusion with a density of
simple fluid. Compressive atelectasis is seen at the right
greater than left lower lobes. There is a moderate-sized
pericardial effusion, with the attenuation of slightly complex
fluid ([**Doctor Last Name **] 15-30). There is coronary arterial calcification, and
the heart is moderately enlarged.
ABDOMEN: Evaluation of the abdominal viscera is limited by lack
of
intravenous contrast. The liver is grossly unremarkable, without
intrahepatic biliary ductal dilatation. The spleen is normal
appearing with note made of marked splenic arterial
calcification. The adrenals are normal bilaterally. The
pancreas demonstrates coarse calcification as noted previously,
consistent with diagnosis of chronic pancreatitis, with atrophy
of the distal body and tail. Within the body of the pancreas,
there is a 1.8 cm ovoid soft tissue focus which is more dense
than the surrounding gland and is stable compared with multiple
priors. A calcification is seen within the wall of the
gallbladder which was not seen on the prior which is likely a
non-dependent or adherent stone. The gallbladder is otherwise
unremarkable. The kidneys are atrophic and there is perinephric
stranding. There is no hydronephrosis and there are no stones,
though note is made of diffuse vascular calcification.
Paraesophageal lymphadenopathy is noted, increased in size
compared with
prior, and likely reactive. The stomach is collapsed and not
well evaluated. Loops of small bowel are normal in caliber and
enhancement. There is fecalization of distal loops of ileum.
There is a moderate amount of abdominal ascites. There is no
intraperitoneal free air. The aorta is
calcified along its course, though normal in caliber. There is a
small
fluid-filled periumbilical hernia. There is no retroperitoneal
hematoma.
There is a fluid-filled left inguinal hernia. There is diffuse
body wall
stranding compatible with anasarca.
PELVIS: The bladder is normal appearing. The prostate and
seminal vesicles
are unremarkable. The rectum is normal. The [**Doctor Last Name 499**] is normal. The
appendix
is normal. There is haziness of the central mesentery and
retroperitoneum,
which is likely resulting from similar process from the
patient's ascites.
BONE WINDOWS: There is multilevel degenerative change of the
thoracolumbar
spine, but no concerning lytic or blastic osseous lesions.
.
[**2172-9-23**] ECHO (TTE): The left atrium is mildly dilated. Left
ventricular wall thicknesses and cavity size are normal. There
is mild global left ventricular hypokinesis (LVEF = 45-50 %).
Right ventricular chamber size and free wall motion are normal.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets are mildly thickened (?#).
There is no aortic valve stenosis. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
mild pulmonary artery systolic hypertension. There is a small to
moderate sized pericardial effusion. The effusion appears
circumferential. There are no echocardiographic signs of
tamponade.
IMPRESSION: Moderate pericardial effusion with no echo signs of
tamponade. Mild symmetric left ventricular hypertrophy with mild
global left ventricular hypokinesis. Mild pulmonary
hypertrension.
Compared with the prior study (images reviewed) of [**2171-11-6**],
the pericardial effusion is new. Left ventricular function is
now mildly depressed. Estimated pulmonary artery pressures are
similar.
.
[**2172-9-23**] ABDOMEN U.S. (COMPLETE STUDY): Study is technically
limited. The liver is grossly normal without focal lesion or
intra- or extra-hepatic biliary ductal dilatation. Moderate
volume ascites is noted. The gallbladder is minimally distended
without wall thickening or edema. There may be a small tiny
adherent stone. The common bile duct is not dilated measuring 3
mm. Pancreas and aorta are not well seen due to overlying bowel
gas. The imaged IVC is unremarkable. The spleen is top normal in
size measuring 12.1 cm. There is no hydronephrosis, stone or
mass bilaterally with the right kidney measuring 10.7 cm and the
left kidney
measuring 10.8 cm.
Pericardial fluid:
NEGATIVE FOR MALIGNANT CELLS.
MRI Head
. Multiple punctate foci of restricted diffusion in the left
cerebellar
hemisphere which represent small acute infarcts in the left
posterior inferior cerebellar artery territory. These are likely
of embolic or hypoxic etiology. MRA was not performed but major
flow voids are grossly patent.
TTE [**10-12**] There is mild symmetric left ventricular hypertrophy
with normal cavity size and global systolic function (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. Right ventricular chamber
size and free wall motion are normal. The aortic valve leaflets
are mildly thickened (?#). There is a very small circumferential
pericardial effusion without RA or RV diastolic collapse. There
are very prominent left pleural and right pleural effusions as
well as ascites.
Brief Hospital Course:
79M with CAD, diastolic CHF (EF 50-55%), afib on Coumadin
admitted with volume overload in setting of N/V at home x 3
days, found to have INR 19 with no bleeding complications and
moderate pericardial effusion with no tamponade physiology
transferred to CCU for hypotension in setting of diuresis. He
was stabilized and went to the floor. On the floor, the patient
was unwilling to participate in most aspects of care. He took
off his telemetry leads, then was found unresponsive by a nurse
and was found to be in PEA arrest, likely secondary to cardiac
tamonade. There was a prolonged amount of time without a pulse.
He was taken back to the CCU, where he underwent intubation and
cooling protocol. Off of sedation, there was evidence of
extensive neurologic damage, and a poor functional recovery was
expected. Because of underlying kidney failure and uremia, he
received hemodialysis to achieve a BUN less than upon admission
(when he was mentating well). Because of poor renal clearance,
serum benzos remained positive. He was given flumazenil to
reverse any effect they may be having, and there was a minimal
response. Ethics was involved and after extensive discussion
with all available contacts, it was decided to make the patient
CMO. The patient expired several hours later on [**2172-10-13**].
Medications on Admission:
HOME MEDICATIONS:
warfarin 3 mg daily
Lipitor 40 mg/day
cilostazol 50 mg [**Hospital1 **]
Vitamin B12
doxazosin 4 mg qhs,
Lasix 40 mg/day
ImDur 90 mg/day
insulin
lisinopril 5 mg daily
Toprol XL 100 mg/day
NTG prn
aspirin 81 mg/day
Protonix 40 mg/day
iron
.
MEDICATIONS ON TRANSFER
- Metolazone 2.5 mg [**Hospital1 **]
- Lasix 15 mg/h IV gtt
- Tylenol 325-650 mg q6h prn pain
- ASA 81 mg daily
- Pantoprazole 40 mg q24h
- Insulin sliding scale
- Atorvastatin 20 mg daily
Discharge Medications:
not applicable
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
Discharge Instructions:
not applicable
Followup Instructions:
not applicable
|
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5,072
| 115,563
|
18373+56939
|
Discharge summary
|
report+addendum
|
Admission Date: [**2140-2-17**] Discharge Date:
Date of Birth: [**2095-7-18**] Sex: M
Service: Bone marrow transplant
HISTORY OF PRESENT ILLNESS: This is a 44 year old male with
[**Location (un) 5622**] chromosome positive acute lymphocytic leukemia,
presents for allo bone marrow transplant protocol. He was
initially diagnosed with [**Location (un) 5622**] chromosome acute
lymphocytic leukemia in [**2139-6-7**]. He initially presented
in [**2139-5-7**] with nausea, abdominal pain, weight loss, and
sweats. At that time he also noted decreased vision in his
left eye and was diagnosed with possible central vein
occlusion. On [**2139-7-2**], his white blood cell count was
noted to be 21,000. A bone marrow biopsy confirmed pre-B
cell acute lymphocytic leukemia positive for [**Location (un) 5622**]
chromosome. A lumbar puncture was positive for lymphoblasts.
He was treated with AP0 induction chemotherapy and received
2400 rads of spinal irradiation. His hospital course
following diagnosis was prolonged and he developed adult
respiratory distress syndrome requiring two week intubation
in the Intensive Care Unit. He then received a cycle of
hyper Cytoxan, Vincristine, Adriamycin and Dexamethasone
followed by Gleevec at 400 mg p.o. b.i.d. He was admitted
[**2140-2-5**] for dehydration, at which time he was
diagnosed with a sinus infection. He was noted to have
recurrence on blasts in his peripheral smear on [**2140-2-5**]. He received Vincristine [**2-6**], Cytoxan [**2-7**], and Prednisone for seven days and was continued on
Gleevec. He developed blurry vision on [**2140-2-8**], a
head magnetic resonance imaging scan at that time was without
abnormalities. An lumbar puncture on [**2140-2-9**] showed
recurrence of leukemia in his cerebrospinal fluid and he has
received three doses of Methotrexate, Solu-Medrol, Ara-C
intrathecal chemotherapy ([**2-10**], [**2-12**], and
[**2-15**]). He returns for intrathecal chemotherapy and a
planned allo bone marrow transplant. He current denies
nausea, vomiting, abdominal pain, shortness of breath, chest
pain, fevers or nightsweats.
PAST MEDICAL HISTORY: 1. Acute lymphocytic leukemia
[**Location (un) 5622**] chromosome positive as described in history of
present illness. 2. Sleep apnea.
MEDICATIONS ON ADMISSION: Nexium, Ativan, Gleevec (which has
been discontinued), Hydromorphone prn and potassium.
ALLERGIES: Acetaminophen (hypotension).
FAMILY HISTORY: No family history of cancer.
SOCIAL HISTORY: Lives with is wife, on leave from the Air
Force, no tobacco or ethanol use.
PHYSICAL EXAMINATION ON ADMISSION: Temperature 98.9, pulse
104, blood pressure 118/72. General: Clinically
ill-appearing middle-aged male, alert and oriented times
three in no acute distress in no respiratory distress. Head,
eyes, ears, nose and throat: Oral mucosa moist, oropharynx
clear. Neck supple, no lymphadenopathy. Cardiac: Regular
rate and rhythm, no murmurs, rubs or gallops. Pulmonary:
Clear to auscultation bilaterally. Abdomen: Normoactive
bowel sounds, soft, nontender, nondistended, no masses.
Extremities: No cyanosis or edema. 2+ dorsalis pedis
bilaterally. Neurological: Cranial nerves II through XII
grossly intact and symmetric bilaterally. 5/5 Strength
throughout. Skin: No rashes noted. Line: Left Hickman,
clean, dry and intact.
LABORATORY DATA: Laboratory studies on admission revealed
white blood cell count 0.9, granulocyte count 510, hematocrit
30.4, platelets 74. MCV 92. Sodium 139, potassium 2.4,
chloride 103, bicarbonate 26, BUN 11, creatinine 0.6, glucose
99. ALT 186, AST 64, LDH 228, alkaline phosphatase 59, total
bilirubin 0.5, direct bilirubin 0.1. Total protein 5.4,
albumin 2.6, calcium 9.1, phosphorus 3.8, magnesium 1.6, uric
acid 5.3. [**2140-2-15**], cerebrospinal fluid, 5 white
blood cells, 23 red blood cells, 5 mono, 91% lymphocytes, 86%
blasts, total protein 29, glucose 58. Gram stain, no polys,
no microorganisms, fluid culture negative, fungal culture
pending, acid fast bacillus culture pending. [**2140-2-5**], echocardiogram, left ventricular ejection fraction
greater than 55%, trivial mitral regurgitation.
HOSPITAL COURSE: 1. Acute lymphocytic leukemia [**Location (un) 5622**]
chromosome positive - The patient received intrathecal
Hydrocortisone, Vincristine, and Ara-C, given history of
positive cytology from cerebrospinal fluid on [**2140-2-17**] and [**2140-2-23**]. The cytology of the fluid from
[**2-17**] was positive for acute lymphocytic leukemia. The
cytology from [**2-23**], cerebrospinal fluid showed
atypical lymphoid cells. Although the patient has evidence
of persistent leukemia in his central nervous system, it is
hoped that the allo bone marrow transplant will induce a
graft for his leukemia response that will eliminate residual
disease. The patient had a bone marrow biopsy on [**2140-2-19**]. The viability of the cells obtained was limited,
however, blasts were reported. Initiation of bone marrow
transplant protocol was initially held due to elevated liver
enzymes. As they began to normalize the protocol was
initialized. At the time of dictation the patient is
currently on day +3 of Cytoxan, Busulfan, Etoposide
transplant protocol. During the receipt of Cytoxan the
patient's electrocardiogram and urinalysis was monitored.
His electrocardiograms remained with no change from baseline
throughout protocol. The patient's urinalysis was noted to
be positive for blood on [**2140-3-1**]. Given concern
that the drip represented cyclophosphamide induced
interstitial nephritis, the patient was aggressively hydrated
and repeat urinalyses were negative. The patient's bone
marrow infusion was delayed from the planned day of [**2140-3-1**] to allow time for clearance of cyclophosphamide.
The patient received his infusion on [**2140-3-2**] which
he tolerated without complications. The patient received his
first dose of Methotrexate on [**2140-3-3**]. This is the
last dose he will receive given severe mucositis. The
patient was started on Cyclosporin drip per protocol and
levels monitored and adjusted to goal Cyclosporin level of
500.
2. Febrile neutropenia - The patient had fever to 101 on
[**2140-2-27**] at which time he was started on Cefepime
and Vancomycin for febrile neutropenia. On that same day his
blood pressure dropped to 70/40 with a heart rate of 130s,
(baseline systolic blood pressure 100 to 120, heart rate 70
to 90). The patient responded well to normal saline boluses,
and since that time the patient's heart rate and blood
pressure have remained stable. Given that the patient
remained afebrile with a stable blood pressure his
antibiotics were discontinued on [**2140-2-29**]. The
patient's efferent hypotension was thought to be secondary to
VP 16 infusion rather than sepsis. However, on [**2140-3-2**], the patient again had a fever. At that time he was
started on Cefepime. Vancomycin was added on [**3-3**] for
persistent fever and Ambazone was added on [**2140-3-4**]
for a persistent fever in the setting of Grade 4 mucositis.
In order to allow improved control of anaerobe the patient
was started on Flagyl on [**2140-3-5**].
3. Mucositis - Ulcers were noted over his lips at admission
with progressive swelling. He was started on Acyclovir
orally initially which was changed to topical Acyclovir while
he was receiving his chemotherapy. However, following his
chemotherapy he developed severe mucositis with minimal
response to gel clear, and bicarbonate rinses. The patient
has required a Dilaudid PCA for pain controls.
Hydrocortisone was added given concern that a history of head
radiation in [**2139-10-7**] may be contributing to mouth
inflammation.
4. Gastrointestinal - The patient was noted to have a
transaminitis on admission. Possible causes include
medication-related (although the patient was on new
medication), leukemia, viral hepatitis, liver or gallbladder
pathology. The patient received three days of Leucovorin
given the concern for intrathecal Methotrexate toxicity.
Additional workup included an ultrasound of his liver which
showed no evidence of abnormalities in the gallbladder or
biliary ductal system but showed fatty infiltration of his
liver. Since that time, the patient's liver function tests
have normalized.
5. Eye swelling - Shortly after admission, the patient was
noted to have right medial eye swelling and erythema.
Ophthalmology was consulted on [**2140-2-19**] who felt
that this was not inflammatory although it could be early
presacral cellulitis. They recommended closely monitoring,
particularly given the patient's history of herpes zoster on
his face and warm compresses. This medial eye swelling and
erythema gradually improved over the course of the hospital
stay.
6. Hematology - The patient's blood counts were supported
with transfusion for hematocrit less than 30 or platelet less
than 30 given severe mucositis.
7. Fluids, electrolytes and nutrition - The patient was
started on total parenteral nutrition on [**2140-3-3**]
given poor p.o. intake. The patient's ins and outs were
closely monitored while receiving chemotherapy, and he was
given intermittent Lasix.
8. Access - Surgery placed a right triple lumen catheter on
[**2140-2-17**]. On [**2140-2-18**], Surgery
repositioned the catheter as it was curled as a chest x-ray
had shown that it was improperly positioned. The patient had
a left Hickman catheter at the time of admission.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4380**], M.D. [**MD Number(1) 10999**]
Dictated By:[**Last Name (NamePattern1) 6008**]
MEDQUIST36
D: [**2140-3-5**] 16:13
T: [**2140-3-5**] 16:34
JOB#: [**Job Number 50600**]
Name: [**Known lastname 9387**], [**Known firstname **] Unit No: [**Numeric Identifier 9388**]
Admission Date: [**2140-2-17**] Discharge Date: [**2140-4-4**]
Date of Birth: [**2095-7-18**] Sex: M
Service:
Please see previous dictation for full details.
Mr. [**Known lastname **] was transferred to the [**Hospital Ward Name 5950**] Intensive Care
Unit for further management after the patient was started to
have fevers with rigors. He was given Demerol on the medical
floor and then his heart rate was noted to be elevated into
the 120s to 160s. The patient was given 5 mg of intravenous
Lopressor and Diltiazem times two with no sustained effect.
He was felt to be in rapid atrial fibrillation. He had been
having increasing confusion on the bone marrow transplant
service and had cut his intravenous lines with some blood
dripping onto the floor. On presentation to the MICU his
temperature was 99.6 axillary, heart rate was 166, blood
pressure 105/70, respiratory rate 14 and he was 100% on room
air. He was placed on neutropenic precautions. He was
confused, but equally reoriented. He thought he was in Nadic
originally. His HEENT was notable for oral ulcers whitish
plaques on his tongue with diffuse erythema on mucous
membranes. Cardiovascular rapid irregular heart rate.
Respiratory examination was coarse breath sounds on left mid
lung field, decreased breath sounds at the right base.
Abdomen with hypoactive bowel sounds, soft, nontender,
nondistended. No guarding. No edema. His peripheral
extremities were warm. He had some papular erythematous rash
on his back.
LABORATORIES ON TRANSFER: Hematocrit 28.3, INR 1.2, normal
chem 7. His T bilirubin had increased to 5.2 from 1.7. His
direct bilirubin was up to 1.4 from 0.6. His calcium was
8.5, phos 3.4, magnesium 2.0. He had some blood cultures,
which were pending off a central, peripheral and Hickman
lines. CMV viral load was negative. His sputum culture was
notable for staph aureus 2+.
HOSPITAL COURSE: This 44 year-old male with [**Location (un) 6913**]
chromosome positive ALL status post BMT [**2140-3-2**] with a
clinical course complicated by febrile neutropenia and
Mucositis with confusion associated with question of PCA
Dilaudid for pain related to mucositis with episode of rigors
prior to transfer was admitted for further observation.
Possible etiologies of his rapid atrial fibrillation included
his fevers, possible underlying lung infection,
thyrotoxicosis possibly medication related or less likely a
structure abnormalities from his Cytoxan related dilated
cardiomyopathy or Daunorubicin associated cardiac toxicity.
Though these two possibilities were considered to be much
less likely. The patient was started on a Diltiazem drip for
management of his rapid atrial fibrillation. His rate
control was improved significantly overnight. A chest x-ray
was done, which showed no evidence of an acute intrapulmonary
process. His TSH was within normal limits so this ruled out
thyrotoxicosis. He had a cardiac echocardiogram to evaluate
his ejection fraction and possible dilated cardiomyopathy.
The echocardiogram showed mild symmetrical left ventricular
hypertrophy with an ejection fraction of 55%, overall normal
function. The left atrium was mildly dilated. There were no
other structural abnormalities noted. No pericardial
effusion. It was felt that the ............ medication could
be contributing to his atrial fibrillation, however, it was
likely his acute illness.
ALL: The [**Initials (NamePattern4) 1325**] [**Last Name (NamePattern4) 6913**] chromosome positive ALL was
seen as involvement. The BMT protocol was continued
according to the BMT fellow recommendations during this
hospitalization. The BMT fellow continued to see the
patient. He was continued on immunosuppression for possible
graft versus host disease. His Cyclosporin level was
monitored daily for adjustment. Given the elevated
bilirubinemia and the faint rash on his back as well as
stomach complaints and worsening renal function, graft versus
host disease was monitored very closely.
Febrile neutropenia: The patient was admitted on Ampicillin,
Vancomycin and Cefepime. Clindamycin was discontinued by BMT
prior to transfer to the Intensive Care Unit. His blood
cultures were followed and were no growth.
Grade four mucositis: The patient was on a Dilaudid PCA for
his grade four mucositis. It was felt this may be
contributing to his confusion. The Dilaudid PCA was stopped
and he was placed on morphine for pain control. He was
continued on the bicarb mouth washes and Nystatin swish and
swallow. The patient's grade four mucositis worsened
significantly during this hospital stay. He became
increasingly agitated and disoriented in the Intensive Care
Unit. On Intensive Care Unit day number three the patient
had to be emergently intubated for agitation and decreased
oxygen saturation. It was felt the patient had some mucous
plugging, which caused him to be acutely hypoxic requiring
intubation. He had suddenly desaturated to 70%. His
oxygenation significantly improved after he was intubated. A
bronchoscopy was done at the time of intubation, which showed
a mucous plug, but no other obvious abnormalities. It was
negative for diffuse alveolar hemorrhage, which had been in
the differential given this patient with status post recent
bone marrow transplant. The patient remained intubated for
seven days. He was extubated on [**2140-3-16**] after sedation had
been appropriately weaned. He did well after extubation with
increased ............ throughout the day. He was slow to
begin to talk. He did have some mild agitation, which was
treated with Haldol and morphine. The patient was stable for
transfer to the general medical floor on [**2140-3-17**].
Acute renal failure: During his stay in the Intensive Care
Unit the patient developed some acute renal failure. The
Renal Service was consulted for assistance with management of
the renal failure. The patient was transfused red blood
cells to increase his renal perfusion. All of his
medications were renally dosed. There was some concern that
this could be possible to a prerenal state versus
Cyclosporin or Ambazone toxicity. His creatinine remained
stable at 1.6 throughout the remainder of his Intensive Care
Unit stay. Renal was continuing to follow the patient on
transfer to the floor.
Mental status changes: During the time in the Intensive Care
Unit the patient was agitated and confused prior to
intubation and after extubation was again somewhat agitated.
There was some concern it was a toxic metabolic state
secondary to steroids, Cyclosporin or central nervous system
involvement from his lymphoma. There had been some
discussion of getting a diagnostic lumbar puncture, though
this had been done repeatedly by the bone marrow transplant
service prior to transfer to the Intensive Care Unit and
there was no central nervous system involvement in the
cerebral spinal fluid. The patient was not able to tolerate
the procedure after extubation. This was deferred until the
patient was transferred to the floor. In addition, the
patient had to be transfused multiple bags of platelets given
that he had some thrombocytopenia from his bone marrow
suppression prior to having a lumbar puncture done. We were
unable to obtain platelets in his Intensive Care Unit stay in
order to perform a lumbar puncture. This should be performed
by the oncology team if this is deemed necessary.
Please see the next discharge summary addendum for the
remainder of his hospital course.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Name8 (MD) 1314**]
MEDQUIST36
D: [**2140-4-27**] 04:27
T: [**2140-4-29**] 07:41
JOB#: [**Job Number 9389**]
|
[
"276.6",
"507.0",
"078.5",
"054.2",
"996.85",
"518.82",
"204.00",
"288.0",
"584.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.25",
"99.04",
"96.04",
"99.15",
"45.16",
"03.31",
"41.31",
"99.28",
"41.05",
"96.72",
"33.23",
"03.92",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
2471, 2501
|
2323, 2454
|
11796, 17650
|
167, 2134
|
2631, 4190
|
2157, 2296
|
2518, 2616
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,578
| 128,666
|
48602
|
Discharge summary
|
report
|
Admission Date: [**2134-3-20**] Discharge Date: [**2134-4-9**]
Date of Birth: [**2081-10-27**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Presented to emergency department after 3 days without bowel
movement and nausea n/v unable to tol PO's, and fever.
Major Surgical or Invasive Procedure:
[**3-20**] Exploratory laparotomy and lysis of adhesions
[**3-25**] Exploratory laparotomy, re-closure of fascia
History of Present Illness:
The patient is a 52-year-old resident of a group living home
with mental retardation and chronic seizure disorder who
presents with a several month history of abdominal bloating.
There were no other symptoms aside from the bloating. Today he
began to have nausea and copious bilious vomiting. He complained
of abdominal pain and came to the emergency room. He was grossly
distended, tympanitic and a CT scan revealed high-grade
obstruction in the small bowel and his right upper quadrant.
There was no mass lesions seen.
He has had no prior surgical abdominal procedures. He was taken
to the operating room for exploration of small bowel
obstruction.
Past Medical History:
PMH:
1. seizure d/o, his sister reports he has multiple sz per day,
2. recurrent nephrolithiasis s/p lithotripsy x4
3. moderate cognitive deficiency
4. anxiety
Social History:
SH: no tobacco/etoh/IVDU; lives in a group home. Usually
requies assistance with most ADLs, mobilizes independently
albeit unsteady.
Family History:
FH: NC
Physical Exam:
On Presentation to the Emergency Department:
PHYSICAL EXAMINATION
Temp:99.0 HR:93 BP:141/82 Resp:18 O(2)Sat:99
Constitutional: Comfortable
Head / Eyes: Normocephalic, atraumatic,
Pupils equal, round and
reactive to light,
Extraocular muscles intact
Chest/Resp: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm,
Normal first and second heart
sounds
GI / Abdominal: Soft, markedly distended, no
r/g, Nontender
Rectal: Heme Negative
Skin: Warm and dry
Neuro: awake, alert, follows
commands, MAE=
Pertinent Results:
[**2134-4-6**] 06:30AM BLOOD WBC-7.2 RBC-4.03* Hgb-11.3* Hct-34.2*
MCV-85 MCH-28.0 MCHC-33.0 RDW-13.4 Plt Ct-337
[**2134-4-2**] 04:27AM BLOOD WBC-11.0 RBC-4.61 Hgb-12.9* Hct-38.3*
MCV-83 MCH-28.0 MCHC-33.7 RDW-13.3 Plt Ct-371
[**2134-4-1**] 03:41AM BLOOD WBC-9.3 RBC-4.38* Hgb-12.3* Hct-37.2*
MCV-85 MCH-28.1 MCHC-33.1 RDW-13.3 Plt Ct-374
[**2134-4-1**] 03:41AM BLOOD Neuts-76.5* Lymphs-13.8* Monos-5.4
Eos-3.9 Baso-0.3
[**2134-3-31**] 05:00AM BLOOD Neuts-79.9* Lymphs-11.7* Monos-7.0
Eos-1.2 Baso-0.3
[**2134-3-20**] 09:50PM BLOOD Neuts-78.7* Lymphs-12.8* Monos-6.8
Eos-1.5 Baso-0.2
[**2134-4-6**] 06:30AM BLOOD Plt Ct-337
[**2134-3-20**] 04:00PM BLOOD PT-11.2 PTT-24.7 INR(PT)-0.9
[**2134-4-6**] 06:30AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-136
K-3.6 Cl-103 HCO3-24 AnGap-13
[**2134-4-4**] 04:37AM BLOOD Glucose-116* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-109* HCO3-26 AnGap-9
[**2134-3-22**] 10:30AM BLOOD ALT-21 AST-19 CK(CPK)-140 AlkPhos-54
TotBili-0.6
[**2134-3-30**] 06:46AM BLOOD proBNP-429*
[**2134-4-6**] 06:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7
[**2134-4-4**] 04:37AM BLOOD Calcium-8.5 Phos-2.1* Mg-2.0
[**2134-4-2**] 04:27AM BLOOD Albumin-3.4* Calcium-9.1 Phos-2.9 Mg-1.9
[**2134-4-6**] 06:30AM BLOOD Phenyto-9.4*
Micro/Imaging:
[**2134-4-1**] CXR decreasing pulmonary effusion and pulmonary
vascular congestion
[**2134-3-31**] CXR b/l pleural effusions new, pleural fluid retention
[**2134-3-30**] CXR no pulmonary edema, no PTX
[**2134-3-28**] KUB distended SB loops
[**2134-3-27**] CXR nothing suggestive of PNA
[**2134-3-20**] Ucx neg
[**2134-3-20**] Bcx pend
Brief Hospital Course:
The patient was admitted [**2134-3-20**] from the PACU to the inpatient
[**Hospital1 **] s/p exploratory laparotomy and lysis of adhesions. The
patient had several episodes of seizure activity post
operatively, based on known epilepsy, neurology was consulted.
Patient was initially treated with 4mg IV Ativan and 1 IV
fosphenytoin. Serum phenytoin levels were followed and
phenytoin doses were adjusted accordingly. The patient was doing
well and was noted to be passing flatus, and progressed well.
Course was complicated by constipation which was treated with
enemas. [**2134-3-25**] The patient was noted by the surgical team to
have a small amount of serosanguinous drainage on his dry
sterile dressing, this drainage dramatically increased after the
patient coughed, the wound was explored at the bedside and bowel
was noted. He was taken emergently to the operating room for a
wound dehiscence. [**2134-3-25**] exploratory laparotomy and fascial
reclosure was preformed. PACU recovery was extended related to
sedation, he was then transferred back to the inpatient [**Hospital1 **].
The patients mental status returned to baseline however his
abdomen remained significantly distended. An abdominal binder
was placed, he patient remained NPO with IV hydration and diet
was progressed only to sips of clear liquids. [**2134-3-28**] abdominal
distension continued, with some emesis and an nasogastric tube
was placed for decompression and the patient was again NPO. The
abdominal wound was noted to be stressed with serosanguinous
drainage. The patient continued to have seizure activity
throughout this time treated with Atavan. TPN was initiated for
nutritional support his abdomen remained distended however he
began to have bowel movements. On the evening of [**2134-3-30**],
patient was noted to have a seizure. He was treated with Ativan
4mg IV and fosphenytoin 1g. After his seizure, he became
tachypneic, and required a non rebreather to maintain oxygen
saturation and was transferred to the [**Hospital Unit Name 153**] for further
management. He was treated with IV Lasix, and albuterol
nebulizers with gradual improvement of his oxygen saturation. He
received one dose of vancomycin and Zosyn out of concern for
possible aspiration. It was thought that this desaturation
likely represented an exacerbation of his OSA due to Ativan,
with possible aspiration and/or fluid overload given rapid
response to Lasix.
[**2134-3-31**] The patient's abdomen remained distended but improved,
the midline wound was noted to have granulation tissue at the
base and wound VAC dressing was placed at the bedside. [**2134-4-2**]
he was transferred to the inpatient [**Hospital1 **] and his neurologic
status continued to show improvement. [**2134-4-3**] bowel function
began to improve with flatus and bowel movement and the patient
tolerated clear liquids. [**2134-4-6**] the patients PICC line was
d/c'd related to positive blood cultures X1 and the line was
sent for culture which showed no significant growth. The patient
was tolerating a regular diet and passing flatus and stool.
Physical therapy and social work was consulted throughout the
admission. At this time the patient was considered stable to be
discharged to an extended care facility with abdominal VAC
dressing in place.
This hospital admission was complicated by frequent seizure
activity which was closely followed by neurology and the
surgical team. The final neurology recommendation included
initiation of Phenytoin 100 TID, Trileptal 900 TID and
Lyrica 100 TID. Tapering may/will be done as outpatient per
Dr.[**Last Name (STitle) 29616**]. Dilantin level corrects to 12.6.
Medications on Admission:
citalopram 10 mg daily
lyrica 100mg tid
potassium citrate-citric acid 1100/334
trileptal 900mg tid
peridex [**Hospital1 **]
fosamax 70mg q week
calcium 500 +D [**Hospital1 **]
buspar 5mg
Discharge Medications:
1. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Oxcarbazepine 300 mg Tablet Sig: Three (3) Tablet PO TID (3
times a day).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q4H (every 4 hours) as
needed for SOB, wheeze.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours).
6. Phenytoin 125 mg/5 mL Suspension Sig: Four (4) mL
mL
mL PO Q8H (every 8 hours).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for wheezing.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
12. Buspirone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 671**] [**Hospital 4094**] Hospital - [**Location (un) 86**]
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Activity Status: Ambulatory - requires close assistance or aid
(walker or cane)
Mental Status: Confused - sometimes
Level of Consciousness: Alert, interactive
Discharge Instructions:
Please call for follow-up with Dr. [**Last Name (STitle) **] in 1- 2 weeks. You
may resume prior diet and activity as tolerated. Follow-up with
your neurologist in the next 1-2 weeks. If you note any of the
following call the office to make an appointment; redness or
drainage from around the wound, or low grade fever. If you
experience any of the following symptoms go directly to the
emergency room; chest pain, shortness of breath, severe pain not
relieved by medication, intractable nausea/vomiting, or any
other concerning symptoms. You may resume all prior medications
unless otherwise instructed, take all new medications as
prescribed. You may shower with the wound vac on, keep the
dressing covered, no tub baths. You have a wound VAC on your
abdomen, it needs to be changed every 3 days; there should be a
white sponge at the base, covered by a black sponge, and it
should be set to 75mmHg of suction.
Followup Instructions:
Call for follow-up with Dr. [**Last Name (STitle) **] in [**1-9**] weeks ([**Telephone/Fax (1) 15665**]
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2134-4-9**]
|
[
"592.0",
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"511.9",
"318.0",
"998.31",
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"300.00",
"568.0",
"E878.8",
"785.0",
"786.09",
"507.0",
"790.7",
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icd9cm
|
[
[
[]
]
] |
[
"83.65",
"54.12",
"99.15",
"54.59",
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] |
icd9pcs
|
[
[
[]
]
] |
9153, 9252
|
4116, 7773
|
438, 553
|
9320, 9400
|
2510, 4093
|
10444, 10719
|
1585, 1593
|
8011, 9130
|
9273, 9299
|
7799, 7988
|
9504, 10421
|
1608, 2491
|
283, 400
|
581, 1234
|
9415, 9480
|
1256, 1417
|
1433, 1569
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,914
| 122,104
|
35326
|
Discharge summary
|
report
|
Admission Date: [**2113-3-7**] Discharge Date: [**2113-3-31**]
Date of Birth: [**2038-12-1**] Sex: F
Service: SURGERY
Allergies:
Morphine / Midazolam
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
Gastric tumor
Major Surgical or Invasive Procedure:
1. Total gastrectomy,
2. Feeding jejunostomy and flexible gastroscopy.
3. PICC line placement
4. fluoroscopic-guided placement of the pigtail drain into
mediastinal fluid collection
History of Present Illness:
This is a 74 F who has been found to have a small,fairly
superficial tumor of her proximal stomach. She also has some
Barrett's esophagus; but this and appears to be in the stomach
proper. Endoscopic ultrasound did not show any
nodal disease, and she presents now for surgical treatment. Of
note is that the patient has a large hiatal hernia and probable
foreshortening of the esophagus.
Past Medical History:
hx L CVA, HTN, uterine ca, breast ca (R), b/l shoulder surgery,
b/l knee surgery
Social History:
Pt is [**Name (NI) **]. She has 7 children. Was married for 25 years,
but now divorced.
Family History:
Mother died at very young age of undisclosed causes.
Physical Exam:
Upon Discharge:
VS: 98.3 97 160/90 22 95% RA
Gen: NAD, AAOx3
HEENT: NCAT. normal dentition
CV: RRR, S1S2
Lungs: CTAB
Abd: Soft, non-tender, non-distended. Midline incision is C/D/I
with steri-strips in place. Jtube is in place and is C/D/I.
Ext: Mild [**1-6**]+ edema in b/l [**Name Prefix (Prefixes) **]
[**Last Name (Prefixes) **]: Pigtail drain located near right scapula. drain is c/d/i
with serosanguinous discharge.
Pertinent Results:
Pathology [**2113-3-7**]
Specimen Type: Esophagogastrectomy.
Tumor site: Gastroesophageal junction/cardia.
Tumor Size-Greatest dimension: 1.7 cm. Additional dimensions:
1.1 cm.
MICROSCOPIC
Histologic Type: Adenocarcinoma.
Histologic Grade: G2: Moderately differentiated.
EXTENT OF INVASION
Primary Tumor: pT2: Tumor invades muscularis propria.
Regional Lymph Nodes: pN0: No regional lymph node metastasis.
Lymph Nodes
Number examined: 21.
Number involved: 0.
Distant metastasis: pMX: Cannot be assessed
Radiology:
UGI with SBFT [**2113-3-13**]: IMPRESSION: Status post total gastrectomy
with patent esophagojejunal anastomosis with no evidence of
leak.
KUB [**2113-3-16**]: IMPRESSION: No colonic distention. No obstruction.
CT abd/pelvis [**2113-3-17**]: IMPRESSION:
1. Complex collection, containing air, fluid, and
hyperattenuating material adjacent to the gastrojejunal
anastomosis, highly concerning for a leak.
2. Ascites.
3. Diffusely hypattenuated left lobe of liver (?post surgical)
with focal
indeterminate lesion in the left lobe of the liver. Suggest
follow with
ultrasound.
4. Right colon wall thickening, compatible with given history of
C. diff
colitis.
5. Bilateral pleural effusions with atelectasis.
CXR [**3-20**]:
FINDINGS: Pigtail pleural catheter remains in place overlying
the lower
mediastinum, reportedly placed adjacent to esophagojejunal
anastomotic staples on CT interventional procedure of [**2113-3-17**]. The position appears slightly different than on the prior
chest radiograph of [**2113-3-18**], but tip of the catheter
continues to overlie a rounded gas collection. Large right
pleural effusion appears increased compared to the prior
examination, but a small left pleural effusion is not
substantially changed. Cardiac silhouette remains enlarged but
there is no evidence of congestive heart failure.
RUQ US [**3-21**]:
IMPRESSION:
1. Gallbladder contains sludge but otherwise is without specific
signs of
cholecystitis, although this study does not exclude
cholecystitis. Sludge may not be unexpected in this patient who
has been fasting.
2. Complex collection surrounding the liver is as seen on recent
CT and
likely represents subhepatic hematoma.
3. Examination of the liver is slightly limited; however, no
focal lesion is seen to correspond with area of hypoattenuation
seen on CT in segment II of the liver.
RUE U/S [**3-22**]:
IMPRESSION: No evidence of DVT in the right upper extremity.
Thrombosis of
radial vein.
Barium Swallow [**3-28**]:
IMPRESSION: Status post total gastrectomy with esophageal
jejunal anastomosis without evidence for leak at the anastomotic
site. Free flow of contrast through the anastomosis.
[**2113-3-7**] 07:02PM BLOOD WBC-9.8# RBC-3.98* Hgb-10.0* Hct-30.0*
MCV-75* MCH-25.1* MCHC-33.4 RDW-18.4* Plt Ct-238
[**2113-3-10**] 07:50AM BLOOD WBC-11.4* RBC-3.24* Hgb-8.0* Hct-24.8*
MCV-76* MCH-24.8* MCHC-32.5 RDW-18.7* Plt Ct-147*
[**2113-3-11**] 08:47PM BLOOD WBC-13.9* RBC-3.09* Hgb-8.3* Hct-24.9*
MCV-81* MCH-26.9* MCHC-33.3 RDW-18.3* Plt Ct-144*
[**2113-3-13**] 04:19PM BLOOD WBC-12.8* RBC-2.99* Hgb-8.3* Hct-24.0*
MCV-80* MCH-27.6 MCHC-34.4 RDW-19.6* Plt Ct-178
[**2113-3-15**] 07:00AM BLOOD WBC-15.1* RBC-3.12* Hgb-8.5* Hct-25.1*
MCV-81* MCH-27.2 MCHC-33.8 RDW-20.0* Plt Ct-275
[**2113-3-16**] 10:46AM BLOOD WBC-20.2* RBC-3.31* Hgb-9.1* Hct-26.9*
MCV-81* MCH-27.6 MCHC-34.0 RDW-20.4* Plt Ct-326
[**2113-3-17**] 05:30AM BLOOD WBC-27.7* RBC-3.20* Hgb-8.7* Hct-26.1*
MCV-82 MCH-27.3 MCHC-33.5 RDW-20.0* Plt Ct-332
[**2113-3-18**] 05:50AM BLOOD WBC-32.0* RBC-3.05* Hgb-8.1* Hct-25.2*
MCV-83 MCH-26.6* MCHC-32.2 RDW-19.5* Plt Ct-406
[**2113-3-19**] 05:35AM BLOOD WBC-23.0* RBC-3.02* Hgb-8.2* Hct-24.9*
MCV-82 MCH-27.2 MCHC-33.0 RDW-20.2* Plt Ct-452*
[**2113-3-20**] 05:33AM BLOOD WBC-19.5* RBC-3.01* Hgb-7.8* Hct-24.5*
MCV-81* MCH-25.9* MCHC-31.8 RDW-19.9* Plt Ct-504*
[**2113-3-22**] 05:26AM BLOOD WBC-18.8* RBC-3.19* Hgb-8.6* Hct-25.2*
MCV-79* MCH-26.9* MCHC-34.1 RDW-20.4* Plt Ct-587*
[**2113-3-23**] 06:25AM BLOOD WBC-22.4* RBC-3.10* Hgb-8.3* Hct-24.6*
MCV-79* MCH-26.7* MCHC-33.7 RDW-20.5* Plt Ct-708*
[**2113-3-24**] 05:18AM BLOOD WBC-16.1* RBC-2.88* Hgb-7.5* Hct-23.0*
MCV-80* MCH-26.0* MCHC-32.6 RDW-20.6* Plt Ct-596*
[**2113-3-25**] 03:43AM BLOOD WBC-14.6* RBC-2.80* Hgb-7.4* Hct-22.2*
MCV-79* MCH-26.3* MCHC-33.1 RDW-20.7* Plt Ct-570*
[**2113-3-26**] 03:49AM BLOOD WBC-14.9* RBC-3.12* Hgb-8.5* Hct-24.8*
MCV-79* MCH-27.3 MCHC-34.5 RDW-20.3* Plt Ct-573*
[**2113-3-27**] 06:17AM BLOOD WBC-15.5* RBC-3.37* Hgb-9.1* Hct-27.4*
MCV-81* MCH-27.1 MCHC-33.3 RDW-19.9* Plt Ct-645*
[**2113-3-28**] 04:25AM BLOOD WBC-17.0* RBC-3.33* Hgb-8.9* Hct-27.4*
MCV-82 MCH-26.6* MCHC-32.4 RDW-19.8* Plt Ct-640*
[**2113-3-29**] 05:30AM BLOOD WBC-11.9* RBC-3.13* Hgb-8.3* Hct-25.5*
MCV-82 MCH-26.4* MCHC-32.4 RDW-20.0* Plt Ct-597*
[**2113-3-30**] 05:15AM BLOOD WBC-11.2* RBC-3.07* Hgb-8.1* Hct-25.0*
MCV-81* MCH-26.5* MCHC-32.5 RDW-20.0* Plt Ct-605*
[**2113-3-31**] 04:15AM BLOOD WBC-11.0 RBC-3.08* Hgb-8.2* Hct-25.1*
MCV-82 MCH-26.6* MCHC-32.5 RDW-20.1* Plt Ct-584*
[**2113-3-10**] 07:50AM BLOOD Neuts-93.1* Lymphs-3.5* Monos-3.0 Eos-0.3
Baso-0.1
[**2113-3-11**] 12:03AM BLOOD Neuts-93.6* Lymphs-3.5* Monos-2.4 Eos-0.5
Baso-0.1
[**2113-3-14**] 06:35AM BLOOD Neuts-84* Bands-7* Lymphs-3* Monos-2
Eos-1 Baso-0 Atyps-0 Metas-3* Myelos-0 NRBC-1*
[**2113-3-27**] 06:17AM BLOOD Neuts-92.3* Lymphs-4.5* Monos-2.6 Eos-0.4
Baso-0.2
[**2113-3-11**] 12:03AM BLOOD PT-13.9* PTT-29.2 INR(PT)-1.2*
[**2113-3-22**] 05:26AM BLOOD PT-15.0* PTT-24.0 INR(PT)-1.3*
[**2113-3-7**] 07:02PM BLOOD Glucose-182* UreaN-36* Creat-1.3* Na-143
K-4.2 Cl-112* HCO3-20* AnGap-15
[**2113-3-10**] 07:50AM BLOOD Glucose-134* UreaN-28* Creat-1.3* Na-139
K-4.3 Cl-111* HCO3-23 AnGap-9
[**2113-3-12**] 03:02AM BLOOD Glucose-112* UreaN-37* Creat-1.5* Na-142
K-4.2 Cl-115* HCO3-20* AnGap-11
[**2113-3-15**] 07:00AM BLOOD Glucose-119* UreaN-27* Creat-0.9 Na-140
K-3.4 Cl-106 HCO3-26 AnGap-11
[**2113-3-17**] 05:30AM BLOOD Glucose-135* UreaN-23* Creat-0.9 Na-132*
K-3.8 Cl-101 HCO3-24 AnGap-11
[**2113-3-22**] 05:26AM BLOOD Glucose-116* UreaN-18 Creat-0.9 Na-131*
K-3.7 Cl-94* HCO3-32 AnGap-9
[**2113-3-23**] 06:25AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-131*
K-4.2 Cl-94* HCO3-29 AnGap-12
[**2113-3-24**] 05:18AM BLOOD Glucose-121* UreaN-22* Creat-0.9 Na-130*
K-4.0 Cl-95* HCO3-30 AnGap-9
[**2113-3-25**] 03:43AM BLOOD Glucose-102 UreaN-20 Creat-0.8 Na-129*
K-3.7 Cl-94* HCO3-31 AnGap-8
[**2113-3-26**] 03:49AM BLOOD Glucose-102 UreaN-22* Creat-0.8 Na-129*
K-4.0 Cl-96 HCO3-29 AnGap-8
[**2113-3-27**] 06:17AM BLOOD Glucose-135* UreaN-30* Creat-0.8 Na-130*
K-4.1 Cl-98 HCO3-25 AnGap-11
[**2113-3-28**] 04:25AM BLOOD Glucose-119* UreaN-31* Creat-0.8 Na-133
K-4.7 Cl-102 HCO3-23 AnGap-13
[**2113-3-29**] 05:30AM BLOOD Glucose-126* UreaN-30* Creat-0.7 Na-135
K-4.6 Cl-104 HCO3-22 AnGap-14
[**2113-3-30**] 05:15AM BLOOD Glucose-127* UreaN-32* Creat-0.7 Na-133
K-4.5 Cl-103 HCO3-23 AnGap-12
[**2113-3-31**] 04:15AM BLOOD Glucose-119* UreaN-26* Creat-0.6 Na-136
K-3.9 Cl-104 HCO3-23 AnGap-13
[**2113-3-18**] 05:50AM BLOOD ALT-236* AST-64* AlkPhos-161* TotBili-1.2
[**2113-3-19**] 05:35AM BLOOD ALT-189* AST-46* AlkPhos-160*
Amylase-126* TotBili-1.1
[**2113-3-21**] 03:54AM BLOOD ALT-137* AST-103* AlkPhos-667*
Amylase-146* TotBili-2.1*
[**2113-3-22**] 05:26AM BLOOD ALT-102* AST-53* AlkPhos-450*
Amylase-112* TotBili-0.9 DirBili-0.5* IndBili-0.4
[**2113-3-23**] 06:25AM BLOOD ALT-89* AST-49* AlkPhos-373* TotBili-1.0
[**2113-3-20**] 05:33AM BLOOD Lipase-73*
[**2113-3-21**] 03:54AM BLOOD Lipase-90*
[**2113-3-22**] 05:26AM BLOOD Lipase-59
[**2113-3-16**] 09:35AM BLOOD CK-MB-2 cTropnT-<0.01
[**2113-3-17**] 07:03AM BLOOD CK-MB-2 cTropnT-<0.01
[**2113-3-17**] 03:20PM BLOOD CK-MB-2 cTropnT-<0.01
[**2113-3-7**] 07:02PM BLOOD Calcium-7.9* Phos-4.5 Mg-1.6
[**2113-3-10**] 07:50AM BLOOD Calcium-7.0* Phos-1.5* Mg-2.5
[**2113-3-12**] 03:02AM BLOOD Calcium-7.8* Phos-3.1 Mg-2.1
[**2113-3-14**] 06:35AM BLOOD Albumin-2.3* Calcium-7.0* Phos-1.5*
Mg-2.1
[**2113-3-17**] 05:30AM BLOOD Calcium-6.7* Phos-2.3* Mg-1.7
[**2113-3-20**] 05:33AM BLOOD Calcium-7.1* Phos-2.5* Mg-1.9
[**2113-3-21**] 03:01PM BLOOD Calcium-7.5* Phos-2.7 Mg-2.4
[**2113-3-24**] 05:18AM BLOOD Calcium-7.2* Phos-3.2 Mg-2.3
[**2113-3-27**] 06:17AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.8
[**2113-3-28**] 04:25AM BLOOD Calcium-7.5* Phos-2.9 Mg-2.1
[**2113-3-30**] 05:15AM BLOOD Calcium-7.4* Phos-2.6* Mg-1.7
[**2113-3-28**] 04:25AM BLOOD Free T4-2.0*
[**2113-3-26**] 03:49AM BLOOD TSH-9.7*
[**2113-3-26**] 02:55PM BLOOD PREALBUMIN-Test
Brief Hospital Course:
Ms. [**Known lastname 43417**] was admitted to [**Hospital1 18**] for her elective surgery.
She tolerated the procedure well and recovered without acute
events in the PACU before being transferred to the floor. An
NGT, Foley, and JP drain were placed in the OR.
Chronological Events:
On [**3-10**] the patient was found to be hypotensive and was
transferred to the ICU for more acute managment. The following
events took place:
[**3-10**]: decreased responsiveness, SBP 70s, O2sat 60-70s on NRB ->
code blue, intubated, fem line placed, transfused 3UPRBC for Hct
20, bolused 1.5L for low UOP, epidural d/c'd
[**3-11**]: extubated, started 1/2 strength J-tube TF, [**Month (only) **] LR to 75,
started Synthroid, d/c'd fem line, started IV metoprolol
[**3-12**]: d/c'd NGT, started Roxicet, metoprolol per JT
The patient was transferred back to floor on [**3-12**] in stable
condition. An UGI study was performed that did not demonstrate
an anastomotic leak and she was started on a clear liquid diet.
Her TFs were continued.
on [**3-14**] she began to have several loose BMs and she was found to
be Cdiff positive. Vancomycin via her jtube was started. Her WBC
began to rise and she spiked a fever on [**3-15**]. She was found to
be more distended and had emesis. On [**3-17**] A CT abd/pelvis was
obtained and she was found to have an anastomotic leak. Thus,
she was sent to IR for placement of a catheter drain. This was
placed into her mediastinal fluid collection. She was also
started on IV vanco/zosyn and continued her treatment for
C.diff. She was made NPO.
On [**3-17**] she was started on fluconazole because her fluid
collection grew yeast.
On [**3-20**] a PICC line was placed.
On [**3-22**] she was found to have elevated LFTs and a RUQ u/s was
obtained. It was within normal limits, and her LFTs trended down
to normal within 2 days.
On [**3-22**] she was started on levaquin which continued through
discharge
On [**3-25**] she was transfused 1 unit of PRBCs. A geriatric consult
was initiated and she was started on Celexa and ritalin for
depression. Her depression mildly improved prior to discharge.
on [**3-26**] her tube feeds were changed to a more concentrated
formula to help correct her mild hyponatremia.
on [**3-28**] she had a repeat UGI study showing no leak. She was
started on a sips diet.
on [**3-29**] she started clear liquids
on [**3-30**] she started and tolerated a softs diet
On [**3-31**] she was discharged to a rehab facility. her picc line
was removed prior to discharge.
Physical Therapy worked with the patient daily, however she was
very reluctant to cooperate. Often, she refused to work with
them. PT did feel that she was capable of working with her
physically, but her reluctance limited her activity.
UTI/Urinary Incontinence/Urgency: The patient was often
incontinent to urine secondary to increased urgency. She was
treated for a UTI with cefepime and then levaquin. She was also
continued on detrol. A foley catheter was intermittently placed
to help her deal with her incontinence.
Medications on Admission:
Alendronate 35 mg weekly, Esomeprazole 40mg qday, Levothyroxine
25 mcg daily, Lisinopril 10 mg daily, Detrol LA 4mg daily,
Triamterene-Hydrochlorothiazid Dosage uncertain, Vit C 500
daily, Vit B Complex, Calcium Carbonate-Vit D3-Min [Caltrate
600+D Plus Minerals, Chondroitin Sulfate A, folic Acid 0.4 mg
daily, glucosamine, Iron 25 mg daily, Methylsulfonylmethane
[MSM]
Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q4H (every 4 hours) as needed for Expiratory
wheezing.
2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj
Injection TID (3 times a day).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. B Complex Vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Tolterodine 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
9. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 10 days: down Jtube.
10. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO QAM (once a day
(in the morning)).
11. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 5 days.
12. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO Q 8 AM ().
13. Methylphenidate 5 mg Tablet Sig: 0.5 Tablet PO Q NOON ().
14. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
16. Insulin Lispro 100 unit/mL Solution Sig: One (1) injection
Subcutaneous ASDIR (AS DIRECTED): SEE sliding scale as printed
in d/c summary.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **]
Discharge Diagnosis:
Primary:
Gastric cancer
Secondary:
Mediastinal Abscess
Post-op respiratory failure
Anemia
Depression
C. diff colitis
hypothyroid
diabetes
osteoporosis
hypertension
Discharge Condition:
Stable. Jtube in place. Mediastinal drain in place.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Other:
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) **] in [**1-6**] weeks. Call his
office ASAP to schedule your appointment. ([**Telephone/Fax (1) 1483**].
Completed by:[**2113-3-31**]
|
[
"453.8",
"553.3",
"788.30",
"250.00",
"276.1",
"997.4",
"112.89",
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"401.9",
"151.0",
"493.20",
"998.59",
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"599.0",
"008.45",
"E878.6",
"530.85",
"513.1",
"311",
"V10.42",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.04",
"96.71",
"96.04",
"38.93",
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"96.6",
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icd9pcs
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[
[
[]
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14979, 15081
|
10184, 13227
|
293, 477
|
15290, 15344
|
1630, 10161
|
16539, 16724
|
1119, 1173
|
13649, 14956
|
15102, 15269
|
13253, 13626
|
15368, 16516
|
1188, 1188
|
240, 255
|
1204, 1611
|
505, 894
|
916, 998
|
1014, 1103
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,938
| 167,820
|
43206
|
Discharge summary
|
report
|
Admission Date: [**2146-6-30**] Discharge Date: [**2146-7-8**]
Date of Birth: [**2073-9-27**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
hypotension, s/p fall, respiratory failure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
72 yoM w/ h/o CAD, CHF (EF 35-40%), recently dx C. diff and RLE
DVT presents from NH following an unwitnessed fall. Per NH
records, patient had T 103.4 today and reported he was
lighhteaded prior to fall. He denied chest pain, N/V, adominal
pain. No LOC or head trauma. He was transported to the ED where
T 102 (rectal), HR 96, bp 130/80, 86% RA -> 93% 4L NC. He
received 2L NS and vancomycin 1 g IV X 1 given erythema noted at
right PICC site and levofloxacin 500 mg IV X 1 given possible
RLL infiltrate. His blood pressure dropped to 80/50 and he
became progressively tachypnic. ABG 7.43/43/55 and patient was
intubated and sedated. Left SC central line was placed, he
received an additional 1L fluid bolus. Levophed gtt was started
to keep MAP >6 and he was admitted to the MICU for further
management.
.
Recently admitted [**Date range (1) 35547**] s/p fall with dehydration and UTI,
treated with 10 days of ceftriaxone. He was readmitted [**6-15**]
-[**6-27**] with fever, N/V, diarrhea, and abdominal pain, and
diagnosed with C. diff (Abd CT showed pan-colitis). He was
discharged on 14 day course of IV Flagyl (due to difficulty
swallowing) and PO vancomycin. He was also noted to have a
non-occlusive right internal iliac DVT, for which he was
discharged on lovenox bridge to coumadin. He was also diagnosed
with possible aspiration pneumonia, and received a 7 day course
of levoquin. A Right arm PICC was inserted [**2146-6-22**] for TPN.
Past Medical History:
1. CAD s/p MI [**2130**]
2. ischemic cardiomyopathy
- TEE [**4-20**]: Anterior septum, distal anterior wall and inferior
wall moderately hypokinetic. 2+ MR, EF 35-40%
- ETT MIBI [**12-21**] 7 min modified [**Doctor First Name **] protocol Mild reversible
defect of the apical portion of the inferior wall and in the
apex. Regional hypokinesia in the apex. EF 48%
3. COPD
3. Borderline hypertension
4. Eczematous eruption on his trunk and proximal extremities
5. Depression and anxiety, treated with Celexa.
6. L MCA [**4-20**] with mild residual R sided hemiplegia
7. S/P Spinal fusion [**1-22**] and revision [**4-21**]
8. Urinary retention
9. C. diff: Diagnosed [**5-22**]
- [**2145-6-19**] Abd CT: No significant change in extensive pancolitis.
No evidence of pneumatosis or perforation. No focal abscess or
fluid collection. Increasing bibasilar consolidations may
represent compressive atelectasis or infectious process
Social History:
Quit tobacco [**2130**]. No current EtOH or other drug use. His wife
and 3 children live in [**Country 26550**]. The patient's sister is his HCP
and is very supportive. Pt is [**Name (NI) 8003**] speaking only. Since his
CVA one year ago, pt is [**Name (NI) 8003**] speaking only, although he
understands some English. He has also had difficulty swallowing
solid foods and difficulty with coordination required to use an
inhaler since his stroke.
Family History:
Positive for Alzheimer's disease in paternal
grandfather, negative otherwise.
Physical Exam:
PE: T 98.9, HR 87, bp 135/77, resp 19, 97%
SIMV TV 600 RR 16, PS 5, FiO2 0.5, PEEP 5
Gen: elderly, chronically-ill appearing male, intubated and
sedated
HEENT: NC/AT, PERRL, anicteric, nl conjunctiva, OMM dry,
intubated, neck supple, no LAD, JVP 8 cm
Cardiac: RRR, II/VI SM at apex
Pulm: Decreased LS at bases bilaterally, coarse ronchi
throughout
Abd: Moderately distended, soft, mild diffuse tenderness without
rebound/guarding, hypoactive bowel sounds.
Ext: 2+ LE edema to mid calf bilaterally, LE cool with 1+ DP
bilaterally . Right arm PICC site with surrounding
erythema/induration.
Neuro: Moves all 4 extremities in response to noxious stimuli.
1+ DTR left [**Name2 (NI) **] and LE, 2+ DTR right [**Name2 (NI) **], 1+ DTR left [**Name2 (NI) **]. Toes
downgoing bilaterally
GU: very edematous scrotum (diameter ~6inches), foley catheter
in place with yellow urine in bag
Pertinent Results:
labs on admission:
[**2146-6-30**] GLUCOSE-110* UREA N-17 CREAT-0.4* SODIUM-134
POTASSIUM-3.3 CHLORIDE-104 TOTAL CO2-26
WBC-19.3* RBC-3.50* HGB-9.9* HCT-30.4* PLT COUNT-381 MCV-87
MCH-28.3 MCHC-32.7 RDW-17.1*
ALBUMIN-1.9* CALCIUM-6.7* PHOSPHATE-3.0 MAGNESIUM-1.6
[**Last Name (un) 104**] stim test - c/w adrenal insufficiency
[**2146-6-30**] 11:25PM CORTISOL-16.3
[**2146-6-30**] 10:55PM CORTISOL-14.5
[**2146-6-30**] 08:10PM CORTISOL-14.4
[**2146-6-30**] 08:40PM FIBRINOGE-388# D-DIMER-3372*
CXR: Bilateral pleural effusions.
Ct: pancolitis.
Brief Hospital Course:
1. Sepsis: In the MICU, the pt was found to be in septic shock,
with blood cultures and PICC line culture positive for MRSA on
[**6-30**]. On admission, pt was hypoxic and in respiratory failure.
He was intubated on [**6-30**] in the ICU and was subsequently
extubated on [**7-3**]. TTE [**7-4**] showed no evidence of vegetations.
Sputum cx also grew MRSA and CXR showed RML pneumonia. PICC
line was removed and a L SC line was placed. The pt was started
on IV vancomycin 1g [**Hospital1 **]. Negative blood cultures on [**7-3**]. He
was found to be adrenally insufficient by [**Last Name (un) 104**] stim testing and
was given 7 days of fludrocort/hydrocort per our sepsis
protocol. Although he initally required pressors and large
amounts of fluid for his hypotension, the pt was quickly weaned
off levophed in the MICU and was able to maintain adequate blood
pressure throughout the remainder of his stay. On transfer to
the floor, the pt's vancomycin was stopped as he was also being
covered with linezolid, which has bacteriostatic activity
against MRSA. Subsequent blood culture has been negative.
Linezolid will be continued for a total of 14 days (today is day
6).
2. Diarrhea - Given his recent history of severe C diff, the
patient was continued on IV flagyl and PO vanco started during
his last admission throughout this admission as well (today is
d22/28 total). All C diff toxin A studies this admission have
come back negative. Currently, C diff toxin B is pending. An
Abd/Pelvis CT on [**7-1**] demostrated an evolving diffuse colitis
with interval increase in pericolonic inflammatory stranding and
free fluid. This was believed to be lagging behind the patient's
clinical picture, which was generally improving over time. A
rectal tube was placed in the MICU for decompression and was
removed upon transfer to the floor. On the day prior to
discharge, rifaximin was added to the patient's antibiotic
regimen for further coverage of C Diff given our high suspicion
regardless of negative toxin screens. (today d2/10) The pt's
abdominal pain and tenderness have resolved. The pt's diarrhea
markedly decreased over the course of his stay on the floor. He
tolerated a liquid diet without problem. GI was formally
consulted and they agreed that the patient was improving with a
negative abdominal exam and therefore required no further
workup. Antibiotics should be continued as an outpatient, as
listed above, and the patient's diet can be advanced as
tolerated. When he is taking good PO, his TPN can be stopped as
it is only for supplementation. Please follow Cdiff toxin A and
B as an outpatient. If negative, pt may stop his antibiotics as
planned above.
3. UTI: Urine cultures on [**6-30**] grew VRE and the pt was started
on linezolid. Subsequent cultures have been negative. Linezolid
will be used to cover both his VRE and his MRSA - requires 14
day course given bacteremia (today day 6).
4. R iliac thrombus - pt has been anticoagulated throughout his
stay with a heparin drip and goal PTT 60-100. Given hypoxia, CTA
in the MICU was negative for PE. On the day prior to admission
the patient's heparin was d/c-ed and he was started on a loading
dose of coumadin 5mg x 1 to be followed by coumadin 2mg qhs as
an outpt. He was also started on Lovenox which can be
discontinued when the patient is at goal INR on coumadin (INR
2-2.5). Please note that flagyl amplifies the effect of
coumadin, thus the pt's INR should be watched closely and if
supratherapeutic, coumadin may be held for 1-2 days and then
restarted.
.
5. hypoxia - Given his initial hypoxia, he was intubated and
sedated in the MICU. His respiratory status improved during his
stay, and he was eventually weaned off the vent, satting well by
nasal cannula. On the day of discharge he was satt-ing well on
RA (93-97%). The pt has baseline COPD and likely baseline sats
are 93-94%. There is likely also a CHF component. Pt received
large amounts of fluid in the MICU for hypotension and has been
making good urine, but is notably anasarcic. HE uses nebulizers
for SOB as he lacks the coordination to use inhalers since his
CVA one year ago. He should continue these as an outpt.
.
6. Anasarca - Secondary to large amount of fluid given in MICU
when septic. Pt also has very low albumin with poor nutritional
status. Pt is third spacing, especially noted in scrotum, with
severe swelling. Pt is making good urine without Lasix, but may
require this in the future, as he had during his last admission.
We are elevating his scrotum and legs to assist in drainage.
Please continue to elevate as an outpt.
7. s/p spinal fusion and fall at rehab - likely orthostatic in
setting of high grade fever. head CT negative for intracranial
process or bleed. Pt should only be OOB with assist. Note that
whenever pt is OOB (even to chair) he must wear his back brace.
8. PICC access- The patient was discharged from his last
admission with a PICC line, which was subsequently infected with
MRSA. The PICC was pulled upon admission and was replaced with a
L subclavian line. On the day of discharge, a new PICC line was
placed for outpt use for TPN and Abx. The pt should only
require IV Abx for one more week. His PO intake is improving.
Please be extremely cautious with the use of his PICC line. We
recommend that TPN be discontinued as soon as the pt is taking
adequate PO, and that sterility and caution be used when
manipulating the patient's PICC line as an outpt.
9. Poor PO intake - the patient's diet was slowly advanced as
tolerated to full liquids. He has difficulty swallowing solids
and is likely a chronic aspirator. His intake was supplemented
by TPN given through a central line daily throughout his stay.
The pt can swallow pills, although he has some difficulty with
large pills.
His diet should be advanced as tolerated as an outpt. TPN has
been used to supplement his nutrition and should be stopped when
he is taking adequate PO.
10. h/o CAD: The pt was ruled out for MI with cardiac enzymes x
3 when he initially present s/p fall. He was continued on his
usual dose of ASA, Plavix, statin. As an outpt he may be
restarted on his Beta Blocker, which was held on admission given
hemodynamics and sepsis.
.
11. Anemia: Iron studies consistent with anemia of chronic
disease.
12. h/o depression: Pt's citalopram was held on admission and
may be restarted as an outpt.
.
13. Ppx: anticoagulated, please continue protonix 40 PO daily as
an outpt.
.
9) Code: DNR documented in chart per sister [**Name (NI) **]. Please discuss
this with her again, as this was a change from his previous
admission.
.
11) Communication: Sister [**Name (NI) **] [**Name (NI) **] (H [**Telephone/Fax (1) 93088**], C
[**Telephone/Fax (1) 93089**])
---
Medications on Admission:
1) Alb/atr nebs q6h
2) ECASA 325 mg PO daily
3) Calcitonin 200 IU daily
4) CA/Vit D 500 mg PO TID
5) Citalopram 20 mg PO daily
6) Plavix 75 mg PO daily
7) Lovenox 80 mg SC q12h
8) Lasix 40 mg PO BID
9) RISS
10) Lactobacillus 1 tab PO TID
11) Lisinopril 10 mg PO daily
12) Toprol XL 12.5 mg PO daily
13) Metronidazole 500 mg IV q8h
14) MV1
15) Pantoprazole 40 mg PO daily
16) Simvastatin 20 mg PO qhs
17) Vancomycin 12.5 mg PO q6h
18) warfarin
19) Tylenol prn
Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) for 8 days.
5. Warfarin Sodium 2 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime): please monitor INR for goal 2.0-2.5 and adjust
coumadin dose accordingly. note concurrent use of flagyl
amplifies coumadin effect and may hold coumadin 1-2d if needed
for supratherapeutic INR.
6. metronidazole
Metronidazole 500mg IV q8hrs x 6 days
7. vancomycin
Vancomycin Oral Liquid 250mg q6hrs x 6 days.
8. Albuterol Sulfate 0.083 % Solution Sig: One (1) nebulization
Inhalation Q6H (every 6 hours) as needed for SOB.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulization
Inhalation Q6H (every 6 hours).
10. morphine sulfate
morphine sulfate (oral solution) 5mg q4-6 hours prn pain.
11. linezolid
Linezolid 250 mg IV q12hrs x 8 days
12. lovenox
Lovenox 60 mg SC q12hrs.
Please monitor INR.
Please stop lovenox when INR is therapeutic (between 2.0 and
2.5) and then continue only coumadin.
13. heparin flush
10 mL NS followed by 2 mL of 100units/mL heparin (100 units
heparin total) in each lumen daily and prn after each use.
Please inspect PICC site three times daily.
14. Insulin sliding scale
please follow attached insulin slide scale.
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
16. Citalopram Hydrobromide 20 mg Tablet Sig: One (1) Tablet PO
once a day.
17. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal once a day.
18. Calcium 500 with Vitamin D 500-125 mg-unit Tablet Sig: One
(1) Tablet PO three times a day.
19. Multivitamin Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - Acute Rehab
Discharge Diagnosis:
C diff colitis
MRSA sepsis likely [**1-19**] PICC line infection
pneumonia
urinary tract infection
Discharge Condition:
Fair.
Discharge Instructions:
If you have fever, chills, increased SOB, chest pain, back pain,
increased diarrhea or abdominal pain, please call Dr. [**Last Name (STitle) 838**]
or come to the emergency department.
Please always wear back brace when moving out of bed (including
to chair).
Please continue vancomycin and flagyl for 6 days after
discharge. Please continue Rifaximin for 8 days after discharge.
Please continue linezolid for 8 days after discharge.
Please continue to advance diet as tolerated. Please stop TPN
when pt is taking adequate PO to minimize the amount of time
PICC line in place. Please d/c PICC line as soon as no longer
needed for Abx or TPN.
Followup Instructions:
Please monitor INR with coumadin. Adjust dose as needed for INR
2-2.5 goal. Please note that simultaneous use of flagyl may
amplify the effect of coumadin so use conservative management.
Coumadin may be stopped for 1-2 days if needed for
supratherapeutic INR and then restarted.
Please check Cdiff toxin A and B in four days. If negative, may
stop flagyl, vanco and rifaximine at that time. If not, please
continue antibiotics.
Please direct questions/concerns to Dr. [**Last Name (STitle) 838**].
Completed by:[**2146-7-8**]
|
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32,793
| 120,773
|
26244
|
Discharge summary
|
report
|
Admission Date: [**2197-12-11**] Discharge Date: [**2197-12-16**]
Date of Birth: [**2117-8-2**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 7055**]
Chief Complaint:
Elective admission for carotid angioplasty
Major Surgical or Invasive Procedure:
carotid angioplasty
History of Present Illness:
80yo F with CAD s/p PCI to LAD and OM, HTN, hyperlipidemia,
IDDM, carotid stenosis who presents electively for carotid
angioplasty. Per the patient, both her PCP (Dr. [**Last Name (STitle) 5310**] and
Dr. [**Last Name (STitle) **] warned her that she would have a stroke sometime in
the next few months if she did not have this procedure performed
thus she presented for elective carotid stenting. On admission,
she had a carotid U/S performed which confirmed the findings of
carotid stenosis. She also underwent an MRI/A of the brain which
revealed severe stenosis, but no evidence of stroke. She was
seen by both vascular surgery and neurology/stroke service who
both agreed with proceeding with stenting.
.
On ROS, she reports some lightheadedness upon standing but
states that it resolves on its own. She denies any dizziness or
presyncope. She had one episode of syncope in [**6-8**] which was
attributed to hypoglycemia. She notes bilateral vision changes
which she describes as a "film" coming down over her eyes. She
states that it lasts minutes at a time, resolves on its own, and
happens multiple times throughout the day. She denies any blurry
vision, diplopia, or difference between eyes. Of note, she had a
left eye hemorrhage in [**2196**] which has since resolved. She is
monitored by an opthamologist as an outpatient on a fairly
regular basis. She denies any chest pain, pressure or
palpitations. She denies any SOB or cough. She denies any URI
sx, except for an occasional runny nose. She denies any changes
in her appetite, but does not some mild nausea post-procedure.
She also is having diarrhea. She denies any urinary [**Year (4 digits) **]
(foley in place). She denies any loss of sensation or muscle
weakness. She denies any rashes, skin changes or edema. She
denies any history of stroke, DVT or PE. She has a history of
claudication but is not having [**Year (4 digits) **] currently.
Past Medical History:
# HTN
# Hyperlipidemia
# DM - on insulin
# CAD - w/ 3VD (LMCA 205 stenosis, LAD occluded after D1, LCx
patent, OM1 70-80% stenosis)
- s/p DES to mid LAD and proximal OM lesions [**2196-1-11**]
- originally attempted POBA of LAD in [**12-6**]
# PAD
- laser atherectomy and balloon angioplasty of L SFA [**2197-7-26**]
- stenting of proximal and mid/distal L SFA lesions [**2196-10-7**]
- stent of R SFA lesion [**2196-9-9**]
- PTA of L SFA [**2196-8-24**]
- *unsuccessful* PTA of L SFA (was totally occluded)
- PTA of R SFA [**2196-2-19**]
# GERD
# Colon cancer s/p right hemicolectomy
# Bilateral carotid stenosis
# s/p CCY
# Left eye hemmorhage in [**5-7**], now resolved
Social History:
Widowed. Currently niece and husband lives with her.
Family History:
Mother had an MI and died at 60 years old.
Physical Exam:
VS - T98.8 BP 128/66 HR 68 RR 18 94%RA
Gen: White 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.
Neck: Supple with JVP of 8cm. + carotid bruit on right.
CV: Distant heart sounds.No m/r/g appreciated but difficult to
assess.
Chest: CTA bilaterally.
Abd: Obese, Soft, NTND. No HSM or tenderness. .
Ext: No c/c/e.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
.
Pulses:
Right: Carotid 2+/+bruit DP dopplerable PT dopplerable
Left: Carotid 2+ DP dopplerable PT dopplerable
Pertinent Results:
Labs:
[**2197-12-16**] 04:10AM BLOOD TSH-1.4
[**2197-12-16**] 04:10AM BLOOD calTIBC-309 Hapto-228* Ferritn-26 TRF-238
[**2197-12-13**] 03:06AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.7
[**2197-12-13**] 05:00AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.7
[**2197-12-13**] 08:30PM BLOOD Calcium-8.5 Phos-3.5 Mg-2.3
[**2197-12-14**] 03:43AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.3
[**2197-12-15**] 03:31AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1
[**2197-12-16**] 04:10AM BLOOD Albumin-3.3* Calcium-8.7 Phos-3.4 Mg-1.9
Iron-35
[**2197-12-12**] 06:50AM BLOOD CK(CPK)-58
[**2197-12-16**] 04:10AM BLOOD ALT-15 AST-28 LD(LDH)-241 AlkPhos-92
TotBili-0.5
[**2197-12-11**] 02:51PM BLOOD Glucose-142* UreaN-16 Creat-1.0 Na-141
K-4.4 Cl-104 HCO3-33* AnGap-8
[**2197-12-12**] 06:50AM BLOOD Glucose-127* UreaN-15 Creat-0.9 Na-141
K-3.9 Cl-102 HCO3-33* AnGap-10
[**2197-12-13**] 03:06AM BLOOD Glucose-117* UreaN-20 Creat-1.1 Na-134
K-4.6 Cl-104 HCO3-21* AnGap-14
[**2197-12-13**] 05:00AM BLOOD Glucose-110* UreaN-20 Creat-1.1 Na-139
K-4.2 Cl-106 HCO3-28 AnGap-9
[**2197-12-13**] 08:30PM BLOOD Glucose-172* UreaN-20 Creat-1.1 Na-137
K-3.9 Cl-103 HCO3-28 AnGap-10
[**2197-12-14**] 03:43AM BLOOD Glucose-90 UreaN-17 Creat-0.9 Na-140
K-3.9 Cl-107 HCO3-28 AnGap-9
[**2197-12-14**] 04:53PM BLOOD Glucose-104 UreaN-15 Creat-1.0 Na-137
K-4.2 Cl-102 HCO3-26 AnGap-13
[**2197-12-15**] 03:31AM BLOOD Glucose-144* UreaN-17 Creat-0.9 Na-141
K-4.0 Cl-104 HCO3-32 AnGap-9
[**2197-12-16**] 04:10AM BLOOD Glucose-141* UreaN-12 Creat-0.9 Na-143
K-3.9 Cl-107 HCO3-27 AnGap-13
[**2197-12-16**] 04:10AM BLOOD Ret Aut-2.6
[**2197-12-12**] 06:50AM BLOOD PT-12.8 PTT-24.2 INR(PT)-1.1
[**2197-12-13**] 05:00AM BLOOD PT-12.6 PTT-24.0 INR(PT)-1.1
[**2197-12-14**] 03:43AM BLOOD PT-11.7 PTT-26.9 INR(PT)-1.0
[**2197-12-16**] 04:10AM BLOOD PT-13.0 PTT-26.6 INR(PT)-1.1
[**2197-12-11**] 02:51PM BLOOD WBC-6.4 RBC-4.14* Hgb-11.9* Hct-36.2
MCV-87 MCH-28.7 MCHC-32.8 RDW-15.9* Plt Ct-223
[**2197-12-12**] 06:50AM BLOOD WBC-5.5 RBC-4.30 Hgb-12.0 Hct-37.0 MCV-86
MCH-27.9 MCHC-32.5 RDW-16.0* Plt Ct-226
[**2197-12-13**] 03:06AM BLOOD WBC-8.7# RBC-3.82* Hgb-10.9* Hct-33.5*
MCV-88 MCH-28.6 MCHC-32.6 RDW-15.6* Plt Ct-192
[**2197-12-13**] 05:00AM BLOOD WBC-6.4 RBC-3.57* Hgb-9.9* Hct-30.4*
MCV-85 MCH-27.8 MCHC-32.6 RDW-15.6* Plt Ct-187
[**2197-12-13**] 08:30PM BLOOD WBC-6.2 RBC-3.24* Hgb-9.5* Hct-28.2*
MCV-87 MCH-29.2 MCHC-33.6 RDW-16.2* Plt Ct-200
[**2197-12-14**] 03:43AM BLOOD WBC-5.6 RBC-3.37* Hgb-9.4* Hct-28.6*
MCV-85 MCH-27.7 MCHC-32.7 RDW-15.8* Plt Ct-186
[**2197-12-15**] 03:31AM BLOOD WBC-5.3 RBC-3.41* Hgb-9.9* Hct-29.5*
MCV-87 MCH-29.1 MCHC-33.5 RDW-16.3* Plt Ct-197
[**2197-12-16**] 04:10AM BLOOD WBC-8.3# RBC-3.17* Hgb-9.2* Hct-27.7*
MCV-87 MCH-29.1 MCHC-33.3 RDW-16.7* Plt Ct-226
[**2197-12-16**] 02:22PM BLOOD WBC-5.4 RBC-3.34* Hgb-9.2* Hct-28.8*
MCV-86 MCH-27.4 MCHC-31.9 RDW-16.3* Plt Ct-199
.
[**2197-12-15**] 11:24PM URINE RBC-21-50* WBC-[**3-6**] Bacteri-MOD Yeast-NONE
Epi-[**3-6**]
[**2197-12-12**] 08:30AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2197-12-15**] 11:24PM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-1 pH-5.0 Leuks-TR
[**2197-12-12**] 08:30AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2197-12-15**] 11:24PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.025
[**2197-12-15**] 11:24PM URINE CastHy-1*
.
Urine Cx [**12-12**]: Negative
Urine Cx [**12-15**]: NGTD
.
Carotid Duplex Series: Bilateral 80 to 99% stenosis. Normal
distal right ICA could not be visualized due to the depth and a
high bifurcation.
.
MRI/MRA head/neck: IMPRESSION:
1. Severe stenoses of the internal carotid artery bulbs
bilaterally. Severe stenosis of the proximal left common carotid
artery and subclavian artery, and possible stenosis of the
proximal right common carotid artery. Moderate stenosis of the
proximal vertebral arteries bilaterally.
2. Normal MRA of the head.
3. Moderate chronic microangiopathic changes with no acute
infarcts.
.
Cardiac Cath:
1. Angiography of the aortic arch revealed 40% origin left
carotid stenosis. The left and right subclavians were patent.
The right carotid was cannulated and found to have a 90%
stenosis at the origin of the [**Country **].
2. Access was via 6F Shuttle sheath at RFA.
3. Limited hemodynamics showed patient to be in sinus rhythm
with
opening BP 153/63. Patient had a vagal episode with sheath
insertion
requiring 1mg of atropine. She had another vagal with balloon
inflation
in the carotid treated successfully with fluid, atropine and
dopamine.
4. Successful stenting of right internal carotid artery with
XACT
8-6mmx40mm stent using Spider wire distal protection.
5. Plan for elective left carotid stenting next week.
FINAL DIAGNOSIS:
1. Bilateral carotid artery stenosis by MRA and dupplex
ultrasound.
2. Successful stenting of right internal carotid artery.
.
CT abdomen/pelvis: IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. A high-attenuation right renal cortical lesion may represent
a hyperdense cyst. However, a solid lesion cannot be excluded
and ultrasound correlation is recommended.
.
CXR: IMPRESSION: Slight cardiomegaly without signs of cardiac
congestion or decompensation. No pleural effusion. No signs of
pneumonia.
Brief Hospital Course:
# CAROTID STENOSIS: Patient has known bilateral carotid stenosis
based on MRI/MRA from [**2195**]. U/S and MRI/A this admission
confirmed bilateral ICA disease. Pt went for R carotid stent on
[**12-12**]. Patient tolerated procedure well, with transient vagal
episode requiring atropine and dopamine. Also was hypotensive
and bradycardic while in the ICU. Treated with dopamine drip to
keep MAP>60. Bradycardia and hypotension eventually improved.
Patient then went for L carotid stenting s/p two stents on [**12-15**]
with transient hypotension requiring dopamine drip. Was weaned
off the dopamine with no complications. Neurological exams
remained unchanged. She will be continued on ASA, Plavix for
life on discharge.
.
# CARDIAC:
1) CAD: Pt is s/p drug eluting stent to LAD and OM. EKG with no
changes and was symptom free during admission. Will continue
ASA, Plavix, Lisinopril, Atenolol. Also will continue on
outpatient Lipitor regimen.
.
2) PUMP: Euvolemic on exam. The patient does not have an ECHO on
file at [**Hospital1 18**]. No evidence of CHF on exam. She will continue
on her outpatient Lasix and Atenolol regimen. No ECHO on file
here, so EF unknown. No evidence of CHF on exam.
.
3) RHYTHM: Sinus bradycardia at baseline, though additional
decreased heart rate in the setting of her R carotid stent
placement. Patient has been asymptomatic. She received one
dose of atropine on the floor for bradycardia, and an additional
dose after her L carotid stenting. As per EP, no need for
pacemaker as bradycardia is likely reflex secondary to
angiography and stenting of carotid artery. However, they do
recommend sleep study test, as this bradycardia may be a sign of
sleep apnea. Atenolol was held during admission for sinus
bradycardia, but it can be restarted as an outpatient.
.
# Diabetes: The patient will continue her diabetic regimen
including Novolin 70/30, Actos and Metformin. She should restart
the Metformin one day after discharge given the nephrotoxic dye
load from her cardiac catheterizations.
.
# PAD: Continued on ASA, Plavix.
.
# L hand paresthesias: Patient has noted L hand tingling in the
ulnar distribution over 48-72 hours of her admission. She did
receive peripheral dopamine on the left, however, no evidence of
skin discoloration or signs of necrosis or other injury. Of
note, she states that she has had chronic ulnar-distribution
paresthesias on the right for many months. Given the bilateral
[**Hospital1 **] and the patient's body habitus, this is likely ulnar
nerve compression secondary to positioning in bed while
sleeping. TSH within normal limits. She should have outpatient
follow up if her [**Hospital1 **] do not resolve.
.
# Vulvovaginal candidiasis: Pt complained of vaginal itching on
her final day of admission. She was given a one time dose of
150mg fluconazole PO. She should follow up with her primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) **] do not resolve.
.
# GERD: Continued home PPI.
.
# CODE: FULL
Medications on Admission:
Atenolol 25mg PO daily
Plavix 75mg PO daily
Lisinopril 5mg PO daily
Metformin 500mg PO daily
Actos 15mg PO daily
Lipitor 20mg PO daily
Protonix 40mg PO daily
Furosemide 40mg PO daily
Aspirin 325mg PO daily
Centrum Silver MVI
Novolin N 20u QAM, 8u QPM
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Tablet(s)
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*0 Tablet(s)* Refills:*0*
6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge
Sig: One (1) 70U QAM, 6U QHS Subcutaneous once a day: Please
return to your home insulin regimen.
8. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
10. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day:
do not re-start until [**12-17**].
11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
VNA centrus home care
Discharge Diagnosis:
Primary
Bilateral Carotid Stenosis
.
Secondary
Diabetes
HTN
Hyperlipidemia
Obesity
PVD
Discharge Condition:
Stable
Discharge Instructions:
You were admitted to the hospital for an elective procedure to
fix the arteries in your neck that had some blockages. You were
found to have 80-99% stenosis in the arteries on both sides of
your neck. You also had an MRI of your brain which was normal.
.
You were continued on all of your home medications. You will
need to take aspirin and plavix EVERY DAY.
.
You will need to follow up with....
- Sleep Neurology for a sleep study (bradycardia at night ? due
to sleep apnea)
- Hand specialist regarding your bilateral ulnar neuropathy
- Your primary care doctor and your outpatient cardiologist
.
If you have any syncope, lightheadedness, dizziness, change in
your vision, nausea, vomiting, muscle weakness or loss of
sensation, chest pain, shortness of breath, nausea, vomiting,
or any other concerning symptom, please call your doctor or
return to the ER.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 5310**] in one to two weeks. His
number is [**Telephone/Fax (1) 5315**].
.
Please call your PCP Dr [**Last Name (STitle) 58201**] [**Telephone/Fax (1) 65012**] and make a
follow-up appointment within the next 2 weeks as well.
|
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359, 380
|
13565, 13574
|
3794, 8554
|
14483, 14760
|
3106, 3150
|
12410, 13359
|
13455, 13544
|
12134, 12387
|
8571, 9082
|
13598, 14460
|
3165, 3775
|
277, 321
|
408, 2322
|
2344, 3019
|
3035, 3090
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
73,498
| 189,581
|
21789+57262
|
Discharge summary
|
report+addendum
|
Admission Date: [**2144-12-20**] Discharge Date: [**2144-12-30**]
Date of Birth: [**2081-1-8**] Sex: F
Service: SURGERY
Allergies:
Biaxin / Penicillins / Cefzil
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
ESRD on PD here for kidney transplant
Major Surgical or Invasive Procedure:
renal transplant [**2144-12-21**]
renal transplant biopsy [**2144-12-28**]
History of Present Illness:
Mrs.[**Known lastname **] is a 63F with ESRD secondary to diabetic
nephropathy. She is currently on PD. She still voids several
times a day. She presents to [**Hospital1 18**] today for kidney
transplantation.
Past Medical History:
ESRD [**3-9**] Diabetic nephropathy, currently on PD, pt still
voids several times a day, IDDM, HTN, LBBB, Constipation, IBS,
Herpes Zoster,
.
PSH: Open CCY, APPY, eye surgery for retinopathy
Social History:
Married, Lives at home with husband, She was a smoker until
[**2103**].
Family History:
Non-Contributory
Physical Exam:
Temp 98.3, HR 60, BP 188/77, RR 18, O2 100% RA, Ht 5'2", Wt 61kg
Gen: Well, NAD, A&O
CV: RRR, No R/G/M
RESP: Lungs CTAB
ABD: SOFT, NT, ND, LLQ PD Cath clean and intact, large RUQ
subcostal incision from open CCY well healed
Ext: Feet WWP, No LE Edema, Palpable PT and DP pulses
bilaterally
Pertinent Results:
On Admission: [**2144-12-20**]
WBC-9.1 RBC-4.07* Hgb-11.1* Hct-32.9* MCV-81* MCH-27.3 MCHC-33.7
RDW-16.2* Plt Ct-327
PT-20.7* PTT-29.0 INR(PT)-1.9*
UreaN-41* Creat-5.6*# Na-144 K-3.0* Cl-104 HCO3-31 AnGap-12
Albumin-3.3* Calcium-9.3 Phos-3.7 Mg-2.0
At Discharge: [**2144-12-30**]
WBC-7.0 RBC-3.46* Hgb-9.9* Hct-29.1* MCV-84 MCH-28.6 MCHC-34.0
RDW-17.9* Plt Ct-208
PT-14.0* PTT-26.1 INR(PT)-1.2*
Glucose-121* UreaN-55* Creat-5.9* Na-142 K-3.9 Cl-109* HCO3-24
AnGap-13
Calcium-8.4 Phos-3.9 Mg-1.8
[**2144-12-24**] HBsAg-NEGATIVE HBsAb-POSITIVE T
B Flow Crossmatch from [**12-28**] Pending
Brief Hospital Course:
63 y/o female with esrd and recent PD initiation who presented
for kidney transplant.
She received a renal transplant on [**12-21**]. Surgeon was Dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **]. Routine induction immunosuppression was given (
Cellcept, Solumedrol with protocol taper, thymoglobulin.
Initial urine output was about 1 liter daily and was anywhere
from 1 - 2 liters daily through the hopitalization, however she
had urine output prior to the surgery.
There was concern for a donor specific antibody. Pre and post
transplant cross matches were done as well as luminex screens.
PLease see Pavlakis' note for details. Per the results, pheresis
was determined unnecesary. She did receive 4 doses of
thymoglobulin (75 mg each).
She experienced delayed graft function with a creatinine that
remained in the 5 - 7 range. Low volume peritoneal dialysis
exchanges were done using the existing PD catheter on [**12-25**] thru
[**12-28**]. She did not have any problems with leakage at this time
and tolerated the treatments.
She was slated to be discharged on [**12-26**] with plan to hold
coumadin for anticipated transplant kidney biopsy the following
week. However, on the morning of [**12-26**] she went into rapid Afib
and required ICU transfer. She was seen by cardiology and was
placed on an amiodarone drip following attempts with IV
lopressor failed to convert her. She also received one dose of
diltiazem. She converted and remained in a sinus.
On [**12-28**], she had an ultrasound guidanced biopsy performed by
nephrologist. This demonstrated no evidence of acute cellular or
humeral rejection. Please refer to pathology report for complete
details.
She did well with medication teaching. Cellcept was well
tolerated. Steroids were tapered off and prograf dosing was
adjusted daily per levels. Prograf was started on postop day 0.
She was discharged home on po lasix. Coumadin was resumed.
Follow up labs were to be drawn on [**1-1**]. She was discharged in
stable condition with average daily urine output of 1.5 liters.
Vital signs were stable. She was tolerating a regular diet and
was ambulating independently.
Medications on Admission:
Albuterol INH PRN, Lipitor 40, Calcitriol 0.5, Procrit 30k
Units Q3 weeks, Lasix 80, Coumadin 2.5 6days/week (not wed),
Diltiazem CD 360, Toprol XL 100, Lantus 40-42 Units QHS
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day).
3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for
wheeze.
4. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY
OTHER DAY (Every Other Day).
5. Lamivudine 10 mg/mL Solution Sig: 2.5 ml PO DAILY (Daily).
Disp:*200 ml* Refills:*2*
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS).
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**2-7**] Tablet,
Chewables PO QID (4 times a day) as needed for indigestion:
TUMS.
10. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 PM.
11. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
13. Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15)
units Subcutaneous at bedtime.
14. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO twice a
day.
15. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 10
days.
Disp:*20 Tablet(s)* Refills:*0*
16. One Touch Ultra System Kit Kit Sig: One (1)
Miscellaneous once a day.
Disp:*1 kit* Refills:*0*
17. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO four times a day
as needed for pain: No aspirin or ibuprofen.
Discharge Disposition:
Home
Discharge Diagnosis:
esrd on PD now s/p kidney transplant
htn
AFIB
DM
delayed graft function
ATN
Discharge Condition:
good
Discharge Instructions:
Please call the Transplant office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
increased abdominal pain, decreased urine output, increased
edema, weight gain of 2 pounds in a day.
Please get lab work drawn on Friday [**1-1**] at the [**Hospital **] Medical
Building. Take prograf 12 hours prior to anticipated blood draw
Thursday night for labs on Friday. Do not take prograf until
blood is drawn.
You will need to have lab work drawn every Monday and Thursday
at [**Last Name (NamePattern1) 439**] starting next week
Empty and record JP drain. Bring record of JP drainage to next
appointment with Dr. [**First Name (STitle) **]. Place new dressing to drain site
daily and as needed
You will need to go home with the Foley (urine catheter). Empty
and record urine output. Will attempt foley removal Friday
Continue Coumadin Continue PT/INR checks with Dr [**First Name4 (NamePattern1) 3535**] [**Last Name (NamePattern1) 57214**],
cardiologist
No heavy lifting
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-1-1**] 1:10
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-1-8**] 3:10
[**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2145-1-11**] 1:40
Completed by:[**2145-1-5**] Name: [**Known lastname 856**],[**Known firstname **] Unit No: [**Numeric Identifier 10651**]
Admission Date: [**2144-12-20**] Discharge Date: [**2144-12-30**]
Date of Birth: [**2081-1-8**] Sex: F
Service: SURGERY
Allergies:
Biaxin / Penicillins / Cefzil
Attending:[**First Name3 (LF) 2648**]
Addendum:
Of note, donor kidney was HBV core positive. [**Known firstname **] was given 2
doses of HBIG and was started on lamivudine on [**2144-12-21**].
Discharge Disposition:
Home
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**]
Completed by:[**2145-1-5**]
|
[
"V58.61",
"427.31",
"458.29",
"585.6",
"403.91",
"564.1",
"250.50",
"250.40",
"584.5",
"287.5",
"362.01",
"285.21",
"E878.0",
"426.3",
"996.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.98",
"00.93",
"55.23",
"55.69"
] |
icd9pcs
|
[
[
[]
]
] |
8116, 8278
|
1922, 4079
|
328, 405
|
6083, 6090
|
1310, 1310
|
7161, 8093
|
967, 985
|
4306, 5934
|
5984, 6062
|
4105, 4283
|
6114, 7138
|
1000, 1291
|
1573, 1899
|
251, 290
|
433, 645
|
1324, 1559
|
667, 861
|
877, 951
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,851
| 142,689
|
8653
|
Discharge summary
|
report
|
Admission Date: [**2176-9-21**] Discharge Date: [**2176-9-25**]
Service: MEDICINE
Allergies:
Tylenol
Attending:[**First Name3 (LF) 4052**]
Chief Complaint:
Diffuse Body pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
87 y/o female with a h/o AD and spinal stenosis who presented to
the ED with diffuse body pain. All history obtained through
hospital records and patient's family as pt was unable to
provide her medical history. Patient lives at home with her
husband who is her primary caregiver. She was diagnosed with AD
about 2 years ago when her family noticed gradual memory loss.
Over the past month or two, her family reports that her mental
status had been declining, to the point where she could no
longer recognize her children. She was unable to take her
medications. Her family states that she has been losing weight
for the past year. She sustained a fall in [**3-26**] which results in
vertebral fractures and since that time she has been mobile only
from chair to chair. She has complained of chronic back pain for
quite some time. Over the past two days, her family noticed that
she was complaining of more pain over several areas of her body.
In addition, her abdomen was becoming more distended and she was
complaining of abdominal discomfort. Her family decided to bring
her to the ED for further evaluation.
.
Vitals upon presentation to the ED: T 95.8 HR 73 BP 136/71 RR 16
100%RA.
.
ED course: She presented to the ED with diffuse body pain.
Initially, there was concern for worsening back pain and she was
admitted to the medical floor. However, the results of her
laboratory testing returned and she was found to have acute
renal failure. CXR were WNL. She was also found to be
hyperkalemic and was given kayexalate, D50, insulin, and calcium
given concern for peaked T waves seen on EKG. She was also given
1 amp of sodium bicarbonate for metabolic acidosis [**2-23**] to ARF.
She was fluid challenged and was given a total of 3L NS without
any urine output or improvement in her ARF. A renal U/S revealed
moderate to severe B/L hydronephrosis. A subsequent CT scan of
her abdomen and pelvis revealed multiple abdominal lesions along
with ascites concerning for metastatic disease. KUB was without
evidence of obstruction. Given her ARF and metabolic acidosis,
she was admitted to the MICU for possible urgent HD vs. urgent
percutaneous nephrostomy tube placement with IR. She arrived to
the floor hemodynamically stable.
.
ROS: No recent F/C per family. No CP or SOB. Weight loss over
the course of one year. No urinary symptoms. Positive for
abdominal distention and diffuse body pain.
Past Medical History:
AD
Spinal stenosis
Chronic low back pain
Osteoporosis
Gastric ulcers s/p partial gastrectomy
s/p C-section x 2
Compression fractures
Social History:
Married with two children and lives with husband. [**Name (NI) **] tobacco. no
EtOH. Former dress maker.
Family History:
non-contrib
Physical Exam:
Vitals:
T 98.8 HR 81 BP 137/71 RR 22 99%RA
General: Frail 87 y/o female in mild distress [**2-23**] to pain.
HEENT: NC/AT. MM extremely dry. OP clear.
Neck: No JVD.
CV: Normal S1, S2 without any m/r/g.
Abd: Soft, distended, diffusely tender with normoactive BS.
Ext: 1+ pitting edema B/L.
Neuro: Unable to provide history or follow commands. Per family,
pt's mental status was at her baseline. Moves all 4 extremities
without difficulty.
Skin: No rash.
Pertinent Results:
[**2176-9-21**] 02:40PM BLOOD WBC-9.2 RBC-4.08* Hgb-12.0 Hct-35.6*
MCV-87 MCH-29.5 MCHC-33.8 RDW-15.3 Plt Ct-196
[**2176-9-22**] 12:12AM BLOOD WBC-8.3 RBC-3.77* Hgb-11.2* Hct-32.8*
MCV-87 MCH-29.7 MCHC-34.1 RDW-15.3 Plt Ct-294
[**2176-9-21**] 02:40PM BLOOD Neuts-79.2* Lymphs-14.5* Monos-5.7
Eos-0.4 Baso-0.2
[**2176-9-22**] 12:12AM BLOOD PT-13.1 PTT-24.4 INR(PT)-1.1
[**2176-9-21**] 02:40PM BLOOD Glucose-78 UreaN-95* Creat-7.1*# Na-138
K-5.6* Cl-104 HCO3-14* AnGap-26*
[**2176-9-22**] 12:12AM BLOOD Glucose-92 UreaN-90* Creat-6.9*# Na-143
K-5.1 Cl-110* HCO3-16* AnGap-22*
[**2176-9-21**] 02:40PM BLOOD ALT-17 AST-28 AlkPhos-91 Amylase-158*
TotBili-0.3
[**2176-9-22**] 12:12AM BLOOD Calcium-7.8* Phos-5.6*# Mg-2.3
.
[**2176-9-21**] Renal U/S
In the setting of moderate-to-severe bilateral hydronephrosis,
retroperitoneal or pelvic mass is a concern and CT of the
abdomen and pelvis is recommended. Moderate ascites.
Incompletely characterized right hepatic lesion could also be
further evaluated with CT.
.
[**2176-9-21**] Abdomen/Pelvis CT
Multiple abdominal omental and mesenteric masses with a large
volume of ascites, likely peritoneal carcinomatosis. Primary
malignancy is not identified. Omental masses would be amenable
to percutaneous biopsy.
Bilateral left greater than right hydronephrosis and hydroureter
tracking down into pelvis without clear visualization of the
point of obstruction.
Hypodense hepatic segment 6 mass, may represent metastasis.
Suggestion of mucosal thickening and irregularity of the gastric
fundus, though evaluation extremely limited. Correlate with
endoscopy.
L1 compression deformity of unknown chronicity.
Leiomyomatous uterus.
.
[**2176-9-21**] KUB
No evidence of bowel obstruction.
Degenerative changes in the spine and SI joints, with possible
compression at L1. Correlation with lateral view is advised.
.
[**2176-9-21**] CXR
No acute cardiopulmonary process.
.
[**2176-9-21**] EKG
NSR at 70 with occasional APCs. No acute ST changes.
Brief Hospital Course:
87 y/o female with a h/o AD and spinal stenosis who presented to
the ED with body pain and was found to be in acute renal failure
[**2-23**] to B/L hydronephrosis from multiple abdominal lesions, as
well as likely metastatic disease.
.
# Acute renal failure/B/L hydronephrosis with metastatic
appearing lesions, poor prognosis. Based on family discussions
as noted below, pt was made CMO. SW was called, met with family
to provide support. Pt's labs and VS were withdrawn, pt made
comfortable.
.
# Code
- DNR/DNI, discussed in full with pt's family, including pt's
husband who is the health care proxy
.
# Dispo - c/o to floor. Family uncomfortable taking home, plan
to provide palliative care on the floor vs. inpatient hospice.
Extensive discussion with the family upon arrival of the patient
to the MICU. [**Name (NI) 1094**] husband [**Name (NI) 382**] and sons present for discussion.
Full discussion with the MICU resident on call and the ICU
attending on call. Informed pt's family of the clinical picture
and treatment options. Given the temporizing measure of placing
B/L percuteneous nephrostomy tubes, the family agreed to not
proceed with that intervention. The pt's CT scan strongly
suggests metastatic cancer. It was explained in full to the
family that we cannot definitely state without pathology/tissue
biopsy that the lesions are cancer. However, the appearance on
the CT scan is highly suggestive of a metastatic cancer process.
The patient's family decided that they did not want to prolong
the patient's suffering and elected not to proceed with IR
percutaneous nephrostomy tube placement and/or hemodialysis.
They wish to proceed with comfort measures at this time. Given
the pt's poor functional status prior to this diagnosis, further
aggressive treatment measures are not what the patient or her
family desires. Family in full agreement with plan. Discussed
with ICU attending on call who was present for family discussion
and nursing staff.
.
# [**Name (NI) **] -
Husband [**Telephone/Fax (1) 30299**]
Son [**Telephone/Fax (1) 30300**]
Medications on Admission:
Aricept
Fosamax
Advil
ASA
Calcium
Vit D
Discharge Disposition:
Expired
Discharge Diagnosis:
Deceased
Discharge Condition:
Deceased
Discharge Instructions:
Deceased
Followup Instructions:
Deceased
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]
Completed by:[**2176-9-26**]
|
[
"199.1",
"276.2",
"591",
"331.0",
"733.00",
"276.7",
"197.6",
"197.7",
"724.00",
"294.10",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
7625, 7634
|
5470, 7534
|
233, 239
|
7686, 7696
|
3463, 5447
|
7753, 7914
|
2961, 2974
|
7655, 7665
|
7560, 7602
|
7720, 7730
|
2989, 3444
|
176, 195
|
267, 2665
|
2687, 2822
|
2838, 2945
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
588
| 170,452
|
13109
|
Discharge summary
|
report
|
Admission Date: [**2200-1-7**] Discharge Date: [**2200-1-28**]
Date of Birth: [**2130-11-18**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 759**]
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
central line placement
History of Present Illness:
68 yo male with ESRD on dialysis, HTN, L BKA, CAD, presents with
fevers (Tm 103.8 per EMS at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]), rigors, hypotension
(90/60s in field, 100/52 in ED) and altered mental status. In
the ED, got 1 gm tylenol PR and ampicillin/sulbactam and
vancomycin for suspected sepsis secondary to decubitus ulcer.
After 2 L NS, his BP did not improve. He was started on
neosynephrine drip which improved his BP to low 100's/60. A left
subclavian was placed after it was not possible to thread a
femoral guidewire. He was noted to have stage 2+ sacral
decubitus ulcers. Heel does not look infected. Last HD on Monday
and usually dialyzes M, W, F in [**Location 9583**].
.
ROS: intermittent nausea/NBNB emesis over last couple weeks,
non-productive cough x 2-3d, back pain at site of ulcer, mild
diarrhea, 30 lbs weight loss over unspecified amount of time,
denies fever, hematochezia, SOB, CP, hematuria
Past Medical History:
ESRD
s/p L BKA
HTN
CAD
DM
Social History:
SH: lives at home with his sister, but has been staying at
[**Name (NI) 2299**] [**Last Name (NamePattern1) **] since [**2199-12-24**]. Previously smoked 4 packs/day x 20
years, but quit in [**2168**]. Drinks occasionally. Since his recent
BKA he has required more help with ADLs
Mr. [**Known lastname 11622**] has lived alone at home in [**Location (un) 7658**], but more recently
his sister [**Name (NI) **] [**Name (NI) **] has stayed with him, occasionally replaced
by
other siblings. He has VNA to help with meals.
Family History:
brother with MI at 70s. Pt has 3 brother, 4 sisters
Physical Exam:
PHYSICAL EXAM:
VS: 98.4 93/64 93 11 100%
GEN: NAD, somnolent
HEENT: PERRL, MM dry
CV: tachy, RR, nl s1/s2, no m/R/G appreciated
Lungs: diffusely rhonchorous but sub-optimal exam
Abd: + BS, s/NT/slight distension, no HSM
Ext: 2+ radial pulse, L BKA, well healed lateral surgical
incision of R ankle, 3 toes on R foot
Neuro: arousable, oriented to person, place, not date; CN II-XII
intact, MAFE, no rigidity
Skin: R gluteal stage II-III ulcer, dry, w/o exudate or
bogginess
Lines: R SC dialysis catheter, L SC placed [**2200-1-7**], R arterial
A-line
Pertinent Results:
[**2200-1-7**] 10:18PM LACTATE-2.1* K+-4.1
[**2200-1-7**] 10:18PM HGB-9.9* calcHCT-30
[**2200-1-7**] 10:10PM GLUCOSE-272* UREA N-30* CREAT-4.7* SODIUM-141
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-27 ANION GAP-19
[**2200-1-7**] 10:10PM WBC-14.8* RBC-3.51* HGB-9.6* HCT-30.7* MCV-87
MCH-27.4 MCHC-31.3 RDW-17.9*
.
[**2200-1-9**] 04:28AM BLOOD CK(CPK)-128
[**2200-1-23**] 02:37AM BLOOD Mg-1.8
[**2200-1-21**] 06:00AM BLOOD Calcium-7.8* Phos-4.0 Mg-2.2
[**2200-1-12**] 02:19AM BLOOD calTIBC-94* Ferritn-1861* TRF-72*
[**2200-1-22**] 11:59AM BLOOD WBC-13.1* RBC-3.16* Hgb-9.5* Hct-28.7*
MCV-91 MCH-30.0 MCHC-33.1 RDW-18.7* Plt Ct-253
[**2200-1-23**] 02:37AM BLOOD WBC-11.2* RBC-3.11* Hgb-9.2* Hct-28.3*
MCV-91 MCH-29.5 MCHC-32.4 RDW-18.6* Plt Ct-258
[**2200-1-11**] 04:59PM BLOOD WBC-13.6* RBC-3.57* Hgb-10.0* Hct-30.4*
MCV-85 MCH-28.0 MCHC-32.9 RDW-17.4* Plt Ct-215
[**2200-1-12**] 08:20PM BLOOD WBC-13.1* RBC-2.79* Hgb-7.8* Hct-23.1*
MCV-83 MCH-28.1 MCHC-34.0 RDW-17.4* Plt Ct-246
[**2200-1-13**] 03:45AM BLOOD WBC-16.1* RBC-3.04* Hgb-8.6* Hct-24.9*
MCV-82 MCH-28.2 MCHC-34.4 RDW-17.1* Plt Ct-237
[**2200-1-23**] 09:06AM BLOOD PT-21.4* PTT-77.2* INR(PT)-2.1*
[**2200-1-23**] 02:37AM BLOOD Plt Ct-258
[**2200-1-23**] 02:37AM BLOOD PT-17.5* PTT-57.5* INR(PT)-1.6*
[**2200-1-22**] 07:33PM BLOOD PTT-62.6*
[**2200-1-22**] 11:59AM BLOOD PT-15.4* PTT-150* INR(PT)-1.4*
[**2200-1-22**] 01:36AM BLOOD PT-13.3* PTT-98.8* INR(PT)-1.2*
[**2200-1-18**] 09:30AM BLOOD ESR-23*
[**2200-1-23**] 02:37AM BLOOD Glucose-55* UreaN-12 Creat-2.6*# Na-139
K-4.0 Cl-104 HCO3-29 AnGap-10
[**2200-1-22**] 01:36AM BLOOD Glucose-209* UreaN-23* Creat-4.4* Na-136
K-4.4 Cl-102 HCO3-24 AnGap-14
[**2200-1-13**] 03:45AM BLOOD ALT-9 AST-14 LD(LDH)-167 AlkPhos-58
Amylase-23 TotBili-0.3
[**2200-1-11**] 02:17AM BLOOD CK-MB-9 cTropnT-1.08*
[**2200-1-10**] 03:19PM BLOOD CK-MB-10 MB Indx-18.5* cTropnT-1.18*
.
Micro:
[**2200-1-7**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL {PREVOTELLA SPECIES} INPATIENT
[**2200-1-7**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC
BOTTLE-FINAL INPATIENT
[**2200-1-8**] CATHETER TIP-IV WOUND CULTURE-FINAL negative.
[**2200-1-8**] 04:01AM BLOOD CK(CPK)-111
[**2200-1-8**] 03:46PM BLOOD CK(CPK)-154
.
Echo [**2200-1-8**]:
Conclusions:
The left atrium is moderately dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
focal akinesis of the inferior and inferolateral walls and
hypokinesis of the anterolateral wall. The remaining left
ventricular segments contract normally. Right ventricular
chamber size is normal with focal basal free wall hypokinesis.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. An eccentric jet of mild to moderate ([**1-28**]+)
mitral regurgitation is seen directed along the lateral wall.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion.
IMPRESSION: Regional left and right ventricular systolic
dysfunction c/w CAD (LV and RV infarction). Mild-moderate mitral
regurgitation. Pulmonary artery systolic hypertension.
.
[**2200-1-16**]:
IMPRESSION: Successful placement of 28 cm (23 cm tip-to-cuff
length) Angiodynamics Even More hemodialysis catheter. The
catheter tip is in the right atrium. The catheter is ready to
employ.
.
Brief Hospital Course:
A/P: 69 yo M w/ ESRD, HTN, DM p/w fever, hypotension from line
sepsis.
.
1. Sepsis:
The pt initially presented to the ICU with sepsis requiring
pressors. The suspected source was the HD catheter and this was
pulled. The patient was covered with broad spectrum empiric
antibiotics. The blood cultures showed Prevotella 1/4 bottles,
which was clearly no confirmatory for line infection, although
no other definitive source was identified and line infection was
most likely. The antibiotics were changed to vanc/unasyn which
was continued until [**1-21**] which was a 14 day course. A new HD
line was placed on [**1-16**].
.
2. Cardiac:
a. Ventricular tachycardia:
On [**1-20**], the pt was being prepared for discharge to rehab and
he was noted to have episodes of non-sustained ventricular
tachycardia noted on telemetry monitor. The patient has EF 35%
and known scar. EP was consulted and in their estimation, the
patient was not a candidate for ICD given the ESRD and infection
risk. Metoprolol was continued. He will be monitored on tele at
the acute rehab facility for one more week.
.
b. Atrial fibrillation:
The patient was noted to have episodes of atrial fibrillation,
although he mostly remained in sinus rhythm. Anticoagulation was
started on [**1-21**] with heparin bridge and coumadin. He was
monitored for bleeding given that he had a significant bleed
from his sacral decubitis ulcer requiring transfusion after
debridement. Metoprolol was continued as well. Amiodarone was
started for maintenence of NSR. This was started at 200 mg TID
and should be continued at this frequency for three more weeks
after discharge. Then frequency should be decreased to once per
day after that. At discharge, his INR was 2.6. At the nursing
facility, the patient will continue to have daily PT/INR until
his INR is stable. He will follow up with Dr. [**Last Name (STitle) **] in
Electrophysiology.
.
b. CHF, EF 35%:
On echo, the patient was noted to have EF 35%. He remained
euvolemic after the sepsis had resolved. Fluid control was with
dialysis. Low dose lisinopril was started towards the end of his
hospital stay.
.
c. CAD:
The pt was noted to have ECG changes and elevated cardiac ezymes
while in the ICU. Per cardiology, this was thought secondary to
demand ischemia, medical management was recommended. The pt was
treated with aspirin, beta blocker, started on high dose statin.
However, the CK bump was quite unremarkable with a peak of
merely 154, which suggests minimal myocardial damage.
.
3. Anemia:
Patient had bleed from sacral decubitus ulcer after debridement.
His last transfusion was [**1-19**]. Hematocrit was followed while on
anticoagulation.
.
4. Depression:
Mood was depressed with decreased speech production and lack of
interest in conversation. SSRI was started, but will take
several weeks to reach effect.
.
5. ESRD/HD:
On Monday/Wednesday/Friday schedule for hemodialysis. Last HD in
hospital was [**2196-1-27**].
.
6. DM2:
The patient was on Glargine and SSI for additional coverage. He
had recurrent episodes of hypoglycemia, so his am Glargine was
decreased from 14 units to 10 units, then 8 units. He still had
a brief hypoglycemic episode on 8 units. It is recommended to
continue on 5 units after discharge and increase dose again if
necessary.
Medications on Admission:
lactulose 30 ml
multivitamin QD
vitamin C 500 mg [**Hospital1 **]
Zinc 220 mg QD
metoprolol 25 mg Q6
dulcolax suppository PR QHS
nepro 60 ml QID
heparin SQ TID
renagel 40 TID
colace 200 mg QHS
fentanyl 100 mcg Q 72 last [**1-5**]
dilaudid 4 mg Q4 PRN moderate pain and prior to HD
dilaudid 8 mg Q4 PRN severe pain
prostat 30 ml QID
ASA 325 mg QD
iron 325 mg QD
prozac 20 mg QD
lipitor 80 mg QD
nephro vite QD
prilosec 20 mg QD
senokot 2 tabs [**Hospital1 **]
Discharge Medications:
1. Ascorbic Acid 500 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2
times a day).
2. Zinc Sulfate 220 (50) mg Capsule [**Hospital1 **]: One (1) Capsule PO
DAILY (Daily).
3. Acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for fever.
4. B Complex-Vitamin C-Folic Acid 1 mg Capsule [**Hospital1 **]: One (1) Cap
PO DAILY (Daily).
5. Atorvastatin 40 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
7. Silver Nitrate Applicators Misc [**Last Name (STitle) **]: One (1) Misc Topical
DAILY (Daily) as needed.
8. SURGIFOAM Powder [**Last Name (STitle) **]: One (1) Mucous membrane PRN (as
needed).
9. Trazodone 50 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO HS (at bedtime) as
needed.
10. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
11. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Thiamine HCl 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY
(Daily).
13. Senna 8.6 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO BID (2 times a day)
as needed.
14. Docusate Sodium 100 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO BID
(2 times a day) as needed.
15. Amiodarone 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times
a day. Tablet(s)
16. Warfarin 2.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO at bedtime:
Dose to be adjusted per INR.
17. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO TID (3 times
a day).
18. Fluoxetine 20 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO DAILY
(Daily).
19. Heparin Lock Flush (Porcine) 100 unit/mL Syringe [**Last Name (STitle) **]: One
(1) ML Intravenous DAILY (Daily) as needed: to each port.
20. Insulin Glargine 100 unit/mL Solution [**Last Name (STitle) **]: Five (5) units
Subcutaneous qam.
21. Insulin Lispro (Human) 100 unit/mL Solution [**Last Name (STitle) **]: 0-10 units
Subcutaneous four times a day: per sliding scale.
22. Outpatient Lab Work
Please draw PT/INR daily
23. Lisinopril 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).
24. RoHo cushion
for stage 4 pressure ulcer, per wound care
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 1186**] - [**Location (un) 538**]
Discharge Diagnosis:
Primary:
1. sepsis, presumed secondary to HD line infection, s/p removal
2. non-sustained ventricular tachycardia
3. atrial fibrillation
4. non-st elevation MI
5. acute blood loss anemia secondary to decubitus ulcer
6. sacral decubitus ulceration
7. peripheral vascular disease s/p BKA on left in [**2199-11-27**]
at [**Hospital1 112**]
8. Delirium
9. Depression
10. Malnutrition
.
Secondary:
1. ESRD on hemodialysis
2. diabetes mellitus type 2, controlled with complications
3. CAD with ischemic cardiomyopathy
Discharge Condition:
Hemodynamically stable, normal sinus rhythm, tolerating POs,
afebrile.
Discharge Instructions:
If you have any fevers, chills, confusion, light-headedness or
passing out, chest pain, or any other concerning symptoms,
please call your doctor or return to the emergency room.
.
You have been started on new medications including coumadin
which is a medicine to thin the blood to prevent strokes since
you have atrial fibrillation which can lead to strokes. You have
also been started on a medicine called amiodarone which is to
prevent abnormal heart rhythms since you have had episodes of an
abnormal heart rhythm. You should be taking amiodarone three
times per day for three more weeks (total of four weeks), then
frequency should be decreased to once per day. You should be
monitored on telemetry for one more week after you have been
discharged from the hospital (total of two weeks).
Followup Instructions:
Amiodarone should be taken three times daily for three more
weeks, then frequency should be decreased to once daily. Patient
should be on telemetry for one more week after discharge from
the hospital.
.
Coumadin was started in hospital. Frequent INR necessary and
dose should be adjusted accordingly.
.
Low dose lisinopril has been started for heart failure. Dose
should be slowly increased as tolerated.
.
Please call your primary care physician to establish [**Name Initial (PRE) **] follow-up
appointment within 1-2 weeks after you leave rehab.
[**Last Name (LF) **],[**First Name3 (LF) **] A. [**Telephone/Fax (1) 2261**]
.
Please also follow up with:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**]
Date/Time:[**2200-2-12**] 3:00
|
[
"414.8",
"250.40",
"428.0",
"995.92",
"038.9",
"427.31",
"585.6",
"285.1",
"707.07",
"410.71",
"293.0",
"263.9",
"996.62",
"427.1",
"707.03",
"998.11",
"V49.75",
"V58.61",
"785.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.6",
"38.95",
"38.93",
"99.04",
"86.04",
"39.95",
"86.28",
"00.17",
"86.05"
] |
icd9pcs
|
[
[
[]
]
] |
12295, 12368
|
6078, 9363
|
336, 360
|
12924, 12997
|
2593, 6055
|
13839, 14651
|
1947, 2000
|
9873, 12272
|
12389, 12903
|
9389, 9850
|
13021, 13816
|
2030, 2574
|
275, 298
|
388, 1344
|
1366, 1394
|
1410, 1931
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,775
| 190,912
|
6520
|
Discharge summary
|
report
|
Admission Date: [**2142-7-27**] Discharge Date: [**2142-8-10**]
Service:
The patient was admitted on [**7-27**] to the Medical Intensive
Care Unit for increasing shortness of breath and observation
for possible elective intubation.
HISTORY OF PRESENT ILLNESS: The patient was an 80-year-old
male with a history of chronic obstructive pulmonary disease
and a recent diagnosis of vasculitis, possibly Wegener's
vasculitis. His vasculitis had been diagnosed 3-4 months
prior to admission when the patient was admitted to [**Hospital6 14475**] for a presumed pneumonia. While in
the hospital the patient apparently developed myalgias and
elevated erythrocyte sedimentation rate, elevated creatine
kinase levels and elevated white blood cell count and signs
of liver and renal failure. Two lymph node biopsies and skin
biopsies were performed and the results were thought to be
consistent with a lymphocytoblastic vasculitis, possibly
Wegener's vasculitis. The patient was, at this time, begun
on Cytoxan and high dose steroid therapy with good results
and was discharged home. Approximately 6 weeks prior to his
[**Hospital1 **] admission. On the day prior to his
admission he noticed worsening shortness of breath. He
visited his PCP and [**Name Initial (PRE) **] routine CBC showed a white blood cell
count of 1,000. At this time the patient was asked to stop
taking his Cytoxan, however, he noted worsening shortness of
breath and was transported to the [**Hospital1 190**] Emergency Room by ambulance on [**7-27**]. At
presentation he was found to have interstitial infiltrates on
chest x-ray, a white blood cell count of 0.2 with no
neutrophils and in the Emergency Room was begun on
Ceftazidime, Bactrim and Solu-Medrol and was admitted to the
MICU for close observation of respiratory status.
PAST MEDICAL HISTORY: Included chronic obstructive pulmonary
disease, Wegener's vasculitis, steroid induced diabetes
mellitus, no history of coronary artery disease.
MEDICATIONS: On admission, Cytoxan 50 mg q d, Prednisone 50
mg q d, Glucophage 850 mg tid, Prevacid 30 mg q d, Rocaltrol
25 mg q d, Procrit, Glyburide 5 mg tid which had recently
been discontinued.
ALLERGIES: The patient reported an allergy to Penicillin.
FAMILY HISTORY: The patient was unable to provide a family
history.
SOCIAL HISTORY: The patient reported that his lived with his
wife in [**Name (NI) 1268**]. The couple had no children.
SUBSTANCE ABUSE: Notable for a 100 pack year history of
tobacco use with the patient having quit smoking
approximately 30 years ago.
REVIEW OF SYSTEMS: Notable for three days of dyspnea on
exertion and fevers and chills on the day prior to admission.
There had been no recent weight changes, no change in the
patient's urinary habits, no change in the patient's bowel
movements and no nausea or vomiting.
PHYSICAL EXAMINATION: At the time of admission the patient
was noted to be an elderly, thin white male lying in a
stretcher in mild distress. His vital signs showed a
temperature of 100.2, heart rate 130, blood pressure 100/63,
respiratory rate 24. Oxygen saturation was 94% on a 12
liters O2 face mask. His head, eyes, ears, nose and throat
exam was notable for pupils which were 3 mm and minimally
reactive. There was no cervical lymphadenopathy. His lungs
revealed coarse breath sounds on the right side, rhonchi and
faint coarse wheezes bilaterally. There were coarse crackles
at both lung bases with crackles greater on the right than on
the left. His cardiac exam revealed tachycardic rhythm and
normal S1 and S2, no murmurs were appreciated and there was
no jugulovenous distension. His abdominal exam showed a soft
abdomen with active bowel sounds. There was no tenderness or
abdominal distention noted. On extremity exam there was no
lower extremity edema and fair distal pulses bilaterally.
Neurologic exam showed the cranial nerves II through XII were
intact. Strength was [**4-14**] throughout all four extremities.
Deep tendon reflexes were 2+ and symmetric throughout and the
patient was alert and oriented times three.
LABORATORY DATA: On admission showed white blood cell count
of 0.2, hematocrit 41.9, platelet count 330,000. On the
differential there were no neutrophils, 75 lymphocytes, 19
monocytes and 6 others. His electrolytes were notable for
sodium of 137, potassium 4.8, chloride 96, CO2 23, BUN 36,
creatinine 1.3 and glucose of 224. CK level was 16. Troponin
level was less than 0.3 and arterial blood gas showed a PH of
7.40, PCO2 40 and PO2 of 77 taken on 12 liters face mask. An
EKG showed a rate of 180 beats/minute, possibly with
suggestions of multifocal atrial tachycardia. There was no
ability to assess the ST-T waves secondary to wandering
baseline on the EKG. His chest x-ray, as mentioned, showed
bilateral interstitial opacity and blunting of the right
costophrenic angle.
HOSPITAL COURSE: The patient was admitted to the medical
Intensive Care Unit for monitoring of respiratory status with
diagnoses of pneumonia and neutropenia. At the time of
admission the following major issues were addressed:
1. Pneumonia. The patient was placed on broad spectrum
antibiotic coverage for pneumonia including Ceftazidime and
Bactrim. Induced sputum were obtained for gram stain culture
and analysis for PCP.
2. Cardiac. The patient was placed on Verapamil to control
his heart rate.
3. Neutropenia. At the time of admission the patient's
neutropenia was thought to be attributable to his Cytoxan and
Prednisone use. These two medications were held at the time
of admission and hematology was consulted to assess the
benefit of beginning the patient on GCSF to assist in
resolution of his neutropenia.
4. Endocrine. Given the patient's prolonged outpatient
steroid course of several months, there was concern that he
might be developing some adrenal insufficiency. The patient
was therefore placed on Prednisone at a dose of 50 mg daily
at the time of admission.
Over the course of the next several days the patient
continued to develop worsening respiratory status. He was on
neutropenic precautions and was begun on GCSF. His
antibiotic coverage was broadened to include Vancomycin
beginning on [**7-28**]. On [**7-31**] the patient was placed on bi-pap
to assist in his breathing. An echocardiogram was also
obtained on this date to assess the role of potential
congestive heart failure in contributing to his shortness of
breath. The echocardiogram showed a relatively well
preserved ejection fraction of between 45 and 55%. On [**8-1**] a
hematology consult concurred that the patient's neutropenia
was likely secondary to his outpatient Cytoxan use and
recommended that this medication should continue to be held
during the [**Hospital 228**] hospital course. At this time the
patient's platelet count was also noted to be 48, down from
330 at the time of admission, several days previous. On [**8-2**]
a rheumatology consult was obtained. Rheumatology
recommended continuing the patient's steroid dose and also
assisted in obtaining outside hospital records to clarify the
patient's diagnosis of vasculitis. Also on [**8-2**] the patient
had a bronchoscopy performed. Bronchoscopy showed friable
airways with mucopurulent discharge. A bronchoalveolar
lavage was also obtained. Overnight, however, on [**8-2**] the
patient's respiratory and cardiopulmonary status further
declined. The patient was placed on Dopamine to support his
blood pressure and he ultimately required intubation
overnight. On [**8-3**] the patient's Bactrim was discontinued
out of concern that this medication may as well be
contributing to his thrombocytopenia and the patient was
placed on Pentamidine to treat possible PCP [**Name Initial (PRE) 2**]. A
chest CT performed that day showed a multifocal pneumonia.
On [**8-4**] the patient spiked new fevers in the MICU and
cultures were obtained. In addition, an induced sputum
culture from [**8-2**] returned results that showed yeast in the
sputum. The patient was begun on AmBisome and infectious
disease consult was obtained. Infectious disease recommended
continuing AmBisome as the yeast was suspicious for invasive
aspergillosis. Infectious disease also recommended
continuing the patient on Vancomycin and Levofloxacin but
discontinuing the patient's Ceftazidime at this point. The
antibiotic course was to be continued for 14 days after the
recovery of the patient's neutropenia and in fact, the
patient's absolute neutrophil count was noted to be greater
than 500 on [**8-5**]. At this time a swelling was also noted in
the patient's right upper extremity and his right arm was
noted to be diffusely warm and erythematous. On [**8-6**], right
upper extremity ultrasound was obtained which showed a deep
venous thrombosis extending from the forearm to the axilla in
one of the brachial veins. At this time the question was
posed to hematology as to whether it would be safe to
anticoagulate the patient with a platelet count of 29.
Heparin induced thrombocytopenia antibody studies were
pending at this time. Overnight on [**8-6**], unfortunately the
patient's condition again deteriorated. He was placed on
Dopamine and given fluid boluses to support his blood
pressure. He remained intubated and his ventilation settings
were changed from pressure support to assist control. In
addition, [**12-14**] blood culture bottles drawn on [**8-5**] returned
positive for yeast. The patient was therefore continued on
his AmBisome course out of concern for fungemia. On [**8-7**] the
patient was transfused one unit of platelets in preparation
for a new femoral line insertion. On the morning after
transfusion, his platelet count was noted to have improved to
69 and at this time the decision was made that it would be
safe to anticoagulate the patient for his right upper
extremity DVT and the patient was begun on a Heparin IV drip.
In addition, an ophthalmology consult was obtained to assess
for fungal endophthalmitis. Ophthalmologic examination by
the ophthalmology consult showed no evidence of
endophthalmitis. On [**8-8**] the patient's cardiopulmonary
status continued to decline and he was begun on
Neo-Synephrine. The Neo-Synephrine rate was increased and he
was eventually weaned off of Dopamine. However, the patient
continued to suffer from hypotension despite pressor support.
In order to assess for the possibility of any other possible
infectious source, an abdominal CT was obtained. This showed
evidence of homogenous liver and spleen but no focal
abdominal abscesses. On [**8-10**] the patient remained intubated
and on pressor support of Neo-Synephrine. She was noted to
be increasingly acidotic. A family decision was made that
the patient's care status should be changed to comfort
measures only. The patient at this time was continued on a
Morphine and Ativan drip for sedation. All other medications
were discontinued at this time and the ventilator settings
were turned down. Shortly before midnight on [**8-10**] the
patient became bradycardic and ultimately went into
cardiopulmonary arrest.
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Name8 (MD) 25007**]
MEDQUIST36
D: [**2142-8-11**] 14:48
T: [**2142-8-14**] 21:09
JOB#: [**Job Number 25008**]
|
[
"484.6",
"491.21",
"584.9",
"285.1",
"288.0",
"427.31",
"447.6",
"482.41",
"117.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.04",
"96.72",
"99.15",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
2262, 2315
|
4899, 11381
|
2869, 4881
|
2592, 2846
|
271, 1817
|
1840, 2245
|
2332, 2572
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
52,588
| 169,401
|
38935
|
Discharge summary
|
report
|
Admission Date: [**2156-2-12**] Discharge Date: [**2156-2-17**]
Date of Birth: [**2078-11-28**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1406**]
Chief Complaint:
Chest pain, left main coronary artery disease
Major Surgical or Invasive Procedure:
[**2156-2-13**] -coronary artery bypass grafts (Left internal mammary
artery->Left anterior descending artery, Saphenous vein
graft->Obtuse marginal artery)
History of Present Illness:
This77 year old female with a history of coronary artery disease
with a stent to LAD in [**2152-10-11**]. She recently developed
chest pain and underwent catheterization at [**Hospital3 26615**]
Hospital. This revealed a 70% left main stenosis. She was
transferred for surgical evaluation.
Past Medical History:
Hypertension
Coronary artery disease -s/p LAD stent [**10-16**]
Hypercholesterolemia
h/o Atrial fibrillation
s/p right kidney surgery (nephrolithiasis?)
s/p right lower extremity vein stripping
s/p total abdominal hysterectomy
Social History:
Last Dental Exam: edentulous
Lives with: alone
Occupation:
Tobacco: never
ETOH: never
Family History:
noncontributory
Physical Exam:
Admission:
Pulse: 84 SR Resp: 20 O2 sat: 97%RA
B/P Right: 144/78 Left:
Height: Weight: 115lb
General:
Skin: Dry [x] intact [x] no rash
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema Varicosities:
moderate varicosities bilaterally, no edema None []
Neuro: Grossly intact x
Pulses:
Femoral Right: 2+ Left: 2+
DP Right: 2+ Left: 2+
PT [**Name (NI) 167**]: 2+ Left: 2+
Radial Right: 2+ Left: 2+
Carotid Bruit: Right: Left: no bruits
Pertinent Results:
[**2156-2-13**] ECHO
Pre-CPB:
No spontaneous echo contrast is seen in the left atrial
appendage.
Overall left ventricular systolic function is low normal (LVEF
50-55%).
Right ventricular chamber size and free wall motion are normal.
There are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen.
The mitral valve leaflets are moderately thickened. Mild to
moderate ([**12-13**]+) mitral regurgitation is seen.
There is no pericardial effusion.
Post-CPB:
The patient is A-Paced, on low dose NTG.
No AI, no MR.
[**First Name (Titles) **] [**Last Name (Titles) 50255**] systolic fxn.
Aorta intact.
[**2156-2-16**] 05:30AM BLOOD WBC-11.4* RBC-3.41* Hgb-10.3* Hct-30.8*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.0 Plt Ct-255
[**2156-2-15**] 02:53AM BLOOD WBC-14.9* RBC-3.47* Hgb-10.1* Hct-29.8*
MCV-86 MCH-29.2 MCHC-34.0 RDW-13.7 Plt Ct-210
[**2156-2-16**] 05:30AM BLOOD Glucose-108* UreaN-19 Creat-0.5 Na-139
K-3.9 Cl-104 HCO3-31 AnGap-8
[**2156-2-15**] 02:53AM BLOOD Glucose-85 UreaN-11 Creat-0.4 Na-137
K-4.3 Cl-103 HCO3-29 AnGap-9
Brief Hospital Course:
Ms. [**Known lastname 22079**] was admitted to the [**Hospital1 18**] on [**2156-2-12**] for surgical
management of her coronary artery disease. She was worked-up in
the usual preoperative manner. On [**2156-2-13**], she was taken to the
Operating Room where she underwent coronary artery bypass
grafting to two vessels. Please see operative note for details.
She weaned from bypass on Neo Synephrine and Propofol infusions.
Postoperatively she was taken to the intensive care unit for
monitoring.
Over the next 24 hours, she had awoke neurologically intact and
was extubated. Pressors were weaned to off and beta blockade,
aspirin and a statin were resumed.
She was diuresed towards her preoperative weight. Physical
Therapy was consulted for strength and mobility. medications
were adjusted for optimization of her medical condition. A stay
at a rehabilitation facility was appropriate for further
recovery prior to return home.
Medications, restrictions and follow up were discussed with her
prior to discharge.
Medications on Admission:
ASA 81 mg daily
Omeprazole 20me [**Hospital1 **]
Pepto bismol prn
Discharge Medications:
1. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig:
One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 1
weeks.
Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 6-8 hours as needed for pain for 4 weeks.
Disp:*50 Tablet(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*
9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 756**] Manor Nursing & Rehab Center - [**Location (un) 5028**]
Discharge Diagnosis:
s/p coronary artery bypssaa grafts
Hypertension
Coronary artery disease
s/p LAD stent [**10-16**]
Hypercholesterolemia
h/o Atrial fibrillation
s/p total hysterectomy
s/p right vein stripping
s/p right renal surgery
Discharge Condition:
Alert and oriented x3, nonfocal
Ambulating, gait steady
Sternal pain managed with Percocet prn
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month until follow up with
surgeon
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns [**Telephone/Fax (1) 170**]
Females: Please wear bra to reduce pulling on incision, avoid
rubbing on lower edge
Followup Instructions:
Please call to schedule appointments
Surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 4 weeks ([**Telephone/Fax (1) 170**]) on [**3-24**] at
2pm
Primary Care: Dr. [**Last Name (STitle) 958**] ([**Telephone/Fax (1) 34088**]in [**12-13**] weeks
Cardiologist: Dr. [**First Name (STitle) 82704**] [**Name (STitle) 82705**] in [**12-13**] weeks
Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse
will schedule
Completed by:[**2156-2-17**]
|
[
"272.0",
"427.1",
"401.9",
"424.0",
"389.7",
"787.91",
"V45.82",
"V45.89",
"414.01",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.72",
"39.64",
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
5424, 5526
|
3125, 4144
|
368, 527
|
5785, 5882
|
1962, 3102
|
6507, 7025
|
1221, 1238
|
4260, 5401
|
5547, 5764
|
4170, 4237
|
5906, 6484
|
1253, 1943
|
283, 330
|
555, 850
|
872, 1101
|
1117, 1205
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,321
| 160,749
|
31924
|
Discharge summary
|
report
|
Admission Date: [**2198-12-4**] Discharge Date: [**2198-12-10**]
Date of Birth: [**2119-4-3**] Sex: F
Service: ORTHOPAEDICS
Allergies:
Cephalosporins / Keflex / Erythromycin Base / Penicillins
Attending:[**First Name3 (LF) 64**]
Chief Complaint:
Retained cement spacer s/p mulitple I&D's of the left knee, left
knee eschar and left heel ulcer
Major Surgical or Invasive Procedure:
[**2198-12-4**] Removal of Antibiotic Spacers, Irrigation and
Debridement Left Knee, Excision and primary closure of full
thickness left knee eschar
[**2198-12-4**] Irrigation and Debridement of Left heel ulcer
History of Present Illness:
Ms. [**Known lastname 74837**] is a 79-year-old woman with osteoarthritis s/p
bilateral knee and shoulder joint replacements who was taken to
the OR today by orthopedic surgery for removal of L knee
antibiotic spacer and I&D of L heel ulcer. Leading up to OR,
patient had a L TKR in [**2198-1-29**] in NY which was complicated
by post-operative MRSA infection. To manage this, she had a
resection arthroplasty in [**Month (only) 216**] during which antibiotic spacer
had been placed. She also received several weeks (details
unavailable) of Vancomycin/Flagyl at home, with some period of
Levaquin therapy. In the OR today, she had 800cc blood loss
intraoperatively through L knee with 2 U PRBCs transfused.
Intra-operatively patient did well from oxygenation standpoint.
One hour later in recovery in the PACU, patient became
acutely/subacutely hypoxic (according to ortho resident) ad was
noted to have PO2 30 on ABG, at which point CXR was performed,
which revealed tube abutting carina, and 3cm pullback of tube
was advised. Patient was also on Neosynephrine drip
post-operatively, and anesthesia was unable to wean. They gave
patient 10 IV lasix prior to transfer because of concern for
fluid overload.
.
On arrival to the [**Hospital Unit Name 153**], patient remained intubated and appeared
comfortable. Wound Vac over left knee was in place. Patient was
maintaining good urine output and oxygenating well.
.
Past Medical History:
- ESBL/MRSA positive deep infection left knee
- Congestive Heart Failure
- CAD
- Hypertension
- Osteoarthritis
- GERD
- Hypothyroidism
- heel and sacral decubiti
- Urinary incontinence
PAST SURGICAL HISTORY:
Left total knee replacement ([**1-/2198**] in NY, c/b MRSA infection)
Right total knee replacement
Left total shoulder replacement
Right total shoulder replacement
Social History:
Widowed, has children, lives at [**Hospital 100**] Rehab, code status is
full. Daughter is HCP. She was accopanied by her son-in-law to
the preoperative care area.
Family History:
NC
Physical Exam:
GEN: Alert, Oriented to self only
HEENT: NCAT. PRRL. MMM. ET tube in place. Large neck, no LAD
LUNGS: CTAB in anterior lung fields
HEART: S1S2 RRR. No appreciable MRG.
ABDOMEN: obese. slightly hypoactive BS. soft, NT/ND. no
appreciable hepatomegaly
EXT: Dopplerable DP on LLE. Flail left lower extremity. Left
heel ulcer is full thickness down to the calcaneous. Incisions
are clean, dry and intact on the left knee and eschar site. No
erythema or drainage is present.
Brief Hospital Course:
The patient was taken to the operating room on [**2198-12-4**] where
she underwent I&D or her right knee with removal of antibiotic
spacers, I&D of her left knee eschar with primary closure and
I&D of her left heel ulcer. Preop antibiotics here held until
cultures were taken. She desaturated during the case and was
found to have a right mainstem intubation of postoperative xray.
She recieved a brief course of neosynepherine and which was
weaned with 2 units of packed red cells. She remained intubated
as a precautionary measure overnight and was extubated in the
MICU on POD1 without complication. Here PE CT scan was negative
and her EKG and cardiac markers were negative. On POD2 she
received an additoinal 2 units of packed red cells and was
transferred to the orthopaedic floor. She was continued on
vanco/cipro/flagyl and recieved lovenox for DVT prophylaxis.
Plastic Surgery was consulted for her left heel ulcer and they
were planning a delayed grafting procedure. However, the
daughter wishes to minimize future surgical intervention. She
recieved moist-to-dry Dressing chagnes [**Hospital1 **] for her left heel.
Her recovery from this point was uneventfull and she was
discharged to [**Hospital 100**] rehab in stable condition on POD6.
Atibiotic Stop Date: [**2198-12-18**]
Suture removal Date: [**2198-12-25**]
Follow up: Dr. [**Last Name (STitle) **] in 1 month
Medications on Admission:
- Vancomycin 1 gram qd
- Metronidazole 500 PO tid
- Levofloxacin 250 PO qd
- Lovenox 40 PO qd
- [**Doctor First Name **]
- Furosemide 20mg PO qd
- Levothyroxine 50 mcg PO qd
- MVI
- Omeprazole 20mg PO qd
- Oxybutynin 5mg PO qd
- Sorbitol 30
- Acetominophen 650
- Bisacodyl, MOM
- Percocet
- [**Name2 (NI) 74838**] iodine
.
Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig:
One (1) 500 mg tablet Intravenous Q8H (every 8 hours).
3. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: Two
(2) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) 40 mg injection
Subcutaneous Q 24H (Every 24 Hours).
8. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed.
10. Ciprofloxacin 200 mg/20 mL Solution Sig: One (1) 250 mg
tablet Intravenous Q12H (every 12 hours).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
14. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1)
gram Intravenous Q 24H (Every 24 Hours).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - MACU
Discharge Diagnosis:
[**2198-12-4**] Removal of Antibiotic Spacers, Irrigation and
Debridement Left Knee
[**2198-12-4**] Irrigation and Debridement of Left heel ulcer
[**2198-12-4**] Excision of left knee eschar with closure of full
thickness defect
Flail Left Knee
Discharge Condition:
Stable
Discharge Instructions:
Weight Bearing Status: Non weight bearing left leg.
Anticoagulation: Take Lovenox 40 mg injections daily for at
least 3 weeks. This will help to decrease the risk of
developing blood clots during your perioperative period. Your
health care facility had you on this medicaiton prior to
admission and will likely continue it indefinitly given that you
are at risk for developing blood clots given your non-ambulatory
status. If lovenox is discontinued, please give 325 mg of
aspiring twice daily for an additional 3 weeks.
Wound Care: Keep your wound clean and dry. You may shower and
allow soap and water to run over your incision. Do not scrub or
submerge your incision. No swimming or bathing until your
staples are removed.
Pain Control: Take your pain medicaiton as prescribed. You may
not drink alcohol, drive a vehicle or operate machinery while
taking narcotic pain medications. It is illegal to share
medicaitons with others. Decrease you usage as your pain
decreases.
Precuations: If you develop fevers, chills, nausea, rendess or
wound drainage, leg swelling, shortness or breath or chest pain,
report to your nearest emergency room or call Dr. [**Last Name (STitle) **] at
[**Telephone/Fax (1) 1228**]. Please call with any concerns or questions.
Physical Therapy:
Eval and treat
Non weight bearing left knee
Keep Pressurs off of left heel
The patient has no knee joint, she has a flail left knee, keep
brace on when moving
Treatments Frequency:
The patient received: FLU VACCINE [**2198-12-5**] and the Pneomonia
Vaccine [**2198-12-6**]
Left Heal Ulcer - Moist to Dry dressing changes twice daily with
normal saline. Do not moisten gauze to remove dressing.
Suture Removal: [**2198-12-25**]
Antibiotic Stope Date: [**2198-12-18**]
Followup Instructions:
Follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 4 weeks. Please call
[**Telephone/Fax (1) 1228**] for an appointment.
Follow up with Plastic Surgery, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3228**] [**Telephone/Fax (1) 4649**],
regarding your left ankle ulcer.
Please cc PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 74839**]
|
[
"707.03",
"428.0",
"V43.65",
"244.9",
"996.66",
"401.9",
"707.07",
"285.1",
"458.29",
"428.20"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.22",
"84.57",
"80.76",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6289, 6355
|
3186, 4526
|
417, 630
|
6645, 6654
|
8464, 8918
|
2670, 2674
|
4953, 6266
|
6376, 6624
|
4605, 4930
|
6678, 7204
|
2306, 2471
|
2689, 3163
|
7968, 8127
|
8149, 8441
|
4537, 4579
|
281, 379
|
7216, 7950
|
658, 2075
|
2097, 2283
|
2487, 2654
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,767
| 150,138
|
42439
|
Discharge summary
|
report
|
Admission Date: [**2154-1-5**] Discharge Date: [**2154-1-9**]
Date of Birth: [**2084-6-4**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Fall, pneumothorax, rib fractures
Major Surgical or Invasive Procedure:
[**2154-1-5**]: Right sided chest tube
History of Present Illness:
67M transfer from OSH after developing progressive subcutaneous
emphysema/facial swelling and subsequent respiratory distress
requiring intubation. He was treated in the OSH ED with
epinephrine, solumedrol, and benadryl with no effect, and
subsequently was intubated for worsening respiratory distress.
Upon arrival to the ED here he had CT scans of the chest,
abdomen, pelvis, and c-spine which revealed extensive
pneumomediastinum, right sided pneumothorax, a smaller
left-sided pneumothorax, and extensive subcutaneous emphysema.
Past Medical History:
Hypertension
Social History:
possible alcohol abuse
Family History:
NC
Physical Exam:
On admission: Intubated and sedated
Vitals: BP: 123/80 HR 102
Intubated CMV 60% /5 : ABG pH 7.32 pCO2 42 pO2 56 HCO3 23
GEN: Sedated
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Bilateral subcutaneus emphysema. Decreased blt respiratory
sounds
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused
Physical examination upon discharge: [**2154-1-9**]:
Vital signs: t=96, bp=90/54, hr=81, resp. rate 20, room air 95%
General: Sitting in chair, NAD, garbled speech related to no
dentures
CV: Ns1, s2, -s3, -s4
LUNGS: decreased bs bases
ABDOMEN: soft, non-tender
EXT: Weak dp bil., ext. cool, mottled, + radial bil. left hand
cool
no calf tendeness, no pedal edema bil
NEURO: alert and oriented x 3, speech garbled, no tremors
SKIN: Crepitus clavicles bil., uppper ant. chest wall, mandible
and neck.
Pertinent Results:
[**2154-1-7**] 02:18AM BLOOD WBC-8.4 RBC-3.30* Hgb-11.8* Hct-33.0*
MCV-100* MCH-35.7* MCHC-35.7* RDW-12.4 Plt Ct-215
[**2154-1-6**] 01:14AM BLOOD WBC-11.5* RBC-3.12* Hgb-10.6* Hct-30.6*
MCV-98 MCH-33.9* MCHC-34.6 RDW-12.7 Plt Ct-171
[**2154-1-5**] 01:53AM BLOOD Neuts-95.3* Lymphs-4.0* Monos-0.6*
Eos-0.1 Baso-0.1
[**2154-1-4**] 09:46PM BLOOD Neuts-96.9* Lymphs-1.8* Monos-1.1*
Eos-0.1 Baso-0.1
[**2154-1-7**] 02:18AM BLOOD Plt Ct-215
[**2154-1-7**] 02:18AM BLOOD Glucose-92 UreaN-8 Creat-0.8 Na-135 K-4.0
Cl-98 HCO3-28 AnGap-13
[**2154-1-6**] 05:30PM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-137
K-3.3 Cl-101 HCO3-27 AnGap-12
[**2154-1-6**] 01:14AM BLOOD ALT-32 AST-51* AlkPhos-95 TotBili-0.3
[**2154-1-7**] 02:18AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1
[**2154-1-6**] 05:30PM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
[**2154-1-5**] 01:12PM BLOOD Lactate-0.2*
[**2154-1-5**] 02:54AM BLOOD Lactate-2.0
[**2154-1-4**]: chest x-ray:
IMPRESSION:
1. Bilateral pneumothoraces and pneumomediastinum not well seen
on this study but are seen on subsequent CT.
2. Endotracheal tube ends 3.7 cm above the carina.
[**2154-1-4**]: cat scan of the head:
IMPRESSION: Extensive subcutaneous air as described above. No
intracranial air. No acute intracranial injury.
[**2154-1-4**]: cat scan of the abdomen:
IMPRESSION:
1. Multiple right-sided rib fractures with bilateral small
pneumothoraces,
extensive pneumomediastinum and tracking of subcutaneous air
along the body wall.
2. Severe pulmonary emphysema with biapical scarring.
3. No solid organ injury in the abdomen or pelvis.
4. Extensive atherosclerosis with abdominal aortic aneurysm to
3.3 cm.
5. ETT and NGT in appropriate position
[**2154-1-4**]: cat scan of the c-spine:
IMPRESSION:
1. No acute fracture or malalignment.
2. Extensive subcutaneous air.
[**2154-1-5**]: chest x-ray:
FINDINGS: Again seen is severe bilateral subcutaneous emphysema
which limits the assessment for small pneumothorax.
Pneumomediastinum is again visualized.
There is a right-sided chest tube. There is mild mediastinal
shift to the
right. A small left basilar pneumothorax is visualized and
probable right
medial pneumothorax.
[**2154-1-7**]: chest x-ray:
Severe widespread subcutaneous emphysema throughout the chest
wall and neck, and severe pneumomediastinum are unchanged over
the past several days. No definite pneumothorax, right pleural
tube in place. Bibasilar atelectasis or aspiration changes,
unchanged since [**1-5**] at 12:29 a.m. Heart size is normal
[**2154-1-7**]: chest x-ray:
There is no large right pneumothorax or appreciable pleural
fluid collection following removal of the right pleural tube,
although a small amount of pleural air would be difficult to
detect in the setting of persistent severe subcutaneous
emphysema and pneumomediastinum. Left basal atelectasis has
cleared. Emphysema is severe. There is probably a small to
moderate left pneumothorax, which has remained stable since the
earliest chest radiographs here on [**1-4**]. Heart is not
enlarged.
Brief Hospital Course:
Mr [**Known lastname 5579**] arrived to [**Hospital1 18**], s/p fall and developed sudden
onset of right sided facial swelling. He was intubated for
increasing respiratory distress. He was taken to the Trauma ICU
for monitoring. Imaging showed right rib fractures and
bilateral pneumothorax. Soon after arrival a right-sided chest
tube was placed by the thoracic surgery team and he was observed
in the ICU until transfer to the floor on [**2154-1-7**].
NEURO: He received acetaminophen and oxycodone with good effect
and adequate pain control.
CV: He exhibited consisent mild-moderate hypertension, so he was
given IV
metoprolol. Once tolerating PO intake, he was transitioned to
oral metoprolol.
PULM: He had a chest tube placed [**1-5**] and was extubated on
[**2154-1-6**], hospital day 2. His chest tube showed a small air leak
the first day it was placed, but no residual pneumothorax was
seen on CXR. The thoracic team removed his chest tube on [**2154-1-7**].
Repeat chest x-ray on [**1-8**] showed no pneumothorax but increased
subcutaneous air in upper chest. His respiratory status was not
compromised.
GI/GU/FEN: While intubated, he was NPO with IV fluids. He was
hyponatremic on arrival, which improved readily after several
liters of NS followed by 1/2 NS. His current sodium is 135.
He had a bedside swallow eval performed [**1-7**] and he was started
on a regular diet.
ID: He had no infectious issues, no antibiotics were indicated.
Endocrine: His blood sugar was monitored throughout his stay and
was maintained on an insulin sliding scale until his blood
glucose values returned to [**Location 213**].
Hematology: His complete blood count was examined routinely; no
transfusions were required.
Prophylaxis: He received subcutaneous heparin and venodyne boots
were used during this stay and was encouraged to ambulate as
early as possible.
He is afebrile and his blood pressure is borderline. His
anti-hypertensives have been held today because of a blood
pressure of 90/50. He is able to ambulate without dizziness or
shortness of breath. His blood pressure was monitored
throughtout the day and has increased to 122/70. He is
tolerating a regular diet. His electrolytes have normalized and
his hematocrit is stable.
He is preparing for discharge home with VNA services who will
monitor his blood pressure. He also has instructions to follow
up with the acute care service and with his primary care
provider to [**Name9 (PRE) 38002**] his anti-hypertensive agents.
Medications on Admission:
MEDS AT HOME: Amlodipine 10', Atenolol 50', Lisinopril 40',ASA,
Folic Acid, Cyanocobalamin, MVI, Thiamine
Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please check BP prior to dose: hold for bp <100, hr <60.
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please check blood pressure prior to dose: hold for blood
pressure <100, hr <60.
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please check blood pressure prior to dose: hold for blood
pressure <100, hr <60.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
All Care VNA of Greater [**Location (un) **]
Discharge Diagnosis:
Trauma: fall
Blt Pneumo R > L / pneumomediastinum
R Rib fx [**8-14**] / 10 is displaced.
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 you had fallen. You
developed swelling of your face, neck and upper chest. You were
also found to have a collapsed lung and rib fractures. You had
an breathing tube placed at the outside hospital and you were
monitored in the intensive care unit. Because of your injuries,
you had swelling of the neck, face and chest. Your vital signs
have stablized and the swelling is decreasing. You are now
preparing for discharge home with the following instructions:
Your injury caused rigth sided [**8-14**] rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).
Followup Instructions:
Name:[**Doctor Last Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 91892**],MD
Specialty: Primary Care
Location: NORTHSHORE PHYSICIANS GROUP
Address: 900 [**Doctor Last Name **] CENTER STE 107T, [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 50485**]
When: Monday, Febrauary 13th at 1:45pm
Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2154-1-28**] at 3:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]
Completed by:[**2154-1-10**]
|
[
"958.7",
"438.89",
"438.10",
"807.09",
"E888.9",
"860.0",
"276.1",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
8581, 8656
|
5061, 7568
|
342, 382
|
8791, 8791
|
2010, 5038
|
10903, 11939
|
1037, 1041
|
7726, 8558
|
8677, 8770
|
7594, 7703
|
8942, 10880
|
1056, 1056
|
269, 304
|
1517, 1991
|
410, 945
|
1070, 1500
|
8806, 8918
|
967, 981
|
997, 1021
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,463
| 122,476
|
35804
|
Discharge summary
|
report
|
Admission Date: [**2154-5-14**] Discharge Date: [**2154-5-19**]
Date of Birth: [**2083-4-10**] Sex: M
Service: MEDICINE
Allergies:
Percocet
Attending:[**First Name3 (LF) 7333**]
Chief Complaint:
elective pulmonary vein isolation, transferred to the MICU then
the CCU for cardiogenic shock
Major Surgical or Invasive Procedure:
Pulmonary vein isolation
CVVH
History of Present Illness:
Mr. [**Known lastname 1637**] is a 71 YOM with atrial fibrilation s/p 7
cardioversions (the last in [**3-13**]) who presented for elective
pulmonary vein isolation on [**2154-4-13**]. He has a past medical
history significant for CABG, ESRD on HD, RCC s/p ablation,
repaired AAA, and previous GIB contraindicating anticoagulation
for his a fib.
.
He underwent successful elective transeptal pulmonary venous
isolation and was cardioverted in to NSR. During the procedure
he was given fentanyl 50mcg, midazolam 2mg, propofol 60mg,
furosemide 20mg, and 4L IVF. Post-op in the PACU he was noted to
have back pain and some agitation and was given 4 mg of haldol,
100mg of neurontin, followed by total of 4mg of morphine for his
back pain. He also developed hypotension to the 70s/50s and
dyspnea. He was bolused another liter of NS and started on
pressors with neosynephrine. He was noted to have atrial
fibrilation with RVR to 140s. An abg showed pH 7.24 and pCO2 42
O2 78. He was evaluated by and transferred to the MICU.
.
Overnight in the MICU the patient was noted to develop a lactic
acidosis of 3.5 --> 11.3. He developed worsened respiratory
failure and was intubated. His pressors were changed to levophed
and vasopressin. Initially he was on propofol and he was
switched to fent/versed for concern for possible propofol
infusion syndrome though it was thought to be unlikely. He had a
brief episode of monomorphic V tach and then later had
polymorphic vtach. He was given Mg and started on amiodarone 150
mg bolus x 2 and 0.5 mg/hr drip. A stat bedside echo showed
regional hypokinesis and EF 40% but no pericardial effusion.
Lenis were attempted, but were aborted due to instability? It
was thought that his hypotension and lactic acidosis were due to
hypovolemia from a retroperitoneal or GI bleed. CT surgery was
called and a CT abdomen was obtained which did not show evidence
of bleed. Infection was in the differential due to elevated WBC,
but this was thought to be less likely. He was pan cultured and
antibiotics were initially held, but then vanc, cefepime, flagyl
were started along with one dose of stress dose steroids.
.
On the morning of transfer, he was started on CVVH for likely
volume overload in the setting of poor oxygenation requiring
fio2 100% and high PEEP. On evaluation, he is intubated and
sedated, lying comfortably in bed.
Past Medical History:
* PAF s/p 7 CV (most recent CV [**3-13**]) not on warfarin given prior
GIB
* CAD s/p CABG [**2154**] Medical Center
* ESRD on HD s/p left AV fistula
-- on HD MWF, access tunneled line
* HTN
* Hyperlipidemia
* Hypothyroidism
* Abdominal hernia
* Renal carcinoma s/p radiofrequency ablation [**2150**], [**2-/2151**] and
[**10/2151**], and
* AAA repair [**6-/2146**]
* Epistaxis requiring packing x 2 in the past year
* Post-polypectomy GIB [**2151**]
* s/p right CEA [**4-/2145**]
* s/p appendectomy [**2131**]
* GERD
.
Social History:
Married. ETOH: [**3-6**] glasses of wine/week, no smoking.
Family History:
non-contributory
Physical Exam:
Vitals 98.6 125 113/68 17 98% on cmv, fio2 60%, peep 15, vt 600
General: intubated, sedated
HEENT Anicteric, pupils reactive bilaterally
Neck JVP difficult to assess, no jvd
Pulm ctab, no rales
Chest R sided HD catheter
CV Regular S1 S2 II/VI systolic murmur
Abd Soft absent bowel sounds, firm abdomen
Groins with femoral venous sheaths in place, minimal oozing.
Extrem cool cyanotic feet but palpable DPs.
Neuro sedated
Pertinent Results:
Labs on admission:
CBC
[**2154-5-14**] 09:30PM BLOOD WBC-17.4*# RBC-3.81* Hgb-11.4* Hct-36.2*
MCV-95 MCH-29.9 MCHC-31.4 RDW-18.5* Plt Ct-158
Diff
[**2154-5-15**] 02:43AM BLOOD Neuts-89.4* Lymphs-5.5* Monos-4.3 Eos-0.3
Baso-0.5
Coags
[**2154-5-14**] 09:30PM BLOOD PT-19.0* PTT->150* INR(PT)-1.7*
Chemistry
[**2154-5-14**] 09:30PM BLOOD Glucose-88 UreaN-59* Creat-5.2* Na-141
K-4.6 Cl-104 HCO3-20* AnGap-22*
LFTs
[**2154-5-15**] 02:43AM BLOOD ALT-846* AST-3204* CK(CPK)-279 AlkPhos-68
TotBili-4.2*
[**2154-5-15**] 01:33PM BLOOD ALT-2576* AST-[**Numeric Identifier **]* LD(LDH)-4450*
CK(CPK)-532* AlkPhos-81 TotBili-5.8*
Cardiac biomarkers
[**2154-5-14**] 09:30PM BLOOD CK-MB-26* MB Indx-16.6* cTropnT-2.13*
[**2154-5-14**] 11:41PM BLOOD CK-MB-36* MB Indx-17.1* cTropnT-3.32*
Other chemistry
[**2154-5-14**] 09:30PM BLOOD Calcium-8.3* Phos-5.7* Mg-2.2
[**2154-5-15**] 02:43AM BLOOD Cortsol-37.0*
[**2154-5-14**] 09:40PM BLOOD Lactate-3.5*
[**2154-5-15**] 03:20AM BLOOD Lactate-10.3*
[**2154-5-15**] 07:04AM BLOOD freeCa-0.96*
[**2154-5-14**] echocardiogram:
The left atrium is markedly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. LV systolic
function appears at least moderately depressed with preserved
basal function. The right ventricular cavity is markedly dilated
with severe global free wall hypokinesis. There is abnormal
diastolic septal motion/position consistent with right
ventricular volume overload. The number of aortic valve leaflets
cannot be determined. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. Mild to moderate
([**2-2**]+) mitral regurgitation is seen. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate to severely depressed biventricular
systolic function. Limited views in an emergency echo. Mild
aortic regurgitation. Mild to moderate mitral regurgitation.
Trivial pericardial effusion.
.
.
[**2154-5-15**] echocardiogram:
The left atrium is moderately dilated. A pulmonary arteriovenous
malformation is probably present (due to slow accumulation of
bubbles in the right atrium, a patent foramen ovale cannot be
excluded). There is mild symmetric left ventricular hypertrophy.
The left ventricular cavity is moderately dilated. There is
severe regional left ventricular systolic dysfunction with
akinesis/severe hypokinesis of the mid to distal left ventricle
. Overall left ventricular systolic function is severely
depressed (LVEF= 25-30 %). A left ventricular mass/thrombus
cannot be excluded. The right ventricular cavity is moderately
dilated with moderate global free wall hypokinesis. There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic root is mildly
dilated at the sinus level. The ascending aorta is moderately
dilated. The aortic arch is mildly dilated. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Trace aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests a restrictive filling
abnormality, with elevated left atrial pressure. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Severely depressed left ventricular systolic
function. Moderately depressed right ventricle function.
Pulmonary AVM vs PFO is present.
.
Compared with the prior study (images reviewed) of [**2154-5-14**],
left ventricular function is better assessed and the severity of
aortic and mitral regurgitation has decreased.
.
.
[**2154-5-14**] Chest x ray:
IMPRESSION:
Mild edema and bilateral effusions.
.
[**2154-5-15**] CT abdomen:
IMPRESSION:
1. Apparent wall thickening of the ascending colon and
transverse colon may be secondary to vascular congestion-heart
failure, under-distension or
colitis. Evaluation is limited due to lack of oral contrast.
Ischemic etiology cannot be excluded, however is less likely due
to lack of distention of the bowel.
2. Right heart strain. Severe atherosclerotic calcifications of
Aorta, celiac trunk and SMA, however, appear proximally patent.
The abdominal aorta is diffusely aneurysmally dilated up to
about 3.8 cm.
3. Bilateral moderate pleural effusions and partial collapse of
the left
lower lobe, and almost complete collapse of the right lower
lobe.
4. Moderate intra-abdominal and pelvic free fluid.
5. Multiple renal hypodensities can be further evaluated with
ultrasound or MRI.
6. Cholelithiasis.
[**2154-5-15**] LENIS:
IMPRESSION:
Severely limited study due to lack of ability to image the
common femoral
veins bilaterally due to intravenous catheters. Normal
compressibility of
bilateral superficial femoral and popliteal veins. Lack of
identification of DVT in no way excludes PE.
Brief Hospital Course:
Mr. [**Known lastname 1637**] is a 71M with coronary artery disease status post
CABG, end stage renal disease on hemodialysis, AAA s/p repair,
atrial fibrilation who underwent elective pulmonary vein
isolation on [**2154-5-14**] and subsequently developed hypotension and
shock.
# Hypotension/shock: The patient's hypotension was likely caused
by cardigenic shock in the setting of fluid overload from
peri-procedure IV fluids during his pulmonary vein isolation.
The most likely trigger was a periprocedure ischemic event. The
patient is on HD and likely was not able to tolerate the 5
liters of IV fluids. This caused him to have decompensated
heart failure which was transferred to the MICU post-procedure
for hypotension, and is now transferred to the CCU for further
management of likely cardiogenic shock.
Unclear etiology. Differential diagnosis included cardiogenic
shock possibly from MI, PE, or decompensated CHF in the setting
of volume overload. No evidence of hemorrhage with stable Hct
and no tamponade on echo. Septic shock also in the differential,
but the rapid onset and temporal relation to post op make this
less likely. Episodes of poly and monoporphic Vtach and
increasing troponin lead one to cardiogenic shock due to
ischemic event. Tachycardia and hypoxia in setting of recent
surgery indicate possible PE.
- continued cvvh at 150 cc/hr fluid removal
- cycled enzymes which started to trend down
- continued levophed/vasporessin
- continued vanc/zosyn for emperic coverage for sepsis
- f/u blood, urine, and urine cx which remained without growth
.
# Tachycardia: Had multiple episodes of monomorphic and
polymorphic VT overnight thought secondary to [**3-5**] ischemia,
given magnesium and started on amiodarone. Currently having
tachycardia, unclear if sinus tach or a fib with abberency.
- continued amio gtt
- EP recs
- trended cardiac enzymes, which were trending down
.
# Metabolic acidosis: Secondary to profoundly elevated lactate
in setting of hypoperfusion and now drifting downward. Abd CT
neg for bowel ischemia and Dr. [**Last Name (STitle) **] following.
- trendd lacate with ABGs which were resolving
- would empirically start thiamine
- med review for agents associated with lactic acidosis
- surgery reccs--did not feel patient has indication for
surgical procedure
.
# Respiratory failure: Likely primarily secondary to volume
overload/pulmonary edema. Oxygenation improving with diuresis
with CVVH. Would also consider PE with INR 1.7 on admission, not
on coumadin b/c of GI bleeds.
- management of heart failure as above
- continued to wean vent settings
- will continue hyperventilation to assist acid-base status
- pt was extubated on [**2154-5-17**] successfully and hypoxia seemed to
improve
.
# Gastroparesis: No bowel sounds. NG lavage revealed stagnant
gastric contents. Medications not likely to be absorbed PO right
now. Pt likely with an ileus in setting of shock.
-- NPO including medications
.
# CAD s/p CABG: holding bb, cont statin, cont asa
.
# Afib: Currently in afib and s/p PVI on [**2154-5-14**] with
complications as described above.
- continued aspirin, amio
- Patient not anticoagulated given history of GIB
.
# ESRD on HD:
- Continue phoslo and nephrocaps (when able to take PO)
- continued cvvh, stopped on Saturday as seemed that pt achieved
relative [**Name (NI) 52753**]
.
# Hypothyroid
- Held levothyroxine as pt was NPO
# Altered mental status: Improving. Thought to be secondary to
weaning of sedation medications now s/p extubation, ICU
delirium, hyponatremia (new). Pt received zyprexa on the night
of [**2154-5-18**] with little effect. Pt was placed in 4 point
restraints for protection.
- continued soft restraints until improves
- Infectious work up
# elevated liver enzymes: improvement given improving INR.
likely shock liver from poor perfusion.
- held statin
- watched for encephalopath
- monitor INR - started to downtrend
- RUQ U/S planned and zosyn DC'd given rising bili
CODE BLUE on [**2154-5-19**]:
Patient was undergoing a KUB to assess his abdominal pain,
during this film the patient became unresponsive and pulseless
with electrical activity. CPR was immediately initiated with
several rounds of epinephrine and bicarbonate given. The patient
regained his pulse 3 times and each time lost his pulse and went
into PEA. The patient at one point had a wide complex
tachycardia and was shocked to no affect. The patient was
started on a dopamine and epinephrine drip in addition to his
vasopressin and norepinephrine. The patient also received
heparin bolus + gtt for empiric PE tx, bicarb for empiric
acidosis and hyperkalemia tx, empiric insulin/glucagon/calcium
for empiric hyperkalemia treatment. EKG revealed ST elevations
in aVR and V1, V2 consistent with global ischemia. Code STEMI
was called and pt was to be taken to the cath lab until he lost
his pulse again. No reversible cause could be identified. After
the third set of CPR of nearly 60 minutes of a code, the patient
remained pulseless and the code was called as it was deemed that
there was no hope for recovery. The patient expired at 11:55am
on [**2154-5-19**].
Medications on Admission:
Medications per OMR
Allopurinol 100mg [**Hospital1 **]
Amiodarone 200mg daily
Atorvastatin 20mg daily
Nephrocaps 1 tab daily
Phoslo 667mg TID
Fenofibrate 48mg [**Hospital1 **]
Furosemide 40mg [**Hospital1 **]
Levothyroxine 75mcg daily
Omeprazole 40mg daily
Discharge Medications:
Expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Expired
Discharge Condition:
Expired
Discharge Instructions:
Expired
Followup Instructions:
Expired
Completed by:[**2154-5-19**]
|
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icd9cm
|
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icd9pcs
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[
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,765
| 124,319
|
43309+58606
|
Discharge summary
|
report+addendum
|
Admission Date: [**2184-3-2**] Discharge Date: [**2184-3-11**]
Date of Birth: [**2120-5-26**] Sex: F
Service: MEDICINE
HISTORY OF PRESENT ILLNESS: This is a 63-year-old woman with
a history of metastatic cancer admitted to the
................. for right-sided pleural effusion and
pulmonary embolism.
The patient's breast cancer history dates back to [**2181**], when
a lump was felt. A year later, biopsy revealed cancer. She
was initially treated with radiation to the right, Cytoxan,
Adriamycin, weekly Taxol, and subsequently Gemcitabine, after
which she had recurrence on these therapies.
More recently, she was started on Navelbine that did not have
response to this either. She has known right and left
axillary, right supraclavicular, and paratracheal
lymphadenopathy, chest wall, skin and liver metastases.
She had pulmonary nodules on initial CT scan and a pleural
effusion since [**2183-11-16**] which was noted to have
increased on imaging ................... She has had
significant right shoulder and neck pain. She was admitted
earlier this month for abdominal pain which improved with
laxatives.
She has had shortness of breath for at least several weeks
but was able to climb a flight of steps and walk a block
without too much difficulty. She has been feeling otherwise
in her usual state of health with fatigue, shortness of
breath, and some pain, until three days prior when she noted
a cough productive of occasional thin white sputum.
Two days prior, she noted worsening shortness of breath she
went to answer the door. Yesterday the visiting nurse
started her on two new medications for her cough (question of
Levaquin, and question of Robitussin).
Last night, she went to the bathroom, and her daughter noted
that her breathing was especially labored and brought her
into the Emergency Department. She has had no chest pain,
fevers, chills, nausea, vomiting, abdominal pain,
constipation or diarrhea. She has had lower extremity
swelling on long trips. She has been eating satisfactorily
(supplementing with Boost).
PAST MEDICAL HISTORY: Asthma (no hospitalizations), [**1-19**]
attacks per year. Apical bullae. Panic disorder versus
generalized anxiety disorder. Childhood TB treated with
Streptomycin. Breast cancer history as noted above. History
of PE. Primary care physician is [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (PRE) **].D. Her
hematology/oncologist is [**Name6 (MD) 93278**] [**Name8 (MD) **], M.D., [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 19**], M.D.
ALLERGIES: ASPIRIN, CODEINE, ..................., SULFA
DRUGS.
MEDICATIONS: Flovent 2 b.i.d., Fentanyl patch 25 mcg q.72
hours, MSIR 10 q.i.d., Albuterol [**12-18**] q.4-6 hours, Lorazepam
0.5 q.[**3-21**], Trazodone 50-100 q.h.s. p.r.n., Colace, Dulcolax,
Nystatin.
FAMILY HISTORY: Breast cancer in mother and aunt. CVA.
SOCIAL HISTORY: Worked in Medical Records here. Divorced.
She lives with daughter. She is on disability. She smoked
for 28 years. She quit tobacco in [**Month (only) **]. Daughter is her
healthcare proxy ([**Name (NI) 93279**] [**Name (NI) 3494**]).
PHYSICAL EXAMINATION: Vital signs: Temperature 98.6??????, blood
pressure 128/66, pulse 130-148, oxygen saturation 100% on 2 L
nasal cannula. General: This was a black female in no acute
distress. .................., in bed, wearing a cap,
breathing approximately 22/min with prolonged expiratory
phase. HEENT: Pupils equal and reactive. Extraocular
movements intact. Neck: Supple. She had large right-sided
lymphadenopathy, supraclavicular lymphadenopathy and
indurated mass. She had radiation changes to her back,
axilla and right breast. She had right axillary
lymphadenopathy. She had right breast masses. Heart: She
was tachycardiac but regular rhythm. No murmurs. Lungs:
Absent breath sounds three-quarters up on the right. Wheezes
on the left. Abdomen: Slightly distended. Nontender.
Positive bowel sounds. No hepatomegaly. Extremities: No
edema. Symmetric 2+ pulses. Neurological: Alert and
oriented times three. Cranial nerves II-XII intact.
Symmetric strength in bilateral upper extremities. Rectal:
Guaiac negative stool.
LABORATORY DATA: On presentation white blood cell count was
8.3, hematocrit 35.3, platelet count 401; INR 1.2;
differential 15 neutrophils, 7 bands, 19 lymphs, 14 monos;
sodium 132, potassium 4.3, chloride 96, bicarb 27, BUN 10,
creatinine 0.5, glucose 111; ALT 24, AST 40, alkaline
phosphatase 127, amylase 34, total bilirubin 0.5, lipase 10,
albumin 3.0.
Electrocardiogram showed sinus tachycardia at 140, normal
axis and intervals, no ST changes, R-prime in V1.
Chest x-ray showed marked increase in right pleural effusion,
compressive atelectasis, left side clear.
CT of the chest showed segmental few subsegmental PEs on the
left, large right-sided pleural effusion with mediastinal
shift, some loculation.
CT of the head showed no hemorrhage.
CT of her abdomen from [**2-22**] showed numerous hyperdense
enhancing lesions within the liver which were consistent with
metastases, increase in the size of the right pleural
effusion, and right lower chest subcutaneous mass, no
evidence of diverticulitis, fibroid uterus.
HOSPITAL COURSE: The patient was admitted to the Intensive
Care Unit with right-sided pleural effusion and PE.
1. Pulmonary: The patient had a right-sided malignant
pleural effusion with a thoracentesis tap of 2 L and
subsequent pneumothorax. The patient then had a VATS
procedure with pleurodesis on [**3-5**]. Chest tube was
placed with suction and removed on [**2184-3-8**].
The patient also had evidence of PE. [**Last Name (un) 93280**] showed left
saphenous vein clot leading to Heparin infusion but no
filters. The patient was started on Coumadin six hours post
removal of her chest tube.
She was continued on her asthma therapy with her inhalers.
She was weaned from her high oxygen requirements of 2 L nasal
cannula.
2. Cardiovascular: The patient has had tachycardia since
[**2184-1-17**] but no electrocardiogram changes. No decrease
in her heart rate with intravenous fluid hydration. It was
felt that this was likely due to increased metabolic demand.
The patient continued to be monitored on Telemetry with sinus
tachycardia which was asymptomatic.
3. Infectious disease: The patient had an elevated white
blood cell count with unknown etiology. She spiked a fever
on [**3-5**] prior to her VATS procedure. Blood, urine and
sputum culture were negative. Pleural fluid showed
coag-negative staph only and no antibiotic therapy was
instituted. Follow-up blood cultures have remained negative.
4. Hematology: The patient was anemic post VATS and
received 2 U packed red blood cells with appropriate
response. She was maintained on a Heparin infusion up until
discharge. She was started on Coumadin post removal of her
chest tube, but this will be discontinued after discharge.
5. FEN; The patient had hyponatremia upon admission which
resolved.
6. GI: The patient had constipation, and with aggressive
bowel regimen, had a subsequent bowel movement.
7. Oncology: A lengthy discussion was held between the
patient, her daughter and her primary oncologist. Eventually
the decision was made not to proceed with further
chemotherapy or aggressive intervention. The patient has
changed her code status to DNR/DNI.
DISCHARGE DIAGNOSIS:
1. Metastatic breast cancer, pulmonary embolism, right
pleural effusion status post VATS.
2. Anxiety.
3. Asthma.
DISCHARGE MEDICATIONS: Morphine Sulfate elixir 10 mg p.o.
q.[**3-21**] p.r.n., Fentanyl patch 25 mcg q.72 hours, Lorazepam
elixir 1 mg p.o. q.[**3-21**] p.r.n., Colace 100 mg p.o. b.i.d.,
Lactulose 15-30 ml p.o. t.i.d. p.r.n. constipation, Bisacodyl
10 mg p.o. q.d. p.r.n. constipation, Senna [**12-18**] tab p.o.
b.i.d., Flovent 110 mcg 2 puffs b.i.d., Albuterol/Atrovent
1-2 puffs q.6 p.r.n.
CONDITION ON DISCHARGE: Poor.
CODE STATUS: DNR/DNI.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**]
Dictated By:[**Last Name (NamePattern1) 4988**]
MEDQUIST36
D: [**2184-3-10**] 15:17
T: [**2184-3-10**] 19:32
JOB#: [**Job Number 93281**]
Name: [**Known lastname 14708**], [**Known firstname 14709**] Unit No: [**Numeric Identifier 14710**]
Admission Date: [**2184-3-2**] Discharge Date: [**2184-3-11**]
Date of Birth: [**2120-5-26**] Sex: F
Service:
ADDENDUM: Please note that the patient's INR was noted to be
greatly elevated; going from 1.3 to 2.4 and then to 25.9
after two doses of Coumadin at 5 mg and 3 mg. This was felt
to be likely secondary to laboratory error given the rapidity
of elevation and the patient's concurrent heparin infusion.
Nonetheless, further Coumadin doses were held. A follow-up
INR check after discontinuation of the heparin drip was 8.3.
Given that the patient had documented pulmonary embolism, and
deep venous thrombosis, and no evidence of active bleeding,
her INR was not reversed and was expected to continue to
trend down.
[**First Name4 (NamePattern1) 963**] [**Last Name (NamePattern1) 964**], M.D. [**MD Number(1) 965**]
Dictated By:[**Last Name (NamePattern1) 14711**]
MEDQUIST36
D: [**2184-3-12**] 10:39
T: [**2184-3-12**] 11:03
JOB#: [**Job Number 14712**]
|
[
"453.8",
"196.3",
"415.19",
"285.1",
"E878.8",
"197.2",
"198.89",
"512.1",
"197.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.39",
"34.92",
"34.91",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
2891, 2932
|
7605, 7977
|
7464, 7581
|
5302, 7443
|
3212, 5284
|
169, 2080
|
2103, 2874
|
2949, 3189
|
8002, 9447
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
17,147
| 105,976
|
51348
|
Discharge summary
|
report
|
Admission Date: [**2109-10-15**] Discharge Date: [**2109-10-17**]
Service:
HISTORY OF PRESENT ILLNESS: This is a 79-year-old woman with
a past medical history of coronary artery disease and labile
hypertension who presents with worsening of her nausea over
the past 24 hours and noted this morning to be unsteady on
her feet and unable to walk straight. She also complains of
a massive headache, she described as if her head was going to
explode. Her called her daughter and her primary care
physician and her primary care physician told her to come to
the Emergency Department. CT in the Emergency Department
showed a questionable small bleed in the left cerebellum.
Patient had a recent history significant for nausea which has
been intractable for several months. She also given history
of her head feeling strange at times but this one seems to be
more intense than most times and patient claims that she is
actually very functional at home and lives by herself.
PAST MEDICAL HISTORY: Includes coronary artery disease,
status post catheterization in [**2095**], coronary artery bypass
graft times three in [**2095**], seizure disorder. Work-up done
here showed only temporal lobe swelling, arthritis.
MEDICATIONS ON ADMISSION: Aspirin, disopromine, Toprol,
Trilafon for nausea, Cozaar and Aldactone.
FAMILY HISTORY: Significant for hypertension and coronary
artery disease.
SOCIAL HISTORY: Patient lives alone. Has a woman who comes
in to help her out with the meals. Ambulates independently.
No alcohol use. Ex-smoker times 15 years.
REVIEW OF SYSTEMS: Has occasional blurriness of vision, no
dull vision, no hearing changes. Cardiovascular: No chest
pain, no shortness of breath, no palpitations, no paroxysmal
nocturnal dyspnea, no significant dyspnea on exertion.
Pulmonary: No shortness of breath, no cough, no fevers, no
chills or night sweats. Gastrointestinal: She was positive
for nausea, no vomiting, no diarrhea, no constipation.
Genitourinary: No urgency, no frequency, no polyuria, no
dysuria, no hematuria, no polydipsia, no heat and cold
tolerance. Heme: No abnormal bleeding.
PHYSICAL EXAM ON ADMISSION: Vital signs of a blood pressure
of 220/120 on admission which was then brought down to 150/90
and patient in general was an alert and oriented woman in no
acute distress. Head, eyes, ears, nose and throat: Neck was
supple, no masses, no carotid bruits. Coronary: Regular
rate and rhythm S1, S2, no murmurs, rubs or gallops.
Pulmonary: Clear to auscultation bilaterally. Abdomen soft,
nontender, nondistended, positive bowel sounds. Extremities:
No cyanosis, clubbing or edema. Neurological: Patient was
alert and oriented times three. Speech is fluent. Memory
for three objects intact at five minutes. Cranial nerves:
Pupils are equal, round, and reactive to light and
accommodation. Extraocular muscles intact with left beating
nystagmus. Visual fields were full. Face was symmetric.
Face sensation intact. Palate elevated symmetrically. Gag
was present. Trapezius strength [**6-8**]. Tongue protrudes in
the midline. Motor is [**6-8**], normal tone, no drift. Sensory
is normal sensation to pinprick in bilateral upper
extremities normal sensation to pinprick in bilateral lower
extremities. Proprioception was intact. Vibratory sense was
intact. Gait was normal with narrow-based gait.
Coordination: Mild finger-to-nose unsteadiness on the left.
Heel-to-shin unsteady on the left, rapid alternating
movements increased on left compared to the right. Reflexes:
Upper extremities 2+ symmetric, left lower extremity 2+ and
symmetric. Toes downgoing bilaterally.
LABORATORIES: Patient had a Chem-7 and CBC which were both
within normal limits. On admission patient's laboratories
were notable for sodium of 129, potassium of 5.0, 93/26 BUN
and creatinine 17/0.9, CK was 70, hematocrit was 42.2.
Patient has chronic hyponatremia 129 being at her baseline.
On day of admission patient's sodium was 132 and was stable.
CT scan of the brain showed questionable cerebellar bleed.
HOSPITAL COURSE: Patient was admitted to the Medical
Intensive Care Unit to have hourly neurological checks.
Patient was stable as was her blood pressure in the Medical
Intensive Care Unit with intravenous nitroprusside. Blood
pressure was well under control. Patient remained
neurologically stable throughout her night stay in the
Medical Intensive Care Unit. Patient had a MRI to follow-up
on the bleed which showed no evidence of any more bleed. The
official read was no hemorrhage, no evidence of any recent
infarct, old right frontal meningioma, basilar bilateral
50-75% carotid stenosis. Patient was neurologically stable
in the Medical Intensive Care Unit. Blood pressure was
stabilized with intravenous nitroprusside. Patient was then
changed back to her po blood pressure medications. Patient
was relatively controlled and blood pressure was stable
130/78. On day of discharge, patient's blood pressure was
134/78. Patient was continued on her medications of aspirin
325 mg, disopromine 20 mg q.d., Toprol XL 100 mg q.d., Cozaar
50 mg q.d., Aldactone 25 mg q.d., Zocor 40 mg q.d. and
Trilafon 4 mg prn nausea. Patient was stable upon discharge
with a blood pressure 138/78, fully awake, alert and
oriented. Patient was evaluated by Physical Therapy for home
safety evaluation but can be discharged home. Patient will
follow-up with Dr. [**Last Name (STitle) **] for further blood pressure control
in the future. Patient was stable upon discharge at the time
she left her blood pressure was in the 130s/70s.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. [**MD Number(1) 10932**]
Dictated By:[**Last Name (NamePattern1) 6234**]
MEDQUIST36
D: [**2109-10-22**] 11:43
T: [**2109-10-22**] 11:43
JOB#: [**Job Number **]
|
[
"780.39",
"401.9",
"V45.81",
"787.02",
"276.1"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
1341, 1400
|
1250, 1324
|
4086, 5876
|
1586, 2147
|
113, 982
|
2792, 4068
|
2162, 2776
|
1005, 1223
|
1417, 1566
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,246
| 105,309
|
2747
|
Discharge summary
|
report
|
Admission Date: [**2126-6-5**] Discharge Date: [**2126-6-8**]
Date of Birth: [**2067-10-24**] Sex: F
Service: CCU
CHIEF COMPLAINT: The patient was transferred from an outside
hospital for mental status changes, acute renal failure,
hyperkalemia, and hypotension.
HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old
female with a long history of coronary artery disease,
congestive heart failure, and arrhythmias, who found down in
her home by her husband. [**Name (NI) **] the outside hospital records,
the husband noticed mental status changes for approximately
two weeks and occasional dyspnea. It was not known at the
time she was admitted, but later it was learned that the
patient had been taking Aldactone starting approximately two
weeks ago at the time that her mental status changes began to
occur. The patient was found on the floor outside of her
bathroom, apparently just after she stood from the toilet.
She was brought to the Emergency Room with a systolic blood
pressure of 80, with no response to 2 liters of fluid in the
Emergency Room. She was found to have a potassium of 6.9, a
BUN 53, and creatinine 2.9; although, her baseline is a
creatinine of 1. She was noted to have wide complex QRS on
her electrocardiogram, was mildly obtunded, and was placed on
dopamine at 4.5 mcg/min for pressure support. Her right
upper quadrant was noted to be painful on physical
examination. Laboratories there were notable for a
bicarbonate of 18, flat creatine kinases, and elevated
digoxin level at 2.5, an INR greater than 7.5, and a
hematocrit of 29. A head CT was performed to rule out
cerebrovascular accident. This was limited by artifact, but
was negative for acute processes. A rushed echocardiogram
showed an ejection fraction of approximately 25%. At the
outside hospital she was given D-50 and insulin times two,
and Kayexalate p.o. and p.r. for her hyperkalemia, as well as
2 units of packed red blood cells for a slightly low
hematocrit of 29.7, and 2 units fresh frozen plasma, as well
as vitamin K for her elevated INR, then transferred to [**Hospital1 1444**].
Upon arrival, the patient complains of right upper quadrant
pain on and off which lasts five minutes at a time, is dull,
is rated [**3-28**] in intensity, and possibly occurs more often
after meals. She reports that Tylenol helps this pain. She
also complains of diarrhea times one month, ultimately loose
and watery, as well as specks of bright red blood in her
stool, but no melena, hematemesis, nausea or vomiting. She
does report a slight decrease in her appetite and p.o.
intake, but does report food fluid intake and increased
thirst. She thinks she may have increased her intake of
salty foods recently. She has been Imodium for her diarrhea.
The rest of her review of systems was remarkable for the
absence of chest pain and palpitations, the presence of
shortness of breath for approximately three weeks,
three-pillow orthopnea, paroxysmal nocturnal dyspnea two
weeks ago, and increased lower extremity edema for several
weeks. She has had no change in her weight but has not
checked this precisely. She denies fevers, chills, and night
sweats, rash, genitourinary complaints.
Regarding her fall, she has recollection of the actual event,
but says that she probably lost consciousness. She reports
leg pain prior to the event, and is unable to clarify clearly
beyond saying that they were weak (left greater than right).
PAST MEDICAL HISTORY: (Significant for)
1. Myocardial infarction in [**2120**] which led to cardiogenic
shock and a new left bundle-branch block. She was
catheterized at that time and had a stent placed to her
proximal left circumflex, and distal right coronary artery
was occluded to 100% at that time. She had an episode of
ventricular tachycardia post myocardial infarction which
required lidocaine, and an episode of atrial fibrillation
which required DC cardioversion.
2. She had a coronary artery bypass graft in [**2120**] which
included a left internal mammary artery to her left anterior
descending artery, and saphenous vein graft to her first
obtuse marginal, and saphenous vein graft to a posterior
descending artery, as well as mitral valve repair.
3. She had a follow-up catheterization in [**2123**] which showed
2-vessel disease with a totally occluded left internal
mammary artery to left anterior descending artery graft as
well as a totally occluded saphenous vein graft to first
obtuse marginal, and saphenous vein graft to right posterior
descending artery graft. The catheterization also showed
severe systolic and diastolic dysfunction bilaterally, and
moderate pulmonary hypertension, and moderate-to-severe
mitral regurgitation.
4. Therefore, she had a follow-up coronary artery bypass
graft in [**2123**] and had a saphenous vein graft to her left
anterior descending artery and her first diagonal and her
first obtuse marginal, as well as a mitral valve replacement
with mechanical valve.
5. She had a pacemaker placed in [**2123**] by Dr. [**Last Name (STitle) 73**].
This pacemaker is a Prodigy DR7860B, atrial lead 4068,
ventricular lead 4024; it is a DDD-type pacer.
6. She also has had an atrial flutter ablation in [**2124**], and
atrial flutter DC cardioversion in [**2124-11-18**], and
atrial fibrillation DC cardioversion in [**2126-4-19**].
7. Stress MIBI in [**2125-11-19**] which showed severe
inferolateral defects, now fixed in contrast to an [**2121-11-19**] study where they were reversible.
8. In [**2125-1-17**], the patient had an echocardiogram
which showed a dilated left ventricular global hypokinesis
and akinesis including the right ventricle, significant
mitral regurgitation over her valve prosthesis, significant
tricuspid regurgitation, mild pulmonary hypertension, and
interval decreased function since her last study with an
ejection fraction of less than 20%.
9. Hypertension.
10. Type 2 diabetes with the last hemoglobin A1c of 8.4 in
[**2126-1-17**]. Hemoglobin A1c were as high as 11.
11. Hypercholesterolemia.
12. Peripheral vascular disease with a claudication and the
requirement that she occasionally have catheterizations by
brachial artery.
13. Depression.
14. Dysfunction uterine bleeding with a thick endometrium
noticed on a [**2125-11-19**] ultrasound.
15. Obesity.
16. Allergic rhinitis.
17. Recent admissions to [**Hospital1 **] [**First Name (Titles) **]
[**Last Name (Titles) 7941**] of her INR and for an atrial fibrillation
cardioversion.
FAMILY HISTORY: Family history was difficult to obtain, but
was negative for coronary artery disease.
SOCIAL HISTORY: The patient has a 70-pack-year history; now
smokes five cigarettes a day. Does not drink alcohol. Takes
no drugs. Lives with her husband.
ALLERGIES: CECLOR causes hives.
MEDICATIONS ON ADMISSION: Medications at home include
Vasotec 2.5 mg p.o. b.i.d., atenolol 25 mg p.o. q.d.,
amiodarone 400 mg p.o. b.i.d., gemfibrozil 600 mg p.o.
b.i.d., digoxin 0.25 mg p.o. Monday through [**Last Name (Titles) 2974**], potassium
chloride 20 mg p.o. b.i.d., Warfarin 5 mg p.o. q.d.,
Lasix 20 mg p.o. b.i.d., Ativan 1 mg p.o. p.r.n. for
insomnia, trazodone 50 mg p.o. q.h.s., Zoloft 150 mg p.o.
q.d., Lipitor 10 mg p.o. q.d., albuterol MDI p.r.n., and no
oral hypoglycemics for diabetes.
REVIEW OF SYSTEMS: See History of Present Illness.
PHYSICAL EXAMINATION ON ADMISSION: On physical examination
vitals were temperature of 97.6, pulse 60, blood
pressure 93/34 (on 3 mcg/min of dopamine), respirations 18,
saturation 98% on 2 liters nasal cannula. In general, this
was a tired, obese female in no acute distress with slightly
inappropriate and delayed answers to questions.
Cardiovascular showed a regular rate and rhythm, a
mechanical-sounding S1, and a holosystolic murmur throughout
her precordium. No rubs or gallops. HEENT examination
showed jugular venous distention to the angle of her jaw at
45 degrees. Pupils were equal, round, and reactive to light.
Extraocular movements were intact. Oropharynx showed
slightly dry mucous membranes. She had cavities bilaterally.
She was normocephalic and atraumatic from her fall.
Pulmonary examination showed crackles bilaterally, left
greater than right, halfway up. Abdominal examination had
normal active bowel sounds, obese, firm, mild tenderness in
her right upper quadrant and right lower quadrant
intermittently. Extremities showed pitting edema as well as
bruises and petechiae in her upper extremities and left
shoulder bruises anteriorly and posteriorly related to a
fall. Her rectal examination showed heme-positive brown
stool. Neurologically, she was alert and oriented times
three, although slightly drowsy and sometimes slightly off
subject when she replied to questions. Cranial nerves II
through XII were intact. Strength was [**3-23**] throughout. Deep
tendon reflexes were 2+ in her knees, deferred in her upper
extremities because of multiple IVs, and decreased at her
ankles. Babinski was equivocal. Finger-to-nose and
heel-to-shin were intact. Alternating movements were intact.
LABORATORY DATA: (At the outside hospital) Showed a sodium
of 138, a potassium that declined from 6.9 to 5.7 with
several interventions, a bicarbonate that fell from 20 to 17
over the course of her stay, BUN 53, and creatinine of 2.9,
and an elevated phosphorous at 5.5, and a low hematocrit
at 33.3, platelets of 143, a white blood cell count of 8.5.
Initial INR of 4.1, D-dimer positive, digoxin 2.5,
fibrinogen 335. Creatine kinase 67, MB 2.2, troponin less
than 0.05. Urinalysis revealed trace blood, 500 protein, 2
to 5 white blood cells.
RADIOLOGY/IMAGING: A V/Q scan was low probability which
showed cardiomegaly. This was probably done because she had
an arterial blood gas of 7.25/39/38.5 which probably
represented a venous blood gas.
Chest x-ray showed increased heart size, mild redistribution
in the upper perihilar vessels, but no pulmonary edema or
effusions.
Head CT showed motion artifacts, but was otherwise within
normal limits.
Renal ultrasound showed normal kidneys at 12.4 cm and
12.2 cm.
Electrocardiogram showed possibly tiny P wave after pacer
spikes and AV-pacing, with a wide QRS at 0.24.
LABORATORY ON ADMISSION: Laboratories at [**Hospital1 346**] were a sodium of 141, potassium 3.9,
chloride 109, bicarbonate 16, BUN 50, creatinine 2.1.
Calcium 8.8, phosphorous 5.2. Normal liver function tests.
An INR of 2. A digoxin of 1.1. A white blood cell count
of 8.5, a hematocrit of 32.1, platelets 141.
RADIOLOGY/IMAGING: Electrocardiogram here showed dual pacer
spikes before V-paced QRS. No evidence of atrial activity.
The rate of 63, axis was left, QRS was 0.16 seconds in
duration. She had T wave flattening in I, L, V5, and V6. ST
changes were not interpreted secondary to her V-pacing.
HOSPITAL COURSE BY SYSTEM: The patient was admitted to the
Coronary Care Unit.
1. CARDIOVASCULAR: As far as her systolic function, the
patient rapidly weaned off dopamine with no drop in her blood
pressure. The patient was given a gentle bolus of 250 cc of
normal saline because of possible intravascular volume
depletion with decreased p.o. intake. Her digoxin was
restarted when her digoxin level returned to [**Location 213**]. Her ACE
inhibitor was restarted when her creatinine returned to 1.5.
Coreg was also started for her congestive heart failure.
As far as her electrical function, her amiodarone was
continued. Her pacer was interrogated, and it was found that
despite the apparent absence of P activity on her
electrocardiogram, the patient was AV-pacing at 60. Her rate
was turned up to 70 at this time, and her intrinsic rate off
pacing was noted to be a ventricular at 30.
As far as valve disease, the patient was heparinized and
coumadinized. Heparin was continued until her INR was
therapeutic at 3.2 on [**6-8**]. Then her heparin was
discontinued, and with adequate anticoagulation for her
mitral valve she was sent home.
Of note, therapy for her urinary tract infection was adjusted
from ciprofloxacin to Macrobid because it was believed the
latter medication would be less disruptive of valve flora and
have less influence on her INR.
As far as coronary arteries, the patient's Lipitor and
gemfibrozil were continued as well as her aspirin. She was
beta blocked with Coreg. Given that her troponin and
creatine kinases were flat at the outside hospital, we had no
concern over any coronary ischemia.
2. GASTROINTESTINAL: The patient was noted to have
heme-positive stool, but no gross blood, and her hematocrit
remained stable throughout her stay. She also developed
diarrhea, and as a result studies for C. difficile, fecal
leukocytes, and stool cultures, and ova and parasites were
sent. Stool cultures were pending at this time. Fecal
leukocytes were negative. Ova and parasites were negative,
and the patient was given Imodium on the last day of her
hospitalization to control her symptoms. She was to follow
up with Gastroenterology as an outpatient to evaluate her
heme-positive stool.
3. RENAL: The patient's acute renal failure resolved over
the period of several days with a normal potassium and then a
potassium requiring supplementation, which was her baseline
state. Her phosphorous normalized. She had a normal urine
output. Studies done to evaluate her renal failure showed a
prerenal state with urine sodium less than 10. At
discharge, her renal function was normal with a creatinine
of 1.
4. PULMONARY: The patient was given one small dose of Lasix
for volume overload and shortness of breath. She then had no
further pulmonary issues.
5. FLUIDS/ELECTROLYTES/NUTRITION: The patient had
electrolytes repleted as indicated and was restarted on her
daily Lasix 20 mg p.o. b.i.d.
6. GENITOURINARY: The patient was noted to have a urinary
tract infection with 17 white blood cells and moderate
bacteria; although, her nitrite remained negative. She was
treated initially for this with ciprofloxacin then changed to
nitrofurantoin upon discharge.
7. ENDOCRINE: The patient was monitored regarding her blood
sugars and followed with a regular insulin sliding-scale
which was not needed as her blood sugars remained normal.
8. NEUROLOGY: The patient's lethargy resolved over the
course of 1.5 days, and at discharge she was fully alert and
interactive.
In summary, it was felt that her hyperkalemia, acute renal
failure, change in mental status, and hypotension were all
related to initiation of Aldactone, possibly complicated by
polypharmacy in general. With discontinuation of the
Aldactone and supportive care, her acute renal failure
resolved. Her hyperkalemia resolved. Cardiac function and
hypotension returned to her baseline state, and her mental
status changes also resolved. The patient was then
re-anticoagulated for her mitral valve and was ready for
discharge.
CONDITION AT DISCHARGE: Condition on discharge was stable.
CODE STATUS: Full code.
DISCHARGE DIAGNOSES:
1. Acute renal failure with hyperkalemia and metabolic
disarray including depressed cardiac function an mental
status changes.
2. Mitral valve replacement, on anticoagulation.
3. Coronary artery disease, status post multiple
catheterizations, and bypass surgeries, and pacemaker
placement.
4. Hypertension.
5. Diabetes.
6. Hypercholesterolemia.
7. Occult gastrointestinal bleeding.
8. Diarrhea of unknown etiology possibly related to her
medications.
MEDICATIONS ON DISCHARGE:
1. Vasotec 2.5 mg p.o. b.i.d.
2. Amiodarone 400 mg p.o. b.i.d.
3. Gemfibrozil 600 mg p.o. b.i.d.
4. Potassium chloride 20 mg p.o. b.i.d.
5. Digoxin 0.25 mg p.o. Monday through [**Month (only) 2974**]
6. Coumadin 5 mg p.o. q.d.
7. Lasix 20 mg p.o. b.i.d.
8. Ativan 1 mg p.o. p.r.n. for insomnia.
9. Trazodone 50 mg p.o. q.h.s.
10. Zoloft 150 mg p.o. q.d.
11. Lipitor 10 mg p.o. q.d.
12. Aspirin 325 mg p.o. q.d. (which was to be held until she
is evaluated by Gastroenterology for a gastrointestinal
bleed).
13. Coreg 3.125 mg p.o.
14. Protonix 40 mg p.o. b.i.d. (to be used until she is
evaluated by Gastroenterology).
15. Imodium 1 tablet p.o. q.6h. p.r.n. for diarrhea.
16. Miconazole powder to a groin rash t.i.d.
17. Albuterol inhaler p.r.n.
18. Macrobid 100 mg p.o. q.i.d.
DISCHARGE FOLLOWUP: Follow-up appointments were arranged
with Dr. [**Last Name (STitle) 120**] (her cardiologist) in four days, and she was
to schedule a Gastroenterology follow-up appointment on her
own or through Dr. [**Last Name (STitle) 120**].
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 126**], M.D. [**MD Number(1) 4062**]
Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36
D: [**2126-6-8**] 15:23
T: [**2126-6-9**] 07:33
JOB#: [**Job Number 13571**]
|
[
"414.01",
"V45.81",
"584.9",
"599.0",
"401.9",
"250.00",
"428.0",
"276.7",
"V43.3"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6527, 6614
|
15005, 15465
|
15492, 16308
|
6834, 7314
|
10863, 14907
|
14922, 14984
|
7334, 7388
|
149, 282
|
16329, 16832
|
311, 3461
|
10248, 10834
|
3484, 6509
|
6631, 6807
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,137
| 124,188
|
30236+57683
|
Discharge summary
|
report+addendum
|
Admission Date: [**2106-3-17**] Discharge Date: [**2106-4-5**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 695**]
Chief Complaint:
Cough, Fatigue, Failure to thrive
Major Surgical or Invasive Procedure:
[**2106-3-18**] EGD with PEG placement
[**2106-3-18**] colonoscopy
History of Present Illness:
Pt is 65 y/o male with h/o OLTx [**2104-8-22**] for ETOH cirrhosis
and HCC, who has had persistent issues with diarrhea,
malnutrition, hyperkalemia, and elevated creatinine, who
presents
with complaints of cough and worsening fatigue for past few
days.
Pt presented to OSH where he had a CXR that was concerning for
left lower lobe pneumonia. In addition, pt had potassium level
of 6.6 and was given dose of humalog and dextrose,
hydrocortisone, and levaquin before being transferred to [**Hospital1 18**]
for further management.
Pt's cough is non-productive and is associated with some
shortness of breath. Pt did have an episode of nausea without
emesis this AM. He further states that he has had problems with
diarrhea ever since before the transplant. He has multiple
episodes of diarrhea per day and pt further states that the
diarrhea affects his quality of life. He denies fevers or
chills, night sweats, lightheadedness, or dizziness. He denies
abd pain, constipation, or dysuria.
Past Medical History:
liver transplant from 19 y.o. brain dead donor ([**2104-8-22**])
EtOH cirrhosis, diagnosed 06/[**2103**].
HCC
Anemia
Essential thrombocytosis
Prior complications of ascites, malnutrition (now on tubefeeds),
portal hypertension with grade 2 esophageal varices. Peritonitis
[**7-18**], Duodenitis [**7-18**], Grade I rectal varices
Social History:
The patient owns business in [**Hospital3 **]: a clothing store and a
limousine business. Recently he started working from home due to
his poor health. He lives with his wife, who is very supportive.
He smokes. No drugs. Stopped EtOH in 6/[**2103**].
Family History:
Non contributory
Physical Exam:
T 98.2 P 88 BP 158/104 R 20 SaO2 95% RA
Gen: no acute distress, cachectic
Heent: non-icteric, oropharyngeal mucosa clear
Neck: supple, no lymphadenopathy
Lungs: decreased breath sounds left lower lobe
Heart: RRR
Abd: soft, nontender, nondistended, bowel sounds +, no guarding,
nonrigid
Extrem: warm, well-perfused
Pertinent Results:
On Admission: [**2106-3-17**]
WBC-9.5# RBC-4.18* Hgb-10.5* Hct-32.6* MCV-78*# MCH-25.2*#
MCHC-32.3 RDW-16.1* Plt Ct-401#
PT-16.3* PTT-44.8* INR(PT)-1.5*
Glucose-94 UreaN-47* Creat-3.2*# Na-140 K-6.3* Cl-119* HCO3-13*
AnGap-14
ALT-47* AST-66* LD(LDH)-511* AlkPhos-48 Amylase-103* TotBili-0.9
Lipase-38 Albumin-3.0* Calcium-7.8* Phos-2.1* Mg-1.8 Iron-18*
Cholest-163
calTIBC-216* Ferritn-1208* TRF-166*
Triglyc-212* HDL-39 CHOL/HD-4.2 LDLcalc-82
TSH-3.8 PTH-189* T4-10.3 T3-62*
AFP-3.0
PSA-0.7
IgA-242
rapmycn-15.0*
tTG-IgA-6
PREALBUMIN 13 (L)
ZINC- 53 (L)
VITAMIN D [**3-7**] DIHYDROXY 10
VITAMIN A (RETINOL) 45
.
At Discharge: [**2106-4-5**]
WBC-8.8 RBC-4.45* Hgb-11.9* Hct-35.5* MCV-80* MCH-26.8*
MCHC-33.6 RDW-17.8* Plt Ct-750*
Glucose-118* UreaN-69* Creat-2.7* Na-137 K-3.9 Cl-102 HCO3-27
AnGap-12
ALT-32 AST-47* AlkPhos-166* TotBili-0.6
rapmycn-4.8*
Brief Hospital Course:
67 y/o male about 2 years out from liver transplant with
multiple issues upon admission.
Patient profoundly weak and emaciated with history of severe
diarrhea, poor PO intake, dehydration. It was determined that
the patient was a candidate for a PEG tube which was placed by
Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. Due to concerns for malabsorption the patient
was initially started on Vivonex, an elemental formula.
GI service performed EGD and colonoscopy and found fatty stool,
and concern was raised for pancreatic insufficiency. A stool
elastase was sent off which was negative. GI mucosal path was
normal.
The renal team was consulted for acute on chronic renal failur.
He was started on bicarbonate. Likely due to RTA.
Anemia of chronic disease treated with continued epogen and
started iron supplementation.
A cardiology consult was obtained. Echo in the past showed an EF
of around 50%. An ECHO was performed and he was found to have :
Severe regional and global left ventricular systolic
dysfunction, c/w CAD. Regional right ventricular systolic
dysfunction, c/w CAD. Moderate secondary mitral regurgitation.
Moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of [**2104-6-3**],
biventricular systolic function has significantly deteriorated,
with probable interim inferoposterior myocardial infarction.
Severity of mitral regurgitation and pulmonary hypertension has
increased.
Treatment was limited by concurrent renal failure and an ACE/[**Last Name (un) **]
could not be started at this time. He was maintain on beta
blocker and ASA. Further evaluation at this time was not
undertaken (stress) but will be followed up as an outpatient.
When he was initially admitted from [**Hospital3 **] Hospital, it was
thought he had a RLL pneumonia. He was started on Levaquin. CT
done on HD 8 showed Heterogeneous perfusion in the liver with
large bilateral pleural effusions, cardiomegaly, and small
amount of ascites are compatible with right heart
failure/hepatic congestion.
The levaquin was d/c following a 10 day course. Pulmonary
consult did not recommend thoracentesis at that time. Pneumonia
prophylaxis complete.
C Diffs had been sent and were negative. Immodium was started
with some relief of the diarrhea. Creon was started on the
advice of the hepatology teasm due to findings of fatty stool.
This in combination with the immodium reduced the stool output
grewatly and in fact the immodium was held for several days
awaiting return of stool. He will remain on the creon as an
outpatient and use the immodium PRN as stooling dictates.
On HD 11, the patient had increased complain of SOB and became
quite anxious. His SaO2 dropped into the 70's and an xray
confirmed worsening pulmonary edema. He was transferred to the
SICU. He was diuresed with excellent results. Cardiology did not
feel this was an acute ischemic event. Using Esmolol briefly and
good diuresis with Lasix he continued to improve his respiratory
status, returned to his best weight of around 44 kg and was able
to be [**Last Name (un) 72013**] transferred back to regular surgical floor.
Serial chest xrays showed resolution of the pulmonary edema. He
is started on Lasix 40 PO daily and will continue this at home.
Tuibe feedings were changed to nutren pulmonary and he did not
have return of diarrhea. He will be discharged to home on this
formula via the PEG tube.
Alk phos took a slight increase to 270. Liver ultrasound showed
concern for some biliary dilitation. However the alk phos was
[**Last Name (un) 7162**] trending down and although an ERCP was considered, it was
not pursued at this time.
One final note on CT of abdomen. a newly apparent 5-mm
arterially enhancing focus in segment IV was seen. For now this
will be followed as an outpatient with no current intervention
planned.
Patient is discharged to home with tube feeds via PEG, Lasix
daily with instructions to weigh daily. Monitor also for return
of diarrhea. He will follow up with cardiology as an otpatient
and may do this with a cardiologist on [**Location (un) **] as desired with
the month.
Some adjustments were made to immunosuppression while in house.
These are reflected in OMR.
Medications on Admission:
Dronabinol 2.5'', Epoetin [**Numeric Identifier 389**] units SC qweekly, Tricor 48,
metoprolol 50'', CellCept [**Pager number **], prednisone 5, Sirolimus 4,
testosterone 2.5 mg/24 hour patch daily, Asa 81, FeSO4 325,
prilosec 20, bactrim 400/80 MWF
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 **]
Discharge Diagnosis:
malnutrition
systolic dysfunction, chronic, ef 19%
acute on chronic renal failure
anemia
gastritis
malnutrition
diarrhea
Discharge Condition:
stable
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if fever, chills,
nausea, vomiting, inability to take any of your medications,
malfunction of the PEG tube, abdominal distension, worsening
diarrhea or continued weight loss.
Weigh yourself daily, your weight should be approximately 96
pounds. Weigh yourself when you get home today and make note of
your weight with your home scale. If you find you are more than
2 pounds above or below this number please call the transplant
office for guidance on your lasix dosing.
Continue outpatient labs per transplant clinic guidelines
Followup Instructions:
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2106-4-14**]
2:00
Follow up with Cardiologist within the month. [**Name6 (MD) 116**] see MD on [**Location (un) 28985**] or come to [**Location (un) 86**] per your preference
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]
Completed by:[**2106-4-6**] Name: [**Known lastname 12047**],[**Known firstname **] H Unit No: [**Numeric Identifier 12048**]
Admission Date: [**2106-3-17**] Discharge Date: [**2106-4-5**]
Date of Birth: [**2039-3-9**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 48**]
Addendum:
Discharge Medications as follows:
Discharge Medications:
1. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO BID (2 times a day).
3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. Epogen 20,000 unit/mL Solution Sig: One (1) ml Injection once
a week.
5. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
8. Testosterone 2.5 mg/24 hr Patch 24 hr Sig: One (1) Patch 24
hr Transdermal DAILY (Daily).
9. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
11. Amylase-Lipase-Protease 33,200-10,000- 37,500 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
Disp:*90 Cap(s)* Refills:*2*
12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Ferrous Sulfate 300 mg (60 mg Iron)/5 mL Liquid Sig: Five
(5) ml PO TID (3 times a day).
Disp:*450 ml* Refills:*2*
14. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
Disp:*30 Capsule(s)* Refills:*2*
15. Loperamide 1 mg/5 mL Liquid Sig: Five (5) ml PO twice a day.
Disp:*300 ml* Refills:*2*
16. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*2*
17. Sirolimus 1 mg/mL Solution Sig: Three (3) PO DAILY (Daily).
18. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*2*
19. Nutrition
Nutrition
Nutren Pulmonary Full strength; Goal rate: 55 ml/hr Continuous
Flush w/ 30 ml water q8h Dispense qs 1 (one) month supply
Refills 2 (Two)
Discharge Disposition:
Home With Service
Facility:
VNA Assoc. of [**Hospital3 709**]
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]
Completed by:[**2106-4-6**]
|
[
"V11.3",
"787.91",
"285.9",
"V42.7",
"263.9",
"486",
"799.4",
"403.90",
"425.4",
"572.3",
"584.9",
"276.51",
"428.0",
"585.4",
"428.23",
"456.21",
"276.7",
"V10.07"
] |
icd9cm
|
[
[
[]
]
] |
[
"43.11",
"45.25",
"45.16",
"38.93",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
11616, 11833
|
3332, 7544
|
345, 414
|
8071, 8080
|
2453, 2453
|
8718, 9609
|
2081, 2099
|
9632, 11593
|
7927, 8050
|
7570, 7822
|
8104, 8695
|
2114, 2434
|
3081, 3309
|
272, 307
|
442, 1440
|
2467, 3067
|
1462, 1794
|
1810, 2065
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
12,118
| 152,517
|
24629
|
Discharge summary
|
report
|
Admission Date: [**2108-3-15**] Discharge Date: [**2108-3-30**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
respiratory distress
Major Surgical or Invasive Procedure:
OR for staged repair, [**3-15**] R femur retrograde rod and L IM rod
removal, 3/24 L IT fx repair
ORIF R femur done - [**2108-3-15**] - WBAT
ORIF L femur IT fracture [**2108-3-16**]
History of Present Illness:
85F w/ htn, demential, osteoporosis, frequent falls, now pod [**2-25**]
s/p staged repair of femoral and intra-chonteric fx now
transferred to micu from ortho for evaluation of resp distress.
Records somewhat limited but extubated [**3-17**] after peri-operative
course c/b hypotension, oliguria requiring neosynephrine.
Transferred to floor when noted to be occasionaly tachycardic,
tachypneic and agiatated. Being treated for UTI. Geriatrics
consult called for evaluation of delirium and noted to be
increasingly tachycardic, hypoxic so undewent chest ct/cta which
did show LUL PE and evidence of diffuse patch bilateral ground
glass opacity c/w pna and bilateral lobe collapse. INitial ABG
7.44/32/50 and by time medical floor team evaluated, pt
tachypneic to 40's, satting in mid 90's on shovel mask. Given
elevated JVP, crackle on exam, initially bipap to icu and
diuresed nearly 2 liters with some improvement to resp status.
However, several hourse into micu course, became increasingly
tachycardic and tachypenic and ultimately intbuated for clinical
demise. Post intubation, pt hypotensive to 60's and marginal
urine output requring pressors and central venous access which
revealed cvp 1.
Past Medical History:
dementia
freqeunt falls
osteoporosis
s/p hip/femoral repair as above
Social History:
lives with husband
son lives upstairs with his family
Family History:
non-contributory
Physical Exam:
Patient passed [**2108-3-30**]
Pertinent Results:
RADIOLOGY [**2108-3-20**]:
=================
CT OF THE CHEST WITH AND WITHOUT IV CONTRAST: Filling defect is
seen within a left upper lobe pulmonary artery, best seen on
series 3, image 126, concerning for pulmonary embolism. Diffuse
multifocal patchy ground-glass opacities are seen within the
lungs bilaterally consistent with infectious process. There is
evidence of bilateral lower lobe collapse and pleural effusions.
Limited views of the upper abdomen are unremarkable.
Degenerative changes are seen throughout the spine and within
the shoulders.
.
IMPRESSION:
1. Left upper lobe pulmonary embolism.
2. Diffuse patchy ground-glass opacities seen within the lungs
bilaterally consistent with pneumonia.
3. Bilateral lower lobe collapse and pleural effusions.
.
ECHO [**3-20**]:
===========
Conclusions:
The left atrium is normal in size. Left ventricular wall
thicknesses and
cavity size are normal. There is moderate regional left
ventricular systolic dysfunction with severe hypokinesis of the
inferior wall, mid inferolateral wall, and distal half of the
septum. The right ventricular cavity is moderately dilated with
focal hypokinesis of the apical half of the free wall. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion. Trace aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Right ventricular cavity enlargement with free wall
hypokinesis. Regional left ventricular systolic dysfunction c/w
CAD. Pulmonary artery systolic hypertension.
Brief Hospital Course:
Respiratory Failure: Patient was transferred to the ICU on
[**2108-3-19**] for hypoxic respiratory failure. Of note, pt had been
just transferred to Medicine from the Orthopaedic service. At
time of initial evaluation, noted to be tachypneic to 40's and
satting in low 90's on non-rebreather. Chest CTA earlier in the
day had demonstrated left segmental pe, multi-lobar PNA, and
evidence of CHF. While patient initially responded to CPAP and
diuresis, her tachypnea persisted and given hypoxia, intubated
on the evening of [**3-19**]. Of note, abg consistently showed
evidence of respiratory alkolosis. As alluded to above, the
etiology of respiratory failure thought to be multifactorial
from PE, CHF and PNA. Managment of PE was complicated however by
bleeding into her L gluteal surgical site s/p PBRC transfusions.
Broad spectrum abx (Ceftaz/Vanco/Flagyl) which was switched to
only vancomycin for MRSA in sputum [**6-29**] day course [**Date range (1) 62187**].
Then placed on Vanco/Zosyn for possible LLL PNA, started
[**2108-3-28**]. Pt was diruesed aiming for negative 1L/day - limited by
hypotension. Was PS 5/5 and then after family meeting the
decision was made to extubate her with no intubation. Since she
did not do well after extubation and interval bipap- family made
her CMO. She was pronounced dead on [**2108-3-30**] secondary to
respiratory failure.
Hypotension: Pt initially tachycardic and mildly hypertensive
upon presentation to MICU. As mentioned above, diuresed as part
of therapy for CHF. Upon intubation, pt noted to become
hypertensive requiring aggressive IVF and Levophed for pressor
support. Initially CVP was 1 suggesting that patient had perhaps
been diursed too quickly for her to equilibrate. This may have
been compounded by sedatives and pna. She was resusciated with
several liters of fluid and by late [**3-20**], has not required
further pressor support. As mentioned above, she does have
evidence of PNA being treated with abx. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 104**] stim did not
reveal evidence of adrenal insuffiency. She was tolerating
diuresis and beta-blocker. She transiently required pressors,
but the week b/f death had normal BP without pressor support.
CHF: Pt did have echo showing ef 30-35 with regional wall
motions. She has no echo for prior comparison although pt did
have positive enzymes during her MICU presentation. As mentioned
above, CHF was thought to be part contributor to her respiratory
failure, and as such, has been diuresed with iv lasix. She was
also started on low dose beta-blocker did not tolerate an ACEI
secondary to hypotension.
NSTEMI: As mentioned above, pt did have positive troponins upon
her presentation to the MICU. It was not clear if cardiomyopathy
is the direct result of her MI. She was managed with Aspirin,
statin, and low dose beta-blocker for her tachycardia.
Anemia: As alluded to above, pt had required several units of
blood. The etiology of her transfusion dependence was thought to
be related to bleeding within her left gluteal surgical site. In
fact, an abominal ct on [**3-24**] demonstrated large hematoma in left
gluteal region that was believed to be associated with left
femoral fracture. Her HCT stabilized even after heparin
restarted.
Pulmonary Embolism: Found with left upper lobe on PE on chest
CTA [**3-19**]. It was thought that this PE may be one contributor to
respiratory failure. She was managed with iv heparin.
Left femoral neck/Right trochanteric fracture: History of
multiple falls and fractures secondary to osteoporosis and pt
was initially transferred to [**Hospital1 18**] from OSH on [**3-15**] after noted
to have right trochanteric fracture. Her case had been
complicated by the discovery of bilateral fractures that was
treated with staged surgery.
Medications on Admission:
Meds on transfer
haldol
hep gtt
vit d
mvi
actonel
metoprolol 50 [**Hospital1 **]
levaquin
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Respiratory Failure
PE
CHF
PNA
Discharge Condition:
Death
Discharge Instructions:
None
Followup Instructions:
None
Completed by:[**2108-4-1**]
|
[
"401.9",
"518.0",
"821.01",
"733.00",
"294.8",
"415.19",
"998.12",
"276.3",
"599.0",
"820.22",
"E885.9",
"285.1",
"V43.65",
"428.20",
"V15.88",
"996.49",
"482.41",
"788.5",
"410.71",
"V09.0",
"518.5",
"276.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"00.17",
"79.15",
"96.04",
"79.35",
"96.6",
"38.93",
"78.65",
"93.90",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7652, 7661
|
3667, 7483
|
281, 466
|
7735, 7742
|
1961, 3644
|
7795, 7829
|
1877, 1895
|
7623, 7629
|
7682, 7714
|
7509, 7600
|
7766, 7772
|
1910, 1942
|
221, 243
|
494, 1696
|
1718, 1788
|
1804, 1861
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,714
| 169,157
|
51695
|
Discharge summary
|
report
|
Admission Date: [**2157-9-26**] Discharge Date: [**2157-10-6**]
Date of Birth: [**2093-5-22**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Fever
Persistent Abdominal Pain
Major Surgical or Invasive Procedure:
Abdominal Wound Drainage
History of Present Illness:
This is a 64 year odl female s/p a Whipple on [**2157-8-25**] that
presents with fevers for the past 2-3 days. She was at the Rehab
facility on TPN and oral Percocet for pain. She does not report
chills or aches. She was doing well at rehab otherwise.
This is her second re-admission for fever and abdominal pain.
Past Medical History:
Fever
Abdominal Abscess
[**2157-8-25**]
1. Pylorus-preserving pancreaticoduodenectomy.
2. Open cholecystectomy.
Afib on coumadin, CAD, HTN, hyperchol, DM (diet controlled),
Arthritis, Gout, Cardiac Stent [**2148**]
Social History:
No smoking, no drinking
Family History:
Sister
Physical Exam:
VS: 99.2, 76, 124/74, 18, 99%RA
GEn: A+O x3
CV: RRR, normal S1, S2, no M/R/G
Abd: Rebound tenderness, no HSM
Ext: Edema in ankles, DP pulses L>R
Wound: C,D,I. No fluid, erythema around wound.
Pertinent Results:
[**2157-9-26**] 09:21PM BLOOD WBC-9.1 RBC-3.18* Hgb-9.6* Hct-29.1*
MCV-92 MCH-30.1 MCHC-32.9 RDW-17.8* Plt Ct-346
[**2157-10-6**] 06:16AM BLOOD WBC-6.2 RBC-2.87* Hgb-8.4* Hct-26.2*
MCV-91 MCH-29.3 MCHC-32.1 RDW-18.1* Plt Ct-389
[**2157-10-6**] 06:16AM BLOOD Plt Ct-389
[**2157-10-4**] 06:17AM BLOOD Glucose-87 UreaN-19 Creat-0.8 Na-132*
K-3.6 Cl-104 HCO3-20* AnGap-12
[**2157-9-26**] 09:21PM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-141
K-3.5 Cl-105 HCO3-31 AnGap-9
[**2157-10-2**] 01:37AM BLOOD ALT-25 AST-107* CK(CPK)-18* AlkPhos-209*
Amylase-27 TotBili-0.4
[**2157-10-5**] 05:31AM BLOOD Phos-3.3 Mg-1.6
CHEST (PA & LAT) [**2157-9-26**] 8:24 PM
[**Hospital 93**] MEDICAL CONDITION:
64 year old woman with fever s/p Whipple [**8-25**]
REASON FOR THIS EXAMINATION:
eval for source of fever, eval placement of PICC line (from
rehab)
CHEST, PA AND LATERAL: Comparison is made to [**2157-9-9**].
The tip of a left-sided PICC line terminates in the superior
vena cava. It terminates approximately 5 cm above the cavoatrial
junction. The cardiac and mediastinal contours are unchanged.
The lungs are clear. There are no pleural effusions or
pneumothorax.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Tip of PICC line in the superior vena cava.
Cardiology Report ECG Study Date of [**2157-9-30**] 3:00:12 AM
Baseline artifact
Regular narrow complex tachycardia - mechanism uncertain
Nonspecific ST-T abnormalities
Since previous tracing of the same date, no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
181 0 90 264/359.57 0 -6 143
Cardiology Report ECG Study Date of [**2157-10-1**] 11:37:34 AM
Sinus rhythm
Normal ECG
Since previous tracing of [**2157-9-30**], sinus tachycardia absent and
Q-Tc interval
appears shorter but may be no significant change
Read by: [**Last Name (LF) **],[**First Name3 (LF) 177**] W.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
79 128 84 392/426.42 6 -22 17
CT ABDOMEN W/CONTRAST [**2157-10-5**] 3:57 PM
INDICATION: 64-year-old female status post Whipple. Please rule
out intra- abdominal abscess.
COMPARISON: CT abdomen and pelvis [**2157-9-9**].
IMPRESSION: Multiple fluid collections within the periportal
region and just below the anterior abdominal wall within the
peritoneum at site of prior inflammatory change and extraluminal
air. These findings are concerning for multiple abscess
formation. There is no evidence of free air or extravasation of
oral contrast.
Brief Hospital Course:
She was admitted from a rehab facility on [**2157-9-26**] for further
work-up of her fever and abdominal pain.
She was made NPO. UA and CXR were done which were negative (no
acute process). Labs were drawn and essentially normal with a
WBC of 9.1 and HCT 29.1.
FEN: She was on TPN for several days. She was then started on a
PO diet and TPN was stopped on [**2157-9-30**]. She was tolerating a
regular diet at time of discharge.
Abd: She had known multiple fluid collections in the anterior
abdomen. Her abdomen was surgically opened and the abscess
drained at the bedside on [**2157-9-27**]. Approximately 100cc of
purulent fluid was drained. The wound was packed and she had
good granulation tissue to that wound. A Grape Juice trial was
negative.
She will continue with [**Hospital1 **] dressing changes.
A CT ABD/Pelvis: On [**2157-10-5**] Multiple fluid collections within
periportal region and just below the anterior abdominal wall
within peritoneum site of prior inflammatory change and
extraluminal air. These will not be drained and she will
continue on LEVO until her follow-up appointment.
Gout: She was noted to have gout to the right ankle.
Rheumatology was consulted and recommended Toradol for pain and
inflammation. Later during her admission, she was restarted on
her Allopurinol and Colchicine.
CV: At 3am on [**2157-9-30**], she woke up with chest pain radiating to
neck and arm associated with diaphoresis. Found to be in SVT
(AVNRT?) at a rate of 180. She was promptly transferred to the
ICU. Given adenosine- converted back to sinus tach. Pain
promptly resolved. Of note, pt's home dose of b-blocker and Ca
channel blocker was d/ced on this admission. Recommended
resuming these meds. She was started back on her home med and
remained in sinus the remainder of her admission. She will be
followed by her PCP for Coumadin management.
PT: She was cleared for home with PT.
Medications on Admission:
Tylenol, zyloprim, dulcolax, cardizem CD, Colace, nexium,
duragesic, heparin, novolin, toprol, MOM, percocet, vitamin K
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*qs Tablet Sustained Release 24HR(s)* Refills:*2*
6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
9. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Abdominal Abscess
Fevers
Discharge Condition:
good
Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain
Please resume all of your regular medications and take any new
medications as ordered.
Continue to ambulate several times per day.
Continue with dressing changes twice/day.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment.
Completed by:[**2157-10-6**]
|
[
"715.90",
"998.59",
"414.01",
"274.9",
"682.2",
"V45.82",
"427.89",
"272.0",
"427.31",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.07",
"86.04",
"81.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
6958, 7016
|
3776, 5679
|
345, 372
|
7085, 7092
|
1247, 1895
|
7474, 7633
|
1012, 1020
|
5849, 6935
|
1932, 1984
|
7037, 7064
|
5705, 5826
|
7116, 7451
|
1035, 1228
|
274, 307
|
2013, 3753
|
400, 716
|
738, 955
|
971, 996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,862
| 185,410
|
2657
|
Discharge summary
|
report
|
Admission Date: [**2189-8-5**] Discharge Date: [**2189-8-19**]
Date of Birth: [**2128-5-9**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Mucositis, rash
Major Surgical or Invasive Procedure:
none
History of Present Illness:
61 yo male with h/o HCC in the setting of HCV cirrhosis
progressed on sorafinib, started cabcitabine on [**7-24**], which was
stopped on [**7-31**] due to mucositis pain and severe scrotal pain.
He is found to be neutropenic on admission. The patient was
admitted for IV fungal therapy. Mr. [**Known lastname 3321**] started the
Xeloda on [**7-24**] and, shortly thereafter, he developed severe
mucositis primarily of oral cavity along with severe dysphagia.
As instructed, he stopped the medication on [**7-31**] but has
remained bed ridden for the past 5
days. His oral intake has been very minimal but has tried to
maintain good fluid intake. He has not been able to take
anything of solid nature including routine medications. He also
complains of sore erythematous area in the right underarm and
severe burning scrotal pain. His wife has tried applying topical
antibiotic to the scrotal area without significant relief. Mr.
[**Known lastname 3321**] has tried the magic mouth wash swish and gargle
(lidocaine, mag hydroxide and benadryl) with minimal relief. He
had multiple episodes of nausea and vomiting over the past few
days with nonbloody emesis on occasions and dry heaves on
others.
ROS is negative for jaundice, pruritis, scleral icterus,
abdominal pain, constitutional symptoms, fatigue, nausea or
vomiting.
Past Medical History:
Asbestosis
Pulmonary nodules and calcified pleural plaques
Alcoholic Cirrhosis, dx [**2163**]
HCV
Hepatocellular carcinoma
ONCOLOGIC HISTORY: Mr. [**Known lastname 3321**] is a 61-year-old male with
history of alcoholic cirrhosis who was noted to have elevated
AFP
in [**3-/2188**] (560) which rose to 944 in [**9-12**]. However, serial
MRIs failed to detect a focal lesion until [**8-/2188**] when a 3-cm
mass at the interface of segments IV and II was seen. However,
the tumor did not display classic features of HCC and was in
close proximity to a dilated intrahepatic bile duct. This raised
the possibility of a mixed histology tumor or possibly
cholangiocarcinoma. Triple phase CT of the liver on [**2188-9-8**]
identified a 3.2-cm focal hypodense lesion in segment II with no
enhancement in the arterial phase or attenuation in the delayed
imaging. The findings were nonspecific for HCC or
cholangiocarcinoma. The high AFP was most consistent with HCC.
Biopsy (and RFA) were not feasible given the close proximity to
the umbilical vein. Despite the uncertainty about the diagnosis,
Mr. [**Known lastname 3321**] elected to proceed with TACE, which took place on
[**2188-9-12**]. Repeat TACE for residual disease occured [**2188-11-11**].
While surveillance MRI in [**12-14**] revealed no clear evidence
of residual or new disease, the one from [**3-14**] detected an
enhancing mass in segment II/[**Doctor First Name 690**], which had increased in size
and represented further growth of residual HCC. The mass
appeared
to be obstructing the left hepatic duct. Subsequent ERCP
revealed
an irregular filling defect in the left main hepatic duct with
peripheral dilation. Cytology revealed "atypical" cells and a
pigtail biliary stent was successfully placed over the
stricture.
On [**2189-4-7**], the patient underwent successful CT-guided
liver biopsy which demonstrated HCC. The tumor cells were
positive for keratin cocktail, CK7, MOC31, and CEA (focally,)
and PAX-2, and negative for HepPar1, CK20, S-100, vimentin,
chromogranin, synaptophysin, and RCC. Morphologically, the tumor
was most consistent with hepatocellular carcinoma. The AFP rose
dramatically over [**Month (only) 547**] and [**2189-4-4**], which was highly
concerning for rapid disease progression. Because the patient
was
uninterested in repeat TACE, systemic therapy was initiated
using
Nexavar on [**2189-5-5**] in the setting of protocol 09-326 but was
taken off of it on [**2189-7-22**] due to disease progression.
Social History:
Married, 3 children, 5 grandchildren, lives in [**Location 686**], never
smoked, quit alcohol abuse in mid [**2158**], works maintenance
supervisor for [**Location (un) 86**] Globe. Worked in construction for many
years.
Family History:
Father passed away from colon cancer. Mother passed away from
cancer of unknown etiology
Physical Exam:
ON ADMISSION:
Vital Signs sheet entries for [**2189-8-5**]:
BP: 128/78. Heart Rate: 100. Weight: 225.8. Height: 67.5. BMI:
34.8. Temperature: 99.1. Resp. Rate: 20. Pain Score: 0. O2
Saturation%: 96.
GEN: Alert and oriented x 3, obviously difficult to speak [**1-6**]
pain and dry mouth, somewhat sleepy.
HEENT: Visible multifocal areas of stomatitis and glossitis. The
hard and soft palate contain areas of denuded mucosa. Lips dry
and cracking.
LYMPHATICS: No cervical or supraclavicular lymphadenopathy.
CARDIAC: RRR, normal S1/S2, no rubs or murmurs.
CHEST: CTA b/l. Bilateral gynecomastia.
BACK: no spinal or CVA tenderness
ABD: +BS, soft, nontender, no palpable HSM or masses. ?shingles
type rash left abdomen/flank, ringworm like lesion right axilla
EXTREMITIES: 2+ Pitting edema of right leg without cyanosis or
clubbing.
NEUROLOGIC: Cranial nerves II through XII grossly intact
bilaterally. Gait not assessed.
Groin: Severely excoriated scrotum and serous drainage on the
patient's underwear. Discharge is maloderous
Pertinent Results:
[**2189-8-5**] 03:50PM BLOOD WBC-1.6* RBC-5.06# Hgb-16.4# Hct-47.2#
MCV-93 MCH-32.4* MCHC-34.7 RDW-13.4 Plt Ct-29*
[**2189-8-5**] 03:50PM BLOOD PT-22.5* PTT-33.4 INR(PT)-2.1*
[**2189-8-5**] 03:50PM BLOOD ALT-29 AST-38 AlkPhos-121 TotBili-4.2*
[**2189-8-5**] 03:50PM BLOOD AFP-4776*
[**2189-8-13**] 05:02AM BLOOD WBC-0.6* RBC-3.00* Hgb-9.9* Hct-29.6*
MCV-99* MCH-33.0* MCHC-33.5 RDW-14.5 Plt Ct-10*
[**8-8**] CXR: NG tube tip is most likely in the fourth portion of the
duodenum.
[**8-9**] Abd U/S: Nondiagnostic ultrasound examination secondary to
body habitus and overlying bowel gas. CT examination
recommended.
Brief Hospital Course:
Mr. [**Known lastname 3321**] is a 61-year-old male with alcoholic cirrhosis
and hepatocellular carcinoma status post transarterial
chemoembolization [**2188-9-12**] and repeat on [**2188-11-11**] for residual
disease. He developed disease recurrence based on MRI in early
[**Month (only) 547**], CT-guided biopsy and precipitous rise in AFP. Mr.
[**Known lastname 13300**] disease progressed after a short course of
sorafenib. He has developed severe dermatitis and mucositis
related to Xeloda started 1.5 weeks before admission.
#. Mucositis - this was thought to be secondary to Xeloda, which
was stopped on [**7-31**]. Patient was given Gelclair along with
magic mouthwash, as well as general oral care. Morphine was
given for pain. The patient had not eaten for several days on
admission, so nutrition was consulted and TPN was begun on [**8-7**]
for proper nutrition. On transfer to the [**Last Name (LF) 153**], [**First Name3 (LF) **] NGtube was
placed to allow for PO medications. The mucositis persisted
through the hospitalization.
#. Axillary rash - the patient presented with an axillary rash
on admission that had been evolving over the previous week and
was described as painful and pruritic. Dermatology was
consulted and biopsied for pathology, with bacterial and fungal
cultures. They also performed DFA on the rash. Acyclovir as
well as IV antifungal treatment were instituted empirically out
of concern for viral and fungal etiologies. The axillary
culture grew out sparse MSSA, most likely a skin colonizer, but
given the patient's neutropenic status, and the plan to continue
neutropenic antibiotic coverage, this was of little clinical
significance.
#. Severe scrotal pain - the patient presented with severe
scrotal ulcerations that had evolved over the last week. It
started as what looked like white papules according to the
patient's family, and subsequently became erythematous and very
painful, making it difficult to urinate. On admission blood
cultures were taken for both bacterial and fungal etiologies.
Dermatology was consulted and believed the rash looked as if it
was viral, and took a biopsy from the axillary area that looked
quite similar. IV antifungal and antiHSV treatment was
instituted during admission as described above. Acyclovir was
planned for a 10 day course.
#. Pancytopenia- the patient was found to be pancytopenic on
admission, but afebrile. This was believed to be secondary to
the patient's xeloda therapy, and of uncertain future duration.
He was put on neutropenic precautions and started on on
vancomycin, ceftazidime, fluconazole and acyclovir for infection
prevention on [**8-5**]. Fluconazole was later discontinued for
micafungin, and ceftazidime discontinued for cefepime. ID was
consulted on [**8-7**], and recommended discontinuing micafungin for
fluconazole. Neupogen was started as well and maintained at 480
mg qdaily. Vancomycin was stopped on [**8-12**]. He was continued on
cefepime, fluconazole, acyclovir, flagyl, with the plan to
discontinue acyclovir after a 10 day course, discontinue flagyl
after a 10 day course, and defer to the oncology service as to
when to discontinue cefepime and fluconazole. His platelet
levels trended down over the hospitalization, and on [**8-13**] he
received a unit of platelets for a count of 10 (goal >10).
#. Altered mental status: on the day after admission, patient
was found to have altered mental status via increased lethargy
and waxing and [**Doctor Last Name 688**] levels of consciousness. Based on exam
findings, etiology was likely due to encephalopathy from
hepatic, infectious, or metabolic causes. Patient was
transferred to the [**Hospital Unit Name 153**] for furhter evaluation/treatment. Given
patient's mental status he had been unable to take his
lactulose, so an NG tube was placed immediately and his
lactulose was aggressively titrated up. His mental status
quickly improved, making an infectious source less likely. An
LP and further imaging were deferred. A RUQ ultrasound was
attempted to evaluate for portal vein thrombus, but given the
patient's large body habitus, the liver and its vasculature
could not be visualized. Another possibility that was
entertained was encephalitis secondary to toxic levels of the
patient's xeloda. Given the patient's improvement in mental
status, no MRI of the brain was pursued to evaluate this
hypothesis. However, given that xeloda is renally cleared, all
further contrast studies that could impair the kidneys (and
therefore impair the clearance of any remaining xeloda) were
deferred. The patient's mental status resolved to near-baseline
and he was transferred to the floors.
#Sepsis and Hepatic Failure: Several days following his transfer
to the floors, the patient was transferred back to the [**Hospital Unit Name 153**] in
the setting of hypotension to 79/45 (from baseline of SBP in the
90s), and several episodes of desaturation to the mid-80s while
on the oncology floor. His cxray showed increased bibasilar
atelectasis, and his WBC had begun to increased to 3.8 (with 17
bands) from 1.9 the day prior. Given these findings, along with
his large amount of oral secretions, he was believed have an
aspiration PNA. His abx coverage was broadened to include vanco
and zosyn in addition to cefepime and metronidazole. He
required 2 pressors in order to maintain MAPs>55, and even then,
was periodically bradycardic to the 30s-40s. His WCC continued
to rise to 15, and his lactate rose to 4. He had worsening
infiltrates on CXR and his mental status continued to
deteriorate. His bilirubin and INR began to rise. Discussions
were held with family regarding the patient's failure to respond
to aggressive therapy, along with the poor prognosis of his
underlying condition. The family opted to make him comfort
measures only. On [**8-19**] at 4:35pm, the patient expired in the
company of his family.
Medications on Admission:
CAPECITABINE [XELODA] - 500 mg Tablet - 3 Tablet(s) by mouth
twice a day (this medicine was stopped on [**7-31**])
FUROSEMIDE - 40 mg Tablet - one Tablet(s) by mouth twice a day
LIDOCAINE-DIPHENHYD-[**Doctor Last Name **]-MAG-[**Doctor Last Name **] [FIRST-MOUTHWASH BLM] - 400
mg-400
mg-40 mg-25 mg-200 mg/30 mL Mouthwash - 10 cc swish, gargle and
spit every 4 hours as needed as needed for mouth pain
LORAZEPAM - 1 mg Tablet - 1 Tablet(s) by mouth 60 minutes prior
to mri may repeat x 1 if needed
MORPHINE - 10 mg/5 mL Solution - 1 -2 teaspoons by mouth every
6-8 hours as needed for Mouth pain
NADOLOL - 20 mg Tablet - 1 Tablet(s) by mouth daily
ONDANSETRON - 8 mg Tablet, Rapid Dissolve - 1 Tablet(s) by mouth
every eight (8) hours as needed for nausea
PROCHLORPERAZINE MALEATE - (Not Taking as Prescribed: not
taking, not needed. but have at home) - 5 mg Tablet - [**12-6**]
Tablet(s) by mouth every 6 hours as needed for Nausea
SILDENAFIL [VIAGRA] - 100 mg Tablet - 1 Tablet(s) by mouth once
a
day as needed for prn
SPIRONOLACTONE - 100 mg Tablet - one Tablet(s) by mouth daily
Medications - OTC
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] - (OTC) - 500 mg Tablet
-
2 Tablet(s) by mouth 1-2 times daily prn for leg pain
Discharge Disposition:
Expired
Discharge Diagnosis:
Primary: Sepsis, Hepatic Failure
Secondary: Hepatocellular Carcinoma, Cirrhosis
Discharge Condition:
Expired [**8-19**] at 4:35pm
|
[
"682.3",
"528.01",
"E933.1",
"V11.3",
"995.92",
"276.4",
"V85.4",
"608.89",
"584.9",
"693.0",
"155.0",
"785.52",
"275.3",
"285.9",
"038.9",
"518.89",
"507.0",
"288.03",
"286.9",
"284.1",
"070.44",
"276.2",
"501",
"571.2",
"V87.41",
"054.9",
"276.8",
"276.0",
"787.20",
"456.21"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.11",
"38.93",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
13475, 13484
|
6273, 9627
|
329, 335
|
13607, 13638
|
5633, 6250
|
4480, 4570
|
13505, 13586
|
12227, 13452
|
4585, 4585
|
274, 291
|
363, 1692
|
4599, 5614
|
9642, 12201
|
1714, 4226
|
4242, 4464
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
55,363
| 153,550
|
52114
|
Discharge summary
|
report
|
Admission Date: [**2136-3-29**] Discharge Date: [**2136-4-2**]
Date of Birth: [**2075-4-23**] Sex: M
Service: NEUROSURGERY
Allergies:
Aspirin / phenobarbital
Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
hand numbness
Major Surgical or Invasive Procedure:
[**2136-3-29**]: C3-4 ACDF
History of Present Illness:
Patient is a 60 year old gentleman who is a patient of Dr
[**Last Name (STitle) 107844**]. He is followed by him for epilepsy which began
following a head injury when he was 17 years of age. He was
being seen by Dr [**Last Name (STitle) **] recently when he was noted to have
weakness and sensory deficit most likely attributable to
cervical spine
disease. As such an MRI scan of the cervical spine was obtained
which showed he had disc herniations at multiple levels of
varying severity. The patient describes numbness in both hands
in a C7/8 distribution. He also describes numbness in both legs
beginning at the knee and radiating down to his ankle. In
addition he says he has had recent visual changes which are
being evaluated by an eye doctor and that he has had a few
episodes of urinary urgency. Of note he was diagnosed with
carpal tunnel by an orthopod following nerve conduction studies
however he does not have clinic signs consistent with the
diagnosis. He denies nausea, headache, vomiting, dizziness,
changes in hearing or speech, or changes in bowel habits.
Past Medical History:
HTN, hep C, seizures, deviated septum, cervical spondylosis,
ADD, Left VI nerve palsy, depression, right shoulder surgery
[**2125**], gonorrhea, syphilis, trigger finger, GERD, Barretts
Esophagitis, peripheral neuropathy
Social History:
works as insurance rep at [**Hospital3 **], no tobacco, rare
etoh, no drugs
Family History:
non-contributory
Physical Exam:
Discharge exam: motor was [**4-7**] bilaterally, sensory intact to
light touch, incision is c/d/i with steri strips. Trachea is
deviated to the left. Hard collar in place
Pertinent Results:
[**3-29**] Cervical X-ray - Multiple lateral views of the cervical
spine from the operating room demonstrates interval placement of
anterior fusion plate and graft material at C3-C4 and at C5-C6.
Please refer to the operative note for additional details. There
are no signs for hardware-related complications.
[**3-30**] Cspine CT - No evidence of acute fracture or malalignment.
Cervical hardware appears appropriately positioned.
[**3-30**] CXR - The ET tube tip is 4.5 cm above the carina. NG tube
tip is in the stomach. Heart size and mediastinum appear to be
stable. Mild pulmonary edema is still present, although improved
since the prior study. Bibasal opacities have improved as well,
most likely consistent with atelectasis.
[**3-31**] CXR - 1. Endotracheal tube remains approximately 3 cm above
the carina. Lung volumes remain low with patchy streaky
opacities throughout, suggestive of residual edema superimposed
on chronic interstitial disease or areas of patchy atelectasis.
Bilateral pneumonia would be much less likely. Multiple
right-sided old rib fractures are again seen. The heart remains
stably enlarged. The mediastinum also remains widened but is
unchanged since [**2136-3-29**], and therefore may be related to
patient positioning rather than representing a true finding. No
pleural effusions. No large pneumothorax.
[**4-1**] CXR - There has been removal of endotracheal tube. There is
fusion plate within the
lower cervical spine. There is cardiomegaly with left
ventricular prominence.
There is atelectasis at the lung bases, right side worse than
left. There is
mild prominence of the pulmonary interstitial markings
suggestive of fluid
overload. Small right CP angle blunting is suggestive of a small
effusion
Brief Hospital Course:
60yo gentleman electively presented for C3-4 ACDF. Surgery was
without complication and he tolerated it well. He was extubated
and transferred to the PACU. While in the PACU he developed
significant tracheal edema and required re-intubation which was
very difficult and required multiple attempts. He was then
started on decadron and transferred to the ICU. On [**3-30**] he was
EO but remained intubated. He was able to MAE's antigravity and
follow simple commands. A CT C-spine was requested and showed
intact hardware. He was transferred to floor on [**3-31**] in stable
condition.
A CXR was obtained on [**3-31**] and [**4-1**] showed evidece of slight
pulmonary edema vs. penumonia. He was diuresed according and
maintained oxygenation. On [**3-23**] he was stable for discharge.
Medications on Admission:
lopressor, norvasc, quinapril, hydralazine, triamterene/HCTZ,
omeprazole, dilantin, neurontin, flonase, ambien,
hydroxychloroquin, ritalin
Discharge Medications:
1. Outpatient Occupational Therapy
please evaluate and treat hand weakness
2. Outpatient Physical Therapy
peripheral neuropathy / poor position sense
please evaluate and treat
pt uses a cane at baseline
3. docusate sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
4. oxycodone-acetaminophen 5-325 mg Tablet [**Month/Year (2) **]: One (1) Tablet
PO every 4-6 hours as needed for pain .
Disp:*80 Tablet(s)* Refills:*0*
5. amlodipine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a
day).
6. phenytoin sodium extended 100 mg Capsule [**Month/Year (2) **]: Two (2) Capsule
PO QAM (once a day (in the morning)).
7. phenytoin sodium extended 100 mg Capsule [**Month/Year (2) **]: Three (3)
Capsule PO QPM (once a day (in the evening)).
8. gabapentin 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*0*
9. hydroxychloroquine 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID
(2 times a day).
10. triamterene-hydrochlorothiazid 37.5-25 mg Capsule [**Month/Year (2) **]: One
(1) Cap PO DAILY (Daily).
11. methylphenidate 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2
times a day).
12. quinapril 20 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO BID (2 times a
day).
13. metoprolol tartrate 50 mg Tablet [**Month/Year (2) **]: 1.5 Tablets PO BID (2
times a day).
14. hydralazine 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q8H (every 8
hours).
15. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
16. dexamethasone 2 mg Tablet [**Last Name (STitle) **]: Taper PO tid () for taper
days: 3 tabs po TID x 2 days
2 tabs po TID x 2 days
1 tab po TID x 2 days
.5 tab po TID x 2 days then discontinue.
Disp:*35 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Cervical Stenosis
laryngeal edema
pulmonary edema
deviated trachea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
?????? Do not smoke.
?????? Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
?????? If you have steri-strips in place. Do not pull them off. They
will fall off on their own or be taken off in the office. You
may trim the edges if they begin to curl.
?????? No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
?????? Limit your use of stairs to 2-3 times per day.
?????? Have a friend or family member check your incision daily for
signs of infection.
?????? If you are required to wear one, wear your cervical collar or
back brace as instructed.
?????? You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
?????? Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
?????? Do not take any medications such as Aspirin unless directed by
your doctor.
- We have increased your metoprolol to 75mg po BID. Thus,
please take an extra [**12-5**] tab twice daily. Follow up with your
PCP [**Name Initial (PRE) 2678**].
Followup Instructions:
Follow Up Instructions/Appointments
??????Please return to the office in [**6-12**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner. Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 6 weeks.
??????You will/will not need x-rays/CT-scan prior to your
appointment.
- Please follow-up with your PCP upon discharge from the
hospital regarding your blood pressure.
Completed by:[**2136-4-3**]
|
[
"530.81",
"518.4",
"401.9",
"530.85",
"314.00",
"070.54",
"345.90",
"356.9",
"722.71",
"311",
"478.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"81.63",
"80.51",
"81.02"
] |
icd9pcs
|
[
[
[]
]
] |
6691, 6697
|
3784, 4574
|
301, 330
|
6808, 6808
|
2015, 3761
|
8140, 8871
|
1788, 1806
|
4764, 6668
|
6718, 6787
|
4600, 4741
|
6959, 8117
|
1821, 1821
|
1837, 1996
|
248, 263
|
358, 1434
|
6823, 6935
|
1456, 1679
|
1695, 1772
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,154
| 130,887
|
53434+53435+59520
|
Discharge summary
|
report+report+addendum
|
Admission Date: [**2200-1-25**] Discharge Date: [**2200-2-12**]
Date of Birth: [**2176-8-29**] Sex: M
Service: SURGERY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Polytrauma - unrestrained MVC vs. pole
Major Surgical or Invasive Procedure:
2/21 ICP Bolt placement
[**1-30**] Tracheostomy, PEG
History of Present Illness:
23yo M in MVC as an unrestrained driver who struck a pole, + LOC
with airbag deployment. He was intubated with an LMA in the
field and then with an ETT in the trauma bay for hypoxia but was
noted to be moving all extremities previously. His injuries
include epidural hemorrhage, basilar
skull fracture, and L rib [**12-12**] fractures. An ICP monitor was
placed by NeuroSurg upon admission, as well as a L chest tube
for PTX.
Past Medical History:
None
Social History:
Lives with family. Drug, ETOH, tobacco use unknown.
Family History:
Non-contributory
Physical Exam:
Upon Admission:
O: T: 95.5 BP: 140/62 HR: 87 R 32 O2Sats 99% (intubated)
Gen: intubated, sedated.
HEENT: Pupils: 2mm equal B/L
Neck: rigid collar.
Lungs: CTA bilaterally. L. side CT
Cardiac: RRR. S1/S2.
Abd: Soft, BS+. Fast negative.
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated, sedated.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 2
mm bilaterally.
Unable to perform exam due to sedation.
Pertinent Results:
[**2200-1-25**] 03:55AM BLOOD WBC-23.2* RBC-5.03 Hgb-14.8 Hct-41.6
MCV-83 MCH-29.4 MCHC-35.5* RDW-13.0 Plt Ct-405
[**2200-1-25**] 05:26AM BLOOD WBC-31.2* RBC-5.10 Hgb-15.0 Hct-42.2
MCV-83 MCH-29.3 MCHC-35.4* RDW-13.1 Plt Ct-340
[**2200-1-25**] 01:49PM BLOOD Hct-37.8*
[**2200-1-25**] 07:44PM BLOOD WBC-25.9* RBC-4.53* Hgb-13.3* Hct-37.1*
MCV-82 MCH-29.4 MCHC-35.9* RDW-13.0 Plt Ct-241
[**2200-1-26**] 01:03AM BLOOD WBC-28.5* RBC-4.57* Hgb-13.5* Hct-37.6*
MCV-82 MCH-29.7 MCHC-36.0* RDW-13.4 Plt Ct-232
[**2200-1-27**] 01:46AM BLOOD WBC-19.5* RBC-3.62* Hgb-10.7* Hct-30.2*
MCV-83 MCH-29.6 MCHC-35.6* RDW-13.2 Plt Ct-193
[**2200-1-28**] 01:58AM BLOOD WBC-14.0* RBC-3.19* Hgb-9.7* Hct-26.1*
MCV-82 MCH-30.3 MCHC-37.1* RDW-13.2 Plt Ct-200
[**2200-1-29**] 02:00AM BLOOD WBC-14.5* RBC-3.35* Hgb-10.3* Hct-27.2*
MCV-81* MCH-30.7 MCHC-37.8* RDW-13.3 Plt Ct-236
[**2200-1-30**] 01:07AM BLOOD WBC-17.9* RBC-3.74* Hgb-10.9* Hct-30.4*
MCV-81* MCH-29.1 MCHC-35.7* RDW-13.5 Plt Ct-337
[**2200-1-31**] 01:05AM BLOOD WBC-20.7* RBC-3.83* Hgb-11.3* Hct-31.0*
MCV-81* MCH-29.7 MCHC-36.6* RDW-13.2 Plt Ct-404
[**2200-2-1**] 02:06AM BLOOD WBC-16.7* RBC-3.83* Hgb-11.0* Hct-31.2*
MCV-82 MCH-28.7 MCHC-35.2* RDW-13.7 Plt Ct-432
[**2200-2-1**] 07:03AM BLOOD Hct-30.8*
[**2200-2-1**] 10:10AM BLOOD WBC-19.1* RBC-3.65* Hgb-10.7* Hct-30.1*
MCV-82 MCH-29.4 MCHC-35.7* RDW-13.5 Plt Ct-542*
[**2200-2-2**] 01:37AM BLOOD WBC-15.9* RBC-3.48* Hgb-10.1* Hct-28.6*
MCV-82 MCH-29.1 MCHC-35.3* RDW-13.4 Plt Ct-504*
[**2200-2-3**] 02:10AM BLOOD WBC-16.3* RBC-3.20* Hgb-9.7* Hct-26.5*
MCV-83 MCH-30.2 MCHC-36.5* RDW-13.6 Plt Ct-545*
[**2200-2-4**] 01:53AM BLOOD WBC-19.5* RBC-3.50* Hgb-10.2* Hct-29.5*
MCV-84 MCH-29.1 MCHC-34.5 RDW-14.1 Plt Ct-621*
[**2200-2-5**] 01:30AM BLOOD WBC-22.0* RBC-3.71* Hgb-11.1* Hct-31.3*
MCV-84 MCH-29.9 MCHC-35.4* RDW-14.4 Plt Ct-726*
[**2200-2-6**] 02:50AM BLOOD WBC-18.9* RBC-3.56* Hgb-10.5* Hct-30.8*
MCV-87 MCH-29.6 MCHC-34.2 RDW-14.6 Plt Ct-741*
[**2200-2-7**] 02:36AM BLOOD WBC-16.5* RBC-3.00* Hgb-9.0* Hct-25.6*
MCV-85 MCH-30.1 MCHC-35.2* RDW-14.5 Plt Ct-636*
[**2200-2-7**] 04:51AM BLOOD WBC-18.8* RBC-3.45* Hgb-10.7* Hct-29.4*
MCV-85 MCH-31.1 MCHC-36.6* RDW-14.5 Plt Ct-737*
[**2200-2-8**] 02:04AM BLOOD WBC-18.0* RBC-3.60* Hgb-10.4* Hct-30.6*
MCV-85 MCH-28.9 MCHC-34.0 RDW-14.7 Plt Ct-762*
[**2200-2-9**] 01:40AM BLOOD WBC-19.6* RBC-3.71* Hgb-11.0* Hct-31.4*
MCV-85 MCH-29.6 MCHC-35.0 RDW-14.7 Plt Ct-878*
[**2200-2-10**] 01:53AM BLOOD WBC-15.5* RBC-3.64* Hgb-10.7* Hct-31.3*
MCV-86 MCH-29.5 MCHC-34.2 RDW-14.9 Plt Ct-746*
[**2200-2-6**] 02:50AM BLOOD WBC-18.9* RBC-3.56* Hgb-10.5* Hct-30.8*
MCV-87 MCH-29.6 MCHC-34.2 RDW-14.6 Plt Ct-741*
[**2200-2-7**] 02:36AM BLOOD WBC-16.5* RBC-3.00* Hgb-9.0* Hct-25.6*
MCV-85 MCH-30.1 MCHC-35.2* RDW-14.5 Plt Ct-636*
[**2200-2-7**] 04:51AM BLOOD WBC-18.8* RBC-3.45* Hgb-10.7* Hct-29.4*
MCV-85 MCH-31.1 MCHC-36.6* RDW-14.5 Plt Ct-737*
[**2200-2-8**] 02:04AM BLOOD WBC-18.0* RBC-3.60* Hgb-10.4* Hct-30.6*
MCV-85 MCH-28.9 MCHC-34.0 RDW-14.7 Plt Ct-762*
[**2200-2-9**] 01:40AM BLOOD WBC-19.6* RBC-3.71* Hgb-11.0* Hct-31.4*
MCV-85 MCH-29.6 MCHC-35.0 RDW-14.7 Plt Ct-878*
[**2200-2-11**] 04:07AM BLOOD WBC-17.1* RBC-3.99* Hgb-11.9* Hct-34.1*
MCV-86 MCH-29.7 MCHC-34.8 RDW-14.5 Plt Ct-899*
[**2200-1-25**] 03:55AM BLOOD PT-14.2* PTT-26.6 INR(PT)-1.2*
[**2200-1-25**] 05:26AM BLOOD PT-15.0* PTT-27.7 INR(PT)-1.3*
[**2200-1-26**] 01:03AM BLOOD PT-17.7* PTT-31.3 INR(PT)-1.6*
[**2200-1-26**] 08:32AM BLOOD PT-17.7* PTT-33.1 INR(PT)-1.6*
[**2200-1-27**] 01:46AM BLOOD PT-14.3* PTT-30.2 INR(PT)-1.2*
[**2200-2-1**] 02:06AM BLOOD PT-14.5* PTT-27.1 INR(PT)-1.3*
[**2200-2-1**] 10:10AM BLOOD PT-14.0* PTT-25.9 INR(PT)-1.2*
[**2200-2-1**] 01:29PM BLOOD PT-14.5* PTT-25.8 INR(PT)-1.3*
[**2200-2-5**] 01:30AM BLOOD PT-15.8* PTT-34.9 INR(PT)-1.4*
[**2200-1-25**] 03:55AM BLOOD UreaN-13 Creat-1.1
[**2200-1-25**] 05:26AM BLOOD Glucose-125* UreaN-12 Creat-0.9 Na-137
K-3.3 Cl-102 HCO3-21* AnGap-17
[**2200-1-25**] 07:44PM BLOOD Glucose-146* UreaN-11 Creat-0.9 Na-138
K-4.6 Cl-104 HCO3-22 AnGap-17
[**2200-1-26**] 01:03AM BLOOD Glucose-147* UreaN-10 Creat-0.8 Na-133
K-4.6 Cl-103 HCO3-23 AnGap-12
[**2200-1-27**] 01:46AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-132*
K-4.1 Cl-100 HCO3-26 AnGap-10
[**2200-1-28**] 01:58AM BLOOD Glucose-112* UreaN-8 Creat-0.6 Na-132*
K-3.8 Cl-101 HCO3-26 AnGap-9
[**2200-1-29**] 02:00AM BLOOD Glucose-113* UreaN-10 Creat-0.6 Na-130*
K-3.4 Cl-97 HCO3-28 AnGap-8
[**2200-1-29**] 03:28PM BLOOD Glucose-113* UreaN-8 Creat-0.7 Na-129*
K-3.6 Cl-98 HCO3-22 AnGap-13
[**2200-1-30**] 01:07AM BLOOD Glucose-117* UreaN-11 Creat-0.6 Na-131*
K-4.0 Cl-100 HCO3-22 AnGap-13
[**2200-1-30**] 01:42PM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-130*
K-3.6 Cl-98 HCO3-20* AnGap-16
[**2200-1-31**] 01:05AM BLOOD Glucose-107* UreaN-12 Creat-0.6 Na-128*
K-4.1 Cl-97 HCO3-22 AnGap-13
[**2200-1-31**] 02:40PM BLOOD Glucose-110* UreaN-11 Creat-0.6 Na-129*
K-4.1 Cl-98 HCO3-22 AnGap-13
[**2200-2-1**] 02:06AM BLOOD Glucose-111* UreaN-11 Creat-0.7 Na-131*
K-3.7 Cl-96 HCO3-26 AnGap-13
[**2200-2-2**] 01:37AM BLOOD Glucose-110* UreaN-12 Creat-0.7 Na-134
K-3.8 Cl-99 HCO3-26 AnGap-13
[**2200-2-3**] 02:10AM BLOOD Glucose-108* UreaN-10 Creat-0.7 Na-135
K-3.8 Cl-101 HCO3-25 AnGap-13
[**2200-2-4**] 01:53AM BLOOD Glucose-115* UreaN-8 Creat-0.7 Na-137
K-3.7 Cl-101 HCO3-29 AnGap-11
[**2200-2-5**] 01:30AM BLOOD Glucose-106* UreaN-12 Creat-0.7 Na-139
K-4.2 Cl-103 HCO3-30 AnGap-10
[**2200-2-6**] 02:50AM BLOOD Glucose-108* UreaN-12 Creat-0.8 Na-138
K-4.3 Cl-103 HCO3-27 AnGap-12
[**2200-2-7**] 02:36AM BLOOD Glucose-164* UreaN-11 Creat-0.4* Na-136
K-3.9 Cl-107 HCO3-21* AnGap-12
[**2200-2-7**] 04:51AM BLOOD Glucose-128* UreaN-12 Creat-0.6 Na-134
K-4.1 Cl-100 HCO3-26 AnGap-12
[**2200-2-7**] 04:51AM BLOOD Glucose-128* UreaN-12 Creat-0.6 Na-134
K-4.1 Cl-100 HCO3-26 AnGap-12
[**2200-2-8**] 02:04AM BLOOD Glucose-114* UreaN-15 Creat-0.6 Na-128*
K-4.4 Cl-95* HCO3-27 AnGap-10
[**2200-2-9**] 01:40AM BLOOD Glucose-107* UreaN-16 Creat-0.6 Na-133
K-4.5 Cl-98 HCO3-26 AnGap-14
[**2200-2-10**] 01:53AM BLOOD Glucose-100 UreaN-15 Creat-0.5 Na-131*
K-4.7 Cl-94* HCO3-28 AnGap-14
[**2200-2-11**] 04:07AM BLOOD Glucose-102 UreaN-18 Creat-0.7 Na-137
K-5.0 Cl-98 HCO3-29 AnGap-15
[**2200-1-25**] 05:26AM BLOOD CK(CPK)-1062*
[**2200-1-25**] 12:22PM BLOOD CK(CPK)-2258*
[**2200-1-26**] 01:03AM BLOOD CK(CPK)-2183*
[**2200-1-28**] 01:58AM BLOOD ALT-33 AST-37 AlkPhos-72 TotBili-0.6
[**2200-2-1**] 01:29PM BLOOD ALT-99* AST-36 AlkPhos-75 TotBili-0.7
[**2200-1-25**] 03:55AM BLOOD Lipase-194*
[**2200-1-28**] 01:58AM BLOOD Lipase-52
[**2200-1-25**] 05:26AM BLOOD CK-MB-12* MB Indx-1.1
[**2200-1-25**] 12:22PM BLOOD CK-MB-17* MB Indx-0.8 cTropnT-0.03*
[**2200-1-26**] 01:03AM BLOOD CK-MB-8 cTropnT-<0.01
[**2200-1-25**] 05:26AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0
[**2200-1-25**] 07:44PM BLOOD Calcium-8.6 Phos-3.2 Mg-1.4*
[**2200-1-26**] 01:03AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.0 Mg-2.2
[**2200-1-27**] 01:46AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.9
[**2200-1-27**] 03:55PM BLOOD Albumin-3.4
[**2200-1-28**] 01:58AM BLOOD Calcium-7.9* Phos-1.8* Mg-1.9
[**2200-1-29**] 02:00AM BLOOD Albumin-3.1* Calcium-7.9* Phos-2.9 Mg-1.9
[**2200-1-29**] 03:28PM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1
[**2200-1-30**] 01:07AM BLOOD Calcium-8.1* Phos-2.9 Mg-2.1
[**2200-1-30**] 01:42PM BLOOD Calcium-7.9* Phos-2.9 Mg-2.0
[**2200-1-31**] 01:05AM BLOOD Calcium-8.6 Phos-3.1 Mg-2.0
[**2200-2-1**] 02:06AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.2
[**2200-2-2**] 01:37AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3
[**2200-2-3**] 02:10AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.2
[**2200-2-4**] 01:53AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.4
[**2200-2-5**] 01:30AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.5
[**2200-2-6**] 02:50AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.4
[**2200-2-7**] 02:36AM BLOOD Calcium-7.3* Phos-3.3 Mg-1.9
[**2200-2-7**] 04:51AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.2
[**2200-2-8**] 02:04AM BLOOD Calcium-9.7 Phos-4.6* Mg-2.3
[**2200-2-9**] 01:40AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.2
[**2200-2-10**] 01:53AM BLOOD Calcium-9.8 Phos-4.7* Mg-2.3
[**2200-2-11**] 04:07AM BLOOD Calcium-10.3* Phos-4.8* Mg-2.4
[**2200-1-25**] 05:26AM BLOOD Triglyc-133
[**2200-1-25**] 03:55AM BLOOD ASA-NEG Ethanol-263* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2200-1-25**] 12:19PM BLOOD freeCa-1.06*
[**2200-1-26**] 02:27PM BLOOD freeCa-1.11*
[**2200-1-28**] 05:52AM BLOOD freeCa-1.02*
[**2200-1-29**] 10:35AM BLOOD freeCa-1.03*
[**2200-1-30**] 01:35AM BLOOD freeCa-1.16
[**2200-1-31**] 02:22AM BLOOD freeCa-1.12
IMAGING:
[**1-25**] CT chest: L rib [**12-12**] fx, mod PTX, apical pulm contusions,
b/l compressive atelectasis, pulm contusion at b/l bases
(abd/pelv neg)
[**1-26**] CT head: persistent sulcal effacement, no change in
epidural hematomas or pneumocephalus, L ICA ?dissection with
assoc sm post-traumatic PSA, no extrav
[**1-27**] CT head: no change in b/l epidural or SDH, new
opacification of mastoid air cells -> hemorrhage
[**1-27**] angio: L ICA PSA (mid cervical) like diverticulum, b/l
carotico-cavernous fistula (not large)
[**1-28**] MRI head: cerebral edema, diffuse axonal injury
[**1-28**] MRI C-spine: L atlanto-occipital joint edema/lig injury
[**1-30**] CT head: no change
[**2-1**] head CT: no change
[**2-3**] CXR: loculated pleural effusion in R right major fissure
[**2-4**] CT temporal bone: fx R temporal bone, abutting anterolat
wall of tympanic portion of the facial nerve canal s evidence of
canal disruption, L temporal bone fx, unchanged epidurals, new
sm L SDH
[**2-5**] CT head: b/l epidurals unchanged, sm b/l SDH unchanged
[**2-5**] CT sinuses: no sinusitis
[**2-6**] CT chest: improving multifocal PNA
[**2-9**] CXR: Cardiac silhouette is mildly enlarged. Patchy and
linear bibasilar atelectasis is again demonstrated. Several left
rib fractures are present, but no pneumothorax or substantial
pleural effusion is evident.
Brief Hospital Course:
Mr. [**Known lastname **] is a 23yo M that was involved in a MVC accident where
he was an unrestrained driver who struck a pole, + LOC with
airbag deployment. He was intubated with an LMA in the field
and then with an ETT in the trauma bay
for hypoxia but was noted to be moving all extremities
previously. His injuries on admition included epidural
hemorrhage, basilar skull fracture, and L rib [**12-12**] fractures.
Once stabalized and transferred to the ICU we placed an ICP
monitor for a GCS <8. Opening pressure was marginally elevated
at 19. He also had a Left sided chest tube placed for his
pneumothorax secondary to his multiple rib fractures.
After a few days of monitoring the ICP monitor was removed since
no elevated ICPs were observed.
Major Events:
2/21 L CT placed, bolt placed, neo for transient hypotension,
febrile
[**1-26**] FFP for elevated INR, trophic TF, small CT leak, CT with
small L ICA PSA -> no anticoag as per vasc [**Doctor First Name **]
[**1-27**] bolt d/c'd, angio, CT head, L SCL placed, Dilantin changed
to Keppra for ?rash, bolused IVF for low UOP
[**1-28**] MRI head/C-spine, KUB neg, +BM, hydral, metoprolol, Lasix
20 x2/KVO, CPAP, vanc/Zosyn for PNA, febrile
[**1-29**] TF held for high residuals, family meeting, Lasix/Diamox,
CT to WS, started NaCl & Florinef for salt wasting, started
Reglan
[**1-30**] trach/PEG, CT d/c'd, inc vanc to 1500", Lasix, started
standing BB & hydral, CT head, Lasix 20x1
[**1-31**]: epistaxis, febrile, started TF, changed abx to
nafcillin/Flagyl
[**2-1**]: PEG with high residuals
[**2-2**]: restarted TF, CVL d/c'd
[**2-3**]: trach mask
[**2-4**]: added PO vanc, ENT consult -> CT temporal bone, NSG
reconsulted for new SDH -> NTD, behavioral neurology c/s done,
started cefepime for new sputum Gram stain
[**2-5**]: added IV vanc & tobra as per ID, CT sinus neg, d/c'd NaCl,
d/c'd Keppra, started Haldol prn
[**2-6**]: BAL, CT chest
[**2-7**]: d/c IV vanc, started methadone 10", restarted NaCl
[**2-8**]: inc NaCl
[**2-9**]: d/c'd Flagyl, cefepime, tobra
[**2-10**]: decreased methadone 7.5", Transferred to floor
[**2-11**]: No major events. Continued to be tachycardic, but
hemodynamically stable.
Upon discharge, the patient was medically stable, though still
with marked neurologic deficit. His eyes were opening
spontaneously, though not tracking. He was responsive to painful
stilmuli. He was non-verbal. He was dishcarged to a rehab
facility.
Medications on Admission:
None
Discharge Medications:
1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
2. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
3. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed.
4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic PRN (as needed).
9. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) as needed for aggitation.
11. Methadone 5 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
14. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO QIDACHS
(4 times a day (before meals and at bedtime)).
15. Sodium Chloride 0.65 % Aerosol, Spray Sig: Four (4) Spray
Nasal QID (4 times a day).
16. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
17. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
18. Metoprolol Tartrate 5 mg IV Q6H:PRN SBP>160
hold for HR<55
19. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q4H:PRN pain
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. bilateral parietotemporal epidural hematomas
2. L ICA pseudoanerusym/dissection
3. basilar skull fx
4. bilat temporal bone fx
5. L occipital condylar fx
6. C1/2 dislocation without ligamentous injury
7. L pneumothorax
8. L [**12-12**] rib fxs
9. L apical pulm contusions
10. Ventilator PNA
11. Right hemiparesis
12. Hyponatremia - cerebral salt wasting
Discharge Condition:
Stable, non-verbal, right hemiparesis. Trach and PEG in place
and functioning. C-collar in place.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
1. Neurosurgical Follow-up:
Please follow-up in 1 mo with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1669**]) with a
cerebral angiogram to re-evaluate CC fistula.
2. Orthopaedic Surgery Follow up for C-spine injury:
Dr. [**Last Name (STitle) 1352**] in 3 weeks ([**Telephone/Fax (1) 1228**])
3. ENT - outpatient audiogram: Dr. [**Last Name (STitle) 3878**] (when stable and
capable)
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
Completed by:[**2200-2-11**] Admission Date: [**2200-2-13**] Discharge Date: [**2200-2-19**]
Date of Birth: [**2176-8-29**] Sex: M
Service: SURGERY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 1481**]
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Pt is a 23M who suffered a devastating neurologic injury as
a result of a MVC on [**2200-1-25**]. He was just discharged from the
Trauma service yesterday. [**Hospital 1319**] Hospital sent him back to
the
[**Hospital1 18**] ED today for fevers to 101.9. The trauma team reports he
had been having low-grade fevers for the past week though all
cultures and imaging were negative. He did complete a course of
PO vancomycin for C Diff.
He was seen by ID today at [**Hospital1 1319**]. The plan was for LP, CT
brain/sinus/chest/abd/pelvis, though it was ultimately felt
easier to transfer him back to the [**Hospital1 18**] for work-up.
The rehab records indicate that his Foley was removed yesterday
and he is voiding spontaneously, though incontinent. He is
noted
to have a non-productive cough without sputum.
The family reports he seemed to be doing well today; they know
of
no other problems.
In the [**Hospital1 18**] ED today he has already received Vanco & Zosyn once
blood and urine cultures were sent. Sputum has not been
obtained.
ALL: phenytoin causes rash
ROS: can not be obtained given patient's neurologic deficit
Past Medical History:
None
Social History:
prior to accident worked in maintenance in [**Hospital1 8**].
Lived in [**Hospital1 8**] his entire life. Parents and girlfriend are
very involved in his care. No known drug or EtOH abuse
Family History:
Non-contributory
Physical Exam:
VS 102.2 101.2 101 129/86 18 100%TM
NAD, lying comfortably in bed.
No jaundice or icterus. trach site C/D/I
CTA B/L, breathing not labored
Sinus tach
Abd soft, NT, ND. G tube site C/D/I
No LE edema. Palpable pedal pulses. Muscle wasting in all
extremities
Neuro: eyes open, does not track. Does not follow commands.
Does
not verbalize. Moves all extremities spontaneously and almost
continuously.
Pertinent Results:
[**2200-2-12**] 06:55AM BLOOD WBC-16.9* RBC-4.30* Hgb-12.4* Hct-37.4*
MCV-87 MCH-28.9 MCHC-33.2 RDW-14.4 Plt Ct-776*
[**2200-2-13**] 03:00PM BLOOD WBC-19.7* RBC-4.23* Hgb-12.2* Hct-36.6*
MCV-87 MCH-28.8 MCHC-33.2 RDW-14.2 Plt Ct-666*
[**2200-2-14**] 06:20AM BLOOD WBC-13.2* RBC-3.70* Hgb-11.0* Hct-32.1*
MCV-87 MCH-29.7 MCHC-34.3 RDW-14.0 Plt Ct-529*
[**2200-2-15**] 06:35AM BLOOD WBC-11.8* RBC-3.81* Hgb-11.3* Hct-33.0*
MCV-87 MCH-29.7 MCHC-34.3 RDW-14.0 Plt Ct-464*
[**2200-2-17**] 06:35AM BLOOD WBC-10.6 RBC-4.09* Hgb-11.9* Hct-35.4*
MCV-86 MCH-29.1 MCHC-33.7 RDW-14.2 Plt Ct-427
[**2200-2-13**] 03:00PM BLOOD Neuts-75.5* Lymphs-15.0* Monos-6.7
Eos-2.4 Baso-0.6
[**2200-2-12**] 06:55AM BLOOD Plt Ct-776*
[**2200-2-13**] 03:00PM BLOOD PT-17.0* PTT-30.8 INR(PT)-1.5*
[**2200-2-13**] 03:00PM BLOOD Plt Ct-666*
[**2200-2-14**] 06:20AM BLOOD Plt Ct-529*
[**2200-2-15**] 06:35AM BLOOD Plt Ct-464*
[**2200-2-17**] 06:35AM BLOOD Plt Ct-427
[**2200-2-12**] 06:55AM BLOOD Glucose-111* UreaN-24* Creat-0.7 Na-142
K-5.0 Cl-104 HCO3-25 AnGap-18
[**2200-2-13**] 03:00PM BLOOD Glucose-108* UreaN-29* Creat-0.8 Na-142
K-4.7 Cl-105 HCO3-25 AnGap-17
[**2200-2-14**] 06:20AM BLOOD Glucose-93 UreaN-21* Creat-0.7 Na-146*
K-4.1 Cl-109* HCO3-24 AnGap-17
[**2200-2-15**] 06:35AM BLOOD Glucose-98 UreaN-16 Creat-0.8 Na-144
K-4.3 Cl-107 HCO3-26 AnGap-15
[**2200-2-17**] 06:35AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-142
K-4.4 Cl-106 HCO3-24 AnGap-16
[**2200-2-14**] 06:20AM BLOOD ALT-50* AST-36 AlkPhos-114 Amylase-54
[**2200-2-14**] 06:20AM BLOOD Lipase-42
[**2200-2-12**] 06:55AM BLOOD Calcium-10.4* Phos-5.0* Mg-2.5
[**2200-2-14**] 06:20AM BLOOD Albumin-3.8 Calcium-9.3 Phos-4.2 Mg-2.4
[**2200-2-15**] 06:35AM BLOOD Calcium-9.4 Phos-4.3 Mg-2.5
[**2200-2-17**] 06:35AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.5
[**2200-2-16**] 07:55PM BLOOD Vanco-4.5*
[**2200-2-13**] 02:56PM BLOOD Lactate-1.5
Cultures:
[**2200-2-17**] Feces negative for C.difficile toxin A & B by EIA
[**2200-2-16**] Feces negative for C.difficile toxin A & B by EIA
[**2200-2-16**] Blood Culture, Routine (Pending)
[**2200-2-15**] Blood Culture, Routine (Pending)
[**2200-2-14**] Feces negative for C.difficile toxin A & B by EIA.
[**2200-2-13**] SPUTUM GRAM STAIN (Final [**2200-2-14**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
RESPIRATORY CULTURE (Final [**2200-2-16**]):
SPARSE GROWTH OROPHARYNGEAL FLORA.
[**2200-2-13**] URINE CULTURE (Final [**2200-2-14**]): NO GROWTH
[**2200-2-13**] BLOOD CULTURE Blood Culture, Routine (Pending)
[**2200-2-13**] Blood Culture, Routine (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET
ONLY.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final [**2200-2-15**]):
REPORTED BY PHONE TO DR. [**Last Name (STitle) **]. [**Doctor Last Name **] ON [**2200-2-15**] AT 0130.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Imaging:
[**2200-2-13**] CXR:
IMPRESSION: New right basilar opacity concerning for pneumonia.
[**2200-2-13**] CT Head:
IMPRESSION:
1. Near resolution of previous bilateral extra-axial hematomas.
Only minimal right temporal extra-axial collection remains,
compatible with interval resorption.
2. No interval development of hydrocephalus, mass effect, or new
site of
hemorrhage.
[**2200-2-14**] Chest CT:
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
Patient was admitted to the trauma surgery service on [**2200-2-13**].
He had blood and urine cultures sent. A chest x-ray was
initally concerning for pneumonia, but a subsequent chest CT
showed no evidence of pneumonia. A tracheal aspirate grew out
oropharyngeal flora. One of two initial blood cultures grew out
STAPHYLOCOCCUS, COAGULASE NEGATIVE. Two repeat blood cultures
have had no growth to date. Urine culture was negative. A
noncontrast head CT showed no hydrocephalus. Infectious disease
was consulted and intially recommended broad spectrum coverage.
He was continued on antibiotics including vancomycin until
[**2200-2-18**], at which point he was only on liquid flagyl for C.
diff. He was discharged back to rehab in stable condition.
Patient remained afebrile for >48 prior to discharge.
Medications on Admission:
1. Sodium Chloride 1 gram PO BID
2. Bisacodyl 10 mg PO DAILY
3. Metoclopramide 5 mg/5 mL PO QIDACHS
4. Docusate Sodium 50 mg/5 mL PO BID
5. Senna 8.6 mg PO BID prn
6. Heparin 5,000 unit TID
7. Fludrocortisone 0.1 mg PO DAILY
8. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Ophthalmic
PRN
9. Aspirin 325 mg PO DAILY
10. Haloperidol 1 mg PO TID prn aggitation.
11. Methadone 7.5 mg Tablet PO BID
12. Metoprolol Tartrate 50 mg PO TID
13. Sodium Chloride 0.65 % Aerosol 4 Spray Nasal QID
Discharge Medications:
1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2
times a day).
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
3. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-6**] Sprays Nasal
QID (4 times a day).
9. Sodium Chloride 1 gram Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS
(4 times a day (before meals and at bedtime)).
11. White Petrolatum-Mineral Oil 42.5-56.8 % Ointment Sig: One
(1) Appl Ophthalmic TID (3 times a day).
12. Acetaminophen 650 mg Suppository Sig: One (1) Suppository
Rectal Q4H (every 4 hours) as needed.
13. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
14. Methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 10 days.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
Primary:
1. Fever
Secondary:
1. bilateral parietotemporal epidural hematomas
2. L ICA pseudoanerusym/dissection
3. basilar skull fx
4. bilat temporal bone fx
5. L occipital condylar fx
6. C1/2 dislocation without ligamentous injury
7. L pneumothorax
8. L [**12-12**] rib fxs
9. L apical pulm contusions
10. Ventilator PNA
11. Right hemiparesis
12. Hyponatremia - cerebral salt wasting
Discharge Condition:
Stable, non-verbal, right hemiparesis. Trach and PEG in place
and functioning. C-collar in place.
Discharge Instructions:
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
1. Neurosurgical Follow-up:
Please follow-up in 3 weeks with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1669**]) with
a
cerebral angiogram to re-evaluate CC fistula.
2. Orthopaedic Surgery Follow up for C-spine injury:
Dr. [**Last Name (STitle) 1352**] in 2 weeks ([**Telephone/Fax (1) 1228**])
3. ENT - outpatient audiogram: Dr. [**Last Name (STitle) 3878**] (when stable and
capable)
Followup Instructions:
Followup Instructions:
1. Neurosurgical Follow-up:
Please follow-up in 3 weeks with Dr. [**First Name (STitle) **] ([**Telephone/Fax (1) 1669**]) with
a
cerebral angiogram to re-evaluate CC fistula.
2. Orthopaedic Surgery Follow up for C-spine injury:
Dr. [**Last Name (STitle) 1352**] in 2 weeks ([**Telephone/Fax (1) 1228**])
3. ENT - outpatient audiogram: Dr. [**Last Name (STitle) 3878**] (when stable and
capable)
Name: [**Known lastname 2343**],[**Known firstname **] Unit No: [**Numeric Identifier 18015**]
Admission Date: [**2200-1-25**] Discharge Date: [**2200-2-12**]
Date of Birth: [**2176-8-29**] Sex: M
Service: SURGERY
Allergies:
Dilantin
Attending:[**First Name3 (LF) 5964**]
Addendum:
This patient was not discharged until [**2200-2-12**] secondary to
coordinating transfer of care to a rehab facility. No major
changes were made to his care.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 41**] - [**Location (un) 42**]
[**First Name11 (Name Pattern1) 1080**] [**Last Name (NamePattern4) 3711**] MD, [**MD Number(3) 5966**]
Completed by:[**2200-2-12**]
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23815, 24306
|
26327, 27187
|
19129, 19529
|
22181, 22617
|
17623, 17631
|
17704, 18845
|
1297, 1422
|
22626, 22952
|
10591, 10882
|
982, 1246
|
1261, 1281
|
18867, 18873
|
18889, 19080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,698
| 167,317
|
28136
|
Discharge summary
|
report
|
Admission Date: [**2160-9-9**] Discharge Date: [**2160-9-16**]
Date of Birth: [**2083-11-17**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Endobronchial mass
Major Surgical or Invasive Procedure:
Excision/Destruction RUL endobronchial mass, removal of foreign
body.
History of Present Illness:
76M with hx of LUL resection for NSCLC 30 years ago who
presented to [**Hospital **] Hospital with massive hemoptysis on
[**2160-9-5**]. At that time, he was intubated for airway protection
and on bronchoscopy, he was found to have an obstruction lesion
of the right mainstem due to a RUL tumor. At that time, he was
transferred to [**Hospital1 18**] on [**2160-9-9**] for a rigid and flexible
bronchscopy where they found that the right mainstem was
approximately 80-90% obstructed by a tumor mass coming from the
right upper lobe. They found foreign bodies which appeared to be
suture material and perhaps a fingernail in that area which was
sent to pathology as well, prompting a possible diagnosis of
foreign body granuloma. They performed multiple biopsies of the
friable mass. Following the biopsies, the tumor was destroyed
with electrocautery and argon plasma coagulation. However, they
were not able to achieve patency of the right upper lobe
bronchus. The right mainstem was completely patent at the end of
the procedure. He was then sent to the SICU where he was
extubated without event. He had a video swallow which showed no
evidence of aspiration.
.
Of note, he originally presented to PCP with [**Name Initial (PRE) **] month of cough
and shortness of breath. He was treated emperically with abx
with no resolution of the mass on cxr, which prompted the
bronchoscopy at [**Location (un) **].
.
At baseline, he can walk 4 blocks without getting SOB.
Past Medical History:
NSCLC
LUL resection 30 years ago
HTN
CAD s/p angioplasty/stent [**2148**]
Social History:
Lives with family and worked 25 years as a plumber. Has a 50
pack year history of smoking and has been exposed to asbestos in
the past. He socially drinks alcohol.
Family History:
Noncontributory
Physical Exam:
Vitals: 97.1 84 159/99 119 25 95%-4LNC
Gen: A+Ox3, NAD, comfortable, pleasant
HEENT: MMM, OP clear
NECK: No JVD, no LAD
CV: RRR, no m/g/r
Pulm: CTAB, no w/r/r, resonant to percussion
Abd: soft, nd, nt, positive bs
Ext: no c/e/c
Neuro: mobilizes all extremities, sensation grossly intact
Pertinent Results:
138 102 12
------------< 151
4.4 30 0.5
Ca: 8.2 Mg: 2.0 P: 2.9
9.0 > 12.1 < 143
34.5
PT: 16.9 PTT: 28.8 INR: 1.6
CXR: No comparison exams at this facility. Satisfactorily
positioned ET tube in distal trachea 3 cm from carina. No
discrete bronchial lesion identified, although the right main
stem bronchus is not visualized. The superior mediastinum is
obscured with no discrete margination of its lateral borders,
and there is slight prominence of the upper lobe pulmonary
markings. No discrete lung mass and no vascular congestion or
consolidations. I doubt the presence of effusions, although the
right lateral CP angle is not imaged. Heart normal size. NG tube
looped in stomach. Slightly elevated left hemidiaphragm. No lung
nodules or bone destruction identified.
BRONCH RUL BX:
Right upper lobe mass, biopsy: Undifferentiated large cell
carcinoma.
CYTOLOGY RUL MASS:
POSITIVE FOR MALIGNANT CELLS.
Consistent with poorly differentiated non-small cell carcinoma.
MRI HEAD:
No evidence of intracranial metastasis.
CT CHEST/ABD/PELVIS:
1. Appearance raising concern for the possibility of a pulmonary
embolus in a right lower lobe branch of the right pulmonary
artery, although indeterminate. this finding was discussed with
Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] at 11 pm on the day of the study.
2. Mediastinal and right hilar lymphadenopathy.
3. Bibasilar mixed ground-glass and consolidative opacities,
which given their recent onset, are most suspicious for an
infection, inflammation, or in the appropriate clinical setting,
hemorrhage.
4. Marked scarring and emphysema in the right upper lobe.
5. Nonspecific pulmonary nodules, for which short-term followup
is recommended.
6. Several subcentimeter vague hypoattenuating foci in the liver
which are nonspecific. Metastatic disease cannot be excluded.
7. Large 3-4 cm nonspecific lesion in the spleen. To evaluate
the significance of this finding, further correlation with prior
studies could be most helpful.
8. A 13 mm lesion along the lower pole of the left kidney with
indeterminate characteristics and too small to characterize
here. It could be helpful to use an ultrasound to determine
whether this definitely represents a mildly dense cyst, if
clinically indicated.
CTA CHEST:
1. Filling defects within the arterial pulmonary vasculature
within the superior portion of the right lower lobe consistent
with pulmonary embolism. Etiology could include primary embolus
versus tumor thrombus.
2. Mixed ground glass and consolidative opacities seen by
bibasilarly. Unchanged compared to the previous study.
3. Unchanged emphysematous changes.
4. Unchanged right hilar mass.
5. Unchanged mediastinal lymphadenopathy.
BONE SCAN:
No definite evidence for osseous metastases.
LENIS:
No evidence of lower extremity DVT.
Brief Hospital Course:
A/P: 76M with hx of LUL resection for NSCLC presents with
hemoptysis and found to have RUL mass with obstruction of right
mainstem.
.
# HEMOPTYSIS: He did not have any hemopytsis during his hospital
course here.
.
# NSCLC: s/p resection of LUL 30 years ago. On this admission,
s/p rigid brochoscopy with laser ablation of RUL mass.
Pathology and cytology from biopsy shows undifferentiated large
cell carcinoma. Heme/Onc was called for consultation. He
received staging scans. Head MRI was negative for mets. Chest
CT showed mediastinal and right hilar LAD. Abd CT showed 3-4cm
lesion in spleen and non-specific lesions in liver. His bone
scan was negative. He will get a PET scan for staging as an
outpatient. He is scheduled for an outpatient follow up with
[**Hospital **] clinic at BIMDC on [**10-2**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1058**]. He
will also follow up with Interventional Pulmonology and CT
Surgery as an outpatient, appointments already scheduled.
.
# PULMONARY EMBOLISM: He has a RLL PE by CTA. His malignancy
probably put him at an increased risk for PE. He will need to
be on Levonox 60mg [**Hospital1 **]. He need to follow up with his primary
care doctor [**First Name (Titles) **] [**Last Name (Titles) **] clinic and pulmonary clinic.
.
# POST-OBSTRUCTIVE PNA: He has radiographic opacities on chest
CT which could be infectious or could be hemorrhage from RUL
ablation (reviewed with radiology). He will finish his course
of antibiotics: levoquin and flagyl. He will also need to
finish his steroid taper. At discharge, he was able to ambulate
comfortably with 2LNC. He will continue to use oxygen
supplement at home as needed.
.
# COPD: He should continue his albuterol and ipratroprium nebs,
and advair for long acting steroids.
.
# HTN: Continue outpt metoprolol. Hctz was added on this
admission for further bp lowering.
Medications on Admission:
Medication at home:
Levalbuterol
Atrovent
Asmacort
Spiriva
Metoprolol
Discharge Medications:
1. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
3. Prednisone 20 mg Tablet Sig: TAPER AS BELOW Tablet PO DAILY
(Daily) for 3 days: [**9-17**]: 40mg
[**9-18**]: 20mg
[**9-19**]: 20mg.
Disp:*4 Tablet(s)* Refills:*0*
4. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 3 days: end [**9-19**].
Disp:*9 Tablet(s)* Refills:*0*
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day
for 3 days: end [**9-19**].
Disp:*3 Tablet(s)* Refills:*0*
6. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) shot
Subcutaneous Q12H (every 12 hours).
Disp:*60 shot* Refills:*2*
7. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
Disp:*60 Disk with Device(s)* Refills:*2*
8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
Disp:*30 caps* Refills:*2*
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
10. OXYGEN
oxygen by nasal cannula (3L) at all times until you see your
doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
Undifferentiated large cell pulmonary carcinoma
Pulmonary embolism
------------------
Htn
h/o non small cell lung cancer s/p resection
Discharge Condition:
Stable
hemodynamically stable, ambulating, afebrile
Discharge Instructions:
Please take all medication as prescribed. Please keep all
appointments listed below. Please seek medical attention
immediately if you cough up blood or if you are bleeding
anywhere. Also seek medical attention immediately if you have
chest pain or shortness of breath. In general, call your doctor
or go to the emergency room if you have any medical questions or
concerns.
.
Please continue to use oxygen at home. Finish the antibiotics
course and predisone taper listed below.
Followup Instructions:
*** PLEASE FOLLOW UP WITH YOUR PRIMARY CARE PHYSICIAN AS SOON AS
FOLLOWUP ***
--------------------
*** PET SCAN
Please go to [**Hospital Ward Name 23**] [**Location (un) **].
You will receive a mail about details.
[**2160-10-2**]. 9:30AM
*** [**Hospital **] CLINIC:
Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2160-10-2**] 2:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**]
Date/Time:[**2160-10-2**] 2:00
-----------------
*** RADIATION [**Month/Day/Year **]:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 21833**], MD Phone:[**0-0-**]
Date/Time:[**2160-10-2**] 3:00
-----------------
*** THORACIC SURGERY:
Dr. [**Last Name (STitle) 952**]. [**2160-10-7**]. 10:30AM.
[**Hospital Ward Name 23**] [**Location (un) **]
[**Telephone/Fax (1) 170**]
-----------------
*** INTERVENTIONAL PULMONOLOGY:
Dr. [**Last Name (STitle) **] on Novemeber 21, [**2159**] at 12:30.
[**Hospital1 **] [**Location (un) **] [**Telephone/Fax (1) 68401**]
.
PULMONARY FUNCTION TESTS:
I am unable to schedule an appointment for you. Please call
[**Telephone/Fax (1) 609**] to make an appointment before you go to
interventional pulmonology.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2160-9-25**]
|
[
"414.01",
"V45.82",
"401.9",
"786.3",
"518.81",
"415.11",
"162.3",
"496"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.27",
"98.15",
"96.04",
"33.24",
"32.01",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
8729, 8735
|
5379, 7292
|
333, 405
|
8914, 8969
|
2534, 5356
|
9499, 10963
|
2195, 2212
|
7413, 8706
|
8756, 8893
|
7318, 7390
|
8993, 9476
|
2227, 2515
|
275, 295
|
433, 1899
|
1921, 1996
|
2012, 2179
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,266
| 146,217
|
21977
|
Discharge summary
|
report
|
Admission Date: [**2200-9-10**] Discharge Date: [**2200-9-16**]
Date of Birth: [**2136-11-27**] Sex: M
Service: [**Hospital Unit Name 196**]
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
burning chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization
History of Present Illness:
63 year old man with 3 vessel coronary artery disease diagnosed
at [**Location 57544**] on the day of admission. He had a stress
MIBI which was positive on [**2200-8-29**] and was scheduled for
outpatient catheterization on the day of admission, but had
recurrent burning chest pain the morning of admission. He
described this as a burning sensation from his head to his toes,
not exertionally related, without shortness of breath,
diaphoresis, vomiting, or radiation. It lasted 1-2 hours, then
subsided. After diagnosing 3 vessel coronary arthery disease at
the OSH, he was transferred to [**Hospital1 18**] for workup for possible
CABG.
Past Medical History:
CAD - exercise MIBI [**2200-8-29**] - distal anterior, apical, and
infralateral reversible defects
- Cardiac catheterization at [**Hospital1 **]: separate LAD/LCx
ostia. LAD - 95% ostial stenosis, mid long 80-90% stenosis,
branch diagonal 60-70% stenosis. Ramus - occluded proximally.
LCx - promixal 75% stenosis, OM3 >90% [**Last Name (un) 2435**], distally 80-90%
stenosis. RCA - 75% midvesssel, severe stenosis of PDA, 60-70%
stenosis of acute marginal branch
HTN
Hyperlipidemia
DM type II
CVA [**12-13**], [**2199**] (hemorrhagic)
s/p cataract surgery
poyneuropathy
gastritis
anxiety
depression
peripheral vascular disease
Social History:
worked as a barber, lives with wife. 20 pack year smoker, quit
30 years ago. no EtOH.
Family History:
mother with DM, father died of stroke at 89.
Physical Exam:
V T99.0 HR 74 RR18 HR74 BP131/72
Gen: NAD, talkative, appears stated age
HEENT: PERRL, op clear, MMM
Neck: no JVD, no thyromegaly
Resp: bibasilar crackles
CV: RRR nl S1S2 II/VI SEM at LLSB
Abd: sl TTP diffusely. soft ND +BS no HSM
Ext: no edema
Neuro: CN 2-12 intact, A+Ox3, strength 5/5 UE/LE
Pertinent Results:
[**2200-9-10**]
11:22p
138 102 23 /
------------- 256
3.9 30 0.9 \
Ca: 9.1 Mg: 1.7 P: 2.8
\ 11.8 /
7.0 ------- 143
/ 33.0 \
N:69.9 L:23.5 M:5.2 E:1.3 Bas:0.2
PT: 12.7 PTT: 28.2 INR: 1.0
CK: 377 MB: 2 Trop-*T*: <0.01
[**2200-9-11**] 07:49PM BLOOD CK-MB-3
[**2200-9-12**] 06:55AM BLOOD CK-MB-2 cTropnT-<0.01
[**2200-9-15**] 01:45PM BLOOD CK-MB-2 cTropnT-<0.01
EKG [**2200-9-11**]
Sinus bradycardia. Long QTc interval. Extensive ST-T wave
changes may be due to
myocardial ischemia. No previous tracing available for
comparison.
Carotid US [**2200-9-11**]
No significant plaque could be found on either side. The
velocities and wave forms in the bilateral carotid and vertebral
arteries were normal, with antegrade flow.
Echo [**2200-9-11**]
The left atrium is normal in size. No atrial septal defect is
seen by 2D or
color Doppler. Left ventricular wall thicknesses are normal. The
left
ventricular cavity size is normal. Overall left ventricular
systolic function
is normal (LVEF 70%). Right ventricular chamber size and free
wall motion are
normal. The ascending aorta is mildly dilated. The aortic valve
leaflets (3)
are mildly thickened but not stenotic. No aortic regurgitation
is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse.
Trivial mitral regurgitation is seen. There is no pericardial
effusion
MRA head [**2200-9-12**]
Normal MRA of the circle of [**Location (un) 431**].
Cath results: see hospital course
Brief Hospital Course:
1) Coronary arteries - The patient had 3 vessel disease with
multiple narrowings. However, the most sever occlusions were in
the LAD and LCx. CT surgery was called, but after discussion it
was decided to take the patient for cardiac catheterization
instead of CABG. While awaiting PCTA over the weekend, he was
maintained on a heparin drip, metoprolol, plavix, and captopril.
Aspirin was added the day before catheterization, which the
patient had not been on due to history of hemorrhagic stroke and
gastritis. Cardiac catheterization was performed on [**2200-9-15**] with
multiple stents placed in the LAD and LCX. The cath showed LMCA-
non existant (dual ostial), LAD (origin 90% lesion), distal
diffuse 90% lesion , LCX: origin had 80% lesion, proximal 90%
lesion, RCA- not injected. Post op patient did well without
complication
2) Pump - an echo was done which demonstrated normal EF.
3) Rhythm - the patient stayed in sinus rhythm during
hospitalization and was monitored by telemetry.
4) Hypertension - the patient became very hypertensive while
hospitalized. A nitroglycerin drip was begin, then gradually
wenaed in favor of maximizing doses of loressor and captopril.
Amylodipine and hydrochlorothiazide were added as additional
agents.
5) history of hemorrhagic stroke - An MRI/MRA of the head was
done to assess risk for re-bleed, which was negative. Carotid
dopplers were done of the neck which showed no stenosis.
6) Diabetes Mellitus type II - the patient was maintained on NPH
insulin according to his home regimen, but his avandia was held.
together with a sliding scale of regular insulin to keep his
sugars below 150 during hospitalization. His avandia was
restarted at discharge.
7) history of depression/anxiety - the patient was continued on
zoloft and trazodone.
Medications on Admission:
NPH insulin 24 units QAM, 12 units QPM
HCTZ 25 mg poqd
plavix 75 mg poqd
lipitor 40 mg poqd
protonix 40 mg poqd
trazodone 50 mg poqd
avandia 4mg po bid
zoloft 50 mg poqd
norvasc 10 mg poqd
Discharge Medications:
Patient should be on aspirin and plavix for three months and
plavix life long
1. Avandia 4 mg Tablet Sig: One (1) Tablet PO twice a day.
2. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig:
One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours)
for 3 months.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 3 months.
Disp:*90 Tablet(s)* Refills:*1*
5. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO QD (once a
day) for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
6. Atenolol 100 mg Tablet Sig: One (1) Tablet PO QD (once a day)
for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
7. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO QD (once a
day) for 3 months.
Disp:*180 Tablet(s)* Refills:*0*
8. Amlodipine Besylate 5 mg Tablet Sig: Two (2) Tablet PO QD
(once a day) for 3 months.
Disp:*180 Tablet(s)* Refills:*0*
9. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO QD
(once a day) for 3 months.
Disp:*90 Tablet(s)* Refills:*0*
10. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO QD (once a day) for 3 months.
Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p stent placement, CAD
Discharge Condition:
stable
Discharge Instructions:
Please return to ED or call your doctor if you develop chest
pain, SOB, or fainting
Please take prescribed meds- you must take Aspirin and Plavix
for three months and then plavix life long
Followup Instructions:
please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1075**]- call [**Telephone/Fax (1) 6256**] within
two weeks
You will need an exercise tolerance test in the future for RCA
eval
Completed by:[**2200-9-16**]
|
[
"401.9",
"250.00",
"411.1",
"V70.7",
"443.9",
"V12.59",
"414.01",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.22",
"36.05",
"36.07",
"88.52",
"88.55",
"99.20"
] |
icd9pcs
|
[
[
[]
]
] |
7113, 7119
|
3709, 5502
|
355, 380
|
7188, 7196
|
2195, 3686
|
7434, 7680
|
1820, 1866
|
5741, 7090
|
7140, 7167
|
5528, 5718
|
7220, 7411
|
1881, 2176
|
297, 317
|
408, 1048
|
1070, 1701
|
1717, 1804
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,874
| 194,437
|
25709
|
Discharge summary
|
report
|
Admission Date: [**2174-7-30**] Discharge Date: [**2174-8-13**]
Date of Birth: [**2140-5-11**] Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
Pedestrian hit by car
Left rib fractures [**3-13**], pneumomediastinum, Left pneumothorax
L elbow laceration
Major Surgical or Invasive Procedure:
Left chest tube [**7-31**]
History of Present Illness:
Patient is 34 year old female pedestrian hit by moving vehicle
on L side at moderate speed (30mph) while crossing street. No
loss of consciousness. Patient landed on [**Doctor Last Name **] of car.
Past Medical History:
Asthma
Social History:
Smoker, occ. ETOH
Physical Exam:
afebrile, VS normal
A&O x3, NAD
RRR, B CTA
Abd soft, NT/ND, BS +
B LE WWP, no edema
L elbow laceration no erythema
Brief Hospital Course:
In the trauma bay, she was found to be hemodynamically stable
with good ventilation. CT scans of the head, c-spine, abdomen,
and a CTA of the chest showed pneumomediastinum and a small left
pneumothorax without any vascular injury. A CXR showed left
serial rib fractures. Her lab works were stable. She was
admitted to the floor with chest PT and pain control. However,
she had to be transferred to the intensive care unit with
worsening respirations, partly due to pain control for her rib
fractures and her worsening contusions. She was intubated
electively in the intensive care unit. She also developed a
pneumonia, which was treated with levaquin. She remained on the
ventilator for one week and could be extubated. She was
transferred to the floor in a good condition and started on a po
diet. The day before dicharge her WBC increased to 17 but
returned to 11 after removal of her central line. She had no
fevers. A chest xray showed new infiltrates on her right side
and she was started on levaquin for 10 days. She was discharged
iin a good condition and will follow-up in the trauma clinic.
Medications on Admission:
None
Discharge Medications:
1. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4H (every 4 hours).
Disp:*1 1* Refills:*2*
2. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours).
Disp:*1 1* Refills:*2*
3. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 10 days.
Disp:*10 Tablet(s)* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for
10 days.
Disp:*20 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Left lateral fractures 3-6th rib
Left pneumothorax, pneumomediastinum
Discharge Condition:
Good
Discharge Instructions:
NO SMOKING
Use incentive spirometer every 2 hrs
Followup Instructions:
F/u in trauma clinic (Dr. [**Last Name (STitle) **] in 2 weeks
Completed by:[**2174-8-13**]
|
[
"881.01",
"486",
"860.0",
"807.04",
"861.21",
"958.7",
"305.1",
"518.5",
"E814.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"93.90",
"33.22",
"38.93",
"99.15",
"33.24",
"34.04",
"96.72",
"96.6"
] |
icd9pcs
|
[
[
[]
]
] |
2493, 2499
|
855, 1957
|
380, 409
|
2613, 2619
|
2715, 2809
|
2012, 2470
|
2520, 2592
|
1983, 1989
|
2643, 2692
|
716, 832
|
232, 342
|
437, 636
|
658, 666
|
682, 701
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68,642
| 125,126
|
512
|
Discharge summary
|
report
|
Admission Date: [**2103-3-5**] Discharge Date: [**2103-3-11**]
Service: MEDICINE
Allergies:
Augmentin
Attending:[**First Name3 (LF) 2297**]
Chief Complaint:
Mixed respiratory failure
Major Surgical or Invasive Procedure:
Intubation
CVL
History of Present Illness:
Mrs. [**Known lastname **] is an 87 year old female with a PMH significant
for HTN, asthma, and chronic mixed respiratory failure followed
by Dr. [**Last Name (STitle) **] now admitted for hypoxemic respiratory failure. The
patient was found by her family this morning in her bedroom
confused after possibly falling. At that time, she was
disoriented and looked short of breath with a "glassy look in
her eyes." Her VNA arrived later this morning and then called
EMS. Of note, the patient was admitted to [**Hospital1 18**] from [**Date range (1) 4256**]
for hypoxemia of unclear etiology with hospital course
complicated by aspiration pneumonia. She has since followed up
with Dr. [**Last Name (STitle) **] of Pulmonary with suspicion for chronic mixed
respiratory failure, possibly from neuromuscular disease,
pulmonary hypertension from dCHF and elevated left-sided
pressures, and kyphoscoliosis.
.
On arrival to the [**Hospital1 18**] ED, initial VS 96.3 120 120/77 20 97%
10L with SaO2 of low 80s in triage. Initial labs were notable
for a BNP of 4238, and the patient was placed on NIPPV. She was
then noted to be persistently hypoxemic and then became
hypotensive, and so was intubated. A RIJ CVL was placed, and the
patient was placed on levophed. Cardiology was consulted for
question of NSTEMI given a TnT of 0.04, who felt that the
patient was not in over cardiogenic shock or having a plaque
rupture. She was then admitted to the MICU for further
management.
Past Medical History:
- Hypoxemia, chronic hypercarbia felt to be secondary to
restrictive physiology from possible neuromuscular deficit.
- History of asthma, but has not been treated with any
medications.
- Hypertension.
- Osteoporosis.
- History of uterine cancer resected in [**2077**] without
recurrence.
- History of kidney stones.
Social History:
Patient lives with her husband and her son.
TOBACCO: [**Name2 (NI) 4084**] smoked
EtOH: Denies
ILLICITS: Denies
Family History:
Reviewed and non-contributory
Physical Exam:
ADMISSION:
VS: 98.2 89 124/76 AC 450/16, 5, 0.40
Gen: Intubated sedated
HEENT: ETT in place
CV: Nl S1+S2
Pulm: Scattered inspiratory wheezes bilaterally
Abd: S/NT/ND +bs
Ext: No c/c/e
Neuro: Pupils 3->2 mm reactive.
Pertinent Results:
[**2103-3-11**] 03:30AM BLOOD WBC-7.5 RBC-4.02* Hgb-12.5 Hct-38.1
MCV-95 MCH-31.1 MCHC-32.8 RDW-13.7 Plt Ct-239
[**2103-3-8**] 03:22AM BLOOD Neuts-82.8* Lymphs-10.1* Monos-5.2
Eos-1.1 Baso-0.8
[**2103-3-11**] 03:30AM BLOOD Glucose-103* UreaN-12 Creat-0.4 Na-148*
K-3.9 Cl-103 HCO3-33* AnGap-16
[**2103-3-9**] 03:00AM BLOOD CK(CPK)-16*
[**2103-3-9**] 03:00AM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-712*
[**2103-3-11**] 03:30AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.3
TTE
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is mild global left
ventricular hypokinesis (LVEF = 40%). The right ventricular
cavity is mildly dilated with mild global free wall hypokinesis.
The ascending aorta is mildly dilated. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild global biventricular systolic dysfunction, most
c/w diffuse process (toxic, metabolic, etc).
Brief Hospital Course:
Mrs. [**Known lastname **] is an 87 year old female with a PMH significant
for HTN, asthma, and chronic mixed respiratory failure followed
by Dr. [**Last Name (STitle) **] admitted for hypoxemic respiratory failure with
hospital course complicated by fevers, atrial fibrillation with
RVR, and inability to clear secretions upon extubation.
1. Mixed respiratory failure/Goals of care: A-a gradient of 145
on admission in setting of likely dynamic hyperinflation with
NIPPV. Patient has a chronic element of CO2 retention with a
HCO3 in the 30-40s since [**2081**], with Dr. [**Last Name (STitle) **] concerned about a
neuromuscular disorder. In addition, she has K-S on CXR and
signs of elevated filling pressures with an estimated TRG 45 in
1/[**2102**]. The patient was treated broadly with vancomycin,
cefepime, levofloxacin, and oseltmavair, which were discontinued
when cultures and Influenza DFA returned negative. Patient was
ultimately extubated on [**3-10**], but was noted to be unable to
clear her secretions. The following day, she was noted to have
likely lobar collapse from mucus plugging. After extensive
discussions with the patient's family, the decision was made to
change her goals of care to DNR/DNI with focus on comfort
without escalation of care. All non-essential medications were
held and she expired shortly thereafter with her children at the
bedside.
Medications on Admission:
Lasix 30 mg daily
Lactulose prn
Miralax prn
Accupril 40 mg daily
Colace
Flovent
Flonase nasal
Duonebs
Discharge Medications:
Patient expired
Discharge Disposition:
Expired
Discharge Diagnosis:
Patient expired
Discharge Condition:
Patient expired
Discharge Instructions:
Patient expired
Followup Instructions:
Patient expired
Completed by:[**2103-3-12**]
|
[
"427.31",
"458.8",
"428.0",
"V49.86",
"V10.42",
"V13.01",
"737.41",
"518.84",
"358.9",
"493.90",
"733.00",
"410.91",
"294.8",
"276.2",
"401.9",
"512.8",
"428.32",
"V66.7"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"96.72",
"38.93",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
5235, 5244
|
3658, 5042
|
242, 258
|
5303, 5320
|
2531, 3635
|
5384, 5430
|
2248, 2279
|
5195, 5212
|
5265, 5282
|
5068, 5172
|
5344, 5361
|
2294, 2512
|
177, 204
|
286, 1763
|
1785, 2102
|
2118, 2232
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,197
| 189,998
|
43903
|
Discharge summary
|
report
|
Admission Date: [**2197-7-10**] Discharge Date: [**2197-7-17**]
Date of Birth: [**2124-12-20**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1267**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
[**2197-7-10**] - Mediastinal Exploration for Bleeding with suture repair
of heart.
History of Present Illness:
This patient is a 72-year-old woman who presented with cardiac
tamponade following perforation which occurred during dialysis
catheter change. She has a history of end-stage renal disease,
diabetes mellitus, status post stroke, bilateral lower extremity
amputations, who had placement of a dialysis catheter and
exchange over a guidewire. The patient developed tamponade
thereafter and
apparently developed a perforation.
Past Medical History:
1. ESRD on HD since [**2189**]
2. Diabetes mellitus II: [**8-13**] A1C of 5.2%
3. Hypertension
4. Hyperlipidemia: [**4-11**] LDL of 49
5. Peripheral [**Month/Year (2) 1106**] disease
6. Diastolic CHF, EF 70%
7. Chronic upper extremities DVTs
8. CVA x2
9. Seizure d/o s/p CVA
[**99**]. h/o MRSA line sepsis/klebsiella bacteremia, coag neg staph
bacteremia
11. h/o Osteomyletis (L3-L4 vertabrae) '[**92**]
12. h/o Pelvic fx
13. h/o psoas abscess
PAST SURGICAL HISTORY:
1. s/p Right BKA
Social History:
Lives at [**Hospital3 **] Home in [**Location (un) 583**], MA. Daughter is
next of [**Doctor First Name **]: [**First Name8 (NamePattern2) **] [**Known lastname **] [**Telephone/Fax (1) 94263**].
No tobacco, EtOH, drug use.
Family History:
Non-contributory
Physical Exam:
Post Surgery as pt was taken to OR emergently
Gen- intubated, responsive to stimuli
Neck- soft, supple, no lymphadenopathy
Heart- RRR
Lungs- coarse BS bilat
Abd- soft, NT, ND
Ext- minimal UE edema
Breast- L breast larger than R, large area of pitting edema on
lateral and inferior portion of L breast but no discrete mass
palpated nor fluctuant mass, no skin ulcerations, no nipple
discharge from either breast, + lymphadenopathy in R axilla
Pertinent Results:
[**2197-7-10**] ECHO
There is severe symmetric left ventricular hypertrophy. The left
ventricular cavity is unusually small. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The right ventricular free wall is
hypertrophied. Right ventricular chamber size is normal. with
moderate global free wall hypokinesis. The aortic valve leaflets
are mildly thickened with at least trace aortic regurgitation
(limited view). The aortic valve is not well seen. The mitral
valve leaflets are mildly thickened; mitral regurgitation not
detected in limited parasternal view. There is a moderate sized
pericardial effusion. The effusion is partially echo dense,
consistent with blood, inflammation or other cellular elements.
There are no echocardiographic signs of tamponade.There are
bubbles in the right atrium consistent with bubbles from
intravenous fluid.
Compared with the prior study (images reviewed) of [**2194-11-10**],
left ventricular cavity size is now significantly smaller. Right
ventricular systolic function appears less vigorous.
[**2197-7-10**] ECHO
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.
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. Regional left
ventricular wall motion is normal. Overall left ventricular
systolic function is mildly depressed (LVEF= 50 %). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta.
The aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen.
The mitral valve appears structurally normal with trivial mitral
regurgitation. There is a small to moderate sized pericardial
effusion. The effusion appears loculated. Dr. [**Last Name (STitle) **] was
notified in person of the results on [**Known firstname **] [**Known lastname **] at 9pm.
[**2197-7-17**] 08:40AM BLOOD WBC-5.7 RBC-3.28* Hgb-9.9* Hct-30.2*
MCV-92 MCH-30.2 MCHC-32.8 RDW-16.5* Plt Ct-272
[**2197-7-17**] 08:40AM BLOOD Plt Ct-272
[**2197-7-13**] 10:00AM BLOOD PT-15.5* PTT-29.5 INR(PT)-1.4*
[**2197-7-17**] 08:40AM BLOOD Glucose-94 UreaN-20 Creat-3.5* Na-135
K-4.2 Cl-98 HCO3-28 AnGap-13
[**2197-7-16**] 06:10AM BLOOD Glucose-125* UreaN-14 Creat-2.6*# Na-137
K-3.9 Cl-100 HCO3-26 AnGap-15
Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2197-7-10**] for hemodialysis
and exchange of her hemodialysis catheter. In the afternoon, she
became acutely hypotensive. An echo revealed tamponade and the
cardiac surgical service was consulted. Pericardiocentesis was
performed which revealed fresh blood. She was taken emergently
to the operating room where she underwent a mediastinal
exploration with a bruised area at the junction of the SVC and
the right atrium was sutured. Postoperatively she was taken to
the intensive care unit for monitoring. She later awoke
neurologically intact and was extubated. She was transferred to
the floor on POD # 2. She was transfused. She required extensive
pulmonary toilet and was started on nebulizers. Her lung exam
improved. She was cultured for fever, all cultures were
negative. She was dialyzed on Monday [**7-17**] and she was ready for
return to Presentation Manor.
Of note, her current dialysis catheter was used under emergent
conditions, however there are no signs or symptoms of exit site
infection and it currently should not be changed.
Medications on Admission:
Nephrocaps 1', Ceftazedime 1gm/HD, Doxazosin 2', Dilaudid 4"",
Lactulose 15", Xalatan gtts, Timolol gtts, Metoprolol 37.5''',
Remeron 15/hs, NTP 1 inch Q6, Oxycodone 10 Q4/prn, Dilantin
200/HS, Dilantin ER 150 QAM, Simvastatin 40'
Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection PRN (as needed) as needed for line flush.
2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
5. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO BID (2
times a day).
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. Phenytoin 125 mg/5 mL Suspension Sig: Two Hundred (200) mg PO
at bedtime.
9. Phenytoin 125 mg/5 mL Suspension Sig: One [**Age over 90 1230**]y (150)
mg PO QAM (once a day (in the morning)).
10. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. Albuterol 90 mcg/Actuation Aerosol Sig: [**2-8**] inh Inhalation
every 4-6 hours as needed for shortness of breath or wheezing.
15. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 8221**] - [**Location (un) 583**]
Discharge Diagnosis:
Pericardial Effusion secondary to perforation
ESRD on HD
Diabetes Mellitus type 2
Hyperlipidemia
PVD
Diastolic CHF
Chronic UE DVT's
CVAx2
Seizure disorder
MRSA Line sepsis
H/O Osteomyelitis
H/o Pelvic fracture
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month.
7) Call with any questions or concerns.
Followup Instructions:
Follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**]
Follow-up with Dr. [**Last Name (STitle) 6968**] in 2 weeks or as directed.
[**Telephone/Fax (1) 42391**]
Scheduled Appointments:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**]
Date/Time:[**2197-9-5**] 1:00
Completed by:[**2197-7-17**]
|
[
"428.0",
"423.3",
"250.00",
"272.4",
"428.30",
"780.39",
"E879.1",
"403.91",
"585.6",
"440.20",
"996.73",
"V12.51",
"438.89",
"294.8",
"440.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.49",
"96.71",
"37.0",
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
7472, 7545
|
4757, 5876
|
334, 420
|
7799, 7808
|
2135, 4734
|
8550, 8949
|
1639, 1657
|
6157, 7449
|
7566, 7778
|
5902, 6134
|
7832, 8527
|
1362, 1381
|
1672, 2116
|
283, 296
|
448, 872
|
894, 1339
|
1397, 1623
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
46,857
| 178,565
|
3465
|
Discharge summary
|
report
|
Admission Date: [**2146-9-7**] Discharge Date: [**2146-9-12**]
Date of Birth: [**2060-8-31**] Sex: F
Service: NEUROLOGY
Allergies:
Penicillin V Calcium / Allopurinol
Attending:[**Last Name (NamePattern1) 11784**]
Chief Complaint:
Transferred from OSH for a right temporal IPH (intubated,
sedated)
Major Surgical or Invasive Procedure:
Central line placement
History of Present Illness:
Ms [**Known lastname 15959**] ([**Last Name (LF) 15960**], [**First Name3 (LF) 11765**]) is an 86 year old right handed
woman with a history of HTN, metastatic leiomyosarcoma,
diabetes,
who was found unresponsive by her daughter around [**8-2**] am today.
No one had spoken to her since the night before when she went to
bed. She was taken by EMS to [**Location (un) 15961**] with a GCS of 9 but
became combative and was intubated for med flight and given 200
of Fentanyl. She was started on propofol and remains intubated
and was transferred to [**Hospital1 18**] for further managmeent. Of note,
she saw her PCP last month and there was mention of SBP>200At
OSH
her SBP was 170/87. HR 76.
On general review of systems from the son, he denies that she
has
had any recent fever or chills. No night sweats or recent
weight
loss or gain. Denies cough, shortness of breath. Denies chest
pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
HYPERTENSION
METASTATIC LEIOMYOSARCOMA with mets to the lungs (followed at
[**Company 2860**])
HYPERLIPIDEMIA
CAD S/P CABG
NEUROPATHIC PAIN
TONSILLECTOMY
APPENDECTOMY [**2082**]
L KNEE ARTHROSCOPY
TYPE 2 DIABETES
GOUT [**2135**]
COMPLEX R ADNEXAL MASS
COLONIC POLYPS
LEFT 5TH PHALANX PAIN
[**First Name8 (NamePattern2) **] [**Location (un) **] SYNDROME
Social History:
She does not smoke and rarelyuses ETOH. She was a
banker.
Family History:
no strokes in family. mother had [**Name2 (NI) 499**] polyps
Physical Exam:
Physical Examination on Admission:
O: BP: 144/50 HR:64 R 12 O2Sats 100%int
Gen: cervical collar. ETT
neck: collar
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft,
Extremities:warm and well perfused
Skin: no
Neurological Examination:
GCS:5
level of arousal - 1
best verbal -1
best motor -4
Mental status: intubated. off sedation grimaces to pain, but
does
not open eyes or follow any direction
Cranial Nerves:
-Pupils equally round and reactive to light,2 to 1 mm
bilaterally.
-no gaze deviation, no bobbing, no nystagmus, no gag, but +
cough.
Motor: Normal tone bilaterally. withdraws to noxious all 4
extremities.
Reflexes: B T Br Pa Ac
Right 1 1 1 1 1
Left 1 1 1 1 1
Toes upgoing bilaterally
PHYSICAL EXAM ON DISCHARGE:
Vital Signs: T 98.8, BP 142/56, HR 56, RR 23, 94% RA
GEN: Elderly woman lying in bed in NAD
HEENT: OP clear
CV: 3/6 systolic murmur heard best at the R 2nd rib space
PULM: CTA-B
ABD: soft, NT, ND
EXT: no peripheral edema
.
Neurological Exam:
.
MS: speech fluent, knew which hospital she was at, knew DOW,
date and year
.
CN: PERRL 2.5->1.5mm, pt has difficulty burying her sclerae on
lateral gaze bilaterally, tongue midline, face symmetrical,
shoulder shrug [**4-28**] bilaterally.
.
MOTOR:
delt bic tric FExt Grip Quad Ham Gastroc TA
R 4+ 5- 5- 5 5 5 5 5 5
L 5- 5 5 5 5 5- 5 5 5
.
normal tone, normal bulk
.
Reflexes: 1's throughout bilaterally, with mute toes bilaterally
.
Sensory: intact to light touch throughout
.
Coordination: FNF intact bilaterally
.
Gait: deferred
Pertinent Results:
Labs on Admission
[**2146-9-7**] 02:25PM BLOOD WBC-11.0 RBC-3.66* Hgb-10.6* Hct-30.5*
MCV-84 MCH-28.9 MCHC-34.7 RDW-14.6 Plt Ct-255
[**2146-9-7**] 02:25PM BLOOD Plt Ct-255
[**2146-9-7**] 02:25PM BLOOD PT-12.2 PTT-25.4 INR(PT)-1.0
[**2146-9-7**] 10:08PM BLOOD Glucose-146* UreaN-40* Creat-1.6* Na-139
K-4.0 Cl-105 HCO3-22 AnGap-16
[**2146-9-7**] 10:08PM BLOOD ALT-12 AST-27 LD(LDH)-438* CK(CPK)-186
AlkPhos-52 TotBili-0.7
[**2146-9-7**] 02:25PM BLOOD cTropnT-0.17*
[**2146-9-7**] 02:25PM BLOOD CK-MB-5
[**2146-9-7**] 10:08PM BLOOD CK-MB-4 cTropnT-0.16*
[**2146-9-8**] 01:53PM BLOOD CK-MB-3 cTropnT-0.10*
[**2146-9-9**] 02:13AM BLOOD CK-MB-3 cTropnT-0.10*
[**2146-9-7**] 10:08PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.6 Mg-1.6
Cholest-195
[**2146-9-7**] 10:00PM BLOOD %HbA1c-8.1* eAG-186*
[**2146-9-7**] 10:08PM BLOOD Triglyc-234* HDL-52 CHOL/HD-3.8
LDLcalc-96
[**2146-9-7**] 10:08PM BLOOD TSH-0.97
[**2146-9-7**] 02:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2146-9-7**] 04:08PM BLOOD Type-ART Rates-[**11-29**] Tidal V-500 PEEP-5
FiO2-60 pO2-166* pCO2-29* pH-7.48* calTCO2-22 Base XS-0
Intubat-INTUBATED
[**2146-9-7**] 02:31PM BLOOD Glucose-185* Lactate-2.0 Na-139 K-4.4
Cl-104 calHCO3-24
[**2146-9-7**] 02:38PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2146-9-7**] 10:09PM URINE RBC-15* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0 RenalEp-<1
[**2146-9-7**] 05:34PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
LABS ON DISCHARGE:
[**2146-9-12**] 05:40AM BLOOD WBC-7.9 RBC-3.44* Hgb-9.9* Hct-29.0*
MCV-84 MCH-28.8 MCHC-34.2 RDW-14.4 Plt Ct-265
[**2146-9-12**] 05:40AM BLOOD Glucose-173* UreaN-56* Creat-1.6* Na-141
K-5.0 Cl-110* HCO3-21* AnGap-15
[**2146-9-12**] 05:40AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.4
Imaging/Other data:
EKG: Sinus rhythm. Possible old septal myocardial infarction.
Left anterior fascicular block. Probable left ventricular
hypertrophy.
CT Head [**2146-9-7**]: right temporal intraparenchymal hemorrhage
with mild
mass effect and leftward shift of midline structures. No new
areas of
hemorrhage noted. MRI can be obtained for further evaluation.
MRI Head [**2146-9-7**]: Mild-to-moderate-sized area of negative
susceptibility in the right capsuloganglionic region,
correlating with the previously noted area of hemorrhage,
measuring approximately 1.4 x 2.2 cm, with mild-to-moderate
amount of surrounding edema. No obvious heterogeneous nodular
component of intermediate signal intensity is noted within this
location to suggest an obvious tumor. However, assessment is
limited due to lack of post-contrast images. These can be
considered when appropriate. Diminutive right vertbral artery in
the head and c spine- can be congenital; correlate with MRA when
appropriate. Diffuse mucosal thickening with fluid in the
mastoid air cells, small amount of fluid in the sphenoid sinus
and mucosal thickening in the ethmoid air cells as described
above.
CT Head [**2146-9-8**]: Unchanged right temporal intraparenchymal
hemorrhage adjacent to the capsuloganglionic region. No new
areas of hemorrhage or edema. This hemorrhage is most consistent
with a hypertensive etiology; however, an underlying mass or
vascular malformation cannot be excluded. Please correlate
clinically for determining further followup.
CT L-Spine: No fracture involving the lumbar spine. Degenerative
change in the low lumbar spine worst at L4-5, where chronic
grade 1 anterolisthesis, disc bulge, and facet arthropathy cause
moderate canal stenosis, though intrathecal detail is poorly
assessed by CT. Pl. see subsequent MRI which shows moderate -
severe canal stenosis, crowding of the roots of cauda and
impingement on L4 and L5 nerves on both sides. Nodule at splenic
hilum- likely splenule; left lumbar paraspinal ovoid lesion- pl.
see prior MR studies. (Pt. has additional h/o malignant spindle
cell neoplasm)
CT T Spine: No fracture or traumatic malalignment involving the
thoracic spine. Mild multilevel degenerative change, without
severe canal narrowing. Numerous pulmonary nodules, the largest
being a 3.1 cm mass in the left lower lobe, compatible with
patient's known metastatic disease.
MRT/L Spine: L4/5: Grade 1 anterolisthesis with pars defects;
bil facet joints resulting in moderate-severe canal and
foraminal stenosis and crowding of cauda; impingement on L4 and
l5 nerves. T spine: no disc herniation or cord compression.
Areas of altered signal intensity in the posterior thecal sac-
likely pulsation artifacts; however, incompletley assessed
MRI C Spine: Multilevel, multifactorial degenerative changes,
with broad-based disc osteophyte complexes indenting the ventral
thecal sac and the ventral surface of the cord at C5-6 and C6-7
levels, with foraminal narrowing as described above. Subtle
linear hyperintense focus, in the C2 body relates to marrow
edema. However, the significance of this finding is uncertain as
there is no definite fracture on the prior CT C-spine study.
Attention on followup can be considered.
MRI T and L-spine: IMPRESSION:
1. No obvious focus of marrow edema to suggest injury.
2. Multilevel, multifactorial degenerative changes in the
thoracic and the
lumbar spine, most prominent at L4-L5 level with mild
anterolisthesis,
bilateral facet degenerative changes, resulting in
moderate-to-severe canal stenosis and moderate-to-severe
foraminal narrowing, with impingement on the L4 and L5 nerves.
3. An ovoid lesion noted in the left paraspinous muscles at
L2-L3 level
measuring approximately 1.2 x 2.3 cm. Please see the details on
prior CT
studies.
4. Areas of altered signal intensity in the posterior thecal
space in the
T-spine may relate to pulsation artifacts. However, these are
inadequately
assessed.
5. A few T2 hyperintense foci in the right side of pelvis on the
localizing images can be better assessed with pelvic ultrasound.
Brief Hospital Course:
Ms. [**Known lastname 15959**] was admitted to the Intensive Care Unit for close
monitoring. She remained afebrile and hemodynamically stable
throughout her ICU stay. She was continued on her home
medications for her comorbidities (including gout), and her
blood pressure was kept below SBP 160 with the help of
intravenous agents. All antiplatelet and anticoagulant agents
were held. The plan is to restart her aspirin on [**9-16**] (10 days
s/p bleed). In our hands on Day 1, she remained intubated and
sedated so as to achieve formal MR imaging of her brain and
C-spine so as to rule out soft tissue injury of the cervical
spine. A follow up NCHCT showed no evidence of enlarging bleed,
and there was no midline shift. With the assistance of the
orthopedic spine service and the general surgery team, her spine
precautions were officially cleared and she was extubated on
[**9-10**].
Following extubation, she did well. Her physical examination did
show some left sided weakness that has remained, but improved
throughout her hospitalization. Her renal function remained at
baseline, and IV contrast agents were avoided including
gadolinium. Her brain MRI showed changes consistent with her
known IPH on the right basal ganglia, no obvious evidence of
metastatic lesion was noted, although this is difficult to tell
in the acute period. She will need to schedule an outpatient
repeat MRI with contrast in 6 weeks (phone number in the
discharge paperwork). Her PCP and primary oncologist were
notified of her admission here.
While here, we continued her chronic prednisone therapy.
PENDING LABS:
Blood Culture x2 [**2146-9-8**]
TRANSITIONAL CARE ISSUES: Patient will need her baby aspirin
restarted on [**9-16**] (10 days s/p bleed). She will need to be
monitored for changes in her neurological exam after this is
started.
Medications on Admission:
ASPIRIN - 81MG Tablet - ONE BY MOUTH EVERY DAY
ATORVASTATIN [LIPITOR] - 20 mg Tablet - 1 Tablet(s) by mouth at
bedtime
FEBUXOSTAT [ULORIC] - (Dose adjustment - no new Rx) - 40 mg
Tablet - Half Tablet(s) by mouth daily
GABAPENTIN - 300 mg Capsule - 2 Capsule(s) by mouth three times
daily
ISOSORBIDE MONONITRATE - 120 mg Tablet Extended Release 24 hr -
1
Tablet(s) by mouth once a day
LIDOCAINE [LIDODERM] - 5 % (700 mg/patch) Adhesive Patch,
Medicated - [**12-26**] patches q 12 hrs as needed for prn
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth daily
MOEXIPRIL - 15 mg Tablet - 1 Tablet(s) by mouth once a day
NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s)
sub lingually prn chest pain
PREDNISONE - (Dose adjustment - no new Rx) - 10 mg Tablet - 4
Tablet(s) by mouth qd x 2 days then 3 tabs x 2 days then 2 tabs
x
2 days then 1 tab daily, for gout attacks. Half a tablet daily
ROLLING WALKER - - use as directed diagnosis = leiomyosarcoma
left leg, gait instability
Medications - OTC
BLOOD SUGAR DIAGNOSTIC [SURESTEP TEST] - Strip - use to
monitor
blood sugar four times a day
INSULIN NPH & REGULAR HUMAN [HUMULIN 70/30] - 100 unit/mL
(70-30)
Suspension - Use as directed once a day 44 U pre-breakfast and
24
U pre-dinner
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
2. febuxostat 40 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
3. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO three times
a day.
4. moexipril 15 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. isosorbide mononitrate 120 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. Lidoderm 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One
(1) Topical once a day as needed for pain: 12hrs on, 12 hrs off
in given 24 hr period.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day as needed for chest pain.
9. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. heparin (porcine) 5,000 unit/mL Solution Sig: 5,000 units
Injection TID (3 times a day).
11. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain, temp >100.4.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] TCU - [**Location (un) 86**]
Discharge Diagnosis:
Primary: Right basal ganglia cerebral hemorrhage.
Secondary: Hypertension, metastatic leiomyosarcoma, diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
NEURO EXAM: weakness in right deltoid, biceps, triceps and left
deltoid and quadriceps
Discharge Instructions:
Dear Ms. [**Known lastname 15959**],
You were seen in the hospital for a bleed in the right side of
your brain. While here you were evaluated with an MRI and it
was shown that your bleed remained stable. You were able to be
sent to a rehabilitation facility to regain as much strength as
possible.
We made the following changes to your medications:
1) We STOPPED your ASPIRIN. You can restart this medication on
[**9-16**] (10 days after your bleed).
2) We STARTED you on TYLENOL 650mg every 6 hours as needed for
pain or fever greater than 100.4 degrees.
3) We STARTED you on SUBCUTANEOUS HEPARIN INJECTIONS. You will
only need to take these while you are at your rehab facility.
They are to prevent DVTs.
If you experience any of the above listed Danger Signs, please
contact your PCP or go to the nearest Emergency Room.
It was a pleasure taking care of you on this hospitalization.
Followup Instructions:
Please call Phone: ([**Telephone/Fax (1) 6713**] to set up an appointment to
have a brain MRI in 6 weeks (beginning of Novemeber).
Department: RHEUMATOLOGY
When: MONDAY [**2146-10-10**] at 9:30 AM
With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], MD [**Telephone/Fax (1) 2226**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**]
Campus: WEST Best Parking: [**Hospital Ward Name **] Garage
Department: NEUROLOGY
When: MONDAY [**2146-11-7**] at 1:30 PM
With: [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD [**Telephone/Fax (1) 2574**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: MONDAY [**2146-11-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"585.9",
"250.00",
"V87.41",
"V10.89",
"288.60",
"V58.67",
"411.89",
"724.02",
"396.2",
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"728.87",
"274.03",
"V17.3",
"431",
"723.4",
"V45.81",
"197.0",
"403.90",
"V58.65",
"285.9",
"272.4",
"V13.01",
"V12.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"96.71"
] |
icd9pcs
|
[
[
[]
]
] |
13989, 14063
|
9774, 11410
|
371, 396
|
14218, 14218
|
3833, 5371
|
15400, 16449
|
1991, 2055
|
12935, 13966
|
14084, 14197
|
11633, 12912
|
14482, 14805
|
2070, 2091
|
2962, 3185
|
14834, 15377
|
3204, 3814
|
265, 333
|
11436, 11607
|
5391, 9751
|
424, 1522
|
2629, 2934
|
2105, 2508
|
14233, 14458
|
1544, 1899
|
1915, 1975
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
13,620
| 169,431
|
29971
|
Discharge summary
|
report
|
Admission Date: [**2149-11-13**] Discharge Date: [**2149-11-28**]
Date of Birth: [**2123-8-23**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Severe abdominal pain
Necrotizing pancreatitis (transferred from [**Hospital 1562**] hospital)
Major Surgical or Invasive Procedure:
None
History of Present Illness:
26 y/o male with no significant PMH, and had been in his usual
state of health when, after eating a cheeseburger developed
severe abdominal pain. The pain lasted through the night and was
accompanied by nausea, vomiting. He went to his local hospital
the following day and was found to have elevated amylase lipase
on bloodwork and abdominal CT showing pancreatitis. Was made
NPO, TPN and IVF was started. Repeat CT done [**11-13**] showed
necrotizing pancreatitis with gallstone, and patient was
transferred to [**Hospital1 18**] for further evaluation.
Past Medical History:
Shoulder injury
Recent wisdom tooth extraction
Social History:
Works as a waiter
Attending community college
Tobacco [**11-25**] - 1 PPD
ETOH: Socially, denies heavy ETOH use
Family History:
N/C
Physical Exam:
VS: 100.4, 121, 130/61, 15, 95%4L Bladder pressure 27
Gen: A+O, Uncomfortable
Card: RR, Tachy
Lungs: Diminshed BS at bases
Abd: Mild-moderately protuberant, diffusely tender
Pertinent Results:
On Admission: [**2149-11-13**] 11:20PM
GLUCOSE-103 UREA N-15 CREAT-0.5 SODIUM-133 POTASSIUM-4.0
CHLORIDE-98 TOTAL CO2-31 ANION GAP-8
ALT(SGPT)-140* AST(SGOT)-50* LD(LDH)-405* ALK PHOS-53 TOT
BILI-0.5
AMYLASE-508 LIPASE-413*
ALBUMIN-2.7* CALCIUM-8.1* PHOSPHATE-1.5* MAGNESIUM-2.1
WBC-12.0* RBC-3.15* HGB-10.4* HCT-28.6 MCV-91 MCH-33.1*
MCHC-36.5* RDW-13.5
PLT COUNT-268
PT-12.1 PTT-27.8 INR(PT)-1.0
FIBRINOGE-730*
On day of discharge
[**2149-11-28**] 07:23AM BLOOD Amylase-68
[**2149-11-28**] 07:23AM BLOOD Lipase-97*
Brief Hospital Course:
26 yo transferred from [**Hospital1 1562**] w/ necrotizing pancreatitis.
CT done at outside hospital showed necrosis of the body of the
pancreas with moderate peri-pancreatic fluid, bowel wall
thickening and prominent CBD.
Patient continued NPO status, NGT in place and TPN was
continued. Admitted to the SICU. Patient continued with
significant abdominal pain, but remained hemodynamically stable.
He was volume resuscitated and plan was made for cholecystectomy
once pancreatitis settled down. Imipenem started on admission
CT obtained on [**11-15**] (HD3) that showed area of nonenhancement
within the pancreas, associated stranding and inflammatory
change consistent with necrotizing pancreatitis. Associated
ascites, bowel wall thickening, retroperitoneal fluid, and
bilateral pleural effusions likely due to hypoalbuminemia were
also seen.
Amylase peak value: 508, Lipase peak value: 413. These were on
admission and continued to fall back to normal except one mild
increase HD [**9-6**].
Patient required Dilaudid PCA for pain relief.
Abdominal pain slowly resolved. Again a plan was formulated for
surgical intervention based on decreasing abdominal pain,
however concern for lack of decrease in size of necrotic area as
seen on [**11-22**] CT, and it was decided to hold on surgery and
continue conservative management.
CT showed: Continuing organization of multiple peripancreatic
fluid collections, without change in size. No change in degree
of pancreatic necrosis. Improving fluid status, with decreased
ascites, pleural effusions and atelectasis, and bowel wall
edema.
Left lower lobe consolidation could represent pneumonia.
Patient started PO intake on [**2149-11-25**], which was tolerated well.
No increase in pain was noted.
TPN was discontinued on [**11-26**]. Patient continued on clears and
was slowly starting full diet by [**11-27**].
Plan is to d/c home on low fat diet, no ETOH. Follow-up visit is
scheduled for 2 weeks with potential for cholecystectomy in one
month. Will be advised to call/return if pain develops before
that time. Also to establish PCP at home.
Medications on Admission:
Vicodin
Discharge Medications:
1. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
Disp:*60 Capsule(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Necrotizing gallstone pancreatitis
Discharge Condition:
Good
Discharge Instructions:
Please call [**Telephone/Fax (1) 673**] or return to the ER if you experience
abdominal pain, nausea, vomiting.
Please follow a low fat diet and avoid alcohol completely.
Follow up regarding Primary Care Provider near your home
Followup Instructions:
[**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2149-12-18**] 8:00
Completed by:[**2149-11-28**]
|
[
"577.0",
"574.51"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
4483, 4489
|
1974, 4068
|
411, 417
|
4568, 4575
|
1431, 1431
|
4851, 5027
|
1216, 1221
|
4126, 4460
|
4510, 4547
|
4094, 4103
|
4599, 4828
|
1236, 1412
|
277, 373
|
445, 1001
|
1445, 1951
|
1023, 1071
|
1087, 1200
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,467
| 104,112
|
46116
|
Discharge summary
|
report
|
Admission Date: [**2142-1-1**] Discharge Date: [**2142-1-3**]
Date of Birth: [**2099-12-31**] Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 9871**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
intubation and mechanical ventilation
History of Present Illness:
42 y/o F PMH Breast Cancer metastatic to lungs, cranium, spine
(epidural T1/T4, cervical/upper thoracic spine) and bone (spine
and sternum) and leptomeniges. According to recent Oncology
notes current treatment is Doxorubicin (last treatment
[**2141-12-26**]), steroids and s/p XRT for leptomenigeal disease.
Patient currently intubated consequently history from OMR and
family.
.
Patient presented to ED T 95.3, BP 129/95, HR 98, O2 Sat 100% (?
oxygen) and triggered for respiratory distress. She was placed
on NRB with O2 Sat 93%. Respiratory status worsened despite
inhalers and patient became increasing somnelent and
consequently was intubated. Patient was given levaquin for
concern of PNA.
.
Per family patient had 1 week history of SOB with exertion.
Breathing increasingly laboured over the past week at rest.
Family reports several months of SOB but with exertion only.
Denies associated fever, chills, cough, hemopytsis. Daughter has
cold, but not severe and requires no antibiotics. No chest pain.
Does report bloody nose last night and usually every other week.
Mother reports patient more disoriented this afternoon and
easily tired. Family not aware of lung metastasis.
.
Of note patient's most recent admission [**2141-10-17**] for headaches
started on steroids/radiation therapy, dyspnea ruled out for PE
felt to be secondary to metastasis. Recent Heme Onc notes
notable for agitation/hallucinations felt to be related to
steroids.
Past Medical History:
Past Oncologic History:
- diagnosed in late [**2135**] with infiltrating ductal carcinomas of
the right breast with positive sentinel node, ER positive, PR
positive, and HER-2/neu negative
- underwent dose-dense AC followed by dose-dense Taxol, then
mastectomy and level 1 axillary node dissection with only one
focus residual DCIS, then postoperative radiation therapy and
hormonal therapy
- developed bone metastases in [**2139-5-31**] and subsequently
received multiple hormonal and chemotherapy regimens and
radiation therapy to symptomatic sites
- began Abraxane and Avastin on [**2141-5-31**], had 3 cycles (last
one on [**2141-7-28**]
- began complaining soon after of increased pain in bilateral
ribs at the mid chest level.
-MRI on [**2141-6-9**], showed further compression of the T4 and
T6 vertebral bodies and new fusiform abnormalities in the
posterior epidural space at T6-8 and T9-10 without evidence of
spinal cord signal abnormality or significant compression.
- C1D1 Gemzar [**2141-8-18**], has recieved 2 cycles (cycle 2 on
[**2141-9-8**])
- Most recent regimen Doxil (Doxorubicin 10mg/m2 d1,d8,d15);
following chemo zometa every 3 months
- Whole brain irradiation from [**Date range (3) 98116**] Dr. [**Last Name (STitle) 3929**]
.
- Depression
Social History:
Lives with her daughter and her mother lives in the [**Last Name (un) **]
downstairs.
- Tobacco: previously smoked 1ppd. Quit 2 months ago.
- etOH: social drinker, last had a drink 2 months ago.
- Illicits: smokes marijuana about every other week.
Family History:
Mother with cervical cancer. No family history of breast or
ovarian cancer.
Physical Exam:
Admission Physical Exam:
VS: BP: 111/58 HR: 74 RR: 27 O2sat: 99% vent
GEN: intubated and sedated, not responsive to verbal stimuli
HEENT: PERRL, anicteric, MMM, op without lesions
RESP: CTA b/l with good air movement anterior
CV: RR, S1 and S2 wnl, no m/r/g
ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly
EXT: no c/c/e
SKIN: no rashes/no jaundice/no splinters
Pertinent Results:
Admission Labs [**2142-1-1**]:
-WBC-7.2 RBC-3.58* Hgb-10.7* Hct-32.0* MCV-89 MCH-29.9 MCHC-33.5
RDW-20.4* Plt Ct-17*
-Neuts-59 Bands-4 Lymphs-13* Monos-12* Eos-3 Baso-0 Atyps-0
Metas-3* Myelos-4* Promyel-2* NRBC-19*
-Hypochr-1+ Anisocy-3+ Poiklo-1+ Macrocy-1+ Microcy-1+
Polychr-1+ Schisto-1+ Tear Dr[**Last Name (STitle) **]1+ Bite-1+
-PT-13.2 PTT-21.9* INR(PT)-1.1
-Fibrino-551*
-Glucose-121* UreaN-24* Creat-0.8 Na-131* K-5.1 Cl-99 HCO3-23
AnGap-14
-ALT-62* AST-73* LD(LDH)-947* AlkPhos-148* TotBili-0.8
-proBNP-411*
-Hapto-<5*
-Type-ART Rates-/16 Tidal V-450 PEEP-5 FiO2-70 pO2-234* pCO2-40
pH-7.42 calTCO2-27 Base XS-1 Intubat-INTUBATED
-Lactate-0.9
.
[**2142-1-3**]:
-Platlets 14*
.
Select Reports:
-CTA: 1. No pulmonary embolus. 2. Progression of metastatic
disease involving mediastinal and right hilar nodes. True extent
of malignancy likely underestimated by low lung volumes and
bibasilar consolidations, due to combination of aspiration and
pneumonia. 3. Given septal thickening at least in part due to
pulmonary edema, lymphangitic spread of carcinomatosis would be
difficult to exclude. 4. Left breast nodule, though
subcentimeter, is larger than in [**2141-8-30**].
.
-TTE: The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF 70%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
Compared with the findings of the prior study (images reviewed)
of [**2140-9-29**], probably no major change.
.
-CT Head: There is no evidence of hemorrhage, edema, mass
effect, or infarction. The ventricles and sulci are normal in
size and configuration. [**Doctor Last Name **]-white matter differentiation is
well preserved. Paranasal sinuses and mastoid air cells are
clear and well aerated. Re-demonstrated is diffuse metastastic
involvement of the calvarium and skull base.
.
-CXR on day of discharge [**2142-1-3**]: In comparison with the study of
[**1-2**], there is increasing diffuse bilateral pulmonary
opacifications. In view of the enlargement of the cardiac
silhouette and blunting costophrenic angles, this could well
represent pulmonary edema. However, the possibility of
supervening pneumonia or even ARDS would have to be considered.
Brief Hospital Course:
A/P: 42 year old female PMH metastatic breast cancer (lung,
spine and leptomeningeal) who presents with respiratory distress
of 1 week duration requiring intubation on arrival to ED. No
specific cause was found for her deterioration whcich was put
down to disease progression following an unchanged TTE, negative
CT-PA for PE, no evidence radiologically for DVTs and no culture
data to suggest an infectious precipitant.
.
.
# Respiratory Distress: Thsi was considered likely due to
progression of knoen metastatic breast cancer. Her primary
oncologist felt that she should not be intubated again. Mrs
[**Known lastname 98114**] was celebrating birthday with family, unable to blow
candles out. She then noted increasing sob, family called EMS.
On NRB at presentation to the EW, sO2 91%. A&O at that time and
stated she would like to be intubated, if needed. She then ecame
tachypneic and lethargic and was intubated and commenced on
propofol. She was transferred to the MICU for further care CXR
showed no evidence of pneumonia. Sputum revealed respiratory
commensal flora. Given progressive shortness of breath without
symptoms of cough/fever concerning for PE especially in setting
of known metastatic disease. She therefore had a CT-[**MD Number(3) 24709**]
showed no evidence of PE but did show progression of metastatic
disease involving mediastinal and right hilar nodes. In
addition, teh report noted that given septal thickening at least
in part due to pulmonary edema, lymphangitic spread of
carcinomatosis was considered difficult to exclude. The Left
breast nodule, was larger than in [**2141-8-30**]. LENIs were done and
were negative for DVTs. Given possible pulmonary edema, she had
a TTE which showed no significant change from prior. She had
furosemide IV prior to extubation given above BNP 411 and she
had a good diuresis to this. She was treated Levofloxacin and
Vancomycin and thsi was stopped post extubation. She was
successfully extubated on the evening of [**1-2**] and passed a SBT.
She was saturating well on room air and transferred to teh
oncology service and was discharged on [**1-3**].
.
# Altered Mental Status: This was initially presnet at time of
hospital admission and peri-intubation and resolved [**1-2**] post
intubation. She had a CT-head which showed no acute process. She
was at her baseline after this.
.
# Thrombocytopenia: Slowly trending down from [**2141-11-10**]. Last
platelet count [**2141-12-28**] 23. Most likely chemotherapy side effect
- received Doxorubicin [**2141-12-26**] - espeically in setting of diff
with metas/myelos/nRBC. This was felt unlikely DIC as PT/PTT
within normal limits, no schistocytes, fibrinogen elevated. This
was trended and trended remaining around 15. There was no sign
of active bleeding.
# Hyponatremia: This was initially felt most likely hypovolemic
or SIADH. Urine Na 49 and urine osmo 441 suggested SIADH. She
has several possible causes for SIADH including metastatic
disease, possible pneumonia or CNS involvement. This was trended
and improved to 140 on discharge.
.
# Anemia: Above baseline 26-29. This was trended.
.
# Transaminitis: Slightly elevated from prior however labs
hemolyzed. Prior CT A/P showed no metastatic disease within the
abdomen and pelvis. This was trended and decreased by teh time
of discharge. No further work-up was performed.
.
# Metastatic breast cancer: Overall poor prognosis due to
metastasis to lung and bone. MR head [**2141-12-20**] near total
resolution of the previously noted pachymeningeal and
leptomeningeal disease compared to [**2141-9-29**] s/p XRT. Per ED,
patient wished to be intubated and also discuss with mother. O/P
oncologist felt that patient should not be intubated in future.
We started dexamethasone 4mg [**Hospital1 **]. - Confirm whether patient
currently taking Dexamethasone 4 mg [**Hospital1 **]. She was extubated on
[**1-2**] and was saturating well on room air. Post extubation, we
restarted her outpatient pain regimen of Fentanyl and Oxycodone.
.
# Depression/Anxiety: WE held Alprazolam while on midazolamd
infusion adn post extubation on [**1-2**] we restarted he home regime
of alprazolam, Setraline and Perphenazine.
Medications on Admission:
ALPRAZOLAM - 0.5 mg Tablet - one Tablet(s) by mouth tab po TID
and one PRN for agitation
DEXAMETHASONE - (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth twice a day
FENTANYL - 50 mcg/hour Patch 72 hr - TD q72H
LIDOCAINE-PRILOCAINE - 2.5 %-2.5 % Cream - Apply topically to
port one hour prior to chemotherapy - No Substitution
OXYCODONE - 20 mg Tablet - 2 Tablet(s) by mouth every 4-6 hours
as needed for pain. - No Substitution
PERPHENAZINE - 2 mg Tablet - one Tablet(s) by mouth [**2-1**]
times/day
SCALP PROSTHESIS - - 174.9
SERTRALINE - 50 mg Tablet - one Tablet(s) by mouth daily
Discharge Medications:
1. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 6 days: to be finished on [**2142-1-9**].
Disp:*6 Tablet(s)* Refills:*0*
2. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
3. alprazolam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for agitation.
4. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
5. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Transdermal q 72
hours: please resume prior schedule.
6. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) application
Topical prior to chemotherapy: Apply topically to
port one hour prior to chemotherapy - No Substitution .
7. oxycodone 20 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours
as needed for pain.
8. perphenazine 2 mg Tablet Sig: One (1) Tablet PO 2 to 3 times
per day.
9. scalp prosthesis Sig: as directed as needed.
10. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
thrombocytopenia
metastatic breast cancer
respiratory distress
pulmonary edema
anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms [**Known lastname 98114**],
You were recently admitted for management of shortness of
breath. You were initially admitted to the Intensive Care Unit
(ICU) where you had a machine helping you breathe. They provided
you with antibiotics and medications to remove excess fluid and
you improved. You were transferred to the floor. We are
providing you with a prescription for an antibiotic to continue
after discharge.
.
Your platelets were discovered to be very low during this
admission. You will need to return for a follow up appointment
tomorrow morning at 9 AM (detail below). You will need to have
your platelets re-checked. Please be very careful that you do
not fall, as injurying yourself could be very dangerous because
with low platelets your blood does not clot appropriately.
.
We are making the following changes to your outpatient regimen:
-Please START Levofloxacin 750 mg by mouth daily until [**2142-1-9**]
Followup Instructions:
Department: HEMATOLOGY/ONCOLOGY
When: TUESDAY [**2142-1-9**] at 10:00 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 73088**], NP [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: NEUROLOGY
When: THURSDAY [**2142-1-18**] at 1:30 PM
With: [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"518.81",
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"287.5",
"198.5",
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] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"33.24",
"96.04"
] |
icd9pcs
|
[
[
[]
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|
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|
323, 363
|
12514, 12514
|
3897, 5818
|
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|
3147, 3396
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,137
| 174,418
|
9815
|
Discharge summary
|
report
|
Admission Date: [**2113-4-10**] Discharge Date: [**2113-4-19**]
Date of Birth: [**2069-8-16**] Sex: M
Service:
DISCHARGE DIAGNOSIS: Left renal mass.
PROCEDURE: Left renal artery embolization and left
nephrectomy with lymph node dissection.
DISCHARGE MEDICATIONS: Percocet.
HISTORY OF PRESENT ILLNESS: This is a 43 year old man with a
history of left renal mass found in response to a new left
varicocele diagnosed in [**2111**]. The varicocele was repaired in
the spring of [**2112**], but he complained of lethargy for several
months in association with anemia. He also had low back
pain. CT scan was performed which revealed a left renal mass
with metastasis. He underwent IL2 therapy for two weeks in
[**2112-12-2**] and has had a 30 pound weight loss. He was
angio-infarcted in [**2113-4-2**] and presents now for debulking
nephrectomy.
PAST MEDICAL HISTORY: As above.
PAST SURGICAL HISTORY: Right shoulder surgery. Left
varicocele repair.
ALLERGIES: None.
SOCIAL HISTORY: Smoking half pack per day for 15 years.
PHYSICAL EXAMINATION: In no acute distress. Abdomen was
soft and nondistended. He had some tenderness in the left
lower quadrant. No peritoneal signs.
LABORATORY DATA: Notable for abdominal and pelvic CT which
revealed this large left renal mass as well as lumbar
metastasis. He had retroperitoneal adenopathy. There was
left adrenal metastasis. Laboratory data were notable for
hematocrit of 35.8, creatinine 0.8.
HOSPITAL COURSE: On [**2113-4-11**] the patient underwent
uncomplicated left nephrectomy and lymph node dissection by
Dr. [**Last Name (STitle) **] with assistance from Dr. [**Last Name (STitle) 33031**]. He received two
units of packed red cells intraoperatively and had 3 liters
estimated blood loss. Postoperatively he was kept intubated
and sedated overnight. He was extubated without difficulty.
Postoperatively hematocrit was stable, but he had some
persistent tachycardia. A VQ scan was obtained and was
indeterminate.
He was transferred from the SICU on [**2113-4-13**]. He remained
comfortable on Dilaudid PCA. He was administered Lasix and
had brisk diuresis. NG tube was maintained until [**2113-4-17**].
It was clamped with low residual at that time and his diet
was slowly advanced. By [**4-19**] he was tolerating a regular
diet and prepared for discharge home. He will follow up with
Dr. [**Last Name (STitle) **].
[**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. [**MD Number(1) 19331**]
Dictated By:[**Name8 (MD) 33032**]
MEDQUIST36
D: [**2113-6-1**] 08:59
T: [**2113-6-3**] 08:02
JOB#: [**Job Number 11497**]
|
[
"198.89",
"189.0",
"997.4",
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"440.0",
"196.2",
"787.02",
"530.81",
"198.5"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.86",
"55.51"
] |
icd9pcs
|
[
[
[]
]
] |
284, 295
|
149, 260
|
1498, 2690
|
928, 997
|
1078, 1480
|
324, 870
|
893, 904
|
1014, 1055
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
16,911
| 164,441
|
50844
|
Discharge summary
|
report
|
Admission Date: [**2136-2-2**] Discharge Date: [**2136-2-11**]
Date of Birth: [**2062-11-15**] Sex: F
Service: MEDICINE
Allergies:
Codeine / Morphine / Zofran / Zofran (PF) in dextrose
Attending:[**First Name3 (LF) 2042**]
Chief Complaint:
Altered mental status, abdominal pain.
Major Surgical or Invasive Procedure:
[**2136-2-2**] Right Femoral Line
History of Present Illness:
73yo F h/o breast cancer s/p L partial mastectomy in [**2124**] and
metastatic ovarian carcinosarcoma diagnosed in [**2128**] s/p multiple
rounds of chemo and XRT who presents with abdominal pain and
altered mental status. Abdominal pain began 2-3 days ago (last
BM yesterday), then became confused today. Was found by EMS
altered, not answering questions, but arousable to voice and
sternal rub. EMS was unable to put in [**Last Name (LF) **], [**First Name3 (LF) **] an IO was placed
in her right leg (per report, nothing given). BP was 70/palp on
the field, HR in 170s.
.
On arrival to the ED, she was in SVT (HR 170s) and hypotensive
to 80s. Pt arousable to voice, not alert but moaning. She
received a 500cc bolus and IV adenosine 6 mg; pt improved to
sinus rhythm, HR 90s, BP 96/60. MS improved: answering
questions, AOx3; reported diffuse abdominal tenderness. A right
femoral line was placed.
Pt given vancomycin, metronidazole, and ciprofloxacin b/c of
concern for sepsis. Noncontrast CT abd/pelvis showed
pericardial effusion, L pleural effusion, increased tumor burden
of ovarian cancer, and left hydronephrosis. Bedside echo showed
moderate pericardial effusion w/o tamponade. Cardiology was
called; pt did not have CP or EKG changes once back in SR, and
pulsus was 10. Cards plans to see pt in the [**Hospital Unit Name 153**]. Pt received
total of 2L in ED. VS at transfer (19:08): T 97.7 ??????F, P 99, RR
18, BP 109/72, SpO2 100.
.
On arrival to the ICU, pt reported mild intermittent nausea and
LLQ abdominal tenderness. She reports no fevers, chills, or
night sweats. No CP, dyspnea. Occasional palpitations but not
currently. No urinary symptoms.
.
Of note, pt had recent hospitalization for confusion and
prerenal [**Last Name (un) **] [**Date range (3) 105723**]. Negative head CT. Confusion
thought to be [**12-29**] dehydration and hypermagnesemia (Mg 6.9).
Past Medical History:
ONCOLOGIC PMH:
-breast cancer s/p L partial mastectomy, SN biopsy and axillary
sampling/XRT ([**8-27**]); on Tamoxifen from [**2125-12-18**] until diagnosis
of ovarian cancer
-ovarian carcinosarcoma stage IV diagnosed [**2128**]; treated with
carboplatin and paclitaxel, which finished in [**2129**]. Had
recurrence, treated with carboplatin and paclitaxel in [**2132**].
[**5-6**] 5 CK treatments to chest wall metastases
[**6-6**] CK treatment to the enlarging left adrenal mass
[**12-8**] CK treatment to subcarinal LN
.
PMH/PSH:
-Hypothryoidism (s/p RAI in [**2103**]; became hypothyroid and was on
HRT [Prempro] for many years)
-HTN, diagnosed [**2122**]
-TAH/BSO [**2128**]
-Ventral hernia repair [**2131**]
-L matacarpal fracture, s/p fixation/pins [**2128**]
Social History:
Married, husband is an ophthalmologist and has [**Name (NI) 5895**]
Disease (stressor); 3 children.
- Tobacco: None
- Alcohol: None
- Illicits: None
Family History:
Maternal grandmother and 3 maternal great aunts with breast
cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: T: 96.1, BP: 121/74, P: 94, RR: 18, SpO2 100% on 2L NC;
pulsus = 7
General: Alert, oriented x2 (not to date/year), NAD
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: CTAB, no wheezes, rales, rhonchi
CV: RRR, I/VI systolic murmur at RUSB, no r/g
Abdomen: soft, fullness in LUQ, diffuse tenderness without
rebound - most pronounced in LUQ
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; right femoral line
Neuro: CN 2-12 intact, grossly moving all extremities equally
Pertinent Results:
ADMISSION LABS:
[**2136-2-2**] 05:08PM LACTATE-1.7
[**2136-2-2**] 03:40PM WBC-16.0* RBC-3.56* HGB-10.1* HCT-31.4*
MCV-88 MCH-28.4 MCHC-32.2 RDW-18.0*
[**2136-2-2**] 03:40PM GLUCOSE-182* UREA N-27* CREAT-2.0* SODIUM-134
POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-19* ANION GAP-20
[**2136-2-2**] 04:50PM ALBUMIN-2.9*
[**2136-2-2**] 03:40PM CALCIUM-9.1 PHOSPHATE-4.4# MAGNESIUM-2.3
[**2136-2-2**] 04:50PM CK-MB-7 cTropnT-0.12*
[**2136-2-2**] 04:50PM ALT(SGPT)-16 AST(SGOT)-58* CK(CPK)-83 ALK
PHOS-146* TOT BILI-0.1
[**2136-2-2**] 05:05PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
.
Imaging:
[**2136-2-2**] CT AB/PELVIS: IMPRESSION:
1. New moderate-sized left-sided pleural effusion and small
pericardial effusion which has also increased in size.
2. Interval increase in metastatic burden with enlargement of
additional intra-abdominal mass anterior to the large left
adrenal lesion. Trace amount of pelvic free fluid, new since
prior.
3. Stable left-sided hydronephrosis, which was present in exam
from [**2136-1-18**].
4. Interval enlargement of right basilar pulmonary nodule.
.
[**2136-2-2**] CXR: IMPRESSION: Left-sided pleural effusion. Left mid
lung pulmonary nodular opacity, new since prior study,
additional site of metastatic disease not excluded. No evidence
of acute consolidation. Right base mass again seen.
.
[**2136-2-3**] ECHO: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 65%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is a small
pericardial effusion. The effusion appears circumferential.
There are no echocardiographic signs of tamponade.
.
[**2136-2-4**] CXR: IMPRESSION: Interval increase in retrocardiac
opacity which may reflect a combination of a layering effusion
with compressive atelectasis, although pneumonia cannot be
entirely excluded. No evidence of pulmonary edema. Rounded
opacity at the right base is unchanged and is felt to correspond
to the pleural-based mass seen on the recent CT study consistent
with metastatic disease. Overall, cardiac and mediastinal
contours are stable. The previously reported lymphadenopathy in
the mediastinum is not well appreciated on the plain film study.
A right subclavian Port-A-Cath with its tip unchanged in the
distal SVC. No pneumothorax. No pulmonary edema. More focal
nodularity in the left mid lung is again seen but less well
visualized than on the prior study of [**2136-2-2**].
.
[**2137-2-6**] CXR: IMPRESSION: Relatively unchanged exam, though new
focal nodularity projecting over the left mid lung may represent
additional metastatic deposit.
.
[**2137-2-7**] ABD U/S: IMPRESSION: Cholelithiasis without evidence for
cholecystitis. No evidence for biliary obstruction.
.
DISCHARGE LABS:
[**2136-2-10**] 12:53AM BLOOD WBC-12.6* RBC-3.91* Hgb-11.0* Hct-33.6*
MCV-86 MCH-28.3 MCHC-32.8 RDW-17.4* Plt Ct-366
[**2136-2-4**] 04:45AM BLOOD Neuts-94.4* Lymphs-1.7* Monos-3.5 Eos-0.4
Baso-0
[**2136-2-10**] 12:53AM BLOOD PT-10.7 PTT-29.3 INR(PT)-1.0
[**2136-2-5**] 06:18AM BLOOD Ret Aut-3.3*
[**2136-2-10**] 12:53AM BLOOD Glucose-129* UreaN-29* Creat-0.9 Na-131*
K-4.7 Cl-99 HCO3-22 AnGap-15
[**2136-2-10**] 12:53AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.3
[**2136-2-10**] 12:53AM BLOOD ALT-53* AST-82* LD(LDH)-1811*
AlkPhos-652* TotBili-0.8
[**2136-2-10**] 12:53AM BLOOD GGT-555*
[**2136-2-2**] 04:50PM BLOOD TSH-40*
[**2136-2-2**] 04:50PM BLOOD T4-4.3* T3-37* Free T4-0.76*
[**2136-2-6**] 05:19AM BLOOD Cortsol-28.7*
[**2136-2-6**] 05:19AM BLOOD CA125-43*
Brief Hospital Course:
73yo woman with HTN, metastatic ovarian CA, and hx of breast CA
admitted for abdominal pain, altered mental status, hypotension,
and SVT. BP was 70/palp in the field per EMS, and HR in 170s.
IV adenosine 6 mg was given in ED and SVT converted to sinus HR
90s, BP 96/60, and mental status immediately improved. She
reported diffuse abdominal tenderness. She was given
vancomycin, metronidazole, and ciprofloxacin x1 for concern for
sepsis, but these were stopped. Non-contrast CT showed
pericardial effusion, left pleural effusion, increased tumor
burden, and stable left hydronephrosis. Echo showed small
pericardial effusion without tamponade. For fever [**2136-2-4**], she
was again given vanco/cipro, both were stopped the next day.
Carboplatin/paclitaxel were given [**2136-2-6**], complicated by
abnormal LFTs.
.
# Abdominal pain: Likely due to progression of disease and large
left adrenal mass compressing stomach. Lipase normal. Given
chemo [**2136-2-6**]. Continued oxycodone and acetaminophen as needed.
Anti-emetics as needed.
.
# Abnormal LFTs: Rising alk phos, GGT, and AST. Possibly chemo
related. U/S showed a gallstone, but no biliary obstruction or
infection. ALP started increasing prior to chemo. Discussed
with ERCP; they were inclined to do an ERCP to rule out
cholangitis, especially given recent fevers and abdominal pain.
However, primary oncologist Dr. [**Last Name (STitle) **] was opposed to any
procedures since she is clinically improving, the ultrasound was
negative, and the white count was coming down. After discussion
with Ms. [**Known lastname 9955**] and the family, ERCP/EUS was not done and
she was discharged to rehab with frequent LFT checks because ALP
and GGT continued to increase. AST began improving.
.
# Sore throat: Started nystatin for thrush.
.
# Encephalopathy: Acute delirium likely due to lorazepam.
Mental status improved. Benzodiazepine doses were limited
thereafter.
.
# Metastatic ovarian CA: Carboplatin/paclitaxel last given
10/[**2132**]. CA-125 trending up, 30 on [**2136-1-18**] and 43 on [**2136-2-6**].
Considered left adrenal mass aspiration, but radiology review
decided it was not cystic. She was given carboplatin AUC5 and
paclitaxel 175mg/m2 [**2136-2-6**] for the rapid rate of progression
with tumor tracking down left ureter causing mild/moderate
hydronephrosis.
.
# Breast CA: Continued outpatient letrozole.
.
# Leukocytosis/Fever: No source identified (tumor?). U/A
negative. CXR negative. Cipro, metronidazole, and vancomycin
stopped after 1st dose, then cipro/vanco restarted [**2136-2-5**] due
to recurrent fever, but stopped again [**2136-2-6**]. Mild hypoxia
[**2136-2-7**] resolved. Repeat CXR unchanged.
.
# Anemia: Acute on chronic. Retic count 3.3 with very high LDH.
High haptoglobin did not favor hemolysis. Transfused 2 Units
RBCs [**2136-2-6**]. Guaic negative x1. Started PPI.
.
# Elevated cardiac enzymes: Cardiac ischemia from demand during
SVT at presentation. Aspirin started in ICU.
.
# Hypothyroidism: Thyroid panel shows continued hypothyroidism.
Increased levothyroxine dose from 100 to 112mcg daily, however
her daughter suspects non-compliance, so this will need close
follow-up as outpatient.
.
# Depression: Psychiatry consulted. Venlafaxine dose further
decreased to 75mg per Psychiatry. Restarted methylphenidate,
increased to [**Hospital1 **], initially held for SVT. Increased dose of
levothyroxine for hypothyroidism.
.
# Pain (abdomen): Oxycodone and acetaminophen analgesia PRN.
.
# Acute renal failure: Improved after IV fluids, which were
discontinued thereafter.
.
# Hyponatremia: Unclear etiology. Plasma osm 267 (low). Urine
Na 62 (high), but she appeared hypovolemic and was orthostatic.
AM cortisol 28.7. Improved with IV normal saline; stopped IV
fluids.
.
# Metabolic acidosis: Non-anion-gap. Possibly dilutional (vs.
RTA). Stable. Stopped IV fluids.
.
# FEN: Regular diet. IV fluids stopped with improved
orthostatic hypotension, ARF, and hyponatremia. Repleted
hypomagnesemia and hypophosphatemia.
.
# DVT PPx: SC heparin.
.
# GI PPx: PPI and bowel regimen.
.
# Precautions: None.
.
# Lines: Peripheral/Port. A right inguinal central line was
placed at admission. After removal, it continued to ooze blood
for days despite pressure dressings. General Surgery placed a
suture prior to discharge.
.
# CODE: DNR/DNI according to patient and daughter.
Medications on Admission:
letrozole (aromatase inhibitor) 2.5 mg PO daily
levothyroxine 100 mcg PO daily
lisinopril 5 mg PO daily
venlafaxine 150 mg PO QHS
lorazepam 0.5 mg PO QHS PRN insomnia
budesonide 32 mcg/actuation spray 1 spray each nostril daily
docusate sodium 100 mg PO BID
Discharge Medications:
1. letrozole 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
4. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for Insomnia.
6. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
7. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO QAM (once
a day (in the morning)).
9. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO NOON (At
Noon).
10. oxycodone 5 mg Tablet Sig: 0.5-1 Tablet PO Q6H (every 6
hours) as needed for pain.
11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID
(3 times a day).
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
13. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
14. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
15. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H
(every 8 hours) as needed for Constipation.
16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for Constipation.
17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
18. potassium & sodium phosphates 280-160-250 mg Powder in
Packet Sig: One (1) Powder in Packet PO BID (2 times a day).
19. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for rash.
20. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) for 7 days.
21. promethazine 12.5 mg Tablet Sig: 1-2 Tablets PO every six
(6) hours as needed for nausea.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 459**] for the Aged - [**Location (un) 550**]
Discharge Diagnosis:
1. Abdominal pain.
2. Hypotension (low blood pressure).
3. SVT (supraventricular tachycardia, very fast heart rate).
4. Altered mental status (acute delirium, confusion).
5. Metastatic ovarian cancer.
6. Carboplatin and paclitaxel (Taxol) chemotherapy.
7. Anemia (low red blood cell count).
9. Abnormal liver function tests.
10. Fever.
11. Leukocytosis (elevated white blood cell count).
12. Cardiac ischemia (heart muscle damage) due to the initial
rapid heart rate.
13. Hypothyroidism (underactive thyroid).
14. Depression.
15. Nausea.
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted to the hospital for abdominal pain, severe
hypotension (low blood pressure), supraventricular tachycardia
(very fast heart rate), and altered mental status (confusion).
You were given a heart rhythm medication called adenosine and
the heart rate and normal quickly became normal. Cardiac
enzymes were elevated suggesting strain on your heart when it
was beating rapidly. Your altered mental status (confusion)
also improved, but did wax and wane during the hospitalization.
For this lorazepam (Ativan) doses were decreased.
Intermittently, you had fevers and were given several doses of
antibiotics, but a specific infection was never uncovered. A CT
scan showed marked progression of ovarian cancer, so you were
restarted on chemotherapy. Liver function tests became markedly
abnormal. An ultrasound of the liver and gallbladder showed no
abnormalities other than gallstones, and did not show an
infection or bile duct blockage. After discussion with Dr.
[**Last Name (STitle) **], no further testing or procedures were done and the
liver function tests will be followed closely. If these
continue to worsen or you develop fevers again, you will need to
be readmitted to the hospital. You were also given a blood
transfusion for anemia (low red blood cell count). Your thyroid
tests were significantly abnormal suggesting you were not taking
your thyroid medication. A higher dose of levothyroxine
(Synthroid) was given and this will need to be followed closely.
Psychiatry was also following you here for depression and made
changes to some of your medications.
.
MEDICATION CHANGES:
1. Decrease venlafaxine to 75mg daily.
2. Continue methylphenidate (Ritalin) 2x a day.
3. Increase levothyroxine to 112mcg daily.
4. Pantoprazole 40mg daily to prevent stomach bleeding.
5. Aspirin daily for heart protection.
6. Prochlorperazine (Compazine) every 6 hours as needed for
nausea.
7. Ondansetron (Zofran) every 8 hours as needed for nausea.
8. Restart lisinopril initially held for low blood pressure.
Followup Instructions:
You should have the suture in your abdomen removed on [**2136-2-14**]
.
BLOOD WORK: CBC, CHEM7, AND LIVER FUNCTION TESTS ON MONDAY,
[**2136-2-13**].
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2136-2-27**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: HEMATOLOGY/ONCOLOGY
When: MONDAY [**2136-2-27**] at 1 PM
With: [**First Name4 (NamePattern1) 4617**] [**Last Name (NamePattern1) 4618**], RN [**Telephone/Fax (1) 22**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
.
Department: GYN SPECIALTY
When: THURSDAY [**2136-5-3**] at 9:00 AM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 5777**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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52,370
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34171
|
Discharge summary
|
report
|
Admission Date: [**2183-8-6**] Discharge Date: [**2183-9-18**]
Date of Birth: [**2126-2-8**] Sex: F
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
abdominal pain, rigors
Major Surgical or Invasive Procedure:
IR-guided paracentesis
[**8-19**] Orthotopic Liver Transplant
History of Present Illness:
This is a 57 y/o female with a pmh Hep C cirrhosis,
complicated by ascites and GI bleeds, recently admitted from
[**2187-7-22**] for fevers, found to have an enterococcus UTI, treated
with ceftriaxone and ampicillin. Yesterday, the patient had a
therapeutic paracentesis at [**Hospital **] Hospital with no
complication. Today, she presents to the ED with ~ 12 hrs
diffuse
abdominal pain, rigors, and a change in mental status
(confusion). She had a dose of ceftriaxone in the ED and a
diagnostic paracentesis with a WBC of 6950.
Past Medical History:
PMH: Chronic hepatitis C infection ([**1-14**] remote cocaine use
(genotype 1)-failed two courses of antiviral therapy in [**2166**] and
[**2168**], interferon nonresponsive), Biopsy-confirmed cirrhosis
PSH: hysterectomy at age 25 [**1-14**] fibroids, umbilical hernia
repair
as a child
Social History:
No Smoking
No EtOH
No Drugs
Family History:
Gastric cancer - EGD in [**Month (only) **] did not show any abnormalities.
Physical Exam:
GEN: alert and oriented x3, conversant and pleasant.
HEENT: no scleral icterus, moist mucous membranes
CHEST: CTA B/L
HEART: RRR, S1/S2
ABD: soft, markedly reduced distention from intial exam,
incision site appears well healed with no discharge, erythema or
warmth
EXT: warm, moderate 2+ pitting edema to the mid shin
bilaterally.
Pertinent Results:
[**2183-8-6**] 10:29PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-0.2 PH-6.0
LEUK-LG
[**2183-8-6**] 10:29PM URINE RBC-6* WBC-28* BACTERIA-FEW YEAST-NONE
EPI-0
[**2183-8-6**] 02:40PM ASCITES TOT PROT-1.7 GLUCOSE-84 ALBUMIN-1.2
MISC-CEA = 1.6
[**2183-8-6**] 02:40PM ASCITES WBC-6950* RBC-2900* POLYS-83* BANDS-3*
LYMPHS-1* MONOS-12* EOS-1*
[**2183-8-6**] 02:30PM GLUCOSE-94 UREA N-21* CREAT-1.6* SODIUM-141
POTASSIUM-4.2 CHLORIDE-111* TOTAL CO2-20* ANION GAP-14
[**2183-8-6**] 02:30PM ALT(SGPT)-29 AST(SGOT)-56* ALK PHOS-37 TOT
BILI-9.0*
[**2183-8-6**] 02:30PM LIPASE-93*
[**2183-8-6**] 02:30PM ALBUMIN-4.0
[**2183-8-6**] 02:30PM WBC-1.6* RBC-3.26* HGB-9.0* HCT-30.2* MCV-93
MCH-27.7 MCHC-29.9* RDW-22.1*
[**2183-8-6**] 02:30PM NEUTS-44* BANDS-8* LYMPHS-44* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2183-8-6**] 02:30PM PLT SMR-LOW PLT COUNT-107*
[**2183-8-6**] 02:30PM PT-21.8* PTT-40.6* INR(PT)-2.0*
[**2183-8-6**] 02:28PM LACTATE-2.7*
[**2183-8-6**] 2:40 pm PERITONEAL FLUID GRAM STAIN (Final
[**2183-8-6**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final [**2183-8-9**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2183-8-12**]): NO GROWTH.
[**2183-8-6**] Blood: negative x 2
[**2183-8-6**] 10:29 pm URINE
URINE CULTURE (Final [**2183-8-8**]):
YEAST. >100,000 ORGANISMS/ML..
[**2183-8-7**] Blood: negative x 2
[**2183-8-8**] 3:38 pm PERITONEAL FLUID
GRAM STAIN (Final [**2183-8-8**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2183-8-11**]): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED
[**8-6**] CT ABD/PELVIS: Cirrhosis with large volume abdominal
ascites. No evidence of bowel injury from recent paracentesis
(no evidence of extravasated oral contrast or free air).
Bibasilar opacities likely represent a combination of
atelectasis and infection. Small bilateral pleural effusions
also present. Diffuse body wall edema.
[**8-13**]:Peritoneal fluid:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, macrophages, lymphocytes and occasional
neutrophils.
GRAM STAIN (Final [**2183-8-13**]):
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final [**2183-8-16**]): NO GROWTH.
ANAEROBIC CULTURE (Final [**2183-8-19**]): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final [**2183-8-14**]):
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
[**8-19**]: Liver US with doppler
IMPRESSION:
1. Normal Doppler evaluation of the transplanted liver.
2. Small right pleural effusion and perihepatic and pelvic free
fluid.
Brief Hospital Course:
The patient was originally admitted to the hepatology service.
She was confused on admission. She remained on lactulose and
rifaximin. A diagnostic paracentesis in the ED was done with
cell count showing a WBC of 6950 and cultures were sent. She was
made NPO. She received intermittent fentanyl for abd
pain.Vanc/cefepime/levo/flagyl were continued. Blood, urine, and
peritoneal cultures were sent. The only positive result was
yeast in her urine. She had an initial presentation of SIRS -
hypotension, increasing O2 requirements, decreasing u/o.
However, on the evening/night of [**8-6**], the patient had
hypotension unresponsive to fluids. She received over 4L of IVF
on the floor with no response in her BP. She was transferred to
the SICU and the transplant surgery service for hemodynamic
monitoring and resuscitation. In the SICU, a RIJ CVL and aline
were placed. Mental status improved during her stay in the ICU.
On [**8-8**] she required shovel mask for decreased O2 sats. Her O2
requirements improved over the week she was in the SICU. There
was concern for pneumonia for her increased O2 requirements.
On [**8-8**], the patient had increased abdominal distention. An NG
was placed. On [**8-8**], a 2L paracentesis was performed with WBC
of 4850. On [**8-11**], a post-pyloric Dobhoff was placed and TF were
started: Isosource 1.5 cal. The TF were intermittently held for
nausea. On [**8-13**], she had a paracentesis with 7L tapped from her
abdomen, with 75 WBCs. Her abdominal exam improved.
Urine output was decreasing with rising creatinine. Nephrology
was consulted on [**8-8**], and felt the patient was in prerenal
failure from hypotension and did not have hepatorenal syndrome.
Renal u/s showed no hydroureter and no obstruction. She received
IV bicarb with improvement. IV Lasix was given with an
appropriate increase in u/o. On [**8-11**], the patient received a
dose of fluconazole for + yeast in her [**8-6**] urine culture. Urine
output gradually improved. On [**8-12**], all antibiotics were d/c'ed.
On [**8-13**], the hepatology team recommended Vanco and cefepime for
pneumonia.
BP, O2 requirements, u/o, and abdominal exam improved by [**8-13**] and
she was transferred out of the SICU to be followed by the
hepatology service on [**8-14**]. She completed a course of vancomycin
and cefepime for HAP. She had developed hypernatremia towards
the end of her ICU stay and this was treated with free water
repletion with tube feeds and via IVF.
On [**8-19**] a liver donor became available and she underwent
orthotopic liver transplant with Roux-en-Y hepaticojejunostomy,
during which she required large amounts of blood products. See
operative report and record for full details. Surgeon was Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**]. Postop, she was transferred to the SICU in stable
condition. SICU course was uneventful, and on POD 1 the patient
was extubated. She remained hemodynamically stable with
improving mental status and on [**8-21**] she was transferred to [**Hospital Ward Name 121**]
10 in stable condition. Her tube feeds were restarted on POD 3.
She had two days on the regular surgical floor, but on [**8-25**] she
was noted to have a hematocrit drop to 18. An NG tube was placed
with increasingly bloody output (dark old blood and with
progression to more fresh blood noted) for which she was
transferred back to the SICU where she received 6 units RBCs, 2
units FFP, 1 units platelets and 2 units of cryo. She underwent
an upper endoscopy which showed
-Erosion in the lower third of the esophagus compatible with
erosion, likely from prior feeding tube
-Blood in the fundus, stomach body and antrum
-Blood in the third part of the duodenum and fourth part of the
duodenum
-Fresh blood was found in distal duodenum or distal jejunal
loop. This was proximal to the anastomosis with the roux-limb.
Unable to advance distally from this due to blood.
The following day she received another 6 units of RBCs, 5 units
of FFP, 3 units of platelets and 6 units of cryo. Her hematocrit
then stabilized and she required no further transfusions.
Platelet count increased to around 130 and then was in the mid
250's by the time of discharge.
She transferred out of the SICU on [**8-29**]. Of note, on [**9-3**], she
spiked a temperature to 102.3 for which she was pan-cultured.
Blood and urine cultures were negative. CVL was removed with tip
cultured. Tip culture was negative. CXR was unremarkable. A
liver duplex was notable for new increase in velocities within
the portal and hepatic arteries, of uncertain significance.
Hepatic veins were patent. There was an increase in size of a
very small subcapsular collection, which measured 2.8 x 1.1 cm.
She was started on IV Vancomycin and Zosyn. She also had a total
of 7 loose stools that day and was started on IV Flagyl. Stool
was negative for C.diff.
Nutrition followed and noted malnutrition and poor appetite. She
demonstrated insufficient kcals. A post pyloric feeding tube was
placed on [**8-29**] and tube feeds were started.
An Abdominal/pelvic CT was done noting 2 loculated collections
adjacent to the liver, the largest measuring 4.2 x 6.4 cm
adjacent to the tip of one of the JP drains. This was felt to
possibly a hematoma. There was no evidence for bowel
obstruction. Radiology was asked to attempt drainage of the
inferior hilar collection, but felt that the collection
represented a hematoma and therefore was not drained. Fluid was
sent from the JP drains as output became cloudy. The lateral JP
fluid isolated sparse growth VRE. Antibiotics were stopped.
Linezolid oral was started on [**9-7**] with a 7 day course. She
remained afebrile.
The remainder of her hospital course was notable for high JP
drain outputs requiring IV fluid replacement. HCT remained
stable. JP output gradually decreased with the medial JP
decreasing to 35 cc/day on [**9-7**] allowing for removal of the
medial JP on that day. The lateral JP outputs were
serosanguinous with output trending down to 1200cc/day.
Patient was pending discharge on [**9-10**] when JP (lateral) output
was noted to increase (4.3 L for the day). While being
ambulated, patient was found to be orthostatic and a trigger was
called. Patient was evaluated and was stable. JP output was
repleted with NS and albumin with hemodynamics stablizing. Liver
ultrasound showed patent vasculature with stable increased
velocities. Blood, urine, and peritoneal fluid cultures were
obtained for a temperature elevation to 101.7, and were all
negative. Patient continued to drain 2-3L of clear fluid. JP
output gradually diminished and JP was removed on [**9-14**].
Abdominal incision remained intact and dry. Abdomen remained
soft, mildly distended and non-tender.
Continuous tube feedings were adjusted to Novasource Renal
formula for hyperkalemia with normalization of potassium.
Feedings were changed to cycled feeds on [**9-18**] as po intake
improved. Rate was increased to 60ml/hour x16 hours. Weight was
55.3 kg on [**9-18**].
Physical therapy followed closely recommending rehab for
deconditioning. Strength and endurance improved over the course
of the hospitalization.
On [**9-18**], LFTs were up slightly and a liver duplex was performed
to evaluate vasculature. Duplex was unremarkable.
Immunosuppression consisted of CellCept 1 gram [**Hospital1 **] that was well
tolerated. Steroids were tapered from IV to oral with protocol
taper. Dose was decreased to 15mg daily on [**9-18**] and will be
tapered down by 2.5mg every 10 days. Prograf was started on [**8-20**]
with dose adjustments to 1.5mg twice daily per daily trough
levels at goal range of 10.5.
A bed was available at [**Hospital1 **] in [**Hospital1 8**] and she will
transfer there today.
Medications on Admission:
Ampicillin 1000'' (until [**8-20**] for UTI), Cefixime 400 qweek after
ampicillin d/c'd, Clotrimazole 50', Escitalopram 5', lactulose
30 ml [**Hospital1 **] (titrate to [**2-13**] BM qd), metoclopramide 5''' prn early
satiety, omeprazole EC 40', Oxazepam 10 qHS, rifaximin 400''',
Ursodiol 1000'', Calcium Carbonate 600/1,500''', folic acid
0.4', loratadine 10' prn itching
Discharge Medications:
1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
Hold for sbp <110 or HR <60.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
5. Glucagon (Human Recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
6. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
7. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day): hold for sbp <110 or HR <60.
13. Insulin Regular Human 100 unit/mL Solution Sig: follow
sliding scale Injection ASDIR (AS DIRECTED): see printed scale.
14. Prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): [**Date range (1) 78747**] 15mg
[**Date range (1) 78748**] 12.5mg
[**Date range (1) 78749**] 10mg
[**Date range (1) 64240**] 7.5mg
[**Date range (1) 78750**] 5mg
[**Date range (1) 78751**] 2.5 then off.
15. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
16. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a
day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital **] Hospital - [**Hospital1 8**]
Discharge Diagnosis:
Status Post Orthotopic Liver Transplant with RNY
postop bleeding
malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Tolerating Tube feeds
Discharge Instructions:
Please call the Transplant Office [**Telephone/Fax (1) 673**] if you experience
any of the warning signs listed below.
You will have labs drawn every Monday and Thursday with results
faxed to the transplant center at [**Telephone/Fax (1) 697**]
No medication changes, especially immunosuppressants should be
changed unless discussed with the transplant clinic
Followup Instructions:
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2183-9-25**]
10:00
Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2183-10-2**]
10:00
Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**]
Date/Time:[**2183-10-9**] 1:20
Completed by:[**2183-9-18**]
|
[
"787.99",
"112.2",
"567.23",
"995.90",
"787.02",
"285.9",
"560.1",
"789.59",
"E878.2",
"585.9",
"E879.8",
"V09.80",
"276.2",
"070.44",
"998.11",
"486",
"276.0",
"998.12",
"276.8",
"305.63",
"584.5",
"571.5",
"276.69"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"45.13",
"38.93",
"33.24",
"38.91",
"96.04",
"00.93",
"96.71",
"96.6",
"50.59"
] |
icd9pcs
|
[
[
[]
]
] |
14724, 14795
|
4891, 12660
|
335, 398
|
14917, 14917
|
1778, 3641
|
15507, 15999
|
1334, 1411
|
13084, 14701
|
14816, 14896
|
12686, 13061
|
15122, 15484
|
1426, 1759
|
4663, 4868
|
4509, 4627
|
273, 297
|
426, 959
|
3677, 3692
|
14932, 15098
|
981, 1272
|
1288, 1318
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
56,850
| 156,694
|
37093
|
Discharge summary
|
report
|
Admission Date: [**2140-11-25**] Discharge Date: [**2140-11-30**]
Date of Birth: [**2108-9-4**] Sex: M
Service: SURGERY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 974**]
Chief Complaint:
s/p abdominal crush injury, transferred from outside hospital
for hemodynamic instability. He was found to have ileal avulsion
and a liver laceration.
Major Surgical or Invasive Procedure:
[**2140-11-25**]
PROCEDURES:
1. Trauma laparotomy with 4-quadrant packing, ultimately
with full kocherization of the duodenum and lesser sac
evaluation as well.
2. Control of mesenteric hemorrhage.
3. Segmental enterectomy.
4. Appendectomy.
5. Hepatorrhaphy, debridement and hemostatic coagulation.
History of Present Illness:
Mr. [**Known lastname 83592**] is a 32 year old gentleman who was involved in an
abdominal crush injury while chopping down a tree. No LOC. He
was transferred from [**Hospital3 4298**] after a CT there showed
an active mesenteric bleed and hematoma and the patient became
hemodynamically unstable.
Past Medical History:
none
Social History:
denies EtOH and recreational drugs
Family History:
estranged from his family
Physical Exam:
T 99.2, HR 71, BP 110/50, RR 16, 96%RA
GEN - NAD, A&O
HEENT - NCAT, EOMI, MMM
CVS - RRR
PULM - CTAB, no respiratory distress
ABD - staples in place, incision healing well, no erythema or
drainage, abdomen soft, nontender, nondistended
EXTREM - warm, dry, no edema
Pertinent Results:
IMAGING:
CXR [**11-25**]: No acute intrathoracic process and nasogastric tube
in need of
advancement as above.
XR Pelvis [**11-25**]: No evidence of fracture or dislocation.
CXR [**11-25**]: One view. Comparison with the previous study done
earlier the same day. The lungs remain clear. The heart and
mediastinal structures are unremarkable in appearance as before.
The bony thorax is grossly intact. An endotracheal tube has been
inserted and ends at the thoracic inlet. A nasogastric tube is
in satisfactory position, advanced since the previous study.
XR T&L spine [**11-26**]: Possible mild anterior loss of height of the
T12 vertebral body of uncertain age. MRI or bone scan may be
helpful if further evaluation is clinically indicated.
[**2140-11-30**] 06:45AM BLOOD WBC-6.9 RBC-3.29* Hgb-9.3* Hct-28.6*
MCV-87 MCH-28.3 MCHC-32.5 RDW-15.3 Plt Ct-277
[**2140-11-29**] 10:20AM BLOOD WBC-6.6 RBC-3.14* Hgb-9.2* Hct-26.8*
MCV-85 MCH-29.3 MCHC-34.4 RDW-14.7 Plt Ct-245
[**2140-11-28**] 05:35PM BLOOD WBC-7.0 RBC-2.88* Hgb-8.5* Hct-24.5*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.4 Plt Ct-197
[**2140-11-27**] 09:10PM BLOOD Hct-25.2*
[**2140-11-27**] 12:33PM BLOOD Hct-26.1*
[**2140-11-27**] 02:00AM BLOOD WBC-12.0* RBC-2.76*# Hgb-8.1* Hct-23.1*#
MCV-84 MCH-29.4 MCHC-35.1* RDW-14.4 Plt Ct-180
[**2140-11-26**] 01:46AM BLOOD WBC-12.8* RBC-3.69* Hgb-10.7* Hct-31.6*
MCV-86 MCH-28.9 MCHC-33.7 RDW-15.1 Plt Ct-156
[**2140-11-25**] 07:27PM BLOOD Hct-34.1*
[**2140-11-25**] 05:33PM BLOOD WBC-11.5* RBC-3.41* Hgb-10.1* Hct-29.4*
MCV-86 MCH-29.8 MCHC-34.5 RDW-14.9 Plt Ct-139*
[**2140-11-25**] 03:05PM BLOOD WBC-17.9* RBC-4.32* Hgb-12.9* Hct-38.4*
MCV-89 MCH-29.7 MCHC-33.5 RDW-14.3 Plt Ct-213
[**2140-11-25**] 05:33PM BLOOD Neuts-91.9* Lymphs-3.5* Monos-4.5 Eos-0.1
Baso-0.1
[**2140-11-30**] 06:45AM BLOOD Plt Ct-277
[**2140-11-29**] 10:20AM BLOOD Plt Ct-245
[**2140-11-28**] 05:35PM BLOOD Plt Ct-197
[**2140-11-27**] 02:00AM BLOOD Plt Ct-180
[**2140-11-26**] 01:46AM BLOOD Plt Ct-156
[**2140-11-26**] 01:46AM BLOOD PT-12.9 PTT-25.6 INR(PT)-1.1
[**2140-11-25**] 05:33PM BLOOD Plt Ct-139*
[**2140-11-25**] 05:33PM BLOOD PT-14.5* PTT-29.9 INR(PT)-1.3*
[**2140-11-25**] 03:05PM BLOOD Plt Ct-213
[**2140-11-25**] 03:05PM BLOOD PT-14.5* PTT-22.3 INR(PT)-1.3*
[**2140-11-25**] 03:05PM BLOOD Fibrino-150
[**2140-11-30**] 06:45AM BLOOD Glucose-94 UreaN-8 Creat-0.6 Na-140 K-3.8
Cl-107 HCO3-24 AnGap-13
[**2140-11-28**] 05:35PM BLOOD Glucose-119* UreaN-7 Creat-0.6 Na-139
K-4.2 Cl-103 HCO3-31 AnGap-9
[**2140-11-27**] 02:00AM BLOOD Glucose-113* UreaN-18 Creat-0.9 Na-138
K-4.3 Cl-106 HCO3-28 AnGap-8
[**2140-11-26**] 01:46AM BLOOD Glucose-130* UreaN-19 Creat-1.0 Na-140
K-4.7 Cl-112* HCO3-20* AnGap-13
[**2140-11-25**] 05:33PM BLOOD Glucose-119* UreaN-20 Creat-0.7 Na-142
K-4.5 Cl-115* HCO3-22 AnGap-10
[**2140-11-25**] 03:05PM BLOOD UreaN-25* Creat-1.1
[**2140-11-25**] 03:05PM BLOOD Lipase-11
[**2140-11-30**] 06:45AM BLOOD Calcium-8.2* Phos-2.9 Mg-1.8
[**2140-11-28**] 05:35PM BLOOD Calcium-8.2* Phos-1.4* Mg-2.0
[**2140-11-27**] 02:00AM BLOOD Calcium-7.7* Phos-2.1*# Mg-2.0
[**2140-11-26**] 01:46AM BLOOD Calcium-7.6* Phos-5.0* Mg-2.2
[**2140-11-25**] 05:33PM BLOOD Calcium-7.3* Phos-3.7 Mg-1.4*
[**2140-11-25**] 03:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2140-11-26**] 01:59AM BLOOD Type-ART pO2-203* pCO2-40 pH-7.35
calTCO2-23 Base XS--3
[**2140-11-25**] 10:25PM BLOOD Type-ART pO2-201* pCO2-38 pH-7.34*
calTCO2-21 Base XS--4
[**2140-11-25**] 07:37PM BLOOD Type-ART pO2-224* pCO2-55* pH-7.22*
calTCO2-24 Base XS--5
[**2140-11-25**] 05:38PM BLOOD Type-ART pO2-398* pCO2-38 pH-7.38
calTCO2-23 Base XS--1
[**2140-11-25**] 04:03PM BLOOD Type-ART pO2-218* pCO2-39 pH-7.30*
calTCO2-20* Base XS--6 Intubat-INTUBATED Vent-CONTROLLED
Comment-O2 DELIVER
[**2140-11-25**] 03:37PM BLOOD Type-ART pO2-261* pCO2-46* pH-7.27*
calTCO2-22 Base XS--5 Intubat-INTUBATED Vent-CONTROLLED
Comment-O2 DELIVER
[**2140-11-26**] 01:59AM BLOOD Lactate-1.6
[**2140-11-25**] 05:38PM BLOOD Lactate-1.3
[**2140-11-25**] 04:03PM BLOOD Glucose-114* Lactate-2.0 Na-137 K-3.7
Cl-117*
[**2140-11-25**] 03:37PM BLOOD Glucose-134* Lactate-2.4* Na-137 K-4.0
Cl-112
[**2140-11-25**] 04:03PM BLOOD Hgb-6.9* calcHCT-21
[**2140-11-25**] 03:37PM BLOOD Hgb-8.7* calcHCT-26 O2 Sat-98 COHgb-0.9
MetHgb-0.0
[**2140-11-26**] 01:59AM BLOOD freeCa-1.08*
[**2140-11-25**] 07:37PM BLOOD freeCa-1.07*
[**2140-11-25**] 04:03PM BLOOD freeCa-0.89*
[**2140-11-25**] 03:37PM BLOOD freeCa-0.95*
Brief Hospital Course:
Upon arrival in the [**Hospital1 18**] ED, primary and secondary survey
revealed intact airway, hypotension, and GCS of 15. The patient
complained of abdominal pain. FAST exam was positive throughout
except for pericardial effusion. The patient was immediately
transfused 2 units of blood and a liter of crystalloid.
Trauma films showed no acute intrathoracic process and no
fracture or dislocation of his pelvis. Given the patient's
hemodynamic instability and positive FAST exam, the patient was
brought urgently to the OR for a trauma exploratory laparotomy.
Intraoperatively, they found a segment of ileum avulsed from its
mesentary and this was resected with primary anastomosis. The
bleeding from the liver laceration was controlled with argon
beam coagulation and an appendectomy was performed. The patient
tolerated the procedure well.
Post-operatively, the patient was transferred to the ICU
intubated but in stable condition. He was extubated the next
day. He was started on cefazolin and flagyl. His pain was
adequately controlled with intermittent IV dilaudid. This was
later switched to an oral pain regimen when he began to tolerate
PO intake. Post-op, the patient's hct fell from 31 to 23 so he
was transfused 2 units of pRBCs with an appropriate bump in his
hct. His hct remained stable throughout the rest of his hospital
course.
The patient's T&L spine was cleared x-rays were negative except
for mild anterior loss of height of the T12 vertebral body of
uncertain age. The patient was transferred to the floor on
[**2140-11-27**]. Over the rest of the [**Hospital 228**] hospital course, his
diet was gradually advanced until he was tolerating a regular
diet. His bowel function eventually returned. He was able to get
out of bed and ambulate and after his Foley catheter was
removed, he voided without problems.
Medications on Admission:
none
Discharge Medications:
1. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain: Do not exceed 4 grams of
acetaminophen per day.
Disp:*120 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
s/p Crush injury
1. Avulsion of distal jejunum and ileum with significant
disruption of the primary tributaries of the superior
mesenteric artery and vein
2. Hepatic laceration grade [**12-18**]
3. Multiple traumatic enterotomies and a retroperitoneal
hematoma
Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent
Discharge Instructions:
AVOID any heavy lifting greater than 10 lbs for the next 8
weeks.
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 [**4-24**] lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
Followup Instructions:
Follow up with Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Trauma Surgery
Phone:[**Telephone/Fax (1) 600**] Date/Time:[**2140-12-7**] 3:30 for removal of your
staples. Office located at [**Last Name (NamePattern1) **], [**Hospital Unit Name **], [**Location (un) 86**], [**Numeric Identifier 16457**]
|
[
"E916",
"868.09",
"868.04",
"864.03",
"958.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.98",
"47.19",
"96.71",
"50.61",
"50.29",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
8225, 8231
|
6011, 7848
|
465, 775
|
8548, 8548
|
1524, 5988
|
10750, 11081
|
1198, 1225
|
7903, 8202
|
8252, 8527
|
7874, 7880
|
8693, 10218
|
10234, 10727
|
1240, 1505
|
275, 427
|
803, 1102
|
8562, 8669
|
1124, 1130
|
1146, 1182
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
50,424
| 144,499
|
48571
|
Discharge summary
|
report
|
Admission Date: [**2165-5-13**] Discharge Date: [**2165-5-21**]
Date of Birth: [**2096-9-4**] Sex: M
Service: MEDICINE
Allergies:
Cephalosporins
Attending:[**First Name3 (LF) 25504**]
Chief Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief this is a 68yo M PMhx SBE c/b brain septic emboli,
complex partial seizure d/o stable on neurontin (last seizure
"many years ago"), AF on coumadin, a/w episode of
unresponsiveness at rehab, initially treated in Neuro-ICU,
including intubation for airway protection, now extubated but w
continued lethargy and AMS, course complicated by aspiration
PNA, now on broad spectrum abx (gent/aztreo/vanco) w improving
respiratory status, stable mental status, being called out to
medicine floor for continued management of PNA and discharge
placement.
Past Medical History:
-hx staph endocarditis in [**2137**] s/p valve replacement and L
occipital bleed [**1-9**] mycotic aneurysm rupture
-seizure disorder - prior notes report episodes of losing track
of time, simple partial seizures manifested as loss of speech
with right arm sensations and some confusion. other events with
distorted auditory sensations. also occasionally with secondary
generalization.
-mild R-sided weakness at baseline
-afib on coumadin
-cognitive problems
-depression
-abdominal abscesses requiring splenectomy and
duodenojejunostomy
-cholecystecotomy
-excision of R hepatic artery aneurysm and ligation of R hepatic
artery
-hepaticojejunostomy
Social History:
Does not smoke, drink or use illicit substances. At current
baseline, can dress, toilet,bath, feed, cook, shop, take public
transportation and is having problems managing his medications.
He has not balanced his own checkbook or paid bills for a long
time. He used to work in real estate, work as a part-time
chaplain, and was a marathon runner. Has 2 brothers and a
sister. [**Name (NI) **] been primarily living in [**Hospital3 **], but most
recently has had increasing difficulty functioning on own,
resulting in recent rehab stays
Family History:
Mother had DVT, unknown cancer. Sister had ? breast CA. 2
brothers with ETOH.
Physical Exam:
ON TRANSFER TO MEDICINE SERVICE
VS: 99.1 75 117/70 95%3L
GEN: Elderly male, NAD, comfortable
HEENT: PERRL, EOMI, OP dry
NECK: supple, no JVD, no LAD
LUNGS: mildly ronchorus throughout
CV: Irregularly irregular, II/VI systolic murmur at RUSB
Abd: Soft, NT/ND, naBS, no [**Doctor Last Name **], no CVA tenderness
Ext: 2+ DP/PT/radial pulses, no c/c/e
Neuro: AOx2 (person+time), 5/5 strength x 4 ext, no pronator
drift
ON DISCHARGE
VS: 96.6 104/54 61 16 92%RA
GEN: Elderly male, NAD, comfortable
HEENT: PERRL, EOMI, OP dry
NECK: supple, no JVD, no LAD
LUNGS: mildly ronchorus at bases, upper airway noises throughout
CV: Irregularly irregular, II/VI systolic murmur at RUSB
Abd: Soft, NT/ND, naBS, no [**Doctor Last Name **], no CVA tenderness
Ext: 2+ DP/PT/radial pulses, no c/c/e
Neuro: AOx3, 5/5 strength x 4 ext, no pronator drift
Pertinent Results:
Blood Counts
[**2165-5-13**] 06:50AM BLOOD WBC-8.4 RBC-4.18* Hgb-14.1 Hct-40.8
MCV-98 MCH-33.7* MCHC-34.4 RDW-14.6 Plt Ct-180
[**2165-5-15**] 01:32AM BLOOD WBC-13.2*# RBC-3.52* Hgb-11.7* Hct-34.4*
MCV-98 MCH-33.4* MCHC-34.1 RDW-14.4 Plt Ct-172
[**2165-5-21**] 05:45AM BLOOD WBC-7.8 RBC-3.53* Hgb-11.6* Hct-33.9*
MCV-96 MCH-32.9* MCHC-34.2 RDW-14.5 Plt Ct-261
Coags
[**2165-5-13**] 06:50AM BLOOD PT-17.5* PTT-24.5 INR(PT)-1.6*
[**2165-5-15**] 01:32AM BLOOD PT-25.2* PTT-31.7 INR(PT)-2.4*
[**2165-5-16**] 11:12AM BLOOD PT-29.8* PTT-36.2* INR(PT)-2.9*
[**2165-5-19**] 02:03AM BLOOD PT-30.4* PTT-31.0 INR(PT)-3.0*
[**2165-5-21**] 05:45AM BLOOD PT-18.9* PTT-25.6 INR(PT)-1.7*
Chemistry
[**2165-5-13**] 06:50AM BLOOD Glucose-90 UreaN-16 Creat-1.2 Na-138
K-9.5* Cl-104 HCO3-29 AnGap-15
[**2165-5-15**] 01:32AM BLOOD Glucose-96 UreaN-16 Creat-1.0 Na-145
K-3.4 Cl-109* HCO3-24 AnGap-15
[**2165-5-21**] 05:45AM BLOOD Glucose-119* UreaN-17 Creat-0.8 Na-141
K-4.3 Cl-103 HCO3-32 AnGap-10
IMAGING
CXR [**2165-5-15**]
Severe bibasilar consolidation, which appeared on [**5-14**], is
still present, probably pneumonia. Cardiomegaly is mild to
moderate and the pulmonary and mediastinal vasculature are
engorged, but there is no pulmonary edema. Patient is not
intubated. Nasogastric tube still ends in the upper stomach.
Transvenous pacer lead position is standard for the right
ventricular apex.
TTE [**2165-5-14**]
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. A bioprosthetic aortic valve
prosthesis is present. The transaortic gradient is normal for
this prosthesis. The mitral valve leaflets are mildly thickened.
Mild to moderate ([**12-9**]+) mitral regurgitation is seen. There is
mild pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. Compared with the
prior study (images reviewed) of [**2163-5-30**], mitral regurgitation
now appears slightly more prominent and there appears to be a
loose chord in the LV.
CTA Head/Neck [**2165-5-13**]
1. No vascular occlusion, stenosis or aneurysm.
2. Proximal left ICA mild hypodensity is likely artefactual,
without
convincing evidence of dissection.
Brief Hospital Course:
HOSPITAL COURSE
This is a 68yo M with a complicated PMHx significant for chronic
neurocognitive deficits [**1-9**] prior septic embolic in setting of
endocarditis who was admitted with an episode of
unresponsiveness at rehab, extensive workup without pertinent
positives except imaginge demonstrating aspiration PNA,
completed 5d course antibioitic therapy, with mental and
respiratory status returning to baseline, discharged to rehab.
.
ACTIVE
# Aspiration Event / Aspiration Pneumonia - Pt was admitted with
an unresponsive episode without subsequent pertinent positives
on work-up including 24hr EEG, pacer interrogation, TTE, Head
CT/CTA; he was initially evaluated in neuro-ICU, but no signs of
neurologic cause. Patient developed bibasilar consolidation and
leukocytosis, suggesting aspiration event as cause (or direct
result) of unresponsiveness. Speech and swallow evaluation
initial demonstrating recurrent aspiration. Patient was treated
with 5d abx and improved to baseline. Re-evaluation by speech
and swallow demonstrated improvement, and patient was advanced
to nectar thickened liquid / pureed solid diet.
.
INACTIVE
#. h/o Epilepsy - No documented seizure activity was observed on
this admisison, although per reports, patient's gabapentin may
have been incorrectly dosed prior to admission. Continued
prescribed gabapentin dosing (1800-1200-1800mg).
.
# Proxysmal Atrial Fibrillation - Continued coumadin and
digoxin. At discharge, patient's INR was 1.7 (goal 2-2.5), but
did not require bridging.
.
# Depression / Axiety - Continued citalopram, clonazepam,
risperidone, traZODONE
.
TRANSITIONAL
1. Code status - Patient remained full code for duration of this
admission
2. Pending - No labs/studies were pending at time of discharge
3. Transition of Care - Patient discharge to rehab facility with
copy of discharge summary. Scheduled for follow-up with
Neurologist Dr. [**First Name (STitle) **] and Cognitive Nerologist Dr. [**Last Name (STitle) **].
Medications on Admission:
-risperdal 0.5 mg [**Hospital1 **]
-celexa 40 mg daily
-folate 1 mg daily
-trazadone 200 mg daily
-vitamin B12 [**2153**] mcg daily
-coumadin 4 mg daily
-clonazepam 1 mg tid
-neurontin 900 mg tid
-digoxin 0.25 mcg daily
Discharge Medications:
1. risperidone 1 mg/mL Solution Sig: 0.5 mL PO BID (2 times a
day).
2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
5. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
6. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4
PM.
7. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
8. gabapentin 600 mg Tablet Sig: Three (3) Tablet PO QAM (once a
day (in the morning)).
9. gabapentin 600 mg Tablet Sig: Two (2) Tablet PO qNoon.
10. gabapentin 600 mg Tablet Sig: Three (3) Tablet PO QPM (once
a day (in the evening)).
11. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
12. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
PRIMARY
Aspiration Pneumonia
SECONDARY
Epilepsy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr [**Known lastname **]--
It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted after being found
unresponsive at your rehabilitation center. You were admitted
to the ICU and evaluated by neurology and medicine doctors. You
were found to have had a pneumonia caused by aspirating (food
going "down the wrong pipe"). You were treated with
antibioitics and evaluated by swallow specialists. You are now
on a special diet to help prevent aspirations. You are being
discharge to a [**Hospital3 2558**] rehabilitation facility to help
you regain your strength.
No changes were made to your medications.
Followup Instructions:
Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) 553**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Location: [**Hospital1 18**], NEUROLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 5, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 3294**]
We are working on a follow up appointment with Dr. [**First Name (STitle) **] within
1-2 weeks. If you have not heard from the office within 2 days
or have any questions, please call the number above.
Department: COGNITIVE NEUROLOGY UNIT
When: TUESDAY [**2165-6-18**] at 4:00 PM
With: MARK [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6929**], MD [**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
[**First Name8 (NamePattern2) 819**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 25507**]
|
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icd9cm
|
[
[
[]
]
] |
[
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icd9pcs
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[
[
[]
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8721, 8791
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5516, 7497
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292, 299
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8884, 8884
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3071, 5493
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9725, 10744
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2123, 2202
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8812, 8863
|
7523, 7744
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9069, 9702
|
2217, 3052
|
236, 254
|
327, 881
|
8899, 9045
|
903, 1555
|
1571, 2107
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,270
| 101,400
|
31144
|
Discharge summary
|
report
|
Admission Date: [**2183-9-8**] Discharge Date: [**2183-9-12**]
Date of Birth: [**2108-1-7**] Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamides) / Lorazepam
Attending:[**First Name3 (LF) 2704**]
Chief Complaint:
Transferred for carotid stenting
Major Surgical or Invasive Procedure:
Percutaneous placement of stent in left internal carotid
History of Present Illness:
75M h/o PVD, small cell lung CA with left neck mass s/p
radiation, and symptomatic bilateral carotid stenoses (90% left,
totally occluded right) transferred from OSH for percutaneous
carotid stenting. He has had several recent "drop attacks"
considered to be TIAs. He has had several months of transient
light-headedness associated with a feeling of his 'legs giving
out' followed by syncope. These episodes have been becoming more
frequent recently. Last week he underwent carotid U/S which
revealed progression of left carotid disease to >70%. The
patient was scheduled for an elective carotid endarterectomy
today at [**Hospital6 33**] that was cancelled as he was
deemed a poor surgical candidate due to multiple comorbidities.
He was started on plavix, given IVFs and mucomyst for renal
protection, and transferred to [**Hospital1 18**] for percutaneous carotid
stenting.
Past Medical History:
h/o metastatic small cell lung CA s/p left neck lymph node
dissection, chemotherapy (6 cycles VP-16 and platinol), and
radiation (436 [**Doctor Last Name 352**], [**2171**])
h/o colon CA s/p right hemicolectomy and chemotherapy (5-FU and
levamisole, [**2174**])
CRI (baseline Cre 2.0)
Bilateral carotid stenoses (90% left, totally occluded right)
h/o TIAs
PVD s/p left fem-[**Doctor Last Name **] bypass and right-to-left fem/fem bypass
Early dementia (short term memory loss)
HTN
PAF
GERD
s/p cataract surgery
DJD
h/o difficult intubation [**3-7**] radiation and neck resection
Social History:
Social history is significant for the absence of current tobacco
use although he is a former smoker (quit 20 years prior). There
is no history of alcohol abuse. Married, lives with his wife. [**Name (NI) **]
is active at baseline.
Family History:
There is a family history of premature coronary artery disease
in his father at age 50. There is also a history of diabetes in
his father, mother, and sister.
Physical Exam:
VS - T 95.1 HR 60 BP left 203/64 right 121/91 RR 16 SpO2 96%/RA
Gen: Weathered elderly male, 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.
Poor dentition. No pain on palpation of oral mucosa or jaw and
no palpable fluid collection.
Neck: Supple with JVP of 8 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. Well-healed midline abdominal
scar.
Ext: No c/c/e. Warm.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Strength 5/5 in upper a lower extremities, sensation
intact to light touch throughout, no dysmetria, CN II-XII intact
.
Pulses:
Right: Carotid absent Radial 1+ Popliteal absent DP dopp
Left: Carotid 2+ Radial 2+ Popliteal absent DP dopp
Pertinent Results:
Admission labs:
[**2183-9-8**] 05:30PM BLOOD WBC-8.0 RBC-4.08* Hgb-13.2* Hct-38.0*
MCV-93 MCH-32.2* MCHC-34.7 RDW-14.2 Plt Ct-192
[**2183-9-8**] 05:30PM BLOOD PT-11.7 PTT-28.6 INR(PT)-1.0
[**2183-9-8**] 05:30PM BLOOD Glucose-89 UreaN-27* Creat-1.9* Na-140
K-4.1 Cl-107 HCO3-25 AnGap-12
[**2183-9-8**] 05:30PM BLOOD Calcium-8.8 Phos-3.3 Mg-2.3
.
Discharge labs:
.
EKG demonstrated NSR, Q-waves III/aVF, <1mm ST depression V5-6
with no significant change compared with prior dated [**2182-8-28**].
.
2D-ECHOCARDIOGRAM performed on [**5-/2180**] demonstrated: EF 60-65%,
trace MR, 2+ TR
.
ETT performed on [**2182-8-24**] demonstrated: No chest pain or
significant ECG changes.
.
Bilateral duplex carotid U/S ([**2183-9-5**]): Right total occlusion,
Left >70% stenosis.
.
Brief Hospital Course:
The patient is a 75 y/o man w/ bilateral critical carotid
stenosis (Right completely occluded and left>70% occluded) who
had a history oif multiple TIAs and drop attacks, who was
transferred from an outside hospital for percutaneous carotid
stenting. He was transfered for percutaneous intervention as he
was a poor operative candidate secondary to multiple medical
comorbidities. He was initially admitted to the floor prior to
the procedure. Post-procedure, he was transfered to the CCU. He
had a drug eluuting stent placed in his left ICA without
complications. On his first night post procedure, he was put on
a neo drip for SBP in the 90s. The neo was discontinued 24 hours
later. He also received fluid boluses with good response.
The patient had a bruit in his right groin area and an
ultrasound was obtained, which showed no pseudoaneurysm or
hematoma. This bruit might have been old and related to his
extensive atherosclerotic disease.
His hematocrit dropped during his hospitalization by about 8
points. Hemolysis laboratories were negative and he was guaiac
negative. CT abdomen and pelvis was negative for bleed. He
received one unit PRBCs and did well post transfusion. His
hematocrit was stable prior to discharge.
For two days after his stent, he was somewhat bradycardic and
hypotensive. This might have been due to autonomic disregulation
due to carotid barorreceptor manipulation. By the third day, his
compensatory responses had normalized. Physical therapy
evaluated him and he was discharged home with PT services and
VNA services. His neurologic exam remained normal throughout
hospitalization. His Aricept was discontinued as it is a drug
known to cause bradycardia and orthostasis. It was recommended
that he undergo posterior circulation evaluation as an
outpatient.
Medications on Admission:
HOME MEDICATIONS:
Amoxicillin 500mg [**Hospital1 **]
Zocor 20mg daily
Aricept 10mg qhs
Toprol XL 50mg daily
Aspirin 325mg daily
.
TRANSFER MEDICATIONS:
Plavix 300mg once
Mucomyst 600mg po once
Aspirin 325mg daily
Amoxicillin 500mg [**Hospital1 **] (2 more days for dental abscess)
Toprol XL 50mg daily
Aricept 10mg daily
Zocor 20mg daily
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*2*
4. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day: Start taking this
medication [**2183-9-14**].
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital3 **] VNA
Discharge Diagnosis:
Carotid stenosis (bilateral)
S/p stenting left internal carotid
Discharge Condition:
Good. No pain. No weakness or dizziness. Ambulatory.
Discharge Instructions:
You were transferred to this hospital because the blood vessel
that carries blood to your brain was critically narrow. The
blood vessel was kept open by means of a stent. The procedure
had no complications.
Please note that you should not take the medicine called
metoprolol (toprol XL) for 2 days. After that, you must begin
taking it as before. You must also take the rest of your
medications as prescribed from the moment of discharge. You are
taking a new medication called plavix (clopidogrel)
Please see your primary care doctor within 4 days of
discharge. Also, call your doctor or return to the Emergency
Department if you experience any more drop attacks, chest pain,
shortness of breatth, bleeding, weakness, or any other
concerning symptoms.
Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 4022**] Follow-up
appointment [**9-23**], 3PM [**Hospital Ward Name 23**]-7, [**Hospital1 18**]
Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 18368**] Call to schedule
appointment, [**2187-9-23**]:10 AM ([**Street Address(1) **], Waymouth)
|
[
"530.81",
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"V10.05",
"433.30",
"294.8",
"585.9",
"443.9",
"403.90",
"V15.3",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"00.40",
"88.41",
"00.63",
"00.61",
"00.45"
] |
icd9pcs
|
[
[
[]
]
] |
6972, 7023
|
4252, 6057
|
324, 383
|
7131, 7186
|
3458, 3458
|
7994, 8423
|
2155, 2315
|
6445, 6949
|
7044, 7110
|
6083, 6083
|
7210, 7971
|
3819, 4229
|
2330, 3439
|
6101, 6213
|
252, 286
|
6235, 6422
|
411, 1289
|
3474, 3803
|
1311, 1891
|
1907, 2139
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
68
| 170,467
|
9138
|
Discharge summary
|
report
|
Admission Date: [**2173-12-15**] Discharge Date: [**2174-1-3**]
Date of Birth: [**2132-2-29**] Sex: F
Service: MEDICINE
Allergies:
Nevirapine / Abacavir / Ampicillin / Tylenol / Zidovudine
Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Productive cough, fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. [**Known lastname 31473**] is a 41yo F with AIDS, cardiomyopathy, asthma, CRF
who presents with two weeks of productive cough. Two weeks ago,
she developed a runny nose and a productive cough that was
stable for one week. Then, approximately one week ago, she began
developing a worsening cough with increasing sputum. The sputum
is green-yellow, without blood. She denies fevers, chills, night
sweats, chest pain (pleuritic or constant), SOB, DOE, orthopnea,
or PND. She has a history of disseminated MAC in [**6-/2173**] and PCP
[**Last Name (NamePattern4) **] [**2163**] and [**2170**]. She had been feeling well prior to this. She
currently denies HA, URI sx, neck pain, chest pain, SOB, abd
pain, back pain, n/v/d/c, dysuria/hematuria, or rash.
In the ED, she was hypothermic at 96.0 and hypotensive in the
60's, which improved to low 90's (her baseline per prior clinic
notes) with one liter NS. She got asa, atovaquone, and
levofloxacin.
Past Medical History:
-AIDS: Dx [**2163**]. Last CD4 5 and VL 70,500 on [**2173-9-1**]
-Disseminated MAC [**6-/2173**]
-HIV Nephropathy (FSGS) - baseline Cr 1.1
-PCP [**2163**] and [**2170**]
-CHF with EF 20-25% on [**6-/2173**] ECHO
-Childhood asthma
-GERD
-Cervical dysplasia
-HSV with subsequent anorectal ulcers
.
Social History:
Born in [**Country **], moved to the US as a teen. Ms. [**Known lastname 31473**] lives
with her 13yo daughter in an apartment in [**Name (NI) 5110**], MA. She
worked as a word processor formerly, now is on disability. She
never smoked and denies EtOH or illicit drug use. Has good
social support system (brother, other family members live
nearby).
Family History:
CAD: mother died at age 57 from an MI
Physical Exam:
T 96.0, BP 92/50, HR 92, RR 18, sat unobtainable (PO2 127 on
ABG)
GEN - cachectic female, looks older than age, mildly
uncomfortable, nad
HEENT - anicteric, op clear with mmm
NECK - supple, no jvd/lad/thyromegaly
CV - rrr, s1s2, ?s4, no m/r/g
PUL - no resp distress/acc muscle use, moves air well, bibasilar
rales r>l, no wheeze
ABD - scaphoid, soft, nt, nd, nabs, no hepatosplenomegaly
BACK - no cva/vert tenderness
EXT - no cyanosis/edema, warm/dry
NAILS - no clubbing, no pitting/color changes/indentations
NEURO - a&ox3, no focal cn/motor deficits
Pertinent Results:
Labs on admission:
WBC 2.8, Hct 26.7, MCV 81, Plt 247
diff: 80N* 2B 10L* 6M 2E
Ddimer 1203, granulocyte count 1090
Glu 83, BUN 34*, Cr 2.8*, Na 134, K 5.5, Cl 106, HCO3 17, AG 17
ALT 18, AST 55, LDH 446, AlkPhos 100, Amyl 237, Lip 133, Tbili
0.3
Ca 7.8, Phos 4.5, Mg 2.0
UA: staw yellow, clear, USG 1.008, LG blood, 500 prot, pH 6.0, 0
RBC, 0-2 WBC, occ bacteria, neg nitrites, neg LE
urine chem: Cr 10, Na 101, Alb 55.1, Prot/Cr 5510.0*
urine eos negative
.
Other labs:
TIBC 152, Ferritin >assay, TRF 117*
plasma osm 280
proBNP [**Numeric Identifier 31474**]
TSH 2.5, PTH 248
cosyntropin stim: random cortisol 19.7, 30 min cortisol 36.7,
60min 42.5
HBsAg neg, HBsAb neg, HBcAb neg, HCV Ab neg
.
Labs on discharge:
WBC 1.9, Hct 24.7, MCV 94, Plt 96
Glu 66, BUN 28, Cr 2.1, Na 135, K 3.6, CL 103, HCO3 23, AG 13
Ca 7.6, Phos 3.1, Mg 1.7
Dig 0.5
Albumin 2.2
.
Micro:
[**2173-12-31**]: stool NEG for C diff
[**2173-12-29**]: stool cx no micro, cyclospora, crypto/giardia, O+P; few
PMNs
[**2173-12-28**]: [**Month/Day/Year 1065**] isolators PND
[**2173-12-28**]: CMV VL not detected
[**2173-12-28**]: stool cx neg for microsp, cyclospora, O+P,
crypto/giardia
[**2173-12-27**]: stool cx for C diff toxin B PND
[**2173-12-27**]: stool cx neg for microspor, cyclospora, isospora, O+P,
Cdiff
[**2173-12-25**]: stool cx NEG for Cdiff
[**2173-12-24**]: blood cx x2 NGTD
[**2173-12-23**]: stool cx AFB PND
[**2173-12-21**]: blood cx x2 NGTD
[**12-18**]: induced sputum: neg for PCP, [**Name10 (NameIs) **] AFB on direct smear,
[**Name10 (NameIs) 1065**] cx NGTD, AFB cx + for AFB (speciation pending at State
Lab)
[**12-18**]: urine cx NGTD
[**12-18**]: blood/[**Month/Day (4) 1065**] cx NGTD
[**12-16**]: urine Legionella neg
[**12-16**]: Rapid Respiratory Viral Antigen Test (Final [**2173-12-17**]):
neg for
ADENO; PARAINFLUENZA 1,2,3; INFLUENZA A,B AND RSV; viral cx
pending
[**12-16**]: cryptococcal Ag: neg
[**12-16**]: CMV VL: negative
[**12-16**]: induced sputum: neg for PCP, [**Name10 (NameIs) 1065**] cx neg, AFB smear neg
[**12-16**]: stool cx neg for salmonella, shigella, campylobacter,
Cdiff
[**12-15**]: blood cx/AFB cx/[**Month/Year (2) 1065**] cx: NGTD
[**12-15**]: urine cx: NGTD
.
Imaging:
[**2173-12-28**]: ECHO - Left ventricular wall thicknesses are normal.
The left ventricular cavity is moderately dilated with evere
global hypokinesis. No left ventricular thrombus is seen. The
right ventricular cavity is mildly dilated with moderate global
wall hypokinesis. The aortic leaflets are normal with good
excursion. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. Mild to moderate ([**12-20**]+) mitral
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is a small to moderate sized circumferential
pericardial effusion without evidence for tamponade physiology.
Compared with the prior study (images reviewed) of [**2173-12-17**],
the pericardial effusion is slightly larger (specifically around
the right atrium). The estimated pulmonary artery systolic
pressure is higher, right ventricular free
wall motion may be slightly worse, and the severities of mitral
and aortic regurgitation are slightly increased.
.
[**2173-12-27**]: portable abdominal film - No dilated loops of large or
small bowel are seen to indicate obstruction. No definite free
intraperitoneal air is seen. There are bilateral pleural
effusions with lower lobe airspace opacities.
.
[**2173-12-24**]: CT a/p - 1. New, bilateral pleural effusions, right
greater than left. Ground-glass opacities at the left lung base
may represent fluid overload. 2. Cardiomegaly with interval
marked enlargement of the cardiac [**Doctor Last Name 1754**] from the previous CT.
Moderate pericardial effusion. 3. Diffuse bowel wall thickening
involving the right colon to a greater extent than the left.
These findings may represent infectious colitis or possibly
typhlitis. 4. Anasarca.
.
[**2173-12-21**]: KUB - Non-specific bowel gas pattern. No air-fluid
levels to suggest obstruction.
.
[**12-18**]: CXR - 1. Stable cardiomegaly. 2. Improvement of the
perihilar opacities with residual opacities at the bases. This
may be secondary to resolving pulmonary edema or infectious
process.
.
[**12-17**]: ECHO - The left atrium is elongated. The left ventricular
cavity size is normal. Overall left ventricular systolic
function is severely depressed. Right ventricular chamber size
is normal. There is mild global right ventricular free wall
hypokinesis. The mitral valve leaflets are structurally normal.
Mild (1+) mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is a small
pericardial effusion. LVEF <= 20%.
.
[**12-17**]: CXR - Successful placement of 39 cm total length double
lumen PICC line with tip in the superior vena cava, ready for
use.
.
[**12-16**]: portable CXR - 1. Enlarged cardiac silhouette suggesting
cardiomegaly or pericardial effusion, which has increased
compared to the prior examination. 2. Bilateral perihilar
opacities, likely due to pulmonary edema, increased compared to
the prior examination. Superimposed infection including PCP
cannot be excluded.
.
[**12-15**]: CXR - Enlargement of the cardiac silhouette suggesting
cardiomegaly or pericardial effusion that has progressed
compared to [**2173-8-13**]. Nonspecific bibasilar opacity suggests
edema or consolidation.
Brief Hospital Course:
# PNEUMONIA: It was felt that Ms. [**Known lastname 31473**] had a pneumonia on
admission. With her history of disseminated MAC and PCP in the
past, she was treated empirically for community-acquired
pneumonia (with 10 days of levaquin), MAC (with clarithromycin
and ethambutol), and PCP (with atovaquone originally, then
clindamycin and primaquine due to nausea and vomiting associated
with the atovaquone). ID was consulted and helped guide her
management throughout her hospital course. She was hypothermic
and hypotensive on admission, which raised concerns for sepsis,
but her BP responded to fluid boluses and her temperature came
up slightly. Induced sputum x3 was sent and were negative for
PCP, [**Name10 (NameIs) **] AFB culture came back positive for AFB on [**1-3**] (AFB
smears were negative x3). Identification of the organism is
still pending, but after confirming this with ID, it was felt
that this was most likely MAC and the patient was being
adequately treated with her current azithromycin dose (1200mg PO
1x/week).
.
# HIV: Ms. [**Known lastname 31473**] was not taking her HAART medications or her
prophylaxis upon admission, so her HAART regimen was suspended
until her acute pneumonia was treated and a discussion could be
had between the patient and her PCP. [**Name10 (NameIs) **] team was concerned that
many of her comorbidities, principally her cardiomyopathy and
her renal failure, were related to her HIV and would only
improve or remain stable with the administration of HAART. Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] met with Ms. [**Known lastname 31473**] on 11R and it was decided to
restart antiretrovirals, with a 5 drug salvage regimen which ID
recommended based on her resistance profile. They also helped
make recommendations for her prophylaxis, so her ethambutol and
clarithromycin were changed to azithromycin 1x/week and her
clindamycin and primaquine were changed to Bactrim. She refused
to take atovaquone because of nausea and vomiting. Because of
her history of a Bactrim allergy, she was brought to the [**Hospital Unit Name 153**]
for Bactrim desensitization. Once she had begun prophylaxis and
tolerated the regimen well, she was restarted on a HAART regimen
which included zidovudine, tipranavir, ritonavir, tenofovir, and
lamivudine. She tolerated that regimen well with no change in
her symptoms (diarrhea, abd pain were unchanged) and she was
discharged on this regimen. Prior to discharge, social work
contact[**Name (NI) **] [**Name (NI) 1022**] [**Last Name (NamePattern1) 3912**] of the [**Name (NI) 392**]/[**Hospital3 **] AIDS Cares
Network at [**Hospital6 10353**] ([**Telephone/Fax (1) 31475**]) to set up
outpatient services for Ms. [**Known lastname 31473**].
.
# CARDIOMYOPATHY: Ms. [**Known lastname 31473**] was tachycardic and hypotensive in
the ER, with SBPs in the 60s. A BNP was checked in the ER and
was 32,538. Her SBP responded well to fluid boluses and came up
to the 90s. Her tachycardia persisted, however, EKGs showed it
was a sinus tachycardia. On the floor, she was monitored on
telemetry and she developed a HR of 170s overnight. She was
given PO and IV diltiazem which dropped her SBP and her HR to
the 70s. She was asymptomatic during this episode, but was
transferred to the [**Hospital Unit Name 153**] for closer monitoring. An ECHO showed
that her EF was < or =20% and she had severely depressed left
ventricular systolic function and mild global right ventricular
free wall hypokinesis. Her SBP came back up to the 90s in the
[**Hospital Unit Name 153**] and she was felt to be hemodynamically stable, so she was
transferred out the floor. Her volume status remained difficult
to assess as she appeared to be both total body overloaded (was
grossly edematous, with bilateral LE edema) and intravascularly
dry (no appreciable JVD, hypotensive, tachycardic, with acute on
chronic renal failure and oliguria). Renal was consulted and
after analyzing her urine sediment, felt that her picture was
most consistent with prerenal azotemia (on top of underlying HIV
nephropathy) and recommended IVF to correct her prerenal state.
She was given multiple liters of IVF with minimal improvement in
her UOP, BP and tachycardia. She become more volume overloaded
so she was given transfusions of pRBC (as her Hct was also in
the low to mid 20s), again with minimal improvement. Her Cr
remained elevated and her UOP remained poor. She was tested for
adrenal insufficiency given her persistently low BP, but she was
not adrenally insufficient by cosyntropin stimulation test. A
repeat ECHO was performed which again showed an EF of < or =
20%, dilated left and right ventricles, and moderate-severe
global hypokinesis bilaterally. There was no tamponade
physiology. Cardiology was informally consulted to see if there
would be utility to placing a line to measure CVP and then
perhaps diuresing her (likely with the addition of a pressor),
but it was felt that less invasive measures would be best in
this patient. She was restarted on digoxin (no loading dose) and
tolerated it well. Her digoxin level prior to discharge was
still subtherapeutic, but because of her renal function, it was
decided to keep her on this dose and recheck a dig level as an
outpatient. She was given metoprolol 12.5mg PO x1 to attempt to
slow down her HR, but dropped her SBP to the 70s. Her BP
responded to IVF boluses, but it was decided to not try any
further medications that could potentially drop her BP. She was
not able to be started on lasix, an ACE or spironolactone for
this reason. She was monitored on telemetry after starting the
digoxin and had one run of NSVT (13 beats).
.
# ARF: On admission, her Cr was 2.8 which appeared to be an
acute on chronic renal failure. Her urine lytes were consistent
with prerenal physiology and she was hydrated with IVF but with
only minimal improvement in her UOP. She maintained UOP of
15cc/hr for most of her hospital stay. Based on her urine
studies, it was felt that she was prerenal and needed IVF. She
was also given bicitra to attempt to correct the acidosis that
was developing from her renal failure. However, the more IVF we
gave, the more she seemed to third space and she developed
anasarca and lower extremity edema which was very troublesome to
her. Her BP was so low that we were never able to safely give
lasix to see if her UOP and edema would improve. With
administration of digoxin, her Cr began to improve and came back
down to her baseline of 2.1 by the time of discharge. She still
had significant proteinuria (spot Prot/Cr of 5510, dipstick
protein of 500) which was attributed to HIV nephropathy. Her
HAART regimen was dosed according to her discharge Cr, so her Cr
will have to be monitored closely as an outpatient and her
medications will need to be adjusted according to her CrCl.
.
# ABDOMINAL PAIN/DIARRHEA: Her abdominal pain became a more
prominent symptom once she developed anasarca. Multiple stool
studies were sent as she had frequent diarrhea, but all
cultures, including O+P and Cdiff, were negative. A CT scan of
her abdomen showed a question of typhlitis. KUB were negative
for free air or for obstruction/toxic megacolon. Ms. [**Known lastname 31476**]
abdominal pain seemed to wax and wane, but became less severe
once she began to autodiurese and her bloating and abdominal
distension resolved. Her greater concern was diarrhea. She felt
that each time she stood up, she had to have a bowel movement
and sometimes she would be incontinent because she could not
control the urge to defecate. All stool studies were negative,
including Cdiff toxin B. She was given loperamide to help
improve her diarrhea, which worked with some success. She was
given a prescription for this upon discharge, with instructions
to follow up on this symptom with her ID doctors as it could be
related to her medications (possibly the azithromycin or maybe
even her HAART regimen).
.
# ANEMIA: Ms. [**Known lastname 31473**] is anemic, with her baseline Hct in the mid
20s. She is asymptomatic from her anemia, but was given several
transfusions during her hospital stay in an attempt to increase
her BP and intravascular volume without causing third spacing.
However, her BP was minimally responsive to transfusions so they
were held unless she became symptomatic. Stools were guaiac
negative. Labs were most consistent with an anemia of chronic
disease. On discharge, her Hct was 24.5.
.
# FEN: IVF were given originally, but had to be held due to
anasarca. Her electrolytes were checked daily and were repleted
as necessary. Her K and HCO3 were often low and needed
repletion. Her Na also trended down, and she was briefly put on
a 1.5L/day fluid restriction to help bring her Na back to
normal. She was given a regular, low salt, heart healthy diet.
She was continued on Megace, though she frequently refused this
medication.
.
# PPX: Ms. [**Known lastname 31473**] was given heparin SC for DVT prophylaxis, but
she soon developed thrombocytopenia and it had to be stopped.
HIT antibodies were never sent. She was then given [**Male First Name (un) **] stockings
and pneumoboots for DVT prophylaxis. She was given a bowel
regimen originally, but by the end of her stay, she was having
frequent diarrhea and no stool softeners were needed. She was
also given a PPI for GI ppx.
.
# Access: She had a peripheral line originally, then a PICC line
was placed in her L arm due to poor IV access. The PICC line
worked well for her throughout her admission, without any
evidence of infection or cellulitis.
.
# Code: FULL. A discussion was had with the patient about her
code status and the patient did not seem to understand what it
meant to code someone or what it would mean for her as the
patient. It was decided, however, that she would be CPR not
indicated in case an event were to occur.
.
# Dispo: To home with services.
Medications on Admission:
Emtriva 200mg daily
Ethambutol 800mg daily (pt states not taking)
Famvir 250mg daily (pt states not taking)
Lisinoprol 10mg daily
Metoprolol 25mg [**Hospital1 **]
Rifabutin 300mg daily (pt states not taking)
Stavudine 30mg [**Hospital1 **]
Discharge Medications:
1. Megace Oral 40 mg/mL Suspension Sig: Ten (10) milliliters PO
once a day.
Disp:*1 bottle* Refills:*2*
2. Zidovudine 300 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*180 Tablet(s)* Refills:*2*
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
Disp:*45 Tablet(s)* Refills:*2*
4. Azithromycin 600 mg Tablet Sig: Two (2) Tablet PO 1X/WEEK
(WE): Please take once a week (every Wednesday).
Disp:*30 Tablet(s)* Refills:*2*
5. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Disp:*90 Tablet(s)* Refills:*2*
6. Tipranavir 250 mg Capsule Sig: Two (2) Capsule PO BID (2
times a day).
Disp:*120 Capsule(s)* Refills:*2*
7. Ritonavir 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times
a day).
Disp:*120 Capsule(s)* Refills:*2*
8. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1)
Tablet PO 2X/WEEK (WE,SA).
Disp:*60 Tablet(s)* Refills:*2*
9. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*90 Tablet(s)* Refills:*2*
10. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times
a day) as needed for diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Company 1519**]
Discharge Diagnosis:
AIDS
Cardiomyopathy
Congestive heart failure (EF <20%)
Acute on chronic renal failure
Pneumonia
Anemia
Discharge Condition:
Good. Afebrile, BP 94/68, HR 108, RR 18, sats 96% on RA
Discharge Instructions:
1. Please call your PCP or go to the ER if you develop any of
the following symptoms: fever >101, cough, chills, shortness of
breath, difficulty breathing, chest pain, palpitations, nausea,
vomiting, persistent diarrhea, abdominal pain, weakness,
swelling in your legs, or any other worrisome symptoms.
2. Please take your medications as prescribed every day. It is
very important that you take Bactrim every day. If you miss even
one or two doses, you may redevelop an allergy to it.
3. Please follow up with Dr. [**Last Name (STitle) **] in the next few weeks. Her
office will call you with an appointment tomorrow.
Followup Instructions:
1. Please follow-up with Dr. [**Last Name (STitle) **] in [**1-21**] weeks. Her office
will call you tomorrow with an appointment.
2. Please call Dr.[**Name (NI) 31477**] office (cardiology) and set up an
appointment with him in [**1-22**] weeks. His office number is
[**Telephone/Fax (1) 4022**].
|
[
"V14.1",
"276.1",
"285.9",
"042",
"428.0",
"284.8",
"585.9",
"V07.1",
"263.9",
"428.20",
"486",
"425.4",
"584.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"99.12",
"99.10",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
19567, 19616
|
8110, 17992
|
340, 347
|
19763, 19821
|
2656, 2661
|
20487, 20788
|
2028, 2068
|
18283, 19544
|
19637, 19742
|
18018, 18260
|
19845, 20464
|
2083, 2637
|
277, 302
|
3371, 8087
|
375, 1326
|
2675, 3115
|
1348, 1646
|
1662, 2012
|
3127, 3352
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
59,367
| 134,528
|
26941
|
Discharge summary
|
report
|
Admission Date: [**2161-10-13**] Discharge Date: [**2161-10-23**]
Date of Birth: [**2089-8-31**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea with exertion/Orthopnea
Major Surgical or Invasive Procedure:
[**2161-10-18**] - Mediastinal Exploration and Evacuation of Clot
[**2161-10-14**] - Redo sternotomy, Aortic and mitral valve replacement
with St. [**Male First Name (un) 923**] mechanical valves. Closure of ASD.
[**2161-10-13**] - Cardiac Catheterization
History of Present Illness:
Mrs. [**Known lastname 66252**] is a 72-year-old lady who has known rheumatic heart
disease, status post mitral valve commissurotomy in the past
through a median sternotomy. She
has developed mitral stenosis, mitral regurgitation and moderate
aortic regurgitation with rheumatic valve changes by
echocardiography. SHe is now symptomatic with DOE and orthopnea.
Past Medical History:
PMH: Rheumatic heart disease, Mitral stenosis, Mitral
regurgitation, Aortic insufficiency, Chronic atrial
fibrillation,
R parietal stroke [**2156**], COPD, h/o acute bronchitis.
PSH: Mitral commissurotomy through a sternotomy in [**2135**], a
hysterectomy in [**2141**], a hemorrhoid surgery in [**2148**] and [**2158**], and
local cyst removal near her sternotomy in [**2160**].
Social History:
She is a retired factory worker. She quit tobacco approximately
in [**2153**]. She admits to only a 10-pack year history. She has no
history of alcohol, previously did not drink alcohol. She
currently lives with her daughter who is employed as a nurse.
Family History:
Her brother also suffered from rheumatic heart disease.
Physical Exam:
PE: 98.6 97.7 82 110/60 18 95RA
NAD. A&Ox3.
Anicteric. MMM.
Irregularly, irregular.
Sternotomy incision c/d/i. No crepitus.
Diminished breath sounds at bases.
Soft. ND. +BS. Minimally tender RUQ. No guarding, rebound, or
other signs of peritonitis.
Warm and well perfused. Trace peripheral edema.
Pertinent Results:
[**2161-10-13**] Cardiac Cath
1. Coronary angiography in this right-dominant system revealed:
--the LMCA had no angiographically apparent disease.
--the LAD had no angiographically apparent disease.
--the LCX had no angiographically apparent disease.
--the RCA had no angiographically apparent disease.
2. Resting hemodynamics revealed high-normal right-sided
filling
pressures with RVEDP 6 mmHg. The PCWP was elevated at 15 mmHg;
the
LVEDP was 9 mmHg. There was mild pulmonary arterial systolic
hypertension with PASP 31 mmHg. The cardiac output was normal
with CI
2.9 L/min/m2. There was normal systemic arterial systolic
pressure,
with SBP 115 mmHg. There was no gradient across the aortic
valve upon
pullback of the angled pigtail catheter from LV to ascending
aorta.
3. Hemodynamic evaluation of the mitral valve revealed the
mitral valve
gradient to be approximately 5 mmHg with a calculated mitral
valve area
of 1.9 cm2.
4. Left ventriculography revealed normal wall motion, LVEF 61%,
and
[**2-24**]+ mitral regurgitation into a dilated left atrium.
5. Supravalvular aortography revealed 2+ aortic regurgitation.
[**2161-10-14**] ECHO
PRE-BYPASS:
1. The left atrium is markedly dilated. A left-to-right shunt
across the interatrial septum is seen at rest. A small secundum
atrial septal defect is present.
2. There is mild symmetric left ventricular hypertrophy.
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 descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is mild aortic valve
stenosis (area 1.2-1.9cm2). Moderate (2+) aortic regurgitation
is seen.
6. The mitral valve leaflets are severely thickened/deformed.
There is moderate valvular mitral stenosis (area 1.0-1.5cm2).
Moderate (2+) mitral regurgitation is seen.
7. There is no pericardial effusion.
Dr. [**Last Name (STitle) **] was notified in person of the results.
POST-BYPASS: For the post-bypass study, the patient was
receiving vasoactive infusions including epinephrine &
phenylephrine and is AV paced.
1. A well-seated bileaflet valve is seen in the mitral position
with normal leaflet motion and gradients (mean gradient = 3
mmHg). Trivial (normal for prosthesis) mitral regurgitation is
seen. Washing jets are seen.
2. A wellseated bileaflet valve is seen in the Aortic position.
Valve is not well seen due to shadowing, leaflets appear to move
well. Mean Gradient is 3 mm of Hg. No significant valvular or
paravalvular jets seen (however cannot exclude smaller jets)
3. Biventricular functions appears unchanged.
4. Aorta is intact post decannulation.
5. Other findings are unchanged.
[**2161-10-17**] CT Scan
1. Mild-to-moderate free intraperitoneal air collecting
underneath the
diaphragm. No definite source is identified, but likely relates
to recent
surgery. Bowel is normal in appearance. There is no
extravasation of oral
contrast material or intra- abdominal or intrapelvic fluid
collection.
2. Large left and small right pleural effusions.
3. Small amount of gas, fluid, and intermediate density material
in the
inferior-most portion of the imaged mediastinum, presumably
related to recent surgery.
4. Bilateral hydroureteronephrosis, right worse than left. No
stones or other filling defect is identified.
[**2161-10-20**] ECHO
Pre evacaution: The left atrium is mildly dilated. There is mild
symmetric left ventricular hypertrophy. The left ventricular
cavity is unusually small. There is mild regional left
ventricular systolic dysfunction with anterior hypokinesis.
Overall left ventricular systolic function is mildly depressed
(LVEF= 40 %). The right ventricular cavity is unusually small.
with moderate global free wall hypokinesis. There is severe
compression of the right atrium and ventricle by a large
retorcardiac mass which is consistent with organizing thrombus.
The right atrium is slit like and severely compressed. There is
a large left pleural effusion. There are simple atheroma in the
ascending aorta. There are complex (>4mm) atheroma in the aortic
arch. There are complex (>4mm) atheroma in the descending
thoracic aorta. A bileaflet aortic valve prosthesis is present.
No aortic regurgitation is seen. Aortic valve gradeints are
normal for prosthesis. A mechanical mitral valve prosthesis is
present. Gradients are normal for prosthesis. Mild (1+) mitral
regurgitation is seen. Moderate to severe [3+] tricuspid
regurgitation is seen.
Post evacuation. The right atrium is now mildly dilated. RV free
wall hypokiensis is mild to moderate. LVEF 40%. Remaining exam
is unchanged. All findings disucssed with surgeons at the time
of the exam
Brief Hospital Course:
Ms. [**Known lastname 66252**] was admitted to the [**Hospital1 18**] on [**2161-10-13**] for a cardiac
catheterization in preparation for her redo valve surgery. Her
cardiac catheterization showed normal coronary arteries, severe
mitral rtegurgitation and moderate aortic regurgitation. On
[**2161-10-14**], Ms. [**Known lastname 66252**] was taken to the operating room where she
underwent [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 66253**], [**First Name3 (LF) **] aortic and mitral valve
replacement with St. [**Male First Name (un) 923**] mechanical valves and closure of an
atrial septal defect. Please see operative note for details.
Postoperatively she was taken to the intensive care unit for
monitoring. On postoperative day one, she awoke neurologically
intact and was extubated. Heparin was tarted for anticoagulation
and coumadin was resumed. On postoperative day two, she was
transferred to the step down unit for further recovery. She was
transfused with red blood cells for postoperative anemia. Gentle
diuresis was initiated. Free air was noted in her belly on x-ray
and a CT scan was obtained. No significant abnormalities were
seen. On [**2161-10-18**], Ms. [**Known lastname 66252**] developed hypotension and and echo
was suggestive of tamponade. She was returned to the operating
room where her mediastinum was explored with evacuation of clot.
No specific bleeding was identified and her sternum was closed.
She was returned to the intensive care unit for monitoring. She
was extubated the next day without issue and transferred back to
the step down unit of [**2161-10-20**]. The physical therapy service was
consulted for assistance with her postoperative strength and
mobility. Coumadin was resumed. She remained in controlled
atrial fibrillation consistent with her preoperative status. By
post-operative day 8 she was ready for discharge to home.
Medications on Admission:
Lasix 20', coumadin, digoxin 0.125', albuterol inhaler prn
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:*0*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): for constipation
.
Disp:*60 Capsule(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*0*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: take 2.5 mg daily or as directed by the office of Dr.
[**First Name8 (NamePattern2) **] [**Name (STitle) **].
Disp:*30 Tablet(s)* Refills:*0*
8. Outpatient Lab Work
INR to be drawn on [**10-26**] with results sent to the office of Dr.
[**Last Name (STitle) **],[**First Name3 (LF) 251**] T. [**Telephone/Fax (1) 4475**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Rheumatic heart disease with MR/MS/AI
History of Mitral valve commissurotomy
AF
CVA
COPD
Tamponade
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 11763**].
Please follow-up with cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks.
Please follow-up with Dr. [**Last Name (STitle) **] in [**1-26**] weeks. ([**Telephone/Fax (1) 40360**].
Completed by:[**2161-10-23**]
|
[
"518.81",
"496",
"E878.1",
"275.41",
"427.31",
"276.8",
"998.11",
"396.8",
"745.5",
"423.3",
"V12.54"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"35.24",
"35.22",
"39.61",
"34.03",
"96.04",
"38.93",
"88.55",
"96.71",
"37.22",
"88.53"
] |
icd9pcs
|
[
[
[]
]
] |
10096, 10154
|
6928, 8821
|
355, 613
|
10297, 10306
|
2097, 6905
|
11083, 11433
|
1696, 1754
|
8930, 10073
|
10175, 10276
|
8847, 8907
|
10330, 11060
|
1769, 2078
|
284, 317
|
641, 1004
|
1026, 1409
|
1425, 1680
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
66,891
| 177,005
|
37874
|
Discharge summary
|
report
|
Admission Date: [**2107-10-6**] Discharge Date: [**2107-10-20**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 4588**]
Chief Complaint:
Traumatic Left frontal SAH, s/p mechanical fall on warfarin
Major Surgical or Invasive Procedure:
None
History of Present Illness:
88 year old right-handed male with past medical history
significant for dementia, prior SDH operated about 1.5 years
prior, HTN who present s/p fall at home with a sub-arachnoid
bleed. The patient was walking up the stairs to
his home. Per his wife he was on the first stair up when she
heard him fall. He fell back on the concrete ground. The wife
believes he seemed out of it for about 30 seconds, but soon
recovered and was able to answer questions appropriately. He
was complaining of a severe headache and he was sent to his
local hospital in NW where a CT scan was performed. He was
noted to have an SAH and was sent to [**Hospital1 18**]. He has remained
conscious since the fall and has been answers questions
appropriately since arrival.
Past Medical History:
Of note the patient has had multiple falls and walks with
a cane. He had a fall two years prior resulting in an SDH that
was treated surgically at [**Hospital1 2025**]. He also has had difficult moving
his left shoulder and it was discovered recently he has a torn
rotator cuff on the left side.
-Gout
-HTN
-b/l cataracts
- blindness in left eye ?ischemic event 3 years prior
- CAD, h/o stent [**10**] years prior
Social History:
Patient lives at home with wife. She largely takes care of all
his needs. He is able to feed himself. He uses a cane to
ambulate. He has been declining cognitively over the last 5
years per the family. He has a long past smoking history (quit
30-40 years ago). He doesn't drink currently (did socially
some time ago) No drug use
Family History:
Non-contributory
Physical Exam:
On Admission:
T:96.1 BP:130/58 HR:50-60 R:18 98%O2Sats
Gen: Elderly thin man, in cervical collar, seems upset
Neck: In cervical 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, knows place in [**Location (un) 86**], and did
not know the date (apparently at baseline)
Recall: [**2-12**] objects at 5 minutes.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils small 2mm and reactive, L pupil surgical. Visual
fields are full to confrontation on R, on L has no visual
acuity.
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: Patient with decreased bulk throughout, normal tone. No
noted pronator drift bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Muscle in UE [**6-14**] with some decreased strength in left UE [**3-14**] to
pain and weakness from rotator cuff repair. Per family this is
at baseline
In LE all muscle groups tested [**6-14**]
-Sensory: No deficits to light touch, pinprick, cold sensation.
-DTRs:
[**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Pertinent Results:
Labs on Admission:
[**2107-10-6**] 07:15PM BLOOD WBC-25.2* RBC-3.45* Hgb-10.0* Hct-32.2*
MCV-93 MCH-28.9 MCHC-30.9* RDW-17.4* Plt Ct-66*
[**2107-10-6**] 07:15PM BLOOD Neuts-84.1* Lymphs-10.9* Monos-4.4 Eos-0
Baso-0.6
[**2107-10-6**] 07:15PM BLOOD PT-12.3 PTT-21.8* INR(PT)-1.0
[**2107-10-6**] 07:15PM BLOOD Glucose-114* UreaN-39* Creat-1.1 Na-145
K-4.3 Cl-109* HCO3-27 AnGap-13
[**2107-10-7**] 03:08AM BLOOD ALT-30 AST-16 AlkPhos-61 TotBili-0.6
[**2107-10-7**] 03:08AM BLOOD Albumin-3.4 Calcium-8.1* Phos-4.0 Mg-2.2
[**2107-10-7**] 05:57PM BLOOD Phenyto-14.8
Labs on Discharge:
7.9
5.9 >-----< 249
24.0
138 105 9
------------------< 87
3.9 24 0.7
MICRO:
[**2107-10-18**] 3:05 pm SPUTUM Source: Expectorated.
GRAM STAIN (Final [**2107-10-18**]):
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS.
1+ (<1 per 1000X FIELD): YEAST(S).
RESPIRATORY CULTURE (Preliminary): RESULTS PENDING.
[**2107-10-16**] 11:34 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2107-10-17**]**
MRSA SCREEN (Final [**2107-10-17**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2107-10-8**] 8:39 am STOOL CONSISTENCY: FORMED
**FINAL REPORT [**2107-10-9**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2107-10-9**]):
REPORTED BY PHONE TO D. HICKCOX, R.N. ON [**2107-10-9**] AT 0415.
CLOSTRIDIUM DIFFICILE.
FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA.
(Reference Range-Negative).
A positive result in a recently treated patient is of
uncertain
significance unless the patient is currently
symptomatic
(relapse).
IMAGING:
Head CT [**10-6**]:NON-CONTRAST HEAD CT: There is right
parietooccipital scalp hematoma, without underlying acute
fracture seen. Two prior burr holes are noted in the right
parietal skull. Diffuse subarachnoid hemorrhage in the right
cerebral hemisphere and also foci in the left frontal lobe
appear similar to that seen on outside hospital CT performed six
hours prior. Several foci of subarachnoid hemorrhage along the
left superior convexity are newly apparent. There are also
bilateral small predominantly frontal subdural hematomas, which
measures up to 4 mm on the left, which appear unchanged. Small
focus of hemorrhagic contusion along the inferior right frontal
lobe is unchanged. There is new intraventricular extension of
hemorrhage layering bilaterally in the occipital horns.
High-density is also noted within the interpeduncular fossa.
Size of the ventricles is unchanged, without evidence of
hydrocephalus. No shift of normally midline structures or
effacement of the basal cisterns is seen. No evidence for large
vascular territorial infarction is seen. The ventricles and
sulci appear normal in size and configuration for the patient's
age. Vascular calcifications are noted along the carotid siphons
and vertebral
arteries. The patient has had prior bilateral lens replacement.
Mild mucosal thickening is noted within anterior ethmoid air
cells and the left maxillary sinus, with small mucus retention
cysts along the floor of the left maxillary sinus. The mastoid
air cells are normally aerated.
IMPRESSION: Acute subarachnoid, subdural, and intraparenchymal
hemorrhages as described above. Compared to six hours prior,
couple of new foci of
subarachnoid hemorrhage along the left superior complexity are
newly apparent, as well as intraventricular extension of
hemorrhage. No shift of normally midline structures, effacement
of the basal cisterns, or hydrocephalus.
Head CT [**10-8**]:
FINDINGS: No significant interval change. There is a
subarachnoid hemorrhage located in the right cerebral hemisphere
and left frontal lobe. Overall, the appearance is similar to
prior study. There is a tiny amount of blood layering along the
falx and tentorium as well as dependently within the bilateral
lateral ventricles, also subtle. There is a right frontal
subdural hematoma, which appears similar compared to prior
study. Previously noted left frontal subdural hematoma is
slightly less prominent. There is an area of contusion in the
right inferior frontal lobe with similar appearance compared to
prior study, with unchanged surrounding edema. There is no
evidence of new hemorrhage. There is no significant shift of
midline structures. The ventricles and sulci are prominent,
which could be due to age-related atrophy and appears similar
compared to prior study. There are bilateral carotids siphons
and vertebral artery calcifications. The patient is status post
two burr holes on the right calvarium. Visualized portion of
paranasal sinuses and mastoid air cells are within normal
limits.
IMPRESSION: Overall unchanged appearance of subarachnoid,
intraparenchymal, and intraventricular hemorrhage allowing for
some redistribution. No shift of midline structures.
CT CHEST W/O CONTRAST Study Date of [**2107-10-14**]
IMPRESSION:
1. Bilateral consolidative changes of the lung bases most likely
suggestive of aspiration, pneumonia is another likely
possibility. Atelectasis is less likely as there is no
associated volume loss.
2. Small bilateral pleural effusions. Loculated effusion is
noted adjacent
to the aorta on the left side.
3. Calcified cyst of the upper pole of the left kidney which
does not meet
the criteria for a simple cyst. For further evaluation, MR of
the abdomen can be obtained.
4. Wedge compression deformity of T4 and T7.
Brief Hospital Course:
The patient was admitted to the neurosurgery service after
falling backwards from a standing position and had a small SAH
found on head CT. The patient had several stable CT scans and
did not require surgery. He was transferred to the neurosurgical
floor on [**2107-10-8**]. He had fevers, elevated WBC, and his stool was
positive for c. difficile. He was started on flagyl. The patient
also had presumed aspiration pneumonia after several episodes of
vomiting. His first CXR did not show signs of pneumonia so
antibiotics were not started for that. However there was
evidence of a mediastinal mass and LUQ masses. He will need CT
of the chest and abdomen to evaluate those further.
.
The patient also had delirium and geriatrics was consulted. They
recommended stopping namenda, aricept, and dilantin. His mental
status improved. However he had a temperature of 101 again on
[**10-13**]. Since the patient had multiple medical issues and did not
require neurosurgery, he was transferred to the geriatrics
service on [**10-13**].
.
On the geriatrics service, the following issues were address:
.
# SAH: As above. Patient will need to follow up with
Neurosurgery as an outpatient. During this appointment,
Neurosurgery will address restarting aspirin 81 mg.
.
# C. diff colitis: Pt should continue for po Flagyl until [**11-1**].
.
# Aspiration pneumonia: Pt denies any dyspnea and he sats
mid-90s on RA. He was treated with 10 day course of ceftriaxone
and vancomycin, to be completed [**10-25**]. Speech and swallow made
the following recommendations:
1.) Diet: nectar thick liquids and pureed solids.
2.) Meds: crushed in puree
3.) TID oral care
4.) 1:1 supervision with meals to maintain aspiration
precautions
.
# Delirium on dementia: His namenda and aricept were held, and
he was started on Ritalin titrated up to 5 mg daily and Celexa 5
mg.
.
# CAD, s/p stent [**10**] years ago: He was continued on his
metoprolol. His aspirin was held. Reinitiation should be
discussed with Neurosurgery but is generally after 1 month
pending stable CT scan.
.
# HTN: This was controlled on his metoprolol.
.
# MDS with refractory anemia: His HCT remained at baseline of
~23. He was started on iron supplements.
.
# Gout: He was continued on allopurinol.
.
# Code: Currently FULL, in discussion with son [**Name (NI) 382**]
Medications on Admission:
ASA 81mg',MVI,FeSO4 325mg',Aricept 10mg',Prilosec
20mg',Allopurinol 100mg',Namenda 10mg",Calcium 125mg",Colchicine
6mg",Metoprolol 12.5"',Cerefolin-NAS QOD
Discharge Medications:
1. Multivitamin Tablet [**Name (NI) **]: One (1) Tablet PO DAILY (Daily).
2. Docusate Sodium 100 mg Capsule [**Name (NI) **]: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Senna 8.6 mg Tablet [**Name (NI) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
4. Allopurinol 100 mg Tablet [**Name (NI) **]: One (1) Tablet PO DAILY
(Daily).
5. Acetaminophen 325 mg Tablet [**Name (NI) **]: Two (2) Tablet PO every six
(6) hours.
6. Calcium Carbonate 500 mg Tablet, Chewable [**Name (NI) **]: Two (2)
Tablet, Chewable PO BID (2 times a day).
7. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Name (NI) **]: Two (2)
Tablet PO DAILY (Daily).
8. Citalopram 20 mg Tablet [**Name (NI) **]: 0.25 Tablet PO DAILY (Daily).
9. Methylphenidate 5 mg Tablet [**Name (NI) **]: One (1) Tablet PO QAM (once
a day (in the morning)).
10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Name (NI) **]: One (1)
Tablet PO DAILY (Daily).
11. Metoprolol Tartrate 25 mg Tablet [**Name (NI) **]: [**2-11**] Tablet PO three
times a day.
12. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): [**Month (only) 116**] be dissolved in
nectar thick liquids.
13. Ceftriaxone in Dextrose,Iso-os 1 gram/50 mL Piggyback [**Month (only) **]:
One (1) gram Intravenous Q24H (every 24 hours) for 5 days.
14. Vancomycin 1,000 mg Recon Soln [**Month (only) **]: 1,000 mg Intravenous
once a day for 5 days: PLs start at 8PM.
15. Metronidazole 500 mg Tablet [**Month (only) **]: One (1) Tablet PO Q6H
(every 6 hours) for 12 days.
16. Ciprofloxacin 0.3 % Drops [**Month (only) **]: 1-2 Drops Ophthalmic Q4H
(every 4 hours) for 7 days.
17. Heparin (Porcine) 5,000 unit/mL Solution [**Month (only) **]: 5,000 units
Injection [**Hospital1 **] (2 times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]
Discharge Diagnosis:
Primary:
Left frontal subarachnoid hemorrhage
.
Secondary:
C. difficle colitis
Aspiration pneumonia
Delirium
Coronary artery disease
Hypertension
Myelodysplastic Syndrome
Gout
Discharge Condition:
Neurologically Stable, afebrile
Discharge Instructions:
You were admitted to the hospital for a bleed in your brain.
This is now stable on CT scans of the head.
During your hospital course, you develop an infection of the
colon called C. difficle colitis. You need to finish your
course of antibiotics. In addition, you also develop a
pneumonia and have two intravenous antibiotics.
You are being discharged to a extended care facility.
The following are recommendations from Neurosurgery:
?????? Exercise should be limited to walking; no lifting, straining,
or excessive bending.
?????? Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc. You must discuss with your Neurosurgeon before
starting aspirin.
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:
Neurosurgery Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
Please follow up with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within
2 weeks of discharge from the extended care facility. Her
clinic number is [**Telephone/Fax (1) 70684**].
|
[
"285.22",
"372.30",
"414.01",
"789.32",
"008.45",
"238.75",
"276.8",
"V45.82",
"V58.61",
"507.0",
"E880.9",
"401.9",
"274.9",
"290.3",
"852.02",
"786.6"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
13614, 13689
|
9196, 11531
|
323, 330
|
13909, 13943
|
3599, 3604
|
15142, 15710
|
1923, 1941
|
11737, 13591
|
13710, 13888
|
11557, 11714
|
13967, 15119
|
1956, 1956
|
4617, 5439
|
224, 285
|
4183, 4579
|
358, 1114
|
2571, 3580
|
5448, 9173
|
3618, 4159
|
2220, 2555
|
1136, 1554
|
1570, 1907
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
808
| 107,825
|
3779
|
Discharge summary
|
report
|
Admission Date: [**2181-7-30**] Discharge Date: [**2181-8-7**]
Date of Birth: [**2126-6-27**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 5552**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
bilateral pleurex catheters were placed
History of Present Illness:
55 yo female with metastatic adenocarcinoma with unknown primary
on C2D1 gemcitabine/irinotecan and with history DVT/PE with IVC
filter placement, history of malignant pleural and pericardial
effusions who presents with 2 days worsening shortness of breath
and orthopnea. She also reports right sided pleuritic chest
pain. She endorses new lower extremity edema for past 2 days.
Also reports non-productive cough. Denies any fevers, chills,
nausea, vomitting, or urinary symptoms. + Constipation.
.
Of note, she has had had 3 recent admissions: on [**5-16**] for dyspnea
and [**6-6**] and [**6-14**] for dizziness/syncope. On admission [**6-6**], the
patient had pericardiocentesis and balloon pericardiotomy with
removal of 520 cc of bloody fluid. [**Month/Year (2) **] on [**6-4**] showed stable
loculated pericardial effusion. [**Month/Year (2) **] [**6-11**] (EF>55%) suggestive of
pericardial constriction, although unchanged in size since prior
admission.
.
Pt. presented to ED with above complaints, and also found to be
tachycardic to 130s. Patient has h/o resting tachycardia
115-120. Electrocardiogram in the ED showed sinus tachycardia
unchanged from prior. In the ED, patient was seen by cardiology
given history of pericardial effusions and bedsided
echocardiogram was performed, and showed moderate effusion but
did not reveal any RV diastolic collapse or significant AV
respirophasic variation to suggest tamponade physiology. Chest
x-ray demonstrated re-accumulated large right-sided pleural
effusion and moderate left-sided effusion. Patient was admitted
due to tachypnea, tachycardia, and difficult course with
previous thoracentesis, which was complicated by post-procedure
pulmonary oedema requiring diuresis.
.
She has is s/p b/l thoracentesis and is now being considered for
pleurx catheter placement on Monday.
.
Currently, she is with mild SOB, pain controlled, no other
complaints
Past Medical History:
- Tuberculosis treated in [**2145**] with normal chest x-ray at [**Hospital1 2025**] in
[**2162**].
- GYN: G2 P2. Tubal ligation [**2156**]. Stopped menstruating at age
50, normal pap's per patient
- Hypertension.
- History of mild asthma, inhalers not used for several years.
- normal mammogram less than one year ago.
- normal colonoscopy 2/[**2178**].
- recent pericardial effusion/tamponade
- right pleural effusion
- large common femoral DVT
- adenocarcinoma of unclear primary
Social History:
She works as a nursing assistant. Lives with her husband, who
keeps very early hours, working at the [**Location (un) **] food market.
Children are 18 and 19.
Family History:
Her father died of stomach cancer at age 72. Mother died of
colon cancer at age 63. She is the 10th of 13 children. She has
lost 3 siblings to motor vehicle accidents.
Physical Exam:
Vitals: 98.3 119/82 118 94-95 2L 18
Gen: Comfortable,
HEENT: Sclera anicteric. PERRL, EOMI. No oral lesions
Neck: Supple
CV: Tachycardic, regular, no M/R/G.
Chest: Decrease B/S b/l R>L
ABD: Soft, NT, ND, +BS. No HSM or tenderness.
Ext: 1+ edema b/l
Neuro: non-focal, CN II-XII grossly intact, moves all
extremities well
Skin: no rash or petechiae noted
Pertinent Results:
[**2181-7-30**] 09:45PM NEUTS-55.6 BANDS-0 LYMPHS-37.4 MONOS-3.5
EOS-1.8 BASOS-1.7
[**2181-7-30**] 09:45PM WBC-2.0*# RBC-3.57* HGB-11.9* HCT-35.4*
MCV-99* MCH-33.3* MCHC-33.5 RDW-19.4*
[**2181-7-30**] 09:45PM CK(CPK)-59
[**2181-7-30**] 09:55PM LACTATE-1.2
[**2181-7-30**] 09:45PM GLUCOSE-104 UREA N-5* CREAT-0.6 SODIUM-134
POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-15
Brief Hospital Course:
55 y/o woman with metastatic adenocarcinoma of unknown primary
with malignant pleural effusions and constrictive pericardial
effusions s/p thoracocentesis with reaccumulation of effusions,
admitted for pleurx catheter placement
.
1. Respiratory distress - Secondary to R-sided malignant
effusion. s/p therapeutic thoracentesis [**8-1**]. SOB was only
transiently relieved by thoracentesis. Pleurx catheter was felt
to be a better plan than pleurodesis as SIRS reaction could
complicate pleurodesis. Pt received her pelurx catheter
placement on [**8-6**] without complications. Pt tolerated the
procedure well and with symptomatic improvement of her dyspnea.
.
2. Constrictive pericardial effusions: [**Month/Year (2) **] [**7-31**] showed chronic
effusion but without tamponade physiology. Pt was seen by
cardiology with recommendations for potential procedure in the
future, but no immediate intervention was thought to be
warranted. Pt was hemodynamically stable throughout admission.
.
3. Mucinous adenocarcinoma of unknown primary: The patient began
chemotherapy on [**2181-6-15**] with Gemzar and CPT-11 for metastatic
disease of unknown primary. Pt was discharged with follow up
appointment with her primary oncologist for resumption of
chemotherapy.
.
4. UTI: Pt was found to have a UTI on admission. She was
discharged with a 10 day course of ciprofloxacin.
Medications on Admission:
1. Lidocaine 5 % DAILY
2. Fentanyl 25 mcg/hr Patch 72 hr
3. Ondansetron 4 mg every 6-8 hours as needed.
4. Docusate Sodium 100 PO BID
5. Enoxaparin 60 mg/0.6 mL Q12H
6. Lorazepam 0.5 mg PO DAILY PRN nausea
7. Megace Oral 40 mg/mL PO once a day.
8. Senna 8.6 mg PO BID as needed for constipation.
9. Metoprolol Tartrate 25 mg PO TID
10. Lomotil 2.5-0.025 mg Tablet PO every 4-6 hours as needed for
diarrhea.
11. Albuterol Sulfate every six (6) hours.
12. Ipratropium Bromide every six (6) hours
Discharge Medications:
1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical QDAILY ().
2. Fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
3. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every 6-8 hours as needed for nausea.
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
5. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours).
6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
as needed for PRN Nausea.
7. Megestrol 40 mg/mL Suspension Sig: Ten (10) mL PO DAILY
(Daily).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
10. Lomotil 2.5-0.025 mg Tablet Sig: One (1) Tablet PO every [**3-16**]
hours as needed for diarrhea.
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 4 days.
Disp:*7 Tablet(s)* Refills:*0*
12. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer
treatment Inhalation Q6H (every 6 hours) as needed.
13. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1)
nebulizer treatment Inhalation Q6H (every 6 hours) as needed.
Discharge Disposition:
Home With Service
Facility:
Physicians Home Care [**Hospital1 392**]
Discharge Diagnosis:
1.) Malignant pleural effusion
2.) Metastatic adenocarcinoma
3.) Urinary tract infection
4.) Pericardial effusion
Discharge Condition:
stable, maintaining O2 sats
Discharge Instructions:
You were admitted because of shortness of breath. You were
found to have a reaccumulation of fluid near your lung. You
underwent a procedure called thoracentesis, or drainage of the
pleural fluid. You also had catheters placed in your lungs to
help drain the fluid. Also while you were in the hospital you
were found to have a urinary tract infection and treated with
antibiotics.
.
Please continue to take all medications as instructed and keep
all health care appointments as scheduled.
.
If you have worsening shortness of breath, chest pain,
lightheadedness, dizziness, fevers, chills, abdominal pain or
vomiting, or if you feel worse in any way, seek immediate
medical attention.
Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-8-8**]
10:00
Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) 13145**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2181-8-15**] 9:00
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4425**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2181-8-15**]
9:30
Completed by:[**2181-8-15**]
|
[
"423.2",
"V12.51",
"199.1",
"401.9",
"288.00",
"493.90",
"197.2",
"599.0"
] |
icd9cm
|
[
[
[]
]
] |
[
"34.91",
"34.04"
] |
icd9pcs
|
[
[
[]
]
] |
7206, 7277
|
3980, 5355
|
334, 376
|
7435, 7465
|
3570, 3957
|
8201, 8657
|
3012, 3181
|
5900, 7183
|
7298, 7414
|
5381, 5877
|
7489, 8178
|
3196, 3551
|
275, 296
|
404, 2312
|
2334, 2819
|
2835, 2996
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
4,220
| 113,425
|
13969
|
Discharge summary
|
report
|
Admission Date: [**2106-4-5**] Discharge Date: [**2106-4-8**]
Service: ORTHOPAEDICS
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain
Major Surgical or Invasive Procedure:
Lumbar laminectomy L3-S1
History of Present Illness:
Mr. [**Known lastname 34210**] has a long history of back and leg pain. He has
attempted conservative therapy including physical therapy and
has failed. He now presents for surgical intervention.
Past Medical History:
DM
CRI
CVA 3 years ago w/residual right sided weakness
?CAD
Spinal stenosis
Lower back pain and hip pain
Social History:
Lives with daughter and wife. Wife has stage IV breast cancer.
Family History:
Not obtained
Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics on the
left, decreased on the right 3-4/5; sensation intact in all
dermatomes; reflexes intact at biceps, triceps and
brachioradialis
BLE- good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL on the left, decreased
on the right [**3-22**]; sensation intact distally
Pertinent Results:
[**2106-4-8**] 06:25AM BLOOD WBC-17.4* RBC-3.84* Hgb-11.3* Hct-34.2*
MCV-89 MCH-29.5 MCHC-33.2 RDW-13.7 Plt Ct-154
[**2106-4-7**] 09:30AM BLOOD Hct-36.0*#
[**2106-4-7**] 12:46AM BLOOD WBC-14.2* RBC-3.16* Hgb-9.5* Hct-27.9*
MCV-88 MCH-30.1 MCHC-34.1 RDW-13.7 Plt Ct-146*
[**2106-4-6**] 02:12PM BLOOD WBC-12.1*# RBC-3.20* Hgb-9.6* Hct-28.3*
MCV-89 MCH-29.9 MCHC-33.8 RDW-13.8 Plt Ct-167
[**2106-4-8**] 06:25AM BLOOD Glucose-98 UreaN-22* Creat-1.2 Na-137
K-4.4 Cl-99 HCO3-24 AnGap-18
[**2106-4-7**] 12:46AM BLOOD Glucose-105 UreaN-20 Creat-1.2 Na-137
K-4.3 Cl-105 HCO3-25 AnGap-11
[**2106-4-6**] 02:12PM BLOOD Glucose-123* UreaN-22* Creat-1.3* Na-139
K-4.4 Cl-105 HCO3-27 AnGap-11
[**2106-4-7**] 12:46AM BLOOD CK-MB-6 cTropnT-<0.01
[**2106-4-6**] 07:49PM BLOOD CK-MB-6 cTropnT-<0.01
[**2106-4-6**] 02:12PM BLOOD CK-MB-7 cTropnT-<0.01
Brief Hospital Course:
Mr. [**Name14 (STitle) 41743**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**]
for a laminctomy at L3-S1. He was informed and consented for
the procedure and elected to proceed. Please see Operative Note
for procedure in detail.
Post-operatively he was administered antibiotics and pain
medication. POD1 his blood pressure was noticed to be low and
he was given 2 liters of fluid in addition to 1 unit of packed
red blood cells. A medicine consult was obtained to evaulate
the continue hypotension and it was recommended that he be
transferred to the MICU. He was medically managed and given an
additional 2 units of PRBCs with good effect on his blood
pressure. He was transferred out to the floor when stable and
was able to work with physical therapy.
His incisions were clean and dry upon discharge. He was passing
flatus but had not had a bowel movement. He was dischargeed
from the hospital to an acute care facility where ther will
monitor his bowel regimen. He was discharged in good condition.
Medications on Admission:
Cymbalta
Simvastatin
Lisinopril
Glipizide
Glargine
Novalog
Oxydodone
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) 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).
6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed.
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. Glipizide 10 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1)
Tab,Sust Rel Osmotic Push 24hr PO once a day.
10. glargine Sig: Fourteen (14) units Subcutaneous qAM.
11. Novalog Sig: Eight (8) units Subcutaneous qPM.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 7665**]
Discharge Diagnosis:
Lumbar stenosis L3-S1
Post-operative anemia
Post-operative hypotension
Discharge Condition:
Good
Discharge Instructions:
Please be sure to call your primary care physician to discuss
the need for an outpatient colonoscopy to be sure you have no
bleeding from your colon to explain your anemia.
Please continue to take your pain medication with an over the
counter laxative. Call the clinic if you notice any redness or
discharge from the incision site. Call the clinic for any
additional concerns.
Physical Therapy:
Activity: Activity as tolerated
Lumbar corset for ambulation
Treatments Frequency:
Please continue to change the dressings daily with dry, sterile
gauze.
Followup Instructions:
Please follow up in the Orthopedic Spine clinic during your
previously scheduled appointments.
Completed by:[**2106-4-8**]
|
[
"518.0",
"458.29",
"585.9",
"250.00",
"285.1",
"438.89",
"721.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"81.08",
"81.62"
] |
icd9pcs
|
[
[
[]
]
] |
4357, 4404
|
2181, 3251
|
282, 309
|
4519, 4525
|
1326, 2158
|
5127, 5252
|
761, 775
|
3370, 4334
|
4425, 4498
|
3277, 3347
|
4549, 4929
|
790, 1307
|
4947, 5010
|
5032, 5104
|
225, 244
|
337, 536
|
558, 664
|
680, 745
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
62,626
| 143,463
|
43991
|
Discharge summary
|
report
|
Admission Date: [**2161-5-12**] Discharge Date: [**2161-5-17**]
Date of Birth: [**2083-5-5**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 2080**]
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
Colonoscopy
History of Present Illness:
78 yo M w hx of CAD, s/p cabg, COPD, AAA s/p repair at [**Hospital1 18**],
reports waking at 3am with BRBPR. He went back to sleep and was
awoken once again with BRBPR. he therefore drove to the OSH ED,
where he continued with BRBPR 3 more times. His hct was 40 at
OSH and he was transfused 2 units of prbc's, and given 1600cc of
IVF. While at the OSh ED he developed abdomenal pain and
lightheadedness and was therefore transferred to [**Hospital1 18**] for
further management.
.
In the ED, initial vs were: T 96.2 P88 BP100/58 R O2100% 2L sat.
his systolic blood pressures ranged in the mid 80-90s. he had
five episodes of BRBPR in the ED. Patient was given 1 unit of
platelets and 3L of NS. he was sent urgently to IR for
embolization where he continued with 300cc BRBPR en route to IR.
.
Unfortunately angiography was unable to visualize the [**Female First Name (un) 899**], and
they were therefore unable to visualize any bleeding source. he
was given 2 units of prbcs with decrease in hct from 36 to 30.
He was then given one more unit of prbcs with increase of hct 30
to 37. he was transferred to the MICU with close surgery and GI
follow-up, and initial plan to undergo colonoscopy in the
morning. If this is unsuccessful surgery will consider segmental
colectomy.
.
The patient reports having a colonoscopy two months ago which
showed only polyps.
.
Review of systems:
(+) Per HPI
Currently denies abdominal pain, fevers, or lightheadedness.
.
Past Medical History:
PMH: CAD, COPD, HL, AAA, Gout
PSH: CABG x 3, Open AAA repair, Lap ventral hernia repair
Social History:
- Alcohol: 2 alcoholic beverages per night.
Family History:
NC
Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, diffusely tender, non-distended, no rebound or
guarding
GU: no foley
Ext: 2+ DP and Pt pulses on right, faint but dopplerable DP and
PT on left.
Pertinent Results:
Admission laboratories:
[**2161-5-12**] 01:50PM BLOOD WBC-10.0 RBC-3.82* Hgb-12.1* Hct-36.0*
MCV-94 MCH-31.6 MCHC-33.5 RDW-14.9 Plt Ct-189
[**2161-5-12**] 01:50PM BLOOD Neuts-77.2* Lymphs-17.2* Monos-4.5
Eos-0.8 Baso-0.3
[**2161-5-12**] 01:50PM BLOOD PT-14.1* PTT-30.5 INR(PT)-1.2*
[**2161-5-12**] 01:50PM BLOOD Glucose-120* UreaN-17 Creat-1.0 Na-141
K-4.6 Cl-111* HCO3-22 AnGap-13
[**2161-5-12**] 08:38PM BLOOD Calcium-8.0* Phos-3.0 Mg-1.7
-----------
MESSENTERIC ([**5-12**]): CTA abd from outside hospital showed extrav
into left colon coming off [**Female First Name (un) 899**] distribution. Our angio done [**5-12**]
showed no filling of [**Female First Name (un) 899**]. SMAgram showed collateral supply to
left colon (arc of Riolan) however no active extravasation.
Attempt made to get into this arc, however it was extremely
tortous and unable to advance catheter.
CXR ([**5-12**]): Some opacification at the base of the left lung could
be due to mild edema, but there is no appreciable pleural
effusion, cardiomegaly or any widening of the upper mediastinum
to suggest vascular engorgement. Moderate hiatus hernia is
present.
[**2161-5-15**] 12:35PM BLOOD Hct-33.3*
[**2161-5-16**] 07:57AM BLOOD WBC-8.9 RBC-3.57* Hgb-10.9* Hct-32.6*
MCV-91 MCH-30.6 MCHC-33.5 RDW-16.0* Plt Ct-179
[**2161-5-16**] 05:20PM BLOOD Hct-32.3*
[**2161-5-17**] 08:20AM BLOOD WBC-8.5 RBC-3.74* Hgb-11.5* Hct-34.9*
MCV-93 MCH-30.7 MCHC-32.8 RDW-15.8*
[**2161-5-17**] 01:55PM BLOOD Hct-32.9*
Discharge labs:
[**2161-5-17**] 01:55PM BLOOD Hct-32.9*
[**2161-5-17**] 08:20AM BLOOD WBC-8.5 RBC-3.74* Hgb-11.5* Hct-34.9*
MCV-93 MCH-30.7 MCHC-32.8 RDW-15.8*
[**2161-5-17**] 08:20AM BLOOD Glucose-138* UreaN-9 Creat-1.1 Na-140
K-3.9 Cl-106 HCO3-22 AnGap-16
.
Colonoscopy:
Diverticulosis of the sigmoid colon and descending colon
Blood at and below the splenic flexure
Polyps in the colon
Brief Hospital Course:
78M with pmh CAD s/p CABG, AAA repair, presenting with BRBPR,
and unsuccessful attempt at IR guided embolization.
.
#Acute blood loss anemia/Lower GI bleed: The patient was
admitted to the ICU after an unsuccessful attempt at IR guided
embolization due to previous AAA repair and lack of
visualization of the [**Female First Name (un) 899**]. His home aspirin and plavix were held.
The patient was noted to have melena. GI was consulted and
performed a colonoscopy which showed diverticuli with clots
without any active bleeding. With sedation and active bleeding,
the patient was transiently hypotensive and received a 750 cc
normal saline bolus and two packs of pRBCs. In total, the
patient received a total of 9 units of pRBCs and 1 unit of
platelets. The patient's diet was advanced to clears. He was
transfered out of the ICU and remained stable on the floor. His
last transfusion was on [**5-13**]. His Hct stabilized at discharge at
32.
.
#CAD s/p CBAG: Given the patient's significant life threatening
bleed, his Aspirin and Plavix were held in house and at
discharge. Patient was advised to follow-up with his
cardiologist and call his doctor the day after discharge
regarding management of his aspirin and plavix going forward.
.
#Code: full (confirmed in ICU)
Medications on Admission:
aspirin 81
plavix 75
simvastatin 20mg
allopurinol 100mg Po daily
Discharge Medications:
1. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
-Acute blood loss anemia/lower GI bleed
Secondary
-Coronary Artery Disease, s/p CABG
- Hypertension, benign
-Hyperlipidema
- history of CVA
Discharge Condition:
mentating well, ambulating independently
Discharge Instructions:
You were admitted to [**Hospital1 69**]
with bleeding from your rectum. While you were here you
required multiple blood transfusions and required a stay in the
intensive care unit. You had a colonoscopy and an interventional
radiology procedure which could not localize the sites of your
bleeding. The bleeding slowed and your blood levels normalized.
You should call your Cardiologist [**Last Name (LF) 766**], [**2161-5-18**] to
discuss re-starting your Aspirin and Plavix. You should also set
up an appointment with your cardiologist for follow-up.
While you were here, your home medications were changed.
You should CONTINUE taking:
simvastatin 80mg daily
allopurinol 100mg daily
You should STOP taking:
Plavix
Aspirin
- UNTIL you discuss this with your cardiologist and PCP. [**Name10 (NameIs) 357**]
call them the day after discharge
Followup Instructions:
It is very important that you see a primary care doctor. You
should see Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] within the next week. His
number is, ([**Telephone/Fax (1) 77725**]. If this is difficult, you should
call [**Hospital3 **] and make an appointment with the [**Hospital **]
Clinic by calling [**Telephone/Fax (1) 1300**].
You should also see Dr. [**First Name (STitle) **] within the next 2 weeks. His
contact information is:
Business Address: [**Apartment Address(1) 94470**]
[**Location (un) 3320**], [**Numeric Identifier 34852**]
Phone: ([**Telephone/Fax (1) 94471**]
|
[
"211.3",
"274.9",
"562.10",
"578.1",
"285.1",
"557.0",
"V45.81",
"272.4",
"496",
"414.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.49",
"45.23",
"88.42"
] |
icd9pcs
|
[
[
[]
]
] |
5912, 5918
|
4368, 5642
|
321, 334
|
6111, 6154
|
2476, 3955
|
7048, 7672
|
2008, 2012
|
5757, 5889
|
5939, 6090
|
5668, 5734
|
6178, 7025
|
3971, 4345
|
2027, 2457
|
1742, 1819
|
276, 283
|
362, 1723
|
1841, 1931
|
1947, 1992
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
14,445
| 178,729
|
14882
|
Discharge summary
|
report
|
Admission Date: [**2102-9-25**] Discharge Date: [**2102-10-4**]
Date of Birth: [**2048-1-14**] Sex: F
Service:
CHIEF COMPLAINT: Motor vehicle crash
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
female who was an unrestrained driver in a motor vehicle
crash going roughly 40 miles an hour head on into a tree.
There was a question of whether or not the patient had fell
asleep at the wheel. There was positive loss of
consciousness at the scene. It was assumed by EMS that the
patient did hit the windshield with her head because of the
damage to the car and the significant injuries to her
forehead. The extrication at the scene did last greater than
15 minutes, but the patient was hemodynamically stable. The
patient at the scene complained of chest pain, upper
abdominal pain and right leg/ankle pain.
PAST MEDICAL HISTORY: None
MEDICATIONS: None
PAST SURGERIES: None
ALLERGIES: None
INITIAL PHYSICAL:
VITAL SIGNS: T-max 100??????, pulse 94, blood pressure 102/49,
20, 97 on room air.
GENERAL: No acute distress.
HEAD, EARS, EYES, NOSE AND THROAT: Pupils equal, round and
reactive to light and accommodation. Tympanic membranes were
clear. GCS of 15 at the scene and on arrival to the
Emergency Department.
CARDIOVASCULAR: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally. No jugular venous
distention.
ABDOMEN: Soft, nontender, nondistended.
CHEST: Chest wall positive ecchymosis over the left chest.
EXTREMITIES: No peripheral edema, +2 DP and PT, positive
ecchymosis over the right leg and right arm. Positive
deformity to the right lower leg with tenderness and
decreased sensation. C-spine no tenderness. Back no
tenderness.
INITIAL LABS: Hematocrit of 31, chem-7 of 140/3.7, 108/19,
13/0.5, 157, amylase of 27, calcium 1.03, lactate of 2.8,
negative urinalysis.
RADIOLOGY: CT scan of the abdomen which showed a grade 4
liver laceration at the prominent pancreatic tail. Right
ankle showed a distal tibia fibula fracture which was status
post reduction at that time by orthopedics. The x-ray also
showed good alignment following the reduction. CT of the
lower limbs included the common medial malleolar and talar
neck fracture. Right tibia fibula films showed a distal
fibula and tibia fracture on the right and no fractures of
the right knee. CT of the C-spine was negative. CT of the
head was also negative. Chest x-ray and pelvis negative.
The major injuries to the patient included a right distal
tibia fibula fracture and a grade 4 liver laceration.
HOSPITAL COURSE: The patient was admitted to the Trauma
Intensive Care Unit on the [**1-25**] and was followed
with serial hematocrits due to the grade 4 liver laceration.
The patient also had a significant laceration to the forehead
which ran superior to inferior over the right eye. Plastic
surgery was consulted and the wound washed with copious
amounts of normal saline prior to a primary closure. The
incision was roughly 7 to 8 cm long and there was also a
second smaller 2 cm laceration at the temporal area. The
patient's Intensive Care Unit stay was fairly uneventful, but
she did receive 2 units of packed red blood cells for a
hematocrit that slowly dropped from 33 to 26. After the 2
units of packed red blood cells, the patient's hematocrit
bumped appropriately and remained stable. Orthopedics
recommendations were to have the leg fixed with open
reduction internal fixation after the patient was stabilized
(1 to 2 weeks). After the patient was deemed to be
clinically stable with stable hematocrit, the patient was
transferred to the floor. The patient continued to have an
uneventful stay interrupt the hospital.
Physical therapy and occupational therapy saw the patient and
helped with ambulation. The patient had a fair deal of
difficulty with movements and it was decided at that time the
patient would be discharged to rehabilitation services prior
to her [**Month (only) **] surgery. During her stay on the floor, the
patient's liver function tests bumped on the 15th to an ALT
of 333, AST of 79 and alkaline phosphatase of 195, total
bilirubin of 7.1 and direct bilirubin of 3.8. Over the 16th
and 17th, the patient's ALT decreased to 278, but AST
increased to 90 and alkaline phosphatase was at 268. Total
bilirubin and direct bilirubin continued to 4.8 and 2.2. On
the 18th, it was decided the patient could be discharged to
rehabilitation services in stable condition.
DISCHARGE PHYSICAL:
VITAL SIGNS: T-max 98.4??????, 84, 106/72, 16, 98 on room air, in
1000, out 1600.
GENERAL: Alert and oriented.
HEAD, EARS, EYES, NOSE AND THROAT: Dressing on forehead was
intact. Clean, dry and intact suture line.
CARDIOVASCULAR: Regular rate and rhythm.
RESPIRATORY: Clear to auscultation bilaterally.
ABDOMEN: Soft, nontender, positive bowel sounds.
EXTREMITIES: Right lower extremity splint.
LABS: Liver function tests from the 17th: ALT 278, AST 90,
alkaline phosphatase 268, total bilirubin 4.8, direct
bilirubin 2.2.
DISCHARGE DIAGNOSES:
1. Status post motor vehicle crash, unrestrained drive with
polytrauma
2. Distal tibia fibula fracture requiring open reduction
internal fixation on the [**2-8**]. Grade 4 liver laceration
4. Forehead laceration
DISCHARGE MEDICATIONS:
1. Protonix 40 mg po q 24 hours
2. Percocet 5/325 1 to 2 tablets po q 4 to 6 hours prn
3. Tylenol 650 mg po q 4 to 6 hours prn
TREATMENTS: The patient will require Venodynes at all times
when in bed. The patient will also require physical therapy
and occupational therapy designed appropriately by the
rehabilitation services. The patient will continue on a
regular diet. The patient will be non weight bearing in the
right lower extremity and should have physical therapy to
reflect the restricted activities. The patient will be
scheduled for the open reduction internal fixation of the
right tibia fibula fracture on the 23rd by [**Hospital1 **] [**Hospital1 **] Department. The patient should have her
liver function tests checked on the 19th and also 21st to
continue to trend the grade 4 liver laceration.
DISCHARGE CONDITION: Good and stable to rehabilitation
services.
FOLLOW UP: The patient will follow up with Dr. [**Last Name (STitle) **] in
the trauma clinic, phone number ([**Telephone/Fax (1) 24484**]. The patient
will also need to be transported back to [**Hospital1 **] either on Sunday or Monday, the 22nd or 23rd for
the open reduction internal fixation of the right tibia
fibula. The patient will be admitted to the [**Hospital1 **]
service at that time. The attending in orthopedics will be
Dr. [**Last Name (STitle) **] at the [**First Name (Titles) **] [**Last Name (Titles) **]
Department.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**]
Dictated By:[**Last Name (NamePattern4) 959**]
MEDQUIST36
D: [**2102-10-4**] 15:29
T: [**2102-10-4**] 15:35
JOB#: [**Job Number **]
|
[
"780.09",
"873.42",
"824.0",
"825.21",
"E816.0",
"355.5",
"285.1",
"864.04"
] |
icd9cm
|
[
[
[]
]
] |
[
"86.59",
"79.07",
"79.06",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
6125, 6170
|
5040, 5257
|
5280, 6103
|
2572, 5019
|
6182, 6982
|
149, 170
|
199, 844
|
867, 2554
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,408
| 186,967
|
5479
|
Discharge summary
|
report
|
Admission Date: [**2160-5-22**] Discharge Date: [**2160-5-27**]
Date of Birth: [**2122-8-27**] Sex: M
Service:
CHIEF COMPLAINT: Melena, bright red blood per rectum (as per
the admitting senior resident).
HISTORY OF PRESENT ILLNESS: This is a 37-year-old male with
a past medical history significant for extensive ethanol
abuse complicated by chronic alcohol induced pancreatitis for
the last eight years, status post endoscopic retrograde
cholangiopancreatography and stent in [**2155**]. Past medical
history also significant for portal and splenic varices, as
well as questionable esophageal varices, as well as
gastroesophageal reflux disease, who was transferred from
[**Hospital 1562**] Hospital for evaluation of a gastrointestinal bleed.
The patient drank heavily on Monday prior to admission. The
patient states that he had one pint of [**Location (un) 22148**] [**Doctor Last Name **] and
subsequently had worsening abdominal pain from a baseline of
[**2168-4-16**] for which the patient took MS Contin, as well as
ibuprofen. The patient states he has been taking more
ibuprofen than usual recently. The patient has had chronic
episodes of melena and bright red blood per rectum, however,
on the afternoon of admission, the patient felt that he was
feeling increasingly weak, presyncopal and did not recall if
he actually passed out or fell asleep.
The patient denies nausea, vomiting, chest pain. He does not
increasing shortness of breath and weakness. The patient has
had decreased po intake over the last several days also. The
patient's wife took him initially to [**Name (NI) 1562**] Hospital where
he was given octreotide drip and started on a Protonix drip.
The patient's gastrointestinal attending physician, [**Last Name (NamePattern4) **].
[**First Name (STitle) 2405**], was contact[**Name (NI) **] and the patient was sent to [**Hospital6 1760**].
At [**Hospital 1562**] Hospital, the patient's blood pressure was 80/60.
Heart rate 150. The patient received 2.5 liters of
intravenous fluids prior to arriving in the Emergency Room.
The patient's vital signs at [**Hospital6 2018**] Emergency Room were temperature of 97.8. Blood
pressure 112/74. Heart rate 89. Respiratory rate 18, 02
saturation 100% on room air. The patient was typed and
crossed for a total of four units packed red blood cells.
The patient was initially continued on the octreotide drip.
Nasogastric lavage was performed which showed a scant coffee
ground. No active bleeding. Subsequently, the patient was
transferred to the Medical Intensive Care Unit for further
management.
PAST MEDICAL HISTORY:
1. Chronic alcohol induced pancreatitis for the last eight
years, status post endoscopic retrograde
cholangiopancreatography and stent in [**2155**].
2. Portal and splenic vein varices, as well as questionable
esophageal varices. Patient is status post multiple
esophagogastroduodenoscopies at outside hospital in [**Hospital3 **]
as well as [**Hospital1 1562**].
3. Depression.
4. Chronic alcohol abuse.
5. History of seizures, DTs, as well as blackouts. Patient
has had numerous admissions for detoxification.
6. Gastroesophageal reflux disease.
7. History of one suicide attempt.
8. History of deep vein thrombosis in [**2142**] and [**2156**], status
post Coumadin and status post IVC filter.
MEDICATIONS ON ADMISSION:
1. Advair.
2. MS Contin.
3. Tavist D b.i.d.
4. Albuterol.
5. Nexium.
6. Singulair.
7. Uniphyl.
8. Ibuprofen prn.
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient is married. He is on
disability. He denies intravenous drug use. He smokes
tobacco, one to two packs a day. Chronic alcohol abuse,
drinking only Mondays once a month now. Patient lives in
[**Location **] on [**Hospital3 **].
PHYSICAL EXAM ON ADMISSION: In general, the patient was
awake, alert and oriented times three in no apparent
distress. Vital signs: Temperature was 98.8. Heart rate
was 84. Blood pressure 107/57. Respiratory rate was 19. 02
saturation 99% on room air. Head, eyes, ears, nose and
throat: Pupils equal, round and reactive to light.
Extraocular movements intact. Oropharynx was dry. Neck was
supple. No lymphadenopathy. No jugular venous distention
was appreciated. Chest was clear to auscultation
bilaterally. No wheezes or crackles were appreciated. Heart
was regular rate and rhythm, S1, S2 were normal. No murmurs,
rubs or gallops were appreciated. Abdomen was thin. There
was epigastric as well as left upper quadrant tenderness as
well as positive bowel sounds. No hepatosplenomegaly was
appreciated. There was no caput medusa, no spider angiomas.
There was no evidence of fluid wave. Extremity exam showed
no cyanosis, clubbing or edema. No palmar erythema.
Neurologically, the patient was moving all four extremities.
Cranial nerves II through XII are intact. There was no
evidence of nystagmus.
LABORATORY VALUES ON ADMISSION: White blood cell count 5.6,
hematocrit 19.7, platelets 175,000. Differential on the
white blood cell count was 59% neutrophils, 35% lymphocytes,
4.5% monocytes. Sodium was 140, potassium 4.1, chloride 112,
bicarbonate 19, BUN 31, creatinine 0.5, blood sugar 19, anion
gap was 9, ALT was 13, AST was 11, amylase was 26, lipase was
46. Urinalysis showed specific gravity of 1.015, negative
bilirubin, negative nitrate, negative leukocyte esterase, no
bacteria, less than 1 white blood cell, 0 red blood cells.
Patient's red blood cells antibody screen was positive. BAT
was negative. [**Name (NI) **] PT was 13.0, PTT 27.1, INR 1.1.
HOSPITAL COURSE:
1. Gastrointestinal: The patient was admitted to the
Intensive Care Unit initially for further management of
probable upper gastrointestinal bleed in the context of
extensive ethanol abuse. Patient was made NPO. Initially,
the octreotide drip was continued, however, subsequently, on
day two of admission, it was discontinued. Patient was
continued on Protonix. On day two of admission, the patient
had an esophagogastroduodenoscopy performed.
Esophagogastroduodenoscopy showed Grade 1 varices with
worsening in the lower third of the esophagus, nonbleeding.
Stomach showed abnormal mucosa noted in the stomach.
Findings compatible with portal gastropathy. There was
nonbleeding varices noted in the cardia and the fundus of the
stomach. Duodenum is normal.
Given these findings on esophagogastroduodenoscopy, the
Gastrointestinal Consult Team recommended to discontinue the
octreotide and continue with the Protonix, as well as
continue with propanolol, as well as to have an abdominal
ultrasound done. The abdominal ultrasound showed varices, as
well as the splenic vein could not be followed in its
entirety. The thrombosplenic vein posterior to the
pancreatic tissue could not be excluded. No secondary signs
of portal hypertension, normal direction of flow within
portal vasculature. Simple right renal cyst, as well as the
tip of the central venous line in the IVC. After this
finding, the tip of the central venous line was pulled back
approximately 11-12 cm and was found to be appropriately in
place in the left subclavian vein.
Subsequently, the patient was transferred to the Medical
Floor for further management. While the patient was on the
medical floor, the patient finally received four units of
packed red blood cells at which time the patient's hematocrit
improved from 19 to approximately 28-29. Patient was advised
to discontinue any NSAIDs for pain control. The Psychiatry
Service was consulted. At the advice of Gastrointestinal,
patient was prepped for a colonoscopy to evaluate for a lower
source for the gastrointestinal bleed. Patient had a
colonoscopy on the day of discharge which was, as per the
fellow, was eventually negative for any acute bleeding.
There were multiple diverticulosis, but no active bleeding.
No biopsies were done of the mucosa.
Given the findings on the ultrasound of possible splenic vein
thrombosis, a CT of the abdomen was done to further evaluate
this finding. CT of the abdomen showed punctate areas of
calcification throughout the pancreas consistent with chronic
pancreatitis. There was no nephrolithiasis. There was a
infrarenal IVC filter in correct position. There was
vascular calcifications throughout the aorta suggesting early
atherosclerotic disease. There was linear opacities at the
lung bases, suggesting scarring and bibasilar atelectasis.
There was no pleural effusions, no pericardial effusions, no
enhancing lesions were found in the liver. There was no
intraductal dilatation. Gallbladder was unremarkable.
Pancreas was heterogenous with some areas of low intensity,
suggesting cystic changes, smaller than 3 mm. Spleen was
measured at 13 cm. Splenic vein was not identified.
Multiple variceal vessels were identified in the short
gastric, as well as a splenorenal shunt. Portal vein at the
level of the confluence was patent. Symmetric excretion of
contrast. There was simple cysts in the right kidney.
Diffuse diverticular disease at the rectosigmoid. Small
amount of fluid in the pelvis. Bowel wall was unremarkable.
Small amounts of lymphadenopathy within the mesentery.
Bladder was intact with no intraluminal filling defects.
There was prostatic calcifications identified. The osseous
and extra abdominal soft tissues were unremarkable.
Patient's hematocrit remained stable throughout the whole
hospital course. After the four units of packed red blood
cells, patient's hematocrit remained at 28-29. Patient had
no further episodes of gastrointestinal bleeding. The
patient symptomatically felt much better after receiving the
four units of packed red blood cells. Psychiatry was
initially consulted to help manage with the alcohol
detoxification. They recommended discontinuing the CIWA
scale and only giving Ativan prn. They did not recommended
any antidepressants or any psychiatric medications at this
time. Given the patient's recent history of a
gastrointestinal bleed, it was felt that there was no reason
to anticoagulate the patient at this point given the history
of the patient's splenic vein thrombosis.
DISCHARGE STATUS: To home.
DISCHARGE DIAGNOSES:
1. Chronic pancreatitis.
2. Splenic vein thrombosis.
3. Gastrointestinal bleed.
4. Gastroesophageal reflux disease.
5. Asthma.
6. Chronic alcohol abuse.
7. History of suicide attempt.
8. History of deep vein thrombosis.
9. Depression.
10. Status post endoscopic retrograde
cholangiopancreatography and stent in [**2155**].
DISCHARGE MEDICATIONS:
1. Albuterol MDI 2 puffs q. [**3-15**] prn.
2. Propanolol 20 mg po b.i.d.
3. Protonix 40 mg po b.i.d.
4. Flovent 220 mcg b.i.d.
5. Singulair 10 mg po q.h.s.
6. Multivitamin 1 tablet po q.d.
7. Thiamine 100 mg po q.d.
8. Folate 1 mg po q.d.
9. Patient was instructed to resume his usual MS Contin that
he takes as an outpatient.
10. Patient was also advised to discontinue the ibuprofen.
DISCHARGE FOLLOW-UP: The patient will follow-up with his
primary care doctor within one week after discharge. The
patient's primary care doctor [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 22149**].
[**First Name11 (Name Pattern1) 4514**] [**Last Name (NamePattern4) 8867**], M.D. [**MD Number(1) 8868**]
Dictated By:[**Name8 (MD) 9784**]
MEDQUIST36
D: [**2160-5-30**] 12:18
T: [**2160-5-30**] 12:18
JOB#: [**Job Number 22150**]
|
[
"303.90",
"577.1",
"578.9",
"263.9",
"572.3",
"456.1",
"456.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"45.23"
] |
icd9pcs
|
[
[
[]
]
] |
10184, 10517
|
10540, 11459
|
3361, 3521
|
5595, 10163
|
145, 222
|
251, 2606
|
4940, 5577
|
2628, 3335
|
3538, 3795
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
47,014
| 139,521
|
31435
|
Discharge summary
|
report
|
Admission Date: [**2196-10-20**] Discharge Date: [**2196-10-24**]
Date of Birth: [**2114-5-19**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Valium / Morphine / Penicillins / Ace Inhibitors
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath/Chest pain
Major Surgical or Invasive Procedure:
[**2196-10-20**] - CABGx1 (Saphenous vein graft->Obtuse marginal artery)
History of Present Illness:
82 year old who presented to [**Hospital3 **] Hospital with SOB
on [**2196-9-25**]. He was found to be in CHF with a troponin leak of
0.1. Transferred to [**Hospital1 18**] in [**Month (only) **] where a cardiac cath
revealed complicated single vessel disease. He was thus referred
for surgical revascularization.
Past Medical History:
Diabetes type II
Hyperlipidemia
Ischemic cardiomyopathy EF 45% secondary to old inferior MI
Advanced COPD/Asthma
BPH
Shoulder surgery
h/o DVT
GERD
DJD s/p L hip replacement
s/p C1 laminectomy and suboccipital craniectomy
s/p colostomy and colectomy for colon cancer in [**2178**]
h/o benign tumor at base of spine -removed
Social History:
Patient is widowed. Lives alone in [**Location (un) 38**]. Non smoker since
[**2163**], no etoh. Former heavy smoker. Two daughters who are
actively involved in his care.
Family History:
Non-contributory
Physical Exam:
Admission
VS - BP 144/44 (122-140)/(44-86) HR 86-90 RR 20 O2 99%
Gen: WDWN elderly male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Neck: Supple with no evidence of JVD.
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. Diffuse wheezes
throughout bilaterally.
Abd: Soft, NTND. No HSM or tenderness.
Ext: Warm, well perfused. 3+ pitting edema. Cath site: c/d/i. No
hematoma. No bruits. Good femoral and distal pulses.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge
VS T 98 BP 104/60 HR 63SR RR 18 O2sat 96%-RA
Gen NAD
Neuro A&Ox3, MAE, nonfocal exam
CV RRR, no M/R/G. Sternum stable, incision CDI
Pulm clear but diminished in bases bilat
Abdm soft, NT/ND/+BS
Ext warm, trace pedal edema bilat
Pertinent Results:
[**2196-10-20**] 12:18PM GLUCOSE-90 NA+-134* K+-3.8
[**2196-10-20**] 12:12PM UREA N-32* CREAT-1.1 CHLORIDE-102 TOTAL
CO2-28
[**2196-10-20**] 12:12PM WBC-4.4# RBC-2.72* HGB-9.2* HCT-25.0* MCV-92
MCH-33.9* MCHC-36.9* RDW-13.7
[**2196-10-20**] 12:12PM PLT COUNT-257
[**2196-10-20**] 12:12PM PT-13.8* PTT-37.9* INR(PT)-1.2*
[**2196-10-23**] 07:10AM BLOOD WBC-6.2 RBC-3.00* Hgb-10.0* Hct-27.6*
MCV-92 MCH-33.4* MCHC-36.3* RDW-13.7 Plt Ct-226
[**2196-10-24**] 05:30AM BLOOD PT-12.4 INR(PT)-1.0
[**2196-10-23**] 07:10AM BLOOD Plt Ct-226
[**2196-10-23**] 07:10AM BLOOD Glucose-159* UreaN-22* Creat-1.1 Na-131*
K-4.1 Cl-97 HCO3-27 AnGap-11
[**2196-10-20**] ECHO
Pre Bypass:
The left atrium and right atrium are normal in cavity size.
There is moderate to severe global left ventricular hypokinesis.
Overall left ventricular systolic function is severely depressed
(LVEF=20 %). Right ventricular chamber size is normal. with
borderline normal free wall function. The ascending aorta is
mildly dilated. There are simple atheroma in the ascending and
descending aorta. There are three aortic valve leaflets. The
aortic valve leaflets (3) are mildly 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 ventricular function is improved. The EF is now around 30%.
The motion of the lateral and anterolateral walls is improved.
Mild MR and mild AI remain. The calculated aortic valve area is
similar. The aorta is intact.
[**Known lastname 74027**],[**Known firstname **] [**Medical Record Number 74028**] M 82 [**2114-5-19**]
Radiology Report CHEST (PA & LAT) Study Date of [**2196-10-23**] 3:18 PM
[**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] FA6A [**2196-10-23**] SCHED
CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 74029**]
Reason: f/u [**Hospital 74030**]
[**Hospital 93**] MEDICAL CONDITION:
82 year old man with s/p cabg
Final Report
STUDY: PA and lateral chest [**2196-10-23**].
HISTORY: 82-year-old man status post CABG.
FINDINGS: The cardiac silhouette is enlarged but stable. There
has been
removal of the right IJ central venous catheter. Median
sternotomy wires are seen. There are no pneumothoraces. There is
no focal consolidation or
pulmonary edema. Small bilateral pleural effusions are seen best
on the
lateral view.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]
Approved: SUN [**2196-10-23**] 7:44 PM
Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2196-10-20**] for elective
surgical management of his coronary artery disease. He was taken
directly to the operating room where he underwent coronary
artery bypass grafting to one vessel (SVG-OM). Please see OR
report for details. He tolerated the operation well and
postoperatively he was taken to the intenisve care unit. Within
24 hours he had awoke neurologically intact and was extubated.
On POD 1 he was transferred to the step down floor for
continuing post-operative management. His heart failure regime
was reinstituted, as was his diabetes medications with the
addition of sliding scale insulin. On the floor he had an
uneventful post-operative course with the exception of
intermittent atrial fibrillation for which anticoagulation was
started.
On POD 4 it was decided he was ready for discharge to
rehabilitation at [**Location (un) 511**] Snai in [**Location (un) 701**].
Medications on Admission:
Theophylline 300'', Singulair 10', Advair 500", Metformin 500",
ASA 160', Flomax 0.4', Proscar 5', Protonix 40', Glyburide 2.5',
Simvastatin 20', Fosamax 70 q week, MVI', Januvia 100'.
Allergies: Codeine/Valium/Morphine/oxycodone-N&V, PCN-rash,
ACE-^K+, Vicryl sutures, Mycins-rash.
Discharge Medications:
1. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO Q12H
(every 12 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
6. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**1-6**]
Tablets PO every 4-6 hours as needed.
7. Insulin Lispro 100 unit/mL Solution Sig: sliding scale
Subcutaneous QAC&HS.
8. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
10. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Theophylline 100 mg Tablet Sustained Release 12 hr Sig:
Three (3) Tablet Sustained Release 12 hr PO BID (2 times a day).
12. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
13. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Puff Inhalation [**Hospital1 **] (2 times a day).
15. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
16. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
17. Amiodarone 200 mg Tablet Sig: as directed below Tablet PO
BID (2 times a day): 400mg [**Hospital1 **] x5 days then 400mg QD x1 wk then
200mg QD.
18. Warfarin 1 mg Tablet Sig: as directed Tablet PO Once Daily
at 4 PM: target INR 2.0 Patient to receive 5mg Coumadin on
[**10-24**].
19. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for
1 doses: [**10-24**] dose.
20. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
CAD s/p CABGx1(Saphenous vein graft->Obtuse marginal artery)
HTN
Colon Cancer
Diabetes
Asthma
BPH
DVT
GERD
CKD
Ischemic cardiomyopathy
Chronicsystolic HF LVEF 30%
Discharge Condition:
Stable
Discharge Instructions:
1) Monitor wounds for signs of infection. These include
redness, drainage or increased pain. In the event that you have
drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at
([**Telephone/Fax (1) 1504**].
2) Report any fever greater then 100.5.
3) Report any weight gain of 2 pounds in 24 hours or 5 pounds
in 1 week.
4) No lotions, creams or powders to incision until it has
healed. You may shower and wash incision. Gently pat the wound
dry. Please shower daily. No bathing or swimming for 1 month.
Use sunscreen on incision if exposed to sun.
5) No lifting greater then 10 pounds for 10 weeks.
6) No driving for 1 month or while taking narcotics for pain.
7) Call with any questions or concerns.
Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month.
Please follow-up with Dr. [**Last Name (STitle) 10543**] 2 weeks after released from
rehab.
Completed by:[**2196-10-24**]
|
[
"493.20",
"250.00",
"530.81",
"427.31",
"272.4",
"V44.3",
"414.01",
"V10.05",
"403.10",
"414.8",
"585.9",
"428.42",
"428.0",
"V43.64",
"600.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.11",
"39.61"
] |
icd9pcs
|
[
[
[]
]
] |
8251, 8323
|
5090, 6049
|
357, 432
|
8530, 8539
|
2405, 4447
|
9316, 9507
|
1327, 1345
|
6385, 8228
|
4484, 5067
|
8344, 8509
|
6075, 6362
|
8563, 9293
|
1360, 2386
|
287, 319
|
460, 775
|
797, 1122
|
1138, 1311
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,039
| 104,767
|
5570+5571
|
Discharge summary
|
report+report
|
Admission Date: [**2198-3-11**] Discharge Date: [**2198-3-15**]
Date of Birth: [**2143-8-20**] Sex: M
Service: Medicine
CHIEF COMPLAINT: Increasing uremia.
HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old
male with a history of insulin-dependent diabetes mellitus
times 40 years with a progressively worsening course of renal
failure. He has been followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for his
renal failure caused by diabetic nephropathy. Over the last
few weeks, he has had increased nausea, anorexia, fatigue,
and weakness and noted by his wife to have slow mentation.
He is status post AV fistula placement in his left arm, and
since then has developed an infection and increasing pain in
the left fourth digit distally. He has also had an
increasing number of falls over the last few weeks and wears
bilateral leg braces for neuropathy. He has multiple small
foot ulcers.
REVIEW OF SYSTEMS: Review of systems is negative for recent
fevers, chills, abdominal pain, diarrhea, melena or bright
red blood per rectum.
PAST MEDICAL HISTORY:
1. Anemia with a baseline hematocrit of 26 to 30.
2. Insulin-dependent diabetes mellitus times 40 years
complicated by neuropathy and retinopathy.
3. Gastroparesis.
4. Status post toe amputation times two on his right foot.
5. Nephropathy.
6. He has had multiple emergency department visits for
hypoglycemia.
7. He has also had hypertension times two years.
8. Status post left AV fistula by Dr. [**Last Name (STitle) **] on [**2197-11-3**].
MEDICATIONS ON ADMISSION: Epogen, insulin regular 5 units
and NPH 15 units q.a.m., Lasix 120 mg p.o. q.a.m. and 80 mg
p.o. q.p.m., Lopressor 50 mg p.o. b.i.d., Phos-Lo 4 tablets
p.o. q.i.d., Norvasc 5 mg p.o. b.i.d., amitriptyline 10 mg
p.o. q.h.s., Zoloft 100 mg p.o. q.d., Rocaltrol 0.5 mcg.
ALLERGIES: VANCOMYCIN causes fever. STRAWBERRIES and SHELL
FISH.
SOCIAL HISTORY: Retired, lives with his wife. Use to work
in sales management. Positive 35-pack-year history of
tobacco. No IV drug use. Now smokes approximately one
cigarette per day. Denies alcohol use.
PHYSICAL EXAMINATION: Vital signs were pulse of 72, blood
pressure 187/89, weight 72.9 kg. In general, he was a thin
54-year-old male in hemodialysis, sleepy but appropriate.
HEENT revealed normocephalic/atraumatic. Pupils were equal,
round and reactive to light. Extraocular movements were
intact. Oropharynx was moist. Cardiovascular had a regular
rate and rhythm, normal S1 and S2. A 2/6 systolic ejection
murmur. Chest was clear to auscultation bilaterally.
Abdomen was soft, nontender, and nondistended, positive bowel
sounds. Extremities revealed no edema. Fourth left digit
tip was dry and gangrenous. Light touch sensation was
intact. Neurologic examination revealed alert and oriented
times three, nonfocal, positive asterixis.
LABORATORY/STUDIES: On [**2198-2-8**], arterial study of
left upper extremity showed diminished flow to the digital
level of the left hand. Significant stenosis of the left arm
AV fistula at the AV anastomosis. No stenosis within the
arterial or venous inflow or outflow tract.
White blood cell count 10.1, hematocrit 25.5, platelets 300.
Sodium 136, potassium 5.3, chloride 98, bicarbonate 19,
BUN 147, creatinine 10.3, glucose 378. ALT 13, AST 13,
LDH 286, alkaline phosphatase 146. Calcium 8.9,
phosphate 5.6.
HOSPITAL COURSE: The patient was admitted to the general
medical service for initiation of hemodialysis for his
increasing uremic symptoms. He was also seen by Dr. [**Last Name (STitle) **],
his transplant surgeon, for evaluation of his AV fistula and
the distal gangrene in his distal left fourth digit. He
appeared to be having a steal syndrome secondary to his AV
fistula. Dr. [**Last Name (STitle) **] recommended ligation of the fistula and
for follow up with hand surgery for a possible amputation of
his finger. The patient was discharged the day after
admission after initiating hemodialysis without
complications. At the time of discharge, he was still
anorexic and fatigued and still somewhat lethargic.
MEDICATIONS ON DISCHARGE:
1. Epogen and Rocaltrol and hemodialysis.
2. Insulin 6 units regular and 15 units NPH q.a.m.
3. Lopressor 50 mg p.o. b.i.d.
4. Norvasc 5 mg p.o. b.i.d.
5. Phos-Lo 4 tablets p.o. t.i.d. with meals.
6. Amitriptyline 10 mg p.o. q.6h.
7. Zoloft 100 mg p.o. q.d.
His Lasix was discontinued. His volume will be taken off in
hemodialysis.
DISCHARGE DIAGNOSES:
1. End-stage renal disease secondary to diabetic neuropathy.
2. Uremia.
FOLLOW-UP PLAN: The patient will follow up with Dr. [**Last Name (STitle) **]
within one week for possible ligation of his fistula and with
hand surgery for evaluation for finger amputation. He will
also follow up with his nephrologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
CONDITION AT DISCHARGE: Stable.
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15463**], M.D. [**MD Number(1) 15464**]
Dictated By:[**Name8 (MD) 22404**]
MEDQUIST36
D: [**2198-3-18**] 20:39
T: [**2198-3-19**] 11:57
JOB#: [**Job Number 22405**]
Admission Date: [**2198-3-11**] Discharge Date: [**2198-3-15**]
Date of Birth: [**2143-8-20**] Sex: M
Service: General Medicine
HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 10653**] is a 54-year-old,
white male with a history of Type I diabetes times 40 years
with end-stage renal disease, peripheral vascular disease,
and hypertension. He is status post recent initiation of
hemodialysis in [**2198-2-15**]. He presented with fevers,
lethargy, and a blood sugar of 629. The patient initiated
hemodialysis approximately one week prior to admission and
had noticed gradually higher blood sugars despite an
increased insulin dose. Five days prior to admission, Mr.
[**Known lastname 10653**] developed fevers and chills as well as sore throat
and cough. He was subsequently placed on Augmentin which
lead to some nausea, vomiting, and diarrhea. This antibiotic
was changed after approximately two days to Levaquin, but the
patient's symptoms of vomiting persisted through this
antibiotic. The patient subsequently reported to the
Emergency Department with fevers and increased blood sugar.
In the Emergency Department, the patient was found to have a
blood sugar of 629 with an anion gap and was felt to be in
diabetic ketoacidosis. Aggressive hydration was started as
well as IV insulin. The patient was admitted to the Medical
Intensive Care Unit for monitoring and initiation of an
insulin drip.
PAST MEDICAL HISTORY: Type I diabetes times 40 years
complicated by retinopathy, neuropathy, and nephropathy;
end-stage renal disease secondary to diabetic nephropathy,
now on hemodialysis; peripheral vascular disease;
hypertension; Bell's palsy; status post left arm AV fistula
placement with complication of distal necrosis which was
subsequently reversed in [**2198-2-15**]; and status post
right first and second toe amputation.
ALLERGIES: Vancomycin and NSAIDs
SOCIAL HISTORY: The patient smoked a pack a day for
approximately 40 years. He denies any history of alcohol or
IV drug abuse.
FAMILY HISTORY: Family history is positive for a mother with
diabetes.
PHYSICAL EXAMINATION: Physical examination on transfer to
the Medicine Floor revealed a temperature of 98.1, heart rate
of 68, respiratory rate of 16, and blood pressure of 126/62.
O2 saturation was 96% on room air. In general, the patient
was a thin, white male resting comfortably in bed in no acute
distress. HEENT: Extraocular motions were full. Pupils
were equal, round, and reactive to light and accommodation.
Sclerae were nonicteric. The oropharynx was moist. There
was no appreciable lymphadenopathy or jugular venous
distention. Carotid pulses were 2+ bilaterally with no
bruits. Heart had a regular rate and rhythm with a II/VI
holosystolic murmur at the left sternal border with radiation
to the apex. There was a dialysis catheter in place in the
right subclavian artery. Lung exam showed bibasilar
crackles. Abdomen was soft, nontender, and nondistended with
positive bowel sounds. Extremities showed no evidence of
cyanosis, clubbing, or edema. There was a small 2 x 3 cm
ulceration on the left heel with no evidence of necrosis. On
neurologic exam, the patient was awake, alert, and oriented
times three. Light touch sensation was mildly decreased in
the lower extremities bilaterally.
LABORATORY STUDIES: On transfer to the Medicine Floor,
hematocrit was 26.3. Sodium was 146, potassium was 4.0,
chloride was 102, bicarbonate was 21, BUN was 62, creatinine
was 5.2, glucose was 99, and calcium was 8.5. Phosphate was
3.0. Blood cultures times four showed no growth to date.
HOSPITAL COURSE: The patient was initially admitted to the
Medical Intensive Care Unit where an insulin drip was started
along with moderate hydration. The patient was hydrated
somewhat gingerly given concerns due to dependence on
hemodialysis. However, with the initiation of the IV fluids
and insulin drip, his blood sugars gradually improved over
the next 24 hours. The anion gap was also seen to close..
An infectious workup was performed with a urinalysis, blood
cultures, and a chest X-ray, but no clear etiology emerged.
The patient was having symptoms of a mildly increased
productive cough, and Mr. [**Known lastname 10653**] was empirically started
on Levaquin. The patient had been complaining of some right
upper quadrant pain two days prior to admission, and a right
upper quadrant ultrasound was performed which showed a stone
in the common duct, but no signs or symptoms of cholecystitis
or cholangitis.
The patient was gradually transitioned off the insulin drip,
and IV fluids were discontinued. When Mr. [**Known lastname 10653**] showed
stable blood sugars on an NPH regimen, he was thought to be
stable to be transferred to the General Medicine Floor. Upon
transfer to the floor, the patient was hemodynamically
stable. He was continued on NPH insulin at 20 units, subcu,
q a.m. and 10 units, subcu, q p.m. Blood sugars were
initially low, felt due to some poor PO intake from symptoms
of the patient's diabetic gastroparesis. The patient was
observed for an initial 24 hours on the floor with initiation
of Reglan as well. Over the next 24 hours, the patient's PO
intake gradually improved, and his blood sugars remained
stable.
At this time, it was felt that Mr. [**Known lastname 10653**] was stable to be
discharged home on his current NPH regimen. He will have
close follow up with the [**Doctor First Name 8392**] Diabetes Center for further
management. He will also continue his hemodialysis as
scheduled.
During the admission, Mr. [**Known lastname 10653**] was also seen by the
Vascular Surgery Service for evaluation of a heel ulcer. It
was their opinion that this was only a superficial ulceration
and recommended simple dry dressings to the heel, changed
daily.
DISCHARGE CONDITION: Stable
DISCHARGE STATUS: Home
DISCHARGE MEDICATIONS:
1. Phoslo, four tabs, PO, q a.c.
2. Norvasc 5 mg, PO, b.i.d.
3. Zoloft 10 mg, PO, q day
4. Amitriptyline 10 mg, PO, q h.s.
5. NPH insulin, 20 units, subcu, q a.m., and 10 units,
subcu, q p.m.
6. Lisinopril 20 mg, PO, q day
7. Reglan 10 mg, PO, b.i.d.
8. Kerington wound gel to heel, b.i.d.
9. Lopressor 100 mg, PO, b.i.d.
10. Levaquin 250 mg, PO, q.o.d., times six more days
DISCHARGE DIAGNOSES:
1. Type I diabetes
2. End-stage renal disease (on hemodialysis)
3. Peripheral vascular disease
4. Diabetic ketoacidosis
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15463**], M.D. [**MD Number(1) 15464**]
Dictated By:[**Name8 (MD) 22406**]
MEDQUIST36
D: [**2198-3-20**] 02:34
T: [**2198-3-20**] 10:06
JOB#: [**Job Number 22407**]
|
[
"250.53",
"585",
"351.0",
"250.13",
"250.63",
"707.15",
"357.2",
"362.01",
"250.43"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.95"
] |
icd9pcs
|
[
[
[]
]
] |
11065, 11098
|
7261, 7317
|
11528, 11920
|
11121, 11507
|
4164, 4506
|
1596, 1935
|
8848, 11043
|
7340, 8830
|
4938, 5359
|
973, 1096
|
155, 175
|
5388, 6644
|
6667, 7114
|
7131, 7244
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,493
| 170,699
|
12936
|
Discharge summary
|
report
|
Admission Date: [**2140-6-3**] Discharge Date: [**2140-7-4**]
Date of Birth: [**2098-9-9**] Sex: F
Service: SURGERY
Allergies:
Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
[**6-3**]: ileocecectomy without re-[**Last Name (LF) 39727**], [**First Name3 (LF) 899**] re-implantation
[**6-5**]: SBR, R colectomy, ileocolic reanastamosis
[**6-28**]: ERCP-choledochal-duodenal fistula proximal to major
papillary opening
[**6-25**]: MRCP- stenosis CBD and hepatic duct, rec ERCP
History of Present Illness:
The patient is a 41-year-old woman with chronic
mesenteric ischemia, IBS, HTN, anxiety, depression, and
fibromyalgia. Pt admitted with sxs of mesenteric
ischemia and s/p ileocecectomy without re-anastomasosis on
[**6-3**], followed by small bowel resection, right colectomy, and
ileocolic reanastomosis on [**6-5**]. Post-op course has been
complicated by pulmonary edema requiring re-intubation on [**6-11**].
After a self-extubation and reintubation and failed attempt at
placing a tracheal stent, she was again extubated on [**6-17**]. Also
found to have cholecystitis s/p MRCP [**6-25**]. s/p ERCP leading to
rise in pancreatic enzymes. Currently resting comfortably.
Denies abdominal pain, +nausea, denies vomitting, diarrhea.
Tolerating PO.
Also with possible generalized seizure
Past Medical History:
-HTN
-Heart murmur
-MVR
-Hyperlipidemia
-Chronic fatigue
-Chronic headaches
-Fibromyalgia
-Depression/Anxiety
-Talus fracture
-Cervical cancer
-GERD
-Hydronephrosis
-Mild COPD
-Appendectomy [**2131**]
Social History:
she has been working in publishing industry (as a
proofreader) x 15 yrs, divorced, has 22 yo son. 30 pack-year
smoking history. History of heavy alcohol use, stopped in [**2136**].
Denies illicits.
Family History:
Mother and aunt with coronary artery disease and carotid
disease.
Physical Exam:
VS: 98.6, 85 130/76, 16 96% RA
Gen: Alert, pleasant, resting comfortably
HEENT: EOMI, MMM, OP clear
Lungs: CTAB
CV: RRR, nl S1S2, +2/6 systolic murmur best heard at apex
Abd: +midline surgical scar, soft, mildly tender to deep
palpation
Pertinent Results:
[**2140-6-3**] 12:30AM URINE MUCOUS-FEW
[**2140-6-3**] 12:30AM URINE RBC-0-2 WBC-0 BACTERIA-RARE YEAST-NONE
EPI-[**6-12**]
[**2140-6-3**] 12:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2140-6-3**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018
[**2140-6-3**] 12:30AM PLT COUNT-457*
[**2140-6-3**] 12:30AM NEUTS-88.9* LYMPHS-7.2* MONOS-3.7 EOS-0.1
BASOS-0.1
[**2140-6-3**] 12:30AM WBC-28.3*# RBC-3.37* HGB-10.9* HCT-33.1*
MCV-98 MCH-32.5* MCHC-33.1 RDW-13.0
[**2140-6-3**] 12:30AM ALBUMIN-3.8
[**2140-6-3**] 12:30AM ALT(SGPT)-11 AST(SGOT)-23 ALK PHOS-149*
AMYLASE-90 TOT BILI-0.4
[**2140-6-3**] 12:30AM estGFR-Using this
[**2140-6-3**] 12:30AM GLUCOSE-144* UREA N-13 CREAT-0.6 SODIUM-138
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-30 ANION GAP-12
[**2140-6-3**] 02:21AM LACTATE-1.0
[**2140-6-3**] 05:57AM HGB-9.7* calcHCT-29
[**2140-6-3**] 05:57AM GLUCOSE-105 LACTATE-2.2*
[**2140-6-3**] 06:36AM freeCa-1.08*
[**2140-6-3**] 06:36AM HGB-8.0* calcHCT-24 O2 SAT-98
[**2140-6-3**] 06:36AM GLUCOSE-131* LACTATE-2.5* NA+-133* K+-3.4*
CL--106
[**2140-6-3**] 06:36AM TYPE-ART PO2-258* PCO2-35 PH-7.42 TOTAL
CO2-23 BASE XS-0 INTUBATED-INTUBATED
[**2140-6-3**] 07:39AM freeCa-1.02*
[**2140-6-3**] 07:39AM HGB-7.9* calcHCT-24 O2 SAT-98
[**2140-6-3**] 07:39AM GLUCOSE-140* LACTATE-2.2* NA+-133* K+-3.0*
CL--110
[**2140-6-3**] 08:44AM GLUCOSE-134* LACTATE-3.3* NA+-134* K+-3.3*
CL--110
[**2140-6-3**] 08:44AM TYPE-ART PO2-208* PCO2-48* PH-7.29* TOTAL
CO2-24 BASE XS--3
[**2140-6-3**] 09:49AM PT-14.2* PTT-37.6* INR(PT)-1.3*
[**2140-6-3**] 09:49AM PLT COUNT-340
[**2140-6-3**] 09:49AM WBC-18.1* RBC-2.55* HGB-8.2* HCT-25.0* MCV-98
MCH-32.2* MCHC-32.8 RDW-13.1
[**2140-6-3**] 09:49AM CALCIUM-8.6 PHOSPHATE-2.8 MAGNESIUM-1.6
[**2140-6-3**] 09:49AM GLUCOSE-119* UREA N-8 CREAT-0.3* SODIUM-137
POTASSIUM-3.4 CHLORIDE-109* TOTAL CO2-22 ANION GAP-9
[**2140-6-3**] 10:00AM LACTATE-2.0
[**2140-6-3**] 10:00AM TYPE-ART PO2-443* PCO2-41 PH-7.36 TOTAL
CO2-24 BASE XS--1
[**2140-6-3**] 10:00AM TYPE-ART PO2-443* PCO2-41 PH-7.36 TOTAL
CO2-24 BASE XS--1
[**2140-6-3**] 12:36PM O2 SAT-98
[**2140-6-3**] 05:46PM CALCIUM-8.5 PHOSPHATE-2.3* MAGNESIUM-1.7
[**2140-6-3**] 05:46PM GLUCOSE-99 UREA N-8 CREAT-0.4 SODIUM-136
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
[**2140-6-3**] 06:00PM O2 SAT-96
[**2140-6-3**] 06:00PM TYPE-ART PO2-84* PCO2-37 PH-7.39 TOTAL CO2-23
BASE XS--1
Brief Hospital Course:
41 yo f a/w mesenteric ischemia s/p ileocecectomy, small bowel
resection, right colectomy, also with cholecystitis s/p MRCP and
ERCP with evidence of choledochoduodenal fistula.
Mesenteric Ischemia:
Pt was admitted on [**2140-6-3**] with abdominal pain. Pt was found to
have acute on chronic mesenteric ischemia and on [**6-3**] underwent
an ileocecetomy wtihout re-[**Month/Day (4) 39727**], and [**Female First Name (un) 899**] reimplantation.
On [**6-5**] pt had a small bowel resection, right colectomy, and
ileocolic reanastamosis. On [**6-25**] pt had persistent abdominal
pain and had an MRCP which showed stenosis of CBD and hepatic
duct and ERCP was recommended. On [**6-28**] ERCP was performed and
demonstrated a choledochal-duodenal fistual proximal to majory
papillary opening. Pt has follow up appointments with vascular
surgery as an outpatient.
Seizure:
On [**6-22**] pt had a witnessed seizure that was thought to be from
ativan withdrawl. Pt had a normal EEG on [**6-24**] and remained
seizure free throughout admisison.
Choledochoduodenal fistula:
Seen on ERCP. Pt remained asymptomatic. And will f/u with GI
as outpt. WBC and pancreatic enzymes trending down on
discharge.
Medications on Admission:
Aspirin 325mg daily every morning
Metoprolol 25mg daily every morning
Simvastatin 20mg daily every morning
Clonazepam 0.5mg, one to five tablets every day as needed
Fluoxetine 10mg daily every morning
Bentyl 10mg three times a day
Ranitidine 150mg twice a day
Prilosec 20mg twice a day
Flexeril 10mg at bedtime
Chantix 1mg twice a day
Nortriptyline 40 mg daily
Percocet 5/325, one quarter tablet four times a day
Discharge Medications:
1. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
2. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal PRN (as needed).
Disp:*1 1* Refills:*2*
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*0*
4. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
6. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*0*
7. Bentyl 10 mg Capsule Sig: One (1) Capsule PO three times a
day.
Disp:*90 Capsule(s)* Refills:*0*
8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*60 Tablet(s)* Refills:*0*
9. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
10. Nortriptyline 10 mg Capsule Sig: Four (4) Capsule PO once a
day.
Disp:*120 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Acute Mesenteric Ischemia
Secondary Diagnosis
Hypertension
Choledochoduodenal fistula
Depression
Anemia
Hyperlipidemia
Discharge Condition:
Stable
Discharge Instructions:
You were admitted with mesenteric ischemia (insufficient oxygen
supply to your bowel) and required multiple abdominal
surgeries.
The following of your medications were changed during your
admission:
Clonazepam was discontinued
Percocet was discontinued
Your other medications should be continued as directed.
If you have any of the symptoms below, you should see your PCP
or go to the ED.
Severe abdominal pain, bloody stool, nausea, vomitting, fever,
chest pain, difficulty breathing, or any other serious concerns.
Followup Instructions:
Please follow up with gastroenterology clinic on [**2140-7-14**]
at 8am with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 463**] ) at the [**Hospital Ward Name 452**] Rosc building
on the [**Location (un) 453**]. You should also follow up with Dr. [**Last Name (STitle) **]
([**Telephone/Fax (1) 1237**]) on [**2140-8-2**] at 3:45. You also have an
appointment with your primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] on
[**7-13**] at 1:50.
Completed by:[**2140-7-10**]
|
[
"576.4",
"575.0",
"518.81",
"577.0",
"305.1",
"401.9",
"519.19",
"557.1",
"729.1",
"V10.41",
"780.39",
"518.4",
"557.0",
"496",
"293.0",
"285.29"
] |
icd9cm
|
[
[
[]
]
] |
[
"51.85",
"99.15",
"96.6",
"33.23",
"96.72",
"45.62",
"45.73",
"96.04",
"88.72",
"39.59",
"33.24",
"38.93",
"33.22",
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
7552, 7558
|
4775, 5981
|
324, 626
|
7740, 7749
|
2240, 4752
|
8319, 8833
|
1899, 1967
|
6445, 7529
|
7579, 7719
|
6007, 6422
|
7773, 8296
|
1982, 2221
|
270, 286
|
654, 1442
|
1464, 1667
|
1683, 1883
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
19,866
| 168,234
|
5226
|
Discharge summary
|
report
|
Admission Date: [**2164-11-30**] Discharge Date: [**2164-12-7**]
Date of Birth: [**2096-4-21**] Sex: F
Service: MEDICINE
Allergies:
Sotalol
Attending:[**First Name3 (LF) 11495**]
Chief Complaint:
Dyspnea on exertion & abdominal bloating
Major Surgical or Invasive Procedure:
Right cardiac catheterization
Pericardial tap
History of Present Illness:
Patient is a 68 yo female with history of PAF/tachy-brady
syndrome s/p [**First Name3 (LF) 4448**] and waxing/[**Doctor Last Name 688**] pericardial effusion of
unclear etiology who presents with worsening abdominal bloating
and DOE x 1 week found to be in AF with RVR and to have worsened
pericardial effusion.
Patient's history with EP started [**5-1**] when she had a [**Month/Year (2) 4448**]
placed for AF/tachy-brady. She was also started on coumadin and
sotalol, however the sotalol was stopped [**3-1**] symptoms of
worsening right heart failure. TTE showed dilated left and right
atria with normal LVEF. In addition, she was noted to have a new
small pericardial effusion of unclear etiology which was
followed by serial imaging and eventually resolved in the Fall
[**2163**]. She states that she was doing well until [**4-2**] when she was
admitted for AF with RVR and CHF exacerbation. She was
rate-controlled, diuresed, and started on dofetilide and
converted to sinus prior to discharge. On follow-up TTE, a small
RA lead mass was noted that was thought to be a thrombus and INR
goal was increased to 3.5. [**9-2**] TTE revealed the stable RA mass
but return of a small pericardial effusion.
She resented to clinic on [**11-30**] for follow-up and reported
worsening abdominal bloating and DOE. She was able to walk to
work prior to [**11-20**] but since this time becomes SOB with minimal
exertion. Notes increased ankle edema but no PND or orthopnea.
Does occasionally have palpitations. Denies chest pain. Found to
have 16mm Hg pulsus paradoxus and worsened pericardial effusion
on TTE but no obvious hemodynamic compromise. Admitted from
clinic for rate-control, diuresis, and further w/u of
pericardial effusion.
On ROS, denies fevers, chills, nausea, vomiting, diarrhea.
Reports anorexia and recent weight loss of unclear amount. No
diabetes, hypertension, or hypercholesterolemia.
Past Medical History:
1)AF/tachy-brady syndrome s/p [**Month/Year (2) 4448**] ([**2162**])
2)CHF
3)h/o stable lung nodules
4)h/o stable ovarian cysts
5)s/p hysterectomy ([**2143**])
6)s/p tubal ligation
7)PAF
8)mild ascending aortic dilatation
Social History:
Professor [**First Name (Titles) **] [**Last Name (Titles) 21362**] at [**Country 21363**]. Denies substance use.
Nonsmoker. Occasional social EtOH.
Family History:
NC
Physical Exam:
vitals T 98.1 HR 130 irregular BP 110/72 (pulsus 12 mm Hg) RR 15
SaO2 97% RA
General: WDWN, thin female, very pleasant, NAD, breathing
comfortably
HEENT: PERRL, EOMi, anicteric sclera
Neck: supple, trachea midline, no thyromegaly or masses, no LAD
Cardiac: irregularly irregular, s1s2 normal, no m/r/g, JVP 9cm
Pulmonary: bibasilar crackles with decreased tactile fremitis
but normal to percussion, no wheezes
Abdomen: +BS, soft, nontender, mild distention and resonant to
percussion, no HSM
Extremities: warm, 2+ DP pulses, no edema
Neuro: A&Ox3, speech clear and logical, CNII-XII intact, moves
all extremities
Pertinent Results:
Laboratory results:
[**2164-11-30**] 11:20AM WBC-6.6 RBC-3.95* HGB-13.1 HCT-38.1 MCV-96
MCH-33.2* MCHC-34.5 RDW-13.2
[**2164-11-30**] 11:20AM PLT COUNT-291#
[**2164-11-30**] 11:20AM PT-39.4* INR(PT)-4.4*
[**2164-11-30**] 11:20AM SED RATE-8
[**2164-11-30**] 11:20AM CRP-11.5*
[**2164-11-30**] 11:20AM TSH-2.8
[**2164-11-30**] 11:20AM UREA N-19 CREAT-0.8 SODIUM-139 POTASSIUM-4.7
CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
[**2164-11-30**] 11:20AM ALT(SGPT)-91* AST(SGOT)-82* ALK PHOS-139*
AMYLASE-43 TOT BILI-0.9
[**2164-11-30**] 11:20AM LIPASE-32
[**2164-12-1**] CK-MB 2 Trop T<0.01
[**2164-12-7**] PT 12.9 PTT 28.7 INR 1.1
11/10/064 WBC 4.3 RBC 3.24* Hgb 11.0 Hct 31.0 Plt 250
[**2164-12-7**] Glu 81 Bun 11 Cr 0.7 Na 139 K 4.3 HCO3 105 Cl
27
Pericardial fluid: WBC 11 RBC 722 Poly 0 Lymph 0 Mono 0
Prot 3.4 Glu 107 LDH 2313 Amylase 23 Albumin
2.2
Culture-no growth
Relevant Imaging:
1)Cardiac catheterization ([**2162**]): 1. Resting hemodynamics
demonstrated mildly elevated right and left-sided filling
pressures with a low cardiac index. There was no equalization
of pressures or blunting of the y-descent in the PCWP tracing
(no evidence of tamponade). 2. After volume loading with 1000 cc
of normal saline, the RA pressure rose to 15 mmHg and the PCWP
rose to 23 mmHg. Again, there was no equalization of pressures
or evidence of tamponade, but cardiac index remained low.
3. After placing a magnet over the patient's [**Year (4 digits) 4448**] which
increased the heart rate to 80 bpm, the hemodynamics were
unchanged.
2)ETT-MIBI ([**4-/2162**]): No angina with uninterpretable ECG in the
presence of multiple arrhythmias. Normal myocardial perfusion
with EF 66%.
3)ECHO([**8-/2164**]): The left atrium is normal in size. A small
mass/thrombus associated with a catheter/pacing wire is seen in
the right atrium and/or right ventricle. No atrial septal defect
is seen by 2D or color Doppler. The inferior vena cava is
dilated (>2.5 cm). There is mild symmetric left ventricular
hypertrophy with normal cavity size and systolic function
(LVEF>55%). Regional left ventricular wall motion is normal.
Right ventricular chamber size and free wall motion are normal.
The 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. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. The
estimated pulmonary artery systolic pressure is normal. There is
a small pericardial effusion. There are no echocardiographic
signs of tamponade.Compared with the prior study (images
reviewed) of [**2164-7-2**], the pericardial effusion is new. The
small mass/thrombus on the pacer wire is unchanged.
4)Cardiac Catheterization [**12-3**]: 1. Hemodynamics revealed mildly
elevated right-sided pressures of 34/18 mmHg in the right
ventricle. Pre-pericardiocentesis mean right atrial pressure was
15 mmHg, post-procedure mean RA pressure was 5 mmHg. Systemic
arterial pressures was 99 mmHg pre and 109 mmHg post
pericardiocentesis. Mean pulmonary capillary wedge pressure was
17 mmHg. Pericardial pressure was 12 mmHg. Findings were
consistent with early tamponade. 2. A successful
pericardiocentesis was performed via the subxiphoid approach,
producing approximately 350 cc of dark, bloody fluid.
5)ECHO([**2164-12-3**]): Left ventricular wall thickness, cavity size,
and systolic function are normal(LVEF>55%). There is a moderate
sized circumferential pericardial effusion without right atrial
or right ventricular diastolic collapse is seen. A catheter is
identified in the pericardial space with agitated saline
identified in the pericardial space.
6)ECHO([**2164-12-4**]): Overall left ventricular systolic function is
normal (LVEF>55%). The right ventricular cavity is dilated.
Right ventricular systolic function is normal. [Intrinsic right
ventricular systolic function is likely more depressed given the
severity of tricuspid regurgitation.] The aortic valve leaflets
are mildly thickened. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. There is a
restrictive/constrictive MV filling pattern. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is a small pericardial effusion.
There are no echo signs of tamponade.Compared with the prior
study (images reviewed) of [**2164-12-3**], the pericardial effusion
is now slightly larger than it was immediately post
pericardiocentesis.
7)ECHO([**2164-12-5**]): The inferior vena cava is dilated (>2.5 cm).
Overall left ventricular systolic function is normal (LVEF>55%).
The right ventricular cavity is dilated. Right ventricular
systolic function appears depressed. There is a small
pericardial effusion. There are no echocardiographic signs of
tamponade. Compared with the prior study (images reviewed) of
[**2164-12-4**], no change.
Brief Hospital Course:
Ms. [**Known lastname 18799**] is a 68 yo female with history of PAF, tachy-brady
syndrome s/p [**Known lastname 4448**], and pericardial effusion who presents
with DOE found to be in atrial fibrillation with RVR with
worsened pericardial effusion and early cardiac tamponade
physiology. Currently stable s/p pericardial tap &
self-cardioversion.
1) Pericardial Effusion: Etiology remains unclear. She has had
extensive outpatient outpatient work-up including a chest CT,
colonoscopy, and pelvis U/S to rule out malignancy. She was also
tested for HIV in [**2160**] which was negative. Rheumatoid factor and
[**Doctor First Name **] were also negative. It was thought that her effusion may
have occurred secondary to taking Coumadin and/or in the setting
of her atrial fibrillation. She was initially treated with Lasix
given evidence of fluid overload on physical exam. She was
started on Indomethacin for pain control. The patient underwent
a right heart cardiac catheterization and a pericardial tap on
[**12-3**], with suggested early cardiac tamponade. Approximately
300cc of bloody fluid was drained from her pericardium. Culture
and cytology of the fluid did not show malignant cells,
bacteria, or fungus. Her Coumadin was stopped and she was
briefly started on Heparin IV for anti-coagulation but this was
d/c'ed prior to her discharge. Post procedure ECHO was done
which showed a small pericardial effusion with no evidence of
tamponade. I have asked her to undergo a repeat ECHO in [**3-2**]
weeks as well as follow-up with one of the cardiologist's at
[**University/College **].
2) Paroxysmal Atrial fibrillation: Patient failed both Sotalol
and Dofetilide trials in the past to control her atrial
fibrillation. She remained in afib with RVR for most of her stay
but remained asymptomatic. The patient was started on Amiodarone
200 TID, as recommended by EP, on [**12-4**] but also
self-cardioverted the same day. She has been asked to continue
with the Amiodarone for 1 month prior to her follow-up with a
cardiologist at [**University/College **]. She was also started on a beta-blocker
for rate control, which was titrated to a dose that her blood
pressure could tolerate. The Coumadin was stopped given the
increased risk of the effusion reoccuring. She will also be
arranged for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor prior to her discharge.
3)CHF: Patient presented with symptoms of heart failure-lower
extremity edema and crackles on physical exam. She was diuresed
with Lasix and had significant improvement in her oxygen
saturations after the pericardial fluid was removed. Initial
cxray on admission showed bilateral pleural effusions &
bibasilar opacities, both of which had improved at time of
discharge.
4) Coagulopathy: Patient was on Coumadin at home for paroxysmal
atrial fibrillation. She presented with a supratherapeutic INR
of 4.4 likely secondary to poor PO intake from her abdominal
bloating. The INR slowly normalized once the Coumadin was
stopped.
5) Elevated LFTs: Likely secondary to hepatic congestion from
right heart failure. Improved as she was diuresed and her volume
status normalized. LFTs were normal at time of discharge.
6) Abdominal bloating: Due to right heart failure and gut edema
leading to poor post-prandial absorbtion and increased gas
production. Her symptoms improved once she was diuresed and the
pericardial fluid was drained. She was symptomatically treated
with Simethicone and a lactose-free diet.
Medications on Admission:
Toprol XL 75mg qd
Coumadin 7mg qd
Dofetilide 500mcg [**Hospital1 **]
Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) for 1 months.
3. Simethicone 80 mg Tablet, Chewable Sig: [**1-30**] Tablet, Chewables
PO QID (4 times a day) as needed for bloating.
4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
5. Indomethacin 25 mg Capsule Sig: One (1) Capsule PO three
times a day.
6. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Discharge Disposition:
Home
Discharge Diagnosis:
Dyspnea on exertion, abdominal bloating
Discharge Condition:
Stable
Discharge Instructions:
Please contact DR. [**First Name (STitle) 21364**] [**Name (STitle) 21365**], a cardiologist at [**University/College **] &
Dr.[**Initials (NamePattern4) 1565**] [**Last Name (NamePattern4) 21366**], for continued monitoring of your
cardiac condition & for follow-up appointments.
.
No heavy lifting or unnecessary exertion for 7 days after
discharge.
.
[**Name8 (MD) **] MD if:
1. Preadmission symptoms recur
2. Temperature >100.4
3. Shortness of Breath or chest pain
Followup Instructions:
Provider: [**Name10 (NameIs) **] CALL Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2164-12-18**]
9:15
Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2165-4-3**]
2:00
Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2165-4-3**]
3:30
.
Please make an appointment to see your primary care physician,
[**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) 1395**], within 1-2 weeks after you leave today:
[**Telephone/Fax (1) 2936**].
|
[
"790.92",
"427.31",
"790.5",
"423.8",
"428.0",
"414.01",
"V45.01"
] |
icd9cm
|
[
[
[]
]
] |
[
"37.0",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
12709, 12715
|
8456, 11966
|
311, 358
|
12798, 12806
|
3372, 4331
|
13324, 13855
|
2719, 2723
|
12085, 12686
|
12736, 12777
|
11992, 12062
|
12830, 13301
|
2738, 3353
|
231, 273
|
4349, 8433
|
386, 2291
|
2313, 2536
|
2552, 2703
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
83,532
| 142,531
|
37134
|
Discharge summary
|
report
|
Admission Date: [**2120-1-30**] Discharge Date: [**2120-2-11**]
Date of Birth: [**2072-1-11**] Sex: M
Service: MEDICINE
Allergies:
Azithromycin / Gadopentetate Dimeglumine / Morphine Sulfate /
Keflex / Iodine-Iodine Containing
Attending:[**Last Name (NamePattern1) 1167**]
Chief Complaint:
Cough, Dyspnea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
48 year-old man with dilated cardiomyopathy (EF 25%) s/p ICD in
[**2117**], HTN, CKD (baseline Cr 1.3-1.6) and asthma p/w chronic
cough, abdominal pain and n/v, unable to take POs.
.
The pt has had a cough, productive of white sputum for the past
2mos, as well as weight gain being managed in Dr.[**Name (NI) 3536**] HF
telemedicine clinic. His lisinopril was changed to losartan out
of concern for cough, and last week his torsemide was increased
to 100mg daily to further managed his HF. He also notes DOE and
orthopnea and ten lb weight gain over the past week and 20 lbs
over the month despite increasing doses of diuretics. In
addition to the increased DOE he has had cough which is
increasing. He has also had vomitting after bouts of coughing.
Because the coughing has been persistent it has been difficult
to take his PO meds. He states that the vommiting has been
mostly in the context of coughing but not always. Additionally
his son has had n/v/d symptoms over the last couple days as
well.
.
In the ED, initial VS: 95.9 105 143/74 22 100%RA. The pt was
found to have K+ 3.1, Cr 1.5, BNP 7000s, INR 2.4, trop <0.01.
CXR showed no significant interval change. Persistent
cardiomegaly, without
overt pulmonary edema. CT ab non con showed no acute process. He
was treated with KCL 60meq PO, morphine 4mg IV,zofran,
promethazine, and torsemide 100mg IVx1.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: Non-ischemic dilated cardiomyopathy; EF 20%
(etiology Takotsubo vs. alcohol-induced per OMR review)
--On coumadin for dilated LV
-CABG: None
-PERCUTANEOUS CORONARY INTERVENTIONS: Percutaneous coronary
intervention, in [**6-9**] without evidence of coronary disease
-PACING/ICD: AICD placement [**2118-10-26**]
3. OTHER PAST MEDICAL HISTORY:
- Asthma
- Depression
- GERD
- Chronic kidney disease, baseline creatinine 1.3
- s/p Achilles repair
Social History:
He lives with his children, not married. Originally from PR,
unemployed x2 years since cardiomyopathy diagnosis. Used to work
as correctional officer. No ETOH x 2 years, used to drink
recreationally. History of recreational cocaine, last used 3
years ago. No tob use.
Family History:
Father (73 years; valve replacement +/- CABG); Mother (68 years;
diabetes, hypertension). He has 3 brothers (hypertension,
asthma). He has 5 children (5-23 years; asthma). Colon cancer in
maternal grandmother and 2 maternal
aunts.
Physical Exam:
ADMISSION EXAM:
VS - 98.3 96.8 108-122/66-82 84-104 18 98%RA
GENERAL - slightly obese man, NAD
HEENT - mildly erythematous oropharynx, MMM
NECK - mildly tender, JVD at 10cm
LUNGS - CTA bilat, no r/rh, minimal wheezing, good air movement,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, mildly tachycardic, 2/6 systolic
murmur
ABDOMEN - epigastric tenderness
EXTREMITIES - No LE edema
SKIN - no rashes or lesions
EXAM ON DISCHARGE:
Weight: 104.8kg
HEENT: no throat erythema
NECK: no JVD
ABDOMEN: much less distended
Otherwise exam unchanged from admission
Pertinent Results:
ADMISSION LABS:
[**2120-1-29**] 06:45PM GLUCOSE-115* UREA N-20 CREAT-1.5* SODIUM-136
POTASSIUM-3.1* CHLORIDE-95* TOTAL CO2-31 ANION GAP-13
[**2120-1-29**] 06:45PM estGFR-Using this
[**2120-1-29**] 06:45PM CALCIUM-9.5 PHOSPHATE-2.7 MAGNESIUM-2.0
[**2120-1-29**] 06:45PM WBC-6.2 RBC-4.25* HGB-11.4* HCT-33.9* MCV-80*
MCH-26.8* MCHC-33.7 RDW-15.6*
[**2120-1-29**] 06:45PM NEUTS-71.5* LYMPHS-21.1 MONOS-6.7 EOS-0.5
BASOS-0.2
[**2120-1-29**] 06:45PM PLT COUNT-181
[**2120-1-29**] 06:45PM ALT(SGPT)-20 AST(SGOT)-23 ALK PHOS-73 TOT
BILI-1.0
[**2120-1-29**] 06:45PM LIPASE-16
[**2120-1-29**] 06:45PM cTropnT-<0.01
[**2120-1-29**] 06:45PM PT-25.4* PTT-42.6* INR(PT)-2.4*
[**2120-1-30**] 12:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
[**2120-1-30**] 12:25PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
STUDIES:
CXR:
FINDINGS: Frontal and lateral views of the chest were obtained.
Single lead left-sided AICD is again seen with leads extending
to the expected position of the right ventricle. Moderate
cardiomegaly persists. There is no overt pulmonary edema.
Mediastinal and hilar contours are stable. No focal
consolidation, pleural effusion, or evidence of pneumothorax is
seen.
IMPRESSION: No significant interval change. Persistent
cardiomegaly, without overt pulmonary edema.
.
CT OF THE ABDOMEN:
The lungs are clear. A pacemaker device is seen ending in the
right
ventricle. The heart is enlarged. There are no focal hepatic
lesions. The
gallbladder, pancreas, spleen, adrenal glands, and kidneys are
normal. There is no evidence of obstructing renal stones or
renal masses. There are only mild atherosclerotic calcifications
of the iliac arteries.
There is no retroperitoneal or mesenteric lymphadenopathy. There
is no free air and no free fluid. The small and large bowel
including the appendix are normal.
CT OF THE PELVIS:
The urinary bladder is normal. There is no pelvic
lymphadenopathy or pelvic free fluid.
BONES: There are no significant degenerative changes.
IMPRESSION: No acute CT findings in the abdomen or pelvis.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of [**2120-1-31**]
7:06 PM
IMPRESSION:
1. No acute intra-abdominal pathology.
2. Cardiomegaly.
Radiology Report DUPLEX DOPP ABD/PEL Study Date of [**2120-2-3**] 2:59
PM
IMPRESSION:
1. Patent hepatic vasculature. Exaggeration of phasicity in the
portal
venous waveform may correspond to the provided history of
congestive heart
disease.
2. Echogenic liver (borderline), suggestive of fatty
infiltration. Other
forms of liver disease, including more significant hepatic
fibrosis or
cirrhosis, cannot be excluded on the basis of this examination.
No focal
liver lesions identified.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2120-2-5**]
10:14 AM
IMPRESSION: AP chest compared to [**1-22**] and 30:
Severe cardiomegaly is chronic. Pulmonary vasculature is
unremarkable, lungs
are clear and there is no pneumothorax. Transvenous right
ventricular pacer
defibrillator lead is in standard position, unchanged.
Cardiovascular Report ECG Study Date of [**2120-2-8**] 10:46:54 AM
Sinus rhythm with first degree A-V conduction delay. Possible
left atrial
abnormality. Prolonged Q-T interval. Rightward axis.
Non-specific
intraventricular conduction delay. Poor R wave progression.
Non-specific
inferolateral T wave flattening. Low QRS voltage in the limb
leads. Compared
to the previous tracing of [**2120-1-29**] the ventricular premature
beats are absent.
Lab Results on Discharge:
[**2120-2-11**] 06:50AM BLOOD WBC-5.1 RBC-4.45* Hgb-11.3* Hct-35.7*
MCV-80* MCH-25.4* MCHC-31.7 RDW-14.9 Plt Ct-208
[**2120-2-11**] 06:50AM BLOOD PT-24.5* PTT-36.8* INR(PT)-2.3*
[**2120-2-11**] 06:50AM BLOOD Glucose-102* UreaN-34* Creat-1.5* Na-129*
K-3.5 Cl-81* HCO3-40* AnGap-12
[**2120-2-7**] 03:14AM BLOOD ALT-91* AST-26 AlkPhos-112 TotBili-0.7
[**2120-2-11**] 06:50AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.0
[**2120-2-1**] 08:05AM BLOOD Lactate-1.8
Brief Hospital Course:
Primary Reason for Hospitalization: Patient is a 48 year-old man
with dilated cardiomyopathy (EF 25%) with 5 admissions this
year, s/p ICD in [**2117**], HTN, CKD (baseline Cr 1.3-1.6) and
asthma, who presented with cough, n/v, most likely from acute on
chronic CHF. Due to the worsening nausea and vomiting, patient
was unable to take his diuretic medications, leading to
worsening of the volume overload with gut edema. He was diuresed
in-house to close to dry weight with resolution of nausea and
vomiting and improvement in coughing. IV Lasix drip with
milrinone was used for diuresis initially but patient was
transitioned to oral diuretics on discharge.
.
ACUTE CARE:
.
1. Acute on chronic Systolic CHF: Before admission, patient
experienced a [**10-19**] lb weight gain over last month despite
increases in his home torsemide dose. BNP found in 7000s in the
ED on amission. At home, he was on torsemide 100mg PO daily and
metolazone MWF, however due to N/V he was unable to take meds
for two days, likely exacerbating symptoms. He presented with
chronic cough and DOE which may be a feature of CHF. He was
placed on Lasix 100mg IV BID, but experienced [**Last Name (un) **] on that dose
with creatinine bump to 2.6. He was transferred from the general
medicine floors to the [**Hospital1 1516**] floors where he was placed on a
lasix drip for closer titration. He initially had improved
kidney function with 3L diuresis but again [**First Name9 (NamePattern2) 83667**] [**Last Name (un) **]
despite halving the drip from 10mg/hour to 5mg/hour, and rate of
diuresis dropped off as well. He was transferred to the CCU
where milrinone was initiated, titrated to goal urine output
2-3L. He remained on the lasix drip. His UOP dropped off
briefly but improved with metolazone 5mg PO once. Patient was
transferred back to the floor from the ICU where he was
transitioned to PO torsemide. Metolazone was discontinued for
now due to difficult to control hypokalemia. Patient's discharge
weight was 104.8kg and he was dishcarged with cardiology
follow-up for volume management. He was continued on coumadin
for left heart thrombus prevention.
2 Nausea/Vomiting/Abdominal Pain: Patient presented with
significant nausea and vomiting, and abdominal tenderness with
difficulty taking POs. It seems that the vomiting was a result
of frequent coughing vs. gut wall edema as CT abd did not show
any acute causes. [**Month (only) 116**] also represent a viral GI illness. Patient
received supportive care for symptom control and to facilitate
tolerating his medications. In particular, he endorsed that
potassium pills really caused nausea. He was given zofran prn
when he felt nauseated with medications. With supportive care
and diuresis, patient had resolution of the nausea and vomiting
and abdominal pain by discharge and tolerated all oral
medications.
.
3. Acute Kidney Injury: Patient's creatinine peaked at 2.6 from
baseline 1.2-1.4 while receiving diuresis on the medical floors.
This was likely prerenal [**Last Name (un) **] from diuresis along with poor
forward flow from sCHF. Patient was transferred to the CCU where
he was diuresed with lasix gtt while receiving milrinone
infusion. Patient had a diuresis of 7.7L. Patient returned to
the cardiology floor for continued IV and PO diuresis and
creatinine improved to 1.3 on discharge. He was discharged home
on home losartan, torsemide, and spironolactone
.
4. Cough: Patient has persistant cough associated with
post-tussive emesis. He was receiving codeine at night for
cough, but that combined with ativan led to over-sedation. He
received codeine and benonatate for cough with good results and
without over-sedation and was discharged home on these
medications.
.
5. Transaminase elevation: Patient experienced a brief
transaminase elevation in-house. HCV negative in [**2116**] and HbsAb
was positive CT abdomen last month without focal hepatic
lesions. No evidence of obstructive hepatopathy. By discharge
the transaminitis had resolved and it was felt likely due to
drug effect vs. congestive hepatopathy.
.
CHRONIC ISSUES:
1. GERD: Patient was continued on pantoprazole.
.
2. Depression: Patient was continued on sertraline.
TRANSITIONAL ISSUES:
1. CODE STATUS: FULL
2. MEDICATION CHANGES:
1. START codeine sulfate 15mg tabs, Take one tab by mouth
before bed as needed for cough
2. START Benzonatate 100mg tabs, take one tab three times
daily as needed for cough
3. STOP taking metolazone
4. CHANGE Torsemide to 80mg by mouth daily
5. CHANGE potassium to 40meq by mouth daily
3. FOLLOW-UP APPOINTMENTS:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2120-2-14**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**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: THURSDAY [**2120-2-15**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2120-2-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
4. OUTSTANDING CLINICAL ISSUES:
-monitoring of weights and titration of diuretics
-consideration of workup for heart transplant
-monitoring of INR/potassium/magnesium balance
Medications on Admission:
ALBUTEROL SULFATE - 90 mcg HFA Aerosol Inhaler - [**1-1**] HFA(s)
inhaled every six (6) hours as needed for Shortness of breath or
wheezing
CITALOPRAM - 20 mg Tablet - 2 Tablet(s) by mouth DAILY (Daily)
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - 20 mg Capsule, Delayed
Release(E.C.) - 1 Capsule(s) by mouth once a day
FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2
Aerosol(s) inhaled twice a day
HYDROCORTISONE ACETATE - 25 mg Suppository - 1 Suppository(s)
rectally at bedtime
LOSARTAN - 25 mg Tablet - 1 Tablet(s) by mouth daily
METOLAZONE - (Prescribed by Other Provider) - 2.5 mg Tablet - 1
Tablet(s) by mouth only on Mon-Wed-Fri
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - 1
Tablet(s) by mouth once a day
MONTELUKAST [SINGULAIR] - 4 mg Tablet, Chewable - 1 Tablet(s) by
mouth daily
POTASSIUM CHLORIDE - 20 mEq Tablet, ER Particles/Crystals - one
Tablet(s) by mouth daily with breakfast
SPIRONOLACTONE - 25 mg Tablet - One Tablet by mouth once a day
TORSEMIDE - 20 mg Tablet - 5 Tablet(s) by mouth daily
WARFARIN - 5 mg Tablet - 1-1.5 Tablet(s) by mouth daily or as
directed by coumadin clinic. last dose [**2118-9-22**] in preparation
for
ICD placement
DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg
Capsule - 1 Capsule(s) by mouth twice a day
LIDOCAINE [ANECREAM] - 4 % Cream - locally use twice a day
MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth DAILY (Daily)
.
ALLERGIES: Azithromycin / Gadopentetate Dimeglumine / Morphine
Sulfate / Keflex / Iodine-Iodine Containing
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.
2. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
3. esomeprazole magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day.
4. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation [**Hospital1 **] (2 times a day).
5. hydrocortisone acetate 25 mg Suppository Sig: One (1)
suppository Rectal at bedtime: please take under direction of
your PCP.
6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. montelukast 4 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
9. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM: Take as directed by the coumadin clinic.
10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. torsemide 20 mg Tablet Sig: Four (4) Tablet PO once a day.
13. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig:
Two (2) Tablet, ER Particles/Crystals PO once a day: please take
with breakfast.
14. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a
day.
15. codeine sulfate 15 mg Tablet Sig: One (1) Tablet PO at
bedtime as needed for cough.
Disp:*15 Tablet(s)* Refills:*0*
16. Outpatient Lab Work
Please draw sodium, potassium, chloride, bicarbonate, BUN,
creatinine, glucose, INR on Wednesday
17. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed for cough.
Disp:*60 Capsule(s)* Refills:*0*
18. Anecream 4 % Cream Sig: One (1) application Topical twice a
day as needed for pain: apply to affected area twice daily as
needed.
19. multivitamin Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. [**Last Name (Titles) 83668**],
It was a pleasure taking part in your care. You were admitted to
the hospital because you experienced nausea and vomiting and you
were unable to take your medications. You had also been
experiencing a gradual increase in cough and abdominal girth due
to fluid buildup from congestive heart failure. In the hospital,
we gave you medications to remove the extra fluid and your acute
nausea and vomiting resolved. You had to stay a few extra days
because your potassium was very low as a side effect of the
medications. You were discharged home with follow-up in
cardiology clinic.
Please make the following changes to your medications:
1. START codeine sulfate 15mg tabs, Take one tab by mouth before
bed as needed for cough
2. START Benzonatate 100mg tabs, take one tab three times daily
as needed for cough
3. STOP taking metolazone
4. CHANGE Torsemide to 80mg by mouth daily
5. CHANGE potassium to 40meq by mouth daily
Please take all other medications as previously prescribed.
Please have outpatient lab work drawn on Wednesday following
discharge.
Please keep all followup appointments.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2120-2-14**] at 11:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**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: THURSDAY [**2120-2-15**] at 8:40 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: CARDIAC SERVICES
When: WEDNESDAY [**2120-2-28**] at 10:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
[
"V45.82",
"585.9",
"276.8",
"584.9",
"311",
"790.4",
"530.81",
"428.23",
"780.52",
"V45.02",
"300.01",
"428.0",
"493.20",
"790.92",
"787.01",
"789.00",
"403.90",
"V58.61",
"425.4"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
16765, 16823
|
7537, 11614
|
389, 395
|
16906, 16906
|
3484, 3484
|
18308, 19281
|
2642, 2874
|
14830, 16742
|
16844, 16885
|
13295, 14807
|
17056, 17704
|
2889, 3321
|
1896, 2207
|
12132, 13269
|
7065, 7514
|
11754, 11778
|
17734, 18285
|
11802, 12107
|
325, 351
|
423, 1788
|
3340, 3465
|
3500, 7050
|
16921, 17032
|
2238, 2340
|
11630, 11733
|
1810, 1876
|
2356, 2626
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,620
| 122,881
|
23156
|
Discharge summary
|
report
|
Admission Date: [**2106-9-17**] Discharge Date: [**2106-9-24**]
Date of Birth: [**2076-7-26**] Sex: F
Service: MEDICINE
Allergies:
Compazine / Cefepime
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
gait instability
Major Surgical or Invasive Procedure:
radiation therapy to back
History of Present Illness:
30 year old woman with history of AML s/p allo BMT in [**12-7**] and
relapse detected in [**5-8**] now s/p MEC treatment ([**6-8**]) and DLI on
[**7-29**] and GVHD (leg pain, high LFT's), and hematochezia p/w leg
pain and unsteady gait. She states that she has felt numbness in
the outside of her right leg for the past week. This has been
steadily getting worse. She noted that her gait has been getting
progressively worse as well. She feels that she has to "waddle"
and to hold onto things to stay upright. She feels that her
right leg just won't hold her. She states that for the past 2
days she has had difficulty starting to urinate. She has no pain
on urination. She feels a sense of urgency but has trouble
initiating the stream. She denies ever losing her bowels or her
urine. She states that 2 nights ago she starting to have pain
over her tailbone. This pain has been intermittent and is not
currently present. She is otherwise in her usual state of
health. She denies fevers, sweats, chills. She has had a 15 lb
weight loss over the past few months.
.
ROS: No headache, vision changes, or neck stiffness. no fevers,
chills, sweats. No chest pain, shortness of breath. No
nausea/vomiting/diarrhea. bloody or tarry stools.
.
Past Medical History:
1)Past Onc: MDS -> AML (8;21 trans) s/p allo BMT in [**12-7**] and
relapse detected in [**5-8**] now s/p MEC treatment ([**6-8**]) and DLI on
[**7-29**] and GVHD (leg pain, high LFT's)
2)HTN
3) s/p gastric bypass 2+ yrs ago
4) s/p tonsillectomy
5) h/o MRSA, VRE, C.diff
6) Line sepsis CNS Ox resistant [**3-8**] with hickman removal
7) hx MRSA bacteremia late [**2105**]
8) Gastric ulcer -> UGIB s/p vessel clipping [**8-8**]
Social History:
Originally from [**Country 3587**] but moved to the US when she
was 2 yrs old, currently lives in [**Doctor Last Name 792**]with her husband
and daughter, used to work as a [**Name (NI) **] and phlebotomist until [**9-6**].
+Tobacco- ~10pk-yrs, quit 2 yrs ago. Denies EtOH and drugs.
Family History:
MGM - CLL, mom DM [**Name (NI) **], HTN, dad HTN, sister asthma
Physical Exam:
wt 183
Vitals:98.9 86 20 110/83 98%RA
HEENT: icteric sclerae, PERRLA, EOMI, no conjunctival pallor,
palate and buccal mucositis, no thrush
Neck: no cervical lymphadenopathy
Chest: CTAB, no end expiratory wheeze
CV: RRR no m/r/g
Abd: obese, soft, NT, ND
Ext: no clubbing/cyanosis, trace edema to feet, 2+DP
Skin: erythema and thickening of face skin
Neuro: A,Ox3; CNII-XII, upper extremities arm flex/ext [**5-7**], hand
grip [**5-7**];
lower ext: hip flex R 5/5 L [**5-7**], knee ext R 5/5 L [**5-7**], knee flex
R 4/5 L [**5-7**], plantar flex bilat [**5-7**], great toe dosiflex bilat
[**3-7**].
Reflex: bicep bilat 2+, brachio bilat 2+ patellar bilat 0 ankles
bilat 0, toes upgoing on L.
[**Last Name (un) **]: light touch intact over face and upper ext.
pinprick R>L up to knee, proprioception symmetric on great toes
coord: FTN, HTS normal and symmetric
gait: narrow based, shuffling/waddling gait. negative Romberg.
Pertinent Results:
[**2106-9-17**] 10:35AM WBC-5.9# RBC-3.24* HGB-11.1* HCT-34.4*
MCV-106* MCH-34.3* MCHC-32.3 RDW-26.0*
[**2106-9-17**] 10:35AM NEUTS-57.0 BANDS-0 LYMPHS-35.6 MONOS-6.8
EOS-0.3 BASOS-0.3
[**2106-9-17**] 10:35AM GLUCOSE-80 UREA N-17 CREAT-0.8 SODIUM-137
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-26 ANION GAP-14
[**2106-9-17**] 10:35AM ALT(SGPT)-149* AST(SGOT)-120* LD(LDH)-300*
ALK PHOS-1139* TOT BILI-5.6* DIR BILI-3.8* INDIR BIL-1.8
[**2106-9-17**] 10:35AM ALBUMIN-3.4 CALCIUM-8.9 PHOSPHATE-2.9
MAGNESIUM-1.8
.
MRI:
[**2106-9-17**]: L spine: Epidural mass extending from L3-4 to L5-S1
level with low T2 and isointense T1 signal could be due to an
epidural hematoma or due to leukemic infiltrates.
[**2106-9-18**]: L spine with contrast: The previously noted mass at the
anterior epidural space at L4 and L5 level does not demonstrate
enhancement. There is enhancement at the superior aspect which
appears to be secondary to venous enhancement. The mass appears
to be extending bilaterally into the neural foramina but no
enhancement is seen. There are no paraspinal abnormalities seen.
Brief Hospital Course:
A/P 30 year old woman with AML s/p allo with relapse, GVHD,
hematochezia p/w progressing gait impairment and sensory deficit
.
1.) Gait impairment: The patient's symptoms and exam were
concerning for cord compression from either an infectious or
neoplastic process in the L5 region. High dose steroids were
started with dexamethasone 10 mg iv x1 and 4mg q6 hours
thereafter. An emergent MRI was attempted. A neurology consult
was obtained. However, due to patient pain and involuntary
movement despite mild sedation, initial imaging was inadequate.
The patient was electively intubated with general anesthesia to
allow for adequate imaging. An epidural mass in the L4-L5
region was identified. A neurosurgical consult was obtained who
recommended CT guided biopsy. A CT guided biopsy was not
performed as it was thought that the lesion was not safely
approachable. She was empirically treated for a chloroma with
radiation therapy. She underwent XRT treatment planning to
receive 10 fractions treating to a total of 20 Gy. She
tolerated the XRT well except for some mild nausea. She
received 4 treatments while inpatient. Her leg strength did
not appreciably improve during her hospital course. She was
able to walk adequately with a walker. She was evaluated by
physical therapy and was witnessed walking stairs safely prior
to discharge. She will receive PT services as an outpatient.
.
2.) AML with GVHD: There was no evidence of peripheral blood
relapse. She continued to receive her home regimen of cellcept.
While she received dexamethasone for her neurologic condition,
her home prednisone for GVHD was held. A bone marrow biopsy was
not not performed while an inpatient, however, this could be
considered as an outpatient.
.
3.) Hx of GIB: The patient was recently admitted for a upper GI
bleed with subsequent clipping of a visible vessel. She had
trace guaiac positive stools, but there was no evidence of
significant bleeding. She continued to receive her home [**Hospital1 **]
PPI, sucralfate
.
4.) Bradycardia: Following transfer back to the BMT service from
the ICU, the patient developed transient asymptomatic
bradycardia with heart rate in the upper 30's. Her blood
pressure was normal. The rhythm was sinus. She underwent a TTE
which revealed normal LV function and estimated filling
pressures. By time of discharge, her heart rate had normalized.
The most likely causes of the bradycardia was sedating
medications, high dose steroids, or physiologic causes for a
young patient.
.
5.) UTI: The patient developed dysuria without vaginal symptoms.
She had a UA that was remarkable for elevated WBC. She
received 3 days of ciprofloxacin. A urine culture was pending
at the time of discharge.
.
6.) CMV viremia: On [**9-17**] the patient had surveillance CMV viral
load drawn. The result was less than 600 copies, but not
"non-detected." She was started on empiric treatment with
valganciclovir with concern for rapid viral replication while on
high dose steroids. A repeat CMV viral load was ~800. She will
complete a 21 day course of valganciclovir.
7.) Prophy: fluc, acyclovir, bactrim, PPI
.
8.) CODE: FULL
.
9.) Dispo: home to have outpatient PT and to return to [**Hospital1 18**] to
complete XRT course. f/u appointment with hematology clinic
scheduled prior to discharge.
Medications on Admission:
Mycophenolate Mofetil 500 mg PO TID
Acyclovir 400 mg PO Q8H
Pantoprazole 40 mg PO Q12H
Fluconazole 400 mg PO Q24H
Prednisone 25 mg PO DAILY
Sucralfate 1 gm PO QID
Hydromorphone 2 mg PO ONCE
Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR
Discharge Medications:
1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a
day).
2. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
4. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day) for 14 days.
Disp:*56 Tablet(s)* Refills:*0*
5. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO
TID (3 times a day).
6. Line Care
Midline line care per protocol
7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
8. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 days.
Disp:*2 Tablet(s)* Refills:*0*
9. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea.
Disp:*30 Tablet(s)* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Epidural mass
Leukemia
.
Secondary:
Chronic graft versus host disease
Cytomegalovirus viremia
Discharge Condition:
good. ambulating with walker. climbing stairs without incident.
tolerating oral nutrition and medications.
Discharge Instructions:
You have been evaluated and treated for your leg weakness and
difficulty walking. These symptoms were attributed to a mass in
your low back that was pressing on your nerves. You received
steroids and radiation therapy to treat this mass. Your
radiation therapy will continue after you leave the hospital as
was discussed while you were here.
.
While you were in the hospital you were found to have a urinary
tract infection. Please take the antibiotic (ciprofloxacin) as
directed and contact your doctor if the pain returns.
.
Please attend your physical therapy and radiation treatments.
.
Please take your medications as prescribed.
.
If you develop any concerning symptoms particularly worsening
leg strength, inability to urinate, fevers to greater than
100.3F, or shortness of breath, please seek medical attention.
Followup Instructions:
You have your next radiation treatment on Monday [**2106-9-27**]. The
radiation therapists will give you the appointment time.
.
Please arrange for physical therapy near your home to start on
Monday.
.
You have an appointment to see Dr. [**First Name (STitle) 1557**] on next Thursday
[**2106-9-30**] at 12:30pm
|
[
"996.85",
"205.30",
"078.5",
"V45.3",
"336.3",
"599.0",
"427.89",
"E878.4",
"205.00",
"401.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"92.29"
] |
icd9pcs
|
[
[
[]
]
] |
9114, 9120
|
4502, 7829
|
298, 325
|
9267, 9376
|
3386, 4479
|
10250, 10565
|
2362, 2427
|
8113, 9091
|
9141, 9246
|
7855, 8090
|
9400, 10227
|
2442, 3367
|
242, 260
|
353, 1592
|
1614, 2043
|
2059, 2346
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
82,041
| 163,524
|
21530
|
Discharge summary
|
report
|
Admission Date: [**2141-7-29**] Discharge Date: [**2141-8-7**]
Date of Birth: [**2084-2-27**] Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 348**]
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
Initiation of Dialysis
Tunneled Dialysis Catheter placement
History of Present Illness:
57yo w/ ESRD, CAD, DM2, HTN, HPL here for witnessed syncope last
night. Pt was setting up for musical performance at aquarium
last night which required a long walk with equipment from the
car. Felt very fatigued upon arriving and as if the "world was
in slow motion". Pt then felt lightheaded and dizzy with
diaphoresis and mild nausea before LOC. Multiple witnesses of
event report LOC x10 mins without convulsions, loss of
bowel/bladder or tongue biting. After ROC denies any post-ictal,
has full memory. Pt denies CP, palpitations or any other
symptoms before or after syncope. Per report fingerstick was 520
at scene, EKG wnl per paramedics, and pt refused EMS and went
home.
Pt does report increasing fatigue for the past month along with
decreased PO due to metallic taste. Recently seen PCP who told
pt that he will need dialysis soon for presumed DM nephropathy,
planned for [**8-7**]. His last BUN/Cr were ~60/7 2 weeks
prior, at which time he was seen and found to have excessive
peripheral edema; his diuretic regimen was changed to torsemide
100 daily with 2.5 metolazone. This regimen removed his edema,
however his BUN/Cr 2 weeks later ([**7-25**]) was 160/11. He notes his
UOP has remained relatively constant over the past few weeks.
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
All other 10-system review negative in detail.
Past Medical History:
DM (DIABETES MELLITUS), TYPE 2, UNCONTROLLED, WITH RENAL
COMPLICATIONS
Chronic kidney disease, stage V
Cataract, nuclear sclerotic senile
Ocular hypertension
Glaucoma suspect
OBESITY UNSPEC
SLEEP APNEA, UNSPEC
VITAMIN D DEFIC, UNSPEC
IMPOTENCE - ORGANIC
DISC DISEASE - LUMBAR
TOBACCO DEPENDENCE
ANEMIA
NEPHROLITHIASIS
HYPERCHOLESTEROLEMIA
HYPERTENSION, ESSENTIAL, BENIGN
CAD s/p MI 3 years prior
Social History:
Works in sales and as a music producer, lives in [**Location 1110**] with his
wife of 25 years. 3 children. Smokes [**2-12**] cigs/day, previously
smoked 1/2ppd x40yrs. No ETOH/Drugs.
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
ED VS: Temp: 99 HR: 95 BP: 191/86 Resp: 18 O(2)Sat: 100
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear. +uremic breath
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, no rales, no ronchi
CV RRR normal S1/S2, no mrg
ABD soft obese NT ND normoactive bowel sounds
EXT WWP 2+ pulses palpable bilaterally, trace-1+ pedal edema
NEURO CNs2-12 intact, motor function grossly normal. -asterixis,
+fine tremor
SKIN no ulcers or lesions
Discharge Physical Exam:
VS - 98.4 112-132/68-77 84-91 19 100 ra
GEN Overweight man sitting in chair. Alert, oriented, no acute
distress.
HEENT NCAT MMM EOMI sclera anicteric, OP clear with poor breath
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi. Tunnelled
dialysis catheter in place in R chest with no signs of
infection.
CV RRR normal S1/S2, no mrg
ABD soft obese NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
Admission Labs:
[**2141-7-29**] 09:55PM COMMENTS-GREEN TOP
[**2141-7-29**] 09:55PM GLUCOSE-274* NA+-140 K+-5.0 CL--106 TCO2-20*
[**2141-7-29**] 09:55PM HGB-9.2* calcHCT-28
[**2141-7-29**] 09:30PM GLUCOSE-292* UREA N-129* CREAT-11.1*
SODIUM-138 POTASSIUM-5.2* CHLORIDE-105 TOTAL CO2-18* ANION
GAP-20
[**2141-7-29**] 09:30PM estGFR-Using this
[**2141-7-29**] 09:30PM ALT(SGPT)-17 AST(SGOT)-1 CK(CPK)-581* ALK
PHOS-128 TOT BILI-0.1
[**2141-7-29**] 09:30PM cTropnT-0.28*
[**2141-7-29**] 09:30PM CK-MB-8
[**2141-7-29**] 09:30PM ALBUMIN-4.1 CALCIUM-7.3* PHOSPHATE-6.4*
MAGNESIUM-2.1
[**2141-7-29**] 09:30PM WBC-7.8 RBC-3.52* HGB-9.0* HCT-28.9* MCV-82
MCH-25.5* MCHC-31.1 RDW-14.2
[**2141-7-29**] 09:30PM NEUTS-67.2 LYMPHS-20.4 MONOS-7.7 EOS-4.3*
BASOS-0.3
[**2141-7-29**] 09:30PM PLT COUNT-222
[**2141-7-29**] 09:30PM PT-10.0 PTT-29.2 INR(PT)-0.9
[**2141-7-31**] 05:55PM BLOOD ALT-13 AST-7 LD(LDH)-189 CK(CPK)-453*
AlkPhos-125 TotBili-0.2
[**2141-7-29**] 09:30PM BLOOD cTropnT-0.28*
Relevant Labs:
[**2141-7-30**] 06:40AM BLOOD CK-MB-7 cTropnT-0.23*
[**2141-7-30**] 08:40PM BLOOD CK-MB-6 cTropnT-0.18*
[**2141-7-31**] 05:55PM BLOOD CK-MB-6 cTropnT-0.24*
[**2141-8-1**] 12:08AM BLOOD CK-MB-6 cTropnT-0.27*
[**2141-8-1**] 08:37AM BLOOD cTropnT-0.29*
Relevant Micro/Path: None
Relevant Imaging:
CT Head [**2141-7-29**]:
No intracranial hemorrhage or fractures
Trans Thoracic Echo [**2141-7-31**]:
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and global
systolic function (LVEF>55%). There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The pulmonary
artery systolic pressure could not be determined.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
No structural cardiac cause of syncope identified.
CLINICAL IMPLICATIONS:
Based on [**2135**] AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Brief Hospital Course:
Assessment and Plan (ICU Course):
57M history of ESRD started HD on [**2141-7-31**], CAD s/p MI 3 years
prior, DM2, HTN, HL who presented with syncope on [**2141-7-29**]
admitted for observation in the setting of ESRD/initiation of HD
with hospital course complicated by "unresponsiveness" episode
on [**7-31**] with spontaneous resolution concerning for dialysis
disequilibrium syndrome vs vasovagal syncope.
# Unresponsive episode
Patient had "unresponsiveness" episode during dialysis with no
loss of pulse or respirations. His vital signs showed abnormal
heart rate and blood pressure that resolved during final portion
of session. He could have the aforementioned dialysis
disequilibrium syndrome given high BUN, first dialysis session,
nausea/vomiting; otherwise may represent a repeat syncopal
episode. There is no malignant arrhythmia although does appear
he had bradycardia, primary neurogenic process such as seizure
(recovered quite fast) is unlikely, no evidence of hypoglycemia,
or other concerning features of his episode. Serial ECG did not
suggest ischemia although troponin continues to be elevated in
the setting of his ESRD. ECHO did not show any overt
abnormalities. The patient was monitored in ICU for 24 hours.
Patient received second session of hemodialysis at bedside in
ICU and remained asymptomatic with no events or hemodynamic
instability during session. He was advised that he should not
drive while he starts dialysis as an outpatient given his
syncopal episodes. If his symptoms persist, the patient was
instructed to follow up in our neurology clinic where his
diagnosis of disequilibrium syndrome may be worked up further.
#Syncope: History favors vasovagal etiology due to classic
prodrome of LH/dizzy, mild nausea, diaphoresis. No post-ictal to
suggest neurologic etiology. Arrhythmogenic etiology is not
favored due to lack of symptoms and prolonged prodrome given no
malignant rhythm detected during hospitalization in first 48
hours or during dialysis. Trop/CK elevation likely secondary to
ESRD; MI is not favored here as etiology for syncope. ECHO
without significant valvular lesions or explanation for syncope.
The patient was monitored on telemetry throughout his hospital
stay with no malignant rhythms noted
#ESRD: BUN/Cr elevated compared to 2 weeks prior, likely in the
setting of aggressive diuresis with torsemide/metolazone.
Regardless, his laboratory abnormalities suggested that he would
require dialysis. He received two episodes of hemodialysis at
time of MICU call out with the assistance of a renal
consultation. His chemistries were trended daily, and
adjustments to his medications were made such as discontinuing
his torsemide, adding Nephrocaps, increasing sevelamer
carbonate, and continuing calcitriol. IVF was avoided during his
hospital stay.
#CAD: s/p MI 3 years prior, not on any cardiac medications for
unclear reason. Trop/CK elevated, MB flat. Not having chest
pain/discomfort, EKG reassuring. The patient was started
aspirin 81mg QD for prophylaxis. A statin was not initiated
given that the patient complains of proximal muscle cramping in
the setting of an elevated CK.
#DM2: A1c measured at ~6.5, and during his hospital course his
insulin requirement decreased quickly due to reduction in renal
clearance. Previously on 70u 70/30 humalog, now currently taking
10-20u [**Hospital1 **] of 70/30.
#HTN: Stable. The patient was continued on home doses of
amlodipine and enalapril for this chronic issue.
Transitional Issues:
-Adding a statin should be readdressed as an outpatient once the
patient's CK and proximal muscle cramping resolves
-Consideration may be made as an outpatient as to starting a
beta blocker
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Enalapril Maleate 20 mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Rosuvastatin Calcium 5 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Torsemide 100 mg PO DAILY
6. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
7. 70/30 10 Units Breakfast
70/30 10 Units Dinner
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Enalapril Maleate 20 mg PO DAILY
4. 70/30 10 Units Breakfast
70/30 10 Units Dinner
5. Aspirin 81 mg PO DAILY
RX *aspirin [Aspirin Low Dose] 81 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
6. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth once a day Disp #*8 Capsule Refills:*0
7. Vitamin D 50,000 UNIT PO 1X/WEEK ([**Doctor First Name **])
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth
three times a day Disp #*180 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Initiation of dialysis
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname **],
As you know you were seen in the hospital for evaluation of your
fainting and to start dialysis. We did a number of studies to
better understand you fainting. We found no irregular heart
rhythms and an ultrasound study of your heart was normal. We
talked with the neurologists who agreed with us that you were
not having a seizure and these episodes are likely related to
transient changes in your blood pressure.
We also started dialysis while you were here. You had an
episode of unresponsiveness while you were having your first
dialysis session, but the kidney doctors think that this was
probably related to the changes that your body was going through
in your first session. You had no major complications in your
later sessions. However, your body may take some time to adjust
after dialysis and you should be careful and not stand up too
fast. Please do not drive till you follow up with Neurology.
We made the following changes to your medications:
Started:
-Aspirin
-Nephrocaps
-Sevelamer Carbonate
Stopped:
-Torsemide
-Rosuvastatin
Followup Instructions:
Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 56756**], MD
Specialty: Primary Care
When: Friday [**8-11**] at 9am
Location: [**Location (un) 2274**]-[**University/College **]
Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 31449**]
Phone: [**Telephone/Fax (1) 56757**]
Please discuss with Dr. [**First Name (STitle) 1022**] about seeing a neurologist for your
recurrent syncopal episodes. Our physicians here recommend you
see an autonomic neurologist. Please discuss this with Dr. [**First Name (STitle) 1022**]
or obtain a referral by calling his office.
|
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25,711
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4159+55549
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Discharge summary
|
report+addendum
|
Admission Date: [**2111-1-23**] Discharge Date: [**2111-1-29**]
Service: MEDICINE
Allergies:
Calcium Channel Blocking Agents-Benzothiazepines / Ace
Inhibitors
Attending:[**First Name3 (LF) 689**]
Chief Complaint:
N/V, Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
[**Age over 90 **] y.o. female, resident at [**Hospital3 2558**] with PMHx significant
for multiple abdominal surgeries, including Billroth 2 revised
with conversion to Roux-en-Y gastrojejunostomy for PUD and
subtotal colectomy with ostomy for perforated bowel as well as
CAD s/p CABG in '[**98**] with patent grafts in '[**06**], atrial
fibrillation, HTN, hypothyroidism who presents with a chief
complaint of RLQ abdominal pain since last night. Patient has
chronic abdominal pain, usually occuring after meals, thought to
be an anginal equivalent - often responding to SL nitro. She is
reported to have suddenly grabbed the RLQ of her abdomen
lastnight complaining of pain. She later had an episode of
"coffee-ground" emesis that was reportedly gastrocult negative.
Her ostomy output has not been melanic or with gross blood. She
denies chest pain, shortness of breath, increased ostomy output,
dysuria or hematuria. She was brought in to the [**Hospital1 18**] ER for
further evaluation.
.
In the ED, vitals were T - 99.6, HR - 90, BP - 138/82, RR - 24,
O2 - 94% (unclear if on room air). She later spiked to 103.6 and
was increased to 4 liters O2 with 96% saturation. Blood cultures
and UA/UCx were drawn with UA strongly positive for UTI. CXR
also showed perihilar opacities concerning for PNA and patient
was empirically started on Levofloxacin and Flagyl. The
abdominal pain was evaluated with a CT abdomen, which was
initially concerning for an obstruction as minimal contrast was
seen at the patient's colostomy. A subsequent KUB then showed
sufficient contrast through to the colostomy site, which along
with an unremarkable surgical evaluation was ressuring for the
absence of a bowel obstruction. EKG showed new STD in the
lateral leads and patient was given ASA. Her blood pressure was
tenuous so she was not given a beta-blocker. CEs were sent off
and the patient was admitted to medicine for further work-up.
ROS: Only remarkable for that mentioned above. Per report from
[**Hospital3 2558**] nurse, patient received her influenza vaccine on
[**2110-11-6**] and her Pneumovax on [**2108-11-1**].
.
On admission to the ICU after being in the ED for 22 hours,
she was feeling well with no real complaints. She did note that
her abdomen was mildly tender diffusely with palpation, but
denied dizziness, cp, sob, nausea, vomiting. Her initial vs on
admission to the ICU were, T 97, BP 142/52, R 18, O2 95% 4 L NC,
HR 72.
Past Medical History:
1. PUD s/p Billroth 2, about 50y ago, recently s/p revision and
conversion to Roux-en-Y gastrojejunostomy with placement of
jejunal feeding tube [**1-3**] due to bleeding marginal ulcer at
anastomotic site
2. CAD s/p CABG [**2098**] SVG -> RCA, SVG -> LAD, SVG -> LCx, cath
[**8-3**] confirmed patent grafts
3. perforated bowel secondary to fecal impaction s/p subtotal
colectomy c ostomy [**2099**]
4. paroxysmal atrial fibrillation
5. hypertension
6. CHF, last echo [**2108-1-27**] EF 30-40%
7. B12 deficiency
8. hypothyroidism
9. breast cancer s/p lumpectomy and XRT [**2101**]
10. macular degeneration
11. chronic renal insufficiency
12. right corona radiata stroke [**1-3**]
13. chronic abdominal pain
Social History:
Smokes a few cigarettes a day, occasional alcohol consumption,
and denies illicit drugs. Patient states that she used to smoke
more. She was born in [**Location (un) 86**] and has been a life-[**First Name8 (NamePattern2) **] [**Location (un) 86**]
resdident. She lives currently at [**Hospital3 **] in [**Location (un) 583**],
MA. Prior to that she lived alone and was independent. Her
husband passed away several years ago. She has 3 daughters who
are all in her 60s. She has 3 grandsons, 1 great-grandson, and 1
great-granddaughter. [**Name (NI) **] health care proxy is her daughter,
[**Name (NI) **] [**Name (NI) 6955**] ([**Telephone/Fax (1) 18144**]).
Family History:
Both parents passed away, unknown cause per patient. Denies
family h/p CAD, MI, cancer, CVA, DM.
Physical Exam:
PE on MICU admission:
Vitals: T 97, BP 142/52, R 18, O2 sat 95% 4L NC, HR 72
General: Awake, alert, oriented x 3, pleasant, NAD
HEENT: NC/AT; PERRLA; OP clear with dry mucous membranes
Neck: Supple, no LAD, no JVD
Chest/CV: S1, S2 nl, no m/r/g appreciated
Lungs: CTAB
Abd: Soft, diffusely tender to palpation, + BS, ostomy in place,
well-appearing, draining green stool that is guaiac positive
Ext: No c/c/e
Neuro: Grossly intact
Skin: No lesions
Pertinent Results:
EKG: sinus, nl intervals, prolonged PR, narrow QRS, TWI in V4-V6
(new compared to prior)
.
Labs: (see below)
.
Imaging:
CXR ([**1-22**]): Patient is status post median sternotomy and CABG.
There
is stable borderline cardiomegaly. The thoracic aorta is
calcified and tortuous. There are new perihilar patchy airspace
opacities concerning for aspiration or pneumonia. No
pneumothorax or sizable pleural effusion. Osseous structures are
grossly unremarkable.
IMPRESSION: Perihilar airspace disease with air bronchograms
concerning for aspiration or pneumonia.
.
CT Abdomen/Pelvis ([**1-23**]):
1. Perihilar and left basilar airspace consolidation concerning
for
aspiration or pneumonia.
2. Mild gaseous distention of the afferent limb of the Roux-en-Y
with enteric contrast seen within the efferent limb extending to
the left pelvis with more distal collapsed loops of distal ileum
extending to the right ileostomy. Some enteric contrast does
appear to extend to the ostomy site. It is unclear if the
findings are secondary to the relatively short oral prep time or
represent
a very early small-bowel obstruction. Continued surveillance is
recommended.
3. Stable cystic lesion in the head of the pancreas.
4. Unchanged severe compression deformity of the L2 vertebral
body.
5. Dense calcification throughout the intra-abdominal arterial
vasculature.
.
KUB ([**1-23**]):
A nonobstructed bowel gas pattern is evident
with oral contrast seen projecting over the right lower lobe
ostomy. There is a dense right renal shadow and contrast seen
within both ureters from a recent CT scan. There is mild gaseous
distention of the stomach. The lungs demonstrate perihilar
airspace opacities concerning for pneumonia or aspiration. The
aorta is calcified and ectatic. Again noted is a compression
fracture of L2 with severe dextroscoliosis of the lumbar spine.
IMPRESSION: Satisfactory bowel gas pattern with progression of
enteric contrast through the right lower abdominal ostomy.
Brief Hospital Course:
A/P: [**Age over 90 **] y.o. female with PMHx of multiple abdominal surgeries,
CAD s/p CABG, a. fib, hypothyroidism who presents with acute on
chronic abdominal pain, found to have UTI and overall septic
picture.
.
# Sepsis from UTI: Pt initially with tacchycardia and
hypotension which resolved with fluids, and + UA. Patient did
have slight lactate elevation to 3.0, which resolved, and
remained afebrile throughout stay. Urine Cx showed
+Pansensitive E.coli. Pt intially started on Vancomycin and
zosyn empirically, narrowed to ceftriaxone, and then cipro for
14 day total course. Foley was removed before discharge.
.
# Abdominal Pain: Pt with chronic abdominal pain which worsened
the morning of [**1-24**] in the setting of suspected sepsis from UTI.
Pain greatest in LUQ pain, but abdomen was soft and mildly
tender. Lactate initially elevated, but resolved. Upright KUB
showed no free air or obstruction. Pt was transitioned to a PPI
[**Hospital1 **] and given tylenol q6hr for pain. C diff was negative x2,
and pt had normal ostomy output. Abdomininal pain improved on
HD 3 when transfered to floor, and pt quickly advanced to full
diet. Did have reoccurance of general abdominal pain, but
reports similar to previous ab pain. Treated with tylenol
# Anemia: Pt had anemia and recieved several blood transfusions.
Subsequent hcts have been stable
.
# Atrial Fibrillation: On Coumadin as an outpatient with
subtherapeutic INR intially. Patient's CHADS2 score is 2 (HTN,
age; patient is reported to have had a CVA, but previous head
imaging is unremarkable), which puts her at moderate risk of
embolic event for which she is on Coumadin. Initially held given
coagulopathy and concern for GIB. Coumadin was restarted at 1
mg of [**1-24**] with a theraputic INR. Concern for interaction with
ciprofloxacin, so ctm INR. PT became tacchycardic to the 130's
and betablockers were titrated to a HR of approximately 80.
Will d/c pt on elevated level of BB; metoprolol XL at 175 [**Hospital1 **].
.
# Tacchypnea: Pt with tachypnea and bilateral basilar crackles
on exam. Perihilar opacities on CXR, but not overtly suggestive
of pna, but with vascular congestion. PT denies cough or sputum
production and remained afebrile. Pt recieved gentle diuresis
with lasix - approx 1 L, with resolution of tacchypnea and
subsequently maintained adequate O2 saturations on room air.
.
# CAD: S/P CABG in [**2098**] with functional grafts demonstrated on
cath in [**2106**]. Currently denies CP, but EKG does show new TWI in
lateral leads. Patient is on BB, ASA, statin as an outpatient.
Transiently held beta-blockade to to hypotension, but then
restarted; patient continued on ASA and statin. Ruled out for MI
with 2 sets of ces 12 hrs apart. Last Echo was [**10-6**] and showed
EF of 50-55%. Continued home statin, asprin and betablocker
.
#. HTN; Initially held antihypertensives in setting of
hypotension, but then returned the BB in form of metoprolol.
Metoprolol increased to titrate HR, with no adverse affect on
BP. Will hold amlodipine as pt has well controled BP and HR on
metoprolol
.
# ARF: Creatinine increased to 1.6, from 1.1, likely prerenal in
the setting of vomiting and insensible losses while febrile. CT
abdomen did not demonstrate kidney stones or signs of
obstruction. Urine lytes c/w prerenal process as una is < 10.
Resolved with IFV
.
# Hypothyroidism; Continue home Levothyroxine
.
# Transaminitis/Elevated Pancreatic Enzymes: resolved in MICU
with hydration
.
# FEN; continued regular diet
.
# [**Month/Year (2) 5**]; continued home coumadin at a lower dose due to concerns
of interaction with cipro. Pt was placed on a PPI
.
# Code status: DNR/DNI per conversation with patient and
patient's daughter. Also documented on previous
hospitalizations. [**Name (NI) **] HCP and daughter is [**Name (NI) **]
[**Name (NI) 6955**], NP - ([**Telephone/Fax (1) 18146**] (c), ([**Telephone/Fax (1) 18147**] (h)
Medications on Admission:
Medications:
Calcitonin Salmon 200 Units Daily
Acetaminophen 325 mg PO Q6H
Levothyroxine Sodium 80 mcg PO Daily
Aluminum-Magnesium Hydrox.-Simethicone 30 ml PO TID
Loperamide 2 mg PO QID:PRN
Amlodipine 5 mg PO HS
Mirtazapine 45 mg PO HS
Artificial Tears 1-2 DROP BOTH EYES TID
Nitroglycerin SL 0.4 mg SL after meals and PRN
Aspirin 81 mg PO DAILY
Pantoprazole 40 mg PO Q24H
Atenolol 100 mg PO DAILY --> metoprolol inpatient
Atorvastatin 10 mg PO HS
Warfarin 2 mg PO DAILY AT 5PM
.
Allergies/Adverse Reactions:
Pt. denies allergies, but per OMR
CCB ([**Last Name (un) 5487**])
Ace-Inhibitors (unknown)
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day).
5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO qid; prn as
needed.
6. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-31**]
Drops Ophthalmic TID (3 times a day).
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual qac and prn.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 10 days.
14. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO twice a day.
15. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO twice a day.
Tablet Sustained Release 24 hr(s)
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 2558**] - [**Location (un) **]
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Good
Discharge Instructions:
You were hospitalized with a urinary tract infection. Which has
been treated with antibiotics (ciprofloxacin)
Treatment:
* Be sure to take the antibiotics exactly as prescribed and
complete the entire course, even if you are feeling better. If
you stop early, the infection could come back.
* We changed your blood pressure medications by increasing your
betablocker and stopping your amlodipine
* We also decreased your warfarin because it can interact with
the antibiotic you are recieving. Please continue to follow
your INR and adjust the coumadin appropriately.
* Otherwise, you should return to your regular home medications
Warning Signs:
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* You have shaking chills or fevers greater than 102 degrees(F)
or lasting more than 24 hours.
* You aren't getting better within 48 hours, or you are getting
worse.
* New or worsening pain in your abdomen (belly) or your back.
* You are vomiting, especially if you are vomiting your
medications.
* Your symptoms come back after you complete treatment.
* Your abdominal pain is worsening your you have any other
concerns
Followup Instructions:
Follow up with your primary care physician in the next two
weeks. Please call [**Telephone/Fax (1) 18145**] to make an appointment
Name: [**Known lastname 2923**],[**Known firstname **] Unit No: [**Numeric Identifier 2924**]
Admission Date: [**2111-1-23**] Discharge Date: [**2111-1-29**]
Date of Birth: [**2019-6-3**] Sex: F
Service: MEDICINE
Allergies:
Calcium Channel Blocking Agents-Benzothiazepines / Ace
Inhibitors
Attending:[**First Name3 (LF) 2925**]
Addendum:
Pt was not discharged due to elevated HR in the 130's. Pt
reamined for an additional day and 30 mg diltiazem q6hr was
added to regimen with good control of HR - in the 80-100 range.
Pt will be discharged with additional medication of Diltiazem XR
30 mg QID.
Discharge Medications:
1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) Nasal DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours).
3. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig:
15-30 MLs PO TID (3 times a day).
5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO qid; prn as
needed.
6. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).
7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-31**]
Drops Ophthalmic TID (3 times a day).
8. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual qac and prn.
9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours) for 8 days.
14. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: Three (3) Tablet Sustained Release 24 hr PO BID (2 times a
day).
15. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 901**] - [**Location (un) 382**]
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Good
Discharge Instructions:
You were hospitalized with a urinary tract infection. Which has
been treated with antibiotics (ciprofloxacin)
Treatment:
* Be sure to take the antibiotics exactly as prescribed and
complete the entire course, even if you are feeling better. If
you stop early, the infection could come back.
* We changed your blood pressure medications so do not take your
previous atenolol and amlodipine
* your new blood pressure medications are Toperol XL and
Diltiazem
* Please check blood pressure and heartrate 4x per day and
notify MD at rehab if SBP < 100 or above 170 or if HR is < 60 or
above 130. Titrate blood pressure and HR medications to
parameters [**Name6 (MD) **] rehab MD
* Please check INR and electrolytes on [**2111-1-30**] and notify MD at
rehab with results. INR will need to be monitored every 2 days
or more often once cipro ends, as INR levels will change.
Please refer to rehab MD
* Otherwise, you should return to your regular home medications
Warning Signs:
Call your doctor or return to the Emergency Department right
away if any of the following problems develop:
* You have shaking chills or fevers greater than 102 degrees(F)
or lasting more than 24 hours.
* You aren't getting better within 48 hours, or you are getting
worse.
* New or worsening pain in your abdomen (belly) or your back.
* You are vomiting, especially if you are vomiting your
medications.
* Your symptoms come back after you complete treatment.
* Your abdominal pain is worsening your you have any other
concerns
Followup Instructions:
Follow up with your primary care physician in the next two
weeks. Please call [**Telephone/Fax (1) 2926**] to make an appointment
[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2927**] MD [**MD Number(2) 2928**]
Completed by:[**2111-1-29**]
|
[
"V44.3",
"789.03",
"V12.71",
"585.9",
"285.9",
"V45.81",
"V44.4",
"414.00",
"244.9",
"428.0",
"266.2",
"038.42",
"995.92",
"305.1",
"403.90",
"599.0",
"584.9",
"427.31",
"578.1",
"V10.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04"
] |
icd9pcs
|
[
[
[]
]
] |
16262, 16334
|
6779, 10709
|
292, 298
|
16402, 16409
|
4783, 6756
|
17964, 18254
|
4201, 4299
|
14942, 16239
|
16355, 16381
|
10735, 11339
|
16433, 17941
|
4314, 4764
|
233, 254
|
326, 2764
|
2786, 3507
|
3523, 4185
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
63,992
| 143,195
|
38883
|
Discharge summary
|
report
|
Admission Date: [**2169-4-5**] Discharge Date: [**2169-5-12**]
Date of Birth: [**2113-6-7**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 32612**]
Chief Complaint:
Gastric adenocarcinoma
Major Surgical or Invasive Procedure:
[**2169-4-5**]:
1. Exploratory laparotomy.
2. Full mobilization of the stomach and porta hepatis with D1
lymphadenectomy.
3. Total gastrectomy.
4. Roux-en-Y esophagojejunostomy.
5. Feeding jejunostomy
.
[**2169-4-16**]: Technically successful CT-guided left flank collection
with 10 French pigtail catheter insertion.
.
[**2169-4-18**]:
1. Mesenteric/splenic arteriograms with coil and Gelfoam
embolization of pseudoaneurysm/transected vessel arising from
the inferior pole branch of splenic artery.
2. Uncomplicated fluoroscopic-guided replacement of left abdomen
10 French drainage catheter with a 12 French catheter
.
[**2169-4-30**]: Technically successful CT-guided left flank collection
with 12 French pigtail catheter insertion.
.
[**2169-5-3**]: Colonoscopy
.
[**2169-5-8**]: Evacuation and drainage of infected perisplenic
hematoma with placement of the VAC.
History of Present Illness:
The patient is a 55 year old Mandarin-speaking male, who
presented with
epigastric pain 1 year ago and decreased appetite. He was
referred for EGD on [**2169-3-20**] (performed by Dr. [**Last Name (STitle) 31960**]
which was revealing for a circumferential 2cm mass at the
cardia, the scope was able to traverse the mass. Biopsy of the
mass returned poorly differential adenocarcinoma. Biopsy of the
GJ junction revealed focal intestinal metaplasia most likely
secondary to Barrett's, and antral biopsy showed chronic active
gastritis with organisms consistent with H.Pylori. The patient
underwent treatment for H.Pylori. He was evaluated (with
interpreter) by Dr. [**Last Name (STitle) **] for total gastrectomy. The elective
operation was scheduled on [**2169-4-5**] after all risk, benefits and
possible outcomes were explaned to the patient and his family.
Past Medical History:
PMH: BPH, hemorrhoids
Social History:
He has never smoked, and does not drink alcohol. He works as a
cook, and lives in an extended family with his son.
Family History:
His family history is unrevealing for any history of carcinoma,
he has 3 brothers and 1 sister all in good health.
Physical Exam:
On Discharge:
VS: 98.6, 67, 128/75, 14, 98% RA
GEN: NAD, AAO x 3
CV: RRR
RESP: Diminished R > L
ABD: Midline abdominal incision well healed. RLQ with JP drain
to bulb suction, site with minimal erythema and yellowish
purulent drainage. Left subcostal incision with wound VAC to
-125 mmHg suction, LLQ old IR drain site OTA with dry dressing
and minimal purulent exudate. LUQ JP drain to bulb suction and
site with minimal erythema, drain with moderate amount of
brownish-bloody drainage. J-tube at midline and patent, site
c/d/i.
Extr: Warm, +PP.
Pertinent Results:
[**2169-4-6**] 5:00 am IMMUNOLOGY
**FINAL REPORT [**2169-4-7**]**
HCV VIRAL LOAD (Final [**2169-4-7**]): HCV-RNA NOT DETECTED.
[**2169-4-5**] EKG:
Sinus rhythm. Compared to the previous tracing of [**2169-3-31**]
tracing remains
normal.
[**2169-4-9**] EKG:
Sinus tachycardia. Incomplete right bundle-branch block.
Compared to the
previous tracing the sinus rate has increased. There is a more
prominent
right-sided conduction delay. Clinical correlation is suggested.
[**2169-4-10**] UPPER GI:
IMPRESSION:
No evidence of leak or stricture.
Pathology Examination
Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 86285**],[**Known firstname 86286**] [**2113-6-7**] 55 Male [**Numeric Identifier 86287**] [**Numeric Identifier 86288**]
Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/dif
SPECIMEN SUBMITTED: Tissue from porta hepatis, gastrohepatic
ligament, gastric node, superior pancreatic node, crus nodule,
additional esophageal margin, stomach.
Procedure date Tissue received Report Date Diagnosed
by
[**2169-4-5**] [**2169-4-5**] [**2169-4-13**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/dsj??????
Previous biopsies: [**Numeric Identifier 86289**] GI BIOPSIES (3 JARS).
DIAGNOSIS:
1. "Tissue from porta hepatis" (A):
Unremarkable fibroadipose tissue, no malignancy identified.
2. Left gastric node (B):
Metastatic adenocarcinoma present in three of four lymph nodes
([**3-5**]).
Confirmed with cytokeratin immunohistochemistry; controls are
adequate.
3. Additional esophageal margin final (C-D):
Unremarkable esophagus; no malignancy identified.
Confirmed with cytokeratin immunohistochemistry on blocks C+D
with adequate controls.
4. Superior pancreatic node (E-F): Metastatic adenocarcinoma
present in three of three lymph nodes ([**3-4**]).
Confirmed with cytokeratin immunohistochemistry, controls are
adequate.
5. Additional esophageal margin, intermediate (G): Unremarkable
esophagus, no malignancy identified.
6. Gastrohepatic ligament (H-J): Unremarkable fibroadipose
tissue, no malignancy identified.
7. Anus nodule (K): Leiomyoma, 0.8 cm; immunohistochemistry is
strongly positive for actin and desmin. Ckit is negative in
lesional cells with adequate controls.
8. Stomach (L-AK): Gastric adenocarcinoma, poorly
differentiated (signet ring cell type); see synoptic report.
Chronic inactive gastritis with intestinal metaplasia.
Immunohistochemical stain for Helicobacter is negative with
adequate controls on blocks X and Y.
Accessory spleen, 0.5 cm.
Stomach: Resection Synopsis
Staging according to American Joint Committee on Cancer Staging
Manual -- 7th Edition, [**2166**]
MACROSCOPIC
Specimen Type: Total gastrectomy.
Tumor Site: Cardia
Tumor configuration: Diffusely infiltrative.
Tumor Size: Greatest Dimension: 6.7 cm. Additional dimensions:
6.3 cm x cm.
MICROSCOPIC
Histologic Type: Signet-ring cell carcinoma (greater than 50%
signet-ring cells).
Histologic Grade: G3: Poorly differentiated.
Primary Tumor: pT4a: Tumor invades serosa (visceral
peritoneum).
Regional Lymph Nodes: pN3: Metastasis in 7 or more perigastric
lymph nodes.
Lymph Nodes
Number examined: 32 (includes specimen #2)
Number involved: 7.
Distant metastasis: pM1: Distant metastasis. Site(s):
Superior pancreatic lymph node (specimen #4).
MARGINS
Proximal margin: Uninvolved by invasive carcinoma.
Distal margin: Uninvolved by invasive carcinoma.
Omental (radical) margin: Uninvolved by invasive carcinoma.
Distance from closest margin: Approximately 12 mm.
Specified margin: Proximal esophageal margin.
Treatment Effect: No prior treatment.
Lymphatic (Small Vessel) Invasion: Present.
Venous (Large vessel) invasion: Absent.
Perineural invasion: Present.
Clinical: Gastric cancer.
[**2169-4-15**] CT ABD:
IMPRESSION:
1. Irregularity of the anterior pole of the spleen suspicious
for splenic
laceration.
2. Perisplenic and left flank fluid collections with internal
hyperdensity
concerning for hemorrhage within the fluid collections, likely
due to splenic laceration. The perisplenic and left flank fluid
collections are
rim-enhancing suggestive of infection.
3. Enhancement of the peritoneum along the left paracolic gutter
extending
from the spleen to the iliac crest consistent with peritonitis.
4. Intermediate density adjacent to the jejunojejunal
anastomosis. This may represent a collapsed bowel loop or could
represent fluid collection; suggest correlation with operative
history.
4. Generalized small bowel ileus extending from the
jejunojejunal anastomosis to the level of the terminal ileum.
5. No definite oral contrast extravasation is identified. The
single phase
study cannot identify active extravasation. CTA recommended if
this is of
concern.
6. Stable appearance of cystic papillary renal cell carcinoma
within the left lower pole.
7. Stable diffuse hepatic cysts.
8. Stable size of papillary RCC within the left lower pole.
8. Scattered colonic diverticulosis without evidence of acute
diverticulitis.
[**2169-4-18**] CTA ABD:
IMPRESSION:
1. Interval marked enlargement of a parasplenic hematoma with
suspicion for active extravasation from an anterior branch of
the splenic artery vs
pseudoaneurysm. An alternative source of bleeding may be the
anterior aspect of the splenic hilum where there is a
laceration. An interventional radiology consultation is
recommended.
3. Moderate blood and blood products within the pelvis.
4. Stable appearance of a previously characterized cystic
papillary renal
cell carcinoma within the lower pole of the left kidney.
[**2169-4-20**] UPPER GI:
IMPRESSION: No extravasation identified. If there is further
concern for
leak, CT with oral gastrografin can be considered.
[**2169-4-25**] UPPER GI:
IMPRESSION: Injection of contrast into the jejunostomy tube and
orally
administered contrast demonstrates normal esophagojejunal
anastomosis without evidence of leak or obstruction. The
jejunojejunal anastomosis could not be visualized. Study was
slightly limited due to the patient's difficulty taking oral
contrast.
[**2169-4-28**] ABD CT:
IMPRESSION:
1. Mild interval decrease in size of perisplenic bilobed
hematoma with a
surgical drain noted at the junction of the two lobes.
2. Previously visualized free fluid throughout the abdomen has
now organized into three rim-enhancing fluid collections, which
are suspicious for infectious as described above. Continued
followup is recommended.
3. There is new thickening of the sigmoid colon suggestive of
colitis.
4. Stable appearance of previously characterized cystic
papillary renal cell carcinoma within the lower pole of the left
kidney.
5. Multiple cysts are again noted in the liver.
6. Small left pleural effusion and trace right pleural effusion
with adjacent atelectasis.
[**2169-5-5**] ABD CT:
CONCLUSION:
1. New hematoma is seen in the left lateral abdominal wall at
the insertion site of the pigtail drain.
2. Mild interval decrease in size of the perisplenic known
organized hematoma (both superior segment and inferior segment).
3. Decrease in size in the small fluid collection superior to
the
jejunojejunostomy.
4. Decrease in size in the right lower lobe fluid collection.
5. Questionable fistula between the descending colon and the
inferior fluid collection.
[**2169-5-5**] FISTULOGRAM:
IMPRESSION: No evidence of perisplenic colonic fistula.
[**2169-5-10**] 06:40AM BLOOD WBC-5.5 RBC-3.05* Hgb-8.6* Hct-27.1*
MCV-89 MCH-28.2 MCHC-31.8 RDW-13.7 Plt Ct-548*
[**2169-5-11**] 06:35AM BLOOD Glucose-132* UreaN-9 Creat-0.5 Na-132*
K-4.1 Cl-100 HCO3-26 AnGap-10
MICRO:
[**2169-5-1**] 8:06 am FLUID,OTHER LEAKING SPECIMEN.
POSSIBLE SPECIMEN CONTAMINATED. INTERPRET RESULTS WITH
CAUTION.
SPECIMEN TYPE WAS CONFIRMED BY DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **](IR
DRAIN).
GRAM STAIN (Final [**2169-5-1**]):
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CHAINS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2169-5-1**]
@1430.
FLUID CULTURE (Final [**2169-5-8**]):
ESCHERICHIA COLI. MODERATE GROWTH.
Piperacillin/tazobactam sensitivity testing available
on request.
DR [**Last Name (STitle) **] [**Name (STitle) **] ([**Numeric Identifier 11536**]) REQUESTED
Piperacillin/Tazobactam
SUSCEPTIBILITIES [**2169-5-1**].
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
ENTEROCOCCUS SP.. SPARSE GROWTH.
Daptomycin REQUESTED BY DR.[**Last Name (STitle) **] #[**Numeric Identifier 86290**] [**2169-5-6**].
SENSITIVE TO Daptomycin MIC = 4.0 MCG/ML, Sensitivity
testing
performed by Etest.
ESCHERICHIA COLI. RARE GROWTH. SECOND MORPHOLOGY.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ENTEROCOCCUS SP.
| | ESCHERICHIA
COLI
| | |
AMIKACIN-------------- <=2 S <=2 S
AMPICILLIN------------ =>32 R =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I 16 I
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- <=1 S 2 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- =>64 R 32 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
DAPTOMYCIN------------ S
GENTAMICIN------------ =>16 R =>16 R
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S <=0.25 S
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- S S
TOBRAMYCIN------------ 8 I 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
VANCOMYCIN------------ =>32 R
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
[**2169-5-1**] 8:07 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT [**2169-5-7**]**
GRAM STAIN (Final [**2169-5-1**]):
3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
IN PAIRS AND CLUSTERS.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
3+ (5-10 per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI.
IN CHAINS.
Reported to and read back by DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2169-5-1**]
@1430.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Final [**2169-5-7**]):
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT in this culture..
STAPH AUREUS COAG +. QUANTITATION NOT AVAILABLE.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
VANCOMYCIN AND Daptomycin REQUESTED BY DR.[**Last Name (STitle) **]#[**Serial Number 86290**]
[**2169-5-6**].
Daptomycin IS SENSITIVE AT 0.19MCG/ML ( Sensitivity
testing
performed by Etest ).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final [**2169-5-5**]):
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
[**2169-5-3**] 7:15 pm BLOOD CULTURE
**FINAL REPORT [**2169-5-9**]**
Blood Culture, Routine (Final [**2169-5-9**]): NO GROWTH.
[**2169-5-4**] 12:12 am URINE Source: CVS.
**FINAL REPORT [**2169-5-5**]**
URINE CULTURE (Final [**2169-5-5**]): NO GROWTH.
Brief Hospital Course:
The patient with biopsy proven gastric adenocarcinoma was
admitted to the Surgical Oncology Service for elective total
gastrectomy. On [**2169-4-5**], the patient underwent exploratory
laparotomy, full mobilization of the stomach and porta hepatis
with D1 lymphadenectomy, total gastrectomy, Roux-en-Y
esophagojejunostomy and placement of J-tube, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO/NGT, on IV fluids and
antibiotics, with a foley catheter, and epidural catheter for
pain control. The patient was hemodynamically stable.
Neuro: The patient received Fentanyl/Bupivacaine via epidural
catheter immediately post op. The patient continued to have
severe post operative pain and epidural was removed on POD # 2,
patient was started on Dilaudid PCA with IV Toradol with good
effect and adequate pain control. PCA was discontinued on POD #
5, the patient's pain was controlled with IV Dilaudid prn. When
tolerating oral intake, the patient was transitioned to liquid
Roxicet which given via patient's J-tube.
CV: The patient remained stable from a cardiovascular standpoint
with episodes of intermittent tachycardia though to be secondary
for pain. The patient's tachycardia continued to persist
throughout hospitalization and he was started on IV Metoprolol
with good effect. HR returned to regular rate.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO with IV fluids.
Tubefeed was started on POD # 1, and tubefeed was advanced to
goal on POD # 4. On POD # 5, patient underwent upper GI study
which was negative for leak and his diet was advanced to sips of
clears on POD # 6. Diet was advanced to clears on POD # 8 and to
fulls on POD # 9. The patient's diet was advanced to regular
post gastrectomy diet. The patient oral intake was inadequate
and tube feed was continued throughout the hospitalization. The
patient was on TPN from [**4-22**] to [**4-26**]. Electrolytes were
routinely followed, and repleted when necessary. The patient was
followed by Nutritional Service during his hospitalization, he
was educated about post gastrectomy diet and importance to
continue to take daily supplements.
GU: The foley catheter was discontinued at midnight of POD# 3.
The patient subsequently voided without problem.
ID/Infected Hematoma: The patient's white blood count and fever
curves were closely watched for signs of infection. Wound was
evaluated daily and on POD # 5 blanching erythema was noticed
around incision. The patient was started on IV Ancef, erythema
started to improve and subsided on POD # 9. The patient received
Ancef/Kefzol for 7 days total. Prior discharge, On POD # 7,
patient spiked low grade fever, his blood and urine were sent to
microbiology and they were negative. He continued to spike fever
and CT was obtained on [**2169-4-15**]. CT demonstrated Perisplenic and
left flank fluid collections concerning for hemorrhage, likely
due to splenic laceration, the perisplenic and left flank fluid
collections were rim-enhancing suggestive of infection. On [**4-16**],
patient underwent IR drainage with drain placement into left
flank collection. On [**4-17**], patient's HCT dropped from 30 to 26
and patient's tachycardia increased to 150 s. The patient
underwent abdominal CTA on [**4-18**], which demonstrated anterior
aspect splenic artery pseudoaneurysm and increased parasplenic
hematoma. The patient's pseudoaneurysm was coiled at the same
day and his pigtail drain was changed to 12 French from 10. The
patient was transferred in ICU after procedure secondary to
tachycardia. The patient received 8 units of pRBC and 4 units of
Plasma during and post procedure, his post transfusion HCT was
38.1. The patient was transferred on the floor on [**2169-4-19**]. JP
amylase was sent on [**4-19**] and was high ([**Numeric Identifier 86291**]) concerning for
possible leak. On [**2169-4-20**], patient underwent upper GI check
which was negative, but TF was held and patient started on TPN.
On [**4-25**] repeat Upper GI swallowing test was negative for leak
and TF was restarted. IR drain was removed on [**2169-4-27**], patient
started to have bloody bowel movements, his abdominal pain
increased and GI was consulted. Repeat abdominal CT on [**4-28**]
demonstrated decreased rim-enhancing perisplenic hematoma
concerning for continued infection and sigmoid colon thickening
suggestive of colitis. Patient's HCT was stable and no
intervention were required at that time. Abdominal pain
continued to increase and on [**4-30**] patient underwent IR guided
left flank collection drainage with 12 French pigtail catheter
insertion, fluid was sent for microbiology. Gram stain was
positive for gram negative and gram positive growth and patient
was started on Vancomycin and Zosyn. On [**2169-5-3**] patient
underwent colonoscopy s/t persistent bloody BMs. Colonoscopy
demonstrated internal hemorrhoids, but no active bleeding was
seen. The patient's cultures came positive for E. Coli, Staph.
Aureus Coag positive and Enterococcus and Zosyn was changed to
Cefepime. The patient continued to have daily fevers and he
developed persistent erythema around his IR drain. On [**5-5**]
patient underwent abdominal CT, which demonstrated new hematoma
is seen in the left lateral abdominal wall at the insertion site
of the pigtail drain, decrease in size of the perisplenic
organized hematoma and questionable fistula between the
descending colon and the inferior fluid collection. The patient
underwent fistulogram at the same day, which showed no evidence
of perisplenic colonic fistula. The final sensitivities were
available on [**5-6**] and patient's antibiotic treatment was changed
to Zosyn and Daptomycin. The patient continued to have
persistent fever and increased left flank pain. On [**5-8**] he
underwent surgical evacuation and drainage of infected
perisplenic
hematoma with placement of vacuum-assisted closure device, the
patient tolerated operation well. Post op he was transferred in
ICU s/t tachycardia and hypotension. He was transferred to the
floor on [**2169-5-9**] in stable condition. The TF was continued at
goal, diet was advanced to regular post gastrectomy diet and IV
fluids were discontinued. The patient continued to do well, PICC
line was placed on [**2169-5-12**].
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible with Physical Therapy.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating TF at goal
minimal amount of the regular diet, ambulating, voiding without
assistance, and pain was well controlled.
Wound VAC was taken down prior discharge and will applied in
Rehab.
Medications on Admission:
None
Discharge Medications:
1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection three times a day.
2. doxazosin 8 mg Tablet Sig: One (1) Tablet PO at bedtime.
3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
6. oxycodone-acetaminophen 5-325 mg/5 mL Solution Sig: 1-2 MLs
PO Q4H (every 4 hours) as needed for pain.
7. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
8. Metoprolol Tartrate 2.5 mg IV Q6H
hold for SBP<100, HR<60
9. Piperacillin-Tazobactam 4.5 g IV Q8H
10. Daptomycin 460 mg IV Q24H
11. HYDROmorphone (Dilaudid) 0.5 mg IV PRN please give before
wound VAC change only
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 105**] Northeast - [**Location (un) 701**]
Discharge Diagnosis:
1. Metastatic signet-ring cell carcinoma (G3T4N3M1)
2. Chronic inactive gastritis with intestinal metaplasia
3. Splenic artery pseudoaneurysm
4. Perisplenic infected hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than [**5-11**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*Midline incision open to air.
*Left upper quadrant incision with VAC dressing. Dressing would
be changed by [**Month/Year (2) 269**] nurses every 72 hours.
*Flush Jtube every 8 hours with 30 cc of tap water and after
each use.
.
JP Drain Care x 2:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or [**Month/Year (2) 269**] nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
PICC Line:
*Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse
practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
Department: SURGICAL SPECIALTIES
When: FRIDAY [**2169-5-26**] at 1:45 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 79168**], MD [**Telephone/Fax (1) 274**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Completed by:[**2169-5-12**]
|
[
"998.59",
"285.1",
"E878.8",
"998.12",
"997.2",
"196.2",
"458.29",
"578.9",
"151.0",
"567.22",
"442.83"
] |
icd9cm
|
[
[
[]
]
] |
[
"41.2",
"96.6",
"99.29",
"54.91",
"39.79",
"96.72",
"43.99",
"40.3",
"88.47",
"46.39",
"45.23",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
24088, 24170
|
16224, 23271
|
325, 1197
|
24389, 24389
|
2981, 13552
|
27676, 28032
|
2282, 2399
|
23326, 24065
|
24191, 24368
|
23297, 23303
|
24540, 25121
|
25136, 27653
|
2414, 2414
|
13585, 16201
|
2428, 2962
|
263, 287
|
1225, 2087
|
24404, 24516
|
2109, 2133
|
2149, 2266
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
31,502
| 125,748
|
39
|
Discharge summary
|
report
|
Admission Date: [**2174-6-19**] Discharge Date: [**2174-7-4**]
Date of Birth: [**2093-11-17**] Sex: F
Service: MEDICINE
Allergies:
Atorvastatin
Attending:[**First Name3 (LF) 425**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Intubation and mechanical ventilation
Transesophageal echocardiogram
Esophagogastroduodenoscopy
History of Present Illness:
Ms. [**Known lastname 426**] is an 80yo woman with h/o CAD s/p recent PCI, severe
AS s/p valvuloplasty [**4-/2174**], and recently treated for possible
pneumonia with ceftazidime [**Date range (1) 427**] admitted with shortness of
breath and hypotension.
Ms. [**Known lastname 428**] husband reports that he has observed her breathing
very fast around 3 or 4 in the morning for the last couple of
nights. On the day of admissin, she woke up short of breath and
breathing quickly. He used a stethoscope (which he has to help
with home maintenance) and heard a hissing/wheezing on her right
chest, which prompted him to call 911. She continued breathing
fast until she was intubated in the ED with her consent. He
notes that she has had a minimally productive cough since her
last admission, though she has not had fevers or chills. She
had diarrhea for about a day recently, but this has resolved.
Her nephrologist contact[**Name (NI) **] her on [**6-16**] and advised her to
decrease her lasix from 160mg daily to 80mg because of her
rising creatinine. Despite this change, her daily weight has
remained stable at 119-120 pounds. She has been compliant with
1L fluid restriction.
In the ED, her initial VS were: 99.8 115 122/75 30s 82%
NRB. She was noted to have crackles on her pulmonary exam. She
was given rocuronium, etomidate, and versed and intubated
urgently. Shortly after propofol gtt was started, she dropped
her pressures into the into the 70s (per report; recorded in the
80s). Bedside Echo was done to evaluate for concern of
tamponade. Echo demonstrated large anterior fat pad and stable
small loculated pericardial effusion. Left cordis was placed
for hypotension; there was concern that the line might be in the
carotid, and CT was done to confirm placement. Radiology
reports that the line is in the left brachiocephalic vein.
Pressures increased to 110s after 500cc IV fluid bolus. She
received vanc, zosyn, levofloxacin, and ceftriaxone in the ED.
On review of symptoms, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, hemoptysis, black stools or red
stools. She denies recent fevers, chills or rigors. She denies
exertional buttock or calf pain.
Cardiac review of systems is notable for absence of chest pain,
ankle edema, palpitations, syncope or presyncope. +3 pillow
orthopnea, although she tends to move to flat position during
sleep. She does not sore and her husband denies witnessed
apneas, though she has never had a formal evaluation.
Past Medical History:
CAD--one vessel disease on cath in [**5-/2174**], s/p stent to LCx
Severe AS s/p valvuloplasty [**4-/2174**] ([**Location (un) 109**] from 0.56->0.74; Grad
from 24->12)
Chronic systolic CHF, EF 30-40%
HTN
s/p right nephrectomy [**2165**] for renal cell carcinoma
CRI with Cr 1.3-2.5 over last month, was on hemodialysis for one
month in [**2174-4-14**]
Scoliosis with chronic back pain on vicodin
h/o MRSA from LLE trauma in [**2173-7-14**]
h/o cholelithiasis
osteoarthritis
herpes zoster
Gastritis
h/o H. pylori
Anemia--baseline Hct 26-30
h/o right inguinal herniorrhaphy in [**2156**]
Myositis s/p muscle biopsy at [**Hospital1 112**], possibly related to statin
use
OUTPATIENT CARDIOLOGIST: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 120**]
PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 132**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**]
Nephrologist: [**First Name4 (NamePattern1) 429**] [**Last Name (NamePattern1) 118**]
ALLERGIES: statin--myositis
Social History:
Social history is significant for the absence of current tobacco
use; she smoked [**12-15**] PPD from age 18 to age 60. There is no
history of alcohol abuse; she occasionally has wine. Uses a
walker; no recent falls.
Family History:
There is a family history of premature coronary artery disease
or sudden death: her father died of a heart valve problem at
age 52 and 4 of her siblings had heart problems (though not
valvular disease).
Physical Exam:
VS: T 100.2, BP 123/85, HR 108, RR 25, O2 100% on AC 0.7 450
22 PEEP 8.
Gen: Elderly woman lying comfortably in bed, intubated,
following commands appropriately.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. Intubated.
Neck: Supple with JVP of 8 cm.
CV: PMI located in 5th intercostal space, midclavicular line.
Regular tachycardia with normal S1, S2. No S4, no S3. +III/VI
harsh systolic murmur at base.
Chest: +scoliosis. Resp were unlabored, no accessory muscle use.
No crackles, wheeze, rhonchi.
Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial
bruits.
Ext: No c/c/e. No femoral bruits.
Skin: No stasis dermatitis, ulcers, scars, or xanthomas.
Pulses:
Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 1+ DP
Pertinent Results:
Labs on admission:
WBC 19->11
Hct 27
BUN/Cr 90/2.3
HCO3 17
Glucose 340
INR 1.3
Cholesterol in [**2168**]:
HDL 43
LDL 128
UA negative
ABG 7.36/46/74 after intubation
EKG demonstrated sinus tachycardia at 122 with LBBB with no
significant change compared with prior dated [**2174-6-6**].
TELEMETRY demonstrated: Sinus tachy at 106
TTE [**2174-6-19**]:
The right atrial pressure is indeterminate. Left ventricular
wall thicknesses and cavity size are normal. Overall left
ventricular systolic function is severely depressed (LVEF<20 %).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are severely thickened/deformed.
Significant aortic stenosis is present (not quantified). The
mitral valve leaflets are mildly thickened. Mild to moderate
([**12-15**]+) mitral regurgitation is seen. [Due to acoustic shadowing,
the severity of mitral regurgitation may be significantly
UNDERestimated.] There is a small, primarily anterior
pericardial effusion most prominent around the right atrium and
right ventricle with a prominent anterior fat pad. No right
atrial or right ventricular diastolic collapse is seen (may be
absent in the setting of pulmonary artery hypertension).
Compared with the prior study (images reviewed) of [**2174-5-30**],
the pericardial effusion is slightly larger (but without
hemodynamic compromise) and left ventricular systolic function
is more depressed.
CXR [**2174-6-19**]:
A right internal jugular catheter terminates in the right
atrium.
An endotracheal tube terminates 2 cm above the carina. A
nasogastric tube
terminates past the stomach with its tip outside the plane of
imaging.
The cardiomediastinal silhouette is mildly enlarged. There is
increased
perihilar haziness with interstitial fluid that is mostly
central. There is also increased peribronchial cuffing. There is
no evidence of pleural
effusion. Moderate S-shaped scolisosis is noted.
IMPRESSION: Acute central pulmomary edema.
CXR [**2174-6-19**]:
Newly inserted nasogastric tube projects over the stomach. The
tip
of the endotracheal tube is 3 cm above the carina. The size of
the cardiac
silhouette and the bilateral parenchymal opacities show no major
change.
CT Chest without contrast [**2174-6-19**]:
1. The left IJ introducer sheath is terminating in the proximal
left
brachiocephalic vein without immediate post-procedure
complications.
2. Diffuse bilateral septal thickening and ground-glass
opacities with
associated small bilateral pleural effusions suggesting moderate
pulmonary
edema. Bibasilar atelectasis and coexistent pneumonia cannot be
excluded and should be clinically correlated.
3. Comparative evaluation of pulmonary nodules is limited due to
respiratory motion and diffuse background pulmonary edema.
Further evaluation for stability should be undertaken post
resolution of background pulmonary edema.
4. Extensive atherosclerotic aortic valvular and coronary
calcifications are unchanged.
5. Large axial hiatal hernia.
6. Stable small pericardial effusion.
TTE [**2174-6-23**]:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. There is symmetric left ventricular
hypertrophy. LV systolic function appears depressed. There are
complex (>4mm) atheroma in the descending thoracic aorta. There
are three aortic valve leaflets. The aortic valve leaflets are
severely thickened/deformed. There is at least moderate aortic
valve stenosis. Trace aortic regurgitation is seen. [Due to
acoustic shadowing, the severity of aortic regurgitation may be
significantly UNDERestimated.] The mitral valve leaflets are
mildly thickened. Mild to moderate ([**12-15**]+) mitral regurgitation
is seen. There is a trivial/physiologic pericardial effusion.
IMPRESSION: No vegetations seen. Significant aortic stenosis,
mild to moderate mitral regurgitation, depressed LV function.
CT Head w/o contrast [**2174-6-26**]:
1. Focal region of hypoattenuation within the right anterior
limb of the
internal capsule. Etiology of this finding is unknown as well as
duration and differential diagnosis includes an old lacunar
infarct versus new region of ischemia. Further evaluation may be
obtained with MRI including diffusion- weighted imaging sequence
to evaluate for acute ischemia.
2. Probable old lacunar infarction within the right corona
radiata.
3. Bifrontal lobe cerebral atrophy.
4. Moderate confluent periventricular white matter chronic
ischemic changes.
MR [**Name13 (STitle) 430**] w/o contrast [**2174-6-27**]:
There is no evidence for acute ischemia or acute hemorrhage.
There are scattered small vessel ischemic sequelae in the
subcortical and
periventricular white matter. There are old lacunes in the right
anterior
limb of the internal capsule. The ventricles and sulci are
prominent but
likely age appropriate.
There is focal prominence of bifrontal extra-axial spaces which
may suggest focal volume loss in the bifrontal lobes. There is
no hydrocephalus.
Intracranial flow voids are maintained.
MRA of the circle of [**Location (un) 431**] demonstrates patency of the anterior
and posterior circulations. There is stenosis within the limits
of this exam. There is a hypoplastic right A1 segment. The right
vertebral artery is relatively hypoplastic. There is a possible
3-mm aneurysm on the left at the junction of the cavernous and
supraclinoid ICA. Additionally, there is a possible 2-mm
aneurysm of the supraclinoid ICA posteriorly in close proximity
to the ICA bifurcation.
Brief Hospital Course:
80yo woman with severe AS, CHF, CRI, admitted with respiratory
failure likely [**1-15**] acute exacerbation of chronic heart failure.
She was diuresed with Lasix, improving her respiratory function
to the point where she no longer required supplemental oxygen,
but subsequently developed CRAO, leading to stroke workup and
anticoagulation with heparin, leading to GIB due to esophagitis
and gastritis, leading to transfusion for dropping hematocrit,
leading to acute exacerbation of chronic heart failure due to
volume overload.
.
# Respiratory failure [**1-15**] acute on chronic heart failure:
Presented in respiratory distress with SaO2 82% on NRB.
Respiratory failure most likely multifactorial, involving
chronic heart failure due to aortic stenosis, exacerbated
acutely by volume overload and pulmonary edema in the setting of
decreased Lasix dosage. Intubated in ED, extubated on hospital
day 2. Continued to require 4LNC, desaturating to 80s on room
air. Diuresed with multiple boluses of Lasix IV. Gradually
weaned to room air, with O2 saturation in mid to high 90s while
resting, but desaturating deeply to upper 80s with ambulation.
Unfortunately, she subsequently developed a GIB, leading to
transfusion of multiple units of PRBCs, resulting in shifts in
volume status and worsening oxygen saturations and increasing
need for supplemental oxygen. She was once again diuresed with
multiple doses of Lasix IV, at times requiring combination with
metolazone. She was gradually weaned off of oxygen until she no
longer required supplemental oxygen and was euvolemic on exam.
.
# GIB:
Vomited a large quantity of blood after starting heparin. Has a
history of gastritis on recent admission in [**2174-5-15**]. GI was
consulted and EGD done, showing gastritis and esophagitis but no
frank bleeding. She was started on an IV PPI and antiemetics.
She was initially transfused two units of blood in the setting
of the acute bleed, and subsequently received another unit for
gradually decreasing hematocrit. Of note, even before her
episode of acute GIB, her stools were noted to be guaiac
positve. GI felt that given that the GIB occurred in the setting
of being started on heparin and having a previous history of
gastritis, there was no need to arrange for GI follow up unless
she desired.
.
# Central Retinal Artery Occlusion:
Awoke one afternoon with sudden loss of vision in R eye.
Ophthalmology was consulted and diagnosed patient with likely
CRAO. Paracentesis was performed to lower intraocular pressure.
Neurology consulted for stroke workup. CT and MRI showed signs
of old ischemia and infarction but no acute events. Started on
heparin drip for concern about emboli, but heparin discontinued
for GIB. Carotid ultrasound showed thrombus in L IJ, possibly
related to recently removed Cordis, but otherwise no significant
stenosis. An appointment was made for her to follow up with a
retinal specialist. Of note, she reports that she is already
followed by a retinal specialist at the MEEI for her macular
degeneration.
.
# Aortic Stenosis:
Currently s/p recent valvuloplasty, with valve area 0.9cm.
Evaluated by cardiothoracic surgery - felt to be poor surgical
candidate, both for valve replacement and for apico-aortic
conduit, given significantly calcified aorta, small body habitus
and poor renal function. Cardiothoracic surgery recommended
considering enrollment in percutaneous valve trial.
.
# Renal Failure:
In consultation with renal team, it was felt that it was
necessary to diurese the patient in order to improve her
pulmonary status. Baseline Cr 1.3-2.5 over last month.
Creatinine increased to 2.7 initially, but subsequently improved
with continued diuresis. HD line removed on hospital day 2 for
gram positive cocci on blood cultures (she required hemodialysis
in [**Month (only) 116**], but has not required it since). The patient was diuresed
to a creatinine of 2.4 on the day of discharge so that she would
be slightly dry on discharge and therefore euvolemic on her home
diet.
.
# Infection:
Initial ED blood culture grew Viridans streptococcus, resistant
to penicillin. HD line tip culture grew staphylococcus aureus,
resistant to oxacillin, sensitive to vancomycin. Pt was treated
with vancomycin starting in the ED. Per infectious disease
consult, due to possibility of endocarditis (absence of
vegetations on TEE did not rule out endocarditis), given blood
culture with Viridans streptococci, the pt will require
treatment with 6 weeks of vancomycin for Viridans streptococcus.
She will require vancomycin, dosed for troughs of under 20,
until [**7-31**]. A PICC line was placed for administration of
antibiotics to treat possible endocarditis.
.
# Anemia:
Hct gradually decreased from near 30 to 20.1 in first day in
CCU. Transfused two units PRBCs to post transfusion hematocrit
26.5. Has h/o diverticulosis and gastritis. Stools guaiacs were
positive. Subsequently transfused two units immediately
following GIB, and then another unit for gradually decreasing
hematocrit. Hematocrit was stable at 32 on discharge.
.
# Mobility:
Evaluated by physical therapy. Will receive PT at home.
Medications on Admission:
Aspirin 325 mg daily
Clopidogrel 75 mg daily
B Complex-Vitamin C-Folic Acid 1 mg daily--not taking due to GI
upset
Fexofenadine 60 mg [**Hospital1 **]
Polyvinyl Alcohol-Povidone 1.4-0.6 % 1-2 Drops PRN
Hydrocodone-Acetaminophen 5-500 mg 1/2-1 Q4H PRN
Carvedilol 3.125 mg [**Hospital1 **]
Losartan 25 mg daily
Prilosec 20mg daily
Ipratropium Bromide neb Q6H PRN
Lasix 160mg daily
Vigamox 1 drop OS QID, 3 doses left of course
Discharge Medications:
1. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous
Q48H (every 48 hours) for 4 weeks: every other day. 1st day [**6-19**].
Last day [**7-31**].
Disp:*30 Recon Soln(s)* Refills:*0*
2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*2 ML(s)* Refills:*2*
3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Ipratropium Bromide 0.02 % Solution Sig: [**12-15**] Inhalation Q6H
(every 6 hours) as needed for wheeze.
7. Carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
9. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
10. Furosemide 80 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
12. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a
day.
13. Outpatient Lab Work
Please draw CBC, Chem 7, and LFTs every Monday or Tuesday (in
coordination with antibiotic infusion) and fax to the ID
(infectious disease) nurse at [**Telephone/Fax (1) 432**].
.
Please draw chem 7 on [**2174-7-7**] after antibiotic infusion and fax
to Dr.[**Name (NI) 433**] office at [**Telephone/Fax (1) 434**]
14. tele monitoring
Please fax tele monitoring (weight and oxygen saturation) to Dr.
[**Last Name (STitle) 118**] at [**Telephone/Fax (1) 434**].
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Primary Diagnosis:
Acute respiratory failure secondary to acute congestive heart
failure
Septicemia
Central retinal artery occlusion
Gastrointestinal bleeding due to esophagitis/gastritis
.
Secondary Diagnoses:
Aortic stenosis
Coronary artery disease
Pulmonary edema
Chronic renal insufficiency
Hypertension
Anemia with chronic GI bleed
Scoliosis
Discharge Condition:
Stable vital signs with appropriate follow-up.
Discharge Instructions:
You were admitted with acute respiratory distress due to fluid
in your lungs. When you initially presented, you required
intubation and mechanical ventilation to provide you with
adequate oxygenation.
Your aortic stenosis (which is the narrowing of one of your
heart valves) makes it very difficult to manage your fluid
status. You were evaluated by cardiothoracic surgery to see if
they would suggest replacing your aortic valve, but they felt
that you would not be a good candidate for surgery because of
your other medical conditions, which would make surgery
extremely risky.
You were treated with Lasix to decrease the amount of fluid in
your lungs, improving your ability to breathe. Your ability to
breathe gradually improved to the point that you did not require
supplemental oxygen.
You developed a loss of vision in your right eye. You were seen
by an ophthalmologist who made a small hole in your eye to drain
some fluid and diagnosed you with likely central retinal artery
occlusion, a condition in which a vessel supplying blood to the
eye becomes clogged. You were started on anticoagulation with
heparin.
You developed a gastrointestinal bleed, vomiting a quantity of
blood and having a number of maroon colored stools. You were
seen by a gastrointestinologist who performed an
esophagogastroduodenoscopy, showing esophagitis and gastritis.
Heparin was discontinued and you were started on IV proton pump
inhibitors.
A sample of your blood showed that you had an infection in your
blood with a bacteria known as Viridans streptococci. You were
initially started on ceftriaxone, an antibiotic, to treat this
bacteria. Because the particular bacteria you were infected with
turned out to be resistant to penicillin, the ceftriaxone was
discontinued and you were treated with vancomycin. You will
require treatment with vancomycin for a total of six weeks,
until [**7-31**]. A PICC line, a special type of IV line, was
placed so that you can continue to receive the vancomycin at
home.
Your hemodialysis catheter was removed. Because you had not
required dialysis recently, it was felt that the catheter was
not necessary. The tip of the cathether was noted to have
another type of bacteria on it, Staphylococcus aureus. This
bacteria was resistant to many antibiotics and required
treatment with vancomycin. You were treated with vancomycin for
the Staphylococcus aureus. This infection required only
treatment for 5-7 days, so this bacteria has probably been
adequately treated already.
When you first were admitted to the hospital, your kidneys were
functioning poorly. Your creatinine, which increases when your
kidneys are not working well, reached a peak of 2.7. As we
treated you with Lasix and decreased the amount of fluid in your
body, your kidney function actually improved.
You were noted to be somewhat anemic. When you first came in,
your hematocrit was near 30. It gradually dropped to
approximately 20. You were given two units of blood, and your
hematocrit increased to the upper 20s. Subsequently, your
hematocrit dropped again after you had your GI bleed. You were
again transfused two units of blood. A few days later, your
hematocrit was noted to trend down, so you were transfused
another unit.
1. Please take all medications as prescribed.
***Medication Changes:***
Your aspirin was changed to 81mg daily. Your carvedilol was
increased and your prilosec increased to twice daily. Your
Cozaar is being held because of your renal function. Vancomycin
was started to treat bacteria in your blood. Sevelamer was
started to regulate the phosphate level in your blood as your
kidneys are not working as well to remove it.
2. Please attend all follow-up appointments listed below.
3. Please call your doctor or return to the hospital if you
develop chest pain, shortness of breath, lightheadedness,
decreased urine output, or any other concerning symptom.
4. Please weigh yourself every morning and call your doctor if
your weight goes up by 3 pounds in 1 day or 6 pounds in 3 days.
5. Please limit yourself to a 2 gm sodium diet; written
information was reviewed with you about your diet.
6. Please limit your fluid intake to a fluid restriction of
1000mL/day.
7. While you are on the vancomycin, you will need to have weekly
labs drawn and faxed to the infectious disease doctors [**Last Name (NamePattern4) **]
[**Telephone/Fax (1) 432**]
Followup Instructions:
1. Nephrology: Please call Dr. [**Last Name (STitle) 118**] after your antibiotic
infusion on [**2174-7-7**] as he will see you at that time. Also you
have an appointment with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **], MD
Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2174-7-20**] 12:30.
.
2. ECHOCARDIOGRAM Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2174-8-18**] 11:00
.
3. PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 131**] on [**2174-7-12**] at 9:15 am. Please call
[**Telephone/Fax (1) 133**] with questions.
.
4. Congestive Heart Failure Clinic, [**Location (un) 436**] of [**Hospital Ward Name 23**]
building: Dr. [**First Name (STitle) 437**] at 11:30 on [**2174-7-18**]. Please call
[**Telephone/Fax (1) 62**] with questions.
.
5. Infectious Disease: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 438**] follow up appointment
made for [**7-25**] at 10:00 AM at [**Last Name (NamePattern1) 439**] in
basement of the building.
.
6. Ophthamology:
[**First Name8 (NamePattern2) 440**] [**Last Name (NamePattern1) 441**], MD Phone: [**Telephone/Fax (1) 253**]. Date/Time: [**7-15**],
[**Hospital Ward Name 23**] [**Location (un) 442**].
|
[
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"423.9",
"V09.0",
"421.0",
"737.30",
"530.10",
"427.89",
"V15.82",
"275.42",
"V45.82",
"585.9",
"424.1",
"428.0",
"275.3",
"584.9",
"403.90",
"041.11",
"280.0",
"428.23",
"V10.52",
"578.9",
"996.62",
"458.9",
"276.3",
"V45.73",
"E934.2",
"E879.8",
"518.81",
"535.11",
"362.30",
"414.01",
"553.3",
"715.90"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.04",
"45.16",
"96.71",
"86.05",
"88.72",
"38.93",
"99.04",
"89.62"
] |
icd9pcs
|
[
[
[]
]
] |
18416, 18474
|
10875, 16002
|
292, 390
|
18865, 18914
|
5370, 5375
|
23348, 24620
|
4266, 4471
|
16477, 18393
|
18495, 18495
|
16028, 16454
|
18938, 22226
|
4486, 5351
|
18706, 18844
|
22245, 23325
|
233, 254
|
418, 2997
|
18514, 18685
|
5389, 10852
|
3019, 4015
|
4031, 4250
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
24,785
| 137,416
|
46489
|
Discharge summary
|
report
|
Admission Date: [**2167-8-8**] Discharge Date: [**2167-8-19**]
Date of Birth: [**2087-10-1**] Sex: M
Service: SURGERY
Allergies:
Percocet
Attending:[**First Name3 (LF) 1234**]
Chief Complaint:
Right ischemic leg/foot
Major Surgical or Invasive Procedure:
Right groin exploration
thrombectomy
TPA catherer placement
arteriogram
History of Present Illness:
71 year-old man well-known to vascular service presents with
sudden onset of Right leg pain that began at 2 PM this
afternoon. Patient was discharged home early [**Month (only) 216**] after having
a 2nd toe amputation for osteomyelitis (done by Podiatry).
During this hospitalization, the patient was evaluated by
vascular surgery to see if his left leg had good enough blood
flow to heal a toe amp of his left foot. At that time, his
right leg had palpable femoral and DP pulses.
His left leg had a palpable femoral pulse and dopplerable pulses
of all arteries below the popliteal. He underwent his toe
amputation without any complications. His hospital stay was
significant for evaluation by hematology, in which they
diagnosed him with likely HIT type 2. They saw a drop in his
platelet count that coincided with the start of his dialysis
(early [**2167-7-7**]), which they attributed to him receiving heparin flushes
during dialysis sessions. He was discharged home, and now
returns with severe right leg pain that begins at his hip and
shoots down to his knee, and that began at 2 PM today. He has
never had pain like this since his Bypass graft was performed
back in [**2161**]. Pain has been constant in both the reclining and
standing positions. His family brought him here to the ED for
further evaluation.
Past Medical History:
1. CHF: diastolic & systolic HF with CRI, EF 40-45% in [**1-13**] and
[**5-14**]
2. CAD s/p 2V-CABG [**2161**]
3. CVA: ([**2154**]) 3-4 days of slurred speech and right facial droop
without residual symptoms. s/p CEA (documented however patient
without memory of this procedure)
4. HTN
5. Hyperlipidemia
6. IDDM (retinopathy, nephropathy, neuropathy)
7. NSVT
8. Afib
9. PVD s/p R fem-[**Doctor Last Name **] ([**2154**]), R 2nd toe amputation, gangrene L
1st toe s/p amp ([**10-11**](?))
10. CRI (b/l around 2.9-3.1)
11. Colon ca s/p hemicolectomy
12. H/o diverticulosis
13. H/o angioectasia in stomach w/UGIB [**3-/2161**] and again [**7-/2166**]
14. Prostate ca (dx'd [**2150**]): s/p orchiectomy ([**2150**]), TURP ([**2153**])
& pelvic XRT ([**2155**]) with radiation 'proctopathy'.
15. Iron deficiency anemia on bone marrow aspirate ([**2157**])
16. Interstitial lung disease w/mediastinal LAD & a negative
CMA. (Differential diagnosis included burned out sarcoidosis
versus interstitial pulmonary fibrosis versus malignancy.) s/p
flexible bronchoscopy and cervical mediastinoscopy with biopsies
([**5-9**])
17. Left cataract surgery
Social History:
Social history is significant for the absence of current tobacco
use; he has a remote history of tobacco use but quit in his 20s.
There is no history of alcohol abuse or illicit drug use.
Patient is widowed and lives in senior citizen home in [**Hospital1 **]
with VNA services 3 times a week. He is independent in his ADLs
but has help with meals. He is a retired foreman for [**Company 2676**].
At
baseline, he gets short of breath walking less than one block
and
uses a walker.
Family History:
father: DM, alcohol related death
mother: DM,passed away giving birth to 22nd child
daughter: macular degeneration
Physical Exam:
EXAM ON Discharge:
VS: T 97.2 HR: 74 (AF) BP: 101/42 RR: 16 O2: 94% RA
Gen: NAD, A&Ox3
Neck: Supple, no bruits
CV: irregularly irregular, no m/r/g
Lungs: Bibasilar crackles, L>R
Abd: soft, NT, ND
EXT: L foot amp site healing well
VASC:
Fem [**Doctor Last Name **] PT DP
R Palp Dop Dop Dop (before thrombectomy, there were
no signals below femoral)
L Palp D Non-dop Palp (his PT was non-dop before the
procedure as well)
Skin: Resolving hematoma of right groin
Pertinent Results:
Admit H/H: 11.5/38.3
Discharge H/H: 9.5/29.7
Admit WBC: 7.3
Discharge WBC: 6.3
Cardiac enzymes were negative X 3, EKG shows no significant
changes compared to previous EKG done before hospitalizations.
Discharge INR:
[**8-5**] NIAS: Significant left sided tibial disease, ABI of 0.88
[**8-6**] LE U/S: No evidence of DVT in his LE
HIT negative X 2
Beta glycoprotein negative
Anti-cardiolipin antibodies negative
Serotonin Releasing Assay negative
***Patient is HIT negative per Heme/Onc***
Brief Hospital Course:
This is a 79-year-old male who was recently discharged from the
hospital 1 day ago, after debriding a left toe and doing a
primary amputation, and the patient
returns with the acute onset of right leg pain at 2:00 p.m.
today. The patient was with his family and they called an
ambulance and he was immediately transported to the [**Hospital1 771**] emergency room. Exam at that time
revealed no femoral pulse and no signals in his right foot along
with normal sensation and normal motor, but a cool foot with
poor capillary refill. Due to a question of
heparin-induced thrombocytopenia the patient was bolused with
Argatrobran and started on an infusion and plans were made for
the operating room. Immediately before going to the operating
room, he regained a femoral pulse, and he was then
brought into the operating room on [**2167-8-8**].
An emergent Angiogram/Angioplasty of his Right SFA and Right AK
popliteal artery and an emergent thrombectomy of his SFA-[**Doctor Last Name **] and
tibial vessels/grafts was done in the OR.
Subsequent trips back to the OR for adjustment of his
thromolysis catheter and repeat thromolysis were done in the
next few days. The patient tolerated each procedure well.
His post-operative course was uncomplicated until the morning of
[**8-15**] (PPD 7 from his initial thromolysis). He developed vague
chest pain, difficulties breathing, and triggered secondary to
his hypotension with his SBP being in the 80's. He did not
recieve his Metoprolol dose that morning. On [**8-14**] he was only
dialysed -400 cc secondary to low BP in the dialysis unit. The
vascular team evaluated him quickly; he indeed was hypotensive
to the 80's with an irregular irregular HR (chronic A-fib) in
the 60's. He was mentating well but was c/o CP which was
reproducible with palpation. He did not have any murmurs but
did have an irregular irregular rhythm on cardiac exam. His
lungs did have bibasilar crackles, L>R. A CXR did suggest
possible effusions, L>R versus intersitial edema. Cardiology
evaluated him and did not think this was a cardiac etiology.
Cardiac enzymes were negative X 3. EKG was unchanged. Renal was
called but they did not want to perform an urgent dialysis as
they did not think he was volume overloaded. Instead the patient
was transfused one unit of PRBCs (chronic low hct of 27-28).
During this entire duration, his oxygen saturation was high 90's
on 2L. Discontining the oxygen did not drop his sats (96% on
RA). We sat him up to his chair, which made him feel
immediately better. Afterwards, the patient was more calm and
his BP was in the 100's. He did well the rest of the hospital
course.
Because his last hospitalization questioned the possibility of
heparin induced thrombocytopenia (HIT), per Heme-Onc, a HIT
panel was ordered. It was negative X 2. Further tests such as
B2 Glycoprotein, Anti-cardiolipin, and Serotonin Releasing Assay
were negative. He was taken off his Agatroban and continued on
coumadin, although the agatroban was stopped one day before all
the tests were negative anyway given that he reached a goal INR
([**4-11**]). Given the results of these tests, heme-onc is deciding
that he is HIT negative.
Physical therapy was consulted and requested he be discharged to
rehabilitation. Case management was advised and screened him.
His PMD (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**]) was [**Name (NI) 653**], and stated that after
he is discharged from his rehabilitation facility, he would be
willing to monitor the patient's INR.
[**2167-8-19**] Day of discharge, the patient is afebrile with a normal
WBC count. His pulse exam remains unchanged after his
procedure. He was hemodialysed. He is ambulating with
assistance. He is mentating well. He is tolerating a regular
diet and moving his bowels. Arrangements were made for him to
have his INR drawn at the [**Hospital 98771**] hospital during HD and results
to be sent to Dr. [**Last Name (STitle) 18323**]. Discharged in good condition.
Medications on Admission:
CALCITRIOL 0.25 mcg Capsule q day
DIGOXIN 125 mcg Tablet - one half tablet po daily
EPOETIN ALFA [PROCRIT] - 2,000 unit/mL Solution - 25,000 units
sc weekly
INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - Lantus 16
units SC every am
METOPROLOL TARTRATE - 75 mg [**Hospital1 **]
PANTOPRAZOLE -40 mg Tablet [**Hospital1 **]
SIMVASTATIN 10 mg Tablet by mouth daily
TORSEMIDE 100 mg - one tablet by mouth in morning; [**1-7**] tablet in
evening
ASPIRIN - 81 mg once daily
FERROUS SULFATE 325 mg q day
Discharge Medications:
1. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Tablet(s)
2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Torsemide 100 mg Tablet Sig: One (1) Tablet PO qAM.
7. Torsemide 100 mg Tablet Sig: 0.5 Tablet PO qPM.
8. Insulin Regular Hum U-500 Conc 500 unit/mL Solution Sig: One
(1) sliding scale Injection four times a day: Please resume your
sliding scale with Humalog like you did before you came into the
hospital.
9. Lantus 100 unit/mL Solution Sig: Thirty Two (32) Units
Subcutaneous four times a day.
10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
11. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection
ASDIR (AS DIRECTED).
12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for PAIN.
13. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
14. Warfarin 1 mg Tablet Sig: Take one (1) on odd numbered days,
2 (2) on even numbered days Tablet PO once a day.
Disp:*45 Tablet(s)* Refills:*2*
15. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
16. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day) as needed for with
meals.
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 86**] VNA
Discharge Diagnosis:
ischemic right leg
Carotid stenosis
s/p CVA ([**2154**])
CRI (Cr 2.3-2.5)
IDDM
retinopathy
neuropathy
CAD
CHF (EF 50% 2/07)
NSVT
HTN
hyperlipidemia
prostate ca s/p pelvic XRT ([**2155**])
colon ca
diverticulosis
angioectasia ([**3-8**], [**7-13**], [**5-14**])
Fe deficiency anemia
interstitial lung disease with mediastinal LAD
Discharge Condition:
good
Discharge Instructions:
Medications:
?????? Take Aspirin 325mg (enteric coated) once daily
?????? If instructed, take Plavix (Clopidogrel) 75mg once daily
?????? Continue all other medications you were taking before surgery,
unless otherwise directed
?????? You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
What to expect when you go home:
It is normal to have slight swelling of the legs:
?????? Elevate your leg above the level of your heart (use [**2-8**]
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
?????? It is normal to feel tired and have a decreased appetite, your
appetite will return with time
?????? Drink plenty of fluids and 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:
?????? When you go home, you may walk and go up and down stairs
?????? You may shower (let the soapy water run over groin incision,
rinse and pat dry)
?????? Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area that is draining, as needed
?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
?????? After 1 week, you may resume sexual activity
?????? After 1 week, gradually increase your activities and distance
walked as you can tolerate
?????? No driving until you are no longer taking pain medications
?????? Call and schedule an appointment to be seen in [**3-10**] weeks for
post procedure check and ultrasound
What to report to office:
?????? Numbness, coldness or pain in lower extremities
?????? Temperature greater than 101.5F for 24 hours
?????? New or increased drainage from incision or white, yellow or
green drainage from incisions
?????? Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
?????? Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call
911 for transfer to closest Emergency Room.
Followup Instructions:
Make an appointment to see Dr. [**Last Name (STitle) **] and have an ultrasound
of your graft in one month.
Follow up with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 18323**]
Completed by:[**2167-8-19**]
|
[
"427.1",
"287.4",
"428.42",
"511.9",
"403.91",
"996.74",
"444.22",
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"250.50",
"537.82",
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"285.21",
"427.31",
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"357.2",
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"250.40",
"272.4",
"428.0",
"515",
"V10.05",
"V12.54",
"038.9",
"250.60"
] |
icd9cm
|
[
[
[]
]
] |
[
"88.48",
"99.04",
"39.50",
"99.10",
"39.49",
"39.95",
"00.40"
] |
icd9pcs
|
[
[
[]
]
] |
10694, 10751
|
4583, 8607
|
291, 365
|
11124, 11130
|
4058, 4560
|
13636, 13858
|
3403, 3519
|
9161, 10671
|
10772, 11103
|
8633, 9138
|
11154, 13039
|
13065, 13613
|
3534, 3534
|
228, 253
|
393, 1718
|
3553, 4039
|
1740, 2885
|
2901, 3387
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,322
| 168,761
|
35517+58016
|
Discharge summary
|
report+addendum
|
Admission Date: [**2192-3-9**] Discharge Date: [**2192-3-16**]
Date of Birth: [**2114-8-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
[**2192-3-12**] Aortic Valve Replacement(27mm Porcine), Mitral Valve
Replacement(29mm Tissue), Full Maze Procedure, Ligation of Left
Atrial Appendage, and Aortic Root Enlargement with Pericardial
Patch
History of Present Illness:
77-year-old woman with known aortic stenosis and aortic
insufficiency as well as mitral regurgitation and mitral
stenosis presents with worsening CHF symptoms. She is well
known to your practice and has been followed by you closely with
serial echocardiograms, which have revealed worsening gradients
and evidence of pulmonary hypertension. She does complain
significantly of dyspnea on exertion, orthopnea, and increasing
fatigue. She does deny any angina or syncope.
Past Medical History:
Aortic stenosis/insufficiency, mitral
stenosis/regurgitation(most likely rheumatic), hypertension,
elevated cholesterol, atrial fibrillation, stroke with mild
right-sided weakness, and osteoarthritis. She has undergone a
hysterectomy and had a St. [**Male First Name (un) 923**] pacemaker placed in [**2180**].
Social History:
Mrs. [**Known lastname 6164**] is retired. She has a remote tobacco history. Her
last dental examination was five months ago. She also denies
use of any alcohol. She is currently living with her husband.
Family History:
Noncontributory
Physical Exam:
On examination, her heart rate is 60 and irregular, respiratory
rate 18, blood pressure on the right 154/64 and on the left
153/60. She is 68 inches tall weighing 225 pounds. She is in
no apparent distress. Skin was unremarkable as well as the
HEENT examination. Neck was supple with full range of motion.
Lungs were clear bilaterally. Heart was irregular in rate and
rhythm with a mixed II/VI diastolic and systolic murmur. Abdomen
was soft, nondistended, and nontender with positive bowel
sounds. Extremities were warm and well perfused with 1+
peripheral. No obvious varicosities were noted. Neurologically,
she is grossly intact with mild right upper extremity weakness.
She has 2+ plus bilateral femoral pulses and radial pulses and
1+ bilateral DP and PT pulses. The systolic murmur transmits to
both carotids.
Pertinent Results:
[**2192-3-9**] WBC-8.3 RBC-4.37 Hgb-13.0 Hct-40.5 MCV-93 MCH-29.8
MCHC-32.1 RDW-13.5 Plt Ct-307
[**2192-3-9**] PT-16.7* PTT-25.6 INR(PT)-1.5*
[**2192-3-9**] Glucose-103 UreaN-15 Creat-0.9 Na-144 K-4.5 Cl-102
HCO3-34* [**2192-3-9**] Albumin-4.7 Calcium-10.0 Phos-3.7 Mg-2.3
[**2192-3-9**] %HbA1c-5.9
[**2192-3-12**] Intraop TEE:
PREBYPASS
1. The left atrium is markedly dilated and is elongated. A
left-to-right shunt across the interatrial septum is seen at
rest. Mod to severe left atrial contrast is noted.2. 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 and descending
thoracic aorta. 5. The aortic valve leaflets are moderately
thickened with some calcification. There is severe aortic valve
stenosis (area <0.8cm2) by continuity equation, area 1.1 by
planimetry which is likely inaccurate due to calcification.
Moderate to severe (3+) aortic regurgitation is seen. 6. The
mitral valve leaflets are severely thickened/deformed. The
mitral valve shows characteristic rheumatic deformity. There is
mild mitral valve prolapse of the anterior leaflet and
restriction of the posterior leaflet.. There is moderate
valvular mitral stenosis (area 1.0-1.5cm2). Mild mitral
regurgitation is seen.
POSTBYPASS
1. Patient is on no infusions and is being paced at 80 2. A
tissue mitral valve is seen. It is well seated and functioning
well. Trace central MR jet is seen, NO perivalvular leaks. Peak
gradient 13, mean gradient 4 3. A tissue aortic valve is seen.
It is well seated and functioning well. No periventricular leaks
are noted. Peak gradient 11, mean gradient 5 4. Aortic contours
are smooth after decannulation
[**2192-3-15**] 07:05AM BLOOD WBC-11.3* RBC-3.13* Hgb-9.4* Hct-29.1*
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.0 Plt Ct-92*
[**2192-3-15**] 07:05AM BLOOD PT-14.8* INR(PT)-1.3*
[**2192-3-14**] 02:46AM BLOOD Glucose-115* UreaN-17 Creat-0.9 Na-138
K-4.5 Cl-105 HCO3-27 AnGap-11
[**2192-3-9**] 07:15PM BLOOD ALT-25 AST-32 LD(LDH)-241 AlkPhos-114
TotBili-0.8
Brief Hospital Course:
Mrs. [**Known lastname 6164**] was admitted preoperatively for intravenous heparin
and preoperative workup. Electrophysiologic interrogation of her
permanent pacemaker revealed that she was pacemaker dependent
with an underlying rhythm of 40 beats per minute, irregular and
with prolonged pauses. The remainder of preoperative course was
uneventful and she was cleared for surgery. Given inpatient
stay was greater than 24 hours prior to surgery, Vancomycin was
given for perioperative antibiotic coverage. On [**3-12**], Dr.
[**Last Name (STitle) 914**] performed aortic and mitral valve replacements, along
with Full Maze procedure. For surgical details, please see
operative note. Following surgery, she was brought to the
cardiovascular intensive care unit for invasive monitoring.
Within 24 hours, she awoke neurologically intact and was
extubated without incident. Her permanent pacemaker was
interrogated. She was weaned from her pressors and her chest
tubes and wires were removed. Coumadin was started given that
she has a history of atrial fibrillation and she underwent a
MAZE procedure. She was transferred in stable condition to the
surgical step down floor. Mrs. [**Known lastname 6164**] was aggressively
diuresed. She was seen in consultation by the physical therapy
service. By post-operative day three she was deemed ready by
Dr. [**Last Name (STitle) 914**] for discharge to an acute care facility for further
diuresis and rehab.
Medications on Admission:
Atenolol 50 mg q.a.m. and 25 mg q.p.m., Digoxin 0.25 mg daily,
Lasix 80 mg daily, Levothyroxine 100 mcg daily, Lisinopril 20 mg
daily, Simvastatin 10 mg daily, Combivent inhaler, Coumadin
daily as directed, Aspirin 81 mg daily, Multivitamin daily, and
Tylenol p.r.n. pain.
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2
times a day): 40mg IV Lasix [**Hospital1 **].
Disp:*qs * Refills:*2*
6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
9. Coumadin 4 mg Tablet Sig: One (1) Tablet PO once a day:
titrate for an INR goal of [**1-31**] for atrial fibrillation.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Location **]
Discharge Diagnosis:
Aortic Stenosis/Aortic Insufffiency
Mitral Stenosis/Regurgitation
Chronic Diastolic Congestive Heart Failure
Atrial Fibrillation
Cerebrovascular Disease
Hypertension
Dyslipidemia
Pacemaker In-Situ
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:
Please follow-up with Dr. [**Last Name (STitle) 914**] in 1 month. ([**Telephone/Fax (1) 1504**]
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 16004**] (PCP)in 2 weeks.
[**Telephone/Fax (1) 3183**]
Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (cardiology) in [**1-31**]
weeks, call for appt
Completed by:[**2192-3-15**] Name: [**Known lastname 749**],[**Known firstname **] Unit No: [**Numeric Identifier 12995**]
Admission Date: [**2192-3-9**] Discharge Date: [**2192-3-16**]
Date of Birth: [**2114-8-19**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1543**]
Addendum:
Ms. [**Known lastname **] was kept in house until post-operative day four for
further diuresis and monitoring. After a discussion with her
cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4720**], amiodarone was started after
her MAZE procedure per our cardiac surgery protocol, digoxin was
decreased to 0.125, and her statin coverage was changed from
simvastatin to pravastatin given that she will now be on
amiodarone. Since amiodarone was started on the day of
discharge and her INR has not yet shown much effect from the
coumadin (1.3 today), her INR level should be closely followed
over the next couple of weeks. On post-operative day she was
discharged to rehab for further diuresis and strength training.
Major Surgical or Invasive Procedure:
[**2192-3-12**] Aortic Valve Replacement(27mm Porcine), Mitral Valve
Replacement(29mm Tissue), Full Maze Procedure with Ligation of
Left Atrial Appendage, and Aortic Root Enlargement with
Pericardial Patch
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
7. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 7 days: then taper to 200mg daily.
Disp:*40 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day:
titrate for an INR goal of [**1-31**] for atrial fibrillation.
Disp:*30 Tablet(s)* Refills:*2*
10. Lasix 80 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days: 80mg PO BID for 5 days, then taper to home dose of 80mg
daily.
Disp:*40 Tablet(s)* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
Lifecare Center of [**Location 12996**]
[**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 1544**] MD [**MD Number(2) 1545**]
Completed by:[**2192-3-16**]
|
[
"401.9",
"729.89",
"V45.01",
"V15.82",
"438.89",
"398.91",
"427.31",
"244.9",
"396.8",
"715.90",
"285.9",
"272.4",
"416.8"
] |
icd9cm
|
[
[
[]
]
] |
[
"39.61",
"88.72",
"37.33",
"35.21",
"35.23"
] |
icd9pcs
|
[
[
[]
]
] |
11741, 11966
|
4617, 6075
|
10227, 10437
|
7832, 7839
|
2500, 4594
|
8637, 10189
|
1622, 1639
|
10460, 11718
|
7612, 7811
|
6101, 6376
|
7863, 8614
|
1654, 2481
|
280, 301
|
570, 1044
|
1066, 1380
|
1396, 1606
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,868
| 125,227
|
44352+58707
|
Discharge summary
|
report+addendum
|
Admission Date: [**2200-6-20**] Discharge Date: [**2200-6-25**]
Service:
HISTORY OF PRESENT ILLNESS: The patient is a [**Age over 90 **]-year-old
woman who fell suffering a subarachnoid hemorrhage and
subdural hematoma. The patient had mental status changes
status post a [**2200**]6 hours prior to admission, which was
unwitnessed. There was no loss of consciousness, no change
in mental status initially, with disorientation and confusion
at the time of admission. The patient had been in an
assisted-living facility prior to admission and mostly was
self-sufficient.
MEDICATIONS ON ADMISSION: 1. Zantac 150 mg q.a.m. 2.
Amoxapine 50 mg p.o. q.h.s. 3. Marplan 10 mg q.i.d. 4.
Halcion 0.25 mg q.h.s.
PAST MEDICAL HISTORY: 1. Anxiety. 2. Hypertension.
ALLERGIES: The patient has no known drug allergies.
LABORATORY DATA: White count was 13.8, hematocrit 38.6,
platelet count 196. Sodium 129, K 3.6, chloride 94, CO2 25,
BUN 10, creatinine 0.5, glucose 162, INR 1.2.
A CT scan was consistent with traumatic subarachnoid
hemorrhage with blood in the left sylvian fissure and
intraparenchymal blood and left frontal bleed.
PHYSICAL EXAMINATION: The patient was confused, oriented x
1. Lungs were clear to auscultation. Heart had a regular
rate and rhythm. Neurological examination showed cranial
nerves II-XII were intact. Frontalis was intact. The right
pupil was surgical. The left pupil was 2.5 and reactive.
Tongue was in the midline. Upper extremities were 4+/5. She
did not follow commands.
HOSPITAL COURSE: She was admitted to the neurological
intensive care unit for observation. She remained
neurologically stable. Repeat head CT showed left temporal
and then frontal intraparenchymal hemorrhage, small subdural
and persistent subarachnoid hemorrhage with no mass effect
. She remained confused, oriented x 1,
somewhat agitated at times requiring a sitter and restraints
intermittently. She was seen by physical therapy and
occupational therapy and felt to require rehabilitation prior
to discharge. Her vital signs have been stable throughout
her hospital stay.
DISCHARGE MEDICATIONS:
1. Propranolol 40 mg p.o. b.i.d.
2. Zantac 150 mg p.o. b.i.d.
3. Haldol p.r.n. for agitation.
CONDITION ON DISCHARGE: Stable.
FOLLOW UP: She will follow up in one month with Dr. [**First Name (STitle) **] with
a repeat head CT.
[**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**]
Dictated By:[**Last Name (NamePattern1) 344**]
MEDQUIST36
D: [**2200-6-24**] 09:02
T: [**2200-6-24**] 09:22
JOB#: [**Job Number 95108**]
Name: [**Known lastname 15047**], [**Known firstname **] Unit No: [**Numeric Identifier 15048**]
Admission Date: [**2200-6-20**] Discharge Date: [**2200-6-26**]
Date of Birth: [**2108-6-28**] Sex: F
Service:
Patient's discharge was delayed until [**2200-6-26**].
Neurologically, patient was much more alert, awake, and
oriented x2. No further agitation, no restraints, and no
sitter at this time. Her neurologic status has improved
greatly. She was stable at the time of discharge with
followup with Dr. [**First Name (STitle) 24**] in one month with repeat head CT scan.
DR.[**First Name (STitle) **],[**First Name3 (LF) 919**] 14-118
Dictated By:[**Last Name (NamePattern1) 366**]
MEDQUIST36
D: [**2200-6-26**] 11:14
T: [**2200-6-26**] 11:37
JOB#: [**Job Number 15049**]
|
[
"852.01",
"401.9",
"365.9",
"E888.9",
"294.8",
"293.0",
"852.21"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
2139, 2234
|
613, 722
|
1552, 2116
|
2280, 3503
|
1173, 1534
|
113, 586
|
745, 1150
|
2259, 2268
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
7,131
| 138,738
|
53504
|
Discharge summary
|
report
|
Admission Date: [**2103-12-19**] Discharge Date: [**2103-12-26**]
Date of Birth: [**2046-5-15**] Sex: F
Service: HEPATO/BILIARY GOLD
HISTORY OF PRESENT ILLNESS: The patient is a 57 year old
female with a history of polymyalgia and fibromyalgia who
complained of feeling ill with weight loss and immediate
post-prandial abdominal pain. She complains of chronic
fatigue.
REVIEW OF SYSTEMS: Review of systems fails to indicate
fevers, chills, nausea, vomiting or jaundice. She denies any
change in the color or consistency of her urine or stool.
She denies hematemesis or hematochezia. She has no focal
neurological symptoms. She was evaluated with a CT scan
angiogram of the pancreas secondary to abdominal pain. This
demonstrated lesion of the head and uncinate process of the
pancreas which appears to be resectable. There was a
component of calcium which resembles mucinous lesions.
PAST MEDICAL HISTORY:
1. Fibromyalgia.
2. Osteoarthritis.
3. Degenerative joint disease.
4. Polymyalgia.
PAST SURGICAL HISTORY:
1. Back surgery in [**2087**].
2. Laparoscopic cholecystectomy.
ALLERGIES: To Clinoril and penicillin.
MEDICATIONS:
1. Prednisone 4 mg p.o. q. day.
2. Neurontin 300 mg p.o. three times a day.
3. Premarin 3.5 mg p.o.d. days one through 25.
4. Provera.
5. Klonopin 1 mg, one tablet 1 to 3 mg q. h.s. p.r.n.
6. Percocet one to two tablets q. four.
7. Oxy-Contin 10 mg p.o. twice a day.
8. Atenolol 50 mg q. day.
9. Hydrochlorothiazide 25 mg q. day.
HOSPITAL COURSE: The patient was admitted and underwent an
elective procedure on [**2103-12-19**]. She had a Whipple
which went without complications. The patient's
postoperative pain was an issue secondary to her extensive
narcotic use secondary to fibromyalgia and polymyalgias.
Acute Pain Service was following and assisted in the pain
management. On postoperative day three, her pain was well
controlled.
Her pain was managed ultimately with 30 mg p.o. twice a day
of Oxy-Contin and Neurontin 300 mg three times a day and
Percocet one to two tablets q. four to six hours p.r.n. for
breakthrough pain. She also had Klonopin 1 to 3 mg p.o. q.
h.s. p.r.n. which provided adequate pain results.
She was on a hydrocortisone taper until taking p.o., then she
was switched to Prednisone 4 mg p.o. q. day.
The [**Hospital 228**] hospital course was uncomplicated. Once she
passed gas, her NG tube was removed. The Foley catheter was
removed. She did not fail the void trial. She was
tolerating adequate p.o. regularly. She was voiding and she
was ambulating with adequate pain control. She was
discharged on [**2103-12-26**], after her [**Location (un) 1661**]-[**Location (un) 1662**] drain
was removed. The [**Location (un) 1661**]-[**Location (un) 1662**] amylase was 495 after her
meal. The patient is scheduled for follow-up with Dr.
[**Last Name (STitle) 468**] in one to two weeks.
DISCHARGE MEDICATIONS:
1. Oxy-Contin 30 mg p.o. twice a day.
2. Percocet one to two tablets p.o. q. four hours.
3. Neurontin 300 mg p.o. three times a day for pain.
She is scheduled for a follow-up with her chronic pain
service and Rheumatology at the [**Hospital6 1708**].
[**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 4984**]
Dictated By:[**Name8 (MD) 6908**]
MEDQUIST36
D: [**2103-12-26**] 13:28
T: [**2103-12-27**] 16:10
JOB#: [**Job Number 16837**]
|
[
"997.3",
"725",
"577.1",
"729.1",
"577.2",
"715.98",
"786.03",
"458.2"
] |
icd9cm
|
[
[
[]
]
] |
[
"52.7"
] |
icd9pcs
|
[
[
[]
]
] |
2930, 3434
|
1523, 2907
|
1044, 1505
|
409, 911
|
179, 389
|
933, 1021
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
58,633
| 170,875
|
35066
|
Discharge summary
|
report
|
Admission Date: [**2192-12-23**] Discharge Date: [**2192-12-31**]
Date of Birth: [**2116-6-2**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
[**2192-12-26**] Aortic Valve Replacment (21mm [**Company 1543**] Mosaic), Septal
Myomectomy
History of Present Illness:
Mrs. [**Known lastname 80106**] is a 76 y/o female with a significant PMH for
coronary artery disease s/p stenting, aortic stenosis and
hypertrophic cardiomyopathy who was admitted for heart failure
management prior to elective valve surgery.
Past Medical History:
Aortic Stenosis and Hypertrophic Cardiomyopathy, Coronary Artery
Disease s/p LAD Bare metal stenting [**11-16**], Congestive Heart
Failure, Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Right Breast Cancer s/p Mastectomy and chemotherapy, Obesity,
Pneumonia [**1-16**], s/p Appendectomy, s/p Cholecystectomy, s/p
Ventral hernia repair, Anemia
Social History:
Widowed and lives alone. She has 3 children, one working as
nurse. [**First Name (Titles) **] [**Last Name (Titles) **].
Family History:
Father died of MI at age 65
Physical Exam:
At discharge:
VS: T97 130/60 P81 18
Gen: No acute distress
Neck: Full range of motion, -vein distention
Chest: Lungs clear
Heart: Regular rate and rhythm, -murmur
Abd: Soft, non-tender, non-distended, +bowel sounds
Ext: Warm, 1+edema
Neuro: Alert and oriented x 3, non-focal
Pertinent Results:
[**12-26**] Echo: The left atrium is markedly dilated. No
mass/thrombus is seen in the left atrium or left atrial
appendage. There is mild symmetric left ventricular hypertrophy.
Overall left ventricular systolic function is mildly depressed
(LVEF= 55%There is no ventricular septal defect. There are
complex (>4mm) atheroma in the ascending aorta. The aortic valve
leaflets are severely thickened/deformed. There is severe aortic
valve stenosis (area <0.8cm2). Trace aortic regurgitation is
seen. The mitral valve leaflets are severely thickened/deformed.
There is moderate valvular mitral stenosis (area 1.0-1.5cm2).
.There is severe Mitral Annular calcification.Moderate (1+)
mitral regurgitation is seen. Post Bypass: patient is on a Neo
Drip @1 mcg/kg/min. There is now a well seated 21 bioprosthetic
valve in place. There is a mean gradient of 15 across the aortic
valve. There is no AI. The mitral stenosis valve area is still
1.2-1.3cm2. Ventricular function is preserved at 55%. There is
mild Chordal [**Male First Name (un) **].
[**2192-12-24**] 06:15AM BLOOD WBC-5.8 RBC-3.46* Hgb-9.8* Hct-28.1*
MCV-81* MCH-28.4 MCHC-34.8 RDW-15.4 Plt Ct-239
[**2192-12-30**] 07:17PM BLOOD WBC-8.5 RBC-3.72* Hgb-10.9* Hct-31.2*
MCV-84 MCH-29.3 MCHC-34.9 RDW-15.8* Plt Ct-257
[**2192-12-24**] 06:15AM BLOOD PT-13.7* PTT-24.3 INR(PT)-1.2*
[**2192-12-29**] 04:29AM BLOOD PT-13.5* PTT-26.0 INR(PT)-1.2*
[**2192-12-24**] 06:15AM BLOOD Glucose-121* UreaN-29* Creat-1.0 Na-138
K-4.7 Cl-102 HCO3-26 AnGap-15
[**2192-12-30**] 07:17PM BLOOD Glucose-149* UreaN-41* Creat-1.0 Na-133
K-4.0 Cl-98 HCO3-27 AnGap-12
[**2192-12-30**] 06:08AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9
Brief Hospital Course:
As mentioned in the HPI, Mrs. [**Known lastname 80106**] was admitted for
management prior to undergoing valve surgery. She had
pre-operative work-up and was medically optimized for surgery.
On [**12-26**] she was brought to the operating room where she
underwent an aortic valve replacement and septal myomectomy.
Please see operative report for surgical details. Following
surgery she was transferred to the CVICU for invasive monitoring
in stable condition. Within 24 hours she was weaned from
sedation, awoke neurologically intact and extubated. Beta
blockers and diuretics were started and she was titrated towards
her pre-op weight. On post-op day two chest tubes were removed.
Epicardial pacing wires were removed on post-op day three.
Several anti-hypertensive medication were added to regime for
maximum BP control. On post-op day four she was transferred to
the telemetry floor for further care. On post-op day five she
appeared to be doing well and was discharged home with VNA
services and the appropriate follow-up appointments.
Medications on Admission:
Metformin 1000mg [**Hospital1 **], Plavix 75mg qd, Aspirin 325mg qd,
Lisinopril 40mg qd, HCTZ 25mg qd, Prilosec 20mg qd, Iron 325mg
qd, MVI qd, Fish Oil 1000mg qd, Vitamin D qd, Toprol XL 75mg qd,
Simvastatin 80mg qd, Amlodipine 5mg qd, Darvon prn
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. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*1*
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*120 Tablet(s)* Refills:*1*
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
7. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*1*
8. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*1*
9. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*1*
10. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q6H (every 6 hours).
Disp:*1 * Refills:*1*
11. 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:*1*
12. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal
Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12
hours) for 10 days.
Disp:*20 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0*
13. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
Moultonboro VNA
Discharge Diagnosis:
Aortic Stenosis and Hypertrophic Cardiomyopathy s/p Aortic Valve
Replacement and Septal Myomectomy
Congestive Heart Failure
PMH: Stroke, Coronary Artery Disease s/p LAD Bare metal stenting
[**11-16**], Hypertension, Hypercholesterolemia, Diabetes Mellitus,
Right Breast Cancer s/p Mastectomy and chemotherapy, Obesity,
Pneumonia [**1-16**], s/p Appendectomy, s/p Cholecystectomy, s/p
Ventral hernia repair, Anemia
Discharge Condition:
Good
Discharge Instructions:
No driving for 4 weeks.
No lifting more than 10 pounds for 10 weeks.
Shower daily, no baths.
Report any temperature greater than 100.5.
Report any weight gain greater than 2 pounds a day or 5 pounds a
week.
Report any redness of, or drainage from incisions.
No lotions, creams or powders to incisions.
Followup Instructions:
Dr. [**Last Name (STitle) **] in 4 weeks
Dr. [**Last Name (STitle) 59323**] in [**2-12**] weeks
Dr. [**Last Name (STitle) 80107**] in [**1-11**] weeks
Completed by:[**2192-12-31**]
|
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"425.1",
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icd9cm
|
[
[
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[
"88.72",
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"35.21",
"37.33",
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icd9pcs
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| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
8,775
| 153,934
|
942
|
Discharge summary
|
report
|
Admission Date: [**2148-5-24**] Discharge Date: [**2148-6-22**]
Date of Birth: [**2078-5-26**] Sex: M
Service: MEDICINE
Allergies:
Cholestyramine / Shellfish
Attending:[**First Name3 (LF) 6169**]
Chief Complaint:
Fever to 101 and dry cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
69 yo M with h/o CLL, d+8 of CEPP chemotherapy, who failed a
recent trial of [**Hospital1 **], and who was recently discharged on
[**2148-5-20**] for abdominal pain secondary to ileus presented to
Heme/[**Hospital **] clinic with fevers to 101 and a dry cough. The patient
reports feeling well after his most recent discharge until the
day of admission. He reports waking up in the morning with a
fever of 101. He also reports noticing a dry, persistent cough,
non-productive, which causes him discomfort on deep inspiration
and expiration. He claims to have had a smaller cough for some
weeks prior, to which he attributed to heartburn. He denies any
sputum production. Nothing makes it better or worse.
.
On review of symptoms, he admits to feeling more fatigued today,
and tired. He denies rash, HA, photophobia, meningismus, chest
pain pleuritic or otherwise, sore throat, abdominal pain, n/v/d
or change in stool, dysuria or flank pain. He denies sick
contacts or travel. He has a dog and has been around his
grandchildren. He reports eating a bagel, cream cheese, and
salmon recently.
Past Medical History:
Onc History:
CLL- s/p rituxan, campath, cytoxan, and IVIG. Has persistent
symptomatic lyphadenopathy which was treated with radiation
therapy to enlarged lymph nodes in the right perauricular site
in [**2148-3-25**]. On [**2148-4-12**] an inguinal node excisional biopsy
confirmed CLL and failed to demonstrate transformation. As a
result he was treated with Cycle 1 CVP on [**2148-4-17**]. He complained
of increased neck node pain and swelling after completing a 5
day course of prednisone on [**4-22**].
Received [**Hospital1 **] on [**6-7**].
.
Past Medical History:
CLL as above,
Kidney stones,
diverticulitis,
hypertension,
high cholesterol.
Social History:
He is accompanied by his wife today. She is
very active in the hospital. Does not drink, smoke, or do any
drugs. Lives in downtown [**Location (un) 86**]
Family History:
His father died from an embolism. His had a nephrectomy from
cancer of uncertain etiology. His FGM died from Hodgkins
disease, and MGR died from Parkinson's.
Physical Exam:
Vitals: T: 100.7 p: 100 BP: 137/75 r: 20 O2sat: 98% on RA
Gen: Tired appearing male. Appears stated age.
HEENT: Oral mucosa is moist. No thrush, no mouth sores. PERRL,
EOMI
NECK: Supple, no thyromegaly, no meningismus.
NODES: + soft, nontender cervical and submandibular LAD
LUNGS: Clear to auscultation and percussion, bilaterally.
HEART: Regular rate and rhythm, no murmurs appreciated.
ABDOMEN: Soft, nontender, nondistended, + hepatosplenomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
PICC on left arm- no signs of infection
SKIN: Warm and well perfused. No petechia or purpura. No rashes
NEURO: Alert and oriented, CN I-XII intact bilaterally,
finger-nose wnl, [**3-29**] upper/lower extremity strength
Pertinent Results:
Labs on Admission:
.
[**2148-5-24**] 03:30PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2148-5-24**] 03:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2148-5-24**] 11:30AM GLUCOSE-89 UREA N-16 CREAT-0.7 SODIUM-139
POTASSIUM-3.2* CHLORIDE-103 TOTAL CO2-27 ANION GAP-12
[**2148-5-24**] 11:30AM ALT(SGPT)-58* AST(SGOT)-37 LD(LDH)-282* ALK
PHOS-79 TOT BILI-1.1
[**2148-5-24**] 11:30AM ALBUMIN-3.4 CALCIUM-8.0* PHOSPHATE-1.4*#
MAGNESIUM-1.6 URIC ACID-4.5
[**2148-5-24**] 11:30AM WBC-0.17*# RBC-2.95* HGB-8.8* HCT-24.8*
MCV-84 MCH-29.9 MCHC-35.6* RDW-16.9*
[**2148-5-24**] 11:30AM NEUTS-32* BANDS-1 LYMPHS-51* MONOS-7 EOS-0
BASOS-0 ATYPS-6* METAS-1* MYELOS-0 OTHER-2*
[**2148-5-24**] 11:30AM PLT COUNT-235
[**2148-5-24**] 11:30AM GRAN CT-50*
.
Imaging:
.
Chest X-Ray ([**2148-5-24**]): PA and lateral chest compared to [**2148-5-12**]:
Tip of the left PIC catheter projects over the superior
cavoatrial junction. Lungs are clear. Heart is normal in size
and there is no pleural effusion.
.
Microbiology:
[**2148-5-24**] 3:30 pm URINE
URINE CULTURE (Final [**2148-5-25**]): NO GROWTH.
.
MRI head [**5-27**]:
Findings of small vessel ischemic changes, unchanged from the
prior examination. No new enhancing lesions or evidence of
infarction.
Head CT [**6-15**]:
No acute intracranial pathology to explain the patient's nausea
identified. No abnormal enhancement or mass effect identified.
Brief Hospital Course:
69 year old M with CLL d+8 of CEPP, s/p [**Hospital1 **] regimen and s/p
recent admission for abdominal pain secondary to ileus, who is
admitted for febrile neutropenia to 101F and increased dry
cough.
.
1 Febrile Neutropenia: Patient was febrile in AM prior to
admssion. Moreover, patient had cough, perhaps indicative of
pulmonary process. Differential diagnosis included bacterial,
fungal, viral infection given neutropenia. Recurrent CLL,
atelectasis, inflammatory process, as well as drug effect, were
also possiblities. CXR did not show any signs of an acute
process. Blood cultures were drawn and CMV viral load was
obtainted. A urine culture was negative. He was started on
Cefipime, acyclovir, and vancomycin, fluconazole, and his
atovaquone was continued. He complained of a funny feeling in
his throat on [**5-25**], and was cultured. On hospital day 2 he was
afebrile. CXR on [**5-28**] showed vol overload, but no overt
infiltrate. Differential diagnosis includes bacterial, fungal,
viral infection given neutropenia, CLL, atelectasis,
inflammatory process, as well as drug effect, are also
possiblities. Cultures all remained negative. CT [**5-29**] showed:
progression of multiple patchy nodular opacities associated with
peribronchial thickening and ground-glass opacity predominantly
in centrilobular distribution, most prominent in right middle
lobe, involving both upper and lower lobes, worsened compared to
the prior study, most likely worsening infectious process with
persistent bilateral axillary, mediastinal, abdominal, and
retroperitoneal lymphadenopathy. ID concerned for fungal
process. Bronchoscopy [**5-31**] showed PCP in BAL despite atovaquone
prophylaxis, therefore pt. started on bactrim 360mg IV q8, with
premedication with compazine, anzemet and olanzapine prior to
dose for h/o projectile vomitting with bactrim. Ambisome,
cefipime, atovaquone, and vanco were d/c'd [**5-31**]. Patient with
4-5L O2 demand [**6-4**], also with shaking to 1 unit prbc's, blood
stopped, sent to lab for transfusion reaction analysis but no
evidence of reaction.
.
He was improving with decreasing O2 demand and tried oral
bactrim [**6-6**] to see if he could complete his course at home
however he had uncontrolable nausea and vomitted with aspiration
and desaturation to 50% and was placed on 100% NRB and went to
98%. ABG showed 7.51/38/76 on 100% NRB. He was transferred to
the ICU for close observation and support, CXR suggested
aspiration. He was treated with levofloxacin and flagyl for 1
week out of concern for aspiration pneumonia but he improved so
rapidly that it was likely a sterile aspiration. He was not
intubated and was stable enough to return to the BMT floor on
[**6-8**]. He was maintained on IV bactrim for 21 days, he was also
maintained on solumedrol which was slowly tapered. His oxygen
requirement decreased and he was able to be weaned off O2. He
ambulated with PT and was noted to desaturate to 86% on room air
but came back to 91% on his own while ambulating, so will be
discharged with home oxygen therapy to wear when working with
PT. He was discharged on dapsone 100mg daily for prophylaxis,
with 20mg daily prednisone to be tapered by Dr. [**First Name (STitle) 1557**] as an
outpatient.
.
2 CLL: At the time of admission he was on CEPP regimen
treatment. Blood counts were low. His Cytoxan was held the day
of admission. However, the patient was continued on
procarbazine per his outpatient medications. We also continued
his Prednisone 100mg q Day for 2 days to complete that part of
the regimen. His WBC continued to be below 1000. Once his
prednisone was completed, he began a taper to prevent adrenal
insufficiency. Moreover, his procarbazine was discontinued
after completion of his regimen due to drug effect. He was
treated with G-CSF for 6 days as ANC responded well and he was
no longer neutropenic. Over [**Date range (1) 6291**] he was noted to have
rapidly increasing bilateral cervical lymphadenopathy. He had a
portacath placed [**6-19**] for further therapy. He will follow-up
with Dr. [**First Name (STitle) 1557**] next week for rituxan.
.
3 Somnolence: On [**5-27**], he had an episode of worsening mental
status with lethargy, as well as fevers to 102. Demerol had
been given for previous shakes, his HR was in the 120s, his BP
was 160s/100's and he was diaphoretic. The differential
included serotonin syndrome, infection, and procarbazine drug
effect. Narcan was administered with slight effect. He was
still lethargic, and was put on telemetry and fluids. The
episode was thought to be due to procarbazine, and it was
discontinued. He continued to have lethargy/somnolence during
his hospital course. An MRI of the head was performed on [**5-27**] to
r/o CNS disease to explain somnolence, which was negative. A
repeat CT with contrast was done 7/22.06, also negative. He was
restarted on effexor out of concern for depressed mood but
tapered off again as he may need procarbazine in the future. He
was started on ritalin twice daily 2.5mg at 0700 and 1300 on
[**6-14**], increased to [**6-20**] to 5mg twice daily. This was decreased
to once daily on [**6-21**] as he felt it could be interfering with
sleep. It is recommended that he follow-up with his psychiatrist
as an outpatient.
.
4 Nausea: During this hospital course nausea was a significant
issue, primarily attributed to chemo and bactrim therapy. He had
a head MRI [**5-27**] and a head CT [**6-15**] to look for central pathology
contributing to nausea which were both negative. He was
evaluated by GI who felt that mechanical obstruction was not
likely to be contributing and that there was no indication for
endoscopy at this time. He also had a speech therapy evaluation
of swallowing to see if that might be contributing, which was
notable for coordinated mastication and swallowing. Nausea was
controlled with compazine, anzemet then zofran, zyprexa, ativa,
and a three day course of emend.
.
# Anemia: A possible chemo effect vs suppression from infection
was considered. On admission, his Hct was below 25 and he was
given 1 unit PRBCs with a good response. His bilirubin was 3.1
on day 2, possibly due to transfusion, and repeat LFTs were
drawn. He required occaisional blood transfussions thorughout
his hospital course with a hct. averaging 27.
.
# Sleep Disordered Breathing: He has a history of sleep
disordered breathing and has been on Bipap in the past but had
not used his machine for 9 months prior to admission but his
machine was tried [**6-5**] to improve sats while sleeping with
minimal improvement prior to aspiration event, but it was not
continued after this event. He is to follow-up with his
outpatient sleep medicine pulmonologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for
assessment and treatment.
Medications on Admission:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Esomeprazole Magnesium 20 mg Capsule, Delayed Release(E.C.)
Sig: Two (2) Capsule, Delayed Release(E.C.) PO QD ().
3. Atovaquone 750 mg/5 mL Suspension Sig: Five (5) ml PO BID (2
times a day).
4. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO QD () for 7
days:
6. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q12H (every
12 hours).
7. Prednisone 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 6 days:
8. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO PRN (as needed).
9. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every six
(6) hours: for breakthrough pain only.
11. Procarbazine 50 mg Capsule Sig: Two (2) Capsule PO once a
day for 10 days
Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
3. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**11-27**] Sprays Nasal
QID (4 times a day) as needed.
Disp:*1 bottle* Refills:*2*
4. Fluticasone 50 mcg/Actuation Aerosol, Spray Sig: Two (2)
Spray Nasal DAILY (Daily).
Disp:*1 bottle* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
Disp:*30 Tablet(s)* Refills:*2*
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
8. Acyclovir 200 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8
hours).
Disp:*3 Capsule(s)* Refills:*2*
9. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO once a
day: Please take in the morning.
Disp:*30 Tablet(s)* Refills:*2*
10. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): To be tapered by Dr. [**First Name (STitle) 1557**].
Disp:*30 Tablet(s)* Refills:*2*
11. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
12. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
13. Ondansetron HCl 4 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for nausea: Do not exceed 32mg in 24 hours.
Disp:*180 Tablet(s)* Refills:*2*
14. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
Disp:*90 Tablet(s)* Refills:*2*
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours.
Disp:*1 inhaler* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
Gentiva/[**Location (un) 86**]
Discharge Diagnosis:
Primary Diagnosis:
1. Febrile neutropenia
2. PCP [**Name Initial (PRE) 1064**]
Secondary diagnoses:
1. Chronic Lymphocytic Leukemia
2. Hypertension
3. Sleep Disordered Breathing
Discharge Condition:
Good.
Discharge Instructions:
1. Please take all medications as prescribed
2. Please keep all follow up appointments
3. Please wear oxygen nasal cannula at all times until
instructed by your doctor that you no longer need supplemental
oxygen. You should not have anyone smoke or be near an open
flame while using oxygen.
4. Please return to the hospital/emergency department
immediately if you experience fevers/chills, chest pain,
shortness of breath, bleeding, sudden severe headache, or any
other symptoms that concern you.
Followup Instructions:
Please follow up with [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) **], RN at Dr.[**Name (NI) 6168**] office
on [**2148-6-25**] at 11:00am, then with Dr. [**First Name (STitle) 1557**] at 11:30am.
Call if questions or concerns ([**Telephone/Fax (1) 3936**].
.
Please follow up with your PCP within one week of discharge.
.
Please call Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for follow-up of your sleep
disordered breathing at ([**Telephone/Fax (1) 3554**].
.
Please call your outpatient psychiatrist for a follow-up
appointment.
|
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icd9cm
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icd9pcs
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14492, 14553
|
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|
314, 321
|
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3232, 3237
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2316, 2478
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248, 276
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349, 1452
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3251, 4728
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2047, 2125
|
2141, 2300
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,271
| 113,059
|
50040
|
Discharge summary
|
report
|
Admission Date: [**2144-7-28**] Discharge Date: [**2144-8-5**]
Date of Birth: [**2069-5-8**] Sex: F
Service: MEDICINE
Allergies:
Naproxen / Nsaids / Narcotic Analgesic & Non-Salicylate Comb
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
right shoulder joint tap
History of Present Illness:
The patient is a 75 y.o. F resident of [**Hospital3 **] with h/o
cardiomyopathy, CAD, HTN, dementia, CRI, incontinence who
presents with lethargy and rigoring x 3 days. At baseline she is
demented but conversational, uses walker to go outside etc. The
staff reports that patient has had decreased po intake since
Sunday. NP saw patient today and she was seen to be rigoring and
not as interactive as usual. She was going to be sent to [**Doctor Last Name 1263**]
lethargy. At [**Last Name (un) **] she had her clothes on backwards and was
drooling. She completed a course of amoxicillin from [**Date range (1) 11010**].
In the ED she was given zosyn. Blood culture box not checked off
prior to administration of abx. She was placed on a sitter in
the ED. 1 LNS hung in the ED.
<br>
ROS could not be obtained from patient thus spoke with [**Date range (1) 802**].
Patient was moved to ALF in [**Month (only) 404**] in [**2141**] when she lost a lot
weight- down to 85 lbs, confusing her medications, failure to
thrive. She was first admitted to the hospital and then
transferred to ALF. She appeared to be doing well to ALF. She
c/o of knee pain which is chronic for her. No worse swelling
noted. Otherwise no c/o.
All other review of systems negative.
<br>
Spoke with [**Year (4 digits) 802**] who last saw her Sunday and she didn't really
see anything wrong with her. She often confuses the dates of
things eg when was the last time she saw her sons and she can't
remember when she last saw people.
Past Medical History:
Taken from ED resident note as only paper work from ALF on
admission was the med sheet.
<br>
Cardiomyopathy
CAD
HTN
Hyperlipidemia
Depression
Anemia
Anxiety
Arthritis
CRI
Dementia
Incontinence
Social History:
Resident at ALF at Gooddard house. Ambulates with walker at
baseline.
First contact: [**Name2 (NI) 3548**] [**Location (un) 104486**] - [**Location (un) 802**] 1 [**Telephone/Fax (1) 104487**]/cp [**Telephone/Fax (1) 104488**]
Second contact: son- [**Name (NI) 104489**] [**Initials (NamePattern4) **] [**Name (NI) **] [**Medical Record Number 104490**]-[**Telephone/Fax (1) 104491**]
Email: [**E-mail address 104492**]
PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 104493**] Elder Service plan/PACE/Geriatrics
<br>
At baseline alert. She is independent with dressing, feeding and
toileting but wears depends in case she can't make it. She
lives in ALF where someone comes to help her write her checks.
She walks to the corner store. Her [**Last Name (STitle) 802**] buys her the "big
stuff".
Family History:
She has one son in [**Name (NI) 1559**] and the rest out of the country.
Her son in [**Name (NI) 13025**] has medical problems but the nieice
couldn't say. No DM or HTN in the family. One sister with
breast cancer and the other sister with lung CA. Her sister died
of a heart attack.
Physical Exam:
per admitting physician:
[**Name10 (NameIs) **] Tm = 99.8 R, P = 82, BP = 149/53, RR = 14, 95%4L
Current vitals on the floor 97.3, 83, RR = 22, 100% on 3L
GENERAL: Elderly female laying in bed. NAD.
Nourishment: Greatly at risk.
Grooming: OK
Mentation: Somnolent, barely arousable to sternal rub.
Eyes:NC/AT, PERRL, EOMI without nystagmus, no scleral icterus
noted
L ear filled with cerumen.
Ears/Nose/Mouth/Throat: dry MM, poorly fitting dentures
Neck: supple, Prominent JVD [**2-29**] to thin habitus but not
elevated.
Respiratory: Lungs CTA bilaterally without R/R/W
Cardiovascular: tachycardic, nl. S1S2, no M/R/G noted
Gastrointestinal: soft, scaphoid, normoactive bowel sounds,
Rectal: External non-bleeding hemmrhoid. Soft stool in vault.
Not impacted. Guaic negative brown stool
Genitourinary: No supra-pubic tenderness.
Skin: no rashes or lesions noted. No pressure ulcer
Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses
b/l.
Lymphatics/Heme/Immun: No cervical, supraclavicular, axillary or
inguinal lymphadenopathy noted.
Neurologic:
-mental status: Alert, oriented x 3. Able to relate history
without difficulty.
-cranial nerves: ? L facial droop.
Withdraws to pain. Could not perform neurologic exam due to
somnolence.
+ foley catheter/ No sacral decubitus
Psychiatric: Could not be assessed secondary to mental status.
Pertinent Results:
136 106 72
--------------< 85
5.4 7 3.9
.
WBC: 23
HCT: 26
PLT: 654
.
PT: 17.9 PTT: 40.7 INR: 1.6
.
[**7-29**]: Head CT: 1. No acute hemorrhage or mass effect. 2.
Bifrontal lobe cerebral atrophy vs bifrontal higromas, follow-up
is recommended. 3. Old lacunar infarction.
.
MRI abd:
1. Full width full thickness tears of the supraspinatus and
infraspinatus
tendons with tendon retraction and a high-riding humeral head.
Associated
marked muscular atrophy and fatty degeneration.
2. Complete tear of the long head of the biceps tendon.
3. Large joint effusion extending into the
subachromial-subdeltoid bursa and biceps tendon sheath with
evidence of synovitis. This could be inflammatory or infectious
in etiology.
4. Post-surgical changes of the AC joint.
5. Extensive degenerative cyst formation about the humeral head.
.
[**8-2**] CT abd:
1. Severely limited evaluation due to lack of IV and p.o.
contrast. No
evidence of dilated loops of bowel.
2. Extensive calcification of the aorta and its branches.
3. Hypodense lesions in the liver which are too small to
characterize.
4. Small amount of free fluid within the dependent portions of
the abdomen
and pelvis.
.
[**8-3**] echo:
IMPRESSION: Severe hypokinesis of the distal [**3-1**] of the left
ventricle. This could be consistent with stress cardiomyopathy
(Takotsubo syndrome) or multi-vessel coronary artery disease.
Diastolic dysfunction. Moderate mitral regurgitation. Moderate
to severe tricuspid regurgitation and at least moderate
pulmonary artery systolic hypertension.
Brief Hospital Course:
75yo woman w hx ? cardiomyopathy, CAD, HTN CRI here metabolic
acidosis, ? infection who ultimately died during hospital stay.
Brief hospital course:
.
Patient presented with metabolic acidosis thought [**2-29**] ARF vs
underlying infection. She received fluid resuscitation in the
ICU with HCO3 and her metabolic acidosis improved. She was seen
by renal and ID to assist with management. Patient was treated
broadly for infectious sources and even had right shoulder tap.
Not clearly c/w septic joint however she remained on broad abx.
Patient had improvement in mental status and hemodynamics.
However, had several episodes of acute pulm edema on the floor
and echo c/w Takotsubo's syndrome. Her SOB improved with lasix
but given the increased frequency of these episodes she was
transferred back to the ICU.
.
In the ICU, patient very clearly stated her interest in DNR DNI.
We also confirmed this with her son, [**Name (NI) 47897**] (HCP). We
initially tried to manage her acute systolic CHF with lasix and
nitro gtt but this was complicated by worsening renal
dysfunction and hypotension. We were unable to give her IVF
given her pulmonary edema. The patient became somewhat
delirious at this time. We discussed her very poor clinical
picture with her HCP and he asked that we focus on comfort care.
The patient was started on morphine and titrated to comfort.
At [**2144-8-5**] at 10:02am the patient was declared dead. Causes of
death include: acute systolic CHF, ARF, and metabolic acidosis.
Family was at the bedside and declined autopsy.
.
Comm: with two brothers and [**Name2 (NI) 802**]
1. [**Name (NI) 47897**] [**Name (NI) **] (son/HCP) [**Medical Record Number 104490**]-[**Telephone/Fax (1) 104494**]. or [**Telephone/Fax (1) 104495**]
2. [**Name (NI) 3548**] [**Location (un) 104486**] ([**Location (un) 802**]) [**Telephone/Fax (1) 104496**], [**Telephone/Fax (1) 104497**],
[**Telephone/Fax (1) 104498**].
3. [**Name (NI) 1158**] (son) [**Telephone/Fax (1) 104499**]
Medications on Admission:
Amoxicillin 500 mg tid 5-21-5-30
Lasix 10 mg qd
Glucosamine/Chondroitin ES
Lidoderm patch 5% qd
Lipitor 20 mg qd
Lisinopril 5 mg qd
MVT qd
Nifedipine 30 ER qd
oxycodone 5 mg qam
oxycodone 2.5 mg [**Hospital1 **]
Salsalate 500 mg tid
Sertraline 125 mg qd
Tylenol 1300 mg tid
Zyprexa 2.5 mg q 8 pm
Discharge Medications:
none
Discharge Disposition:
Expired
Discharge Diagnosis:
Causes of death:
Acute systolic CHF - hours
ARF - days
Metabolic Acidosis - days
Discharge Condition:
expired
Discharge Instructions:
Patient came in with profound metabolic acidosis and found to
have acute renal failure and elevated WBC. Infection suspected
so patient was covered broadly. Etiology of infection not
entirely clear. Patient then developed acute systolic CHF and
worsening renal failure. Patient requested DNR DNI status.
Given worsening status, patient's HCP requested focus on
comfort. patient expired on [**2144-8-5**] at 10:02am.
Followup Instructions:
none
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"294.8",
"718.91",
"276.2",
"585.9",
"414.01",
"428.0",
"411.89",
"397.0",
"424.0",
"276.51",
"416.8",
"288.60",
"429.83",
"496",
"599.0",
"584.9",
"711.01",
"428.21",
"285.9",
"300.4",
"427.89",
"726.10",
"293.0",
"V66.7",
"788.30",
"427.31",
"518.81",
"403.90",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.04",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
8579, 8588
|
6354, 8203
|
348, 375
|
8713, 8723
|
4640, 4757
|
9192, 9336
|
2971, 3258
|
8550, 8556
|
8609, 8692
|
8229, 8527
|
8747, 9169
|
4428, 4621
|
3273, 4332
|
287, 310
|
403, 1911
|
4766, 6182
|
4347, 4411
|
1933, 2127
|
2143, 2955
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
30,305
| 134,686
|
31745
|
Discharge summary
|
report
|
Admission Date: [**2173-10-7**] Discharge Date: [**2173-10-10**]
Date of Birth: [**2118-1-17**] Sex: M
Service: CARDIOTHORACIC
Allergies:
Codeine / Zithromax
Attending:[**First Name3 (LF) 922**]
Chief Complaint:
Increased fatigue
Major Surgical or Invasive Procedure:
Mitral valve repair (38 mm CE PhysioRing)
History of Present Illness:
This is a 55 year old man with Staphylococcus aureus
endocarditis who presents with increased fatigue and mitral
regurgitation on echo (4+) with vegetations noted. He presents
for repair of his mitral valve.
Past Medical History:
Endocarditis, MVP (myxomatous), renal calculi, [**10-2**] MVA, s/p
tonsillectomy, uvulectomy, vasectomy
Social History:
Works as a carpenter, lives with wife
Quit smoking [**2139**]
No alcohol
no recreational drug use
Family History:
Father with MVR at age 78
Pertinent Results:
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *7.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: *6.2 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: *7.1 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Findings
LEFT ATRIUM: Marked LA enlargement. No spontaneous echo contrast
in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No spontaneous echo contrast or
thrombus in the body of the [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] LAA. No spontaneous echo
contrast is seen in the LAA.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or
pacing wire is seen in the RA and extending into the RV. No ASD
by 2D or color Doppler. Prominent Eustachian valve (normal
variant).
LEFT VENTRICLE: Wall thickness and cavity dimensions were
obtained from 2D images. Normal LV wall thickness. Severely
dilated LV cavity. Overall normal LVEF (>55%). [Intrinsic LV
systolic function likely depressed given the severity of
valvular regurgitation.]
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter. Normal
descending aorta diameter. Simple atheroma in descending aorta.
AORTIC VALVE: Three aortic valve leaflets. Mildly thickened
aortic valve leaflets. No AS. Mild (1+) AR. Eccentric AR jet
directed toward the anterior mitral leaflet.
MITRAL VALVE: Severely thickened/deformed mitral valve leaflets.
Partial mitral leaflet flail. Mitral leaflets fail to fully
coapt. Torn mitral chordae. No MS. [**Name13 (STitle) 650**] (4+) MR.
Uninterpretable LV inflow pattern due to MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets
with physiologic 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. The patient was under general anesthesia throughout
the procedure. The patient received antibiotic prophylaxis. The
TEE probe was passed with assistance from the anesthesioology
staff using a laryngoscope. No TEE related complications.
REGIONAL LEFT VENTRICULAR WALL MOTION:
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
PRE-CPB:1. The left atrium is markedly dilated. No spontaneous
echo contrast is seen in the body of the left atrium or left
atrial appendage. No spontaneous echo contrast or thrombus is
seen in the body of the left atrium or left atrial appendage. No
spontaneous echo contrast is seen in the left atrial appendage.
No atrial septal defect is seen by 2D or color Doppler.
2. Left ventricular wall thicknesses are normal. The left
ventricular cavity is severely dilated. Overall left ventricular
systolic function is normal (LVEF>55%). [Intrinsic left
ventricular systolic function is likely more depressed given the
severity of valvular regurgitation.]
3. Right ventricular chamber size and free wall motion are
normal. There is a thebesian valve seen at the entrance to the
coronary sinus.
4. There are simple atheroma in the descending thoracic aorta.
5. There are three aortic valve leaflets. The aortic valve
leaflets are mildly thickened. There is no aortic valve
stenosis. Mild (1+) aortic regurgitation is seen. The aortic
regurgitation jet is eccentric, directed toward the anterior
mitral leaflet.
6. The mitral valve leaflets are severely thickened/deformed.
There is partial mitral leaflet flail. The mitral valve leaflets
do not fully coapt. Torn mitral chordae are present. Severe (4+)
mitral regurgitation is seen. There is systolic flow reversal
seen in the LUPV. The annulus is enlarged and measures 4.2 cm.
7. There is a trivial/physiologic pericardial effusion.
POST-CPB: On infusions of epinephrine and nitroglycerine:
1. Mitral valve annulopasty ring is present and well seated.
There is no evidence of mitral regurgitation, prolapse or flail.
Gradient across valve was 1mmHg.
2. Prior to coming off CBP, there was visible air in left
ventricle with inferior wall dyskinesis, which improved with
nitroglycerin and inotropic support. Inferior wall post bypass
is normal.
3. Maintained biventricular function.
4. Aortic regurgitation remains mild 1+.
5. Aortic contours are intact post decannulation.
Brief Hospital Course:
Mr. [**Known lastname **] was admitted after undergoing a mitral valve repair
with a 38 mm CE PhysioRing. He did well post-operatively and
his lines and drains were removed. He was transferred to the
floor on POD1. He continued to do well as he completed his
antibiotic course and was discharged home on POD3 in good
condition with follow up instructions
Medications on Admission:
Nafcillin
Discharge Medications:
1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours) for 1 weeks.
Disp:*14 Tablet(s)* Refills:*0*
2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two
(2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1
weeks.
Disp:*28 Capsule, Sustained Release(s)* Refills:*0*
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).
Disp:*60 Tablet(s)* Refills:*2*
5. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO HS (at bedtime) as needed for constipation.
9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
10. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital **] homecare and hospice
Discharge Diagnosis:
Mitral regurgitation, endocarditis
Discharge Condition:
Good
Discharge Instructions:
Shower daily, no bathing or swimming for 1 month
No creams, lotions, or powders to any incisions
No driving for 1 month
No lifting > 10 lbs. for 10 weeks
Followup Instructions:
F/U with Dr. [**Last Name (STitle) 914**] in 4 wks
F/U with cardiologist in [**1-30**] wks
F/U with Dr. [**Last Name (STitle) 32848**] in [**1-30**] wks
|
[
"V15.82",
"414.01",
"421.0",
"396.3",
"041.11",
"429.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.00",
"96.04",
"39.63",
"96.71",
"39.61",
"35.12"
] |
icd9pcs
|
[
[
[]
]
] |
7144, 7211
|
5425, 5784
|
304, 348
|
7290, 7297
|
890, 3262
|
7499, 7655
|
844, 871
|
5844, 7121
|
7232, 7269
|
5810, 5821
|
7321, 7476
|
3311, 5402
|
247, 266
|
376, 586
|
608, 713
|
729, 828
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,315
| 110,147
|
14680+14681
|
Discharge summary
|
report+report
|
Admission Date: [**2166-11-29**] Discharge Date:
Date of Birth: [**2096-7-26**] Sex: M
Service:
HISTORY OF PRESENT ILLNESS: The patient is a 70 year old
male with a history of bilateral lung cancer, status post
resection and chemotherapy and radiation who experienced
shortness of breath and diaphoresis the morning of his
admission. He called his family and they found him to be
short of breath, diaphoretic and they called Emergency
Medical Services. The patient then had a PEA witnessed
arrest, cardiopulmonary resuscitation was initiated. The
patient was intubated in the field. He was given Epinephrine
via his endotracheal tube, Atropine and his pulse and blood
pressure were covered in the ambulance. The patient was
taken to [**Hospital 882**] Hospital. At [**Hospital 882**] Hospital he again
arrested (PEA arrest), cardiopulmonary resuscitation was
initiated again and he was resuscitated with 2 mg of
Epinephrine, 1 mg of bicarbonate and his first arterial blood
gas was 6.90 pH, pCO2 of 111 and pAO2 of 123. He was started
on a Dopamine drip. A left subclavian central line was
placed and the patient was started on a Versed drip. He was
transferred to [**Hospital6 256**] for
further management as he received his care here.
PAST MEDICAL HISTORY: 1. Right upper lung cancer, right
upper lobe biopsy in [**2166-4-26**] consistent with
adenocarcinoma, status post wedge resection, left upper lobe
bronchial washings with poorly differentiated large cell
cancer, status post lobectomy. The patient underwent
chemotherapy with Carboplatin and Taxol and radiation there
which he finished the week prior to his admission. 2.
Hypertension. 3. Hypercholesterolemia. 4. Peptic ulcer
disease. 5. Chronic sinusitis.
SOCIAL HISTORY: Positive tobacco use with a 50 pack year
history until [**2165**]. He had a history of occupational
exposure to asbestos.
FAMILY HISTORY: Positive for skin cancer, question melanoma,
grandfather with carcinoma of the lip.
MEDICATIONS ON ADMISSION: Amiodarone 200 mg p.o. q. day,
Atenolol 25 mg p.o. q. day, Hydrochlorothiazide 25 mg p.o. q.
day, Lipitor 10 mg p.o. q. day, Colace and Percocet prn,
Trazodone 50 mg p.o. q.h.s., Tylenol, Flovent, Atrovent,
Nasocort, Levaquin 500 q. day times seven days, Compazine
prn, Metamucil, Robitussin, Oxycodone prn, Oxacillin prn.
ALLERGIES: No known drug allergies.
PHYSICAL EXAMINATION: Physical examination on admission
revealed temperature 93.3, blood pressure 75/54, heartrate
129. Ventilator settings, assist control 800 by 16 with a
rate of 16, 100% FIO2 and 5 positive end-expiratory pressure.
In general he was intubated and not responsive to painful
stimuli. Head, eyes, ears, nose and throat, pupils dilated,
not responsive to light. Neck, unable to assess jugulovenous
pressure. Cardiovascular, tachycardiac, regular rate, no
murmurs. Lungs, coarse breathsounds bilaterally anterior
with question of slightly diminished breathsounds at the left
base. Abdomen, decreased bowel sounds, soft, nondistended.
Rectal deferred. Obstetrics negative at outside hospital.
Extremities, cool, mottled, positive dorsalis pedis pulses
bilaterally. No edema and no urine was noted in his Foley
catheter bag.
LABORATORY DATA: On admission white count was 4.3,
hematocrit 33.1, platelets 161, INR 1.4, PTT 38.5, ALT 314,
AST 325, ALV 922, alkaline phosphatase 133, amylase 148,
calcium 1.1, free calcium 1.17, lactate 6.9, sodium 142,
potassium 3.3, chloride 101, bicarbonate 20, BUN 23,
creatinine 1.1, anion gap of 20. Phosphorus 7.8, albumin
3.0. His electrocardiogram showed sinus tachycardia with
right bundle branch block, T wave inversions in V1 and V2, T
wave inversion in V3. Lower extremity ultrasound showed
bilateral common femoral deep vein thrombosis and left
superior clot. Chest x-ray showed right upper lobe
infiltrate.
HOSPITAL COURSE: 1. Pulmonary - The patient underwent a
computed tomographic angiography which showed multiple
pulmonary embolisms. He underwent thrombectomy with directed
total parenteral alimentation. An inferior vena cava filter
was placed by Interventional Radiology. He was started on
heparin. He experienced hypoxemia and ventilatory failure
secondary to pulmonary embolism but he also has a history of
underlying lung disease including wedge resections,
radiation, likely chronic obstructive pulmonary disease.
During his hospital course the patient was treated for his
pulmonary emboli and he was able to be slowly weaned from the
ventilator. On [**2166-12-5**], the patient had a
self-extubation which failed. He was reintubated and
experienced likely intubation-associated pneumonia. His
sputum grew out Methicillin-resistant Staphylococcus aureus.
He was started on Vancomycin. He had a bedside tracheostomy
performed and has since that time been slowly able to be
weaned from the ventilator. He, at this time, is able to be
weaned to tracheostomy mask for three to four hours per day.
2. Infectious disease - The patient had 2 out of 2 positive
blood cultures from a left subclavian line that was
discontinued and he was started on Vancomycin. His
peripheral cultures remained no growth deep. He had
Methicillin-resistant Staphylococcus aureus pneumonia and has
been treated with Vancomycin to complete a two week course.
3. Heme - The patient received one unit of blood. His
hematocrit remained stable. His platelets initially
decreased but later recovered and have since then been
normal. It was felt that he had likely consumption from his
large clot burden as well as poor production given his recent
chemotherapy. He was therapeutic on heparin and Coumadin was
started prior to discharge.
4. Renal - Initially the patient had his creatinine bumped
to 2.5, likely secondary to acute tubular necrosis from his
arrest and also in the setting of large diload for computed
tomographic angiography and angiogram. His creatinine
trended down. He had good urine output and his kidney
function was normal at the time of discharge.
5. Gastrointestinal - He initially had elevated liver
function tests which recovered over his initial hospital
stay. It was felt this was secondary to shock liver. He
also had coffee ground emesis through his nasogastric tube
after his total parenteral alimentation. He was started on
Protonix and he had no further bleeding. At the time of
discharge he was having normal bowel movements that were
guaiac negative.
6. Nutrition - The patient was started on tube feeds via his
percutaneous endoscopic gastrostomy that was placed at the
bedside by Gastroenterology. He was tolerating them well.
7. Cardiovascular - The patient remained off of his
antihypertensive medications during his hospital stay. These
can be restarted as needed after discharge.
8. Access - The patient will be evaluated for a PICC line to
be placed prior to discharge to complete his course of
antibiotics. He has a tracheostomy and percutaneous
endoscopic gastrostomy tube.
The remaining discharge summary will be dictated as an
addendum with discharge medications.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 9422**]
MEDQUIST36
D: [**2166-12-14**] 10:50
T: [**2166-12-14**] 10:56
JOB#: [**Job Number 43212**]
Admission Date: [**2166-11-29**] Discharge Date: [**2166-12-19**]
Date of Birth: [**2096-7-26**] Sex: M
Service:
ADDENDUM: There is one correction from initial discharge
summary under hospital course.
HOSPITAL COURSE: The patient underwent thrombectomy with
directed TPA, which is tissue plasminogen activator not total
parenteral alimentation.
From an pulmonary standpoint the patient remained off the
ventilator and on a 40% tracheostomy mask for greater periods
of time throughout the day. He was off the ventilator for a
total of 48 hours and on the trach mask at which time he then
fatigued and required resting on minimal amounts of pressure
support and at this time is able to tolerate tracheostomy
mask for over twelve hours per day. He had a Passy Muir
valve placed and tolerates it well. His cough has improved.
He is able to clear his own secretions requires less
suctioning.
From an infectious disease standpoint, the patient is to
complete his course of Vancomycin for MRSA pneumonia on
[**2166-11-19**]. At this time he remains afebrile, although his
white count has been slowly rising, all remaining cultures
have been no growth to date and he will need to be monitored
after discharge for any evidence of persistent infection
after his antibiotics are completed. Blood cultures were
sent on [**12-19**] from his right sided PICC line as well as C-diff
stool cultures sent on [**12-18**], which is pending at this time.
Hematology, the patient received one additional unit of
packed red blood cells on [**11-17**] for a hematocrit of 23.
There has been no evidence of active bleeding. His stools
have been guaiac negative. This was felt secondary to
frequent phlebotomy. His hematocrit bumped to 28
appropriately and has remained stable.
Nutrition, the patient remained on tube feeds at his goal
rate of 60 cc per hour. He is having normal bowel movements
and remains on Prevacid for a history of upper
gastrointestinal bleed, which is stable.
Cardiovascular, the patient was restarted on Lopresor as well
as Lipitor for his history of hypertension and
hypercholesterolemia. He was not restarted on Amiodarone
given the potential lung toxicity.
Psychiatric, over the past several days the patient had
episodes of increased confusion and agitation. His
benzodiazepines and opiates were discontinued and the patient
was started on Zyprexa, which will be increased to 5 mg po
q.h.s., which has improved his overall mental status. On the
day of this dictation the patient is oriented to person and
time, but not to place, but he is less agitated and is
pleasant and cooperative. On [**11-17**] he had an episode of
agitation where he removed his tracheostomy, which was
replaced without incident and he has been doing well since
that time.
Access, the patient has a right sided PICC line placed on
[**12-15**], tracheostomy placed [**12-9**] and changed on [**12-18**], PEG
placed on [**12-10**], Foley catheter and he will have a voiding
trial today remains in place at this time.
DISCHARGE MEDICATIONS: Lipitor 10 mg per G tube q day,
Lopressor 50 mg per G tube b.i.d., intravenous heparin,
regular insulin sliding scale b.i.d., Prevacid 30 mg per G
tube q day, Zyprexa 5 mg po q.h.s., Atrovent nebulizers one
neb q six hours. Coumadin 5 mg po q day and Vancomycin 1
gram intravenous q 18 hours until [**2166-11-19**]. Nystatin
applied topically as needed and Lidocaine jelly 2% applied
topically as needed to his sacrum. Desitin and Miconazole
powder applied as needed. Nystatin oral solution 5 ml po
t.i.d. prn swish and swallow. Albuterol one to two puffs
inhaled q 4 hours prn. Trazodone 75 mg po q.h.s. prn.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3795**]
Dictated By:[**Last Name (NamePattern1) 9422**]
MEDQUIST36
D: [**2166-12-19**] 12:50
T: [**2166-12-19**] 12:55
JOB#: [**Job Number 43213**]
|
[
"496",
"584.5",
"415.19",
"427.5",
"287.5",
"276.2",
"482.41",
"570",
"518.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.7",
"96.72",
"31.1",
"99.29",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
1917, 2002
|
10430, 11324
|
2029, 2391
|
7610, 10406
|
2414, 3872
|
144, 1268
|
1291, 1759
|
1776, 1900
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,656
| 120,392
|
7209
|
Discharge summary
|
report
|
Admission Date: [**2174-4-26**] Discharge Date: [**2174-5-2**]
Date of Birth: [**2093-9-25**] Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1505**]
Chief Complaint:
Presyncope
Major Surgical or Invasive Procedure:
[**2174-4-27**] Aortic valve replacement 21-mm St. [**Hospital 923**] Medical Biocor
tissue valve
History of Present Illness:
80 year old male with severe aortic stenosis, admitted [**1-14**] for
presyncope, attributed to micturition syncope, and in [**2-14**] with
chest pain, likely [**3-9**] aortic stenosis or CAD (ruled out for
ACS). On that admission he underwent stress testing but only
achieved 2.2 mets, he was discharged with addition of ASA 81mg
to his medication regimen. He remains active and has been able
to walk up/down stairs in his home w/o symptoms. He had a
cardiac cath on [**3-22**] which revealed nonobstructive CAD. He is
admitted today for heparin bridge with plans for AVR
Past Medical History:
Mohs resection of an invasive squamous cell carcinoma in the
right postauricular area which required a repeat resection with
skin grafting. A lymph node showed direct extension of atypical
squamous cells, but there were no other lymph node metastases.
treated postoperative radiation therapy
Dyslipidemia
Hypertension
PTCA/PCI to RCA in [**2164**]
tachy-brady syndrome s/p PPM [**2169**] **last interrogated [**2-15**]
PPM placed [**2169-12-6**] Guidant PPM Model# 1283 Serial# [**Numeric Identifier 26722**], on coumadin
Aortic stenosis valve area 0.9cm2 with peak gradient 69, mean
gradient 42
CVA in [**2154**], residual left-sided weakness, uses cane, brace on
left leg
OSA, not using CPAP for past couple years [**3-9**] discomfort after
SCC removal
BPH
Benign thyroid nodule
carotid artery stenosis s/p left CEA 4 years ago with
100% occlusion on the right - Chronic R internal carotid artery
occlusion. <40% carotid stenosis on left
basal cell(?), pt reports squamous cell carcinoma status post
resections
Social History:
Lives with:wife
Occupation:retired. photo engraver
Tobacco:quit smoking 20 yrs ago, previously 1 small pack cigars
for 2 years
ETOH:occasionally drinks [**2-6**] glasses wine per evening
Family History:
Mother died of MI at 70-75yo. Father died of MI at 80yo. His
family history is significant for Alzheimer's disease. His
sister also has a heart murmur.
Physical Exam:
General: AAO X 3 in NAD
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [] Irregular [x] Murmur: III/VI systolic ejection
murmur with radiation to the left carotid.
Abdomen: Soft [x] non-distended [x] non-tender [x]
bowel sounds + [x]
Extremities: Warm [x], well-perfused [x] no Edema
no Varicosities; decreased strength left leg; not using his left
arm with hand deformed.
Neuro: Grossly intact
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
PT [**Name (NI) 167**]: 1+ Left: 1+
Radial Right: 2+ Left: 2+
Carotid Bruit Right: no Left: referred bruit from
cardiac murmur
Pertinent Results:
[**2174-5-2**] 09:10AM BLOOD WBC-5.4 RBC-3.27* Hgb-10.3* Hct-29.6*
MCV-90 MCH-31.5 MCHC-34.8 RDW-15.6* Plt Ct-139*
[**2174-4-26**] 07:20PM BLOOD WBC-5.4 RBC-4.18* Hgb-13.4* Hct-40.2
MCV-96 MCH-31.9 MCHC-33.3 RDW-13.8 Plt Ct-137*
[**2174-5-2**] 09:10AM BLOOD PT-15.7* INR(PT)-1.4*
[**2174-4-26**] 07:20PM BLOOD Plt Ct-137*
[**2174-4-27**] 12:43PM BLOOD Fibrino-168
[**2174-5-2**] 09:10AM BLOOD Glucose-106* UreaN-25* Creat-0.9 Na-137
K-4.3 Cl-101 HCO3-29 AnGap-11
[**2174-4-26**] 07:20PM BLOOD Glucose-126* UreaN-21* Creat-1.0 Na-142
K-4.3 Cl-106 HCO3-29 AnGap-11
[**2174-4-26**] 07:20PM BLOOD ALT-26 AST-34 LD(LDH)-256* AlkPhos-99
TotBili-0.6
[**2174-4-26**] 07:20PM BLOOD Lipase-89*
[**2174-5-2**] 09:10AM BLOOD Mg-2.2
[**2174-4-26**] 07:20PM BLOOD Calcium-9.5 Phos-3.4 Mg-1.8
[**2174-4-26**] 07:20PM BLOOD %HbA1c-5.7 eAG-117
[**2174-4-29**] 12:00AM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: *4.8 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 3.4 cm <= 5.2 cm
Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm
Left Ventricle - Ejection Fraction: 55% to 60% >= 55%
Aorta - Annulus: 2.2 cm <= 3.0 cm
Aorta - Sinus Level: 2.9 cm <= 3.6 cm
Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm
Aorta - Ascending: 3.2 cm <= 3.4 cm
Aortic Valve - Peak Velocity: *3.9 m/sec <= 2.0 m/sec
Aortic Valve - Peak Gradient: *60 mm Hg < 20 mm Hg
Aortic Valve - Mean Gradient: 45 mm Hg
Aortic Valve - LVOT diam: 2.0 cm
Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2
Findings
LEFT ATRIUM: Mild LA enlargement. No thrombus in the LAA.
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. Overall normal LVEF (>55%).
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal ascending aorta diameter. Complex (>4mm) atheroma
in the descending thoracic aorta. No thoracic aortic dissection.
AORTIC VALVE: Bicuspid aortic valve. Severely thickened/deformed
aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR.
MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
mitral annular calcification. Mild (1+) MR.
TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets.
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. The TEE probe was passed with assistance from the
anesthesioology staff using a laryngoscope. No TEE related
complications. Results were personally reviewed with the MD
caring for the patient.
Conclusions
PRE-CPB:
The left atrium is mildly dilated. No thrombus is seen in the
left atrial appendage. No atrial septal defect is seen by 2D or
color Doppler.
There is mild symmetric left ventricular hypertrophy. Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
There are complex (>4mm) atheroma in the descending thoracic
aorta and the distal arch. No mobile components are seen. No
thoracic aortic dissection is seen.
The aortic valve is functionally bicuspid with fusion of the
left and right coronary cusps. 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.
POST-CPB:
There is a bioprosthetic valve in the aortic position. The valve
is well-seated with normal leaflet mobility. There is a small
sewing ring leak seen in the deep transgastric view that is not
well visualized in the mid-esophageal long-axis or AV en face
views. This leak disappeared after protamine administration.
There is no AI.
There is evidence of [**Male First Name (un) **] with turbulent flow in the LVOT by
color Doppler and increased MR. This was managed medically with
volume loading and increasing afterload with phenylephrine
infusion. [**Male First Name (un) **] resolved with these maneuvers and there was return
of laminar flow in LVOT and the MR returned to mild.
The LV chamber is small, consistent with hypovolemia. The LV
systolic function remains normal.
There is no evidence of dissection.
Brief Hospital Course:
Admitted preoperatively for bridge from coumadin, placed on
heparin drip for anticoagulation. He completed preoperative
workup and on [**4-27**] was brought to the operating room and
underwent aortic valve replacement. See operative report for
further details. Post-operatively he was transferred to the
intensive care unit for post operative management. In the first
twenty four hours he was weaned from sedation, awoke, and was
extubated without complications. His internal pacemaker was
interrogated postoperatively by cardiology. He had increased
confusion after extubation and resolved with discontinuation of
narcotic pain medications.
Neurologically he is oriented, pleasant and cooperative. He was
resumed on coumadin for atrial fibrillation and started on
amiodarone. He continued to progress and was ready for
discharge to rehab on post operative day five.
Rehab [**Last Name (un) 1687**] House
Medications on Admission:
ATENOLOL 25 mg Tablet daily
ATORVASTATIN 80 mg daily
CELEXA 20 mg Tablet once a day
DOXAZOSIN 2 mg by mouth at bedtime
EMOLLIENT Gel apply to the affected area 3-4 times/day
FINASTERIDE 5 mg ONCE A DAY
WARFARIN 2 mg Tablet 2 Tablet(s) by mouth once a day as directed
by [**Hospital 2786**] clinic,
ACETAMINOPHEN 500 mg Tablet 2 Tablet(s) by mouth tid x 1 week,
then [**Hospital1 **], ASPIRIN 81 mg by mouth once a day,
NIACIN 500 mg by mouth twice a day
Discharge Medications:
1. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day.
2. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
3. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: Three (3) ml Inhalation every four (4) hours
as needed for shortness of breath or wheezing.
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every six (6)
hours as needed for pain.
5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day:
please take 200mg twice a day for 7 days then decrease to 200 mg
daily .
6. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two
(2) Puff Inhalation Q6H (every 6 hours).
7. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
9. finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day.
Tablet(s)
10. niacin 500 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO BID (2 times a day).
11. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day for 2
weeks.
15. warfarin 4 mg Tablet Sig: One (1) Tablet PO once [**5-3**]: INR
to be drawn [**5-4**] for further dosing .
16. Outpatient [**Month/Year (2) **] Work
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0-2.5
First draw [**5-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease to twice a week if dose stable
Rehab physician to dose coumadin will at rehab - please arrange
for coumadin follow up when discharged from rehab with PCP
office thank you
Has received 5 mg on [**4-30**] and [**5-1**], then 4 mg on [**5-2**] - with
plan for 4 mg on [**5-3**] with [**Month/Year (2) **] draw [**5-4**] - INR on [**5-2**] was 1.4 -
home dose 6 mg however now on amiodarone
17. doxazosin 2 mg Tablet Sig: One (1) Tablet PO at bedtime.
Discharge Disposition:
Extended Care
Facility:
[**Last Name (un) 1687**] - [**Location (un) 745**]
Discharge Diagnosis:
Aortic stenosis s/p AVR
Dyslipidemia
Hypertension
tachy-brady syndrome s/p PPM [**2169**]
Atrial fibrillation
Stoke in [**2154**], residual left-sided weakness, cane and brace left
leg
Obstructive sleep apnea
Benign prostatic hypertrophy
Benign thyroid nodule
squamous cell carcinoma
Carotid artery disease
Discharge Condition:
Alert and oriented x3, right side 5/5 strength, left arm has not
used since previous stroke and left leg 3/5 strength
Ambulating with assistance, brace on left leg
Sternal pain managed with tylenol as needed
Sternal Incision - healing well, no erythema or drainage
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 [**Telephone/Fax (1) 1988**] for the following appointments
Surgeon: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] on [**2174-5-19**] 2:00
Cardiologist: Dr [**Last Name (STitle) **] office will contact you with appt
PCP: [**Name10 (NameIs) **] [**Name (NI) **] [**Telephone/Fax (1) 250**] [**2174-5-19**] at 920 am
These are appts that were already booked
[**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern1) 13280**], MD Phone:[**Telephone/Fax (1) 3965**] Date/Time:[**2174-8-22**]
1:45
**Please call cardiac surgery office with any questions or
concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call
person during off hours**
Labs: PT/INR for Coumadin ?????? indication atrial fibrillation
Goal INR 2.0-2.5
First draw [**5-4**]
Then please do INR checks Monday, Wednesday, and Friday for 2
weeks then decrease to twice a week if dose stable
Rehab physician to dose coumadin will at rehab - please arrange
for coumadin follow up when discharged from rehab with PCP
office thank you
Completed by:[**2174-5-2**]
|
[
"E935.8",
"496",
"424.1",
"292.81",
"V58.61",
"401.9",
"327.23",
"414.01",
"V45.01",
"V45.82",
"V10.83",
"272.4",
"427.31"
] |
icd9cm
|
[
[
[]
]
] |
[
"35.21",
"39.61",
"89.45"
] |
icd9pcs
|
[
[
[]
]
] |
11185, 11263
|
7694, 8608
|
321, 421
|
11614, 11881
|
3185, 7671
|
12722, 13794
|
2286, 2439
|
9112, 11162
|
11284, 11593
|
8634, 9089
|
11905, 12699
|
2454, 3166
|
270, 283
|
449, 1025
|
1047, 2064
|
2080, 2270
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
60,720
| 109,909
|
34891
|
Discharge summary
|
report
|
Admission Date: [**2174-10-20**] Discharge Date: [**2174-10-25**]
Date of Birth: [**2108-5-9**] Sex: F
Service: MEDICINE
Allergies:
Latex / Benadryl / Penicillins / Clindamycin / Shellfish Derived
/ Ibuprofen / Codeine / Bactrim / Aspirin
Attending:[**First Name3 (LF) 99**]
Chief Complaint:
shortness of breath and fevers
Major Surgical or Invasive Procedure:
PICC line insertion
History of Present Illness:
66 yo F with PMH of morbid obesity, PAF, DM2, COPD on 2L home
oxygen, CAD and recent diagnosis of PE who presents from OSH
with SOB and fevers. She was taken from rehab to [**Hospital3 **]
hospital with SOB and fever to 100. She was recently at [**Hospital1 18**] in
the beginning of [**Month (only) **] with SOB. It was thought that she likely
had PE. Given her shellfish allergy, she had a VQ scan rather
than a CTA. This returned indeterminant and the decision was
made to treat her with coumadin for presumed PE. She also had a
cellulitis on her pannus and was sent to rehab on vancomycin and
ceftazidine which ended on [**2174-10-13**].
.
In the ED, her initial vitals were T 101.8, HR 94, BP 166/30, RR
28, O2sat 95% 3L NC. She was noted to have a subtherapeutic [**Date Range 263**]
of 1.8 and she was started on a heparin gtt. She also complained
to RUQ pain and had an ultrasound which was negative. A CXR was
also negative. A U/A was positive and it was thought she had a
UTI from a foley catheter. She was admitted to CC7 for further
work up. On admission there, she was in no acute distress. She
noted her SOB was improved but was still having fevers. She was
given vancomycin and ceftriaxone for UTI antibiotics and the
plan was to likely send her home in the AM.
.
A trigger was called shortly after admission for hypoxia and
tachypnea. She was found to have blue lips and SOB. She also
felt chest pain that was across her entire chest wall and around
to her back. She had an EKG which was unchanged, given
nitroglycerin which did not change her pain. She was also given
nebulizers for wheezing, and given lasix but did not put out
much to it. Another CXR was performed which was largely
unchanged. She had an ABG which was 7.26/65/339 on NRB. She was
changed to a 35% face mask. She was transferred to the ICU for
further care.
.
Currently, she feels her breathing is slightly improved but
still not at baseline. She still has some chest pain as well.
+nausea. No vomiting. No abdominal pain currently. +fevers. No
chills. Can not assess dysuria given foley in place. No
diarrhea.
Past Medical History:
PMHx: per patient and OSH records:
-spina bifida repair at 10days old
-atrial fibrillation
-DM2
-COPD on home oxygen of 2L NC
-asthma
-CAD
-h/o pulmonary embolisms
-GERD
-depression
-angiodysplasia
-anxiety
-h/o cellulitis
-multiple ICU admissions for sepsis, cellulitis, anaphylaxis
-skin graft for ulcers
-benign left breast mass
-OSA uses BiPAP 12/8 with 2L oxygen
Social History:
Smoked in the past but quit 20 years ago. Currently wheelchair
bound and oxygen depended on 2L NC from COPD. Has a sister who
is next of [**Doctor First Name **]. Currently lives at nursing home on the [**Hospital **].
Family History:
Noncontributory.
Physical Exam:
VS - T 102, BP 134/84, RR 35, HR 86 O2Sat 94% on 3L
GENERAL: morbidly obese, NAD, mildly tachypnic. Using some
excessory muscles when breathing.
HEENT: PERRL, EOMI, anicteric sclera. Clear conjunctiva. Dry
mucous membranes.
CVS: irregular,irregular, no m/r/g
PULM: bibasilar scattered rales, no wheezing or rhonchi
ABD: Obese. +BS, soft, moderate tenderness at epigastrum, no
rebound or guarding, some tenderness to percussion over RUQ. No
lesions or ulcerations under abdominal panus.
EXT: 2+ pitting edema bilaterally, venous stasis changes in
lower calfs at medial margins. Skin breakdown in folds of
posterior calf bilaterally. Small sacrul ulcer. Mild erythema of
L posterior thigh.
Pertinent Results:
Admission Labs:
WBC-7.3 RBC-3.67* Hgb-10.1* Hct-31.1* MCV-85 MCH-27.6 MCHC-32.5
RDW-15.1 Plt Ct-140*
Neuts-89.4* Lymphs-7.4* Monos-2.1 Eos-0.6 Baso-0.4
PT-19.7* PTT-27.3 [**Hospital 263**](PT)-1.8*
Glucose-98 UreaN-18 Creat-0.8 Na-138 K-4.4 Cl-97 HCO3-30
ALT-13 AST-22 CK(CPK)-17* AlkPhos-82 Amylase-45 TotBili-0.3
Calcium-8.7 Phos-2.4* Mg-1.7
cTropnT-<0.01
TSH-4.5*
BLOOD Type-ART pO2-339* pCO2-65* pH-7.26* calTCO2-31* Base XS-0
Glucose-94 Lactate-2.4* Na-140 K-4.4 freeCa-0.45*
URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017
URINE Blood-MOD Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
URINE RBC-0-2 WBC->50 Bacteri-MANY Yeast-NONE Epi-0
[**2174-10-20**] 2:20 pm URINE Site: CATHETER
**FINAL REPORT [**2174-10-23**]**
URINE CULTURE (Final [**2174-10-23**]):
ENTEROBACTER CLOACAE. >100,000 ORGANISMS/ML..
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.
ENTEROBACTER CLOACAE. 10,000-100,000 ORGANISMS/ML..
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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE
| ENTEROBACTER CLOACAE
| |
CEFEPIME-------------- 2 S 8 S
CEFTAZIDIME----------- =>64 R =>64 R
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 64 I 64 I
PIPERACILLIN---------- =>128 R =>128 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
[**2174-10-20**] 11:05 am BLOOD CULTURE FROM PICC LINE # 1.
**FINAL REPORT [**2174-10-23**]**
Blood Culture, Routine (Final [**2174-10-23**]):
ENTEROBACTER CLOACAE. FINAL SENSITIVITIES.
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
_________________________________________________________
ENTEROBACTER CLOACAE
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN---------- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final [**2174-10-21**]):
REPORTED BY PHONE TO [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] @ 1:39A [**2174-10-21**].
GRAM NEGATIVE RODS.
Anaerobic Bottle Gram Stain (Final [**2174-10-21**]): GRAM
NEGATIVE RODS.
Studies:
[**2174-10-20**] EKG: Sinus rhythm with premature ventricular
contractions. Prolonged A-V conduction. Left axis deviation.
Right bundle-branch block with left anterior fascicular block.
Lateral ST-T wave changes. Compared to the previous tracing of
[**2174-10-5**] the premature ventricular contractions are new.
[**2174-10-20**] RUQ ultrasound: IMPRESSION:
1. Normal-appearing gallbladder without gallstones or signs
suggestive of cholecystitis.
2. Echogenic liver consistent with fatty infiltration. Other
forms of liver disease and more advanced liver disease including
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
[**2174-10-20**] CXR - Right PICC line has been replaced or advanced to
the low SVC. Lung volumes are low, but aside from mild linear
scarring or atelectasis at the right base, clear. Moderate
cardiomegaly is stable. Mediastinal vascular engorgement is
persistent, either an indication of elevated central venous
pressure or anatomic variant.
[**2174-10-21**] bilateral LE veins: IMPRESSION: No evidence of deep
vein thrombosis in either leg.
[**2174-10-22**] CXR - IMPRESSION: Probable right lower lobe pneumonia.
[**2174-10-22**] CT abdomen & pelvis - IMPRESSION:
1. Nonobstructed subcentimeter right intrarenal calculus. No
evidence for
hydronephrosis. No ureteral calculus.
2. No evidence for acute bowel pathology.
3. Severe degenerative changes of the spine.
Brief Hospital Course:
66 yo F with PMH of morbid obesity, PAF, DM2, COPD on 2L home
oxygen, CAD and recent diagnosis of PE who presents from OSH
with SOB and fevers.
.
# SOB: Most likely due to aspiration given coughing with food
observed on morning rounds. PNA is unlikely, but was started on
ceftriaxone and vancomycin in the setting of fevers and GNR
bacteremia. LENIs were negative for DVT. Steroids, vancomycin
and ceftriaxone were stopped on [**10-22**]. The patient was placed
on BiPAP at night per her home regimen. Her shortness of breath
was likely due to a combination of COPD and aspiration of
secretions. She was evaluated by speech and swallow who
determined that she was not aspirating food or liquids but did
have thick secretions which she was aspirating. She can eat a
regular, heart healthy diet and should have appropriate COPD
treatment as per her home regimen.
.
# GNR Bacteremia: Likely from a urine source. Blood is growing
Enterobacter that is ceftriaxone/cephalosporin resistant. On
[**10-22**] she was switched to ciprofloxacin when sensitivities
became available. She should complete a 14 day course of cipro
for her bacteremia. This will end on [**2174-11-4**]. She also had an
abdominal CT that was negative for perinephric abscess given
bacteremia from presumed pyelonephritis.
.
# Hypocalcemia: On presentation the patient had acute
hypocalcemia on venous blood gas. She was repleted with 4g
calcium gluconate and her calcium has remained stable since.
Ionized calciums were trended.
.
# COPD: The patient was initially treated for a COPD flare, but
this was stopped as it was felt that her SOB was more likely
related to aspiration. She was continued on her home regimen of
advair and singular.
.
# PE: Unclear if the patient actually had a PE on prior
admission given that her area of mismatch on V/Q scan was in the
same location as a pleural effusion. She was started on a
heparin gtt on admission and it was stopped on [**10-22**] when she
was therapeutic on warfarin. She became supratherapeutic on
Warfarin due to her antibiotics and it was stopped on [**2174-10-24**].
Please see below for further instructions regarding
anticoagulation.
.
# Afib: The patient was continued on metoprolol. She had some
episodes of RVR on [**10-23**] and her metoprolol dose was increased
to 75 mg PO TID. Her anticoagulation was managed as discussed
below with heparin and coumadin.
.
# Anticoagulation: The patient was subtherapeutic on warfarin on
admission ([**Month/Year (2) 263**] 1.8). She was started on heparin gtt and
warfarin was continued. Heparin was stopped when [**Month/Year (2) 263**] became
therapeutic. The patient was started on ciprofloxacin for
bacteremia from a urine source on [**10-22**]. As fluoroquinolone
antibiotics interact with warfarin and prolong the [**Month/Year (2) 263**] ([**Month/Year (2) 263**] 3.5
on [**2174-10-25**], the morning of discharge), her warfarin dose should
be decreased from 3 mg to 2mg daily and her [**Date Range 263**] more closely
monitored on discharge so that her warfarin dose can be adjusted
accordingly. When she finishes her course of ciprofloxacin her
warfarin dose will need to be increased accordingly so that she
does not become subtherapeutic.
.
# CAD: not on asa given allergy. Continue BB as above. Not on
statin, unclear why.
.
# DM2: The patient was placed on an insulin sliding scale and
metformin was held for imaging.
.
# Depression: Sertraline was continued per home regimen.
.
# Chronic pain: Gabapentin and tramadol continued per home
regimen.
.
# FEN: Regular diet, not aspirating per speech and swallow
evaluation.
.
# PPX: warfarin for anticoagulation. H2 blocker per home regimen
for GI ppx. bowel regimen.
.
# Access: PICC line placed and then removed given bacteremia.
.
# Code: pt was DNR/DNI but reversed her code status to full code
during her trigger on the floor. Her code status should be
reassessed.
Medications on Admission:
Per last d/c summary:
-Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
-Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
-Levothyroxine 237 mcg daily
-Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID
-Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours.
-Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): hold for oversedation or RR<10 .
-Insulin Lispro 100 unit/mL Solution Sig: AS DIR
Subcutaneous ASDIR (AS DIRECTED): Continue prior SSI coverage:
Start at 6 Units for 201-250, 8 Units for 251-300, 10 Units for
301 to 350 range and 12 Units for 351-400 range FSG levels at
mealtime and reduce each level by 2 for qhs scale .
-Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
-Os-Cal 500 + D 500 (1,250)-400 mg-unit Tablet, Chewable Sig:
One (1) Tablet, Chewable PO twice a day.
-Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
-Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
-Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID
-Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for constipation.
-Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H as needed for wheeze.
-Azo Cranberry [**Medical Record Number 18595**] mg-mg-million Tablet Sig: One (1)
Tablet PO twice a day.
-Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 2 weeks.
-Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO three times
a day as needed.
-Warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day:
Discharge Medications:
1. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
2. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Levothyroxine 100 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
5. Levothyroxine 75 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
9. Hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed.
10. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
11. Ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 14 days. Start date = [**2174-10-22**], Last day =
[**2174-11-4**]
12. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
13. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at
bedtime.
14. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a
day.
15. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1)
Inhalation every six (6) hours as needed for wheezing.
16. Miconazole Nitrate Powder Sig: One (1) application
Miscellaneous twice a day.
17. Outpatient Lab Work
Please check [**Month/Day/Year 263**] daily. Resume Coumadin dosing when [**Month/Day/Year 263**] between
2 and 3.
Discharge Disposition:
Extended Care
Facility:
[**Location (un) 38380**] Skilled Nursing nad Rehab
Discharge Diagnosis:
Primary Diagnoses:
1. Urinary Tract Infection
2. Bacteremia due to Enterobacter
3. Aspiration of Secretions
4. Atrial fibrillation with rapid ventricular rate
5. Chronic obstructive pulmonary disease
Secondary Diagnoses:
1. Type 2 diabetes
2. Asthma
3. Gastroesophageal reflux disease
4. History of pulmonary embolisms
5. Obstructive sleep apnea
6. Depression
Discharge Condition:
Stable, at baseline O2 requirements, afebrile.
Discharge Instructions:
You were admitted to the hospital for shortness of breath and
fevers. You were found to have bacteria in your blood, likely
because you had a urinary tract infection which spread to the
blood. You are being treated with the antibiotic ciprofloxacin
and will need to complete a total of 14 days of treatment with
this antibiotic. Because this antibiotic interacts with
warfarin, your [**Location (un) 263**] will need to be monitored and your warfarin
dose adjusted accordingly.
You were also noted to have difficulties breathing while you are
eating. You had a special swallow study and you are not
aspirating food at this time, however, you are aspirating some
of your secretions and this may be contributing to your
shortness of breath and chest discomfort. Please eat all meals
sitting upright and continue to wear your BiPAP machine at
night. Please attend to oral hygiene to reduce the bacteria in
your mouth.
The following changes were made in your medications.
Please take ciprofloxacin 750 mg Q12H through [**2174-11-4**].
Your metoprolol dose was increased to 75 mg TID.
Your warfarin dose was decreased to 2 mg while you are on
ciprofloxacin but your [**Month/Day/Year 263**] is still high so your coumadin was
held. Once your [**Month/Day/Year 263**] is between 2 and 3, you should re-start
coumadin at 2mg, and it should be increased back to 3 mg when
you are finished with the ciprofloxacin. You should have your
[**Month/Day/Year 263**] checked every day to determine the proper dosing of
Coumadin.
Please call your physician or return to the hospital if you
develop fevers > 100.4, chills, night sweats, worsening
shortness of breath, productive cough or other symptoms that
concern you.
Followup Instructions:
Please follow-up with your primary care provider within the next
2 weeks.
|
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15,894
| 141,084
|
16263
|
Discharge summary
|
report
|
Admission Date: [**2122-1-13**] Discharge Date: [**2122-1-23**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 9569**]
Chief Complaint:
Hypotension.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The pt. is a 85 year-old male with multiple medical problems who
was found unresponsive at his [**Hospital3 **] facility. Per
notes, the pt. was found lying on the floor by his neighbor the
morning of admission. He was noted to be cyanotic and his blood
pressure was noted to be 80/40.
He was originally treated at an OSH ED where he was determined
to be in rapid atrial fibrillation and found to be hypotensive
(systolic BP in the 60's). A chest X-ray was performed which
was suggestive of CHF and a urinalysis was sent which was
consistent with a urinary tract infection. He was also found to
be hyperkalemic and was treated with insulin, D50, and
bicarbonate. He was given 500cc of normal saline and was
started on levofloxacin and gentamicin. A head CT was performed
and was negative for any acute intracranial process. A CK and
troponin were noted to be "negative."
He was subsequently transferred to [**Hospital1 18**] for further care. In
the ED, his blood pressure was 70/40 on arrival. His
temperature was 100.4 rectally. He was initiated on the sepsis
protocol and he underwent placement of a central venous catheter
and received 250cc of IV fluid. A lactate was found to be 2.2.
He was given one unit of PRBCs for a hematocrit of 28. He was
also started on a levophed drip. He was admitted to the ICU for
treatment of a CHF exacerbation, atrial fibrillation and
possible urosepsis.
On presentation to the MICU, the pt. offered no specific
complaints other than fatigue. He was unable to recall the
events surrounding the fall which led to his admission. He
stated that he has not felt well over the last week,
specifically that he has been experiencing increasing dyspnea
and PND. He denied orthopnea. He also c/o dysuria over the
past week. He denied chest pain, nausea, vomiting, diarrhea,
BRBPR, melena. He denied dietary indiscretion. He has been
taking all of his medications as prescribed.
Past Medical History:
1) Congestive heart failure, EF 35%
2) CAD s/p 4 vessel CABG
3) Atrial fibrillation.
4) Aortic stenosis
5) Hypertension.
6) Hypercholesterolemia.
7)History of cerebral vascular accident, s/p bilateral CEA
10) History of upper gastrointestinal bleed s/p EGD [**2121-6-10**]
showing gastritis
11) Cecal adenoma x2
[**29**]) S/P laproscopic right hemicolectomy [**2121-7-16**]
13) Diverticulosis
14) S/P cholecystectomy
[**32**]) Prostate cancer, s/p XRT
16) Hypothyroidism.
17) S/P L THR
18) Mitral regurgitation
Social History:
The pt. lives in an assisted-living facility. He is widowed and
has a daughter who lives in the area. He denied use of tobacco
or alcohol.
Family History:
Noncontributory.
Physical Exam:
T: 100.4F P: 110 R: 28 BP: 119/69 SaO2: 100% on 3L O2 via NC
General: Elderly male, awake, alert, NAD
HEENT: PERRL, + cataract of L eye, EOMI, sclerae anicteric, dry
MM, clear OP
Neck: supple, JVD to 10cm
Pulm: bibasilar rales 1/3 up lung fields
Cardiac: tachycardic, irregularly irregular rhythm, S1S2, III/VI
SEM at LSB
Abdomen: +fluid wave, soft, NT/ND, active BS
Extremities: 1+ bilateral LE pitting edema, 2+ DP pulses
bilaterally
Neurologic: Alert and oriented x 3. Moving all four extremities.
Uncooperative with the remainder of exam.
Skin: no rashes noted.
Pertinent Results:
[**2122-1-13**] 10:07PM WBC-4.8 RBC-3.14* HGB-9.0* HCT-28.1* MCV-90#
MCH-28.6 MCHC-32.0 RDW-16.3*
[**2122-1-13**] 10:07PM PLT COUNT-258
[**2122-1-13**] 10:07PM NEUTS-71.1* LYMPHS-19.1 MONOS-7.1 EOS-2.1
BASOS-0.7
[**2122-1-13**] 10:07PM HYPOCHROM-3+ ANISOCYT-1+ POIKILOCY-1+
[**2122-1-13**] 10:07PM GLUCOSE-81 UREA N-43* CREAT-1.3* SODIUM-143
POTASSIUM-4.6 CHLORIDE-107 TOTAL CO2-28 ANION GAP-13
[**2122-1-13**] 10:47PM CALCIUM-8.4 PHOSPHATE-2.9 MAGNESIUM-2.2
[**2122-1-13**] 10:47PM ALT(SGPT)-7 AST(SGOT)-14 CK(CPK)-30* ALK
PHOS-114 TOT BILI-1.1
[**2122-1-13**] 10:51PM LACTATE-2.2*
[**2122-1-13**] 10:47PM CK-MB-NotDone cTropnT-0.04*
[**2122-1-13**] 11:01PM PT-15.1* PTT-31.6 INR(PT)-1.4
[**2122-1-13**] 11:10PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.015
[**2122-1-13**] 11:10PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-6.5
LEUK-MOD
[**2122-1-13**] 11:10PM URINE RBC-[**7-17**]* WBC->50 BACTERIA-MANY
YEAST-NONE EPI-0
Brief Hospital Course:
Mr. [**Name13 (STitle) **] is an 85 year-old man with a history of CAD s/p
CABG, left ventricular systolic dysfunction with EF of 25%,
history of atrial fibrillation admitted from an OSH after being
found unresponsive at [**Hospital3 **] facility. On transfer he
was hypotensive with low grade fever. He was initially admitted
to the [**Hospital Ward Name 332**] ICU. The following issues were addressed on this
admission.
Concerning his cardiovascular disease: Concerning ischemic
disease. He has a history of CAD s/p CABG and was ruled out
here. Troponins and CK's remained flat. OSH reported no
elevation in enzymes. His troponins were from 0.04-0.06
attributed to demand from heart failure and rapid atrial
fibrillation. He was maintained on aspirin, statin. ACE
inhibition was added once patient's pressures stabilized.
Unable to add beta-blockade given low pressures.
Concerning his pump function: Patient with depressed EF
estimated 25%. Echo here demonstrated echo less than 20% but
this was in setting of decompensation. Also has 3+MR/ moderate
to severe AS. Patient admitted with low pressures and RVR to
afib. In ICU low pressures felt likely due to urosepsis vs.
heart failure. Patient first treated for urosepsis with sepsis
protocol with pressors. He was not diuresed and other load
medications could not be initiated with continued low pressors.
Never with swan placed. Once he was stabilized in ICU and felt
not to be septic, weaned from pressors, patient transferred to
floor afebrile, but still with low pressures. Felt to be
decompensated heart failure. Patient initially placed on lasix
and dopamine but patient had lots of increased ectopy and
continued low pressures so both were stopped. As pressures came
up with no intervention, lasix iv and ace were added. Patient
then diuresed and drastically improved. Patient's oxygen
requirement resolved and now satting 99% room air. Also with no
orthopnea, creatinine rising slightly (in normal range), and
exam greatly improved with decreaed edema and only minimal
basilar crackles. Patient transitioned to current ACE/lasix
levels. His pressures continue to run low (high 80's-low 90's
systolic) and these pressures should be tolerated. The patient
needs afterload reduction with ACE inhibition and daily lasix to
remain euvolemic, esp. given 3+MR and AS. His actual EF is very
low given MR/AS.
Should continue lasix, ace and add beta-blocker as blood
pressures/heart rates can tolerate. Also titrate ace as
possible, down-titrate lasix as needed if patient becoming dry,
especially if creatinine rising and add beta-blocker (was at
12.5 metoprolol [**Hospital1 **] on admit and lisinopril 15 on admit.)
Patient also should be maintained on spirinolactone.
Concerning his rhythm: The patient admitted in afib with RVR.
No attempts made to cardiovert given large atrium and long
history of afib, veyr unlikely that he could be cardioverted.
Beta-blockade and calcium channel inhibition could not be
utilized due to low pressures. Digixon was maintained with good
rate control.
OF NOTE: The patient had runs of SVT with aberrancy vs. Vtach on
telemetry. EP was consulted numerous times to evaluate these
rhythms. All were felt to due to SVT with aberrancy. We will
attach copies of tele strips for comparison.
Continue to monitor dig levels, they have been around 0.8 to low
1.0's here. Goal is right around 1.0. Normal TSH and free T4.
Concerning anticoag: holding coumadin for afib given guiaic
positive stools. Patient was not on coumadin previously, with
known afib because of history of gastritis, guiaic positive
stools. Had colonoscopy in [**Month (only) 205**] which showed diverticulosis of
the ascending colon and sigmoid colon
Anastomosis site visualized in ascending colon without any
evidence of bleeding
Otherwise normal colonoscopy to ascending colon. Discussed issue
with PCP. [**Name10 (NameIs) **] defer decision to start coumadin to PCP. [**Name10 (NameIs) **] not
been on coumadin since [**Month (only) 205**] with GI bleeding. Will defer
coloscopy now given history of recent polyp removal, no other
lesions found and known gastritis by EGD.
Concerning history of ischemia/depressed ef: Given that patient
wishes to be DNR/DNI, placement of AICD deferred.
Concerning ? of sepsis/UTI: Patient admitted to ICU with concern
for urosepsis given low grade fevers, hypotension. Originally
on pressors, quickly weaned and transferred to floor. Patient
with E. Coli UTI by [**1-13**] urine culture, originally on levaquin,
but sensitivities came back negative once on floor so changed to
ceftriaxone. Received 7 days of ceftriaxone and then switched
to cefpodoxime for d/c. Repeat urine cultures came back
negative on [**1-18**]. Given that he improved with inadequate
treatment, and negative blood cultures, unlikely that patient
was actually septic. Pressures likely low due to CHF. All
blood and sputum cultures remained negative. Patient afebrile
with normal WBC for 7 days before discharge.
Patient with history of anemia: Felt to be secondary to
gastritis. Colonoscopies in [**Month (only) 116**] and [**Month (only) 205**] of this year, and has
been off coumadin since gastritis and polyp removal. Also
guiaic positive on this admission. Crit stable throughout
course but patient remains anemic. Patient needs outpatient
colonoscopy. Will hold iron at this time for better diagnostic
accuracy with anticipated colonoscopy. Crit on discharge is 31.
Continue to monitor.
We are holding coumadin for afib given history of recent history
of GI bleeding. PCP and cardiologist can made decision to
re-add. Of note, had upper GI bleed in [**6-10**], had polyp removal
in [**8-10**] colonoscopy with no evidence of bleeding.
Concerning his hypothyroidism: TSH and free T4 normal here.
Continued current synthroid dosing.
Patient discharged in stable condition to rehab facility.
The patient is DNR/DNI and does not wish to be admitted to
CCU/ICU level care.
Medications on Admission:
-lasix 20mg po daily
-protonix 40mg po daily
-ipratropium 2puffs ih [**Hospital1 **]
-lisinopril 15mg po daily
-atorvastatin 10mg po daily
-metoprolol 12.5mg po daily
-ASA 325mg po daily
-FeSO4 325mg po daily
-MVI
-aldactone 25mg po daily
-synthroid 125mcg po daily
-trazodone 50mg po daily
-remeron 30mg po daily
-seroquel 30mg po daily
-colace 100mg po bid
-senna 2 tabs po bid
Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
2. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Levothyroxine Sodium 125 mcg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY
(Every Other Day).
6. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO
Q12H (every 12 hours) for 7 days.
7. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Trazodone HCl 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Quetiapine Fumarate 25 mg Tablet Sig: One (1) Tablet PO QHS
(once a day (at bedtime)).
12. Ipratropium Bromide 0.06 % Aerosol, Spray Sig: Two (2) puffs
Nasal twice a day.
13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily).
15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.)
Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24
hours).
16. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
17. Haloperidol 2 mg Tablet Sig: 1.5-2.5 Tablets PO HS (at
bedtime) as needed for agitation.
18. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
congestive heart failure, UTI, anemia
Discharge Condition:
stable
Discharge Instructions:
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
Adhere to 2 gm sodium diet
Fluid Restriction: 2 liters
Take all medications as prescribed.
Call your doctor if you have any chest pain or have increasing
shortness of breath.
If you become light-headed or dizzy, call your doctor.
Followup Instructions:
Patient has appointment with Dr. [**Last Name (STitle) **] at 12:30 on Thursday,
[**1-29**].
Provider: [**Name10 (NameIs) 7476**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7476**] AND [**Doctor Last Name 9613**] Where: [**Doctor Last Name 7476**] AND
[**Doctor Last Name 9613**] Date/Time:[**2122-1-29**] 12:30 [**Telephone/Fax (1) 7477**]
|
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[
[]
]
] |
[
"38.93",
"99.04",
"00.13"
] |
icd9pcs
|
[
[
[]
]
] |
12567, 12637
|
4608, 10599
|
275, 282
|
12719, 12727
|
3568, 4585
|
13078, 13441
|
2949, 2967
|
11030, 12544
|
12658, 12698
|
10625, 11007
|
12751, 13055
|
2982, 3549
|
223, 237
|
310, 2240
|
2262, 2775
|
2791, 2933
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,777
| 189,754
|
31790
|
Discharge summary
|
report
|
Admission Date: [**2174-8-19**] Discharge Date: [**2174-8-27**]
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 106**]
Chief Complaint:
Shortness of breath - intubated on arrival.
Major Surgical or Invasive Procedure:
Direct cardioversion
Cardiac catheterization
History of Present Illness:
86-year-old female with systolic congestive heart failure,
cardiomyopathy (ischemic in nature), severe mitral regurg and
atrial
flutter with multiple admissions for CHF/pulmonary edema,
presenting
with acute respiratory distress due to CHF exacerbation,
transferred from [**Hospital **] [**Hospital3 628**] s/p intubation.
.
On [**8-17**] she was complaining of difficulty breathing. Her
respiratory rate was 38-40. She was given nebulizers. She became
cyanotic with O2 sats of 62%, 9-1-1 was called and the patient
reversed her DNR/DNI status and the patient was made full code.
Per rehab notes the patient had been getting her diuretics, was
not febrile, and her weight was stable.
.
At [**Location (un) 620**], she had persistent hypoxia and was intubated. She
did not respond to diuresis, with minimal urine output after 120
mg IV lasix. She developed hypotension which was managed with
fluid resuscitation, and her b-blocker and Ace-I were held. As
far as for her atrial flutter on Coumadin, she was started on an
amiodarone drip and coumadin was held since her INR level was
elevated. She also had a drop in her hematocrit which was
thought to be due to hemodilution.
.
Intubated, sedated on transfer. Unable to obtain further
history/ROS
Past Medical History:
CAD, s/p AMI with PTCA stent x2 in [**12/2173**]
CHF, EF 28%, severe MR
Afib on coumadin
Hyperlipidemia
Hypertension
Hypothyroidism
Chronic kidney disease, Cr 1.3 at baseline
GERD
COPD
Osteoporosis
[**Doctor First Name **] cysts
Hernia
Colonic polyps
Social History:
Patient currently was at [**Hospital 100**] Rehab from hospitalization for
SOB at [**Hospital1 **]/[**Hospital 1475**] Hospital. She normally at lives home
alone. No history of tobacco use. She enjoys a glass of [**Doctor First Name **]
before dinner.
Family History:
Mother died of MI at 84 yo. Father had a stroke. Brother is
[**Age over 90 **] [**Name2 (NI) **].
Physical Exam:
GENERAL: intubated, sedated
HEENT: Sclera anicteric.
NECK: Supple
CARDIAC: irregularly irregular, exam limited by breath sounds
LUNGS: clear anteriorly bilaterally. diffuse rhonchi at bases
bilaterally
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 1+ pitting edema bilaterally in lower extremities,
SKIN: warm, moist; + buttock erythema with wound
Pertinent Results:
[**2174-8-19**] 05:25PM BLOOD WBC-8.4# RBC-2.82* Hgb-8.9* Hct-27.7*
MCV-99* MCH-31.5 MCHC-32.0 RDW-15.1 Plt Ct-229
[**2174-8-20**] 05:21AM BLOOD WBC-7.2 RBC-2.53* Hgb-8.2* Hct-25.1*
MCV-99* MCH-32.2* MCHC-32.5 RDW-15.0 Plt Ct-220
[**2174-8-21**] 05:44AM BLOOD WBC-5.8 RBC-2.82* Hgb-8.9* Hct-27.8*
MCV-99* MCH-31.7 MCHC-32.1 RDW-15.1 Plt Ct-223
[**2174-8-24**] 05:28AM BLOOD WBC-5.5 RBC-2.61* Hgb-8.6* Hct-25.3*
MCV-97 MCH-32.8* MCHC-33.8 RDW-15.0 Plt Ct-246
[**2174-8-25**] 03:48AM BLOOD WBC-7.3 RBC-2.78* Hgb-9.0* Hct-27.3*
MCV-98 MCH-32.2* MCHC-32.9 RDW-14.7 Plt Ct-298
[**2174-8-19**] 05:25PM BLOOD PT-45.5* PTT-57.9* INR(PT)-4.9*
[**2174-8-20**] 05:21AM BLOOD PT-41.5* INR(PT)-4.4*
[**2174-8-22**] 04:52AM BLOOD PT-44.8* INR(PT)-4.8*
[**2174-8-23**] 04:16AM BLOOD PT-19.2* PTT-42.8* INR(PT)-1.8*
[**2174-8-25**] 03:48AM BLOOD PT-16.0* PTT-56.3* INR(PT)-1.4*
[**2174-8-19**] 05:25PM BLOOD Glucose-115* UreaN-26* Creat-1.3* Na-145
K-3.5 Cl-113* HCO3-25 AnGap-11
[**2174-8-20**] 05:21AM BLOOD Glucose-97 UreaN-27* Creat-1.1 Na-148*
K-4.0 Cl-117* HCO3-25 AnGap-10
[**2174-8-20**] 03:41PM BLOOD Na-149* K-3.3 Cl-116*
[**2174-8-23**] 04:16AM BLOOD Glucose-104* UreaN-28* Creat-1.1 Na-150*
K-3.9 Cl-113* HCO3-30 AnGap-11
[**2174-8-24**] 05:28AM BLOOD Glucose-96 UreaN-26* Creat-1.2* Na-148*
K-3.8 Cl-107 HCO3-34* AnGap-11
[**2174-8-25**] 03:48AM BLOOD Glucose-105* UreaN-22* Creat-1.1 Na-150*
K-3.4 Cl-107 HCO3-37* AnGap-9
[**2174-8-19**] 05:25PM BLOOD Calcium-7.7* Phos-2.4* Mg-1.9
[**2174-8-20**] 05:21AM BLOOD Calcium-7.7* Phos-2.3* Mg-2.4
[**2174-8-24**] 05:28AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.1
[**2174-8-25**] 03:48AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0
[**2174-8-21**] 05:44AM BLOOD TSH-5.7*
[**2174-8-21**] 05:44AM BLOOD T4-6.0
Urine culture - no growth
Blood culture - no growth to date, some cultures still pending
CXR [**8-20**]: ET tube tip is 4 cm above the carina. NG tube tip is
in the stomach. The lungs are hyperinflated. There is no evident
pneumothorax. Retrocardiac atelectasis, mild pulmonary edema,
and small bilateral pleural effusions are stable. There are no
new lung abnormalities.
[**8-21**]:
Mild cardiomegaly is stable. The lungs are hyperinflated. Left
lower
retrocardiac atelectasis has minimally improved. Pulmonary edema
has
improved. Persistent focal opacity in the left upper lobe could
represent a focal pneumonic consolidation. There is no
pneumothorax or enlarging pleural effusions. ET tube and NG tube
remain in place.
[**8-22**]:
FINDINGS: The ET tube is in standard location, terminating 3.2
cm above the carina. NG tube is extending into the stomach and
out of the field of view. There is mild pulmonary edema,
minimally worse than the prior study. There is no significant
pleural effusion, pneumothorax, focal consolidation. There is
mild bibasilar opacity, particularly in the retrocardiac region
that could be atelectasis.
IMPRESSION: Mild pulmonary edema, minimally worse than the
prior.
Echo [**8-20**]: The left atrium is mildly dilated. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. There is mild global left ventricular hypokinesis (LVEF
= 45 %). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are moderately thickened. There is a
minimally increased gradient consistent with minimal aortic
valve stenosis. The mitral valve leaflets are mildly thickened.
There is no mitral valve prolapse. Moderate (2+) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
EKG [**8-20**]: Underlying rhythm is probably coarse atrial
fibrillation. Incomplete left bundle-branch block. Poor R poor
progression. Consider prior anteroseptal myocardial infarction
versus normal variant. Compared to the previous tracing of
[**2174-8-11**] criteria for prior inferior myocardial infarction are
not clearly seen on the current tracing.
Cardiac Cath: COMMENTS:
1. Coronary angiography in this right-dominant systems
demonstrated
moderate three vessel primarily branch coronary artery disease.
The
LMCA was heavily calcified with minimal plaquing. The LAD was
heavilty
calcified with minimal in-stent restenosis in the mid LAD. The
D2 was
moderate in caliber and there was a larger branching D4. There
was
moderate stenosis at the origin of a small D3. The LCx was
patent and
supplied OM2 and LPL, as well as a small high OM1 with moderate
ostial
tubular stenosis. Ther was mild plaquing in the AV groove at
OM2. The
RCA was very heavily calcified. There was 60% in-stent
restenosis in
the mid RCA. There was diffuse disease (40-45%) in the distal
RCA.
There was a 70% stenosis at the RPDA origin, and a large RPL
with a
distal 80% stenosis.
2. Resting hemodynamics revealed mildly elevated right- and
left-sided
filling pressures with an RVEDP of 15 mmHg and LVEDP of 26 mmHg.
There
was mild pulmonary hypertension with a PA systolic presure of 49
mmHg.
The was an artifactual PCW-LVEDP gradient during the initial
measurements due to air bubbles in the manifold system, absent
upon
repeat R and L heart catheterization post-angiography with a
re-flushed
manifold. Post-angiography measurements did reveal mild
left-sided
volume overload with a PCWP mean of 29 mmHg. Cardiac output was
preserved with a cardiac index of 2.8 l/min/m2. There was
moderate
systemic systolic arterial hypertension with an SBP of 171 mmHg.
FINAL DIAGNOSIS:
1. Moderate 3 vessel primarily branch coronary artery disease.
2. 60% in-stent restonsis of the mid RCA.
3. Mild LV diastolic heart failure.
4. Mild pulmonary arterial hypertension.
5. Systemic systolic arterial hypertension.
6. Medical management of non-obstructive CAD.
7. Vasodilator therapy (nitroglycerine drip) initiated in cath
lab.
CT Head - IMPRESSION: No acute intracranial injury or fracture
detected.
Upper extremity U/S: RIGHT UPPER EXTREMITY ULTRASOUND:
Grayscale, color, and Doppler images of the bilateral subclavian
and right internal jugular, axillary, brachial, basilic, and
cephalic veins were obtained. There is normal compressibility,
flow, and augmentation throughout. Catheter (PICC) noted in the
cephalic vein.
IMPRESSION: No evidence of right upper extremity DVT.
Brief Hospital Course:
86-year-old female with systolic congestive heart failure,
cardiomyopathy (ischemic in nature), severe mitral regurg and
atrial flutter with multiple admissions for CHF/pulmonary edema,
presenting with acute respiratory distress due to CHF
exacerbation, transferred from [**Hospital **] [**Hospital3 628**] s/p
intubation. Prior hx includes dynamic LV function with changes
in MR on repeated echos - admitted for further evaluation.
.
# CHF Exacerbation: History of recent CHF exacerbations of
unclear etiology, possibly related to atrial flutter and severe
inopperable mitral regurgitation. Was on home regimen of
Furosemide 40 mg daily and lisinopril 7.5 mg daily and compliant
with medications per rehab notes. Given lasix with poor response
at outside hospital but has diuresed well in house, -5.6L for
length of stay. She was intubated at outside hospital for
respiratory failure likely [**2-1**] to arrythmia and CHF w severe MR.
She was admitted to [**Hospital1 18**] for further work up of reversible
cardiac etiology of SOB and CHF. ECHO on [**8-21**] showed global LV
hypokinesis and LVEF 45%. She underwent right and left heart
cath on [**8-23**] to eval total function of heart with no reversible
defects detected. She was diuresed with IV lasix. Plan was made
to extubate without intention of reintubating if clinical
decompensation. Successful extubation w/o complication on [**8-24**]
and diuresed additionally with home lasix dose.
.
# Respiratory Status: Admitted from OSH already intubated for
respiratory distress likely [**2-1**] to CHF and severe MR. She was
diuresed and family plan was to avoid re-intubation. She was
extubated [**8-24**] on day after her cath, patient feels breathing is
comfortable. She is currently on O2 via NC and denies sob, DOE,
chest pain. Sputum cx: gs 25 pmns, 10 epith (neg), culture ngtd.
Speech and swallow evaluation cleared pt for advancement of diet
as tolerated.
.
# Aflutter/Afib on Coumadin: home regimen of Amiodarone 200 mg
[**Hospital1 **], Metoprolol Tartrate 50 mg [**Hospital1 **], Warfarin 1.5 mg daily, and
Aspirin 325 mg. Rhythm poorly controlled at OSH and pt was
started on amiodarone drip. INR found to be supratherapeutic at
OSH. s/p DC cardioversion on [**8-22**] with conversion to sustained
normal sinus rhythm. She was continued on amiodarone 200mg daily
and uptitrated on her betablocker. She was restaretd on coumadin
home dose 1.5mg and ASA.
.
# Code Status/Plan of Care: Family meeting with patient included
on [**8-25**] with a decision to make pt [**Name (NI) 3225**] with plan to discharge to
inpatient hospice after rehab. Plan to continue medical
management to maintain comfort and minimize symptomatology. She
has had multiple hospital admissions within the last 6 months
for SOB secondarily to CHF due to MR with a decreased quality of
life. We do not think she will be able to have her independence
as before, when she was driving and traveling from [**State 108**]. Her
MR is above and beyond treatment according to OSH evaluation and
our second oppinion. She does wish to be hospitalized if this
were to happen again and would like to be intubated, however she
does not want to be resuscitated. Her code status is currently
intubate, do not resuscitate.
.
# Fall: On [**8-24**] pt fell out of chair while reaching for drink,
no LOC, no CP/sob, no events on tele. A stat head CT showed no
evidence of fracture or acute intracranial process); family made
aware immed. Pt mentating well, denying any somatic complaints.
No bruising.
.
#Hypertension ?????? Increased lisinopril to 20mg PO daily and cont
home betablocker therapy. Then, once transitioned to [**Month/Year (2) 3225**] her
lisinopril was stopped and betablocker were continued (given she
feels palpitations and SOB without them).
Medications on Admission:
Amiodarone 200 mg [**Hospital1 **]
Calcium Carbonate 500 mg TID
Cholecalciferol 400 unit daily
Levothyroxine 100 mcg daily
Metoprolol Tartrate 50 mg [**Hospital1 **]
Omeprazole 20 mg daily
Simvastatin 20 mg daily
Albuterol nebulizer q4 prn SOB
Bisacodyl 10 mg daily
Ipratropium nebulizer q4 prn SOB
Senna 8.6 mg daily
Aspirin 325 mg daily
Furosemide 40 mg daily
Lisinopril 7.5 mg daily
Warfarin 1.5 mg daily
Discharge Medications:
1. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a
day.
2. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
One (1) Inhalation every 4-6 hours as needed for shortness of
breath or wheezing.
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**4-5**]
hours as needed for fever or pain.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO once a day.
6. Zofran 2 mg/mL Solution Sig: Four (4) mg Intravenous every
four (4) hours as needed for nausea.
7. Morphine 100 mg/4 mL Solution Sig: 1-4 mg Intravenous every
4-6 hours as needed for pain, shortness of breath.
8. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Commons Residence At Orchard - [**Location (un) 2624**] (a.k.a. [**Location (un) 5481**])
Discharge Diagnosis:
Primary: Acute on chronic congestive heart failure exacerbation,
atrial fibrillation
Secondary: COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. [**Known lastname 21004**],
It was a pleasure taking care of you during your
hospitalization. You were admitted with difficulty breathing
that required a breathing tube and a machine to help you breath.
The breathing difficulty was from fluid in your lungs secondary
to your heart failure. We started you on a medication, lasix,
that helps remove extra fluid from your body. You responded
well to this medication and we were able to remove the tube
without difficulty. We checked your heart enzymes and you did
not have a heart attack. You had a cardiac catheterization to
look at the arteries that supply the heart and you did not have
any blockages in them, nor any problems in the heart valves that
would cause you to have fluid in your heart. We did give your
heart an electric shock that converted it from an abnormal
rhythm to a normal one. You were started on a medication that
helps keep your heart in this normal rhythm. As this has
happened many times before, we held discussions with you and
your family and it was decided that rather than continuing to
hospitalize you, we would transition you to hospice care where
your quality of life would be most important and the focus would
be on making you comfortable.
We changed your medication regimen so you are only taking
medications that will make you feel comfortable.
We started:
Senna 8.6 mg Tablet one tablet twice a day as needed for
constipation
Levothyroxine 100 mcg Tablet by mouth daily
Acetaminophen 650 mg Tablet 1 tablet by mouth every 4-6 hours
as needed for fever or pain.
Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler One
Inhalation every six hours as needed for shortness of breath or
wheezing.
Colace 100 mg One Capsule by mouth twice a day as needed for
constipation.
Zofran 4mg IV q8hours as needed for nausea
Morphine 1-4mg IV q4-6 hours PRN pain, shortness of breath
Metoprolol Succinate 50 mg one Tablet by mouth daily - This
medication slows your heart rate and keeps it in a normal range
Amiodarone 200 mg Tablet One Tablet PO once a day - This
medication is to help keep your heart beating in a normal
rhythm.
Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.
Followup Instructions:
Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 4469**] as needed.
Completed by:[**2174-8-29**]
|
[
"428.0",
"428.23",
"414.01",
"244.9",
"E884.2",
"E849.7",
"996.72",
"518.81",
"496",
"403.90",
"585.9",
"733.00",
"V58.61",
"530.81",
"427.31",
"424.0",
"414.8",
"427.32"
] |
icd9cm
|
[
[
[]
]
] |
[
"99.62",
"96.72",
"88.56",
"96.6",
"37.23"
] |
icd9pcs
|
[
[
[]
]
] |
14063, 14179
|
8990, 12777
|
305, 352
|
14325, 14325
|
2691, 8155
|
16761, 16897
|
2194, 2295
|
13235, 14040
|
14200, 14304
|
12803, 13212
|
8172, 8967
|
14508, 16738
|
2310, 2672
|
222, 267
|
380, 1630
|
14340, 14484
|
1652, 1905
|
1921, 2178
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
10,859
| 104,246
|
45288
|
Discharge summary
|
report
|
Admission Date: [**2176-11-9**] Discharge Date: [**2176-11-18**]
Date of Birth: [**2107-6-22**] Sex: M
Service: Cardiothoracic Surgery
HISTORY OF PRESENT ILLNESS: The patient is a 69-year-old
male with end-stage renal disease, who was three hours into a
hemodialysis session when it was stopped secondary to nausea
and tightness at his throat. He does have a history of
peripheral vascular disease with bilateral renal artery
stenosis and had stenting. He also has a history of
hypertension and hyperlipidemia.
In the Emergency Department, he was chest pain free and found
to be hypertensive with a blood pressure of 194/74. He went
to CT scan to rule out pulmonary embolus and on routine, was
noted to have [**Street Address(2) 4793**] depressions on telemetry, but no EKG
changes. He did complain of [**5-28**] chest pressure, which was
treated with sublingual nitroglycerin and a nitroglycerin
drip was started. He also received 5 of IV Lopressor and 325
mg of aspirin. Upon admission, he was chest pain free and
without shortness of breath.
PAST MEDICAL HISTORY:
1. Hypertension.
2. Peripheral vascular disease status post right iliac stent
and left iliac stent with claudication.
3. Renal artery stenosis severe bilaterally, and he is status
post stents bilaterally.
4. End-stage renal disease on hemodialysis.
5. Diabetes mellitus.
6. Depression.
SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] does not smoke
and he does not drink.
ALLERGIES: He has no known drug allergies.
MEDICATIONS ON ADMISSION:
1. Aspirin 325 mg p.o. q.d.
2. Glipizide 5 mg p.o. q.d.
3. Isosorbide mononitrate 30 mg p.o. q.d.
4. Labetalol 400 mg p.o. b.i.d.
5. Lipitor 20 mg p.o. q.d.
6. Norvasc 10 mg p.o. b.i.d.
7. Plavix 75 mg p.o. q.d.
8. Ramipril one tablet p.o. q.d.
9. Fluoxetine 20 mg p.o. q.d.
PHYSICAL EXAMINATION: On physical exam, his temperature is
97.6, heart rate 74, blood pressure is 148/100. He is alert
and oriented times three, pleasant male in no apparent
distress. His HEENT includes PERRL. EOMI. His pharynx is
clear. His neck is supple with no JVD. Hemodialysis
catheter on the left, this is clean, dry, and intact. His
heart is regular, rate, and rhythm without murmurs, rubs, or
gallops. His lungs were clear to auscultation bilaterally.
His abdomen was soft, nontender, nondistended with positive
bowel sounds. He has no hepatosplenomegaly. His extremities
are without clubbing, cyanosis, or edema. He has no ulcers
and no palpable cords. His neurologic examination shows his
cranial nerves to be intact and remainder of his examination
to be grossly intact.
His chest x-ray showed normal pulmonary vasculature and no
evidence of CHF.
A CT scan showed no sign of pulmonary embolus.
His laboratories include a white count of 9.8, hematocrit is
47.4%, platelet count of 302,000. Sodium 138, potassium 4.7,
chloride ......., CO2 29, BUN 52, creatinine 5.7, and a blood
glucose of 156. His PT 12.5, PTT of 30, and an INR of 1.
Troponin was 0.07 with a CK of 57.
His echocardiogram which was done a month prior showed an EF
of greater than 55% with normal valves; and a stress test
previous [**Month (only) 956**] showed no ischemic or anginal symptoms.
While in the hospital, he remained asymptomatic while
awaiting eventual cardiac catheterization. He did undergo
hemodialysis on [**11-11**] and also that day had a cardiac
catheterization, which showed right dominant coronary system
with left main having tubular 50% stenosis, LAD with an 80%
ostial angulated disease, and a mid segment 60% tubular
lesion left circumflex, and a 60% ostial lesion with a 70%
tubular lesion of the distal segment at the trifurcation of
the OM-2 and the right coronary artery to be a dominant
vessel with a distal 90% lesion.
Dr. [**Last Name (STitle) **] was then consulted for probable coronary artery
bypass grafting. Patient underwent one more round of
hemodialysis prior to cardiac surgery. On [**2176-11-13**],
he underwent coronary artery bypass grafting x4 with a left
internal mammary artery to the proximal LAD, saphenous vein
graft to the distal LAD, saphenous vein graft to the OM, and
saphenous vein graft to the PDA. This surgery was performed
under general endotracheal anesthesia with a cardiopulmonary
bypass time of 70 minutes and cross-clamp time of 60 minutes.
The surgery was performed by Dr. [**Last Name (STitle) **] with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 96760**],
NP, and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. as assistant. The patient
tolerated the procedure well and was transferred to the
Cardiac Surgery Recovery Unit in A paced at 88 on
Neo-Synephrine and propofol drips.
He was able to awaken from the anesthesia easily and was
extubated on the operative night. He did require insulin
drip on the operative night, but this was weaned off during
the night. He was then transferred to the Surgical Floor on
postoperative day #2.
On postoperative day #2, he underwent hemodialysis again and
began to resume his usual schedule. He continued to progress
well on postoperative day #3. He had his wires and chest
tube D/C'd without incident. He worked with Physical
Therapy, and increased his ambulation and began to enter more
aggressive cardiac rehab.
On the morning of [**11-18**], he did receive final run of
hemodialysis prior to discharge home. He will be discharged
home today as he is doing very well, and visiting nurse
services will follow him there.
His discharge exam shows him to be afebrile with a heart rate
of 69, blood pressure of 123/65, respirations 18, and O2
saturation of 96% on room air. He is alert and oriented
times three and in no apparent distress. His heart is
regular, rate, and rhythm. His lungs are clear to
auscultation bilaterally. His abdomen is soft, nontender,
nondistended, and his wounds are clean, dry, and intact, and
the sternum is stable.
His laboratories include a white count of 8.6, hematocrit of
24.3%, platelet count of 335,000. Sodium is 134, potassium
3.9, chloride 99, CO2 23, BUN 60, creatinine 6.8, and a blood
glucose of 148.
His discharge chest x-ray is clear with no signs of effusion
and very minimal atelectasis. With this exam and considering
how he has been doing with Physical Therapy, it is felt that
he will be ready to be discharged to home with visiting nurse
services on postoperative day #5.
DISCHARGE CONDITION: Good.
DISCHARGE DIAGNOSES:
1. Coronary artery bypass grafting x4.
2. Renal artery stenosis.
3. End-stage renal disease on hemodialysis.
4. Diabetes mellitus.
DISCHARGE MEDICATIONS:
1. Aspirin 325 mg p.o. q.d.
2. Lipitor 20 mg p.o. q.d.
3. Fluoxetine 20 mg p.o. q.d.
4. Multivitamin one cap p.o. q.d.
5. Plavix 75 mg p.o. q.d.
6. Lopressor 12.5 mg p.o. b.i.d.
7. Glipizide 5 mg p.o. q.d.
8. Calcium acetate 667 mg tablet p.o. t.i.d.
9. Percocet 5/325 mg 1-2 tablets p.o. q.4h. prn pain.
FOLLOW-UP INSTRUCTIONS: He should follow up with his primary
care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1968**] in [**12-21**] weeks or as
scheduled on [**12-18**]. He should follow up with his
cardiologist in [**1-22**] weeks and with Dr. [**Last Name (STitle) **] in four weeks.
He should also have contact with his hemodialysis center and
resume the schedule there and follow up with his nephrologist
in [**12-21**] weeks. He should have his cardiopulmonary status and
wound healing monitored by visiting nurse and be encouraged
to cough and deep breathe and ambulate, and he should check
his fingerstick blood sugars 3-4x a day.
[**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**]
Dictated By:[**Last Name (NamePattern1) 96761**]
MEDQUIST36
D: [**2176-11-18**] 13:40
T: [**2176-11-18**] 13:52
JOB#: [**Job Number 96762**]
|
[
"443.9",
"285.9",
"250.00",
"272.4",
"410.71",
"403.91",
"414.01",
"311",
"440.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"36.15",
"88.56",
"36.13",
"37.22",
"39.61",
"38.93",
"39.95"
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icd9pcs
|
[
[
[]
]
] |
6445, 6452
|
6473, 6605
|
6628, 6934
|
1553, 1829
|
1852, 6423
|
185, 1075
|
6959, 7921
|
1097, 1384
|
1401, 1527
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
26,001
| 150,942
|
15841
|
Discharge summary
|
report
|
Admission Date: [**2115-11-16**] Discharge Date: [**2115-11-27**]
Date of Birth: [**2085-11-28**] Sex: M
Service: GENERAL SURGERY BLUE
HISTORY OF PRESENT ILLNESS: The patient is a 29 year-old
gentleman with a history of depression and multiple suicide
attempts who was admitted to the Medical Intensive Care Unit on
[**2115-11-16**] for Tegretol and tricyclic antidepressant
overdose. The patient has had at least three suicide attempts
PAST MEDICAL HISTORY: Depression with multiple suicide
attempts, allergic rhinitis and migraines.
OUTPATIENT MEDICATIONS: [**Last Name (LF) 6196**], [**First Name3 (LF) **], Tegretol,
Fioricet, NyQuil, Remeron.
SOCIAL HISTORY: Positive for tobacco and alcohol use.
FAMILY HISTORY: Noncontributory.
LABORATORY: CT scan of the abdomen and pelvis on [**2115-11-18**] showed bowel ischemia in the cecum, ascending colon and
terminal ileum. Pneumatosis was seen in the hepatic flexure.
HOSPITAL COURSE: The patient was admitted to the Medical
Intensive Care Unit for observation. The patient was in fact
intubated on [**11-16**] and was extubated on [**11-18**].
The patient was taken to the Operating Room for an
exploratory laparotomy and abdominal colectomy and an end
ileostomy on [**2115-11-18**] for infarction of the right and
transverse colon.
Postoperatively, the patient was stable. Estimated blood
loss was 300 cc. The patient was kept on Levofloxacin,
Metronidazole and Ampicillin for a brief period postoperatively.
The patient was started on a morphine PCA for pain control. On
postop day number two the pain was well controlled with morphine
PCA. On postop day number three, the patient was able to get out
of bed to chair. A PICC line was placed on postoperative day
number three. On postoperative day number four total parenteral
nutrition was started through the PICC line at the rate of 73.5
cc an hour. On postoperative day number five nasogastric tube was
clamped. On postoperative day number six the nasogastric
tube was taken out. On postop day number seven the patient
was advanced to a clear liquid diet. On postoperative day
number eight to a regular diet. Medications were switched to
oral form. On postoperative day number nine the patient was
tolerating a regular diet, total parenteral nutrition was
discontinued and IV was heplocked. PICC line was taken out
on postoperative day nine and peripheral intravenous access
was obtained. The patient was discharged to an inpatient
psychiatric facility on postoperative day number nine.
CONDITION ON DISCHARGE: Stable.
DISCHARGE STATUS: Inpatient psychiatric facility.
DISCHARGE DIAGNOSES:
1. Bowel ischemia.
2. Suicidal Ideation Depression with multiple suicidal attempts.
3. Hypovolemic Shock
4. Drug Overdose
5. Respiratory Failure
6. Malnutrition
DISCHARGE MEDICATIONS: 1. Percocet 5/325 one to two tablets
po q 4 to 6 hours. 2. Albuterol nebulizer q 6 hours prn.
3. Haldol 1 to 5 mg intravenous q 4 hours prn. 4. [**Year (4 digits) 6196**]
40 mg po q day. 5. Lorazepam 1 to 2 mg intravenous q 4
hours prn. 6. Heparin 5000 units subQ t.i.d. 7. Tylenol
prn.
FOLLOW UP PLANS: The patient is to follow up with Dr. [**First Name (STitle) 2819**].
The patient is also to follow up with the patient's own
psychiatrist after discharge from psychiatric facility.
Please call Dr.[**Name (NI) 11471**] office for follow up.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 19318**]
Dictated By:[**Last Name (NamePattern1) 1909**]
MEDQUIST36
D: [**2115-11-27**] 07:10
T: [**2115-11-27**] 07:25
JOB#: [**Job Number 45537**]
|
[
"969.0",
"751.0",
"296.20",
"966.3",
"E950.4",
"557.0",
"518.81",
"785.59",
"E950.3"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"46.21",
"96.04",
"47.19",
"99.15",
"96.71",
"45.73",
"45.33"
] |
icd9pcs
|
[
[
[]
]
] |
750, 954
|
2652, 2820
|
2844, 3683
|
972, 2545
|
586, 677
|
184, 461
|
484, 561
|
694, 733
|
2570, 2631
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
65,962
| 109,495
|
38172
|
Discharge summary
|
report
|
Admission Date: [**2139-4-27**] Discharge Date: [**2139-5-6**]
Date of Birth: [**2085-9-26**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Paralysis, epidural hematoma
Major Surgical or Invasive Procedure:
Placement of a peripherally inserted central catheter (PICC
line)
Endotracheal Intubation
Blood Transfusion
Arterial Line
History of Present Illness:
Mr. [**Known lastname **] is a 53 year old man with a history of anxiety,
polysubstance abuse (hepatitis B and C), peripheral vascular
disease, HTN, COPD who presented with 3-4 days of increasing
lower extremity weakness. Unfortunately, he is currently
intubated/sedated and cannot provide a history. Per review of
nursing home records and emergency department records, he noted
decreased sensation in his lower extremities, starting on the
left. This was accompanied by increasing weakness. These
symptoms occured in the setting of his girlfriend moving a
pillow for him 3-4 days ago. Apparently denied trauma. He was
initially seen at an OSH where he had an L-spine MRI that showed
an acute to subacute fx at L1-L2.
In the ED, initial vs were: 97.4 HR 111 100/63 RR 20 94% on
6 L. He was intubated for an MRI. In the MRI, he became
hypotensive with SBP to 80-90s. He was started on levophed and
was given vancomycin and zosyn. For sedation he was given
versed 5 mg IV and vecuronium 8 mg for MRI and was started on
versed/fent drips. MRI revealed a compression fx at T6-7 with
an epidural collection likely hematoma. Per radiology read,
there is suggestion of mass effect on cord. Per neurosurgery
review of films, neurosurgery feels that there is in fact no
mass effect. Neurosurgery attending was contact[**Name (NI) **] by both the
neurology and [**Name (NI) **]. It was felt that Mr. [**Known lastname **] would not
benefit from an immediate surgical intervention and would best
be served on the medical service. Of note a RIJ was placed in
the ED prior to transfer to the floor.
.
On the floor, he is intubated and sedated. He grimaces to pain
but does not respond to simple commands.
Past Medical History:
- Anxiety,
- Hep B and C
- SAH
- PVD
- HTN
- COPD on [**4-23**] L O2 at home
- Recent Pneumonia
Social History:
Mr. [**Known lastname **] has been at [**Hospital 5503**] Rehab Hospital, recently
admitted OSH w/ discharge diagnosis of COPD exacerbation on IV
vancomycin and solumedrol.
-H/O IVDU, states he has not used in years.
Family History:
Unable to obtain on admission
Physical Exam:
General: Intubated, sedated
HEENT: Sclera anicteric
Neck: supple, no LAD
Lungs: Anterior breath sounds clear, no wheezes, rales, ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: No foley
Ext: Cool, 1+ pulses, no clubbing, cyanosis or edema
Skin: Multiple ecchymoses, Stage 2-3 sacral decubitus ulcer
Neuro: Strength/sensation unable to assess, patellar refelx
0/ankle jerk 0, Babinski equivocal
Pertinent Results:
Imaging
.
[**2139-4-27**] MRI Spine
IMPRESSION:
1. Mild-to-moderate compression fractures of T5 through T7 with
a
heterogeneously enhancing epidural collection, concerning for
ostemyelitis
with evolving epidural abscess. However, the lack of extensive
enhancement
including the disc space is unusual for pyogenic infection and
there may be a combination of chronic neurogenic
spondyloarthropathy with hematoma/phlegmon and superimposed
infection. TB could have this appearance and should be
correlated with clinical and laboratory findings. There is
resultant severe encroachment on the spinal canal anteriorly
with cord deformity and abnormal cord signal.
2. Findings concerning for a developing secondary infection at
C5-6 without cord compression. While the endplate and disc edema
could be post-traumatic, the extent of epidural enhancement
would be very unusal in the setting of trauma.
3. Mild compression fractures of L1 and L2 without cord or cauda
equina
compression.
4. Additional degenerative changes as detailed.
5. Pulmonary findings concerning for pleural and/or parenchymal
disease for which chest CT has been recommended and please see
that report for further details.
.
[**2139-4-28**] CT Chest
IMPRESSION:
1. Severe bilateral, occlusive bronchial mucoid impaction.
2. No appreciable pleural effusion, loculated or otherwise.
Right basal
atelectasis is moderate.
3. Diffuse centrilobular emphysema.
4. Possible aspiration effect, right middle lobe and right lower
lobes
5. Diffuse debris is noted within the tracheobronchial tree.
Dense secretions are noted in the right lower lobe and left
lower lobe bronchi.
6. Vertebral body wedge compressions T5, T7 , T8, L1 with
suggestion of lytic lesions in at least in T8, possible
paraspinal hematoma, tumor, and/or marrow, better described on
same day CT and MR.5.
7. 7 x 9 mm nodule, left upper lobe, could be malignant.
.
[**2139-4-28**] Lower Extremity Doppler
IMPRESSION: No evidence of DVT in the lower extremities
bilaterally.
.
[**2139-4-28**] ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses are normal. The left ventricular cavity size is
normal/small. Left ventricular systolic function appears grossly
preserved. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
free wall motion appears borderline preserved in suboptimal
views. The ascending aorta is mildly dilated. The aortic valve
is not well seen. The mitral valve leaflets are structurally
normal. The estimated pulmonary artery systolic pressure is
normal. There is a very small pericardial effusion. No valvular
regurgitation is identified in suboptimal views.
.
[**2139-4-28**] CT Spine
IMPRESSION:
1. Multiple thoracolumbar compression fractures as described
above.
2. Mild multilevel degenerative disease with grade 1
retrolisthesis of L5 on S1, posterior disc bulge with mild
central canal narrowing.
3. At T7 level, there is paravertebral soft tissue thickening
which appears to be subpleural in location
.
[**2139-4-30**] MRI SPine
IMPRESSION:
1. Continued abnormal signal in the cervical spine at C6-7
level, but
significant decrease in epidural collection at this level.
2. Multiple T5-7 compression fractures are again seen, with
minimal decrease in epidural collection at this level, but
continued abnormal cord signal thought due to mass effect.
For more detailed description of degenerative changes at other
levels, please refer to previous extensive report from three
days prior
.
[**2139-5-1**] CXR
IMPRESSION: No significant change of bibasilar atelectasis.
Stable positions.
.
[**2139-5-6**] CXR
Report pending at discharge.
of ET tube and right central venous catheter.
.
Microbiology
[**2139-5-3**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-5-3**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-5-2**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-4-30**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY
CULTURE-FINAL {YEAST}; LEGIONELLA CULTURE-pending;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-negative
[**2139-4-29**] CATHETER TIP-IV WOUND CULTURE-negative
[**2139-4-28**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-negative;
RESPIRATORY CULTURE-FINAL {YEAST}; LEGIONELLA CULTURE-negative;
Immunoflourescent test for Pneumocystis jirovecii
(carinii)-negative
[**2139-4-28**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-4-28**] MRSA SCREEN MRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}
[**2139-4-28**] BLOOD CULTURE Blood Culture, Routine-negative
[**2139-4-27**] URINE URINE CULTURE-FINAL {YEAST}
[**2139-4-27**] BLOOD CULTURE Blood Culture- pending at discharge
.
Laboratory Results
[**2139-4-27**] 08:00PM BLOOD WBC-15.9* RBC-3.04* Hgb-9.3* Hct-28.1*
MCV-92 MCH-30.6 MCHC-33.2 RDW-18.6* Plt Ct-318
[**2139-4-29**] 03:24AM BLOOD WBC-14.5* RBC-2.62* Hgb-7.9* Hct-23.8*
MCV-91 MCH-30.1 MCHC-33.1 RDW-18.7* Plt Ct-358
[**2139-5-1**] 06:17AM BLOOD WBC-10.1 RBC-2.63* Hgb-8.1* Hct-24.1*
MCV-91 MCH-30.6 MCHC-33.5 RDW-18.8* Plt Ct-371
[**2139-5-3**] 05:45AM BLOOD WBC-8.9 RBC-2.44* Hgb-7.5* Hct-22.1*
MCV-91 MCH-31.0 MCHC-34.1 RDW-18.8* Plt Ct-370
[**2139-5-4**] 09:40AM BLOOD WBC-11.0 RBC-3.30*# Hgb-10.0*# Hct-29.4*#
MCV-89 MCH-30.4 MCHC-34.1 RDW-18.3* Plt Ct-323
[**2139-5-5**] 05:53AM BLOOD WBC-8.6 RBC-2.90* Hgb-9.2* Hct-26.0*
MCV-90 MCH-31.6 MCHC-35.2* RDW-18.4* Plt Ct-285
[**2139-5-6**] 05:37AM BLOOD WBC-8.7 RBC-3.15* Hgb-9.5* Hct-28.5*
MCV-91 MCH-30.2 MCHC-33.4 RDW-18.0* Plt Ct-344
[**2139-4-27**] 08:00PM BLOOD Glucose-74 UreaN-41* Creat-0.9 Na-133
K-4.8 Cl-91* HCO3-35* AnGap-12
[**2139-4-29**] 03:24AM BLOOD Glucose-91 UreaN-29* Creat-0.6 Na-136
K-4.2 Cl-99 HCO3-30 AnGap-11
[**2139-4-30**] 06:16PM BLOOD Glucose-92 UreaN-28* Creat-0.6 Na-139
K-3.9 Cl-98 HCO3-33* AnGap-12
[**2139-5-2**] 06:29AM BLOOD Glucose-84 UreaN-30* Creat-0.6 Na-136
K-3.9 Cl-96 HCO3-34* AnGap-10
[**2139-5-3**] 05:45AM BLOOD Glucose-80 UreaN-28* Creat-0.4* Na-136
K-3.8 Cl-98 HCO3-33* AnGap-9
[**2139-5-6**] 05:37AM BLOOD Glucose-71 UreaN-25* Creat-0.5 Na-137
K-3.8 Cl-99 HCO3-33* AnGap-9
[**2139-4-28**] 03:40AM BLOOD CK(CPK)-112
[**2139-4-28**] 09:27AM BLOOD CK(CPK)-78
[**2139-4-28**] 04:44PM BLOOD CK(CPK)-57
[**2139-4-29**] 03:24AM BLOOD CK(CPK)-42*
[**2139-4-27**] 08:00PM BLOOD Lipase-27
[**2139-4-28**] 03:40AM BLOOD CK-MB-4 cTropnT-0.12*
[**2139-4-28**] 09:27AM BLOOD CK-MB-NotDone cTropnT-0.08*
[**2139-4-28**] 04:44PM BLOOD CK-MB-NotDone cTropnT-0.05*
[**2139-4-29**] 03:24AM BLOOD CK-MB-NotDone cTropnT-0.03*
[**2139-4-28**] 03:40AM BLOOD Calcium-8.1* Phos-4.2 Mg-2.0
[**2139-5-6**] 05:37AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.9
[**2139-5-3**] 05:45AM BLOOD calTIBC-209* Ferritn-1101* TRF-161*
[**2139-4-28**] 03:40AM BLOOD Cortsol-7.7
[**2139-4-29**] 03:24AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-POSITIVE
[**2139-4-27**] 08:00PM BLOOD CRP-69.1*
[**2139-5-3**] 05:45AM BLOOD PEP-NO SPECIFI
[**2139-5-2**] 06:29AM BLOOD HIV Ab-NEGATIVE
[**2139-4-29**] 08:13AM BLOOD Vanco-23.1*
[**2139-4-29**] 09:35PM BLOOD Vanco-15.5
[**2139-5-1**] 06:17AM BLOOD Vanco-20.8*
[**2139-5-2**] 06:29AM BLOOD Vanco-20.2*
[**2139-5-5**] 05:53AM BLOOD Vanco-23.8*
[**2139-4-27**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2139-4-28**] 01:48AM BLOOD Type-ART Rates-14/ Tidal V-450 PEEP-5
pO2-195* pCO2-58* pH-7.35 calTCO2-33* Base XS-4 -ASSIST/CON
Intubat-INTUBATED
[**2139-5-2**] 02:08PM BLOOD Type-ART Temp-36.8 pO2-63* pCO2-45
pH-7.49* calTCO2-35* Base XS-9
[**2139-4-27**] 08:30PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
[**2139-4-27**] 08:30PM URINE RBC-[**2-20**]* WBC-[**5-28**]* Bacteri-FEW Yeast-MOD
Epi-0-2
Brief Hospital Course:
Mr. [**Known lastname **] is a 53 year old man with anxiety, hepatitis C,
PVD, HTN, COPD on home O2 who presented with paralysis secondary
to a compression fracture and epidural abscess/hematoma.
.
# Blood pressure: Mr. [**Known lastname **] met SIRS criteria on admission
with leukocytosis and tachycardia. He was initially treated with
levophed and IV boluses for a goal MAP over 60. He was able to
be weaned from pressors and his blood pressures then remained
stable. His blood pressures remained stable throughout the rest
of the hospitalization, but his home medications were not
restarted. He was started on metoprolol for atrial tachycardia.
His home lisinopril and furosemide should be restarted at rehab
as his blood pressure allows.
.
# Epidural Abscess/Bacteremia: Mr. [**Known lastname **] was seen by
neurology and neurosurgery on admission. He was unable to move
or have sensation in his lower extremities. He had no rectal
tone. Given the extent of his deficit, the timing of the injury,
and his comorbidities, neurosurgery did not feel surgery would
be beneficial. He was covered broadly with vancomycin/zosyn
initially for bacteremia and possible epidural abscess. ID was
consulted. Blood cultures from the OSH were positive for MRSA
and his antibiotic coverage was changed to vancomycin based on
sensitivities. After blood cultures were negative here at [**Hospital1 18**]
a PICC was placed. He will need a total of eight weeks of
antibiotic therapy. He will be followed by the [**Hospital **] clinic. He
will need weekly blood draws of vanc trough, chem-7, CRP, ESR,
CBC, and LFT's. He will follow up in [**Hospital **] clinic in two weeks.
Neurosurgery would like him to have a repeat MRI in three months
([**2139-7-19**]). He will need a vanc trough on [**5-7**].
.
# Lung Nodule: Mr. [**Known lastname **] had a lung nodule seen on chest
imaging (9mm). This will need to be followed up with a repeat CT
in 3 months.
.
# COPD/Respiratory failure: Mr. [**Known lastname **] was initially intubated
on arrival in order to have imaging studies performed. He was
able to be quickly extubated on hospital day #2. The following
morning he desaturated to the 70's with increased WOB. He was
reintubated. He remained reintubated overnight and was extubated
the next day. On the floor, he was able to be weaned to 4 L
(home dose 5-6 L). He was initially continued on high dose
steroids for his COPD flare. However, this was decreased to 40
mg of prednisone. He remained on 4 L. His goal oxygen saturation
was 90-92%. He should continue to be slowly tapered on
prednisone while at rehab. He should have a slow taper given his
extended use of solumedrol. He should continue on Bactrim while
on high dose steroids.
.
Compression Fractures: Mr. [**Known lastname **] had compression fractures.
He was started on calcium, vitamin D, and calcitonin. He was
fitted for a TLSO brace. He should always wear the brace when he
is elevated above 30 degrees.
.
Bowel/Bladder Care: Mr. [**Known lastname **] has no rectal tone. He is
unable to sense his bladder and bowels being full. A voiding
trial was attempted, but was unsuccessful. A foley was replaced.
He should have a repeat voiding trial at rehab. He had not moved
his bowels for several days during the hospitalization. He was
given an aggressive bowel regimen. A disimpaction was attempted,
but there was no stool in the rectum. He spontaneously moved his
bowels on the day of discharge. His difficulty with bowel and
bladder symptoms is likely related to his paralysis. His high
dose of narcotics is also worsening the problem.
.
Anemia: Mr. [**Known lastname **] had a slowly decreasing hematocrit. He was
guiac negative. He received two units of pRBC's with an
appropriate increase. His anemia was consistent with anemia of
chronic disease.
.
Pain: Mr. [**Known lastname **] had severe pain related to his compression
fractures. He was started on a PCA with hydromorphone. This was
transitioned to IV and then orals. He was also started on a
lidocaine patch. He was continued on his home methadone dose of
120 mg, but this was spaced out in TID dosing given concerns of
somnolence.
.
Anxiety: Mr. [**Known lastname **] was continued on his home dose of
lorazepam.
.
Lytic Lesions: Mr. [**Known lastname **] was noted to have lytic lesions on
imaging studies. An SPEP was negative. This should be further
evaluated as an outpatient.
.
Wound Care: Mr. [**Known lastname **] was admitted with an unstageable
decubitus ulcer. There were no signs of infection during the
hospitalization. He was followed by wound care. They recommended
daily dressing changes and pressure reduction.
.
Prophylaxis: Neurosurgery felt that it was safe to start DVT
prophylaxis. Based on their recommendation, he was started on
enoxaparin on [**5-3**].
.
Code: Mr. [**Known lastname **] was a full code.
Medications on Admission:
- Lasix 40 daily
- heparin flush
- lisinopril 5 daily
- lorazapam 0.5 TID
- methadone 120 mg
- omeprazole 20
- polyethylene glycol 17 gm daily
- senna daily
- singulair 10 mg daily
- solumedrol 40mg TID
- spiriva 18 mcg
- MVI
- Xopenex neb q6 hours
- Vancomycin (started on [**4-22**] for unclear reason)
- Tylenol
- [**Name (NI) 85137**]
- Bisac-evac
- Guaifenesin
- Ibuprofen
- lorazapam prn
- zolpidem prn
- morphine 2 mg q4 h as needed
Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.
2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
3. Methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day).
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO twice a day.
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Singulair 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO TID (3 times a day).
10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation not relieved by colace/senna.
12. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours).
13. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
15. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
16. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
17. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin rash.
18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply
to back.
19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as
needed for SOB.
20. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed for SOB.
21. Hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO Q3H (every 3
hours) as needed for pain.
22. Vancomycin 500 mg Recon Soln Sig: Five Hundred (500) Recon
Soln Intravenous Q 12H (Every 12 Hours): Please continue until
[**6-23**].
23. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig:
One (1) spray Nasal DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
[**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**]
Discharge Diagnosis:
Primary Diagnosis:
Compression Fractures
Epidural Abscess/Hematoma
Chronic Obstructive Pulmonary Disease
Bacteremia
Decubitis Ulcer
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:
Thank you for allowing us to take part in your care. You were
admitted to the hospital with lower extremity weakness and loss
of sensation. You were found to have collections of fluid
pressing against your spinal cord. You met with neurosurgeons
who did not feel an operation would improve your sensation. You
were discharged to a rehab facility to work on improving your
mobility.
We made several changes to your medications:
We STARTED vancomycin (an antibiotic). You will take this until
[**6-23**].
We STOPPED lisinopril and lasix.
We CHANGED your methadone to three times a day at lower doses
(same total dose).
We INCREASED your bowel medications.
WE CHANGED your steroids from solumedrol to prednisone.
We INCREASED your nebulizers to albuterol and ipratropium.
We STARTED calcitonin, calcium, and vitamin D for your bones.
We STARTED oral hydromorphone for breakthrough pain.
We STARTED enoxaparin (Lovenox) to prevent clots from forming.
Followup Instructions:
It is very important that you have a primary care provider. [**Name10 (NameIs) **]
have several medical issues that are important to follow up on.
You will have a physician at your rehab facility. This physician
is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 85138**] [**Name (STitle) 85139**].
You have a pulmonary nodule. You need to have a repeat CT scan
in 3 months to see if this lesion has changed. Please discuss
this with Dr. [**Last Name (STitle) 85139**].
You have an appointment scheduled with Dr. [**Last Name (STitle) 85140**] on [**5-27**] at
10:50. The appointment is located at [**Last Name (NamePattern1) 439**] on the
ground floor. This is to discuss your antibiotics. Please call
[**Telephone/Fax (1) 457**] with any questions.
Department: [**Hospital1 **] MRI (MOBILE)
When: TUESDAY [**2139-8-4**] at 10:35 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: [**Hospital1 **] MRI (MOBILE)
When: TUESDAY [**2139-8-4**] at 11:15 AM
With: MRI [**Telephone/Fax (1) 327**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
You have an appointment with Dr. [**Last Name (STitle) **] the neurosurgeon on
[**8-4**] at 1 PM in the [**Hospital **] Medical Office Building 3B.
|
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8,209
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26902
|
Discharge summary
|
report
|
Admission Date: [**2106-4-2**] Discharge Date: [**2106-4-9**]
Date of Birth: [**2028-2-4**] Sex: F
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 783**]
Chief Complaint:
Transfer from OSH after seizure in setting of recent spinal cord
surgery and meningitis.
Major Surgical or Invasive Procedure:
femoral central line placement [**2106-4-2**]
History of Present Illness:
Pt is a 78 yof with PMH Of T2DM, Spinal stenosis who was
admitted to [**Hospital3 **] on [**3-16**] for elective decompression
of spinal stenosis. She underwent decompressive L3, L4, L5
laminectomies and radical left L5 and S1 formainectomies. ?L4
level dural perforation, reporedly no spillage of csf in notes.
She had serosanguineous drainage from surgical wound. Pt febrile
to 101.5 postop day 1 she had received peri op oxicillin. She
was transfereed to TCU for rehab. On [**3-21**] pt noted to have
increased confusion and per family had visual hallucinations.
This was attributed to discontinuation of cymbalta. Cymbalta was
restarted and her symptoms improved. She had a urine culture
sent which grew Pseudomonas ([**Last Name (un) 36**] to zosyn, ceftz and amikcin).
Head CT at the time unremarkable. She continued to have drainage
from back. [**3-26**] area noted to be erythematous and pt was
febrile. On [**4-1**] she underwent exploration in OR where 2 JP
drains were placed. Wound culture grew, Pseudomonas, Klebsiella
and Enteroccus. CSF analysis done in [**3-30**] showed 5950 wbc (71P,
8L, 21M) 3 RBC, glucose 22, (protein not reported). Pt was
started on Ceftaz, Amikacin and Ampicillin at OSH.
.
Earlier day of admission pt was complaining of back pain. She
received demerol around 2:15pm and another dose 5:15pm per
family. 5 [**Name (NI) **] pt noted to be choking followed by jerking
motions of upper ext. Unknown lower extremities movement. no
incontinence. Also at this time pt noted to have a wide complex
tachycardia. Pt soon bacame pulseless and and was shocked X 1
with 200J and became responsive thereafter. Episode lasted 5
[**Name (NI) **]. After discussion with family pt was transferred to [**Hospital1 18**].
.
On transfer here pt denies any complaints. Denies any headache,
chest pain, shortness of breath. She is somnolent however easily
arousable. Denies any photophobia.
.
MICU Course: Pt was given Amikacin, Ceftaz IV. Ampicillin IV
was held given it lowers the seizure threshold, awaiting ID
input. Neuro was curbsided, and stated that there is no benefit
to dilantin for meningitis for seizure prophylaxis, so this was
discontinued. Neuro stated if the sz recurs, to formally
consult and give Ativan 2mg IV. Ortho was consulted. From a
cardiac standpoint, we still do not have a clear cause for
pulseless VT. The pt was ruled out by 2 sets of negative
cardiac enzymes. Cardiology was notified upon transfer of the
pt to the medical floor, and plan was made to discuss EKGs,
antiarrhythmics and obtain TTE. The pt underwent LE doppler US
on [**2106-4-3**] to rule out DVT. Femoral line was d/c'd.
.
Past Medical History:
Lung cancer resected 15 years ago
spinal stenosis
pancreatitis
hypertension
anxiety
depression
reflux
hypothyroid
diabetes type 2
s/p appendectomy
s/p hysterectomy
r hip replacement
Social History:
SH: retired foremrly worked in highschool cafeteria serving
food. former smoker, no etoh.
Family History:
FH: unknown.
Physical Exam:
T 96.7 BP 122/50 HR 52 RR 19 O2sat 100% 3LNC.
GEN: Elderly female lying in bed in nad. Drowsy but easily
arousable able to cooperate with exam.
HEENT: PERRL, MMM, EOMI
Chest: CTAB, no crackles
CVR: RRR, nl s1, s2, no r/m/g
Abdomen: soft, nt, nd, obese
Ext: no edema, 1+dp/pt pulses.
Back: Incision site with staples intact, some erythema around
the site no warmth. 2 JP drains in place.
Neuro: CN II-XII intact. [**6-4**] UE and LE strength. sensation
intact to light touch thruout. 2+ patellar reflex.
.
PE on call out from MICU:
Vitals: Tm: 98.6 Tc: 98.6 BP: 148/79 P: 80s RR: 16 O2sat: 100%
2L NC I/O: 1480/405 +1.07.
General: 78 y/o CF in NAD. Pleasant, cooperative, joking with
staff. AOX3.
HEENT: PERRL, MMM. OP clear.
Lungs: CTAB
CV: RRR S1 and S2 audible w/o M/R/G
Abd: obese, Soft, NT, ND. NABS, No masses, No HSM. + [**Female First Name (un) **]
intertrigo in skin folds under pannus. 2 JP drains in place in
the back ~5 cc serosanguinous drainage in each. Incision sites
appear clean.
Peripheral: 2+ edema, ext wwp, moving all extremities, no focal
neuro deficits. No clonus.
Pertinent Results:
Imaging:
[**2106-4-2**] CXR: IMPRESSION:
1. Cardiomegaly without evidence of pulmonary edema.
2. No evidence of pneumonia.
.
[**2106-4-3**]: RLE dopper: negative for DVT
.
ECG read by MICU (unable to find EKG in chart): sinus rhythm,
bradycardic, left axis, qt ~500. twave flattening diffusely
V2-V6.
Rhythm strip from OSH: demonstrating a wide complex tachycardia,
monomorphic VT.
.
CULTURE DATA:
[**2106-4-2**]: Blood culture negative
[**2106-4-3**]: Urine culture negative
[**2106-4-3**]: Blood culture negative
.
ABD US [**2106-4-5**]
Impression: Likely post operative ileus. Tubular foreign bodies
over the lumbar spine and right abdomen, as discussed above.
Clinical correlation with placed drains placed in the OR
recommended.
.
ECHOCARDIOGRAM [**2106-4-6**]
MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: 4.6 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.7 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Inferolateral Thickness: *1.6 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 4.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: >= 55% (nl >=55%)
Aorta - Valve Level: 3.6 cm (nl <= 3.6 cm)
Aortic Valve - Peak Velocity: 1.6 m/sec (nl <= 2.0 m/sec)
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 1.0 m/sec
Mitral Valve - E/A Ratio: 0.70
Mitral Valve - E Wave Deceleration Time: 291 msec
TR Gradient (+ RA = PASP): *31 mm Hg (nl <= 25 mm Hg)
Conclusions:
The left atrium is normal in size. There is moderate symmetric
left
ventricular hypertrophy with normal cavity size and systolic
function (LVEF >55%). Regional left ventricular wall motion is
normal. Right ventricular chamber size and free wall motion are
normal. The aortic valve leaflets appear structurally normal
with good leaflet excursion. No aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. Mild (1+)
mitral regurgitation is seen. There is mild pulmonary artery
systolic hypertension. There is an anterior space which most
likely represents a fat pad.
IMPRESSION: Symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Mild pulmonary artery systolic hypertension. Mild mitral
regurgitation.
.
CT L spine, done [**2106-4-9**] and formal read pending.
Brief Hospital Course:
Impression: Pt is a 78 yo female with h/o lung cancer, Type II
Diabetes Mellitus and spinal stenosis s/p recent
laminectomy/foraminectomy surgery complicated by nosocomial
meningitis who is transferred to [**Hospital1 18**] after seizure, pulseless
VT arrest.
.
# Pulseless Ventricular tachycardia at outside hospital, in
normal sinus rhythm status post shock with 200 joules - Unclear
etiology of pulseless VT, precipitant. No EKGs from OSH prior
to or immediately after pulseless VT. One strip from OSH with
code blue note demonstrated monomorphic VT. The pt was ruled
out for myocardial infarction by cardiac enzymes here. A 12
Lead EKG obtained here was significant for prolonged QTc at
450-470 msec, however this was felt to be acquired long QT
syndrome, unrelated to her pulseless VT episode. Her fluoxetine
and amitryptline was discontinued, however, given the pt has
severe depression, added fluoxetine back and followed QTc with
EKGs. Cardiology, Electrophysiology was consulted and
recommened pt undergo electophysiology study/T wave
alternans/possible VT ablation, however, given her infectious
issues, it was decided by the primary medicine team to hold off
until her antibiotic course was continued. Her electrolytes were
repleted aggresively to keep K>4.0, Mg>2.0. TTE completed
[**2106-4-6**] showing EF>55%, 1+ MR, otherwise preserved biventricular
systolic function, no evid of structural heart disease playing a
role in VT. The patient will continue a beta blocker,
metoprolol upon discharge to rehab. She is to follow up with EP
as an outpatient for EPS/TW alternans/VT ablation. An
appointment has been set up for her.
.
# Meningitis - Bacterial meningitis with Pseudomonas and
Klebsiella per report, growing out of wound cx with Enterococcus
growing out of broth only. ID was consulted here, and there was
communication between the OSH ID attending, Dr. [**Last Name (STitle) 51919**], and
our ID team. The pt was treated with Ceftazidime 2g IV q8 and
Amikacin 500mg IV q12h for now, planned 21 day course (day
[**7-21**]). We obtained Amikacin peak and trough labs: (directions
on how to obtain accurate troughs and peaks: 30 min prior to
giving dose, and 1 hour after infusing dose with goal peak
20-30, goal trough <8). Of note, there was a question here on
whether there was hardware in the back after her laminectomy, as
the pt underwent KUB, and curvilinear densities were seen L2-L4,
which were discussed w/ Dr. [**Last Name (STitle) 363**] and felt to be the JP drains.
These were removed [**2106-4-7**]. There was also an ongoing academic
discussion on the true efficacy of the Ceftaz. Per Dr.
[**Last Name (STitle) 51919**], the Pseudomonas (which is [**Last Name (un) 36**] to only Amikacin and
Ceftaz) tested positive on Extended Spectrum Beta Lactamase test
at OSH, and furthermore, the Pseudomonas was Aztreonam
resistant, which are both indications the Ceftazidime is not
really having much effect on the Pseudomonas. It was felt the
Amikacin was responsible for her improvement, however,
aminoglycosides do not penetrate CSF as well, and w/ signficant
side effects, therefore not an ideal choice, however, the pt
does not have many other options given the resistant
Pseudomonas. The pt did not undergo repeat LP given she was
doing clinically very well, with no HA, nuchal rigidity,
afebrile. To obtain idea of baseline lumbar fluid
collection/surgical site-- ID requesting CT lumbar spine. Pt
agreed and will order (pt refused MRI). Will d/c after C-spine
MRI with ID follow up in 3 weeks w/ Dr. [**Last Name (STitle) **]. Of note, after the
JP drains were removed, there was minimal drainage from the JP
sites seen on her bandages. Her surgical site is with minimal
erythema, no drainage, sutures intact and appears to be healing
well. Since the pt is on amikacin IV, which causes hearing
loss, she was set for audiology eval, however, b/c of back and
hip pain, was not able to tolerate being transported in
wheelchair. She will need to have an audiology eval as an
outpatient. She has a PICC line in the left arm for IV
antibiotics, and will complete 15 more days. She continues to
look clinically well, with no headache, neck stiffness,
weakness, or pain.
.
# Seizure - Unclear if patient has a primary seizure disorder.
No previous history per family. Continue management of
meningitis as above. Pt could also have become hypoxic after
pulseless VT/arrest and thus seized [**3-4**] hypoxia/decreased
cerebral blood flow. Also in ddx: pt received demerol, which
can lower seizure threshold. she was loaded with dilantin at
OSH. We consulted neurology about continuing dilantin however
consult stated that dilantin has not been shown to prevent
seizures in meningitides, so we discontinued it.
.
# Post op Spine surgery - Ortho Spine at [**Hospital1 18**] with Dr. [**Last Name (STitle) 363**]
was following the patient throughout her course. The surgical
site appears clean, with minimal drainage, and healing well.
.
# Type 2 DM - Her blood sugars were well controlled on glipizide
ER 20mg po qAM, and an ISS. She is tolerating po well.
.
# HTN - well controlled:
- incr metoprolol to 37.5 mg po tid, dilt 90mg po qid,
triam/HCTZ 37.5/25 po qd.
- all w/ hold parameters.
.
# Anxiety/depression - Stable.
- added back fluoxetine 40mg po qd.
# [**Female First Name (un) 564**] intertrigo: The pt demonstrated marked improvement on
ketoconazole 2% topically [**Hospital1 **] under her pannus and groin area.
She can be transitioned to nystatin powder [**Hospital1 **] at rehab.
.
#FEN: diabetic/cardiac diet.
.
#Prophy: SC heparin, Protonix at home
.
#Access: PICC line placed in left arm
.
#Comm: Daughter [**Name (NI) 2270**] [**Name (NI) **] (HCP) H [**Telephone/Fax (1) 66184**]; Cell
[**Telephone/Fax (1) 66185**].
.
#Code: Full
Medications on Admission:
levothyroixine
glipizide
digoxin
cartia
pravachol
propranolol
colace
amitriptyline
senokot.
Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*100 Tablet(s)* Refills:*3*
2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1)
Appl Rectal TID (3 times a day).
Disp:*qs 1 tube* Refills:*2*
5. Diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4
times a day).
Disp:*360 Tablet(s)* Refills:*2*
6. Trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as
needed.
Disp:*15 Tablet(s)* Refills:*2*
7. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
Disp:*135 Tablet(s)* Refills:*2*
8. Amikacin 500 mg IV Q12H
9. Ceftazidime 2 gm IV Q8H
10. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
Disp:*60 Capsule(s)* Refills:*2*
11. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H UNTIL BM DAILY ().
Disp:*qs ML(s)* Refills:*2*
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
Disp:*1 disk w/ device* Refills:*2*
14. Glipizide 10 mg Tab, Sust Release Osmotic Push Sig: One (1)
Tab, Sust Release Osmotic Push PO DAILY (Daily).
Disp:*30 Tab, Sust Release Osmotic Push(s)* Refills:*2*
15. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
Disp:*30 Cap(s)* Refills:*2*
16. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every
8 hours) as needed.
Disp:*qs ML(s)* Refills:*2*
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
Disp:*60 Capsule(s)* Refills:*2*
18. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2
times a day) for 7 days.
Disp:*1 largest stock tube* Refills:*0*
19. Morphine 15 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain for 14 days.
Disp:*100 Tablet(s)* Refills:*0*
20. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN. Inspect site every shift.
21. Outpatient Lab Work
Please check CBC with differential, chem 10, LFTs q week. Also
check Amikacin peak and trough qweek (30 minutes prior to giving
amikacin dose, draw level for trough, and 1 hour after infusing
amikacin, draw level for peak). Fax these results to Dr.
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at Infectious Disease clinic. Her fax number is:
[**Telephone/Fax (1) 1419**].
22. antibiotic instructions
You will have a minimum of 21 days on Amikacin IV and
Ceftazidime IV, you are on day 6 of therapy. You will need to
see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (see appointment) in follow up for
re-evaluation of how long you need to take your antibiotic.
Discharge Disposition:
Extended Care
Facility:
[**Hospital6 85**] - [**Location (un) 86**]
Discharge Diagnosis:
1. Nosocomial Meningitis status post laminectomy,
foraminectomy, possible dural tear
2. Pulseless Ventricular Tachycardia
3. history of seizure at outside hospital prior to transfer
4. Type II Diabetes Mellitus
5. Hypertension
6. Anxiety disorder
7. Major Depressive Disorder
8. history of spinal stenosis
Discharge Condition:
Good, stable
Discharge Instructions:
If you experience any worsening of your symptoms, including
headache, weakness in your legs, numbness, urinary or bowel
incontinence, decreased sensation in your extremities, neck
stiffness, chest pain, palpititations, please report to the
emergency dept. immediately.
Please take all of your medications as directed.
Please follow up with your physicians, information below.
Followup Instructions:
1. You have a follow up appointment with your Primary Care
Physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 18323**] on Friday, [**2106-4-16**], at 1:45pm.
His office number is: [**Telephone/Fax (1) 18325**].
2. You have a follow up appointment with Infectious Disease
with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Your appointment is set for [**2106-4-30**] at 10:00am at the [**Hospital Unit Name **], basement, suite J, [**Hospital1 1535**] [**Hospital Ward Name 517**]. Her office number
is: [**Telephone/Fax (1) 457**] if you have any questions.
3. You will need to follow up with Cardiology/Electrophysiology
for possible procedure on your heart for your abnormal rhythm.
Your appointment is for Wednesday, [**2106-5-12**] at 12:30pm, in
[**Hospital Ward Name 23**] 7, [**Hospital Ward Name 516**] [**Hospital1 18**], with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]. His
office number is: [**Telephone/Fax (1) 902**].
4. Repeat CT L-spine w/ contrast on Monday, [**4-12**] at 8:00
AM. Go to [**Hospital Ward Name 452**] 3. No solid foods 3 hours prior. Please call
[**Telephone/Fax (1) 18715**] if questions.
[**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]
Completed by:[**2106-4-9**]
|
[
"780.39",
"300.00",
"401.9",
"V10.11",
"112.3",
"320.82",
"599.0",
"426.82",
"998.59",
"250.00"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
16121, 16191
|
6978, 12785
|
400, 447
|
16549, 16564
|
4596, 6955
|
16988, 18385
|
3453, 3467
|
12927, 16098
|
16212, 16528
|
12811, 12904
|
16588, 16965
|
3482, 4577
|
272, 362
|
475, 3125
|
3147, 3330
|
3346, 3437
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
81,662
| 124,697
|
9606
|
Discharge summary
|
report
|
Admission Date: [**2109-9-21**] [**Month/Day/Year **] Date: [**2109-9-22**]
Date of Birth: [**2063-4-22**] Sex: F
Service: MEDICINE
Allergies:
Trazodone
Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
unresponsiveness
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
46F history of suicide attempts by overdose, recent MAO-I
toxicity [**6-/2109**], found unresponsive by her husband. She was in
her usual state of health in the preceeding days prior to
admission. Last night she awoke around 2AM and told her husband
that she could not sleep. Her husband was unsure whether she
took additional medications. She went back to sleep, and was
noted to be sleeping and breathing normally in the morning.
Around lunch time her husband went to wake her and she could not
be aroused. He then called EMS. She was intubated en route to
the ED. CXR showed left basilar atelectasis but no pneumonia,
effusion or pneumothorax. ET tube was pulled back 3cm. CT head
was negative for intracranial hemorrhage. Toxicology was
consulted, had not seen patient by time of transfer. She had 2
medications brought in by EMS including clonidine and
levothyroxine. Received 1L NS in the ED. Activated charcoal not
given because ingestion time was not known and suspected to be
>1H. ED noted clonus on exam. Vitals prior to transfer were 82
103/66 12 100% AC 480/12/5/50%. 2 PIV. She was sedated with
fentanyl and versed. Family is with her.
.
She was recently hospitalized and discharged in [**2109-6-14**] for
MAO-I toxicity (took her home medication Parnate). During that
hospitalization she was found to be hyperthermic, rigid and with
labile hemodynamics and developed rhabdomyolysis, ATN and liver
injury. She was seen by psychiatry who determined she was not
actively suicidal and she was discharged home with follow up
with her psychiatrist and social worker.
.
On arrival to the MICU, she followed commands, denied pain.
Fentanyl/versed drips were stopped, she was placed on SBT [**4-18**]
and ABG was 7.41/33/172. She was successfully extubated. She
was originally disoriented. Approximately 1 hour after
extubation we met with the patient and asked her about the
details of the prior night. She stated she did not remember
anything after waking up in the middle of the night and not
being able to sleep. She cannot remember if she took additional
sleep aids or other medications. She appears uncomfortable
answering our questions, at times stating her throat is too sore
to talk, but then talks at great length about her disdain for
[**Hospital1 18**]. She says she has a law suit against the psychiatry
department here regarding a medical error and refuses to be seen
by them. She requests to go home immediately. When we say she
needs to be observed as she has only been extubated for 1 hour,
she says she wants to be transferred to a different hospital.
We explained request transfer to another hospital cannot be
granted at 2AM. We expressed concern over her safety. She
requests to have her regular sleeping medications administered
now. Overall she demonstrates poor insight into the severity of
her unresponsiveness event requiring intubation.
.
Review of systems: Denied fever/chills, feeling unwell prior to
admission, no current SOB, CP, abdominal pain, N/V.
Past Medical History:
- Depression/Anxiety with multiple prior suicide attempts
(recent hospitalization at [**Hospital3 **] Psychiatry Unit in
[**7-/2108**])
- Chronic ETOH Dependence; h/o alcoholism years ago, per husband
- Prescription drug abuse (abuse of Ativan and Soma in the past)
- MAO-I toxicity [**2109-6-14**] during which time she developed ATN,
acute liver injury, and mildly depressed LVEF 55% (just had
repeat stress test at [**Hospital1 2177**] this week).
Social History:
- Tobacco: No current tobacco use.
- EtOH: Prior alcoholism history, husband reports she has not
had problems with alcohol abuse in years.
- Illicit Drugs: Per husband, denies known history of illicit
drug abuse. However has h/o prescription medication abuse,
including benzodiazepines and soma. Prior OB/GYN physician at
[**Hospital1 2177**], now moving to a different career, has not practiced for 1
year. Married with 2 kids, lives with husband at home.
Family History:
patient is adopted
Physical Exam:
General: No longer intubated, Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, NT/ND, NABS, no HSM
Ext: warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS:
[**2109-9-21**] 03:15PM BLOOD Neuts-27* Bands-0 Lymphs-64* Monos-3
Eos-4 Baso-0 Atyps-2* Metas-0 Myelos-0
[**2109-9-21**] 03:15PM BLOOD PT-11.0 PTT-20.1* INR(PT)-0.9
[**2109-9-21**] 03:15PM BLOOD Glucose-107* UreaN-14 Creat-1.0 Na-138
K-4.1 Cl-104 HCO3-25 AnGap-13
[**2109-9-21**] 03:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2109-9-21**] 10:35PM BLOOD Type-ART Temp-36.3 Rates-/24 FiO2-40
pO2-172* pCO2-33* pH-7.41 calTCO2-22 Base XS--2
Intubat-INTUBATED Vent-SPONTANEOU
[**2109-9-21**] 04:20PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.022
[**2109-9-21**] 04:20PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
[**2109-9-21**] 04:20PM URINE RBC-<1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
[**2109-9-21**] 04:20PM URINE Mucous-RARE
[**2109-9-21**] 04:20PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-POS mthdone-NEG
[**Month/Day/Year 894**] LABS:
[**2109-9-22**] 03:07PM BLOOD WBC-4.2 RBC-4.05* Hgb-11.0* Hct-33.9*
MCV-84 MCH-27.2 MCHC-32.5 RDW-12.0 Plt Ct-193
[**2109-9-22**] 04:57AM BLOOD Glucose-74 UreaN-10 Creat-0.8 Na-140
K-3.4 Cl-108 HCO3-24 AnGap-11
[**2109-9-22**] 04:57AM BLOOD Calcium-8.1* Phos-2.3*# Mg-1.8
MICROBIOLOGY:
Urine culture [**9-21**] pending
IMAGING:
CXR [**9-21**]:
1. Endotracheal tube in the proximal left main bronchus. The
findings were
discussed with Dr.[**Last Name (STitle) **] on [**2109-9-21**].
2. Low lung volumes with bibasal opacities, could represent
atelectasis or
aspiration.
CT Head [**9-21**]: No acute intracranial abnormality.
CXR [**9-21**]:
1. Endotracheal tube in good position.
2. No evidence for active cardiopulmonary disease.
Brief Hospital Course:
46 y/o w/ depression and prior suicide attempts and MAOI
overdose/toxicity, presents after being found unresponsive
concerning for medication overdose.
ACTIVE ISSUES:
#) Altered mental status: Pt was found unresponsive at home and
was intubated prior to transport. Upon transfer to the ICU, pt
was extubated shortly. Her vital signs and labs were normal.
The serum tox is positive for amphetamine and benzodiazepine
which were consistent with patient's medication list. Pt
reported that she took 27 tablets of soma for insomnia and
anxiety the night prior to admission. Mostly likely etiology of
her unresponsiveness was soma overdose. Pt's outpatient
psychiastrist Dr. [**Last Name (STitle) **] was contact[**Name (NI) **]. Pt was evalauted by the
inpatient psychiatrist, who felt that there is no evidence of
suicide intention, and involuntary psychiatric admission was not
warranted in this setting.
OUTPATIENT ISSUES:
- please AVOID soma in the future
- please consider sleep study
TRANSITIONAL ISSUES:
-patient should follow-up with outpatient psychiatrist Dr. [**Last Name (STitle) **]
on Tuesday [**2109-9-24**]
-patient may benefit from outpatient sleep study
Medications on Admission:
1. cymbalta 60mg daily
2. clonidine (not taking per husband), has helped in past with
anxiety
3. clonazepam 0.5mg 1-2 tabs TID PRN anxiety
4. dextramphetamine 10mg 2 caps daily
5. levothyroxine (to augment psychiatric medications)
6. zolpidem 12.5mg PO qHS
7. oral contraceptive
8. stool softener
[**Year (4 digits) **] Medications:
1. Cymbalta 60 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
2. dextramphetamine Sig: One (1) 10mg 2 caps once a day.
3. OCP
continue taking your OCP
4. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day
as needed for anxiety.
5. levothyroxine Oral
[**Year (4 digits) **] Disposition:
Home
[**Year (4 digits) **] Diagnosis:
Soma overdose
[**Year (4 digits) **] Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
[**Year (4 digits) **] Instructions:
You were admitted to [**Hospital1 69**] for
altered mental status from taking too much Soma. You will need
to STOP taking this medication until you meet with your
psychiatrist.
You briefly required a breathing tube for support, but this was
quickly removed as you were able to breathe on your own. You
were evaluated by our psychiatry team, who also spoke with your
outpatient psychiatrist, who felt it was safe for you to be
discharged home. It is very important that you follow-up with
Dr. [**Last Name (STitle) **] on Tuesday. You will also need to schedule a sleep
study for further evaluation of your sleeping difficulties.
Medication Changes:
STOP taking Soma or any other sleep medications
Continue all other medications as prescribed
Followup Instructions:
Please follow up with your psychiatrist on Tuesday, [**9-24**].
Department: WEST [**Hospital 2002**] CLINIC
When: TUESDAY [**2109-11-26**] at 4:00 PM
With: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. [**Telephone/Fax (1) 721**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
|
[
"300.4",
"E855.1",
"301.83",
"968.0",
"780.09",
"780.52"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
6446, 6599
|
306, 319
|
4696, 4696
|
9358, 9927
|
4334, 4355
|
7649, 8421
|
4370, 4677
|
7460, 7623
|
3269, 3367
|
9240, 9335
|
250, 268
|
6614, 6625
|
347, 3249
|
4712, 6423
|
8436, 9220
|
3389, 3843
|
3859, 4318
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,763
| 105,952
|
27935
|
Discharge summary
|
report
|
Admission Date: [**2192-3-8**] Discharge Date: [**2192-3-14**]
Date of Birth: [**2127-10-16**] Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
RECURRENT RIGHT RETROPERITONEAL SARCOMA/SDA
Major Surgical or Invasive Procedure:
s/p ex-lap, LOA extensive, R. RP exploration, partial sarcoma
resection
History of Present Illness:
The patient is a 66-year-old male with a
multiply recurrent low grade leiomyosarcoma of the right
retroperitoneum. He has undergone preoperative radiation. The
sarcoma involves a large mass in the mesentery and two
additional masses in the distal and posterior portions of the
inferior vena cava and anterior to the left renal vein and
vena cava. He presents at this time for abdominal exploration
and possible resection of this tumor per General Surgery and
Vascular Surgery.
Past Medical History:
Recurrent liposarcoma, OSA, HTN, HLD, DM, BPH, COPD, Memory
deficits status post head trauma from MVA, s/p TURP
Social History:
Mr. [**Known lastname 68044**] is retired. He smokes a pack a day and has done so
for almost all his life. He does not drink alcohol. He
previously used to work in a warehouse.
Family History:
There is a family history of colon cancer in his
mother. His father died in his 60s of a "massive heart attack."
Physical Exam:
At Discharge:
Vitals: 98.5, 81, 154/69, 20, 98% on RA
GEN: NAD, A/Ox3
CV: RRR, no m/r/g
RESP: CTAB, no w/r/r
ABD: large, soft, appropriately TTP, +BS, +FLATUS, +BM
Incision: Large midline abdominal incision OTA with staples,CDI
Extrem: no c/c/e
Pertinent Results:
[**2192-3-8**] 07:10PM BLOOD WBC-9.9 RBC-3.20* Hgb-9.5* Hct-26.9*
MCV-84 MCH-29.7 MCHC-35.3* RDW-15.5 Plt Ct-166
[**2192-3-10**] 02:35AM BLOOD WBC-14.1*# RBC-3.50* Hgb-10.1* Hct-29.5*
MCV-84 MCH-29.0 MCHC-34.3 RDW-16.0* Plt Ct-207
[**2192-3-10**] 02:12PM BLOOD WBC-14.9* RBC-3.52* Hgb-10.4* Hct-29.6*
MCV-84 MCH-29.5 MCHC-35.1* RDW-16.0* Plt Ct-226
[**2192-3-12**] 02:13AM BLOOD WBC-11.3* RBC-3.34* Hgb-9.7* Hct-28.4*
MCV-85 MCH-28.9 MCHC-34.1 RDW-15.8* Plt Ct-275
[**2192-3-13**] 04:32AM BLOOD WBC-8.0 RBC-3.22* Hgb-9.8* Hct-28.0*
MCV-87 MCH-30.4 MCHC-35.0 RDW-15.2 Plt Ct-260
[**2192-3-13**] 04:32AM BLOOD PT-13.1 PTT-27.5 INR(PT)-1.1
[**2192-3-8**] 04:14PM BLOOD PT-15.5* PTT-33.8 INR(PT)-1.4*
[**2192-3-13**] 04:32AM BLOOD Glucose-134* UreaN-41* Creat-1.7* Na-141
K-4.0 Cl-106 HCO3-25 AnGap-14
[**2192-3-12**] 02:13AM BLOOD Glucose-155* UreaN-34* Creat-1.6* Na-143
K-4.2 Cl-111* HCO3-25 AnGap-11
[**2192-3-8**] 07:10PM BLOOD Glucose-182* UreaN-32* Creat-1.9* Na-136
K-5.9* Cl-110* HCO3-20* AnGap-12
[**2192-3-12**] 02:13AM BLOOD ALT-34 AST-21 LD(LDH)-194 AlkPhos-65
TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2192-3-11**] 02:28AM BLOOD ALT-41* AST-29 LD(LDH)-186 AlkPhos-64
TotBili-0.6 DirBili-0.3 IndBili-0.3
[**2192-3-10**] 02:35AM BLOOD ALT-51* AST-40 LD(LDH)-187 AlkPhos-52
TotBili-0.5 DirBili-0.2 IndBili-0.3
[**2192-3-13**] 04:32AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
[**2192-3-12**] 02:13AM BLOOD Albumin-2.8* Calcium-8.8 Phos-3.2 Mg-2.4
[**2192-3-11**] 02:28AM BLOOD Albumin-2.6* Calcium-8.4 Phos-4.6* Mg-2.3
.
Brief Hospital Course:
Mr. [**Known lastname 68045**] operative course was prolonged and extensive. He
was trasferred from the PACU to TICU secondary to extensive
surgical measures, intubation, pressure support and low urine
output.
.
[**2192-3-9**]: [**Location (un) 109**] line switched to triple lumen CVL. Monitored urine
output and CVP, given fluid boluses as needed to maintain urine
output. Chest XRAYS revealed bilateral pleural effusions. Fluid
hydration tapered to minimize pulmonary edema. Vitals and
labwork stable.
.
[**3-10**]: weaned sedation and vent -> extubated and doing well; on
BiPAP overnight; decreased IVF with maintained adequate UOP/BP;
added back several inhalers
[**3-11**]: negative fluid balance, hypertension cooperative with no
pressor support. Home medications resumed as indicated.
Continued to stabilize.
.
Patient was transferred to [**Hospital Ward Name 1950**] 5 POD 5 from TICU. He had a
foley and IVF for hydration. On POD 6 patient's Foley and
central venous line were removed. Patient had no difficulty
voiding. Upon return of bowel function his diet was increased
from sips to regular which he tolerated well. Continued to pass
flatus and had a bowel movement a few days post-op. Tolerating
oral medication for pain. Continues with home medication
regimen.
Patient ambulates indpendently, has a large support system and
did not need a physical therapy during this admission.
Discharge paperwork reviewed with patient and advised to call
Dr.[**Name (NI) 12822**] office to make a follow up appointment for removal
of incisional staples.
Medications on Admission:
Atenolol 25', Citalopram 20', Diltiazem 120', Doxazosin 4',
Lantus 25', Metformin 1000', Benicar 20', Actos 30', Simvastatin
40', ASA 81', Omeprazole 20', Ped MVI 0.4 mg-300 mcg-250 mcg
Tablet
Discharge Medications:
1. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. Metformin 500 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. Erythromycin 5 mg/g Ointment Sig: 0.5 mg/g Ophthalmic QID (4
times a day) as needed for both eyes.
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain for 2 weeks: Please do
not exceed more than 4000mg of acetaminophen in 24 hrs. .
Disp:*35 Tablet(s)* Refills:*0*
11. Benicar 20 mg Tablet Sig: One (1) Tablet PO once a day.
12. Actos 30 mg Tablet Sig: One (1) Tablet PO once a day.
13. Lantus 100 unit/mL Solution Sig: Twenty Five (25) Units
Subcutaneous at bedtime.
14. Multivitamin Tablet Sig: One (1) Tablet PO once a day.
15. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation for 2 weeks: Take only if pain
medication constipates you.
Disp:*14 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Right retroperitoneal liposarcoma
Hypotension
Low urine output post op
Anemia related to acute blood loss
.
Secondary:
Recurrent liposarcoma, OSA, HTN, HLD, DM, BPH, COPD, memory
deficits status post head trauma from MVA, s/p TURP
Discharge Condition:
Stable.
Tolerating a regular diet.
Pain well controlled with oral pain medications.
Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.
*Avoid driving or operating heavy machinery while taking pain
medications.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.
.
Incision Care:
-Your staples will be removed at your follow up appointment with
Dr. [**Last Name (STitle) 1924**] in [**2-10**] weeks.
-Steri-strips will be applied and they will fall off on their
own. Please remove any remaining strips 7-10 days after
application.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Followup Instructions:
1. Please call Dr.[**Name (NI) 12822**] office [**Telephone/Fax (1) 7508**] to make a follow
up appointment in [**2-10**] weeks.
2. Please call your PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) 68046**] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 41556**] to make a
follow up appointment in 1 week or as needed.
Completed by:[**2192-3-14**]
|
[
"V85.36",
"E870.0",
"496",
"E878.8",
"285.1",
"158.0",
"V15.3",
"272.4",
"568.0",
"997.5",
"V45.73",
"250.00",
"459.2",
"327.23",
"458.29",
"401.9",
"788.5",
"998.2",
"305.1"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.71",
"46.73",
"54.4",
"39.32",
"93.90",
"54.59",
"38.93"
] |
icd9pcs
|
[
[
[]
]
] |
6405, 6411
|
3182, 4740
|
315, 389
|
6695, 6781
|
1640, 3159
|
8350, 8702
|
1244, 1360
|
4984, 6382
|
6432, 6674
|
4767, 4961
|
6805, 7842
|
7857, 8327
|
1375, 1375
|
1389, 1621
|
232, 277
|
417, 896
|
918, 1031
|
1047, 1228
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
57,366
| 123,536
|
33455
|
Discharge summary
|
report
|
Admission Date: [**2195-6-20**] Discharge Date: [**2195-6-25**]
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 3531**]
Chief Complaint:
Increasing Abdominal Pain, Decreased PO Intake
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
This is a [**Age over 90 **] year old male with PMH of Alzheimer's disease,
bilateral inguinal hernias, BPH, constipation, bilateral heel
ulcers, s/p 3 documented falls since [**2195-2-13**] presenting
with increasing abdominal pain and decreased PO intake over the
past week. The patient started developing abdominal pain 6 days
ago. The pain has become increasingly severe and is diffuse in
nature. He stopped taking solid foods PO 5 days prior to
presentation and stopped taking fluids 3 days prior to
presentation. Prior to this past week he was described as having
a robust appetite. He saw his PCP yesterday and was started on
enemas and magnesium citrate PO as well as cipro/flagyl to
empirically cover for a GI source of infection. According to the
patient's family he has been having bowel movements as they
report that the nursing home has been changing his
undergarments.
.
The patient has been in severe pain from his bilateral heel
ulcers and is on an aggressive opiate pain regimen with a
minimal bowel regimen. He is seen by a wound specialist and gets
debrided once weekly with dressing changes of his wounds twice
daily. He has fallen three times in [**2195**] and has a residual
hematoma on his left forehead from one of his falls.
.
In the ED, initial vs were: T=98.4, P=97, BP=130/70, R=18 O2
sat=94% RA. He was noted to have a rigid abdomen and
non-reducible >6 cm, hard bilateral inguinal hernias with
concern for strangulation in the right scrotum. He also had a
leukocytosis to 26.4 and a Cr=1.9. CXR and KUB showed no
evidence of free air under diaphragm. Non contract CT of abdomen
and pelvis preliminariy showed fecal loading, large inguinal
hernias without evidence of obstruction or strangulation or
volvulus. Surgery was consulted and recommended no surgical
intervention. A Foley was placed and drained 1.5L of urine.
Blood cultures were drawn. Patient was given ciprofloxacin and
flagyl, 2L of NS boluses, and morphine 4mg IV.
.
On the floor, the patient was somnolent, but briefly arousable.
He would not answer questions appropriately but was noted to be
in severe pain secondary to his heels and his abdomen.
.
Review of sytems:
Unable to obtain as patient is too somnolent
Past Medical History:
-Bradycardia - never worked up; asymptomatic per son. Noted on
physical exam
-BPH
-constipation
-post-herpetic neuralgia
-he denies CAD, DM, cancer
Social History:
Lives at [**Location 19168**] on the [**Doctor Last Name **]. Denies history of tobacco
use. Occassional alcohol use.
Family History:
Non-contributory
Physical Exam:
Admission Exam:
Vitals: T: 98 BP: 139/46 P: 110s-130s R: 18 O2: 94% RA
General: Elderly male, somnolent, but will respond to his name
HEENT: Sclera anicteric, dry MM, oropharynx clear, hematoma
noted on the left side of his forehead
Neck: supple, JVP flat
Lungs: Clear to auscultation anteriorly
CV: Irregularly irregular, tachycardic
Abdomen: firm, diffusely tender, distended, hypoactive bowel
sounds, no rebound tenderness or guarding
GU: Foley in place
Ext: warm, well perfused; Dopplerable pulses; no clubbing,
cyanosis or edema; bilateral necrotic heel ulcers noted
Pertinent Results:
STUDIES:
CXR ([**2195-6-20**]) - IMPRESSION:
1. No evidence of free intra-abdominal air.
2. Small right pleural effusion.
.
KUB ([**2195-6-20**]) - IMPRESSION:
1. Massive amount of stool within mildly dilated large bowel.
2. herniated loops of bowel at the right inguinal region.
3. Dilated loops of small bowel seen on the lateral decubitus
views, could be due to a focal ileus or early obstruction.
4. No evidence of free air.
.
CT A/P ([**2195-6-20**]) - IMPRESSION:
1. Massive bowel-containing inguinal hernias without definite
evidence for
obstruction or ischemia although the right hernia in particular
is probably at risk for torsion potentially in the future.
2. Marked fecal impaction in the rectal vault.
3. Porceline gallbladder with cholelithiasis, generally
considered to
represent a substantial risk of developing gallbladder cancer.
4. Small right pleural effusion with asymmetric right pulmonary
interlobular septal thickening which could represent asymmetric
edema or an inflammatory process in the right lung, although if
patient has history of primary malignancy, differential
consideration includes lymphangiocarcinomatosis. If acute
pulmonary symptoms are clinically present, a PA/Lateral chest
radiograph is recommended. A chest CT should also be considered
for further evaluation when clinically appropriate.
5. Mild bilateral hydronephrosis with hydroureter on the left
without
definite source. One possibility is that the degree of fecal
impaction is so great as to induce extrinsic compression. Renal
ultrasound following fecal disimpaction may be potentially
helpful to see if the renal findings improve.
6. Diffuse severe atherosclerotic disease.
.
.
[**2195-6-22**] TTE:
Conclusions
The left atrium is moderately dilated. There is mild
(non-obstructive) focal hypertrophy of the basal septum. 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 aortic root is
mildly dilated at the sinus level. The aortic valve leaflets are
mildly thickened (?#). There is no valvular aortic stenosis. The
increased transaortic velocity is likely related to high cardiac
output. Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are moderately thickened. There is mild functional
mitral stenosis (mean gradient 3 mmHg) due to mitral annular
calcification. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] There is moderate pulmonary
artery systolic hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of [**2195-2-17**], the
rhythm still appears to be atrial fibrillation. Left ventricular
function is less dynamic (but still normal). Estimated pulmonary
artery pressures are higher. There is no longer a gradient
across the outflow tract.
.
.
[**2195-6-21**] FOOT XRAY:
IMPRESSION:
1. Soft tissue swelling involving both right and left feet.
.
2. Right calcaneus -- relative [**Name (NI) **] in posterior calcaneus --
ddx include reactive osteopenia, vs usbtle osteomyelitis. No
cortical interruption of discrete lytic lesion detected.
.
3. Left calcaneus -- No obvious calcaneal bone destruction is
detected to
confirm the presence of osteomyelitis, but the ulcer does lie in
close
proximity of the bone.
.
4. Right 5th proximal phalanx -- focal ostepenia, ? lytic
lesion. In the
absence of overlying soft tissue infection, this would most
likely represent an enchondroma. Clinical correlation requested.
.
.
LABS:
[**2195-6-20**] 12:30PM BLOOD WBC-26.4*# RBC-4.33* Hgb-11.6* Hct-35.9*
MCV-83 MCH-26.8* MCHC-32.3 RDW-15.4 Plt Ct-236
[**2195-6-20**] 07:05PM BLOOD WBC-18.4* RBC-3.57* Hgb-9.6* Hct-30.2*
MCV-85 MCH-26.8* MCHC-31.7 RDW-15.1 Plt Ct-207
[**2195-6-21**] 04:48AM BLOOD WBC-15.3* RBC-3.65* Hgb-10.0* Hct-31.1*
MCV-85 MCH-27.4 MCHC-32.2 RDW-14.9 Plt Ct-202
[**2195-6-22**] 06:15AM BLOOD WBC-11.8* RBC-3.62* Hgb-9.8* Hct-30.8*
MCV-85 MCH-27.1 MCHC-31.9 RDW-14.5 Plt Ct-188
[**2195-6-23**] 07:16AM BLOOD WBC-10.6 RBC-3.71* Hgb-10.2* Hct-31.7*
MCV-86 MCH-27.6 MCHC-32.2 RDW-14.8 Plt Ct-197
[**2195-6-24**] 03:15PM BLOOD WBC-12.0* RBC-4.16* Hgb-10.7* Hct-34.6*
MCV-83 MCH-25.8* MCHC-31.0 RDW-14.2 Plt Ct-246
[**2195-6-25**] 07:25AM BLOOD WBC-11.0 RBC-4.30* Hgb-11.1* Hct-35.5*
MCV-83 MCH-25.7* MCHC-31.2 RDW-14.5 Plt Ct-236
[**2195-6-20**] 12:30PM BLOOD Neuts-92* Bands-0 Lymphs-2* Monos-6 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2195-6-20**] 07:05PM BLOOD Neuts-92.3* Lymphs-2.9* Monos-4.4 Eos-0.4
Baso-0
[**2195-6-20**] 12:30PM BLOOD PT-13.2 PTT-24.8 INR(PT)-1.1
[**2195-6-21**] 04:48AM BLOOD PT-13.8* PTT-26.6 INR(PT)-1.2*
[**2195-6-22**] 06:15AM BLOOD PT-15.2* PTT-29.4 INR(PT)-1.3*
[**2195-6-23**] 07:16AM BLOOD ESR-17*
[**2195-6-20**] 12:30PM BLOOD Glucose-233* UreaN-50* Creat-1.9*# Na-144
K-3.9 Cl-103 HCO3-31 AnGap-14
[**2195-6-21**] 04:48AM BLOOD Glucose-197* UreaN-37* Creat-0.9 Na-149*
K-3.6 Cl-111* HCO3-33* AnGap-9
[**2195-6-22**] 06:15AM BLOOD Glucose-183* UreaN-24* Creat-0.6 Na-147*
K-3.1* Cl-109* HCO3-32 AnGap-9
[**2195-6-23**] 07:16AM BLOOD Glucose-130* UreaN-14 Creat-0.5 Na-140
K-3.5 Cl-105 HCO3-29 AnGap-10
[**2195-6-24**] 03:15PM BLOOD Glucose-135* UreaN-10 Creat-0.5 Na-136
K-3.2* Cl-101 HCO3-24 AnGap-14
[**2195-6-25**] 07:25AM BLOOD Glucose-128* UreaN-8 Creat-0.5 Na-137
K-3.0* Cl-100 HCO3-28 AnGap-12
[**2195-6-21**] 04:48AM BLOOD CK(CPK)-23*
[**2195-6-25**] 07:25AM BLOOD ALT-19 AST-28 AlkPhos-100 TotBili-0.4
[**2195-6-20**] 12:30PM BLOOD ALT-18 AST-15 AlkPhos-129 TotBili-0.5
[**2195-6-20**] 12:30PM BLOOD Lipase-8
[**2195-6-20**] 07:05PM BLOOD CK-MB-2 cTropnT-0.03*
[**2195-6-21**] 04:48AM BLOOD CK-MB-3 cTropnT-0.03*
[**2195-6-20**] 07:05PM BLOOD Calcium-7.8* Phos-3.5 Mg-2.5
[**2195-6-22**] 06:00PM BLOOD Mg-1.9
[**2195-6-24**] 03:15PM BLOOD Calcium-8.0* Phos-2.6* Mg-1.8
[**2195-6-25**] 07:25AM BLOOD Calcium-8.3* Phos-2.6* Mg-1.9
[**2195-6-21**] 04:48AM BLOOD %HbA1c-6.8* eAG-148*
[**2195-6-23**] 07:16AM BLOOD CRP-85.9*
[**2195-6-21**] 04:48AM BLOOD TSH-1.2
[**2195-6-20**] 07:05PM BLOOD Osmolal-309
[**2195-6-20**] 12:40PM BLOOD Lactate-1.9
[**2195-6-20**] 12:55PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.022
[**2195-6-21**] 04:48AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.018
[**2195-6-24**] 04:43PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016
[**2195-6-20**] 12:55PM URINE Blood-NEG Nitrite-NEG Protein-25
Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-SM
[**2195-6-21**] 04:48AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG
[**2195-6-24**] 04:43PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
[**2195-6-20**] 12:55PM URINE RBC-0-2 WBC-[**7-23**]* Bacteri-MANY Yeast-NONE
Epi-0
[**2195-6-21**] 04:48AM URINE RBC-158* WBC-65* Bacteri-NONE Yeast-NONE
Epi-0
[**2195-6-24**] 04:43PM URINE RBC-29* WBC-5 Bacteri-FEW Yeast-NONE
Epi-<1
[**2195-6-21**] 04:48AM URINE CastHy-8*
[**2195-6-20**] 12:55PM URINE Mucous-MANY
[**2195-6-21**] 04:48AM URINE Mucous-MOD
[**2195-6-24**] 04:43PM URINE Mucous-FEW
[**2195-6-20**] 12:55PM URINE CaOxalX-MOD
.
.
MICROBIOLOGY:
[**2195-6-20**] 12:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
.
.
[**2195-6-21**] 4:48 am STOOL CONSISTENCY: SOFT
**FINAL REPORT [**2195-6-22**]**
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2195-6-22**]):
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
.
.
[**2195-6-21**] 4:48 am URINE Site: CATHETER
**FINAL REPORT [**2195-6-22**]**
URINE CULTURE (Final [**2195-6-22**]): NO GROWTH.
.
.
[**2195-6-21**] 4:48 am SWAB Site: RECTAL
**FINAL REPORT [**2195-6-24**]**
R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2195-6-24**]):
ENTEROCOCCUS SP.. Sensitivity testing performed by
Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
.
.
Brief Hospital Course:
[**Age over 90 **]M h/o alzheimer's dementia and BPH admitted with 1 week of
increasing abdominal pain and found to have severe diffuse fecal
loading with massive inguinal hernias containing loops of colon
as well as acute kidney injury.
.
# abdominal pain / constipation / impaction - pt's abdominal
pain was felt to likely be secondary to constipation, given his
imaging with severe diffuse fecal loading and massive inguinal
hernias containing loops of colon. On arrival to the ICU, the
patient was noted to aspirate oral medications and was therefore
made NPO. He was treated with aggressive bowel regimen,
including senna, colace, bisacodyl, lactulose enemas. He also
underwent manual disimpaction, which revealed hard trace guaiaic
positive stools.
.
Given loops of bowel in scrotum, and concern for incarceration,
surgical service was consulted, who recommended conservative
management. After disimpaction his bowel began moving, and he
was called out to the medical floor.
.
Upon arrival to the medical floor, he was continued on
aggressive bowel regimen including daily tap water and/or
mineral oil enemas, disimpaction x1. He continued to have daily
bowel movements, his abdomen became soft, and the loops of bowel
in the scrotum became notable soft. Surgical service signed
off, and pt was discharged back to rehab with instructions to
continue aggressive daily bowel regimen with goal of 2 soft BMs
per day. Given ongoing bowel movements, his diet was advanced
back to regular diet without difficulty.
.
.
# acute kidney injury / urinary retention - Patient was noted to
have a creatinine of 1.9 from a baseline of 0.5. The etiology
was felt to be both prerenal and postrenal. Upon arrival to the
ED, a Foley was placed and drained 1.5 Liters of urine. It was
felt that the patient's diffuse fecal loading was causing an
element of obstruction and that his decreased PO intake was
leading to a component of prerenal azotemia. His creatinine
resolved with IVF.
.
His urinary retention was felt possible [**3-17**] narcotic use and
constipation. Voiding trial was attempted x2 and was
unsucessful, despite restarting his doxazosin. He was
discharged to Rehab with foley catheter in place. Repeat
voiding trial should be attempted within 7d of discharge, should
he fail again, he should follow-up with urology clinic.
.
.
# leukocytosis - etiology was initially felt possibly [**3-17**] UTI
versus heel ulcers. After discussion with podiatry, heel
infection was felt less likely, and vancomycin was discontinued.
His leukocytosis resolved with treatment of UTI and
constipation.
.
.
# bilateral heel ulcers - The patient had necrotic areas
overlying both heels which were draining fibrinous material
initially concerning for infection. He had a documented history
of MRSA at his nursing facility from a heel swab on [**5-31**] and was
reporedly undergoing weekly debridements there. IV vancomycin
was started empirically on admission, and podiatry service was
consulted, who felt there was no evidence of infection. Foot
XRAY was obtained which raised concern for possible
osteomyeletis, however, after discussion with podiatry, this was
felt unlikely. ESR was 17, and CRP was 85, however felt there
was contribution from UTI and constipation.
.
Podiatry made wound care recommendations as below, including
treatment with enzymatic debridement:
-offloading with multipodus boots bilaterally
-daily wet to dry dressing changes
-santyl enzymatic dressing changes on the right heel.
.
.
Pt instructed to follow-up with podiatry within [**2-14**] month of
discharge.
.
.
# altered mental status - the patient has Alzheimer's disease at
baseline and the family had noted a marked decrease in his
functional status since [**2195-2-13**] when he was hospitalized
for a fall. His initial delerium was felt multifactorial with
contribution from narcotic administration,
anticholinergics/benzo's at his nursing home, constipation,
urinary tract infection. With treatment of his constipation,
and UTI, his mental status slowly improved, though he remained
A&Ox2, his son's corroborated that he was approaching his
baseline.
.
.
# atrial fibrillation - pt has no previous record of atrial
fibrillation. TSH was 1.2. He was treated with iv metoprolol
prn in ICU, however did not require additional rate control
medications upon arrival to the floor. He was intermittently
back in NSR. His CHADs score is [**2-14**] (not clearly diabetic),
therefore he should be covered with aspirin daily. This was
started at the time of his discharge. Should he have elevated
heart rates, he can be started on low dose metoprolol, which can
be uptitrated as needed. TTE was performed which showed
preserved EF.
.
.
# BPH - Home doxazosin was held on admission given hypotension,
and resumed prior to discharge.
.
.
# hypokalemia - pt with K=3.0 prior to discharge, this was
repleted without difficulty. he should have repeat potassium
checked on 1d after discharge, and repleted as needed, for goal
K>3.7 given atrial fibrillation above.
.
.
# hyperglycemia - no h/o diabetes, mildly elevated FSBS in ICU,
A1c 6.8. not requiring insulin on floor. he was discharged to
rehab without starting insulin, and instructed to follow-up with
his PCP.
.
.
# CODE - DNR/DNI.
.
.
# COMM - Patient; [**Name (NI) 32851**] [**Name (NI) **] (son/HCP/retired ENT physician)
[**Telephone/Fax (1) 77596**] (home) + [**Telephone/Fax (1) 77597**] (cell); [**Name (NI) 122**] [**Name (NI) 77598**]
(son) [**Telephone/Fax (1) 77599**]; Newbridge on the [**Doctor Last Name **] nursing facility
[**Telephone/Fax (1) 77600**]
Medications on Admission:
(Per Nursing Home Records)
- Ciprofloxacin 500mg PO BID (started [**6-19**])
- Flagyl 500mg PO TID (started [**6-19**])
- Oxycodone IR 2.5mg-10mg PO q4 PRN pain
- Oxycodone IR 2.5mg daily at 7AM
- Morphine 4mg PO hourly PRN
- Lorazepam 0.5mg PO q4 PRN
- Artificial tears 1gtt OU [**Hospital1 **]
- Milk of Magnesia 30cc PO daily PRN
- Bisacodyl 10mg PR PRN
- Doxazosin 2mg PO HS
- Simethicone 40mg TID PRN
- EMLA cream PRN to heels prior to debridement
- Hyoscyamine sulfate 0.25mg q6 PRN
- Prochlorperazine 25mg PR q12 PRN
- Senna 17.2mg PO HS
- Lactulose 10gm daily
Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain: please try tylenol first, use
oxycodone only if pain is severe.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**2-14**]
Drops Ophthalmic [**Hospital1 **] (2 times a day).
4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO
BID (2 times a day) as needed for constipation: titrate to 2
soft bowel movements daily.
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for constipation: titrate to 2
soft bowel movements daily.
9. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4
times a day): titrate to 2 soft bowel movements daily.
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): titrate to 2 soft bowel movements daily.
11. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
12. Collagenase Clostridium hist. 250 unit/g Ointment Sig: One
(1) Appl Topical DAILY (Daily): apply to right heel.
13. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Extended Care
Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]
Discharge Diagnosis:
severe constipation/impaction
inguinal hernia
urinary tract infection, bacterial
delerium
bilateral heel ulcers
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
you were admitted to the hospital with severe constipation,
confusion, and urinary tract infection. you were seen by the
surgical service given your inguinal hernias, who felt that no
surgical intervention was required.
.
you were treated with aggressive bowel regimen, enemas, and
disimpaction, and your constipation resolved.
.
you were treated with an antibiotic for your UTI.
.
your mental status was felt to be back to baseline per your
sons.
.
your heel ulcers were evaluated by the podiatry service, and not
felt to be infected. wound care recommendations were made.
.
the following changes were made to your medication regimen:
1. you were started on an aggressive bowel regimen including
daily senna, colace, bisacodyl, lactulose, miralax, and tap
water/mineral oil enemas daily as needed to facilitate 2 soft
bowel movements per day.
2. you were started/continued on ciprofloxacin to complete a 5
day course for your UTI.
Followup Instructions:
upon arriving home, please contact your primary care physician,
[**Name10 (NameIs) **] arrange to be seen within 1-2 weeks of your discharge for
routine follow-up.
.
upon arriving home, please contact your podiatrist, and arrange
to have routine follow-up of your heel ulcers as needed.
|
[
"707.25",
"599.0",
"564.09",
"788.20",
"427.31",
"276.8",
"331.0",
"600.00",
"584.9",
"550.12",
"294.10",
"707.07"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
19531, 19625
|
11824, 17437
|
266, 274
|
19781, 19781
|
3461, 10823
|
20924, 21214
|
2835, 2853
|
18056, 19508
|
19646, 19760
|
17463, 18033
|
19966, 20901
|
2868, 3442
|
10857, 11801
|
180, 228
|
2466, 2512
|
302, 2448
|
19796, 19942
|
2534, 2684
|
2700, 2819
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
23,949
| 164,146
|
48767+59114
|
Discharge summary
|
report+addendum
|
Admission Date: [**2149-7-3**] Discharge Date: [**2149-7-12**]
Date of Birth: [**2077-5-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 1711**]
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
72 yo AA male, pt of Dr. [**First Name (STitle) 437**], hx of CHF, COPD, [**First Name (STitle) **] s/p
stenting, DM, HTN, HLD, came to hospital for an elective
angiogram for nonhealing wound over lateral right foot. Patient
got worsening SOB in the PACU. When patient was laid on his
back, got 200-300 bicarbonate, he developed tachypnea, and
desatted to ~85% on 4L O2. He was put on nebulizer, received 40
mg iv lasix, and 40 mEq of K for K 3.8. Of note, patient did
not receive his morning dose of lasix prior to the procedure.
.
Patient was notably wheelchair bound, on 2L O2 at home. He
endorse exertional chest pain, described as sharp, midstern,
with no radiation, reaching [**2148-6-13**], with relief from rest or
nitroglycerin in the past a few months. He had a 8 lbs weight
gain since [**Month (only) **] by record. ROS is also notable for PND,
orthopnea, but no palpitation, syncope or presyncope.
.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Past Medical History:
-Coronary Artery Disease [[**Month (only) **] to RCA ([**11/2143**]), BMS to pLAD
([**2134**])]
-Diastolic and systolic heart failure with LVEF of 45-50%.
-Hypertension
-Pulmonary hypertension
-COPD
-OSA, on CPAP
-s/p hip fracture, with back pain, uses motorized scooter
-Diabetes (followed at [**Last Name (un) **])
-Mitral Regurgitation
-Hip fracture and chronic pain: has narcotic contract
-Ongoing cocaine abuse
-PUD, treated for H. pylori
-Glaucoma
-GERD, H. Pylori +, s/p four drug tx.
Social History:
He lives alone in senior housing. The patient is a retired
cook, previously in the Navy. He has nine children who help him
out with finances and groceries, errands, etc. His daughter is
involved in his care. Nephew visits him frequently.
Tob: 80-pack-year smoking history, still smoking few
cigaretts/day
EtOH: occasional (last had some J+B last night)
Illicits: cocaine abuse (last in [**5-/2148**]), h/o IV cocaine use in
the past.
Family History:
Father [**Year (4 digits) **] - MI in his 50s
Mother died last [**2147-10-8**] at [**Age over 90 **] years old
Physical Exam:
ADMISSION EXAM
VS: T=97.8, BP=137/51, HR=54, RR=16, O2 sat=98% on 10L
GENERAL: NAD. somnolent
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NT, distended. No HSM or tenderness. Abd aorta
not enlarged by palpation. No abdominial bruits.
EXTREMITIES: 4+ pitting edema bilaterally. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Right/Left LE: dopplerable bilaterally
DISCHARGE EXAM
GENERAL: alert, oriented.
HEENT: PERRLA, no pharyngeal erythemia, mucous membs dry, no
lymphadenopathy, JVP at 10cm
CHEST: decreased at bases, no rhonchi or wheezes, better air
movement
CV: S1 S2 Normal in quality and intensity with S3 present. RRR
no murmurs rubs or gallops
ABD: obese, non-tender, BS normoactive. no rebound/guarding.
EXT: wwp, 2+ edema to knees. Feet warm.
NEURO: CNs II-XII intact. 5/5 strength in U/L extremities.
SKIN: no rash
PSYCH: much more alert. Oriented.
Pertinent Results:
ADMISSION LABS
[**2149-7-3**] 10:30AM BLOOD WBC-3.9* RBC-3.77* Hgb-8.4*# Hct-28.7*#
MCV-76*# MCH-22.4*# MCHC-29.4*# RDW-20.1* Plt Ct-274
[**2149-7-3**] 10:30AM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.2*
[**2149-7-3**] 10:30AM BLOOD Glucose-277* UreaN-23* Creat-1.4* Na-140
K-3.8 Cl-101 HCO3-32 AnGap-11
[**2149-7-3**] 06:45PM BLOOD ALT-17 AST-20 LD(LDH)-242 CK(CPK)-77
AlkPhos-129 TotBili-0.4
[**2149-7-3**] 10:30AM BLOOD proBNP-2961*
[**2149-7-3**] 10:30AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.2 Mg-2.2
Iron-30*
.
PERTINENT LABS
[**2149-7-3**] 10:30AM BLOOD Fibrino-411*
[**2149-7-3**] 10:30AM BLOOD proBNP-2961*
[**2149-7-3**] 10:30AM BLOOD calTIBC-476* VitB12-296 Folate-12.1
Ferritn-37 TRF-366*
[**2149-7-3**] 10:30AM BLOOD %HbA1c-8.5* eAG-197*
[**2149-7-3**] 02:38PM BLOOD Type-ART Rates-/27 O2 Flow-4 pO2-85
pCO2-64* pH-7.34* calTCO2-36* Base XS-5 Intubat-NOT INTUBA
[**2149-7-4**] 08:24PM BLOOD Type-ART pO2-62* pCO2-56* pH-7.41
calTCO2-37* Base XS-8 Intubat-NOT INTUBA
.
LABS:
[**2149-7-3**] 06:45PM BLOOD WBC-3.9* RBC-3.54* Hgb-7.9* Hct-27.3*
MCV-77* MCH-22.3* MCHC-29.0* RDW-19.8* Plt Ct-270
[**2149-7-6**] 04:40AM BLOOD WBC-4.4 RBC-3.43* Hgb-7.7* Hct-26.3*
MCV-77* MCH-22.3* MCHC-29.2* RDW-20.1* Plt Ct-236
[**2149-7-10**] 06:30AM BLOOD WBC-3.9* RBC-3.76* Hgb-8.4* Hct-29.4*
MCV-78* MCH-22.3* MCHC-28.6* RDW-20.7* Plt Ct-217
[**2149-7-12**] 05:45AM BLOOD WBC-3.6* RBC-3.88* Hgb-8.9* Hct-30.0*
MCV-77* MCH-23.1* MCHC-29.8* RDW-21.7* Plt Ct-226
[**2149-7-3**] 10:30AM BLOOD PT-14.3* PTT-26.3 INR(PT)-1.2*
[**2149-7-12**] 05:45AM BLOOD Plt Ct-226
[**2149-7-3**] 10:30AM BLOOD Fibrino-411*
[**2149-7-3**] 10:30AM BLOOD Ret Aut-2.0
[**2149-7-3**] 10:30AM BLOOD Glucose-277* UreaN-23* Creat-1.4* Na-140
K-3.8 Cl-101 HCO3-32 AnGap-11
[**2149-7-4**] 02:55PM BLOOD Glucose-230* UreaN-26* Creat-1.5* Na-140
K-3.9 Cl-101 HCO3-32 AnGap-11
[**2149-7-6**] 04:40AM BLOOD Glucose-284* UreaN-31* Creat-1.5* Na-140
K-3.5 Cl-100 HCO3-34* AnGap-10
[**2149-7-9**] 06:00PM BLOOD Glucose-196* UreaN-30* Creat-1.8* Na-139
K-3.7 Cl-96 HCO3-36* AnGap-11
[**2149-7-11**] 04:51AM BLOOD Glucose-154* UreaN-25* Creat-1.5* Na-139
K-3.7 Cl-100 HCO3-31 AnGap-12
[**2149-7-12**] 05:45AM BLOOD Glucose-168* UreaN-24* Creat-1.5* Na-139
K-3.4 Cl-99 HCO3-34* AnGap-9
[**2149-7-3**] 10:30AM BLOOD proBNP-2961*
[**2149-7-3**] 10:30AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.2 Mg-2.2
Iron-30*
[**2149-7-4**] 02:55PM BLOOD Calcium-8.6 Phos-3.2 Mg-2.1
[**2149-7-6**] 02:38PM BLOOD Mg-2.1
[**2149-7-10**] 06:30AM BLOOD Mg-2.4
[**2149-7-12**] 05:45AM BLOOD Mg-2.0
[**2149-7-3**] 10:30AM BLOOD calTIBC-476* VitB12-296 Folate-12.1
Ferritn-37 TRF-366*
[**2149-7-3**] 06:45PM BLOOD Hapto-199
[**2149-7-3**] 10:30AM BLOOD %HbA1c-8.5* eAG-197*
[**2149-7-3**] 02:38PM BLOOD Type-ART Rates-/27 O2 Flow-4 pO2-85
pCO2-64* pH-7.34* calTCO2-36* Base XS-5 Intubat-NOT INTUBA
[**2149-7-4**] 08:24PM BLOOD Type-ART pO2-62* pCO2-56* pH-7.41
calTCO2-37* Base XS-8 Intubat-NOT INTUBA
[**2149-7-7**] 12:53PM BLOOD Type-ART Temp-36.7 pO2-87 pCO2-70*
pH-7.38 calTCO2-43* Base XS-12 Intubat-NOT INTUBA
[**2149-7-10**] 02:21AM BLOOD Type-[**Last Name (un) **] pO2-33* pCO2-69* pH-7.36
calTCO2-41* Base XS-9
PERTINENT STUDIES
# TTE ([**2149-7-4**]):
The left atrium is mildly dilated. The right atrium is
moderately dilated. There is mild symmetric left ventricular
hypertrophy. LV systolic function appears mildly-to-moderately
depressed (ejection fraction 40 percent) secondary to
hypokinesis/akinesis of the inferior and posterior walls. The
basal inferior and posterior walls are thin and fibrotic. The
inferior septum is also hypokinetic. Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is dilated with
depressed free wall contractility. 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. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
There is borderline pulmonary artery systolic hypertension.
There is no pericardial effusion.
.
# CXR ([**2149-7-3**]):
Cardiac silhouette remains enlarged, and is accompanied by
pulmonary vascular congestion and new perihilar haziness and
peribronchial cuffing suggestive of edema. An asymmetrical area
of confluent opacity in the
right lower lobe is also new, with an adjacent pleural effusion.
It is
uncertain whether this represents a focus of asymmetrical edema
or a
superimposed process such as aspiration or developing infectious
pneumonia.
.
Brief Hospital Course:
PRIMARY REASON FOR ADMISSION: 72 year old African American
gentleman with a history of CHF, COPD, [**Month/Day/Year **] s/p stenting, DM,
HTN, HLD, who initially came to hospital for an elective
peripheral angiogram but was found to have CHF exacerbation and
was admitted to the CCU.
ACTIVE ISSUES:
# CHF: Pt presented with SOB in setting of recent weight gain,
missing medication and questionable nondiscretionary diet
choices. Chest X-ray showed significant fluid overload. Patient
was treated with IV Lasix gtt in the CCU, with foley in place
for in/out measurement. ECHO was done on HD#2, which showed
interval worsening of LVEF 40%(from 50%) with mild dilation of
LA, moderate dilation of RA, motion abnormality in
inferior/posterior, septum. Pt tolerated diuresis well with
improvement in respiration. He was transitioned to oral
torsemide for further diuresis at rehab. This may be
supplemented with additional boluses of 80mg IV lasix as needed.
He has a 2L home O2 requirement, which was stable at the time of
discharge.
# [**Month/Day/Year **]: Pt had hx of 2 vessel disease s/p stenting and angina
symptoms at baseline. EKG showed frequent monomorphic PVC,
consistent with scarring. Acute MI was ruled out with baseline
EKGs and absence of enzymes. His home medications were continued
and we restarted Imdur 30 mg qd after discussion Dr. [**First Name (STitle) 17766**].
# ANEMIA: On presentation, pt had a HCT drop to 28.7 from 42
([**10-16**]). The pattern of anemia was consistent with iron
deficiency and a component of insufficient BM response. B12 and
folate levels were normal and no evidence of hemolysis was
found. Pt was found to be guaiac negative. However, he had hx
of gastric ulcer likely secondary to H. pylori. Colonoscopy was
negative in [**2144**]. He was given iron supplement and should have
his reticulocyte count checked in 2 weeks following Fe
replacement (started [**7-4**]).
# FOOT WOUND: The patient was initially admitted for elective
angiogram due to a non-healing left foot ulcer. Vascular surgery
followed the patient during the hospitalization. The plan at the
time of discharge was for the patient to be re-evaluated by
vascular surgery for the peripheral angiography once stable post
discharge.
CHRONIC ISSUES:
# COPD: Pt had history of COPD. Recent [**Month/Year (2) 1570**] consistent with mixed
restrictive and obstructive pattern. His home medication was
continued including albuterol, ipratropium, tiotropium and
Advair. He requires baseline O2 to prevent desats and becomes
dyspneic without O2.
# DECREASED LIVER SYNTHETIC FUNCTION: Pt has low Albumin (3.2)
and elevated INR (1.2). He is high risk for NASH/NAFLD. This
should be followed and potentially further evaluated as an
outpatient.
# HYPERTENSION: Continued carvedilol 25mg [**Hospital1 **], lisinopril 40mg
qday and imdur 30mg qday. Patient's BP was well controlled
throughout his hospitalization.
# DM: Pt followed at [**Last Name (un) **], was covered with SSI during his
hospitalization, on discharge was continued on glargine and
humalog sliding scale.
TRANSITIONAL ISSUES:
-Continue diuresis with PO torsemide and prn IV lasix
-Check blood sugars QAHCS and cover with humalog sliding scale
-PICC line in place, CXR confirming placement being sent
-Wound consult for left foot ulcer
-Ambulate with walker [**Hospital1 **]
-Continue CPAP at night
-Continue supplemental O2 prn sats > 92%
Medications on Admission:
- ASA 325 mg qd
- albuterol 90 mcg 1-2 puffs q4-6hr
- amlodipine 5 mg qd
- atorvastatin 80 mg qd
- carvedilol 25 mg [**Hospital1 **]
- plavix 75 mg qd
- fluticasone/salmeterol 500 mcg-50 mcg 1 puff [**Hospital1 **]
- furosemide 80 mg [**Hospital1 **]
- insulin 75/25 24 units qd, lispro ssc
- ipratropium albuterol 18 mcg-103 mcg 2 puffs qid prn
- latanoprost 0.005% drop, 1 drop qhs
- lisinopril 40 mg qd
- omeprazole 20 mg qd
- oxycodone - acetominophen tid
- tiotropium 18 mcg 1 capsule qd
- docusate sodium 100 mg [**Hospital1 **]
- senna - 8.6 mg [**Hospital1 **]
Discharge Medications:
1. torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for Constipation.
5. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
10. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
11. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
12. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
13. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
14. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
15. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
16. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: One
(1) Inhalation four times a day.
17. Lantus 100 unit/mL Solution Sig: Seventeen (17) units
Subcutaneous every morning.
18. Humalog 100 unit/mL Cartridge Sig: ASDIR Subcutaneous
QAHCS: Check FS QAHCS and give sliding scale humalog insulin as
directed.
19. furosemide 10 mg/mL Solution Sig: Eighty (80) Injection
twice a day as needed for to achieve net diuresis of [**12-8**] L
daily: 80mg IV furosemide up to twice daily as needed to achieve
net diuresis of [**12-8**] liters daily.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Hospital 1263**] Hospital
Discharge Diagnosis:
Acute on Chronic Systolic Congestive heart failure
Hypertension
Chronic obstructive pulmonary disease
Severe sleep apnea
Diabetes mellitus
Coronary artery disease
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted for an angiogram and possible intervention on
your leg veins to help heal ulcers on your right toe and both
legs. The procedure was cancelled because you developed acute
congestive heart failure. You were admitted for aggressive
diuresis and your weight at discharge is 132.4 kg. Weigh
yourself every morning, call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Telephone/Fax (1) 62**] if weight goes up more than 3 lbs in 1 day or 5
pounds in 3 days.
We also discovered that you were anemic and have started you on
iron supplements to help address this. It is important that this
be followed up by your primary care physician to further
evaluate the cause of your anemia and to see if the iron
supplements are helping.
You will return at some point to get the angiogram once you are
more stable.
We have adjusted your insulin to better control your blood
sugars.
It is extremely important that you use your CPAP every night for
as long as you can because you cannot function the next day if
you don't. You mask and settings were adjusted during your stay.
.
We made the following changes to your medicines:
1. Changed furosemide 80mg [**Hospital1 **] to torsemide 100mg po BID
2. Started glargine (long-term insulin) in the mornings and
adjusted your humalog insulin with meals
3. Started Iron supplements for your anemia
Followup Instructions:
Cardiology:
Department: CARDIAC SERVICES
When: WEDNESDAY [**2149-8-6**] at 10:00 AM
With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PODIATRY
When: [**Hospital Ward Name **] [**2149-7-14**] at 3:40 PM
With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**]
Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST Best Parking: [**Street Address(1) 592**] Garage
Department: MEDICAL SPECIALTIES
When: FRIDAY [**2149-10-3**] at 10:50 AM
With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Name: [**Known lastname 16540**],[**Known firstname **] Unit No: [**Numeric Identifier 16541**]
Admission Date: [**2149-7-3**] Discharge Date: [**2149-7-12**]
Date of Birth: [**2077-5-3**] Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending:[**First Name3 (LF) 713**]
Addendum:
The patient's peripheral vascular disease was related to the
patient's diabetes.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 **] at [**Hospital 1699**] Hospital
[**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 714**] MD [**MD Number(1) 715**]
Completed by:[**2149-8-28**]
|
[
"443.81",
"365.9",
"496",
"250.70",
"530.81",
"278.01",
"V85.36",
"278.00",
"416.8",
"401.9",
"276.2",
"305.63",
"V45.82",
"573.8",
"280.9",
"428.0",
"414.01",
"327.23",
"V15.81",
"413.9",
"V12.71",
"427.1",
"707.15",
"428.43",
"424.0",
"272.4"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.97"
] |
icd9pcs
|
[
[
[]
]
] |
18006, 18238
|
8685, 8970
|
290, 296
|
14890, 14958
|
4016, 8662
|
16498, 17983
|
2586, 2699
|
12721, 14585
|
14704, 14869
|
12127, 12698
|
15066, 16475
|
2714, 3997
|
11787, 12101
|
231, 252
|
8986, 10933
|
324, 1598
|
14973, 15042
|
10950, 11766
|
1620, 2113
|
2129, 2570
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
21,448
| 154,095
|
45773
|
Discharge summary
|
report
|
Admission Date: [**2124-5-27**] Discharge Date: [**2124-5-29**]
Date of Birth: [**2069-5-31**] Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending:[**First Name3 (LF) 1936**]
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. [**Known lastname 14879**] is a 54 year old gentleman with a PMH significant for
EtOH abuse, afib, cardiomyopathy, and HCV cirrhosis admitted for
hypotension. Of note, the patient is very volatile and unwilling
to talk to the medical team or allow a physical exam. The
patient was brought into the [**Hospital1 18**] ED after being found unable
to walk, which he states is a long-standing issue. In the ED, he
was complaining of [**5-26**] non-radiating left-sided chest pressure
not associated with SOB, nausea, palpitations. Symptoms lasted
for a few minutes and then resolved. Of note, on review of old
records patient appears to have chronic chest pain symptoms.
The patient was also admitted from [**Date range (1) 97529**] for EtOH
intoxication and respiratory failure.
.
In the [**Hospital1 18**] ED, VS 96.2 140/111 54 17 99%RA. He was noted to
have intermitent hypotension with SBP 60-80s lasting for a few
minutes although mentating well before SBP>100. He was also
noted in the ED to by bradycardic to the 40s that became
tachycardic and then returned to 100s. The patient received 3L
IVF (bananna bag, NS, NaHCO3), 10 mg po valium, ASA 325 mg daily
and was transferred to the MICU for further management.
.
Currently, the patient as above is refusing to talk at length
with the medical team or allow for a physical exam. The patient
does state that he last drank 2 days ago, and at baseline drinks
[**11-19**] pint or more of vodka daily. Denies any current CP or
nausea.
Past Medical History:
Atrial fibrillation
Cardiomyopathy (LVEF [**4-25**] >55%)
Alcohol abuse
Hypertension
Pancreatic cyst
Status post knee replacement
Hepatitis C cirrhosis
Back arthritis
C.diff colitis - diagnosed during last admission, completed 14
day course of flagyl.
Social History:
Active drinker, drinks at least [**11-19**] pint vodka daily, + tobacco
2ppd for 40 years, denies other drug use. Lives alone in
[**Location (un) **] housing. Not married.
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
PATIENT REFUSED EXAM
VS on discharge: Tm99.2 98.6 159/80s 76 18 98%RA
Gen: Angry age appropriate male yelling at staff.
Pertinent Results:
CTA: IMPRESSION: [**2124-5-27**]
1. No evidence of pulmonary embolus.
2. Left upper lobe linear opacities in a subpleural distribution
and ground
glass density, consistent with infectious or inflammatory
process, with
additional bibasilar dependent atelectasis.
3. Mediastinal lymphadenopathy, could be reactive, but increased
from
previous examination. FOllow up CT after treatment is
recommended.
4. Small hiatal hernia.
.
CXR [**5-27**]: improving R basilar infiltrate, nothing new. .
.
no leukocytosis
hgb [**6-25**] stable, MCV 100s
plt 200s
BUN 8, creat 0.8 (was 1.4 on admission)
INR 1.1
S tox +benzo Utox +benzo
.
LFTs AST 52, ALT 37, mildly chronically elevated, improved from
last admission
lipase 138 on [**5-24**] (last admission)
.
blood cx [**5-27**] 1 of 2 with GPC in clusters-->pending speciation
.
UA [**5-27**] negative
.
thiamine pending at discharge
Brief Hospital Course:
[**Hospital Unit Name 153**] course:
Mr. [**Known lastname 14879**] is a 54 year old male with a PMH significant for ETOH
abuse, cardiomyopathy, afib, recent long hospital stay for
PNA/resp failure/etoh withdrawal/cdiff (discharged [**5-22**]) admitted
to the MICU for hypotension and presumed EtOH withdrawl.
Etiology of hypotenstion unclear at time of admit, but responded
well to IVF's in ED. On transfer to [**Hospital Unit Name 153**] patient was stable.
Shortly after admission, pts BP dropped to 82/48 and was given
2.5 L NS over the next 8 hours, which he responded well to.
CE's negative times 3. TSH and cortisol WNL. Elevated
creatinine returned to baseline overnight. Pt's outpatient
atenolol and diltiazam held due to hypotension but resumed by
time of discharge. Blood pressure remained stable thus
transfered to floor.
.
He also recieved 5 mg PO Valium and 2 mg Ativan on arrival to
ICU for CIWA >10 and agitation presumably due to alcohol
withdrawal. He was combative and making verbal threats
throughout the night and required additional ativan, haldol and
a sitter. Mr. [**Known lastname 14879**] showed no signs of active withdrawal after
the initial dose of valium, with CIWA <5 thereafeter. Patient
also recieved IV thiamine, folate and MV due to history of
alcoholism, each switched to PO prior to transfer to the floor.
Psychiatry was consulted due to labile behavior and recommended
haldol prn, scheduled ativan and alcohol risk counseling.
.
While in ICU, CT chest noted to have ground glass opacities
thought likely due to chronic process as he did not have any
fevers/leukocytosis/cough, thus Abx were not started (he
recently completed Abx for PNA)
.
Floor course: Mood remained labile. Psych was following, placed
on ativan [**Hospital1 **]. Was calm on [**5-28**]. Plan was to have PT see him for
his gait complaints. Continued to not require any valium (no s/s
ETOH withdrawal). Overnight, called by micro re: 1 of 2 blood cx
with GPC in clusters. Pt has peripheral IV. No leukocytosis.
Remained afebrile. Morning on [**5-29**], again very hostile, labile
mood, beligerant to staff, wanting to leave AMA. At this time,
tried to explain to him the concern for sepsis since he was
hypotensive on admission with blood cx now growing GPC as well
as the the need for abx and follow up cultures (reviewed risks
of bacteremia, including death), however pt insisting he be
allowed to leave. He wanted to be sent to [**Hospital1 2025**] but I explained to
him that I cannot easily make this transfer happen without first
finding out why he is so dissatisfied and angry, especially
started yelling at me and the staff. Security was called. Psych
was called STAT to evaluate competency and they did feel he WAS
competent to leave as he was able to relay back an understanding
of the risks of leaving AMA, esp with newly positive blood cx.
He signed out AMA before i was able to complete any paperwork. I
believe his intention is to go to [**Hospital1 2025**]. He should have repeat BC
done there and follow up of speciation from blood cx [**5-27**]. His
thiamine level is also pending at time of discharge. He aggreed
to following up with Dr. [**Last Name (STitle) 2204**] or going straight to ER if he
felt unwell. I have also communicated the above with Dr.
[**Last Name (STitle) 2204**] on day of discharge.
Medications on Admission:
Medications (from discharge on [**2124-5-22**]):
ASA 81 mg daily
Thiamine 100 mg daily
B12 50 mcg daily
Pantoprazole 40 mg daily
Atenolol 100 mg daily
Diltiazem SR 300 mg daily
HCTZ 12.5 mg daily
Discharge Medications:
he will resume above meds on discharge.
Discharge Disposition:
Home
Discharge Diagnosis:
hypotension
etoh abuse
gait difficulties
labile mood/hostile behaviour
hcv cirrhosis
HTN
afib
Discharge Condition:
at risk for bacteremia
Discharge Instructions:
you have signed out AMA, please go to ER if you feel unwell. you
may have bacteria in your blood which is very dangerous, but you
did not allow us to give you antibiotics or further work this
up.
Followup Instructions:
see Dr. [**Last Name (STitle) **] as soon as possible
|
[
"427.31",
"276.2",
"070.70",
"584.9",
"458.9",
"793.1",
"305.1",
"296.99",
"721.90",
"425.4",
"571.5",
"401.9",
"291.81"
] |
icd9cm
|
[
[
[]
]
] |
[
"94.62"
] |
icd9pcs
|
[
[
[]
]
] |
7189, 7195
|
3536, 6878
|
296, 302
|
7333, 7357
|
2639, 3513
|
7601, 7657
|
2309, 2479
|
7125, 7166
|
7216, 7312
|
6904, 7102
|
7381, 7578
|
2494, 2518
|
2532, 2620
|
245, 258
|
330, 1825
|
1847, 2101
|
2117, 2293
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
78,988
| 143,865
|
41301
|
Discharge summary
|
report
|
Admission Date: [**2118-12-28**] Discharge Date: [**2119-1-9**]
Date of Birth: [**2070-10-6**] Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD [**2118-12-30**]
Intubation [**2118-12-30**]
CVL [**2118-12-31**]
EGD [**2118-12-31**]
IR procedure, no embolization [**2118-12-31**]
History of Present Illness:
48 yo F with h/o chronic alcoholic pancreatitis complicated by
pancreatic duct stones, multiple pseudocysts who presented to
OSH with acute abdominal pain x1 week. The pain began after a
"stomach virus" prior to [**Holiday **] that caused her to have large
amounts of "black" emesis (no diarrhea or melena). Other family
members had a similar illness. After the stomach virus she
developed a gnawing epigastric pain. She denies fever or chills
at home, but endorses sweats, 10lb weight loss, and mid-back
pain. Her last EtOH use was over [**Holiday 1451**].
Since the patient presented to OSH with abdominal pain on
[**2118-12-18**] she has continued to have epigastric pain. Initial
imaging showed stable pseduocysts slightly improved in size and
pt was initially managed with pain control and IVF. She improved
in terms of her pain and tolerating clears, but then had
recurrence of her pain without fevers or chills, 2 days prior to
transfer. Notably, Alk phos increased from 140 to 400, but with
normal ALT/AST (had been slightly elevated previously). The pt
had a repeat Abd CT [**2118-12-25**] with new enlarging cyst roughly 5cm.
Also, noted SMV thrombosis which was not seen on admit CT, but
per discussion with pt's outpatient gastroenterologist, Dr.
[**Last Name (STitle) **], she has had this before and anticoagulation was
discontinued. MRI was done which showed e/o chronic
inflammation and narrowing of pancreatic duct (no comment
biliary pathology but was not an MRCP). OSH discussed case with
Dr. [**Last Name (STitle) **] who requested patient be transferred for further
evaluation and consideration of J-tube placement if symptoms
persist. Abdominal pain improves with morphine, not worse with
clears PO intake. Per nursing report from OSH, this afternoon
the patient vomited coffee ground emesis.
Of note, the patient had occasional fevers (Tm 101.5) during the
hospitalization at OSH, and had a urine culture that grew 80,000
Ecoli (pansensitive) from [**2118-12-18**] that was not treated as the
pt was considered "asymptomatic." Her WBC remained elevated
during her hospitalization at 15,000.
ROS: Denies chills, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
diarrhea, BRBPR, melena, hematochezia, dysuria, hematuria.
Constipation for ~1 week. All other ROS negative.
Past Medical History:
chronic alcoholic pancreatitis complicated by pancreatic duct
stones, multiple pseudocysts
SMV thrombosis, not on anticoagulation
Social History:
She is a waitress, currently not employed. Smokes 10 cigarettes
a day. Drinks "a few glasses of vodka" occasionally, last EtOH
over [**Holiday 1451**].
Family History:
Maternal aunt has breast cancer. Paternal grandmother had breast
cancer. No family members with pancreatitis, colon/pancreatic
cancer.
Physical Exam:
VS: Afeb (99), HR 100, BP 90's/60's, 98%RA
GENERAL: Thin woman in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored.
ABDOMEN: Soft/NT/ND, no masses or HSM, no rebound/guarding.
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: No rashes or lesions.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, muscle strength
[**4-29**] throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, steady gait.
Pertinent Results:
WBC 12.9
Hct 30.1
Plt 428
INR 1.5
Cr 0.4
Tbil 0.3
Dbil <0.1
AST 19
ALT 28
Alk Phos 414
Tprot 7.1
Alb 2.8
OSH MRI Abd [**2118-12-28**]
Majority of pancreas is replaced by heterogenous fluid
collections and ill-defined soft-tissue/fibrosis. Moderate
peripancr inflam change. Loculated fluid collection b/w
pancreatic neck and left lobe liver which measures 3.8cmx3.3cm.
Multiple other fluid collections.
[**2118-12-30**] CTA:
IMPRESSION:
1. Acute on chronic pancreatitis. Multiple pseudocysts.
Increasing size of
hemorrhagic pseudocyst within the lesser sac compressing upon
the gastric
antrum and duodenum. The GDA courses adjacent to the pseudocyst
and attention to this vessel is recommended if interventional
angiography is contemplated. Non-visualization of splenic vein
and SMV which may be compressed or occluded. Small areas of
non-enhancment may indicate necrosis.
2. No evidence of active contrast extravasation.
[**2118-12-31**] Angiography:
FINDINGS:
1. Conventional anatomy of the celiac axis with well-visualized
gastroduodenal artery without active bleeding.
2. Conventional anatomy of the SMA origin with active
extravasation seen from a small branch of the inferior
pancreaticoduodenal artery.
IMPRESSION:
1. Active extravasation of a branch of the inferior
pancreaticoduodenal
artery, which could not be selectively catheterized.
2. Successful placement of a triple-lumen central venous
catheter in the
right internal jugular vein with the tip in the lower SVC. Line
is ready to use.
Brief Hospital Course:
After being admitted to the ICU, she had several problems which
were managed there:
-Acute blood loss anemia/GI bleeding/hematemesis: Patient has
not been forthcoming with active bleeding via emesis and per
rectum - with ?depression given significant flat affect. While
on the floor, patient was noted to have significant upper and
lower GI bleeding with hct drop from 28->22, for which she was
transferred to the ICU and kept on PPI drip. ERCP performed EGD
and noted significant amounts of blood, no active bleed and
likely external compression by a pseudocyst, which was eroding
into the pylorus/duodenum. Patient re-bled in the ICU, was
intubated for airway protection, transfused 4 units PRBCs and
sent to CTA, however no source was localized. IR and surgery
made aware. The following day, repeat EGD showed stable mass, 2
AVMs (duodenum and stomach) that were thermally treated and no
clear treatable source of bleeding. Patient was transfused
another unit of PRBCs. Her second night in the ICU, she again
began bleeding >1.5 liters bright red blood from above and
below. She was bolused IVFs, started on phenylephrine and
transfused 8 units of blood, 2 units of platelets and 4 units of
FFP. She was taken to IR who found bleeding from the inferior
pancreaticoduodenal artery but this was too small to embolize.
After the scope, on [**12-31**], the patient then did not have any
bleeding.
-Acute on chronic pancreatitis, abdominal pain: History of
pancreatitis is felt to be due to alcohol abuse. The patient had
been actively consuming alcohol prior to admission to OSH. Her
pancreatitis has been complicated by pseudocysts and thrombi
(likely from cirrhosis). Fevers (Tmax 101) raised the
possibility of a superinfection, ?UTI, ?pancreatic necrosis
although most recent imaging was negative.
-Fever/leukocytosis - The patient has been afebrile at [**Hospital1 18**] but
with persistent and worsening leukocytosis. Gram negative rods
growing in blood and patient was started on cefepime in the ICU
which was then changed to ciprofloxacin after a urine and blood
culture grew back pan-sensitive E. Coli.
-Liver cirrhosis - Unclear but does not seem to have been
previously complicated by ascites, SBP, variceal bleeding,
encephalopathy. Patient with known gastroepiploic varices, no
esophageal varices.
-Elevated alk phos: Most likely biliary, possibly in setting of
recent alcohol consumption/cirrhosis. Total and direct bili also
elevated.
-Anemia: Last hct in OMR is 31, so on transfer appeared to be
close to baseline at 29.5. However, upper and lower GI bleeding
with significant hct drop propmted her transfer to the ICU.
Large bore IVs placed and active T+S maintained. Patient had 2
isolated episodes of massive GIB from above and below, each
requiring significant transfusions. See above.
-Depression: Flat affect, chronic illness (pancreatitis/pain).
Patient had been trying to hide her GI bleeding, and there is a
question on passive suicidality. Social work was consulted.
Constipation: Initially managed on senna, colace and miralax.
Constipation resolved with GI bleeding.
On [**2119-1-3**], the patient was exubated and did well afterwards.
On [**2119-1-4**], the patient was felt to be safe for the floor and
was transferred to the floor. She has not had any evidence of
bleeding either clinically or lab since being transferred to the
floor. She was continued on TPN and started on sips on [**2119-1-5**],
which she tolerated well.
Her diet was advanced to regular and her TPN weaned. She
tolerated a regular diet on [**1-8**] in addition to Glucerna shakes
with meals. Her antibiotic course finished on [**1-9**], and she
experienced no additional GI bleeding. Her abdominal pain
resolved, and her labs remained stable. On [**1-9**], she was
tolerating a regular diet, reporting no abdominal symptoms, and
ambulating independently. She was instructed to continue her
Glucerna supplements and to weigh herself weekly. She will call
to schedule outpatient nutrition follow up, as well as to
schedule an appointment with her PCP [**Name Initial (PRE) 176**] 7 days to discuss
elevated glucose while inpatient without a prior diagnosis of
diabetes. She will follow up with Dr. [**Last Name (STitle) **] and Dr. [**First Name (STitle) **] on
[**2119-2-10**] and will have a CT abdomen-pancreas protocol earlier the
same day. Ms. [**Known lastname 62132**] understood these instructions and agrees
with the plan. She was discharged to home in good condition on
[**2119-1-9**].
Medications on Admission:
Home:
Creon
Percocet
Multivitamins
On transfer:
Ativan 1mg po qhs
Oxycodone 10mg prn
Maalox
Protonix
Zofran
Trazodone
morphine 4mg IV prn
Tylenol prn
Discharge Medications:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain for 5 days.
Disp:*12 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent pancreatitis, GI bleed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please resume your home medications; take new medications as
prescribed.
Do not drive or drink alcohol while taking pain medication.
You may resume a regular diet - please also drink a glucerna
shake with each meal.
You may resume your usual activities, however, take it easy -
avoid strenuous exercise or lifting >15 lbs until you see Dr.
[**First Name (STitle) **] in clinic.
Please contact your PCP [**Name Initial (PRE) 176**] 7 days to schedule an appointment
to address your glucose levels/control, and any complaints of
shoulder tendonitis you may still be having.
Please weigh yourself weekly and record. Bring these numbers to
your follow up appointment.
Please call [**Telephone/Fax (1) 3681**] to schedule an outpatient appointment
with one of our nutritionists after discharge.
Followup Instructions:
Please contact your PCP [**Name Initial (PRE) 176**] 7 days to schedule an appointment
to address your glucose levels/control, and any complaints of
shoulder tendonitis you may still be having.
Please weigh yourself weekly and record. Bring these numbers to
your follow up appointment.
Please call [**Telephone/Fax (1) 3681**] to schedule an outpatient appointment
with one of our nutritionists after discharge.
Please follow up with Dr. [**Last Name (STitle) **] on
[**2119-2-10**] 12:30p [**Last Name (LF) **],[**First Name3 (LF) 1948**] S.
[**Hospital Unit Name **]([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX),[**Location (un) **] GI FACULTY
(SB)
Please call [**Telephone/Fax (1) 2998**] to schedule a follow up appointment
with Dr. [**First Name (STitle) **] for the same day ([**2-10**]). You should have a CT
scan of your abdomen that same day, prior to your appointments.
|
[
"303.90",
"577.1",
"V16.3",
"V85.0",
"V12.51",
"577.2",
"571.2",
"262",
"285.1",
"456.8",
"564.00",
"790.7",
"537.83",
"577.0",
"599.0",
"041.49"
] |
icd9cm
|
[
[
[]
]
] |
[
"45.13",
"38.97",
"88.47",
"96.04",
"96.72",
"44.43",
"38.91",
"99.15"
] |
icd9pcs
|
[
[
[]
]
] |
10738, 10744
|
5537, 10056
|
318, 457
|
10821, 10821
|
4007, 5514
|
11787, 12694
|
3176, 3312
|
10257, 10715
|
10765, 10800
|
10082, 10234
|
10972, 11764
|
3327, 3988
|
264, 280
|
485, 2837
|
10836, 10948
|
2859, 2991
|
3007, 3160
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
79,069
| 115,164
|
54931
|
Discharge summary
|
report
|
Admission Date: [**2200-10-20**] Discharge Date: [**2200-10-24**]
Date of Birth: [**2146-4-28**] Sex: M
Service: MEDICINE
Allergies:
spironolactone
Attending:[**Last Name (un) 11974**]
Chief Complaint:
s/p VT ablation
Major Surgical or Invasive Procedure:
Ablation of ventricluar ectopic automaticity focus
History of Present Illness:
54 year old man with HTN, HLD, CAD with h/o anterior MI s/p DES
to LAD ([**7-/2198**]), systolic CHF NYHA Class III(EF 30-35% from TTE
[**5-/2200**]), h/o sustained VT s/p BIV ICD (BIV pacing turned off
[**5-/2200**]), and COPD requiring 2L at day and night. Recent device
interrogation revealed 23 episodes of NSVT lasting between 1 and
5 seconds. There were 11 logs of SVT by the device with episodes
lasting between 9 seconds and 2 minutes and 42 seconds. He had
one episode of pace terminated monomorphic VT that fell in the
VF zone but has never had an ICD shock. Due to his underlying
heart failure and COPD, Dr. [**Last Name (STitle) 23246**] does not feel that he is a
candidate for antiarrhythmic medication given COPD and has
referred him for VT ablation.
.
In the last several months the patient reports frequent episodes
of pre-syncope and palpitations with the sensation that "my
heart's going to come right out of my chest." These episodes
occur multiple times per day and last for 10-15 minutes at a
time. He reports having associated chest tightness and a feeling
that he is starved for air. He also describes multiple episodes
of feeling like he is going to pass out but denies any frank
syncope. These episodes are unrelated to activity. Occasional
diaphoresis, no PND, no Orthopnea.
.
In EP Lab tandem heart inserted prior to VT ablation for
prophylactic support. Were able to recreate NSVT not sustained
VT -> successful ablation -> extubated, tandem heart removed;
- 21F venous sheath on R, 8F arterial sheath on R, 15F arterial
sheath on L, 7F and 9F venous sheaths on L;
- Bed rest till 10pm
- 4L positive; goal 2L negative by midnight; got 40 IV lasix in
lab
- full dose aspirin
.
On arrival to the CCU, HR 90, 120/75, SpO2 98 on 100% facemask.
.
REVIEW OF SYSTEMS: Pt difficult historian.
On review of systems denies recent illness, does confirm
pre-syncopal episodes for about 6 months, worse recently and
palpitations.
.
Cardiac review of systems is notable for some mild chest pain
with episodes, sometimes diaphoresis, both symptoms resolve on
own. No orthopnea or PND.
Past Medical History:
- Hypertension
- Hyperlipidemia
- CAD s/p anterior wall MI [**7-/2198**] treated with a DES to the LAD
- Systolic CHF (LVEF 30-35% or 10-15%? unclear)
- Sustained ventricular tachycardia- [**2199-11-2**]; [**2200-3-5**]
- S/p BIV -ICD implant [**11/2199**] at [**Hospital6 **]; BIV
pacing
turned off [**5-15**]?
- Underlying bifasicular block
- Severe COPD on 2L home day and nightO2; referred to [**Hospital1 2025**] for
consideration of heart lung transplant, turned down on basis of
lacking social supports (heavy smoker, poor social support)
- Was evaluated by [**Hospital1 2025**] for heart/lung tx and declined due to
poor social support
Social History:
Single, lives alone. No children. Disabled. Quit smoking [**3-7**]
years ago, previously smoked 1.5 ppd for 39 years.
- Former heavy drinker
Family History:
Adopted
Physical Exam:
Wt 90 kg
Ht 72 inches
.
VS: 97.8, 80/54, 75, 99% on facemask
GENERAL: Caucasian man, looks stated age, with facemask laying
flat and complaining of back pain.
HEENT: EOMI, Sclera anicteric. MMM.
NECK: JVP difficult to appreciate given large habitus, seems to
be to angle of jaw?
CARDIAC: +S1+S2 but distant heart sounds, difficult to hear.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. Hypoacive BS.
EXTREMITIES: Warm, Right radial aline, left PIV, groin bandages
clean/dry.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Dopplerable b/l LE
Pertinent Results:
[**2200-10-20**] 07:10AM PT-10.9 INR(PT)-1.0
[**2200-10-20**] 07:10AM PLT COUNT-340
[**2200-10-20**] 07:10AM WBC-10.6 RBC-5.17 HGB-13.8* HCT-44.7 MCV-86
MCH-26.7* MCHC-30.9* RDW-16.8*
[**2200-10-20**] 07:10AM estGFR-Using this
[**2200-10-20**] 07:10AM GLUCOSE-95 UREA N-15 CREAT-0.9 SODIUM-142
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-38* ANION GAP-11
[**2200-10-20**] 07:44AM freeCa-1.13
[**2200-10-20**] 07:44AM HGB-13.0* calcHCT-39
[**2200-10-20**] 07:44AM GLUCOSE-95 LACTATE-0.6 NA+-140 K+-3.8 CL--92*
[**2200-10-20**] 07:44AM TYPE-ART PO2-203* PCO2-73* PH-7.35 TOTAL
CO2-42* BASE XS-11
[**2200-10-20**] 10:03AM TYPE-ART PO2-339* PCO2-56* PH-7.40 TOTAL
CO2-36* BASE XS-8 INTUBATED-INTUBATED VENT-CONTROLLED
[**2200-10-20**] 01:44PM freeCa-1.00*
[**2200-10-20**] 01:44PM HGB-9.7* calcHCT-29 O2 SAT-99
[**2200-10-20**] 01:44PM GLUCOSE-99 LACTATE-0.8 NA+-138 K+-3.4 CL--102
[**2200-10-20**] 01:44PM TYPE-ART PO2-350* PCO2-54* PH-7.40 TOTAL
CO2-35* BASE XS-7
[**2200-10-20**] 07:56PM PLT COUNT-244
[**2200-10-20**] 07:56PM WBC-13.3* RBC-3.69*# HGB-9.9*# HCT-31.8*#
MCV-86 MCH-26.7* MCHC-31.0 RDW-17.0*
[**2200-10-20**] 07:56PM ALBUMIN-3.4* CALCIUM-7.8* PHOSPHATE-3.4
MAGNESIUM-1.7
[**2200-10-20**] 07:56PM GLUCOSE-123* UREA N-15 CREAT-0.7 SODIUM-144
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-34* ANION GAP-10
[**2200-10-20**] 09:30PM HCT-30.8*
.
EKG: 80-90bpm, sinus, LAD, PR < .2, QRS > .12, RBBB, LAFB, Q in
V3,V4, II, III, aVF (old inferior septal MI)
.
STRESS MIBI ([**2200-5-7**]): Large fixed severe defect, almost total
anterior septum and apex. RV enlarged. EF 23%.
.
TTE ([**2200-5-27**]): EF 30-35% with apex, septum, and distal anterior
wall akinetic; remainder of LV hypokinetic. Mildly dilated right
ventricle with normal function.
.
TTE at [**Hospital1 112**] ([**2199-11-29**]): LV function severely reduced with
regional variability. LVEF 25-30%. Mild generalized RV systolic
dysfunction. No evidence of pericardial effusion or tamponade.
Brief Hospital Course:
54 year old man h/o anterior MI in [**2199-7-3**] and with BIV-ICD
since [**2199-12-3**], found to have multiple episodes of VT and NSVT
on device interrogation and also symptomatic of
presyncope/palpitation, referred to [**Hospital1 18**] for ablation of
Ventricluar ectopic automaticity focus. Now s/p Ventricular
ablation.
.
# Ventricular Tachycardia - Ablation performed on [**10-20**]. Post
ablation patient was in sinus rhythm with occasional PVCs. VT
was Found on device interrogation which prompted his admission.
On ROS pt endorsed palpitation and pre-syncope. Of note, patient
is a poor Amiodarone candidate given severe COPD. On discharge
pt denied palpitations, pre-syncope.
.
# Acute blood loss - Post procedure pt developed severe
abdominal pain and low back pain, with a Hct that was 29, down
from 44 on admission. A Non-Con CT Abd/Pelvis showed small
perinephric hematoma with no extravasation, but some tracking
into the pelvis. His HCT was monitored serially and had a HCT
nadir of 24.3. On [**10-23**], his abdominal pain acutely woresened
after transfusion of 1U PRBCs, repeat CT at that time did not
show enlargement of the hematoma. His abdominal pain resolved
after he had a BM. He recieved a second unit of PRBCs and his
HCT increased to 27.3 and he was discharged home in stable
condition. His back and and abdominal pain resolved prior to
discharge.
# Ischemic Cadiomyopathy with sCHF EF 30-35%: volume status was
overloaded on admission, on 40mg PO Lasix daily at home.
Received 3L IVF during ablation, followed by 40mg IV Lasix. Dry
Weight 97kg, currently 90kg. He was gently diuresed during
admission until his O2 requirement decreased to his baseline of
2L, and he was not objectively overloaded on exam. Metop
succinate 25 mg was started which is half of his home dose and
was increased back to 50mg prior to discharge. In addition, the
following medications were continued: Aspirin 81mg (lower dose
than when he came in [**3-6**] acute blood loss), furosemide, and
rosuvastatin.
.
# Chronic COPD with 2L requirement at home day and night -
currently on facemask SaO2 99%, no wheezing, and moving air
well. He was diuresed as mentioned above and weaned to his home
O2 requirement of 2L. In addition, his combivent was continued
q6h during this hospital admission.
.
# CAD - asymptomatic currently. AMI in [**2198-7-3**] DES to LAD in
[**2198**]. Rosuvastatin 10, Metop succinate 50 mg, Plavix 75, ASA 81.
His cardiologist notes intolerant to Lisinopril, can consider
[**Last Name (un) **] as an outpatient.
.
TRANSITIONAL
- Pt was placed on medications based on list from his primary
cardiologist prior to discharge.
- CHECK HCT in 1 Week
- consider starting [**Last Name (un) **] [**3-6**] ACE intolerance (per Cardiologist)
as an outpatient
- consider f/u scan to make sure RP bleed resolved on own, and
consider this etiology if patient continues to complain of
abdominal/back pain
- DNR/Ok to intubate
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PCP.
1. Clopidogrel 75 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 100, hr < 55
4. Pantoprazole 40 mg PO Q24H
5. Rosuvastatin Calcium 10 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Aspirin 162 mg PO DAILY
8. ALPRAZolam 1 mg PO QID:PRN anxiety
hold for rr< 12
9. Albuterol-Ipratropium 2 PUFF IH Q6H wheezing/sob
10. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
11. Nitroglycerin SL 0.4 mg SL PRN chest pain, inform HO
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Albuterol-Ipratropium 2 PUFF IH Q6H wheezing/sob
3. Aspirin 81 mg PO DAILY
4. ALPRAZolam 1 mg PO QID:PRN anxiety
hold for rr< 12
5. Clopidogrel 75 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
hold for sbp < 100, hr < 55
8. Nitroglycerin SL 0.4 mg SL PRN chest pain, inform HO
9. Pantoprazole 40 mg PO Q24H
10. Rosuvastatin Calcium 10 mg PO DAILY
11. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Ventricular tachycardia
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. [**Known lastname 112187**],
You were admitted to [**Hospital1 18**] to fix the irregular beating in your
heart. The procedure was done without complications on [**10-20**].
After the procedure you had several episodes of abdominal pain.
We performed a CT scan which showed a small amount of blood in
your abdomen, but not a concerning amount. We monitored your lab
results, which were not concerning and stable. Your vital signs
were stable and normal during the duration of your stay.
We have made an appointment for you with Dr. [**Last Name (STitle) **], who
performed the procedure.
Followup Instructions:
PCP
Primary care Appointment: [**Last Name (LF) 766**], [**10-27**] at 1:30pm
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 112188**],MD
Location: HILLTOP FAMILY PRACTICE
Address: [**Location (un) **], SOMERSWORTH,[**Numeric Identifier 112189**]
Phone: [**Telephone/Fax (1) 87160**]
.
CARDS:
Department: CARDIAC SERVICES
When: FRIDAY [**2200-11-7**] at 11:00 AM
With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**]
Completed by:[**2200-10-26**]
|
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icd9cm
|
[
[
[]
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] |
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"37.28",
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"37.26",
"37.34",
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] |
icd9pcs
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|
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| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
43,320
| 154,851
|
1745+55310
|
Discharge summary
|
report+addendum
|
Admission Date: [**2128-8-10**] Discharge Date: [**2128-10-19**]
Date of Birth: [**2054-11-9**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1232**]
Chief Complaint:
Bladder Cancer
Major Surgical or Invasive Procedure:
[**2128-8-10**]: Radical cystoprostatectomy, lymph node dissection,
and ileal conduit urinary diversion
[**2128-9-7**]: Lysis of adhesions, exploratory laparotomy and
evacuation of hematoma in pelvis.
History of Present Illness:
73yo male who underwent a restaging TUR bladder tumor on
[**2128-6-11**]. The final result indicated carcinoma in situ with
invasion into [**First Name8 (NamePattern2) **] [**Last Name (Prefixes) 9911**] nests but no muscle invasive disease.
There was a question of a lamina propria invasion. All of these
factors point to a losing battle with intravesical immuno and
chemotherapy, which we have been doing for over four years. He
was therefore scheduled for cystectomy.
Past Medical History:
PAST MEDICAL / SURGICAL HISTORY:
Bladder Cancer s/p radical cystoprostatectomy, lymph node
dissection, and ileal conduit urinary diversion on [**8-10**]
Atrial fibrillation
Aortic Root dilatation/aneurysm, AR s/p mechanical AVR [**2110**]
Hypertension
s/p right inguinal hernia repair
s/p right hydrocelectomy x 2
s/p TURP [**7-/2127**]
FOREIGN BODIES:
Mechanical AVR
Surgical Hx:
Surgical History significant for AVR, hernia repair, tonsils,
hydrocelectomy [**2120**], TURBT [**12/2123**], Bladder biopsy [**2123**] and
7/[**2124**].
Social History:
The patient is married. He is a retired barber. +
history of EtOH abuse, sober x 16 years. Tobacco use of 1ppdx
~20
years. Pt denies illicit drug use.
Family History:
Father with [**Name2 (NI) 499**] cancer in his 70s
Physical Exam:
GENERAL - alert, NAD, AVSS. Wearing glasses. Soft spoken. Alert,
oriented. Smiling at times/appropriately.
HEENT - NC/AT, MMM,
NECK - supple, no cervical LAD
LUNGS - CTA anteriorly aside from some mild bibasilar rales,
good air movement, resp unlabored, no accessory muscle use
HEART - irreg rhythm, no MRG, audible mechanical valve
ABDOMEN: soft, non-tender, protuberant appearing
Incision line c/d/i w/ exception to umbilicus wound packed with
[**12-24**]" gauze daily. Cephalid aspect of incision line is well
healed but suture is exposed and visible. Some TTP at suprapubic
area.
Ileal conduit is with pink stoma, yellow urine out put.
J-tube with tube feeds running, at goal, 45cc/hr.
Lower extremities bilateral with trace edema but no calf pain to
deep palpation. His right lower extremity has some medial calf
to medial malleolus ethema/? rash unchanged in the past few
weeks.
Healing Stage II coccygeal ulcer
Scrotum with moderate edema. Uncircumcised. Right testicular
pain has resolved.
Pertinent Results:
Listed here are most recent labs with some pertinent culture
results. This is not a complete list of hospital course data.
[**2128-10-18**] 07:20AM BLOOD WBC-3.5* RBC-3.01* Hgb-9.1* Hct-27.6*
MCV-92 MCH-30.3 MCHC-33.2 RDW-15.8* Plt Ct-164
[**2128-10-17**] 03:32PM BLOOD WBC-3.4* RBC-3.07* Hgb-9.3* Hct-27.8*
MCV-91 MCH-30.3 MCHC-33.4 RDW-15.8* Plt Ct-167
[**2128-10-16**] 04:29AM BLOOD WBC-3.9* RBC-2.93* Hgb-8.8* Hct-26.7*
MCV-91 MCH-30.0 MCHC-32.9 RDW-16.6* Plt Ct-143*
[**2128-10-12**] 06:06AM BLOOD Neuts-75* Bands-1 Lymphs-12* Monos-8
Eos-3 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2128-10-10**] 06:18AM BLOOD Neuts-73.5* Lymphs-16.5* Monos-8.7
Eos-1.0 Baso-0.3
[**2128-10-14**] 12:31AM BLOOD PT-21.0* PTT-43.0* INR(PT)-1.9*
[**2128-10-18**] 07:20AM BLOOD
[**2128-10-17**] 03:32PM BLOOD
[**2128-10-16**] 04:29AM BLOOD
[**2128-10-18**] 07:20AM BLOOD Glucose-111* UreaN-21* Creat-1.0 Na-136
K-4.0 Cl-99 HCO3-31 AnGap-10
[**2128-10-17**] 03:32PM BLOOD Glucose-128* UreaN-20 Creat-1.1 Na-137
K-4.1 Cl-98 HCO3-34* AnGap-9
[**2128-10-16**] 04:29AM BLOOD Glucose-125* UreaN-22* Creat-1.1 Na-139
K-3.9 Cl-99 HCO3-33* AnGap-11
[**2128-8-10**] 05:45PM BLOOD Glucose-159* UreaN-14 Creat-1.1 Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
[**2128-8-11**] 05:50AM BLOOD Glucose-140* UreaN-14 Creat-1.0 Na-141
K-3.9 Cl-106 HCO3-29 AnGap-10
[**2128-10-11**] 05:51AM BLOOD ALT-91* AST-38 AlkPhos-185* TotBili-0.8
[**2128-10-10**] 06:18AM BLOOD ALT-122* AST-43* AlkPhos-197* TotBili-0.7
[**2128-9-16**] 05:40AM BLOOD Lipase-83*
[**2128-10-18**] 07:20AM BLOOD Calcium-7.7* Phos-3.0 Mg-2.0
[**2128-10-17**] 03:32PM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
[**2128-9-24**] 06:02AM BLOOD VitB12-655 Folate-13.6
[**2128-9-22**] 06:00AM BLOOD Triglyc-71
[**2128-9-22**] 06:00AM BLOOD TSH-2.6
[**2128-9-24**] 06:02AM BLOOD Cortsol-19.4
[**2128-10-6**] 05:36AM BLOOD Digoxin-0.6*
[**2128-10-6**] 03:18AM BLOOD Lactate-0.9
[**2128-9-7**] 05:00PM BLOOD freeCa-1.18
[**2128-9-28**] 5:30 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT [**2128-9-30**]**
MRSA SCREEN (Final [**2128-9-30**]):
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
[**2128-10-15**] 2:39 pm URINE Source: Catheter.
**FINAL REPORT [**2128-10-16**]**
URINE CULTURE (Final [**2128-10-16**]): NO GROWTH.
[**2128-9-28**] 10:15 am BLOOD CULTURE Source: Venipuncture 1 OF
2.
**FINAL REPORT [**2128-10-1**]**
Blood Culture, Routine (Final [**2128-10-1**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
355-9382C
[**2128-9-28**].
ENTEROCOCCUS FAECALIS.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
[**Numeric Identifier 9912**]
FROM [**2128-9-28**].
Anaerobic Bottle Gram Stain (Final [**2128-9-28**]): GRAM
NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2128-9-29**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2128-9-28**] 10:15 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2128-10-1**]**
Blood Culture, Routine (Final [**2128-10-1**]):
ESCHERICHIA COLI.
Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
[**Last Name (NamePattern1) 3060**]. FINAL SENSITIVITIES.
CEFEPIME sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
ENTEROCOCCUS FAECALIS.
SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 9912**] FROM
[**2128-9-28**].
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final [**2128-9-30**]):
THIS IS A CORRECTED REPORT [**2128-9-30**].
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN CHAINS.
PREVIOUSLY REPORTED WITHOUT THE GRAM POSITIVE COCCI IN
CHAINS
[**2128-9-28**].
Aerobic Bottle Gram Stain (Final [**2128-9-28**]):
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN CHAINS.
[**2128-9-28**] 12:12 am BLOOD CULTURE Source: Line-PICC.
**FINAL REPORT [**2128-9-30**]**
Blood Culture, Routine (Final [**2128-9-30**]):
ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES.
HIGH LEVEL GENTAMICIN SCREEN: Resistant to 500 mcg/ml
of
gentamicin. Screen predicts NO synergy with penicillins
or
vancomycin. Consult ID for treatment options.
HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
streptomycin. Screen predicts NO synergy with
penicillins or
vancomycin. Consult ID for treatment options. .
BETA LACTAMASE NEGATIVE.
Daptomycin Sensitivity testing performed by Etest.
Daptomycin = 1 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
PENICILLIN G---------- 4 S
VANCOMYCIN------------ 1 S
Anaerobic Bottle Gram Stain (Final [**2128-9-28**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9913**] AT 1:20PM ON
[**2128-9-28**].
Aerobic Bottle Gram Stain (Final [**2128-9-28**]):
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
[**2128-9-18**] 3:45 pm URINE Source: Catheter.
**FINAL REPORT [**2128-9-24**]**
URINE CULTURE (Final [**2128-9-24**]):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
Cefepime sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
SERRATIA MARCESCENS. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
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
| SERRATIA MARCESCENS
| |
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- =>64 R <=1 S
CEFTRIAXONE----------- 32 R <=1 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S =>512 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
Brief Hospital Course:
Mr. [**Known lastname 9908**] is a 73 y/o M with PMHx significant for bladder
cancer, mechanical aVR on warfarin, TAA, atrial fibrillation,
who was initially admitted on [**2128-8-10**] for radial
cystoprostatectomy, LN dissection, ileal conduit. [**Hospital 8351**]
hospital course has been quite prolonged with multiple
complications. He had a post-op SBO and is s/p ex-lap with clot
evaluation, lysis of adhesions on [**2128-9-7**]. He had a brief ICU
admission at that time for hypotension. He ultimately had a
j-tube placement for nutrition; however, he did not tolerate
tube feed and was placed on TPN. On [**2128-9-28**], he developed afib
with RVR, hypotension requiring pressors, respiratory distress
requiring intubation. He was again transferred to the ICU. He
was found to have e.coli and enterococcus bacteremia and was
started on vancomycin/zosyn, ultimately narrowed to zosyn only.
He was seen by cardiology and placed on metoprolol and diltiazem
for rate control. He was transferred back to the urology
service. On [**2128-10-4**], he developed fever and dyspnea and was
transferred back to the ICU. This was thought to be [**1-22**] HCAP.
Antibiotics were broadened to vancomycin/meropenem. There was
also some concern for potential PE, but pt was unable to undergo
CTA [**1-22**] elevated Cr. LE ultrasound was performed, which showed
occlusive thrombus in the left posterior tibial vein. The
patient has been started on lovenox (given that this occured
while on coumadin). Respiratory status had since improved. The
patient was transferred back to the floor under the care of the
medicine service where he was subsequently transferred back to
the Urology service where he remained until discharge on
[**2128-10-19**].
Active issues are as follows:
(1) ID/Bacteremia/HCAP: Pt currently on vancomycin/meropenem.
Respiratory status currently improved, weaned to nasal cannula
use at night as he does not use CPAP for his OSA. He remains on
room air throughout the day and oxygenation is greather than
92%. He has had no further positive blood cultures. ID has since
signed off. Vancomycin and meropenem were completed [**2128-10-14**]
(which will complete a 2-week course for bacteremia and 10 days
for presumed hospital-acquired PNA). Likely sources for
bacteremia included PICC and urine.
Other antibiotics given during hospitalization:
- Cefepime ([**9-28**] - [**9-30**])
- Zosyn ([**9-30**] - [**10-4**])
- Vancomycin ([**9-28**] - [**10-1**]; [**10-4**] - 25)
- Meropenem ([**10-5**] - [**10-14**])
(2) DVT: Pt with LENI showing occlusive thrombus in the left
posterior tibial vein. Heme/onc evaluated patient and
recommended anticoagulation with lovenox, given that this clot
occurred while on coumadin. Discused with cardiology, given
mechanical valve, and they agreed but recommended following
factor Xa levels. His Lovenox is at maximim of 100mg SubQ [**Hospital1 **].
His factor Xa levels have been stable. He will follow up with
heme/onc in [**2128-11-20**] and have discussion regarding
transition off lovenox.
(3) Afib: Currently on dilt, metoprolol, digoxin. Rate
well-controlled. Cardiology has signed off. He is monitored on
telemetry but this should not be required indefinately.
(4) Bladder Cancer s/p Radical Cysoprostatectomy: Ileal conduit
has been funtioning well and training for routine ostomy care
has been carried out by Ostomy nurse specialist.
(5) Depression: Psych has been following and has since signed
off.
(6) Sacral Decubitus Ulcer: Getting wound care.
(7) Nutrition: Tolerating tube feeds at goal.
(8) [**Last Name (un) **]/ARF likely secondary to sepsis vs. volume overload vs.
contrast. Per ICU report, Cr did improve with diuresis. Now
resolved.
(9) Anemia: Felt to be multifactorial, including AOCD and
multiple surgeries and poor nutrition due to lack of diet/po
intake.
(10) Code Status: FULL. Wife [**Doctor First Name 8368**] [**0-0-**]
(11) Ambulatory status: Ambulates with walker assistance. He
has deconditioned and lost muscle mass and tone given his
[**Hospital 9914**] hospital course. Physical therapy has been working with
him regularly.
On discharge Mr.[**Known lastname 9908**] was at POD 70 and 42. At discharge,
Mr. [**Known lastname 9908**] was not taking any pain medications, he was
tolerating tube feeds at goal and having bowel movements,
ambulating with walker AND with assistance. He was using nasal
canula overnight in lieu of CPAP and he was making good urine.
He is discharged to [**Hospital1 **] ([**Location (un) 701**]) with
instructions to follow up with cardiology, urology,
hematology/oncology, gerontology and his other
providers/specialists as directed.
It has been a prolonged hospital course but it has been a
pleasure participating in Mr. [**Known lastname 9915**] care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Diltiazem 90 mg PO QID
3. Ketorolac 15 mg IV Q6H:PRN pain Duration: 3 Days
4. Metoclopramide 10 mg IV Q6H
5. Metoprolol Tartrate 5 mg IV Q6H
6. Ondansetron 4 mg IV Q8H:PRN nausea
7. Warfarin Dose is Unknown PO DAILY16
8. Lovastatin *NF* 10 mg Oral daily
9. Ascorbic Acid 1000 mg PO BID
10. coenzyme Q10 *NF* 200 mg Oral daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
3. Ascorbic Acid 1000 mg PO DAILY
4. coenzyme Q10 *NF* 10 mg Oral daily
* Patient Taking Own Meds *
5. Diltiazem 90 mg PO Q6H
6. Gabapentin 300 mg PO TID
7. Methylnaltrexone 12 mg SUBCUT EVERY OTHER DAY
8. MethylPHENIDATE (Ritalin) 2.5 mg PO QAM
9. Metoprolol Tartrate 50 mg PO Q6H
hold for sbp <100, hr <60
10. Mirtazapine 15 mg PO HS
11. Ondansetron 4-8 mg IV Q8H:PRN nausea
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
may give per JT
13. Simvastatin 5 mg PO DAILY
14. Digoxin 0.125 mg PO DAILY
15. Enoxaparin Sodium 100 mg SC BID
16. Furosemide 20 mg PO DAILY
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
18. Docusate Sodium 100 mg PO BID
19. Lovastatin *NF* 10 mg ORAL DAILY
20. Metoclopramide 10 mg IV Q6H:PRN nausea
21. Multivitamins W/minerals 1 TAB PO DAILY
22. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 700**] - [**Location (un) 701**]
Discharge Diagnosis:
Bladder Cancer, Small bowel obstruction, Atrial fibrillation,
history of aortic valve replacement, sepsis, + MRSA screen, Deep
Vein Thrombosis while on coumadin (noted [**2128-10-5**]), Acute
Kidney injury/ARF (secondary to sepsis), Depression, Stage II
coccygeal ulcer, RIGHT lower extremity rash (possibly tinea,
eczema or psoriasis), Obstructive Sleep Apnea, Anemia (of
chronic disease/multiple surgeries), right testicular pain
(resolved)
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:
-Tylenol should be your first line pain medication. Max daily
Tylenol dose is 4gm. You may also take gabapentin for pain.
-You may shower, but do not immerse incision, no tub
baths/swimming
- Your abdominal incision has been healing nicely. The suture at
the upper most aspect (closest to head) is exposed. Please
protect from accidental trauma (scratching, pulling). Cover with
bandage if necessary.
- Wound to the gluteal area should be dressed per wound care
nurse recommendations and protected from further breakdown.
-If you have fevers > 101.5 F, vomiting, or increased redness,
swelling, or discharge from your incision, call your doctor or
go to the nearest ER
-Please continue with routine management of the ileal conduit.
- Ambulate daily with walker and assistance. OOB to chair.
- Tube feeds will continue for nutritional support
- Continue with Lovenox indefinately as you are NO LONGER
taking Coumadin/Warfarin. You will follow-up with
hematology/oncology.
Followup Instructions:
Please contact Dr.[**Doctor Last Name **] office for follow up in [**1-23**] weeks
time.
Dr.[**Doctor Last Name **] office: ([**Telephone/Fax (1) 4276**]
Multiple specialties were involved in your care. Please follow
up with cardiology, hematology/oncology and psychiatry as
directed.
Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **], Dr [**First Name (STitle) **] [**Name (STitle) 9916**]
(Gastroenterology)
[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 9917**] (Cardiology)
(Psychiatry) [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**] (PCP): [**Telephone/Fax (1) 9918**]
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2129-6-29**]
11:20
[**2128-12-10**] 10:30a [**Last Name (LF) **],[**First Name3 (LF) 569**]
SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
HEMATOLOGY/ONCOLOGY-SC
Completed by:[**2128-10-19**] Name: [**Known lastname 1359**],[**Known firstname 672**] Unit No: [**Numeric Identifier 1360**]
Admission Date: [**2128-8-10**] Discharge Date: [**2128-10-19**]
Date of Birth: [**2054-11-9**] Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1361**]
Addendum:
Included with the discharge summary are the following reports:
PORTABLE TEE [**2128-10-5**]
Chest PA/LAT [**2128-10-17**]
CT ABD/PELVIS w/ contrast [**2128-10-4**]
BILAT Lower Ext Veins [**2128-10-5**]
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 49**] - [**Location (un) 50**]
[**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1362**] MD [**MD Number(1) 1363**]
Completed by:[**2128-10-19**]
|
[
"998.59",
"427.31",
"518.0",
"V42.2",
"995.92",
"608.86",
"453.42",
"707.22",
"285.29",
"298.0",
"V58.61",
"783.0",
"584.9",
"998.12",
"782.1",
"560.9",
"E878.2",
"707.03",
"188.1",
"599.0",
"560.1",
"327.23",
"038.0",
"V02.54",
"997.49",
"401.9",
"486",
"997.2",
"427.1",
"785.52",
"568.0",
"518.81",
"441.2",
"038.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.59",
"99.15",
"96.6",
"96.71",
"40.3",
"46.39",
"57.71",
"88.72",
"56.51"
] |
icd9pcs
|
[
[
[]
]
] |
20138, 20368
|
10596, 15377
|
319, 523
|
17338, 17338
|
2861, 10573
|
18531, 20115
|
1771, 1824
|
15850, 16756
|
16872, 17317
|
15403, 15827
|
17521, 18508
|
1839, 2842
|
265, 281
|
551, 1025
|
17353, 17497
|
1047, 1585
|
1602, 1755
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
1,621
| 157,632
|
9927
|
Discharge summary
|
report
|
Admission Date: [**2193-1-12**] Discharge Date: [**2193-1-19**]
Service: MEDICINE
Allergies:
Penicillins / Ciprofloxacin / Atenolol / Amiodarone /
Diphenhydramine / Neosporin / Tetanus Toxoid,Adsorbed /
Vancomycin / Bactrim Ds / Heparin Agents
Attending:[**First Name3 (LF) 338**]
Chief Complaint:
hemoptysis/hypotension
Major Surgical or Invasive Procedure:
EGD
Bronchoscopy
Left IJ central line
Left Arterial line
intubation
History of Present Illness:
89 year old woman w/ MMP including h/o colon CA and HIT referred
from [**Hospital3 7**] w/ hypotension and hemoptysis. She has
been convalescing at [**Hospital1 **] after recent MICU stay for
urosepsis. Was doing well until 2 days ago, when she developed
hypotension w/ SBP in 80s and low urine output. She was started
on dopamine gtt and treated w/ lasix, but urine output remained
low at 100cc in 24 hours. This AM, she developed hemoptysis w/
suctioning of frank blood from the oropharynx in the setting of
INR 5.8, prompting referral to the [**Hospital1 18**] ED. Before transfer,
she was reportedly treated w/ 2 units FFP and 2.5mg vitamin K.
.
In the ED, she had significant hemoptysis and was intubated for
airway protection. She was transiently hypotensive to nadir of
48/20's while transiently off dopamine. A left fem line was
placed but was complicated by significant groin ecchymosis,
prompting removal of the line and placement of a new right
femoral line. Treatment was continued with dopamine gtt. CT
torso was completed, and she was admitted to the MICU for
ongoing care.
.
Currently, she is intubated and sedated w/ dried blood on her
face, but no frank blood on ETT suctioning
Past Medical History:
CAD s/p left circumflex stent in [**2182**]
COPD
CHF
HTN
Hyperlipidemia
Sick sinus syndrome s/p pacemaker placement [**2188**]
Syncope
PAF
GERD
Diverticulosis of the sigmoid colon
s/p colon resection [**12-28**] colonc cancer
History of VRE in urine and stool
Spinal stenosis
Iron deficiency anemia
Social History:
From [**Hospital **] rehab. h/o smoking. Good family supports.
Family History:
Noncontributory.
Physical Exam:
PE: T 95.6 axillary, BP 135/81, HR 117 irregular, O2 sat 99% on
AC
Gen: morbidly obese woman lying flat in bed, intubated and
sedated
HEENT: anicteric, surgical pupils b/l, OP w/ dried blood and ETT
in place, dried blood over face and chin, no JVD
CV: reg s1/s2, + 2/6 systolic murmur at apex, no s3/s4/r
Pulm: coarse BS throughout, no crackles or wheezes
Abd: obese, +BS, soft, NT
Ext: cool, 2+ pitting edema to thighs and to elbows b/l,
dopplerable but not palpable DP b/l, 10cm ecchymosis at the left
groin w/ no hematoma, right femoral vein TLC in place, scattered
ecchymoses over the arms b/l.
Neuro: sedated, does not respond to commands
Pertinent Results:
EKG: low voltage, afib w/ RVR at 120 bpm, nl axis, nl intervals,
poor R wave progression, no change from prior tracing.
.
CT head: no hemorrhage or midline shift.
.
CT chest: IMPRESSION:
1. Limited examination with poor contrast bolus may be secondary
to poor cardiac function. Additionally, diffuse anasarca and
intra-abdominal ascites suggest volume overload/congestive heart
failure.
2. Patchy airspace consolidation in the left lower and right
lower and right upper lung lobes. Moderate left pleural
effusion.
.
Femoral vascular US: LEFT TARGETED FEMORAL ULTRASOUD: Single
Doppler image of the right greater saphenous vein shows flow,
but with mixed arterial and venous waveforms. This indicates
arterial venous fistula.
,
.
ECHO: The right atrium is moderately dilated. The estimated
right atrial pressure is
16-20 mmHg. There is mild symmetric left ventricular hypertrophy
with normal
cavity size. Regional left ventricular wall motion is normal.
The right
ventricular cavity is dilated. Free wall motion is normal.
[Intrinsic right
ventricular systolic function is likely more depressed given the
severity of
tricuspid regurgitation.] The aortic valve leaflets (3) are
mildly thickened
but aortic stenosis is not present. No masses or vegetations are
seen on the
aortic valve. Trace aortic regurgitation is seen. The mitral
valve leaflets
are mildly thickened. No mass or vegetation is seen on the
mitral valve. Mild
to moderate ([**11-27**]+) mitral regurgitation is seen. The tricuspid
valve leaflets
are mildly thickened. Moderate to severe [3+] tricuspid
regurgitation is seen.
There is moderate pulmonary artery systolic hypertension. There
is no
pericardial effusion.
Compared with the prior study (images reviewed) of [**2192-10-24**],
the findings
are similar.
Labs on Admission: [**2193-1-12**]
WBC-20.7*# RBC-3.14* Hgb-9.4* Hct-29.8* MCV-95 MCH-29.9
MCHC-31.5 RDW-18.8* Plt Ct-157#
.
PT-52.2* PTT-54.9* INR(PT)-6.2*
Glucose-117* UreaN-50* Creat-1.5* Na-137 K-3.5 Cl-105 HCO3-18*
ALT-17 AST-31 LD(LDH)-272* CK(CPK)-55 AlkPhos-354* Amylase-23
TotBili-1.8* DirBili-1.1* IndBili-0.7
Albumin-2.9* Calcium-8.3* Phos-4.6*# Mg-2.1
.
ABG: pO2-75* pCO2-36 pH-7.34* calTCO2-20* Base XS--5
Lactate-2.7*
Brief Hospital Course:
Pt is an 89-yo-woman w/ CAD, CHF, COPD, HTN, HIT, afib w/ pacer,
transferred from [**Hospital3 7**] w/ hemoptysis and
hypotension. Her active issues during this hosp course include:
.
# Resp Failure: Pt was initially intubated for hypoxia from
pneumonia and anasarca affecting wall motion. Over the hospital
course, she showed no improvement and was unable to be weaned
from ventilator. She remained unresponsive despite trials of no
sedation. Ultimately, after many conversations with family, it
was decided that given her extremely morbid prognosis, she would
be CMO. Family was present and actively involved in the
decision making process. On 1:45PM [**1-18**], pt made CMO.
.
# Pneumonia: Prior to this hospitalization, she had been
hospitalized for urosepsis. It was felt that while she was still
recovering from her sepsis, she also developed a pneumonia,
which was supported by elevated WBC and consolidation on CXR.
Lactate 2.7 on admission. TTE negative for vegetation. She was
initially covered with ceftaz (due to numerous Abx allergies)
and linezolid was added after blood cultures grew enterococcus.
Sputum cx positive for MRSA.
.
# Hypotension: Felt to be multifactorial from sepsic shock and
initial possible hemoptysis/blood loss. She continued Levophed
at minimal dosesto keep BP up to facilitate diuresis. Levophed
was unable to be weaned.
.
# Anasarca: She had profound anasarca felt [**12-28**] fluid
resuscitation in recent prolonged ICU course w/ some component
of CHF and hypoalbuminemia. Bumex was used for diuresis.
Unfortunately, she did not respond to daily attempts at diuresis
and limiting factors included worsening renal function and
hypotension.
.
# OP bleeding/Hemoptysis: Initially, there was concern for
hemoptysis given presentation of blood in ETT. However, bronch
revealed lack of endobronchial lesions, no active bleeding, and
adherent clot visible in right middle lobe. Ultimately, it was
felt to be actually related to an upper/oropharyngeal cause from
suctioning and mouth care in setting if high INR. NG lavage was
indeterminate. GI [**Month/Day (2) 4221**] EGD revealed erosive gastritis but
no active bleeding. ENT was curbsided and recommended watch
until INR normalizes, most likely [**12-28**] friable tissue/trauma from
intubation/suctioning. After INR improved and suctioning
decreased, bleeding stopped.
.
# HIT: h/o positive HIT Ab, but negative serotonin release
assay. On coumadin for the past 6 weeks for treatment; no h/o
thrombus in this setting. Risk of bleeding outweighs the risk of
thrombosis from HIT at this time.
.
# Renal failure: baseline 1.3. Has been 1.6-1.7 range this hosp
course. most likely from prerenal azotemia w/ possible component
of ATN after hypotension.
.
# COPD: controlled w/ advair, combivent INH, and prn albuterol
.
# Atrial fib: She had no active issues during this admission.
She maintained reasonably rate controlled despite stopping her
outpatient metoprolol for hypotension.
.
# Proph: pneumoboots, PPI
.
# Access:
- Left IJ
- left A-line
- a femoral line was attempted; however, complicated by AV
fistula. This was removed and evaluated with U/S.
Medications on Admission:
warfarin 2 mg qhs
Toprol XL 25 mg qday
Isosorbide mononitrate 60 mg qday
Lipitor 10 mg daily
Lasix 40 mg po bid
Atarax 10 mg po q6 prn
Fexodenadine 60 mg qday
Fluticasone/salmeterol 500/50 1 puff [**Hospital1 **]
Combivent inhalers- three times a day
Pantoprazole 40 mg [**Hospital1 **]
Pepcid 20 mg [**Hospital1 **]
Darbepoetin alpha 60 mcg qc qweek
Ferrous sulfate 325 mg [**Hospital1 **]
Tylenol 650 mg q6 prn
Bisacodyl 10 mg qday
MOM
[**Name (NI) 33274**] 1200 mg [**Hospital1 **]
Colace 100 mg [**Hospital1 **]
Potassium chloride 20 mEq qday
Discharge Medications:
N/A
Discharge Disposition:
Expired
Discharge Diagnosis:
expired
Discharge Condition:
expired
|
[
"584.9",
"287.4",
"286.9",
"428.0",
"E879.8",
"997.2",
"995.92",
"518.81",
"E934.2",
"V53.31",
"482.41",
"496",
"447.0",
"255.4",
"038.0",
"786.3",
"V09.91",
"427.31",
"535.40"
] |
icd9cm
|
[
[
[]
]
] |
[
"96.72",
"00.17",
"96.04",
"99.04",
"33.24",
"99.07",
"96.6",
"00.14",
"38.93",
"45.13"
] |
icd9pcs
|
[
[
[]
]
] |
8798, 8807
|
5028, 8172
|
380, 449
|
8858, 8868
|
2794, 2916
|
2096, 2114
|
8770, 8775
|
8828, 8837
|
8198, 8747
|
2129, 2775
|
318, 342
|
477, 1674
|
2925, 4577
|
4591, 5005
|
1696, 1997
|
2013, 2080
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
20,824
| 173,849
|
28040
|
Discharge summary
|
report
|
Admission Date: [**2186-2-8**] Discharge Date: [**2186-2-17**]
Date of Birth: [**2124-9-2**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 603**]
Chief Complaint:
Fever, Altered Mental Status
Major Surgical or Invasive Procedure:
PEG tube
History of Present Illness:
61 y/o man with history of etoh abuse, dementia, DM, CAD, CHF,
living in extended care presenting with reports of fever, cough,
and lethargy x several days. Per reports, has had decreased
verbalization. Was febrile on AM of admission and labs drawn @
[**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] were notable for WBC 2.7, K+ 5.4.
.
In ED: was febrile to 101.2 and received Vanc/Levo/Flagyl/CTX.
CXR withoutu infiltrate or effusion. Blood/urine cultures sent
and LP performed with 1WBC, 1RBC. EKG with J-point elevation and
first set CE negative. LFTs within normal limits. CT head with
stable old frontal encephalomalacia, generalized atrophy, and
stigmata of chronic ischemic changes. During ER work-up patient
missed many of his daily medications and became markedly
hypertensive to 230s systolic. Multiple medications were given
including hydral 10mg IV x 1, 60mg po x 1, isosorbide 40mg po x
1, lopressor 5mg IV x 2, and lopressor 150mg po x 1 and he was
ultimately placed on labetalol gtt and transfered to the unit.
Past Medical History:
# Alcohol Abuse
# Cirrhosis
# Dementia
# CAD - Cardiac Cath [**Hospital2 **] [**Hospital3 6783**] Hosp [**2184**] w/3VD
# CHF - echo @ [**Hospital1 18**] [**2184**] w/EF 20-25% with both systolic and
diastolic dysfunction
# Right Hip Fracture s/p ORIF [**2184**] @ [**Hospital1 18**]
# PEG [**2184**] @ [**Hospital1 18**] [**2-25**] fialed s/s, pt self d/c'd [**9-/2186**]
# Chronic renal insufficiency (Cr ~ 1.9 at outside facility)
# Diabetes, on Insulin
# Hepatitis C
# Hypertension
# Seizure disorder, on dilantin
# Prior cocaine abuse
Social History:
Current resident @ [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] Nursing Home in [**Location (un) **].
further history per previous notes such as prior etoh and
substance abuse.
Family History:
Noncontributory
Physical Exam:
98.8 109 193/112 97% on 2LNC
Gen: somnolent, opens eyes slowly, but does not follow other
comands. Sat up when foley placed and asked "what are you doing"
HEENT: Poor Dentition, moist mucus membranes
NECK: Supple, trachea midline. Jugular vein not prominent
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: coarse breath sounds bilaterally, hoarse gurggling in
upper airway.
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO EXAM: does not follow commands. Pupils are dilated but
equal bilaterally. No increased tone and moves all extremities
spontaneously.
Pertinent Results:
[**2186-2-8**] 09:45AM PT-13.3 PTT-31.3 INR(PT)-1.1
[**2186-2-8**] 09:45AM PLT COUNT-142*
[**2186-2-8**] 09:45AM NEUTS-75.1* LYMPHS-17.8* MONOS-4.9 EOS-1.6
BASOS-0.5
[**2186-2-8**] 09:45AM WBC-5.8 RBC-4.02*# HGB-12.3*# HCT-38.0*#
MCV-95# MCH-30.7 MCHC-32.5# RDW-12.9
[**2186-2-8**] 09:45AM CALCIUM-8.9 PHOSPHATE-3.4 MAGNESIUM-2.0
[**2186-2-8**] 09:45AM CK-MB-3
[**2186-2-8**] 09:45AM cTropnT-0.04*
[**2186-2-8**] 09:45AM CK(CPK)-161
[**2186-2-8**] 09:45AM estGFR-Using this
[**2186-2-8**] 09:45AM GLUCOSE-115* UREA N-31* CREAT-1.8* SODIUM-138
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-24 ANION GAP-11
[**2186-2-8**] 09:49AM LACTATE-1.0
[**2186-2-8**] 12:25PM URINE WBCCLUMP-RARE
[**2186-2-8**] 12:25PM URINE RBC-21-50* WBC-0-2 BACTERIA-RARE
YEAST-NONE EPI-0-2
[**2186-2-8**] 12:25PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-8* PH-7.0
LEUK-NEG
[**2186-2-8**] 12:25PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.021
[**2186-2-8**] 07:20PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1*
POLYS-10 LYMPHS-72 MONOS-18
[**2186-2-8**] 07:20PM CEREBROSPINAL FLUID (CSF) PROTEIN-68*
GLUCOSE-74
[**2186-2-8**] 08:15PM PLT COUNT-105*
[**2186-2-8**] 08:15PM NEUTS-84.1* LYMPHS-11.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2186-2-8**] 08:15PM WBC-7.1 RBC-3.94* HGB-12.5* HCT-37.5* MCV-95
MCH-31.6 MCHC-33.2 RDW-12.8
[**2186-2-8**] 08:15PM NEUTS-84.1* LYMPHS-11.3* MONOS-3.9 EOS-0.6
BASOS-0.2
[**2186-2-8**] 08:15PM WBC-7.1 RBC-3.94* HGB-12.5* HCT-37.5* MCV-95
MCH-31.6 MCHC-33.2 RDW-12.8
[**2186-2-8**] 08:15PM AMMONIA-<6
[**2186-2-8**] 08:15PM CALCIUM-8.5 PHOSPHATE-3.4 MAGNESIUM-1.7
[**2186-2-8**] 08:15PM CK-MB-4
[**2186-2-8**] 08:15PM cTropnT-<0.01 proBNP-[**2157**]*
[**2186-2-8**] 08:15PM LIPASE-37
[**2186-2-8**] 08:15PM ALT(SGPT)-21 AST(SGOT)-26 CK(CPK)-151 ALK
PHOS-73 TOT BILI-0.6
[**2186-2-8**] 08:15PM GLUCOSE-174* UREA N-29* CREAT-1.6* SODIUM-140
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-23 ANION GAP-16
.
AT DISCHARGE
.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2186-2-17**] 06:44AM 4.1 3.25* 10.3* 30.2* 93 31.5 34.0 12.4
111*
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas
Myelos
[**2186-2-9**] 02:40AM 61 19* 8* 9 0 0 3* 0 0
[**2186-2-9**] 02:40AM 82.4* 0 12.0* 4.7 0.3 0.6
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2186-2-9**] 02:40AM NORMAL NORMAL NORMAL NORMAL NORMAL NORMAL
BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct
INR(PT)
[**2186-2-17**] 06:44AM 111*
[**2186-2-17**] 06:44AM 13.11 40.8* 1.1
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2186-2-17**] 06:44AM 132* 15 1.2 135 3.7 107 21* 11
ESTIMATED GFR (MDRD CALCULATION) estGFR
[**2186-2-15**] 09:50AM Using this1
DIL,PEP ADDED 12:15PM
1 Using this patient's age, gender, and serum creatinine value
of 1.3,
Estimated GFR = 56 if non African-American (mL/min/1.73 m2)
Estimated GFR = 68 if African-American (mL/min/1.73 m2)
For comparison, mean GFR for age group 60-69 is 85 (mL/min/1.73
m2)
GFR<60 = Chronic Kidney Disease, GFR<15 = Kidney Failure
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2186-2-17**] 06:44AM 13 20
.
[**2186-2-8**] KUB: No evidence of obstruction or free air.
..
[**2186-2-8**] CXR: No evidence of pneumonia.
.
[**2186-2-9**] CXR: Worsening opacification at the bases which may
represent atelectasis or new early pneumonia, as well as small
effusions. Recommend close attention on followup radiographs.
.
[**2186-2-10**] CXR: In comparison with the study of [**2-9**], the right
base is somewhat clearer than on the previous study and the
minimal opacification above it most likely represents merely
atelectatic change. Opacification at the left base in the
retrocardiac region is again seen consistent with atelectasis.
Probable left pleural effusion as well. The upper lung zones are
within normal limits.
.
[**2186-2-14**] RENAL ULTRASOUND
.
61 year old man with Hypertensive Urgency. Please evaluate for
renal artery stenosis
REASON FOR THIS EXAMINATION:
Renal artery stenosis
HISTORY: 61-year-old male with hypertensive urgency, concern for
renal artery stenosis.
RENAL ULTRASOUND WITH DOPPLER: Grayscale, color, and pulse
Doppler son[**Name (NI) 1417**] of both kidneys were performed. Both kidneys
are normal in grayscale appearance, with the right kidney
measuring 10.8 cm and the left kidney 11.1 cm. There is no
evidence of hydronephrosis, stones, or solid renal mass. Doppler
evaluation demonstrates patency of the bilateral main renal
arteries and veins. There are appropriate waveforms
demonstrated. Intrarenal resistive indices of the right kidney
range from 0.66 to 0.71 and on the left from 0.70 to 0.73.
IMPRESSION: Unremarkable renal ultrasound. Patent renal
vasculature. No definite evidence of renal artery stenosis.
.
[**2186-2-9**] CT ABDOMEN AND PELVIS
.
CT ABDOMEN: Visualized lung bases show patchy areas of dependent
airspace opacity that is heterogeneous. There are a few areas of
bronchiectasis in the lower lobes. There is no pleural or
pericardial effusion. Cardiomegaly is unchanged.
Absence of intravenous contrast limits evaluation of the
abdominal parenchymal organs and vasculature. Liver is nodular
and shrunken, unchanged from prior exam, and consistent with
history of cirrhosis. No focal intrahepatic mass or biliary
ductal dilatation. There is no ascites. Gallbladder, pancreas,
spleen, adrenal glands, kidneys, stomach and intra-abdominal
loops of bowel demonstrate normal non-contrast appearance. There
is no free air or free intraperitoneal fluid. There is no
abnormal intra-abdominal lymphadenopathy.
CT PELVIS: Foley catheter balloon is in place within a
decompressed bladder. Pelvic loops of large and small bowel are
unremarkable. There is no free pelvic fluid or abnormal pelvic
or inguinal lymphadenopathy.
There is moderate atherosclerotic calcification of the abdominal
aorta and its branches, without focal dilatation.
OSSEOUS STRUCTURES: Old right femoral fracture fixed with
dynamic hip screw is unchanged. Old fractures of the left
inferior pubic ramus and left pubic symphysis also unchanged.
Compression deformity of the superior endplate of L3 is
unchanged.
IMPRESSION:
1. No acute process in the abdomen or pelvis.
2. Bilateral lower lobe airspace opacities raise concern for
recent aspiration or pneumonia superimposed on chronic lung
disease with areas of bronchiectasis.
3. Unchanged cirrhotic liver.
.
CT HEAD WO CONTRAST [**2186-2-8**]
.
CT HEAD WITHOUT INTRAVENOUS CONTRAST: There is an unchanged area
of cystic encephalomalacia within the left frontal lobe. There
is stable prominence of the ventricles and sulci consistent with
atrophic change. Periventricular and subcortical white matter
hypodensity presumably represents chronic microvascular ischemic
change. There is no evidence for major or minor vascular
territorial infarct, acute hemorrhage, shift of normally midline
structures or hydrocephalus. No fractures are identified. There
is opacification of several anterior ethmoid air cells and mild
thickening within the frontal sinuses. The visualized mastoid
air cells and middle ear cavities are normally pneumatized and
aerated. Again seen is a 13 x 5 mm lipoma along the paramedian
right occipital subcutaneous tissues.
IMPRESSION:
1. No intracranial hemorrhage or mass effect. Stable area of
encephalomalacia in the left frontal lobe which may represent
sequela of old trauma or infarct.
2. Stable moderate atrophy and chronic changes of microvascular
ischemia.
MRI is more sensitive than CT for detection of acute ischemia.
Brief Hospital Course:
Mr. [**Known lastname 1169**] is a 61 y/o man with a history of DM, Etoh abuse,
Dementia, CAD, CHF who presented with fever, altered mental
status, and hypertension.
.
# Fever/Altered Mental status: Considered due to hypertensive
encephalopathy as well as sedation from several psychotropic
drugs. All cultures were negative including influenza DFA. Hie
mental status cleared progressively back to baseline. He
benefited from stopping Ativan and starting 50 mg Provigil
daily.
.
# Hypertension: Initially it was very poorly controlled, >200s,
requiring labetalol/nitro gtt, then transitioned to nitro paste.
He converted to topical and oral medications within 48 hours. He
persistently had somewhat elevated BP and his regimen slowly
adjusted. His ACE inhibitor has been increased, currently at 20
mg/day with improved control, this might be increased further if
necessary. Renal US negative for renal artery stenosis. He will
need to have his BP monitored and medications adjuested if
necessary.
.
# Nausea/vomiting: LFTs within normal limits. Given antiemetics
and the symptoms resolved. Hepatitis serologies have been sent,
results pending at time of discharge.
.
# Chronic Systolic and Diastolic Heart Failure: He had increased
frothy secretions initially, but CXR was without evidence of
pulmonary edema. He has a jugular vein that moves with pulse,
but is not particularly distended. He is euvolemic. He required
no diuresis. These might have been oral secretions in view of
his dysphagia. Secretions resolved prior to discharge. He will
require comfort mouth care.
.
# Chronic Renal Failure with Proteinuria: Chronic hypertensive
disease and diabetic nephropathy, with some component of
prerenal azotemia that responded to gentle hydration
.
# Cirrhosis: Secondary to etoh abuse and hepatitis C. No
coagulopathy or stigmata of decompensation. LFTs remained
normal. Some hepatitis serologies pending as stated above.
.
# History of Seizure Disorder: Unkown details, note made in med
book from [**First Name4 (NamePattern1) 3504**] [**Last Name (NamePattern1) **] that keppra is discontinued, or held for
now. He came on dilantin but his level was 0.6. He was loaded
with one gram and subsequently placed on his regimen of 100 mg
TID. He will need a level drawn within 2-3 weeks.
.
DNR DNI
Medications on Admission:
Metoprolol 150mg po BID
Hydralazine 60mg po Q6Hours
Terazosin 2mg po Qday
Isosorbide 40mg po TID
Remeron 15mg po Qhs
Donepezil 10mg po QHS
Trazadone 25mg po BID
Lorazepam 0.5mg po Qday @ 7am
Lorazepam 0.5mg po Q4h prn anxiety/agitation
Glargine 10 Units po Qday
Regular Insulin Sliding Scale [**Hospital1 **] 4-10 units
Ranitidine 150mg po BID
Albuterol 2puffs po BID prn
Keppra 500mg po Qday (but note made to hold)
Immodium prn
Senna
Dulcolax prn
Milk of Magnesia prn
Discharge Medications:
1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever or pain.
3. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig:
[**1-25**] inh Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
4. Terazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
9. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
10. Hydralazine 50 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
12. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
14. Modafinil 100 mg Tablet Sig: 0.5 Tablet PO daily am ().
15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours): For
one month. Then switch to one tablet 40 mg daily.
16. Phenytoin 100 mg/4 mL Suspension Sig: Four (4) mL PO TID (3
times a day).
17. Insulin sliding scale if needed (attached)
usually [**Hospital1 **] 4-10 units
18. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. Zofran 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
20. glargine Sig: Ten (10) units once a day.
Discharge Disposition:
Extended Care
Facility:
[**Hospital1 2670**] - [**Location (un) 2716**] House - [**Hospital1 1559**]
Discharge Diagnosis:
Hypertensive urgency
Dementia
Fever
Discharge Condition:
Good. Tolerating tube feeds. Pain free. Baseline mental status
Discharge Instructions:
Admitted with hypertensive urgency with mental status changes.
This has been getting under control with medication.
.
A PEG tube was started for nutrition, goal 60 cc/hour.
Tolerating well.
.
Started on provigil for alertness and depression.
.
Please adhere to medication regimen and f/u with doctors as
written below.
Followup Instructions:
With Dr [**Last Name (STitle) 5762**] within 1-2 weeks of discharge. Phone nr [**Telephone/Fax (1) 40619**]
Please call a GI doctor if any issues with PEG , phone nr [**Numeric Identifier 68258**]
|
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"585.9",
"403.90",
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"584.9",
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icd9cm
|
[
[
[]
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] |
[
"43.11",
"96.6",
"45.13",
"03.31"
] |
icd9pcs
|
[
[
[]
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15222, 15325
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10590, 10774
|
341, 352
|
15405, 15470
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2891, 6980
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380, 1429
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1451, 1993
|
2009, 2212
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
48,974
| 155,902
|
37453
|
Discharge summary
|
report
|
Admission Date: [**2172-2-13**] Discharge Date: [**2172-3-15**]
Date of Birth: [**2111-11-21**] Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending:[**First Name3 (LF) 1384**]
Chief Complaint:
Right lower extremity ulcer while being listed for liver
[**First Name3 (LF) **]
Major Surgical or Invasive Procedure:
[**2172-2-16**]: paracentesis
[**2172-2-17**]: exploratory laparotomy for pneumoperitoneum
[**2172-2-17**]: exploratory laparotomy for continuing bleeding
[**2172-2-18**]: Exploratory laparotomy, xxtended right colectomy,
abdominal packing.
[**2172-2-20**]: Washout, resection of terminal ileum, maturation
of ileostomy, and abdominal closure.
[**2172-2-25**]: percutaneous cholecystostomy tube placement
History of Present Illness:
60 year old male with a history of HCV cirrhosis complicated by
ascities, grade II varices, encophalopathy, SBP, currently being
listed for liver [**Year (4 digits) **], who was evaluated in clinic by Dr.
[**Last Name (STitle) 497**] on [**2172-2-13**] and directedly admitted for evaluation of his
right lower extremity ulcer. Patient notes that he has been
having chronic swelling for the past year. He does not think it
is acutely worse, but does think it has been getting gradually
worse for the past 5-6 months. He has been adherent to his salt
intake (aprox 1200mg per day) and fluid restriction (<2L per
day). He has gradually noted that his foot has been weeping.
He is unsure how long he has had an open wound, but it has been
present for at least a week. A visiting nurse noted it one day
prior to admit and called [**Date Range **] office for visit. In
clinic visit on [**2-13**] his foot was noted to be cold and with an
open wound. He was directly admited to the [**Month/Year (2) **] floor for
vascular evaluation.
.
Of note patient had a recent admit for shoulder pain. He was
discharged at the end of [**2171-12-28**].
.
Review of sytems:
(+) Per HPI. +nausea, no emesis. 10 lbs weight loss over two
weeks, but over past 6 months total weight gain of 20lbs.
Diarrhea with lactulose.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness, palpitations. Denied
vomiting, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
.
On floor, patient was without complaints. Notes that he is at
his baseline pain of [**4-5**].
Past Medical History:
- Chronic hepatitis C virus infection
* genotype III
* diagnosed [**2154**], after he donated blood to American Red Cross
- Cirrhosis
* liver biopsy [**2157**], results unknown
* complicated by portal hypertension, ascites, peripheral edema,
thrombocytopenia, grade 2 esophageal varices on EGD ([**9-/2170**]),
SBP on daily cipro, encephalopathy manifested as memory loss
- hypertension
- asthma
- s/p cervical laminectomy at [**Hospital6 2910**] [**2166**]
- s/p angioplasty [**2154**]
- s/p left shoulder arthroscopy [**2165**]
- s/p abdominoplasty
- colonic polyps s/p removal [**9-/2171**]
- Prior psychologist: Dr. [**Last Name (STitle) 84158**], on bupropion, Klonipin
Social History:
-Former Marine
-Brother is primary caregiver
-[**Name (NI) 3003**] hx of tobacco, occasional alcohol, remote cocaine &
marijuana use. No current use of ETOH, tobacco, illicits.
Family History:
(per OMR)
- Father died from complications of a cerebral aneurysm, also
had premature coronary artery disease and obesity
- Mother died from complications of COPD, having been a heavy
cigarette smoker
- Brother is overweight, no other medical illnesses
Physical Exam:
Admission Exam:
.
VS - Temp 96.0 F, BP 106/58, HR 95, R 20, O2-sat 100% RA
Gen: sitting upright in bed, pleasant, no acute distress,
alert and oriented x3, good attention
Cardiac: RRR, normal S1, S2, diffuse systolic murmur ("had since
childhood")
Pulm: unlabored breathing, CTAB
Abd: moderately distended, + ascites, normoactive bowel sounds,
no tenderness
NEURO: CN II-XII grossly intact, strength 5/5 throughout,
sensation intact in lower extremities bilaterally, slightly
decrased on RLE relative to [**Name (NI) **]
[**Name (NI) **]: bilateral swollen lower extremities with erythema to the
mid shins; 1 x 1 cm ulcer on dorsal surface of right foot with
suppurative drainage; dopplerable pulses in bilateral lower
extremities; ABI 1.09
.
Pertinent Results:
Admission Labs: [**2172-2-13**]
11.1 >---< 66
31.4
128 | 94 | 23
-------------< 122
4.6 | 24 | 1.2
Ca 8.9, Mg 2.1 PHos 3.0
ALT/AST 130/163
LDH 410
AP 119
Tbil 4.9
RUQ U/S ([**2172-2-15**]):
Targeted son[**Name (NI) 867**] in all four quadrants reveals a small to
moderate amount of ascites throughout the abdomen, with the
largest pocket
seen in the left lower quadrant. Small to moderate ascites.
CT Abdomen ([**2172-2-16**]):
IMPRESSION:
1. Extensive pneumoperitoneum out of proportion to expected from
that of a
paracentesis. Recommend clinical correlation, and surgical
consultation. If further imaging is deemed necessary, CT with
intravenous and oral contrast (Gastrografin) can be performed to
evaluate for visceral injury.
2. Known cirrhotic liver. Known sequelae of portal hypertension
with
splenomegaly, varices and moderate-to-large amount of simple
intra-abdominal ascites. No high attenuation to suggest
hemoperitoneum.
3. No evidence of hematoma adjacent to the paracentesis entry
site.
RUQ US ([**2172-2-23**]):
IMPRESSION:
1. Lack of wall-to-wall color flow within the left portal vein,
which could indicate either slow flow or nonocclusive thrombus.
Correlation with CT or MR could be obtained for further
evaluation. Hepatofugal flow is identified within the left
portal vein.
2. Remaining hepatic vasculature is patent with normal
waveforms.
3. Cirrhosis with splenomegaly.
4. Small right pleural effusion.
5. Distended gallbladder with a stone within the gallbladder
neck and
gallbladder wall thickening. Findings may represent acute
cholecystitis in
the correct clinical setting, and further evaluation with HIDA
scan can be
obtained.
HIDA scan ([**2172-2-23**]): Serial images over the abdomen show
undetectable uptake of tracer into the hepatic parenchyma after
60 minutes. The study is therefore non-diagnostic.
Bilateral LE Duplex ([**2172-2-24**]):
IMPRESSION:
1. Deep venous thrombus of the right posterior tibial vein. The
remainder of the right lower extremity venous system is patent.
2. No DVT in the left lower extremity.
RUQ US ([**2172-2-25**]): Continued distention of the gallbladder.
Acute cholecystitis cannot be excluded and plans are being made
for percutaneous cholecystostomy
CT A/P ([**2172-2-28**]):
IMPRESSION:
1. Limited study without IV contrast but no evidence of
hydroureteronephrosis or renal calculi.
2. Diffusely thickened jejunal wall, non-specific, likely third
spacing.
3. No small-bowel obstruction. Percutaneous cholecystostomy
drain in situ.
Interval decrease of small ascites. No drainable fluid
collection.
4. Cirrhotic liver and splenomegaly. Numerous porta hepatis,
celiac and
mesenteric nodes.
5. Moderate generalized anasarca.
6. Right basilar subtotal atelectasis. Patchy nodular opacity in
the right
lower lobe, non-specific, but cannot exclude infectious process.
RLE Duplex ([**2172-2-28**])
IMPRESSION:
Unchanged deep vein thrombosis seen in one of the two right
posterior tibial veins which has not propagated.
Brief Hospital Course:
Last update [**2172-3-6**]:
60 year old male with a history of HCV cirrhosis complicated by
ascities, grade II varices, encophalopathy, SBP, was being
listed for liver [**Month/Day/Year **], who was evaluated in clinic by Dr.
[**Last Name (STitle) 497**] on [**2172-2-13**] and directedly admitted to medical service for
evaluation of his right lower extremity ulcer. Patient was
evaluated by Vascular surgery and found to have no vascular
compromise and was recommended to have his leg ace-wrapped,
elevated to reduce edema.
On [**2172-2-16**], patient underwent a bedside paracentesis by medical
team. 2.5L of clear fluid was withdrawn. Patient developed
abdominal pain and shaking chills after the procedure and his
Hct decreased to 23.4 from 27.7. The abdomen was also found to
be more distended despite the removal of 2.5L of ascites. A CT
scan of his abdomen showed free intraperitoneal air. [**Date Range 1326**]
surgery was consulted and the patient was emergently taken to
the operating room for exploratory laparotomy. In the operating
room, the right colon, where the paracentesis had been done, was
found to have a small area of serosal tear which looked like a
sealed perforation. The area was repaired and a drain was
placed. He was also found to be extremely coagulapathic and
thrombocytopenic with a number of areas that were oozing.
SurgiNet was placed which seemed to stop the bleeding. The
patient was then transferred to the SICU where he was continued
to be resuscitated with blood products, crysalloid and colloid.
It was evident in the SICU that his drain continued to put out
large amount of sanguious fluid and patient was hemodynamically
unstable. The decision was made to brought the patient back to
the operating for relook and control of hemorrhage. The patient
was found to have extensive oozing so his abdomen was packed and
left open, transferred to SICU.
On [**2172-2-18**], a day after his second exploratory laparotomy, he
was taken back to the OR for washout of the abdomen. His right
colon was found to have several areas of patchy necrosis. An
extended R colectomy was performed with mobilization of the
hepatic flexure. He was left in discontinuity and transferred
back to SICU for ongoing resuscitation. On [**2172-2-20**], the patient
was again brought back to the OR. The TI was resection, ostomy
was matured, and abdomen was closed. He was left intubated and
transferred back to the SICU for management. Due to his
coagulopathy, the patient continued to receive blood products
along with with his resusciating fluids and pressors.
Patient's total bilirubin rose from baseline of 4.7 on [**2-13**] to
21.9 after his closure of the abdomen. His level continued to
rise and an RUQ US on [**2-23**] showed gallbladder edema with stone
at the neck. HIDA scan was non-diagnostic. A Dobbhoff tube was
placed but was unable to advance post-pylorus on multiple
attempts by IR.
Patient was succesfully extubated on [**2-23**]. His RLE was noted to
be swollen and LENI showed PT DVT. He was not anticoagulated
because of his coagulopathy. Vascular consult was obtained and
recommended follow up LENI, which showed no change on [**2-28**].
On [**2172-2-25**], patient's WBC increased to 17K. The decision was made
to place a percutaneous cholecystostomy. Bile fluid was sent for
culture which was negative for growth. During this course,
patient continue to receive blood products (pRBC, FFP, plts) and
albumin. His drain output and perc cholecystomy tube continue to
drain high volume, which gave him negative fluid balance. His
pressors were weaned off. His peritoneal fluid and sputum
cutlure obtained on [**2-23**] grew out yeast (C. albicans) and
patient was started on Fluconazole on [**2-26**]. His urine culture on
[**2-27**] grew [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] and his antifungal was switched to
micafungin on [**3-1**]. Due to nutritional requirement, his TF was
started via the Dobbhoff (not post-pylorus) on [**2-29**] and advanced
to goal. The Dobbhoff was advanced to post-pylorus by hepatology
on [**3-2**].
On [**3-4**], patient was noted to have increased abdominal
distention, decreased hct and evidence of UGIB. Endoscopy by
hepatology showed "esophageal varices, blood in the stomach,
abnormal mucosa in the stomach, ulcers in the lower third of the
esophagus". Esophageal varices was banded and patient was
started on octreotide. The Dobbhoff tube was also removed.
Patient abdomen continued to be distended and his ostomy output
decreased. KUB on [**3-5**] showed unchanged small bowel dilation,
worsening bowel wall edema. Patient had increased work of
breathing on [**3-6**]. CXR showed "slightly increased vascular
diameter, suggesting mild overhydration" and furosemide gtt was
started. Abdominal fluid was tapped by IR for diagnostic purpose
which showed persistent SBP. Albumin 5% (500ml TID) was switched
to 25% (12.5g TID) to decrease fluid intake. No longer
havingmelena, started midodrine
[**3-6**]: Pt had an U/S guided tap of fluid, started lasix gtt and
swtiched to 25% albumin crystalloid off, resp distress w fluid
overload, NPO (minimal ostomy output), 1U FFP with US guided
tap. Started lasix gtt, IVF chenged to 25% albumin
[**Date range (1) 84162**]: Per hepatotology recs: started linezolid (for VRE
coverage), cont octreotide, started on TPN [**3-9**]. Treated
hypernatremia by decreasing Na in TPN and meds and needed free
water for a few days. Lasix gtt stopped. He had a repeat CT
torso and EGD on [**3-10**] for another epsisode of GI bleeding.
Varices were banded/glued and he was cont'd on a ocreotide and
left intubated given the significant transufion requirement from
his GI bleed. A BAL/bronch was performed as well to rule out
pneumonia as a cause of sepsis. Per report his airways looked
good and the BAL was negative. On [**3-12**] renal was consulted for
CVVH intitiation. He had an HD line (left Mahurkar) placed with
signif EBL. 4FFP + 1 Plt + 2 PRBC's. CVVH initiated. He
continued to require daily transfusion ([**3-13**]: 4u FFp, 2plt, 1
cryo; [**3-14**]: 1u PRBC). A multidisciplinary discussion was had
and it was decided that he would be taken to the OR on [**3-15**] for
attempted washout as a last effort in helping this patient.
Unfortunately in the OR he had diffuse bleeding throughout as
his abdomen was being opened and he was closed with drain placed
and he was returned to the SICU to be CMO per discussions with
the family. Again, ongoing discussion with the patients family
and HCP have been had and it was decided to make him CMO.
Patient expired several hours later.
Medications on Admission:
1. Ciprofloxacin 250 mg PO once a day
2. Bupropion HCl 150 mg Sustained Release daily
3. Rifaximin 550 mg [**Hospital1 **]
4. Lidocaine 5 %(700 mg/patch) daily
5. Folic acid 1 mg daily
6. Pravastatin 10 mg qHS
7. Omeprazole 40 mg daily
8. Testosterone 5 mg/24 hr TD patch (at home pt uses gel)
9. Fluticasone-salmeterol 500-50 mcg/dose Disk [**Hospital1 **]
10. Lactulose 30ml TID
11. Tolvaptan 15 mg daily
12. Albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler
13. Furosemide 80 mg Tablet daily
14. Spironolactone 200 mg daily
15. Aspirin 81 mg daily
16. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H
17. Gabapentin 100 mg [**Hospital1 **]
18. Magnesium oxide 400 mg daily
19. Thiamine HCl 100 mg daily
20. Multivitamin daily
21. Vitamin D 1,000 unit daily
22. Lorazepam 0.5 mg [**Hospital1 **] prn anxiety
23. Cyclobenzaprine 10 mg qHS
Discharge Medications:
CMO
Discharge Disposition:
Expired
Discharge Diagnosis:
CMO - expired
Discharge Condition:
CMO - expired
Discharge Instructions:
CMO - expired
Followup Instructions:
CMO - expired
|
[
"E870.5",
"584.5",
"276.69",
"275.42",
"572.3",
"V15.82",
"456.20",
"453.42",
"070.44",
"567.23",
"537.89",
"286.7",
"401.9",
"682.7",
"276.0",
"276.1",
"E849.7",
"112.89",
"285.1",
"789.59",
"V49.87",
"493.20",
"707.15",
"998.0",
"V49.83",
"998.2",
"557.0",
"571.5",
"287.5",
"263.9"
] |
icd9cm
|
[
[
[]
]
] |
[
"54.91",
"39.95",
"96.6",
"96.04",
"46.75",
"33.24",
"45.13",
"99.15",
"00.14",
"46.20",
"45.73",
"96.72",
"38.95",
"51.01",
"54.12",
"42.33",
"45.62"
] |
icd9pcs
|
[
[
[]
]
] |
15081, 15090
|
7515, 14149
|
385, 792
|
15147, 15162
|
4491, 4491
|
15224, 15240
|
3457, 3712
|
15053, 15058
|
15111, 15126
|
14175, 15030
|
15186, 15201
|
3727, 4472
|
265, 347
|
1983, 2546
|
820, 1965
|
4507, 7492
|
2568, 3246
|
3262, 3441
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
9,054
| 117,653
|
3448
|
Discharge summary
|
report
|
Admission Date: [**2102-2-8**] Discharge Date: [**2102-2-27**]
Date of Birth: [**2031-8-15**] Sex: M
Service: [**Last Name (un) 7081**]
HISTORY OF PRESENT ILLNESS: This is a 70 year old male with
Stage 2A esophageal cancer status post chemo and radiation
treatment. Also of note, this patient has myasthenia [**Last Name (un) 2902**]
status post thymectomy and apheresis, transient ischemic
attack in the past, silent myocardial infarction in [**2092**],
hematuria and rosacea. The patient is admitted at this time
for planned laparoscopic and thoracoscopic
esophagogastrectomy to be performed by Dr. [**Last Name (STitle) **] and Dr.
[**Last Name (STitle) 952**]. Mr. [**Known lastname 4427**] has a history of developing regurgitation
that began in [**2101-7-31**] that was associated with
dysphagia without odynophagia and in addition, lost 15 lb.
over the months following [**2101-7-31**]. He had a barium
swallow which showed a 3 cm polypoid mass in the distal
esophagus. Biopsy and esophagoscopy by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 15908**]
confirmed esophageal carcinoma. An infiltrative, fungated and
partially obstructing nonbleeding 5 cm mass was seen at the
lower third of the esophagus. On endoscopic ultrasound, it
extended through the muscularis propriate consistent with a
T3 lesion. No other areas were PET positive.
PHYSICAL EXAMINATION: On admission, weight was 206 lb.,
pulse 81, blood pressure 134/81, temperature 97.5 degrees F.,
O2 saturation 97 percent with a respiratory rate of 14
breaths per minute. Generally, this was a well-appearing male
in no acute distress. Oropharynx was moist and clear with no
mucositis or thrush. Sclerae were anicteric. Extraocular
motions were intact. Neck was supple with no lymphadenopathy
cervically or supraclavicularly and there was no
infraclavicular lymphadenopathy as well. The heart was in
regular rate and rhythm. There were no murmurs, rubs or
gallops. Back showed no spinal or costovertebral angle
tenderness. Chest was clear to auscultation bilaterally.
Abdomen was soft, nontender, protuberant, obese with
normoactive bowel sounds. Extremities revealed no clubbing or
edema. Skin revealed minimal bilateral nasal rosacea, a well-
healed mid sternal scar, minimal erythema on the back from
radiation skin changes and a port site that was clean, dry
and intact with no erythema and was nontender.
HOSPITAL COURSE: Thus, at this time, the patient was
admitted for further treatment and evaluation at the [**Hospital1 1444**] in the form of a
laparoscopic/thorascopic esophagogastrectomy and on [**2-8**], the patient was brought to the operating room after having
been fully preoperatively evaluated where the patient
underwent laparoscopic/thorascopic esophagogastrectomy
performed by Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) **]. The patient
received 5.8 liters of crystalloid fluid in the operating
room and there was a blood loss of an estimated 200 ml during
the operation. In the immediate postoperative period, the
patient was brought to the Surgical Intensive Care Unit after
also having received 750 ml of albumin, 500 mcg of fentanyl
and 7 mg of vecuronium. He was extubated shortly after the
operation on the afternoon of [**2102-2-8**] and was
complaining of only peri-incisional pain and tenderness near
the right posterior back incision. He stated that he was not
short of breath at this time and did not feel weak and did
not feel he was having any diplopia. On postoperative day 1,
the patient required a bolus of 500 cc of Lactated Ringers
for mean arterial pressure near 65 and an elevated lactate,
responded well to this and the patient was continued on
maintenance level IV fluids. The patient was briefly out of
bed during this time. The patient was also followed by the
Neuromuscular Service and their plan was to commence Mestinon
and CellCept for his myasthenia [**Last Name (un) 2902**] in that if the patient
began suffering increasing weakness or worsening respiratory
status, to call Neurology at once and not to increase the
Mestinon and to consider possibly plasmapheresis. The patient
was on a planned six doses of Kefzol and Flagyl during this
time. The patient was also seen by the Nutrition Service on
postoperative day 1 and suggested jejunal tube feeds
progressing from half to three-quarter strength. On
postoperative day 1, in the evening, the patient seemed to be
developing fatigability and respiratory issues and was shown
to have some aspect of congestive heart failure on a chest x-
ray. The Neurology Service was consulted at once and
suggested that the vital capacity and negative inspiratory
force be checked every 2 hours and that the patient may need
intubation and diuresis. The patient was having a significant
oxygen requirement at this time and was also complaining of
shortness of breath. He did receive Lasix 10 mg IV times two
overnight and was on a nonrebreather mask with an FIO2 of 100
percent. His urine output was noted to briskly increase after
both doses of Lasix with some improvement in symptoms and
exam. Trophic tube feeds were also started at this time. His
central venous line was also removed during this time. On
[**2102-2-10**], postoperative day 2, the patient received
a bronchoscopy and there was noted to be multiple plugs of
mucus in the lower lobes, right greater than left. These were
removed. The patient required intubation as well on the
second postoperative day due to increased oxygen requirement
and fatigability. On postoperative day 3, the patient was
noted to be febrile and somewhat hypotensive with blood
pressure into the low 100s and high 90s on occasion. The
patient was pancultured at this time, was continued on fluids
and vancomycin and Zosyn were started empirically. A Tensilon
test during this time was noted to be negative. The patient
was bronchoscoped again on [**2102-2-11**] and noted to
again have nonpurulent heme secretions, but that it was noted
to be a much improved exam from [**2-10**], the previous
day. On postoperative day 4, the patient was noted to have
had episodes over the last 24 hours of hypotension, again
requiring fluid boluses with fever to 102 degrees. He was
recultured at this time. The patient at this time also had
bilateral chest tubes with the left putting out copious
drainage and the patient was also transfused with 1 unit of
packed red blood cells at this time. The patient was again
continued to be diuresed at this time with goal 1 [**1-1**] to 2
liters negative. On postoperative day 5, the patient
underwent a Cortrosyn stimulation test that was normal and
then on Monday, [**2102-2-13**], a percutaneous
tracheostomy was performed as the patient was appearing to
require the vent for a significantly longer period of time at
this point. This was done under bronchoscopic guidance. There
were no complications to the procedure and the tracheostomy
was placed carefully and safely. Tube feeds were at goal at
this point and the goal continued to be to wean the
ventilator if possible. The patient was started on physical
therapy at this point and was consistently out of bed to the
chair during this time. On postoperative day 7, his right
jugular venous line was changed for fevers and he was noted
to be tolerating a pressure support wean fairly well and was
down to pressures [**4-4**] and PEEP of 5 at 50 percent for 4
hours. On [**2102-2-15**], the patient had received
bronchoscopy again and the patient tolerated this well. There
were noted to be copious secretions with mucus plugging and a
therapeutic aspiration was performed especially in the right
lower lobe. The patient received another transfusion of 1
unit of packed red blood cells at this time for a hematocrit
of 28.7. His aspirin was restarted at this point and the
patient was out of bed and continued to exercise with
Physical Therapy. On [**2-16**], postoperative day 8, on
chest x-ray, it appeared the patient had a right sided
pneumonia. Vancomycin and Zosyn were continued and the goal
at this point was to establish a trach mask. The patient had
not had a bowel movement and a Fleet enema was instituted.
The patient was ambulating at this point. Also, at this time,
the patient received a CTA that was negative for pulmonary
embolus. On postoperative day 10, a trial of trach mask was
attempted that failed. The patient developed increasing
dyspnea and on the chest x-ray, it was noted that the patient
had a large right pneumothorax. A chest tube was placed on
the right and the hematocrit came back at 26.1 and 1 unit of
packed red blood cells was given. Blood pressure was noted to
improve at this time and a Cortrosyn stimulation test was
performed again that was negative. The patient then received
bronchoscopy again on postoperative day 10, [**2102-2-18**]. There were noted to be some thin secretions and
bronchus intermedius and a bronchoalveolar lavage was sent
for culture. The patient tolerated this procedure well and
seemed to benefit from it. Then, on postoperative day 11,
[**2102-2-19**], the patient was noted to be improving. He
was receiving chest physical therapy also at this time. Of
note, there were still no positive cultures of any kind at
this time from the blood, sputum, urine or pleural fluid. On
postoperative day 12, the patient was noted to be tachypneic
with decreases in pressure support and attempted weans. Also,
of note, the patient's central line was removed for these
fevers. The patient received a bedside swallowing evaluation
on [**2102-2-20**] and was noted to be doing well, but to
be maintained NPO until an upper GI study ruled out free
reflux or regurgitation of material into oropharynx in
regards to maintaining a safety against aspiration. The
patient received a Passy-Muir valve also at this time and
appropriate Passy-Muir precautions were observed. On
postoperative day 13, pressure support was noted to be at 10.
The barium swallow had been normal with normal gastric
emptying the previous day and nystatin was started for an
oral thrush that was observed on physical examination. The
plan at this point was for plasmapheresis for myasthenia
[**Last Name (un) 2902**] issues. On postoperative day 14, the patient had
another chest x-ray done after the removal of the right chest
tube. There was no pneumothorax and the patient was allowed
to advance his diet after the swallow studies. On
postoperative day 14, later in the day, the patient suffered
another right-sided pneumothorax requiring placement of a
chest tube that was placed mid clavicularly in the second
intercostal space. The lung was noted to re-expand well on
chest x-ray that followed the placement of this tube.
Diuresis was continued at this point with Lasix and Diamox.
All antibiotics were stopped at this time. No cultures had
grown back any organisms. On postoperative day 16, the
patient was started on cycled tube feeds, running from 5 p.m.
to 9 a.m. and a rehabilitation screen at this point was in
progress. The patient received another bedside swallowing
evaluation on [**2102-2-24**] that showed him to be a risk
for aspiration of thin liquids and pureed solids. The patient
was recommended to remain NPO until a further study had been
performed. On postoperative day 16, later in the day, the
patient was noted to have decreased breath sounds on the
right by the nurse taking care of the patient and a chest x-
ray was obtained at this time that showed reacquired right
pneumothorax. This chest tube was then again placed back on
suction and the lung was noted to re-expand on chest x-ray
that followed. Tube feeds were resumed at this time. On
[**2-26**], postoperative day 18, the patient was noted to
have tolerated trach mask the previous 24 hours, 9 of those
hours. Tube feeds were advanced to goal. The patient
continued to be gently diuresed with Lasix. On [**2102-2-27**], the patient was deemed fit for discharge and was stable
and had been on trach mask upwards of 10 hours the previous
day.
DISCHARGE INSTRUCTIONS: The patient is to be discharged to
[**Hospital 15909**] Rehabilitation Facility with ventilator to be used
via tracheostomy as needed. The patient is to be placed on
tracheostomy mask during the day when suitable and to receive
is having shortness of breath, chest pain, fevers, chills,
nausea or vomiting or if there are any questions or concerns.
The patient is to receive tube feeds according to enclosed
instructions.
FINAL DIAGNOSIS: Esophageal cancer, myasthenia [**Last Name (un) 2902**],
coronary artery disease, right-sided pneumothorax times
three, status post esophagogastrectomy.
RECOMMENDED FOLLOW-UP: The patient is to follow up with Dr.
[**Last Name (STitle) 952**] in two weeks and appointment to be scheduled at [**Telephone/Fax (1) 15910**]. The patient is to follow up with Dr. [**Last Name (STitle) **] of
Neurology on [**2102-3-20**].
MAJOR SURGICAL AND INVASIVE PROCEDURES:
Laparoscopic/thorascopic esophagogastrectomy, jejunal feeding
tube placement, chest tube placement times three, central
venous line placement, Foley catheter placement.
CONDITION ON DISCHARGE: Good.
DISCHARGE MEDICATIONS: Heparin 5000 units subcutaneously
tid, dorzolamide/timolol 2/0.5 percent drops, one drop
ophthalmic [**Hospital1 **], brimonidine tartrate 0.2 percent drops, one
drop ophthalmic q12h, albuterol sulfate one inhalation q6h as
needed, ipratropium bromide 0.02 percent solution, one
nebulizer q6h, potassium and sodium phosphates [**Telephone/Fax (3) 4228**] mg
packet, pyridostigmine bromide 60 mg per 5 ml, 5 ml to be
given every 8 hours, glutamine 10 g, half a packet po bid to
be given, ferrous sulfate 325 mg po daily in liquid form,
albuterol 90 mcg 2-4 puffs q2-4h, Tylenol 325 mg to 650 mg po
q4-6h as needed and mycophenolate mofetil 200 mg/ml po bid,
Colace 100 mg in liquid form po bid, lorazepam 0.5 mg po q4-
6h as needed for anxiety, Travoprost 0.004 percent drops, one
ophthalmic every other day as needed for glaucoma,
nitroglycerin 0.3 mg tablets sublingual as needed for chest
pain, aspirin 81 mg po daily, lansoprazole 30 mg po daily,
zolpidem tartrate 5 mg po at bedtime, insulin Regular
subcutaneous to be enclosed with discharge materials,
oxycodone/acetaminophen 5/325 ml solution [**5-9**] ml po q4-6h as
needed, potassium chloride 20 mEq packets, two packets po prn
as needed for K less than 3.5, nystatin 5 ml po tid as needed
for oral thrush, bisacodyl 10 mg po bid as needed delayed-
release, acetylcysteine 20 percent in 200 mg/ml solution [**3-4**]
ml q8h as needed, citalopram hydrobromide 20 mg po daily,
calcium gluconate 100 mg/ml and magnesium sulfate as needed.
DISPOSITION: The patient is to be discharged to [**Hospital3 6373**] Facility.
[**First Name11 (Name Pattern1) 951**] [**Last Name (NamePattern4) **], [**MD Number(1) 15911**]
Dictated By:[**Last Name (NamePattern1) 15912**]
MEDQUIST36
D: [**2102-2-26**] 16:50:41
T: [**2102-2-26**] 18:36:47
Job#: [**Job Number 15913**]
|
[
"427.1",
"568.0",
"787.2",
"278.00",
"518.5",
"414.01",
"934.1",
"358.00",
"150.5",
"500",
"512.1",
"486",
"272.4",
"V03.82",
"428.0",
"280.0",
"401.9",
"112.0",
"V44.4",
"458.29",
"786.52"
] |
icd9cm
|
[
[
[]
]
] |
[
"33.24",
"88.43",
"96.72",
"99.04",
"38.93",
"96.04",
"96.05",
"54.51",
"31.1",
"99.55",
"96.6",
"40.3",
"34.04",
"43.5",
"42.23",
"38.91"
] |
icd9pcs
|
[
[
[]
]
] |
13153, 15002
|
2440, 12001
|
12467, 13097
|
12026, 12449
|
1412, 2422
|
186, 1389
|
13122, 13129
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
29,570
| 161,020
|
53284
|
Discharge summary
|
report
|
Admission Date: [**2136-4-29**] Discharge Date: [**2136-5-25**]
Date of Birth: [**2064-11-27**] Sex: F
Service: MEDICINE
Allergies:
Phenothiazines / Piperacillin Sodium/Tazobactam
Attending:[**First Name3 (LF) 5893**]
Chief Complaint:
Vomiting.
Major Surgical or Invasive Procedure:
NGT placement
A-line placement
PICC-line placement
Endotracheal intubation ([**5-5**])
History of Present Illness:
A 71 year-old woman with past medical history of COPD and MR,
who presented to the ED on the morning of admission with one day
of intractable vomiting. The patient reports that for the last
12-24 hours she has been nauseated and vomiting yellowish,
non-bloody material. She denies associated symptoms such as
abdominal pain, CP, F/C. She believes she last moved her bowels
this morning.
On arrival, initial vitals were HR 118, 155/109, RA O2 sat 88%.
She was placed on NIPPV briefly and her oxygenation improved.
Labs were remarkable for polycythemia (HCT 63) and lactate of
2.3, later noted to rise to 4.1 (question of spurious sample)
before falling to 3.0 in the setting of 10L NS fluid repletion.
A CT scan of her abdomen was performed and demonstrated a high
grade SBO with a transition point in the region of distal
jejunum/proximal ileum, as well as a question of a pulmonary
infarct. The patient was emperically treated with vancomycin,
Flagyl, levofloxacin, SoluMedrol, ASA and antiemetics. The
surgery service was consulted concerning this and advised NGT
placement, supportive therapy and close clinical observation, as
they feel she is a poor operative candidate. The hematology
service was also consulted concerning the pt's polycytemia and
advised ASA, fluids and therepeutic phlebotomy which was
performed with 340cc of blood removed.
On arrival to the [**Hospital Unit Name 153**], the patient is generally comfortable.
She reports some ongoing nausea but again denies abdominal pain.
She states she feels her breathing is at her baseline.
The patient denies fever, chills, weight change or difficulty
swallowing. No chest, jaw or arm pain. No palpitations. No
cough, wheeze or SOB. No urinary symptoms. No dizziness or
weakness.
Past Medical History:
1. COPD - PFTs in [**12/2133**] with FEV1 0.77 (40% predicted), FVC
0.91 (33%) and FEV1/FVC 118%. Spirometry limited by poor patient
cooperation.
2. Mental retardation
3. Bipolar disorder
4. Gastroesophageal reflux disease
Social History:
Patient reports smoking approximately [**1-6**] ppd and has for many
years. She denies alcohol or illicits. She lives independently
at an apartment in JP with visiting assistance and is followed
by the Department of Mental Retardation.
Family History:
Mother lived to her mid-90s then suffered an MI. Father lived to
his mid-70s before dying of natural causes. No other significant
FH.
Physical Exam:
Gen: Uncomfortable appearing adult woman, ill but not in
extremis. NGT in place.
HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented.
Neck: Supple, without adenopathy or JVD. No tenderness with
palpation.
Chest: Diffuse wheezes and rhonchi.
Cor: Normal S1, S2. RRR. No murmurs appreciated.
Abdomen: Hyperative bowel sounds. Soft, non-tender and
non-distended. No HSM.
Extremity: Warm, with trace edema. 2+ DP pulses bilat.
Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact
in all extremities. Sensation intact grossly.
====================
At the time of discharge:
BP= 112/49-148/95, HR= 103 (93-120), Tmax= 98.7
Pt is sat'ing 90-93% on 4L nasal cannula. He lung fields are
diffusely ronchorous with somewhat decreased BS at the left
base. She is tachycardic generally in the 100-110 range with
frequent ectopy but otherwise regular rhythm. She has a
fungal-appearing rash over her buttocks bilaterally. Otherwise
physical exam is unchanged from admission physical listed above.
Pertinent Results:
Labs at Admission:
[**2136-4-29**] 12:45PM BLOOD WBC-9.9 RBC-7.28*# Hgb-19.5*# Hct-63.0*#
MCV-83 MCH-25.7* MCHC-30.9* RDW-16.8* Plt Ct-355
[**2136-4-29**] 12:45PM BLOOD Neuts-86.2* Lymphs-9.3* Monos-3.6 Eos-0.4
Baso-0.5
[**2136-4-30**] 12:54AM BLOOD PT-13.9* PTT-35.8* INR(PT)-1.2*
[**2136-4-29**] 12:45PM BLOOD Glucose-218* UreaN-14 Creat-0.9 Na-141
K-5.1 Cl-96 HCO3-27 AnGap-23*
[**2136-4-29**] 12:45PM BLOOD ALT-32 AST-40 CK(CPK)-70 AlkPhos-148*
TotBili-0.5
[**2136-4-29**] 12:45PM BLOOD Lipase-32
[**2136-4-29**] 12:45PM BLOOD Albumin-4.7
[**2136-4-30**] 12:54AM BLOOD Albumin-3.0* Calcium-6.7* Phos-3.9
Mg-1.3*
[**2136-5-4**] 05:10AM BLOOD Triglyc-108
[**2136-4-29**] 01:00PM BLOOD Lactate-2.3*
Imaging Studies:
CT abdomen and pelvis ([**4-29**]):
1. High-grade small-bowel obstruction with a transition point
noted at the approximate junction of the jejunum and ileum with
collapsed loops of distal ileum identified (in the right lower
quadrant, reference series 300a
image 16). No evidence of bowel ischemia or perforation.
2. Multiple nodular opacities within the visualized lung in
addition to a wedge-shaped area of opacification in the right
lower lobe. These findings may be attributed to an infectious
process. However, given the wedge-shaped appearance of the right
lower lobe opacity, pulmonary infarct cannot be excluded.
Follow-up with cross-sectional imaging is recomended to ensure
clearance.
3. Fibroid uterus.
CT chest angiogram ([**4-30**])
1. Negative examination for pulmonary embolism. Main pulmonary
artery is slightly enlarged, which suggests possible pulmonary
hypertension.
2. Rapidly progressing lower lobe consolidations as well as
additional widespread multifocal opacities are likely due to an
evolving pneumonia, possibly secondary to aspiration.
3. Enlarged hilar and mediastinal lymph nodes that are increased
in size compared to study in [**2132**], are likely reactive to the
infectious process. Follow-up CT in three months is suggested to
assess for resolution.
PICC placement ([**5-1**])
Uncomplicated fluoroscopically guided PICC line exchange for a
new 4 French single-lumen PICC line. Final internal length is 45
cm, with the tip positioned in the SVC. The line is ready to
use.
Pelvic ultrasound ([**5-10**]): Limited examination shows abnormally
thickened endometrium for postmenopausal patient, and probable
uterine fibroid. Malignancy cannot be excluded in the setting of
postmenopausal bleeding.
ECHO [**5-18**]:
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. The estimated right atrial pressure is
0-10mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%).
[Intrinsic left ventricular systolic function is likely more
depressed given the severity of valvular regurgitation.] Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (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. Moderate (2+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. There is an
anterior space which most likely represents a fat pad.
Compared with the prior study (images reviewed) of [**2136-5-14**],
the severity of mitral regurgitation has increased slightly. The
estimated pulmonary artery systoocli pressures are higher. A
bubble study demonstrates no apparent intracardiac shunt.
Resting heart rate is higher.
CTA of chest [**5-18**]:
1. Severely limited study secondary to cardiac and respiratory
motion
artifact. Evaluation of the lobar, segmental and subsegmental
pulmonary
arteries is non- diagnostic. No massive central pulmonary
embolus identified.
2. Improving multifocal pneumonia with persistent collapse of
the left lower lobe and partial opacification of the left lower
lobe bronchus. An
obstructing lesion cannot be excluded, and bronchoscopy is
recommended for
further evaluation.
3. Mediastinal and hilar lymphadenopathy, likely reactive.
4. Stable mild pulmonary edema and small bilateral pleural
effusions.
5. Stable sternal fracture.
6. Marked tracheomalacia.
CXR on day of discharge [**5-24**]:
There is no interval change in the left retrocardiac atelectasis
but slightly improved aeration of the lateral portion of the
left base most likely due to decreased pleural effusion. The
lungs otherwise unchanged with no interval development of
pulmonary edema with new focal opacities. Compared to [**2136-5-21**], there is interval significant improvement of left lower
lobe atelectasis with more central position of the mediastinum.
DISCHARGE LABS: [**5-25**]
CBC WBC Hgb Hct MCV Plt Ct
12.2* 14.4 44.1 83 189
chem7 Glucose UreaN Creat Na K Cl HCO3
120 18 0.7 137 4.2 93 33
EKG [**5-23**]: Atrial rhythm at 115 c/w either sinus tachycardia with
frequent atrial ectopy vs MAT. No ST-T changes concerning for
ischemia.
Brief Hospital Course:
70 year-old woman with known COPD presents with nausea &
vomiting secondary to SBO which was conservatively managed to
resolution, then had bilateral lower lobe pneumonia secondary to
aspiration (treatment course completed) requiring transient
intubation. Subsequently she had repeated episodes of hypoxia
attributed to aspiration vs mucus plugging in the setting of
severe COPD.
# Pneumonia and respiratory status:
CTA showed bilateral lower lobe pneumonia with mediastinal and
hilar lymphadenopathy, consistent with evolving aspiration
pneumonia. She was started on vancomycin and Zosyn initially;
this was switched to levofloxacin and Flagyl after she developed
a rash on Vanco/Zosyn. In addition to the antibiotics, she was
diuresed with small boluses of IV Lasix due to pleural effusions
on imaging. BiPAP was attempted for mild respiratory acidosis on
serial ABGs; however, patient could not tolerate this.
Initially, her respiratory status improved with the above
treatments. However, around the fifth hospital day, she was
noted to have increasing oxygen requirements, also with low
grade temperature and increasing white count. There was concern
that the antibiotic coverage (levo/Flagyl) was not adequate and
she was broadened back to vancomycin with aztreonam added for
treatment of gram negatives and Pseudomonas; Flagyl was
continued for treatment of anaerobes. Solumedrol was added for
possible inflammatory component, as wheezes were heard on exam.
Ultimately, due to hypoxemia on maximum supportive oxygen, she
was intubated on hospital day 7. Pt was bronched for suctioning
of secretions with improvement in hypercarbia. She was able to
be extubated on hospital day 10 and oxygenating well on nasal
cannula with no further fevers. She was called out to the floor
where she intially did well on 3-4L NC. She had an episode of
dyspnea during which she was found to be hypoxemic so was given
O2 via NRB and transfered back to the ICU.
During her second stay in the ICU she went on BiPAP for a brief
time. There was concern that she may have re-aspirated. She
was noted to frequently have episodes of coughing and
desaturation after eating. Speech and swallow followed her and
recommended that she remain NPO despite a relatively normal
video swallow evlaution b/c the temporal association btw her
eating and desaturations was so strong. She had an NG tube
placed and tolerated tube feeds. She was restarted on
ceftriaxone and Flagyl for possible aspiration pneumonia on [**5-12**].
On [**5-18**], one day after she had been transferred back to the
floor from her second stay in the ICU, she was noted to have
decreased oxygen saturations (in the 70's) on a non-rebreather.
No information is available about the quality of the pleth on
the pulse oximeter at that time. An ABG was performed which
showed 7.49/55/44. A chest x-ray was performed which showed no
new infiltrates or vascular congestion. She was transferred back
to the ICU for a third time. There, she continued to have
episodes of significant hypoxia not associated with eating as
she was receiving tube feeds at that point. We were concerened
for PE, shunt, and mucus plugging. A CTA was non-diagnostic
seconday to motion artifact, but ECHO showed no sign of RV
strain and Lower ext dopplers were neagative for DVT. Echo was
a bubble study and effectively ruled out intracardiac shunt.
There was a low suspicion for infectious etiology given lack of
leukocytosis or fever. Given that her O2 requirement improved
over 2-3 days with mucomyst nebs, aggressive chest PT,
reinitiation of steroid taper, and that her Chest CT was
improved, this transient hypoxia was attributed to mucus
plugging in the setting of severe COPD. As below, she is on a
dysphagia diet at the time of discharge and will need repeat
evaluation by speeach and swallow. An appointment has been made
for her in pulmonary clinic for follow-up. She was discharged on
a three week prednisone taper.
On the day prior to discharge, she was transitioned back to
tiotropium from ipratropium, so we would recommend restarting
ipratropium if her oxygen requirement increases. She will need
chest PT several times per day and given her cognitive
impairment, she will need frequent cardiopulmonary assessment as
she will not be able to ask for her prn nebulizer treatments.
She should also have a f/u CT scan done within 1-2 months--the
need for this was communicated to her PCP. [**Name10 (NameIs) 23278**] Chest x-rays
should be done while in pulmonary rehab on a weekly basis to
ensure continued improvement in LLL atelectasis.
# Nausea/vomiting/SBO
Small bowel obstruction was confirmed on CT prior to admission.
The etiology of the SBO was unclear. Surgery was contact[**Name (NI) **] in
the [**Name (NI) **] and recommended for NGT to suction, NPO and conservative
management. She was hydrated with IVF and kept NPO until the
fourth hospital day, when bowel sounds returned and she began to
have increased stools. She was then started on tube feeds with
no complication. Resumption of oral diet on hospital day 11 per
Speech and Swallow, who continued to follow, as above.
# Polycythemia
She has a long-standing history of high-normal hematocrit.
Evaluated by Heme who thought that red cell concentration on
admission labs was multifactorial, occurring in the setting of
heavy tobacco use, hypoxia [**2-6**] chronic lung disease, probable
dehydration on presentation and not truly consistent with
polycythemia [**Doctor First Name **]. The hematocrit returned to baseline with IV
hydration.
# Tachycardia:
Her tachycardia was initially felt to be multifactorial in the
setting of pneumonia and respiratory distress. A CTA was done to
work-up PE and further evaluate lung parenchyma. This was
negative for PE but did show bilateral lower lobe consolidations
consistent with aspiration pneumonia as above. The tachycardia
transiently resolved with treatment of dehydration and
pneumonia. For the week prior to discharge, her avg HR
increased from 90 to 110. A second CTA was non-diagnositic
secondary to motion artifact. ECHO showed moderate pulm HTN and
preserved LVEF 60%. Lower ext US were neagtive for DVT--we were
confident that this did not represent PE as her hypoxia and O2
requirement were improving during this time. Multiple p-wave
morpholgies noted on EKG were c/w Multifocal atrial tach for
which COPD is an excellent substrate. Metoprolol 25mg TID was
started and should be up-titrated with goal of resting HR ~80bpm
to prevent tachycardia-induced myopathy.
# Chronic obstructive pulmonary disease:
We continued her home albuterol and substituted ipratropium nebs
for tiotropium. As above, solumedrol was added when her
respiratory status did not improve, and she was gradually weaned
back to prednisone. She is being discharged on 20mg prednisone
daily to be tapered as per attached med sheet. She does have a
hx of repeat flares soon after completions of tapers.
# Diahrrea: Pt with increased output of semi-liquid stool on day
prior to discharge. CDIFF toxin sent and pending at the time of
discharge. Would continue to trend WBC and stool output. Would
check two more c.diff toxins post-transfer.
# Rising White Count: WBC=12.2 at time of transfer. Pt has been
afebrile after completion of her Abx courses. Serial chest
x-rays and improving respiratory status imply that she is not
developing another respiratory infection at the time of
transfer. We were unable to repeat UA/UCx prior to transfer,
please consider re-checking. Please continue to trend WBC every
other day.
# Possible drug rash: Erythematous rash over chest noted when pt
was on zosyn, this resolved with discontinuation and partially
recurred on ceftriaxone to a much lesser degree. Decision made
to continue ceftriaxone to completion as already on day 5 of 7
([**5-16**]) when rash was noted. No peripheral Eos noted.
# Bipolar Disorder
Home psychiatric medications in the setting of SBO. Zoloft 150mg
daily and haldol 5mg qam were discontinued and should be
restarted at the discretion of her PCP. [**Name Initial (NameIs) 3755**] (1.5mg qam and
1mf qpm) was replaced with Ativan 1mg [**Hospital1 **]. Olanzapine 7.5mg
daily was continued and additional prn doses were used as needed
for agitation.
# Gastroesophageal reflux disease
Pantoprazole 40mg daily was continued.
# Fungal rash on buttocks: maintain area dry and continue
miconazole.
# Food, electrolytes, nutrition.
Initially she was NPO. On the third hospital day, TPN was
started via PICC line. This was weaned down as her diet was
progressed slowly as above. Pt underwent video swallow
evaluation on hospital day 11 s/p extubation and was started on
pureed solid, nectar-thick liquid diet per S/S recs. However,
given possible aspiration this was discontinued, and she was NPO
until tubefeeds started [**5-15**]. Repeat evaluation by speeach and
swallow cleared her for the dysphagia diet on which she will be
discharged--as per S&S, she should be re-evaluated within one
week of transfer. Until then, she should be supervised with
every meal.
# Legal Guardianship:
[**Name2 (NI) 3003**] to admission, pt lived semi-independently in an apartment
with ~70 hours of home services per week. Due to her serious
ongoing medical issues and her inability to make medical
decisions given life-long cognitive impairment, legal
guardianship was pursued and assignment of a legal guardian is
pending at the time of transfer. A health care proxy was
assigned: [**Name (NI) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) 26160**] [**Telephone/Fax (1) 109657**], [**Telephone/Fax (1) 109658**].
Documentation attached.
Medications on Admission:
Albuterol
[**Telephone/Fax (1) 3755**] 1.5mg qAM, 1mg qPM
Advair 250-50 [**Hospital1 **]
Haldol 5mg QAM
Olanzapine 7.5 mg daily
pantoprazole 40 mg daily
Zoloft 150mg daily
Spiriva
Trazodone 50 qHS
Discharge Medications:
1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID
(4 times a day) as needed for pruritis.
2. Olanzapine 7.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid
Dissolve PO BID (2 times a day) as needed for agitation.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as
needed for shortness of breath.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
7. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation
Q6H (every 6 hours) as needed for shortness of breath.
8. 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.
9. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
11. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily): taper to 20mg daily on [**5-31**], then taper to 10mg daily
on [**6-8**], then taper to 5mg daily on [**6-13**] and complete
course on [**6-18**].
12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO QID (4
times a day): uptitrate as needed to maintain resting heart rate
at 100.
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day.
14. Insulin Lispro 100 unit/mL Solution Sig: as per chart
Subcutaneous ASDIR (AS DIRECTED): see attached sliding scale.
15. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
inhalation Inhalation twice a day: on hold during this admission
as receiving systemic steroids, restart when course complete.
Discharge Disposition:
Extended Care
Facility:
[**Hospital3 672**] Hospital
Discharge Diagnosis:
Primary Diagnoses
Small bowel obstruction
Aspiration pneumonia
Chronic Obstructive Pulmonary Disease
Secondary Diagnoses
Cognitive impairment
Bipolar disorder
Gastroesophageal reflux disease
Discharge Condition:
Medically stable for discharge to rehab facility
Discharge Instructions:
You were hospitalized for treatment of small bowel obstruction
and pneumonia. You were treated conservatively for the
obstruction. You were treated with antibiotics for the
pneumonia. Due to the severity of the pneumonia, you were
intubated and assisted by a ventilator. Extubation went without
complication. Because of thick mucous, you had some episodes of
shortness of breath and hypoxia. These episodes may also be
related to food inappropriately entering your airways.
We made the following changes to your medicines:
1. [**Hospital3 3755**] has been stopped and Ativan 1mg twice daily has been
started
2. Haldol and Zoloft have been stopped
3. Prednisone taper has been started
4. Metoprolol 25mg three times per day has been started
Please call your physician or return to the ED for:
-worsening belly pain, nausea or vomiting
-fever or difficulty breathing
-any other symptoms concerning to you
Followup Instructions:
After discharge from rehab, please follow up with your PCP:
[**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Telephone/Fax (1) 608**]
An appointment in the pulmonary clinic has been made for you:
MD: Dr. [**Last Name (STitle) **]
Specialty: Pulmonary
Date and time: Monday [**2136-6-25**] at 2:30 PM
Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) **] Medical
Specialities
Phone number: [**Telephone/Fax (1) 109659**]
Completed by:[**2136-5-25**]
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32,234
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6394
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Discharge summary
|
report
|
Admission Date: [**2146-8-13**] Discharge Date: [**2146-8-22**]
Date of Birth: [**2085-4-10**] Sex: F
Service: CARDIOTHORACIC
Allergies:
Wellbutrin / Darvon
Attending:[**First Name3 (LF) 165**]
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cardiac Catherization [**2146-8-16**]
Off pump coronary artery bypass graft x1 (left internal mammary
artery > left anterior descending) [**2146-8-17**]
History of Present Illness:
61 year old presented with chest pain. States it developed at
4pm and coming and going for the next several hours. Presented
to the emergency room for further evaluation. Ruled in for
NSTEMI with troponin 0.11.
Past Medical History:
- DM I on insulin pump ranging 0.3-0.8units/hour basal rate, c/b
neuropathy and retinopathy
- PAD, s/p R fem-[**Doctor Last Name **] vein graft [**2127**]; s/p urokinase [**11/2127**];
vein
patch angioplasty of R fem-[**Doctor Last Name **] bypass in 09/[**2140**].
- Hypothyroidism
- HSV2
- Fatigue with question of autonomic disorder
- S/p vitrectomy and cataract
Social History:
former smoker with >80 pack years, quit 2.5y ago. Retired from
organizational consulting. Lives alone. No alcohol or illicit
drugs.
Family History:
father had first MI at age 42, brother with SCD in 50's, autopsy
showed extensive 3V CAD.
Physical Exam:
VS: T 98.5, BP 101/56, HR 79, RR 18, O2sat 100% RA
GENERAL: WDWN F in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Dry MM
NECK: Supple with flat JVP
CARDIAC: PMI located in 5th intercostal space, midclavicular
line. RR, normal S1, S2. Systolic murmur loudest at the 2nd
intercostal space, right sternal border.
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. Insulin pump
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: Carotid 2+ Femoral 2+ PT 1+, DP not palp
Left: Carotid 2+ Femoral 2+ DP/PT not palp
Pertinent Results:
[**8-16**] Cath: 1. Selective coronary angiography of this right
dominant system revealed two vessel coronary artery disease. The
LMCA had mild-moderate plaquing that tapered to a distal 40%
stenosis; the LMCA was also heavily calcified. The heavily
calcified LAD had an ostial 20% stenosis, and a mid 70% stenosis
at a branching D1. There was a more distal 50% stenosis in the
mid LAD and diffuse plaquing throughout the LAD. There were
septal and apical collaterals to RPDA and RPL. The LCx had mild
diffuse plaquing throughout with an ostial LCX ulcer. The AV
groove CX vessel supplied a long OM2, a long OM3, and several
small distal LPL's. The RCA had a 70% ostial lesion with
pressure dampening when engaged, as well as a mid total
occlusion with scant distal filling via vasa collaterals. 2.
Limited resting hemodynamics revealed an LVEDP of 23 and a
systemic arterial pressure of 183/57 mm Hg. 3. Left
ventriculography was deferred.
[**8-17**] 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. A patent foramen ovale is
present. A left-to-right shunt across the interatrial septum is
seen at rest. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
are simple atheroma in the descending thoracic aorta. The aortic
valve leaflets (3) are mildly thickened 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 a trivial/physiologic pericardial effusion. After
bypass grafting, there were no significant changes in the
echocardiographic findings. Dr. [**Last Name (STitle) **] was notified in
person of the results in the operating room at the time of the
study.
[**2146-8-13**] 07:45PM BLOOD WBC-9.7# RBC-3.16* Hgb-10.2* Hct-30.8*
MCV-97 MCH-32.3* MCHC-33.2 RDW-13.5 Plt Ct-237
[**2146-8-18**] 01:36AM BLOOD WBC-10.4 RBC-3.46* Hgb-10.8* Hct-31.1*
MCV-90 MCH-31.1 MCHC-34.6 RDW-15.5 Plt Ct-184
[**2146-8-22**] 05:30AM BLOOD WBC-7.2 RBC-2.59* Hgb-8.4* Hct-24.7*
MCV-95 MCH-32.3* MCHC-33.9 RDW-14.7 Plt Ct-262
[**2146-8-13**] 07:45PM BLOOD PT-13.5* PTT-26.8 INR(PT)-1.2*
[**2146-8-17**] 07:45AM BLOOD PT-13.1 PTT-24.7 INR(PT)-1.1
[**2146-8-21**] 01:39AM BLOOD PT-13.0 PTT-27.1 INR(PT)-1.1
[**2146-8-13**] 07:45PM BLOOD Glucose-676* UreaN-43* Creat-1.5* Na-132*
K-5.0 Cl-99 HCO3-17* AnGap-21
[**2146-8-17**] 07:45AM BLOOD Glucose-165* UreaN-13 Creat-1.0 Na-146*
K-3.6 Cl-108 HCO3-28 AnGap-14
[**2146-8-22**] 05:30AM BLOOD Glucose-247* UreaN-20 Creat-1.0 Na-139
K-3.6 Cl-107 HCO3-22 AnGap-14
[**2146-8-16**] 10:00AM BLOOD ALT-19 AST-26 LD(LDH)-188 AlkPhos-54
TotBili-0.3
[**2146-8-22**] 05:30AM BLOOD WBC-7.2 RBC-2.59* Hgb-8.4* Hct-24.7*
MCV-95 MCH-32.3* MCHC-33.9 RDW-14.7 Plt Ct-262
[**Known lastname **],[**Known firstname **] W [**Medical Record Number 24669**] F 61 [**2085-4-10**]
Radiology Report CHEST (PORTABLE AP) Study Date of [**2146-8-18**] 9:15
AM
[**Last Name (LF) **],[**First Name3 (LF) **] CSURG CSRU [**2146-8-18**] SCHED
CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 24670**]
Reason: introducer changed to Dual lumen rt IJ and s/p ct
removal ?P
[**Hospital 93**] MEDICAL CONDITION:
61 year old woman with s.p cabg
REASON FOR THIS EXAMINATION:
introducer changed to Dual lumen rt IJ and s/p ct removal
?PTX
Provisional Findings Impression: [**First Name9 (NamePattern2) 24671**] [**Name2 (NI) **] [**2146-8-18**] 11:21 AM
No pneumothorax or sizeable pleural effusion, right IJ catheter
tip in the
superior SVC.
Final Report
REASON FOR EXAM: Assess for pneumothorax, patient post-CABG,
chest tube
removed, and changed dual-lumen right IJ.
There is no pneumothorax or enlarging pleural effusions. Right
IJ catheter
tip is in the SVC. Slight increase in left lower lobe
atelectasis. There are
low lung volumes. Cardiomediastinal silhouette is unchanged.
Mediastinal
wires are aligned. There is no pulmonary edema.
IMPRESSION: No pneumothorax. Right IJ catheter tip can be
followed until the
superior SVC but the distal tip could be in the lower SVC, is
not clearly
visualized.
DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**]
DR. [**First Name4 (NamePattern1) 2618**] [**Last Name (NamePattern1) 2619**]
Approved: [**Doctor First Name **] [**2146-8-18**] 5:24 PM
Imaging Lab
[**2146-8-22**] 05:30AM BLOOD Glucose-247* UreaN-20 Creat-1.0 Na-139
K-3.6 Cl-107 HCO3-22 AnGap-14
Brief Hospital Course:
In the ED, initial vitals were T 98.7, HR 103, RR 18, BP 131/46.
EKG showed ST depressions and TWI laterally. She received 2SL
NTG which resolved with resolution of pain. She was started on
heparin gtt. Initial BG 676. Received 8U Insulin SC. Initial
lytes showed gap of 17. + Ketones in urine. Pt evaluated by
cardiology in ED. Reported nausea, no vomiting. Pt felt like she
was going into DKA. Pt also noted thirst. Received additional
10U insulin in ED. Repeat AG 13. n arrival to the medical floor
the pt was resting comfortably. She initially denied chest pain
or shortness of breath. No nausea. The pt stated she had
previously refused a cardiac cath and continues to think that
she would only want to undergo a cath in the event of a life
threatening emergency. She has had an insulin pump for the past
1 [**1-26**] yrs and only other episode of possible DKA was during her
previous hospitalization for NSTEMI. She was started on Lovenox
as the patient did not want to have q6hour lab draws for PTT
monitoring. Throughout the morning, her finger sticks went from
313 down to 152. Her next lab draw showed a BG of 462 and gap of
19. On the floor, she gave herself 4 units of insulin via her
pump, supplemented by an additional 4 units SC. It was felt that
she would be better managed on an insulin drip and was
transferred to the CCU for that purpose. She underwent cardiac
cath that revealed coronary artery disease and was referred for
cardiac surgery. She underwent preoperative workup and went to
the operating room for off pump coronary artery bypass graft x1
on [**8-17**]. Right coronary artery unable to bypass due to anatomy.
She received vanco for perioperative antibiotics due to being in
the hospital preoperatively. See operative report for further
details. She was transferred to the intensive care unit for
hemodynamic monitoring. She was weaned from sedation, awoke
neurologically intact, and was extubated without complications.
She continued to progress and was ready for transfer to the
floor postoperative day 1 except for frequent blood glucose
monitoring due to type 1 diabetes with her insulin pump ([**Last Name (un) **]
assisted with diabetes treatment). Chest tubes and epicardial
pacing wires were removed per protocol. She slowly recovered
while working with physical therapy for strength and mobility.
On post-op day five she was discharged home with VNA services.
Medications on Admission:
aspirin 325mg daily, atorvastatin 80 mg daily, clopidogrel 75 mg
daily, Cymbalta 20 mg daily, Zetia 10 mg daily, insulin pump,
synthroid 125 mcg daily, metoprolol XL 12.5mg daily,
nitroglycerin p.r.n., Fosamax 35mg weekly
Discharge Medications:
1. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
4. Lipitor 80 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*1*
5. Cymbalta 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
6. Duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*1*
7. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
8. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day.
Disp:*30 Tablet(s)* Refills:*1*
9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
10. 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*
11. 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*
12. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7
days.
Disp:*14 Tablet(s)* Refills:*0*
13. Subcutaneous Insulin Pump Misc Sig: One (1)
Miscellaneous once a day: Continue Self Administering Medication
(Novolog).
Discharge Disposition:
Home With Service
Facility:
[**Hospital 119**] Homecare
Discharge Diagnosis:
Coronary Artery disease s/p Coronary Artery Bypass Graft x 1
Myocardial Infarction
PMH: Diabetes mellitus type 1, Neuropathy, Retinopathy,
Peripheral vascular disease s/p right Fem-[**Doctor Last Name **] bypass, Carotid
stenosis, Hypothyroidism, s/p Appendectomy, s/p cataract surgery
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**]
Blood glucose monitoring, please attempt to maintain tight
control and follow up with [**Last Name (un) **] if BG are greater than 200
Followup Instructions:
Please call to schedule appointments with
Dr [**First Name (STitle) **] for 4 weeks [**Telephone/Fax (1) 170**]
Dr [**Last Name (STitle) **] for 2-3 weeks
Dr [**Last Name (STitle) 1007**] for 1 week [**Telephone/Fax (1) 10492**]
Already scheduled appointments\nProvider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 722**], DPM
Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2146-9-12**] 10:35
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 24672**], MD Phone:[**Telephone/Fax (1) 24673**]
Date/Time:[**2146-9-15**] 3:20
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 10491**], MD Phone:[**Telephone/Fax (1) 142**]
Date/Time:[**2147-1-9**] 1:30
[**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**]
Completed by:[**2146-8-22**]
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46,904
| 152,514
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30561
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Discharge summary
|
report
|
Admission Date: [**2136-11-23**] Discharge Date: [**2136-11-30**]
Date of Birth: [**2085-7-4**] Sex: M
Service: MEDICINE
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**Doctor First Name 3290**]
Chief Complaint:
lethargy/hypotension
Major Surgical or Invasive Procedure:
CVL placement
History of Present Illness:
51yo man with COP on steroid taper currently on prednisone 20mg
daily, dCHF, PE [**2136-6-2**], COPD, obesity-hypoventilation
syndrome, chronic pain on narcotics, and DM2, recently admitted
to MICU [**Date range (1) 51720**] with hypotension and [**Last Name (un) **] secondary to adrenal
insufficiwency now presenting with presyncope, lightheadedness,
dyspnea on exertion, and hypotension. Patient reports that he
has felt lightheaded with standing, particularly over the last
several days but has felt lethargic for the last 1-1.5 weeks. He
notes decreased PO intake and appetite with nausea and
occasional dry heaves bu no diarrhea. States he was feeling
great after discharge but then noted progressive weakness
despite no changes in medications. Also reports DOE with several
steps and recently has had to crawl up stairs while he was
walking around mall just after discharge on [**11-11**]. He wanted to
avoid the hospital so did not call PCP until today. States he
has been taking all of his medications as prescribed including
prednisone 20mg and his antihypertensives and diuretics.
.
In the ED, initial vs were: 96.9 127/108 70 20 95%RA. BP dropped
to 60s/40s, but he was reportedly mentating appropriately. He
was given 1L NS with minimal improvement so was started on
peripheral dopamine. He also received hydrocortisone 100mg,
vancomycin, levofloxacin, and zosyn. CVL was placed and he was
admitted to MICU. Labs significant for renal failure, Cr 3.6
from 1.3. ABG 7.42/57/79. CXR and ECG were unremarkable. Prior
to transfer, VS: 98.6 114/55 80 16 96%2L NC on 2mcg/min dopamine
gtt.
.
On the floor, he states he feels overall improved and is
requesting a diet. Denies CP, palpitations. Reports overall
weight loss and decreased LE edema with stable assymmetric R>L
edema. Denies calf pain. States he has had several falls to
ground with presyncope but no head trauma and no LOC. Denies
fever, chills, cough, SOB at rest, melena, hematochezia,
abdominal pain. States he has been using his BiPap as usual
every night.
.
Review of systems:
(+) Per HPI. Also + for blurry vision x months.
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies cough, shortness of
breath, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Past Medical History:
-Cryptogenic organizing pneumonia, dx via RML wedge resection
[**2-/2136**], on chronic prednisone.
-PEs; subsegmental, d/x [**2136-6-7**].
-Fracture of L2 and multiple ribs after mechanical fall.
-Crush injury to his legs after being involved in a [**Doctor Last Name 9808**]
collapse in [**2116**], leading to right knee replacement and
bilateral femoral pins.
-Multiple gunshot wounds to legs/back/buttocks, complicated by
osteomyelitis, in [**2106**] after being involved in an altercation
with a neighbor.
-Obesity
-tracheobronchomalacia with difficult intubation
-Severe obstructive sleep apnea -- restarted biPAP [**5-/2136**]
-HTN
-Hyperlipidemia
-Diastolic CHF, EF>55% in [**8-11**]
-Diabetes mellitus -- developed secondary to steroids
-Depression and PTSD
-Tobacco abuse
-Alcohol abuse
-Squamous cell carcinoma on dorsum of right hand s/p Mohs
micrographic surgery
-Back pain s/p multiple surgeries in cervical through lumbar
spine on narcotics contract
-Questionable h/o pericarditis with pericarial effusion
requiring drainage at [**Hospital1 **] (patient report)
Social History:
Lives alone in [**Location (un) 5289**]. On disability, but formerly worked in
construction doing wrecking. He was a certified asbestos
remover and had significant asbestos exposure 20-30 years ago.
- Tobacco history: Smoked 1.5 pk/day x30 years, recently
restarted smoking a couple cigarettes per day.
- ETOH: Last drink 3 days ago. Has drank 1-2 drinks of vodka on
two occasions this week. deneis daily ETOH use. Reports history
of occasionally drinking more than 20 beers at a sitting but not
recently. Asserts that he drinks minimally now because of his
health.
- Illicit drugs: None.
- Herbal/alternative therapy: None.
- He is divorced, but close with his ex-wife. Two children, son
died last year in [**Name (NI) 8751**].
Family History:
- Brother with heart transplant for pericarditis
- No other family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
- mother had melanoma and died of perforated peptic ulcer at 71
Physical Exam:
Vitals: T: BP: P: R: 18 O2:
General: Alert, oriented x 3, no acute distress
HEENT: +facial plethora, Sclera anicteric, MM dry, oropharynx
clear, no thrush
Neck: supple, unable to appreciate JVP, no LAD, RIJ in place
with minimal oozing
Lungs: Exp wheezes bilaterally with fine crackles in bases, no
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, obese, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: 3+ edema, slight erythema RLE>LLE, warm, well perfused, 2+
pulses, no clubbing, cyanosis
Neuro: + fine shaking tremor UEs b/l. No asterixis present
Pertinent Results:
[**2136-11-23**] 10:30PM GLUCOSE-126* UREA N-41* CREAT-2.5*#
SODIUM-136 POTASSIUM-4.3 CHLORIDE-91* TOTAL CO2-37* ANION GAP-12
[**2136-11-23**] 10:30PM CK(CPK)-36*
[**2136-11-23**] 10:30PM CK-MB-2 cTropnT-<0.01
[**2136-11-23**] 10:30PM CALCIUM-12.5* PHOSPHATE-4.1 MAGNESIUM-2.2
[**2136-11-23**] 07:04PM URINE HOURS-RANDOM CREAT-30 SODIUM-27
POTASSIUM-27 CHLORIDE-37 TOT PROT-13 PROT/CREA-0.4*
[**2136-11-23**] 07:04PM URINE OSMOLAL-189
[**2136-11-23**] 03:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.005
[**2136-11-23**] 03:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2136-11-23**] 03:30PM URINE RBC-0-2 WBC-0-2 BACTERIA-RARE YEAST-NONE
EPI-0-2
[**2136-11-23**] 01:47PM PO2-79* PCO2-57* PH-7.42 TOTAL CO2-38* BASE
XS-9
[**2136-11-23**] 12:15PM COMMENTS-GREEN TOP
[**2136-11-23**] 12:15PM LACTATE-3.2*
[**2136-11-23**] 12:05PM GLUCOSE-139* UREA N-44* CREAT-3.6*#
SODIUM-129* POTASSIUM-4.1 CHLORIDE-82* TOTAL CO2-37* ANION
GAP-14
[**2136-11-23**] 12:05PM estGFR-Using this
[**2136-11-23**] 12:05PM ALT(SGPT)-14 AST(SGOT)-16 LD(LDH)-229
CK(CPK)-41* ALK PHOS-54 TOT BILI-0.3
[**2136-11-23**] 12:05PM CK-MB-2 cTropnT-0.01 proBNP-162*
[**2136-11-23**] 12:05PM ALBUMIN-4.4
[**2136-11-23**] 12:05PM OSMOLAL-286
[**2136-11-23**] 12:05PM CORTISOL-19.2
[**2136-11-23**] 12:05PM WBC-12.6* RBC-3.92* HGB-11.0* HCT-32.3*
MCV-82 MCH-28.1 MCHC-34.1 RDW-19.8*
[**2136-11-23**] 12:05PM NEUTS-84.3* LYMPHS-11.9* MONOS-2.9 EOS-0.4
BASOS-0.5
[**2136-11-23**] 12:05PM PLT COUNT-242
[**2136-11-23**] 12:05PM PT-11.7 PTT-23.2 INR(PT)-1.0
UPRIGHT AP VIEW OF THE CHEST: The heart size is normal,
decreased from prior.
The mediastinal and hilar contours are unchanged, with widening
of the
superior mediastinum compatible with mediastinal lipomatosis.
Reticular
opacities within both upper lobes appear improved from the
prior, compatible
with patient's history of cryptogenic organizing pneumonia. No
new areas of
focal consolidation are seen. No pleural effusion or
pneumothorax is
identified. Several old right-sided healed rib fractures are
again noted.
IMPRESSION: Interval improvement in reticular opacities within
both upper
lobes compatible with patient's history of cryptogenic
organizing pneumonia.
No new areas of focal consolidation seen.
Renal US:
FINDINGS: No hydronephrosis, stones, or masses are seen
bilaterally. The
right kidney measures 11.8 cm and the left kidney measures 10.9
cm.
IMPRESSION: Normal renal son[**Name (NI) **].
Brief Hospital Course:
51 year old male with COP on chronic prednisone, dCHF, COPD, DM,
obesity hypoventilation syndrome, recent MICU admission for
hypotension and [**Last Name (un) **] attributed to adrenal insufficiency now
presenting with hypotension and [**Last Name (un) **].
.
# Hypotension: Patient admitted to [**Hospital Unit Name 153**] with hypotension and
shock requiring pressors. He received 2L NS in ED and still
appears volume depleted, likely contributing to hypotension. He
was initially started on broad spectrum antibiotics in case the
hypotension was from sepsis, but no infectious etiology found,
so antibiotics stopped. Unclear etiology of his hypotension.
ALthough he insists on complete medical compliance, it is
possible that this represented an adrenal crisis if he did not
take his prednisone as prescribed. He was given hydrocortisone
IV q8 hours initially. Another possibiliity is that he was
overmedicated - on holding his prazosin, metoprolol, aldactone
and lisinopril he was normotensive for many days on the medical
floor.
.
# Acute Kidney Injury: Cr 3.6 from 1.3 on [**11-10**]. Likely secondary
to prerenal azotemia vs ATN exacerbated by ongoing ACE and
diuretic use. AIN unlikely given no recent medications.
Normalized to 1.2 after fluid resuscitateion.
.
#. CHF: Patient does not have known systolic heart failure, and
has ? diastolic CHF. While on the medical floor he was found to
have significant bilateral LE edema and was agressively
diuresced with lasix. On the day of discharge he was found to
be 328 lbs, and was discharged on 120 mg po lasix daily, with
instructions to increase his lasix if his weight were to
increase by 3 lbs. Given that he doesn't have known systolic
heart failure, cardiology service agreed with holding aldactone
and metoprolol. ACE-I was continued given renoprotective
effects with his diabetes.
# Knee Pain: Patient c/o severe right knee pain. On exam,
found to have significant right knee effusion. Patient is
approximately 20 years TKR. He was evaluated by orthopedic
surgery service who did an arthrocentesis. No e/o septic joint
or crystal disease on tap. Ortho felt that pain/effusion
secondary to break down of TKR and advised re-do of his TKR as
an outpatient. F/u appt set up with Dr [**Last Name (STitle) 64940**] [**Name (STitle) 5322**] of
orthopedics. Patient very much in agreement.
# COP/ILD: Patient had CT scan during this admission that
showed Bilateral upper lobe crazy paving ground-glass opacities
with slight interval improvement in the left upper lobe since
[**2136-11-7**]. Despite having two biopsies of this area, patient
lacks definitive diagnosis of these areas. PUlmonary service
requested evaluation by thoracic surgery for VATS in order to
make definitive diagnosis. Thoracics felt that surgery would be
very high risk in this patient with his multiple comorbidities,
difficulty with intubation secondary to tracheomalacia and
because he would need an thoracotomy for the procedure given his
size. This was discussed with the pulmonary service. Given
that he is clinically stable despite these findings, we agreed
to attempt a slow taper of the prednisone to assess his response
and before re-consideration of an open thoracotomy.
# Edema: Patient with significant improvement in LE edema
after diuresis, but right le slightly larger than left, so LENI
done x 2 to r/o DVT - both of which were negative. Patient has
known history of PE, but is off anticoagulation because he
completed three months and had GI bleed. Edema appears to be
largely due to venous insufficiency.
# Recurrent Readmissions: This readmit represents the patient's
10th admission this year. The patient and I discussed this at
length - on discharge his medication regimen was simplified as
much as possible and his follow up appointments were
consolidated as much as possible so as to reduce the need for
multiple visits to [**Location (un) 86**]. I faxed his prescription list to
[**Location (un) 57911**] Apothecary, and they will provide him with bubble packs
of his meds and group them into morning and evening doses. We
discussed his responsibility in working with VNA, taking
medications and following dietary advice.
He was also seen by SW [**First Name8 (NamePattern2) 636**] [**Last Name (NamePattern1) 12471**], who has followed him over
the past several admissions. Patient still grieving the death
of his son. SW feels that it would be beneficial to have family
meeting at next readmit to discuss concerns regarding his
readmissions.
# Obesity hypoventilation: BiPap 14/10. Full face mask, on O2.
.
#. Anemia: Stable at baseline 32.
.
#. Tobacco abuse: Counseled him about smoking cessation.
- Nicotine patch daily
# Diabetes Mellitus; Well controlled. Continue lantus 15
units sc. A1c 6.4
Medications on Admission:
1. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
3. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO BID (2 times a day).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO QAM (once a day (in the morning)).
7. spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO MWF (Monday-Wednesday-Friday).
9. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
10. oxycodone 5 mg Tablet Sig: Six (6) Tablet PO Q4H (every 4
hours) as needed for pain.
11. oxycodone 60 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
13. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
16. Prednisone 20mg PO daily
Disp:*70 Tablet(s)* Refills:*1*
17. prazosin 1 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
18. Vitamin D 50,000 unit Capsule Oral
19. insulin glargine 100 unit/mL Solution Sig: [**1-24**] u
Subcutaneous at bedtime: please take as directed.
20. furosemide 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a
day).
21. simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
Discharge Medications:
1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
3. bupropion HCl 150 mg Tablet Sustained Release Sig: One (1)
Tablet Sustained Release PO once a day.
4. oxycodone 20 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours) for 1
months.
Disp:*252 Tablet Sustained Release 12 hr(s)* Refills:*0*
5. Lasix 40 mg Tablet Sig: Three (3) Tablet PO qam: PLEASE CHECK
YOUR WEIGHT DAILY. IF YOUR WEIGHT GOES UP BY 3 POUNDS, PLEASE
TAKE 3 ADDITIONAL LASIX TABLETS IN THE EVENING. .
6. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO QMOWEFR (Monday -Wednesday-Friday).
7. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO 1X/WEEK (FR): for 6 weeks.
9. prednisone 10 mg Tablet Sig: Three (3) Tablet PO once a day:
Please take three tablets (30mg) a day until [**12-4**].
On [**12-5**], please start 2.5 tablets daily (25 mg) for one week.
starting [**12-12**], please take 2 tablets (20mg) daily until you see
Dr [**Last Name (STitle) **] in pulmonary clinic. .
10. insulin glargine 100 unit/mL Solution Sig: 15 units
Subcutaneous once a day.
11. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day.
12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily) for 1 months: DO NOT SMOKE WHILE YOU
ARE USING THE PATCH .
14. oxycodone 30 mg Tablet Sig: One (1) Tablet PO every [**5-8**]
hours for 1 months.
Disp:*112 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
[**Location (un) 1110**] VNA
Discharge Diagnosis:
Hypotension, multifactorial
Acute renal failure
COOP
chronic diastolic CHF
OSA
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please adhere to a low salt, low sugar diet, and do not drink
more than 1.5 L of fluid a day.
You were admitted with low blood pressure, likely due to
combination of your medicines. We have eliminated three
medicines from your regimen that can decrease blood pressure -
prazosin, spironolactone and metoprolol. You also had excess
fluid in your legs - due to congestive heart failure. You were
given lasix (diuretic) for several days in order to eliminate
this fluid. On [**11-30**], your weight is 328 pounds. Please take
an additional 3 tablets of lasix in the evening if your weight
goes up by three pounds. Also, you have increased pain in your
right knee because your knee replacement is failing. You will
need a knee replacement, and have been [**Month/Year (2) 1988**] to see the
orthopedic surgeons soon. Your pulmonary (lung) doctors [**Name5 (PTitle) **]
decide [**Name5 (PTitle) **] and when to continue reducing your prednisone dose
when they see you and will determine if you need an additional
biopsy of your lung. YOUR MEDICATIONS WILL BE READY FOR YOU
TOMORROW AT [**Location (un) **] PHARMACY.
Followup Instructions:
Department: [**Hospital3 249**]
When: FRIDAY [**2136-12-7**] at 3:00 PM
With: [**Known firstname **] [**Last Name (NamePattern1) 24385**], MD [**Telephone/Fax (1) 250**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: PULMONARY FUNCTION LAB
When: WEDNESDAY [**2136-12-19**] at 1:10 PM
With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: MEDICAL SPECIALTIES
When: WEDNESDAY [**2136-12-19**] at 1:30 PM
With: DR [**Last Name (STitle) **] & DR [**Last Name (STitle) **] [**Telephone/Fax (1) 612**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: [**Hospital3 1935**] CENTER
When: MONDAY [**2136-12-24**] at 2:00 PM
With: [**Doctor Last Name **] [**Doctor Last Name **] [**Doctor Last Name 22344**], OD [**Telephone/Fax (1) 253**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2136-12-19**] at 11:40 AM
With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
Department: ORTHOPEDICS
When: WEDNESDAY [**2136-12-19**] at 12:00 PM
With: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1228**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**]
Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage
|
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"276.1",
"518.89",
"V43.65",
"V58.65",
"458.29",
"278.03",
"327.23",
"309.81",
"428.0",
"E947.8",
"275.42",
"516.8",
"V85.42"
] |
icd9cm
|
[
[
[]
]
] |
[
"38.93",
"81.91"
] |
icd9pcs
|
[
[
[]
]
] |
16529, 16588
|
8233, 13037
|
338, 354
|
16736, 16736
|
5651, 8210
|
18032, 19843
|
4755, 4963
|
14792, 16506
|
16609, 16715
|
13063, 14769
|
16887, 18009
|
4978, 5632
|
2433, 2870
|
278, 300
|
382, 2414
|
16751, 16863
|
2914, 3992
|
4008, 4739
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
53,346
| 142,400
|
51109
|
Discharge summary
|
report
|
Admission Date: [**2105-9-7**] Discharge Date: [**2105-9-13**]
Service: NEUROLOGY
Allergies:
Patient recorded as having No Known Allergies to Drugs
Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
Right eye deviation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
[**Age over 90 **] y/o female with PMHx significant for HTN, dementia and
hypercholesterolemia who presents with right eye deviation.
According to her son with whom she lives with, she was at her
normal baseline this past Saturday ([**9-5**]) helping him pay the
bills at 1-2pm. At ~9pm she was described as "slowing down" as
if she was getting sick (hesitating with actions and needing
more
verbal explanations). The following day she was again slower
than the previous day and did not want to attend church like she
normally does. She then went to bed but spent the majority of
the night getting up. This morning at ~5am her son then noticed
a right gaze preference, [**Name (NI) 653**] EMS who brought her to [**Hospital1 18**]
for evaluation.
Past Medical History:
Hypertension
Depression
Hypercholesterolemia
Cognitive decline
Cervical stenosis with impingement of cord
Glaucoma
Tonsillectomy
Question of TIA
Social History:
Patient lives with her son in [**Name (NI) 86**]. She has 1 daughter and 2
sons. She has a home aid and PT. There is a h/o tobacco usage
but unclear amount and lenght. No EtOH or illicit drug usage.
She ambulated with a walker and does many of her ADLs with help.
She is able to communicate in near full sentences and enjoys
talking politics with her daughter.
Family History:
NC
Physical Exam:
- VS: Tc 98.6 HR 82 BP 172/80
- General: Awake, laying in bed, NAD
- HEENT: NCAT, mucous membranes moist and pink, sclera
non-icteric
- Neck: Supple, no thyromegaly, no lymphadenopathy, no bruits
- Lungs: Clear bilaterally, good aeration, no wheezing/crackles
- Cardiac: Normal S1 and S2, no murmur
- Abdomen: S/NT/ND, normoactive BS, no masses
- Extremities: no C/C/E, warm
- Skin: no rashes, hypo-/hyperpigmented macules
Neurologic Examination:
- MS: Awake, alert, inattentive. Able to say "hi" and answers
intermittent "yes"/"no" questions. Remainder of spoken words are
faint and difficult to understand. Follows simple commands
(thumbs up) with her right arm otherwise no other commands.
Mimics many exam testing (fingers with visual testing) and picks
at objects on myself at other times.
- Cranial Nerves:
I: not tested
II: Blinks to threat on right, none on left; PERRL bilaterally
III, IV, VI: does not cooperate with full EOMI testing however
at no point did her eyes cross midline to the left
V: withdrew during testing
VII: no obvious droop or asymmetry
VIII: turns towards loud sounds on appropraiate side grossly
IX, X: Palate elevates midline and symmetrically, gag intact
[**Doctor First Name 81**]: unable to assess fully but able to hold head in midline
XII: would not protrude tongue, no fasciculations
- Motor: Decreased bulk and normal tone, no tremor, rigidity;
raises right arm off bed and keeps elevated; does not
spontaneously move left arm however slightly withdraws during
noxious stimulation. Actively moves bilateral legs
spontaneously,
antigravity and to resistance.
- Coordination: unable to assess fully
- Reflexes: No clonus, withdrawals toes
[**Hospital1 **] Tri [**Last Name (un) 1035**] Pat Ach
C5-6 C7-8 C5-6 L3-4 S1-2
Right 2 2 2 2 2
Left 2 2 2 2 2
Pertinent Results:
[**2105-9-7**] 07:15AM BLOOD WBC-10.5 RBC-4.07* Hgb-11.3* Hct-33.7*
MCV-83 MCH-27.8 MCHC-33.4 RDW-16.7* Plt Ct-353
[**2105-9-7**] 07:15AM BLOOD PT-12.2 PTT-25.0 INR(PT)-1.0
[**2105-9-7**] 07:15AM BLOOD Fibrino-555*
[**2105-9-8**] 08:54PM BLOOD Glucose-121* UreaN-19 Creat-0.7 Na-142
K-3.0* Cl-106 HCO3-26 AnGap-13
[**2105-9-7**] 07:15AM BLOOD ALT-17 AST-18 LD(LDH)-254* AlkPhos-91
TotBili-0.9
[**2105-9-8**] 08:54PM BLOOD Calcium-7.7* Phos-3.8 Mg-2.0
[**2105-9-7**] 07:15AM BLOOD Albumin-4.2
[**2105-9-11**] 04:30AM BLOOD Ammonia-19
[**2105-9-7**] 07:15AM BLOOD TSH-0.37
[**2105-9-7**] 07:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2105-9-7**] 07:24AM BLOOD Lactate-0.9
[**2105-9-7**] 09:39AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2105-9-7**] 09:39AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-50 Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG
[**2105-9-8**] 08:53PM URINE RBC-[**11-7**]* WBC-[**5-28**]* Bacteri-MOD
Yeast-NONE Epi-0
MICRO:
urine, blood, stool cx negative
IMAGING:
HEAD CT- 1. No acute intracranial findings.
2. Chronic atrophy and small vessel disease.
CXR- Possible calcified hilar lymph nodes, but no
consolidations.
PLAIN FILM SURVERY FOR PRE-MRI SCREEN
1. No metallic foreign body within the soft tissues and no
evidence of a
pacemaker.
2. No lytic or sclerotic bony lesions.
3. Old healed fracture through the proximal left humerus and
right inferior
pubic ramus.
EEG
This EEG telemetry showed a slow background on the left
side, relatively constant throughout and suggesting an
encephalopathy.
There was continued concern about the low voltage tracing on the
right
side, raising the possibility of widespread cortical dysfunction
or
fluid over that area, as on the previous recording.
Nevertheless, there
were no clear epileptiform features or electrographic seizures.
Brief Hospital Course:
[**Age over 90 **] YO RHW presented with decreased responsiveness, eyes deviated
to the right.
NEURO:
Patient presented with worsening alteration in mental status,
eyes deviated to the right. She had a negative head CT in the
ED, and was initially admitted for concern of stroke to the
stroke service. Her neurologic examination was nonfocal. She was
initially unable to undergo MRI due to concern for metal foreign
body in her eye, which no family member could provide history
of. While awaiting resolution of this question, patient was
found to be tachycardic, hypoxic and hypertensive. She then
began developed right facial twitching, which progresses to
generalized tonic clonic seizure that lasted about 3 minutes.
Seizure resolved with Ativan. She was then loaded with IV Keppra
and continued on maintenance dosing. Given severity of vital
signs changes, patient was transferred to ICU for 48 hours of
continuous EEG monitoring. She had no futher clinical seizres.
EEG showed encephalopathy but no seizures or epileptiform
changes. Patient was then transferred back to neurology floor.
She failed to improve her mental status. Repeat head CT was
unchanged.
It was thought that patient's decline was multifactorial due to
infection, seizure, and underlying suspectible brain with
atrophy and white matter disease. When she failed to improve
despite treatment of each of the factors, goals of care
discussion occurred. Palliative care was consulted. Patient was
made DNR/DNI and then discharged home with home hospice care.
She will continue taking standing Ativan for seizure ppx.
ID:
Patient had respiratory distress and fever upon admission. She
was started with CTX and azithromycin initially. CXR did not
show any infiltrate, although there was still high suspicion for
PNA. When patient failed to improve, abx coverage was broadened
to vanco, zosyn, azithromycin. Blood, urine, stool cx all
negative.
GI/FEN:
Patient's mental status was significantly altered and
speech/swallow thought her unsafe to take POs without
aspiration. Given goals of care, patient will continue to take
POs for comfort and pleaure as she wishes.
GOALS OF CARE: Palliative care consulted. Patient's daughter
(HCP) and son were in complete agreement about patient's wishes
to not pursue aggressive treatments. She was made DNR and DNI.
Decision was made not to pursue feeding tube. Patient was
discharged with home hospice.
Medications on Admission:
-HCTZ 12.5mg daily (recently decreased from 25mg daily)
-clopidogrel 75mg daily
-MVI daily
-levobunolol 0.5% eye drops daily
-trandolapril 2mg daily
-calcium 500mg [**Hospital1 **]
-Vit D 400 units daily
-loratidine 10mg prn allergies
Discharge Medications:
1. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day: please give SL.
Disp:*90 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
[**Hospital 3005**] Hospice and Palliative Care
Discharge Diagnosis:
seizure
pneumonia
delirium
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
You were admitted for altered mental status and difficulty
communicating. You were found to have a seizure and an
infection. You were treated with anti-epilepsy medications and
antibiotics. You had difficulty swallowing, and should eat only
soft foods carefully.
You will receive services at home to ensure you are comfortable.
You will take Ativan for seizures.
Followup Instructions:
You will follow up with your PCP and hospice care teams.
|
[
"780.09",
"272.0",
"780.39",
"348.30",
"799.02",
"401.9",
"486",
"294.8"
] |
icd9cm
|
[
[
[]
]
] |
[] |
icd9pcs
|
[
[
[]
]
] |
8306, 8384
|
5464, 7878
|
283, 290
|
8455, 8455
|
3562, 5441
|
8979, 9039
|
1639, 1643
|
8164, 8283
|
8405, 8434
|
7904, 8141
|
8592, 8956
|
1658, 2091
|
223, 245
|
318, 1071
|
2484, 3543
|
8470, 8568
|
2115, 2468
|
1093, 1239
|
1255, 1623
|
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